acute leukaemias myelodyplasia - semmelweis egyetem€¦ · idarubicin 12 mg/m2 iv. on day 2, 4, 6,...

Acute leukaemiasMyelodyplasia

Dr. Varga GergelyDr. Varga GergelySemmelweis Egyetem

III. Sz. Belgyógyászati Klinika

Acute leukaemia

1st case: 84 y.o. maleHx: myocardial infarct, hypertension.C/o fatigue, weakness and leg oedema, looks pale.Painful ulcers in the mouth for one week.O/E Hepatosplenomegaly, no lymphadenomegaly.Lab.: WBC: 136.000, Hb 85 g/l, PLT: 18.000, LDH: 3288

U/lU/lBloodfilm:

Diagnosis: acute leukaemia

AML: typical signsAnaemia:

Palor, weakness, palpitationThrombocytopenia:

GI & nasal bleeding, petechias

Neutropenia:Infections: Infections: Mouth: neutropenic ulcerPneumonia (fungal!)

Hyperviscosity: confusion

Bony pain

Hyperthermia/fever (due to the proliferation)

1st case: 84 y.o. maleTreatable / curable?

Myeloid or lymphoid in origin?Morphology, immunohystochemistryFlow cytometryFlow cytometry

Prognosis?Cytogenetics (cytogenetics, FISH, PCR)

Is stem cell transplant an option?

The demography of the AML

100

Incidency/ 100.000

50

Sibling Allogeneic Transplant

MUD transplant

High dose chemo

0

20 40 60 800 Age

De novo, young, no comorbidity:Good prognosis

Elderly, post-MDS, post chemo,several comorbidity: poor prognosis

?Low dose chemotherapy

Only supportion (BSC)

1st case: 84 y.o. maleTreatable / curable? No curative treatment in this age

group, BSC, cytoreduction if necessary

Myeloid or lymphoid in origin?Morphology, immunohystochemistryFlow cytometry



1st case: 84 y.o. maleTreatable / curable? Kuratív kezelés reménytelen.

Cytoreductio, supportio indokolt.

Myeloid or lymphoid in origin?Morphology, immunohystochemistryFlow cytometry



Morphology: AML M0

Morphology: AML M2

Morphology: AML M3

Auer rods

Hypogranular APL

Morphology: AML M4 (myelomonocytic)

Morphology: AML M6 (erythroid)

Morphology: AML M7 (megakaryocytic)

Morphology: ALL

Morphology: ALL (Burkitt)

Immunohistochemistry

Gyűjtő

Flow cytometry

anti

antiCD7

antiCD33

antiCD13

CD34 CD33

CD13

Flow cytometry

10 1 10 2 10 3 10 4

CD13- FITC -->

10

110

210

310

4

CD

34 P

E -

->CD

34

Flow cytometry in AML

10 20 30 40 50 60

FSC-Height -->

10

20

30

40

50

60

SS

C-H

eigh

t -->

SSC

10 20 30 40 50 60

FSC-Height -->

10

20

30

40

50

60

SS

C-H

eigh

t -->

10 1 10 2 10 3 10 4

CD45 PerCP -->

10

20

30

40

50

60

SS

C-H

eigh

t -->

SSC

CD45

10 1 10 2 10 3 10 4

CD7 FITC -->

10

110

210

310

4

CD

33 P

E -

->CD

33

CD7

CD13- FITC -->

CD13FSC-Height -->

10 1 10 2 10 3 10 4

CD45 PerCP -->

10

20

30

40

50

60

SS

C-H

eigh

t -->

FSC

CD45

FSC-Height -->

FSC

WHO classification of AL



Myeloid or lymphoid in origin?Morphology, immunohystochemistryFlow cytometry: AML, M1





Myeloid or lymphoid in origin?Morphology, immunohystochemistryFlow cytometry: AML, M1

Prognosis: poorCytogenetics (cytogenetics, FISH, PCR)Not done

Is stem cell transplant an option?No

1st case: 84 y.o. maleHistory of treatment:Transfusion, antibiotics, mouth care continously.1. Low dose azacitidin trial: short lived response, then

progression.2. Hidroxyurea (oral) for cytoreduction: no response.3. Etoposid (oral): tolerated well with a relatively good 3. Etoposid (oral): tolerated well with a relatively good

response for 4 months.Then he developed a pneumonia showed no response

to antibiotics.PM: fungal chest infection with brain involvement.

2nd case: 23 y.o. womanNothing remarkable in her medical historyAdmitted to ICU with quickly developed neurological

problems leading to seizures. CT showed subdural haemorrhageWBC: 3.600, hgb: 66 g/l, PLT: 15.000, LDH: 1200, INR:

4,5, APTT: 100, D-dimer: 10,2, fibrinogen 0.14,5, APTT: 100, D-dimer: 10,2, fibrinogen 0.1Bloodfilm:

Diagnosis:

2nd case: 23 y.o. womanNothing remarkable in her medical historyAdmitted to ICU with quickly developed neurological

problems leading to seizures. CT showed subdural haemorrhageWBC: 3.600, hgb: 66 g/l, PLT: 15.000, LDH: 1200, INR:

4,5, APTT: 100, D-dimer: 10,2, fibrinogen 0.14,5, APTT: 100, D-dimer: 10,2, fibrinogen 0.1Bloodfilm:

Diagnosis: probable acute promyelocytic leukaemia complicated with DIC

Acute promyelocytic leukaemia (APL, FAB M3)

Young adultsWBC is usually normalHypergranular promyelocytes

(hypo-, microgranular in 20%)

Diffuse intravascularcoagulation (DIC)coagulation (DIC)

Flow cytometry: CD13+, CD33+, CD34-, HLA DR-Cytogenetics: t(15;17)PCR: PML-RARαBefore the ‘90s 50% periinduction mortality due to DICNow: complett response (CR): 80-90%

Cytogenetics

PML-RARα: block of differerentation

N-CoR: nuclear coreceptors, HDAC: histone deacetylase

PML-RARα: genes involvedClass of genes Examples

Regulators of the cell cycle Cyclins, cyclin-dependent kinases and CDK inhibitors

Cell surface adhesion molecules

CD11b, CD18

Intrinsic host defense systems and extrinsic cytokines

Monocyte chemo-attractant factor, interleukins

Neutrophil granule proteins Defensin, secondary granule proteins, leukocyte alkaline phosphatase, lactoferrinalkaline phosphatase, lactoferrin

Colony-stimulating factors IL-1, IL-8, G-CSF

Colony-stimulating factor receptors

M-CSFR, G-CSFR

Regulators of apoptosis and terminal cell division

Transglutaminase II, bcl2

Structural proteins, enzymes, chromatin components

Clotting factors Thrombomodulin, tissue factor, urokinase, tissue plasminogen activator and its inhibitors

Transcription factors RARs, STATs, Hox genes

Mechanism of DIC in APL

Lab. signs: PLT↓, INR↑, APTT↑, Fibrinogen ↓, D-dimer↑

Mediators secreted by the abnormal granulocytes activate the coagulation cascade and the fibrinolysis

Treatment:Supportion: FFP, PLT transfusionall trans retionic acid (ATRA) + chemotherapy alternatively arsenic trioxide

ATRA syndrome (Capillary leak syndrome)Signs:• Fever• High WBC: ATRA facilitates the maturation of neutrophils. This

often results in increasing WBC. These cells infilrates the lung, the liver etc leading to organ failure.

• Oedema: Mediators secreted by the neutrophils increase the membrane permeability leading to capillary leakage, which membrane permeability leading to capillary leakage, which results in extravasal fluid retention.

More frequent if initial WBC>10.000Typically in first week25% in ATRA monotherapy;

2nd case: 23 y.o. womanTreatable / curable?

Yes: young with no major comorbidity

Diagnosis megerősítéseImmunohistochemistryFlow cytometryFlow cytometryCytogenetics (cytogenetics, FISH, PCR)

Is stem cell transplant an option?Siblings?MUD search?



Diagnosis: APLImmunohistochemistryFlow cytometry: CD13+, CD33+, CD34-, HLA DR-Flow cytometry: CD13+, CD33+, CD34-, HLA DR-Cytogenetics (cytogenetics, FISH, PCR):

46XY, t(15;17), PML-RARA confirmed with PCR




Diagnosis: APLImmunohistochemistryFlow cytometry: CD13+, CD33+, CD34-, HLA DR-Flow cytometry: CD13+, CD33+, CD34-, HLA DR-Cytogenetics (cytogenetics, FISH, PCR):

46XY, t(15;17), PML-RARA confirmed with PCR

Is stem cell transplant an option?Siblings: noMUD search? no (curable with conventional chemo)

Treatment aproach generally in AMLAML

Good: M2 t(8;21),M4 inv(16):

Intermediate: normal, del 7q, +8, t(9,11), -y

Poor: -7, -5, complexcytogenetical abnorm (>2), inv(3), t(6,9), flt3 ITD?

treatable patient

Supportion only

APL M3 t(15;17):different treatment

Chemotherapy

If no remission orrelapse

In case of HLA identicalsibling donor transplant in 1st remission

Transplant in case ofeither HLA identical sibor MUD donor

In case of relapse

Chemotherapy

Chemotherapy

The treatment of APL

ATRA 45 mg/m2 orallyidarubicin 12 mg/m2 iv. on day 2, 4, 6, 8

APL M3 t(15;17):different treatment from the othe types of AML

Anthracyclin based postremission treatment

Treatment of relapse:Treatment of relapse:As2O3 (arsenic trioxide)Autologues transplant Mylotarg (anti CD 33 antibody)Combination chemoAllogeneic transplant


Maintenance treatment for 2 years:6 MP/100 mg/m2/dayMTX 10 mg/m2/weekATRA for 2 weeks in every 3 months

2nd case: 23 y.o. woman

Developed ATRA syndrome and DIC

� stop ATRA, add

ATRA 45 mg/m2 orallyidarubicin 12 mg/m2 iv. on day 2, 4, 6, 8

APL M3 t(15;17):different treatment from the othe types of AML

Anthracyclin based postremission treatment � stop ATRA, add dexamethason

Died in fungal sepsis


Maintenance treatment for 2 years:6 MP/100 mg/m2/dayMTX 10 mg/m2/weekATRA for 2 weeks in every 3 months

3rd case: 54 y.o. maleNothing remarkable in his medical history.

C/o fatigue, weakness for1 month.

Admitted to general ward with perianal infection.with perianal infection.

WBC: 9.600,hgb: 76 g/l, PLT: 35.000, flagged by the lab with immatured cells in the differential

Sent for outpatient haematologist review

3rd case: 54 y.o. maleO/E:

no hepatosplenomegaly,

no lymphadenomegaly,

gingival hyperplasia

Diagnosis:

possible acute leukaemia

monocytic?

Admitted to haematology

ward

3rd case: 54 y.o. male

Marrow:

Diagnosis: acute leukaemia

3rd case: 54 y.o. maleTreatable / curable?

Yes: young with no comorbidity, consented for chemo.

Myeloid or lymphoid in origin?ImmunohistochemistryFlow cytometryFlow cytometry

Prognosis?Cytogenetics (cytogenetics, FISH, PCR).




Myeloid or lymphoid in origin?ImmunohistochemistryFlow cytometry: AML-M4Flow cytometry: AML-M4



AML 5 survival (AML11 trial)Good: M3 t(15;17), M2 t(8;21), M4 inv(16):

curable in 70-75%Intermediate: normal, del 7q, +8, t(9,11), -y

normal & flt3 ITD -ve: curable in aprx 55%normal & flt3 ITD +ve: curable in

Cytogenetics


Yes: young with no comorbidity, consented for chemo.Myeloid or lymphoid in origin?

ImmunohistochemistryFlow cytometry: AML-M4

Prognosis?Cytogenetics (cytogenetics, FISH, PCR).46XY, flt3 ITD +ve: poor prognosis




ImmunohistochemistryFlow cytometry: AML-M4

Prognosis?Cytogenetics (cytogenetics, FISH, PCR)46XY, flt3 ITD +ve: poor prognosis




Immunohistochemistry.Flow cytometry: AML-M4.

Prognosis?Cytogenetics (cytogenetics, FISH, PCR).46XY, flt3 ITD +ve: poor prognosis

Is stem cell transplant an option? YesSiblings: one HLA identical sib 48 y.o. healthy maleMUD search? no

OS DFS

Role of transplant in the treatment of AML

Only chemo n=1314Age: 66 years (44-91)CR in 60%5 OS only in 13%

Transpalnt (RIC) n=253Age: 55 years (18-72)2 DFS: 41%

AML

Good: M2 t(8;21),M4 inv(16):



treatable patient

Supportion only


Role of transplant in the treatment of AML

Chemotherapy




In case of relapse

Chemotherapy

Chemotherapy

3rd case: tratmentAML

1. 7+3 (DA) induction:BM showed 8% residual blasts

2. FlagIDA reinduction: CRHLA identical sib identified

3. 2x HD-AC consolidation

treatable patient


Organising the transplant 4. Succesful transplant in the first

remission with no major problem5. Alive and well

Chemotherapy


4th case: 55 y.o. maleHx of diabetes for 10 years, on oral antidiabetics.C/o fatigue, weakness for 1 month.Admitted to the general ward

with fever and skin lumps.WBC: 100.000, HGB 98 g/l,

PLT 80.000.For haematologist review

due too these.

4th case: 55 y.o. maleO/E marked hepatosplenomegaly.Bloodfim:

Diagnosis: acute leukaemia (myelomonocytás?)

4th case: 55 y.o. maleTreatable / curable?


Myeloid or lymphoid in origin?Flow cytometry

Prognosis?Prognosis?Cytogenetics (cytogenetics, FISH, PCR)




Myeloid or lymphoid in origin?Flow cytometry: AML M4

Prognosis?Prognosis?Cytogenetics (cytogenetics, FISH, PCR).





Prognosis: Prognosis: Good (46XY, inv 16)






Is stem cell transplant an option?Siblings? No.MUD search? No. (only in relapse)





Is stem cell transplant an option?Siblings? No.MUD search? No. (only in relapse)

Plan: Chemotherapy, monitoring of gene mutation

Terápiás válasz, minimális reziduális betegségIndukction Consolidation chemotherapies

1012

109

N of BlastsMorphology

Flow cytometry (abnormal coexpression of CD markers)

Cytogenetics?

No remission: poor prognosis� more aggressive treatment & transpalnt

„7+3” „7+3” „HD-AC” „HD-AC”„HD-AC”

10

106

103

Cytogenetics

Molecular genetics (bcr-abl in ALL)

?

?

FISH (inv 16)

Diagnosis Controll marrow tests

The fluorescens in situ hibridisation (FISH) test

Hybridisation

5q- 7q- +8

Options for FISH

AML

Good: M2 t(8;21),M4 inv(16):



treatable patient

Supportion only


Treatment plan at presentation

Chemotherapy




In case of relapse

Chemotherapy

Chemotherapy

AML

Good: M2 t(8;21),M4 inv(16):



treatable patient

Supportion only


The signification of the BM test on day 28

1st cycle chemo


1st cycle chemo

Chemotherapy

CR after induction chemo?

Salvage treatment (Flag-IDA)

No

Carry on according to the original plan

Yes

5th case: 60 y.o. male60 y.o. male.Hx: Diabetes, hypertension.Long standing anaemia, GP prescribed iron. Now developed pancytopenia, sent for haematologsist

outpatient review.WBC: 2.600, (ne: 23%), hgb: 81, MCV: 102, PLT: WBC: 2.600, (ne: 23%), hgb: 81, MCV: 102, PLT:

65.000, LDH: 300Bloodfim:Pseudo-Pelger anomaly, hypogranulatedgranulocytes, abnormal RBC morphology

Diagnosis: myelodysplasia→ Needs Transfusion→ Needs BM for staging

5th case: 60 y.o. male: bone marrow

Dysplasiás granulocyták

MicromegakaryocytákMicromegakaryocyták

MyelodysplasiaClonal disease, praeleukaemiaAbnormalities in 1/2/3 cell line. Hyperrcellular marrow, with dysplastic maturation → cytopenia

Rarely hypocellular marrow (differential: aplastic anaemia)

Patomechanism: deletion of genes rosponsible for maturation, apoptosis.

Patomechanism: deletion of genes rosponsible for maturation, apoptosis.

Growth advantege of the clone which suppresses the normal marrow.

Progression toward acute leukaemia.

MyelodysplasiaMainly in elderly pts (avearage 70 yo.) Primery or secoundery: post chemo- or radiotherapy

Currently no available treatment, except trials.

MDS blast

Myelodysplasia

Dysplastic cells, intramedullary apoptosis

Myelodysplasia: WHO classification

Myelodysplasia: IPSS

Myelodysplasia: kezelés• Szupporton

– transfusion + iron depletion!

• Intermediate:– biological modificators:

– EPO, GCSF– Immunsuppression– Thalidomid, lenalidomid

IPSSLow, Intermed-1

– Thalidomid, lenalidomid

– low dose chemo– Ara-C– 5-azacytidin

• Intensive chemo– AML type induction

• SC transplant– RISCT

IPSSIntermed-2, High


Maybe

Myeloid vagy lymphoid:Flow cytometry

Prognosis?Prognosis?Cytogenetics (cytogenetics, FISH, PCR)



Maybe

Myeloid vagy lymphoid: egyértelmű. Dg: RCMD.Flow cytometry: number of blasts: 5-10%

Prognosis?Prognosis?Cytogenetics (cytogenetics, FISH, PCR).



Maybe.

Myeloid vagy lymphoid: egyértelmű. Dg: RCMD.Flow cytometry: number of blasts: 5-10%

Prognosis: IPSS: High/IntermedPrognosis: IPSS: High/IntermedCytogenetics : 45XY, -7: poor prognosis



Maybe.

Myeloid vagy lymphoid: egyértelmű. Dg: RCMD.Flow cytometry: megerősítés, blast arány: 5-10%

Prognosis: IPSS: High/IntermedPrognosis: IPSS: High/IntermedCytogenetics : 45XY, -7: poor prognosis

Is stem cell transplant an option? YesSiblings? NoMUD search? ASAP

6th. case: 23 y.o. maleNothing ramarkable in medical history.Unwell for 2 weeks, fever and boney pain since

yesterday.WBC: 26.000, ne: 13%, hgb: 103, PLT: 35e, LDH: 3500Boodfim:Immatured blastsprobable lymphoid origin

Diagnosis: ALL?→ Needs BM for flow cytometry (diagnosis)cytogenetic (prognosis)

6th. case: 23 y.o. male

6th. case: ALL prognosis

ALL in generalMore common in children

ALL in general

Treatable / curable? Yes

Myeloid vagy lymphoid:Flow cytometry:

Prognosis?





Myeloid vagy lymphoid:Flow cytometry: pre B-ALL

Prognosis?






Prognosis?


Prognosis?Cytogenetics: no t(9;22), t(4;11) or hyperdiploid




Prognosis?


Prognosis?Cytogenetics: no t(9;22), t(4;11) or hyperdiploid

Is stem cell transplant an option?Siblings? Needs HLA testingMUD search? If no remission or MRD positive

6th. case: 23 y.o. maleHappy end1st week periferal blood clear4th week BM morpologically normal8th week BM flow cytometry showed no abnormal

phenotype

in remission for 4 years.

Allogén őssejtátültetés

J Clin Invest. 1959; 38: 1709–1716.

Seattle csoport:

• Kutyakísérletek

• 1977, 100 végstádiumú AML

Súlyos morbiditás

Bortin, MM A compendium of reported human bone marrow transplants. Transplantation 1970

Acute GvHDInkompatibilitás•HLA antigének•Tumor antigének•Vírus antigének

Immunrendszer•Kondicionálás okozta

szövetkárosodásT-sejtek szövetkárosodás•IL-1, TNF, GM-CSF•T-sejt-aktiváció•Citokin vihar

Rizikó faktorok•Kondicionálás•Életkor•Nem•Fertőzések•SC forrás•T-sejt-tartalom

T-sejtek

Egyéb halálos

toxicitás

Chemotherapy dózisa és a gyógyulás esélye

Irreverzibilis csontvel ő-

károsítás

Esély a kurabilitásra

Autológ transzplantá-ció

Elég lenne az autológ „átültetés”?

• Nagydózisú kemoterápia adható

• Nincs donorkeresés• Alacsony mortalitás (5%)• Tárgyi feltételei egyszerűek

• Ritkán kuratív• Szennyezett graft• Hosszú távú toxicitás:

szekunder tumorok

Transzplantáció utáni halálozás1998-2002

Toxikus szerv-károsodás

Rokon donor Idegen donorGvHD

SUM05_20.ppt

Infekció

Egyéb

Ismeretlen

Center for International Blood and Marrow Transplant Research

Autológ

Relapsus (75%)

Syngenikus átültetés CML-ben

Ann Intern Med. 1994 120(8):646-52

Mi a különbség oka?

RECIPIENS DONOR

GvHD

GVL

Bizonyítékok a GVL hatásra:

1. Kevesebb relapsus allogénben, mint

autológban

2. Kevesebb relapsus GvHD kialakulása caseén, 2. Kevesebb relapsus GvHD kialakulása caseén,

mint ha nincs GvHD

3. Relapsus reagálhat az immunszuppresszió

leállítására

4. Relapsus reagálhat DLI-re

A GVL hatás mértéke:

Jelentős CMLLow grade NHL

Mérsékelt AMLMérsékelt AMLHodgkin-lymphomaMyeloma

Alig/nem ALLHigh grade NHL

Transzplantáció mérlegelése

Agresszív betegség Kemoterápiától gyógyulásAgresszív betegségRelapszusFiatal, kevés társbetegségMagas GVL hatás

Kemoterápiától gyógyulásvárhatóAlacsony GVL hatásNincs donor

Transzplantáció Kemoterápa

acute leukaemias myelodyplasia - semmelweis egyetem€¦ · idarubicin 12 mg/m2 iv. on day 2, 4, 6,...

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