SESSION 1 Reactive cytopenia and dysplasia Falko Fend, Tübingen & Alexandar Tzankov, Basel 1
Disclosure of speaker s interests (Potential) conflict of interest none Potentially relevant company relationships in connection with event none
BM Workshop Session 1. Reactive cytopenia and dysplasia Introduction ----------------------------------------------------------------------------------------------------------------- 1.1. Aplastic anemia and paroxysmal nocturnal hemoglobinuria (FEND) Oral: 101 Chronic neutrophilic leukemia evolving in/from SAA Summary: 102 PNH; 104 Evolving aplastic anemia/mds? in association with a PNH clone; 107 Aplastic anemia, successfully treated?; 202 Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population 1.2. Reactive cytopenias without bone marrow aplasia (TZANKOV) Oral: 103 Pure red cell aplasia following ibrutinib; 112 EBV-associated hemophagocytic lymphohistiocytosis; 116 Autoimmune myelofibrosis; 117 Gamma-delta T-cell granular lymphocytic leukemia Summary incl. 105 Reactive changes in SLE; 110 Hemophagocytic lymphohistiocytosis; 111 Evans syndrome; 114 Toxic myelopathy; 115 Hemolytic anemia 1.3. Cytopenias in proven/suspect inborn bone marrow failure states (TZANKOV) Summary incl. 108 Hereditary bone marrow failure syndrome with dysplastic features, probably autosomal recessive Oral: 109 Bone marrow failure in a patient with USB1 gene mutation ----------------------------------------------------------------------------------------------------------------- Take homes
Introduction Cytopenia is a very common indication for BM biopsy Dysplasia can be encountered in a variety of settings Detailed clinical history Peripheral blood counts Marrow aspirate and histology Immunophenotype Genetics and cytogenetics
Clinically: peripheral cytopenia Morphologically: BM features suggesting MDS Hypercellular marrow with ineffective hematopoiesis (cytopenia) +/- macrocytosis Deficiency states Autoimmune/collagen vascular disorders Chronic infections Hepatic disorders Aplastic anemia Splenomegaly Toxins Medications Paraneoplastic Constitutional bone marrow disorders Dysplasia +/- Ring sideroblasts +/- Increase in blasts Other myeloid neoplasms Chronic lymphoid neoplasms (T-LGL, HCL) Bone marrow carcinosis Idiopathic cytopenia of unknown significance (ICUS) Idiopathic dysplasia of unknown significance (IDUS) Hypocellular marrow with cytopenia +/- macrocytosis Dysplasia +/- Ring sideroblasts +/- Increase in blasts
1.1. (acquired) Aplastic Anaemia Diagnosis of exclusion Exclude hypocellular neoplasms (e.g. hypomds, congenital BM failure syndromes) Occurs in all age groups Most cases are idiopathic (autoimmune T-cell mediated destruction of BM stem cells) response to immunosuppressive therapy Variety of etiologies can cause AA A subset of cases progresses to MDS or AML Detection of cytogenetic abnormalities and mutations New onset, persistent cytopenia and hypocellular BM Requires a representative BM biopsy and immunostains to rule out a neoplasm
16-year-old male, pancytopenia CD34 7
Definition of AA
Weinzierl & Arber, AJCP 2013
Weinzierl & Arber, AJCP 2013 Parvovirus B19
Mutational profile of AA Ogawa S, Blood 2016 50% of AA show clonal genetic alterations PIGA, BCOR/BCORL1 and 6pUPD highly associated with AA Clonal hematopoiesis associated with progression to MDS, AML and PNH
Ogawa S, Blood 2016
1.1. paroxysmal nocturnal hemoglobinuria (PNH) Rare, acquired clonal disorder of HSC Intravascular hemolysis, cytopenia, renal failure, thrombotic events Mutation of phosphatidylinositol glycan class A (PIG-A) Expansion of PIG-A-mutated clone following injury and autoimmunemediated destruction of normal BM cells Required for synthesis of GPI-anchor Defect of GPI-anchored membrane proteins Lack of complement regulatory factors lead to hemolysis Diagnosis of PNH is made by FCM Associated with AA (usually minor PNH clone) Risk of progression to AML (5%) and MDS (2.5%)
Devalet et al, Eur J Haematol 2015
1.1. Case summaries 102 M. Yabe, NY, USA: PNH (panel: agree) 104 M. Yabe, NY, USA: Evolving aplastic anemia in association with a PNH clone (panel: agree) 107 A. Bogusz, Philadelphia, USA: Aplastic anemia (with a PRPF40B VUS) (panel: agree, successfully treated?) 202 L.Jiang, Jacksonville, USA: Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population (panel: agree)
Case 102 (Yabe) - 12 year-old boy, since 6 months "not feeling" well, and tired". - Hb 5,9; Leuko 3.1; Plt. 26; LDH 286; Haptoglobin <8, Bili 1.3
Flow, Peripheral blood RBCs Granulocytes Monocytes PNH clone on RBCs TYPE III (complete deficiency) 29.8% TYPE II (partial deficiency) 5.2% PNH clone on Granulocytes 66.2% PNH clone on Monocytes 63.6%
Molecular analysis Normal karyotype, no leukemia-specific translocations Next generation for specific mutations in 30 genes: NEGATIVE Gene tested NPM1, FLT3, CEBPA, JAK2, MPL, KIT, DNMT3A, IDH1, IDH2, ASXL1, JAK1, RUNX1, CBL, SF3B1, JAK3, SH2B3, SUZ12, ETV6, KRAS, TET1, EZH2, TET2, TET3, HRAS, NRAS, TP53, PHF6, TYK2, PTEN, WT1. Case 102 Diagnosis: Paroxysmal nocturnal hemoglobinuria (PNH) Panel Diagnosis: agree
Case 104, Yabe 52-year-old female, found to have anemia (Hb 9.7) and thrombocytopenia (16) during workup for breast cancer
No dysplasia in erythroid and myeloid lineages, no increase in blasts
Flow, Peripheral blood RBCs Granulocytes Monocytes PNH clone on RBCs TYPE III (complete deficiency) 0.10% TYPE II (partial deficiency) 0.0076% PNH clone on Granulocytes 0.20% PNH clone on Monocytes 0.089% Case 104 Diagnosis: evolving aplastic anemia in association with a PNH clone Panel diagnosis: agree
Case 107 A. Bogusz 76 year old man with pancytopenia. WBC 1.1, Hgb 9.3, Plt 47, MCV 95, Retic 0; ANC 0.15.
Bone marrow aspirate, 50x
No PNH clone Case 107, A. Bogusz Karyotype: normal 46,XY[20] Sequencing studies revealed a variant of unknown (VUS) significance in PRPF40B gene: PRPF40B p.p751s c.2251c>t Diagnosis: acquired idiopathic aplastic anemia Panel diagnosis: aplastic anemia (successfully treated?)
Case 202, L. Jiang 47-year-old female with chronic pancytopenia Hb 11.8; Leukocytes 2.3 (abs. Neutrophil 0.94), Plt 100 Left shifted eythropoiesis, no dysplasia, no blasts FCM shows small NK cell population in PB (3%) and BM (5%): CD16, CD2, CD7 (dim), CD56, CD57, CD94, NKG2a; negative for CD4, CD8, gamma/delta, CD3, CD5, and CD26 Cytogenetics 46, XX [20], molecular cytogenetics and mutational analysis negative Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population Panel: agree
CD4 CD3 CD3 CD94 CD2 CD5 CD7 Flow cytometry analysis CD3 CD3 CD3 CD3 CD8 CD56 CD57 A distinct small NK cell population is identified in peripheral blood (3% of total events) and bone marrow aspiration specimens (5% of total events), CD2+CD7+CD56+CD57+CD94+NKG2a+; negative for CD3, CD5, CD4, CD8, or gamma/delta NKG2A