1. Bone Marrow Failure Syndromes
Brian Boulmay, MD

2. Bone Marrow Failure
Ineffective marrow-poeisis is the final endpoint of many diseases.
Congenital
Acquired
Genetic
Environmental or iatrogenic causes
Congenital marrow failure can present at any age.
Usually in childhood.
Some exceptions
Marrow failure often presents with single lineage declines

3. Bone Marrow Failure
Early onset of marrow disorders can give a clue to genetic v. acquired syndromes
Dysmorphic body findings
Some may present later in life:
dyskeratosis congenita
Genetic testing will be confirmatory

4. Inherited Syndromes
Inheritance patterns of inherited forms of marrow failure are variable:
X linked
Autosomal recessive
Autosomal dominant
Not every inherited syndrome has a clear genetic etiology

5. Inherited Syndromes
Many of the inherited syndromes have an increased risk of acute leukemia and solid tumors.
Penetrance of a disorder may vary within a family.

6. Marrow morphology
Examination of marrow morphology in a patient with single or multi-lineage cytopenias can be very non-specific.
Often just see decreased marrow elements
Clinical correlates and genetic/molecular analysis is key.

7. Inherited/Constitutional Causes
Shwachman- Diamond Syndrome
Diamond- Blackfan Anemia
Dyskeratosis congenita
Fanconi Anemia
Down’s Syndrome
Familial HLH

8. Shwachman-Diamond Syndrome
Autosomal recessive.
Mutation of SBDS gene on Chr 7.
The SBDS protein is involved with mitotic spindle stabilization
Causes a proliferative defect
Short, pancreatic exocrine deficiency, neutropenia.
May have severe anemia, thrombocytopenia
Longterm increased risk of MDS/AML
Androgens, G-CSF are temporizing measure
SCT will correct the hematologic abnormality

9. Diamond-Blackfan Syndrome
Autosomal dominant
Pure red cell aplasia
Mutation of the RPS19 gene on Chr 19
Plurality of patients, 25%
Involved in ribosome assembly
Considerable variation in presentation:
Hydrops fetalispresentation in adulthood
Physical phenotype: “tow-colored hair, snub nose, wide set eyes, intelligent expression”
Web neck, short stature, triphalangeal thumb
Cathie Arch Dis Chil 1950

11. Diamond-Blackfan Syndrome
Marrow and peripheral blood triad:
Anemia
Reticulocytopenia
Absence of red cell precursors in the marrow
(Multilineage hypoplasia may develop in long term survivors)
Erythrocyte adenosine deaminase (ADA) levels high
Glucocorticosteroids are the classic therapy
Not effective in all. Adverse effects in children.
SCT the definitive therapy.

12. Dyskeratosis congenita
X-linked, autosomal dominant or autosomal recessive.
Very rare
Mutations involve genes of telomere maintenance or the telomere complex*
DKC1- X linked
TERC- Dominant form
TERT

13. Dyskeratosis congenita
Physical findings. The mucocutaneous triad:
Leukoplakia
Nail dystrophy
Reticulated skin hyperpigmentation
Can be subtle and only appear later in life.

14. Dermopath.com, accessed 1/2014

15. Dyskeratosis congenita
Typically starts with anemia, with high MCV and Hgb F and thrombocytopenia
Progresses to pancytopenia
Median age at presentation is 16 years old
Diagnosis made by flow-FISH of telomere length or quant PCR of telomere DNA or leukocytes

16. Fanconi Anemia Very rare (1:1,000,000 births)
Autosomal recessive inheritance
Due to mutation in the FANC gene
Protein products of this gene family protect against DNA cross linking.
Most patients present around 8 years old.
Can present in adulthood.

17. Fanconi Anemia 60% of patients have a physical exam finding
Absent radius, absent thumb
Short
Microcephaly, hypertelorism
Skin pigment abnormalities (café au lait spots)
Confirmatory testing: lymphocyte chromosomal breakage on diepoxybutane exposure.
Differentiates from aplastic anemia

18. Fanconi.co.za, accessed 12/2013

19. Fanconi Anemia Therapy: Risks: Androgenic steroids SCT
Increased risk for solid tumors, MDS and AML

20. Acquired single lineage marrow failure
Parvovirus B19
Thymoma associated pure red cell aplasia
Iron Deficiency
Anemia of chronic inflammation
Nutritional deficiencies
B12
Folate
Levamisole tainted cocaine

21. Acquired multilineage marrow syndromes
Aplastic anemia (autoimmune)
Paroxysmal nocturnal hemoglobinuria
Myelodysplastic syndrome
HIV B12 def.
Hepatitis C Pregnancy
Bone marrow replacement SLE
Cancer
Myelofibrosis

22. Aplastic anemia Frequency 1:1,000,000 Occurs at any age
Progressive pancytopenia
Often presents with severe pancytopenia
Needs to be differentiated from FA or DC, even in adults.
Consider PNH in differential.
Rule out other marrow injuries
HIV
Hepatitis
Drugs/radiation
Sulfas, seizure meds, HIV meds
ETOH

23. Aplastic Anemia
Cellularity <25% of normal Maturation usually normal Remnant cellularity usually lymphs, plasma cells Consider hypocellular MDS or PNH

24. Aplastic anemia On marrow: Cytogenetics should be normal No fibrosis
No malignant cells
Hemapoietic precursors do not appear dysplastic
Cytogenetics should be normal

25. Aplastic Anemia
A population of CD55- and CD59- cells may be found in patients with AA
Maybe as high as 23% of lymphocytes
Does not mean patient has PNH
Don’t treat as PNH
Predicts response to ATG/CyA
Sugimori Blood 2006

26. Aplastic Anemia Classification: Moderate aplastic anemia
Bone marrow cellularity <30 percent
Absence of severe pancytopenia
Depression of at least two of three blood elements below normal
Severe aplastic anemia 
A bone marrow biopsy showing <25 percent of normal cellularity, or
A bone marrow biopsy showing <50 percent normal
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; or platelet count <20,000/microliter.
Very severe aplastic anemia 
Criteria for severe aplastic anemia are met and the ANC is <200 

27. Aplastic Anemia Therapy:
Combination of ATG /MP/ CyA results in higher response rates than with ATG/ MP alone
70% v 41% at four months
Lifetime relapse rates ultimately the same in both arms.
Frickhofen Blood 2003

28. Aplastic Anemia

29. Aplastic Anemia

30. Aplastic Anemia Horse ATG versus rabbit ATG:
Primary study endpoint was hematologic response at 6 months:
68% versus 38%
3 year OS favored horse ATG
96% versus 76%
Scheinberg NEJM 2011

31. Aplastic Anemia

32. Aplastic Anemia CyA should be stopped at 6 months
2 year taper after the usual 6 months can delay relapse, but does not appear to prevent it.
Young Abs 2406 ASH 2011

33. Aplastic Anemia Therapy guidelines:
<20 with an HLA matched donor: transplant
Cat 2C rec for MUD.
with an HLA matched donor: transplant
>50: immunosuppression

34. Aplastic Anemia Role of mimetics
G-CSF and erythropoietin have no effect in AA
Eltrombopag (ELT) is a TPO mimetic:
Triggers the mpl surface receptor.
Approved for use in ITP
24 patients treated with ELT with refractory AA
40% response rate
Mpl mutation now implicated in some familial AA
Walne Hematologica 2011; Olnes NEJM 2012

35. Paroxysmal nocturnal hemoglobinuria
Defect in the glycosylphophatidylinositol anchor on the cell membrane.
Loss of the anchor results in absence of GPI linked proteins.
GPI encoded on the PIG-A gene
CD55: decay accelerating factor
CD59: membrane inhibitor of reactive lysis

36. PNH Result of CD59 loss: Hemolysis is intravascular Other symptoms:
Sensitivity of red cells to complement mediated hemolysis
Hemolysis is intravascular
Positive DAT (C3d)
Negative indirect Coombs
Other symptoms:
Unprovoked clotting, clots in unusual places
Aplasia
Myelodysplasia

37. PNH Historically, diagnosed with the Ham test or sucrose lysis test
Now, flow cytometry of RBC or leukocytes evaluating for absence of CD59 and CD55
PNH clones can be found in AA
Need to consider the clinical scenario

38. PNH 28% survival at 25 years Median survival 14 years Rates:
pancytopenia 15%
myelodysplasia 5%
thrombosis 28%
Hillman NEJM 1995: Socie Lancet 1996

39. PNH Therapeutic considerations: Eculizumab (TRIUMPH Trial):
Binds C5 complement and inhibits terminal complement activation
Results in no need for transfusions
Decreased hemolysis defined by decreased baseline LDH
Hillmen NEJM 2006

40. PNH Therapeutic considerations: SHEPERD Study €300,000 per year
Similar results as TRIUMPH
96% of patients free of thrombosis over one year
Decreased need for transfusions
€300,000 per year
Brodsky Blood 2008

41. PNH
Housekeeping:
Iron replacement
Folic acid
Prophylactic anti-coagulation:
Retrospective data suggests it is indicated
All therapy is supportive and does not impact the natural history of the underlying disorder.
Unless transplanted

42. Myelodyplastic Syndromes
MDS is a group of diseases characterized by:
1) Ineffective red cell production
2) Risk of transformation to leukemia
3) Disorder arises from transformed hematopoietic stem cell
4) Lineage decrease resulting in one or more cytopenias
Approximately 10,000 cases diagnosed per year
Aul Br J Hema 1992

43. Myelodysplastic Syndromes
Median age at diagnosis is greater than 65 with a male predominance.
Associated with:
Benzene
Trisomy 21
Fanconi Anemia
PNH
TERT/TERC mutations

44. MDS- The CBC Most all patients with MDS will have anemia.
Classically macrocytic
Only 5% of patients with MDS will present with cytopenias WITHOUT anemia.
Thrombocytosis can be present.
5q- syndrome
3q21q26 syndrome
Thrombocytopenia without anemia or other cytopenias
Think del(20q)
Koeffler 1980

45. MDS- The Bone Marrow Characteristic cytogenetic features:
-7 or del 7q
-5 or del 5q
del 13q
del 11q
del 12p
del 9q
t(11;16)
t(2;11)
No matter what the blast count:
t(8;21)
inv 16
t(15;17)
This is leukemia and needs to be treated as such

46. MDS- What else could it be
Idiopathic cytopenia of undetermined significance:
An isolated cytopenia with minimal dysplasia and no cytogenetic abnormalities.
10% go onto acute leukemia
AML
Schroder Ann Onc 2010

47. MDS- What else could it be
MDS/MPN- A disorder in which dysplasia and proliferation are present.
BCR/Abl negative CML: ‘atypical CML’
Often characterized by dysplasia in neutrophils
CMML: Overproduction of monocytes
Anemia, thrombocyopenia, splenomegaly
Does not, by definition, have BCR/Abl, PDFR alpha or beta rearrangements

48. MDS- What else could it be
Aplastic Anemia:
Most patients with MDS have normo/ hypercellular marrow.
Hypocellular marrows with normal cytogenetics: think AA
MDS with hypocellularity: think therapy related MDS
Myelofibrosis:
Marrow fibrosis is common in MDS, sometimes appraching that of PMF
Hyperfibotic MDS: usually no splenomegaly
PMF: 50% will have JAK2 V617F mutation

49. MDS- What else could it be
HIV-
Can be hypercellular, dysplastic, fibrotic
Improves long periods of time with good HIV control

50. MDS Classification World Health Organization Classification:
Refractory cytopenia with unilineage dysplasia <5%
RA with ringed sideroblasts <5%
Refractory cytopenias with multilineage dysplasia 70%
Refractory anemia with excess blasts 25%
5q- 5%
MDS, NOS 5%

51. MDS Therapy Most patients are palliative intent
Therapy is indicated if:
Symptomatic anemia
Symptomatic thrombocytopenia
Infection complications from neutropenia

52. MDS Therapy IPSS (old): Percentage of Bone Marrow Blasts Karyotype
<5 percent (0 points)
5 to 10 percent (0.5 points)
11 to 20 percent (1.5 points)
21 to 30 percent (2.0 points)
Karyotype
Normal, Y-, 5q-, 20q- (0 points)
Abnormal chromosome 7 or 3 or more abnormalities (1.0 points)
All other cytogenic abnormalities (0.5 points)
Cytopenias (defined as hemoglobin <10, ANC<1800, platelet count <100K)
No cytopenia or cytopenia of 1 cell type (0 points)
Cytopenia of 2 or 3 cell types (0.5 points)

53. MDS Therapy- The IPSS Score
0 Points: Low (Median Survival of 5.7 yrs)
0.5-1 Points: Intermediate 1 (Median Survival of 3.5 yrs.)
Points: Intermediate 2 (Median Survival of 1.2 yrs.)
Points: High (Median Survival of 0.4 yrs.)

54. MDS Therapy Options: Hypomethylating agents SCT Best Supportive Care
Usually limited role for growth factors

55. A word on the D-L Antibody
Paroxysmal cold hemoglobinuria (PCH):
rare form of autoimmune hemolytic anemia.
The autoantibody that causes this syndrome is called the Donath Landsteiner antibody.
A biphasic cold hemolysin:
Binds to red blood cells at cold temperatures and causes complement mediated hemolysis after warming to body temperature.
The autoantibody often has specificity for the P blood group antigen.
The test:
Drawing two tubes of blood:
One is incubated at 37o C for one hour.
The other tube incubated in an ice bath for 30 minutes and then transferred to a 37o C water bath for an additional 30 minutes.
Both tubes are centrifuged:
If the serum of the tube incubated in the cold is hemoglobin-tinged and the serum of the tube that remained at 37o C is clear, the patient has a Donath Landsteiner antibody.