LEUKEMIAS AND MYELOPROLIFERATIVE DISEASES > Leukemias and myeloproliferative diseases are CLONAL disorders resulting from a mutation of DNA within a pluripotent marrow stem cell or very early progenitor cell. CLONAL POPULATION OF CELLS - cells with growth and/or proliferation advantage over against normal bone marrow cells. Mutation of DNA can result in the expression of fusion genes that encode fusion proteins that are oncogenic or in the underexpression of genes that encode molecules critical to control of cell growth or progremmed cell death. DEFINITION John Hughes Bennett: Two Cases of Disease and Enlargement of the Spleen, in which death took place from presence of purulent matter in the blood, 1845 The young John Hughes Bennett C:\Dokumenty\Michael\Kapitoly do knih a skript\Veterinární krev\Historie fotografie\Bennett-leukemie.JPG Dr. R.L.K. Virchow Rudolf Virchow: Weisses Blut. Frorieps Notizen, 36, s. 152 – 156, 1845 Weisses blut pluripotent stem cell slow proliferating cell, self-reneval cell very early progenitor cell rapid proliferating cell late progenitor cells FIG.: SCHEME OF HEMATOPOIESIS lymphoblast myeloblast proerythroblast differentiation Myeloproliferative disorders - polycythemia vera - essential thrombocytemia - myelofibrosis Leukemias - acute - chronic Myelodysplastic syndromes - „preleukemias“ CLASSIFICATION OF MALIGNANT HEMATOPOIETIC DISEASES - shortened myelogenous lymphoblastic myeloid lymphocytic hairy cell In reality, chronic myeloid leukemia is one of myeloproliferative disorders. - chronic myeloid leukemia Frequency of occurence All leukemias affect 13/100 000 M 10/100 000 F THERE IS A SLIGHT INCREASE COMAPRING WITH 70S. 40 % CLL (the most common leukemia of Caucasians), 25 % AML, 15 % CML, 11 % ALL, 2 % HCL, 7 % other Myeloproliferative disorders without CML 1-3/100 000 Myelodysplastic syndromes 1-3/100 000 ALL CML AML CLL per 100 000 Symptoms affecting patients Frequency infection, fever bleeding thrombosis, DIC lymph nodes enlargement splenomegaly hepatomegaly mediastinal tumor CNS involvemet involvement of another organs 36 % (all) 33 % (APL, AML) 10 % (APL, ET, PV) 57 % (ALL, CLL) 56 % (CML, CLL, PV, MF) 47 % (CML, AML) 14 % (ALL, CLL) 7 % (ALL, AML M5) 9 % (all) Clinical symptoms of malignant diseases of blood and bone marrow CAVE: All symptoms of hematologic diseases are non-specific! Differential diagnosis SPLENOMEGALY LYMPHADENOPATHY Myelofibrosis, CML, HCL CLL, CML ALL (occasionally) CLL, ALL (CML, AML) C:\Dokumenty\M I C H A E L\Přednášky\2004\Leukemie - sestry\Uzliny - článek.jpg C:\Dokumenty\M I C H A E L\Přednášky\2004\Leukemie - sestry\Uzliny - obrázek.jpg Differential diagnosis THROMBOCYTHEMIA THROMBOCYTOPENIA ALL, AML, HCL, MDS myelofibrosis CLL (autoimmune phenomenon) CML (accelerated phase, blast crisis) PMF, ET, PV, CML MDS (5q-), MDS/MPS C:\Dokumenty\M I C H A E L\Přednášky\2004\Leukemie - sestry\Petechie.jpg C:\Dokumenty\M I C H A E L\Přednášky\2004\Leukemie - sestry\Krvácení.jpg 9,5 - pro prezentaci LEUKEMIAS Do you know differences between acute and chronic leukemias? Briefly: Acute leukemia - there is defect of proliferation, proliferation of young bone marrow cells (blasts) is increased! Chronic leukemia - there is defect of apoptosis (programmed cell death), apoptosis of mature cells is decreased, mature cells are accumulated in the body! CAVE: CL can switch to AL (CML in blast crisis, CLL in Richter´s syndrome) LEUKEMIAS – PREDISPOSING FACTORS Increased risk of leukemia is in: Genetic syndromes – M. Down, FA, ataxia telangiectasia Drugs (chemotherapy, alkylating agents) Radiation (can cause all leukemias except CLL) Socioeconomic factors (increased incidence of childhood ALL in industrial countries, probably due to later contact of children with alergens or banal childhood infections) Viruses (EBV, HTLV I, HIV) Benzene, toluene, etc. LEUKEMIAS – ETIOLOGY Molecular lesion Lesion LEUKEMIAS AND MYELOPROLIFERATIVE DISEASES Blood and bone marrow features What can we found in periperal blood (WBC, RBC, platelets)? - acute leukemia - chronic leukemia - myeloproliferative diseases What can we found in bone marrow? - acute leukemia - chronic leukemia - myeloproliferative diseases Laboratory diagnostics Peripheral blood count with differential WBC Bone marrow Flow cytometry (analysis of CD antigens) (ALL, CLL, LGL) Cytogenetic analysis (CML, AL, MDS, CLL - ?) Molecular genetic analysis (CML, APL) Cytology a cytochemistry Histology (necessary in myeloproliferative diseases) Do you know differences between trephine biopsy and sternal puncture? Sternal puncure - we can collect only marrow blood. SP fits for diagnostics of leukemias. Biochemical analysis of blood (elevated LD in myeloproliferative diseases) Coagulation – DIC, thrombophilia, bleeding fibrinogen, aPTT, PT, AT III, DD, EGT Other (Chest X ray, abdominal sonography, ECG, heart sonography, serology – CMV…) - we have to exclude focal infections and to evaluate function of heart, kidneys, liver and lungs (chemotherapy is nephrotoxic, hepatotoxic or cardiotoxic) Laboratory diagnostics Differential diagnosis of malignant hematologic diseases LEUKOPENIA is typical finding in hairy cell leukemia acute leukemias (ALL, AML M3, secondary or treatment related AL) myelofibrosis LGL (T-LGL) MDS (RA, RC, RCMD, RARS, RAEB) LEUKOCYTOSIS variant hairy cell leukemia acute leukemias (worse prognosis) CML, CLL ET, PV myelofibrosis MDS, MDS/MPS Hyperleukocytic syndrome develops when WBC is over 200 leu/uL in CML or AL, or over 500 leu/uL in CLL (smaller cells in CLL). The circulation of CNS, lungs, retina or penis is most sensitive to the effect of leucostasis. There are hemorrhage, dyspnea, priapism, vascular oclusion and disruption. Treatment: leukapheresis and or cytoreduction chemotherapy. Differential diagnosis of malignant hematologic diseases C:\WINDOWS\Plocha\Vak po leukaferéze 1.JPG E:\Dokumenty\Obrázky\Leukostáza při hyperleukocytóze.jpg Classification of leukemias FAB (1982) WHO (1999-) Classification according to morphology, cytogenetic features, flow cytometry, and molecular genetic features Classification according to morphology of malignant cells Classification of AML FAB (1982) divides AML among WHO (1999-) divides AML among AML with recurrent chromosomal abnormality t(8,21), t(15,17), t(16,16), translocation of 11q23 AML developed from MDS Treatment related AML – topoisomerase II inhibitors, alkylating agents Remainder AML – see FAB AML M0, M1, M2, M3, M4, M5, M6, M7 Classification of ALL FAB (1982) WHO (1999) includes ALL in malignancies from B or T precursor cells EGIL classification divides ALL among T ALL pro T, pre T, thymic T, mature T B ALL pro B, common B, pre B, mature B ALL L1, L2, L3 Classification of chronic lymphoproliferative diseases WHO (1999-) includes CLL, PLL, HCL, and plasma cell leukemia in malignancies from B or T peripheral cells Classification of myeloproliferative diseases FAB (1982) WHO (1999-) CML, PV, ET, MF CML, CNL, HES/CEL, ET, PV, MMM Myeloproliferative/myelodysplastic disorders atypical CML, JMML, CMML CLL The most common leukemia of Caucasians. CLL is a disorder characterized by the accumulation of small mature-appearing lymphocytes in the blood, marrow, and lymphoid tissues. Laboratory and clinical features: leukocytosis (absolute lymphocytosis), lymphadenopathy, splenomegaly, hepatomegaly, anemia, thrombocytopena, often autoimune diseases (hemolysis). Prognosis – different (better in CLL from „memory cells“ (mutated genes for IgH), in CLL with del 13q14, with focal bone marrow involvment. Median survival of CLL patients is 8 – 10 years. C:\Dokumenty\Články do časopisů, knih a skript\Knihy a skripta\CLL pro pacienty\Obrázek 3 - CLL - buňky.jpg C:\Dokumenty\Články do časopisů, knih a skript\Knihy a skripta\CLL pro pacienty\Obrázek 4 - CLL - průtoková cytometrie.jpg CLL B - symptoms - fever, weight loss, sweat Indication for therapy: anemia, thrombocytopenia, B-symptoms, painful spleen, doubling time of peripheral blood lymphocytes 6 months or shorter, symptomatic lymphadenopathy. Therapy: chlorambucil, fludarabin, cyklofosfamid, anthracyklins, anti CD52 antibody (alemtuzumab), anti CD20 antibody (rituximab) Prognosis of CLL according cytogenetic features 5b 2a B lymphocytes maturation (Freda a kol., Adv. Cancer Res., 2001; Chiorazzi a kol., N. Engl. J. Med., 2005) Kostní dřeň Sekundární lymfatické orgány Pro-B Pre-B Nezralá-B B buňka marginální zóny Plazmatická-B Paměťová-B Antigen + T-lymfocyty (germinální centrum, mutovaný IgVH) Antigen bez T-lymfocytů (mimo germinální centrum, mutovaný i nemutovaný IgVH) CLL B buňka folikulárního centra CLL Bone marrow Secondary lymphatic organs OS at 3 years 83% vs. 87% p = 0,012 PFS at 3 years 45% vs. 65% p < 0,0001 CLL – FCR regimen treatment Clonal evolution in CLL – TP53 treatment Before treatment SFB3, NOTCH1, BIRC3, TP53 mutations CHRONIC MYELOID LEUKEMIA CML is a pluripotent stem cell disease that is characterized by extreme blood granulocytosis, basophilia, often thrombocytosis, anemia, and splenomegaly. Stages of untreated CML: chronic phase, accelerated phase (rapid increase of WBC, worsening of thrombocytopenia, new cytogenetic features, resistence to treatment), blast crisis (resembles to acute leukemia) Etiologic role of chromosome discovered in Philadelphia - Ph chromosome! http://pathy.med.nagoya-u.ac.jp/atlas/img/t2/img0006.jpg - Ph chromosome arises from t(9;22) - chimeric gene BCR-ABL arises from Ph chromosome - BCR-ABL gene produces BCR-ABL tyrosinkinase - BCR-ABL tyrosinkinase induces defect of apoptosis There is no BCR-ABL negative CML! http://www.infobiogen.fr/services/chromcancer/Anomalies/Images/9t(9;22)CMLGRShem.gif ABL BCR BCR-ABL C:\Dokumenty\M I C H A E L\Přednášky\2004\Leukemie - sestry\FISH.jpg Minimal residual disease during treatment - Hematologic monitoring - - Cytogenetic monitoring - reveal 1 pathologic cell from 100 - - Molecular genetic monitoring - reveal 1 pathologic cell from 100 000 months after SCT 10 20 30 40 0,0001 BCR-ABL (%) 0,001 0,01 0,1 1 10 100 molecular relapse cytogenetic relapse hematologic relapse DLI IFN DLI CsA IFN Minimal residual disease after treatment or BM/PBSC transplantation Molecular relapse is manageable compared with cytogenetic or hematologic relapse Lissauer Arsenik – As2O3 Lissauer: Zwei Fälle von Leucaemie. Berlin. Klin. Wochenschrift, 2, 1865, s. 403 - 404 CML management years 2 4 6 8 25 50 75 100 10 allogeneic transplantation IFN Prognosis of CML patients HU survival (%) imatinib CLASSICAL HAIRY CELL LEUKEMIA HCL is characterized by leukopenia and splenomegaly Leukemia with excellent prognosis Treatment of choice - cladribine for 7 days (treatment is recommended only for symptomatic, neutropenic, thrombocytopenic or anemic patients) http://pathy.med.nagoya-u.ac.jp/atlas/img/t8/img56.jpg ACUTE MYELOBLASTIC LEUKEMIA AML is clonal malignant disease that is characterized by the proliferation of abnormal (leukemic) blasts, principially in the marrow, and impaired production of normal blood cells. Signs and symptoms of AML include pallor, fatigue, weakness, palpitations, bleeding, fever, and dyspnena. In bone marrow, there is more than 20% of blast cells. (less than 20% - myelodysplastic syndrome) Median survival of untreated patients is 6 weeks. http://pathy.med.nagoya-u.ac.jp/atlas/img/t6/img023.jpg 6a00d8342ae08153ef0128764a7a44970c-800wi Induction 3 + 7 followed by bone marrow aplasia (2 – 4 weeks) Complete remission (normal BM, blasts bellow 5 % in BM) Partial remission (decrease of blast cells) Progression Consolidation (2 courses), treatment is completed by allogeneic or autologouc BMT/PBSCTin younger patients Reinduction Salvage chemotherapy bone marrow aplasia after each course (2 - 4 weeks) Palliative or symptomatic treatment in non-responders Treatment of AML Treatment of choice of AML are courses of chemotherapy, the most potent drugs are cytosinarabinoside and anthracyclines. Acute promyelocytic leukemia, AML M3 APL is variant of AML (constitutes about 5-10% of AML in central Europe, about 25% of AML southern Europe, and 50 % of AML in eastern Asia). There are prominent hemorrhagic complications (DIC, melena, hematuria, pulmonary bleeding, CNS bleeding) Prognosis of APL was very poor 25 years ago (almost all patients died). Nowadays, DFS is 80%. Acute promyelocytic leukemia, AML M3 Promyelocytes are granular cells. In granula are coagulopathy-inducing factors (tissue factor…). Majority of APL is characterized by t(15,17). A translocation between chromosome 17 and 15 results in chimeric fusion gene PML-RARα. PML-RARα gene produces PML-RARα abnormal recepror for retinoids. (Retinoids are necessary for normal bone marrow cells differentiation). In cells with t(15,17) normal differentiation is stopped. We can restore differentiation by means of ATRA. Acute promyelocytic leukemia, AML M3 Chemotherapy + ATRA is treatment of choice for APL! Or aresink trioxide http://pathy.med.nagoya-u.ac.jp/atlas/img/t5/img14.jpg Auer rods, „faggots“ granular plasma C:\Dokumenty\M I C H A E L\Články a kapitoly\Krvácení - Penka\Krvácení - konečná verze\Obr.2.jpg Survival of AML patients children and young adults APL Prognosis of AML according to cytogenetic features years 1 2 3 4 25 50 75 100 t (15,17) normal caryotype 5 t (8,21) inv (16) komplex. - 7 - 5 survival good risk standard risk poor risk AKCUTE LYMPHOBLASTIC LEUKEMIA The most common leukemia in childhood. In children - very good prognosis. In adults - very poor prognosis. ALL is a neoplastic disease resulting from somatic mutation in a single lymphoid progenitor cell. BM - more than 20% of lymphoblasts (usually 80 - 100%). C:\Dokumenty\Michael\ALL seminář\ALL obrázky zmenšeno\ALL obrázek.jpg Chromosomal translocations in ALL children adults SP – monitorace MDR B-prekurzorová, T- ALL, 15 – 65 let (dny) ALL – therapeutic protocol Pacienty ve věku 55 – 65 let zařazovat do studie podle klinického stavu PRE-FÁZE INDUKCE I INDUKCE II OZÁŘENÍ CNS KONZOLIDACE I POKUD JE CR SBĚR PBSC Donor search 0 (stanovení dg.) 11 24 44 71 Stratifikace I podle rizikových faktorů STANDARDNÍ RIZIKO VYSOKÉ A VELMI VYSOKÉ RIZIKO KONZOLIDACE II HDMTX/ASP DÁRCE NENALEZEN DÁRCE NALEZEN RANDOMIZACE KONZOLIDACE II IFO/ARA-C KONZOLIDACE II FLAG-IDA ALLO MUD AUTO DLT podle MRD a GvHD SP – monitorace MDR (týdny) 16 22 REINDUKCE KONZOLIDACE III - IV KONZOLIDACE V - VI 30 41 52 SP-MRD po 2-3 měsících Stratifikace II podle MRD MRD negativní MRD pozitivní KONEC TERAPIE SCT 1. ALLO 2. AUTO 3. MUD INTENZIFIKOVANÁ UDRŽOVACÍ TERAPIE EXPERIMENTÁLNÍ TERAPIE EXPERIMENTÁLNÍ TERAPIE pro Ph/bcr-abl pozitivní C:\Dokumenty\Michael\ALL seminář\ALL - preziti podle cytogenetiky.JPG Childhood ALL - survival adults MYELODYSPLASTIC SYNDROMES Heterogeneous group of malignant diseases with different prognosis (preleukemias). In BM - blasts bellow 20 % and dysplastic features (hypogranular cells, cells with atypical shape of nucleus, hypergranular cells, cells with abnormal plasma) The only curative option is BMT/PBSCT in high risk patients. Patients asyptomatic or without donor - only symptomatic treatment or watch and wait strategy. Score Prognostic marker 0 0.5 1.0 1.5 2.0 Bone marrow blasts (%) < 5 5–10 11–20 21–30 Karyotype* Good Intermediate Poor Cytopenia 0/1 2/3 Score IPSS subgroup Median survival (years) 0 Low 5.7 0.5–1.0 Int-1 3.5 1.5–2.0 Int-2 1.2 > 2.5 High 0.4 . MDS - prognosis Therapeutic options in MDS •Supportiv care, transfusions, prophylaxis of iron overload • •Immnosupressive therapy •Arsenic trioxide •Low dose chemotherapy • •Epigenetic therapy •Allo-SCT, intensive chemo Prognostic group MDS risk score Low High risk MPN PV PMF ET POLYCYTHEMIA Polycythemia is characterized by an increase of the total red cell volume. It exists in the primary form (PV, clonal neoplastic disorder) and in secondary forms due to appropriate or inappropriate increases in levels of EPO (hemoglobins with high affinity to oxygen, high altitudes, pulomary and heart diseases, tumours producing EPO). PV is characterised by increases not only of the number of red cells but also of the granulocytes and platelets and splenomegaly. POLYCYTHEMIA VERA Peripheral blood count Histology of bone marrow Total erythrocyte volum Analysis of growth of erythroid precursors (BFU-E) without EPO JAK2 V617F mutation We have to exclude all secondary polycythemias. Secondary polycyhemias are more frequent than PV. Prognosis – median survival is 15 years. Complications - bleeding, thrombosis, leukemia Diagnosis Differential diagnosis We have to distinguish between primary and secondary polycythemias. Treatment of polycythemia vera 1) 2) ALL PATIENTS phlebotomy - decrease and maintain hematocrit below 45%, Anopyrin 50 - 100 mg/d, or anticoagulants BELLOW 40 YEARS 40 - 60 YEARS OLD PATIENTS BM donor YES BM donor NO consider TRANSPLANTATION INTERFERON HYDROXYUREA ESSENTIAL THROMBOCYTHEMIA Clonal proliferation of megakaryocytes in bone marrow. Result: incresed peripheral blood platalet count. JAK2 mutation, calreticulin mutation Differential diagnosis: We have to distinguish Secondary thrombocytemias (sideropenia, chronic infection, splenectomy, malignancies, bleeding, hemolysis). Myeloproliferative disorders, MDS Prognosis – median survival is 12 - 15 years. Complications - bleeding, thrombosis, leukemia Algorythm of treatment of ET INTERFERON or ANAGRELIDE BELOW 60 YEARS ABOVE 60 YEARS ALL PATIENTS Anopyrin 100 mg/d when trombocytes are below 1000.109/L (when above Anypyrin is not reccomended) TROMBOCYTES ABOVE 1000x109/L TROMBOCYTES BELOW 1000x109/L HYDROXYUREA ANTIAGREGANTS sejmout0001 PRIMARY MYELOFIBROSIS Clonal disorder chracterized by transformation of normal bone marrow to fibrotic and non-functional bone marrow. JAK2 mutation in cca 50% of cases. Hyperplastic stage - increased precurors of platalets in BM, increased WBC, RBC and PLT. Late stage – fibrosis (extramedullary hematopoiesis leading to massive splenomegaly). Prognosis – median survival only 3 - 5 years. Treatment of choice - BMT/PBSCT (Patients not eligible for BMT/PBSCT - symptomatic approach or watch and wait). File:Portulaca grandiflora mutant1.jpg „Positive mutation“ mutation