MIELOPROLIFERATIVE MIELOPROLIFERATIVE DISORDERSDISORDERS

INSTITUTUL REGIONAL DE INSTITUTUL REGIONAL DE ONCOLOGIE IASIONCOLOGIE IASI

CLINICA HEMATOLOGIECLINICA HEMATOLOGIE

2012-20132012-2013

CHRONIC MYELOPROLIFERATIVE CHRONIC MYELOPROLIFERATIVE DISORDERS (MPD)DISORDERS (MPD)

MPD are clonal diseases originating in MPD are clonal diseases originating in pluripotential haematopoieticpluripotential haematopoietic stem cell. stem cell.

The clonal expansion results in increased and The clonal expansion results in increased and abnormal haematopoiesis and produces a abnormal haematopoiesis and produces a group of interrelated syndromes, classified group of interrelated syndromes, classified according to the predominant phenotypic according to the predominant phenotypic expression of the myeloproliferative clone.expression of the myeloproliferative clone.

CHRONIC MYELOPROLIFERATIVE CHRONIC MYELOPROLIFERATIVE DISORDERS (MPD)DISORDERS (MPD)

Neoplastic (clonal) disorders of hemopoietic stem cells

Over-production of all cell lines, with usually one line in particular

Fibrosis is a secondary event

Acute Myeloid Leukemia may occur

HAEMATOPOIESISHAEMATOPOIESIS

HEMATOPOIETIC PROGENITORSHEMATOPOIETIC PROGENITORS

GeneticMutation

National Cancer Institute

GENERALITIESGENERALITIES

Hemopoietic stem cell disorderHemopoietic stem cell disorder– ClonalClonal– Characterized by proliferationCharacterized by proliferation

– GranulocyticGranulocytic

– ErythroidErythroid

– MegakaryocyticMegakaryocytic

Interrelationship betweenInterrelationship between– PolycythaemiaPolycythaemia– Essential thrombocythaemiaEssential thrombocythaemia– myelofibrosismyelofibrosis

GENERALITIESGENERALITIES

Normal maturation (effective)Normal maturation (effective)Increased number ofIncreased number of

Red cellsRed cellsGranulocytesGranulocytesPlateletsPlatelets

(Note: myeloproliferation in myelodysplastic syndrome is ineffective)(Note: myeloproliferation in myelodysplastic syndrome is ineffective)

Frequent overlap of the clinical, laboratory & morphologic Frequent overlap of the clinical, laboratory & morphologic findingsfindings

Leucocytosis, thrombocytosis, increased Leucocytosis, thrombocytosis, increased megakaeryocytes, fibrosis & organomegaly blurs the megakaeryocytes, fibrosis & organomegaly blurs the boundariesboundaries

Hepatosplenomegaly Hepatosplenomegaly Sequestration of excess bloodSequestration of excess bloodExtramedullary haematopoiesisExtramedullary haematopoiesisLeukaemic infiltrationLeukaemic infiltration

Rationale for classificationRationale for classification

Classification is based on the lineage of the Classification is based on the lineage of the predominant proliferationpredominant proliferation

Level of marrow fibrosisLevel of marrow fibrosis

Clinical and laboratory data (FBP, BM, Clinical and laboratory data (FBP, BM, cytogenetic & molecular genetic)cytogenetic & molecular genetic)

CHRONIC MYELOPROLIFERATIVE CHRONIC MYELOPROLIFERATIVE DISORDERSDISORDERS

WHO Classification of CMPDWHO Classification of CMPD

Ch Myeloid leukemiaCh Myeloid leukemiaCh Neutrophillic leukemiaCh Neutrophillic leukemiaCh Eosinophillic leukemia / Hyper Eo SyndCh Eosinophillic leukemia / Hyper Eo SyndPolycythemia VeraPolycythemia VeraEssential ThrombocythemiaEssential ThrombocythemiaMyelofibrosisMyelofibrosisCMPD unclassifiableCMPD unclassifiable

MYELOPROLIFERATIVE MYELOPROLIFERATIVE DISORDERSDISORDERS

MPD•PRV•ET•MF

AML

MDS•RA•RARS•RAEB I•RAEB II

CMML

CML

CHRONIC MYELOPROLIFERATIVE CHRONIC MYELOPROLIFERATIVE DISORDERSDISORDERS

Chronic Myeloid leukemia (Chronic Myeloid leukemia (BCR-ABL positive)BCR-ABL positive)Polycythemia VeraPolycythemia VeraEssential ThrombocythemiaEssential ThrombocythemiaMyelofibrosisMyelofibrosis

– Specific clincopathologic criteria for diagnosis and Specific clincopathologic criteria for diagnosis and distinct diseases, have common featuresdistinct diseases, have common features

– Increased number of one or more myeloid cellsIncreased number of one or more myeloid cells– HepatosplenomegalyHepatosplenomegaly– HypercatabolismHypercatabolism– Clonal marrow hyperplasia without dysplasiaClonal marrow hyperplasia without dysplasia– Predisposition to evolvePredisposition to evolve

Bone marrow stem cell

Clonal abnormality

Granulocyte precursors

Red cell precursors

Megakaryocytes Reactive fibrosis

Essentialthrombocytosis

(ET)

Polycythaemia rubra vera

(PRV)

Myelofibrosis

AML

Chronic myeloid leukemia

70%

10% 10%

30%

CHRONIC CHRONIC MYELOGENOUS MYELOGENOUS LEUKEMIA (CML)LEUKEMIA (CML)

CML - INTRODUCTIONCML - INTRODUCTION

Clonal malignant myeloproliferative disorder Clonal malignant myeloproliferative disorder characterized by increased proliferation of the characterized by increased proliferation of the granulocytic cell line without the loss of their granulocytic cell line without the loss of their capacity to differentiate capacity to differentiate

Results in increases in myeloid cells, erythroid cells Results in increases in myeloid cells, erythroid cells and platelets in peripheral blood and marked myeloid and platelets in peripheral blood and marked myeloid hyperplasia in the bone marrow hyperplasia in the bone marrow

Originate in a single abnormal haemopoietic stem cellOriginate in a single abnormal haemopoietic stem cell

CML - BACKGROUNDCML - BACKGROUND

CML was the first human malignancyCML was the first human malignancy to be to be associated with a specific genetic lesion, the associated with a specific genetic lesion, the PhiladelphiaPhiladelphia chromosome, harboring the chromosome, harboring the BCR-BCR-ABLABL oncogene. Since then, it has oncogene. Since then, it has become a become a paradigm for the discovery of molecular paradigm for the discovery of molecular mechanismsmechanisms and targeted therapeutic and targeted therapeutic approaches in the field of hematologicapproaches in the field of hematologic

neoplasias.neoplasias.

CML - EPIDEMIOLOGYCML - EPIDEMIOLOGYCML accounts for 20% of all leukemias CML accounts for 20% of all leukemias affecting adultsaffecting adults..

Frequency - 10-15 new cases, each year, Frequency - 10-15 new cases, each year, for one million population. for one million population.

In general, this disease occurs in the In general, this disease occurs in the fourth and fifth decades of life. fourth and fifth decades of life.

Younger patients aged 20-29 years may Younger patients aged 20-29 years may be affected and may present with a more be affected and may present with a more aggressive form, such as in accelerated aggressive form, such as in accelerated phase or blast crisis. phase or blast crisis.

Sex ratioSex ratio is 1,4-2,2 (m/f). is 1,4-2,2 (m/f).

CML - ETIOLOGYCML - ETIOLOGY

EtiologyEtiology– Not clearNot clear– Little evidence of genetic factors linked to the Little evidence of genetic factors linked to the

diseasedisease– Increased incidence Increased incidence

Survivors of the atomic disasters at Nagasaki & Survivors of the atomic disasters at Nagasaki & HiroshimaHiroshima

Post radiation therapyPost radiation therapy

LEUKEMOGENESISLEUKEMOGENESIS

Philadelphia chromosome is an Philadelphia chromosome is an acquired cytogenetic anomaly acquired cytogenetic anomaly that is characterizes in all that is characterizes in all leukaemic cells in CMLleukaemic cells in CML

90-95% of CML pts have Ph 90-95% of CML pts have Ph chromosomechromosome

Reciprocal translocation of Reciprocal translocation of chromosome 22 and chromosome 22 and chromosome 9chromosome 9

CML - Ph CHROMOSOMECML - Ph CHROMOSOME

LEUKEMOGENESISLEUKEMOGENESIS

BCR (breakpoint cluster region)BCR (breakpoint cluster region) gene on gene on chromosome 22 fused to the chromosome 22 fused to the ABL (Ableson ABL (Ableson leukemia virus)leukemia virus) gene on chromosome 9 gene on chromosome 9

Ph chromosome is found on myeloid, Ph chromosome is found on myeloid, monocytic, erythroid, megakaryocytic, B-cells monocytic, erythroid, megakaryocytic, B-cells and sometimes T-cell proof that CML derived and sometimes T-cell proof that CML derived from pluripotent stem cellfrom pluripotent stem cell

LMC - CROMOZOMUL PhLMC - CROMOZOMUL Ph

a11

5’ 3’

Ib Ia a2 a3

Gena ABL – Crs 9

5’ 3’ e1 e1’ e2’ e6 b2 b3 e19

m-bcr M-bcr μ-bcr

Gena BCR – Crs 22

P190

P210

P230

BCR

ABL

Consequences of p210Consequences of p210BCR-ABLBCR-ABL

Molecular consequence of the t(9;22) is the fusion Molecular consequence of the t(9;22) is the fusion protein BCR–ABL, which has increased in tyrosine protein BCR–ABL, which has increased in tyrosine kinase activitykinase activityBCR-ABL protein transform hematopoietic cells so that BCR-ABL protein transform hematopoietic cells so that their growth and survival become independent of their growth and survival become independent of cytokinescytokinesIt protects hematopoietic cells from programmed cell It protects hematopoietic cells from programmed cell death (apoptosis) death (apoptosis)

– deregulated cellular proliferation,deregulated cellular proliferation,

– decreased adherence of leukemia cells to the bone marrow stroma decreased adherence of leukemia cells to the bone marrow stroma

– reduced apoptotic response to mutagenic stimuli reduced apoptotic response to mutagenic stimuli

LMC - CROMOZOMUL PhLMC - CROMOZOMUL Ph

CML – HISTORY (I)CML – HISTORY (I)

Disease is biphasic, sometimes triphasicDisease is biphasic, sometimes triphasicThe clinical manifestations of CML are insidious and The clinical manifestations of CML are insidious and are often discovered incidentally are often discovered incidentally - - 40% 40% asymptomaticasymptomaticChronic phaseChronic phaseSplenomegaly often massiveSplenomegaly often massiveSymptoms related to hypermetabolismSymptoms related to hypermetabolism– Weight lossWeight loss– AnorexiaAnorexia– LassitudeLassitude– Night sweatsNight sweats

CML – HISTORY (II)CML – HISTORY (II)

Features of anaemiaFeatures of anaemia– Pallor, dyspnoea, tachycardiaPallor, dyspnoea, tachycardia

Abnormal platelet functionAbnormal platelet function– Bruising, epistaxis, menorrhagiaBruising, epistaxis, menorrhagia

Hyperleukocytosis Hyperleukocytosis – thrombosisthrombosis– Increased purine breakdown : goutIncreased purine breakdown : gout– Visual disturbancesVisual disturbances– PriapismPriapism

Some patients may present with complications – Some patients may present with complications – spleen infarction, spleen fracture, peptic ulcer with spleen infarction, spleen fracture, peptic ulcer with hemorrhagia. hemorrhagia.

CML – PHYSICAL (I)CML – PHYSICAL (I)

SplenomegalySplenomegaly ( (70–85%70–85%) - ) - is the most is the most common physical finding in patients with common physical finding in patients with CML.CML.– The size of the spleen correlates with the The size of the spleen correlates with the

peripheral blood granulocyte countsperipheral blood granulocyte counts– A very large spleen is usually a harbinger of the A very large spleen is usually a harbinger of the

transformation into an acute blast crisis form of the transformation into an acute blast crisis form of the diseasedisease

HepatomegalyHepatomegaly also occurs, although less also occurs, although less commonly than splenomegalycommonly than splenomegaly , in , in 20–45%20–45%,,LymphadehopatiesLymphadehopaties - signifie the evolution to - signifie the evolution to the accelerated/blastic phase.the accelerated/blastic phase.

CML – PHYSICAL (II)CML – PHYSICAL (II)Fever, purpura.Fever, purpura.Physical findings of Physical findings of leukostasisleukostasis and and hyperviscosityhyperviscosity can occur in some patients, can occur in some patients, with extraordinary elevation of their WBC with extraordinary elevation of their WBC counts, exceeding 300,000-600,000 counts, exceeding 300,000-600,000 cells/mmccells/mmc :: – headache, headache, – dizziness, dizziness, – vertigo, vertigo, – tinnitus, tinnitus, – visual disturbances, visual disturbances, – angina pectoris, or angina pectoris, or – intermittent claudications.intermittent claudications.

CML – CML – PERIPHERAL BLOODPERIPHERAL BLOOD LeucocytosisLeucocytosis ( (a total WBC count of 20,000-over a total WBC count of 20,000-over 100.000 cells/100.000 cells/L) with circulating immature cells L) with circulating immature cells from the bone marrow, such as myeloblasts, from the bone marrow, such as myeloblasts, myelocytes, metamyelocytes, and nucleated red blood myelocytes, metamyelocytes, and nucleated red blood cells, mimicking the findings in the bone marrow. cells, mimicking the findings in the bone marrow. BasophiliaBasophilia - 2-4%, over 7% in 10 – 15 % patients - 2-4%, over 7% in 10 – 15 % patientsEosinophiliaEosinophiliaMild-to-moderate Mild-to-moderate anemiaanemia usually normochromic and usually normochromic and normocyticnormocytic ThrombocitosisThrombocitosis - 500.000–600.000/mm - 500.000–600.000/mm33, to 1–2 , to 1–2 million/mmmillion/mm33..

CML – CML – PERIPHERAL BLOODPERIPHERAL BLOOD

CML – CML – PERIPHERAL BLOODPERIPHERAL BLOOD

CML – BONE MARROWCML – BONE MARROW

Marrow aspirateMarrow aspirate - - Bone marrow isBone marrow is– Hypercellular (reduced fat spaces)Hypercellular (reduced fat spaces)

– Myeloid:erythroid ratio – 10:1 to 30:1 (N : 2:1)Myeloid:erythroid ratio – 10:1 to 30:1 (N : 2:1)

– Myelocyte predominant cell, blasts less 10%Myelocyte predominant cell, blasts less 10%

– Megakaryocytes increased & dysplasticMegakaryocytes increased & dysplastic

– Increase reticulin fibrosis in 30-40%Increase reticulin fibrosis in 30-40%

BOMBOM - confirm - confirmss the hyperplasia of the hyperplasia of hematopoietic tissue. hematopoietic tissue. Mild fibrosis is often Mild fibrosis is often seen in the reticulin stain.seen in the reticulin stain.

CML – BONE MARROWCML – BONE MARROW

CML – BONE MARROWCML – BONE MARROW

CML – BIOLOGYCML – BIOLOGY

the the leukocyte alkaline phosphataseleukocyte alkaline phosphatase stains very low stains very low to absent in most cells, resulting in a low scoreto absent in most cells, resulting in a low score ..markedly elevatedmarkedly elevated serum vitamin B-12–binding serum vitamin B-12–binding proteinprotein (TC-I) (TC-I);;hemostasishemostasis thrombocytopathia with prolonged thrombocytopathia with prolonged bleeding time bleeding time andand decreased platelet decreased platelet aggregability. aggregability. hyperuricemiahyperuricemia andand hyperuricuriahyperuricuria, elevated , elevated LDHLDH;;hyperhistaminemiahyperhistaminemia;;

CML - EVOLUTIONCML - EVOLUTIONChronic phaseChronic phaseAccelerated phaseAccelerated phaseAcute phase (blastic phase)Acute phase (blastic phase)ComplicationsComplications– anemia, infecanemia, infectionstions, , – bleeding or thrombosis (priapism), bleeding or thrombosis (priapism), – spleen infarction or fracture, spleen infarction or fracture, – pulmonary (infarction, infecpulmonary (infarction, infectionstions), ), – bone (pains, distrucbone (pains, distructiontion, hypercalcemia), , hypercalcemia), – neurologic (leucostasis, hemorragia, thrombosis), neurologic (leucostasis, hemorragia, thrombosis), – metabolic (gout)metabolic (gout)

LMC – ACCELERATED PHASELMC – ACCELERATED PHASEMedian duration is 3.5 – 5 yrs before evolving to Median duration is 3.5 – 5 yrs before evolving to more aggressive phasesmore aggressive phasesMay last for several months.May last for several months.– Clinical featuresClinical features

Increasing splenomegaly refractory to chemoIncreasing splenomegaly refractory to chemoIncreasing chemotherapy requirementIncreasing chemotherapy requirement

– Lab featuresLab featuresBlasts>15% in bloodBlasts>15% in bloodBlast & promyelocyte > 30% in bloodBlast & promyelocyte > 30% in bloodBasophil 20% in bloodBasophil 20% in bloodThrombocytopeniaThrombocytopeniaCytogenetic: clonal evolutionCytogenetic: clonal evolution

CML – BLASTIC PHASECML – BLASTIC PHASE

Criteria :Criteria :– Resembles acute leukaemiaResembles acute leukaemia

– Diagnosis requires > 30% blast in marrowDiagnosis requires > 30% blast in marrow

– 2/3 transform to myeloid blastic phase and 1/3 to lymphoid 2/3 transform to myeloid blastic phase and 1/3 to lymphoid blastic phaseblastic phase

– Survival : 9 mos vs 3 mos (lym vs myeloid)Survival : 9 mos vs 3 mos (lym vs myeloid)

BCR-ABL – detection techniquesBCR-ABL – detection techniques

Conventional cytogeneticConventional cytogenetic analysisanalysisFluorescece in situu hybridisation (FISH)Fluorescece in situu hybridisation (FISH)Polymerase chain reaction (PCR)Polymerase chain reaction (PCR)Reverse transcriptase – PCR (RT-PCR)Reverse transcriptase – PCR (RT-PCR)Real-time quantitative PCR (RQ-PCR) for BCR-Real-time quantitative PCR (RQ-PCR) for BCR-ABLABL mRNAmRNAUtility :Utility :– Diagnosis positif and differentialDiagnosis positif and differential– Monitorising drug therapyMonitorising drug therapy– Assesment of minimal residual disease (MRD)Assesment of minimal residual disease (MRD)

Diagnostic Considerations in Diagnostic Considerations in Chronic Myeloid LeukemiaChronic Myeloid Leukemia

Karyotyping in CML

1) Allows for the diagnosis of CML

2) Requires a bone marrow aspirate for optimal metaphases

3) Allows for evaluation of clonal evolution as well as additional chromosomal abnormalities in the non-Ph+ clones

4) Occasional cryptic and complex karyotypes can result in the missed identification of the t(9;22)

Demonstrating the presence of the t(9;22) or its gene product is absolutely essential in diagnosing a patient with CML

Source Undetermined

Diagnostic Considerations in Diagnostic Considerations in Chronic Myeloid LeukemiaChronic Myeloid Leukemia

Fluorescence in-situ hybridization(FISH) in CML:

1) Allows for the diagnosis of CML2) Does not require a bone marrow aspirate for optimal results3) Allows for the identification of potential duplications of the Ph chromosome 4) Allows for the identification of the loss of the der (9) chromsome5) Allows for the identification of cryptic translocations involving Bcr-Abl

Bcr- Ch 22

Abl – Ch 9

Bcr-Abl Fusion

Source Undetermined

LMC - FISHLMC - FISH

Diagnostic Considerations in Diagnostic Considerations in Chronic Myeloid LeukemiaChronic Myeloid Leukemia

Bcr-Abl

Bcr

Abl

cDNA

Quantitative RT-PCR for Bcr-Abl in CML

1) Allows for the diagnosis of CML

2) Does not require a bone marrow aspirate for optimal results

3) Can quantify the amount of disease

4) Allows for the identification of cryptic translocations involving Bcr-Abl

5) Many primers sets only detect the p190 and/or the p210 translocation and may miss the p230 or alternative translocations

Source Undetermined

CML – PROGNOSTICCML – PROGNOSTICPoor prognosis features in patients with CML Poor prognosis features in patients with CML include :include :– older ageolder age – symptomatic presentationsymptomatic presentation – poor performance statuspoor performance status – Hepatomegaly,Hepatomegaly, splenomegalysplenomegaly – negative Ph chromosome or negative Ph chromosome or bcr-ablbcr-abl – anemiaanemia – thrombocytopenia/thrombocytosis, thrombocytopenia/thrombocytosis, – basophilia, or myelofibrosis (increased reticulin or basophilia, or myelofibrosis (increased reticulin or

collagen) collagen) – longer time to hematologic remission with longer time to hematologic remission with

myelosuppression therapy myelosuppression therapy

CML – PROGNOSTICCML – PROGNOSTIC Sokal Score Sokal Score

(+)/(+)/0(t) = Exp 0,0116 (0(t) = Exp 0,0116 (AgeAge - 43,4) + - 43,4) + 0,0345 (0,0345 (spleenspleen - 7,51)+ 0,188 - 7,51)+ 0,188 ((PtPt/700)/700)22 - -

0,5630,563 + 0,0887 ( + 0,0887 (blablasststs - 2,10) - 2,10)

ScoreScore Median survivalMedian survival Survival at 48 months Survival at 48 months

– IS = < 0,8IS = < 0,8 60 months60 months 62%62%– IS = 0,8 - 1,2IS = 0,8 - 1,2 44 months 44 months 43%43%– IS = >1,2IS = >1,2 32 months32 months 33%33%

CML – GENERAL CML – GENERAL MANAGEMENTMANAGEMENT

Discussion with familyDiscussion with family– The disease & diagnosisThe disease & diagnosis– Prognosis Prognosis – Choices of treatmentChoices of treatment

Cytotoxic drug vs bone marrow transplantCytotoxic drug vs bone marrow transplant

Side effectSide effect

CML – PRINCIPLES OF CML – PRINCIPLES OF TREATMENTTREATMENT

Relieve symptoms of hyperleukocytosis, Relieve symptoms of hyperleukocytosis, splenomegaly and thrombocytosissplenomegaly and thrombocytosis– HydrationHydration

– Chemotherapy (bulsuphan, Hydoxyurea)Chemotherapy (bulsuphan, Hydoxyurea)

Control and prolong chronic phase (non-curative)Control and prolong chronic phase (non-curative)– alpha interferon+chemotherapyalpha interferon+chemotherapy

– imatinib mesylate imatinib mesylate

– chemotherapy (hydroxyurea)chemotherapy (hydroxyurea)

CML – PRINCIPLES OF CML – PRINCIPLES OF TREATMENTTREATMENT

Treatment cont…Treatment cont…

Eradicate malignant clone (curative)Eradicate malignant clone (curative)– allogeneic transplantationallogeneic transplantation– alpha interferon ?alpha interferon ?– imatinib mesylate/STI 571 ?(Thyrosine kinase imatinib mesylate/STI 571 ?(Thyrosine kinase

inhibitor)inhibitor)

LMC – MEDICAL CARELMC – MEDICAL CARE

Myelosupresive drugsMyelosupresive drugs

InterferonInterferon

ImatinibImatinib

Allogenic hematopoietic stem cell Allogenic hematopoietic stem cell transplantation transplantation

Autologous hematopoietic stem cell Autologous hematopoietic stem cell transplantationtransplantation

Experimental drugsExperimental drugs

CHEMOTHERAPYCHEMOTHERAPY

BusulphanBusulphan– Alkylating agentAlkylating agent– Preferred in older pts (not candidate for transplant)Preferred in older pts (not candidate for transplant)– Side effect :Side effect :

prolonged myelosuppressionprolonged myelosuppressionPulmonary fibrosisPulmonary fibrosisSkin pigmentationSkin pigmentationinfertilityinfertility

CHEMOTHERAPYCHEMOTHERAPY

HydoxyuresHydoxyures– Fewer side effectFewer side effect

– Acts by inhibiting the enzyme ribonucleotide reductaseActs by inhibiting the enzyme ribonucleotide reductase

Haematological remissions obtain in 80% for both Haematological remissions obtain in 80% for both drugs drugs

However disease progression not altered and However disease progression not altered and persistence of Ph chromosome containing clonepersistence of Ph chromosome containing clone

CHEMOTHERAPYCHEMOTHERAPY

Recombinant human α- InterferonRecombinant human α- Interferon– Optimal dose : Optimal dose : 3-5 MUI/m3-5 MUI/m22/d/d– Prolong chronic phase and increase survivalProlong chronic phase and increase survival– Haematogical and cytogenetic remissionHaematogical and cytogenetic remission– Side effect Side effect

Flu like symptomsFlu like symptoms

Fever and chillsFever and chills

AnorexiaAnorexia

DepressionDepression

CML – THERAPEUTICAL AIMCML – THERAPEUTICAL AIM

Therapeutic responseTherapeutic response– Hematologic responseHematologic response– Cytogenetic responseCytogenetic response– Molecular responseMolecular response

SurvivalSurvival– Overall survival (OS)Overall survival (OS)– Progression-free survival (PFS)Progression-free survival (PFS)– Disease free survival (DFS)Disease free survival (DFS)– Time to progression (TTP)Time to progression (TTP)

HEMATOLOGIC RHEMATOLOGIC REESPONSESPONSEComplete hematologic Complete hematologic responseresponseWBC count normalised (under 10.000/mmWBC count normalised (under 10.000/mm33))Disapearance of immature cells of peripheral blood Disapearance of immature cells of peripheral blood Platelets count normalised (under 350.000/mmPlatelets count normalised (under 350.000/mm33))Disapearance of all signs and symptoms of diseaseDisapearance of all signs and symptoms of diseaseSpleen normalisedSpleen normalised

Partial hematologic responsePartial hematologic responseDecreasing with at least 50% of leucocytosis (10.000 si Decreasing with at least 50% of leucocytosis (10.000 si

20.000/mm20.000/mm33 ) )or completor completee hematologic response with persistent hematologic response with persistent

splenomegalysplenomegaly

CYTOGENETIC RESPONSECYTOGENETIC RESPONSE

% cells Ph+ in bone marrow% cells Ph+ in bone marrow

Complete :Complete : 00ParParttial :ial : < 35< 35Major :Major : complet + parcomplet + parţţialialMinor :Minor : 35 - 9535 - 95Minimal :Minimal : > 95> 95EEşşec :ec : 100100

MOLECULAR RMOLECULAR REESPONSESPONSE

Major molecularMajor molecular response (MajMR)response (MajMR) = a = a 3 log reduction in3 log reduction in BCR-ABL/BCRBCR-ABL/BCR level level when compared to the median when compared to the median pretreatment level.pretreatment level.

Major molecularMajor molecular response(MajMR)response(MajMR) = = BCR-ABL/BCR 0.045%BCR-ABL/BCR 0.045%

Complete molecularComplete molecular response(CMR)response(CMR) = = BCR-ABL unedetectable or reduction BCR-ABL unedetectable or reduction BCR-ABL/BCR with > 4.5 logBCR-ABL/BCR with > 4.5 log

Normal Bcr-Abl Signaling*Normal Bcr-Abl Signaling*

The kinase domain The kinase domain activates a substrate activates a substrate protein, eg, PI3 kinase, protein, eg, PI3 kinase, by phosphorylationby phosphorylation

This activated substrate This activated substrate initiates a signaling initiates a signaling cascade culminating in cascade culminating in cell proliferation and cell proliferation and survivalsurvival PP P

ADP P

P

PP P

ATP

SIGNALING

Bcr-Abl

Substrate

Effector

ADP = adenosine diphosphate; ATP = adenosine triphosphate; P = phosphate.Savage and Antman. N Engl J Med. 2002;346:683Scheijen and Griffin. Oncogene. 2002;21:3314.

Imatinib Mesylate: Imatinib Mesylate: Mechanism of Action*Mechanism of Action*

Imatinib mesylate Imatinib mesylate occupies the ATP occupies the ATP binding pocket of the binding pocket of the Abl kinase domainAbl kinase domain

This prevents This prevents substrate substrate phosphorylation and phosphorylation and signalingsignaling

A lack of signaling A lack of signaling inhibits proliferation inhibits proliferation and survivaland survival

P

PP P

ATP

SIGNALING

Imatinib mesylate

Bcr-Abl

Savage and Antman. N Engl J Med. 2002;346:683.

Imatinib Mesylate in Chronic Phase Imatinib Mesylate in Chronic Phase CML Following IFN-CML Following IFN- Failure: Overall Failure: Overall

Survival*Survival*

Kantarjian et al. Blood. 2004;104;1979. Copyright American Society of Hematology, used with permission.

0 24 48 72 96

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Months

Su

rviv

al p

rob

abili

ty

Total Dead

261 31

251 193

Imatinib mesylate

Others

(P<0.0001)

Imatinib - schema terapeuticaImatinib - schema terapeutica

Recomendede dose : Recomendede dose : – 400 mg/d for patients in chronic phase 400 mg/d for patients in chronic phase – 600 – 800 mg/d for patients in accelerated 600 – 800 mg/d for patients in accelerated

phase or in blastic phase. phase or in blastic phase.

The daily dose is administred in one dose, The daily dose is administred in one dose, with lunch, associated withat least 250 ml with lunch, associated withat least 250 ml waterwater

Allogenic hematopoietic stem cell Allogenic hematopoietic stem cell transplantation (AHSCT)transplantation (AHSCT)

““For the momentFor the moment a allogeneic bone marrow or llogeneic bone marrow or stem cell transplantation is the best and only stem cell transplantation is the best and only one treatment for cure of this disease.one treatment for cure of this disease. ” ”

ButBut

The procedure is limited by the existance of a The procedure is limited by the existance of a potential donor and the high toxicity which limits potential donor and the high toxicity which limits the age of the patients with potential indication the age of the patients with potential indication for transplantation.for transplantation.

Source of HSCSource of HSC

Source :Source :Bone marrow – bone marrow transplantationBone marrow – bone marrow transplantation

Peripheral blood – peripheral blood HSC Peripheral blood – peripheral blood HSC transplantationtransplantation

Peripheral blood source is preferred - Peripheral blood source is preferred - becausebecause

Quicker engraftmentQuicker engraftment

Less regimen related toxicityLess regimen related toxicity

Shorter post-therapeutic aplasiaShorter post-therapeutic aplasia

Longer disease free – GvL effect is strongerLonger disease free – GvL effect is stronger

POLYCYTHEMIA VERAPOLYCYTHEMIA VERA

POLYCYTHEMIA VERA (PV) POLYCYTHEMIA VERA (PV) (Polycythaemia rubra vera)(Polycythaemia rubra vera)

Definition of polycythemiaDefinition of polycythemiaRaised packed cell volume (PCV / HCT)Raised packed cell volume (PCV / HCT)Male > 0.51 (50%)Male > 0.51 (50%)Female > 0.48 (48%)Female > 0.48 (48%)

ClassificationClassificationAbsoluteAbsolute

Primary proliferative polycythaemia (polycythaemia vera)Primary proliferative polycythaemia (polycythaemia vera)Secondary polycythaemiaSecondary polycythaemiaIdiopathic erythrocytosisIdiopathic erythrocytosis

ApparentApparentPlasma volume or red cell mass changesPlasma volume or red cell mass changes

POLYCYTHEMIAPOLYCYTHEMIA

True / AbsoluteTrue / Absolute– Primary PolycythemiaPrimary Polycythemia– Secondary PolycythemiaSecondary Polycythemia

Epo dependentEpo dependent– Hypoxia dependentHypoxia dependent– Hypoxia independentHypoxia independent

Epo independentEpo independent

Apparent / RelativeApparent / Relative– Reduction in plasma volumeReduction in plasma volume

6767

ERYTHROCYTOSIS ERYTHROCYTOSIS (Classification)(Classification) (1)(1)

I. Absolute erythrocytosis (Polycythemia):I. Absolute erythrocytosis (Polycythemia):A. Secondary erythrocytosis (abnormal increase of serumA. Secondary erythrocytosis (abnormal increase of serum erythropoietin erythropoietin level)level)

1. Erythrocytosis secondary to decreased tissue oxygenation:1. Erythrocytosis secondary to decreased tissue oxygenation:a) chronic lung diseasesa) chronic lung diseasesb) cyanotic congenital heart diseasesb) cyanotic congenital heart diseasesc) high-altitude erythrocytosis (Monge disease)c) high-altitude erythrocytosis (Monge disease)d) hypoventilation syndromes (Sleep apnoe)d) hypoventilation syndromes (Sleep apnoe)e) hemoglobin-oxygen dissociation abnormalitiese) hemoglobin-oxygen dissociation abnormalities- hemoglobinopathies associated with high oxygen affinity- hemoglobinopathies associated with high oxygen affinity- carboxyhemoglobin in „smoker’s polycythemia”- carboxyhemoglobin in „smoker’s polycythemia”

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ERYTHROCYTOSIS (Classification)ERYTHROCYTOSIS (Classification) (2)(2)

I.I. Absolute erythrocytosis (Polycythemia):Absolute erythrocytosis (Polycythemia):

A. Secondary erythrocytosis (abnormal increase of serumA. Secondary erythrocytosis (abnormal increase of serum erythropoietin level)erythropoietin level) 2. Secondary to aberrant erythropoietin production or response: 2. Secondary to aberrant erythropoietin production or response: a) Erythropoietin-producting tumors: hepatoma, uterine leiomyoma,a) Erythropoietin-producting tumors: hepatoma, uterine leiomyoma,

cerebellar hemangioblastoma, ovarian carcinoma, pheochromocytoma cerebellar hemangioblastoma, ovarian carcinoma, pheochromocytoma b) Renal diseases: renal cell carcinoma, kidney cysts andb) Renal diseases: renal cell carcinoma, kidney cysts and

hydronephrosis, renal transplantation. hydronephrosis, renal transplantation. c) Androgen abuse: adrenal cortical hypersecretion, exogenous c) Androgen abuse: adrenal cortical hypersecretion, exogenous

androgensandrogensB. Primery erythrocytosisB. Primery erythrocytosis

1. Polycythemia vera1. Polycythemia vera2. Familial erythrocytosis2. Familial erythrocytosis

II. Relative erythrocytosis (pseudopolycythemia):II. Relative erythrocytosis (pseudopolycythemia):1. Hemoconcentration1. Hemoconcentration2. Spurious polycythemia (Gaisboek syndrome)2. Spurious polycythemia (Gaisboek syndrome)

POLYCYTHEMIA VERA (PV)POLYCYTHEMIA VERA (PV)

Polycythaemia vera is a clonal stem cell disorder Polycythaemia vera is a clonal stem cell disorder characterised by increased red cell productioncharacterised by increased red cell production

Abnormal clones behave autonomousAbnormal clones behave autonomous

Same abnormal stem cell give rise to granulocytes and plateletsSame abnormal stem cell give rise to granulocytes and platelets

Disease phaseDisease phaseProliferative phaseProliferative phase

““Spent” post-polycythaemic phaseSpent” post-polycythaemic phase

Rarely transformed into acute leukemiaRarely transformed into acute leukemia

EpidemiologyEpidemiology– 2-3 / 1000002-3 / 100000

– Median age at presentation: 55-60Median age at presentation: 55-60

– M/F: 0.8:1.2 M/F: 0.8:1.2

POLYCYTHEMIA VERA (PV)POLYCYTHEMIA VERA (PV)

Clinical featuresClinical features

AgeAge– 55-60 years55-60 years– May occur in young adults and rare in childhoodMay occur in young adults and rare in childhood

Symptoms common to all erythrocytosisSymptoms common to all erythrocytosis– Headache, Headache, mental acuity, weaknessmental acuity, weakness

Symptoms more specific to P vera and myeloproliferative Symptoms more specific to P vera and myeloproliferative diseases.diseases.– Pruritis Pruritis after bathingafter bathing– ErythromelalgiaErythromelalgia– Hypermetabolic symptomsHypermetabolic symptoms– ThrombosisThrombosis (arterial or venous) (arterial or venous)– HemorrhageHemorrhage

POLYCYTHEMIA VERAPOLYCYTHEMIA VERA physical examinationphysical examination

1.1. Splenomegaly – is present in 75% of patients at the Splenomegaly – is present in 75% of patients at the time of diagnosis.time of diagnosis.

2.2. Hepatomegaly - is present in approximately 30% of Hepatomegaly - is present in approximately 30% of patients at the time of diagnosis. patients at the time of diagnosis.

3.3. HypertensionHypertension

4.4. On examination of the eye grounds, the vessels may be On examination of the eye grounds, the vessels may be engorged, tortuous, and irregular in diameter; the veins engorged, tortuous, and irregular in diameter; the veins may be dark purple.( fundus policythaemicus)may be dark purple.( fundus policythaemicus)

Facial plethoraFacial plethora

POLYCYTHEMIA VERAPOLYCYTHEMIA VERA physical examinationphysical examination

HepatosplenomegalyHepatosplenomegaly

ErythromelalgiaErythromelalgia

– Increased skin tempIncreased skin temp

– Burning sensationBurning sensation

– RednessRedness

Liver40%

Spleen70%

Erythromelalgia

POLYCYTHEMIA VERAPOLYCYTHEMIA VERA Lab FindingsLab Findings

CBCCBC Hgb/HctHgb/Hct WBC in 45%WBC in 45% Plts in 65%Plts in 65%– BasophiliaBasophilia (seen in all MPDs) (seen in all MPDs)

Uric acid (can lead to gout) and B12Uric acid (can lead to gout) and B12 Leukocyte alkaline phosphatase scoreLeukocyte alkaline phosphatase scoreLow epo levelsLow epo levelsPositive JAK2 V617FPositive JAK2 V617F

PV - typical blood countPV - typical blood countWBC x 109/L 18.0 [4-11]

Hb g/L 200 [140-180]

HCt 0.62 [.42-.51]

MCV fl 75 [80-100]

Platelets x 109/L 850 [150-450]

Neuts x 109/L 14.6 [2-7.5]

Lymphs x 109/L 2.0 [1.5-4]

Monos x 109/L 0.8 [0.2-0.8]

Eos x 109/L 0.1 [0-0.7]

Basos x 109/L 0.5 [0-0.1]

Film: microcytosis: large and abnormal platelets present

PRV - DIAGNOSISPRV - DIAGNOSIS

exclude secondary polycythemia

look for features of primary polycythemia

measure erythropoietin

JAK-2 mutation analysis

SECONDARY POLYCYTHEMIASECONDARY POLYCYTHEMIA

Arterial blood gasArterial blood gasHb electrophoresisHb electrophoresisOxygen dissociation curveOxygen dissociation curveEPO levelEPO levelUltrasound abdomenUltrasound abdomenChest X rayChest X rayTotal red cell volume(51Cr)Total red cell volume(51Cr)Total plasma volume(125 I-albumin)Total plasma volume(125 I-albumin)

Diagnostic Criteria for Primary PVDiagnostic Criteria for Primary PV

2008 WHO Diagnostic Criteria for Primary Polycythemia Vera

Major Criteria▪ Elevated RBC mass

>36 cc/kg in men >32 cc/kg in women

▪ Oxygen saturation >92%▪ Splenomegaly

Minor Criteria▪ Plt count > 400,000▪ WBC > 12,000▪ Elevated LAP score (>100)▪ Serum vitamin B12 >900 pg/mL or serum unbound B12 binding capacity >2,200 pg/mL

→ All 3 major criteria OR the first 2 major and any 2 minor criteria ←

Polycythemia Vera Study Group (PVSG) Criteria for PV

Major Criteria1) Hgb > 18.5g/dl (♂) or 16.5g/dl (♀) or Hgb or Hct > 99% or Hgb > 17g/dl (♂) or 15 g/dl (♀) and a documented increase of 2 g/dl or RBC mass > 25% of mean normal

2) Presence of a JAK2 V617F or similar mutation

Minor Criteria1) Bone marrow trilineage expansion2) Subnormal EPO level3) Endogenous erytyhroid colony growth

→ two major or first major and two minor criteria ←

Tefferi et al. Leukemia (2008) 22, 14–22

PV - TREATMENTPV - TREATMENT

PhlebotomyPhlebotomy

Myelosuppressive agentsMyelosuppressive agents– HydroxyureaHydroxyurea– Alkylating agents such as busulfanAlkylating agents such as busulfan– 3232PP

Interferon alphaInterferon alpha

PV - PHLEBOTOMYPV - PHLEBOTOMY

Generally, the best initial treatment for P veraGenerally, the best initial treatment for P vera– No increase in progression to AMLNo increase in progression to AML– Rapid onsetRapid onset– No BM suppressionNo BM suppression

Remove 500 cc blood 1-2x/wk to target Hct 45%, Remove 500 cc blood 1-2x/wk to target Hct 45%, then maintainthen maintainDownsides:Downsides:– Increased risk of thrombosisIncreased risk of thrombosis– No effect on progression to spent phaseNo effect on progression to spent phase– May be insufficient to control diseaseMay be insufficient to control disease

PV - MYELOSUPPRETIONPV - MYELOSUPPRETION

Hydroxyurea Hydroxyurea – can be used in conjunction with phlebotomycan be used in conjunction with phlebotomy– May increase the risk of leukemic transformation from 1-May increase the risk of leukemic transformation from 1-

2% to 4-5%2% to 4-5%3232PP– increase the risk of leukemic transformation from 1-2% to increase the risk of leukemic transformation from 1-2% to

11%11%– May be appropriate for pts intolerant of medications or for May be appropriate for pts intolerant of medications or for

elderly patientselderly patients– Single injection may control hemoglobin and platelet count Single injection may control hemoglobin and platelet count

for a year or more.for a year or more.

PV – INTERFERON ALPHAPV – INTERFERON ALPHABenefitsBenefits– No myelosuppressionNo myelosuppression– No increase in progression to AMLNo increase in progression to AML– No increase in thrombosis riskNo increase in thrombosis risk– OK in pregnancyOK in pregnancy

DrawbacksDrawbacks– Must be given by injectionMust be given by injection– Side effects may be intolerable in many pts, Side effects may be intolerable in many pts,

include flu-like symptoms, fatigue, fever, include flu-like symptoms, fatigue, fever, myalgias, malaisemyalgias, malaise

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POLYCYTHEMIA VERAPOLYCYTHEMIA VERA

I. I. Patients under the age of 50 with no history of thrombosis and without Patients under the age of 50 with no history of thrombosis and without severe thrombocytosis (greater than 1000G/L)-severe thrombocytosis (greater than 1000G/L)-phlebotomy alonephlebotomy alone

- initially 450-500 ml phlebotomy every every other day until the - initially 450-500 ml phlebotomy every every other day until the

hematocrit is less than 46%hematocrit is less than 46%

- older patients or these with underlying cardiovascular disase - older patients or these with underlying cardiovascular disase shouldshould

undergo smaller phlebotomies 200-300mL twice weekly orundergo smaller phlebotomies 200-300mL twice weekly or

100-150mLevery day until Ht<46% 100-150mLevery day until Ht<46%

- subsequently, Ht should be mainted between 42-46%- subsequently, Ht should be mainted between 42-46%

- fluid replacement so that the patients remains isovolemic- fluid replacement so that the patients remains isovolemic

II. Patients over the age of 70, or with history of thrombosis and with severe II. Patients over the age of 70, or with history of thrombosis and with severe thrombocytosis (greater than 1000G/L)-thrombocytosis (greater than 1000G/L)-myelosuppresive agentmyelosuppresive agent

- Hydroxyurea 15-30mg/kg- Hydroxyurea 15-30mg/kg

III. Patients 50-70 years with no history of thrombosis and without severe III. Patients 50-70 years with no history of thrombosis and without severe thrombocytosis (greater than 1000G/L)thrombocytosis (greater than 1000G/L) individualize therapy I or II individualize therapy I or II

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POLYCYTHEMIA VERAPOLYCYTHEMIA VERA

IV. Antiplatelets agentsIV. Antiplatelets agents

Aspirin initially 150-300mg/d, Aspirin initially 150-300mg/d,

maintence therapy 75-100 mgmaintence therapy 75-100 mg

Tiklid 2x1Tiklid 2x1

DipyridamolDipyridamol

Anagrelide 2-2,5 mg/dAnagrelide 2-2,5 mg/d

V. Other modalitiesV. Other modalities

1. Radioactive phosphorus (in older than 75 years)1. Radioactive phosphorus (in older than 75 years)

2. Interferon alpha 3 million units 3 times weekly2. Interferon alpha 3 million units 3 times weekly

VI. Special TopicsVI. Special Topics

1. Pruritus:antihistaminic agent, cyproheptadine-4mg three times per day 1. Pruritus:antihistaminic agent, cyproheptadine-4mg three times per day

2. Hyperuricemia-allopurinol 300mg/day2. Hyperuricemia-allopurinol 300mg/day

ESSENTIAL ESSENTIAL THROMBOCYTHEMIA (ET)THROMBOCYTHEMIA (ET)

THROMBOCYTOSISTHROMBOCYTOSIS

Etiology of ThrombocytosisEtiology of Thrombocytosis PrimaryPrimary - if the thrombocytosis is caused by a myeloproliferative neoplasm, the - if the thrombocytosis is caused by a myeloproliferative neoplasm, the

platelets are frequently abnormal and the patient may be prone to both bleeding and platelets are frequently abnormal and the patient may be prone to both bleeding and clotting events.clotting events.

Secondary Secondary - if thrombocytosis is secondary to another disorder (reactive), even - if thrombocytosis is secondary to another disorder (reactive), even patients with extremely high platelet counts (e.g., > 1,000,000 cells/patients with extremely high platelet counts (e.g., > 1,000,000 cells/μμl) are usually l) are usually asymptomatic.asymptomatic.

Differential Diagnosis of secondary thrombocytosis:Differential Diagnosis of secondary thrombocytosis: 1.1. MalignanciesMalignancies 2. Infections and inflammatory disorders (e.g., Crohn’s disease)2. Infections and inflammatory disorders (e.g., Crohn’s disease) 3. Post surgical status3. Post surgical status 4.4. Connective tissue disordersConnective tissue disorders 5.5. Iron deficiency anemiaIron deficiency anemia 6.6. SplenectomySplenectomy 7. Recovery of the bone marrow from a stress (chemotherapy or alcohol)7. Recovery of the bone marrow from a stress (chemotherapy or alcohol) 8. Essential Thrombocythemia8. Essential Thrombocythemia

Definition: thrombocytosis is defined as a platelet count > 450,000 cells/μL

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ESSENTIAL THROMBOCYTHEMIA ESSENTIAL THROMBOCYTHEMIA (ET)(ET)

ET is a clonal myeloproliferative disorder ET is a clonal myeloproliferative disorder characterized by bone marrow hyperplasia characterized by bone marrow hyperplasia with excessive proliferation of with excessive proliferation of megakaryocytes and sustained elevation of megakaryocytes and sustained elevation of the platelet count. the platelet count.

ESSENTIAL ESSENTIAL THROMBOCYTHEMIA (ET)THROMBOCYTHEMIA (ET)

Neoplastic stem cell disorder causing dysregulated production of large numbers of abnormal platelets

Some cases non-clonal (esp young women)

Abnormal platelets aggregate in vivo, causing thrombosis

Abnormal platelets also cause bleeding

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ESSENTIAL THROMBOCYTHEMIAESSENTIAL THROMBOCYTHEMIA clinical pictureclinical picture

1. 1. Thrombotic complications (intermittent or permanent occlusion of small Thrombotic complications (intermittent or permanent occlusion of small blood vessels)blood vessels)

transient cerebral and ocular ischemic episodes that maytransient cerebral and ocular ischemic episodes that may progress to progress to infarction infarction

peripheral arterial occlusive disease associated with peripheral arterial occlusive disease associated with „erythromelalgia”„erythromelalgia” (intermittent, painful errythema and(intermittent, painful errythema and cyanosis of cyanosis of the fingers and toes the fingers and toes

2. Hemorrhagic complications - bleeding after surgery and spontaneus upper 2. Hemorrhagic complications - bleeding after surgery and spontaneus upper gastrointestinal bleeding (the hemorrhagic tendency is worsened if gastrointestinal bleeding (the hemorrhagic tendency is worsened if nonsteroidal anti-inflammatory agent are administerednonsteroidal anti-inflammatory agent are administered

3. Splenomegaly - 20-50% patients3. Splenomegaly - 20-50% patients

4. Hepatomegaly - rarely4. Hepatomegaly - rarely

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ESSENTIAL THROMBOCYTHEMIAESSENTIAL THROMBOCYTHEMIA laboratory findingslaboratory findings

Thrombocytosis (in most patients patients>1000 G/l)Thrombocytosis (in most patients patients>1000 G/l)

Numerous thrombocyte aggregates in peripheral blood Numerous thrombocyte aggregates in peripheral blood smearsmear

Leukocytosis, usually less than 20G/lLeukocytosis, usually less than 20G/l

Neutrophilia and a mild shift to the left(usually toNeutrophilia and a mild shift to the left(usually to

metamyelocyte)metamyelocyte)

Slight eosinophilia and basophiliaSlight eosinophilia and basophilia

Marked hyperplasia of the megakaryocytes in the boneMarked hyperplasia of the megakaryocytes in the bone

marrowmarrow

ET-ET-Typical Blood CountTypical Blood CountWBC x 109/L 10.0 [4-11]Hb g/L 156 [140-180]MCV fl 85 [80-100]Platelets x 109/L 1560 [150-450]

Neuts x 109/L 7.0 [2-7.5]Lymphs x 109/L 2.0 [1.5-4]Monos x 109/L 0.8 [0.2-0.8]Eos x 109/L 0.1 [0-0.7]Basos x 109/L 0.1 [0-0.1]

Film Comment: many large and abnormal platelets present

ET – DIAGNOSTIC CRITERIAET – DIAGNOSTIC CRITERIA

→ Diagnosis of essential thrombocythemia requires meeting all four major criteria ←

Teferri et al. Leukemia (2008) 22, 14–22

2008 WHO Diagnostic Criteria for Essential Thrombocytosis

1. Platelet count > 450,0002. Megakaryocytic proliferation with large, mature morphology and with little granulocytic or erythroid expansion3. Not meeting WHO criteria for CML, PV, PMF, MDS or other myeloid neoplasm4. Demonstration of the JAK2V617F or other clonal marker or lack of evidence of a secondary (reactive thrombocytosis)

ET - DIAGNOSISET - DIAGNOSIS

Criteria of exclusionCriteria of exclusion– No evidence of Polycythaemia veraNo evidence of Polycythaemia vera– No evidence of CMLNo evidence of CML– No evidence of myelofibrosis (CIMF)No evidence of myelofibrosis (CIMF)– No evidence of myelodysplastic syndromeNo evidence of myelodysplastic syndrome– No evidence of reactive thrombocytosisNo evidence of reactive thrombocytosis

BleedingBleedingTraumaTraumaPost operationPost operationChronic iron defChronic iron defMalignancyMalignancyChronic infectionChronic infectionConnective tissue disordersConnective tissue disordersPost splenectomyPost splenectomy

ET - OUTCOMESET - OUTCOMES

Most patients with ET enjoy a normal life expectancy Most patients with ET enjoy a normal life expectancy

Like PV, the major risks are secondary to thrombosis and disease Like PV, the major risks are secondary to thrombosis and disease transformation:transformation:

▪▪ 15-year cumulative risks: 15-year cumulative risks: ▪▪ thrombosis - 17% riskthrombosis - 17% risk

▪▪ clonal evolution into either myelofibrosis (4%) or AML (2%)clonal evolution into either myelofibrosis (4%) or AML (2%)

High risk for thrombosis: High risk for thrombosis: ▪ ▪ age ≥ 60age ≥ 60 ▪ ▪ prior thrombosisprior thrombosis ▪ ▪ long-term exposure to a plt count of > 1,000,000long-term exposure to a plt count of > 1,000,000

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ESSENTIAL THROMBOCYTHEMIAESSENTIAL THROMBOCYTHEMIA -THERAPY-THERAPY

1. No treatment- asymptomatic( without thrombotic and bleeding1. No treatment- asymptomatic( without thrombotic and bleeding

complications), young (< 60 r.ż.) patients with platelet count<1000G/Lcomplications), young (< 60 r.ż.) patients with platelet count<1000G/L

2. 2. Cytoreductive therapy Cytoreductive therapy – patients with platelet count>1000 G/L, especially– patients with platelet count>1000 G/L, especially for these with previous thrombotic or bleeding problems for these with previous thrombotic or bleeding problems

- hydroxyurea at doses 15-30mg/kg,, to maintein platelet count - hydroxyurea at doses 15-30mg/kg,, to maintein platelet count

between 400-600 G/lbetween 400-600 G/l

3. Anti-aggregating therapy: 3. Anti-aggregating therapy: AspirinAspirin 75-150mg/d 75-150mg/d dipyridamol for older dipyridamol for older

patients and/or with a cardiovascular risk patients and/or with a cardiovascular risk

4. 4. Anagrelide (Agrylin)- Anagrelide (Agrylin)- drug that produces selective platelet cytoreduction, drug that produces selective platelet cytoreduction,

and it also inhibits platelet activation and it also inhibits platelet activation doses from 0,5mg every 6 hours, doses from 0,5mg every 6 hours,

to max. 10 mg/d ) to max. 10 mg/d )

5. Interferon-5. Interferon-: 3 million units/d s.c.: 3 million units/d s.c.

ESSENTIAL THROMBOCYTHEMIA ESSENTIAL THROMBOCYTHEMIA -THERAPY -THERAPY

Low Risk:Low Risk: ▪▪ Age <60 years Age <60 years ▪▪ No previous history of thrombosis No previous history of thrombosis ▪▪ Platelet count <1 million/Platelet count <1 million/μμll → → aspirin (81 mg daily) if vasomotor Sx or other medical need for ASAaspirin (81 mg daily) if vasomotor Sx or other medical need for ASA → → if otherwise low risk and plt >1.5 X 10if otherwise low risk and plt >1.5 X 1066, screen for an acquired von Willebrand , screen for an acquired von Willebrand

disease before instituting ASAdisease before instituting ASA

High Risk:High Risk: ▪▪ Age ≥60 years Age ≥60 years ▪▪ A previous history of thrombosis A previous history of thrombosis → → hydroxyurea + aspirin (81 mg daily)hydroxyurea + aspirin (81 mg daily) → → if plt >1.5 X 10if plt >1.5 X 1066, screen for an acquired von Willebrand disease before instituting , screen for an acquired von Willebrand disease before instituting

ASAASA → → anagrelide is an option, but when c/w hydroxyurea, it was assn with an increased anagrelide is an option, but when c/w hydroxyurea, it was assn with an increased

risk of arterial thrombosis, venous thrombosis, serious risk of arterial thrombosis, venous thrombosis, serious hemorrhage, or death from vascular causes hemorrhage, or death from vascular causes

MYELOFIBROSISMYELOFIBROSIS

MYELOFIBROSISMYELOFIBROSIS

AKA: agnogenic myeloid metaplasia with myelofibrosisAKA: agnogenic myeloid metaplasia with myelofibrosis

Clonal stem cell disorder affecting megakaryocytes Clonal stem cell disorder affecting megakaryocytes predominantlypredominantly

All myeloproliferative disorders can result in a spent phase All myeloproliferative disorders can result in a spent phase which can be difficult to distinguish from primary MFwhich can be difficult to distinguish from primary MF

Myeloid metaplasia refers to earlier proliferative phase where Myeloid metaplasia refers to earlier proliferative phase where extramedullary hematopoiesis predominates.extramedullary hematopoiesis predominates.

MYELOFIBROSISMYELOFIBROSISMyelofibrosis is a chronic myeloproliferative disease with Myelofibrosis is a chronic myeloproliferative disease with clonal hematopoesis and secondary(non-clonal) clonal hematopoesis and secondary(non-clonal) hyperproliferation of fibroblasts (stimulated by PDGF, EGF, hyperproliferation of fibroblasts (stimulated by PDGF, EGF, TGF-TGF- released from myeloid cells, mainly from neoplastic released from myeloid cells, mainly from neoplastic megakaryocytes) with increased collagen synthesis. It megakaryocytes) with increased collagen synthesis. It produces bone marrow fibrosis and to extramedullary produces bone marrow fibrosis and to extramedullary hematopoesis in the spleen or in multiple organshematopoesis in the spleen or in multiple organs

Other terms – agnogenic myeloid metaplasia

– primary myelofibrosis,

– osteomyelofibrosis,

– idiopathic myelofibrosis,

– myelofibrosis with myeloid metaplasia

MYELOFIBROSISMYELOFIBROSISInsidious onset in older peopleInsidious onset in older people– asymptomatic (15% - 30%)asymptomatic (15% - 30%)

– severe fatiguesevere fatigueSplenomegaly- massiveSplenomegaly- massiveHepatomegalyHepatomegalyHypermetabolic symptomsHypermetabolic symptoms– Loss of weight, fever and night Loss of weight, fever and night

sweatssweats

Bleeding problemsBleeding problemsBone painBone painGoutGoutCan transform to acute Can transform to acute leukaemia in 10-20% of casesleukaemia in 10-20% of cases

MYELOFIBROSISMYELOFIBROSISAnaemiaAnaemiaHigh WBC at presentationHigh WBC at presentationLater leucopenia and Later leucopenia and thrombocytopeniathrombocytopeniaLeucoerythroblastic blood filmLeucoerythroblastic blood filmTear drops red cellsTear drops red cellsBone marrow aspiration- Failed Bone marrow aspiration- Failed due to fibrosisdue to fibrosisTrephine biopsy- fibrotic Trephine biopsy- fibrotic hypercellular marrowhypercellular marrowIncrease in NAP scoreIncrease in NAP scoreJAK2JAK2++ (V617F) in (V617F) in approximately 50% of casesapproximately 50% of cases

Tefferi A. N Engl J Med 2000;342:1255-1265

Pathological Features of Peripheral Blood and Bone Marrow in Patients with Myelofibrosis with Myeloid

Metaplasia

MF – DIAGNOSTIC CRITERIAMF – DIAGNOSTIC CRITERIA

→ Diagnosis of primary myelofibrosis (PMF) requires meeting all three major criteria and two minor criteria ←

Teferri et al. Leukemia (2008) 22, 14–22

2008 WHO Diagnostic Criteria for Primary Myelofibrosis

Major:1. Megakaryocytic proliferation and atypia with either reticulin or collagen fibrosis or If no fibrosis, mekakaryocytic expansion must be assn. w/increased BM

cellularity2. Does not meet WHO criteria for CML, PV, MDS, or other myeloid neoplasm3. Demonstration of the JAK2 V617F mutation or other clonal marker or no other evidence of a reactive marrow fibrosisMinor: 1. Leukoerythroblastosis (immature RBCs and WBCs in the PB) 2. Increased LDH 3. Anemia 4. splenomegaly

MF - OUTCOMEMF - OUTCOME As fibrosis progresses, cytopenias worsen leading to a transfusion As fibrosis progresses, cytopenias worsen leading to a transfusion

dependencydependency

▪▪ symptoms related to extrmedullary hematopoiesis increase (worsening symptoms related to extrmedullary hematopoiesis increase (worsening splenomegaly and ‘B’ symptoms) also are frequently identifiedsplenomegaly and ‘B’ symptoms) also are frequently identified

Rarely do patients transform to Acute Leukemia (~ 4%)Rarely do patients transform to Acute Leukemia (~ 4%)

▪▪ clonal evolution was common in these patientsclonal evolution was common in these patients

▪▪ some evidence that in all MPNs, cases of JAK2 some evidence that in all MPNs, cases of JAK2 (-)(-) Acute Leukemia arise Acute Leukemia arise out of a JAKout of a JAK++ MPN, causing speculation that there are additional genetic MPN, causing speculation that there are additional genetic changes that either initiate and/or propagate these diseaseschanges that either initiate and/or propagate these diseases

Despite the lack of transformation to leukemia, three-year survival rate is Despite the lack of transformation to leukemia, three-year survival rate is approximately 52%approximately 52%

MF – RISK ASSASSEMENTMF – RISK ASSASSEMENT

Mayo Scoring System

(pts age < 60)

Score Median Survival

0 173 mo

1 61 mo

≥ 2 26 mo

Risk Factors: Hemoglobin <10 g/dL White blood cell count <4000/μl or >30,000/ μl Absolute monocyte count >1000 μL Platelet count <100,000/ μL

Transplant Scoring System

(pts age < 55)

Score Median Survival

0 or 1 15 yrs

≥ 2 3 yrs

Risk factors: Hemoglobin <10 g/dL ‘B’ symptoms present (eg, fever, NS, weight loss) Circulating blasts >1 percent

Elliott et al. Leuk Res. 2007;31(11):1503-9. Dupriez et al. Blood 1996 Aug 1;88(3):1013-8.

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MYELOFIBROSIS - MYELOFIBROSIS - TREATMENTTREATMENT

AndrogensAndrogens(oxymetholone 2-4mg/kg) in anemia from decreased red cell (oxymetholone 2-4mg/kg) in anemia from decreased red cell production -overall response is about 40%production -overall response is about 40%

CortykosteroidsCortykosteroids(prednisone 1mg/kg)(prednisone 1mg/kg) in anemia with shortened red cell in anemia with shortened red cell life-span-response in 25-50% of patientslife-span-response in 25-50% of patients

Hydroksyurea Hydroksyurea (15- 20mg/kg) for the control of leukocytosis, (15- 20mg/kg) for the control of leukocytosis, thrombocytosis, or organomegalythrombocytosis, or organomegaly

Allopurinol-Allopurinol-to prevent hyperuricaemiato prevent hyperuricaemia

Vit. DVit. D33-analogues-analogues(1,25-dihydroxycholecalciferol-1ug/d ((1,25-dihydroxycholecalciferol-1ug/d (?)?)

Transfusions of packed red cells Transfusions of packed red cells for anemia or for anemia or platelets platelets for for thrombocytopenia with bleeding thrombocytopenia with bleeding

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MYELOFIBROSIS - MYELOFIBROSIS - TREATMENTTREATMENT

Splenectomy should be considered for: Splenectomy should be considered for: portal hypertension, painful portal hypertension, painful splenomegaly, refractory anemia and thrombocytopenia, or splenomegaly, refractory anemia and thrombocytopenia, or exccessive transfusion requirement. However,the procedere is exccessive transfusion requirement. However,the procedere is hazardous (an operative mortality is up to 38%). hazardous (an operative mortality is up to 38%).

Splenic irradiation: Splenic irradiation: when there is a contrindication to splenectomywhen there is a contrindication to splenectomy

Allogeneic stem-cell transplantation:Allogeneic stem-cell transplantation: for young patients who have for young patients who have a poor prognosis and have a suitable donor identified. a poor prognosis and have a suitable donor identified.

Experimental therapies:Experimental therapies: Interferon- Interferon-, antifibrotic and , antifibrotic and antiangiogenic drugs (anagrelide, suramin, pirfenidone, antiangiogenic drugs (anagrelide, suramin, pirfenidone, thalidomide,)thalidomide,)

MF - TREATMENTMF - TREATMENT

Risk stratification is critical in deciding on therapeutic options Risk stratification is critical in deciding on therapeutic options

(see previous scoring systems)(see previous scoring systems)

‘‘Low Risk’ without symptoms – expectant managementLow Risk’ without symptoms – expectant management

‘‘Low Risk’ with symptoms – hydroxyureaLow Risk’ with symptoms – hydroxyurea

androgenic and corticosteroidsandrogenic and corticosteroids

splenectomy if adequate BM hematopoiesissplenectomy if adequate BM hematopoiesis

splenic irradiationsplenic irradiation

thalidomide or lenalidomide thalidomide or lenalidomide

‘‘High Risk’ and age < 55(?) – consider a reduced intensity allogeneic BMTHigh Risk’ and age < 55(?) – consider a reduced intensity allogeneic BMT

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MYELOFIBROSISMYELOFIBROSIS- prognosis- prognosis

- - a median survival of 3,5 to 5,5 yearsa median survival of 3,5 to 5,5 years

- the principal causes of death are infections, - the principal causes of death are infections, thrombohemorrhagic events, heart failure, and thrombohemorrhagic events, heart failure, and leukemic transformationleukemic transformation

- leukemic transformation occurs in - leukemic transformation occurs in approximately 20% of patients during first 10 approximately 20% of patients during first 10 years years