Aplastic Anemia

Tissue Conference 1/19/00 Brad Kahl, MD

Pancytopenia
Reduction of counts in all three cell lines Differential Diagnosis
aplastic anemia myelodysplasia marrow replacement
leukemia, lymphoma, carcinoma, myelofibrosis

B12, folate chemotherapy induced

Pancytopenia
Differential Diagnosis continued
splenomegaly (any cause) PNH SLE Congenital
Fanconis, Schwamann-Diamond, Folate uptake def

Pancytopenia
Presentation varies with degree of cytopenia
anemia thrombocytopenia neutropenia fatigue bruising/bleeding infection

Approach
history
constitutional symptoms, pain, early satiety, etc... diet, EtOH, exposures, occupation

Pancytopenia
Approach
PE
nodes, spleen, sensory, portal htn

Labs
B12, folate, LFTs, PNH, ANA view smear (macrocytosis, megaloblastosis, tear drops, nuc RBCs, malignant cells) abdominal imaging bone marrow evaluation

Aplastic Anemia
Bone Marrow Failure
WHY??????????
Stem cell defect (seed) Stromal cell defect (soil) Growth Factor defect (fertilizer)

Evidence suggests that majority of cases of idiopathic AA are due to immune suppression of the hematopoietic stem cell

Aplastic Anemia Classification

Direct Toxicity
Iatrogenic (radiation, chemotherapy) Benzene Drug metabolites

Immune Mediated
Drug metabolites transfusion associated hepatitis associated idiopathic

Aplastic Anemia Pathophysiology

Evidence for an immunological basis arose from observations after BMT
unexpected improvement of pancytopenia in some patients after allogeneic graft failure successful BMT of identical twins generally requires some sort of immunosuppressive conditioning regimen

Aplastic Anemia Pathophysiology

Evidence for stem cells (seed) as targets
in vitro colony forming assays are used to define the stem cell compartment two papers in 1996 showed profound deficits in the stem cell population in patients with AA at the time of clinical presentation the absolute number of stem cells is < 1% of normal

Aplastic Anemia Pathophysiology

What about the stroma (soil) and growth factors (fertilizer)?
successful BMT implies intact stroma since it is not replaced in the transplant laboratory studies have shown the stroma of AA patients is able to support normal stem cell growth stromal cells of AA patients tend to make increased levels of several growth factors (EPO, TPO, G-CSF) clinical studies using factor replacement havent worked

Aplastic Anemia Pathophysiology

Laboratory Evidence for Immune Destruction of Hematopoietic Stem Cells
mononuclear cells from blood and marrow of AA patients suppress hematopoietic colony formation by normal marrow stem cells if selectively remove T cells from the sample, generally improve in vitro colony formation

Aplastic Anemia Pathophysiology

What are the T cells doing?
Direct cellular cytotoxicity
blood and marrow of AA patients contain increased numbers of activated cytotoxic lymphocytes the number and activity of these cells decreases after successful treatment with ATG

Aplastic Anemia Pathophysiology

Cytokines
T cells of AA patients overproduce both IFN-gamma and TNF-alpha both of these cytokines inhibit colony formation in vitro
IFN-gamma induces nitric oxide synthase (NOS) and production of nitric oxide (NO) both induce expression of Fas receptor on CD34+ cells and activation of this receptor by its ligand induces apoptosis

both appear to inhibit mitosis

IFN-gamma increases IFN regulatory factor 1 which inhibits transcription of cellular genes and entry into the cell cycle

Aplastic Anemia Pathophysiology

Aplastic Anemia Pathophysiology

Inciting Events
much less clear, most cases--no clue a few cases clearly associated with a non-A, non-B, non-C, non-G hepatitis
severe pancytopenia 1-2 months after an apparent viral hepatitis patients tend to have a marked activation of cytotoxic lymphocytes and tend to respond favorably to immunosuppressive therapy

Aplastic Anemia Pathophysiology

Drugs
implicated in 15-25% cases (difficult to study) no animal model some cases may be a direct toxic effect some cases appear immune mediated in general patients have similar characteristics as idiopathic AA and respond similarly to immunosuppression

Aplastic Anemia Treatment

Options
BMT from donor vs. immunosuppression with ATG, CSA, or ATG/CSA combination steroids, androgens generally ineffective

Trend towards separating severe AA and non-severe AA in current clinical trials

Aplastic Anemia Treatment

Severe Aplastic Anemia Criteria
blood:
neutrophils < 500/mm3 platelets < 20k retics < 1% (corrected)

marrow
severe hypocellularity moderate hypocellularity with hematopoietic cells representing < 30% of residual cells

need 2/3 blood and one marrow criteria

Aplastic Anemia Treatment

Non-severe AA (Blood, April 99)
patients randomized to CSA vs. ATG/CSA Overall Response Rate at 6 months
CSA 46% ATG/CSA 74% P=.02

Similar early toxicity/infections

Aplastic Anemia Treatment

Severe AA (Ann Int Med 1997) Allo BMT vs. Immunosuppression
ORR 15 Yr OS allogeneic BMT 89% 69% Immunosuppression 44% 38% 40% BMT patients clinically extensive chronic GVHD 1/227 receiving immunosuppression got ATG/CSA 50/227 received ATG + mismatched bone marrow

Aplastic Anemia Treatment

Severe Aplastic Anemia
NEJM 1991

ATG/Pred ATG/Pred/CSA
Blood 1992

ORR 31% 65%

36% 48% 78%

ATG/LDM/oxymethalone ATG/HDM/oxymetholone
Blood 1995

ATG/CSA

Aplastic Anemia Treatment

Future
High Dose Cyclophosphamide vs. ATG Addition of MMF to ATG/CSA combinations ? allo BMT vs optimal immunosuppression?

Aplastic Anemia Summary

idiopathic AA appears to be an AI disorder directed against hematopoietic stem cells mediated by cytotoxic T cells and cytokines allo BMT is the gold standard treatment intensive immunosuppressive therapy has improved the outlook for patients ineligible for BMT due to age or lack of a suitable donor expect further refinements in therapy as the pathophysiology is further elucidated