Bone Marrow Biopsy and Aspirate Evaluation in 90 Patients with Essential Thrombocythemia Treated with PEG Interferon alpha-2b. Preliminary Results.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1523-1523 ◽  
Author(s):  
L. Gugliotta ◽  
S. Bulgarelli ◽  
A. Tieghi ◽  
S. Asioli ◽  
G. Gardini ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Platelet Count ◽  
Bone Marrow Biopsy ◽  
Essential Thrombocythemia ◽  
Bone Marrow Fibrosis ◽  
Minor Response ◽  
Bone Marrow Biopsies ◽  
Hematological Response ◽  
Second Year ◽  
Marrow Fibrosis

Abstract Ninety patients with Essential Thrombocythemia (ET) where object of a phase II prospective multicentre study designed to evaluate efficacy, safety and tolerability of a two years treatment with PEG Interferon α-2b (PEG Intron, Schering Plough). The patients, 30 M and 60 F, 18–72 years old (median 45), observed in 16 Hematological Institutions of the Gruppo Italiano Malattie Mieloproliferative Croniche (GIMMC), received the ET diagnosis according to the PVSG criteria. At PEG Intron treatment start the patients showed: previous cytoreduction 97% (IFN α 31%), platelet count >1000 x 109/L 81%, splenomegaly 22%. At the end of the first year The PEG Intron starting dose of 25 μg/week resulted increased to a mean value of 55 μg/week and the Hematological Response (HR = Plts <500x109/L) was registered in 79% of the patients still on treatment. At the end of second year 65 patient still receiving PEG Intron (mean dose 31 μg/week) showed a maintenance of the HR (66%), a Partial Response (17%) and a Minor Response (17%). By utilizing the data included in the study CRFs we preliminarily evaluated the bone marrow biopsy and aspirate both performed at baseline, after 1 and 2 years in 89 and 86, 79 and 67, 57 and 50 patients, respectively. Data concerning the bone marrow biopsies after 1 year of treatment are reported: BONE MARROW BIOPSY BASELINE % 1 YR % 2 YRS % Cellularity increased 56 51 48 Granulopoiesis increased 51 54 39 Erytropoiesis increased 29 24 23 MK number increased 99 90 84 MK size increased 78 69 62 MK ploidy 54 51 42 MK dystrophy 52 56 59 Fibrosis mild 40 37 46 Fibrosis moderate 7 25 26 The increase of bone marrow fibrosis registered after one year (representative also of second year data) resulted not related to patient gender, age >45 years, platelet count >1000 x109/L, Hb <12 g/dL, splenomegaly, previous IFN treatment, PEG Intron dose >50 μg/week. In conclusion, the present study shows that in ET patients a two years PEG Intron treatment, able to induce and to maintain the Hematological Response in the majority of cases, is associated to a decrease of bone marrow cellularity, granulopoiesis, erytropoiesis, MK number, size and ploidy and, moreover, with an increase of MK dystrophy and of bone marrow fibrosis. These preliminary data on bone biopsy and aspirate will be object of a planned centralized reevaluation by a Panel of Pathologists and Clinicians.

scholarly journals Splenectomy in a Child of X-Linked Thrombocytopenia with Thalassemia and Bone Marrow Fibrosis : Hemoglobin and Platelet Count Were Improved

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1367-1367
Author(s):  
Yang Wan ◽  
Xiaofan Zhu ◽  
Xiaojuan Chen ◽  
Wenbin An ◽  
Peihong Zhang ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Platelet Count ◽  
Bone Marrow Biopsy ◽  
Peripheral Blood ◽  
Clinical Characteristics ◽  
Blood Count ◽  
Complete Blood Count ◽  
Conflicts Of Interest ◽  
Bone Marrow Fibrosis ◽  
Marrow Fibrosis

Abstract X-linked thrombocytopenia with thalass emia (XLTT)(OMIM 314050)was first described by Thompson in 1977(Thompson et al. J Blood 1977 50(2):303-16). This rare inherent disorder was caused by a nucleotide change G>A at position 647, which leads to an amino acid substitution of arginine to glutamine (R216Q) in the gene of GATA-1 on the band p11-12 ohuman X chromosome(Raskind et al. Blood 2000, 95(7):2262-8 ;Yu et al.J Blood 2002,100(6): 2040-2045). GATA-1, belonging to the GATA family of transcription factors plays a crucial role in the development of several hematopoietic cell lines ( Ferreira et al. J Mol Cell Biol 2005,25(4): 1215-1227) . The missense mutation(R216Q) in XLTT affects GATA-1 binding to palindromic DNA sites (Yu et al.J Blood 2002,100(6): 2040-2045). The clinical characteristics of XLTT are mild thrombocytopenia, splenomegaly, reticulocytosis, hemolytic anemia and unbalanced hemoglobin (Hb) chain synthesis resembling ¦Â-thalassemia (Raskind et al. Blood 2000, 95(7):2262-8 ; Balduini et al. J Thromb Haemost 2004, Jan;91(1):129-40). About 7 families of XLTT were reported before (Millikan et al.J Semin Thromb Hemost 2011,37(6): 682-689; Danielsson et al. J Lakartidningen 2012 ,109(34-35): 1474-1477).Bone marrow fibrosis is described only in tow Swedish families ( Danielsson et al. J Lakartidningen 2012 ,109(34-35): 1474-1477).But there is limited data about the treament and prognosis of the diesase. Here we describe the full clinical characteristics of a boy of XLTT who was treated by splenectomy. The patient was first admitted at the age of 1year and 8 months in 2011.The chief complain was skin petechia and pale for more than one month. The boy had lower weight but no visible malformation. Feeding difficult and lag of language development were also complained.His Liver was 2.3cm below the right ribs and spleen was 3.2cm below the left. Peripheral blood count showed hemoglobin 8 g/dL, MCV76.7fl, MCH21.8 pg,MCHC284 g/L and reticulocyte count 0.1764¡Á1012/L. Peripheral blood smear demonstrated marked anisopoikilocytosis, polychromasia and nucleated RBCs.Platelet count was 64¡Á109/L with normal morphology.Wight blood cell was normal in number and morphology.elevated to 0.226(normal range 0-0.025) while HBA2 and hemoglobin electrophoresis was normal. Bone marrow biopsy and aspirate smear revealed a hypercellular marrow with dysplasia of erythrocyte series and megakaryoblasts (Figure 1 A). Polynuclear erythroblast ,micromegakaryocytes and hypolobated megakaryocytes could be easily seen (Figure 1 B). Fibrosis proliferation was obvious (Figure 1 A). Genetic analysis discovered a mutantion of GATA-1(R216Q)and excluded mutations of hemoglobin gnens and JAK-2. Patient was treated with dexamethasone and thalidomide which got little effect. The baseline hemoglobin was 6-8 g/dL.Platelet count ranged from 30 to 70¡Á109/L. Splenectomy was done at the age of 5years and 4 months because of constantly RBC transfusion and splenomegaly. Fibrosis proliferation and extramedullary hematopoiesis in spleen were proved by biopsy (Figure 1 C,D).The boy's complete blood count was recovered 4 months after splenectomy. Hemoglobin rose to11.6 g/dL and platelet count was 337¡Á109/L. HBF was still high at 0.226. Multifocal fibrosis proliferation still existed in bone marrow biopsy but with no myelodysplasia (Figure 1 E,F). Hepatomegaly didn't progress. He has good quality of life,and normal growth and intelligence development. Splenectomy can be a therapeutic strategy of X-linked thrombocytopenia with thalassemia. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals Prolonged Myelosuppression due to Progressive Bone Marrow Fibrosis in a Patient with Acute Promyelocytic Leukemia

2019 ◽  
Vol 2019 ◽  
pp. 1-7
Author(s):  
Yuta Inagawa ◽  
Yukiko Komeno ◽  
Satoshi Saito ◽  
Yuji Maenohara ◽  
Tetsuro Yamagishi ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Acute Promyelocytic Leukemia ◽  
Bone Marrow Biopsy ◽  
Gastric Fluid ◽  
Promyelocytic Leukemia ◽  
Consolidation Therapy ◽  
Bone Marrow Fibrosis ◽  
All Trans Retinoic Acid ◽  
Phlegmonous Gastritis ◽  
Marrow Fibrosis

A 34-year-old woman was diagnosed with acute promyelocytic leukemia. Chemotherapy was administered following the JALSG APL204 protocol. Induction therapy with all-trans retinoic acid resulted in complete remission on day 49. She developed coccygeal pain from day 18, which spread to the spine and cheekbones and lasted 5 weeks. She had similar bone pain on days 7–10 of the first consolidation therapy and on days 4–12 of the second consolidation therapy. Oral loxoprofen was prescribed for pain relief. On day 33 of the third consolidation, white blood cell and neutrophil counts were 320/μL and 20/μL, respectively. After she developed epigastralgia and hematemesis, she developed septic shock. Gastroendoscopy revealed markedly thickened folds and diffusely damaged mucosa with blood oozing. Computed tomography revealed thickened walls of the antrum and the pylorus. Despite emergency treatments, she died. Bacterial culture of the gastric fluid yielded Enterobacter cloacae and enterococci growth. Collectively, she was diagnosed with phlegmonous gastritis. Retrospective examination of serial bone marrow biopsy specimens demonstrated progressive bone marrow fibrosis, which may have caused prolonged myelosuppression. Thus, evaluation of bone marrow fibrosis by bone marrow biopsy after each treatment cycle might serve as a predictor of persistent myelosuppression induced by chemotherapy.

Is Thalidomide the Sole Treatment of Primary Myelofibrosis? Report of a Case with Complete Reversal of Bone Marrow Fibrosis and Splenomegaly.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 4905-4905
Author(s):  
Alain Berrebi ◽  
Lev Shvidel ◽  
Irena Shpivak ◽  
Edit Feldberg
Keyword(s):  
Bone Marrow ◽  
Folic Acid ◽  
Bone Marrow Biopsy ◽  
Low Dose ◽  
Oral Prednisone ◽  
Young Patients ◽  
Primary Myelofibrosis ◽  
Bone Marrow Fibrosis ◽  
Complete Reversal ◽  
Marrow Fibrosis

Abstract Primary myelofibrosis (MF) is a chronic progressive disorder incurable except for allo-transplantation in young patients. Thalidomide which down-regulates cytokine release involved in fibrosis (VEGF, TGF-beta, beta-FGF, PDGF) and angiogenesis has been used with variable responses in the treatment of MF. We report a patient who achieved a complete response of MF after being treated with low doses thalidomide. An 82-year-old patient, with no other medical problems, was followed since 1993 because of erythrocytosis and mild splenomegaly, his bone marrow biopsy revealed tree-lineage hyperplasia and moderate fibrosis. The patient was initially treated with phlebotomy when needed, and afterwards by a low dose of hydroxyurea. Five years later, when anemia developed (Hb&lt;10 g/dl) together with prominent splenomegaly (18 cm) and aggravation of bone marrow fibrosis, combination treatment with androgen, vitamin B complex and folic acid was started. Since 2003 the patient became transfusion dependent (2 packed red cells every 3 weeks). He had a huge splenomegaly (up to the pubis), Hb 8.3 g/dl, WBC 4×109/l with occasionally blasts, platelet count 75×109/l, and LDH 1220 U. Bone marrow biopsy revealed severe reticulin and collagen fibrosis with no hematopoiesis. In view of the progressive painful splenomegaly and deep pancytopenia, splenectomy was advised which was refused by the patient. Therefore alternative treatment with thalidomide was considered and started at a dose of 50 mg/day together with 5 mg/day prednisone in March, 2004. B-complex and folic acid were continued. Four months later, the blood transfusion requirement decreased, and gradually was abolished. The spleen size started to be smaller and became impalpable. Currently after 30 months of treatment blood count showed Hb 12.0 g/dl, WBC 2.6×109//l, Plt 140×109/l. The repeated bone biopsy showed a dramatic change with complete normalization of hematopoiesis and total resolution of collagen. The blood film doesn’t disclose any tear drops. Thalidomide monotherapy in moderate and high doses (200–800 mg/day) produces a 20–50% response rate in MF-associated anemia and thrombocytopenia, has mild impact on splenomegaly, but is poorly tolerated. Most patients are withdrawn from treatment because of adverse effects in first three months. Mesa et al (Blood, 2003) improved tolerability and efficacy of therapy using thalidomide in low dose 50 mg/day along with a three months oral prednisone. An objective clinical response was demonstrated in 62% patients; however, complete reversal of fibrosis has never been mentioned before. In conclusion, we report a patient with a very advanced MF who showed complete hematological response to low dose thalidomide with complete reversal of bone marrow fibrosis and splenomegaly. We suggest that this exceptional response might be due to the long continuous tolerable low dose treatment (30 months) and a combination with prednisone, B-complex vitamins and folic acid.

NS-018, a Selective JAK2V617F Inhibitor, Improves JAK2V617F-Induced Murine Myelofibrosis Without Decreasing The Erythrocyte Or Platelet Count

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 3847-3847
Author(s):  
Yohei Nakaya ◽  
Kotaro Shide ◽  
Haruna Naito ◽  
Tomoko Niwa ◽  
Tatsuya Horio ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Hydrogen Bonding ◽  
Platelet Count ◽  
Carbonyl Group ◽  
Wild Type ◽  
Bone Marrow Fibrosis ◽  
Platelet Counts ◽  
Unique Mode ◽  
Marrow Fibrosis ◽  
Jak2 Inhibitors

Abstract A single somatic mutation, V617F, in Janus kinase 2 (JAK2) is one of the causes of myeloproliferative neoplasms (MPN), including primary myelofibrosis, and the mutant kinase JAK2V617F is a therapeutic target in MPN. However, inhibition of wild-type JAK2 (JAK2WT) can decrease the red blood cell (RBC) or platelet count. Therefore, a JAK2 inhibitor that produces a smaller reduction in the RBC and platelet counts in the therapeutic window would have clinical benefit. NS-018 is a potent and selective inhibitor of JAK2 and Src-family kinases which is currently in an early-phase clinical trial for MPN. To compare the inhibitory effect of NS-018 on JAK2WT and JAK2V617F in the cell, we assessed the antiproliferative activity of NS-018 against Ba/F3 cells expressing murine JAK2WT or JAK2V617F. NS-018 suppressed the growth of Ba/F3-JAK2V617F cells with an IC50 value of 470 nM, whereas it suppressed the growth of Ba/F3-JAK2WT cells stimulated with IL-3 with an IC50value of 2000 nM. Thus, NS-018 showed 4.3-fold selectivity for Ba/F3-JAK2V617F over Ba/F3-JAK2WT cells (V617F/WT ratio). Other JAK2 inhibitors also showed selectivity for Ba/F3-JAK2V617F over Ba/F3-JAK2WT cells, though their selectivity was lower. For example, INCB018424 (ruxolitinib) and TG101348 showed V617F/WT ratios of 2.0 and 1.5, respectively. Among the eight JAK2 inhibitors tested, NS-018 showed the highest selectivity for JAK2V617F cells. NS-018 also inhibited erythroid colony formation in JAK2V617F transgenic mice at significantly lower concentrations than in wild-type mice. To assess the ability of NS-018 to selectively inhibit JAK2V617F-harboring cells in vivo, we established a JAK2V617F bone marrow transplantation (BMT) mouse model. NS-018 was administered by oral gavage twice a day for 40 days at a dose of 50 mg/kg. When assessment was carried out 50 days after the start of the study, NS-018 was found to have significantly prolonged the survival of JAK2V617F BMT mice, decreased their splenomegaly and restored their disrupted splenic architecture. NS-018 also partially suppressed bone marrow fibrosis in JAK2V617F BMT mice. All vehicle-treated mice that had survived to the study endpoint had mild-to-moderate reticulin fibrosis, whereas all mice treated with NS-018 had slight-to-little reticulin fibrosis, except for one mouse with mild fibrosis. Although vehicle-treated JAK2V617F BMT mice showed marked leukocytosis, NS-018 treatment achieved a 95% suppression of this increase. In spite of the marked effects of NS-018 in JAK2V617F BMT mice described above, NS-018 treatment had not decreased the RBC or reticulocyte count after 50 days of administration. JAK2V617F BMT mice showed a 78% decrease in the platelet count compared with control mice, and NS-018 treatment did not further decrease the count. To better understand the ability of NS-018 to preferentially inhibit the mutated form of JAK2, we explored the X-ray co-crystal structure of NS-018 bound to activated JAK2 and focused on the flipped carbonyl group of Gly933, which is located immediately N-terminal to the DFG (Asp-Phe-Gly) motif in the activation loop of JAK2. We identified two kinds of hydrogen-bonding interactions between NS-018 and the carbonyl group of Gly993: water-mediated hydrogen bonding involving a nitrogen atom of NS-018 and a CH•••O hydrogen bond involving an aromatic CH of NS-018. The unique mode of binding of NS-018 to activated JAK2 provides a plausible explanation for its JAK2V617F selectivity. In summary, NS-018 preferentially inhibited the growth of JAK2V617F-harboring cells over JAK2WT-harboring cells. NS-018 was also effective against leukocytosis, splenomegaly, and bone marrow fibrosis, and prolonged survival in JAK2V617F BMT mice with no reduction in the RBC or platelet counts. These characteristics of NS-018 may be explained at least in part by its unique mode of binding to the activated form of JAK2. NS-018 may have therapeutic benefit for MPN patients in virtue of its simultaneous satisfaction of the two requirements of efficacy and reduced hematologic adverse effects. Disclosures: Nakaya: Nippon Shinyaku: Employment. Naito:Nippon Shinyaku: Employment. Niwa:Nippon Shinyaku: Employment. Horio:Nippon Shinyaku: Employment.

Bone Marrow Fibrosis and Diagnosis of Essential Thrombocythemia

2009 ◽  
Vol 27 (34) ◽  
pp. e220-e221 ◽  
Author(s):  
Juergen Thiele ◽  
Hans Michael Kvasnicka ◽  
James W. Vardiman ◽  
Attilio Orazi ◽  
Vito Franco ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Essential Thrombocythemia ◽  
Bone Marrow Fibrosis ◽  
Marrow Fibrosis

scholarly journals A Phase 3, Double-Blind, Placebo-Controlled, Randomized Study Evaluating Navitoclax in Combination with Ruxolitinib in Patients with Myelofibrosis (TRANSFORM-1)

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 4-4
Author(s):  
Jalaja Potluri ◽  
Jason Harb ◽  
Abdullah A. Masud ◽  
Jessica E. Hutti
Keyword(s):  
Bone Marrow ◽  
Platelet Count ◽  
Stock Options ◽  
Myeloproliferative Neoplasm ◽  
Bone Marrow Fibrosis ◽  
Double Blind ◽  
Starting Dose ◽  
Secondary Endpoints ◽  
Marrow Fibrosis

Background: Myelofibrosis (MF) is a rare myeloproliferative neoplasm with poor clinical outcomes. It is characterized by bone marrow fibrosis and an array of constitutional symptoms that impair quality of life. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only potential curative therapy for MF, but HSCT is only accessible to a minority of patients and is associated with high morbidity and high rates of transplant-related mortality. JAK inhibitors (JAKi), including the JAK1/2i ruxolitinib and JAK2i fedratinib, are approved for the treatment of primary and secondary MF based on reduction in splenomegaly and disease-related symptoms; however, they have little impact on bone marrow fibrosis and are not effective at managing all clinical manifestations of MF. Therefore, a substantial clinical need for novel therapies to improve the disease course of MF exists. Navitoclax is an oral, potent, small-molecule inhibitor of the antiapoptotic B-cell lymphoma 2 (BCL-2) family proteins BCL-XL, BCL-2, and BCL-w and has demonstrated cell-killing activity in myeloproliferative neoplasm-derived cell lines and primary specimens ex vivo. Preliminary data from a Phase 2 study (NCT03222609) of ruxolitinib-experienced patients with primary or secondary MF have shown favorable spleen responses and tolerability with navitoclax plus ruxolitinib (Harrison et al. EHA 2020. EP1081). TRANSFORM-1 aims to evaluate the combination of navitoclax and ruxolitinib vs placebo and ruxolitinib in adults with primary or secondary MF who have not previously received a JAK2i. Study Design and Methods: In this Phase 3, double-blind, placebo-controlled study (NCT04472598), patients aged ≥18 years with intermediate-2 or high-risk MF with measurable splenomegaly, evidence of MF-related symptoms, no prior treatment with JAK2i, and Eastern Cooperative Oncology Group Performance Score ≤2 will be eligible for enrollment. Candidates for allo-HSCT and those who have received prior treatment with a BH3-mimetic compound or BET inhibitor will be excluded. Patients will be enrolled across 130 sites in approximately 17 countries. Planned target enrollment is 230 patients. Patients will be randomized 1:1 to receive navitoclax or placebo, plus ruxolitinib. Randomization stratification factors include intermediate-2 vs high-risk MF and platelet count ≤200 × 109/L vs &gt;200 × 109/L. Navitoclax will be administered orally at a starting dose of 200 mg (platelet count &gt;150 × 109/L) or 100 mg escalated to 200 mg once daily if tolerated after ≥7 days (platelet count ≤150 × 109/L). Ruxolitinib will be administered orally at a starting dose of 20 mg (platelet count &gt;200 × 109/L) or 15 mg (platelet count 100-200 × 109/L) twice daily. Treatment may continue until the end of clinical benefit, unacceptable toxicity, or discontinuation criteria have been met. Patients who discontinue without progression will enter post-treatment follow-up; after disease progression or initiation of post-treatment cancer therapy, patients will enter survival follow-up. The primary endpoint of the study is ≥35% reduction in spleen volume from baseline (SVR35) at Week 24, as measured by magnetic resonance imaging or computed tomography, per International Working Group (IWG) criteria. Secondary endpoints include ≥50% reduction in total symptom score from baseline at Week 24 (measured by Myelofibrosis Symptom Assessment Form v4.0), duration of SVR35, change in fatigue from baseline, time to deterioration of physical functioning, anemia response per IWG criteria, SVR35 per IWG, reduction in grade of bone marrow fibrosis from baseline, overall survival, leukemia-free survival, and overall response and composite response per IWG criteria. Exploratory endpoints include progression-free survival. Safety will be assessed throughout the study via adverse event (AE) monitoring, physical examinations, vital sign measurements, electrocardiogram variables, and clinical laboratory testing. AEs will be graded per National Cancer Institute Common Terminology Criteria for AEs v5.0. The primary statistical analysis will be conducted using a stratified Cochran-Mantel-Haenszel test, and time-to-event secondary endpoints will be analyzed using a stratified log-rank test and Kaplan-Meier methodology. Hazard ratios will be estimated using stratified Cox proportional hazards model. Disclosures Potluri: AbbVie: Current Employment, Other: may hold stock or stock options. Harb:AbbVie: Current Employment, Other: may hold stock or stock options. Masud:AbbVie: Current Employment, Other: may hold stock or stock options . Hutti:AbbVie Inc.: Current Employment, Other: may hold stock or stock options. OffLabel Disclosure: Navitoclax is an investigational drug for the treatment of myelofibrosis

scholarly journals Impact of bone marrow fibrosis grade in post‐polycythemia vera and post‐essential thrombocythemia myelofibrosis: A study of the MYSEC group

2019 ◽  
Vol 95 (1) ◽  
Author(s):  
Barbara Mora ◽  
Paola Guglielmelli ◽  
Elisa Rumi ◽  
Margherita Maffioli ◽  
Daniela Barraco ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Polycythemia Vera ◽  
Essential Thrombocythemia ◽  
Bone Marrow Fibrosis ◽  
Marrow Fibrosis

scholarly journals Megakaryocyte Apoptosis in the Bone Marrow of Patients with Immune Thrombocytopenia

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1379-1379
Author(s):  
John R Vrbensky ◽  
Ishac Nazy ◽  
Lisa J Toltl ◽  
Catherine Ross ◽  
John G. Kelton ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Platelet Count ◽  
Bone Marrow Biopsy ◽  
Research Funding ◽  
Immune Thrombocytopenia ◽  
Tunel Staining ◽  
Bone Marrow Biopsies ◽  
Entire Study ◽  
Platelet Counts ◽  
Normal Platelet

Abstract Introduction: Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder in which autoantibodies promote the destruction and underproduction of platelets. Recent evidence suggests that immune-mediated destruction of bone marrow megakaryocytes is associated with the pathogenesis of this disease. In addition, the attenuation of megakaryocyte apoptosis can lead to platelet underproduction since this process appears to be involved in thrombopoiesis. In the current study, we investigated megakaryocyte apoptosis as a possible mechanism in the pathogenesis of ITP. Patients/Methods: Bone marrow biopsy sections from ITP patients and controls were stained with anti-human CD61 to enumerate megakaryocytes. Terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling (TUNEL) staining was performed as a measure of megakaryocyte apoptosis. The samples were coded and reviewed by an experienced hematopathologist who was blinded to the diagnosis. Adult primary ITP patients had isolated thrombocytopenia with no underlying cause and a platelet count less than 100 x109/L at the time of bone marrow biopsy procurement. Patients with secondary ITP (in the context of medications, lymphoproliferative disease, HIV, hepatitis B or C infection) were excluded, as were patients who received prior treatment with thrombopoietin receptor agonists or other hematopoietic growth factors. Thrombocytopenic controls were patients with myelodysplastic syndrome (MDS) who had platelet counts below 100 x109/L. Control patients with normal platelet counts had bone marrow biopsies performed as part of investigations for lymphoma or plasma cell dyscrasia with negative test results. Results: The average platelet count for ITP patients, MDS patients, and controls were 18 x109/L (range 2-76 x109/L), 29 x109/L (range 9-60 x109/L), and 281 x109/L (range 171-400 x109/L), respectively. Elevated megakaryocyte counts were observed in the bone marrow sections of 5/14 (36%) ITP patients, 0/8 (0%) MDS patients, and 2/11 (18%) controls. Megakaryocyte apoptosis was comparable between ITP patients and MDS patients [2/14 (14%) vs 1/8 (13%) (p=1.00)], while fewer ITP patients exhibited megakaryocyte apoptosis compared to controls with normal platelet counts [2/14 (14%) vs 7/11 (64%) (p=0.02)]. In the entire study cohort, the average platelet counts of patients with negative and positive TUNEL staining were 66 x109/L (range 2-378 x109/L) and 206 x109/L (range 20-400 x109/L), respectively (p=0.01). In addition, the normalized megakaryocyte counts (per high powered field) were 8.2 ± 5.5 and 5.4 ± 2.5 in patients with negative and positive TUNEL staining, respectively (p=0.05). Conclusion: Megakaryocyte apoptosis was reduced in ITP bone marrow samples compared to controls with normal platelet counts, but was also low in thrombocytopenic MDS patients. Reduced megakaryocyte apoptosis was found to be associated with a low platelet count, and may be related to thrombocytopenia regardless of etiology. Our study is consistent with the hypothesis that attenuated megakaryocyte apoptosis is relevant in the context of platelet underproduction in ITP. Disclosures Arnold: Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

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