Intro. We rarely speak about MPNs, as about old fashioned, classic, boring and well known topic? Or just have not enough experience on that?

Transcription

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2 Intro We rarely speak about MPNs, as about old fashioned, classic, boring and well known topic? Or just have not enough experience on that?

3 Normal BM

4 Contents BM biopsy algorithmic approach WHO basics: ET/PV/MF trio Fibrosis Grey zones about MPNs MPN+ smth else (NHL) Techno remarks Future directions

5 WHO 2008: MPNs Chronic myelogenous leukaemia (CML), BCR-ABL 1 positive Chronic neutrophilic leukaemia Polycythaemia vera (PV) Primary myelofibrosis (PMF) Essential thrombocythaemia (ET) Chronic eosinophilic leukaemia (CEL), NOS Mastocytosis Myeloproliferative neoplasm, unclassifiable

6 VPC 2011 LIGA ATVEJŲ SKAIČIUS Esencinė trombocitemija 54 Idiopatinė mielofibrozė 43 Akceleracijos fazė 1 Fibrozinė fazė 33 Ląstelinga fazė 9 Lėtinė mieloleukemija 27 Akceleracijos fazė 2 Blastinė transformacija 1 Lėtinė fazė 22 Nenurodyta 2 Lėtinė mielomonocitinė leukemija 14 CMML1 13 Nenurodyta 1 Mišrus MPD/MDS NOS 7 RARS-T 3 Nenurodyta 4 MPN, NOS 5 acml 1 Nenurodyta 4 Tikroji policitemija 4 Fibrozinė fazė 4 VISO:

7 BM: algorithmic approach Cellularity (hemato/lipo area %); Architecture (diffuse); Fibrosis; Megakariocytes; Erythron; Blast count; Clinical check-out 1 (outpatient); Clinical check-out 2 (inpatient): flow, molecs; Reevaluation and cross-check; Final signout.

8 1. Cellularity by age HIGH? YES: MPN vs REACTIVE; NO: A) normal: NO MPN (rare exceptions) vs OTHER; B) Low: NO MPN, OTHER.

9 2. Architecture effaced/diffuse? YES: MPN: MF vs MPD/MDS vs MDS/AML vs reactive? NO: MPN: ET, CML > PV vs reactive.

10 BM: ET

11 B yrs old female; Clin.: MPN; 2005 eyeball lesion; blood: WBC (*10e9/l) 17.2, RBC (*10e12/l) 4.1, Hb (g/l) - 132, Plt (*10e9/l) 715; 2012 February: LDH (U/L) 302; WBC (*10e9/l) 17,18; RBC (*10e12/l) 4,56; HgB (g/l) 132; Plt (*10e9/l) 1363; 2012 February: BM biopsy;

12 B NASDE

13 Cellularity: 60% (N) M/E 4-5/1 (N); Architecture intact (N); Large megas with hyperlobation, loose and coarse clustering 20/HPF ( ); NO fibrosis (MF-0); JAK2 (-); 2012 February: BM biopsy: ET, MF-0. B

14 ET

15 3.Fibrosis (European consensus) YES: MPN: PMF > PV vs other (MDS/AML); NO: ET vs reactive. Grading Description* Scattered linear reticulin with no intersections (cross-overs), MF - 0 corresponding to normal bone marrow Loose network of reticulin with many intersections, especially in MF - 1 perivascular areas Diffuse and dense increase in reticulin with extensive intersections, occasionally with only focal bundles of collagen and/or focal MF - 2 osteosclerosis Diffuse and dense increase in reticulin with extensive intersections with coarse bundles of collagen, often associated with significant MF - 3 osteosclerosis *Fiber density should be assessed in hematopoietic (cellular) areas.

16 B MPN NOS: MF-0 Post PV: MF-2 CMML1 MF-1 B Post PV: MF-3

17 4. Megakaryocytes large and clustered? YES: MPN: A) Coarse/ tight clusters + dysplastic large: PMF > PV; B) Loose clusters: ET > PV; NO: A) normal: REACTIVE; B) Small dysplastic: MDS, CML.

18 Mega s hall of fame LT B MDS 5q-: small/medium, hypolobated B PMF: more dysplastic and bizarre B PV: large hyperlobated B ET: large hyperlobated

19 PMF

20 Prefibrotic/ cellular phase; Fibrotic phase; Transformation/ AML. PMF

21 B yrs old female; Treated for breast ca; 2012 March: blood: WBC 6,44 (*10e9/l); RBC (*10e12/l) 4,75; Hb 127; Plt (*10e9/l) 505; Splenomegaly; Clin.: PMF; 2012 March BM biopsy;

22 B NASDE

23 B GSPS

24 Cellularity: 20-80% ( ); M/E 3/1 ( ); Diffuse and disrupted architecture; Medium-large bizarre megas with hyperlobation, dysplasia and coarse clustering 22/HPF ( ); MF-2/3; Dilated sinusoids with intrasinusoidal hematopoiesis; Molecs? 2012 March BM biopsy (B ): PMF (MF 3). B

25 B yrs female; 2011 June; Splenomegaly. Tumor? Macro: spleen 19x14x5,5 cm, bright and dark brown coloured motley nodule 6x5,8x4 cm; Blood: unknown;

26 B Spleen Glycophorin C Tumor

27 B vwf

28 B

29 B NASDE GSPS

30 B yrs old female; Post splenectomy 3 months; 2011 September: BM biopsy B : PMF (MF-3); JAK2 V617F (-); Blood: LDH 883 U/l (N= ); WBC (*10e9/l) 16,47 (N= ); RBC (*10e12/l) 3,579 (N= (M); (F)); Plt (*10e9/l) 1368 (N= ) Therapy: Hydrea 2012 February: Blood: WBC (*10e9/l) 6,82; RBC (*10e12/l) 2,83; Plt (*10e9/l) 794.

31 Extramedullary proliferations Localisations: Spleen; Liver; Lymph nodes; Other: CNS, epidural space, ovary, skin, testis, soft tissue, synovium, kidney, lung/pleura, stomach, heart. Forms: Interstitial; Mass/tumor forming; +/- sclerosis; Trilineage, unilineage. Predisposition: PMF, PV; Fetal EMH; TTP, immunodeficiency, HUS, transplantation

32 YES- MPN PV vs reactive; NO: A) normal: ET vs reactive; B) Depressed: CML. 5. Erythron expanded?

33 BM: PV

34 PV Prepolycytemic phase (ET like); Polycythemic phase; Postpolycythe mic/spent phase (post PV MF); Progression Transformation / AML

35 B yrs old female; 2012 January: BM biopsy (B ); Clin.: MPN PV from 2009; Hydrea; Blood 2008 February: WBC (*10e9/l) 3.460; RBC (*10e12/l) 6.123; Hb (g/l) ; Plt (*10e9/l) ; 2011 September: CNS infarction; 2012 February: blood: WBC (*10e9/l) 3,44; RBC (*10e12/l) 5,93; HgB (g/l) 133,0; Plt (*10e9/l) 1277.

36 B NASDE

37 Architecture: slightly effaced; M/E 3/1 ( ); Eryhtro: expanded, diffuse; Megas: large, hyperlobated and pleomorphic (dysplastic), clustered ( ); Fe(-); 2012 January: BM biopsy (B ): MPN PV, MF-0; Molecs: JAK2+. B

38 Acceleration/progression/ transformation Almost uniform model of understanding of MPNs (except ET); Acceleration/phase= blast count <20% (CML); Transformation (blastic phase) = AML (PMF >PV); Progression: A) Evolution of fibrosis; B) Progression/ Transdifferentiation = cell line change (PV- acml/cnl; PV- CMML; etc.).

39 5. Blast count elevated (CD34)? YES: MPN acceleration vs MPN/MPD vs MDS/AML; NO: MPN vs oth.

40 B yrs old male; Post PV MF-2: blastic phase, blasts 15%; PV for 12 yrs: Hydrea/aphereses. Blood: WBC (*10e9/l ) 15,0; Blasts-13 %; RBC (*10e12/l) 2,5; Hb 96 g/l; Plt (*10e9/l) 184. BM aspirate: blasts-21%; 2012 March: BM biopsy (B ): PV, MF-3 B

41 B CD34 GSPS

42 MPN training set CML: granulopoiesis, erythropoiesis, small dysplastic megas ; ET: normal BM+ large hyperlobated staghorn loosely clustering megas + no fibrosis; PV: granulopoiesis, erythropoiesis, large hyperlobated/dysplastic tightly clustering megas, Fe (-); MPF: fibrosis+ architectural disruption + large hyperlobated/dysplastic tightly clustering megas.

43 B yrs old female; 2012 February: BM biopsy (B ); Clin.: CML? Blood: WBC (*10e9/l) 25,42; NEU (%) 64,9; RBC (*10e12/l) 4,73; HgB (g/l) 135; Plt (*10e9/l) 542; LDH (U/L) 386.

44 B NASDE

45 Architecture: retained; M/E >7-8/1 ( ); Erythro: depressed; Megas: small, hypolobated (dysplastic) ( ); Molecs: Bcr Abl1 (p210 b3a2)+ 100%; 2012 February: BM biopsy (B ): CML, chronic phase; MF-0; NASDE

46 MPN: DX Acute megakaryoblastic leukaemia Acute panmyelosis with myelofibrosis/ AML with fibrosis MDS with fibrosis CML with fibrosis MDS/MPN: CMML Myelodysplastic/ myeloproliferative neoplasm (MDS/MPN), unclassifiable: Refractory anaemia with ring sideroblasts, associated with marked thrombocytosis Reactive changes/ hyperplasias Mts (fibrosis) Miscelaneous

47 MPN differential training set MDS: architectural disruption, hyper/normo/hypocellular, ALIP, granulopoiesis, erythropoiesis, small dysplastic megas +/- fibrosis, CD34 blast count, Fe+; CMML: CML+ monocytoid clusters+/- PDC clusters; RARS-T: MDS+ ET like megas; AML: CD34+ blast count + molecs+/-fibrosis; CEL: CML+ Eosinophilia; PDGFRA/B, FGFRA associated MPN: CML or CMML+ Eosinophilia +/- LBL/oth.

48 B yrs old female; 2012 February: BM biopsy (B ); Clin.: AML: B symptoms; Hepatomegaly; Hypoechogenic nodules in the spleen/liver; Blood: Blasts (%) - 48,7, WBC (*10e9/l) - 11,19, RBC (*10e12/l) - 1,58, Hb (g/l) - 46, Plt (*10e9/l) 327; PB flow: 36% small blasts: CD45+dim, CD33+het, CD34+, CD117+, HLA-DR+, CD38+, CD99+het, CD7+het, cmpo(-): Undifferentiated vs AML; Molecs: Bcr-Abl1(-); Main AML mutations (-);

49 B NASDE GSPS

50 B yrs old female; 2012 February: BM biopsy (B ): AML, M7, MF-3; 2012 April: AWD. B

51 B yrs old female; Clin.: PMF; Weakness; Blood: WBC-44,5; Blasts 1%; MON-15 %; Hb-122g/l; RBC 5,04; Plt 195; 2010 April: BM biopsy (B ): CMML 1; B

52 B CD68

53 MPN NOS and smth else MPN, NOS- not enough criteria for definite categorisation; Another tumor influence on MPN; Often MPN, NOS due to architectural changes; Incidental findings; CCL, MCL, MM, oth. (risk in MPN ).

54 B yrs old male; 2012 March: BM biopsy (B ); Clin.: Myeloma? Blood: WBC (*10e9/l) 6,39; RBC (*10e12/l) 3,84; Hb (g/l) 121; Plt (*10e9/l) 311; Ig gama (%) 30,7% (N=11-19); LDH (U/L) 170; Ig M (g/l) (N(male)= ); B2 microglob (mg/l) 4.27 (N=0,97-2,64).

55 B NASDE

56 B CD138 GSPS CD34

57 B yrs old male; Flow: Aberrant plasma cells: CD38+ CD138+ CD45(+dim) CD19(-) CD5(+); Other plasma cells: CD38+ CD138+ CD45(+) CD19(+) CD56(-) CD20(-) 1,25 10/-3 (0,125%) kappa : lambda = 4 :1; CD38+ CD138+ CD45(+) CD19(-) CD56(-) CD20(-) 3,9 10/-4 (0,039%) kappa : lambda = 6,6 : 1; 2012 March: BM biopsy (B ): A. Myeloma vs LPL, 20%: CD138/Ig Kappa/IgM+, CD117+, IgD/CD20/CyclinD1(-); B. MPN NOS. MF-1. Molecs: JAK2 V617F+.

58 Therapy influence on MPNs Blured prefibrotic picture; Dysplastic changes on megas: Hydrea, Busulfan (not Anagrelid); Other: serous degeneration.

59 TECHNO REMARKS Mr. Anonymous: 0,4 cm Mr. Andrew

60 Ugly threpine: B ! GSPS: at least MF-1? Megas: clustering? NASDE: M/E and architecture intact Megas: hyperlobated

61 Ugly threpine: B ! 51 yrs old female; JAK2 V617F mutated; Clin.: ET from 1996 (!), under Hydrea from 1996; MI in 1996; 2012 February: blood: LDH (U/L) 263; WBC (*10e9/l) 8,09; RBC (*10e12/l) 5,56; Hb (g/l) 160; Plt (*10e9/l) 627.

62 ET (ET for ~15 yrs)? Mr. Anonymous: 0,4 cm Mr. Andrew

63 FUTURE DIRECTIONS: STUDIES Every PMN diagnosis must be approved! Clinical info is more, than essential; Threpine biopsy is MARROW biopsy! MF stage is rarely informative: post PV? Post CML? Primary? Red zones: PMF (Cellular phase, MF-0); Early PV (prepolycythemic); Yellow zones: MDS-F, AML-F (acute myelosis/ panmyelosis/m7, etc.), MDS-MPNs Green zones: reactive states, post-therapy changes; Grey zones always exist, especially when data absent!

64 Basics: 1. Swerdlow S. H., C.E., Harris N.L., Jaffe E.S., Pileri S.A., Stein H., Thiele J., Vardiman J.W. (eds.), WHO classification of tumours of haematopoietic and lymphoid tissues. WHO classification of tumours. 2008, IARC: Lyon. 2. A. Orazi, D. P. O Malley, D. A. Arber, Illustrated pathology of the bone marrow, Cambridge University Press, B. J. Bain, D. M. Clark, B. S. Wilkins, Bone marrow pathology, 4th Edition, Wiley-Blackwell, A. Porwit, J. McCullough, W.N. Erber, Blood and bone Marrow pathology, Elsevier, A. Orazi, D. A. Arber, USCAP short course Modern approach to the diagnosis and classification of myeloid neoplasms, Vancouver, Canada, 2012.

65 Readings: 5. Buhr T, Hebeda K, Kaloutsi V, Porwit A, Van der Walt J, Kreipe H. European Bone Marrow Working Group trial on reproducibility of World Health Organization criteria to discriminate essential thrombocythemia from prefibrotic primary myelofibrosis. Haematologica Mar;97(3): Thiele J, Kvasnicka HM, Facchetti F, Franco V, van der Walt J, Orazi A. European consensus on grading bone marrow fibrosis and assessment of cellularity. Haematologica Aug;90(8): O'Malley DP. Benign extramedullary myeloid proliferations. Mod Pathol Apr;20(4):

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