NON-LEUKAEMIC

MYELOPROLIFERATIVE NEOPLASMS

BY
DR A.H. ISA

06/14/2021 Dr A. H. Isa 1
Introduction
• Defination – myeloproliferative neoplasms
(MPN) are a group of stem cell disorders:
– Characterized by clonal proliferation
– Involving one or more haemopoietic components
– In the bone marrow and in many cases the liver
and the spleen

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Outline
• Introduction
• Pathophysiology
• Polycythaemia
• Polycytaemia vera
• Essential thrombocythaemia
• Primary myelofibrosis
• Other myeloid neoplasms associated with
point mutations
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Introduction cont’
• There 3 major MPN
– Polycythaemia vera
– Essential thrombocythaemia
– Primary myelofibrosi
• They are closely related to each other
• Transitional forms can occur
• Capacity to evolve from one entity into
another

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Introduction cont’

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Pathophysiology
• MPN are associated with clonal abnormalities
involving genes that code for receptor or cytoplasmic
tyrosine kinase
• The most common one is cytoplasmic tyrosine kinase
Janus-associated kinase 2(JAK 2)(V617Phe).
• This mutated kinase has a negative regulatory effect
on JAK 2 kinase, allowing the JAK 2 protein to become
activated even when no growth factor is bound to it.
• This result in increased cell survival and proliferation

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Pathophysiology cont’

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 Polycythaemia
• Definition: An ↑Hb concentration above the upper limit
of normal for the age and sex of the patient
• Classification:
– Absolute polycythaemia (erythrocytosis)
• Red cell mass (volume) is raised to > 125% of that
expected for body mass and gender
• Normal red cell mass:
– male =25-35mL/kg,
– female = 22-32mL/kg
• Total plasma volume is normal (40 -50mL/kg)
• Absolute polycythaemia is further divided into
06/14/2021primary and secondary
Dr A. H. Isapoly cythaemia 8
 Polycythaemia cont’
– Relative (pseudopolycythaemia)
• The red cell volume is normal
• Plasma volume is reduced
• Note:
– If the PCV is > 0.60 (60%) then the red cell mass
is certainly raised
– Hb of > 18.5g/dL or PCV of >0.52(52%) in men,
and Hb of > 16.5g/dL or PCV of >0.48(48%) in
women indicate that erythrocytosis is likely but
the plasma must be measured to confirm this
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 Polycythaemia cont’
• Causes of polycythaemia
– Primary erythrocytosis
• Congenital : erythropoietin receptor mutations
• Acquired : polythaemia vera
– Secondary erythtrocytosis
• Congenital
– Defects of the oxygen-sensing pathway: VHL gene
mutation, PHD2 mutations, HIF-2α mutations
– Other congenital defects: high oxygen-affinity hb
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 Polycythaemia cont’
•Acquired
–Erythropoietin-mediated : central hypoxia, chronic lung
disease, right to left cardiopulmonary shunts, carbon
monoxide poisoning, smoking, obstructive sleep apnoea, high
altitude
–Local hypoxia: renal artery stenosis, end-stage renal disease,
hydronephrosis, renal cyst, post-renal transplant
erythrocytosis
–Pathologic erythropoietin production
»Tumours: cerebellar haemangioblastoma, meningioma,
parathyroid tumours, hepatocellular carcinoma, renal cell
cancer, phaeochromocytoma, uterine leiomyoma
»Drug-associated: erythropoietin administration, androgen
administration
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 Differential diagnosis of Polycythaemia
• There is a three-stage approach to
diagnosis of polycythaemia
– Stage 1: History and examination
• FBC/Film
• JAK2 mutation
• Serum ferritin
• Renal and liver function tests
If JAK2 mutation is negative and there is no clear
secondary cause, proceed to stage 2
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Differential diagnosis of Polycythaemia cont’
– Stage 2: Red cell mass
• Arterial oxygen saturation
• Abdominal ultrasound
• Serum erythropoietin level
• Bone marrow aspiration and trephine
• Cytogenetic analysis
• BFUE culture
Specialized tests may then be required
– Stage 3: Arterial oxygen dissociation
• Sleep study
• Lung function studies
06/14/2021 • Gene mutations
Dr A. H. Isa
EPOR, VHL, PHD2 13
 Polycythaemia vera
• It is and acquired erythrocytosis caused by
mutations in the JAK2 gene
• There is a somatic mutation of a single stem cell
giving its progeny a polyferative advantage
• The JAK 2 mutation is seen in 95% of cases
• Mutation in exon 12 is seen in < 5%
• There is polycythaemia, and also granulocytosis
and thrombocytosis in many patients
• There may be a family history of MPN
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 Polycythaemia vera cont’
• Clinical features: mainly due to hyperviscosity,
hypervolumia or hypermetabolism.
– Occur mainly in the elderly with equal sex incidence
– Headaches, dyspnoea, blurre vision, night sweats. Pruritus
especially after hot bath
– Plethoric appearance: ruddy cyanosis, conjunctival
suffusion
– Splenomegaly
– Haemorrhage (GIT, uterine, cerebral) or thrombosis
( arterial or venous) gangrene
– Hypertention
–06/14/2021
Gout. Dr A. H. Isa 15
 Polycythaemia vera cont’
• Laboratory features
– Hb and PCV and red cell count are increased
– Neutrophilia in > 50% of patients and basophilia
in some
– Thrombocytosis in about 50% of patients
– JAK2 mutations in bone marrow and peripheral
blood granulocytes in >95% of patients
– Bone marrow biopsy: trilineage hypercellularity
(panmyelosis)
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 Polycythaemia vera
– Serum erythropoietin is low
– Serum uric acid is often raised.
– Serum LDH is normal
– Increased presence of circulating erythroid
progenitors (CFUE, BFUE) and grow in vitro
independent of added erythropoietin
– Chromosomal abnormalities: deletions 9p
or 20q and TET-2 occur in 10-20%
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 Polycythaemia vera
Treatment : the aim is to maintain a normal
FBC (PCV at about 45% and PLT < 400 x109/L)
• Venesection:
– to reduce the PCV to <45%.
– Useful at start of therapy
– More beneficial in younger patients and in mild
disease.
– Complicated by iron deficiency
– Does not reduce platelet count
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• Chemotherapy
– To induce myelosupression
– Indicated in poor tolerance of venesection,
symptomatic splenomegaly, thrombocytosis,
weight loss or night sweats
– Use may be associated with increased
transformation to leukaemia especially with
busulphan
– Drugs:
• Daily hydroxyurea
• Busulphan intermitently and mostly in the older
patients
• Pipobroman alkylating
06/14/2021 agent like activity
Dr A. H. Isa 20
 Polycythaemia vera
• Radiotherapy using Phosphorus-32
indicated only in older patients with severe
disease. May cause secondary leukaemia
• Interferon. Often used in younger patients
to avoid early exposure to chemotherapy.
Side effects are frequent
• Aspirin : low dose is given to reduce
thrombotic complications
• JAK2 inhibitors are undergoing clinical trials
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 Polycythaemia vera
• Course and prognosis
– Generally good. Median survival of 10-
16 years
– Major clinical problems are thrombosis
and haemorrhage
– About 30% of patients transform to
myelofibrosis and 5% to acute leukaemia
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 Essential thrombocythaemia (ET)
• This is characterized by
– Megakaryocyte proliferation resulting in
sustained increase in plt count of >450x 109/L
– 50% of patients show the JAK2 mutation
– About 4% show the MPL mutations
– A rare primary familial form in children have been
associated with mutations in the genes for
thrombopoietin or its receptor MPL

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 ET cont’
• Clinical features:
– Most cases are asymptomatic and diagnosis is
coincidental
– They present mainly with thrombosis
(arterial/venous) or haemorrhage (due to
abnormal platelet function)
– Some patients (JAK2 +) may present with Budd-
Chiari syndrome
– Erythromyalgia , relieved by aspirin
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 ET cont’
• Laboratory features:
– Bood film: abnormal large plts and
megakaryocytes fragments may be seen
– BM biopsy: hyperplastic, predominantly the
megakaryocytic lineage with abnormal
megakaryocytes
– Cytogenetic and molecular analysis must be
done to rule out BCR-ABL positive CML
– Other causes of thrombocythaemia must also be
excluded
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ET cont’

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 ET cont’
• Diagnosis: certain diagnostic criteria have been
suggested:
A1=sustained plt count of > 450 x 109/L
A2 = presense of acquired pathogenetic mutation (in
JAK2 or MPL)
A3= no other myeloid malignancy: PV, myelofibrosis,
CML or MDS
A4 = no reactive cause for thrombocytosis and
normal iron stores
A5= BM trephine histology showing increased
megakaryocytes with dyslastic forms
Diagosis requires A1-A3 or A1 + A3-A5
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 ET cont’
• Treatment : the aim is to reduce the risk of
thrombosis or haemorrhage
– Patients are classified into:
– High- risk: > 60yrs of age, previous thrombosis, or plt
count of >1500 x109/L. They should be treated with
drugs such as hydroxyurea to reduce the plt count.
Anagrlide can be used as a second line drug. The two
drug can be combined.
– Medium –risk:
– Low-risk: <40yrs of age . Aspirin is sufficient
– α-interferon in younger patients or during pregnancy
– JAK2 inhibitors
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 ET cont’
• Course and prognosis
– The disease is often stationary for 10-20yrs
– May transform to myelofibrosis or
leukaemia

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 Primary Myelofibrosis (PMF)
• PMF is a clonal stem cell ds characterized by:
– Progressive generalized reactive fibrosis of the bone
marrow
– Associated myeloid metaplasia ( extramedullary
haemopoiesis in the spleen and liver
– JAK2 mutation occuring in about 50% of patients
– TET-2 mutation in about 15%
– MPL mutations in a few
– Other non-specific cytogenetic abnormalities
– Previous history of PV or ET in about 33% of patients
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 PMF cont’
• Clinical features:
– Has an insidious onset especially in older patients
with symptoms of anaemia
– Massive splenomegaly (>20%) with associated
symptoms
– Hypermetabolic symptoms: wt loss, fever,
anorexia, night sweats
– Haemorrhage
– Bone pain
– Gout
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 PMF cont’
• Laboratory features:
– FBC:
• Anaemia is usual but Hb may be increased in
some patients
• WBC and plt count are frequently high initially
but at later stage leucopenia and
thromcytopenia set in
• Blood film show leucoerythroblastic feature
and tear drop poikilocytosis
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PMF cont’
– BM:
• Aspiration is usually unobtainable.
• Trephine biopsy shows a fibrotic hypecellulr
marrow
• Increased megakaryocytes is frequent
• Increased bone formation in 10%
– JAK2 mutation in about 50%
– High serum urate and LDH levels
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PMF cont’

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 PMF cont’
• Treatment: usually palliative and aimed at the
effects of anaemia and splenomegaly
– Blood transfusion and regular folic acid
– Hydroxyurea for splenomegaly and
hypermetabolic symptoms
– Thalidomide, lenalidomide, azacytidine and
histones deacetylase some of which are
undergoing clinical trials
– Danazole and androgen may improve anaemia
06/14/2021 Dr A. H. Isa 35
PMF cont’
– Erythropoietin
– Splenectomy indicated in patients with
severe symptomatic splenomegaly
– Splenic radiation as an option to
splenectomy
– Allopurinol
– Allogeneic stem cell transplantation
06/14/2021 Dr A. H. Isa 36
 PMF cont’
• Course and prognosis
– Median survival is < 5years
– Bad prognosis when: Hb is < 10g/dL,
leucopenia of < 4 x 109/L or >30 x 109/L
and presence of abnormal chromosomes
– 10-20% may transform to AML

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Mastocytosis
• Assignment

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