Chronic phase

Chronic myeloproliferative neoplasms
Prof. Judit Demeter
Semmelweis University
Ist Department of Medicine
White blood cell maturation sequence
1.
2.
3.
4.
5.
1.: myeloblast;
4.: metamyelocyte;
2.: promyelocyte;
5.: band (stab);
3.: myelocyte;
6.: segment;
6.
Chronic myeloid leukemia
• Incidence: 1–2 / 100,000, increases with age . 15-20% of all
leukemias.
• More frequent in atomic bomb survivors, and patients treated
with radiotherapy
• Mean age at diagnosis: 50-53 years
• Male-female ratio—1.3:1
– The diagnosis is made in 50% of cases by routine lab screen
– 85% of cases are diagnosed in the chronic phase of the disease
Diagnostic steps in CML
- Physical examination (+ spleen size, below costal margin)
1. Full blood count (and reticulocyte count), microscopic evaluation of
peripheral smear.
2. Flow cytometry in blastic crisis only: to characterise blast cells
3. Biochemic parameters ( + LDH).
4. Bone marrow aspiration
- cytogenetics by band staining
- morphology, proportion of blasts and promyelocytes
- FISH BCR/ABL
- bcr/abl expression levels (real-time PCR).
5. Bone marrow biopsy
- histological examination
- blast ratio
- presence of fibrosis
6. Performance status (ECOG)
Clinical course: Clinical phases of
CML
Progressive phases
Chronic phase
usually 5- 6 years
stabilisation
Accelerated phase
Blastic phase
Usual duration
Survival
6–9 months
3–6 months
CML progression
Chronic
Accelerated
Blasic
 Differenciation
Cell cycle
 apoptosis
Pointmutations
chromosome D-k
Instability
proliferation
BCR/ABL
Progression index
OR?
Characteristics of the chronic phase of CML
Non-symptomatic in 25-35% of cases
Cell numbers:
granulocytosis (often 10-50 G/l)
left shift in the differential blood count
Eosinophilia,basophilia
Thrombocytosis
If leukocytes > 200-400 G/l, symptoms of hyperviscosity (blurred vision,
priapism)
Splenomegaly (progressive)
Bone marrow:
increased cellularity
Granulopoetic hyperplasia, but myeloblast less than 10%
Myeloblast+promyelocyte ratio less than 30
Cytogenetics: t(9;22) Philadelphia chromosome positivity (BCR/ABL pos.)
Criteria of the accelerated and blastic phase
in chronic myeloid leukemia (CML)
Accelerated phase
10-19% blasts in the peripheral blood or the bone marrow
At least 20% basophils in the peripheral blood
Lasting thrombocytopenia (< 100 G/l ) or
lasting, treatment-refractory thrombocytosis (1000 G/l)
Increasing spleen size and leukocyte number refractory to treatment
Signs of clonal evolution cytogenetically
Blastic phase
20 % or more blasts in the bone marrow or in the peripheral blood
Extramedullary blastic proliferation
Great foci of blasts or clusters in the bone marrow biopsy sample
White blood cell mass removed by leukapheresis in CML blastic phase
( 10 liters)
Chronic myeloid leukemia
• Myeloproliferative disease characterized by
proliferation of myeloid cells without loss of
their capacity to differentiate.
• Besides being interesting on its own, CML
became a model to study, how to understand,
and how to treat neoplasia.
Three ways to understanding:
• Cytogenetics.
• Oncovirology.
• Signalling molecules.
Philadelphia chromosome. Reciprocal
translocation between chromosomes 9 and 22.
Janet D. Rowley, 1973.
This for the first time suggested that:
• A specific neoplasm is associated with a
specific genetic change;
• This change in CML is located in either
chromosome 9 or 22;
• Further elaboration of this phenomenon may
provide a clue to both understanding, and to
the treatment of this particular disease.
The Ph chromosome: t(9;22)translocation
9
9
(q+)
Ph
22
(22q-)
bcr
bcr-abl
abl
Fusion protein with
tyrosin kinase
activity
Mechanisms implicated in the pathogenesis of CML
Possibilities of integrated diagnosis in oncohematology:
CML
• Clinical data: leukocytosis, basophilia, thrombocytosis.
splenomegaly
Morphology:
Peripheral blood smear
and
bone marrow smear
CML diagnostics
Determination of
histological subtype
Karyotype
t (9;22) FISH
BCR/ABL transcript
Quantitative determination
CML diagnostics
Determination of
histological subtype
9
9
(q+)
Karyotype
Ph
22
(22q-)
t (9;22) FISH
bcr
bcr-abl
BCR/ABL transcript
Quantitative determination
abl
Fuziós PROTEIN
TYROSINKINASE
aktivitással
CML diagnostics
Histological subtype
normal
Karyotype
t (9;22) FISH
t (9;22)
BCR/ABL transcript
quantitative determination
CML diagnostics
Determination of histological
subtype
Kariotype
t (9;22) FISH
BCR/ABL transcript
quantitative determination
Formation of BCR-ABL fusion gene
140 years in the treatment of CML
Palliative treatment
Curative treatment (?)
Arsenic salts
No treatment
Splenic irradiation
Busulfan
Hydroxyurea (Litalir)
Stem cell transplantation
Interferon-alpha
Imatinib
Dasatinib, Nilotinib
3rd gen. tyrosinkinase inhibitors
1867
1915
1932 1964
1975 1983 1999 2005 2007
Imatinib and
second generation TK inhibitors nilotinib and dasatinib
Criteria of response in CML
 Hematological response
–Complete:
Normal blood count
WBC <10 x 109/L
PLt <450 x 109/L
lack of immature cells
•
•
Disappearence of splenomegaly
no pathological finding on physical
exam
 Cytogenetic
response
– Major:
Complete: 0% Ph+ cell
Partial: 1%–35% Ph+ cell
– Minor:
36%–95% Ph+ cell
 Major molecular response
- BCL-ABL transcript levels ≤0,1%
measured by RT-PCR
Prognostic factors in CML
Disease phase
Sokal score
Age
Spleen size
Platelet count
Blast percentage
Treatment response
Clinical factors required for Hasford score
(baseline values only)
Age
Spleen size (in cms)
Blast percentage
Eosinophil percentage
Basophil percentage
Platelet count
Pharmacoepidemiology Research Group.
Copyright © 1999. (Hasford score)
Hasford or Euroscore (Hasford J et al, 1998)
-
blast count in the peripheral blood
basophils (ratio)
eosinophils (ratio)
size of spleen in cm, below costal margin
platelet count
Hasford score calculator @
http://www.pharmacoepi.de/cgi-bin/pharmacoepi/cmlscore.cgi
The Hasford score can differentiate between patient groups
Small risk < = 780
Intermediate risk > 780, < = 1480
High risk > 1480
High prognostic value
(96, 65 és 42 month survival in the different risk groups, P<0,001).
Gratwohl-EBMT score for estimation of risk of allogenic BMT CML
Donor type
-
HLA identical syster donor
MUD (matched unrelated donor)
Phase of the disease
First chronic phase
Accelerated phase
Blastic phase or not first chronic phase
Recipient age
< 20 ys
20 – 40 ys
> 40 ys
Donor – recipiens age combination
Male recipient/female donor
All else
Time from diagnosis to stem cell transplantation
< 12 months
> 12 months
0
1
0
1
2
0
1
2
1
0
0
1
Total Gratwohl (EBMT) score: between 0 and 7
score 2: a transplant related mortality < 20 %,
Score between 5 - 7 : probability of 5 year survival: 25 %.
Success of transplant depends on : conditioning treatment
Severity of acute and chronic GvHD
Prof. Dr Endre Kelemen
www.ebmt.org
BCR/ABL transcript level in a 70 ys old CML patient constantly on
400 mg imatinib /day
1000
260%
100
127%
87%
24%
9%
7%
BCR-ABL%
10
2%
2%
2%
0,4%
1
0,4%
0,1%
0,1
0,04%
0,01
0,02%
0,001
2008. ápr. 2008. jún.
2008.
jún/2
2008. júl.
2008.
aug.
2008.
szept.
2008. okt.
2008.
okt./2
2008.
dec.
2009.
márc.
2009. ápr. 2009. jún. 2009. júl.
2009.
aug.
BCR/ABL fusion transcript level in a 35 ys old CML patient
constantly on 400 mg imatinib (Glivec) /day
1000
BCR-ABL%
100
50%
10
1,1%
1%
1
0,1
0,006%
0,01
0%
0,001
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Date
WBC
X G/l
PLT Hb
X G/l g/l
FISH
Quant. RT-PCR
12/ 2002
79,0
Blast:
25%
3268
84 46, X,Y (1)
46, XY t(9,22)(
29)
-
1309
CML score: 4277
(high risk.)
02/2003
4,1
500
134 46, X,Y (24)
46, XY t(9,22)(
6)
12%
bcr/abl+
32
05/2003
4,9
179
146 -
negatív
BM .hypoplasia
08/2003
4,1
163
147 -
-
negativ
11/2003
4,9
150
141 -
-
0,75
04/2006
4,6
No Phil
negative
11/2013
4,9 186
-
0,0000
144
Citogenetics
normal
-
2. Generation TK inhibitors given second or
third line in CML
Jabbour, Leukemia, 2009
Disease duration and survival in CML
Before year 2000
Chronic phase
Accelerated phase
3-5 years
12-18 months
Blastic phase
3-9 months
After year 2000 (in the majority of patients)
Chronic phase
More than 20 years?
Cure (without allogenic stem cell
transplantation?)
Treatment of accelerated / blastic phase CML
• In TKI naïve patients:
• Imatinib or dasatinib in elevated dosage
• If no optimal response, allogenic stem cell transplant
(allo-HSCT) is recommended
• Intensive chemotherapy may be required to make patients
eligible for allo-HSCT
• In TKI pre-treated patients:
• Consider any TKI different from previously given
• Consider 3rd line TKI
• Allo-HSCT is recommended after response
• Intensive chemotherapy may be necessary to achieve
remission before Tx
POLYCYTHAEMIA RUBRA VERA (PRV)
Chronic myeloproliferative disorder with pancytosis.
Autonomic proliferation of all three bone marrow cell lines,
with dominating erythropoetic hyperplasia.
Occurrence: usually after 55 years of age
normal
P. vera
Polycythaemia vera – clinical presentation
Symptons of increased red cell production:
• Plethora
• Microvascular symptoms:
• Aquagenic pruritus
• Erythromelalgia: burning pain or tingling in a hand-feet localisation
following to hot water exposure (e.g. showering)
• Thrombotic events that are recurrent or present in an atypical
localisation – visceral thrombosis:
• Hepatic vein thrombosis (Budd-Chiari syndrome)
• Portal thrombosis
• Splenic vein thrombosis
• Others
 Known PV patients should be referred to abdominal CT in case of sudden
abdominal pain to rule out visceral thrombotic event
Bone marrow histology: normal cellularity
PV
Bone marrow biopsy: increased cellularity with trilineage hyperplasia
JAK/STAT signal transduction pathway in responses to hematopoietic growth factors
Under normal conditions (A), erythroid and megakaryocytic progenitors require binding
of erythropoietin (Epo) or thrombopoietin (Tpo) to their respective receptors (Epo-R or
Tpo-R) to initiate the intracellular sequence of phosphorylation and activation events
leading to transcriptional activation of growth factor–responsive target genes
In hematopoietic progenitor cells of patients with MPDs who have the JAK2-V617F
mutation (B), this JAK/STAT signal transduction pathway is constitutively activated in the
absence of binding of Epo or Tpo to their respective receptors. Schafer, Blood, 2006
Acquired JAK2 mutation
Pointmutation within the JH2 pseudokinase
domain of the JAK gene (V617F)
Valin instead of Phenylalanin in position 617 of the
JAK2 tyrosinkinase protein
JAK V 617 F mutation analysis
percentage of JAK-2 positivity
PV
(65-97%)
78
ET
(23-57%)
35
MF
(35-90%)
50 %
More significant positive than negative predictive value
DNA examination does not replace bone marrow examination
but is very useful clinically
Polycythaemia vera –differential diagnosis
1. Relative polyglobulia-pseudopolyglobulia
total red cell mass determination (51Cr labeled RBCs)
ruling out exsiccosis
2. Secundary polyglobulia:
hypoxia
- determination of arterial O2 saturation
exogenous: - staying at high altitudes- anamnesis
endogenous: - pulmonary and heart disorders (mainly valve disease)
- Hb-function disturbance
(congenital methaemoglobinaemia)
- smoking-carboxyhaemoglobin (“smokers polyglobulia”)
autonomic erythropoetin production - paraneoplastic syndrome
(e.g. Renal cell carcinoma, cerebellar tumors, hepatoma.)
The aim of treatment is patient care, directed at
normalization of cell numbers and prevention of
complications. The Ht shlould be kept below 0,45
First line treatment: phlebotomies
•
Repeated removal of 300 ml blood volume
•
Replacement with physiologic saline infusion
•
Keep hematocrit values below 0,45
Polycythaemia vera – reasons for additional treatment besides phlebotomy
High risk of thrombosis:
• Age >60 years
• Previous arterial OR venous thrombosis
Hematocrit uncontrollable by phlebotomy
Slightly lower cell counts (spent phase) – BUT: significant cytopenias may
be sign of transformation to AML
Platelet count above 1500 G/L:
• Paradoxic tendency for bleeding
• Mechanism: secondary von Willebrand disease – increased platelet
mass uses up plasma von Willebrand factor
• Acetilsalycilic acid should be immediately discontinued
Additional treatment of polycythaemia vera:
Standard treatment: hydroxyurea (Litalir)
daily dose: 0,5-2g
Interferon-alpha treatment: 3x weekly 3ME IFN, subcutan injections
the frequency of secondary leukemia did not increase
suitable also for fertile patients plannning a family
Anagrelide in cases with severe thrombocytosis
refractory to hydroxyurea and/or IFN
Polycythaemia vera –additional care:
Allopurinol (Milurit) for patients with increased uric
acid levels.
Platelet aggregation inhibitors
acetylsalicylic acid ( cave ulcus!)
Aquagenic pruritus: no adequate drug (antihistamines,
H2 blockers can be attempted)
Summary:
Polycythaemia vera prognosis: the overall survival in treated patients
is 10-12 years, in untreated patients only two years.
Potential side effects:
Phlebotomy: volume deficit
volume replacement + hydration !!!!
iron-deficiency
MYELOFIBROSIS
hepatosplenomegaly
Myelofibrosis
Chronic, clonal, malignant disorder
splenomegaly, leukoerythroblastic blood count
-teardrop shaped redblood cells (dacryocytes) in the peripheral smear
Varying degree bone marrow fibrosis and extramedullary
hemopoesis
Incurable with conventional chemotherapy
Survival: 4-5 years – worst prognosis among chronic MPNs
Occurrence:
male/female ratio: 1,2:1
Median age:
65 years
Myelofibrosis: peripheral smear
Myelofibrosis, peripheral smear : leukoerythroblastic blood picture
Myelofibrosis : bone marrow fibrosis (bone marrow biopsy)
MYELOFIBROSIS :clinical signs
anaemia,
hepatosplenomegaly
Symptoms of hypermetabolism ,
Thromboembolic events
(pl. Budd-Chiari syndrom),
Autoimmune phenomena e.g.
haemolysis
The degree of hypocholesterinaemia
parallels with the size of the spleen
Prognosis: in case of chromosomal
aberrations
(e.g. 13q14 deletion) worse
Usually: 2-3 years
MYELOFIBROSIS :treatment
Treatment indications
great transfusion need (under 100 g/L hb )
increase in the number of blasts in the peripheral blood
significant increase of serum LDH
extreme splenomegaly
general symptoms (fever, night sweats, weight loss)
No established treatment algorhytm
Treatment options
androgens (oxymetholon ) in case of anaemia
hydroxyurea (Litalir) and/or -interferon in cases with leukocytosis and
thrombocytosis,
steroids in cases with immunhemolysis+hypersplenism
splenic irradiation in case of transfusion dependent anaemia and extreme
splenomegaly, also repeatedly CAVE : cytopenia!
desferrioxamin for transfusion dependent patients agains sec. haemochromatosis
In special cases with age < 55 years and and HLA-identical sibling donor, BMT
might be condsidered
FDA Approves Ruxolitinib, First Drug Ever for Myelofibrosis
Oral JAK inhibitor
November 16, 2011 — The first drug treatment ever for myelofibrosis,
ruxolitinib (Jakafi, Incyte Corp), was approved today by the US Food and
Drug Administration (FDA).
"We observed significant reductions in spleen size and significant
improvements in symptoms.”
Ruxolitinib is approved for use in patients with intermediate or highrisk myelofibrosis, which represents 80% to 90% of all patients with
myelofibrosis.
Essential thrombocythaemia
Essentialis thrombocythaemia: ET
Chr. myeloproliferative disorder characterized by
thrombocytosis.
Bone marrow: the number of megakaryocytes is increased
arterial thrombophilia
+
increased proneness to bleeding
Essential thrombocythaemia:
Diagnostic criteria:
Diagnosis of „exclusion” :
•
•
•
significant thrombocytosis (>600.000/l) on repeated
occasions
Exclusion of symptomatic (secondary) thrombocytosis
Exclusion of other chronic myeloproliferative disorders
•CML: bcr-abl, cytogenetics
•PV : BM biopsy
•myelofibrosis: BM biopsy
ET: increased number of megakaryocytes in bone marrow
Essential thrombocythaemia: bone marrow histology
increased number of megakaryocytes
Treatment of essential
thrombocythaemia
Is treatment necessary? Determinants
1. age
2. Presence of disease related symptoms (or former presence)
3. The platelet count
Treatment is necessary
1. At any age, if the number of platelets is above 1500 G/l
2. In case of complications, already with platelet counts above 450
G/l
3. In asymptomatic elderly patients already when platelet count is
600 G/l
cytoreductive treatment
+
platelet aggregation inhibitors
Hydroxyurea induced leg ulcer
at diagnosis
8 weeks after omission of HU
Treatment of essential thrombocythaemia
In case of emergency: Platelet-pheresis
Permanent cytoreduction
A. Cytostatic drugs: hydroxyurea (Litalir)
Daily dose:
500 - 1500 mg
well tolerable
risks:
leukemogenic
ulcus cruris
spinocellular cc. !
Treatment goal: platelet count below 400 G/l
B. Interferon-alfa maintenance dose 2-3x3 MU weekly
not mutagenic
not leucemogenic
can be given also to young, fertile women
might be continued also during pregnancy in symptomatic cases
Platelet aggregation inhibitors
the platelet count should be reduced previously
Contraindicated in case of bleeding in the medical history
prophylaxis: 75-100 mg/die acetylsalicilic acid if the
platelet count is between 400-1000 G/l
treatment: 100 mg acetilsalicilyc acid in case of
microcirculatory disturbance (erythromelalgia, cerebrovascular
ischaemia) or arterial thromboembolism
No platelet aggregation inhibitors should be administered with platelet
counts above 1500 G/L (risk of bleeding due to secondary von
Willebrand disease)
Thank you for your attention!