Complex MLL rearrangement in a patient with T‐cell acute lymphoblastic leukemia

MLL (also known as ALL‐1, HTRX, or HRX) gene translocations are among the most common chromosomal abnormalities recognized in both B‐lineage acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). However, MLL gene rearrangements are uncommon in T‐cell ALL. We recently detected an MLL gene rearrangement in a patient with typical T‐cell ALL (CD2⁺, CD4⁺, CD5⁺, CD7⁺, CD8⁺, HLA DR⁻) and an apparently normal karyotype (46.XX). The rearrangement was cloned and characterized; a DNA fragment distal to the breakpoint was mapped by fluorescence in situ hybridization (FISH) to 19p13, indicating that the leukemic blasts had undergone a cytogenetically undetected rearrangement involving chromosomes 11 and 19. A reverse transcriptase‐polymerase chain reaction (RT‐PCR) assay demonstrated an in‐frame fusion mRNA between the amino terminus of MLL and the carboxy terminus of ENL (also known as MLLT1 or LTG19), a gene that has been mapped to 19p13. In addition, MLL sequences distal (telomeric) to the breakpoint were deleted from the genome, which precludes the formation of a reciprocal ENL/MLL fusion protein. These findings suggest that an MLL/ENL fusion protein (and not a reciprocal ENL/MLL fusion) was likely to be pathogenic in this patient, and they reinforce previous studies showing that leukemic blasts with apparently normal karyotype may harbor MLL rearrangements. Additionally, this report provides the first conclusive evidence of an MLL/ENL gene fusion characterized at a molecular level in a patient with T‐cell ALL.