1. Myeloproliferative disorders Clonal haematopoeitic disorders Proliferation of one of myeloid lineages –Granulocytic –Erythroid –Megakaryocytic Relatively normal maturation

2. Myeloproliferative disorders WHO Classification of CMPD Ch Myeloid leukemia Ch Neutrophillic leukemia Ch Eosinophillic leukemia / Hyper Eo Synd Polycythemia Vera Essential Thrombocythemia Myelofibrosis CMPD unclassifiable

3. Myeloproliferative disorders MPD PRV ET MF AML MDS RA RARS RAEB I RAEB II CMML CML

4. Myeloproliferative disorders Ch Myeloid leukemia (BCR-ABL positive) Polycythemia Vera Essential Thrombocythemia Myelofibrosis –Specific clincopathologic criteria for diagnosis and distinct diseases, have common features –Increased number of one or more myeloid cells –Hepatosplenomegaly –Hypercatabolism –Clonal marrow hyperplasia without dysplasia –Predisposition to evolve

5. Bone marrow stem cell Clonal abnormality Granulocyte precursors Red cell precursors MegakaryocytesReactive fibrosis Essential thrombocytosis (ET) Polycythaemia rubra vera (PRV) Myelofibrosis AML Chronic myeloid leukemia 70% 10% 30%

6. Epidemiology of CML Median age range at presentation: 45 to 55 years Incidence increases with age – 12% - 30% of patients are >60 years old At presentation – 50% diagnosed by routine laboratory tests – 85% diagnosed during chronic phase

7. Ionizing radiationLatent Period Atomic bomb survivors 11 years ( 2-25) Ankylosing spondylitis pts 3.6 years (1-6) No evidence of other genetic factors Chemical have not been associated with CML Incidence 1-1.5/100,000 population Male predominance Epidemiology of CML

8. Presentation Insidious onset Anorexia and weight loss Symptoms of anaemia Splenomegaly –maybe massive Pt. maybe asymptomatic

10. The Philadelphia Chromosome 23451 7891011126 131415161718 202122XY19

11. The Philadelphia Chromosome: t(9;22) Translocation bcr-abl Fusion protein with tyrosine kinase activity 22 bcr abl Ph 9 9+ Philadelphia chromosome

12. Clinical Course: Phases of CML Chronic phase Median 4–6 years stabilization Accelerated phase Median duration up to 1 year Blastic phase (blast crisis) Median survival 3–6 months Terminal phase Advanced phases

13. Treatment of Chronic Myeloid leukemia ArsenicLissauer, 1865 RadiotherapyPusey, 1902 BusulfanGalton, 1953 HydroxyureaFishbein et al, 1964 AutograftingBuckner et al, 1974 Allogeneic BMT (SD)Doney et al, 1978 InterferonTalpaz et al, 1983 Allogeneic BMT (UD)Beatty et al, 1989 Donor Leukocytes Kolb et al, 1990 ImatinibDruker et al, 1998 Imatinib/Combination therapyO’Brien et al, 200……

14. CML Treatment Chemotherapy to reduce WCC - Hydroxyurea Interferon based treatment Allogeneic bone marrow transplant Molecular therapy - Imatinib

15. CML- CP survival post BMT (IBMTR 1994-1999) Years Probability %

16. Issues related to BMT 70% long term cure rate Donor Availability Age of patient Length/stage of disease Treatment related mortality Long term sequalae – infertility, cGVHD

17. The Ideal Target for Molecular Therapy Present in the majority of patients with a specific disease Determined to be the causative abnormality Has unique activity that is - Required for disease induction - Dispensable for normal cellular function

18. Mechanism of Action of Imatinib Goldman JM. Lancet. 2000;355:1031-1032. Bcr-Abl ATP Substrate Imatinib Y = Tyrosine P = Phosphate Bcr-Abl Substrate P P P P

19. Imatinib compared with interferon and low dose Cytarabine for newly diagnosed chronic-phase Chronic Myeloid leukemia S.G. O’Brien et al New England Journal of Medicine Vol. 348 March 2003

20. Imatinib vs Interferon in newly diagnosed CP Chronic Myeloid leukemia (18 months) CHR96%67% MCR83%20% CCR68% 7% Intolerance0.7%23% Progressive1.5% 7% disease Imatinib 400mg Interferon and Ara-C

21. Evolution of treatment goals HRMCRCCRPCR - HU IFN Imatinib BMT

22. Issues related to Imatinib Very few molecular responses (5-10%) Resistance in some patients Lack of response in some patients Expensive Long term toxicity/side effects unknown

23. CML Diagnosis Young with a well-matched donor Cosider for Allograft Allo SCT Start Imatinib at 400mg/day Poor response or Initial response Followed by Loss of response Add or substitute Other agents Allo-SCT Auto Good response maintained Continue Imatinib indefinitely

24. Polycythemia True / Absolute –Primary Polycythemia –Secondary Polycythemia Epo dependent –Hypoxia dependent –Hypoxia independent Epo independent Apparent / Relative –Reduction in plasma volume

25. Causes of secondary polycythemia ERYTHROPOIETIN (EPO)-MEDIATED –Hypoxia-Driven Chronic lung disease Right-to-left cardiopulmonary vascular shunts High-altitude habitat Chronic carbon monoxide exposure (e.g., smoking) Hypoventilation syndromes including sleep apnea Renal artery stenosis or an equivalent renal pathology –Hypoxia-Independent (Pathologic EPO Production) Malignant tumors –Hepatocellular carcinoma –Renal cell cancer –Cerebellar hemangioblastoma Nonmalignant conditions –Uterine leiomyomas –Renal cysts –Postrenal transplantation –Adrenal tumors EPO RECEPTOR–MEDIATED –Activating mutation of the erythropoietin receptor DRUG-ASSOCIATED –EPO Doping –Treatment with Androgen Preparations

26. POLYCYTHEMIA VERA Chronic, clonal myeloproliferative disorder characterized by an absolute increase in number of RBCs 2-3 / 100000 Median age at presentation: 55-60 M/F: 0.8:1.2

27. POLYCYTHEMIA VERA JAK2 Mutation JAK/STAT: cellular proliferation and cell survival deficiency in mice at embryonic stage is lethal due to the absence of definitive erythropoiesis Abnormal signaling in PV through JAK2 was first proposed in 2004 a single nucleotide JAK2 somatic mutation (JAK2V617F mutation) in the majority of PV patients

28. Clinical features Plethora Persistent leukocytosis Persistent thrombocytosis Microcytosis secondary to iron deficiency Splenomegaly Generalized pruritus (after bathing) Unusual thrombosis (e.g., Budd-Chiari syndrome) Erythromelalgia (acral dysesthesia and erythema)

29. Clinical features Hypertention Gout Leukaemic transformation Myelofibrosis

30. Diagnostic Criteria A1Raised red cell mass A2Normal O2 sats and EPO A3Palpable spleen A4No BCR-ABL fusion B1Thrombocytosis >400 x 109/L B2Neutrophilia >10 x 109/L B3Radiological splenomegaly B4Endogenous erythroid colonies A1+A2+either another A or two B establishes PV

32. Treatment The mainstay of therapy in PV remains phlebotomy to keep the hematocrit below 45 percent in men and 42 percent in women Additional hydroxyurea in high-risk pts for thrombosis (age over 70, prior thrombosis, platelet count >1,500,000/microL, presence of cardiovascular risk factors) Aspirin (75-100 mg/d) if no CI IFNa (3mu three times per week) in patients with refractory pruritus, pregnancy Anagrelide (0.5 mg qds/d) is used mainly to manage thrombocytosis in patients refractory to other treatments. Allopurinol

33. Essential Thrombocythaemia (ET) Clonal MPD Persistent elevation of Plt>600 x109/l Poorly understood Lack of positive diagnostic criteria 2.5 cases/100000 M:F 2:1 Median age at diagnosis: 60, however 20% cases <40yrs

34. Clinical Features Vasomotor –Headache –Lightheadedness –Syncope –Erythromelalgia (burning pain of the hands or feet associated with erythema and warmth) –Transient visual disturbances (eg, amaurosis fujax, scintillating scotomata, ocular migraine) Thrombosis and Haemorrhage Transformation

35. Investigations ET is a diagnosis of exclusion Rule out other causes of elevated platelet count

36. Diagnostic criteria for ET Platelet count >600 x 109/L for at least 2 months Megakaryocytic hyperplasia on bone marrow aspiration and biopsy No cause for reactive thrombocytosis Absence of the Philadelphia chromosome Normal red blood cell (RBC) mass or a HCT <0.48 Presence of stainable iron in a bone marrow aspiration No evidence of myelofibrosis No evidence of MDS

40. Therapy of ET based on the risk of thrombosis

41. Thrombophilia Barry White National Haemophilia Director Director, National Centre for Hereditary Coagulation Disorders, St James’s Hospital

42. Virchow’s Triad Disorder of blood vessel wall Disordered blood flow (stasis) Abnormality of blood constituents

43. Venous thrombosis - a multifactorial disease Acquired risk factors pregnancy, surgery, hormonal therapy, malignancy Inherited risk factors single gene defects e.g. antithrombin multigenic defects e.g. antithrombin + FV leiden

44. Thrombophilia Inherited or acquired predisposition to venous thrombosis Laboratory abnormalities

47. Increased procoagulants FVIII FIX FXI Prothrombin 20210A Fibrinogen Thrombin activator fibrinolysis inhibitor (TAFI)

48. Decreased anticoagulants Antithrombin deficiency Protein C deficiency Protein S deficiency Activated PC resistance (FV Leiden)

49. Unknown mechanism Antiphospholipid syndrome Hyperhomocysteinemia

50. Activated protein C resistance Factor V leiden (R506Q) in 90% of cases Coagulation based assay (+/-FV def plasma) PCR based assay 2%-15% 2.0 –2.3% of Irish population are heterozygous FVL Livingstone et al 2000 20% of unselected VTE Relative risk 3-8 fold for heterozygotes

51. APC Factor V (normal) APC Factor V Leiden

52. Prothrombin G20210A Poort 1996 Mutation in 3’ UTR associated with increased prothrombin levels 1.3% of Irish population heterozygous (Keenan et al 2000) 6-8% of unselected VTE 16% of familial VTE

53. Hyperhomocysteinemia Definite risk factor for arterial vascular disease >18.5  mol/l in 5% of normal population >18.5  mol/l in 10% of VTE Homozygous MTHFR (C677T) - 10% Irish population Acquired B12, folate, B6 deficiency

54. Antiphospholipid syndrome Venous, arterial or small vessel except superficial venous thrombosis 3 consecutive unexplained fetal loss Severe pre-eclampsia or placental insufficiency leading to prematurity (<34w) Unexplained single fetal loss >10 wks with normal morphology

55. APLS - laboratory diagnosis ACL IgG or IgM (> 3SD above normal) Lupus anticoagulant Need 2 positive tests (either test will do) at least 6 weeks apart Anti B2-Glycoprotein I

56. Hormonal therapy OCP risk of VTE increased x 2-3 fold (baseline risk 1:10,000) FVL risk of VTE increased x 3-7 fold OCP + FVL risk of VTE increased x 33 fold (30:10,000 = 0.3%) Need to screen 2 million to save one life Similar synergistic interaction with other thrombophilic defects HRT likely to be similar

57. Pregnancy and Virchow’s triad Venous stasis - changes in tone and obstruction Vascular damage at time of delivery  APTT, PS (free and total), APCr  FVIII:C, VWF, Fibrinogen  PAI-1 and PAI-2

58. Pregnancy and venous thromboembolic disease Pregnancy increases risk x 5-10 fold 0.86/1000 deliveries 0.71/1000 (DVT) : 0.15/1000 (PE) Left leg >80% Ileofemoral more common than calf vein (72% versus 9%) Increased with age, caesarian section, bed rest and prior history of DVT/PE

59. Clinical practice – DVT/PE Diagnosis DVT – doppler ultrasound primarily (venogram gold standard) PE – ventilation perfusions scan primarily (pulmonary angiogram is gold standard) Treatment Heparin x 5-10 days until at least 5 days of warfarin Warfarin x 6 months ( indefinite for second thrombosis)