MYELODYSPLASTIC SYNDROME Vivienne Fairley Clinical Nurse Specialist Sheffield
MDS INCIDENCE 1/100,000/YEAR 3,250/YEAR MEDIAN AGE 70
MDS HYPO OR HYPERCELLULAR BONE MARROW BLOOD CYTOPENIAS (EARLY STAGES DUE TO APOPTOSIS) INEFFECTIVE BLOOD PRODUCTION ALL 3 LINES CAN BE AFFECTED PRODUCE CELLS THAT HAVE LOST THEIR ABILITY TO DIFFERENTIATE PREMALIGNANT PRIMARY OR SECONDARY(60-70% NO CAUSATIVE FACTOR)
SIGNS AND SYMPTOMS BONE MARROW FAILURE- anaemia, bleeding, frequent infections SPLENOMEGALY CMML ~50% ASYMPTOMATIC AND HAVE AN INCIDENTAL FINDING
DIAGNOSIS FULL BLOOD COUNT AND FILM?BONE MARROW ASPIRATE AND TREPHINE( 5-19% BLAST CELLS AND DYSPLASTIC FEATURES IN >10% CELLS)?CYTOGENETICS RULE OUT OTHER CAUSES(MEGALOBLASTIC ANAEMIA, HIV, ALCOHOLISM, RECENT CHEMOTHERAPY, SEVERE CONCOMMITANT ILLNESS) PNH CLONAL STUDIES FULL HISTORY FAMILY HISTORY MDS/AML FERRITIN, FOLATE, B12
MDS VARYING CLINICAL CONDITION INDOLENT TO AGGRESSIVE RA(REFRACTORY ANAEMIA) PROLONGED CLINICAL COURSE LOW RISK PROGRESSION TO AML RAEB(refractory anaemia with excess blasts) SHORT CLINICAL COURSE MORE LIKELY TO TRANFORM TO AML
WHO CLASSIFICATION OF MDS DISEASE BLOOD BONE MARROW REFRACTORY ANAEMIA(RA) RA WITH RINGED SIDEROBLASTS(RARS) ANAEMIA NO OR RARE BLASTS ANAEMIA NO BLASTS ERYTHROID DYSPLASIA ONLY, <5% BLASTS ERYTHROID DYSPLASIA ONLY, <5% BLASTS, >15% RINGED SIDEROBLASTS REFRACTORY CYTOPENIA WITH MULTILINEAGE DYSPLASIA(RCMD) RCMD-RS REFRACTORY ANAEMIA WITH EXCESS BLASTS 1(RAEB-1) RAEB-2 MDS UNCLASSIFIED(MDS-U) MDS WITH DELETED 5Q(MDS del5(q)) CYTOPENIAS NO OR RARE BLASTS CYTOPENIAS NO OR RARE BLASTS CYTOPENIAS <5% BLASTS CYTOPENIAS 5-19% BLASTS CYTOPENIAS NO OR RARE BLASTS ANAEMIA <5% BLASTS DYSPLASIA IN >10% CELLS IN 2 OR MORE MYELOID LINES, <5% BLASTS DYSPLASIA IN >10% CELLS IN 2 OR MORE MYELOID LINES, <5% BLASTS, >15% RINGED SIDEROBLASTS UNI OR MULTILINEAGE DYSPLASIA 5-19% BLASTS UNI OR MULTILINEAGE DYSPLASIA 10-19% BLASTS UNILINEAGE DYSPLASIA IN GRANULOCYTES OR MEGAKARYOCYTES <5% BLASTS NORMAL INCREASED MEGAKARYOCYTES, <5% BLASTS, ISOLATED del5(q)
MDS IPSS SCORE BASED ON CYTOPENIAS, CYTOGENETICS AND BLAST PERCENTAGE AGE NEW WHO SCORE TAKING INTO ACCOUNT TRANSFUSION REQUIREMENTS
IPSS-R 0 1 1.5 1.5 2.5 3.5 5 cytogenetics Very good good int poor Very poor blasts <5% 5-10% 11-30% Hb >/- 10 <10 platelets >/- 100 <100 ANC >/-0.8 <0.8
PROGNOSTIC RISK 1. Very low 0-2 2. Good >2-3.5 GROUPS/SCORES 3. Intermediate >3.5-5 4. High >5-6 5. Very high >6 For consideration of age (age in years-70)x 0.04, add result to sum of other variables
IPSS-R: PROGNOSTIC SUBGROUP CLINICAL OUTCOMES( median in years) 1 2 3 4 5 Very low Good Intermediate Poor Very high OS (overall survival) 8.7 5.3 3.0 1.6 0.8 AML 25% NR 10.7 4.0 1.4 0.8
CATEGORIES AND SURVIVAL SUBTYPE % CASES SURVIVAL MONTHS RA 8 69 RCMD 24 33 RARS 11 69 RAEB-1 21 18 RAEB-2 18 10 5q- 3 116 RCMDRS 15 32
PROGNOSTIC FACTORS GOOD YOUNGER, NORMAL OR MODERATELY LOW NEUTOPHILS AND PLATELETS, LOW BLASTS IN BONE MARROW, NO BLASTS IN PERIPHERAL BLOOD, NO AUER RODS OR RINGED SIDEROBLASTS, NORMAL OR MIXED KARYOTYPE WITHOUT COMPLEX CYTOGENETICS, NO LEUKAEMIC GROWTH PATTERN IN CULTURE POOR ADVANCED AGE, SEVERE NEUTROPENIA AND THROMBOCYTOPENIA, BLASTS IN PERIPHERAL BLOOD, ABOVE 20% BLASTS IN BONE MARROW, AUER RODS, ABNORMAL OR COMPLEX KARYOTYPE, LEUKAEMIC GROWTH PATTERN IN CULTURE
LOW RISK DISEASE APPROX 2/3 HAVE LOW RISK DISEASE LOW INT-1 IPSS SCORE BUT CAN HAVE A POOR PROGNOSIS EXISTING TOOLS DO NOT DIFFERENTIATE FOR THIS DECREASED SURVIVAL IF PLATELETS <50, AGE >60, UNFAVOURABLE CYTOGENETICS, Hb<10, BLASTS IN BONE MARROW >4-10% 30% PROGRESS TO AML
TRIALS TRANSPLANT GROWTH FACTORS SUPPORTIVE TREATMENT REVLIMID(5q-)70% CYTOGENETIC RESPONSE LOW DOSE ARA-C HYDROXYCARBAMIDE 5 AZACITADINE CHEMOTHERAPY IRON CHELATION
TREATMENT - TRIALS INTENSIVE TREATMENT POTENTIALLY LEADING TO TRANSPLANT MUST BE HIGH RISK MDS WITH >10% BLASTS IN BONE MARROW UNDER 60 AML 17 OVER 60 NO CURRENT TRIAL AVAILABLE
TREATMENT CHEMOTHERAPY STANDARD TREATMENT OFF TRIAL DA 3+10 LOW DOSE S/C CYTARABINE HYDROXYCARBAMIDE
TREATMENT 5-AZACITADINE EXERT AN ANTICANCER EFFECT BY CAUSING DNA DEMETHYLATION OR HYPOMETHYLATION IN ABNORMAL MARROW CELLS RESTORE NORMAL FUNCTION TO THE TUMOUR SUPPRESSOR GENES RESPONSIBLE FOR REGULATING CELL DIFFERENTIATION AND GROWTH RETARDS THE PROGRESSION OF MDS TO AML COMPARED TO BEST SUPPORTIVE CARE 5-AZA HAD A 60% LONGER TIME TO PROGREESION TO AML AND AN IMPROVEMENT IN QUALITY OF LIFE, BUT NO SURVIVAL BENEFIT PHASE III TRIAL 5-AZA INCREASED OS AND 2 YEAR SURVIVAL DOUBLED COMPARED TO CONVENTIONAL THERAPY TREATMENT 75MG/M2(CAN BE INCREASED IF TOLERATED) S/C FOR 7 DAYS EVERY 4 WEEKS MAIN SIDE EFFECTS INJECTION SITE INFLAMMATION, INITIAL LOWREING OF BLOOD COUNTS
TREATMENT LENALIDOMIDE THOUGHT TO INTERFERE WITH THE IMMUNE SYSTEM AND ACTS ON ANGIOGENESIS IN-VIVO HAS DIRECT ANTI-TUMOUR EFFECTS, INHIBITS THE MICRO-ENVIRONMENT SUPPORT FOR TUMOUR CELLS AND HAS AN IMMUNOMODULATORY ROLE IN-VITRO INDUCES TUMOUR CELL APOPTOSIS DIRECTLY, AND INDIRECTLY INHIBITS BONE MARROW STROMAL CELL SUPPORT, ANTI-ANGIOGENIC AND ANTIOSTEROCLASTIC EFFECTS ON TRIAL 63% OF PATIENTS ACHIEVED RBC INDEPENDENCE ACCOMPANIED BY A MEDIAN INCREASE OF 5.8G/Dl Hb MAJOR CYTOGENETIC RESPONSE 44% MINOR 24% 10MG PO FOR 21 28 DAYS AS LONG AS EFFECTIVE INCREASED RISK OF PROGRESSING TO AML RESPONSE AROUND~2 YEARS
TREATMENT ATG ANTI-LYMPHOCYTE GLOBULIN USED IN CONJUNCTION WITH CYCLOSPORIN HYPOPLASTIC MDS? AUTO-IMMUNE COMPONENT 5 DAYS ATG WITH ~6 MONTHS CYCLOSPORIN
TREATMENT GROWTH FACTORS G-CSF AND EPO EFFECTIVENES OF EPO~ 30% IN MDS PHASE II STUDY SHOWED A RESPONSE OF 60% IN LOW RISK IPSS WITH SERUM EPO LEVELS<500U/L? COMBINATION INCREASES EFFICACY A REANALYSIS OF DATA DEMONSTRATED A BETTER RESPONSE IN RARS(70%) THAN RCMD-RS(9%)? DUE TO ABILITY OF G-CSF TO INHIBIT CYTOCHROME C RELEASE AND HENCE MITOCHONDRIA MEDIATED APOPTOSIS IN RARS ERYTHROBLASTS WAITING FOR TRIAL START DATE
TREATMENT SUPPORTIVE G-CSF BLOOD/PLATELET TRANSFUSIONS PREVENTATIVE ANTIMICROBIALS NURSE LED CLINICS HOME VISITS DECISIONS RE TREATMENT
TREATMENT IRON CHELATION RECOMMENDATIONS FOR IRON CHELATION BASED ON LIMITED DATA EVIDENCE SUGGESTS THAT IRON OVERLOAD CAN LEAD TO ORGAN FAILURE AND MORBIDITY IN THE BONE MARROW IT MAY ADD TO EARLY CELLULAR APOPTOSIS CONTROLLED BY MICROENVIRONMENT TRIAL OF 170 PATIENTS WITH MDS 76 RECEIVED CHELATION OS 115 MONTHS VS 51 IN NON CHELATED SHOULD BE CONSIDERED WHEN A PATIENT HAS RECEIVED 5G OF IRON( APPROX 25 UNITS OF RED CELLS) ONLY IN PATIENTS REQUIRING LONG TERM TRANSFUSION THERAPY WITH LIFE EXPECTANCY OF 2-4+ YEARS TWO MAIN METHODS SUB-CUTANEOUS DESFERRIOXAMINE(DESFERRAL) AND ORAL DEFERASIROX(EX- JADE)
TREATMENT IRON CHELATION DESFERRAL S/C OVER 12 HOURS UP TO 5 DAYS EACH WEEK INFUSORS OR SYRINGE DRIVERS EXCRETED RENALLY( CAUTION IN RENAL INSUFFICIENCY) INCREASED RISK OF YERSINIA INFECTIONS NEED YEARLY EYE/HEARING TESTS NEED TO REDUCE DOSE WHEN FERRITIN LEVELS FALL BELOW 1000ug/L( normal range 22-322ug/L) VITAMIN C ENHANCES SECRETION SIDE EFFECTS PAIN, SWELLING, INFLAMMATION AT INJECTION SITE, VERY RARE ANAPHYLAXIS, DIZZINESS
TREATMENT IRON CHELATION EX-JADE ORAL PREPARATION ONCE DAILY DOSING ½ LIFE 8-16 HOURS FAECALLY ELIMINATED TAKEN ON AN EMPTY STOMACH 30MINS BEFORE FOOD NEED REGULAR U+E BLOOD TEST SIDE EFFECTS ALLERGIC REACTIONS, NAUSEA, WORSENING RENAL/LIVER FUNCTION, RASH, FLU-LIKE SYMPTOMS, DIARRHOEA
? TO CHELATE COMPLICATIONS OF IRON OVERLOAD DEVELOP AFTER MANY YEARS OF TARGET ORGAN EXPOSURE MORE THAN 85% PATIENTS ARE DIAGNOSED OVER THE AGE OF 60 WITH 3 YEAR SURVIVAL BEING 35% MDS IN A LOW RISK CATEGORY BUT REQUIRING TRANSFUSIONS OFTEN ASSOCIATED WITH INFERIOR OS AND LEUKAEMIA FREE SURVIVAL SERUM FERRITIN USED AS A MARKER OF IRON OVERLOAD CORRELATES WITH TRANSFUSION LOAD DIFFICULT TO DECIPHER ITS INDEPENDENT PROGNOSTIC VALUE MYOCARDIAL OR HEPATIC IRON DEPOSITION SELDOM CITED AS A CAUSE OF DEATH IN MDS
SUPPORTIVE CARE INFORMATION, EDUCATION MDM SURVIVORSHIP HOLISTIC ASSESSMENT FERTILITY LEUKAEMIA CARE, WILLOW FOUNDATION KEYWORKER NURSE LED CLINIC HOME VISITS DN/ MACMILLAN DLA/AA/MACMILLAN GRANTS DIETETIC/OT/PT/SW SUPPORT GROUPS(MDS UK PATIENT SUPPORT GROUP, LOCAL GROUP)
READING LIST HEALTHLIBRARY.EPRET.COM EMEDICINE NORTH TRENT HAEMATO-ONCOLOGY NETWORK GUIDELINES VERSION 1 FEBRUARY 2007 GARCIA-MANERO ET AL 2008; A PROGNOSTIC SCORE FOR PATIENTS WITH LOWER RISK MDS LEUKAEMIA 22(3) 538-543 SCHMID ET AL 2009; EX-JADE IS EFFECTIVE AND WELL TOLERATED IN CHELATION NAÏVE AND PREVIOUSLY CHELATED PATIENTS IN TRANSFUSION DEPENDANT MDS BLOOD 111(22) LIST ET AL 2009; 2 YEAR ANALYSIS OF EFFICACY OF DESFERRIOX TREATMENT IN MDS BLOOD 114(22) FOX ET AL 2009; MATCHED PAIR ANALYSIS OF 186 MDS PATIENTS RECEIVING CHELATION THERAPY OR TRANSFUSION THERAPY ONLY BLOOD 114(22) TEFFERI ET AL 2009; IRON CHELATION THERAPY IN MDS- CUI BONO LEUKAEMIA 23 1373 MALCOVATI ET AL 2005; PROGNOSTIC FACTORS AND LIFE EXPECTANCY IN MDS CLASSIFIED ACCORDING TO WHO CRITERIA J CLIN ONCOL 23 7594-7603 FENAUX ET AL 2007;AZACITADINE TREATMENT PROLONGS OVERALL SURVIVAL IN HIGHER RISK MDS PATIENTS COMPARED WITH CONVENTIONAL CARE REGIMENS ASH ANNUAL MEETING ABSTRACTS 110 817 LIST ET AL 2006; LENALIDOMIDE IN THE MDS SYNDROME WITH CHROMOSOME 5q DELETION N ENG J MED 355 1456-1465 GREENBERG ET AL 1989; INTERNATIONAL SCORING SYSTEM FOR EVALUATING PROGNOSIS IN MDS BLOOD (6) 2079-88 LIST ET AL 2005; EFFICACY OF LENALIDOMIDE IN MDS N ENG J MED (6) 549-57 SILVERMAN ET AL 2006; FURTHER ANALYSIS OF TRIALS WITH AZACITADINE IN PATIENTS WITH MDS J CLIN ONCOL 24(24) 3895-903
READING LIST VARDIMAN 2006: HAEMATOPATHOLOGICAL CONCEPTS AND CONTROVERSIES IN THE DIAGNOSIS OF MDS HAEMATOLOGY AMERICAN SOCIETY OF HAEMATOLOGY 199-204 AUL ET AL : EMERGING TREATMENT OPTIONS FOR ADULT MDS: A CLINICAL PERSPECTIVE MDS FOUNDATION INC FENAUX ET AL 2006; TREATMENT OF THE 5q- SYNDROME AMERICAN SOCIETY OF HAEMATOLOGY 192-198 DE WITTE ET AL 2007: AUTOLOGOUS AND ALLOGENEIC STEM CELL TRANSPLANTATION FOR MDS BLOOD REVIEWS 21 49-59 BENNETT 2008; CONSENSUS STATEMENT ON IRON OVERLOAD IN MDS AMERICAN JOURNAL OF HAEMATOLOGY 1-4