Myeloproliferative Neoplasms

Transcription

1 Myeloproliferative Neoplasms Judit Demeter & Csaba Bödör Semmelweis University, I st Department of Internal Medicine I st Department of Pathology and Experimental Cancer Research március 6.. bodor.csaba1@med.semmelweis-univ.hu

2 Myeloproliferative Neoplasms (MPN) - Genetics?

3 Chronic myeloid leukemia (CML) Clonal disorder of the hematopoietic stem cells Aberrant granulopoesis Leukocytosis, basophilia, thrombocytosis Splenomegaly Normal CML

4 Defining Phases of CML Baccarani M, et al. Blood. 2013;122: ELN (European Leukemia Net) definitions of CML-CP, -AP, and BP Phase Definition Chronic None of the criteria for AP or BP are met Accelerated Blast 15%-29% blasts in blood or bone marrow > 30% blasts plus promyelocytes in blood or bone marrow, with < 30% blasts only 20% basophils in blood Persistent thrombocytopenia (platelet count < /L) unrelated to therapy Major route CCA/Ph+ on treatment 30% blasts in blood or bone marrow Extramedullary blast proliferation, apart from spleen AP, accelerated phase; BP, blast phase; CCA/Ph+, clonal chromosomal abnormalities in Philadelphia chromosome positive cells. 1. Baccarani M, et al. Blood. 2006;108: ; 2. Baccarani M, et al. J Clin Oncol. 2009;27:

5 Features of the chronic phase of CML 25-35% of all cases is asymptomatic, but accelerated and blastic phase Blood count: Physical exam: granulocytosis (frequently G/l) left shift in differenteial blood count Eosinophila,basophilia Thrombocytosis splenomegalia

6 Leukemic white cell mass removed by cytapheresis from a 34-years-old patient diagnosed with blastic phase CML

7 140 years in the treatment CML (up to 2000) No treatment Palliative care Curative treatment Arsenic salts Splenic irradiation Busulphan Hydroxyurea (Litalir) Stem cell transplant Interferon-alpha

8 Once upon a time CML BCR-ABL1. Imatinib Philadelphia chromosome t(9;22) translocation BCR-ABL fusion proterin B. Druker STI 571 Imatinib (Glivec)

9 Once upon a time The breakthrough yrs survival>80%! Minimal side effects FDA appr Glivec (Imatinib), Novartis 9 22 Substrate 22q11.2 bcr abl bcr-abl IMATINIB Y Survival IM Proliferation ATP P P P Migration 9q34 Continuous treatment

10 Molecular targets for TKIs used in treatment of CML Imatinib Dasatinib Nilotinib Bosutinib Ponatinib PDGFR SRC ABL1 BCR-ABL1 BCR-ABL1 KIT SRC kinases (FGR, FYN, HCK, LCK, LYN) KIT BCR-ABL1 BCR-ABL1 PDGFRB Inhibition of STAT5 phosphorilatio n SRC kinases (LYN, HCK) FLT3 PDGFRA SRC KIT ARG PDGFRB PDGFR EPHB4 KIT BTK Ephrin receptor TKs FGFR1 VEGFR Hochhaus A et al.: Causes of resistance and treatment choices of second- and third-line treatment in chronic myelogenous leukemia patients. Ann Hematol (2015).94(Suppl 2):S133 S140.

11 Chronic myelogenous leukemia Significance of early molecular response BCR/AB L1 IS Nilotinib 2x300 mg Nilotinib 2x400 mg Imatinib 1x400 mg Estimated progression free survival on study (%) 10% 95,2 96,9 97,7 >10% 82,9 89,0 82,6 Estimated overall survival on study (%) 10% 96,7 96,9 98,9 >10% 86,7 92,7 83,6 Hughes TP et al.: Early molecular response predicts outcomes in patients with chronic myeloid leukemia in chronic phase treated with frontline nilotinib or imatinib. Blood. 2014;123(9):

12 Before 2000 Disease duration and survival in CML Chronic phase Accelerated phase Blastic phase 3-5 years months 3-9 months After 2000 (most patients TKI treatment) Chronic phase Survival > 20 years? Permanent cure (w/o ASCT)? Ca patients in Hungary today (prevalence)

13 Chronic myeloid leukemia (CML) as a model disease Prevalence: 1200 patients in Hungary ~5% Targeted therapies: Imatinib (650k HUF/mo)=7.8 Million HUF/y Nilotinib (738k HUF/mo) Dasatinib (1000k HUF/mo) TKI therapy Monitoring Molecular diagnostics: BCR-ABL1 RQ-PCR (45k HUF/testing) = 180k HUF/y Y253H mutation

14 Chronic myeloid leukemia (CML) as a model disease Prevalence: 1200 patients in Hungary Targeted therapies: Imatinib (650k HUF/mo)=7.8 Million HUF/y Nilotinib (738k HUF/mo) Dasatinib (1000k HUF/mo) TKI therapy ~5% Monitoring Molecular diagnostics: BCR-ABL1 RQ-PCR (45k HUF/testing) = 180k HUF/y

15 Treatment and monitoring of CML: International recommendations Treatment and monitoring based on Hungarians and ELN recommendations RQ-PCR every 3 months, mutation analysis in non-responders RQ-PCR testing yearly count (SE-I.Pat) Monitoring cost for 1200 CML patients in one year (4 test/pt): ~200 million HUF Imatinib yearly cost: ~9 billionhuf

16 Meanwhile in our deparment Case study(2003) 35-years old male patient (Dx:CML), accelerated phase? Unfavorable prognosis

17 Date WBC X G/l 12/ ,0 Blas t: 25% PLT X G/l Hb g/l , X,Y (1) Citogenetics FISH Quant. RT- PCR 46, XY t(9,22)( 29) 02/2003 4, , X,Y (24) 46, XY t(9,22)( 6) % bcr/abl+ 05/2003 4, negative - CML score: 4277 (high risk.) 32 BM.hypoplasia 08/2003 4, negative 11/2003 4, ,75 04/2006 4,6 normal No Phil negative 11/2013 4, ,0000

18 CML - calculation of relative risk Clinical study calculation Definition of risk groups Sokal et al Exp 0,0116 x (age-43,4) + 0,0345 x (spleen size 7,51) + 0,188 x [(platelet count + 700) 2 0,563] + 0,0887 x (blasts 2,1) Low risk: <0,8 Intermediate risk: 0,8-1,2 High risk:>1,2 Euro Hasford et al ,666, if age >50 ys + (0,042 x spleem) + 1,0956, if platelet count > 1500 G/L + (0,0584 x blast cells) + 0,20399, if basophils >3% + (0,0413 x eosiophils) x 100 Low risk: 780 Közepes kockázat: High risk>:1481 EUTOS Hasford et al Spleen x4 + basophils x 7 Low risk: 87 High risk: >87 Age is measured in years. Spleen size is measured in largest distance from costal arc in centimetres. Blast cells, eosinophils and basophils are calculated in percentage based on peripheral smear. ELN 2013 Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

19 CML calculation of relative risk online risk calculator bloodref.com Sokal, Hasford and Eutos Score Calculator elérve

20 CML - calculation of relative risk Clinical study calculation Definition of risk groups Sokal et al Exp 0,0116 x (age-43,4) + 0,0345 x (spleen size 7,51) + 0,188 x [(platelet count + 700) 2 0,563] + 0,0887 x (blasts 2,1) Low risk: <0,8 Intermediate risk: 0,8-1,2 High risk:>1,2 Euro Hasford et al ,666, if age >50 ys + (0,042 x spleem) + 1,0956, if platelet count > 1500 G/L + (0,0584 x blast cells) + 0,20399, if basophils >3% + (0,0413 x eosiophils) x 100 Low risk: 780 Közepes kockázat: High risk>:1481 Significance of risk stratification in choice of first line TKI high risk score supports using II. generation TKI in first line treatment. EUTOS Hasford et al Spleen x4 + basophils x 7 Low risk: 87 High risk: >87 Age is measured in years. Spleen size is measured in largest distance from costal arc in centimetres. Blast cells, eosinophils and basophils are calculated in percentage based on peripheral smear. ELN 2013 Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

21 Meanwhile in the lab. Molecular diagnostics

22 Molecular monitoring in CML Fusion gene Fusion transcript Fusion transcript Philadelphia chromosome t(9;22) bcr abl BCR-ABL1 Citogenetics FISH RQ-PCR Flow-citometry

23 Molecular monitoring in CML BCR-ABL1 fusion transcript and ABL1 kinase domain mutations Real Time PCR Direct sequencing BCR (22q11) ABL (9q34)

24 Monitoring of the disease Time (months) International guidelines (Baccarani et al, Blood 2013)

25 Baccarani M, et al. Blood. 2013;122: ELN definitions of hematological and cytogenetic responses are unchanged from prior recommendations 1,2 Response Hematologic CHR Cytogenetic Definition WBC count < /L Basophils < 5% No myelocytes, promyelocytes, myeloblasts in the differential Platelet count < /L Spleen nonpalpable CCyR No Ph+ metaphases PCyR 1%-35% Ph+ metaphases mcyr 36%-65% Ph+ metaphases mincyr 66%-95% Ph+ metaphases None > 95% Ph+ metaphases CCyR, complete cytogenetic response; CHR, complete hematologic response; mcyr, minor cytogenetic response; mincyr, minimal cytogenetic response; PCyR, partial cytogenetic response; WBC, white blood cell. 1. Baccarani M, et al. Blood. 2006;108: ; 2. Baccarani M, et al. J Clin Oncol. 2009;27:

26 Chronic myelogenous leukemia CP CML First line treatment Available first line treatment: Imatinib (Glivec) 1x400 mg Nilotinib (Tasigna) 2x300 mg Dasatinib (Sprycel)1x100 mg (hydroxycarbamide short course cytoreduction; IFN-A if TKIs contraindicated Search for allogenic transplant donor and HLA typing warranted: Related donor: Warning signs at diagnosis (high risk, CCA/Ph+) TKI intolerance Failure of first line TKI treatment MUD search, if no available related donor: Failure of 2nd generation TKI in first line treatment Presence of T315I mutation Accelerated, or blast phase. Allogenic HSCT is mostly recommended for 3rd line of treatment. For indicating allo HSCT additional risk factors are also to be considered (HCT-CI, EMBT) Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

27 Chronic myelogenous leukemia CP CML 2nd line treatment Possible indications for switch therapy: Intolerance to first line treatment Failure of first line treatment (insufficient therapeutic response) Relapse (loss of therapeutic response / progression) BUT: in case of confirmed T315I mutation only effective TKI is ponatinib, allohsct should be considered. Available TKIs: Nilotinib: treatment of choice in case of concurrent heart disease, COPD, hypertension, autoimmune disease, certain mutations (V299L, F317L, Q252H) Dasatinib: treatment of choice in case of concurrent diabetes mellitus, hepatic or pancreatic conditions,, certain mutations (E255K/V,Y253H,F359C/V) IN CASE OF FAILURE OF ABOVE TREATMENT Bosutinib Ponatinib: only efficient treatment with underlying T315I mutation, FDA approved Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

28 Baccarani M, et al. Blood. 2013;122: Evaluating Therapeutic Efficacy ELN recommendations for treatment of patients with CML-CP are made primarily on the basis of efficacy However, it is important to note that many variables, such as safety/tolerability, patient characteristics, and any comorbidities present, influence the choice of treatment Therapeutic efficacy is evaluated on the basis of clinical outcomes (eg, PFS and OS) However, due to the long periods required for evaluation of survival outcomes, early surrogate markers such as molecular and cytogenetic responses are also used to evaluate efficacy Definitions of progression and failure vary across studies; thus, survival data should be interpreted with caution OS, overall survival; PFS, progression-free survival.

29 Deep Molecular Responses The ELN recommends use of MR 4.0 and MR 4.5 when reporting deep molecular responses, and provide standardized definitions for these endpoints 1 They have further recommended use of the term molecularly undetectable leukemia instead of CMR to describe undetectable minimal residual disease 1 This should be accompanied by specification of the number of control gene transcripts present in the sample Accurate descriptions of molecular monitoring assay sensitivity and/or adoption of the international scale will become increasingly important The clinical benefit of achieving deep molecular response, beyond the possibility to attempt treatment-free remission, remains to be established Opportunity to provide data on long-term outcomes in patients with deep molecular response vs MMR or CCyR 1. Baccarani M, et al. Blood. 2013;122:

30 Baccarani M, et al. Blood. 2013;122: ELN 2013 Recommendations: Third-Line Treatment of Patients With CML-CP and Treatment of Patients With the T315I Mutation Recommendation 3rd line Any line Failure of or intolerance to 2 TKIs T315I mutation Treat with any one of the remaining TKIs AlloSCT recommended in all eligible patients Treat with ponatinib HLA type patients and siblings; search for an unrelated stem cell donor; consider allosct For third-line/subsequent therapy, imatinib, nilotinib, dasatinib, bosutinib, or ponatinib can be used Additional therapies with limited availability include radotinib (approved in South Korea) and omacetaxine (approved in the United States) For patients with the T315I mutation, treatment with ponatinib is recommended

31 CML evaluation of response for first line of treatment based on ELN recommendations Time of evaluation (months) Optimal Therapeutic response Failure At diagnosis NA NA 3 6 BCR-ABL 10% Ph+ 35% BCR-ABL<1% Ph+ 0% 12 BCR-ABL 0,1% At any time on treatment Stable or improving tendency No CHR Ph+>95% BCR-ABL>10% Ph+>35% BCR-ABL>1% Ph+>0% Loss of CHR, CCgR, MMolR based on 2 or more measurement, or chromosomal abnormalities or mutations with Ph+ Alarm signs Clonal chormosomal abnormalities or high risk patient BCR-ABL>10% Ph+36-95% BCR-ABL 1-10% Ph+1-35% BCR-ABL 0,1-1% Ph-, but chromosomal changes (del7, 7q-) NA=not applicable; CHR=complete hematological remission; Ph+=Philadelphia positive cells (%); CCgR=complete cytogenetic remission, MMolR=major molecular response: BCR-ABL expression is < 0,1% compared to gene expression of ABL1 Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

32 CML evaluation of response for second line TKIs after failure of first line of treatment based on ELN recommendations Time of evaluation (months) Optimal Therapeutic response Failure Alarm signs Diagnóziskor NA NA No CHR previously on imatinib, loss of CHR, or no acquired CCgR, or high risk patient 3 BCR-ABL1 10% and/or Ph+ 65% No CHR, or Ph+>95%, or New mutations BCR-ABL>10% and/or Ph+36-95% 6 BCR-ABL1<10% and/or Ph+ 35% BCR-ABL>10% and/or Ph+>65% and/or novel mutations Ph+36-65% 12 BCR-ABL<1% and/or Ph+ 0% BCR-ABL>10% and/or Ph+>35% and/or novel mutations BCR-ABL1 1-10% and/or Ph+ 1-35% At any time on treatment BCR-ABL1 0,1% Loss of CHR, CCgR, MMolR based on 2 or more measurement, or chromosomal abnormalities or mutations with Ph+ Ph-, but chromosomal changes (del7, 7q-), or BCR-ABL1>0,1% NA=not applicable; CHR=complete hematological remission; Ph+=Philadelphia positive cells (%); CCgR=complete cytogenetic remission, MMolR=major molecular response: BCR-ABL expression is < 0,1% compared to gene expression of ABL1 Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

33 Molecular monitoring in CML: The workflow % 21,6% Peripheral blood BCR-ABL% ,1 0,01 M351T 5% 1,4% RNA extraction 0, febr nov máj szept. cdna synthesis BCR-ABL1 mutation analysis RQ-PCR Direct sequencing BCR-ABL1 / control gene

34 Meanwhile at the clinic. Case report (2003) Molecular result: Transplant or continuation of the TKI treatment

35 Date WB C X G/l 12/ ,0 Blas t: 25% PLT X G/l Hb g/l , X,Y (1) Citogenetics FISH Quant. RT- PCR 46, XY t(9,22)( 29) 02/2003 4, , X,Y (24) 46, XY t(9,22)( 6) % bcr/abl+ 05/2003 4, negative - CML score: 4277 (high risk.) 32 BM.hypoplasia 08/2003 4, negative 11/2003 4, ,75 04/2006 4,6 normal No Phil negative 11/2013 4, ,0000

36 Meanwhile at the clinic. Case report ( ) Molecular result: 100 E.T. male patient BCE-ABL1 levels (%) ,1 0,01 0,001 Transplant or continuation of the TKI treatment

37

38 Failure of the TKI therapy

39 Imatinib resistance Philadelphia chromosome t(9;22) translocation BCR-ABL1 fusion gene B. Druker STI 571 Imatinib (Glivec) m

40 Imatinib resistance: Personalised therapy The main resistance mechanism: ABL1 KD mutations 2G-TKIs BCR-ABL Imatinib BCR-ABL Dasatinib BCR-ABL Nilotinib

41 BCR-ABL% BCR-ABL% Therapy modification based on the mutation status ,1 0,01 130% 21,6% 5% 1,4% 64% Nilotinib 0,9% 0,12% 0,09% ~ MMolR ,1 0,01 57,55% 15,7% 48% 15% 82% Nilotinib 1,3% 1,6% 2,4% 0, febr nov máj szept ápr febr ápr aug. 0, jan jún okt febr júl márc máj szept.

42 Therapy switch based on mutation status and clinical data CML patient (chronic phase) IGEN No CHR (3 months) No MinCyR (6 months) No MCyR (12 months) No CCyR (18 months) Loss of response (any time) Any level of cytogenetic response NEM IM dose escalation Switch to 2nd gen TKI Failure of therapy Switch to 2nd gen TKI Mutation analysis No mutation F317L V299L Q252H E255K/V Y253H F359C/V T315I Nilotinib Dasatinib Transplantation Clinical study Otherwise well Young!! Hypertension Pulmonary disease COPD Severe diabetes Pancreatitis ponatinib???? Nilotinib Dasatinib

43 BCR-ABL% Malepatient, CML 65-years-old on diagnosis Imatinib intolerance 177% 146% 22% Dasatinib 140 mg 100 mg 50 mg 70 mg 100 mg ,8% 2,5% 0,1 0,01 0,09% 0,06% 0% 0,05% 0,1% 0,002% 0,04% 0,1% 0,06% 0,1% 0,04% 0,006% 0,006% 0,05% 0,07% 0,08% 0, febr aug jan jún nov jan márc ápr ápr/ máj jún szept okt nov dec jan márc máj jún júl okt.

44 Proposed schema for individualizing therapy based on comorbidities, goals of therapy, and disease risk profile. Hughes T, and White D Hematology 2013;2013: by American Society of Hematology

45 Second generation TKIs as first line treatment ENESTnd - 4 years of follow-up CCyR MMR MR 4.5 Imatinib 1x400 mg 65% 56% 23% Nilotinib 2x300 mg 80 % 76% 40% Nilotinib 2x400 mg NA 73% 37% DASISION 3 years of follow-up CCyR MMR MR 4.5 Imatinib 1x400 mg 77% 55% 12% Dasatinib 1x100 mg 82% 69% 22% BELA 24 months of follow-up 3 Cumulative CCyR MMR4 Imatinib 1x400 mg 80% 41% Bosutinib 1x500 mg 79% 47% 1: Hughes TP et al.: Early molecular response predicts outcomes in patients with chronic myeloid leukemia in chronic phase treated with frontline nilotinib or imatinib. Blood 2014; 123: : Jabbour E et al.: Early response with dasatinib or imatinib in chronic myeloid leukemia: 3-year follow-up from a randomized phase 3 trial (DASISION). Blood, 2014; 123: : Brümmendorf JH et al.: Bosutinib versus imatinib in newly diagnosed chronic-phase chronic myeloid leukaemia: results from the 24-month follow-up of the BELA trial. Brit J Hematol. 2015; 168:69-81

46 CML alternative treatment beside 1st and 2nd line TKIs 3rd generation TKIs: Bosutinib: applicable in case of resistance to 1st and 2nd line TKIs. Ponatinib: FDA approval as first line treatment. In the presence of T315I mutation leading to resistance against other TKIs this agent constitutes the only effective TKI treatment. Expedited FDA approval in november 2012, but FDA later released black box warning due to high rates of arterial and venous thromboembolic events (9-27% - EPIC study), indication was thus limited to T315I positive cases and to disease refractory to all other TKIs Radotinib: TKI applied in South Korea. Resistant chronic / accelerated phase CML: Ometaxin-succynate: FDA-approved, non-tki subcutaneous agent Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

47 Baccarani M, et al. Blood. 2013;122: Treatment Discontinuation Current ELN recommendations are that patients with CML with optimal response to treatment continue indefinitely at the standard recommended dose Clinical data available to date on discontinuation of TKI therapy are insufficient to make recommendations on discontinuing treatment outside well-designed, prospective, controlled clinical studies In special situations, such as for women who are pregnant or planning to become pregnant, discontinuation of therapy after achievement of an optimal response may be considered outside clinical trials on an individual basis if close, proper, high-quality, certified monitoring is performed

48 Treatment-Free Remission (TFR) Discontinuation of TKI therapy is not recommended outside of a clinical trial 1,2 However, the ELN recommendations include the possibility to consider discontinuation in individual patients with sustained, deep molecular response if rigorous molecular monitoring can be assured 1 Nilotinib is a valuable treatment option for patients and physicians whose ultimate goal is TFR Frontline nilotinib affords higher rates of MR 4.0 and MR 4.5 vs imatinib 3 Switch to nilotinib enables achievement of deep molecular response in many patients without such responses on long-term imatinib 4 Ongoing nilotinib TFR studies will provide many nilotinib-treated patients the opportunity to attempt TFR Data produced in these studies may help guide future recommendations on discontinuation of TKI therapy 1. Baccarani M, et al. Blood. 2013;122: NCCN Clinical Practice Guidelines in Oncology. Chronic Myelogenous Leukemia. Version Hochhaus A, et al. Haematologica. 2013; (s1): [abstract P712]. 4. Spector N, et al. J Clin Oncol. 2013s; [abstract 7053].

49 Treatment strategies in AP or BP CML AP and BP in newly diagnosed, TKI-naïve patients AP and BP evolving beside TKI treatment as progression from CP. Imatinib 400 mg BID Dasatinib 140 mg QD, or Nilotinib 700 mg BID. Search for stem cell donor AlloHSCT is recommended for all BP patients and AP patients who fail to achieve optimal response. Chemotherapy may be necessary to achieve remission before allohsct. Any TKI that was not used prior to progression (ponatinib in the presence of T315I mutation), then allohsct Chermotherapy is often required before allohsct. Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

50 Further considerations for treating AP and BP CML AP in TKI naïve patiens is a condition similar to high-risk BP, thus treatment should be based on 2nd generation TKIs. Patients developing progression to AP/BP on TKI treatment expected response to further treatment is poor, thus all patients eligible should undergo allohsct. Cytotoxic chemotherapy is often required beside TKI treatment to achieve remission In case of ucontrollable, resistant BP allohsct is not recommended. Baccarani M et al.: European LeukemiaNet recommendations for the management of chronic myeloid leukemia: Blood. 2013;122(6):

51 Myeloproliferative Neoplasms (MPN) - Genetics?

52 The evolving landscape of Ph- MPNs (2016) Ph. kr. JAK2 V617F JAK2 e 12 MPL CALR

53 CALRETICULIN mutations in ET and PMF (2013)

54 CALRETICULIN mutations in ET and PMF (2013) Younger male patients ET: lower Hb, lower wbc, MF: lower wbc, Lower risk of thrombosis Longer survival

55 PV, ET és MF - Clinical factors PV pancytosis, dominant polyglobulia splenomegalia aquagenic pruritus thrombotic risk increased ET platelet counts above 450 G/L Arterial thrombotic risk and bleeding tendencies Myelofibrosis (MF)

56 Polycythaemia vera WHO diagnostic criteria (2008) Presence of both major or presence of first major and two minor criteria is required Major criteria: 1. Hb>185 g/l (male), or Hb>165 g/l (female) 2. Presence of JAK v617f, or JAK exon 12 mutation Minor criteria: 1. Trilinear proliferation in bone marrow 2. Serum EPO level below normal 3. Endogenous erythroid colony formation Incidence: ca. 2/100 thousand population/years Life expectancy on adequate treatment: ca. 15 years from diagnosis Tefferi A et al.: Proposals and rationale for revision of the WHO diagnostic criteria for PV, ET, and PMF: Recommendations from an ad hoc international expert panel. Blood 2007;110:

57 Polycythaemia vera differential diagnosis 1. Relative polyglobulia-pseudopolyglobulia total red cell mass determination ( 51 Cr 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 )

58 The aim of treatment is patient care, directed at normalization of cell numbers and prevention of complication. The Hct shlould be kept below 0,45 First line treatment: phlebotomy Repeated removal of 300 ml blood volume Replacement with physiologic saline infusion Keep hematocrit values below 0,45

59 Polycythaemia vera reasons for additional treatment other than 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

60 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

61 TREATMENT OPTIONS OF THE PAST YEARS Busulphan treatment: alkylating agent, not used because association with increased transformation to acute leukemia Radiophosphorus: ß-emitting 32-phosphorus, excellent for old or non-compliance patients

62 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)

63 Summary: Polycythaemia vera prognosis: the overall survival in treated patients is years, in untreated patients only two years. Potential side effects: Phlebotomy: volume deficit volume replacement + hydration!!!! iron-deficiency

64 Side effect of myelosuppressive treatment: bone marrow depression Secondary leukemia? Side effects of IFN treatment: bone marrow depression, influenza-like symptoms (fever, headache), tiredness, skin eruptions, depression but not leukemogenic!!!

65 MYELOFIBROSIS hepatosplenomegaly

66 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

67 Myelofibrosis: peripheral smear

68 Myelofibrosis, peripheral smear : leukoerythroblastic blood picture

69 Myelofibrosis : bone marrow fibrosis (bone marrow biopsy)

70 MYELOFIBROSIS :clinical signs Prognosis: in case of chromosomal aberrations 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

71 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,

72 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 high-risk myelofibrosis, which represents 80% to 90% of all patients with myelofibrosis.

73 Essential thrombocythaemia

74 Essentialis thrombocythaemia: ET Chr. myeloproliferative disorder characterized by thrombocytosis. Bone marrow: the number of megakaryocytes is increased arterial thrombophilia + Significant tendency for bleeding

75 Essential thrombocytemia WHO diagnostic criteria (2008) Fulfilment of all 4 criteria is required: 1.Platelet count > 450 G/L 2.Megakaryocytr proliferation with enlarged megakaryocytes showing normal maturation 3. Does NOT meet WHO criteria for CML, PV, PMF, MDS or other myeloid disease 4. Presence of JAK V617F or other clonal marker, OR No evidence for reactive thrombocytosis Tefferi A et al.: Proposals and rationale for revision of the WHO diagnostic criteria for PV, ET, and PMF: Recommendations from an ad hoc international expert panel. Blood 2007;110:

76 ET: increased number of megakaryocytes in bone marrow

77 Essential thrombocythaemia: bone marrow histology increased number of megakaryocytes

78 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

79

80 2011.

81 Hydroxyurea induced leg ulcer at diagnosis 8 weeks after omission of HU

82

83 Treatment of essential thrombocythaemia In case of emergency: Platelet-pheresis Permanent cytoreduction A. Cytostatic drugs: hydroxyurea (Litalir) Daily dose: 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

84 Essential thrombocythaemia Change of platelet count during interferon-alfa treatment Lehoczky D. MBA 1996; 49:

85 Essential thrombocythaemia 31 year old woman change of platelet count during r- interferon-alfa treatment Pregnancy Lehoczky D. MBA 1996; 49:

86 Essential thrombocythaemia 47 year old man change of platelet count during r-interferonalpha treatment (weekly -1x 3 ME) Lehoczky D. MBA 1996; 49:

87 Treatment of essential thrombocythaemia Anagrelide: quinazolin derivative reduces the number of platelets in a dose depedent manner with a parallel inhibition of platelet aggregation Not mutagenic, not leukemogenic. 84% of cases well-tolerated 16% of cases intolerable side effect (Thromboreductin [AOP], 0.5 mg tablets)

88 Platelet aggregation inhibitors the platelet count should be reduced previously Contraindicated in case of bleeding in the medical history prophylaxis: mg/die acetylsalicilic acid if the platelet count is between 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)

89 Thank you for your attention!