Mr Matthew Eby. Dr Humphrey Pullon

Transcription

1 Dr Humphrey Pullon Haematologist Hamilton Mr Matthew Eby Senior Support Services Coordinator Leukaemia & Blood Cancer Foundation New Zealand Hamilton 16:30-17:25 WS #64: Managing Haemopoetic Disease in the Community 17:35-18:30 WS #76: Managing Haemopoetic Disease in the Community (Repeated)

2 Dr. Humphrey Pullon Haematologist, Waikato Hospital Mr. Matthew Eby Midlands Region Senior Support Services Coordinator, Leukaemia and Blood Cancer New Zealand

3 Managing Haematopoietic Disease in the Community Hyperferritinaemia MGUS Myeloma CML CLL MPNs PRV/ET/MF NHL/HL Acute Leukaemia Late Effects Psycho-social support

4 ULN is ug/l Hyperferritinaemia Given that Ferritin is an acute phase reactant, only really need to be concerned if the Ferritin is >600ug/L. Always look at the iron studies too a high Ferritin WITH a high iron saturation is much more suspicious of underlying haemochromatosis Genetic testing for the HFe gene is readily available typically test for the C282Y, H63D and S65C mutations Genetic carriers amongst Caucasians are common 1 in 200 To be genetically at risk for Hereditary Haemochromatosis, one must be homozygous or a double heterozygote

5 Hyperferritinaemia Treatment of haemochromatosis involves: Venesection/Phlebotomy 450mls per time Do an abdominal ultrasound if the presenting Ferritin is > 1000ug/L. Aim to reduce the Ferritin down to 50ug/L Must avoid over-venesection watch the Hb level Maintenance venesection: Target ug/L Genetic Testing of all 1 st degree relatives is a must Use LBC resources, especially the venesection diary If the HFe genetic test result does not suggest haemochromatosis, there is usually NO NEED to venesect those patients!!

6 Hyperferritinaemia Causes of non-haemochromatosis hyperferritinaemia : Steatohepatitis/NASH/Fatty Liver Chronic viral hepatitis Auto-immune hepatitis Alcoholic liver disease Active chronic inflammation Multi-transfused patients Must enquire about risk factors : Alcohol intake, calculate the BMI, Exercise/Activity? Check: LFTs, Viral hepatitis markers, HbA1c, Lipids Arrange an Abdominal Ultrasound scan liver echotexture Please DO NOT REFER TO HAEMATOLOGY!!

7 Monoclonal Gammopathy (MGUS) Monoclonal Gammopathy of Uncertain Significance (MGUS) a very common, pre-malignant condition Paraproteinaemia without skeletal destruction, marrow infiltration or renal damage (cf. multiple myeloma) Diagnosis often made incidentally (by its very nature) The risk of progression to myeloma is 1 % per year, but is higher if: Paraprotein >15 g/l Non-IgG paraprotein Associated immunoparesis High B2microglobulin Abnormal serum free light chain ratio

8 Monoclonal Gammopathy (MGUS) Four to Six-monthly: Full blood count Corrected calcium Serum free light chains Renal function Protein electrophoresis Immunoglobulin levels Refer to Haematologist if: Anaemia Hb <100 g/l Corrected Calcium > 2.70 mmol/l Creatinine > 120 umol/l (no other known cause) Serum free light chain ratio >100:1 or level >400mg/L New skeletal pain, especially if lytic lesions on imaging

9 Myeloma Always do a bone marrow examination Plasma cell quantitation, especially on the trephine biopsy BM Cytogenetics and FISH testing is of prognostic importance Imaging Now use either CT or MRI to look very hard for occult bony lytic lesions Renal function Look at SFLC levels as a predictor of LC nephropathy Hypercalcaemia IV bisphosphonates have transformed the management

10 Myeloma Newer drugs have improved the treatment outcome considerably Cyclophosphamide.Melphalan Bortezomib/Velcade + Dexamethasone Thalidomide.Lenalidomide.Pomalidomide Carfilzomib.oral PI s Maintenance treatment Mel 200 ASCT Now standard for most patients younger than yrs Bony disease Now managed effectively with regular bisphosphonates Median survival is now in excess of 7 years

11 Chronic Myeloid Leukaemia (CML)

12 Chronic Myeloid Leukaemia Tyrosine Kinase Inhibitor (TKI) drugs are now extremely effective at controlling chronic phase disease Imatinib, Dasatinib, Nilotinib Not without side effects Rash, G/I, pleural effusions, arterial disease Regular monitoring, measuring the bcr/abl transcript level by q pcr is important Survival is now markedly improved Some studies show that after a prolonged period of very effective therapy, about 50% of patients can successfully discontinue TKI therapy

13 Chronic Lymphocytic Leukaemia (CLL) Often found incidentally on a routine full blood count, showing a lymphocytosis (lymphocyte count >5.0 x 10 9 /L), often with smear/smudge cells. Diagnosis is usually made by immunoflow cytometry Annual estimated incidence of 3-4 per 100,000 (roughly 120 new cases in NZ per year), typically >60 years Indolent disease, only requiring treatment in advanced stages Does result in compromised immunity Indications for referral to a haematologist: - progressive anaemia or thrombocytopenia - lymphocyte doubling time < 6 months - bulky lymphadenopathy or splenomegaly (> 4 cm below costal margin) - systemic symptoms fever, night sweats, weight loss > 10%

14 Early stage CLL in General Practice A patient with: Hb>100g/L, Lymphocyte count <30 x 10 9 /L and no lymphadenopathy has: - an 80% chance of still being alive in 10 years time - only has a 15% chance of (ever) requiring active treatment G.P. Management: - Six-monthly full blood counts - Annual influenza vaccination - Five-yearly Pneumococcal vaccination - Regular skin surveillance, with sun protection ++ - Optimization of other medical problems - Always looking out for any signs of other malignancies

15 Chronic Lymphocytic Leukaemia (CLL) The identification of poorer risk sub-groups of CLL has improved outcomes Chemotherapy treatment, usually in combination with an anti-cd20 immunotherapy (Rituximab or Obinutuzumab) is quite effective for most patients. Newer oral targeted therapies, such as Ibrutinib are now starting to become available IV Immunoglobulin replacement therapy is important for those with severe secondary hypogammaglobulinaemia Allogeneic BMT still has a role in the treatment of younger patients Overall, the prognosis for CLL patients requiring treatment is improving

16 Myeloproliferative Neoplasms (MPNs) Jack too or Jak-2?

17 Jak-2 mutation (V617F) Discovered by 4 different groups in 2005 Is a hallmark of myeloproliferative disorders If present, it reflects an abnormal clonal process, developing as a primary event within the BM Frequency of Jak-2 Mutation PRV 95% ET 55% MF 50%

18 Other genetic mutations in MPNs Other Jak-2 mutations in Exon 12 Can be found in some cases of PRV that are negative for the V617F Jak-2 mutant Calreticulin Found in approximately 35% of patients with ET Mutually exclusive of Jak-2 (V617F) Has a lower risk of thrombosis cf. Jak-2 +ve ET Mpl mutation Accounts for approximately 10% of cases of ET

19 PRV ET Treatment of MPNs Aspirin; Venesection; Hydroxyurea Aspirin; Hydroxyurea in some; SC Alpha interferon in pregnancy MF Hydroxyurea if still proliferative Splenectomy Jak-2 inhibitors Ruxolitinib Allogeneic BMT

20 Non-Hodgkin s Lymphoma Increasing incidence now the 6 th most common cancer in NZ Data from NZ Ministry of Health

21 Survival in NHL is improving

22 An increasing number of lymphoma patients are either cured or have prolonged disease-free survival Hodgkin s Lymphoma Cure rates now in excess of 85% - dependent on stage Aggressive NHL Cure rates of 60-70%, but lower in the elderly Low grade NHL Most patients achieve a prolonged CR1 Mantle Cell NHL is still difficult to treat Better drugs and better supportive care Rituximab, Bendamustine, Ibrutinib, G-CSF

23 Acute Leukaemia (ALL & AML) Still a very serious disease, requiring treatment with intensive chemotherapy, and prolonged hospital stay The outcomes of treating Children with ALL are now very good, with >80% cure rates Treatment in adults is less effective, with dismal outcomes in the elderly (>70 years) Long-term survival (UK data) Age % Age % Age >64 5%

24 Late effects of treating blood cancers Source: Inamoto and Lee. Haematologica April :

25 Survivorship - an emerging concept amongst those previously treated for blood cancers Survival has continued to improve since the 1980 s Less acute chemotherapy- related toxicities More targeted therapy More maintenance therapy, which is often oral Late effects of previous treatment are more recognized, with an ever-present risk of secondary malignancies It is estimated that over 21,000 New Zealanders are now either living with, or have had a previous haematological malignancy There is an increasing role for General Practitioners in the management of this group of patients

26 Health issues for the survivor Disease relapse Probably the biggest fear for most patients and their whanau The time from the completion of treatment without recurrence is of the greatest reassurance Must emphasise making the most of time in remission - friends, family, and the bucket list If relapse occurs, there are often effective treatment options so re-refer promptly, and see what may be possible Treatment-related toxicities Often takes months, or even years to fully recover Encourage participation in support groups Encourage increasing physical exercise Encourage return to paid work, if possible Don t be shy asking about sexual function refer for assistance if necessary

27 Second Cancers Will occur in 4 10% of the survivors of blood cancers In some cases this will include secondary myelodysplasia and AML May be related to prior chemo and radiotherapy (not always) Historically was more common in the curative malignancies (e.g. Hodgkin lymphoma), but not necessarily nowadays Future risk is lower with contemporary treatment, however the risk rises exponentially with the number of lines of treatment Autologous or Allogeneic BMT has a significantly higher risk Risk modification stop smoking, avoid alcohol excess, normalize the BMI, encourage regular exercise, have regular skin checks Participation in national screening programmes (breast, cervical, colorectal)

28 Psychological Aspects Survivor guilt Relapse anxiety (and increased overall health anxiety) Post-traumatic stress disorder Sexual and relationship dysfunction Delayed or impaired psychosocial development (particularly in adolescents/young adults) Support Services for patients are available from Leukaemia & Blood Cancer New Zealand

29 Thank you, and over to Matt