1. MYELOPROLIFERATIVE NEOPLASMS WHO 2016
Chronic myeloid leukemia, BCR-ABL 1 positive
Chronic neutrophilic leukemia
Polycythaemia vera
Primary myelofibrosis
Essential thrombocythaemia
Chronic eosinophilic leukaemia, NOS
Chronic neutrophilic leukemia, NOS
Myeloproliferative neoplasm, unclassifiable

2. Chronic myeloid leukemia (CML) lat. Myelosis chronica
CHRONIC myelogenous leukemia (CML) is a malignant hematological disorder of the human hematopoietic stem cells
CML arises from a pluripotent hematopoietic stem cell that has undergone a reciprocal translocation between the BCR gene on chromosome 22 and the ABL proto-oncogene on chromosome 9
Fusion gene BCR-ABL has been found detected in all myeloid lineages, in B lymphocytes and some other lymphoid cells

3. Pathogenesis
CML was the first cancer demonstrated to have underlying genetic abnormality. It was discovered in 1960 in Philadelphia by Peter Nowell and David Hungerford – chromosome Philadelphia.

4. t(9;22)(q34;q11) is responsible for the oncogenic BCR-ABL gene fusion, located on the shorter derivative 22 chromosome.
This gene encodes the continuously activated BCR-ABL fusion protein
Protein products (transcripts of BCR-ABL oncogene) formed during
the transcription process can have different isoforms, depending on the precise location of the fusion:
p190 – usually associated with ALL -p210 – associated with CML (and sometimes with ALL)
p230 – associated with CNL, trombocytosis
FISH

5. BCR-ABL has tyrosine-kinase activity and participates in intracellular signal transduction.
Activity imparts growth advantage to leukemic cells:
Increased proliferation and cytokine-independent growth
Inhibition of apoptosis
Alteration of adhesion pathways

6. Epidemiology of CML
CML accounts for 15 to 20 percent of all adult leukemias.
M > F (1.3: 1)
The incidence in adults is 1-2 cases per 100,000 population per year,, median age at diagnosis is years.
CML is rare in persons aged < 19 years (1-2 cases per million population) Leukemogens - Exposure to very high doses of ionizing radiation can increase the occurrence of CML above the expected frequency in comparable populations (e.g. Hiroshima & Nagasaki, Chernobyl); the other etiologic agents are actually not to be known.

7. Clinical presentation of CML

8. Chronic phase
Majority – above 80% - of cases diagnosed in the chronic phase of CML, the disease is sometimes recognized incidentally
Clinical onset of chronic phase may by insidious
70% of patients who are symptomatic may present with easy fatigability, loss of sense of well-being, decreased tolerance to exertion, anorexia, abdominal discomfort, early satiety and left upper quadrant pain or mass (related to hepatosplenomegaly), weight loss, and excessive sweating.
Physical examination:
hepatomegaly
splenomegaly
paleness
Remember that some patient may present with leukostasis!

9. Laboratory results WBC > 20 000/μl (often > 100000/μl),
Increased granulocytes of all types, typically including mature myeloid cells
Neutrophil hypersegmentation
Increased number of basophils
decreased Hb concentration (sometimes)
platelet count normal or increased

10. Myeloid maturation MATURATION myeloblast promyelocyte myelocyte
metamyelocyte
band
neutrophil
MATURATION
Adapted and modified from U Va website

11. Leukostasis
accumulation of blasts in microcirculation with impaired perfusion lungs: hypoxemia, pulmonary infiltrates
CNS: stroke, loss of consciousness
headache, vision disorders
sometimes priapism
seen with WBC >> 100 x 109/L, esp. when WBC > /L (10% patients)

12. Diagnosis: Whole blood count + peripheral blood smear evaluation
BM smear evaluation and trephine biopsy
Special stains – cytochemistry
Classic cytogenetics – to look for t(9;22) translocation
FISH – to show the presence of BCR-ABL fusion gene
Molecular investigations – RT-PCR, RQ-PCR – to detect transcript of BCR-ABL oncogene (p190, p210, p230) and to evalute response to the treatment (molecular response)

13. Peripheral blood

14. Bone marrow

15. BCR/ABL dual fusion t(9;22)(q34;q11)
RRGG
Normal signal pattern
BCR/ABL dual fusion t(9;22)(q34;q11) 9
der(9) 22
der(22)
ABL
9q34
BCR
22q11
FFRG
Typical abnormal
FISH
Fluorescent In Situ Hybridisation

16. Philadelphia chromosome and/or BCR-ABL detection
CML diagnosis
Philadelphia chromosome and/or BCR-ABL detection

17. The presence of Ph+/BCR-ABL1+ cells
CML biology before IFN/TKI era
„health”
Diagnosis
Disease
App 6 yrs
3-4 yrs
3-12 m
app 20 m
Chronic phase
advanced disease
WBC /ul
WBC /ul
Death
The presence of Ph+/BCR-ABL1+ cells

18. CML- early and advanced phases
Chronic phase
Accelerated phase
10–19% myeloblasts in the blood or bone marrow smear
- >20% basophils in the blood or bone marrow
- Platelet count <100,000, unrelated to therapy
- Platelet count >1,000,000, unresponsive to therapy
- Cytogenetic evolution with new abnormalities in addition to the Philadelphia chromosome
Increasing splenomegaly or white blood cell count, unresponsive to therapy
Blast crisis
- >20% myeloblasts or lymphoblasts in the blood or bone marrow smear
- large clusters of blasts in the bone marrow on biopsy
Development of a chloroma (solid focus of leukemia outside the bone marrow), or another extramedullary presentation

19. Principles of treatment
Tyrosine Kinase Inhibitors:
imatinib – the first generation of TKI
dasatinib, nilotinib– the second generation of TKI
bosutinib, ponatinib
Interferon alfa 2b- in specific clinical situations
Alkylating agents – Ara-C, Hydroxyurea and steroids in the past, in rare situation nowadays
Allogeneic HSCT

20. The aim of the treatment
Complete hematologic remission (CHR)
Cytogenetic response
Molecular response
Leukemia-free survival
The cure
Hochhaus, Venice 2006

21. Therapy- history and present
Hydroxyurea, busulfan- cytoreductive treatment ( )
no ifluence on overall survival, no cytogenetic response, leukocyte count reduction, decresed of splenomegaly, hematologic response, better qauality of life
AlloHSCT (1979/1981)
Cure of 50-60% of patients
Interferon alfa (1982)
Complete hematologic response (CHR ) 50-80%, major cytogentic response 30%, complete cytogenetic response in up to 10% of patients
Imatinib- first TKI (1998)
CHR 95%, major cytogenetic response 85%, including complete CyR 75%
TKI - second generation: ( )
Dasatinib
Nilotinib
Ponatinib
Bosutinib

22. Imatinib

23. Imatinib Chronic phase 400 mg Accelerated phase/blast crisis
600/800 mg with/wo chemtherapy

24. Event free survival patients treated with IM (IRIS study)

25. Monitoring: every 3 months untill CCyR
Cytogenetic response
Definition:
Complete CCyR: Ph+ 0% Partial PCyR: Ph+ 1%-35% Minor (MCyR: Ph+ 36%-65%
Minimal: Ph+ 66%-95% Lack of response : Ph+ >95%
Monitoring: every 3 months untill CCyR

26. Molecular response
Definition:
Deep (MolR):
transcript BCR-ABL undetectable
Major (MMolR):
BCR-ABL ≤ 0.1%
Monitoring: every 3 months

27. Response to TKI Optimal Failure 3 months CHR BCR-ABL  10% Ph  35%
No CHR
Ph > 95%
6 months
BCR-ABL  1%
Ph 0%
BCR-ABL > 10%
Ph > 35%
12 months
BCR-ABL  0.1%
BCR-ABL > 1%
Ph > 0%
CHR- complete hematologic response

28. First line treatment Imatinib 400 mg/d Dasatinib 100 mg/d
Nilotinib 2x 300 mg/d

29. Second line treatment TKI switch Intolerance of first line treatment
Failure after 3-5 months of first line treatment
T315I mutation- ponatinib
AlloHSCT
Blast crisis
Should be considered after failure of first line treatment, recommended after failure of second line treatment
Treatment failure in patients with T351I mutation

30. Allogeneic HSCT The only (?) curative method of treatment
Leukemia free survival > 60-70% of patients
Treatment related mortality 10-15%
Relapse rate 20%
Relapse treatment
Donor lymphocyte infusion
TKI

31. Survival after HLA Matched Sibling HCT for CML, 2005-2015
Slide 31: Allogeneic transplants for CML are currently reserved for patients where tyrosine kinase inhibitors have failed or are poorly tolerated. The CIBMTR has data for 2,015 HLA-matched sibling donor transplants for CML from 2005 to Three-year probabilities of survival were 66% ± 1%, 51% ± 4% and 29% ± 4% for patients in chronic phase, in accelerated phase and blast phase; respectively.

32. Chronic graft versus host disease

33. Overview CML registry data
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
number of allografts
1361
1028
990
819
758
644
564
386
241
260
RIC
136
132
162
187
194
159
107 56
number of autografts
143 66 44 28 15 13 6 4
Related donors
unrelated donors
842
508
674
345
610
372
464
351
432
318
352
282
306
252
175
206
134
status at alloTx:
CP1
CP2 AP BC
996 90
121 61
690 99 81
627
131
125 51
444
124 54
448
111 92 45
390 82 68 85 71 49
163 72 53 40 88 62 21 38
age > 50 years
262
183
180
152
178
105
108 73

34. Selected Disease Trends for Allogeneic HCT in the US
Slide 14: This slide represents trends in the utility of allogeneic transplants for various indications and shows that allogeneic transplant activity is decreasing in lymphomas and CLL highlighting the availability of non-transplant therapeutic options.

35. OS in IRIS study- Imatinib 400mg
OS after alloHSCT
OS in IRIS study- Imatinib 400mg