Haem2 Flashcards
Which one of the following is the most important component in the pathogenesis of β thalassaemia?
A. Iron overload.
B. α/β globin chain imbalance.
C. Ineffective erythropoiesis.
D. Dysfunctional β globin.
E. Haemolytic anaemia.
**B. α/β globin chain imbalance.
Excess alpha chains are unstable and precipitate - RBC membrane damage (target cell)
Results in:
- Intramedullary and peripheral haemolysis
- Erythroid hyperplasia,
- Ineffective erythropoeisis due to intramedullary destruction of erythroid cells.**
- What are the three different kinds of haemoglobin?
- Which forms the majority of adult Hb?
- On what genes are haemoglobin alpha and beta located?
HBA (A2B2)- a tetramer of two alpha and two beta chains
HBA2 (a2δ2) tetramer forms - 1-2% adult Hb
HBF - a2γ2 tetramer forms - fetal Hb but <1% of adult Hb
- 98% adult Hb primarily HBa
2 alpha-globin genes - Cr16, w/ no substitutes.
B-globin gene - Cr11, adjacent to B-like glob in genes delta δ and gamma γ
In the context of thalassaemia, define the following terms:
- Trait
- Intermedia
- Major
- Trait - lab features, no clinical impact
- Intermedia - occastional transfusion requirement
- Major - life threatening or transfusion dependent - most die of iron overload.
Describe the pathogenesis of alpha-thalassaemia
Alpha thalassaemia - Cr16 x 2
- due to gene deletions —> reduced a-globin chain synthesis
- each gene produces 1/4 of total alpha-globin quantity
- all adult Hb are alpha containing, so there will never be any change in percentage distribution of it on Hb EPG.
- Severe forms: excess B chains will form B2B2 tetramer (H bodies), or HbH which are highly unstable.
Describe the clinical features of alpha thalassaemia
Southeast Asians and Chinese
- aa/a- : silent carrier
- aa/— or a-/a- : Clinically normal, mild microcytic anaemia
- a-/— : HbH disease - chronic haemolytic anaemia of variable severity (minor or intermedia) with pallor and splenomegaly. Intermittent transfusions only (infection / stress or by RBC production shutdown (aplastic crisis) by certain viruses (i.e. parvovirus).)
- —/— : Hydrops fetalis (no normal Hb is produced only Bart’s y4) - fetus is stillborn
Describe the lab findings for alpha-thalassaemia trait and HbH disease.
Trait - MCV (60-75)
- normal or increased RBC count
- smear: microcytes, hypochromia, occ target cells, acanthocytes.
- retic and iron counts normal
- Hb EPG: no change in percent HbA2/F/or HbH
- dx of exclusion
HbH disease
- marked anaemia HCT 22-32%
- very low MCV 60-70
- smear: hypochromia, microcytosis, target cells, poikilocytosis (annoying term that means ‘varied’!)
- elevated retics, elevated/normal RBC count
- Hb EPG: fast migrating haemoglobin (HbH) accounting for 10-40% of the Hb.
- Can stain smear with supra vital dye to show HbH
Describe the pathogenesis of beta-thalassaemia
Beta thalassamia - Cr 11 point mutation
- little to no B-Hb –> more HBA2 & HbF on EPG
- excess alpha chains precipitate –> RBC membrane damage
- intramedullary and peripheral haemolysis, erythroid hyperplasia
Absent b-chains: B0
Reduced b-chains: B+ (variable severity)
Severe disease
- marrow expansion –> bone deformities, osteopaenia, path fractures
Describe the clinical manifestations of all forms of beta-thalassaemia
Homozygotes (B0/B0 or B+/B+)
- thal major
- normal @ birth, severe tfusion dependence at 6/12 (HbF–>HbA)
- Stunted growth
- Bony deformities (frontal bossing, chipmunk facies, path fractures)
- Hepatosplenomegaly
- Cirrhosis, jaundice (due to gallstones), thrombophilia
- Iron overload (due to transfusion) –> heart failure & arrythmias, cirrhosis, endocrinopathies, pseudoxanthoma elasticum - calcification of epithelial cells of skin, retina, CVS) due to inability to excrete iron. Poor survival.
Homozygosity for milder B+/B+: chronic haemolytic anaemia, transfusions only during aplastic crises. May still develop iron overload, hepatosplenomegaly and bony deformities but survive into adulthood.
Heterozygosity for B/B0 or B/B+ : thalassaemia minor, clinically insignificant microcytic anaemia
What are the lab findings for beta-thal major and minor?
B-thal minor:
- Modest anaemia - HCT 28-40%, MCV 55-75
- RBC count normal or increased
- Retic count - normal or slightly elevated
- Smear: Hypochromia, microcytosis, target cells, basophilic stippling
- Hb EPG: Increased HBA2 to 4-8%, occ increased HbF - 1-5%
B-thal major:
- severe anaemia - HCT to <!0% w/o transfusion
- smear: severe poikilocytosis, hypochromia, microcytosis, target cells, basophilic stiplling, nucleated RBCs.
- HbEPG - little to no HbA, variable amt HBa2, major Hb present is HbF
How do you differentiate thalassaemia from iron deficiency anaemia?
How is the diagnosis of b-thal and a-thal made?
Compared to Fe+ deficiency anaemia
- lower MCV
- normal or elevated RBC count
- more abnormal smear at modest lvld anaemia
- normal or elevated transferrin sat/ferritin (or both)
Dx of b-thal made with above plus HbEPG showing elevated HbA2 and F (assuming iron replete)
Dx of a-thal is one of exclusion since HbEPG levels of a-globin remains the same.
Other microcytic anaemia with normal or elevated RBC count is Fe+ deficiency + PCV
Describe the treatment for all forms of thalassaemia
Treatment
Mild a or b - no treatment but need identification so they don’t keep getting investigated for Fe deficiency anaemia!
HbH - Folic acid, avoid medicinal iron and oxidative drugs (sulphonamides)
Severe thalassaemia - regular transfusion, folic acid and iron chelation.
Allogeneic SCT - treatment of choice for B-thal major, only cure, and in kids w/o Fe+ overload or chronic organ toxicity - long term survival of >80%.
Which one of the following occurs most frequently in the α thalassaemia syndromes?
A. Mental retardation.
B. Reduced mean corpuscular volume.
C. Gene deletions.
D. Haemoglobin H inclusion bodies.
E. Reduced haemoglobin.
C. Gene deletions.
AMP 1999 Question 30
In which one of the following conditions has initial therapy with imatinib been shown to cause the best improvement in survival?
A. Multiple myeloma.
B. Low grade non-Hodgkin’s lymphoma.
C. Chronic myeloid leukaemia.
D. Chronic lymphocytic leukaemia.
E. T-cell acute lymphocytic leukaemia.
C. CML
TKIs (Imatinib, Dasatinib, Nilotinib, Ponatinib) • specific competitive binders in the ATP-pocket of BCR-ABL tyrosine kinase. Associated with >80% progression free at 8 years.
What is the pathogenesis of CML?
Chromosomal abnormality
Reciprocal translocation of Cr9 to 22
Cr9q Abl protoncogene fused to BCR on Cr22q
then
Molecular abnormality
Fusion gene deregulates abl tyrosine kinase activity —> autophosphyrlation, altered adhesion, inhibition of apoptosis
then
Myeloid proliferation
What are the clinical findings of CML?
- Middle aged, more men
- May be asymptomatic - discovered incidentally on an FBC with elevated WCC
• Hyper metabolic sx; night sweats, low-grade fever caused by overproduction of white cells
- May have splenomegaly and or sternal tenderness from marrow overexpansion
- Rarely; leukostasis: blurred vision, resp distress, priapism (usually w/ very high white cell counts
- Acceleration: Fever in absence of infection, bone pain and splenomegaly.
What are the lab findings in CML?
- Early CML: normal BM function, normal WBCs, normal neutrophils
- Untreated: accelerated then acute blast phase - indistinguishable from acute leukaemia
- Median WBC count >150
- Blood film: Left-shifted (immature cells present) with cells present in proportion to their degree of maturation (i.e. blasts <5%), normal RBC morphology, normal or elevated platelets (abnormal megakaryocytes)
- Basophilia and eosinophilia of granulocytes is pathognomic
- Peripheral blood PCR (required for diagnosis): Increased levels of BCR-ABL gene.
- BM: Hypercellular w/ left shift myelopoesis
What is the diagnostic criteria for CML?
- Peripheral blood: bcr/able gene present on PCR - hallmark of the disease – this is diagnostic criterai
- BMB is NOT necessary for dx but useful for prognosis and detecting additional chromosomal abnormalities
How is the blast phase of CML defined?
What is it associated with?
One or more of:
o Blasts composing >20% of nucleated bone marrow cells.
o Extramedullary blast proliferation
o Large foci or clusters of blasts in the bone marrow biopsy
Evolution to a blast cell crisis in CML associated w/:
o Non-random secondary chromosomal changes
o Mutations or deletions of tumour suppressor genes
How do you differentiate CML from infection and other blood disorders?
- Infection - no splenomegaly, WBC <50, no bcr/abl gene
- Other blood disorders - normal RBCs, no nucleated RBCs, definitive finding of bcr/abl gene
Define the types and goals of therapy in CML
Treatment
- Untreated progresses from chronic phase (3-5 years) to blast crisis
- Chronic-phase CML: TKI aiming for complete remission w/ normalisation of blood count and splenomegaly within 3 months initiation. Aim for MAJOR molecular response in 1 year.
- Blast/accelerated phase: ASCT + myelosuppressive therapy
- Hyperleukocytosis (priapism, respiratory distress, visual blurring, altered mental state): emergency leukapheresis + myelosuppressive therapy.
What do the terms major molecular response, and complete molecular response refer to in the context of CML?
Major molecular response
- 3-log reduction of bcr/abl transcript on PCR within a year (corresponds to bcr/abl RATIO (compared to alb) of <0.01).
- Goal is to achieve MMR within a year
- excellent prognosis - up to 100% progression-free at 8 years.
Complete MR = >4.5 log reduction ie undetectable
What is the mechanism of action of tyrosine kinase inhibitors?
What are the side effects?
Tyrosine Kinase Inhibitors
- specific competitive binders in the ATP-pocket of BCR-ABL tyrosine kinase
- Imatinib: first line, MMR @ 30% at 1 year in chronic phase. SEs: NV, chronic diarrhea, intolerable fatigue
- Dasatinib: pleural effusions esp. in the elderly, pneumonitis, pulmonary hypertension, bleeding, possibly increased infection risk
- Nilotinib: cardiac SEs: esp IHD, CVA, PAD (inc limb ischaemia, claudication), also increases cholesterol and LDL
- 3rd gen agents may be more effective - can salvage 90% of patients who do not respond to imatinib. Are now approved as first line agents.
What is the mechanism of tyrosine kinase inhibitor resistance?
How is it managed in CML?
• Due to:
- drug influx/efflux due to low OCT-1 expression
- amplification and over expression of BCR-ABL
- Mutations of BCR-ABL kinase domain (found in 50-90% w/ secondary resistance)
- can increase dose with variable response (depends on mutation
- or use alternative TKIs
How is disease progression in CML monitored?
Peripheral blood PCR, if it increases on therapy check compliance, check for a new abl mutation, may be able to get away with increased dose of Imatinib, otherwise switch to a new inhibitor.
What is the course and prognosis of CML?
Course & Prognosis
- 80% w/o progression at 9 years w/ TKIs
- essentially 100% survival at 9 years if good molecular response
- Complete (undetectable bcr/abl) response lasting > 2years may be able to cease therapy all together.
- Untreated progresses from chronic phase (3-5 years) to blast crisis
What is the pathogenesis of CLL?
Pathogenesis
- B Cell lymphocytosis w/ coexpression of CD19, CD5 (pathognomic: aberrant T-cell marker) on lymphocytes.
- indolent, long lived small (unactivated) lymphocytes
- immunoincompetent, poorly antigenic responsive
- immunosuppression,
- BM failure
- organ infiltration with lymphocytes
- inadequate antibody production
- damage due to direct tissue introduction
What is the epidemiology of CLL?
Epidemiology
- 25% of all leukemias (2.7/100,000) , increasing
- Unknown aetiology
- Increased other malig (SCC)
- Only leukemia NOT linked to radiation
- M:F=2:1, less in Asian’s
- Disease of old age - median at presentation is age 70
What are the clinical findings in CLL?
Clinical Findings
- incidental: lymphocytosis - usually indolent
- symptomatic: fatigue or lymphadenopathy
- 80% will have lymphadenopathy, 50% splenomegaly
- subtype prolymphocytic leukaemia (larger and more immature cells) is more aggressive but rare
- maybe complicated by AIHA or autoimmune thrombocytopaenia
- 5% of systemic cases may have an isolated lymph node transform into an aggressive large cell lymphoma (Richter syndrome)
What is the Rai staging system used for? Can you describe it?
Used to stage CLL
Staging - Rai
Stage 0 - lymphocytosis (low-risk)
Stage II - organomegaly (low risk)
Stage III - anaemia (high risk)
Stage IV - thrombocytopaenia (high risk)
What is the diagnostic criteria for CLL?
Diagnostic criteria
Peripheral absolute B lymphocyte count > 5 x 109/L w/ mainly morphologically mature lymphocytes
Flow cytometry: clonality of circulating B-lymphocytes w/ low levels of SmIg and either kappa or lambda (not both) and expression of B-cell antigens (CD19, 20, 23), and expression of T-Cell associated antigen CD5.
Name the investigations you would do when working up CLL
Ix
- FBE,differential; lymphocytosis,cytopenias
- Flowcytometry: CD19/5,Ig(weak),CD23
- Coombes test
- LDH, B2 microglobulin
- Uric acid, calcium
- BMBx – cytopenias– ‘assessment’ pre-treatment – cytogenetics
- +/-CTscan
Describe the lab findings in CLL for the
FBC
Smear
BMBx
Cytogenetics.
Lab Findings
- hallmark: isolated lymphocytosis
- WBC >20k, >75% small and mature lymphocytes, normal HCT and platelets.
- may have cytopaenias inc neutropaenia.
- smear: normal-looking small lymphocytes predominate with reduced numbers of larger activated lymphocytes, SMUDGE CELLS
- BMBx: Infiltrated w/ small lymphocytes
Immunophenotype (Flow): Coexpression of CD19 with T-lymphocyte marker CD5 - ONLY found in CLL and mantle-cell lymphoma (Not mantle cell lymphoma if: expression of CD23, low expression of surface Ig and CD20, absence of cyclin D1)
Cytogenetics (BMBx)
- Associated mutation of Ig (Vh) gene = more indolent disease
- Genomic changes assessed by flow cytometry or FISH
o Chromosome 17p (p53) deletion or 11q (ATM) = POOR prognosis
o Isolated 13q deletion = favourable prognosis (in Myeloma, it’s BAD!)
• 50% have hypogammaglobulinaemia, more common with advanced disease, may have a small amt of IgM paraprotein.
Describe the chromosomal abnormalities that are associated with good and poor prognoses in CLL
o Chromosome 17p (p53) deletion or 11q (ATM) = POOR prognosis
o Isolated 13q deletion = GOOD prognosis (in Myeloma, it’s BAD!)
DDx of CLL?
DDx
- Exclude viral infections that cause lymphocytosis (i.e. Pertussis)
- Fever in CLL may be concomitant bacterial infection
- Other B-Cellopathies are distinguished on morphology and immunophenotype.
- Monoclonal B-cell lymphocytosis (<5x109) is a precursor to B-CLL
Describe the treatment approaches and what you would use for each of the following groups in CLL:
Comorbid elderly
Robust older patient
Younger patient
Comorbid elderly - symptom control, QOL —> observe or ‘gently oral CTx with chlorambucil or cyclophosphmade
Robust older pt - QOL, bulk reduction, deepest achievable response —> observe is asymptomatic, otherwise multi drug CTx, ritux + fludarabine for prolonged remission.
Younger pt - as above, possible allogeneic BMTc
What prophylaxis should you use when giving fludarabine or alemtuzumab in CLL?
Prophylaxis
- Fludarabine or alemtuzumab —> PJP pneumonia, HSV, HZV and fungal prophylaxis.
- Alemtuzumab - monitor for CMV reactivation
- Lower strength ‘nonmyeloablative’ transplant + drugs good for older people.
What are the prognostic features of CLL?
Prognostic features
Stage 0-1: 10-15 years,
Stage 3-4: >90% at 2 years w/ fludarabine
High risk disease: Allogeneic transplant may lead to long term disease control.
Serum LDH and B2-microglobulin
Unmutated IgH (adverse) vs mutated
- ZAP 70 (zeta chain associated protein) (bad if positive) , CD38 + (bad if +)
- Cytogenetic translocations (not trisomies or deletions)
- ~5% terminally “Richter’s syndrome”; consider if: B-Sx, painful, rapidly enlarging mass rapid unexpected rise in LDH
What is Richters Syndrome?
Transformation of CLL
5-10% of CLL patients
B-Sx, painful, rapidly enlarging nodal mass and rapid unexpected rise in LDH
fast-growing diffuse large B cell lymphoma
BAD prognosis
What is alemtuzumab and when is it used?
Alemtuzumab (mAb to mature lymphocyte CD52), but immunosuppression, severe and fatal infections.
Used in CLL
What is Ibrutinib and when is it used?
What is a Bruton’s tyrosine kinase?
Used in CLL
Ibrutinib (PCI-02765) a Bruton’s TKI.
Bruton’s tyrosine kinase (BTK) BTK is a kinase that plays a crucial role in B-cell development
How do you treat AIHA in CLL?
AIHA: rituximab, prednisone or splenectomy - AVOID fludarabine as may exacerbate (but concurrent rituximab reduces this risk)
What is the pathogenesis of multiple myeloma?
Monoclonal proliferation (kappa/lambda light chain restriction) of plasma cells in the BM (any percentage) or as a tumor (plasmacytoma) resulting in:
End-organ damage:
C - Hypercalcaemia
R - Renal failure
A - Anaemia
B - Bone disease
Recurrent infections w/ encapsulated organisms (due to b-cell deficiency)
Plasmacytomas
Hyperviscosity syndrome
Who is most susceptible to overwhelming infection with encapsulated organisms?
Asplenic patients B-cell deficient patients Complement deficiency (esp C3 and C5+ (MAC complex)
Children 6/12 - 1 year
Name the encapsulated organisms.
Why are they important?
Streptococcus pneumoniae
Haemophilus influenzae type B (B polysaccharide)
Neisseria meningitidis
Klebsiella pneumoniae
Salmonella typhi
Pseudomonas aeruginosa
Cryptococcus neoformans
only encapsulated fungal pathogen
Other encapsulated bacteria
Anti-phagocytic - susceptible to antibody (B-Cells) and not cell mediated responses. People w/ B-cell deficiencies are highly susceptible.
What is the mechanism and outcome of hyperviscosity syndrome in multiple myeloma?
Excess paraprotein production (monoclonal Igs) in addition to excess plasma cells —> hyperviscosity —> spont.bleeding, retinopathy/vision disturb, vertigo, nausea, seizures, coma
What is the mechanism of renal failure in multiple myeloma?
Cast nephropathy: Tumour mass expansion —> FLC serum concentration exceeds renal absorptive capacity →excess light chains—> direct damage to PCT—> casts at distal tubules (containing BJP and tamm-horsfall proteins) —> FLC in urine, positive BJP
Monoclonal Ig deposition disease (usually light chains)—> glomerular disease, proteinuria
Hypercalcaemia —>nephrocalcinosis
Cryoglobulins, Fanconi syndrome (type2 RTA, phosphaturia, glycosuria, uricosuria & osteomalacia), hyperuricemia
What is the mechanism of recurrent infection in multiple myeloma?
Underproduction of normal Ig + neutropenia + CTx immunosuppression —> recurrent infections esp encapsulated organisms.
What are the clinical findings of multiple myeloma and who does it affect?
Older adults - i.e. 65 y old
Pallor, bone tenderness, soft tissue masses
Bone tenderness/pain: hips, back, ribs, path # esp fem neck, vertebrae
Neurologic signs: neuropathy, SC compression (plasmacytoma)
Primary amyloid —> enlarged tongue, peripheral/autonomic neuropathy, CHF, hepatomegaly
NO splenomegaly unless amyloidosis
NO fever unless infection
What are the lab findings of multiple myeloma?
What is the predominant paraprotein?
FBE: Rouleaux (high protein), cytopenias, macrocytosis
ESR elevated
Normal urine ‘dip-stick’ (i.e BJP): may be + if nephrotic (albumin)
Electrolytes: Renal function, calcium, ALP normal
Low B12
Protein EPG (serum or urine) - detects a clonal protein
- Monoclonal spike in b or gamma globulin region, known as ‘M-protein’
IEPG - identifies the clonal protein
- Paraprotein estimation: Serum/urine: IgG(70%) >IgA(20%) >IgD(5%) >LCD(5%) >NS(2.5) >>IgM
- no paraprotein = nonsecretory myeloma = BAD
Elevated B2 microglobulin (prognostic test)
What are free light chains and what is the role of the serum free light chain test?
Free Light Chains
- Ig are heavy chains – the light chains (kappa or lambda) produced separately
- kappa and lambda bound to heavy chains, but free light chains produced in healthy people when there are more light chains than heavy chains
- bound and free light chains are structurally identical
- Free light chains reach a threshold before detectable in urine - need for serum FLC.
- 15% will have no paraprotein due to free light chain only disease which pass freely into the urine.
Serum FLC (free light chains)
Will pick up light chains in non-secretory myeloma (too low to be detected in urine)
- use at dx of all types of myeloma inc MGUS, plasmacytoma and AL amyloidosis
- use in combo with EPG/IEPG - sufficient to screen for all except AL amyloid (which needs more serum tests and urine IEPG)
When would you do a bone marrow in multiple myeloma?
What would it show?
How do you differentiate it from reactive (benign) plasmacytosis?
Bone marrow (only for symptomatic - i.e. paraprotein plus end organ damage)
Morphologically abnormal plasma cells
Skewing of kappa to lambda light chain ratio
May have reactive (benign) plasmacytosis - but atypical cells, LC restriction and effacement of normal BM = myeloma
In multiple myeloma, when would you do a:
Skeletal survey
Nuclear bone scan
MRI/PET?
and what would they show?
Symptomatic myeloma: Skeletal survey (whole body x-ray)
- lytic lesions of axial skeleton; skull, spine, prix long bones, ribs
- OR general OP only
Wouldn’t - Nuclear bone scan - unuseful, no osteoblastic component
MRI - severe back pain, suspected vertebral compression, isolated plasmacytoma
- really good but expensive, pick up lesions that x-ray doesn’t
PET - pre CTx
What is the differential diagnosis of a positive paraprotein on EPG?
CLL
Waldenstrom
NHL
primary amyloid
cryoglubinaemia
MGUS
What is the definition and risk factors for progression of MGUS to MM?
BM monoclonal plasma cells <10% or serum M-protein <30g/L)
No end organ damage or other B-cell disorder
1/4 progresses to malignant disease in 10 years (1%/year)
Must be distinguished from reactive (benign) polyclonal hypergammaglobulinaemia
Risk factors for progression
Size of M-band (best predictor of risk)
IgM or IgA monoclonal protein
Eleveated serum FLC
What is the definition of smoldering myeloma?
BM monoclonal plasma cells >10% or serum M-protein >30g/L
No end-organ damage
What is the treatment for MGUS and smoldering myeloma?
Observe
What is the role of auto-sct and thalidomide in multiple myeloma?
Auto-SCT
- prolongs duration of remission and overall survival, long treatment-free intervals
- thalido/lenalidomide prolong remission and survival as post-transplant maintenance therapy
What is the treatment of symptomatic myeloma in the non-transplant candidate?
Non-transplant candidate: Melphalan + Pred + Thalidomide > Melphalan, Pred, bortezomib
What is the treatment of symptomatic multiple myeloma in an eligible candidate?
–Auto-Transplant ‘candidate’ (<76)
» Induction therapy: chemotherapy +/- thalidomide, bortezomib, lenalidomide
» Melphalan (alkylator) stem cell transplant [tandem v single]
» Maintenance: steroids, thalidomide
What is bortezomib, when is it used and it’s side effects?
Bortezomib (proteosome inhibitor)
Relapsed MM /poor prognosis –> rapid response.
SE: neuropathy (peripheral/autonomic), less if given SC (instead of IV)
What is thalidomide/lenalidomide, when is it used and it’s side effects?
Inhibits angiogenesis
Used for multiple myeloma and leprosy
Thalidomide/Lenalidomide SEs
- Somnolence
- Thalidomide neuropathy – painful neuropathy, reduced sens nerve AP (AP)
- Constipation, tremor, skin rash and oedema
- Thrombosis
- Myelosuppression
Define the international staging system - what is it used for?
International Staging System
B2 microglobulin (both stages) and albumin (stage 1)
Stage 1 - low B2 (<3.5mg/L), normal albumin - survival >5 years
Stage 2 – not stage 1 or 3
Stage 3 - High B2 (>5.5mg/L), survival <2 years]
Multiple Myeloma
What are the cytogenetics of multiple myeloma and the associated prognoses?
Cytogenetics:
Chrom 13 del (bad but good in CLL!),
Hypodiploidy (bad),
17p del (bad)
FISH: T(4:14) T(14;16)(bad) – by FISH only
T(11;14) ‘good’
Describe the sites of mutations and cell heritage for the following
What do they all have in common?
Chronic lymphocytic leukaemia
Acute lymphocytic leukaemia
Follicular lymphoma
Diffuse large b-cell lymphoma
Multiple myeloma
Chronic lymphocytic leukaemia- lymphoid tissue, mature naive b-cell
Acute lymphocytic leukaemia - bone marrow, pre-b-cell
Follicular lymphoma - lymphoid tissue, germinal centre b-cell
Diffuse large b-cell lymphoma - lymphoid tissue, germinal centre be cell
Multiple myeloma - plasma cell
Hodgkin lymphoma - lymphoid tissue, germinal centre b-cell
What are the unfavourable classifications of Hodgkin’s lymphoma?
Unfavorable Early Stage (B-Sx, age >50, ESR >50, bulky, 3+ areas)
Advanced Stage (III-IV)
What does ABVD stand for in the treatment of Hodgkin lymphoma?
What are the side effects?
Adriamycin
Bleomycin
Vinblastine
Dacarbazine
SEs
- Hair loss
- Neutropenia
- Cardiotoxicity from adriamycin
- Lung toxicity from bleomycin
- Low risk of infertility
What does BEACOPP stand for in the treatment of Hodgkins lymphoma?
When is it used?
What are the drawbacks?
Bleomycin, Etoposide, Adriamycin, Cyclophosphomide, O-Vincristine, Procarbazine, Prednisone
Used for advanced Hodgkins or unfavourable stage
More risk of infertility and late-stage cancers
Why is low dose RTx used (where necessary) in Hodgkin’s lymphoma?
Reduces risk of late breast cancer in young women
What are the adverse prognostic factors in Hodgkin’s lymphoma? (Hasenclever Index)
What is the difference between having 1 or 5 or more of these?
Serum albumin < 40 g/L
Haemoglobin < 10.5 g/dL
Male gender
Stage IV disease
Total WCC > 15
Lymphocytes < 0.6, or < 8% of total WCC
Age > 45 years
Survival drops cumulatively - >5 = <50% PFS
Which chemotherapy drugs are associated with secondary CML?
Alkylators and etoposide
Aside from CML and breast cancer, what are the other cancers associated with Hodgkin’s treatment?
Which treatment do they stem from?
Thyroid, lung, bone - mainly XRT
Brain - unknown cause
What is the mechanism of secondary cardiovascular disease due to Hodgkins lymphoma treatment?
XRT
What are the survivorship issues in long term survivors of Hodgkin’s lymphoma?
Infertility - worse in men, worse if older
Second cancers - breast, lung, colon, leukaemia
Organ damage - heart (coronary disease), lung, thyroid
What is the significan of PET positive and PET negative disease in Hodgkin’s lymphoma?
FAR worse survival if PET positive
What is nodular lymphocyte predominant Hodgkin’s lymphoma?
Why is a misnomer?
How is it treated?
Unusual form of B-cell lympoma (Reed-Steenberg cells express CD20)
A misnomer due to the CD20 expression - it is a non-hodgkin’s lymphoma
May progress to DLBCL
Long survival if localised (surg +/- RTx)
Responds to anti-CD20 agent Rituximab - long survival interspersed with relapses
What are the commonest types of Non-Hodgkin lymphoma?
What are the other main types?
Follicular lymphoma
Diffuse large b-cell lymphoma
Others
Burkitt
SLL/CLL
MALT
Mantle cell
What are the cytogenetics of follicular non-Hodgkin lymphoma?
t(14;18) and bcl-2 rearrangement in > 85%
Follicular
- t(14;18) —> overexpresson of BCL-2 —> failure of apoptosis (the usual mechanism of B-Cell death)
What is the epidemiology of follicular non-hodgkin lymphoma?
Median age at dx 60-65y
Male = Female
Western countries
What are the clinical features of follicular non-hodgkin lymphoma?
Generalised lymphadenopathy w/ BM involvement
+/- splenomegaly or hepatomegaly
Indolent clinical course
Cumulative risk of histologic transformation around 25%
B-symptoms in 10%
Should indolent stage IV non-hodgkin lymphoma be observed or treated? Why?
Treated with anti-CD20 antibodies (Rituximab)
Much better survival
What are the prognostic factors of follicular lymphoma? (Follicular lymphoma international prognostic index - FLIPI)
Age >60
Ann Arbor stage III/IV
Hb <120
LDH > ULN (Upper limit of normal)
>4 involved nodal sites
What is CHOP and R-CHOP?
When is it used?
Cyclophosphamide, H -Doxorubicin (Adriamycin), O-Vincristine, Prednisone
R- Rituximab
Used for Non-Hodgkin Lymphoma
What is the role of rituximab-maintenance therapy in NHL?
Improves event-free rate in comparison to observation alone.
Given for 2 years.
What is the potential role of lenalidomide in follicular lymphoma?
Augments rituximab, improves PFS - may replace CHOP in future.
What are the cytogenetics of DLBCL?
t(14;18) and bcl-2 rearrangement in < 30%
What is the epidemiology of DLBCL?
Median age at dx 55-60
Male >female
Minimal geographic variation
Around 50% disseminated at dx
What are the clinical features of DLBCL?
Usually
- localised lymphadenopathy
- BM involvement uncommon
- B-sx in 30-40%
- Aggressive but curable around 60% of cases
- Risk of CNS involvement around 5%
When is the international prognostic index used?
What are it’s factors?
Predicts survival in NHL.
Performance status > 2
Age > 60 years
Ann Arbor stage III or IV
LDH above normal
2 extranodal sites of disease
Describe the ECOG score
0 – Asymptomatic
1 – Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory. ie light housework, office work)
2 – Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
3 – Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
4 – Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
5 – Death
What two prognostic subgroups have been identified by DNA microarray analysis in DLBCL? Which one has better survival?
Germinal-center B-Cell like (better survival)
Type 3 (worse)
Activated B-cell like (worst)
What is first line therapy for DLBCL?
R-CHOP
What are the most significant risk factors for CNS disease in lymphoma?
What are the independent risk factors?
- testicular involvement
- clinical stage
- IPI score
Independent
- elevated LDH
- >1 extranodal disease site
- ECOG >2
When is intrathethecal methotrexate used? Why is concurrent IV used?
What is the role of rituximab?
Used in DLBCL if risk factors for CNS disease present (extranodal site + 1 other risk factor i.e. LDG, ecog, testicular)
Intrathecal does not get into brain parenchyma, high dose MTx crosses the BBB.
Reduces CNS disease in patients with IPI of 0 or 1
What is a ‘double hit’ lymphoma?
What is it’s relevance?
Dual positivity for BCL-2 + C-MYC portends a poor prognosis, either de novo or with t-FL
No standard treatment
Rituximab-containing therapy provides a benefit but is still inadequate
What are the cytogenetics of Burkitt’s NHL?
Burkitt’s NHL: t(8;14) & c-myc, highly aggressive, curable
- t(8;14) —> overexpreesion of c-myc —> malignant transformation through excess b-cell proliferation
- associated with abdominal pain/fullness as disease prefers abdomen
What is associated with primary cerebral NHL? What is the standard treatment?
HIV-related or sporadic
Standard is high dost MTx and XRT
What viruses are associated with HIV-related NHL?
HHV-8, EBV, also related to CD4 count
Often extra-nodal, aggressive.
What are the cytogenetics and location of disease in mantle-cell NHL?
- t(11;14) and bcl-1 translocation (cyclin D1)
- frequent GI involvement (lymphomatous polyposis)
- aggressive clinical behaviour, treatment difficult
What genetic mutation is associated with 100% of hairy-cell leukaemias?
B-RAF
What does overexpression of BCL-2 result in, in the context of lymphoma?
resistance to apoptosis
What is Bruton’s tyrosine kinase?
When is an anti-BTK drug useful?
BTK is a kinase that plays a crucial role in B-cell development.
Ibrutinib Is Highly Effective in Relapsed /Refractory CLL
What are the marginal zone lymphomas?
MALT type
Nodal type
Splenic type
Name the indolent lymphomas
- follicular, marginal zone, SLL/CLL
What is the treatment for MALT lymphoma?
MALT - H-pylori and PPIs w/ frequent endoscopy, or whole-stomach XRT
Name the aggressive lymphomas
DLBCL, Mantle cell lymphoma, primary CNS lymphoma, T-Cell lymphoma, high grade (Burkitt or lymphoblastic)
What is the treatment for DLBCL and mantle-cell lymphoma?
R-CHOP
Maybe Auto-SCT
What is the treatment for primary CNS lymphoma?
Repetitive cycles of high-dose intravenous methotrexate with rituximab early in the treatment course produce better results than whole brain radiotherapy and with less cogni- tive impairment.
What is the treatment for high grade lymphomas? (Burkitt or Lymphoblastic)
Intense, cyclic chemotherapy in the hospital similar to that given for ALL, and they also require intrathecal chemotherapy as central nervous system prophylaxis.
How do peripheral t-cell lymphomas fare compared to B-cell disease?
Peripheral T-cell lymphomas usually have advanced stage nodal and extranodal disease and typically have inferior response rates to therapy compared to patients with aggressive B-cell disease
What is the prognosis of indolent non-hodgkin lymphoma?
10–15 years. These diseases ultimately become refractory to chemotherapy.
What is the likelihood of survival after relapse of non-hodgkins lymphoma?
Depends on whether the lymphoma is still responsive to chemotherapy. If the lymphoma remains responsive to chemotherapy, autologous hematopoietic stem cell transplantation offers a 50% chance of long-term lymphoma-free survival.
Describe the Ann-Arbor staging system.
What is it used for?
Used for Hodgkin’s lymphoma.
Ann Arbor
I - one LN
II - 2 or more on one side of diaphragm
III - Both sides of diaphragm
IV - disseminated w/ extranodal involvement
A - no constitutinal sx
B - 10% wt loss of six months, fever, drenching night sweats (one or more)
What are the clinical findings of Hodgkin Lymphoma?
Bimodal - age 20s and then age 50s
Painless mass, commonly in the neck
Constitutional symptoms
Pain in lymph node following alcohol ingestion
Starts in one lymph node then spreads contiguously
What is the treatment for Hodgkin lymphoma?
Treatment
- RTx for stage 1A with high cervical LN and low ESR
Otherwise - ABVD (BEACOPP if bad but toxic + infertility and no definite survival advantage)
Stage I-II - usually short course ABVD +/- RTx
- full course if bulky disease
II-IV - full course ABVD w/ no RTx
Must watch for bleomycin plum toxicity.
Relapse may still be curable with CTx - high dose + auto SCT - 35-50% chance of cure.
What is the prognosis of Hodgkin lymphoma?
Prognosis
Factors: Stage, age, gender, Hb, alb, abc and lymphocyte count
Cure rate 75% if zero to two factors present, excess of 90% if Ia or IIa disease.
What is the pathogenesis of non hodgkin lymphoma?
Oncogene juxtaposed next to a either an Ig-gene (B-cell lymphoma) or t-cell receptor or related gene (t-cell lymphoma) —> painless lymphadenopathy —> indolent to rapidly progressive.
What are the prominent non-hodgkin lymphomas?
85% of NHL are B-cell, mainly DLBCL and follicular
What are the lab findings in non-hodgkin’s lymphoma?
Normal peripheral blood, no circulating lymphoma cells
Elevated LDH (prognostic)
BMB - paratrabecular monoclonal lymphoid aggregates
LP - (high grade) - meningeal involvement w/ malignant cytology
CXR - mediastinal mass
How do you make the diagnosis of non-hodgkin’s lymphoma?
Tissue bx (LN or extra nodal tissue) for dx and classification
What is the treatment for the indolent non-hodgkin lymphomas?
Indolent (follicular, marginal zone, SLL/CLL)
Limited disease (1-2 contiguous LNs) —> XRT for cure
Most are disseminated though.
- R-CHOP or R-CVP
- allo-SCT if aggressive and low grade
MALT - H-pylori and PPIs w/ frequent endoscopy, or whole-stomach XRT
What is the treatment for the aggressive non-hodgkin lymphomas?
DLBCL - RCHOP +/-Auto SCT if responsive to chemo
Mantle cell - as above
Primary CNS - high dose IV MTx + rituximab
High grade lymphoma (Burkitt/Lymphoblastic) - intense CTx plus intrathecal CTx as prophylaxis
Peripheral T-cell lymphomas - poor response, usually disseminated disease.
What is the prognosis for the indolent lymphomas?
Indolent - 10-15 years, ultimately becomes refractory and progresses
What is the IPI (International Prognostic Index) used for in regards to non-hodgkin lymphoma?
What are the factors?
IPI (International Prognostic Index) stratifies risk of those with intermediate grade lymphoma
factors:
Age >60,
elevated LDH,
Stage III, or IV disease.
80% chance of complete response rate with no or one risk factors
What are the two critical histopathological features of Hodgkin lymphoma?
Reed-Sternberg cells in an appropriately reactive (inflammatory) cellular background
What are the clinical findings of Hodgkin lymphoma?
Bimodal - age 20s and then age 50s
Painless mass, commonly in the neck
Constitutional symptoms
Pain in lymph node following alcohol ingestion
Starts in one lymph node then spreads contiguously
What are the prognostic factors for Hodgkin lymphoma?
Prognosis
Factors: Stage, age, gender, Hb, alb, WBC and lymphocyte count
Cure rate 75% if zero to two factors present, excess of 90% if Ia or IIa disease.
What is the aetiology of the acute leukaemias?
Aetiology
- AML: adult disease around 60, increased incidence with age
- ALL: 20% of adult acute leukaemia’s
- no clear cause
- radiation, benzene
- prior Ctx - cyclophos, melphalan, other alkylators, etoposide
- after toxins/CTx —> MDS w/ Cr 5 & 7 abnormalities; etoposide Cr 11q23
What is APL? Why does it differ from the other acute leukaemias?
APL (Acute promyelocytic leukaemia)
- t(15;17) —> PML-RARa fusion gene -> interacts w/ retinoid acid receptor causing differentiation block.
- can give ATRA —> differentiated into neutrophils occur —> neutrophils apoptose within minutes —> cure!
What are the favourable cytogenetics in AML?
Favourable - ‘core binding factors’ 15% of cases
- t(8;21)
- inv(16)
- p(13;q22)
What are the unfavourable cytogenetics in AML?
Unfavourable - poor prognosis
-5, -7, del(5q), Abnormal 3q, Complex cytogenetics
2 or more monosomy’s
3 or more separate cytogenetic abnormalities
What is the significance of the intermediate-risk subgroup of AML?
- normal cytogenetics or abnormalities w/o strong prognostic significance
- new molecular markers
- FLT3-ITD (internal tandem duplication)
- 30% of CN-AML (cytogenetically normal AML)
- very poor prognosis
- NPM1 (nucleophospmin 1) - favorable prognosis
What are the molecular markers of AML and what are their prognoses?
- FLT3-ITD (internal tandem duplication)
- 30% of CN-AML (cytogenetically normal AML)
- very poor prognosis
- NPM1 (nucleophospmin 1) - favorable prognosis
What are the cytogenetics of ALL?
- Common, early B, or T-cell
Hyperdiploidy has a better prognosis but is in kids
Unfavourable: Philadelphia chromosome and t(4;11) which has fusion genes involving the MLL gene at 11q23
What are the clinical findings of ALL?
Clinical findings
- presentation of days to weeks
- bleeding of skin and mucosal surfaces due to thrombocytopaenia
- DIC (APL and monocytic leukaemia)
- Infection due to neutropaenia; gram negative bacteria (e.coli, Klebsiella, pseudomonas), or fungi (candida, aspergillus —> cellulitis, pneumonia, perirectal infections.
- Gum hypertrophy, bone and joint pain
- Hyperleukocytosis - impaired circulation —> headache, confusion, dyspnoea, need urgent leukopheresis and chemotherapy - 40% mortality
What are the examination findings in ALL?
Pale, purpura, petechiae
Stomatits, gum hypertrophy and rectal fissues in monocytic leukaemia
Hepatosplengomegaly, lymphadenopathy
Bone tenderness: sternum, tibia, femur
What are the lab findings in ALL?
Hallmark: Pancytopaenia with circulating blasts
Bone marrow: Hypercellular, >20% blasts
Hyperuricaemia
DIC: low fibrinogen, fibrin degradations products
ALL: Mediastinal mass on CXR
Meningeal leukaemia: Blasts in spinal fluid - 5% of cases, mainly monocytic AML
Myeloperoxidase stain: Auer rod - eosinophilic needle-like inclusion in the cytoplasm = pathognomonic of AML (but has been superceded by flow cytometry)
(Not in ALL because peroxidase is only in myeloid cells)
Describe the flow cytometry findings of AML and ALL.
Flow cytometry:
AML - CD13 or CD33 (myeloid antigens)
ALL - B-lineage: CD19 (all B-Cells), and CD10 (common ALL antigen)
T-lineage - CD2, 5, and 7 (some combo of), but NOT mature t-cell markers, i.e. 3, 4, or 8, and not surface iG.
Almost all ALL cells express terminal deoxynucleotidyl transferase (TdT) (but not Burkitt type ALL)
What is the treatment of AML?
- Anthracycline (daunorubicin or idarubicin) plus cytarabine - complete remission in 80-90% under 60, 50-60% older patients
- Intermediate risk - cure rates ascend from 35-40% w/ CTx to 50-60% with allo-transplant
- Positive core binding factor cytogenetics have a more favourable prognosis with CTx, while CTx alone is not helpful if unfavourable profile.
- FLT3 inhibitors are in trial.
Unfavourable - allo-transplant but poor cure rates 20-30%, worse if over 60 even if in first remission - may be a role for reduced intensity allo-transplant.
- Prognosis drops with recurrence after first remission.
What is the treatment of APL?
- Anthracycline plus ATRA - 90-95% CR
- High risk (higher WBC count) - added arsenic improves outcomes
- Arsenic can produce second remission in 90% of cases if required.
What is the treatment of ALL? What if they are Ph+?
- Vincristine, Daunorubicin, Asparaginase, PreD (VDAC)
- CR in 90%
- Ph+ needs TKI in addition to standard CTx as T315i (resistant to all 3 TKIs) mutation much more common than in CML, unless older - 90% can achieve remission
- Need CNS prophylaxis to avoid meningeal sequestration of leukaemia cells.
- Low risk: 70% chance of cure with
- Intermediate: 30-50% chance
- High risk (adverse cytogenetics or poor response to CTx) —> Allo-BMT
What is the prognosis in AML?
AML: High dose post remission CTx —> cure in 35-40%, high dose cytarabine superior
Allo BMT curative in 50-60% of cases
Cure rates for older patients very low even with remission
How is complete remission (CR)
in AML defined?
<5% blasts on bmbx
Which leukaemia is a widened mediastinum a hallmark of?
ALL
Question 5
In females under 20 years of age treated successfully with radiotherapy for Hodgkin’s disease, which one of the following is the most frequent second tumour occurring after 10 years?
A. Acute leukaemia.
B. Thyroid cancer.
C. Non-Hodgkin’s lymphoma.
D. Breast cancer.
E. Ovarian carcinoma.
D
A 32-year-old man presents with weight loss, splenomegaly 20 cm below the left costal margin and a white cell count of 480 x 109/L [3.5-9.5]. Bone marrow examination confirms the diagnosis of an accelerated phase myeloid leukaemia in chronic phase.
Which treatment option offers this man the best chance of long-term disease-free survival?
A. Imatinib.
B. Interferon and cytarabine.
C. Hydroxyurea.
D. Autologous bone marrow transplantation.
E. Allogenic stem cell transplantation.
A.
Patients with advanced-stage disease (accelerated phase or myeloid/lymphoid blast crisis) should be treated with a tyrosine kinase inhibitor alone or in combination with myelosuppressive chemotherapy. The doses of tyrosine kinase inhibitors in that setting are usually higher than those appropriate for chronic-phase disease. Since the duration of response to tyrosine kinase inhibitors in this setting is limited, these patients should ultimately be con- sidered for allogeneic stem cell transplantation.
A 62-year-old woman underwent an elective cholecystectomy. Routine full blood examination revealed:
Physical examination revealed no lymphadenopathy and no hepatosplenomegaly. The woman was asymptomatic. Flow cytometry revealed that the lymphocytosis marked as CD5+, CD19+ and CD23+.
What is the most appropriate management of this patient?
A. Observation alone.
B. Prednis(ol)one.
C. Chlorambucil.
D. Combination chemotherapy.
E. Autologous bone marrow transplantation.
Answer - A
Treatment
Early stage - observation
Indications for tx: progressive fatigue, symptomatic lymphadenopathy, anaemia or thrombocytopaenia (either symptomatic and progressive Rai II, or stage III/IV disease)
Staging - Rai
Stage 0 - lymphocytosis (low-risk)
Stage II - organomegaly (low risk)
Stage III - anaemia (high risk)
Stage IV - thrombocytopaenia (high risk)
