1、,Bone Marrow Failure,Blanche P Alter, MD, MPH Clinical Genetics Branch Division of Cancer Epidemiology and Genetics Bethesda, MD,Case Presentation,16 year old male Seen by family doctor because tennis instructor noticed that he was tiring easily History of trip outside the USA 5 months earlier Noted
2、 to have pallor and a large bruise on arm (where hit by tennis ball) CBC: Hb 8.5 g/dL, platelets 40,000/mL, WBC 2000/mL (20% neutrophils),Next Step,Look at blood smear R/o circulating blasts Do a bone marrow Aspirate Cell types Cytogenetics Biopsy Cellularity,Pancytopenia with Hypocellular Marrow,Ac
3、quired aplastic anemia Inherited bone marrow failure syndrome Hypocellular Myelodysplastic Syndrome Aleukemic leukemia Marrow lymphoma,Pancytopenia with Cellular Marrow,Primary marrow disease Leukemia Myelodysplastic syndrome Paroxysmal nocturnal hemoglobinuria Systemic disease Lupus Hypersplenism I
4、nfection, e.g. brucellosis, sarcoidosis, tuberculosis,Bone Marrow (BM) Biopsy,Normal,Aplastic,Aplastic Anemia: Signs and Symptoms,Anemia fatigue, lassitude, dyspnea Thrombocytopenia bruises, petechiae serious bleeding Neutropenia infections,Severity of Aplastic Anemia,Severe 2 of the following 3: ne
5、utrophils 500/mL, platelets 20,000/mL, reticulocytes 20,000/mL BM cellularity 25% with 30% hematopoietic cells Very severe Neutrophils 200/mL Non-severe (moderate) Better than severe,Nosology of Aplastic Anemia,Genetics Acquired Inherited Cell biology Stem cell Immune,Acquired Aplastic Anemia,Radiat
6、ion Drugs (cytotoxics, chloramphenicol, nonsteroidals, anticonvulsants, gold) Chemicals (benzene, insecticides, pesticides, fertilizer) Viruses (Epstein-Barr, hepatitis non-A,B,C, human immunodeficiency) Genetic polymorphisms in detoxifying enzymes Paroxysmal nocturnal hemoglobinuria (PNH) Pregnancy
7、 Immune diseases (eosinophilic fasciitis, hypoimmunoglobulinemia, thymoma) IDIOPATHIC,Evidence for Immune Disease,Autologous recovery after immunosuppression for transplant Even syngeneic transplants require conditioning Response to immunosuppression (ATG/CsA; Cp) Oligoclonal expansion of Vb subfami
8、lies Activated T cells Increased frequency of HLA-DR2 Increased apoptosis,Copyright 2006 American Society of Hematology. Copyright restrictions may apply.,Young, N.S. et al. Blood 2006;108:2509-2519,Immune Pathophysiology of Acquired Aplastic Anemia,Inciting event (virus or drug), aberrant immune re
9、sponse, oligoclonal expansion of cytotoxic T cells, destroys stem cells. BMT or IST eradicate or suppress pathogenic T-cell clones. Immune response recurs, selection of PNH, MDS, or AML cells.,PNH,Treatment for Acquired Aplastic Anemia,Stem cell transplant ATG/CsA Cyclophosphamide Support Transfusio
10、ns Platelets ?G-CSF,Overlapping Syndromes,AA,TERC, TERT, TINF2,Other,FA,DC,MDS,AML,PNH,Acquired,Inherited Bone Marrow Failure Syndromes (IBMFS): Young Children,3 yo FA,4 yo DBA,NB TAR,2 yo SDS,10 yo DC,1.5 yo SCN,5 yo Amega,IBMFS: Adults and Older Children,26 FA,23 FA,16 SDS,21 DC,32 DBA,42 TAR,IBMF
11、S: Benign Hematology Oncology,These disorders are the major “Inherited Bone Marrow Failure Syndromes.”,History: Guido Fanconi,Fanconi Anemia (Fanconi pancytopenia syndrome): 1927 - 3 brothers with pancytopenia and physical abnormalities, “perniziosiforme” Fanconi Syndrome (renal Fanconi syndrome): 1
12、936 - proteinuria, glucosuria, phosphaturia, aminoaciduria, citraturia, and proximal renal tubular acidosis,Fanconi Anemia - Children,Photos with permission,Fanconi Anemia: Adults,Absent radius, 0,Aplastic anemia, 5,?, 6,Aplastic anemia, 16,Cancer, 30,BMT donor, 55,Literature: Physical Findings,All
13、findings biased by under- or over-reporting!,Laboratory Findings in FA,Low blood counts (pancytopenia) Large red cells (macrocytosis) Increased fetal hemoglobin (Hb F) Chromosome breakage in lymphocytes or fibroblasts cultured with a DNA crosslinker, e.g. diepoxybutane (DEB) or mitomycin C (MMC),Fan
14、coni Anemia - Definition,Autosomal recessive (1 X-linked recessive gene) Physical findings Aplastic anemia Leukemia Solid tumors Chromosome instability DNA repair defect 13 genes,FANC Genes,Adapted from Joenje, 2006,D1 = BRCA2,*J and N interact with BRCA1 and BRCA2,FA Complementation Groups/Genes,BR
15、IP1 is “BRCA1 interacting protein”; PALB2 is “partner and localizer of BRCA2”,FA DNA Repair Pathway,B,D2,DNA Repair,DNA Damage,C,E,F,I,G,M,L,A,PCNA,NBS1,RAD51,J/BACH1,BRCA1,D2,Ub,D1/BRCA2,N/PALB2,Who Should be Tested for FA?,Characteristic birth defects (eg thumbs, kidneys, poor growth, etc) Aplasti
16、c Anemia (AA) Myelodysplastic Syndrome (MDS) Acute Myeloid Leukemia (AML) Decreased fertility Early characteristic cancer Siblings of FA patients,What are the Tests for FA?,Blood chromosome breakage (DEB or MMC) Skin fibroblast chromosome breakage Flow cytometry for G2 arrest Western blot for ubiqui
17、tinated D2 Retroviral FA gene correction of FA phenotype FA gene sequencing,D2 Ubiquitination,Shimamura et al, Blood, 2002,FANCA,Retrovirus-mediated Correction of FA Cells,FA Complications,Aplastic Anemia Acute Leukemia Myelodysplastic Syndrome Solid Tumors Liver tumors,FA Aplastic Anemia,Adapted fr
18、om Kutler et al, Blood, 2003,80% by age 15, 90% overall,FA Literature: Cancer 1927-2007,179 solid tumors and 163 leukemias in 330/1865 patients; 29 had 2-4 cancers,Risk of Cancer in FA by O/E Ratio,North American Survey;German FA Registry;Israeli FA Registry; National Cancer Institute,NCI FA Cumulat
19、ive Incidence and Cause-specific Hazards,Competing Risks of Cancer,Fanconi Anemia: Phenotype/Outcome,Rosenberg, Huang, Alter, Blood 2004,Phenotype predicts age and incidence of marrow failure and solid tumors.,Abnormal phenotype = radii, plus abnormal development, heart or lung, kidney, hearing, and
20、 head. Competing risk analyses.,Transplant and Head and Neck Cancer in Fanconi Anemia,DATA: Transplant increasedcancer by 4.4-fold; Shifted median age to 16 years younger; All cancer patients had graft vs host disease.,Paris,Rosenberg, Socie, Gluckman, Alter: Blood, 2005; Biol Blood & Marrow Transpl
21、, 2005,LESSON: Improve transplant preparation to reduce graft vs host disease.,USA,Diagnosis of FA after Cancer,Tongue SCC age 30 Skin SCCs age 33 Short, 80 lbs, hearing aids, menopause age 30 XRT side effects Normal blood counts PB chromosomes no breaks; skin breaks,Skin,Gene conversion, loss of ex
22、on 27 frameshift 2585delCT,Blood,Somatic Mosaicism, FANCA,Alter, Joenje, Oostra, Pals, Arch Otolaryngol, 2005,Hematopoietic Mosaicism,Mosaicism from Recombination,a,A,A,a,a,A,A,a,a,A,A,a,FANCD1/BRCA2 Proband; Adult FANCA,Photos with parental and patient consent,Odds Ratios for Complications in FA an
23、d FANCD1/BRCA2,FANCD1/BRCA2 is associated with extremely high incidences of VACTERL-H association, AML, and specific Solid Tumors (Wilms, medulloblastoma).,Alter, Brody, Rosenberg: J Med Genet 2007,Genotype/Phenotype/Outcome: 27 FA with Biallelic Mutations in BRCA2,Alter: Br J Haematol, 2006,Alter,
24、Brody, Rosenberg: J Med Genet, 2007,FANCD1/BRCA2 Mutations,What is the risk of cancer in carriers of these missense mutations?,1Chi square of expected frequency across the gene. 2Permutation test of range between the extremes.,Alter, Brody, Rosenberg: J Med Genet, 2007,Why do patients with biallelic
25、 deleterious/deleterious or deleterious/missense mutations in BRCA2 both develop FA and cancer?,FA: When to Treat,Cytopenias Hb 8 g/dL or symptoms Platelets 30,000/mm3 WBC 500/mm3 MDS Morphologic + cytopenias Not for clone alone,Leukemia Blasts in blood 20% blasts in marrow Solid tumors or liver tum
26、ors When detected,FA: Guidelines for Diagnosis and Management, 2008,FA: How to Treat,Hematologic disease (benign or malignant) Stem cell transplant Androgens Hematopoietic growth factors (G-CSF, Ep) Chemotherapy Folic acid Blood products: not family; leukodeplete; irradiate Gene therapy? Liver tumor
27、s Stop androgens Solid tumors Conservative/focused radiation Chemotherapy that does not cross-link DNA New modalities, e.g. cetuximab,FA: Guidelines for Diagnosis and Management, 2008,FA Surveillance: Cancer,Hematopoiesis AA, MDS, aML Blood counts every 3-4 months Bone marrow aspirate, biopsy, cytog
28、enetics annually Oral cavity and pharynx - role of HPV vaccine? Age 10 years BMT 1 year Gynecologic - role of HPV vaccine? Age 16 years Menarche Liver Liver enzymes every 3-4 months Liver ultrasound every 6-12 months Skin Annual exam,Case Presentation,16 year old male Seen by family doctor because t
29、ennis instructor noticed that he was tiring easily History of trip outside the USA 5 months earlier Noted to have pallor and a large bruise on arm (where hit by tennis ball) CBC: Hb 8.5 g/dL, platelets 40,000/mL, WBC 2000/mL (20% neutrophils) Diagnosis: Fanconi Anemia, newly diagnosed in an adolesce
30、nt,Dyskeratosis Congenita,Dyskeratosis Congenita - Kids,2 yo, HH,1.5 yo, HH,6 yo, TINF2,10 yo, TINF2,Dyskeratosis Congenita - Adults,22 yo, DKC1,48 and 16 yo, TERC,27 yo, TINF2,24 yo, TINF2,Physical Findings in DC,Dystrophic nails* Lacey pigmentation* Leukoplakia* Epiphora, blepharitis Developmental
31、 delay Pulmonary disease Short stature Dental caries Liver disease,Esophageal stricture Early grey hair, hair loss, sparse eyelashes Hyperhidrosis Cerebellar hypoplasia Hypogonadism Microcephaly Urethral stricture Osteoporosis, avascular necrosis,*Diagnostic Triad (need 2/3). Or, 1 of the triad, + h
32、ypoplastic bone marrow, + 2 of the other findings.,X-linked recessive (XLR), Autosomal dominant (AD), Autosomal recessive (AR) Mutations in telomerase and shelterin pathways: DKC1 (XLR) TERC (AD) TERT (AD, AR) TINF2 (AD),DC Inheritance,NOLA2 (AR)NOLA3 (AR)Others (50%),Major Complications in DC,Hemat
33、ologic Bone marrow failure Myelodysplastic syndrome Leukemia Solid tumors Head and neck Anogenital Pulmonary fibrosis,44 cancers in 36/425 patients,DC Literature: Cancer 1910-2007,What is the End of the Shoelace?,The aglet,Telomeres and Chromosomal Instability,Long TTAGGG repeats Shorten with each c
34、ell division Many proteins interact to regulate telomere length and stabilize structure Lack of telomere maintenance leads to erosion of chromosome ends, genomic instability, cell crisis and cell death,FISH: telomeres,Courtesy of Peter Lansdorp,Telomere Biology Pathway,Armanios, Annu Rev Genomics Hu
35、m Genet, 2009,Kirwan and Dokal, BBA, 2009,Laboratory Diagnostic Test: Telomere Length by flow-FISH,Alter, Baerlocher, Savage, Lansdorp: Blood, 2007,Almost all patients with DC have very short telomeres in blood cells, including 3 silent carriers and 6 lacking the triad.,Most patients with other IBMF
36、S have normal telomeres.,Telomere Length in Multiplex Family,Ethics: Denny et al: AJMG, 2008 Gene discovery: Savage et al: AJHG, 2008,TINF2 is Mutated in DC,Lys 280 Glu,Hoyeraal-Hreidarsson Syndrome,Revesz Syndrome,Savage et al: AJHG, 2008,NCI IBMFS Cohort: Relative Risk of Cancer (O/E Ratio),NCI DC
37、 Compared with All FA,DC Surveillance and Treatment,Similar to Fanconi Anemia Role of HPV vaccine? Stem cell transplant complicated by pulmonary disease No role for immunosuppression Features unique to DC: Androgen sensitive Splenic peliosis and rupture on androgens + G-CSF Pulmonary fibrosis Hepati
38、c fibrosis, cirrhosis Telomere length assay: diagnosis of patients, silent carriers; surveillance and genetic counseling,Diamond-Blackfan Anemia,Diamond-Blackfan Anemia,Normochromic, usually macrocytic anemia, developing in infancy Reticulocytopenia Marrow erythroblastopenia Normal or slightly decre
39、ased leukocytes Normal or increased platelets Increased fetal hemoglobin (Hb F) Increased red cell adenosine deaminase (ADA) 25% with physical findings: short, abnormal thumbs, etc,DBA Literature 2008: Physical Findings,Denominator = 900, but no data in many reports.,DBA Inheritance,Autosomal domina
40、nt 25% RPS19 2% RPS24 1% RPS17 40s ribosome biogenesis Haploinsufficiency,7% RPL5 5% RPL11 2% RPL35a,30 cancers in 30/899 patients; 3 MDS not included,DBA Literature: Cancer 1936-2008,DBA Surveillance and Treatment,Monitor blood counts Annual bone marrows (no consensus) Treat when Hb 8 g/dL, or symp
41、toms Corticosteroids Transfuse during first year and puberty (no consensus) Cyclosporin A (rare) Metoclopramide (rare),Shwachman-Diamond Syndrome,Exocrine pancreatic insufficiency Decreased trypsinogen and isoamylase (age-dependent) Pancreas small or fatty on imaging Bone marrow failure Neutropenia:
42、 1500/mL Anemia: Macrocytosis Thrombocytopenia Myelodysplastic syndrome/acute leukemia Bones Metaphyseal dysostosis Autosomal recessive SBDS = Shwachman-Bodian-Diamond Syndrome 60s ribosome biogenesis,SDS Literature: Leukemia 1949-2007,36 leukemias in 36/510 patients,SDS Surveillance and Treatment,S
43、imilar to Fanconi Anemia G-CSF - neutropenia Stem cell transplant - cardiotoxicity from cyclophosphamide? Features unique to SDS: Malabsorption - pancreatic enzymes, ADEK Metaphyseal dysostosis - surgery as needed Cytogenetic clones - monitor,Severe Congenital Neutropenia,No physical phenotype ANC 5
44、00/mL Pyogenic infections Rx G-CSF Autosomal dominant ELA2 GFI1 Autosomal recessive (Kostmann Syndrome) HAX1 X-linked recessive WAS,SCN and Leukemia,(Rosenberg, Alter, Dale: Blood, 2006),Poor responders to G-CSF have a higher risk of leukemia. These may have a more severely abnormal stem cell. Early
45、 bone marrow transplantation should be considered for the poor responders.,3 cases of AML prior to the G-CSF era; 44 since. Does G-CSF cause leukemia?,Amegakaryocytic Thrombocytopenia,Neonatal thrombocytopenia Decreased megakaryocytes No anomalies Evolution to aplastic anemia and/or leukemia AR: 1p,
46、 mpl, thrombopoietin receptor Type I: nonsense mutations, severe Type II: missense mutations, milder,Thrombocytopenia Absent Radii,Neonatal thrombocytopenia Absent radii, thumbs present Megakaryocytes absent, reduced, hypoplastic, immature 4 cases of leukemia 2 mo; 1, 5, 41 yrs No gene identified Mi
47、crodeletion 200 kb at 1q21.1; digenic,Treatment and Outcome,Summary/Conclusions,Patients known to have an IBMFS have a high risk of neoplasia Patients with atypical presentations of neoplasms may have an undiagnosed IBMFS The molecular mechanisms depend on the IBMFS The magnitude of these problems merits further study,FA chromosome breakage DC telomere length DBA red cell ADA SD trypsinogen, isoamylase SCN, Amega, TAR clinical diagnosesSequence candidate genes,Screening Tests for Suspected IBMFS,And, Next,www.marrowfailure.cancer.gov,
