2. Seyyed Reza Safaee MD Internist- Hematologist&Oncologist Hematology&Oncology& Hematopoietic Stem Cell Transplantation Ward Imam Khomeini General Hospital Tehran University Of Medical Sciences (Tehran-Iran)

3. Aplastic anemia Aplastic anemia is characterized by diminished or absent hematopoietic precursors in the bone marrow, most often due to injury to the pluripotent stem cell. The disease is estimated to occur in two to four subjects per million population per year.

4. CAUSES AND MECHANISMS OF STEM CELL FAILURE Congenital: Fanconi anemia Dyskeratosis congenita Shwachman-Diamond syndrome Amegakaryocytic thrombocytopenia Acquired: External radiation Drugs: nonsteroidal antiinflammatory drugs (particularly phenylbutazone) chloramphenicol, gold, sulfonamides, antiepileptic drugs (eg, felbamate, carbamazepine, valproic acid,phenytoin), nifedipine solvents/degreasing agents Industrial chemicals Aninsecticides(benzene) Viral infection: parvovirus B19,Hepatitis viruses A,B,C,G HIV Idiopathic aplastic anemia

5. Fanconi anemia Upper extremity deformities are present in over half of Fanconi anemia patients in over half of Fanconi anemia patients Radial hypoplasia Absent thumbs,radius, wrist Syndactyly Short stature, microcephaly, microphthalmia, small chin

6. Dyskeratosis Congenita Abnormal Fingernails and Toenails: Abnormal Fingernails and Toenails: ridges, splitting, wrinkled, soft, poor nail growth Reticular Pigmentation of the Neck and Chest and Chest Oral Leukoplakia: white patches in the inside of the mouth and tongue

7. Idiopathic aplastic anemia Idiopathic aplastic anemia Many of these patients respond to immunosuppressive therapy. There is an association of aplastic anemia with the rare immunologic disease, eosinophilic fasciitis. Aplasia can occur in the context of graft-versus-host disease following allogeneic hematopoietic cell transplantation. Bone marrow lymphocytes of patients with aplastic anemia can inhibit hematopoiesis when cocultured with patient or normal marrow. Clonal disorder: There is a close relationship between aplastic anemia and the clonal multilineage hematopoietic disorders: paroxysmal nocturnal hemoglobinuria, myelodysplastic syndrome with a hypoplastic bone marrow.

8. CLINICAL MANIFESTATIONS Anemia:PallorFatigue Cardiopulmonary compromise Thrombocytopenia: Mucosal hemorrhage Increased menstrual flow Petechiae, Purpura, Echymosis Neutropenia: Bacterial sepsis Pneumonia Urinary tract infection Invasive fungal infection Viral infection

14. The liver, spleen, and lymph nodes are not enlarged.

15. DIAGNOSIS Complete blood count: Complete blood count: Pancytopenia Reduced reticulocytes Peripheral Blood Smear: The red blood cells are normocytic but occasionally may be macrocytic. The remaining cellular elements are morphologically normal.

16. PBS

17. Bone marrow examination Aspiration an adequate BIOPSY of the bone marrow

18. Bone marrow examination Aspiration and adequate BIOPSY of the bone marrow The marrow space is composed mostly of fat cells and marrow stroma The marrow space is composed mostly of fat cells and marrow stroma The bone marrow is profoundly hypocellular with a decrease in all elements The bone marrow is profoundly hypocellular with a decrease in all elements Infiltration of the bone marrow with malignant cells or fibrosis is not present Infiltration of the bone marrow with malignant cells or fibrosis is not present Residual hematopoietic cells are morphologically normal and hematopoiesis Residual hematopoietic cells are morphologically normal and hematopoiesis is not megaloblastic is not megaloblastic

19. Bone Marrow Cellularity NormalHypercellularHypocellular

20. Normal BM

21. Hypocellular BM

22. Other tests or findings can confirm other potential diagnoses: Measurement of red cell membrane CD59,CD55 by flow cytometry: PNH ( coincident hemolysis or venous thromboembolism with Aplastic anemia) Cytogenetic analysis: Hypoplastic myelodysplastic syndrome Increased chromosomal breakage in lymphocytes cultured in presence of DNAcross-linking agents: Fanconi anemia The viral hemophagocytic syndrome, which may also present with pancytopenia, is characterized by the presence of bone marrow macrophages engorged with hematopoietic cells

23. Diagnostic criteria Moderate aplastic anemia: Bone marrow cellularity <30% Absence of severe pancytopenia Depression of at least two of three blood elements below normal Very severe aplastic anemia: Very severe aplastic anemia: Severe aplastic anemia: A bone marrow biopsy showing <25% of normal cellularity or: A bone marrow biopsy showing <50 percent normal cellularity in which fewer than 30 percent of the cells are hematopoietic and at least two of the following are present: absolute reticulocyte count <40,000/microliter; absolute neutrophil count (ANC) <500/microliter platelet count <20,000/microliter Severe aplastic anemia &the ANC is <200/microliter

24. Prognosis Factors Disease severity Unless patients with SAA or vSAA are successfully treated, over 70 percent will be dead within one year. Patient age The increase in mortality in the older patients was mainly due to infection or bleeding.

25. OCCURRENCE OF CLONAL DISORDERS following treatment for AA Myelodysplastic syndrome (MDS) Acute myeloid leukemia (AML) Paroxysmal nocturnal hemoglobinuria (PNH)) Solid tumors

27. Myelodysplastic syndrome (MDS) A heterogeneous group of malignant stem cell disorders characterized by dysplastic and ineffective blood cell production (ie, apoptotic death) and a variable risk of transformation to acute leukemia. These disorders may occur de novo or arise years after exposure to potentially mutagenic therapy (radiation exposure, chemotherapy).

28. The risk of developing MDS increases with age. The median age in most series is ≥65 years, with a male predominance. Onset of the disease earlier than age 50 is unusual,with the exception of treatment- induced MDS.

29. CLINICAL PRESENTATION CLINICAL PRESENTATION Many patients are asymptomatic, with the diagnosis established upon routine laboratory screening. Symptoms resulting from: Anemia( fatigue, weakness, exercise intolerance, angina, dizziness, cognitive impairment, or an altered sense of well being) Infection (De to neutropenia& granulocyte dysfunction) : Bacterial,fungal,viral,mycobacterial Easy bruising or Bleeding Fever and Weight loss (uncommon) Autoimmune manifestations Autoimmune manifestations

30. Connective tissue disorders: Relapsing polychondritis Polymyalgia rheumatica Raynaud phenomenon Sjögren's syndrome Inflammatory bowel disease Pyoderma gangrenosum Glomerulonephritis Cutaneous vasculitis Monoarticular arthritis Pericarditis Pleural effusions Skin ulcerations IritisMyositis Peripheral neuropathy Pure red cell aplasia

31. Physical findings Physical findings Chronic myelomonocytic leukemia (CMML) is exception: Splenomegaly is massive in up to 25 percent of patients and is often accompanied by hepatomegaly,lymphadenopathy and nodular cutaneous leukemic infiltrates. Paleness(60%) Petechiae and/or Purpura(26%) Hepatomegaly (uncommon) Splenomegaly (uncommon) Lymphadenopathy(uncommon) Cutaneous manifestations ( uncommon) : Sweet's syndrome (acute febrile neutrophilic dermatosis) Myeloid sarcoma (granulocytic sarcoma or chloroma)

32. LABORATORY FINDINGS LABORATORY FINDINGS CBC: Anemia (almost uniformly present) Pancytopenia(50%) Isolated neutropenia (<5%) Isolated thrombocytopenia (<5%) Monocytosis (<5%) PBS : Normocytic,Macrocytic,Microcytic Hypochromic red cells Ovalomacrocytosis, Elliptocytes,Teardrops, Stomatocytes, Acanthocytes Basophilic stippling Howell-Jolly bodies Megaloblastoid nucleated red cells

33. Peripheral Smear Anisopoikilocytosis

34. Peripheral Blood Smear Peripheral Blood Smear Macrocytic Anemia Ovalocytes&Macrocytosis Teardrop cells

35. Dimorphic Red Cell Population

36. Pelgeroid (pseudo Pelger-Huet) Neutrophil

39. BONE MARROW EXAMINATION Bone Marrow aplasia or hypoplasia or hyperplasia or normal Ringed sideroblasts Erythroid hyperplasia (ineffective erythropoiesis) Red cell aplasia or hypoplasia Internuclear bridging characterized by chromatin threads tethering dissociated nuclei, reflects impaired mitosis

40. Bone Marrow Biopsy Bone Marrow Biopsy Hypocellular

42. Dyserythropoeisis on Bone Marrow Aspirate

43. Bone Marrow Dysplastic Erythroid Precursors

44. Dyserythropoiesis on Bone Marrow Aspirate

45. Megaloblastoid Change on Bone Marrow Aspirate

46. Megaloblastoid Change

48. Hypersegmented Neutrophil

49. Micromegakaryocyte

50. Bone Marrow Dysplastic Megakaryocytes

51. Hypolobated megakaryocytes

53. MDS/MPD

54. Ringed Sideroblasts

56. CLASSIFICATION Refractory anemia Refractory anemia with ringed sideroblasts Refractory cytopenia with multilineage dysplasia Refractory anemia with excess blasts Refractory anemia with excess blasts in transformation Refractory anemia with excess blasts in transformation Chronic myelomonocytic leukemia Chronic myelomonocytic leukemia 5q- syndrome 5q- syndrome

57. Refractory anemia is characterized by less than 5 percent bone marrow (BM) blasts, ≤1 percent blasts in the peripheral blood. Monocytosis, significant numbers of ringed sideroblasts, and Auer rods are absent.

58. Refractory anemia with ringed sideroblasts Refractory anemia with ringed sideroblasts fulfills all of the criteria for RA plus >15 percent ringed sideroblasts.

59. Refractory cytopenia with multilineage dysplasia Refractory cytopenia with multilineage dysplasia is characterized by less than 5 percent BM blasts but severe dysplasia in two or more cell lineages.

60. Refractory anemia with excess blasts Refractory anemia with excess blasts is characterized by 5 to 19 percent BM blasts.

61. Refractory anemia with excess blasts in transformation Refractory anemia with excess blasts in transformation Refractory anemia with excess blasts in transformation (RAEB-T) in the FAB classification system is characterized by 21 to 30 percent BM blasts or ≥5 percent blasts in the blood or the presence of Auer rods. However, in the WHO classification system this category is considered an evolving acute myeloid leukemia (AML) or AML with multilineage dysplasia

62. Chronic myelomonocytic leukemia Chronic myelomonocytic leukemia Chronic myelomonocytic leukemia is considered by the WHO to be one of the myelodysplastic/myeloproliferative diseases, as it has features of both disorders. CMML is associated with up to 20 percent BM blasts, 1000/microL. Auer rods are absent and ringed sideroblasts may or may not be present. In some classification systems, CMML has been divided into two subtypes: patients with a white blood cell count (WBC) ≤12,000/microL who are generally considered to have MDS, and the proliferative-type of CMML with a WBC >12,000/microL, who are often considered to have a myeloproliferative disorder

63. 5q- syndrome 5q- syndrome The finding of an interstitial deletion of the long arm of chromosome 5 in some patients with MDS has led to an appreciation of this MDS subtype. Female predominance (7:3) with a median age at diagnosis of 68 years Transfusion-dependent anemia (80 %) Low incidence of neutropenia( infection), thrombocytopenia (bleeding) Normal or increased platelet counts along with bone marrow hyperplasia of hypolobulated micromegakaryocytes Low incidence of transformation into acute leukemia (16%)

64. DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS Megaloblastic anemia Megaloblastic anemia Aplastic anemia Myelofibrosis Myelofibrosis Atypical CML HIV infection HIV infection