骨髓衰竭综合征课件

1、骨髓衰竭综合征骨髓衰竭综合征Case Presentation16 year old maleSeen by family doctor because tennis instructor noticed that he was tiring easilyHistory of trip outside the USA 5 months earlierNoted 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

2、(20% neutrophils)Case Presentation16 year old mNext StepLook at blood smearR/o circulating blastsDo a bone marrowAspirateCell typesCytogeneticsBiopsyCellularityNext StepLook at blood smearPancytopenia with Hypocellular MarrowAcquired aplastic anemiaInherited bone marrow failure syndromeHypocellular

3、Myelodysplastic SyndromeAleukemic leukemiaMarrow lymphomaPancytopenia with HypocellularPancytopenia with Cellular MarrowPrimary marrow diseaseLeukemiaMyelodysplastic syndromeParoxysmal nocturnal hemoglobinuriaSystemic diseaseLupusHypersplenismInfection, e.g. brucellosis, sarcoidosis, tuberculosisPan

4、cytopenia with Cellular MarBone Marrow (BM) BiopsyNormalAplasticBone Marrow (BM) BiopsyNormalAAplastic Anemia: Signs and SymptomsAnemiafatigue, lassitude, dyspneaThrombocytopeniabruises, petechiaeserious bleedingNeutropeniainfectionsAplastic Anemia: Signs and SymSeverity of Aplastic AnemiaSevere2 of

5、 the following 3: neutrophils 500/mL, platelets 20,000/mL, reticulocytes 20,000/mLBM cellularity 25% with 30% hematopoietic cellsVery severeNeutrophils 13 genesFanconi Anemia - DefinitionAutFANC GenesAdapted from Joenje, 2006D1 = BRCA2*J and N interact with BRCA1 and BRCA2FANC GenesAdapted from Joen

6、je,FA Complementation Groups/GenesGroupLocuscDNAExonsAA%A16q24.35.543145570BXp22.312.810859RareC9q22.34.61455810D1/BRCA213q12.311.4273418RareD23p25.35441451RareE6p21-222.5105365F11p151.31374RareG/XRCC99p132.51462210I/KIAA179415q25-264.5381328RareJ/BACH1/BRIP117q22.34.6201249RareL/PHF9/POG2p15-16.11.

7、714375RareM/Hef14q21.36.5222014RareN/PALB216p12.13.5131186RareBRIP1 is “BRCA1 interacting protein”; PALB2 is “partner and localizer of BRCA2”FA Complementation Groups/GeneFA DNA Repair PathwayBD2DNA RepairDNA DamageCEFIGMLAPCNANBS1RAD51J/BACH1BRCA1D2UbD1/BRCA2D2UbN/PALB2FA DNA Repair PathwayBD2DNA R

8、eWho Should be Tested for FA?Characteristic birth defects (eg thumbs, kidneys, poor growth, etc)Aplastic Anemia (AA)Myelodysplastic Syndrome (MDS)Acute Myeloid Leukemia (AML)Decreased fertilityEarly characteristic cancerSiblings of FA patientsWho Should be Tested for FA?ChWhat are the Tests for FA?B

9、lood chromosome breakage (DEB or MMC)Skin fibroblast chromosome breakageFlow cytometry for G2 arrestWestern blot for ubiquitinated D2Retroviral FA gene correction of FA phenotypeFA gene sequencingWhat are the Tests for FA?BlooD2 UbiquitinationShimamura et al, Blood, 2002LIJ (BRIP1)BMD2 Ubiquitinatio

10、nShimamura et Retrovirus-mediated Correction of TA 0252s T-cells analyzed by flow cytometry after five days of MMC-Incubation0204060801001101001000c (MMC) nMcells alive %S11EGSFAS11FCIEGS11FEIEG2S11FFIEGS11FGFANCARetrovirus-mediated Correction of FA CellsRetrovirus-mediated CorrectionFA Complication

11、sAplastic AnemiaAcute LeukemiaMyelodysplastic SyndromeSolid TumorsLiver tumorsFA ComplicationsFA Aplastic AnemiaAdapted fromKutler et al,Blood, 200380% by age 15,90% overallFA Aplastic AnemiaAdapted fromFA Literature: Cancer 1927-2007179 solid tumors and 163 leukemias in 330/1865 patients; 29 had 2-

12、4 cancersAMLLiverHNSCCBrainVulvaWilmsALLEsophagusFA Literature: Cancer 1927-200Shifted median age to 16 years younger;All Solid TumorsNew modalities, e.Blood 2006;108:2509-2519Infection, e.Literature: Physical FindingsIBMFS: Adults and Older Children*J and N interact with BRCA1 and BRCA2FA chromosom

13、e breakageSequence candidate genespatient consentClonal evolutionImprove transplant preparation to reduce graft vs host disease.Dale: Blood, 2006)Acquired aplastic anemiaRisk of Cancer in FA by O/E RatioFA CohortsParameterNASGEFAISFARNCINumber of Patients145182Person-Years20002818All Cancers52x44xAl

14、l Solid Tumors51x26xOral Cavity/Pharynx706x240 xVulvar4317x2411xAML785x868xMDS8559x4559xNorth American Survey;German FA Registry;Israeli FA Registry; National Cancer InstituteShifted median age to 16 yearsNCI FA Cumulative Incidence and Cause-specific HazardsNCI FA Cumulative Incidence anCompeting R

15、isks of CancerCompeting Risks of CancerFanconi Anemia: Phenotype/OutcomeRosenberg, Huang, Alter, Blood 2004Phenotype predicts age and incidence of marrow failure and solid tumors.Normal PhenotypeAbnormal PhenotypeAbnormal phenotype = radii, plus abnormal development, heart or lung, kidney, hearing,

16、and head. Competing risk analyses.Fanconi Anemia: Phenotype/OutcTransplant and Head and Neck Cancer in Fanconi AnemiaBMTNo BMTDATA:Transplant increased cancer by ; Shifted median age to 16 years younger;All cancer patients had graft vs host disease.ParisRosenberg, Socie, Gluckman, Alter: Blood, 2005

17、; Biol Blood & Marrow Transpl, 2005LESSON:Improve transplant preparation to reduce graft vs host disease.USATransplant and Head and Neck CDiagnosis of FA after CancerTongue SCC age 30Skin SCCs age 33Short, 80 lbs, hearing aids, menopause age 30XRT side effectsNormal blood countsPB chromosomes no bre

18、aks; skin breaksExon 8: 790 C T; Q264X; Gln264StopExon 27: 2585delCT; Frameshift, Cys846fsX20SkinGene conversion, loss of exon 27 frameshift 2585delCTBloodSomatic Mosaicism, FANCAAlter, Joenje, Oostra, Pals, Arch Otolaryngol, 2005Diagnosis of FA after CancerToHematopoietic Mosaicism Hematopoietic Mo

19、saicism Mosaicism from RecombinationaAAaaAAaaAAaMosaicism from RecombinationaAFANCD1/BRCA2 Proband; Adult FANCAPhotos with parental andpatient consentFANCD1/BRCA2 Proband; Adult FAOdds Ratios for Complications in FA and FANCD1/BRCA2General PopulationFAFA vs GenlFA-D1FA-D1 vs FAFA-D1 vs GenlVATER2.6/

20、1065/10019,0005/273.771,000AML1/1059/14580010/278.97,000Any Cancer10/10523/1455025/27663300FANCD1/BRCA2 is associated with extremely high incidences of VACTERL-H association, AML, and specific Solid Tumors (Wilms, medulloblastoma).Alter, Brody, Rosenberg: J Med Genet 2007Odds Ratios for Complication

21、sGenotype/Phenotype/Outcome: 27 FA with Biallelic Mutations in BRCA2Alter: Br J Haematol, 2006Alter, Brody, Rosenberg: J Med Genet, 200778% by age 10(AML, ALL)HR 7.7 (CI 2-29), p = 0.00383% by age 7(Wilms, Medulloblastoma)97% by age 6Genotype/Phenotype/Outcome: 27FANCD1/BRCA2 MutationsMutationsUnifo

22、rmity1Cluster2MissenseNo, p = 0.01Yes, p = 0.001DeleteriousYes, p = 0.6No, p = 0.3What 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, 2007Why do pat

23、ients with biallelic deleterious/deleterious or deleterious/missense mutations in BRCA2 both develop FA and cancer?FANCD1/BRCA2 MutationsMutationFA: When to TreatCytopeniasHb 8 g/dL or symptomsPlatelets 30,000/mm3WBC 20% blasts in marrowSolid tumors or liver tumorsWhen detectedFA: Guidelines for Dia

24、gnosis and Management, FA: When to TreatCytopeniasLeuFA: How to TreatHematologic disease (benign or malignant)Stem cell transplantAndrogensHematopoietic growth factors (G-CSF, Ep)ChemotherapyFolic acidBlood products: not family; leukodeplete; irradiateGene therapy?Liver tumorsStop androgensSolid tum

25、orsConservative/focused radiationChemotherapy that does not cross-link DNANew modalities, e.g. cetuximabFA: Guidelines for Diagnosis and Management, FA: How to TreatHematologic diFA Surveillance: CancerHematopoiesis AA, MDS, aMLBlood counts every 3-4 monthsBone marrow aspirate, biopsy, cytogenetics

26、annuallyOral cavity and pharynx - role of HPV vaccine?Age 10 yearsBMT 1 yearGynecologic - role of HPV vaccine?Age 16 yearsMenarcheLiverLiver enzymes every 3-4 monthsLiver ultrasound every 6-12 monthsSkinAnnual examFA Surveillance: CancerHematopCase Presentation16 year old maleSeen by family doctor b

27、ecause tennis instructor noticed that he was tiring easilyHistory of trip outside the USA 5 months earlierNoted 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 adol

28、escentCase Presentation16 year old mDyskeratosis CongenitaDyskeratosis CongenitaDyskeratosis Congenita - Kids2 yo, HH1.5 yo, HH6 yo, TINF210 yo, TINF2Dyskeratosis Congenita - Kids2Dyskeratosis Congenita - Adults22 yo, DKC148 and 16 yo, TERC27 yo, TINF224 yo, TINF2Dyskeratosis Congenita - AdultPhysic

29、al Findings in DCDystrophic nails*Lacey pigmentation*Leukoplakia*Epiphora, blepharitisDevelopmental delayPulmonary diseaseShort statureDental cariesLiver diseaseEsophageal strictureEarly grey hair, hair loss, sparse eyelashesHyperhidrosisCerebellar hypoplasiaHypogonadismMicrocephalyUrethral strictur

30、eOsteoporosis, avascular necrosis*Diagnostic Triad (need 2/3). Or, 1 of the triad, + hypoplastic bone marrow, + 2 of the other findings. Physical Findings in DCDystropX-linked recessive (XLR), Autosomal dominant (AD), Autosomal recessive (AR)Mutations in telomerase and shelterin pathways: DKC1 (XLR)

31、TERC (AD)TERT (AD, AR)TINF2 (AD)DC Inheritance NOLA2 (AR) NOLA3 (AR) Others (50%)X-linked recessive (XLR), AutoMajor Complications in DCHematologicBone marrow failureMyelodysplastic syndromeLeukemiaSolid tumorsHead and neckAnogenitalPulmonary fibrosisMajor Complications in DCHemat44 cancers in 36/42

32、5 patientsDC Literature: Cancer 1910-2007HNSCCRectalStomach44 cancers in 36/425 patientsDWhat is the End of the Shoelace?The agletWhat is the End of the ShoelacTelomeres and Chromosomal InstabilityLong TTAGGG repeatsShorten with each cell divisionMany proteins interact to regulate telomere length an

33、d stabilize structureLack of telomere maintenance leads to erosion of chromosome ends, genomic instability, cell crisis and cell deathFISH: telomeresCourtesy of Peter LansdorpTelomeres and Chromosomal InstTelomere Biology PathwayArmanios, Annu Rev Genomics Hum Genet, Kirwan and Dokal, BBA, Telomere

34、Biology PathwayArmaniLaboratory Diagnostic Test: Telomere Length by flow-FISHAlter, Baerlocher, Savage, Lansdorp: Blood, 2007Almost all patients with DC have very short telomeres in blood cells, including 3 silent carriers and 6 lacking the triad. Most patients with other IBMFS have normal telomeres

35、.Laboratory Diagnostic Test: TTelomere Length in Multiplex FamilyEthics: Denny et al: AJMG, Gene discovery: Savage et al: AJHG, Telomere Length in Multiplex FTINF2 is Mutated in DCArg 282 SerLys 280 GluArg 282 HisHoyeraal-Hreidarsson SyndromeRevesz SyndromeSavage et al: AJHG, TINF2 is Mutated in DCA

36、rg 282 NCI IBMFS Cohort: Relative Risk of Cancer (O/E Ratio)ParameterFADCNumberPerson-YearsAll CancersAll Solid TumorsTongueAMLMDSNCI IBMFS Cohort: Relative RiNCI DC Compared with All FANCI DC Compared with All FADC Surveillance and TreatmentSimilar to Fanconi AnemiaRole of HPV vaccine?Stem cell tra

37、nsplant complicated by pulmonary diseaseNo role for immunosuppressionFeatures unique to DC:Androgen sensitiveSplenic peliosis and rupture on androgens + G-CSFPulmonary fibrosisHepatic fibrosis, cirrhosisTelomere length assay: diagnosis of patients, silent carriers; surveillance and genetic counselin

38、gDC Surveillance and TreatmentSDiamond-Blackfan AnemiaDiamond-Blackfan AnemiaDiamond-Blackfan AnemiaNormochromic, usually macrocytic anemia, developing in infancyReticulocytopeniaMarrow erythroblastopeniaNormal or slightly decreased leukocytesNormal or increased plateletsIncreased fetal hemoglobin (

39、Hb F)Increased red cell adenosine deaminase (ADA)25% with physical findings: short, abnormal thumbs, etcDiamond-Blackfan AnemiaNormochDBA Literature : Physical FindingsFindingNumber%Any abnormality including short stature22425Any abnormality other than short stature15321Short stature only354Thumb an

40、omaly576Triphalangeal thumb243Cleft palate243Denominator = 900, but no data in many reports.DBA Literature : Physical FiDBA InheritanceAutosomal dominant25% RPS192% RPS241% RPS1740s ribosome biogenesisHaploinsufficiency7% RPL55% RPL112% RPL35aDBA InheritanceAutosomal domin30 cancers in 30/899 patien

41、ts; 3 MDS not includedDBA Literature: Cancer 1936- 30 cancers in 30/899 patients;DBA Surveillance and TreatmentMonitor blood countsAnnual bone marrows (no consensus)Treat when Hb 8 g/dL, or symptomsCorticosteroidsTransfuse during first year and puberty (no consensus)Cyclosporin A (rare)Metoclopramid

42、e (rare)DBA Surveillance and TreatmentShwachman-Diamond SyndromeExocrine pancreatic insufficiencyDecreased trypsinogen and isoamylase (age-dependent)Pancreas small or fatty on imagingBone marrow failureNeutropenia: 1500/mLAnemia: MacrocytosisThrombocytopeniaMyelodysplastic syndrome/acute leukemiaBon

43、esMetaphyseal dysostosisAutosomal recessiveSBDS = Shwachman-Bodian-Diamond Syndrome60s ribosome biogenesisShwachman-Diamond SyndromeExocSDS Literature: Leukemia 1949-200736 leukemias in 36/510 patients AMLALLSDS Literature: Leukemia 1949-SDS Surveillance and TreatmentSimilar to Fanconi AnemiaG-CSF -

44、 neutropeniaStem cell transplant - cardiotoxicity from cyclophosphamide?Features unique to SDS:Malabsorption - pancreatic enzymes, ADEKMetaphyseal dysostosis - surgery as neededCytogenetic clones - monitorSDS Surveillance and TreatmentSevere Congenital NeutropeniaNo physical phenotypeANC 500/mLPyoge

45、nic infectionsRx G-CSFAutosomal dominantELA2GFI1Autosomal recessive (Kostmann Syndrome)HAX1X-linked recessiveWASSevere Congenital NeutropeniaNSCN and Leukemia(Rosenberg, Alter, .Dale: Blood, 2006)High Dose, Poor ANCLow Dose, Good ANCYears on G-CSFYears on G-CSFPoor responders to G-CSF have a higher

46、risk of leukemia.These may have a more severely abnormal stem cell.Early 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?SCN and Leukemia(Rosenberg, AlAmegakaryocytic ThrombocytopeniaNeonatal thrombocytopeniaDecreased megakaryocytesNo anomaliesEvolution to aplastic anemia and/or leukemiaAR: 1p, mpl, thrombopoietin receptorType I: nonsense mutations, se