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YR5 Haematology > Myelodysplastic Syndromes and Bone Marrow Failure > Flashcards

Myelodysplastic Syndromes and Bone Marrow Failure Flashcards

1
Q

What are myelodysplastic syndromes (MDS)?

A

Biologically heterogeneous group of acquired haemopoietic stem cell disorders (~ 4 per 100,000 persons).

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2
Q

What is MDS characterised by?

A

Development of a clone of marrow stem cells with abnormal maturation resulting in functionally defective blood cells + a numerical reduction.

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3
Q

What does the development of a clone of marrow cells with abnormal maturation in MDS result in?

A

Cytopenia(s)

Qualitative (functional) abnormalities of erythroid, myeloid + megakaryocytic maturation

Increased risk of transformation to leukaemia (AML)

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4
Q

What is the epidemiology of MDS?

A

Typically disorder of elderly.

Sx + signs are those of general marrow failure.

Develops over weeks + months.

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5
Q

List 5 blood and bone marrow morphological features of MDS?

A
  • Pelger-Huet anomaly (bilobed neutrophils)
  • Dysgranulopoieses of neutrophils
  • Dyserythropoiesis of red cells
  • Dysplastic megakaryocytes e.g. micromegakaryocytes
  • Increased proportion of blast cells in marrow (normal < 5%)
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6
Q

What is this?

A

Normal neutrophils

Multilobed with granules in cytoplasm

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7
Q

What is this?

A

Pelger-Heut anomaly

Only 2 lobules, connected by thin bridge of cytoplasm

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8
Q

What is this?

A

Refractory anaemia dysgranulopoiesis

Abnormal lack of granules in neutrophils

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9
Q

What is this?

A

Myelokathexis

Condensed nuclei with thin intrasegmented filaments + vacuoles

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10
Q

What is this?

A

Refractory anaemia-dyserythropoiesis

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11
Q

What is this?

A

Refractory anaemia-dyserythropoiesis

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12
Q

What is this?

A

Ringed sideroblasts

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13
Q

What is this?

A

Myeloblasts with Auer rods

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14
Q

What are Auer rods a sign of?

A

AML

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15
Q

Which prognostic variables are included in the Revised International Prognostic Scoring System (IPSS-R) in MDS (2012)?

A

BM blasts (%)

Karyotype

Hb (g/L)

Platelets (x10^9/L)

Neutrophils (x10^9/L)

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16
Q

How is the IPSS-R score interpreted?

A

The higher the score, the lower the survival + time to progress to AML.

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17
Q

Which driver mutations in MDS carry prognostic significance?

A

TP53, EZH2, ETV6, RUNX1, ASXL1

Others: SF3B1, TET2, DNMT3A

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18
Q

In which group of MDS patients are the majority of common mutations found in?

A

More frequently in high risk MDS than low risk

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19
Q

What is the sequelae of disease in MDS?

A

Deterioration of blood counts: Worsening consequences of marrow failure.

Development of AML:

  • Develops in 5-50% < 1y (depends on subtype)
  • Some cases of MDS are much slower to evolve
  • AML from MDS has an extremely poor prognosis + is usually not curable
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20
Q

Why is AML from MDS much harder to treat than those with AML without prior MDS?

A

Those without prior MDS more likely to have normal stem cells in BM

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21
Q

What is the rule of thumb for outcomes of MDS progression?

A

⅓ die from infection (low neutrophils, can’t fight)

⅓ die from bleeding (low platelets)

⅓ die from acute leukaemia

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22
Q

What is the treatment of MDS?

A

Allogeneic stem cell transplantation (SCT)

Or

Intensive chemotherapy

(Only minority of patients can benefit from these, as most are too old/ frail)

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23
Q

What supportive care can be given to those with MDS?

A

Blood product support: transfusions

Abx for infections

Growth factors to enhance residual BM activity

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24
Q

What growth factors can be given to those with MDS? What cell lineage is each given to enhance?

A

EPO: Hb

G-CSF: Neutrophils

Thrombopoetin (TPO) receptor agonists: Platelets

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25
Q

What biological modifiers are used in the treatment of MDS?

A

Immunosuppressive therapy

Hypomethylating agents: Azacytidine + Decitabine

Lenalidomide

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26
Q

Which forms of chemotherapy may be used in MDS?

A
  1. Oral Hydroxyurea
  2. Subcutaneous low dose Cytarabine
  3. Intensive chemo (for high risk): designed to treat AML
27
Q

Which one of the following about MDS is true?:
A. Myelodysplasia has a bi-modal age distribution

B. The primary modality of treatment of MDS is by intensive chemotherapy

C. ⅓ of MDS patients can be expected to die from leukaemic transformation

D. There is no good correlation between the severity of cytopenias and the overall life expectancy

E. White cell function is frequently well preserved in MDS

A

C. ⅓ of MDS patients can be expected to die from leukaemictransformation

28
Q

What can the common myeloid progenitor give rise to?

A
  1. RBCs
  2. Mast cells
  3. Megakaryocytes which give rise to platelets
  4. Myeloblasts which give rise to basophils, neutrophils, eosinophils + monocytes
29
Q

What can the common lymphoid progenitor give rise to?

A
  1. Natural killer cells
  2. B Lymphocytes
  3. T Lymphocytes
30
Q

How does stage of maturation in the bone marrow determine the lineages affected?

A

Pluripotent haematopoeitic cell: impairs production of ALL peripheral blood cells (Rare)

Committed progenitor cells: Bi- or unicytopenias

31
Q

What are 3 congenital causes of primary bone marrow failure?

A

Fanconi’s anaemia (multipotent stem cell)

Diamond-Blackfan anaemia (red cell progenitors)

Kostmann’s syndrome (neutrophil progenitors)

These are more commonly seen in kids

32
Q

What is an acquired causes of primary bone marrow failure?

A

Idiopathic aplastic anaemia (multipotent stem cell)

Most common primary BM failure syndrome (over congenital)

33
Q

Which form of bone marrow failure is more common?

A

Secondary is more common than primary

Primary are relatively rare

34
Q

What are secondary causes of bone marrow failure?

A

Marrow infiltration

Haematological (leukaemia, lymphoma, myelofibrosis)

Non-haematological (Solid tumours)

Radiation

Drugs

Chemicals (benzene)

Autoimmune

Infection (Parvovirus, Viral hepatitis)

35
Q

Which drugs can cause bone marrow failure?

A

PREDICTABLE (dose-dependent, common): Cytotoxic drugs.

IDIOSYNCRATIC (NOT dose-dependent, rare): Phenylbutazone, Gold salts.

Abx: Chloramphenicol, Sulphonamide.

DIURETICS: Thiazides.

ANTITHYROID DRUGS: Carbimazole.

36
Q

What is the epidemiology of aplastic anaemia?

A

2-5 cases/million/yr (world-wide)

All age groups can be affected

Peak incidence: 15-24y + > 60y

37
Q

Give 2 characteristic test findings in aplastic anaemia

A

Blood: Cytopenia

BM: Hypocellular

38
Q

How is aplastic anaemia classified?

A

Severe aplastic anaemia (SAA)

Non-severe aplastic anaemia (NSAA)

Using Camitta criteria based on % reticulocytes, neutrophils + platelets in peripheral blood

+ cellularity of BM

39
Q

Describe the aetiological classification of aplastic anaemia

A

Idiopathic: 70-80% (majority)

Inherited: Dyskeratosis congenita, Fanconi anaemia, Scwachman-Diamond syndrome

“Secondary”: Radiation, cytotoxics, SLE

Idiosyncratic: Chloramphenicol, NSAIDs, hepatitis viruses

Paroxysmal Nocturnal Haemaglobinuria

40
Q

What is the pathophysiology of idiopathic aplastic anaemia?

A

Failure of BM to produce blood cells

“Stem cell” problem (CD34, LTC-IC) [Long-Term Culture-Initiating Cells].

Immune attack: Humoral or cellular (T cell) attack against multipotent haematopoietic stem cell.

41
Q

What is the triad of bone marrow failure findings in aplastic anaemia?

A

Anaemia: Fatigue, breathlessness.

Leucopenia: Infections

Platelets: Easy bruising/ bleeding

42
Q

What is this?

A

Normal bone marrow

White = fat

43
Q

What is this?

A

Aplastic bone marrow

Few cells, majority fat

44
Q

List 6 differentials to aplastic anaemia for findings of pancytopenia and hypo cellular marrow

A

Hypoplastic MDS/ AML

Hypocellular ALL

Hairy cell leukaemia

Mycobacterial (usually atypical) infection

Anorexia Nervosa

Idiopathic Thrombocytopenic Purpura

45
Q

Give 6 approaches to management of aplastic anaemia

A
  1. Seek + remove a cause
  2. Supportive
  3. Immunosuppressive therapy
  4. Drugs to promote marrow recovery
  5. Stem cell transplantation
  6. Other tx in refractory cases
46
Q

What supportive treatment can be given to those with aplastic anaemia?

A

Blood/ platelet transfusions (Leucodepleted, CMV -ve, irradiated)

Abx

Iron Chelation Therapy

47
Q

What is the specific treatment for idiopathic aplastic anaemia based on?

A

Severity of illness

Age of patient

Potential sibling donor

48
Q

What are the specific treatments for aplastic anaemia?

A

Immunosuppressive therapy – older patient:

  • Anti-Lymphocyte Globulin (ALG)
  • Ciclosporin
  • Eltrombopag

Androgens: oxymethalone

Stem cell transplantation:

  • Young with donor (80% cure)
  • VUD/MUD for > 40 yrs (50% survival)
49
Q

What are complications associated with aplastic anaemia?

A
  1. Relapse of AA (35% >15y)
  2. Clonal haematological disorders
  3. Solid tumours ~3% risk
50
Q

Which clonal haematological disorders may arise as a complication following immunotherapy for aplastic anaemia?

A

Myelodysplasia

Leukaemia ~20% risk over 10y

PNH (paroxysmal nocturnal haemoglobinuria): May be a transient phenomenon.

51
Q

Regarding Aplastic Anaemia – which one answer is true?

A. Immunosuppressive therapy is only used to treat a minority of patients with aplastic anaemia.

B. If treated with immunosuppression, then relapse of Aplastic Anaemia occurs in less than 15% of cases.

C. The cure rate of AA treated by sibling-related allogeneic stem cell transplantation in a patient under 40 years old is > 70%.

D. Severe aplastic anaemia is differentiated from non-severe aplastic anaemia on the basis of the acquired cytogenetic abnormalities in the bone marrow.

E. Leucodepletion of cellular blood products is only exceptionally undertaken for patients with aplastic anaemia.

A

C. Cure rate of AA treated by sibling-related allogeneic stem cell transplantation in a patient <40y is > 70%.

52
Q

What is Fanconi Anaemia?

A

Most common form of inherited aplastic anaemia.

Autosomal recessive or X-linked inheritance.

Multiple mutated genes are responsible. When these genes become mutated, results in:

  • Abnormalities in DNA repair
  • Chromosomal fragility (breakage in the presence of in-vitro mitomycin or diepoxybutane)
53
Q

What are 6 congenital abnormalities associated with Fanconi Anaemia?

A
  • Short Stature
  • Hypopigmented spots + café-au-lait spots
  • Abnormality of thumbs
  • Microcephaly or hydrocephaly
  • Hyogonadism
  • Developmental delay

No abnormalities 30%

54
Q

List 5 complications that arise in fanconis anaemia with their prevalence

A

Aplastic anaemia: 90%

Myelodysplasia: 32%

Leukaemia: 10%

Cancer (epithelial): 5%

Liver disease: 4%

55
Q

What is Dyskeratosis Congenita (DC)?

A

An inherited disorder characterised by:

  • Marrow failure
  • Cancer predisposition
  • Somatic abnormalities
56
Q

What is the classical triad of dyskeratosis congenita?

A

Skin pigmentation

Nail dystrophy

Leukoplakia (white patches on tongue)

57
Q

List 4 somatic abnormalities/ complications in dyskeratosis congenita

A

Abnormal skin pigmentation: 89%

Nail dystrophy: 88%

BM failure: 85.5%

Leukoplakia: 78%

58
Q

What is the general approach to management of bone marrow failure e.g. in congenital syndromes?

A
  1. Supportive: Blood/platelet transfusions, Abx +/- Iron Chelation Therapy
  2. Drugs to promote marrow recovery: TPO receptor agonists
    (e.g. eltrombopag),
    ?Oxymetholone,
    ?Growth factors
  3. Stem cell transplantation
  4. Future ? haemopoietic gene therapy
59
Q

What are telomeres?

A

Found at the end of chr

Act to prevent chr fusion/ rearrangements during chr replication

Protect the genes at the end of the chr from degradation

60
Q

What is the association between telomeres and dyskeratosis congenita?

A

Telomere length is reduced in marrow failure diseases (especially short in patients with DC)

61
Q

What is maintenance of telomere length required for?

A

Indefinite proliferation of human cells

62
Q

What is the genetic basis of dyskeratosis congenita?

A

X-linked recessive trait: most common inherited pattern (mutated DKC1 gene: defective telomerase function).

Autosomal dominant trait: (Mutated TERC gene: encodes the RNA component of telomerase).

Autosomal recessive trait: gene for this form of DC not yet identified.

63
Q

Which one of the following is true?

A. Telomeric shortening is a feature of both idiopathic aplastic anaemia and dyskeratosis congenita.

B. Development of malignancy is an uncommon complication of Fanconi Anaemia.

C. A single genetic defect has been identified as the underlying cause for Fanconi Anaemia.

D. Fanconi Anaemia is usually inherited in an autosomal dominant fashion.

E. Telomeric function is considered to be unimportant in the pathophysiology of Dyskeratosis Congenita.

A

A. Telomeric shortening is a feature of both idiopathic aplastic anaemia and dyskeratosis congenita.

64
Q

Why is immunosuppression used in aplastic anaemia?

A

Most cases of AA have immunological// immune mediated attack on stem cells

Immunesuppression dampens AI attack on stem cells

Allow stem cells to recover

YR5 Haematology (20 decks)

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