Sindroamele

mieloproliferative
cronice

Leucemia mieloida
cronica
SINDROAME SINDROAME
MIELOPROLIFERATIVE LIMFOPROLIFERATIVE

Acute: Acute:
-LAM -LAL

Cronice
Cronice - LLC
- PV - HCL
- TE - LNH
- _LGC - BH
- MMM - BW
- MM
 Neoplasmele mieloproliferative (MPN)

 Clasificarea WHO
=grup de afectiuni clonale, (World Health
secundare unor mutatii
genetice survenite la
Organization) 2008
nivelul progenitorilor Neoplasmelor
celulelor hematopietice, cu Mieloproliferative:
proliferare crescuta, cu
cresterea in sangele
periferic a:  Leucemia mieloida cronica
 Leucocitelor Ph1 pozitiva
 Eritrocitelor  Policitemia vera
 Trombocitelor  Trombocitemia esentiala
 Mielofibroza primara
LEUCEMIA MIELOIDA CRONICA
 LMC: Definitie

 Boala mieloproliferativa clonala a celulei stem

pluripotente
  proliferare granulocitara

 Capacitate de diferentiere pastrata ( deviere la stanga a

formulei leucocitare)
 Marker citogenetic: Cromozom Philadelphia (Ph)

 Marker Molecular: oncogena Bcr-Abl

 Epidemiologie in LMC

 1.5:1 raport barbati: femei

 Varsta medie la diagnostic: 55 ani

 12% - 30% pacienti – 60 ani sau >60ani

 Majoritatea pacientilor sunt diagnosticati in std incipiente

 85% faza cronica

 5% - 10% faza accelerata sau blastica

6
 Incidenta in LMC
reprezinta 15-20% din totalul cazurilor de leucemie diagnosticate la adult
Incidenta in raport cu varsta

Age
• Incidenta = 1 .5 pacienti/ 100,000 cazuri /an

7
 DEFINITIE

Proliferare clonala crescuta a celulelor hematopoietice

pluripotente, dar cu pastrarea capacitatii de diferentiere si
maturare

Anomalii la nivelul hematopoiezei:

 proliferarea excesiva a progenitorilor granulocitari cu
descresterea sensibilitatii la agentii reglatori – cresterea
numarului de leucocite in sangele periferic
 Megakariopoieza deseori crescuta
 Eritropoieza in general scazuta
 Functie normala a neutrofilelor si trombocitelor
 Patogeneza
Cromozomul Ph
 LMC se caracterizeaza prin prezenta anomaliei cromozomiale
cunoscute sub denumirea cromozomul Ph (Philadelphia).

 Cromozomul Ph: anomalie dobandita = translocatie reciproca

intre cromozomul 9 si cromozomul 22 t(9;22).

 Cauza aparitiei acestei anomalii: necunoscuta.

 La < 10% din pacienti, cromozomul Ph nu este prezent (LMC

atipica).

 Descoperirea cromozomului Ph (1960) a fost prima

demonstratie a legaturii dintre o anomalie cromozomiala si o
forma de cancer.
Cr Ph = t(9;22)(q34;q11)
Cromozomul Philadelphia t(9;22)
BCR-ABL codifica proteina p210 cu activitate tirozin- kinazica
Structure of the p210Bcr-Abl fusion protein and mechanisms of leukemogenesis

Hematology 2003;2003:597-618
 Ce sunt ‘tyrosine kinazele’?

Enzima care transfera gruparea

fosfat de la ATP la un rest de
tirozina din structura unei
proteine.

Fosforilarea proteinelor de
catre kinaze este un mecanism
important in transductia
semnalului pentru reglarea
activitatii enzimatice.

Blocarea buzunarului kinazic blocheaza

procesul de fosforilarea si activare a proceselor
ulterioare
 Manifestari clinice:

 Asimptomatici (30%)
 Astenie fizica
 Scadere ponderala
 Anorexie, satietate precoce, dureri, discomfort
abdominal
 Febra, transpiratii, dureri osoase
 Manifestari respiratorii, neurologice in f.
hiperleucocitare.
 Examen clinic:

 Splenomegalia ( grd III – IV) – consistenta ferma,

mobila cu respiratia, indolora ( exc inafarct splenic),
cu margine anterioara crenelata, cu suprafata
boselata, dc au existat infarcte splenice anterioare
 Hepatomegalie
 Rar limfadenopatii ( rareori > 1cm)
 Dureri sternale la percutie ( semn Crayer)
 Srd hemoragipar, paloare
LMC – Aspecte clinice
F. hiperleucocitare
 Manifestari respiratorii: dispnee,
tahipnee→IRA, exitus, ausc raluri
pulmonare, Rx infiltrate pulmonare
 Manifestari SNC: cefalee, stupor → coma, ↓
AV, FO - hemoragii
 Priapism
 Faze clinice:

1) Initial faza cronica

2) faza accelerata

3) puseu blastic
 Nu toti pacientii respecta ordinea faza cronica ---- faza accelerata ---- puseu blastic.
 Semne si simptome pentru boala progresiva:

 Sdr hemoragipar cutaneo-mucos: sangerare,

petesii, echimoze
 Dureri osoase, febra fara focar infectios
decelabil clinic
 Agravarea anemiei, trombocitopeniei,
bazofiliei; cresterea dimensiunilor splinei
 LMC: diagnostic de laborator

 Hemograma
 FAL (Fosfataza Alcalina Leucocitara)
 Medulograma
 Examen citogenetidc
 Examen Molecular
 LMC faza cronica: criterii de diagnostic

 Hemograma:
- leucocitoza importanta cu neutrofilie, PLT↑, Hb ↓
- deviere la stanga a formulei leucocitare (curba de
distributie cu doua varfuri la Mi / Mt, Ns/ S)
- Bazofilie 5-10%
- Monocite sub 3%
1. LMC faza cronica:
2. 4. FAL=0
MiBl
1%, Mi
7%, Mt
1%, S
3. 66%,
E 5%
B 8%
L 10%
M 2% 5. Cromozom Ph1 +

Oncoproteina BCR/ABL1
 LMC faza accelerata/puseu blastic
: criterii de diagnostic
 Fz accelerata
- FL deviata la stanga pana la Bl si
Ba
- Bl 10 -19% Sg si MO
- Bazofile > 20% Sg
 Fz blastica – Bl > 20%
 Dg diferential: LMC faza cronica vs reactie
leucemoida
 Reactia leucemoida:
- leucocitoza importanta cu neutrofilie (rar >
50 000/mmc)
- deviere la stanga a formulei leucocitare, dar fara
Mbl
- Bazofilie absenta
 Tabloul clinic:
- cancer
- inflamatii
- sepsis
 LMC: diagnostic de laborator

 Hemograma
 FAL (Fosfataza Alcalina Leucocitara)
 Medulograma
 Examen citogenetidc
 Examen Molecular
 LMC - MO

 Fz cronica: MO hipercelulara, proliferarea

seriei granulocitare, in detrimentul seriei
eritroide cu raport (G/E – 10:1), Bl < 5%
 Fz blastica: Bl >20%
 BOM: - prezenta/ absenta fibrozei medulare,
+/- histiocite “albastre ca marea”
Cromozomul Philadelphia
Analiza citogenetica care
detecteaza crz. Ph stabileste
diagnosticul de LMC.
Crz. Ph: detectare mai usoara
in celulele in diviziune din MOH

Analiza standard: 20 – 30 celule

aflate in metafaza; in LMC,
majoritatea acestora contin crs
Ph.

NCCN: examenul citogenetic

trebuie efectutat la diagnostic.
+/- Anomaliile citogenetice
aditionale
 Fluorescence in-situ hybridization
(FISH) in LMC:

1) hibridization fluorescenta a probelor marcate de

AND a celulelor aflate in interfaza in ciclul
celular (non-diviziune)/ metafaze

2) Nu necesita aspirat medular pentru rezultate

optime

3) Permite un diagnostic rapid ~24h

4) dezavantaj: nu identifica anomaliile

cromozomiale aditionale.
 BCR BCR
22q11 22q11

ABL ABL
9q34 9q34

9 9 22 22

Semnal Normal

BCR/ABL
t(9;22)(q34;q11)

BCR
BCR
22q11 ABL

ABL ABL
9q34
BCR

9 der(9) 22 der(22)

Semnal anormal FISH

Fluorescent In Situ Hybridisation
 Biologie moleculara RT-PCR
 Nu necesita aspirat medular pentru rezultate optime

 RT-PCR detecteaza diferitele puncte de ruptura: proteine

BCR-ABL 190, 210 si 230 kDa.

 Util in diferentierea LMC si LAL.

 PCR cantitativa si calitativa.

 La diagnostic si in dinamica

 PCR cantitativa - monitorizarea raspunsului si boala

minima reziduala
 CML: Investigare moleculara

Multiplex PCR Metodologia

RQ-PCR
PCR
CALITATIV Light Cycler

Tipul de
Numarul
transcript
de copii
Bcr-Abl
Bcr-Abl
IDENTIFICAREA TRANSCRIPTILOR BCR-
ABL PRIN PCR CALITATIV

Multiplex PCR – probe migrate în gel de agaroză 2%.

Imagine captată cu cameră foto digitală (sistem BioCapt TM).
 Centru de Hematologie si Transplant Medular Fundeni
Laborator de Biologie Moleculara

% P ac ient 1
BCR-ABL

90
80 78
70
60
50
40
30
20
10
0 0.5 0.2 0.03 0.05
1 2 3 4 5

8.11.2007 13.03.2008 10.04.2008 9.10.2008 14.01.2009

J.C., ♂, 41 ani, dg-LMC-FC din 2007, din 2007 IM 400 mg

 Centru de Hematologie si Transplant Medular Fundeni
Laborator de Biologie Moleculara

% P ac ient 2
BCR-ABL

60
50 48
40 Atentie terapia anticoagulanta trebuie
44 oprita cu

30
24 h inainte de travaliu
30
si reinceputa imediat 30
postpartum (12-24 h) cel putin sase saptamani.
20 20
10 12
0
1
19.06.2007 2
20.09.2008 3
14.02.2008 4
19.03.2008 17.04.2008 5 10.02 2009 6

B.N., ♂, 54 ani, dg-LMC-FC din 2003, 2004-2008 IM 400-800 mg,

oct 2008
 Diagnostic si monitorizare in LMC

Test Target Tesut Sensibilitate Utilitate

(%)
Citogenetic Cromozom Asiprat 1-10 ▪ LMC diagnostic
Ph medular ▪ Evaluarea cariotipului

 alte anomalii decat Ph

( ex evolutie clonala)
FISH Juxtapozitia SP/MO 0.5-5 ▪ Confirmarea
bcr si abl diagnositicul LMC
 ▪ monitorizarea
raspunsului
▪ monitorizarea BMR

RT-PCR bcr-abl SP/MO 0.0001-0.001 ▪ monitorizare BMR

mRNA ▪ determinarea
locurilor de ruptura la
nivelul genei de fuziune
 Alte analize
 FAL ↓↓ - 0
 Acid uric ↑
 LDH ↑
 Vitamina B 12 ↑
 Histamina serica, metaboliti urinari ↑ ---
Bazofile ↑ (fenomene urticariene, ulcere
digestive, prurit)
Leucemia Mieloidă Cronică - Diagnostic

Tablou hematologic caracteristic Citogenetica convenţională FISH

Real-Time PCR Determinarea locurilor de rupere Secvenţierea

e1 b2 a2
b2a2 p210
e1 b2 b3 a2
b3a2 p210
e1 a2
e1a2 p190
e1 e19 a2
e19a2 p230
 Diagnostic diferential
 Celelalte SMPC
 Reactiile leucemoide
 LA
 LMMC
Evolutia clinica a cazurilor netratate
LMC
Faze avansate
Faza cronica
Faza accelerata Puseu blastic

Suprav medie Suprav medie Suprav medie

3–4 ani 6–9 luni 3–6 luni
 LMC: evolutie

 Faza Cronica: blasti < 10%

 Faza Accelerata: absenta raspunsului la terapie,

febra, splenomegalie, anemie, bazofilie, anomalii
cromozomiale aditionale

blasti peste 10%

 Faza Blastica (criza blastica):

blasti peste 20%
 CML in blastic phase
 Natural history: blastic phase occurs after 4-8 years of
chronic phase

 Sometimes preceded by the ACCELERATED PHASE:

 Decreased effectiveness of therapy
 Increased symptoms
 Progressive splenomegaly
 Increased leukocytosis
 Basophilia >20%
 Anemia and/or thrombocytopenia unrelated to therapy
 Increased blasts 10-19%
 New cytogenetic abnormalities: Ph-Ph, 8+, 19+, etc
 Full blown BLASTIC PHASE is defined by:
 Blasts > 20% (peripheral blood or bone marrow)

 Clinically and hematologically, CML in blastic

phase resembles to acute leukemias:
 Symptoms of anemia
 Bleeding due to thrombocytopenia
 Infections due to neutropenia

 The phenotype of the blasts is:

 Myeloid in 85% of cases – acute myeloid leukemia
 Lymphoid in 15% of cases – acute lymphoid leukemia
 Tratament

 Controlul numarului crescut de leucocite

 Reducerea simptomatologiei secundare
splenomegaliei
 Prevenirea progresiei bolii
 Prelungirea duratei de viata
3 obiective ale tratamentului in LMC

a) Remisiune hematologica ( HLG normala, fara

organomegalie)

b) Remisiune citogenetica (absenta crom.Ph)

c) Remisiune moleculara (absenta ARNm

BCR/ABL la examentul RT-PCR). (complet
scaderea cu 4,5 log sau major 3 log)
 Response criteria:
 Hematologic response (blood count, blood smear)
 Complete hematologic response (CHR)
 No splenomegaly
 Normal blood count, normal differential count

 Cytogenetic response (karyotype):

 Complete cytogenetic response (CCyR): Ph1= 0%
 Major cytogenetic response (MCyR): 1-35% Ph1)
 Minor cytogenetic response (nCyR): 35-95% Ph1)

 Molecular response (rqPCR):

 Major molecular response (MMR): <0.1% BCR-ABL
(>1000x reduction)
 Complete molecular response (CMR): BCR-ABL
undetectable
 Tratament
faza cronica
 Tratament adjuvant (suportiv)
Masuri generale:
 Hidratare iv + po
 Hiperuricemie – Allopurinol

 Combaterea trombocitozei
 Leucafereza – numar foarte mare de
leucocite si simptomatologie secundara
leucostazei ( respiratorie, neurologica)
 Srd. liza tumorala - monitorizare fct renala
(creatinina , uree, electroliti), acid uric
 LMC: pana in 2000
 Boala fatala cu
supravietuire mediana : 3-
5 ani
 Transpant medular
allogeneic curativ in 40%
- 70% din pacienti
 mortalitate si toxicitate
mare
 Interferon alfa ±
cytarabine:
 supravietuirea
mediana : 6-7 ani
 Alte optiuni: hydroxyurea,
busulfan
 A new approach to
treatment
of this disease is
to directly inhibit the
molecular cause
of the disease.

…using a protein-
tyrosine
kinase inhibitor
that inhibits
the bcr-abl tyrosine kinase
Imatinib blocks the ATP-binding site on the BCR-ABL protein
 Tratament - Inhibitori de tirozin – kinaza ( I)

 Imatinib ( GLiVEC): inhiba proliferarea si induce

apoptoza in liniile celulare Ph 1+ din LMC
 Doza standard: fz cronica 400mg/zi →→ faza acc/
blastica 600- 800mg/zi
 Efecte adverse:
Mielosupresie grd 3-4 ( control HLG)
Retentie de lichide si edeme ( edem periorbital, lichid pleural,
pericardita, anasarca)
Greata, varsaturi – divizarea dozei, ingestie cu mancare,
antiemetice
Crampe musulare – suplimente cu Ca, K
Eruptie cutanata – anitihistaminice, CS
Hepatotoxicitate - sist enzimatic CYP 3A4/5 P-450
Obtiuni terapeutice pentru cei cu boala refractara
la ITK generatia I (Imatinib)

1) Escaladarea dozei de imatinib 600-800mg zilnic

2) ITK de generatie aIIa

3) Transplant medular

4) Complianta pacientului
 Tratament - Inhibitori de tirozin – kinaza ( II)
DASATINIB:
 Indicatii- fz. cronica, accelerata, blastica cu rezistenta la
Imatinib
 Doza 100mg /zi
 Solubilitatea ~~ pH ( !! Antiacide ↓ abs. )
 Efecte adverse: mielosupresie, efuziuni pleurale, sangerari
GI, pneumonie, dispnee, IC, diaree etc

NILOTINIB:
 Indicatii- fz. cronica, accelerata, blastica cu rezistenta la
Imatinib
 Doza 300mg x2 /zi→→ ESCALADARE 600mg X2/zi.

PONATINIB – 45 mg/zi – eficient T315I

 Treatment of chronic phase CML:

 Tyrosine kinase inhibitors (TKI)

 Imatinib (1st generation TKI) - current standard first
line therapy
 90-95% CHR
 70-90% CCyR

 30-50% MMR
 Dasatinib, Nilotinib (2nd generation TKI)
 Active in most cases of resistance to imatinib

 Responses are quicker and deeper than imatinib –

may become standard treatment in the near future
 Transplantul medular
Allotransplantul medular ramane singura optiune
curativa in LMC

Asociat cu morbiditate si mortalitate (10%-30%)

Asadar nu reprezinta o indicatie terapeutica de prima

linie in LMC

Indicatie terapeutica pentru cei cazurile

rezistente/refractare la ITK

▪ eficienta transplantului depinde de momentul

stabilirii indicatiei detransplant : CP>AP>BP
 Tratament pre TKI
 INF α = efect antiproliferativ si de diferentiere
celulara
- remisiune hematologica 50-70%
- remisiune citogenetice 10-20%
- 3 -5 mil UI /m2/zi
- efecte adverse: simpt de tip gripal - mialgii, febra;
cutanate - rash, prurit; depresie, neuropatie
- unic agent terapeutic/in asociere cu CT (ARA-C)
- indicatie terapeutica – in sarcina
 Tratament pre TKI
Chimioterapie conventionala
 Nu amelioreaza semnificativ durata de
supravietuire
 Amelioreaza calitatea vietii in fz cronica
 Hidroxiureea ( HU) = antimetabolit
- actiune rapida, insa de scurta durata →adm
continua
- dz de atac 1-3g/zi, apoi de intretinere 1-2 grame/zi
- la ora actuala – indic. Terapie citoreductoare
inainte de imatinib.
 Treatment of chronic phase CML

– Other drugs (older):

• Hydroxiurea – may induce CHR, no
cytogenetic response
• α- Interferon (IFN) – mai induce CCyR in
10-20% of pts

– Allogeneic stem cell transplantation

• Currently the only cure
• Still plagued by high transplant-related
mortality (TRM)
 Monitorizarea pacientilor cu LMC
HEMATOLOGIC CITOGENETIC MOLECULAR

la fiecare 2 spt pana la la 3 luni pana la La 3 luni RT-PCR

confirmarea RHC confirmarea RCC

La 18 luni
La 3-4 La 6 luni
saptamani

BMS confidential; for internal use only

 Tratament -
Faza accelerata si puseu blastic
 I linie
 Pacienti ITK naivi - AlloHSCT, precedat de
imatinib 600 / 800 mg/ dasatinib/ nilotinib, in cazul
asocierii unor mutatii rezistente la imatinb

 aII a linie
 Pacienti tratati anterior cu Imatinib - AlloHSCT,
precedat de dasatinib sau nilotinib, chimioterapie
~LA
 Treatment of blastic phase CML
 Combination chemotherapy
 AML/ALL type regimens
 High toxicity
 Low response rate
 Allogeneic stem cell transplant
 High toxicity
 Low response rate
 Imatinib, Dasatinib, Nilotinib
 Low toxicity
 Transitory hematological response in 50% of
patients, sometimes lasting years
 Sometimes also CCyR, MMR
 LMC: dupa 2000
 Boala indolenta cu prognostic excelent
 Supravietuire la 5-ani : 90%
 supravietuire mediana: ≥ 25 ani
 Terapie de prima linie: imatinib mesylate
 Terapie de a doua linia: inhibitori TK gen
II, transplant medular
 Clasificarea WHO (World Health
Organization) 2008 Neoplasmelor
Mieloproliferative:

 Leucemia mieloida cronica Ph1 pozitiva

 Policitemia vera
 Trombocitemia esentiala
 Mielofibroza primara
 POLYCYTHEMIA VERA
 Definition:
 MPN characterized by increased red cell number
(polyglobulia) due to autonomous, non-stimulated
proliferation of erythrocytes.
 Characterized by the abnormality of the JAK2 TK

 Epidemiology
 incidence: 5-15/1,000,000/year
 incidence peak – 50-60 years
 predominance in males
 “Red Face”
 Clinical Picture
 Red skin, especially face and palms
 Dizziness, vertigo, blurred vision
 itching, particularly after exposure to warm water, present
in approximately 40% of patients.
 A rare but classic symptom of PV is erythromelalgia,
 Sometimes stroke, heart attacks, thromboembolism
 Rarely bleeding
 Splenomegaly, rarely hepatomegaly
 hyperviscosity
and thrombotic risk

 the risk of
acutisation is
relatively low
5-10%
erythromelalgia, characterized by severe burning
pain in the hands or feet, usually accompanied by
a reddish or bluish coloration of the skin an caused
by an increased platelet count or increased platelet
"stickiness" (aggregation), resulting in the
formation of tiny blood clots in the vessels of the
extremity.
 Laboratory findings
 Increased red cell mass
 Hgb>18.5g/dl (♂) or >16.5g/dl (♀), Hct->51% (♂) or
>48% (♀), often >60%, RC >6 mil/l

 Leucocytosis, usually <50,000/l with left shift

 Thrombocytosis, sometimes > 1000,000/l
 Biochemistry
 High LDH
 Low iron
 High histamin
 Blood gas assay: normal oxygen saturation
 Low/normal erythropoietin levels
 JAK2 V617F in 95% of cases
 Diagnostic criteria (WHO 2008):
 Major criteria:
1. Hgb>18.5g/dl in men or >16.5g/dl in women
2. Presence of the JAK2 V617F mutation

 Minor criteria
1. Bone marrow tri-lineage proliferation
2. Low serum erythropoietin (EPO) levels
3. Endogenous erythroid colony (EEC) growth

 Diagnostic algorithm:
 2 major criteria + 1 minor criteria
 Major criterion 1 + 2 minor criteria
 Differential diagnosis:
 Secondary polycythemia
 Living at altitude - >3000m
 Diseases associated with chronic hypoxia

 chronic bronchitis
 chain smokers
 Renal hipoxy (transplant/hydronephrosis etc)

 congenital cardiopathies
 renal artery stenosis
 EPO secreting tumors
 Treatment of PV
 Phlebotomy
 300-400ml per phlebotomy until Hct 40-45%,
 then one/2 weeks - 1 month
 Antiplatelet drugs:
 Aspirin 75-150mg/day
 Plavix 75 mg
 Hydroxyurea 1-2g/day
 Antihistamine drugs
 IFN
 Ruxolitinib (Jakavi) JAK inhibitor
 Evolution, Complications
 When treated correctly, most cases have a good
prognosis
 Most frequent complications – stroke,
myocardial infarction, DVT, Budd-Chiarri sdr
 5–10% acutisation – secondary AML

 5-10% progress towards myelofibrosis

 Clasificarea WHO (World Health
Organization) 2008 Neoplasmelor
Mieloproliferative:

 Leucemia mieloida cronica Ph1 pozitiva

 Policitemia vera
 Trombocitemia esentiala
 Mielofibroza primara
 ESSENTIAL THROMBOCYTHEMIA

 Definition:
 Persistent thrombocytosis (>450,000/l) without
other causes.
 It is a difficult diagnosis: requires exclusion of
other conditions that may display
thrombocytosis

 Epidemiology
 Incidence: 7/1,000,000/year

 Peak of incidence: 50-70 years

 Etiopathogenesis
 Etiology unknown
 Autonomous growth of megakaryocytes
 About 50% have the JAK2 V617F mutation (2005)
 25-30% : mutations of the CALR (calreticulin) gene
(2013)

 Clinical picture
 Most patients non-symptomatic
 20-40% present with thrombosis
 10-15% present with hemorrhage
Necrotic lesions due to repeated thrombosis in a case of
essential thrombocythemia
 Laboratory findings
 Plt > 450,000, often >1,000,000/
 WBC sometimes high
 Left shift, basophilia
 Normal serum iron, ferritin
 Absence of Ph1
 Absence of polycythemia
 Megakaryocytic hyperplasia
 JAK2 V617F mutation in 50-60% of cases
 CALR mutations in 25-30% of cases
Peripheral thrombocytosis in a case of ET
Megakariocytic hyperplasia in ET
 Diagnostic criteria (WHO 2008)
1. Platelets >450,000/µl
2. Megakaryocyte hyperproliferation with large,
lobulated megakaryocytes
3. Exclusion of other myeloid proliferations
(CML, PV, PMF, MDS)
4. Presence of the JAK2 V617F mutation or other
clonal mutation (CALR?) or exclusion of
reactive thrombocytosis

 Diagnostic algorithm: for ET diagnosis, all 4

criteria must be present
 Treatment
 Low risk: Plt<1,500,000, <40 years, no thrombosis, no hemorrhage
 aspirin low-dose (75-150mg/day)

 Intermediate risk: Plt<1,500,000, 40-60 years

 aspirin low-dose (75-150mg/day)
 If other risk factors for thrombosis (HT, diabetes, heart disease,
etc) are present, cytoreductive treatment is added - hydroxiurea or
anagrelide

 High-risk: Plt >1,500,000 and/or history of thrombotic events

 hydroxiurea or anagrelide + low-dose aspirin

 If hemorrhage – avoid aspirin

 In case of very high platelet count and acute hemorrhage or

thrombosis – platelet apheresis
 Prognosis
 If complications (mainly thrombotic) are
avoided, most patients have normal life span
 3-5% develop acute leukemia

 Often neurologic complications and sequelae

from stroke
 Polycythemia vera and essential thrombocythemia: 2015 update on
diagnosis, risk‐stratification and management

American Journal of Hematology

Volume 90, Issue 2, pages 162-173, 21 JAN 2015 DOI: 10.1002/ajh.23895
http://onlinelibrary.wiley.com/doi/10.1002/ajh.23895/full#ajh23895-fig-0003
 Clasificarea WHO (World Health
Organization) 2008 Neoplasmelor
Mieloproliferative:

 Leucemia mieloida cronica Ph1 pozitiva

 Policitemia vera
 Trombocitemia esentiala
 Mielofibroza primara
 PRIMARY MYELOFIBROSIS (PMF)
 Definition
 MPN characterized by myelofibrosis,
hepatosplenomegaly, progressive cytopenias

 Epidemiology
 Incidence : 1/100,000/year
 Peak of incidence – 60 years

 Etiopathogenesis
 Etiology – unknown
 Proliferation of dysplastic megakaryocytes – production
of cytokines, especially platelet derived growth factor
(PDGF) that stimulate fibroblasts – myelofibrosis
 JAK2 V617F mutation in 50-70% (2005)
 CALR mutations in 25-30% (2013)
 Clinical Picture
 Symptoms of anemia
 Weight loss, sweating, fever

 Abdominal pain, bloating

 Splenomegaly – huge

 Hepatomegaly

 Hemorrhage
Huge splenomegaly in a case of primary myelofibrosis
 Laboratory Findings
 Anemia, sometimes severe
 Leucoerythroblastic picture on the peripheral smear:
left-shift + erythroblasts
 Presence of tear-drop red cells (dacriocytes)
 Sometimes autoimmune hemolytic anemia, AHAI
(reticulocytosis, jaundice, positive Coombs test)
 Moderate leukocytosis, usually <50,000
 Thrombocytopenia
 Bone marrow biopsy – Gomori stain – myelofibrosis of
various degrees
 JAK2 V617F in 50-70% of cases
 CALR mutations in 25-30% of cases
Dacryocytes (tear drop shaped red cells)
Myelofibrosis – Gomori stain
 Diagnostic criteria (WHO 2008)
 Major criteria:
1. Proliferation with atypical megakaryocytes +
reticulin/colagen fibrosis
2. Exclusion of other myeloid proliferations (CML, PV, ET,
MDS)
3. The presence of the JAK2 V617F mutation, (CALR?) or
exclusion of reactive myelofibrosis

 Minor criteria:
1. Leucoerythroblastic peripheral smear
2. High serum LDH
3. Anemia
4. Splenomegaly

 Diagnostic algorithm: 3 major criteria + 2 minor

criteria
+ JAK2 V617F mutation, (CALR?)
 Treatment
 Mostly transfusions for anemia
 Hydroxiurea and IFN can sometimes reduce
splenomegaly
 Corticosteroids if AHAI
 Splenectomy: if huge, painful splenomegaly
 Recently: JAK2 inhibitors (ruxolitinib) were found to be
beneficial in some cases, reducing splenomegaly and
symptoms
 Allogeneic stem cell transplant

 Prognosis
 Median survival 5-6 years (2-15)
 Acutisation in 10-20% of cases
Confirmarea diagnosticului de LMC este dat
de:

A. Prezenta cromozonului PH1

B. Prezenta celuleor Burkitt-like
C. Splenomegalia marcata
D. Devierea la stânga a seriei granulocitare
E. Bazofilie
Diagnosticul diferential al LMC se face cu
urmatoarele, CU EXCEPTIA:

A. Policitemia vera
B. Trombocitemia esentiala
C. Reactiile leucemoide
D. Infectia cu CMV
E. LAM

R= D
 Complement multiplu

 Faza accelerata a LMC se caracterizeaza prin:

A. Aparitia rezistentei la tratament
B. Crestere progresiva a splinei
C. Trombocitopenie persistenta
D. Scadere FAL
E. Febra

R= A,B,C,E
 Examinarile paraclinice in faza cronica
evidentiaza:

A.Hiperleucocitoza
B.Anemie normocroma normocitara
C.Absenta bazofiliei
D.Fosfataza alcalina leucocitara crescuta
E. Nivele crescute de histamine serica

R=A,B,E