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We used the genomic breakpoint between and genes for the DNA-based monitoring of minimal residual disease (MRD) in 48 patients with childhood acute lymphoblastic leukemia (ALL). Comparing the results with standard MRD monitoring based on immunoglobulin/T-cell receptor (Ig/TCR) gene rearrangements and with quantification of deletion, we observed very good correlation for the methods in a majority of patients; however,>20% of children (25% [8/32] with minor and 12.5% [1/8] with major- variants in the consecutive cohorts) had significantly (>1 log) higher levels of fusion than Ig/TCR rearrangements and/or deletion. We performed cell sorting of the diagnostic material and assessed the frequency of -positive cells in various hematopoietic subpopulations; 12% to 83% of non-ALL B lymphocytes, T cells, and/or myeloid cells harbored the fusion in patients with discrepant MRD results. The multilineage involvement of the -positive clone demonstrates that in some patients diagnosed with-positive ALL, a multipotent hematopoietic progenitor is affected by the fusion. These patients have-positive clonal hematopoiesis resembling a chronic myeloid leukemia (CML)-like disease manifesting in "lymphoid blast crisis." The biological heterogeneity of -positive ALL may impact the patient outcomes and optimal treatment (early stem cell transplantation vs long-term administration of tyrosine-kinase inhibitors) as well as on MRD testing. Therefore, we recommend further investigations on CML-like-positive ALL.

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