Leukemia is a cancer of the blood cells.

While the exact cause(s) of leukemia is not known, risk factors have been identified.
Leukemias are grouped by how quickly the disease develops (acute or chronic) as
well as by the type of blood cell that is affected (lymphocytes or myelocytes). The
four main types of leukemia include acute lymphocytic leukemia (ALL), chronic
lymphocytic leukemia (CLL), acute myelocytic leukemia (AML), and chronic
myelocytic leukemia (CML).
People with leukemia are at significantly increased risk for developing infections,
anemia, and bleeding. Other symptoms and signs include easy bruising, weight loss,
night sweats, and unexplained fevers.
The diagnosis of leukemia is supported by findings of the medical history and
examination, and examining blood and bone marrow samples under a microscope.
Treatment of leukemia depends on the type of leukemia, certain features of the
leukemia cells, the extent of the disease, and prior history of treatment, as well as
the age and health of the patient.
Most patients with leukemia are treated with chemotherapy. Some patients also
may have radiation therapy and/or bone marrow transplantation.
There is no known way to prevent leukemia.
The prognosis of leukemia depends upon several factors, including the patient's
age, the type of leukemia, and the extent to which the cancer has spread.
When you're told that you have cancer, it's natural to wonder what may have caused the disease. No
one knows the exact causes of leukemia. Doctors seldom know why one person gets leukemia and
another doesn't. However, research shows that certain risk factors increase the chance that a person
will get this disease.
The risk factors may be different for the different types of leukemia:

Radiation: People exposed to very high levels of radiation are much more likely than others
to get acute myeloid leukemia, chronic myeloid leukemia, or acute lymphocytic leukemia.
o
Atomic bomb explosions: Very high levels of radiation have been caused by atomic

bomb explosions (such as those in Japan during World War II). People, especially children,
who survive atomic bomb explosions are at increased risk of leukemia.
Radiation therapy: Another source of exposure to high levels of radiation is medical

treatment for cancer and other conditions. Radiation therapy can increase the risk of
leukemia.
Diagnostic x-rays: Dental x-rays and other diagnostic x-rays (such as CT scans)
expose people to much lower levels of radiation. It's not known yet whether this low level of

radiation to children or adults is linked to leukemia. Researchers are studying whether

having many x-rays may increase the risk of leukemia. They are also studying whether CT
scans during childhood are linked with increased risk of developing leukemia.

Smoking: Smoking cigarettes increases the risk of acute myeloid leukemia.

Benzene: Exposure to benzene in the workplace can cause acute myeloid leukemia. It may
also cause chronic myeloid leukemia or acute lymphocytic leukemia. Benzene is used widely in
the chemical industry. It's also found in cigarette smoke and gasoline.

Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs

sometimes later get acute myeloid leukemia or acute lymphocytic leukemia. For example, being
treated with drugs known as alkylating agents or topoisomerase inhibitors is linked with a small
chance of later developing acute leukemia.

Down syndrome and certain other inherited diseases: Down syndrome and certain other
inherited diseases increase the risk of developing acute leukemia.

Myelodysplastic syndrome and certain other blood disorders: People with certain blood
disorders are at increased risk of acute myeloid leukemia.

Human T-cell leukemia virus type I (HTLV-I): People with HTLV-I infection are at increased
risk of a rare type of leukemia known as adult T-cell leukemia. Although the HTLV-I virus may
cause this rare disease, adult T-cell leukemia and other types of leukemia are not contagious.

Family history of leukemia: It's rare for more than one person in a family to have leukemia.
When it does happen, it's most likely to involve chronic lymphocytic leukemia. However, only a
few people with chronic lymphocytic leukemia have a father, mother, brother, sister, or child who
also has the disease.
Having one or more risk factors does not mean that a person will get leukemia. Most people who
have risk factors never develop the disease.
An unanticipated complication of gene therapy has been confirmed as the cause of T-cell leukemia in
two boys receiving the pioneering treatment for X-linked severe combined immunodeficiency (XSCID). In the October 17 Science, an international research team confirms that inappropriate insertion
of the retroviral vector near the proto-oncogene LMO2 promoter led to uncontrolled clonal proliferation
of mature T cells (Science, 302:415-419, October 17, 2003).
This is the nightmare scenario, said Terry Rabbitts of the Medical Research
Council's (MRC) Laboratory of Molecular Biology in Cambridge, whose previous work on LMO2 played a
key role in the investigation. It's time to step back and give ourselves some breathing space.
The affected children were the youngest of 10 boys with X-SCID enrolled in the gene therapy trial
at Hpital Necker Enfants Maladesunder the direction of Alain Fischer. Inherited X-SCID, the so-called
baby in the bubble disease, is characterized by a lack of both T and B cells. The only certain cure at
present is a bone marrow transplant from a histocompatible sibling. For the vast majority of children,
however, an allogenic transplant is the best option, which carries a 5-year success rate of just 65%.
Building on the discovery that X-SCID was due to a defect in the common ( c) chain of the
interleukin 2 receptor on chromosome Xq13, Fischer and colleagues at the Necker Hospital developed

analternative therapy based on the ex vivo transfer of the c gene into autologous hematopoietic
precursor cells, employing a vector derived from a defective Moloney murine leukemia virus.
Fourteen children with X-SCID10 in France and four at Great Ormond Street Hospital in London
were subsequently treated and showed an impressive and sustained clinical response. These children
are coping with lots of infections, have a fully functioning immune system, and are effectively cured,
said Professor Rabbits.
In October of last year, the first serious side effect in a trial subject who exhibited a leukemia-like
syndrome 30 months after therapy was reported. In January, the development of similar
complications in a second participant in the French trial triggered a moratorium and frantic
investigations aimed at discovering what had gone wrong.
The Science paper, a collaboration among Fischer's team, the MRC, and experts in the United States
and Australia, confirms that insertional mutagenesisoriginally perceived as a possible but remote
complicationcaused both children's leukemias. Using molecular techniques, Hacein-Bey-Abina et al.
observed that clones from the patients showed retrovirus insertion in proximity to the promoter
of LMO2, which encodes a transcription factor required for hematopoiesis.
Until this report, retroviral insertion in the context of gene therapy has been considered an
untargeted and largely random event, comment David A. Williams and Christopher Baum in an
accompanying Perspectives article. Indeed, such insertional leukemogenesis without widespread viral
replication was reported injust one of thousands of preclinical experiments.
What remains unclear is why the viral vector inserted near the LMO2promoter locus in just two of 14
children treated with the same technique. Fischer believes that disease- and protocol-specific issues
may have played a part.
These patients were the youngest to be treatedjust 1 and 3 monthswhile the others were all at
least 6 months old, Fischer told The Scientist. They also received the highest number of corrected
cells. So, statistically speaking, the more you inject, the higher the probability.
Professor Hidde Haisma, from the Department of Therapeutic Gene Modulation at the University of
Gronigen, agreed that the patients' age may be significant. Very young infants have a different
subset of stem cells, with a higher proportion of precursor T cells, so they may be at higher risk of
insertional mutagenesis, he said. The Necker team is already testing the age hypothesis in mice.
Another worrying aspect of the study is the apparent preference of the retrovirus vector to insert in or
near active genes. Professor Christine Kinnon, head of the Centre for Gene Therapy of Childhood
Disease at Great Ormond Street Hospital for Children, commented that gene therapy in X-SCID
children involves introducing a strong selective advantage, which would inevitably carry a theoretical
risk of leukemia.

The insertional activation of the LMO2 locus in two independent leukemias suggests an essential
event that is required for the initiation of a malignant cascade, add Williams and Baum. Given the
lack of similar side effects in previous studies, a combinatorial process seems to be the likely culprit.
In addition to identifying patient-related risk factors, attempts are also underway to develop a vector
with a reduced propensity for insertional genotoxicity. Retroviruses were the logical choice, as they
had a good track record and can relatively easily infect bone marrow cells, said Haisma. But we
could use lentiviruses or adenoassociated viruses, or even artificial systems in which DNA is combined
with proteins to do the same job.
Fischer said his team is already making progress toward the next generation of highly selective
vectors. I expect that by next year, we will be in a position where we have a safer therapeutic
approach and can start treating patients once again, he said.
Kinnon agrees that vector modifications hold the key to success. In the meantime, the Great Ormond
Street trial is continuing to recruit X-SCID children for gene therapy, albeit on a case-by-case basis
and only when authorized by the Gene Therapy Advisory Committee.
I still believe gene therapy has a relatively good riskbenefit ratio, Kinnon said, noting that all 14
children treated to date are alive and well, and the two boys who developed leukemia responded well
to chemotherapy and are in complete clinical remission. With a mismatched bone marrow transplant,
at least one third would have died by nowthat's four or five children versus noneso it's still an
huge improvement on current options. If it were my child, I would give them this treatment.

Individuals with a number of life-threatening genetic diseases of the immune

system have been successfully treated by gene therapy -- that is, they were
infused with early precursors of immune cells that had the correct form of the
defective gene delivered into them by agents known as retroviral vectors.
However, some patients later developed leukemia. This slowed progress in the field and has led to
detailed studies seeking to determine the mechanisms underlying the cause of leukemia and whether
other genes that are candidates for gene therapy approaches might pose a similar risk.
A new study, carried out by Hans-Peter Kiem and colleagues, at the Fred Hutchinson Cancer Research
Center, Seattle, has now indicated that early precursors of immune cells that had the gene HOXB4
delivered into them by a gammaretroviral vector became leukemic in 2 of 2 dogs and 1 of 2 macaques.
In vitro analysis established a clear link between HOXB4 expression and leukemia, leading the authors to
conclude that the use of HOXB4-based gene therapy would probably carry a high risk of leukemia and
that extreme caution is needed when considering gene therapy approaches.
The need for caution is echoed in an accompany commentary by Andre Larochelle and Cynthia E.
Dunbar, at the National Institutes of Health, Bethesda, who discuss how important large animal studies,
such as those reported by Hans-Peter Kiem and colleagues, are to minimize the risk of adverse events in
humans receiving gene therapy in the future.
The recent news that a child participating in a flagship gene therapy trial had developed
cancer, almost certainly as a result of the treatment strategy, rocked the gene therapy
community. However, should similar trials be halted indefinitely, possibly at the expense of
other very sick children?

There are over 600 clinical trials of gene therapy completed, ongoing or pending throughout
the world. Almost 2000 patients have been entered into these trials and about 40 have been
children with disorders attributable to mutations in single genes (monogenic). Such diseases
are rare but are the best candidates for treatment with gene therapy.
X-linked severe combined immunodeficiency (X-linked SCID) is one such disease that is
devastating. Those affected die young, often within the first year of life. Bone marrow
transplantation from a matched donor is an effective treatment, but matched unrelated
donors are rare. Moreover, transplantation of mismatched bone marrow has a high mortality
rate (2030%), and even when successful can result in long-term complications. One of
these complications is the possibility of treatment-induced cancer.1
It was attempts to find an alternative treatment for X-linked SCID that resulted in one of the
first great success stories for gene therapy. In their landmark clinical trial, Alain Fischer's
group successfully treated children with X-linked SCID with genes delivered using retroviral
vectors.2
Two and a half years after treatment, one of the patients involved in the Fischer trial has
developed a peripheral T-cell count that is 10 times normal. In addition, the patient's T cells
appear to be monoclonal and overexpressing a potential oncogene found at the site of
retroviral insertion.3,4 This site has been identified as being the first intron of the LMO-2
gene on chromosome 11.3,4 LMO-2 is involved in the development of both the lymphoid and
myeloid series and is the site of a translocation that occurs in leukaemia.
These observations clearly suggest that retroviral gene insertion may have been the cause
of the leukaemia here. However, other factors such as genetic background and preceding
viral infection may have also played a role in the development of this child's disease. A press
release from the French regulatory authority rather coyly describes this child's condition as
a 'lymphoproliferative disorder': perhaps acute T-cell leukaemia might be another
description of this complication.3
Long-term integration of gene sequences into a patient's genome is the very property that
makes retroviruses attractive vectors for delivering genes to correct inherited mono-genic
disorders. Only a few studies in animal models of gene therapy have suggested that vectormediated insertional mutagenesis could be a problem. However, its spectre has always
loomed over the field and now it has apparently been made flesh.
In France, the trial sponsor and the Agence Francaise de Securite Sanitaire des Produits de
Sante (AFSSPS) have put a hold on this trial. Similarly, the Biologicals Respone Modifiers
Advisory Committee of the FDA's Center for Biologics Evaluation and Research (CBER)
halted the recruitment of patients for three similar US studies. Both agencies commented
that these actions are 'as a precautionary measure, and until analysis and identification of
the mechanism(s) responsible' and 'pending further analysis of this event'. 3,4
In experimental medicine, serious side effects have to be considered in relation to their
predictability, their frequency and their severity. In UK trials of gene therapy for inherited
disorders that have involved retroviral vectors, patients and relatives have always been
specifically warned of the danger of insertional mutagenesis leading to cancer. Similarly, the
Fischer trial considered this to be a possibility and warned the families of the patients who
were participating.
It is very unusual for a serious adverse event (SAE) that patients have been formally
informed about to halt patient recruitment for phase I or II studies. The frequency of a side

effect is impossible to assess in the early stages of any trial, and if a predicted SAE occurs,
it is more usual to institute extra reporting and monitoring mechanisms than to stop a
study.
In this case, the SAE developed 2 years after treatment. Thus, if one wished to suspend
patient recruitment in order to assess this event more fully, the only logical course of action
would be to stop patient entry for at least this length of time. Even this would not be an
entirely accurate assessment of the situation, because we know from longitudinal studies in
cancer patients and retrospective analyses of bone marrow recipients, that the risk of
subsequent malignancy is very hard to predict until many years have passed.
Long-term follow-up clinical data is always going to be a vital component of any risk
assessment of this (or any other) gene therapy strategy. It is thus illogical to put such trials
'on hold'. It would be more consistent to close them; after all suspending patient
recruitment for the required time to complete accurate risk assessment (35 years) is
tantamount to closure. Further laboratory work alone will not give us an answer to the
frequency of treatment-induced malignancy in patients treated with retrovirally based gene
therapies.
In the UK, the Department of Health's Gene Therapy Advisory Committee (GTAC) suggests
that clinical work should continue albeit with renewed caution. New clinical and laboratory
information will be assessed prior to any children being recruited in the future. Permission
for treatment will be sought on a case-by-case basis.5 Thus, independent risk assessment
can be made for each individual in the light of the very latest data.
Keeping the trial open in this way allows a balance to be struck between risk and caution.
Perhaps the most important feature of this compromise position is that parents are drawn in
closer to decisions that affect the conduct of clinical trials that have a direct relevance to
their children's desperate plight. Interestingly, it is reported that advice to the FDA has now
changed and it is now more in line with the GTAC's view, which is that these studies should
conti-nue to proceed, but with extra caution.
The toxicity of any treatment needs to be evaluated in two contexts: what is the therapeutic
intent (palliative or curative) and what are the other available treatment options? The intent
of gene therapy is curative and the alternative of a bone marrow transplant anyway carries
with it the risk of inducing a malignancy. Furthermore, the options for children with X-linked
SCID if they do not have a matched sibling are pretty dismal.
Parents have always known that there is a risk of treatment-induced malignancy from
retrovirally based gene therapies. This recent sad news does not give them any
fundamentally new information; clinicians involved in these trials will still warn of the risk of
malignancy and this warning will remain in patient information sheets. I suspect shutting
down clinical trials in this area is not what the parents of these children want.
Scientists for the first time have used gene therapy to successfully destroy cancer tumors in patients with advanced
disease a goal that has taken 20 years to achieve.
Researchers at the University of Pennsylvania engineered patients own pathogen-fighting T-cells to target a
molecule found on the surface of leukemia cells.
The altered T-cells were grown outside of the body and infused back into patients suffering from late-stage chronic
lymphocytic leukemia (CLL), which affects the blood and bone marrow and is the most common form of leukemia.

Two participants in the Phase I trial have been in remission for up to a year. A third had a strong anti-tumor response,
and his cancer remains in check. The research group plans to treat four more patients with CLL before moving into a
larger Phase II trial.
We put a key onto the surface of the T-cells that fits into a lock that only the cancer cells have, said Dr. Michael
Kalos, director of translational and correlative studies at the University of Pennsylvanias Perelman School of
Medicine and an investigator on the study.
The results provide a tumor-attack roadmap for the treatment of other cancers, including those of the lung and
ovaries as well as myeloma and melanoma, researchers said.
The findings were published simultaneously Wednesday in the New England Journal of Medicine and Science
Translational Medicine.
Kalos said past efforts to use the technique, known as adoptive T-cell transfer, failed either because the T-cell
response was too weak or proved too toxic for normal tissue.
NEW METHODOLOGY
The technique differs from other cancer therapies designed to harness the bodys own immune system to fight tumors
such as therapeutic cancer vaccines.
We are saying forget about stimulating an immune response. We are going to give you an immune response, Kalos
said.
The treatment appears safe, but researchers said more study was needed. The leukemia patients in the Phase I trial
had to be treated with an immunity-boosting drug since the targeted molecule, CD-19, is also present on certain
normal immune-system cells.
To deliver the gene therapy, the researchers used a virus that can only infect cells once. It was used to carry a
chimeric antigen receptor targeting CD-19 coupled with receptors for two other components of T-cell activity.
About two weeks after the gene therapy, patients began to experience tumor lysis syndrome chills, nausea and
fever caused by the break-down products of dying cancer cells.
The engineered T-cells were detected in patients blood for several months afterward, and a portion of them turned
into memory T-cells, which could provide ongoing protection against cancer recurrence, researchers surmised.
Dr. Walter Urba of the Providence Cancer Center in Portland Oregon cautioned that continued presence of activated
T-cells and memory cells might be more of a problem in other types of cancer where toxic effects on normal tissue
could be more severe.
In addition, the long-term viability of the treatment is still unknown.
One of the big questions is will those persistent T-cells continue to work and prevent that tumor from coming
back, said Urba, who was not involved in the study.
All of the funding for the University of Pennsylvanias gene therapy work has come from the academic community, but
the work is expensive.
We are looking for corporate partners as we head into Phase II trials, Kalos said.
Further study will show whether the latest results reflect an authentic advance toward a clinically applicable and
effective therapy or yet another promising lead that runs into a barrier that cannot be easily overcome, Urba said in
an NEJM editorial.