Upload
vomien
View
225
Download
0
Embed Size (px)
Citation preview
Leucemia Linfoblastica Acuta
(adulto)
Classificazione delle leucemie linfoidi acute, WHO 2008
Leucemie linfoblastiche acute a cellule «precursor» B
• Leucemia/linfoma linfoblastica/o B, NAS
• Leucemia/linfoma linfoblastica/o B con anomalie genetiche ricorrenti
• Leucemia/linfoma linfoblastica/o B con t(9;22) (q34;q11.2);BCR-ABL1
• Leucemia/linfoma linfoblastica/o B con t(v;11q23); MLL riarrangiata
• Leucemia/linfoma linfoblastica/o B con t(12;21)(p13;q22); TEL-AML1(ETV6-RUNX1)
• Leucemia/linfoma linfoblastica/o B con iperdiploidia
• Leucemia/linfoma linfoblastica/o B con ipodiploidia
• Leucemia/linfoma linfoblastica/o B con t(5;14)(q31;q32);IL3-IGH
• Leucemia/linfoma linfoblastica/o B con t(1;19)(q23;p13.3); E2APBX1 (TCF3-PBX1)
Leucemie linfoblastiche acute a cellule «precursor» T
• Leucemia/linfoma linfoblastica/o T
Neoplasie a cellule B mature
• Linfoma di Burkitt (include anche la rara variante leucemica, L3 FAB)
NB Esistono poi forme miste, indifferenziate, bifenotipiche, bilineari…
LLA: Esami diagnostici
Sangue periferico:
Emocromo con formula leucocitaria ed esame morfologico (ematologo esperto) mediante striscio periferico
blasti > 2=% (leucocitosi non sempre presente, neutropenia, piastrinopenia, anemia)
Immunofenotipo (citometria a flusso): linea linfoide (CD13-; CD14-), linea B (CD10+, CD19+, CD20+, CD22+)
o T (CD1a+, CD3+, CD4+, CD7+, CD8+). Altri antigeni: CD34, HLA-Dr, TdT
Citogenetica/FISH e biologia molecolare: cromosoma Philadelphia / traslocazione BCR/ABL (30 % circa nel paziente
adulto;
va eseguita in tutti i pazienti indipendentemente dall’età, per la possibilità di terapia con TKI)
Aspirato midollare:
Striscio con mielogramma per valutazione (ematologo esperto)della percentuale di blasti midollari e della riserva
emopoietica
Citochimica: non più consigliata (puo’ essre utile la perossidai: negativa)
Immunofenotipo (citometria a flusso: linea linfoide (CD13-; CD14-), linea B (CD10+, CD19+, CD20+, CD22+)
o T ( CD1a+, CD3+, CD4+, CD7+, CD8+). Altri antigeni: CD34, HLA-Dr, TdT.
Citogenetica/FISH e biologia molecolare: cromosoma Philadelphia / traslocazione BCR/ABL
Biopsia osteomidollare:
Raramente necessaria (aspirato midollare povero di cellule) e nel caso immunoistochimica
NB. In tutti i pazienti es. del liquor (morfologico ed immuofenotipico)
LLA: Diagnostica avanzata
• Identificazione forme Ph-like (altri geni di fusione: potrebbero giovarsi di terapia con TKI come le LAL Ph+)
• Mutazione di IKZ (valore prognostico nelle forme sia Ph+che Ph-)
• TAC total body (nelle forme T massa mediastinica, nelle Burkitt-like o L3 masse toracoa-addominali)
• NGS (identificazione di sottogruppi di mutazioni sensibili a nuovi farmaci)
LLA: Follow-up
• Valutazione della minimal residual disease
(MRD), dopo consolidamento nelle forme Ph-, al
termine della prima fase di terapia con TKI, in
genere 80-90 giorni nelle Ph+.
• MRD: Ph+ molecolare
• MRD: Ph- immunofenotipo
Leucemia Mieloide Acuta
984-993 LEUCEMIE MIELOIDI
LAM con traslocazioni citogenetiche ricorrenti:9896/3 LAM con t(8;21)(q22;22), AML1(CBFα)/ETO M29866/3 LA Promielocitica [LAM con t(15;17)(q22;q21) e varianti, PML/RAR-α] M39871/3 LAM con ipereosinofilia midollare [inv(16)(p13;q22) o t(16;16), cbfb/myh11] M4eo9897/3 LAM con anomalie 11q23 (MLL)
LAM con displasia multilineare 9895/3 LAM con/senza precedente sindrome mielodisplastica9920/3 LAM e sindromi mielodisplastiche correlate a terapie agenti alchilanti, epipodofillotossine, altri tipi
LAM non altrimenti classificate9872/3 LAM scarsamente differenziata M09873/3 LAM senza maturazione M19874/3 LAM con maturazione M29866/3 LA promielocitica M39867/3 LA mielomonocitica M49891/3 LA monocitica M59840/3 LA eritroide M69910/3 LA megacariocitica M79870/3 LA basofilica9931/3 Panmielosi acuta con mielofibrosi
9805/3 Leucemie acute bifenotipiche
9860/3 Leucemia mieloide, NAS
9861/3 Leucemia mieloide acuta, NAS
Classificazione WHO 1997
Emocromo con formula leucocitaria (ematologo esperto in morfologia)
• Blasti > 20% condizione necessaria e sufficiente
Di solito si associa anemia, neutropenia, piastrinopenia, non sempre è
presente leucocitosi (se presente >10.000/µL)
Può essere anche l’unico esame se paziente molto anziano e/o frail, nel quale si
decide esclusivamente terapia di supporto
Diagnosi di LAM Su sangue periferico:
• Striscio + Mielogramma
valutazione morfologica e quantitativa del midollo al microscopio ottico
(ematologo esperto in morfologia) per valutare la percentuale e la morfologia dei
blasti e la riserva emopoietica
• Citofluorimetria cellule fenotipo immunologico:
CD34, CD13+, CD14+, CD33+ (markers di differenziazione della linea mieloide)
Il pannello viene allargato ad altri antigeni anche allo scopo di identificare i LAIP da utilizzare
nello studio della MRD
• BOM:
solo in caso di aspirato non informativo
Diagnosi di LMA
Su agoaspirato midollare:
LAM: Citogenetica e biologia molecolare
• Citogenetica: ricerca di traslocazioni specifiche
utili a definire la prognosi
• Biologia molecolare: mutazione di FLT3, NPM1
e mutazione biallelica di CEBPa (definizione del
rischio nella citogenetica normale secondo le
raccomandazioni ELN e NCCN)
• FISH in casi selezionati
Leucemia promielocitica, FAB M3 APL
La traslocazione t(15;17) coinvolge il gene che codifica per il recettore nucleare a dell'acido retinoico RAR sul cromosoma 17 ed il gene PML (promielocitica) sul cromosoma 15 11 t(15;17)(q22;q11).
Fondamentale per la diagnosi e la terapia la
biologia molecolare con il monitoraggio del gene
ibrido PML-RARalpha, che va eseguito al termine
del consolidamento e poi ogni 2-3 mesi
LMA: Diagnostica avanzata
• Congelamento di cellule patologiche all’esordio
(utile per studi futuri)
• NGS (possibilità di sottogruppi sensibili a farmaci
in grado di inibire specifiche mutazioni)
LMA: Follow up
• RC: valutazione morfologica
• MRD: solo in studi clinici
• MRD: “mandatory” nella LAP
• Different clonal neoplastic disorders of hematopoietic stem cells
• Heterogeneous biologic and clinical characteristics
• “Rich marrow” (dysplastic, ineffective myelopoiesis due to excess
of apoptosis) and “poor peripheral blood “ (variously combined
cytopenias: anemia, leucopenia, thrombocytopenia)
• Low-to-high risk of leukemic transformation
• Very variable prognosis
Myelodysplastic Syndromes: a lot of directions
Myelodysplastic Syndromes
Increased apoptosis
Ineffective hemopoiesis
Lower-risk MDS: 75%
Apoptosis
Proliferation
Myelodysplastic Syndromes
Reduced apoptosis
Genetic evolution
Leukemic transformation
Higher-risk MDS: 25%
Proliferation
Apoptosis
Diagnosis and Evaluation
No specific clinical feature that distinguishes MDS from other causes of anemia (or other cytopenias)
Lab evaluation often prompted by signs or symptoms of the underlying cytopenias
– Fatigue, pallor, cardiac failure (anemia)– Infections (neutropenia)– Bleeding, ecchymoses, petechiae (thrombocytopenia)
Minimum work-up (1)
• Detailed patient’s history of transfusion need, professional toxic exposure and chemotherapic or radio-therapic treatments*, as well as severe co-morbidities
• Complete blood count, a peripheral blood smear examination with differential leukocyte count and a bone marrow aspiration with cytogenetics and morphologic evaluation, including Perls staining
• Bone marrow biopsy in order to assess marrow architecture, cellularity (hypoplastic MDS), fibrosis (primary myelofibrosis) and percentage of blasts
SIE, SIES and GITMO Guidelines, Santini et al. Leuk Res 2010* Secondary/Therapy-related MDS
• Serum erythropoietin determination in patients with symptomatic anaemia
• Iron status evaluation, i.e. serum ferritin and transferrin saturation in patients who are transfusion dependent or who start transfusion therapy
• DEB test in patients younger than 30 years who are possible candidates for high-dose chemotherapy or allogeneic HSCT, in order to exclude a Fanconi anaemia-associated MDS that is contraindicating chemotherapy
• HLA typing in patients eligible for HSCT, and those with an hypoplastic bone marrow (HLA-Dr15), in order to further support decision on immunosuppressive therapy
Minimum work-up (2)
SIE, SIES and GITMO Guidelines, Santini et al. Leuk Res 2010
Malcovati et al, European LeukemiaNet Guidelines, Blood 2013
B-2
* Prothrombin time
*
Malcovati et al, European LeukemiaNet Guidelines, Blood 2013
*
*
* and monocytes
301
530 529
0
100
200
300
400
500
Hb < 8 gr/dl Hb da 8 a 10 gr/dl Hb > 10 gr/dl
22% 39% 39%
FISM data: Cytopenias in 1361 MDS patients
232
339
786
0
100
200
300
400
500
600
700
800
<50 51-100 >100
17% 25% 58%
161213
371
573
0
100
200
300
400
500
600
<500 501-1000 1001-2000 >2000
12% 16% 28% 44%
Anemia
Thrombocytopenia
Neutropenia
• Idiopathic
• Cytopenia/Dysplasia
• Undetermined
• Significance
• Might be MDS, but might not
• Needs follow-up, no treatment!
A definitive diagnosis
of MDS may be not
immediate!
ICUS / IDUS
Tefferi and Vardiman, N Engl J Med, 2009
• It demonstrates the clonality of the disease, resolving problems of differential diagnosis
• It allows to identify specific genomic regions where genes involved in the pathogenesis of the disease are located
• It contributes to recognize specific biological and clinical entities
• It is probably the most important prognostic factor
• It may be helpful for monitoring the effects of therapies applied
Clinical relevance of detecting chromosomal abnormalities at diagnosis
Malcovati L, Educational Book, EHA 2012
Recurring chromosomal abnormalities in
t - MDS / t - AML
Normal
8%Balanced
4%
Other
12%
Abnl 5
22%
Abnl 7
30%
Both 5/7
24%
SingleDel(11q)-Y
Schanz et al, J Clin Oncol 2011
Prognostic relevance of cytogenetic abnormalities in MDS
FAB WHO• Not described Uni/Multilineage dysplasia
• Not described MDS with isolated del(5q)
• RAEB-T (BM blasts 20-30%) > AML
• CMML > MDS/MPD
• del5q as unique chromosomal abnormality
• Macrocytic anaemia, slight leucopenia, normal to elevated platelet
• Small, hypolobated, mononuclear, spheronuclear megakaryocytes
• Predominantly middle-aged to older women
• < 15% blasts in blood and marrow
• Refractory anaemia, erythroid dysplasia/ hypoplasia, transfusion dependence
• Indolent course, 10–15% acute myeloid leukaemia, median survival > 5 years
• Interstitial, variable size 5q13-33 deletions (CDB: “common deleted band” 5q 31-32) in hematopoietic stem cells
• Marked hematological and cytogenetic response to lenalidomide
5q- “syndrome”: a distinct form of MDS in a subset of patients with isolated del 5q
Evidence suggests that haploinsufficiency of genes encompassed in or around the CDB
5q32–33 leads to the development of 5q– syndrome
Disease complexity and heterogeneity in MDS with del(5q)
MDS del(5q)
• There is a general belief that MDS with del(5q) as an isolated cytogenetic abnormality has a favorable prognosis
• This is probably due to confusion about an old definition of the term “5q-syndrome”, that should be reserved only
to a distinct form of MDS in a subset of patients with isolated del 5q and well defined clinical and morphological
characteristics (see above)
• Today, there is increasing evidence that del(5q) MDS is heterogeneous with respect to clinical, pathological,
molecular and prognostic findings
Platelet count
Karyotype
complexity
Extend of
deletion Transfusion
status
Age/Sex
TP53
mutationsErythroid
hypoplasiaBM Blast count
WHO
morphology
The FAB had also already arbitrarily
categorized CMML into MDS-like and
MPD-like groups, using a white blood
count of 13x109/L as a cut-off to
differentiate the two entities.
Chronic Myelo-Monocytic Leukemia
Refractory anaemia with ring sideroblasts (RARS) and RARS with marked thrombocytosis (RARS-T):
provisional entity in the WHO 2008 classification characterized by high proportion of JAK2V617F and SF3B1 mutations
Cazzola et al, Blood, 2013
RARS
RARS-T
International Prognostic Scoring System (IPSS)
Punteggio RischioSopravvivenza
mediana(anni)
0 Basso 5,7
0,5-1,0 Intermedio-1 3,5
1,5-2,0 Intermedio-2 1,2
2,5 Alto 0,4
Modificata da Greenberg P, et al. Blood 1997;89:2079-2088.
* ANC <1500/mm3, Hb <10 g/dl, PLT <100.000/mm3
Punteggio
Variabili prognostiche 0 0,5 1,0 1,5 2,0
Blasti midollari <5 5-10 – 11-20 21-30
CariotipoNormale o-Y o del 5qo del 20q
Altre anomalieAnomalie
complesseo del cr.7
Citopenie* 0-1 2-3
Effect of comorbidity on survival of MDS patients
Overall Survival Risk of Non-Leukemic Death
Della Porta et al, Haematologica 2009
Italian registry for MDS:
Presence of comorbidities (n = 388)
• CIRS, Cumulative Illness Rating Scale.
142
99
7770
0
20
40
60
80
100
120
140
160
Grade 0–2 n. 1 n. 2 n. > 2
20% 18%25%37%
Pa
tie
nts
, n
Comorbidities
63% with (at least one) comorbidities degree > 3 (CIRS)
5
12
19 18
3634
29
14
0
5
10
15
20
25
30
35
40
< 60 anni 61-70 71-80 > 80 anni
MDS indipendente MDS correlabile
22
5
149
1510
38
54
0
10
20
30
40
50
60
%
RA/RARS RCMD CMML RAEB
MDS indipenenti MDS correlabili
55
27
15
39
0
10
20
30
40
50
60
%
IPSS low-int1 IPSS int2-high
MDS indipendente MDS correlabile
Dati su 167 decessi in pazienti con SMD
Bejar, Haematologica 2014
Impact of mutations on survival of MDS patients
0 5 10 15 20 25 30 35 40Time from randomization (months)
0
10
20
30
40
50
60
70
80
90
100
Pe
rcen
tage s
urv
ivin
g
CCR
AZA
Difference in median OS was 9.4 months
24.4 months
15 months
50.8%
26.2%
100 200 300 400 500
1.0
0
0.25
0.50
0.75
0
0
Duration, months
Pro
po
rtio
n
su
rviv
ing
Non-chelated (n = 336)
Chelated (n = 264)
Lyons RM, et al. Blood. 2012;120:abstract 3800.
Fenaux et al, Blood 2011
Park et al, Blood 2008
Fenaux P, et al. Lancet Oncol. 2009;10:223-32.
Impact of novel treatments on survival of MDS patients
Erythropoietin
Chelation therapy
P < 0.0001 Lenalidomide
Azacitidine