Download - Childhood mds unlocking the old mystery
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CHILDHOOD MDS: Unlocking the old
mystery
Mohamed Elsawy MD
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Definition - MDS
A heterogeneous clonal hematopoietic disorderderived from an abnormal multipotent progenitor
Characterized by cytopenias
Hyperproliferative bone marrow, dysplasia of thecellular elements, and ineffective hematopoiesis
Increased risk of progression to acute myeloidleukemia
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Epling-Burnett and List. Curr Opin Hematol 2009;16:70
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Myelodysplastic Syndromes (MDS), WHO 2008Refractory cytopenia with unilineage dysplasia
- Refractory anemia
- Refractory neutropenia
- Refractory thrombocytopenia
Refractory anemia with ring sideroblasts
Refractory cytopenia with multilineage dysplasia
Refractory anemia with excess of blasts
Myelodysplastic syndrome with isolated del(5q)
Myelodysplastic syndrome, unclassifiable
Childhood myelodysplastic syndrome
- Refractory Cytopenia of Childhood (RCC)—Provisional entity
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• Blast count alone is insufficient to differentiateAML from MDS
• Diagnostics criteria based on:
- Comprehensive assessment of clinical features
- Natural course
- Morphology
- Immunophenotype
- Cytogenetics
Implications of the WHO 2008classification in pediatrics
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Limitations of the adult MDSclassification for pediatric MDS
No categories available to account for:
Pre-existing constitutional syndromes (30% of pediatricMDS)
Pre-existing bone marrow failure syndromes
Features unique to pediatric MDS Higher incidence of fibrosis
Lack of correlation of low blast percentage with prognosis (asseen in adults)
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Three main groups:
• Childhood Myelodysplastic Syndromes− Refractory cytopenia of childhood
− Refractory anemia with excess of blasts (RAEB)− Refractory anemia with excess of blasts (RAEB-T)
• Juvenile Myelomonocytic Leukemia (JMML)
• Myeloid Disorders of Down syndrome
Myelodysplastic and MyeloproliferativeSyndromes in Children
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Types of Pediatric MDS• De novo or Primary
- previously healthy child
- without a known predisposing condition
• Secondary
- In patients who received chemo- or radiation
(therapy-related MDS)
• Constitutional BM failure disorders
- Familial MDS
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Disease No. %Incidence
6/10
AcuteLymphoblastic 815 79 38.5
AcuteMyeloid 115 11 5.4
Myelodysplasia 38 4 1.8
JMML 25 2 1.2
DownSyndrome+AML 19 2 0.9
ChronicMyeloid 13 1 0.6
Other 6 <1 0.2
Incidence
Hasle H et al. Leukemia 17: 277-282, 2003
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Clinical and laboratory features inchildren with MDS
• Pancytopenia(s)
• Occasional single lineage cytopenia
• Incidental finding during a routine work-up
• Fetal hemoglobin (HbF) is frequently moderatelyelevated
• WBC counts: low to normal
• Leucocytosis is generally not seen
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Refractory Cytopenia of Childhood (RCC)Clinical features:
•Malaise, bleeding, fever and infection
•Lymphadenomegaly, secondary to infection
•Hepatosplenomegaly is rare
•Asymptomatic, up to 20% of patients
•Platelet < 150x109/L, 3/4 of the cases
•Anemia, Hb < 10g/dL, < 1/2 of the cases
•Severe neutropenia, noted in 25% of the patients
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Refractory Cytopenia of Childhood
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Cytogenetic features of RefractoryCytopenia of Childhood
• Majority of the patients have normal Karyotype
• Monosomy 7 is the most common cytogeneticabnormality
• Complex karyotype can also be seen
• There is NO morphological difference between thecases with and without Monosomy 7
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Differential Diagnosis for RefractoryCytopenia of Childhood
Infections ( CMV, HSV, PV B19, Leishmaniais)
Vitamin deficiency ( B12, folate, Vit E)
Metabolic disorders (eg. Mevalonate kinase Def.)
Rheumatic disease
Autoimmune lymphoproliferative disorders
Inherited BM failure (Fanconi anemia, Dyskeratosis
congenita, Schwachmann-Diamond Syndrome, etc…)
PNH (paroxysmal nocturnal hemoglubinuria)
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RAEB and RAEB-T(Advanced Myelodysplastic Syndrome)
• Abnormal karyotype
- 55% of children with advanced primary MDS
- 76% with secondary advanced MDS
• Monosomy 7 is the most common cytogeneticabnormality (25% of the patients) followed byacquired trisomy 8 and trisomy 21
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IPSSSubgroups
ChildrenN=142Mediansurvival(%)(years)
AdultsN=816Mediansurvival
(%)(years)
Low 7 >10 33 5.7
Intermediate1 47 9.7 38 3.5
Intermediate2 25 4.5 22 1.2
High 21 2.2 7 0.4
Prognosis Adult vs. Pediatric MDS
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Niemeyer C and Baumann I, ASH, 2011
Secondary MDS
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Constitutional bone marrow failure
• Increased risk of MDS/AML
• The risk varies greatly
• Highest risk• Fanconi anemia• Dyskeratosis congenita• Severe congenital neutropenia (Kostmann)• Shwachman-Diamond syndrome
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Dyskeratosis congenita• Cumulative incidence of MDS/AML may be as high as in
Fanconi anemia
• Most patients carry mutations in genes encodingcomponents of the telomerase complex—DKC1,
TERC,TERT, TINF2
- impairing telomerase activity
- causing excessive telomere shortening
- inducing cellular senescence and apoptosis
• Screening of telomere length and telomerase mutationsin sibling donors –to prevent potentially fatal graft failure
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Telomere Biology
Seven of these genes abnormalities (Dyskerin,TERT, TERC, NHPP2, NOP10, WDR79/TCAB1 and
TIN2) have associated with DKC
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Familial MDS
• MDS occurring in patients with a first degree relativesuffering from MDS or AML without the diagnosis ofone of the known BM failure disorders
• Often show monosomy 7
• Germline mutations in RUNX1, CEBPA, GATA2 maycause familial MDS/AML
• The genetic cause remains obscure in most reportedpedigrees
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Spectrum of Hematological MalignanciesAssociated with RUNX1/AML1 point mutations
Journal of Cellular BiochemistryVolume 112, Issue 2, pages 425-432, 25 JAN 2011 DOI: 10.1002/jcb.22974
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Familial MDS/AML (RUNX1) Mutations
Preudhomme C et al. Blood 2009;113:5583-5587©2009 by American Society of Hematology
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GATA2 Mutations and Diseases
Nature Genetics 43: 929–931, 2011
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Familial MDS/AML (GATA2 mutations)
Nat Genet. 43:1012-7, 2011
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Emberger Syndrome (GATA2) Autosomal dominant trait
Sensorineural deafness
Immune dysfunction
Cutaneous warts
Myelodysplasia
Monosomy 7
Nature Genetics 43: 929–931, 2011
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Other GATA2 Related Syndromes
• Monocytopenia, B-cell and NK-cell lymphopenia, andmycobacterial, fungal, and viral infections isassociated with MDS/AML, cytogeneticabnormalities, and pulmonary alveolar proteinosis
• Immunodeficiency syndrome that involved loss ofdendritic cells, monocytes, and B and natural killercells (DCML) deficiency
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Marked genetic heterogeneity in familialmyelodysplasia/acute myeloid leukaemia
British Journal of HaematologyVolume 158, Issue 2, pages 242-248, 26 APR 2012 DOI: 10.1111/j.1365-2141.2012.09136.x
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History
A previously healthy 12 year-old African American male presents with several days of cough, vomiting and high fevers and was found to be pancytopenic: WBC 1.3 K/dL, Hgb 6.4 g/dL, MCV 94.4 fL, Plt 69 K/dL. His family history is significant for a half-sister who was diagnosed with monosomy 7 associated acute myeloid leukemia 2 years previously.
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Details
Bone marrow aspirate and clot section: Hypocellular marrow with increased and highly dysplastic megakaryocytes forming clusters, decreased myeloid lineage, no increase in blasts but limited dysplastic maturation to segmented neutrophils and decreased erythroid lineage with megaloblastic maturation and occasional irregular budding.
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Bone marrow aspirate: Numerous small and/or mononuclear megakaryocytes, few erythoid precursors and virtually no myeloid precursors.
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Bone marrow aspirate smear: Megaloblastic erythropoieis
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Bone marrow aspirate: Extremely limited granulopoiesis including a bilobed neutrophil
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Bone marrow clot section: Hypocellular marrow with increased, clustered and dysplastic megakaryocytes, reduced erythropoiesis and virtually no myelopoiesis.
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Cytogenetic Findings
• 45,XY,-7[8]/90,XXYY,-7,-7[1]/46,XY[11] • FISH analysis confirmed the monosomy 7
clone
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Consensus Diagnosis
Familial monosomy 7 syndrome associated with childhood myelodysplastic syndrome
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Interesting Features
Familial monosomy 7 syndrome associated with myeloid neoplasm is extremely rare, with only 14 kindreds reported. It follows an autosomal dominant inheritance pattern with variable penetrance. The precise molecular mechanism of this disease is uncertain at this time. In this case, since the siblings did not share the same father, the mother is an obligate carrier
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