SESSION 1

Reactive cytopenia and dysplasia

Falko Fend, Tübingen & Alexandar Tzankov, Basel

1

• (Potential) conflict of interest

• Potentially relevant company relationships in connection with event

• none

• none

Disclosure of speaker’s interests

BM Workshop Session 1. Reactive cytopenia and dysplasia

Introduction ----------------------------------------------------------------------------------------------------------------- 1.1. Aplastic anemia and paroxysmal nocturnal hemoglobinuria (FEND) Oral: 101 Chronic neutrophilic leukemia evolving in/from SAA Summary: 102 PNH; 104 Evolving aplastic anemia/MDS? in association with a PNH clone; 107 Aplastic anemia, successfully treated?; 202 Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population 1.2. Reactive cytopenias without bone marrow aplasia (TZANKOV) Oral: 103 Pure red cell aplasia following ibrutinib; 112 EBV-associated hemophagocytic lymphohistiocytosis; 116 Autoimmune myelofibrosis; 117 Gamma-delta T-cell granular lymphocytic leukemia Summary incl. 105 Reactive changes in SLE; 110 Hemophagocytic lymphohistiocytosis; 111 Evans syndrome; 114 Toxic myelopathy; 115 Hemolytic anemia 1.3. Cytopenias in proven/suspect inborn bone marrow failure states (TZANKOV) Summary incl. 108 Hereditary bone marrow failure syndrome with dysplastic features, probably autosomal recessive Oral: 109 Bone marrow failure in a patient with USB1 gene mutation ----------------------------------------------------------------------------------------------------------------- Take homes

Introduction

• Cytopenia is a very common indication for BM biopsy

• Dysplasia can be encountered in a variety of settings

Detailed clinical history

Peripheral blood counts

Marrow aspirate and histology

Immunophenotype

Genetics and cytogenetics

Deficiency states

Autoimmune/collagen vascular disorders

Chronic infections

Hepatic disorders

Aplastic anemia

Splenomegaly

Toxins

Medications

Paraneoplastic

Constitutional bone marrow disorders

Other myeloid neoplasms

Chronic lymphoid neoplasms

(T-LGL, HCL)

Bone marrow carcinosis

Idiopathic cytopenia of unknown significance (ICUS)

Idiopathic dysplasia of unknown significance (IDUS)

Hypercellular marrow with ineffective

hematopoiesis (cytopenia)

+/- macrocytosis

Dysplasia +/- Ring sideroblasts +/- Increase in blasts

Hypocellular marrow with

cytopenia +/- macrocytosis

Dysplasia

+/- Ring sideroblasts +/- Increase in blasts

Clinically: peripheral cytopenia

Morphologically: BM features suggesting MDS

1.1. (acquired) Aplastic Anaemia

• Diagnosis of exclusion – Exclude hypocellular neoplasms (e.g. hypoMDS, congenital BM

failure syndromes)

• Occurs in all age groups • Most cases are idiopathic (autoimmune T-cell mediated

destruction of BM stem cells) – response to immunosuppressive therapy – Variety of etiologies can cause AA

• A subset of cases progresses to MDS or AML – Detection of cytogenetic abnormalities and mutations

• New onset, persistent cytopenia and hypocellular BM – Requires a representative BM biopsy and immunostains to rule

out a neoplasm

16-year-old male, pancytopenia

7

CD34

Definition of AA

Weinzierl & Arber, AJCP 2013

Weinzierl & Arber, AJCP 2013

Parvovirus B19

Mutational profile of AA

Ogawa S, Blood 2016

50% of AA show clonal genetic alterations PIGA, BCOR/BCORL1 and 6pUPD highly associated with AA Clonal hematopoiesis associated with progression to MDS, AML and PNH

Ogawa S, Blood 2016

• Rare, acquired clonal disorder of HSC

• Intravascular hemolysis, cytopenia, renal failure, thrombotic events

– Mutation of phosphatidylinositol glycan class A (PIG-A) • Expansion of PIG-A-mutated clone following injury and autoimmune-

mediated destruction of normal BM cells

– Required for synthesis of GPI-anchor

– Defect of GPI-anchored membrane proteins

– Lack of complement regulatory factors lead to hemolysis

• Diagnosis of PNH is made by FCM

• Associated with AA (usually minor PNH clone)

• Risk of progression to AML (5%) and MDS (2.5%)

1.1. paroxysmal nocturnal hemoglobinuria (PNH)

Devalet et al, Eur J Haematol 2015

1.1. Case summaries

• 102 M. Yabe, NY, USA: PNH (panel: agree)

• 104 M. Yabe, NY, USA: Evolving aplastic anemia in association with a PNH clone (panel: agree)

• 107 A. Bogusz, Philadelphia, USA: Aplastic anemia (with a PRPF40B VUS) (panel: agree, successfully treated?)

• 202 L.Jiang, Jacksonville, USA: Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population (panel: agree)

Case 102 (Yabe)

- 12 year-old boy, since 6 months "not feeling" well, and “tired".

- Hb 5,9; Leuko 3.1; Plt. 26; LDH 286; Haptoglobin <8, Bili 1.3

RBCs Granulocytes Monocytes

Flow, Peripheral blood

PNH clone on RBCs

TYPE III (complete deficiency)

29.8%

TYPE II (partial deficiency)

5.2%

PNH clone on Granulocytes

66.2%

PNH clone on Monocytes

63.6%

Molecular analysis

Normal karyotype, no leukemia-specific translocations

Next generation for specific mutations in 30 genes: NEGATIVE

Gene tested

NPM1, FLT3, CEBPA, JAK2, MPL, KIT, DNMT3A, IDH1,

IDH2, ASXL1, JAK1, RUNX1, CBL, SF3B1, JAK3, SH2B3,

SUZ12, ETV6, KRAS, TET1, EZH2, TET2, TET3, HRAS,

NRAS, TP53, PHF6, TYK2, PTEN, WT1.

Case 102

Diagnosis: Paroxysmal nocturnal hemoglobinuria (PNH)

Panel Diagnosis: agree

Case 104, Yabe

52-year-old female, found to have anemia (Hb 9.7) and thrombocytopenia (16) during workup for breast cancer

No dysplasia in erythroid and myeloid lineages,

no increase in blasts

Flow, Peripheral blood

PNH clone on RBCs

TYPE III (complete deficiency)

0.10%

TYPE II (partial deficiency)

0.0076%

PNH clone on Granulocytes

0.20%

PNH clone on Monocytes

0.089%

Granulocytes Monocytes RBCs

Case 104 Diagnosis: evolving aplastic anemia in association with a PNH clone Panel diagnosis: agree

Case 107 A. Bogusz • 76 year old man with pancytopenia.

• WBC 1.1, Hgb 9.3, Plt 47, MCV 95, Retic 0; ANC 0.15.

Bone marrow aspirate, 50x

No PNH clone

Karyotype: normal 46,XY[20]

• Sequencing studies revealed a variant of unknown (VUS) significance in PRPF40B gene:

– PRPF40B p.P751S c.2251C>T

Diagnosis: acquired idiopathic aplastic anemia

Panel diagnosis: aplastic anemia (successfully treated?)

Case 107, A. Bogusz

Case 202, L. Jiang 47-year-old female with chronic pancytopenia Hb 11.8; Leukocytes 2.3 (abs. Neutrophil 0.94), Plt 100 Left shifted eythropoiesis, no dysplasia, no blasts FCM shows small NK cell population in PB (3%) and BM (5%): CD16, CD2, CD7 (dim), CD56, CD57, CD94, NKG2a; negative for CD4, CD8, gamma/delta, CD3, CD5, and CD26 Cytogenetics 46, XX [20], molecular cytogenetics and mutational analysis negative

Idiopathic cytopenia of unknown etiology/aplastic anemia with small NK cell population Panel: agree

Flow cytometry analysis

CD3

CD

2

CD3 CD3

CD

7

CD

4

CD8

CD

5

CD3

A distinct small NK cell population is identified in peripheral blood (3% of total events) and bone marrow aspiration specimens (5% of total events), CD2+CD7+CD56+CD57+CD94+NKG2a+; negative for CD3, CD5, CD4, CD8, or gamma/delta

CD

3

CD56

CD

3

CD57

CD

94

NKG2A