Enclonar, Kimberly / MLS 3A

Myeloproliferative Neoplasms
May 19, 2021
Keziah Amor S. Catulong, RMT

Myeloproliferative Neoplasms
• Insidious - 3 to 4 years; cytosis; can mature to end
stage; non-functional
• Can transform to an acute phase
• Clonal hematopoietic disorders caused by genetic
mutations in the hematopoietic stem cells
• Results in expansion, excessive production, and
accumulation of erythrocytes, granulocytes, and
platelets
• Predominantly chronic with accelerated, subacute, or
acute phases
• Myeloproliferation due to:
o Hypersensitivity to cytokines or independence to
normal cytokine regulation by mature cells

WHO Classification
• Chronic Myelogenous Leukemia
• Polycythemia vera
• Primary myelofibrosis
• Essential Thrombocythemia

Myeloproliferative Disorders
• Myelo - BM; Proliferative - Production; Disorders -
Abnormal
• Pluripotent stem cells → Primary myelofibrosis
o Myeloid stem cell →
▪ Prorythroblasts → RBCs → PV
▪ Myeloblasts → neuts, eosi, baso → CML
▪ Monoblasts → mono
▪ Megakaryoblasts → megakaryocyte → plts
→ Essential Thrombocythemia
o Lymphoid stem cell → NK, T, B
• Receptor tyrosine kinase defect
o Regulates cell division and differentiation
• Common presentation
o Organ infiltration
Philadelphia Chromosome
• BCR-ABL is not conclusive of CML
Chronic Myelogenous Leukemia (CML) o Acute leukemias were previously CML, but are
• Arises from a single genetic translocation in a not detected early
pluripotent hematopoietic stem cell • BCR-ABL1 - cytoplasm
o Philadelphia chromosome - reciprocal o ABL - proto-oncogene, band q34
translocation in long arm of 9 and 22 o BCR - band q11
• Results to the overproduction of the myeloid cell line • Wild type chromosome 9 (ABL) - codes for protein
(immature neutrophils predominate) 125
• Disease Phase (Untreated) o Protein 125 - responsible for normal tyrosine
o Chronic clinical phase kinase activity
o Accelerated phase (3-4 years) ▪ TK regulates signal transduction pathway
o Acute phase (end phase) (switch)
• Incidence ▪ Activates regulatory genes
o Predominant among males than in females ▪ Phosphorylation - auto-phosphorylation
o Age: 46-53 years using TK
• Primary Clinical Features o 3 parts (domains)
o Pathologic accumulation of myeloid progenitor ▪ SH1 - binding site for ATP
cells in BM, PB, and extramedullary tissues ▪ SH2 - docking point
▪ Impaired apoptotic function ▪ SH3 - phosphorylation
▪ Increased RPI • Wild type chromosome 22 (BCR1) - codes for protein
o PBS shows neutrophilia with all maturation 160
stages present, basophilia, eosinophilia, and o Expresses serine and threonine kinase activity
***thrombocytosis o Important for regulation of cell growth
• Secondary Clinical Features • Translocation happens near SH3
o Frequent infection o Abnormality in the rate and timing of
o Anemia phosphorylation
o Bleeding o Hyperactivation of signal transduction
o Splenomegaly o Reduce differentiation
 Enclonar, Kimberly / MLS 3A
o F-actin and stromal cells are affected → • Leukemoid reaction
decreased adhesion o increase in WBC, but not CML
o Loss of sensitivity to protein regulators; factor o Normal cells
independent due to RASP gene o High LAP score
• More vulnerable to mutations → more mutations →
more resistance to treatment or blast formation Treatment
• Chimeric genes • Past goal (Pre-imatinib era): reduction of tumor
o 4 chimeric genes → 3 different proteins burden
• 6-thioguanine and busulfan
o Interferon alpha
• Increases adhesion
• Hydroxyurea and 6-mercaptopurine
• Cytarabine
• Autologous or allogenic bone marrow and
• Stem cell transplant
• First Generation: IMATINIB MESYLATE → TK inhibitor
o Imatinib Resistance
▪ Acquisition of additional BCR-ABL1
mutations
▪ Expression of point mutations at ATP
binding sites
▪ ***T31BI mutation
• Second generation: DASATINIB, NILOTINIB, &
BOSUTINIB
o Except for patients with T31BI mutation
o Increased affinity to the binding sites
• Third generation: PONATINIB or A-loop inhibitors
o Overcomes T31BI mutations

Imatinib Mesylate (Gleevec)

• Treatment Goal:
o Complete hematologic, cytogenetic and
molecular remission
o Absence of Ph1 by karyotype analysis
o Absence of measurable BCR/ABL transcripts
• Most sensitive measure of treatment effectiveness:
Real Time RT-PCR
o Reduced log number of BCR-ABL transcripts

Accelerated Phase Blast Phase

Increase in aggressiveness of Blasts 20% or more of PB
disease WBCs and/or BM
nucleated cells
Persistent or increasing WBC Extramedullary blast
(>10x109/L) + increasing proliferations
spleen size unresponsive to
therapy
Persistent thrombocytosis Can progress to ALL or
(>1000x109/L) + unresponsive AML
to therapy
Persistent thrombocytopenia
(<100x109/L) unrelated to
therapy
Polycythemia Vera (PV)
Cytogenic evidence of clonal • Also known as Polycythemia Rubra Vera
evolution o Vera - "true"
• Neoplastic clonal myeloproliferative disorder
Laboratory Findings • Common manifestation: "panmyelosis"
• Hyperuricemia and uricosuria • (+) splenomegaly
o Increase uric acid • Two phases
• WBC count >300x10/L o Overt polycythemia characterized by a
o Abnormal WBC proliferation of erythroid cells
• Vascular stasis o Late phase of BM exhaustion referred to as post-
• Intravascular consumption of the leukocytes polycythemia vera myelofibrosis (post PV MF)
• Leukocyte alkaline phosphatase (LAP score) "spent phase"
o Low LAP Score ▪ Similar to primary myelofibrosis
• Detection of t(9:22) and BCR-ABL fusion gene • Manifestations
o Via FISH or RT-PCR
 Enclonar, Kimberly / MLS 3A
o Myeloid stem cell → proerythroblast → RBCs →
lungs (oxygen exchange)
o Too much sensitivity of EPO or independence to How is it Diagnosed?
EPO → large number of RBCs
o Increased vessel blockage
o Hepatic vein thrombosis
o Retinal vein thrombosis
o Pruritis (release of histamine)

Clinical features
• Classic manifestation: red cheeks "Ruddy cyanosis"
• Headache and dizziness
• MI
• Stroke
• Paresthesias
• Deep vein thrombosis
• Plethora (excessive number of cells)
• Hepatosplenomegaly

Secondary vs Relative Polycythemia

Secondary Relative polythemia
Inappropriate response Increased because the other
(EPO-BM) is decreased
Reaction

Pathophysiology
• Point mutation JAK2 V617F
• Exon 14 → guanine is replaced with thymine
o Valine to Phenylalanine (Position 617)
• Inactive JAK2 (no mutation)
o Regulatory proteins that helps in the folding of
JH2
▪ SOCS1 (suppressor of cytokine signalling)
▪ JAB (Janus Binding Protein)
• Active JAK2 (with mutation)
o JH2 - pseudokinase domain
o JH1 - kinase domain
o Inhibited inhibitors and no folding
o Activate signal transduction pathway
▪ STAT 5, 3
▪ P13K/AKT
▪ MAP kinase
o Activation of pathways causes activation of BCL-
X → anti-apoptosis → cell proliferation
• Alteration in the EPO receptors
o Hypoxia → release of EPO → BM → increase
cells
o JAK2 mutation causes conformational change in
the EPO receptor → dimerization → produces a
docking head at the FERM 2 (band 4.1, ezrin,
radexin, moysin) → conformational change in Postpolycythemic Myeloid Metaplasia "Spent Phase"
JAK2 → phosphorylation → release of valine → • Triad of
o Bone marrow fibrosis
converts in to Active Tyrosine Kinase
o JAK2 can also bind other cells → STAT → o Splenomegaly
o Anemia with "tear-drop" poikilocyte
hyperproliferation
o Causes ▪ with morphologic features similar to PMF
▪ Increased cell differentiation
▪ Increased cell division Prognosis
▪ Resistance to BCL x • Without treatment: Poor: few months
• Can bind • With treatment:
o Interleukin o Good: 15 to 20 years
o Prolactin o 20% die due to AML or MDS
o MPL
o GCSF-R Treatment
o GMCSF-R • Therapeutic phlebotomy
• Hydroxyurea or interferon gamma
• JAK inhibitors (INCB018424: Ruxolitinib)
 Enclonar, Kimberly / MLS 3A
Essential Thrombocythemia (ET) Prognosis
• Relative long survival provided they remain free of
• Other names
o Primary thrombocythemia serious thromboembolic complications
o Idiopathic thrombocytosis • Median survival time: 20 years
o Hemorrhagic thrombocythemia • Some may develop post ET myelofibrosis
• Clonal MPN with increased megakaryopoiesis and
Treatment
thrombocytosis >600x109/L or >1000x109/L
o Problem in megakaryoblast • Prevention of early alleviation of hemorrhagic or
vassocclusive complications
• WHO criteria: 450x109/L
• Almost the same mutation as PV • Suppression of marrow megakaryocyte
o JAK2 V617F; 55% • Hydroxyurea
o MPL exon 10 mutation, 3% • Low dose aspirin
o TET2 4.4%
o ASXL1 5.6% Primary Myelofibrosis
o LNK 3-6% • Other names
• 1st phase: Thrombosis o Agnogenic myelofibrosis with myeloid
o Head: Headache, dizziness, weakness metaplasia (AMMM)
o Hands: numbness, burning o Chronic idiopathic myelofibrosis (CIM)
• 2nd phase: Bleeding o Myelofibrosis with Myeloid metaplasia (MMM)
o Reduced vWF • A clonal disorder of HSCs
o Abnormal platelets • Megakaryocytes and granulocytes predominate
o Nosebleed, bruises, • Reactive fibrosis
• Clinical presentation • Megakaryocytes and platelets release several
o Thrombotic tendencies cytotoxins that stimulate fibrosis
o Microvascular disease o PDGF, TGF beta, bFGF, CIMF
o Embolism • Extramedullary hematopoiesis
• Primary myelofibrosis
o Excess production of connective tissue (collagen)
o Myeloid metaplasia
o Abdominal fullness
o Bone pain
PERIPHERAL BLOOD
Prefibrotic stage Fibrotic
Mild to moderate anemia Moderate to marked
anemia
Leukocytosis Variable WBC and plt count
Thrombocytosis Myelopthisis
Progenitor cells in the Tear-drop cell
circulation
BONE MARROW
Hypercellularity Bone marrow becomes less
cellular
Prominent megakaryocytes Increase prominence of the
and show clustering with megakaryocytes
abnormal nuclear lobation
and bare nuclei
Ring sideroblasts are present Development of collagen
How is it Diagnosed? (some cases) and reticulin fibrosis
• Diagnosed in a routine checkup Dry Tap - Do trephine
WHO biopsy

1. Sustained plt count ≥450x109/L Prognosis

2. BM biopsy showing proliferation mainly of the
megakaryocytic lineage
3. With increased numbers of enlarged mature
megakaryocytes; no increase or left shift of neutrophil
granulopoiesis and erythropoiesis
4. Not meeting WHO criteria for PV, PM, CML, MDS or
other myeloid neoplasm Treatment
5. Demonstration of JAK2 or other clonal marker, or in
the absence of a clonal marker, no evidence for
reactive thrombocytosis
• Average survival time: 5 years
• Increasing numbers and pleomorphy of
megakaryocytes lead to progressive marrow failure
• Death is associated with infection, hemorrhage, post-
splenectomy complications, and transformation to
acute leukemia
• Transfusion of blood products
• Splenectomy
• Stem cell transplant
• Chemotherapy
• JAK inhibitors