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Clinical Discernment, Bone Marrow, and Molecular Diagnostics Are Equally Important to Solve the Phenotypic Mimicry among Subtypes of Myeloproliferative Neoplasms. REPORTS 2021. [DOI: 10.3390/reports4030027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The 2016 WHO classification integrates clinical, bone marrow (BM)-morphology, and molecular features to define disease entities. This together with the advancements in molecular detection and standardization of BM features enable an accurate diagnosis of myeloproliferative neoplasms (MPN) in the majority of patients. Diagnostic challenges remain due to phenotypic mimicry of MPN, failing specificity of BM-morphology, and the fact that phenotype-driver mutations, such as JAK2V617F, are not exclusive to a particular MPN, and their absence does not preclude any of these. We present a series of cases to illustrate themes to be considered in complex cases of MPN, such as triple-negative (TN)-MPN or MPN-unclassifiable (MPN-U). Eleven patients labelled as TN-MPN or MPN-U were included. Serum tryptase and NGS were part of a systematic/sequential multidisciplinary evaluation. Results were clustered into four categories based on diagnostic entities and/or how these diagnoses were made: (A) With expanding molecular techniques, BCR-ABL1 and karyotyping should not be missed; (B) systemic mastocytosis is underdiagnosed and often missed; (C) benign non-clonal disorders could mimic MPN; and (D) NGS could prove clonality in some “TN”-MPN cases. The prognostic/therapeutic consequences of an accurate diagnosis are immense. In TN-MPN or MPN-U cases, a multidisciplinary re-evaluation integrating molecular results, BM-morphology, and clinical judgment is crucial.
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Singh S, Kaur K, Paul D, Jain K, Singh J, Narang V, Garg B, Sood N, Dhillon B. Clinical and Molecular Attributes of Patients With BCR/ABL1-negative Myeloproliferative Neoplasms in India: Real-world Data and Challenges. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e569-e578. [PMID: 33757770 DOI: 10.1016/j.clml.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Classic BCR/ABL1-negative myeloproliferative neoplasms (MPNs) are characterized by clinical and genetic heterogeneity and include 4 distinct constituents. Very little data on clinical presentation and epidemiology of the same is available from the Indian setting. PATIENTS AND METHODS Patients referred to Hematology-Oncology from January 2018 to August 2020 with suspected MPNs were included in the analysis and prospectively followed-up. All patients were initially screened, and only those meeting the updated World Health Organization 2016 criteria were included in the analysis. Epidemiologic, clinical, and molecular characteristics were documented, and patients were followed-up prospectively. RESULTS A total of 233 patients were referred for evaluation of MPN, of which 63 were included in the analysis, including 39 males and 24 females. The median age at diagnosis was 57 years (range, 28-82 years), and 38% patients were younger than 50 years of age. The most common presentations were incidental detection in 35 (55.5%), abdominal symptoms in 13 (20%), fatiguability in 7 (11%), and recent vascular events in 6 (9.5%) patients. Final diagnosis was polycythemia vera in 27, essential thrombocytosis (ET) in 21, prefibrotic myelofibrosis in 9, and myelofibrosis in 6 patients. The frequency of driver mutations in polycythemia vera included JAK2 in 75%; in ET, JAK2 in 33%, CALR in 33%, and MPL in 4%; and in prefibrotic myelofibrosis, JAK2 in 66% and CALR in 33%. Aspirin was used for all patients along with risk-adapted cytoreduction with hydroxyurea. Ruxolitinib was reserved for symptoms refractory to hydroxyurea. After a median follow-up of 15 months (interquartile range, 10-28 months) from diagnosis, disease progression was noted in 4 patients. Two patients died at the end of the follow-up period, including 1 with secondary acute myeloid leukemia post myelofibrosis and one with ET and coexistent oral malignancy. The remaining 61 patients are alive and on regular treatment. RESULTS This is one of the first systematic descriptions and prospective follow-up of patients with BCR/ABL-negative MPNs from India. Our study indicates a younger median age of presentation and higher proportion of JAK2-unmutated disease across all subtypes. The primary role of bone marrow morphology and supportive role of somatic mutations in differentiating MPN subtypes is indicated. CONCLUSIONS This study sets the stage for a collaborative registry for defining epidemiologic data and long-term outcomes with MPN in India.
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Affiliation(s)
- Suvir Singh
- Department of Clinical Haematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
| | - Komalpreet Kaur
- Department of Clinical Haematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Davinder Paul
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Kunal Jain
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Jagdeep Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Vikram Narang
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Bhavna Garg
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Neena Sood
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Barjinderjit Dhillon
- Molecular Genetics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Hasselbalch HC. Time for revival of the red blood cell count and red cell mass in the differential diagnosis between essential thrombocythemia and polycythemia vera? Haematologica 2020; 104:2119-2125. [PMID: 31666340 DOI: 10.3324/haematol.2019.229039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Jakovic L, Gotic M, Gisslinger H, Soldatovic I, Sefer D, Tirnanic M, Lekovic D, Jovanovic MP, Schalling M, Gisslinger B, Beham-Schmid C, Simonitsch-Klupp I, Thiele J. The WHO diagnostic criteria for polycythemia vera—role of red cell mass versus hemoglobin/hematocrit level and morphology. Ann Hematol 2018; 97:1581-1590. [DOI: 10.1007/s00277-018-3344-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 04/22/2018] [Indexed: 11/24/2022]
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018. [PMID: 29426921 DOI: 10.1038/s41408-018-0054-y.pmid:29426921;pmcid:pmc5807384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018; 8:15. [PMID: 29426921 PMCID: PMC5807384 DOI: 10.1038/s41408-018-0054-y] [Citation(s) in RCA: 366] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 12/17/2022] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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Barbui T, Thiele J, Vannucchi AM, Tefferi A. Myeloproliferative neoplasms: Morphology and clinical practice. Am J Hematol 2016; 91:430-3. [PMID: 26718907 DOI: 10.1002/ajh.24288] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
In myeloproliferative neoplasms (MPNs), controversy persists regarding the usefulness and reproducibility of bone marrow (BM) features. Disagreements concerning the WHO classification are mainly focused on the discrimination between essential thrombocythemia (ET) and prefibrotic/early primary myelofibrosis (prePMF) and prodromal polycythemia vera (PV). Criticism mostly refers to lack of standardization of distinctive BM features precluding correct morphological pattern recognition. The distinction between WHO-defined ET and prePMF is not trivial because outcome is significantly worse in prePMF. Morphology was generally considered to be non-specific for the diagnosis of PV. Recent studies have revealed under-diagnosis of morphologically and biologically consistent PV.
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Affiliation(s)
- Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Jürgen Thiele
- Institute of pathology, University of Cologne; Cologne Germany
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Abstract
The new World Health Organization (WHO) diagnostic criteria for essential thrombocythemia (ET) issued in 2008 made an important distinction between true ET and early myelofibrosis (MF), which has helped to identify a more homogenous population for the diagnosis with longer survival and much less transformation to overt MF. The recent finding of a new mutation (CALR), which is mutually exclusive with JAK2 and MPL mutations, adds to the characterization of ET patients, since there are important phenotypic differences between the mutation types. CALR patients are younger, have lower white blood cell counts (WBC) and a lower thrombosis incidence. A growing field of interest is the state of hypercoagulation due to dysfunction of hemostatic systems, cell-cell interaction and hereditary prothrombotic traits. Activation of platelets, WBC and endothelial cells has been found, making the whole intravascular milieu prothrombotic. Several risk score models, based on retrospective studies, have been developed lately, distinguishing patient groups with graded risk for complications and death. Even if these may be helpful in evaluating patients, they have not been validated in prospective studies and there are not enough data to support their use as a basis for treatment algorithms. The traditional risk factors age, previous thrombosis and platelets >1500 × 10(9)/l are still recommended for the distinction between high risk and low risk ET and the decision to give cytoreductive therapy. However, cardiovascular (CV) risk factors add to thrombosis risk and should be considered both for specific treatment in any risk group and for upgrading low risk patients with high CV risk to an intermediary group where active therapy with aspirin and cytoreduction may be considered. First-line cytoreductive therapy differs with age; in younger patients interferon (IFN) or anagrelide are preferable, in older patients hydroxycarbamide (HC). Second-line therapy for younger patients is HC, for older patients IFN or anagrelide (ANA). JAK2 inhibitors may be suitable in rare cases with symptoms not responding to other therapy.
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Affiliation(s)
- Gunnar Birgegård
- Department of Medical Sciences, University Hospital, Uppsala University, Uppsala 75185, Sweden
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Limitations of fibrosis grade as diagnostic criteria for post polycythemia vera and essential thrombocytosis myelofibrosis. Leuk Res 2015; 39:684-8. [PMID: 25922307 DOI: 10.1016/j.leukres.2015.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/23/2015] [Accepted: 04/06/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND The clinical phenotype of patients with myeloproliferative neoplasms (MPNs) including primary myelofibrosis (PMF), polycythemia vera (PV), and essential thrombocytosis (ET) whom manifest WHO grade 1 marrow fibrosis is poorly defined. Current IWG-MRT criteria require 2+ marrow fibrosis for diagnosis of post PV/ET myelofibrosis (MF). In contrast, the 2008 WHO definition of PMF does not require a minimum fibrosis threshold. METHODS We retrospectively analyzed the clinical characteristics of 91 MPN patients with 1+ marrow fibrosis. We compared the clinical phenotype of sub threshold fibrosis PV/ET with that manifested by PMF. We applied the IWG-MRT criteria for post-PV/ET MF with the fibrosis component omitted and evaluated for percentage of criteria fulfillment. RESULTS When IWG-MRT criteria were applied to the PV/ET group, 38/58 (66%) of patients fulfilled criteria for diagnosis of post-PV/ET myelofibrosis except for the 2+ fibrosis requirement. Comparison of sub threshold fibrotic PV/ET clinical phenotype to PMF revealed similar characteristics including heavy symptomatic burden (57% and 52%), presence of splenomegaly (43% and 55%), leukoerythroblastic blood smear (38% and 45%), and median hemoglobin (12.8g/dL and 11.1g/dL). CONCLUSION MPN progression represents a biological spectrum and definitions of progression in ET/PV may benefit from criteria not restricted by degree of fibrosis.
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Gianelli U, Iurlo A, Cattaneo D, Bossi A, Cortinovis I, Augello C, Moro A, Savi F, Castelli R, Brambilla C, Bianchi P, Primignani M, Cortelezzi A, Bosari S. Discrepancies between bone marrow histopathology and clinical phenotype in BCR-ABL1-negative myeloproliferative neoplasms associated with splanchnic vein thrombosis. Leuk Res 2015; 39:525-9. [PMID: 25840747 DOI: 10.1016/j.leukres.2015.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 02/17/2015] [Accepted: 03/05/2015] [Indexed: 01/30/2023]
Abstract
We examined a consecutive series of 29 patients with myeloproliferative neoplasms (MPNs) associated with splanchnic vein thrombosis (SVT) in order to evaluate their bone marrow morphology and identify possible associations between histological findings and clinical features. Eleven patients showed the morphological features of polycythemia vera (PV), 11 of primary myelofibrosis (PMF) and six of essential thrombocythemia (ET). Molecular analyses identified the JAK2 V617F mutation in 27 patients; one of the JAK2-negative patients carried the MPL W515K mutation, the other was "triple-negative" (no JAK2, MPL or CALR mutation). On the basis of the WHO classification, three patients were classified as having PV, 11 as having PMF, and two as having ET; the remaining 13 cases fell into the MPN-unclassifiable category as there were discrepancies between their morphological and clinical features. In conclusion, our findings suggest that bone marrow histology should always be considered a key component of the diagnostic algorithm in patients with SVT, but that it is not enough to distinguish the different entities. This is particularly important because diagnoses of PV, PMF or ET have very different prognoses and obviously imply different therapies. It is therefore necessary to adopt a comprehensive approach that considers morphological, clinical and molecular data.
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Affiliation(s)
- Umberto Gianelli
- Hematopathology Service, Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Alessandra Iurlo
- Oncohematology of the Elderly Unit, Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Anna Bossi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Ivan Cortinovis
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Claudia Augello
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Alessia Moro
- Division of Pathology, San Paolo Hospital, Milan, Italy.
| | - Federica Savi
- Division of Pathology, San Paolo Hospital, Milan, Italy.
| | - Roberto Castelli
- Department of Medicine and Medical Specialities, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Cecilia Brambilla
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Paola Bianchi
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Massimo Primignani
- First Division of Gastroenterology, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Agostino Cortelezzi
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Silvano Bosari
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
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Wu Z, Zhang X, Xu X, Chen Y, Hu T, Kang Z, Li S, Wang H, Liu W, Ma X, Guan M. The mutation profile of JAK2 and CALR in Chinese Han patients with Philadelphia chromosome-negative myeloproliferative neoplasms. J Hematol Oncol 2014; 7:48. [PMID: 25023898 PMCID: PMC4223390 DOI: 10.1186/s13045-014-0048-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/29/2014] [Indexed: 01/31/2023] Open
Abstract
Mutations in JAK2, MPL and CALR are highly relevant to the Philadelphia chromosome (Ph)-negative myeloproliferative neoplasms (MPNs). We performed high resolution melting analysis and Sanger sequencing together with T-A cloning to elucidate the unique mutation profile of these genes, in Chinese patients with MPNs. Peripheral blood DNA samples were obtained from 80 patients with polycythemia vera (PV), 80 patients with essential thrombocytosis (ET) and 50 patients with primary myelofibrosis (PMF). Ten PV patients were identified with diverse JAK2 exon 12 mutations. Five novel JAK2 Exon 12 mutation patterns (M532V/E543G, N533D, M535I/H538Y/K549I, E543G and D544N) were described. JAK2 V617F was detected in 140 samples (66 PV, 45 ET and 29 PMF). JAK2 Exon 12 mutations were prevalent (13%) and variable in the Chinese patients. Compared with PV patients with JAK2 V617F mutations, PV patients with JAK2 exon 12 mutations had an earlier median onset of disease (P = 0.0013). MPL W515L/K mutations were discerned in 4 ET and 3 PMF patients. Two kinds of CALR mutation, c. 1179_1230del and c. 1234_1235insTTGTC were detected in 20 ET and 16 PMF patients. A novel CALR mutation pattern (c. 1173_1223del/c. 1179_1230del) was identified in 2 PMF samples. In addition, 17 scattered point mutations in CALR c.1153 to c.1255 were also detected in 13 cases with CALR frame-shifting variations and 2 cases without CALR frame-shifting variations. Female patients showed a predisposition to CALR mutations (P = 0.0035). Chinese Ph-negative MPN patients have a unique mutation landscape in the common molecular markers of MPN diagnosis. Validation of the molecular diagnostic pipeline should be emphasized since there is a considerable ethnical diversity in the molecular profiles of Ph-negative MPNs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Ming Guan
- Central Laboratory, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.
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