ANEMIA

Parameters

Epo

Growth factors

+ SCF, IL3, GM-CSF

- TGFβ, TNFα, IFNγ

SREFe

ERYTHROPOIESISRegulation

Kidney Bone marrow Macrophages

Hormones (androgens,

thyroid)

Vitamins

(folate, B12)

CirculatingRBC

Liver

Plasma

Intestinalabsorption

Macrophages(RE cells)

Erythroidmarrow

1 mg

3 mg

25 mg25 mg

3 mg

IRON METABOLISMIron compartments

Fe

• GR (106/µL) 4.4-5.7 4.0-5.2

• Hb (gr/dL) 13.5-17.0 12.0-15.0

• Hct (%) 40-52 36-45

• MCV (µ3) 80-100

• MCH (pg) 27-33

• %HYPO (%) < 5%

• Reticulocytes (103/µL) 25-100

• Reticulocytes (%) 0.5-2.5

• CHr (pg) 26-31

RBCRBC parameters

Men Women

• MCV (µ3) : Hct/GR = volume

→ Anemia Microcytic MCV < 80Normocytic MCV 80-100Macrocytic MCV > 100

• MCH (pg) : Hb/GR = amount of Hb per RBC

→ Anemia Hypochromic MCH < 27Normochromic MCH 27-33Hyperchromic MCH > 33

• MCHC (g/dL) : Hb/Hct (not interesting)

RBCRBC parameters

SHIFT RETICULOCYTOSIS

IRON PARAMETERSStorage iron : serum ferritin

CirculatingRBC

Liver

Plasma

Macrophages(RE cells)

Erythroidmarrow

FERRITINSerum ferritin

• Represents iron stores (macrophages and hepatocytes)

1 µg/L = 120 µg/kg storage iron

• Low ferritin (< 12 to 30 µg/L according to assay)

100% specific for iron deficiency

• Normal range varies with age and sex

ASH slide bank

• Conditions with falsely elevated serum ferritin– Inflammation (including cancer)

FERRITINSerum ferritin

Witte et al, Am J Clin Pathol 90:85, 1988

0

50

100

150

200

250

300

Normal Inflammation

ID

Adequateiron stores

Seru

m f

err

itin

(µ

g/L

)

• Lower limit = 100 (40–120) µg/L• Lower levels define absolute ID in cancer patients

FERRITINSerum ferritin

• Conditions with falsely elevated serum ferritin– Inflammation (including cancer)

• Lower limit 40–120 µg/L

• Lower levels define absolute iron deficiency in cancer

patients

– Some forms of cancer (e.g. neuroblastoma)

– Renal failure (lower limit 40–100 µg/L)

– Liver damage

– Hyperthyroidism

– Poorly controlled diabetes mellitus (ferritin glycosylation)

– Hyperferritin-cataract syndrome

– Benign hyperferritinaemia

CirculatingRBC

Liver

Plasma

Macrophages(RE cells)

Erythroidmarrow

IRON PARAMETERSPlasma iron : transferrin saturation

TRANSFERRIN SATURATIONNormal

Plasma

Transferrin

Macrophages Marrow

Fe

Fe

Red blood

cells

Dynamic equilibrium of

transferrin saturation

Recycling and storage

of iron from red blood

cells

Sufficient iron

available for

erythropoiesis

Senescent RBCs

taken-up by

macrophages

SeFe 8-30 µmol/L

Tsat 20-45 %

FIDFID

FIDFID

Inflammation

EPO therapy

HemochromatosisIron deficiency

Aplasia

Hemolysis

Ineffective erythropoiesis

CirculatingRBC

Liver

Plasma

Macrophages(RE cells)

Erythroidmarrow

IRON PARAMETERSErythroid marrow: sTfR

SOLUBLE TRANSFERRIN RECEPTORErythropoiesis

AA CRF Chemo0

2

4

6

8

10

(n=20) (n=61)(n=58)

Normals

TfR

(m

g/L

)

AIHA HS Thal HbH PC0

10

20

30

40

50

60

70

(n=20) (n=11)(n=72)

Normal

(n=12)(n=8)

sT

fR (

mg

/L)

Hyperplastic Hypoplastic

sTfR 3-7 µg/l

Punnonen et al. Blood 1997;89:1052–1057

sTfR Ferritin

Gold standard = marrow iron

SOLUBLE TRANSFERRIN RECEPTORIDA vs. ACD vs. combined ACD+ID

CirculatingRBC

Liver

Plasma

Macrophages(RE cells)

Erythroidmarrow

IRON PARAMETERSRBC iron: % HYPO and CHr

Hypochromic erythrocytes• Normal : < 5%

• ID erythropoiesis : > 5–10 %

→ long term indicator of ID erythropoiesis

(RBC lifespan : 120 d)

% Hypo

24.4%

Hb content of reticulocytes (CHr)• Normal : 28-32 pg

• ID erythropoiesis : < 28 pg

→ short term indicator of ID erythropoiesis (Retic lifespan : 4 d)

Nu

mb

er o

f cells

Haemoglobin (pg/cell)

Day 13

500

Day 4

500

Day 0

MCHCHr

Brugnara, Blood 83:3100, 1994

RBC INDICES%HYPO & CHr

CirculatingRBC

Liver

Plasma

Intestinalabsorption

Macrophages(RE cells)

Erythroidmarrow

IRON METABOLISMHepcidin

Ganz et al. Blood 2008;112:4292–4297

NL, normal; CRP, C-reactive protein (inflammation); MM, multiple myeloma;

ACKD & PCKD, adult & paediatric CKD (not dialysed); IDA, ID anaemia

IRON METABOLISMSerum hepcidin : patients

ERYTHROPOIETINSerum erythropoietin

Serum EPO 10-20 U/ml

Relative to degree of anemia !

Cazzola et al,

Blood 89:4250, 1997

ERYTHROPOIETINSerum Epo & erythropoietic activity

ERYTHROID FUNCTIONParameters

Retic (effective erythropoiesis)

Hb - Hct - RBC

MCV - MCH

SeFe

Tf sat(marrow iron supply)

sTfR(total erythropoiesis)

Ferritin(iron stores)

Macrophages

EPO

CHr

Hypochromic RBC(marrow iron supply)

ANEMIA

Anemias due to

defective red cell production

RED BLOOD CELL PHYSIOLOGYBasics

Production Destruction

2-20 x 106 RBC/sec

Hb

• Red cell production- Erythroid marrow- Erythropoietin- Iron

ANEMIA3 major mechanisms

• Red cell loss - Hemolysis

- Hemorrhage

• Maturation defects

- DNA (folate, B12, …)

- Hb • Globin

• Heme

- Myelodysplasia

• Decreased erythroid precursors - Marrow damage :

• Global : SAA, chemotherapy, …

• Pure red cell aplasia

- Marrow replacement : myelofibrosis, tumor cells

- Marrow inhibition

• Decreased Epo production- Renal failure

- Hypothyroidism, hypopituitarism

• Decreased iron availability- Absolute : ID

- Functional : inflammation

ANEMIADefective red cell production

• Microcytic : serum iron / TSat- Low : ID or inflammation

- High : maturation defect (globin, heme)

• Normocytic : reticulocytes- N/low : acute hemorrhage or ↓ erythropoiesis

- High : subacute hemorrhage or hemolysis

• Macrocytic : reticulocytes- N/low : maturation defect (DNA, MDS, alcohol)

- High : hemolysis

ANEMIADifferential diagnosis

• Marrow damage - Aplasia : SAA - Hypoplasia

• Chemotherapy, radiotherapy • Toxic, irradiation, drugs • Idiopathic

• Marrow replacement- Myelofibrosis- Tumor cells Leukemia

Lymphoma – MyelomaSolid tumors

• Red cell hypoproliferation- Auto-immune : Pure red cell aplasia - Cytokines : ACD- Hormonal : Hypopituitarism

Hypothyroidism, hypoadrenalism

ANEMIAHypoproliferative anemia

Normocytic normochromic, low retics

+ neutropenia

thrombocytopenia

HYPOPLASTIC ANEMIAPRCA (1)

• Isolated RBC aplasia, normal WBC/platelets

• Etiology- Congenital : Diamond-Blackfan anemia

- Acquired :

* Transient erythroblastopenia of childhood

* Idiopathic auto-immune

* Secondary chronic Thymoma

CLL

Biermer, B6 deficiency

SLE, RA

Some solid tumors

Anti-rHuEpo Ab (SC Eprex® in CRF)

* Secondary transient Parvovirus B19, CMV, HIV

Dapsone, sulfasalazine, rifampicin

Thiamphenicol, chloramphenicol

HYPOPLASTIC ANEMIAPRCA (2)

• Biological features- Normocytic normochromic anemia

- Reticulocytes < 1%

- Normal WBC & platelets

- BM : normocellular without erythroblasts

• Management- Transfusion

- Treat underlying condition

- Thymoma : surgery

- Parvovirus : IV Ig

- Immunosuppression :

steroids, ciclosporin, cyclophosphamide, ATG, azathioprim …

• Prognosis→ 15% spontaneous CR, 65% respond to IS, 50% relapse

ERYTHROPOIETINInadequate endogenous Epo

• Chronic renal disease

• Chronic inflammatory disease

• HIV infection

• Cancer

• Premature infants

• Early pregnancy

• Allogeneic bone marrow transplantation

• Congestive heart failure

Normocytic normochromic, low retics

Treatment = rHuEpo

ANEMIA IN CANCER Epo deficit : serum Epo levels

• Normal - Solid tumors

- Leukemia

• Reduced - Multiple myeloma

- Lymphoma

• Highly variable - MDS

ACD

=

Anemia

of

inflammation

Associated

diseases

Anemia in cancer patientsPathogenesis

Anemia due to

other causes

Treatment-induced

anemia

Anemia of cancer

(AOC)

• Chemotherapy(CIA)

• Radiotherapy

• Bone marrow infiltration

• ACD :- Hemodilution- Decreased RBC survival- Decreased RBC production

Defective Epo productionInhibition of erythropoiesisIron sequestration

Increased RBC loss• Hemodilution (spleen, hyper-γ…)• Hemolysis (AIHA, µ-angiopathic…)• Hemophagocytosis• Hypersplenism• Bleeding (GI, gynecologic…)

Impaired RBC production• Nutrition. defic. (B12, folate…)• Iron deficiency• Renal dysfunction• Marrow impairment (MDS, BM

necrosis, PRCA…)FIDHypochromic microcytic anemia

↓ SeFe & TSat

↑ Ferritin

ACDPathogenesis : cytokines

Hepcidin

TNF IL-1 IL-6

Monocytes

Epo Fe

Macrophages

Hemodilution

?↓ RBC lifespan

IFN- IFN-

Lymphocytes

HEPCIDINMediator of iron blockade

IL-6 Hepcidin

Ferroportin

Macrophage

Transferrin

ANEMIA

Anemia of cancer

Treatment

CASES

Iron & Epo therapy

IRON OR EPO ?Case 1

• 25-yr-old female

• Hodgkin, stage IV, ABVD

• Hb 9.5 g/dL, normocytic

• Serum ferritin 856 µg/L

• Tsat 14%

IRON OR EPO ?Case 1

• 25-yr-old female

• Hodgkin, stage IV, ABVD

• Hb 9.5 g/dL, normocytic

• Serum ferritin 856 µg/L

• Tsat 14%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None

IRON OR EPO ?Case 2

• 65-yr-old female

• Active rhumatoid arthritis, CRP 184 mg/L

• Hb 11.5 g/dL, microcytic

• Serum ferritin 42 µg/L

• Tsat 17%

IRON OR EPO ?Case 2

• 65-yr-old female

• Active rhumatoid arthritis, CRP 184 mg/L

• Hb 11.5 g/dL, microcytic

• Serum ferritin 42 µg/L

• Tsat 17%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None

IRON OR EPO ?Case 3

• 15-yr-old female

• Asthenia, dyspnea when running

• Hb 9.5 g/dL, microcytic

• Serum ferritin 12 µg/L

• Tsat 8%

IRON OR EPO ?Case 3

• 15-yr-old female

• Asthenia, dyspnea when running

• Hb 9.5 g/dL, microcytic

• Serum ferritin 12 µg/L

• Tsat 8%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None

ACDTreatment

• Treat underlying disease

• Transfusions

• rHuEpo

• IV iron

ANEMIATreatment

Production Destruction

Hb

Transfusions = cover-up

EPO THERAPY IN CANCER EPO vs transfusions : slow vs fast

Vaupel et al, The Oncologist 13(Suppl 3):21, 2008

Hb + 1 g/dL : 4 wks

Hb + 2 g/dL : 8 wks

EPO THERAPY IN CANCER 2/3 patients respond

0

100

80

60

40

20

Weeks

rHuEpo 30,000 IU/week

67%

8 10 12 14 16

27%

Placebo

4 6

p<0.0001

Österborg et al.

J Clin Oncol 2002; 20: 2486–2494

Patients with lymphoproliferative malignancies achieving

haemoglobin increase of ≥2.0 g/dL from baseline

K-M

% p

ati

en

ts (

95

% C

I)

0

10

20

30

40

50

60

70

80

Lymphoma Myeloma

64%

23%

p<0.001

56%

13%

p<0.001

Aranesp®

Placebo

K-M

% p

ati

en

ts (

95

% C

I)

0

10

20

30

40

50

60

70

80

Lymphoma Myeloma

64%

23%

p<0.001

56%

13%

p<0.001

Aranesp®

Placebo

Hedenus M et al.

Br J Haematol 2003;122:394–403

EPO THERAPY IN CANCER Transfusion risk decreased

Glaspy et al,

JCO 1997;15:1218

Hedenus M et al.

Br J Haematol 2003;122:394–403

K-M

% p

ati

en

ts

0

5

10

15

20

25

30

35

40

45

50

Lymphoma

27%

49%

Myeloma

p<0.002 p=0.042

35%

48% Aranesp®

Placebo

K-M

% p

ati

en

ts

0

5

10

15

20

25

30

35

40

45

50

Lymphoma

27%

49%

Myeloma

p<0.002 p=0.042

35%

48% Aranesp®

Placebo

Patients with lymphoproliferative

malignancies receiving RBC transfusion from

week 5 to EOTP

Transfusion risk decreased by 20-50 %,

but only after 1 month

EPO THERAPY IN CANCER QOL increased

Overa

ll Q

oL

(10

0-m

m L

AS

A)

Hb (g/dL)

7 8 9 10 11 12 13 14

70

65

60

55

50

45

40

Gabrilove

1 x 40,000 IU/week

Glaspy

3 x 10,000 IU/week

Demetri

3 x 10,000 IU/week

EPO THERAPY IN CANCER Resistance

• Infections, inflammation, surgery

• Bleeding, hemolysis

• Intensive chemotherapy, limited residual

hematopoiesis

• Marrow fibrosis, major marrow involvement

• Anti-Epo antibodies

• Folate/B12 deficiency

• (Functional) iron deficiency

EPO THERAPY IN CANCERResistance : inflammation

0 100 200 300 4000

3000

6000

9000

12000

15000

6

8

10

12

14

16Acute pancreatitis

Transfusions

rHuEpo

Days post-transplant

sT

fR (

µg

/L) Hb

(g/d

L)

Hb

sTfR

Absolute ID

Empty iron stores

FIDFIDFunctional ID

(Inflammation/cancer)Blocked iron release

FIDFID

Functional ID

(EPO therapy)Iron need exceeds delivery

MacrophagesRed blood cells Plasma transferrin Marrow

EPO THERAPY IN CANCERResistance : (Functional) iron deficiency

• Absolute iron deficiency

= no iron stores

• Functional iron deficiency

= iron stores present but ID in erythroid bone marrow

a) Iron sequestration in macrophages

- Inflammation (ACD, anemia of chronic disease)

b) Increased iron requirements

- EPO therapy

IRON DEFICIENCYEtiology

Functional ID

Iron

demand

Iron

supply

Adequate iron supply

Iron

consumption

Storage

iron

release

IV iron

EPO THERAPYFunctional iron deficiency

May occur even with

increased iron stores

IRON DEFICIENCYOvercoming hepcidin block with IV iron

15 mg/dFe

15 mg/d

Fe

Fe

IV iron therapy

Fillet et al, Blood, 74:844, 1989

Aapro et al, Ann.Oncol 23:1954, 2012

Fe

Fe

25 mg/d

Normal

Macrophages Plasma

transferrin

Fe

Fe

15 mg/d

Cancer

Macrophages Plasma

transferrin

EPO THERAPY IN CANCER IV iron

Henry et al,

Oncologist 12:231-242, 2007

No iron Oral iron IV iron0

20

40

60

80

100

p=.0029p=.0099

All patients : rHuEPO

% r

es

po

ns

e

No iron Oral iron IV iron0

20

40

60

80

100

p=.0029p=.0099

All patients : rHuEPO

% r

es

po

ns

e

Bastit et al,

JCO 26:1611, 2008

Hedenus et al,

Leukemia 21:627, 2007

More

responses

Fewer

transfusions

Less

Epo use

All patients : DA

All patients : DA

EPO THERAPY IN CANCER IV iron gluconate

Henry et al, Oncologist 12:231-242, 2007

TSAT <20%(serum ferritin mostly over 100 ng/mL)

TSAT ≥20%(regardless of serum ferritin level)

100

80

60

40

20

0

Eva

lua

ble

po

pu

lati

on

(%

)

p=0.0091, oral vs ferric gluconate

p=0.0027, no iron vs ferric gluconate

p=0.535, oral vs no iron

Ferric

gluconate

Oral iron No iron

100

80

60

40

20

0

Eva

lua

ble

po

pu

lati

on

(%

)

Ferric

gluconate

Oral iron No iron

4852

68

27

37

81

Cazzola et al., Blood 1996, 87:4824

Hb sTfR Ferritin

ANEMIA IN JUVENILE ARTHRITISIV iron therapy

PlasmaMacrophages Marrow

Venofer 300 mg IV in 1 H

qow x 3 doses

Injectafer 1000 mg IV in 30 min

Faster response

Higher response rate

Fewer transfusions

Less EPO used

EPO THERAPY IN CANCERIV iron

PlasmaMacrophages Marrow

IV iron

EPO THERAPY IN CANCERExcessive IV iron

Hepatocytes& others

Acute reactions

Organ damage

EPO THERAPY IN CANCERFID : safe IV iron administration

PlasmaMacrophages Marrow

(1) Do not exceed recommended dose (compound-specific)

(2) Withhold IV iron:- On the days of chemotherapy

(anthracyclins)

- During infection

- If TS > 40-50%

- If ferritin > 1,000 µg/L

- If severe liver or heart dysfunction

EPO THERAPY IN CANCER Side effects

2007 update : 1.67 [1.35-2.06]

2007 update : 1.24 [1.00-1.54]

Thrombo-embolic events

Hypertension

rHuEpo during radiotherapy for H&N Ca

EPO & SURVIVAL IN CANCERH&N cancer and radiotherapy

Tumor hypoxia

Henke et al, Lancet 362:1255, 2003

Loco-regional PFS

EPO & SURVIVAL IN CANCER Tumor hypoxia

Nowrousian et al, Strahlenther Onkol 2008

Vaupel et al, The Oncologist 13(Suppl 3):21, 2008

Henke et al, Lancet 362:1255, 2003

Vaupel et al, Onkologie, 28:216, 2005

Groupe

placebo

Groupe

Epo

COCHRANE REVIEWMortality

Group No pts RR p value

All patients on-study 13,933 1.17 (1.06-1.30) 0.003

long-term 1.06 (1.00-1.12) 0.046

Chemo on-study 10,441 1.10 (0.98-1.24) 0.12

long-term 1.04 (0.97-1.11) 0.26

Bohlius et al, Lancet 373: 1532–1542, 2009

EPO & SURVIVAL IN CANCERDLBCL

Delarue R et al. J Clin Oncol 2011;29 (suppl): Abstr 9048GELA LNH03-6B trial

EPO THERAPY IN CANCEREORTC guidelines 2008

Indication

• On chemotherapy

• On radiotherapy or no anti-cancer treatment

EPO THERAPY IN CANCER EORTC guidelines 2008

• Recommended : treatment of cancer patients receiving

chemotherapy (chemo-radiotherapy ?)

• Not recommended :

– Anemia due to other causes (ID…)

– Prophylactic use (normal Hb)

– Radiotherapy alone

– No cancer treatment

((EORTC : careful assessment of need !))

Bokemeyer et al. Eur J Cancer 2007; 43: 258-271

Aapro et al. The Oncologist 2008; 13(Suppl.3): 33-36

EPO THERAPY IN CANCERRecommendations

• Dose : SC - rHuEPO 30-40,000 U/wk (500 U/kg/wk)

(Neorecormon®, Eprex®)- Darbepoetin 150 µg/1 wk (2.25 µg/kg/1 wk)

300 µg/2 wks * (4.5 µg/kg/2 wks) 500 µg/3 wks (6.75 µg/kg/3 wks)

(Aranesp®)

• In case of no response- do not increase dose- verify and treat causes of resistance (iron !)- stop EPO

• IV iron supplements (Venofer / Injectafer)in case of functional iron deficiency

* Not on SmPC

CASES

Iron & Epo therapy

IRON OR EPO ?Case 1

• 25-yr-old female

• Hodgkin, stage IV, ABVD

• Hb 9.5 g/dL, normocytic

• Serum ferritin 856 µg/L

• Tsat 14%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None

IRON OR EPO ?Case 2

• 65-yr-old female

• Active rhumatoid arthritis, CRP 184 mg/L

• Hb 11.5 g/dL, microcytic

• Serum ferritin 42 µg/L

• Tsat 17%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None

IRON OR EPO ?Case 3

• 15-yr-old female

• Asthenia, dyspnea when running

• Hb 8.5 g/dL, microcytic

• Serum ferritin 12 µg/L

• Tsat 8%1. EPO

2. Oral iron

3. IV iron

4. EPO + oral iron

5. EPO + IV iron

6. None