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For personal use only. 1991 77: 238-242 Hybridization protection assay: a rapid, sensitive, and specific method for detection of Philadelphia chromosome-positive leukemias K Dhingra, M Talpaz, MG Riggs, PS Eastman, T Zipf, S Ku and R Kurzrock Updated information and services can be found at: http://www.bloodjournal.org/content/77/2/238.full.html Articles on similar topics can be found in the following Blood collections Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036. Copyright 2011 by The American Society of Hematology; all rights reserved. From www.bloodjournal.org by guest on November 14, 2014. For personal use only. RAPID COMMUNICATION Hybridization Protection Assay: A Rapid, Sensitive, and Specific Method for Detection of Philadelphia Chromosome-Positive Leukemias By Kapil Dhingra, Moshe Talpaz, Michael G. Riggs, P. Scott Eastman, Theodore Zipf, Stella Ku, and Razelle Kurzrock The Philadelphia (Ph’) chromosome is present in greater than 90% of patients with chronic myelogenous leukemia (CML) and in 2% t o 20% of those with acute leukemias, for which it is an important prognostic marker too. The chimeric BCRABL mRNAs resulting from the translocation encode either a 210-Kd or a 190-Kd protein. The techniques used t o detect Ph’ chromosome include karyotyping, Southern analysis t o demonstrate bcr rearrangement, and polymerase chain reaction t o amplify the BCR-ABL transcripts. However, the routine performance of these methods by clinical laboratories is cumbersome, time consuming, and exposes laboratory personnel t o radioisotopes. We describe here the clinical application of a new method, the hybridization protection assay (HPA), which uses chemiluminescent acridinium-esterlabeled probes in conjunction with PCR for detection of the amplified BCR-ABL sequences. The method is sensitive, specific, and can reliably distinguish between the transcripts In contrast t o the 2 days or for P190”R-ABLand P21OBCRpgL. longer required for conventional hybridization, HPA analysis can be completed in less than 30 minutes. We have successfully used this method t o analyze 60 leukemia samples (34 from Ph’-negative acute leukemias; 6 from Ph’-positive acute leukemias; and 20 from CML) with complete correlation (of BCR-ABL positivity or negativity) with the results of karyotype or Southern Blot analysis of genomic DNA for bcr rearrangement. Therefore, the HPA, in conjunction with PCR, appears t o provide a rapid and reliable test for the diagnosis of Ph‘-positivity. 0 1991by The American Society of Hematology. THE 70% of their Ph’-negative counterparts are alive at 5 years. Similarly, in adults with this disorder, the median remission duration is less than 1 year. Therefore, alternative treatment strategies have been advocated for patients with Phl-positive acute leukemias.I6Hence, it is desirable to have a method that allows rapid and easy diagnosis of Ph’ translocation, both in acute leukemia and CML. Amplification of the chimeric BCR-ABL transcripts by PCR has been used to diagnose Ph’ positivity, to detect minimal residual disease in patients with CML, and to study the presence and significance of alternative splicing of BCR-ABL mRNA.I7 However, the technique, as currently used in most laboratories, is time consuming and requires radioisotopes. We describe here the clinical application of a hybridization technique involving acridinium-ester-labeled oligonucleotide probes that is sensitive, specific, and does not require the use of radioisotopes. This technique, in conjunction with PCR, allows same-day detection of BCRABL positivity from small amounts of peripheral blood. PHILADELPHIA (Ph’) translocation [t(9;22) (q34; qll)], a hallmark of chronic myelogenous leukemia (CML)’-*results from a break within a 5.8-kb region (the breakpoint cluster region or bcr) in the central part of the BCR gene on chromosome 2Z3and leads to juxtapositioning of theABL oncogene (chromosome 9) with the BCR gene:,’ The resulting hybrid BCR-ABL mRNA codes for a tumorspecific 210-Kd protein6 with enhanced tyrosine kinase enzymatic a~tivity.~,’ At least two different species of this hybrid mRNA exist depending on whether exon 2 or exon 3 of bcr is spliced to exon 2 of the ABL gene, thereby giving rise to two closely related 210-Kd proteins? In contrast, in about half the cases of Ph’-positive acute leukemias, the Ph’ chromosome, although cytogenetically indistinguishable from that in patients with CML, results from a breakpoint in the first intron of the BCR gene (proximal to the bcr)‘0,1’2’2 and leads to the production of a truncated BCR-ABL transcript encoding a 190-Kd protein.”’14 The Ph’ chromosome is discernable in approximately 20% of adults with acute lymphoblastic leukemia (ALL),” 2% of adults with acute myeloblastic leukemia (AML), and 5% of children with ALL.’6 It is an important prognostic marker for both adult and pediatric ALL. Less than 30% of children with Phl-positive ALL are long-term survivors,’6whereas 60% to From the Department of Clinical Immunology and Biological Therapy, and the Department of Pediatrics, The University of Texas M.D. Anderson Cancer Center, Houston; and Gen-Probe, Inc, San Diego, CA. Submitted September IO, 1990; accepted October 29, 1990. Address reprint requests to Kapil Dhingra, MD, Department of Clinical Immunology and Biological Therapy, Box 41, The University of T m s M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. section I734 solely to indicate this fact. 0 1991 by The American Society of Hematology. 0006-4971l91/7702-0021$3.00/0 238 MATERIALS AND METHODS Patients. Blood samples were collected from patients with diagnosis of CML (chronic phase or blast crisis), or acute leukemia (both Ph’-positive and Ph’-negative). Informed consent was obtained from all patients before venesection. Sample preparation and amplification. Total cellular RNA was extracted by previously described methods.” RNA from K562 cells, an erythroid blast crisis cell line, and RNA from patient W, a Ph’-positive CML patient, were used as positive controls for mRNA containing bcr exon 3-ABL exon III9 and bcr exon 2-ABL exon I1 junctions: respectively. The ALL-1 cell line (kindly provided by Dr G. Rovera, Wistar Institute) was used as a positive control for the transcript encoding P19@CR-ABL.” HL-60 (a promyelocytic leukemia cell line) and normal human endometrial RNA were used as negative controls. One microgram of total RNA from cell lines or Xothof the total amount of RNA from 50 to 200 million white blood cells (WBCs) from patient samples was used for amplification reactions. The amplification method and the primers have been previously described.” Amplification was performed for 40 cycles. Blood, Vol77, No 2 (January 15). 1991: pp 238-242 From www.bloodjournal.org by guest on November 14, 2014. For personal use only. BCR-ABL HYBRIDIZATION PROTECTIONASSAY Because contamination has proven to be a significant problem in some laboratories using this exquisitely sensitive technique, we took the following precautions to ensure the accuracy of our results: (1) the thermal cycler was kept in a separate laboratory, away from the room where cell collection, RNA processing, and cDNA synthesis was performed; (2) no amplified samples were allowed to be brought back into the room where RNA processing was performed; (3) at least one negative control was run for each experiment; and (4) samples on each patient were run on at least two different occasions. Hybridizationprotection assay (HPA). Acridinium-ester-labeled oligonucleotides complementary to the BCR-ABL junction sequences were synthesized by Gen-Probe, Inc (San Diego, CA). The basic methodology for preparation of these probes has been described previously?' The chemical labeling of the DNA probes with acridinium-ester was achieved by reacting alkylamine linkerarms, which were introduced during DNA synthesis, and an N-hydroxysuccinimide ester of a methyl acridinium phenyl ester. The bcr2-ABLII probe was a 28mer with 22 bases in bcr exon 2 and the bcr3-ABLII probe was a 25mer with 11 bases in bcr exon 3. These probes were used to detect transcripts encoding P2108CR.ABL. The BCRI-ABLII probe was a 26mer with 17 bases in BCRI and was used to detect transcripts coding for P190BCR-ABL. For hybridization, 10 pL of the amplified product was diluted to 50 pL in a 12 X 75-mm polypropylene tube. The sample was heated to 95°C for 3 minutes to denature the DNA and quick chilled on ice. Fifty microliters of the hybridization solution containing 0.05 pm of the probe was added to this (the 2X hybridization solution is a 0.1 mol/L lithium succinate buffer, pH 4.7, containing 20% lithium lauryl sulfate, 1.2 m o m lithium chloride, 20 mmol/LEDTA, and 20 mmol/L of [ethylenebis(oxyethylenitrilo)]tetraacetic acid [EGTA]). The sample was lightly vortexed, incubated at 60°C for 10 minutes, and allowed to cool at room temperature for 1minute. Differential hydrolysis of the bound versus free probe was performed by the addition of 300 p L of hydrolysis buffer (0.6 m o m sodium tetraborate buffer, containing 10 mL of Triton X-100 surfactant [Sigma, St Louis, MO] per liter, at pH 8.5) and incubating at 60°C for 6 minutes. After the sample had cooled at room temperature for a few minutes, chemiluminescence was measured in a Leader I luminometer (Gen-Probe, Inc) using an automated reagentinjection method involving two detection reagents. Injection of 200 pL of Detection Reagent I (0.1% H,O,, vol/vol; 1 mmol/L nitric acid) was followed, after a 1-second delay, by injection of 200 FL of Detection Reagent I1 (1 mol/L NaOH). The resulting chemiluminescence was integrated for 2 seconds and the reading expressed in relative light units (RLUs). All these steps were performed in a single 12 x 75-mm polypropylene tube. Southem hybridization. To verify the results obtained by HPA, conventional Southern blotting and hybridization of all amplified samples was performed. Ten microliters of the amplified product was run on 3% Nusieve/l% Seakem (FMC, Rockland, ME) composite gels, transferred ovemight to Genescreen Plus membrane (New England, Nuclear, Boston, MA), and baked at 80°C for 2 hours. Oligonucleotide probes complementary to the junctional BCR-ABL sequence^'^ were 5' end-labeled with 32Pand hybridization performed overnight using hybridization buffer with (for bcr3-ABLII and BCRI-ABLII) or without (for bcr2-ABLII probe) formamide. The membranes were washed as recommended by the manufacturer and exposed to Kodak XAR film (Eastman Kodak Co, Rochester, NY) for 3 to 48 hours. The bcr3-ABLII and bcr2-ABLII probes detect 200-bp and 125-bp long amplification products, respectively, while the BCRI-ABLII probe detects a 307-bp product. 239 RESULTS To determine the time of differential hydrolysis that will maximize the chemiluminescence from hybridized probe while reducing the signal from unhybridized probe to a minimum, hybridization reactions were performed in the presence or absence of the target. The hybridization mixtures were then incubated with the differential hydrolysis buffer at 60°C for various lengths of time and the residual chemiluminescence measured. The results of such an analysis for the bcr3-ABLII probe are presented in Fig 1. The half-life of the hybridized probe was approximately 9 minutes while that of the free probe was 19 seconds. Thus, the TIn of the hybridized probe compared with the free probe results in a differential hydrolysis ratio of 28. Similarly, the bcr2-ABLII and the BCRI-ABLII probes both demonstrated differential hydrolysis ratios of 30. Accordingly, a 6-minute differential hydrolysis step was chosen. In our initial experiments we attempted to establish the sensitivity and specificity of the amplification process and detection of amplified products by HPA. These results are shown in Fig. 2. Starting with 1 pg of total RNA from the K562 or the ALL-1 cells, serial 10-fold dilutions were performed with normal human endometrial RNA. After 40 cycles of amplification, the BCR-ABL message could be detected at a dilution of 1:106 and 1:104 with K562 and ALL-1 RNA, respectively. Because one-tenth of the final amplification product was used for analysis, this represents the equivalent of total RNA from "th of a cell and one cell, respectively (at 10 pgkell). The sensitivity of detection of chimeric transcripts with HPA was identical to that on Southern blots and there was no cross-reactivity between the probes detecting P190BcR-ABL and P210BCR-ABL. Subsequently, we used HPA to analyze samples from patients with CML and various types of acute leukemias. These included 20 cases of childhood ALL (19,Ph'- 0 h dp b 4 0 10 20 30 40 Time (minutes) Fig 1. Kinetic analysis of ester hydrolysis rates of hybridized and free acridinium-ester-labeled bcr3-ABLII probe. The chemiluminescent measurements were plotted as log percent initial chemiluminescence with time. From www.bloodjournal.org by guest on November 14, 2014. For personal use only. DHINGRA ET AL 240 Fig 2. Comparison of the sensitivity of radiolabeled probes and HPAfordetecting PCR-amplified products. Lane 1, K562 RNA; lanes 2 through 8, Serial 10-fold dilutions of K562 RNA; lane 9, ALL-1 RNA; lanes 10 through 14, serial 10-fold dilutions of ALL-1 RNA; lane 15, HL-60 (negative control) RNA. HPA counts on the samples are shown below each lane. bcrB-ABL II and BCRI-ABLII probes were used t o detect amplified products from K562 and ALL-1, respectively. negative; 1, Ph'-positive), 20 cases of CML (18, Phipositive; 2 Phl-negative but bcr-rearrangement positive) and 20 adult acute leukemias (15, Phl-negative; 5, Ph'Represenpositive-3 for P190wR'"''i.and 2 for P210""~"'"~). tative results from these are shown in Fig 3. In every case, the resultsof HPA were consistent with those obtained with karyotypes and Southern blots. Interestingly, two acute leukemia patients who were positive by HPA were not known to be Ph'-positive because of inadequate metaphases on karyotyping at thc time of presentation. Subsequent cytogenetic evaluation at thc time of leukemic relapse in both these patients showed the presence of the Ph' chromosome. In addition, two CML patients who had a diploid karyotype but were positive by HPA were also found to have bcr rearrangement on Southern blots. All samples from Ph'-positive leukemias had HPA counts greater than 100,000 RLUs on HPA and could be clearly distinguished from samples from Phi-negative leukemias, which were usually less than 1,OOO RLUs. We have also used this technique successfully to dctcct minimal residual disease in individuals who are in complete cytogenetic remission following a-interferon therapy or allogeneic bone marrow transplantation (data not shown). DISCUSSION Fig 3. Comparison of the sensitivity of radiolabeled probes and HPA in detecting PCR-amplfied p r o d u m from clinical specimens. Lane 1, Ph'-positive pediatric ALL; lanes 2 through 4; Ph'-negative pediatric ALL; lanes 5 and 6, Ph'-positive adult acute leukemia; lanes 7 and 8. Phhegative adult acute leukemia; lanes 9 and 10, chronicphase CML; lanes 11 and 12, blast-crisis CML; lane 13, K562; lane 14, ALL-1; lane 15, HL-60 (negative control). (A) BCRI-ABLII probe; ( 6 ) bcr-ABLII probe HPA counts on the specimens are shown below each lane. Rapid advances in our understanding of the molecular basis of human neoplasia have led to an increasing emphasis on the potential clinical applications of these discovcries. While the use of polymerase chain reaction (PCR) has increased the sensitivity of detection of the Ph' chromosome, confirmation of the amplified product has required Southern blotting, hybridization with radiolabeled probes, extensive washing, and, finally, autoradiography. As an alternative, HPA was investigated for the dctection of PCR-amplified product. HPA is an entirely homogeneous format that not only is nonradioactive, but also requires no physical separation of free versus hybridized probe. In the presence of the differential hydrolysis buffer, the rate of hydrolysis of free probe is much faster than that of the hybridized probe. As a consequence, separation Of hybridized probe from free probe on a solid Support iS UnnCCeSsary. Furthermore, elevated backgrounds traditionally associated with physical separation techniques are not a problcm with HPA. Acridiniumesters have high chcmilumin~scentquantum yield and rapid chemiluminescent reaction kinetics. Alkyl- From www.bloodjournal.org by guest on November 14, 2014. For personal use only. 241 BCR-ABL HYBRIDIZATION PROTECTIONASSAY amine linker-arms can be attached to synthetic DNA probes during DNA synthesis. The alkylamines are then used as labeling sites for acridinium esters. Such acridiniumester-labeled probes are fully compatible with solution hybridization methods. Solution hybridizations, as used by the HPA format, allow for faster kinetics relative to hybridizations performed on solid supports. Furthermore, with the ability to hydrolyze all free probe before detection with HPA, the amount of input probe can be adjusted to further drive the reaction kinetics. The amount of probe used and the time of hybridization for each of the probes was based on COTlndeterminations (data not shown). Using the HPA format described in this report, the sensitivity of detection of chimeric BCR-ABL transcripts is equal to that with radiolabeled probes while the background signal from unhybridized probe is in the 0.002% to 0.005% range, thus allowing a clear distinction between the positive and negative samples. The probes used allow a differentiation between the transcripts encoding P190BcR-ABL and P210BCR-mL. Because this method is used in conjunction with PCR, it requires a much smaller sample than Southern blotting and, unlike cytogenetics, can be performed on peripheral blood. Furthermore, it can be successfully applied in instances where karyotyping is unsuccessful because of a lack of adequate metaphases. The rapidity of HPA allows the nonradioactive detection of the Phl translocation on the same day that the sample is obtained and, therefore, can help the physician make a more accurate assessment of prognosis before initiating therapy. Finally, our dilution experiments indicate one leukemic cell in a population of a million or more normal cells will give a positive result by this method, indicating that it may be used to detect minimal residual disease. It should be noted that the counts obtained by HPA may not increase linearly with the increase in the quantity of the starting template or the final amplification product. This result may be because of (1) nonlinearity inherent in the PCR system (due to varying efficiency of amplification depending on the amount of starting template); (2) the inability of the photomultiplier tube in the luminometer to discriminate individual chemiluminescent events above a certain signal-input level, especially signals greater than 100,000 RLUs; and (3) the competition between the opposite strand of the PCRamplified product and the probe for the probe target region during hybridization. Besides its use for the detection of Phl-positive leukemias, HPA has potential for other clinical applications, too. Because of its ability to provide high stringency between closely related target sequences, the technique may be used to detect point mutations in cancer-related genes. Indeed, it has already been shown that one- or two-base mismatches in DNA from closely related bacteria such as meningococcus and gonococcus can be detected by HPA.” Preliminary results suggest that it can also be exploited to discern point mutations in RAS protooncogenes.*I Finally, an increasing number of cytogenetic defects are being discovered in various tumors and, recently, other translocations encoding novel proteins have been cloned?2 This method should be easily applicable to the diagnosis and follow-up of these neoplasms. ACKNOWLEDGMENT We thank Kristie Lykstad for excellent technical assistance and Mehrdad Majlessi for synthesis and purification of the acridiniumester-labeled probes. REFERENCES 1. Nowell PC, Hungerford D A A minute chromosome in human chronic granulocytic leukemia. Science 132:1497,1960 2. Rowley JD: A new consistent chromosomal abnormality in chronic myelogenous leukaemia identified by quinacrine fluorescence and Giemsa staining. Nature 243:290,1973 3. Groffen J, Stephenson JR, Heisterkamp N, de Klein A, Bartram CR, Grosveld G: Philadelphia chromosomal breakpoints are clustered within a limited region, bcr, on chromosome 22. Cell 36:93, 1984 4. Bartram CR, de Klein A, Hagemeijer A, van Agthoven T, Geurts van Kessel A, Bootsma D, Grosveld G, Ferguson-Smith MA: Translocation of the c-ab1 oncogene correlates with the presence of a Philadelphia chromosome in chronic myelocytic leukemia. Nature 306:277,1983 5. Heisterkamp N, Stephenson JR, Grofen J, Hansen PF, de Klein A, Bartram CR, Grosveld G: Localization of the c-ab1 oncogene adjacent to a translocation break point in chronic myelocytic leukemia. Nature 306:239,1983 6. Shtivelman E, Lifshitz B, Gale RP, Roe BA, Canaani E: Fused transcript of ab1 and bcr genes in chronic myelogenous leukemia. Nature 315:550,1985 7. Konopka JB, Watanabe SM, Witte ON: An alteration of the human c-ab1 protein in K562 leukemia cells unmasks associated tyrosine kinase activity. Cell 37:1035, 1984 8. 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Lee MS, Chang KS, Freireich EJ, Kantarjian HM, Talpaz M, Trujillo JM, Stass S A Detection of minimal residual bcr/abl transcripts by a modified polymerase chain reaction. Blood 72:893, 1988 18. Maniatis T, Frisch EF, Sambrook J: Molecular cloning-A Laboratory Manual. Cold Spring Harbor, NY,Cold Spring Harbor Laboratory, 1982, p 187 19. Kawasaki ES, Clark SS, Coyne MY, Smith SD, Champlin R, DHINGRA ET AL Witte ON, McCormick FP: Diagnosis of chronic myeloid and acute lymphocytic leukemias by detection of leukemia-specific mRNA sequences amplified in vitro. Proc Natl Acad Sci USA 855698, 1988 20. Fainstein E, Marcelle C, Rosner A, Canaani E, Gale RP, Dreazen 0, Smith SD, Croce CM: A new fused transcript in Philadelphia chromosome positive acute lymphocytic leukeamia. Nature 330386,1987 21. Arnold LJ Jr, Hammond PW, Wiese WA, Nelson N C Assay formats involving acridinium-ester-labeled DNA probes. Clin Chem 35:1588,1989 22. 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