Algoritmo diagnostico efattori prognostici

Francesco PassamontiClinica EmatologicaUniversità di Pavia

Fondazione IRCCS Policlinico San Matteo, Pavia

Molecular basis of MPNCytogenetic

abnormalitiesMutation ofoncogenesJAK2-V617FJAK2-ex12MPL-W515LMPL-W515KMPL-S505NMPL-A506TMPL-A519T

TET2

del13qdel20qdel7pdel7qdel12p

Normal cells

MPNphenotype

Phen

otyp

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Non phenotypic

lesion

Mutational status in MPN: state of the art

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Updated criteria for diagnosis

ETPVPMF

Post-ET MFPost-PV MF

WHO, 2008

IWG-MRT, 2007

Policitemia veraCriteri maggiori1. Hb > 18,5 g/dL (M), > 16.5 g/dL (F)2. Mutazione JAK2 (V617F) o esone 12Criteri minori1. Ipercellularità midollare con iperplasia trilineare2. Bassi livelli serici di eritropoietina3. Crescita spontanea di colonie eritroidi

Diagnosi:2 criteri maggiori e 1 tra i minoriPrimo maggiore e 2 tra i minori

Trombocitemia essenzialeCriteri1. Piastrine > 450 x 109/L2. Proliferazione prominente megacariociti3. Esclusione PV, PMF, LMC, MDS4. Mutazione JAK2 (V617F) o altre anomalie

clonali; se assenti escludere cause secondarie

Diagnosi: 4 criteri

Mielofibrosi primariaCriteri maggiori1. Proliferazione megacariociti con atipie e fibrosi reticolinica;

se non fibrosi reticolinica proliferazione megacariociti conatipie, iperplasia granulocitaria, ipoplasia eritroide

2. Esclusione PV, LMC, MDS3. Mutazione JAK2 (V617F), o altre anomalie clonali (mutazioni

MPL); se assenti, escludere cause secondarieCriteri minori1. Screzio leucoeritroblastico2. Incremento LDH3. Anemia4. Splenomegalia palpabile

Diagnosi: 3 maggiori e 2 tra i minori

Comments on WHO classification• Based on practical and reproducible clinical,

histopathological and molecular findings• Evidence of clonal hematopoieis• Bone marrow findings• Erythropoietin• Increase of hemoglobin over time• Red cell mass (the end)• Prefibrotic myelofibrosis: a vanishing entity

Cellularity

Erythropoiesis

Megacaryocyte

Fibrosis

Thrombocytosis

• Pre fibroticMF

• ET

WHO 2001

Cellularity

Erythropoiesis

Megacaryocyte

Fibrosis

Thrombocytosis

•⇑ LDH•Anemia•Splenomegaly•Leukoerythrobl.

PMFET

WHO 2008

Algoritmi diagnostici perl’inquadramento delle MPN

↑ Hb

JAK2 V617F & Epo

JAK2+ Epo ↓ JAK2- Epo N/↑ JAK2- Epo ↓

BOM+Ex12+

BOM+Ex12-

BOM-Ex12-

BOM & JAK2 Ex. 12

•EGA •Test respiratori •Scan addome

Spuria ?

PV BOM+Ex12+

BOM+Ex12-

BOM & JAK2 Ex. 12

BOM-Ex12-

PV

EI

Check EF

Familiarità MPN ?

EECPV + -- -

PV: policitemia veraEF: eritrocitosi familiareEI: eritrocitosi idiopatica

Check EF

↑ PLT

Studi molecolari & BOM

BCR/ABL+

•Ves, PCR •Stato marziale •Markers neo •Scan addome

LMC

Familiarità MPN ?

BOM⇑ MCCfibrosi

• ⇑ LDH• Anemia• Splenomegalia• Screzio LE

MPJAK2 ±MPL ±

SMD

BOM⇑ MCC

Non fibrosi⇑ Mieloide⇓ Eritroide

BOM⇑ MCC

Non fibrosiN MieloideN Eritroide

TEJAK2 ±MPL ±

JAK2MPL

BOMPerls

≥ 2<2

LMC: leucemia miel cron.MP: mielofibrosi primariaSMD: sindr.mielododisplastica

JAK2MPL

↑ GB ↑ Hb ↑ PLT

JAK2 V617F & Epo

Non familiarità MPN

JAK2+ Epo ↓ JAK2- Epo N/↑ JAK2- Epo ↓

BOM+Ex12+

BOM+Ex12-

BOM & JAK2 Ex. 12

PV

PV

MPNuncl.

BOM-Ex12-

F-up

BOM+Ex12+

BOM+Ex12-

BOM-Ex12-

BOM & JAK2 Ex. 12

PV F-up.

PV: policitemia veraTE: trombocitemia essenzialeMPN uncl: non classificabile

Disease evolution

Post-ET MFRequired Criteria• Previous diagnosis of essential thrombocythemia (WHO criteria)• BM fibrosis grade 2-3 (EUNMET) or grade 3-4 (US)

Additional Criteria (2 required)• Anemia or ≥ 2 g/dL decrease from baseline Hb level• A leukoerythroblastic peripheral blood picture• Increasing splenomegaly (≥ 5 cm from the left CM; newlypalpable splenomegaly)• Increased LDH• Development of ≥ 1 of 3 constitutional symptoms: >10% weightloss in 6 months, night sweats, unexplained fever (>37.5 C)

Post-PV MFRequired Criteria• Previous diagnosis of polycythemia vera (WHO criteria)• BM fibrosis grade 2-3 (EUNMET) or grade 3-4 (US)

Additional Criteria (2 required)• Anemia; no requirement of phlebotomy or cytoreduction• A leukoerythroblastic peripheral blood picture• Increasing splenomegaly (≥ 5 cm from the left CM;newly palpable splenomegaly)• Development of ≥ 1 of 3 constitutional symptoms: >10%weight loss in 6 months, night sweats, unexplained fever(>37.5 C)

Prognostic factorsfor disease evolution

Risks and risk factors in ET(n=605, 4596 person-years of f-up)

ThrombosisThrombosis10-year 10-year riskrisk: 14%: 14%RiskRisk factorsfactors: : ageage >60; >60; priorprior thrombosisthrombosis

Myelofibrosis10-year risk: 3.9%Risk factor: Anemia

Leukemia10-year risk: 2.6%Risk factor: Age >60

Passamonti et al, Haematologica 2008

Passamonti et al, Haematologica 2008

ET (n=605, 4596 person-years of f-up)

3.9%MyelofibrosisRisk factors:• anemia

Degree of bone marrow fibrosisto predict events of ET

Campbell et al, JCO 2009

N= 361 patients

Fibrosis grade (0 to4)# grade 0-1: 135

# grade 2: 146

# grade 3-4: 80

A relationship with:

Passamonti et al, Haematologica 2008

ET (n=605, 4596 person-years of f-up)

2.6%

LeukemiaRisk factors:• age > 60 years

• No relationshipwityh cytotoxictherapy

Leukemia-free survival of ET(N=605)

Gangatet al, Leukemia 2007

Risk factors

•anemia

•PLT >1000x 109/L

1 pt

14 pts5 pts

• Relationship withage, not withcytotoxic therapy

Life-expectancy of ET

Passamonti et al, Am. J. Med. 2004

N = 435 patientsMedian follow-up• 9.3 yearsSurvival• 22. 6 years

no differencecompared tothe generalpopulation

Prognostic model to predictsurvival at diagnosis of ET

Gangatet al, Leukemia 2007

•N= 605 patients

•Risk factors

•Age > 60 years

•Anemia

•WBC >15 x 109/L

•Median survival

•LR 278 months

•IR 200 months

•HR 111 months

Risk factors of PV at diagnosis(ECLAP study 1638 patients)

ThrombosisIncidence: 5.5 x 100 p/yRisk factors: age >65 years; prior thrombosis

Myelofibrosis & LeukemiaIncidence: 1.3 x 100 p/yRisk factors for MF: long disease durationRisk factors fo AL: age >70

Marchioli et al, JCO 2005

Does evolution in myelofibrosis affectsurvival of PV patients? YES

Passamonti et al, Blood 2008

WBC >15 x 109/Lat diagnosis of

PV is a riskfactor for MF

evolution

Cox proportional hazard regression model withMF as a time-dependend covariate

Survival of PV at post-PV MF phasea dynamic prognostic model

Passamonti et al, Blood 2008

N= 68 patientsRisk factors• Hb < 10 g/dL• PLT < 100 x 109/L• WBC > 30 x 109/LSurvival• H.R. 4.2

no risk factors

1 risk factor

2 risk factors3 risk factors

Advantage ofa dynamic model

More realistic definition of low-risk category comparedto non time dependent analysis. In fact, low risk groupincludes patients who never acquire risk factors duringfollow-up.

More realistic definition of low-risk group compared tonon time dependent analysis. In fact, low risk groupincludes patients who stay at low risk along the wholefollow-up, i.e. never acquiring risk factors.

Advantage of aa dynamic model

More accurate definition of high-risk categorycompared to non time dependent analysis. As the modelincludes within high risk group also patients duringfollow-up, the sample size is much larger.

Survival of PV at blastic phase

Passamonti et al, Cancer, 2005

Life expectancy of PV

N = 396 patientsMedian follow-up• 9.6 yearsSurvival• 19 years

Passamonti et al, Am. J. Med. 2004

reductioncompared tothe generalpopulation

Prognostic model to predictsurvival of PV at diagnosis

Gangat et al, BJH 2007

•N= 459 patients

•Risk factors

•age > 60 years

•WBC >15 x 109/L

•Median survival

•LR 272 months

•IR 162 months

•HR 108 months

Life expectancy of PMF

Number• 1054 patientsMedian follow-up• 1980-2007

Cervantes et al, Blood 2008

reductioncompared tothe generalpopulation

Prognostic model to predictsurvival of PMF (IWG-MRT)

Cervantes et al, Blood 2008

N= 1054 patientsRisk factors• Age > 65 years• Const. symptoms• Hb < 10 g/dL• WBC > 25 x 109/L• Blood blasts ≥ 1%Risk group• Low 0• Int-1 1• Int-2 2• High ≥3

135 months

95 months

48 months

27 months

Risk factors• Hb < 10 g/dL• PLT < 100 x109/L• PS >1• Fav. karyotype

• 20q, 13q, +9• Normal diploid

• V-, Unfav. karyotype• 5q, 7q, complex• 17q

MDACC prognostic model for survival in PMF

Tam et al, Blood 2009

Survival of PMF at blastic phase

Mesa et al, Blood 2005

•N=91•No impact of treatment

Is JAK2 (V617) a risk factorfor disease evolution in MPN?

Thrombosis (?)MyelofibrosisLeukemia (?)

Clinical phenotype

Disease-complicationsand evolution

Allele burdenJAK2 (V617F)

IntermediateLow High

PLTWBC Hb PLTWBC Hb PLTWBC Hb Normal range

The allele burden effect

PassamontiPassamonti & Rumi,& Rumi, HaematologicaHaematologica 2009 2009

PV vs post-PV MF: JAK2 (V617F)

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PassamontiPassamonti et al, et al, Blood 2006

The allele burdenis significantlydifferent

Disease evolution in PV and ET(GIMEMA-MPD WP)

•Post-PV MF occurred more frequentlyamong homozygous (11.5%) thanheterozygous (1.4%) PV patients.

•Post-ET MF occurred more frequentlyamong homozygous (14.3%) thanheterozygous (4.7%) and WT (1.6%) ETpatients.

VannucchiVannucchi et al, et al, Blood 2007

JAK2 (V617F) in PMF

P= 0.0008

No impact on leukemia

P= 0.5

Lower burden: shorter OS

JAK2 + vs JAK2- JAK2 allele burden

Tefferi et al, Leukemia 2008

• Age > 60 years• Thrombosis/hemorrage• PLT count > 1500 x 109/L

Caveat if:• Leukocytosis• JAK2 (V617F) burden

Patients with PV and ET at diagnosis

Post-PV MF Post-ET MF AL

• Hb < 10 g/dL• PLT < 100 x 109/L• WBC > 30 x 109/L

• PMF-like score • Candidatefor BMT

Monitor: CBC count, blood smear, spleen size, serum LDH, circulating CD34+

• Cardiovascularfactors

• Age > 65 years• Const. symptoms• Hb < 10 g/dL• WBC > 25 x 109/L• Blood blasts ≥ 1%

Patients with PMF at diagnosis

AL• Candidate

for BMT

Monitor: CBC count, blood smear,spleen size

Consider cytogenetic• Favourable: 20q, 13q, +9, normal• Unfavourable: 5q, 7q, complex, 17q