MYELOFIBROSISMYELOFIBROSIS THE ITALIAN EXPERIENCE

Giovanni Barosi IRCCS Policlinico S. Matteo. Pavia. Italy

Angers, 1-3 October 2004

Myelofibrosis in the eightiesMyelofibrosis in the eighties

• A poorly characterized biological syndrome

• Heterogeneity of clinical presentations

• No effective therapies• No effective therapies

Erythrokinetic Classification of Myelofibrosis (G. Barosi et al, BJH 1981, 26 cases from our(G. Barosi et al, BJH 1981, 26 cases from our

Institution)Class I (42%)( )• Highly expanded erythropoiesis• Centrifugal active marrow displacement• Red cell mass normal or increasedRed cell mass normal or increased• Ineffective erythropoiesis

l ( )Class II (46%)• Slightly increased erythropoiesis• Axial erythropoiesis• Red cell mass normal or decreased• Peripheral hemolysis

Class III (12%)• Erythroid failure• Decreased red cell volume• Decreased red cell volume

Prognostic Classification of Myelofibrosis (GPrognostic Classification of Myelofibrosis (G. Barosi et al, BJH 1988; 137 cases from our

Institution))

137Age >45

31 106Hb <13

IMC>24%

Hb <13

87IMC>24%

87

27 4 19 46 41

Low Intermediate High

Anatomo-clinical Classification of Myelofibrosisy

Hyperplastic type (20%)yp p yp ( )• Young age (<50)• High expansion of erythropoiesis• Mild or no anemiaMild or no anemia• Possibly post-polycythemia• Good prognosis

Dysplastic type (50%)• Megacaryocytic dysplasia• Mild anemia• Mild anemia• Intermediate prognosis

Aplastic type (30%)Aplastic type (30%)• Erythroid failure• Severe anemia• Bad prognosis• Bad prognosis

Myelofibrosis: a difficult disease for research

•The disease is rare

•The cases are dispersed•The cases are dispersed

•The disease is undefined

The Italian Consensus Conference for the Diagnostic Criteria of MMM (Barosi et al. BJH, 1998)Diagnostic Criteria of MMM (Barosi et al. BJH, 1998)

NECESSARY CRITERIAA. Diffuse bone marrow fibrosis

OPTIONAL CRITERIA

B. Absence of Philadelphia chromosome or BCR-ABL rearrangement in peripheral blood cells

OPTIONAL CRITERIA1. Splenomegaly of any grade2. Anisopoikilocytosis with tear-drop erythrocytes3. Presence of circulating immature myeloid cells4. Presence of circulating erythroblasts5. Presence of clusters of megakaryoblasts and anomalous g y

megakaryocytes in bone marrow sections6. Myeloid metaplasia

DIAGNOSIS OF MMM IS ACCEPTABLE IF THE FOLLOWING COMBINATIONS ARE PRESENTThe two necessary criteria plus any other two optional criteria when splenomegaly is present, or plus any other four when splenomegaly is absent

RIMM- An Italian Research Registry forRIMM An Italian Research Registry for Myelofibrosis with Myeloid Metaplasia

(1999-…..)

A permanent organizational structure that maintains a data file for patients who have a specific disease collected within a geographical region with different research objectives

RIMM-Objectives

• Nationwide epidemiology of the disease di i h d di d di i i i

RIMM-Objectives

according with standardized diagnostic criteria

• Process of care of patients with MMM in Italy• Process of care of patients with MMM in Italy

• Population-based natural history of the diseasep y

• Population-based outcome of the disease

• New treatment approaches (population-adjusted clinical trials)adjusted clinical trials)

• Biology of the disease gy

RIMM – The Model

DATA

AGENTS

APPLICATIONS

AGENTS

POLICIES

COMMUNICATION INFRASTRUCTURE

POLICIES

COMMUNICATION INFRASTRUCTURE

1 i i i i f (I

RIMM – The Model

1st tier: communication infrastructure (Internet-based applications, prepaid transport and mailing services);

2nd tier: collaborative policies (ownership, liability, intellectual property, confidentiality, security);p p y, y, y);

3rd tier: agents (coordinating team and participants);

4th tier: applications (research programs and clinical trials implemented in the registry);

5th tier: data (a web-accessible data base for data of all consecutive cases of MMM).

RIMM- Expected-Observed New Cases

• Based on the incidence rates reported in the literature, we expected from 175 to 800 new cases per yearwe expected from 175 to 800 new cases per year

• 1005 patients were registered from June 1999 to September 2004

h f ll f d d– 954 with fully verified diagnostic criteria– 51 without the criteria

MMM- Age at diagnosis

35%

40%

20%

25%

30%

10%

15%

20%

0%

5%

<45 45-55 55-65 65-75 75-85 >85<45 45-55 55-65 65-75 75-85 >85

Age, years

Range = 25-96 yrRange = 25-96 yrMedian = 72 yrMean = 70 yr

RIMM- Characteristics of the Patients

From From internistsFrom hematologists

From internists

Median age 69 76Median age (yrs)

69 76

Previous PV/TE 15% 18%Previous PV/TE 15% 18%

Spleen > 10 cm f th CM

19% 25%from the CMLeukocytosis (>30)

6% 11%(>30)Severe anemia (Hb < 10g/dL)

14% 21%(Hb < 10g/dL)

Performance of Italian Diagnostic CriteriaPerformance of Italian Diagnostic Criteria475 Reported cases (Italian Registry of MMM)

461

Not fulfilling the Italian diagnostic criteria

Fulfilling the Italian diagnostic criteria 14 (2 9%)461criteria 14 (2.9%)

Ad hoc Committee

Alternative diagnosis Confirmed MMM (false

4 10 (2.1%)

Alternative diagnosisAtypical CML Mixed myeloproliferative myelodysplastic syndrome

Confirmed MMM (false negative)

MDS with bone marrow fibrosis

Georgii/Thiele Vision of MyelofibrosisGeorgii/Thiele Vision of Myelofibrosis

MyelofibrosisMyelofibrosis

Initial prefibrotic stage of the disease: Chronic MegakaryocyticMegakaryocytic-Granulocytic Myelosis

Di ti C it i f MMM C l iDiagnostic Criteria for MMM - Conclusion

• The nominalistic approach to the ppdiagnosis is not able today to identify all cases of MMM

• Need of revision of diagnostic criteria

• Need of a better disease stratification• Need of a better disease stratification

St i MMMStaging MMM

- To stratify the disease according to survival

- To stratify the disease according toTo stratify the disease according to intermediate outcomes (provide a correspondence between treatment requirements and available therapeutic resources)and available therapeutic resources)

- To identify unusual disease presentationsthat may prove to be clinically relevanty p y

L i l f ti t ithLearning sample of patients with Idiopathic Myelofibrosis

• 100 consecutive patients with IMF (post-ET and100 consecutive patients with IMF (post ET and post-PV excluded) followed at IRCCS Policlinico S. Matteo in Pavia and diagnosed from 1980 to 2000

• M/F =63/37

• Median age = 61.5 yrs (range 16-81 yrs)

• Median follow-up = 48 months (range 16-268 months)

S l i d 123 (12%)• Splenectomized = 123 (12%)

• Dead = 24 (24%)

Outcome Prediction of Hb >12 g/dL (at Diagnosis)-RIMM cases

1 0 1 0

ANEMIA SPLENOMEGALY

0 7

0,8

0,9

1,0

/=10

g/d

L Log rank test P=0.002

0,7

0,8

0,9

1,0

<10

cm

fro

m Log rank test= NS

0 4

0,5

0,6

0,7

on w

ith

Hb

>/

Hb>=12 g/dL

0,4

0,5

0,6

n w

ith

spl

een

<LC

M

Hb>=12 g/dL

0,1

0,2

0,3

0,4

Pro

port

io

Hb< 12 g/dL

0 50 100 150 200 250 3000,0

0,1

0,2

0,3

Pro

port

ion

Hb< 12 g/dL

0 50 100 150 200 250 300

Time from diagnosis (months)

0,1 0 50 100 150 200 250 300

Time from diagnosis (months)

Outcome Prediction of WBC >10x109/L (at Diagnosis)(at Diagnosis)

ANEMIA SPLENOMEGALY

0,7

0,8

0,9

1,0

10 c

m f

rom

0 8

0,9

1,0

10 g

/dL Log rank test =

NS

Log rank test P=0.003

0,4

0,5

0,6

,

th S

plee

n <

1LC

M

0,6

0,7

0,8

n w

ith

Hb

> 1

WBC <10x109/L

0,0

0,1

0,2

0,3

Pro

port

ion

wit

0,4

0,5

Pro

port

io

WBC <10x109/L

WBC > 10 109/LWBC >=10x109/L

0 50 100 150 200 250 300

Time from diagnosis (months)

-0,1

0,0P0 50 100 150 200 250 300

Time from diagnosis (months)

0,3WBC >=10x109/L

Outcome Prediction of Spleen Volume (at Diagnosis)

1 0

ANEMIA SPLENOMEGALY

0,8

0,9

1,0

>10

g/d

L

Log rank test P=0.009

0,7

0,8

0,9

1,0

> 1

0 cm

fro

m Log rank test P=0.0002

Spleen grade 0-1

0,5

0,6

0,7

ion

wit

h H

b >

0 3

0,4

0,5

0,6

ith

a sp

leen

>LC

M

Spleen grade 0-1Spleen grade 0 1

0,3

0,4

Pro

port

i

0,0

0,1

0,2

0,3

Pro

port

ion

wi

Spleen grade 2-4Spleen grade 2-4

0 50 100 150 200 250 300

Time from diagnosis (months)

0,20 50 100 150 200 250 300

Time from diagnosis (months)

-0,1

Outcome Prediction of Bone Marrow Fibrosis (at Diagnosis)

ANEMIA SPLENOMEGALY

1,0

cm

Log rank test P=0.009

0,9

1,0

L

Log rank test P=0.002

0,6

0,8

a sp

leen

<10

LC

M

0,6

0,7

0,8

,

h H

b >

10 g

/dL

BM fibrosis absent or modest

0,2

0,4

port

ion

wit

h a

from

0,3

0,4

0,5

,

ropo

rtio

n w

ith

BM fibrosis absent or modest

BM fibrosis intense BM fib i

0 50 100 150 200 250 300

Time from diagnosis (months)

0,0Pro

p

0 50 100 150 200 250 300

Time from diagnosis (months)

0,1

0,2

Pr intense BM fibrosis

intense

g ( )

Outcome Prediction of CD34+ Cells >20 x106/L (at Diagnosis)(at Diagnosis)

ANEMIA SPLENOMEGALY

0,8

0,9

1,0

cm f

rom

th

e

Log rank test P=<0.05

0 7

0,8

0,9

1,0

0 g/

dL

CD34+ <20x106/L

Log rank test P=<0.04

0,5

0,6

0,7

a Sp

leen

<10

LC

M

0,4

0,5

0,6

0,7

n w

ith

Hb

>10

/

0,2

0,3

0,4

opor

tion

wit

h a

CD34+ <20x106/L

CD34+ >20x106/L0 0

0,1

0,2

0,3

Pro

port

ion

CD34+ >20x106/L

0 50 100 150 200 250 300

Time from diagnosis (months)

0,1Pro

0 50 100 150 200 250 300

Time from diagnosis (months)

-0,1

0,0

OUTCOME PREDICTION IN MMMOUTCOME PREDICTION IN MMM

• Hb, spleen volume, bone marrow fibrosis and CD34+ cells at diagnosis predict the development of anemiadevelopment of anemia

• WBC, spleen volume, CD34+ cells and bone marrow fibrosis at diagnosis predict the g pdevelopment of splenomegaly

• They may be used for staging the disease

Multivariate Prediction (by Regression CoxMultivariate Prediction (by Regression Cox Model)

• Hb >12 g/dL, and

• WBC <10 x109/l and >5 x109/L, and

• CD34+ cells in peripheral blood <20 x109/L

yes no

Neither development of anemia nor splenomegaly

Development of anemia or splenomegaly p g y

(Early stage IMF)p g y

(Advanced stages of IMF)

Predictive Power of Early Stage IMF

0,9

1,0

L

1,0

m f

romEarly Stage IMF Early Stage IMF

ANEMIA SPLENOMEGALY

0 5

0,6

0,7

0,8

0,9

wit

h H

b >

10 g

/dL

0,4

0,6

0,8

h sp

leen

< 1

0 cm

LCM

0,2

0,3

0,4

0,5

Pro

port

ion

w

0,0

0,2

,

Pro

port

ion

wit

h

Advanced stages IMFAdvanced stages IMF

0 50 100 150 200 250 300

Time from diagnosis (months)

0,10 50 100 150 200 250

Time from diagnosis (months)

1,0

g

E l S IMF

0,6

0,7

0,8

0,9

port

ion

Surv

ivin

SURVIVAL

Early Stage IMF

0,2

0,3

0,4

0,5

Cum

ulat

ive

ProSURVIVAL

Advanced stages IMF

0 50 100 150 200 250 300

Time from diagnosis (months)

0,1

Early Stage IMF Advanced stages (Indolent Myelofibrosis)

• N= 13 (13%)

IMF• N= 87 (87%)

• Age = 34.5 years (16-72)• M/F = 8/5

S l l b t 3/13

• Age = 65 years (19-81)• M/F = 58/29

S l l b t 10/87• Splenomegaly absent = 3/13 (23%)• Hb = 13.4 (12-16,4)

• Splenomegaly absent = 10/87 (11.4%)• Hb = 12 (6.2-18)

• WBC = 7.5 (5.2-10)• Ptl count = 465 x109/L (255-1 100)

• WBC = 9.1 (2.1-35)• Ptl count = 327 x109/L (43-1 196)1,100)

• Bone marrow fibrosis absent = 2/13 (15.3%)

1,196)-• Bone marrow fibrosis absent = 3/87 (3.4%)

• LDH = 679 (336-1146)• CD34=11.4 (range 2.7-20)

• LDH = 784 (191-2455)• CD34=26.4 (range 1.2-375)

• Splanchnic vein thrombosis at diagnosis =4/13 (31%)

• Splanchnic vein thrombosis at diagnosis = 2/87 (2.3%)

Early Stage IMF (Indolent Myelofibrosis): Possibly Corresponding

Syndromes

An atypical myeloproliferative disorder ith hi h th b ti i k d l di

Syndromes

with high thrombotic risk and slow disease progression (Barosi et al, Cancer, 1991)

• Young age

• No myeloproliferative evolution

• High tendency to develop thrombosis in atypical itsites

Early Stage IMF (Indolent Myelofibrosis): Possibly Corresponding

Syndromes

Formes frustes in myeloproliferative di d (R id t l L t 1982)

Syndromes

disorders (Reid et al, Lancet, 1982)

• Peripheral vascular disease

l h l l d l l• Slightly elevated platelet count

• Endogenous erythroid colonies

Early Stage of IdiopathicEarly Stage of Idiopathic Myelofibrosis

• An early stage of IMF exists

• This has been probably overlooked (misdiagnosis, no symptoms)

• It does not completely correspond to the “prefibrotic” picture of the disease

In some case it takes the form of a very indolent• In some case it takes the form of a very indolent disease (more than 10 years without evolution)

• Diagnostic criteria?Diagnostic criteria?

• Biology?

Angiogenesis in MMM

• Marrow vascularity in patients with MMM is substantially increased compared with normals andsubstantially increased compared with normals and patients with PV and ET

Visual MVD grade

MMM (N=114)

Normals (N= 44)

PV (N=15)

ET (N=17)

g

1 (Normal)

1.8% 77.3% 26.7% 23.5%

2 28% 22.7% 40% 64.7%

3 37.7% 0% 33% 12%

4 32.5% 0% 0% 0%

Mesa et al, Blood 2000;96:3374

Angiogenesis in MMM

• Capillary microvessel density in the spleen of patients with MMM correlates with spleen size

200000

ity

rea

120000

160000

ar d

ensi

copi

c a

80000

120000

vasc

ula

/mic

rosc

40000

apill

ary

vic

ron2 )/

300 400 500 600 700 800 900

2

0

Ca

(mi

Barosi et al. BJH Spleen index (cm 2) 2004

Angiogenesis in MMM

• Capillary microvessel density of the spleen of patients with MMM correlates with the extent of

180000

amyeloid metaplasia

140000

dens

ityop

ic a

rea

100000scul

ar d

icro

sco

60000llary

vas

on2 )/m

i

20000

Cap

il(m

icr

Barosi et al. BJH 0 2 4 6 8 10 12 14 16

Spleen CD34+ Cells (%)2004

Pro-angiogenic Factors inPro-angiogenic Factors in Myelofibrosis

• Elevated expression of plasma and BM• Elevated expression of plasma and BM VEFG, b-FGF and TGF-β is consistently documented in MMMdocumented in MMM

• Poor evidence of their pathogenetic role in angiogenesis of MMMangiogenesis of MMM

Angiogenesis – cellularAngiogenesis – cellular mechanism

• During development, new vessels are formed by differentiation of progenitor cells (endothelialby differentiation of progenitor cells (endothelial progenitor cells or angioblasts)

• In adult life endothelial progenitor cells• In adult life, endothelial progenitor cells circulate in normal subjects and are increased in patients with vascular injury (trauma, myocardial p j y ( , yinfarction, angina..)

• In some tumors mature endothelial cells may• In some tumors, mature endothelial cells may bear the same cytogenetic aberration of hematopoietic progenitor cells (CML, lymphoma)

Endothelial Progenitor Cells (EPC) in Myelofibrosis

• The phenotypically characterized circulating EPC• The phenotypically characterized circulating EPC are consistently elevated in a significant proportion of MMM patients p p p

40︵%

︶

25

30

35

R-2

+ C

ells

10

15

20

33+V

EG

FR

Rosti ASH 20030

5

10

0 1 2 3 4D34

+C

D13

MMM Ph1-CMPDs Normals0 1 2 3 4C

120Endothelial Progenitor Cells

100

120

Analysis of chromosomal

(EPC) in Myelofibrosis

80

100aberration documents that CFU-End of patients with MMM derive from a l l ll

60

clonal progenitor cell

40

20

0

MMM Ph1-CMPDs Normals

Endothelial Progenitor Cells (EPC) in Myelofibrosis - Conclusions

• Increased number of EPCs (immunophenotype and endothelial cell colture) is a distinctiveand endothelial cell colture) is a distinctive characteristic of MMM

• Circulating EPCs belong to the malignant clone• Circulating EPCs belong to the malignant clone

• New mechanisms for angiogenesis may be hypothesizedhypothesized