Chronic Myeloproliferative
Neoplasies (CMPN)
Myeloid NeoplasiesWHO Classification
• Myeloproliferative neoplasies (MPN)• Myelodysplastic syndromes (MDS)• Myelodysplastic /Myeloproliferative
neoplasies – Chronic myelomonocytic leukemia (CMML)– Juvenile myelomonocytic leukemia (JMML)– Atypical Chr.. Myeloid Leukemia (BCR/ABL -)
• Eosinophilia and PDGFRA/PDGFRB or FGFR1 mutation + myeloid or lymphoid neoplasies
• Acute myeloid neoplasies
• Chronic myelocytic leukemia (CML) (Bcr-abl +)
• Chronic Neutrophylic Leukemia• Polycythemia Vera• Primary Myelofibrosis• Essential Thrombocythemia• Chronic Eosinophylic Leukemia• Mastocytosis• Unclassified types
Chronic Myeloproliferative Neoplasies (MPN)
Systemic mastocytosis
Polycythemia (rubra) vera
Essential thrombocytemia
Hypereosinophylic syndrome
Myeloproliferative Neoplasies
Chronic myeloid leukemia
Chronic myelomonocytic leukemiaMyelofibrosis with myeloid metaplasia
CMPN -concepts• Clonal disorders of hemopoietic stem
cell• Overproduction of one or more cell lines• Extramedullary hematopoesis, myelofibrosis and
leukemic transformation can occur• Increased risk of thrombosis
Polycythemia
Cells (RBC)
plasma
Blood
6
Hct: b/aNormal
Dehydration Hct: elevated
1 2 3
True polycythemia
a
b
Polycythemia–Relative
• Dehydration• Gaisbock’s syndr
(Nephropathy, Hypertension, Erythrocytosis)• Stress polycythemia
–Absolute/true• Secondary• Primary
– PRV– Familial
KidneyBone marrow
Erythropoetin
Increased red cell productionHypoksia
Oxygen transport capacity of the blood increases
Increased Hb level
Anemia
KidneyBone marrow
Erythropoetin
Increased red cell productionCauses of
hypoksia other than anemia Erythrocytosis
(Polycythemia)
CO intoxicationHigh altitudeHigh O2 affinity HbMethemoglobinemiaLung diseaseRespir. center dysfunction
Sleep apneaRight to left shunts
Bone marrowIncreased red cell production
Increased EPO levels without hypoxia
Erythrocytosis(Polycythemia)
High EPO due to Renal disease Renal cysts Hydronephrosis R.Artery stenosis Renal transplantation Focal glomerulonephritis Bartter’s syndromeInappropriate EPO productionEPO production by Tumors Hypernephroma Hepatoma Cerebellar hemangioblastoma Adrenal adenoma Pheocromocytoma Meningioma Uterine fibromyomaAndrogen therapyEPO administrationOther
Congenital /familial erythrocytosisEg: EPO receptor hypersensitivity
Bone marrow
Overproduction of RBCs + WBCs+ Platelets
Stem cell disease
Polycythemia vera
PV (PRV)• First described by Vaquez in 1892• Epidemiology:
– Incidence:2/100.000-year– Median age: 60
(may occur in younger also, 7% < 40 y)– M/F: 1-2:1
• General characteristics:– Erytrocytosis,leukocytosis,thrombocytosis– Thrombosis,– Bleeding– Transformation:
• Myelofibrosis/acute leukemia
PRV: Etiology-Pathophysiology• PRV erythroid progenitors are
resistant to apoptosis induced by EPO deprivation.
• Non-EPO dependent overproduction of erythroid lineage
• Increased sensitivity to cytokines or HGF :
eg: IL-3, GM-CSF, SCF, TPO, IGF-1,• JAK-2 mutation !!!!!!!!!!!!!
• Progenitors in PRV gain clonal predominance and supress the proliferation of normal progenitor cells.
• During the later stages of the disease myelofibrosis and extramedullary hematopoesis (in the liver , spleen and lymph nodes) may occur.
PRV: Etiology-Pathophysiology
PRV:Etiology-Pathophysiology
• JAK2 mutations (chr 9p):TK activity: 97%*
• Increased levels of PRV-1 mRNA in granulocytes
*Kenneth Kaushansky, On the Molecular Origins of the Chronic Myeloproliferative Disorders: It All Makes Sense.ASH Education Book 2005,p 533-537
EPO related signal EPO unrelated signal
Campbell P and Green A. N Engl J Med 2006;355:2452-2466 JAK2 mutation (Chr 9p): 97 % of cases !!!!!!!
• Asymptomatic• Plethora,cyanosis,• Vertigo • Tinnitus• Headache• Visual disturbances• Paresthesias• Systolic hypertension• Erythromelalgia • Pruritus (aggravated by bath)• Weight loss• Arthralgia
• Decreased exercise capacity,• Dyspnea• Excessive sweating• Vascular occlusion
• TIA , stroke,MI• Venous thrombosis
• Digital ischemia• Easy bruising • GI bleeding• Splenomegaly (70%)• Gout or/and kidney stones• Pulmonary hypertension
PRV: Clinical features
• Late stage disease – Secondary bone marrow fibrosis and
extramedullary hematopoesis• Increased spleen size and/or hepatomegaly• Decreasing red cell mass• Leuko-erythroblastic blood picture with tear
drop poikilocytosis• Bone marrow fibrosis
PRV: Clinical features
Blood counts of a PV case
Disease presentation:• Some cases have isolated
erythrocytosis• Some may have trilinegae
hyperplasia– erythrocytosis – leukocytosis – thrombocytosis
• Some cases may present with isolated lekocytosis or thrombocytosis in the beginning of the disease followed by erythrocytosis .
PRV• Hct > 60% in men and > 55% in
women usually indicates red cell mass increase
• Iron deficiency or hypersplenism may cause an underestimation of red cell mass due to a decreased Hct
• Serum levels of– LDH– Uric acid – Vit B12 or B12 binding capacity may
increaseand – EPO is decreased
• Leukocyte alkaline phosphatase level increases
• JAK2 (+)• Red cell mass is increased• Bone marrow is
– hypercellular (trilineage hyperplasia, red cell and megakaryocytic lineage may be prominent) and ,
– iron strores may be decreased.– fibrosis may be a late finding
Diagnosis• Exclude other causes of
polycythemia• Search for the criteria for
the diagnosis of PRV
PV 2008 WHO Diagnostic Criteria– Major criteria1. Increased RBC mass
• Hgb>18.5 g/dL (male)• >16.5 g/dL (female)or• Hgb ya da Hct >99 percentile or• Increased RBC mass (> % 25 of normal)(Cr51)
2. JAK2V617F (%90-95) or JAK2 exon 12 mutation (%5-10)
– Minor criteria• Bone Marrow: Proliferation of all three cell lines • Serum EPO: Decreased• Endogenous erythroid colonies
• 2 major and 1 minör or
• First major and 2 minor criteria are needed for diagnosis
Complications• Myelofibrosis• Acute leukemia• Peptic ulcer• Vascular occlusions:Arterial or venous• Bleeding:Platelet defects , acquired vWD• Splenic infarction• Increase in uric acid levels and gout or renal
stones
PRV: Prognosis• Proliferative phase followed by
postpolycythemic myelofibrosis and extramedullary hematopoesis
• Life expectancy: > 10 years– Less than normal age/sex group
• Thrombosis• Transformation
– AML– MF
PRV Treatment• Venesection to keep Hct: < %45• Low dose aspirin (if it’s not contraindicated)• Prevent/control reversible thrombotic risk
factors– EG:Hypertension,smoking, obesity,
hypercholesterolemia,DM etc• Myelosupressive treatment : If there is;
– Thrombosis– Age > 60– Intolerance to phlebotomy– Prominent thrombocytosis – Symptomatic/progressive splenomegaly
Myelosupressive agents:– Hydroxyurea– IFN– Busulphan– Radioactive “P” (32P)– Anegrelide (only to supress platelet
production)
PV: TreatmentRisk group Treatment
High risk patients:– Thrombosis history+– Age > 60– Platelets > 1.500.000/mm3
Intermediate risk– Without high/low risk features
Low risk:– Age < 40– Without any risk factor
VenesectionLow dose aspirin +Hydroksyurea (anegrelide or interpheron)
Low dose aspirin + VenesectionMyelosupressive treatment if CVS risk factors are present.
Low dose aspirin + Venesection
Peter J. Campbell and Anthony R. Green. Management of Polycythemia Vera andEssential Thrombocythemia,ASH Education Book 2005,p201-208
Causes of thrombocytosis• ET and other MPD• Iron deficiency anemia• Splenectomy or hyposplenism• Malignancy• Collagen vascular disease• Infection• Hemolysis or bleeding• Myelodysplastic Syndrome• Surgery • Drugs,etc
• First described by Epstein and Goedel in 1934 as “haemorrhagic thrombocytemia”
• In 1951 Dameshek defined it as a MPD
Essential Thrombocytemia(ET)
Essential Thrombocytemia (ET)
• 1-2/100.000- year• Age: Median:50-60
– Second peak at age 30 (mostly female)
• M/F:slight female predominance• Median survival > 10 years• Etiology : unknown
– JAK2 mutation: 57 %
ET: Clinical• Some patients may be asymptomatic• Vasomotor symptoms:
– Visual disturbances– Lightheadedness– Headaches– Palpitations– Atypical chest pain– Erythromelalgia– Livedo reticularis– Acral paresthesias
ET: Clinical• Thrombosis:
– At presentation or during the course of the disease– Deep Vein Thrombosis , Pulmonary
Embolism– Digital ischemia– Portal vein thrombosis– CVA– Coronary ischemia
• Bleeding:– Most common : GIS– NSAID increase the risk– Major bleeding:5%
• Splenomegaly : 20-25%
Diagnosis of ET: WHO 2008– 4 criteria must be present
1. Thrombocytosis > 450 x 10^9/L – More than two months on more than two
occasions 2. Megakaryocytic proliferation without
granulocytic and erythroid proliferation 3. Without diagnostic criteria of
CML,PV,IMF,MDS and other CMPN4. JAK2V617F (50%) or cMPL mutation
(MPLW515L and MPLW515K) + or no evidence of reactive thrombocytosis
– Exclude other causes of thrombocytosis • Reactive
– Anemias » Iron deficiency» Hemolytic» Acute blood loss
• Post splenectomy • Inflammation
– Bone marrow findings• Normo-Hypercellular with megakaryocytic
hypeplasia• Normal iron score • Normal erythropoesis• Without significant fibrosis
Diagnosis of ET: WHO 2008 (2)
Prognosis• Myelofibrosis: (spent phase)• Acute leukemia:• Mortality: mostly because of
thrombosis or bleeding
ET: Treatment• Prevent/Manage cardiovascular risk
factors• Low dose aspirin
– if there is no contra-indication• Myelosupressive treatment:
– High risk patients • > 60 y, • prior thrombosis,• plt > 1500000/mm3
• Thrombopheresis– Rapid reduction of very high plt counts
ET: TreatmentRisk group Treatment
High risk patients:– Thrombosis history+– Age > 60– Platelets > 1.500.000/mm3
Intermediate risk– Age: 40-60– Without high risk features
Low risk:– Age < 40– Without any risk factor
Low dose aspirin +Hydroksyurea (anegrelide or interpheron)
Low dose aspirin +Myelosupressive treatment if CVS risk factors are present.
Low dose aspirin +
Reference: Peter J. Campbell and Anthony R. Green. Management of Polycythemia Vera andEssential Thrombocythemia,ASH Education Book 2005,p201-208
Causes of myelofibrosisIdiopathic myelofibrosis and PRV ,ET,
CML, MDS Lymphoma,M MyelomaA.Leukemia (ANLL-M7,ALL)Hairy cell leukemia Metastatic carcinomaInfection :eg: Tbc,Fungal inf. SLE,Systemic sclerosisSystemic MastocytosisHypovit. D , renal osteodystrophyHypoparathyroidism,Hyperparathyroidism etc
Etiology : Unknown (radiation ? other?)Epidemiology: 0.4 – 1.3 / 100000-yearAge: Median 60-65 (wide age distribution)
Survival: median:3-5 years
Myelofibrosis with myeloid metaplasia (Idiopathic myelofibrosis)
(Idiopathic Myelofibrosis)(Myelofibrosis with Myeloid Metaplasia)
bone
IMF• Fibroblasts are not part of the clonal
process• Megakaryocyte derived cytokines
– PDGF– TGF-Beta are the cause of fibrosis
• There is extramedullary hematopoesis• Cytogenetic abnormalities are found in
50%• 13 q- , 20q- , 12p- , trisomy 8, trisomy 9• JAK2 mutation (50%) (or other . Eg MPL)
• Symptoms related to anemia or marrow failure
• Hypermetabolic state– Sweating– Weight loss– Low grade fever
• Oedema• Abdominal fullness/organomegaly
(splenomegaly and or hepatomegaly) • Portal hypertension• Splenic infarction (sudden LUQ pain)• Effusions • LAP
IMF:Clinical
IMF: LAB• Anemia• WBC : normal / leukopenia /
leukocytosis• Plt : normal /thrombocytosis
/thrombocytopenia• Blood smear :
– Red cell poikilocytosis with teardrop shapes
– Leuko-erythroblastic : erythroblasts + young myeloid cells*
*(promyelocytes, myelocytes , meta , band and polys.)
IMF: LAB• LDH , uric acid: increased • Bone marrow :
–Aspiration : Dry tap–Biopsy: Increased fibrosis and
megakaryopoesis JAK2 mutation:50%**
** Kenneth Kaushansky, On the Molecular Origins of the Chronic Myeloproliferative Disorders: It All Makes Sense.ASH Education Book 2005,p 533-537
IMF: Diagnosis• Typical blood findings• Splenomegaly• Bone marrow
– Dry tap aspirate– Bone marrow fibrosis and megakaryocytic
diysplasia (biopsy finding)• JAK2 ( about 50%)• Other causes excluded
Complications• Transformation to acute leukemia• Gout• Infections• Termination to a stage of deep marrow
failurePrognosis• Death due to
– Infection– ANLL (20% in first ten years)
IMF: Treatment• Transfusions when indicated• Androgens• Corticosteroids & other
Myelosupressive treatment• HydroxyureaOther• Splenectomy• Splenic irradiation?Stem Cell Transplantation :
– The only treatment with cure potential– Can be performed in a limited number of
patients
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