Clinical Perspective The Hematologist s View

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1 SPLANCHNIC VEIN THROMBOSIS. TYPICAL OR ATYPICAL MPN? Giovanni Barosi Unit of Clinical Epidemiology/Center ofr the Study of Myelofibrosis. IRCCS Policlinico S. Matteo Foundation, Pavia Lisbon, 4-5 May 2012 Clinical Perspective The Hematologist s View 1

2 An atypical myeloproliferative disorder with high thrombotic risk and slow disease progression (G. Barosi et al, Cancer 1991;68:2310) The records of all patients with CMD seen form October 1969 through October 1989 were reviewed. N= had a definite diagnosis of CMD 18 (2.4%) unclassifiable at presentation: Red cell mass <32 or 36 ml/kg Ptl count lower than 600 x10 9 /L BM fibrosis lower 1/3 of BM area No extramedullary erytropoiesis at ferrokinetics, no anispoikilocytosis or tear drop cells in PB Ph1 neg An atypical myeloproliferative disorder with high thrombotic risk and slow disease progression. G. Barosi et al, Cancer 1991;68:2310 Clinical presentation Nine men and 9 women Median age 31.5 In 8 patients (44%) the presenting symptoms were related to major thrombotic events (mainly in splanchnic area) 2

3 An atypical myeloproliferative disorder with high thrombotic risk and slow disease progression. G. Barosi et al, Cancer 1991;68:2310 Bone marrow findings Clll Cellularity normal or increased Hyperplasia of granulopoietic series Abundance of megakaryocytes (median number 30.9/mm 2 normal 7 15/mm 2 ). Most megakaryocytes were enlarged with a complex lobated nucleus; other had a small size with non lobated or bilobated nuclei. Clustering of megakaryocytes was common Mean grade of fibrosis 1.18 (range 0 2) An atypical myeloproliferative disorder with high thrombotic risk and slow disease progression. G. Barosi et al, Cancer 1991;68:2310 Follow up Two patients died after splenectomy (mesenteric artery thrombosis and portal vein thrombosis) One patient did for myocardial infarction Fifteen of the 18 patients were alive after a median follow up of 50 months None of the patients had transformation into a recognizable CMD 3

4 An atypical myeloproliferative disorder with high thrombotic risk and slow disease progression. G. Barosi et al, Cancer 1991;68:2310 Lessons An atypical, not easily identifiable CMD occurs in young people It may be heralded by a thrombotic event (mainly in splanchnic area) l l h Clinical Perspective The Gastroenterologist s View 4

5 Role of the JAK2 mutation in the diagnosis of CMD in splanchnic vein thrombosis (Primignani et al. Hepatology 2006;44:1528) Patients 93 consecutive patients with idiopathic SVT referred to the Gastroenterology Unit in Milano. None of the patients had a prior history of MPD JAK2 V617F 34 of 93 patients with SVT (36.5%) had the JAK2 V617F mutation Clonality (HUMARA) 43 informative female were tested for clonality. 28 (65.1%) had clonal hematopoiesis BM biopsy 74 patients had BM biopsy analyzed according the WHO criteria. 55.4% had a diagnosis of MPN Role of the JAK2 mutation in the diagnosis of CMD in splanchnic vein thrombosis (Primignani et al. Hepatology 2006;44:1528) The high h positive ii predictive power for MPN of the JAK2 V617F mutation allowed to calculate the sensitivity (true positive frequency) of diagnostic criteria Parameter Sensitivity Hematocrit level 54% 10% Leukocyte count 10 x 10 9 /L 47.8% Platelet count 400 x 10 9 /L 46.1% Spleen diameter 20 cm 25% Clonality of hematopoiesis 86.6% BM biopsy 93.5% 5

6 Role of the JAK2 mutation in the diagnosis of CMD in splanchnic vein thrombosis (Primignani et al. Hepatology 2006;44:1528) Histological characterisitcs of BM biopsy in 74 patients with SVT revised according to WHO Criteria Diagnosis MPD (n=41) No MPD (n=33) Increased cellularity Incrased granulo. Increased mega. Clusters of mega. Fibrosis 94.4% 88.8% 100% 83.3% 33.3% 14.3% 14.3% 15% 5% 0% Role of the JAK2 mutation in the diagnosis of CMD in splanchnic vein thrombosis (Primignani et al. Hepatology 2006;44:1528) Lessons The estimated prevalence of MPD in SVT is 53.3% 3% The conventional hematological criteria are very insensitive to diagnose MPD (atypical nature of SVTassociated MPD) BM was the single most useful technique for the diagnosis of SVT associated MPD JAK2 V617Fi h li bl i i l l JAK2 V617F is the most reliable non invasive molecular marker of the disease and should be viewed as the first test for the diagnosis of SVT associated MPD 6

7 Diagnostic algorithm for SVT associated MPN SVT JAK2V617F Mutated SVT associated MPN Non mutated BM biopsy SVT associated MPN No SVTassociated MPN Biological Perspective 7

8 High frequency of endothelial colony forming cells marks a non active myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) Aim Study the clinical significance of endothelial progenitor cells in MPN Design Cross section analysis on 214 patients with classical Ph neg Measurement ECFCs in PB High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) Adapted from Yoder MC, et al. Blood 2007;109:1801 8

9 1,0 0,8 * (P<0.05) High frequency of endothelial colony forming cells marks a non active myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) ) ECFC (/10 7 MNC) 0,6 0,4 0,2 0,0-0,2 Frequency (/10 7 MNCs) median (range) PMF PV ET Normals PMF ET PV Normal (n= 155) (n= 21 ) (n= 38) (n= 43) 0.77 (0 17.1) 0 (0 0.8) 0 (0 4.4) 0.05 (0 0.59) High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) ECFCs in MPNs ECFC number was not correlated with: Disease duration Spleen size JAk2V617F mutational status or JAK2V617F allele burden Severity score 9

10 High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) 2,0 ECFCs (/10 7 MNC) 1,8 16 1,6 1,4 1,2 1,0 0,8 0,6 40% of patients with prefibrotic myelofibrosis had elevated frequency (>0.59/10 7 MNCs) of ECFCs P< ,4 0,2 0,0 Diagnosis with BM fibrosis (N=99) Diagnosis with prefibrotic BM (N=48) High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) ECF FCs (/10 7 MNCs) 3,0 2,8 2,6 2,4 2,2 2,0 1,8 1,6 1,4 1,2 1,0 0,8 0,6 0,4 0,2 0,0 64.3% of patients with history of splanchnic vein thrombosis had elevated frequency (>0.59/10 7 MNCs) of ECFCs P= No history of splanchnic vein History of splanchnic vein thrombosis (N= 119) thrombosis (N=28)

11 High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) Ability of hematological parameters to identify patients with increased frequency of ECFCs Parameter Hemoglobin, g/dl Sensitivity % Specificity % Cut off value AUC (95% CI) <= ( ) WBC, 10 9 /L <= ( ) Platelet count, 10 9 /L <= ( ) P level < AUC = Area under the curve Disease characteristics associated with increased frequency of ECFCs Variable High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) Patients (n/n) Univariate analysis Female sex 102/ ( ) Age lower than 50 years Multivariate analysis OR (95% CI) P value OR (95% CI) P value 99/ ( ) Diagnosis of 56/ prefibrotic MF ( ) Phenotype of nonactive disease History of splanchnic vein thrombosis 27/ ( ) 35/ ( ) ( ) < ( ) <

12 High frequency of endothelial colony forming cells marks a nonactive myeloproliferative neoplasm with high risk of splanchnic vein thrombosis (Rosti et al. PLoS One 2010; 12; e15277) Lesson High frequency of ECFCs in PMF is independently associated with diagnosis of history of SVT, and non active disease. These patients are mostly young and females. A Matter of Classification 12

13 Evidence that prefibrotic myelofibrosis is aligned along a clinical and biological continuum featuring primary myerlofibrosis (Barosi et al. PLos One 2012 (in press) Aim To investigate whether pre MF may be aligned along a clinical and biological continuum in 683 consecutive patients who received a WHO diagnosis of PMF Evidence that prefibrotic myelofibrosis is aligned along a clinical and biological continuum featuring primary myerlofibrosis (Barosi et al. PLos One 2012 (in press) Prefibrotic myelofibrosis Myelofibrosis fibrotic type Number 132 (19.3%) 551 (80.7%) Female 60.3 % 33.4% Age at onset of the disease, yrs, mean Hb g/dl WBC x10 9 /L Platelet count x10 9 /L Patients with SVT at diagnosis 30.3% 6.7% or in the year before diagnosis 13

14 Evidence that prefibrotic myelofibrosis is aligned along a clinical and biological continuum featuring primary myerlofibrosis (Barosi et al. PLos One 2012 (in press) SVT at diagnosis or in the year preceding the diagnosis was associated with lower platelet count (374 vs.716), larger spleen index, and higher frequency of JAK2 V617F mutation (86.2% vs. 59.5%) Conclusion SVT associated MPN is characterized by Young age at presentation Female predominance Non active hematological disease BM mostly of prefibrotic myelofibrosis High frequency of JAK2 V617F mutation (86.2%) A variant of prefibrotic myelofibrosis? Bi l i ll di i di? (A i bili i Biologically distinct disease? (An increase mobilization of endothelial progenitor cells is a distinctive feature) 14

15 RIMM Italian Registry of Myelofibrosis. IRCCS Policlinico S. Matteo Foundation Coordination and Clinical studies G. Barosi Cell coltures E. Gattoni V. Rosti C. Azzan E. Bonetti Cytology R. Invernizzi A. Pecci FACS M. Massa R. Campanelli G. Viarengo Clonality and JAK2 G. Bergamaschi L. Villani GIMEMA. Working Party on CMPD T. Barbui, Bergamo A.M. Vannucchi, Florence Gastroenterology, Ospedale Maggiore Foundation, Milan M. Primignani Pathology U. Magrini MPD Research Consortium 15