Anagrelid In Essential Thrombocythaemia Treatment of a Patient Under 12 Months

Abstract Abstract 4680 Essential thrombocythaemia (ET) is a chronic myeloproliferative disorder. It occurs mostly in adults and rarely in young children. We present the case of ET in an 8 –month- old girl, who was treated with Anagrelid for 13 months. The girl was admitted to the hospital because of elevated platelet count. She had stomach pains periodically. On admission the child's condition was good but on palpation her stomach was sore and her spleen was enlarged. Laboratory investigations showed an elevated platelet count (1.5m) and hypercalaemia (6.3mEq/l). Thrombopoetin was normal. Acesan was added to the treatment. A morphology performed after 1 month revealed further elevation of platelets (up to 2.65m). On the basis of the laboratory investigations, bone-marrow biopsy and trepanobiopsy, we eliminated an oncological disease and infectious diseases of connective tissues. On bone-marrow investigation, acquired mutation of JAK2 (V617F) tyrosine kinase was diagnosed, which confirmed ET. On account of the growing number of platelets, which was life - threatening, we decided to administer Anagrelid, starting with a dose of 0.25 mg per day. The number of platelets decreased to 1.4m, so the dose was increased to 0,25 mg twice daily after 3 weeks. At present, after 13 months of Anagrelid treatment, the number of platelets in the child ranges between 400 and 650. The patient comes to our, department for monthly check-up of morphology, biochemical tests, ECG and echocardiography. In international literature there is no information on the use of Anagrelid in ET treatment of children under 12 months old. However, on the basis of our observations and initial results of treatment, it seems that the above protocol for Anagrelid administration is safe for infants of this age. Disclosures: No relevant conflicts of interest to declare.

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Long-term Use of Anagrelid in Essential Thrombocythemia Treatment of a Child Under 12 Months

Blood ◽

10.1182/blood.v120.21.5072.5072 ◽

2012 ◽

Vol 120 (21) ◽

pp. 5072-5072

Author(s):

Pawel Laguna ◽

Anna Klukowska ◽

Katarzyna Pawelec ◽

Michal Matysiak

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Essential Thrombocythemia ◽

Conflicts Of Interest ◽

Jak2 V617f ◽

Biochemical Tests ◽

Results Of Treatment ◽

Life Threatening ◽

Laboratory Investigations ◽

Chronic Myeloproliferative Disorder

Abstract Abstract 5072 Essential thrombocythemia (ET) is currently classified as a chronic myeloproliferative disorder. Anagrelide is a novel platelet lowering agent that has recently been approved for use n ET. We present the case of ET in an 8 –month- old girl, who was treated with Anagrelid for 13 months. The girl was admitted to hospital because of elevated platelet count. She had stomach pains periodically. On admission the child's condition was good but on palpation her stomach was sore and her spleen was enlarged. Laboratory investigations showed an elevated platelet count (1. 5m) and hypercalemia (6. 3mEq/l). Thrombopoetin was normal. Acesan was added to the treatment. A morphology performed after 1 month revealed further elevation of platelets (up to 2. 65m). On the basis of laboratory investigations, bone-marrow biopsy and trepanobiopsy, we eliminated an oncological disease and infectious diseases of connective tissues. On bone-marrow investigation, acquired mutation of JAK2 (V617F) tyrosine kinase was diagnosed, which confirmed ET. On account of the growing number of platelets, which was life - threatening, we decided to administer anagrelid, starting with a dose of 0. 25 mg per day. The number of platelets decreased to 1. 4m, so the dose was increased to 0. 25 mg twice daily after 3 weeks. At present, after 37 months of anagrelide treatment, the number of platelets in the child ranges between 400 and 650. The patient visits our, department for monthly check-up (morphology, biochemical tests, ECG and echocardiography). In international literature there is no information on the use of Anagrelid in ET treatment of children under 12 months old. However, on the basis of our observations and initial results of treatment, it seems that the above protocol for Anagrelid administration is safe for infants of this age. Disclosures: No relevant conflicts of interest to declare.

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Cultivation of Megakaryocytes On a Collagen Matrix: A More Sensitive and Reproducible Test for the Diagnosis of Patients with Essential Thrombocythaemia.

Blood ◽

10.1182/blood.v114.22.4970.4970 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4970-4970

Author(s):

Adrian Emanuel Schmidt ◽

Patricia Darlington ◽

Lucie Kopfstein ◽

Elisabeth Ischi ◽

Elisabeth Oppliger Leibundgut ◽

...

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Negative Predictive Value ◽

Predictive Value ◽

Healthy Subjects ◽

Myeloproliferative Neoplasms ◽

Jak2 V617f ◽

Essential Thrombocythaemia ◽

Jak2 Mutation ◽

Spontaneous Proliferation

Abstract Abstract 4970 Background Essential thrombocythaemia (ET) is one of the chronic myeloproliferative neoplasms (MPN), along with polycythaemia vera (PV), primary myelofibrosis (PMF) and chronic myeloid leukaemia (CML). Their common feature is excessive proliferation of a certain stem or progenitor cell in the bone marrow; in the case of ET, the megakaryocytic lineage is affected. Clinical manifestations include thrombotic events and haemorrhage. Diagnosis of ET according to new WHO-criteria requires a sustained high platelet count, bone marrow biopsy showing proliferation of the megakaryocytic lineage with large and mature morphology, demonstration of JAK2 V617F (although only present in about 50% of patients with ET) or another clonal marker and explicit exclusion of other myeloid and myeloproliferative neoplasms as well as signs of reactive thrombocytosis. Additionally, spontaneous proliferation of megakaryocytes obtained from peripheral blood can be detected in in vitro culture assays. Presently, we use agar as a matrix for megakaryocyte cultivation, although this assay has never been validated in connection with ET. The identification of megakaryocytic colonies grown on agar can sometimes be quite difficult. Our aims were therefore to technically evaluate the use of a collagen based matrix and to investigate its suitability to identify patients with ET. Patients and Methods We have examined 63 patients (26 with ET, 21 with PV, 8 with myelofibrosis [MF; including PMF and post-ET/PV-MF], 6 with secondary or idiopathic erythrocytosis and 2 with secondary thrombocytosis; mean age=59.8, male=33, female=30, mean platelet count 457 G/l) and 5 healthy subjects. Following informed consent, both clinical and laboratory data was collected. Medication intake, phlebotomies, smoking habits and regular haemogram results were noted in order to recognise possible confounding factors influencing laboratory results. Results of megakaryocyte cultivation on both agar and collagen matrixes were recorded, considering both spontaneous growth and growth stimulated by megakaryocyte derived growth factor (MDGF). Results Based on our collagen culture results we were able to define 2 or more spontaneously grown megakaryocyte colonies as the most optimal cut-off for the identification of patients with MPN (sensitivity 71%, specificity 100% with positive and negative predictive values of 100% and 45%, respectively). Compared to the agar culture results (where a specificity and a positive predictive value of 100% were demonstrated at a cut-off value of ≥ 10 CFU-Mega) we found a higher accuracy and better reproducibility. In addition, we observed an improved negative predictive value (45% with collagen versus 25% with agar cultures) reducing false negative results. Healthy subjects and patients with secondary thrombocytosis showed no significant spontaneous megakaryocyte proliferation. In patients with MF, we observed strong spontaneous and MDGF-stimulated growth of megakaryocytic colonies. At a cut-off value of ≥ 50 CFU-Mega (after stimulation with MDGF), the collagen assay showed a sensitivity of 100% and a specifity of 70% for this special form of MPN, resulting in a negative predictive value of 100%. We found no confounding clinical or laboratory parameters such as medication intake (particularly cytoreductive treatment with hydroxyurea) or phlebotomies influencing our culture results, and no significant effect of the Jak2-V617F mutation on the growth behaviour of megakaryocytic colonies. Conclusion The results of this ongoing study imply that the collagen based assay is more sensitive, specific, time efficient and user friendly regarding the detection of spontaneous proliferation of megakaryocytes than the currently used agar based culture assay. In addition, the collagen based assay also has the great advantage that it allows isolation of single megakaryocytic colonies for further analyses, for example PCR-based identification of a JAK2 mutation. Furthermore, the collagen based assay facilitates the diagnosis of patients with MPN, especially in cases where conventional diagnostic criteria are lacking, such as in ET without a JAK2 mutation. Ultimately, the new assay may well be able to detect transformation from PV/ET to MF. Disclosures No relevant conflicts of interest to declare.

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In vivo adenovirus vector-mediated transfer of the human thrombopoietin cDNA maintains platelet levels during radiation-and chemotherapy- induced bone marrow suppression

Blood ◽

10.1182/blood.v88.3.778.778 ◽

1996 ◽

Vol 88 (3) ◽

pp. 778-784 ◽

Cited By ~ 36

Author(s):

A Ohwada ◽

S Rafii ◽

MA Moore ◽

RG Crystal

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Adenovirus Vector ◽

Bone Marrow Suppression ◽

Single Administration ◽

Platelet Recovery ◽

Platelet Production ◽

Life Threatening ◽

Bone Abnormalities

Abstract Thrombopoietin (TPO, c-mpl ligand) has emerged as a major hematopoietic cytokine stimulating megakaryocyte proliferation, endomitosis, and platelet production. This study shows that a single administration of an adenovirus (Ad) vector encoding TPO (AdCMV.TPO) abrogates thrombocytopenia induced in mice by carboplatin and irradiation. Normal Balb/c mice receiving the vector had increased platelet counts peaking at 7 days and returning to baseline by day 15. Mice rendered pancytopenic with 500 rads and 1.2 mg of carboplatin had a nadir platelet count of five percent of the baseline. Mice receiving AdCMV.TPO 3 days before receiving irradiation and chemotherapy achieved a platelet nadir fourfold higher, and had significant reduction in duration of thrombocytopenia, than mice receiving the control Ad vector. Introduction of AdCMV.TPO the same day of chemotherapy and irradiation was equally effective in acceleration of platelet recovery, but administration of AdCMV.TPO 3 days after chemotherapy-radiation had little effect on platelet recovery. At 30 days after therapy bone marrow and spleen of mice treated with AdCMV.TPO were populated with a large number of polyploid megakaryocytes, but there was no evidence of circulating megakaryocytes in the liver or lungs and no pathologic bone abnormalities such as osteosclerosis or myelofibrosis. These observations suggest that an Ad vector may be an excellent delivery system to provide adequate TPO production to maintain platelet levels in circumstances associated with life-threatening thrombocytopenia.

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A Novel Mutation in MPL (Y252H) Results in Increased Thrombopoietin Sensitivity and Moderate Thrombocytosis in a Pediatric Patient with Essential Thrombocytosis

Blood ◽

10.1182/blood.v118.21.2817.2817 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2817-2817

Author(s):

Michele Lambert ◽

Jing Jiang ◽

Wei Tong

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Bone Marrow Cells ◽

Novel Mutation ◽

Missense Variant ◽

Jak2 V617f ◽

Jak2 Mutation ◽

Hematopoietic Malignancies ◽

Healthy Control ◽

Pediatric Populations

Abstract Abstract 2817 Myeproliferative neoplams (MPNs) constitute a group of hematopoietic malignancies that feature enhanced proliferation and/or survival of one or more myeloid lineage cells, including Essential Thrombocythemia (ET). MPN development is rare in children with an estimated annual incidence of ET of 0.09/106 children. The WHO defines ET as persistent platelet count >600 k/mcL in the absence of known cause of reactive/secondary thrombocytosis. The JAK2 V617F mutation is most commonly reported in both children and adults with ET although the reported frequency varies in pediatric populations from 0 to 36% of patients. Mutations in the thrombopoietin receptor (TPO receptor or MPL) intracellular domain, specifically W515K/L, have also been reported in both adult and pediatric ET patients. Here we report a novel mutation in the MPL extracellular domain, Y252H, causing mild thrombocytosis. The patient presented at 2 years of age with a platelet count of 765 k/mcL. During the 3-year follow-up period, she possessed platelet counts between 600–700k/mcL, without any obvious indication of reactive/secondary thrombocytosis. Because of the persistently increased platelet count, her bone marrow was evaluated and it demonstrated increased numbers of megakaryocytes with focal clustering. JAK2 mutation analysis was negative and cytogenetics did not show any clonal abnormalities. Sequencing of the MPL gene showed a missense variant at c.754 T>C resulting in a tyr252his amino acid substitution. To investigate if this Y252H mutation in MPL dysregulates TPO/MPL- mediated cell growth, we introduced it into cytokine-dependent BaF3 cells. Cells stably expressing the mutant MPL allele showed increased proliferation to TPO, in particular at low concentration, in comparison to cells expressing wildtype (WT) MPL. Upon cytokine withdrawal, BaF3 cells expressing the MPL Y252H mutant survived better than that of WT MPL. Primary bone marrow cells from this patient along with the healthy control were subjected to colony forming unit -megakaryocyte (CFU-meg) assays in response to a serial dose of TPO. The Y252H MPL bone marrow showed significantly increased megakaryocyte colonies at low dose of TPO when compared to control bone marrow (17.5 ± 2.5 colonies versus 4.75 ± 1.1 colonies at 15 ng/mL TPO, p<0.001). These results are consistent with the clinically mild thrombocytosis. In summary, our results suggest a novel MPL mutation, Y252H, results in pediatric ET. Further evaluation of the mechanisms of increased TPO sensitivity imparted by this mutation should contribute to our understanding of the molecular pathogenesis of ET. Disclosures: Lambert: Cangene: Honoraria.

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JAK2 Signaling Specifies Phenotypic Pleiotropy In Myeloproliferative Neoplasms

Blood ◽

10.1182/blood.v122.21.1608.1608 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1608-1608

Author(s):

Lily Huang ◽

Huiyu Yao ◽

Yue Ma

Keyword(s):

Bone Marrow ◽

Conflicts Of Interest ◽

Phenotypic Diversity ◽

Myeloproliferative Neoplasms ◽

Jak2 V617f ◽

Wild Type ◽

Gain Of Function ◽

Hematopoietic Stem ◽

Phenotypic Differences ◽

V617f Mutation

Abstract Myeloproliferative neoplasms (MPNs) are a phenotypically diverse group of pre-leukemic diseases characterized by overproduction of one or more of the myeloid cell lineages. Gain-of -function mutations in the Janus tyrosine kinase 2 (JAK2) are major determinants in MPNs, These include the V617F mutation and mutations in exon 12. Interestingly, MPN phenotype in patients with exon 12 mutations is distinct from that of patients with the V617F mutation. Mechanisms underlying the phenotypic differences are not well understood. We performed an unbiased screen for residues essential for JAK2 auto-inhibition, and identified a panel of novel gain-of-function mutations. Interestingly, three of them with similar kinase activities in vitro elicited distinctive hematopoietic abnormalities in mice. Specifically, JAK2(K539I) results primarily in erythrocytosis, JAK2(N622I) predominantly granulocytosis, and JAK2(V617F) in both. These phenotypes are consistent with clinical data showing that patients with the V617F mutation exhibit erythrocytosis and granulocytosis, whereas those with mutations in exon 12 (where K539 resides) exhibit erythrocytosis only. To determine the mechanisms underlying the phenotypic differences by different JAK2 mutants, we characterized hematopoietic progenitors and precursor subsets in these mice for their proliferation, apoptosis and differentiation. Quantification of the hematopoietic stem and progenitor population showed an increased percentage of granulocyte-monocyte progenitors (GMP) and skewing of differentiation towards the granulocytic lineage in JAK2(V617F) and JAK2(N622I) mice compared to JAK2(K539I) or wild-type JAK2 mice. Because no difference was observed in the proliferation or apoptosis of bone marrow progenitors from JAK2 mutant mice, differentiation of the common myeloid progenitors (CMP) was likely skewed towards GMP by JAK2(V617F) and JAK2(N622I). Consistent with this hypothesis, similar results were observed in colony forming assays from sorted CMP populations. In the spleen, a decrease in GMP apoptosis and an increase in apoptosis of the megakaryocyte-erythrocyte progenitors (MEP) also contributed to the skewing towards the granulocytic lineage in JAK2(N622I) mice. Similar to MPN patients, mice expressing JAK2 mutants exhibited splenomegaly. We found that JAK2 mutants caused redistribution of hematopoietic stem and progenitors from the bone marrow to spleen. As a result, more differentiated precursors were expanded in the spleens of JAK2 mutants mice compared to mice expressing wild-type JAK2. Consistent with their phenotypes, the percentage of Annexin V＋7AAD－erythroblasts in JAK2(K539I) and JAK2(V617F) mice was significantly less than in JAK2(N622I) or wild-type JAK2 mice. On the other hand, both proliferation and apoptosis contribute to the differential degrees of granulocytosis among mice expressing different JAK2 mutants. In line with the different effects elicited by different JAK2 mutants in progenitor and precursor cells, signal transduction pathways were differentially activated downstream of different JAK2 mutants. In summary, our results showed that JAK2 mutants differentially skew differentiation in early stem and progenitor compartments, and also regulate apoptosis and proliferation of distinct precursor subsets to cause erythrocytosis or granulocytosis in mice. These results provide the mechanistic basis for the phenotypic diversity observed in MPNs with different JAK2 mutants. Disclosures: No relevant conflicts of interest to declare.

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IL-1β Plays An Important Role On Thrombocytosis In An Immune Vasculitis Model Via Promoting Megakaryopoiesis

Blood ◽

10.1182/blood.v122.21.2325.2325 ◽

2013 ◽

Vol 122 (21) ◽

pp. 2325-2325

Author(s):

Mo Yang ◽

Min Zhou ◽

Su yi Li ◽

Beng Chong ◽

Xiao jing Li

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Platelet Aggregation ◽

Conflicts Of Interest ◽

Serum Levels ◽

Control Group ◽

Type I ◽

Anti Inflammation ◽

Immune Vasculitis

Abstract Thrombocytosis and inflammation cytokines may be involved in the pathogenesis of vasculitis. Our previous study have showed that major inflammation cytokine IL-1β play an important role on in-vitro megakaryopoiesis (Yang M et al, Br J Haematol 2000). In this study, we investigated the changes of IL-1β and megakaryopoiesis and the effect of aspirin in an immune vasculitis model. Rabbit immune vasculitis model was established by intravenous injection of bovine serum albumin. In this model, platelet number and function of periphery blood, megakaryocyte number and the CFU-MK formation of the bone marrow, and serum levels of inflammatory cytokines were investigated. After treatment with BSA for 7 days, the platelet count, platelet aggregation and the expression of AnnexinⅤ were significantly increased in this vasculitis model group compared with normal control group (n=6). The serum levels of inflammatory cytokine IL-1β was also significantly higher in vasculitis model. There were positive correlations between platelet count and IL-1β levels (R=0.55), platelet aggregation and IL-1β levels (R=0.603). Treatment with aspirin (100 mg/kg/d) significantly decreased all these parameters, showing aspirin had anti-platelets and anti-inflammation effects. Our results also demonstrated that megakaryocyte number and the formation of CFU-MK were significantly increased in vasculitis group as compared to those in normal group. Treatment with aspirin significantly reduced the number of megakaryocytes and the formations of CFU-MK in bone marrow in this immune vasculitis model. Our study further demonstrated that IL-1β alone or in combination with TPO induced in-vitro CFU-MK formation. Using RT-PCR techniques, the mRNA of of IL-1 type I and type II receptors (IL-1 RI and RII) were detected in cultured CD61+ CD41+ cells and four megakaryocytic cell lines. The expression of IL-1 RI and RII was also confirmed by flow cytometry and immunofluorescence staining in bone marrow megakaryocytes. Moreover, the IL-1R bloker can reduced IL-1β induced megakaryopoiesis. This sudy showed that IL-1β may play an important role in the pathogenesis of immune vasculitis. Aspirin has anti-inflammation effects in this model which may be mediated via inhibiting megakaryopoiesis and platelet formation. Disclosures: No relevant conflicts of interest to declare.

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Next Generation Humanized Mice Support Engraftment of Myelofibrosis CD34+ Cells

Blood ◽

10.1182/blood.v124.21.1880.1880 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1880-1880

Author(s):

Alexandre P.A. Theocharides ◽

Rouven Müller ◽

Yasuyuki Saito ◽

Richard A. Flavell ◽

Markus G. Manz

Keyword(s):

Bone Marrow ◽

Peripheral Blood ◽

Conflicts Of Interest ◽

Constitutive Expression ◽

Xenograft Model ◽

Jak2 V617f ◽

Spleen Weight ◽

Patient Sample ◽

Nsg Mice ◽

Cd34 Cells

Abstract Introduction While the key transforming genetic events occur in the developing cancerous cell, this cell is dependent on its environmental context and interaction for competitive outgrowth and subsequent tumor-development. Myelofibrosis (MF) represents a model cancer disease with stepwise development from a chronic state that depends on microenvironmental interactions to a more aggressive disease. Engraftment of primary MF patient cells in murine xenograft models is poor (Wang et al., JCI 2012) and is possibly explained by the lack of supportive microenvironmental factors. Thrombopoietin (TPO) has been implicated in the pathogenesis of MF (Schepers et al., Cell Stem Cell 2013, Dadfarnia et al., Blood 2014, Abdel-Wahab et al., Annu Rev Med 2009). Also, the interaction between human hematopoietic cells and SIRPα expressed on mouse macrophages is critical for human engraftment in xenografts (Takenaka et al., Nature Immunology 2007). We hypothesized that the constitutive expression of human TPO and human SIRPα may promote the development of the human MF clone in mouse xenografts. Methods Purified peripheral blood CD34+ cells were collected from six patients with primary MF or post-PV/ET MF and low to intermediate 2 risk disease according to the dynamic international prognostic scoring system (DIPSS). Four patients carried a JAK2-V617F mutation and two patients carried a calreticulin (CALR) mutation. CD34+ cells were intrahepatically transplanted into sublethally irradiated newborn humanSIRPα-transgenic/humanTPO-knockin Rag2-/- gamma-/- (TPO-SIRPα) mice (Rongvaux et al., Ann Rev. Immunol 2013). NSG mice were used as controls and injected with the same number of CD34+ cells. Two to three mice were injected with ≥1 million CD34+ cells from the same patient sample each. Mice were sacrificed 12-16 weeks after transplantation and human engraftment and hematopoietic cell lineage distribution was assessed by flow cytometry using human specific antibodies. Tissues were collected for immunohistochemistry, assessment of fibrosis and spleen weight. DNA was extracted from whole bone marrow and a qualitative PCR was performed to determine the presence of the JAK2-V617F or CALR-mutations. Results Three out of six samples generated a human graft of ≥20% human CD45+ cells, while the three other samples generated engraftment of 0.1-3%. The human graft was mainly composed of myeloid cells and monocytic differentiation was observed. In 2/2 experiments analysed, a JAK2-V617F and a CALR type 2 mutation were detected in the bone marrow of engrafted mice transplanted with the respective patient sample. Development of fibrosis was not observed three months post-transplantation, presumably due to the short observation time. Spleen weight was significantly increased in mice engrafted with human MF and was the consequence of increased murine extramedullary hematopoiesis. We then aimed to identify factors that could predict human MF engraftment in TPO-SIRPα mice. While neither the DIPSS, nor the presence of myeloid precursors in the peripheral blood (blasts excluded) were predictive of human MF engraftment, the presence of blasts in the peripheral blood significantly correlated with engraftment potential. Importantly, none of the patients developed acute leukemia during follow-up. Finally, preliminary evidence suggests that TPO-SIRPα mice are more supportive of human MF engraftment than NSG mice. Conclusions This is the first xenograft model that supports robust engraftment of human peripheral blood MF cells and further supports a role for TPO in the pathogenesis of MF. In contrast to previous models TPO-SIRPα mice strongly promote myeloid rather than lymphoid engraftment. The tight correlation between the presence of peripheral blood blasts and the human MF engraftment potential suggests that human MF stem cells reside in the blast population. In summary, the xenograft model presented here constitutes a powerful tool to assess heterogeneity regarding MF biology, microenvironmental dependence of the MF clone and likely also therapeutic response of MF in vivo. Disclosures No relevant conflicts of interest to declare.

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Leukopenie – ein diagnostischer Leitfaden für die Praxis

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/s-0043-113123 ◽

2017 ◽

Vol 142 (23) ◽

pp. 1744-1749 ◽

Cited By ~ 1

Author(s):

Deborah Christen ◽

Tim Brümmendorf ◽

Jens Panse

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Blood Smear ◽

Peripheral Blood Smear ◽

Blood Cell Count ◽

Essential Step ◽

Cell Counts ◽

Life Threatening ◽

Red Blood Cell Count ◽

The Right

AbstractReasons for leukopenia can be numerous. To get close to the diagnosis it’s always useful to check previous blood counts of the patient to get a feeling for the dynamic development of the leukopenia. Furthermore, it’s important to check the red blood cell count and platelet count as well; a bi- or a pancytopenia usually implies an insufficient production in the bone marrow. Nevertheless, a manual counted peripheral blood smear is an essential step towards the right diagnosis in leukopenia: Beside cell counts of the single subgroups of leucocytes it also provides information on potential causes such as dysplasia.Leukopenia can be life-threatening for the patient especially if the patient presents with an agranulocytosis and fever: In this case admission is mandatory and the patient has to be treated immediately with broad-spectrum antibiotics to reduce mortality.

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Differential Diagnosis of Hereditary and Acquired Thrombocytopenia By the Immature Platelet Fraction and Thrombopoietin Levels

Blood ◽

10.1182/blood.v126.23.1049.1049 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1049-1049 ◽

Cited By ~ 1

Author(s):

Fabio Luiz Bandeira Ferreira ◽

Marina Pereira Colella ◽

Samuel de Souza Medina ◽

Maiara Marx Luz Fiusa ◽

Loredana Nilkenes Gomes da Costa ◽

...

Keyword(s):

Bone Marrow ◽

Differential Diagnosis ◽

Platelet Count ◽

Healthy Volunteers ◽

Complete Blood Count ◽

Conflicts Of Interest ◽

Bone Marrow Failure ◽

Healthy Individuals ◽

Technical Limitation ◽

Immature Platelet Fraction

Abstract Introduction: The differential diagnosis of hereditary and acquired thrombocytopenias can be challenging, especially when between immune thrombocytopenia (ITP) and less well characterized hereditary thrombocytopenias (HT) such as MYH9-related disorders. Fundamental differences in the management of these two conditions add clinical relevance to the search for novel parameters that differentiate these conditions. The immature platelet count (IPF) represents the fraction of platelets with higher RNA content, and in analogy to the reticulocyte count for erythropoiesis is a biomarker of thrombopoietic activity. In a recent report (Miyazaki et al, 2015), IPF values that were more than 5-fold higher than those observed in ITP patients were reported in a population of 15 patients with HT. However, whether this increased values represented a real increase in thrombopoietic activity, or reflected a technical limitation of IPF determination in large platelets could not be clarified. Here, we aimed to evaluate the role of IPF determination in the differential diagnosis between HT and several forms of acquired thrombocytopenia in a larger and more diverse population of patients. We also evaluated thrombopoietin (TPO) levels in HT compared to ITP, to further investigate the mechanisms by which extremely large IPF values are observed in HT. Methods: IPF and mean platelet volume (MPV) were prospectively determined using a Sysmex XE5000 hematologic analyzer (as part of the complete blood count) in a cohort of patients with post-chemotherapy thrombocytopenia (n=56), bone marrow failure (myelodysplastic syndromes and aplastic anemia; n=22), ITP (ITP; n=105) and inherited thrombocytopenias (n=27). The latter population consists of a well-defined cohort of individuals with HT thrombocytopenia characterized by clinical, familial, laboratory and molecular data. TPO levels were determined by ELISA (R&D Systems) in 21 HT patients and 22 ITP patients matched for platelet count and age. A group of 178 healthy volunteers were used to determine normal IPF and MPV values. Results: Median platelet counts were similar in post-chemotherapy patients (CTx) (32.0*109/L), bone marrow failure (BMF) (33.5*109/L), ITP (52.0*109/L) and HT (52.0*109/L) (P=0.15). Similar IPF levels were observed in CTx and BMF patients (5.6%; IQR 3.4-8.8% and 6.5%; IQR 3.5-13.7%. Compared to these two groups, higher IPF values were observed in both ITP (12.3%; 7.0-21.0%) and HT patients (29.8%; 17.5-56.4%) (both P values < 0.05). In addition, IPF were significantly higher in HT compared to ITP (Kruskall-Wallis test and Dunn's post test,P=0.001). MPV values were different between HT and CTx/BMF groups, but could not differentiate ITP from HT. TPO levels. The accuracy of IPF to discriminate HT from all other causes of thrombocytopenia estimated by ROC analysis was 0.88 (CI95%0.8-0.96, p<0.0001). Similar TPO levels were observed in platelet count-matched ITP, HT patients and healthy volunteers without thrombocytopenia. Interestingly, TPO presented marked correlations with both platelet count (Rs = - 0.61, P=0.002) and IPF (Rs= 0.59, P=0.003), even with TPO levels in the same range of healthy individuals. In contrast, no significant correlation could be observed between TPO and IPF or platelet count in HT patients. Conclusions: IPF represents an informative biomarker for the differential diagnosis of hereditary and acquired thrombocytopenias, and accurately differentiates ITP from the most common HT. As expected, TPO levels in patients with ITP were not higher than in individuals with normal platelets counts. The inverse correlation between TPO and platelet count in these patients confirm a blunted TPO response to thrombocytopenia in these patients. Similarly, patients with HT did not present increased TPO levels compared to healthy individuals. Accordingly, increased IPF levels in these patients cannot be attributed to higher TPO levels. Disclosures No relevant conflicts of interest to declare.

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Outcome of acute Myeloid Leukemia in Adults Patients Treated According to Morocco National AML-MA-2011 Protocol in Casablanca, Morocco

Blood ◽

10.1182/blood.v128.22.5173.5173 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5173-5173

Author(s):

Romaric Massi ◽

Mouna Lamchahab ◽

Hanaa Bencharef ◽

Bienvenu Houssou ◽

Nisrine Khoubila ◽

...

Keyword(s):

Bone Marrow ◽

Platelet Count ◽

Complete Remission ◽

Supportive Care ◽

Clinical Symptoms ◽

Conflicts Of Interest ◽

International Standards ◽

Banding Technique ◽

Persistent Fever ◽

Delay In Diagnosis

Abstract Introduction Treatment of AML in developing countries is a very great challenge. In Morocco, the major causes of therapy failure are delay in diagnosis, early (prior to start of therapy) and induction deaths, induction failures and abandonment of therapy. In 2011, the national AML-MA-2011 protocol was initiated to treat AML patients according to international standards and was focused on the improvement of supportive care with particular the prevention and management of infection, transfusion support, the patient, family and nurses education on hygien. The objective of this new protocol was to obtained more than 70% of complete remission, deaths in inductions less than 10%, and EFS at 4years at 40%. The aim of this study is to evaluate the results in adults AML patients treated with AML MA 2011 protocol in Casablanca Hematology Departement. Patients and Methods : Were reviewed the data ofpatients (aged 18-60yrs) treated according to AML-MA-2011 protocol from 1st january 2011 to 31th december 2015. Patients with APL or secondary AML were excluded. AML was diagnosed by studying peripheral blood smears, bone marrow aspiration, and biopsy slides stained with May-Grünwald Giemsa and myeloperoxidase. Immunophenotypic and cytogenetic studies were performed at diagnosis on bone marrow samples. AML was defined as the presence of more than 20% of myeloblasts in the bone marrow. Subtype of AML was recorded according to French-American-British (FAB) classification. Karyotype was performed on marrow sample, R banding technique was used. WHO 2008 prognostic classification was adopted. Patients with hyperleukocytosis (WBC≥ 50G/L) received as a pre-phase 4 days of hydroxyurea to 50mg/kg/day. The two courses of induction associated Cytarabine (100mg/m² q 12h (day 1-10)), Daunorubicin (50 mg/m² (day 2, 4, 6) for the first course, on days 1, 3, 5 for the second course) and etoposide (100mg/m² only at second course of induction). The consolidation included Cytarabine (3g/m² q 12h (day1-3) for first and second course and 1 g/m² (day1-3) on third course) plus Daunorubicin (30mg/m² (day 3-4 and day 1-3) at the first and third consolidation. L-Asparaginase 6000UI/m² on day 4 was give at second consolidation. Patients received CNS prophylaxis. Platelet support was provided in the case of bleeding, or whenever the platelet count was less than 10 × 109/L. For infections, Ceftazidime was the first line of antibiotic used. Amikacin was added for persistent fever beyomd 48-h or clinical deterioration. Imipenem was used for persistent fever. Additional antibiotic or antifungal or antiviral was dictated by clinical and biological findings. Complete remission (CR) was defined as the absence of abnormal clinical symptoms and having less than 5% of myeloblasts in the bone marrow, absence of blasts with Auer rods; absence of extramedullary disease; absolute neutrophil count >1.0 × 109/L; platelet count >75 × 109/L; independence of red cell transfusions. The analysis of data was done by SPSS 18.0 Résultats : 559 adults patients were diagnosed for AML,323 was treated by AML-MA-2011 protocol from 2011-2015. The median age was 38 years (18-60), the sex ratio M/F was 1.10 ; the median hemoglobin (g/dl) was 7.15 (2.6-16.3) ; the median platelet (G/L) was 38.5 (1-620) ; the median leukocyte (G/L) was 17.97 (0.85-377). For cytology, according to FAB the dominants types was M1 : 98 (30.34%), M2 : 97 (30.03%), M4 : 51(15.78%). 249 (77.08%) patients had immunophenotyping. According to karyotype, 46 (14.24%) had good prognosis ; 216 (66.87%) was in intermediate group, 61 (18.88%) had adverse prognosis. Complete remission after two inductions was obtained with 197(60.99%) patients, inductions failure was noticed on 49(15.17%) patients, 98(30.34%) patients died during inductions cycles ; 152(47.05%) achieved the second consolidation cycles, 66 (33.50%) patients whose were in complete remission relapse. The OS at 3-years was estimated at 48.4%. The analysis of therapeutics results is summarized in the table. Conclusion : The therapeutics results of AML-MA-2011 protocol in the treatement of adults AML patients are satisfactory but could be improved with reduction of infection toxic deaths and improvement of supportive care therapy. Disclosures No relevant conflicts of interest to declare.

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