BCR-ABL1

BCR-ABL1 testing is used to:

• Help diagnose chronic myelogenous leukemia (CML) or a type of acute lymphoblastic leukemia (ALL)
• Monitor treatment
• Monitor for recurrence
• Detect resistance to therapy

BCR-ABL1 refers to a gene sequence found in an abnormal chromosome 22 of some people with certain forms of leukemia. Testing is ordered to detect the Philadelphia (Ph) chromosome and BCR-ABL1 gene sequence. It is used to help diagnose CML and specific types of ALL and, rarely, acute myeloid leukemia (AML) in which the BCR-ABL1 gene sequence is present (BCR-ABL1-positive). It is also used to monitor response to treatment and to monitor for disease recurrence. At diagnosis, 90-95% of cases of CML are BCR-ABL1-positive. About one in four adults with ALL have the sequence.

Several types of tests may be ordered to detect BCR-ABL1. These include chromosome analysis, the qualitative or quantitative BCR-ABL1 molecular genetic test, and/or fluorescence in situ hybridization (FISH). These help establish the initial diagnosis of CML or Ph-positive ALL. The quantitative test is also used to monitor how well someone responds to therapy.

Tests for BCR-ABL1 are often performed along with other tests if a health practitioner suspects that someone has leukemia and is trying to diagnose or rule out CML and Ph-positive ALL. The chromosomal analysis and FISH can also help to determine what percentage of the person's blood or bone marrow cells are affected.

The BCR-ABL1 can produce proteins of differing sizes and weights, depending on where the break in chromosome 22 occurred. In CML, the breakpoint in BCR is almost always in the major breakpoint cluster region (M-BCR), leading to the production of BCR-ABL1 protein of a larger size (the protein is called p210). Breaks in the minor breakpoint cluster region (m-BCR) leads to a shorter fusion protein (called p190), which is most frequently associated with Ph chromosome-positive ALL.

The quantitative BCR-ABL1 molecular test measures either of the breakpoints in the fusion gene. It is used to establish a baseline value and then to monitor the person's response to treatment and, if the person achieves remission, to monitor for recurrence. If treatment resistance or disease recurrence occurs, the BCR-ABL1 kinase domain mutation analysis should be performed to guide further treatment.

BCR-ABL1 testing is ordered when a health practitioner suspects that a person has CML or Philadelphia chromosome (Ph)-positive ALL. Initial testing may be indicated when a person has nonspecific signs or symptoms such as:

• Fatigue
• Weight loss
• Joint or bone pain
• Enlarged spleen
• As follow-up to abnormal findings on a complete blood count (CBC)

Early in the disease, a person may have few or no symptoms. As time passes and normal blood cells are crowded out of the bone marrow and the number of abnormal leukemic cells increases, a person may experience anemia, prolonged bleeding, and recurrent infections.

Once CML or Ph chromosome-positive ALL has been diagnosed, BCR-ABL1 quantitative genetic testing is ordered periodically (typically every 3 months) to monitor the response to treatment and monitor for recurrence.

When a person is not responding and treatment resistance is suspected or disease recurrence occurs after remission, the BCR-ABL1 kinase domain mutation analysis may be performed.

If a person has abnormal white blood cells in the bone marrow and has the Philadelphia (Ph) chromosome and BCR-ABL1 gene sequence, then the individual is diagnosed with CML or Ph-positive ALL.

Of those who have CML, 90-95% have the Ph chromosome if tested by cytogenetics and 100% have the BCR-ABL1 gene sequence by FISH and/or qualitative BCR-ABL1 molecular testing. About 25% of adults with ALL and 2-4% of children with ALL are positive for the Ph chromosome and/or the BCR-ABL1 gene sequence.

A small percentage of people with CML will have the BCR-ABL1 gene sequence but not the Ph chromosome. These cases either have variant translocations that involve a third or even a fourth chromosome in addition to 9 and 22 or have a hidden translocation involving 9 and 22 that can not be identified by routine chromosomal analysis. Since the treatment for BCR-ABL1-related leukemias specifically targets the tyrosine kinase protein produced, these people can still be monitored with quantitative BCR-ABL1 molecular testing.

In general, if the amount of BCR-ABL1 in the blood or bone marrow decreases over time, then the person is responding to treatment. If the quantity of BCR-ABL1 drops below the test's detection level and the person's blood cell counts are normal, then the person is considered to be in remission.

If the BCR-ABL1 level rises, then it indicates disease progression or recurrence. It may also indicate that the person has become resistant to imatinib, the first-generation tyrosine kinase inhibitor. Additional genetic testing is often performed to detect the development of BCR-ABL1 kinase domain mutations associated with imatinib resistance.

If an individual's leukemia is resistant to imatinib, a second generation tyrosine kinase inhibitor may be given. Those tyrosine kinase inhibitors, developed after imatinib, are also given in case the side effects from imatinib are too severe or in case of a rare BCR-ABL mutation. They include ponatib, bosutinib, nilotinib, and dasatinib.

If a person with ALL is not positive for the Ph chromosome and the BCR-ABL1 gene sequence, then that person will not be given a tyrosine kinase inhibitor drug and BCR-ABL1 molecular testing cannot be used to monitor the person.

Recognition of disease progression and transformation is important for prognosis and treatment. CML goes through three phases:

• Chronic phase—most people with CML are diagnosed in the chronic phase, which usually has an insidious onset, meaning that leukemia symptoms may be absent or subtle. The chronic phase may last for a month to several years. This is the phase when there are few or no symptoms and also the time period when treatment is most successful.
• Accelerated phase—changes include but are not limited to increasing white blood cell (WBC) counts and additional changes to cells like an increase in blasts in blood and/or bone marrow (but less than 20%) and lack of therapeutic response to standard treatment
• Blast phase—when blasts are 20% or more of the cells in the blood or bone marrow or when there is blast proliferation outside the bone marrow

Both blood and bone marrow are often evaluated as part of the initial diagnosis, but the majority of follow-up monitoring is performed on blood samples. There is significant test variability among laboratories using different test platforms. Therefore, for a given patient, the quantitative BCR-ABL1 molecular testing should be performed by the same laboratory or referred to a laboratory that follows universal reporting criteria. Rising and falling levels of BCR-ABL1 are usually more important than a single test result.

Your health care provider may order chromosome analysis periodically to determine if you have developed any additional chromosome abnormalities. Additional changes are often seen with disease progression and acceleration.