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Pathologie Stephan Dirnhofer
Myeloproliferative Neoplasms (MPN)
PathoBasic: Bone Marrow 20. Oktober 2015
• Cytology
• Cytochemistry
• Histology
• Immunohistochemistry
• FISH
• Flow cytometry
• Genetics
• Cytogenetics
• FISH
• Molecular genetics
• In vitro Culture
• Clinical information
BM investigation: diagnostic tools
&
BM aspirate BM trephine biopsy
- Cytology - Flow cytometry - Karyotype, FISH - Molecular biology
- Histology - Immunohistochemistry - FISH - Molecular biology
COMPLEMENTARY INFORMATION
Courtesy of Prof. L. De Leval
Strength and limits of BM cytology
Strength
Morphology – dysplastic changes
Auer rods, Chediak Higashi granules
Blast counts
Ring sideroblasts
Cytochemistry
Limits
Hodgkin lymphoma/FL
Fibrosis
Cellularity
Topography of the cells
Carcinoma infiltration
Granulomas
PAS Iron
Strength and limits of BM histology
Strength
Cellularity
Topography of the hematopoiesis
Immunohistochemistry
CD34+ counts and localization
Hodgkin and Reed Sternberg cells
Evaluation of fibrosis
Limits
Dysplastic changes
Blast cells
Auer rods and other changes
CD34
Gö
CD30
Clinical Information is essential
• Blood count (CBC) with differential
• Aspirate, FCM, Genetics
• Drug history
• Previous diagnosis of (hemtological) disease
• (Previous) Therapies
• Serology
• ………
• i.e. complete
N.S.
MPN
• CML, BCR-ABL1 +
• CNL
• ET
• PV
• PMF
• CEL, NOS
• SM
• MPN,u
• MPN/MDS
• aCML
• CMML
• JMML
• RARS-T
• MDS
Kralovics et al (2005) NEJM, 352: 1779-90
JAK2 Mutation in MPN
MPN mutations overview
MPN “phenotypic driver” mutations
mainly
initiation
MPN progression
“non-phenotypic driver” mutations
“important passenger mutations”
PV
ET
PMF
sAML
AML
MDS
ALL
CML
RARS-T
MPL
JAK2
exon 12 exon 16V617F TET2 DNMT3a CBL
IDH1
IDH2 EZH2CALR ASXL1
Courtesy of Prof. R. Skoda
ET: Diagnostic Criteria (WHO 2008)
1. Sustained platelet count ≥450x109/L
2. Bone marrow biopsy specimen showing proliferation mainly of the megakaryocytic lineage with increased numbers of enlarged, mature megakaryocytes. No significant increase or left-shift of neutrophil granulopoiesis or erythropoiesis
3. Not meeting WHO criteria for PV, PMF, BCR-ALB1 positive CML or MDS or other myeloid neoplasm
4. Demonstration of JAK2 V617F or other clonal marker, or in the absence of JAK2 V617F, no evidence for reactive thrombocytosis
ET: all 4 criteria
ET: Morphology
H&E
PV: Diagnostic Criteria (WHO 2008)
Major criteria
1. Hb >18.5 g/dl in men, >16.5 g/dl in women or > RCV
2. JAK2 V617F or similar mutation
Minor criteria
1. BM biopsy: panmyelosis
2. EPO below reference range
3. Endogenous EC formation in vitro
PV: 2+1 or 1.+2
PV: Morphology
Post-PV/ET myelofibrosis (spent phase)
~ 30 %
Blast phase
~ 10 - 15 %
Manifestation
(t)
10 - 15 yrs.
definite increase in red cell mass
Evolution
Initial stage Polycythemic stage Terminal stage
Transformation
Dynamics of the disease process in PV (ET)
~10%-15% mimicking “ET”
JAK2 +/- JAK2 +/+ EPO
Thiele & Kvasnicka, 2008
post-PV/ET MF: Diagnostic Criteria
Required criteria:
- Previous dx of WHO-defined PV/ET
- BM-fibrosis grade 2-3
Additional criteria (2 required):
- Anemia
- Leukoerythroblastic PB picture
- Increasing splenomegaly
- Increased LDH
- Development of constitutional symptoms
(WHO 2008)
PMF: Diagnostic Criteria (WHO 2008)
Major criteria
1. Presence of megakaryocyte proliferation/atypia, accompanied by reticulin and/or collagen fibrosis, or
in the absence of fibrosis, the megakoryocyte changes accompanied by an increased bm cellularity characterized by granulocytic proliferation (i.e. prefibrotic cellular-phase disease).
2. Not meeting criteria for PV, CML, MDS, or other clonal marker
3. JAK2 V617F or other clonal marker (e.g. MPL W515K/L),or
in the absence of a clonal marker, no evidence that the bm fibrosis or other changes are secondary
PMF: Diagnostic Criteria (WHO 2008)
Minor criteria
1. Leukoerythroblastosis
2. Increase in serum LDH
3. Aneamia
4. Splenomegaly
PMF: all 3 major plus 2 minor criteria
Key features of prePMF according to WHO
increased cellularity (age-matched) with predominant neutrophil
granulopoiesis
increased megakaryopoiesis, small to large
atypical histotopography of megakaryocytes
endosteal translocation
formation of dense clusters*
distinctive nuclear features of megakaryocytes
hypolobulation (bulbous/cloudlike)
maturation defects
* WHO definition of a megakaryocyte cluster: 3 or more megakaryocytes lying strictly adjacent
- without other hematopoietic cells lying in between
Courtesy of Prof. Kvasnicka
PMF: Morphology
PMF: Morphology
Göm
PMF: Morphology
Disease evolution in Primary Myelofibrosis
Courtesy of Prof. Kvasnicka
Myelofibrosis - Definition
• Increase of reticulin fibers (+/- collagenous fibers) in
the bone marrow
• +/- Osteosclerosis
• Focal/diffuse
• Grade 0-3
• Not a specific diagnosis/entity
• Symptom for underlying disease
• “Clinical thermometer of the bone marrow”
• Biopsy: “sine qua non”
A biopsy is essential whenever there is myelofibrosis,
and the classification of some entities, particularly MPN,
relies heavily on trephine sections.
J.W. Vardiman, WHO 2008
• MPN: BM-Biopsy essential
• Major and/or minor diagnostic criteria (WHO 2008)
MF-0
MF-2
MF-1
MF-3
Grading of BM (Reticulin-)fibrosis
Grading of Collagen and Osteosclerosis
Coll-0
Coll-1
Coll-2
Coll-3
Os-0
Os-1
Os-2
Os-3
According to upcoming 2015 consensus criteria
Kvasnicka et al, Histopathology 2015
Summary
• BM investigation: interdisciplinary diagnostic approach
• MPN: histology essential diagnostic step
• Myelofibrosis:
• symptom – not a specific entity
• only by histology, grade 0-3
• Gentics: JAK2, CALR, MPL
Well, ...it looks like
you broke the
Jamishidi-needle
...
• Causes of discrepancies
• Incorrect interpretation
• Sampling disparity
• Different perspective of the
same disease/situation
• Different methods reveal
diverse aspects
• What to do?
• Mutual information
• Review of the case
• Discussion and consensus
• Consider the worse result
• Comprehensive result to the
treating physician
How to deal with contradictive findings?
Dirnhofer S, Went Ph and Tichelli A. 2007
?
Myelofibrosis - causes
• MPN
• MDSf
• MPN/MDS
• AML (APMF, M7)
• Lymphoma-Infiltration (HCL, FL, HL)
• Metastasis
• Autoimmune-Myelofibrosis
• Drugs, RT
• Chronic inflammatory disorders
• Metabolic disorders (Vit-D deficiency, renal, …)
• Idiopathic