1
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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2
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Cuccuini W, Collonge-Rame MA, Auger N, Douet-Guilbert N, Coster L, Lafage-Pochitaloff M. Cytogenetics in the management of bone marrow failure syndromes: Guidelines from the Groupe Francophone de Cytogénétique Hématologique (GFCH). Curr Res Transl Med 2023; 71:103423. [PMID: 38016422 DOI: 10.1016/j.retram.2023.103423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 11/30/2023]
Abstract
Bone marrow failure syndromes are rare disorders characterized by bone marrow hypocellularity and resultant peripheral cytopenias. The most frequent form is acquired, so-called aplastic anemia or idiopathic aplastic anemia, an auto-immune disorder frequently associated with paroxysmal nocturnal hemoglobinuria, whereas inherited bone marrow failure syndromes are related to pathogenic germline variants. Among newly identified germline variants, GATA2 deficiency and SAMD9/9L syndromes have a special significance. Other germline variants impacting biological processes, such as DNA repair, telomere biology, and ribosome biogenesis, may cause major syndromes including Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, and Shwachman-Diamond syndrome. Bone marrow failure syndromes are at risk of secondary progression towards myeloid neoplasms in the form of myelodysplastic neoplasms or acute myeloid leukemia. Acquired clonal cytogenetic abnormalities may be present before or at the onset of progression; some have prognostic value and/or represent somatic rescue mechanisms in inherited syndromes. On the other hand, the differential diagnosis between aplastic anemia and hypoplastic myelodysplastic neoplasm remains challenging. Here we discuss the value of cytogenetic abnormalities in bone marrow failure syndromes and propose recommendations for cytogenetic diagnosis and follow-up.
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Affiliation(s)
- Wendy Cuccuini
- Laboratoire d'Hématologie, Unité de Cytogénétique, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), 75475, Paris Cedex 10, France.
| | - Marie-Agnes Collonge-Rame
- Oncobiologie Génétique Bioinformatique UF Cytogénétique et Génétique Moléculaire, CHU de Besançon, Hôpital Minjoz, 25030, Besançon, France
| | - Nathalie Auger
- Laboratoire de Cytogénétique/Génétique des Tumeurs, Gustave Roussy, 94805, Villejuif, France
| | - Nathalie Douet-Guilbert
- Laboratoire de Génétique Chromosomique, CHU Brest, Hôpital Morvan, 29609, Brest Cedex, France
| | - Lucie Coster
- Laboratoire d'Hématologie, Secteur de Cytogénétique, Institut Universitaire de Cancérologie de Toulouse, CHU de Toulouse, 31059, Toulouse Cedex 9, France
| | - Marina Lafage-Pochitaloff
- Laboratoire de Cytogénétique Hématologique, CHU Timone, Assistance Publique Hôpitaux de Marseille (APHM), Aix Marseille Université, 13005, Marseille, France
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3
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Groarke EM, Patel BA, Shalhoub R, Gutierrez-Rodrigues F, Desai P, Leuva H, Zaimoku Y, Paton C, Spitofsky N, Lotter J, Rios O, Childs RW, Young DJ, Dulau-Florea A, Dunbar CE, Calvo KR, Wu CO, Young NS. Predictors of clonal evolution and myeloid neoplasia following immunosuppressive therapy in severe aplastic anemia. Leukemia 2022; 36:2328-2337. [PMID: 35896822 PMCID: PMC9701554 DOI: 10.1038/s41375-022-01636-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 12/18/2022]
Abstract
Predictors, genetic characteristics, and long-term outcomes of patients with SAA who clonally evolved after immunosuppressive therapy (IST) were assessed. SAA patients were treated with IST from 1989-2020. Clonal evolution was categorized as "high-risk" (overt myeloid neoplasm [meeting WHO criteria for dysplasia, MPN or acute leukemia] or isolated chromosome-7 abnormality/complex karyotype without dysplasia or overt myeloid neoplasia) or "low-risk" (non-7 or non-complex chromosome abnormalities without morphological evidence of dysplasia or myeloid neoplasia). Univariate and multivariate analysis using Fine-Gray competing risk regression model determined predictors. Long-term outcomes included relapse, overall survival (OS) and hematopoietic stem cell transplant (HSCT). Somatic mutations in myeloid cancer genes were assessed in evolvers and in 407 patients 6 months after IST. Of 663 SAA patients, 95 developed clonal evolution. Pre-treatment age >48 years and ANC > 0.87 × 109/L were strong predictors of high-risk evolution. OS was 37% in high-risk clonal evolution by 5 years compared to 94% in low-risk. High-risk patients who underwent HSCT had improved OS. Eltrombopag did not increase high-risk evolution. Splicing factors and RUNX1 somatic variants were detected exclusively at high-risk evolution; DNMT3A, BCOR/L1 and ASXL1 were present in both. RUNX1, splicing factors and ASXL1 somatic mutations detected at 6 months after IST predicted high-risk evolution.
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Affiliation(s)
- Emma M. Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bhavisha A. Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Ruba Shalhoub
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Parth Desai
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Harshraj Leuva
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Yoshitaka Zaimoku
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Casey Paton
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Nina Spitofsky
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Jennifer Lotter
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Olga Rios
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Richard W. Childs
- Transplant Immunotherapy, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David J. Young
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Alina Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Cynthia E. Dunbar
- Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Katherine R. Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Colin O. Wu
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Neal S. Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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4
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Keel S. The clinical and laboratory evaluation of patients with suspected hypocellular marrow failure. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:134-142. [PMID: 34889426 PMCID: PMC8791137 DOI: 10.1182/hematology.2021000244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The overlap in clinical presentation and bone marrow features of acquired and inherited causes of hypocellular marrow failure poses a significant diagnostic challenge in real case scenarios, particularly in nonsevere disease. The distinction between acquired aplastic anemia (aAA), hypocellular myelodysplastic syndrome (MDS), and inherited bone marrow failure syndromes presenting with marrow hypocellularity is critical to inform appropriate care. Here, we review the workup of hypocellular marrow failure in adolescents through adults. Given the limitations of relying on clinical stigmata or family history to identify patients with inherited etiologies, we outline a diagnostic approach incorporating comprehensive genetic testing in patients with hypocellular marrow failure that does not require immediate therapy and thus allows time to complete the evaluation. We also review the clinical utility of marrow array to detect acquired 6p copy number-neutral loss of heterozygosity to support a diagnosis of aAA, the complexities of telomere length testing in patients with aAA, short telomere syndromes, and other inherited bone marrow failure syndromes, as well as the limitations of somatic mutation testing for mutations in myeloid malignancy genes for discriminating between the various diagnostic possibilities.
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Affiliation(s)
- Siobán Keel
- University of Washington, Seattle, WA
- Correspondence Siobán Keel, University of Washington, Division of Hematology, Seattle, WA 98105; e-mail:
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5
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Groarke EM, Young NS, Calvo KR. Distinguishing constitutional from acquired bone marrow failure in the hematology clinic. Best Pract Res Clin Haematol 2021; 34:101275. [PMID: 34404527 DOI: 10.1016/j.beha.2021.101275] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 12/23/2022]
Abstract
Distinguishing constitutional from immune bone marrow failure (BMF) has important clinical implications. However, the diagnosis is not always straightforward, and immune aplastic anemia, the commonest BMF, is a diagnosis of exclusion. In this review, we discuss a general approach to the evaluation of BMF, focusing on clinical presentations particular to immune and various constitutional disorders as well as the interpretation of bone marrow histology, flow cytometry, and karyotyping. Additionally, we examine the role of specialized testing in both immune and inherited BMF, and discuss genetic testing, both its role in patient evaluation and interpretation of results.
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Affiliation(s)
- Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Clinical Center, Building 10, 3-E, room 3-5240, 10 Center Drive, Bethesda, MD, 20892, United States.
| | - Neal S Young
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Clinical Center, Building 10, 3-E, room 3-5240, 10 Center Drive, Bethesda, MD, 20892, United States.
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Clinical Center, Building 10, Department of Laboratory Medicine, 10 Center Drive, Bethesda, MD, 20892, United States.
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6
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Sun L, Babushok DV. Secondary myelodysplastic syndrome and leukemia in acquired aplastic anemia and paroxysmal nocturnal hemoglobinuria. Blood 2020; 136:36-49. [PMID: 32430502 PMCID: PMC7332901 DOI: 10.1182/blood.2019000940] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are pathogenically related nonmalignant bone marrow failure disorders linked to T-cell-mediated autoimmunity; they are associated with an increased risk of secondary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Approximately 15% to 20% of AA patients and 2% to 6% of PNH patients go on to develop secondary MDS/AML by 10 years of follow-up. Factors determining an individual patient's risk of malignant transformation remain poorly defined. Recent studies identified nearly ubiquitous clonal hematopoiesis (CH) in AA patients. Similarly, CH with additional, non-PIGA, somatic alterations occurs in the majority of patients with PNH. Factors associated with progression to secondary MDS/AML include longer duration of disease, increased telomere attrition, presence of adverse prognostic mutations, and multiple mutations, particularly when occurring early in the disease course and at a high allelic burden. Here, we will review the prevalence and characteristics of somatic alterations in AA and PNH and will explore their prognostic significance and mechanisms of clonal selection. We will then discuss the available data on post-AA and post-PNH progression to secondary MDS/AML and provide practical guidance for approaching patients with PNH and AA who have CH.
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MESH Headings
- Age of Onset
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/genetics
- Anemia, Aplastic/pathology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Benzoates/adverse effects
- Benzoates/therapeutic use
- Bone Marrow/pathology
- Chromosome Aberrations
- Chromosomes, Human, Pair 7/genetics
- Clonal Evolution/drug effects
- Clone Cells/drug effects
- Clone Cells/pathology
- Disease Progression
- Granulocyte Colony-Stimulating Factor/adverse effects
- Granulocyte Colony-Stimulating Factor/therapeutic use
- Hemoglobinuria, Paroxysmal/drug therapy
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/pathology
- Humans
- Hydrazines/adverse effects
- Hydrazines/therapeutic use
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Models, Biological
- Monosomy
- Mutation
- Myelodysplastic Syndromes/epidemiology
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Oncogene Proteins, Fusion/genetics
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Selection, Genetic
- Telomere Shortening
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Affiliation(s)
- Lova Sun
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Daria V Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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7
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Brzeźniakiewicz-Janus K, Rupa-Matysek J, Gil L. Acquired Aplastic Anemia as a Clonal Disorder of Hematopoietic Stem Cells. Stem Cell Rev Rep 2020; 16:472-481. [PMID: 32270433 PMCID: PMC7253510 DOI: 10.1007/s12015-020-09971-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aplastic anemia is rare disorder presenting with bone marrow failure syndrome due to autoimmune destruction of early hematopoietic stem cells (HSCs) and stem cell progenitors. Recent advances in newer genomic sequencing and other molecular techniques have contributed to a better understanding of the pathogenesis of aplastic anemia with respect to the inflammaging, somatic mutations, cytogenetic abnormalities and defective telomerase functions of HSCs. These have been summarized in this review and may be helpful in differentiating aplastic anemia from hypocellular myelodysplastic syndrome. Furthermore, responses to immunosuppressive therapy and outcomes may be determined by molecular pathogenesis of HSCs autoimmune destruction, as well as treatment personalization in the future.
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Affiliation(s)
- Katarzyna Brzeźniakiewicz-Janus
- Department of Hematology, Multi-Specialist Hospital Gorzów Wielkopolski, Faculty of Medicine and Health Science, University of Zielona Góra, Gorzów Wielkopolski, Poland.
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
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8
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Liu C, Sun Y, Shao Z. Current Concepts of the Pathogenesis of Aplastic Anemia. Curr Pharm Des 2020; 25:236-241. [PMID: 30864496 DOI: 10.2174/1381612825666190313113601] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/08/2019] [Indexed: 02/07/2023]
Abstract
Abnormal activation of the immune system plays an important role in the pathogenesis of aplastic anemia (AA). Various immune cells and cytokines constitute a complex immune network, leading to bone marrow failure. The known pathogenesis is an increase of the myeloid dendritic cell (mDC)/ plasmacytoid dendritic cell (pDC) ratio, which causes the ratio of T helper (Th)1/Th2 to be skewed in favor of Th1 and eventually leads to an abnormal activation of cytotoxic T lymphocyte (CTL). The antigens that stimulate T cells in the context of AA remain unknown. In this process, regulatory T (Treg), Th17, natural killer (NK) cell, memory T cell and negative hematopoietic regulatory factors are also involved. In addition, genetic background (e.g., chromosomal abnormalities, telomere attrition, somatic cell mutations), abnormal bone marrow hematopoietic microenvironment and viral infection may also contribute to the pathogenesis of AA. This review summarizes the recent studies of the pathogenesis of AA and the current status of AA research.
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Affiliation(s)
- Chunyan Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin, China
| | - Yingying Sun
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan St, Heping District, Tianjin, China
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9
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Shallis RM, Ahmad R, Zeidan AM. Aplastic anemia: Etiology, molecular pathogenesis, and emerging concepts. Eur J Haematol 2018; 101:711-720. [PMID: 30055055 DOI: 10.1111/ejh.13153] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022]
Abstract
Aplastic anemia (AA) is rare disorder of bone marrow failure which if severe and not appropriately treated is highly fatal. AA is characterized by morphologic marrow features, namely hypocellularity, and resultant peripheral cytopenias. The molecular pathogenesis of AA is not fully understood, and a uniform process may not be the culprit across all cases. An antigen-driven and likely autoimmune dysregulated T-cell homeostasis is implicated in the hematopoietic stem cell injury which ultimately founds the pathologic features of the disease. Defective telomerase function and repair may also play a role in some cases as evidenced by recurring mutations in related telomerase complex genes such as TERT and TERC. In addition, recurring mutations in BCOR/BCORL, PIGA, DNMT3A, and ASXL1 as well as cytogenetic abnormalities, namely monosomy 7, trisomy 8, and uniparental disomy of the 6p arm seem to be intimately related to AA pathogenesis. The increased incidence of late clonal disease has also provided clues to accurately describe plausible predispositions to the development of AA. The emergence of newer genomic sequencing and other techniques is incrementally improving the understanding of the pathogenic mechanisms of AA, the detection of the disease, and ultimately offers the potential to improve patient outcomes. In this comprehensive review, we discuss the current understanding of the immunobiology, molecular pathogenesis, and future directions of such for AA.
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Affiliation(s)
- Rory M Shallis
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Rami Ahmad
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Amer M Zeidan
- Division of Hematology/Medical Oncology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
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10
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DeZern AE, Zahurak M, Symons H, Cooke K, Jones RJ, Brodsky RA. Alternative Donor Transplantation with High-Dose Post-Transplantation Cyclophosphamide for Refractory Severe Aplastic Anemia. Biol Blood Marrow Transplant 2017; 23:498-504. [PMID: 28013015 PMCID: PMC5373094 DOI: 10.1016/j.bbmt.2016.12.628] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
Severe aplastic anemia (SAA) is a life-threatening hematopoietic stem cell disorder that is treated with bone marrow transplantation (BMT) or immunosuppressive therapy (IST). The management of patients with refractory SAA after IST is a major challenge. Alternative donor BMT is the best chance for cure in refractory SAA, but morbidity and mortality from graft failure and complications of graft-versus-host disease (GVHD) have limited enthusiasm for this approach. Here, we employed post-transplantation high-dose cyclophosphamide in an effort to safely expand the donor pool in 16 consecutive patients with refractory SAA who did not have a matched sibling donor. Between July 2011 and August 2016, 16 patients underwent allogeneic (allo) BMT for refractory SAA from 13 haploidentical donors and 3 unrelated donors. The nonmyeloablative conditioning regimen consisted of antithymocyte globulin, fludarabine, low-dose cyclophosphamide, and total body irradiation. Post-transplantation cyclophosphamide 50 mg/kg/day i.v. on days +3 and +4 was administered for GVHD prophylaxis. Additionally, patients received mycophenolate mofetil on days +5 through 35 and tacrolimus from day +5 through 1 year. The median age of the patients at the time of transplantation was 30 (range, 11 to 69) years. The median time to neutrophil recovery over 1000 × 103/mm3 for 3 consecutive days was 19 (range, 16 to 27) days, to red cell engraftment was 25 (range, 2 to 58) days, and to last platelet transfusion to keep platelets counts over 50 × 103/mm3 was 27.5 (range, 22 to 108) days. Graft failure, primary or secondary, was not seen in any of the patients. All 16 patients are alive, transfusion independent, and without evidence of clonality. The median follow-up is 21 (range, 3 to 64) months. Two patients had grade 1 or 2 skin-only acute GVHD. These same 2 also had mild chronic GVHD of the skin/mouth requiring systemic steroids. One of these GVHD patients was able to come off all IST by 15 months and the other by 17 months. All other patients stopped IST at 1 year. Nonmyeloablative alloBMT using post-transplantation cyclophosphamide allowed for safe expansion of the donor pool to include HLA-haploidentical donors. This approach appears promising in refractory SAA patients. Importantly, engraftment was 100%, pre-existing clonal disease was eradicated, and the risk of GVHD was low.
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Affiliation(s)
- Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland.
| | - Marianna Zahurak
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Heather Symons
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Kenneth Cooke
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Medicine, Division of Hematology, Johns Hopkins University, Baltimore, Maryland
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11
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Stanley N, Olson TS, Babushok DV. Recent advances in understanding clonal haematopoiesis in aplastic anaemia. Br J Haematol 2017; 177:509-525. [PMID: 28107566 DOI: 10.1111/bjh.14510] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acquired aplastic anaemia (AA) is an immune-mediated bone marrow failure disorder inextricably linked to clonal haematopoiesis. The majority of AA patients have somatic mutations and/or structural chromosomal abnormalities detected as early as at diagnosis. In contrast to other conditions linked to clonal haematopoiesis, the clonal signature of AA reflects its immune pathophysiology. The most common alterations are clonal expansions of cells lacking glycophosphotidylinositol-anchored proteins, loss of human leucocyte antigen alleles, and mutations in BCOR/BCORL1, ASXL1 and DNMT3A. Here, we present the current knowledge of clonal haematopoiesis in AA as it relates to aging, inherited bone marrow failure, and the grey-zone overlap of AA and myelodysplastic syndrome (MDS). We conclude by discussing the significance of clonal haematopoiesis both for improved diagnosis of AA, as well as for a more precise, personalized approach to prognostication of outcomes and therapy choices.
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Affiliation(s)
- Natasha Stanley
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy S Olson
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Blood and Marrow Transplant Program, Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Daria V Babushok
- Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Hematology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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12
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Abstract
Hypoproliferative anemia results from the inability of bone marrow to produce adequate numbers of red blood cells. The list of conditions that cause hypoproliferative anemia is long, starting from common etiologies as iron deficiency to rarer diagnoses of constitutional bone marrow failure syndromes. There is no perfect diagnostic algorithm, and clinical data may not always clearly distinguish "normal" from "abnormal", yet it is important for practicing clinicians to recognize each condition so that treatment can be initiated promptly. This review describes diagnostic approaches to hypoproliferative anemia, with particular emphasis on bone marrow failure syndromes.
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Affiliation(s)
- Kazusa Ishii
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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13
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Rare cytogenetic abnormalities in myelodysplastic syndromes. Mediterr J Hematol Infect Dis 2015; 7:e2015034. [PMID: 25960862 PMCID: PMC4418404 DOI: 10.4084/mjhid.2015.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 04/20/2015] [Indexed: 02/03/2023] Open
Abstract
The karyotype represents one of the main cornerstones for the International Prognostic Scoring System (IPSS) and the revised IPSS-R (IPSS-R) that are most widely used for prognostication in patients with myelodysplastic syndromes (MDS). The most frequent cytogenetic abnormalities in MDS, i.e. del(5q), -7/del(7q), +8, complex karyotypes, or -Y have been extensively explored for their prognostic impact. The IPSS-R also considers some less frequent abnormalities such as del(11q), isochromosome 17, +19, or 3q abnormalities. However, more than 600 different cytogenetic categories had been identified in a previous MDS study. This review aims to focus interest on selected rare cytogenetic abnormalities in patients with MDS. Examples are numerical gains of the chromosomes 11 (indicating rapid progression), of chromosome 14 or 14q (prognostically intermediate to favorable), -X (in females, with an intermediate prognosis), or numerical abnormalities of chromosome 21. Structural abnormalities are also considered, e.g. del(13q) that is associated with bone marrow failure syndromes and favorable response to immunosuppressive therapy. These and other rare cytogenetic abnormalities should be integrated into existing prognostication systems such as the IPSS-R. However, due to the very low number of cases, this is clearly dependent on international collaboration. Hopefully, this article will help to inaugurate this process.
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14
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Holbro A, Jotterand M, Passweg JR, Buser A, Tichelli A, Rovó A. Comment to "Favorable outcome of patients who have 13q deletion: a suggestion for revision of the WHO 'MDS-U' designation" Haematologica. 2012;97(12):1845-9. Haematologica 2013; 98:e46-7. [PMID: 23300181 DOI: 10.3324/haematol.2012.082875] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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15
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Ichikawa M, Kurokawa M. [Bone marrow failure syndrome (idiopathic hematopoietic disorders): progress in diagnosis and treatment. Topics: III. Diagnosis and treatments; 3. Myelodysplastic syndrome]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2012; 101:1945-1952. [PMID: 22896998 DOI: 10.2169/naika.101.1945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Motoshi Ichikawa
- Department of Hematology and Oncology, Graduate School of Medicine, the University of Tokyo, Japan
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16
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Hosokawa K, Katagiri T, Sugimori N, Ishiyama K, Sasaki Y, Seiki Y, Sato-Otsubo A, Sanada M, Ogawa S, Nakao S. Favorable outcome of patients who have 13q deletion: a suggestion for revision of the WHO 'MDS-U' designation. Haematologica 2012; 97:1845-9. [PMID: 22689682 DOI: 10.3324/haematol.2011.061127] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
To characterize bone marrow failure with del(13q), we reviewed clinical records of 22 bone marrow failure patients possessing del(13q) alone or del(13q) plus other abnormalities. All del(13q) patients were diagnosed with myelodysplastic syndrome-unclassified due to the absence of apparent dysplasia. Elevated glycosylphosphatidylinositol-anchored protein-deficient blood cell percentages were detected in all 16 with del(13q) alone and 3 of 6 (50%) patients with del(13q) plus other abnormalities. All 14 patients with del(13q) alone and 2 of 5 (40%) patients with del(13q) plus other abnormalities responded to immunosuppressive therapy with 10-year overall survival rates of 83% and 67%, respectively. Only 2 patients who had abnormalities in addition to the del(13q) abnormality developed acute myeloid leukemia. Given that myelodysplastic syndrome-unclassified with del(13q) is a benign bone marrow failure subset characterized by good response to immunosuppressive therapy and a high prevalence of increased glycosylphosphatidylinositol-anchored protein-deficient cells, del(13q) should not be considered an intermediate-risk chromosomal abnormality.
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Affiliation(s)
- Kohei Hosokawa
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8640, Japan
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17
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Abstract
Survival in severe aplastic anemia (SAA) has markedly improved in the past 4 decades because of advances in hematopoietic stem cell transplantation, immunosuppressive biologics and drugs, and supportive care. However, management of SAA patients remains challenging, both acutely in addressing the immediate consequences of pancytopenia and in the long term because of the disease's natural history and the consequences of therapy. Recent insights into pathophysiology have practical implications. We review key aspects of differential diagnosis, considerations in the choice of first- and second-line therapies, and the management of patients after immunosuppression, based on both a critical review of the recent literature and our large personal and research protocol experience of bone marrow failure in the Hematology Branch of the National Heart, Lung, and Blood Institute.
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18
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Kasahara I, Nishio M, Endo T, Fujimoto K, Koike T, Sugimori N, Katagiri T, Nakao S. Sustained trilineage hematopoietic recovery in a patient with refractory anemia, del(13)(q12q22), and paroxysmal nocturnal hemoglobinuria-type cells treated with immunosuppressive therapy. Leuk Res 2011; 35:e147-8. [PMID: 21641038 DOI: 10.1016/j.leukres.2011.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/21/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
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19
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Marsh JCW, Ball SE, Cavenagh J, Darbyshire P, Dokal I, Gordon-Smith EC, Keidan J, Laurie A, Martin A, Mercieca J, Killick SB, Stewart R, Yin JAL. Guidelines for the diagnosis and management of aplastic anaemia. Br J Haematol 2009; 147:43-70. [PMID: 19673883 DOI: 10.1111/j.1365-2141.2009.07842.x] [Citation(s) in RCA: 386] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Judith C W Marsh
- Department of Haematological Medicine, King's College Hospital, London, UK.
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20
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Gupta V, Brooker C, Tooze JA, Yi QL, Sage D, Turner D, Kangasabapathy P, Marsh JCW. Clinical relevance of cytogenetic abnormalities at diagnosis of acquired aplastic anaemia in adults. Br J Haematol 2006; 134:95-9. [PMID: 16803574 DOI: 10.1111/j.1365-2141.2006.06105.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The outcome of 81 adult aplastic anaemia patients who had successful cytogenetics at diagnosis and received immunosuppressive therapy was evaluated. Ten patients had an abnormal karyotype, six of which had a trisomy. Four of five evaluable patients with a trisomy responded. One patient with monosomy 7 achieved a complete response and later developed haemolytic paroxysmal nocturnal haemoglobinuria but no recurrence of monosomy 7. None of the patients with a non-numerical karyotypic abnormality responded. No significant differences in survival or later clonal disorders were observed between patients with a normal karyotype and those with an abnormal karyotype.
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Affiliation(s)
- Vikas Gupta
- Department of Haematology, St George's Hospital, London, UK
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21
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Abstract
Abstract
Aplastic anemia is a term describing the common findings of pancytopenia and marrow hypoplasia arising from a variety of disease states, including acquired aplastic anemia and a variety of congenital marrow failure states. The management of children with these disorders has been confounded by difficulties of diagnosis. The availability of molecular testing has assisted in partial resolution of this problem but has raised new issues, such as the potential of genetic predisposition and the management of asymptomatic individuals with molecular markers. Longitudinal data from large cohort studies and disease registries are providing a rational basis for making more informed treatment decisions for children with these disorders. In particular, the ability to subset patients more accurately has improved triage of treatments. Approaches to hematopoietic stem cell transplantation (SCT), using both conventional and alternative donors, are changing rapidly, and the long-term sequelae of newer approaches are not entirely clear. Improved diagnosis and longer survival have fostered an understanding of the multidisciplinary approach necessary to manage both the underlying problems and the significant sequelae of treatment in both acquired and congenital disease.
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Affiliation(s)
- Eva C Guinan
- Dana-Farber Cancer Inst., 44 Binney Street, Room D354, Boston, MA 02115, USA.
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22
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Abstract
Abstract
The primary therapeutic approach to acquired aplastic anemia (AA) in older adults differs from the primary approach used in children and younger adults because in the former group, the results of allogeneic bone marrow transplantation (BMT) are less favorable. With increasing age of the patients, immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine (CsA) constitutes the primary treatment option and may be better than BMT. There are very few clinical clues as to the selection of patients likely to respond to immunosuppression. Repeated ATG/CsA cycles are often used as salvage regimens, but in refractory patients BMT may be the best treatment option, as the prognosis for non-responders is poor without definitive treatment. Conservative therapy such as intense immunosuppression is associated with a high relapse rate but does not impact the survival and overall prognosis. The inability to eliminate autoimmune T cell clones using current therapeutic strategies suggests that prolonged immunosuppressive maintenance therapy may be needed for a substantial proportion of patients. Late clonal complications of conservatively treated patients include evolution to myelodysplasia and paroxysmal nocturnal hemoglobinuria and may develop in 20% of the patients. However, BMT also has several sequelae including an increased frequency of solid tumors. Novel immunosuppressive and immunomodulatory agents and constantly improving results of allogeneic BMT will further improve the survival rate of adult patients with AA.
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Affiliation(s)
- Jaroslaw P Maciejewski
- The Cleveland Clinic Foundation, Taussig Cancer Center, Cleveland Clinic College of Medicine of the Case Western Reserve University, Cleveland, Ohio 44195, USA.
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23
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Nagasawa M, Tomizawa D, Tsuji Y, Kajiwara M, Morio T, Nonoyama S, Asada M, Mizutani S. Pancytopenia presenting with monosomy 7 which disappeared after immunosuppressive therapy. Leuk Res 2004; 28:315-9. [PMID: 14687628 DOI: 10.1016/s0145-2126(03)00263-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Monosomy 7 syndrome in infant is considered as pre-leukemic condition of poor prognosis. However, it seems controversial recently, because some cases of monosomy 7 syndrome showed spontaneous remission. We report 2-year-old girl with severe pancytopenia, who presented with monosomy 7. Morphologically, there was little dysplasia in the trilineage hematopoiesis. Monosomy 7 clone of CD34 positive cells, bone marrow mononuclear cells (BMMNC), and peripheral nuclear cells was 4.0, 40, and 3.8%, respectively. Immunosuppressive therapy was effective along with the disappearance of monosomy 7 clone. WT1 mRNA expression was not increased in monosomy 7 clone. Pathogenesis of monosomy 7 and its relation to aplastic anemia is discussed.
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Affiliation(s)
- Masayuki Nagasawa
- Department of Pediatrics and Developmental Biology, Graduate School, Tokyo Medical and Dental University, 5-45, Yushima 1-chome, Bunkyo-ku, Tokyo 113-8519, Japan.
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24
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Marsh JCW, Ball SE, Darbyshire P, Gordon-Smith EC, Keidan AJ, Martin A, McCann SR, Mercieca J, Oscier D, Roques AWW, Yin JAL. Guidelines for the diagnosis and management of acquired aplastic anaemia. Br J Haematol 2003; 123:782-801. [PMID: 14632769 DOI: 10.1046/j.1365-2141.2003.04721.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J C W Marsh
- St. George's Hospital Medical School, London, UK.
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