醫(yī)學(xué)課件再障和低危MDS的鑒別

1、病 例患者，女，38歲主訴：發(fā)現(xiàn)貧血八年余，加重半月病史：患者八年余前產(chǎn)檢發(fā)現(xiàn)貧血，無不適，予輸血對(duì)癥治療（具體不詳），后復(fù)查血常規(guī)指標(biāo)較前升高（未見報(bào)告），患者未予重視。三年前患者勞累后出現(xiàn)頭暈乏力，偶有頭痛，余無不適。至浙一就診，血常規(guī)：WBC2.7*109/L，N1.4*109/L，HB 85g/L，PLT125*109/L，Ret2.0。骨髓涂片：有核細(xì)胞量少，粒紅系增生活躍，巨核細(xì)胞數(shù)量中等, 產(chǎn)板功能佳。VitB12、葉酸、血清鐵、自身抗體無殊。 Coombs試驗(yàn)陰性。CD55、CD59檢測未見異常，予升血寧及鐵劑等對(duì)癥治療，自覺上述癥狀好轉(zhuǎn)。病 例患者，女，38歲半月前上述癥狀加

2、重，勞累時(shí)出現(xiàn)頭痛，有耳鳴，聽力下降，至當(dāng)?shù)夭檠Ｒ?guī) WBC1.78*109/L,N1.6*109/L,HB69g/L, PLT 123*10E9/L”，予中藥治療自覺無好轉(zhuǎn)，遂至我院門診，2015-8-17擬“貧血”收住。 半月前上述癥狀加重，勞累時(shí)出現(xiàn)頭痛，有耳鳴，聽力下降，至當(dāng)?shù)匮Ｒ?guī)：WBC 2.2，N 1.2，L 0.8，HB 45，MCV 110.3，MCH 38.5，PLT98，Ret 3.2%。葉酸 8.42，血清維生素B12 532pg/ml，鐵蛋白585.6ng/ml.CD55,CD59表達(dá)正常。抗核抗體等檢查陰性。血常規(guī)：WBC 2.2，N 1.2，L 0.8，HB 45

3、，骨髓小粒少,有核細(xì)胞量顯著減少，易見多量脂肪滴。 粒系增生活躍，以中幼粒以下階段增生為主。各階段比例，形態(tài)無殊。 紅系增生活躍，以中晚幼紅細(xì)胞增生為主。幼紅細(xì)胞可偶見核出芽。成熟紅細(xì)胞輕度大小不一。 成熟淋巴細(xì)胞比例明顯增高占35%，形態(tài)無殊。 巨核細(xì)胞數(shù)量減少，全片共見巨核2個(gè)，皆為顆巨. 骨髓小粒呈空架狀，以非造血細(xì)胞增生為主，外鐵(無小粒) 內(nèi)鐵：幼紅細(xì)胞少 4骨髓小粒少,有核細(xì)胞量顯著減少，易見多量脂肪滴。4骨髓流式檢查：未見明顯異常原始以及幼稚細(xì)胞。骨髓活檢：骨髓造血組織增生十分低下，可見少量粒紅造血血細(xì)胞以中晚幼為主，巨核細(xì)胞偶見，并見多小簇幼稚細(xì)胞增生，網(wǎng)狀纖維輕度增生。染色體

4、：46，XY20基因突變：DNMT3A(+), IDH1/2(-), SFSB1(-), U2AF1(-), SRSF2(-)骨髓流式檢查：未見明顯異常原始以及幼稚細(xì)胞。診斷： 再生障礙性貧血？低增生性骨髓增生異常綜合征？診斷：AA診斷思路除外其他引起全血細(xì)胞減少的疾病多部位骨髓檢查，明確診斷再生障礙性貧血，是一組骨髓造血組織減少，造血功能衰竭，導(dǎo)致周圍血全血細(xì)胞減少的綜合病征。良AA診斷思路除外其他引起全血細(xì)胞減少的疾病多部位骨髓檢查，明MDS診斷思路排除反應(yīng)性病態(tài)造血和其他血細(xì)胞減少證明病態(tài)造血和血細(xì)胞減少是MDS克隆所致骨髓增生異常綜合征是起源于造血干細(xì)胞的一組異質(zhì)性髓系克隆性疾病惡MD

5、S診斷思路排除反應(yīng)性病態(tài)造血和其他血細(xì)胞減少證明病態(tài)造血Overlap in bone marrow failure syndromesOverlap in bone marrow failurehaematologica | 2009; 94(2)鑒別診斷應(yīng)做的檢查多部位骨穿，包括胸骨穿刺haematologica | 2009; 94(2)鑒別診骨髓細(xì)胞學(xué)骨髓活檢形態(tài)學(xué)染色體核型分析FISH細(xì)胞遺傳學(xué)結(jié)合臨床80%MDS患者可以診斷20%？骨髓細(xì)胞學(xué)形態(tài)學(xué)染色體核型分析細(xì)胞遺傳學(xué)結(jié)合臨床20%？AA 與hMDS鑒別診斷1. 形態(tài)2.克隆證據(jù)3.克隆演變AA 與hMDS鑒別診斷1. 形態(tài)di

6、fference in morphologic diagnosesDiscordance, defined as a difference in morphologic diagnoses between the referring center and MDACC, was documented in 109 of the 915 (12%) patients.difference in morphologic diagMorphological differentiation of severe aplastic anaemia from hypocellular refractory c

7、ytopenia of childhoodHistopathology (2012) 61, 1017RCC, Refractory cytopenia of childhood; SAA, severe aplastic anaemiaMorphological differentiation 形態(tài)易鑒別原始比例（5%）有病態(tài)，病態(tài)比例高，有特殊病態(tài)類型(RARS)合并較明顯骨髓纖維化-MDS合并MPN形態(tài)易鑒別原始比例（5%）紅系粒系巨核系細(xì)胞核 核出芽，核間橋 核碎裂，多核（奇數(shù)） 核分葉減少， 核分葉呈花瓣?duì)?、核不?guī)則、子母核 巨幼樣變 胞質(zhì) 環(huán)狀鐵粒幼細(xì)胞 空泡 PAS染色陽性 胞體

8、小或異常增大核分葉減少（假Pelger-Hut；pelgeriod）不規(guī)則核分葉增多環(huán)狀核胞質(zhì)顆粒減少或無顆粒假Chediak-Higashi顆粒Auer小體 小巨核細(xì)胞核分葉減少 多核（正常巨核細(xì)胞為單核分葉） 單圓核多圓核微巨核胞質(zhì)巨大血小板氣球樣血小板紅系巨幼變診斷MDS意義最小，微巨核細(xì)胞為最可靠的發(fā)育異常標(biāo)志。各系發(fā)育異常表現(xiàn)各系特征性形態(tài)改變紅系粒系巨核系細(xì)胞核胞體小或異常增大小巨核細(xì)胞紅系巨幼變診斷MDS形態(tài)學(xué)改變( 病態(tài)發(fā)育）最常見的骨髓細(xì)胞發(fā)育異常征象多核35%巨幼變56%細(xì)胞核改變40%假性佩爾格爾細(xì)胞49%顆粒形成減少45%單圓核巨核細(xì)胞47%核碎裂32%小巨核細(xì)胞29%

9、MDS形態(tài)學(xué)改變( 病態(tài)發(fā)育）最常見的骨髓細(xì)胞發(fā)育異常征象多單純病態(tài)發(fā)育如何鑒別？部分AA可有輕度紅系病態(tài)（巨幼樣變）單一輕度紅系病態(tài)慎重診斷為MDS粒系和巨核系病態(tài)對(duì)MDS重要意義病態(tài)發(fā)育并非MDS特有單純病態(tài)發(fā)育如何鑒別？部分AA可有輕度紅系病態(tài)（巨幼樣變）骨髓活檢的鑒別價(jià)值不成熟前體細(xì)胞異常定位、原始細(xì)胞簇hMDS脂肪組織增生AA網(wǎng)硬蛋白超過（+），排除AAJ Clin Pathol 1985;38:1218-24.骨髓活檢的鑒別價(jià)值不成熟前體細(xì)胞異常定位、原始細(xì)胞簇hMDAA 與hMDS鑒別診斷1. 形態(tài)2.克隆證據(jù)3.克隆演變AA 與hMDS鑒別診斷1. 形態(tài)中國專家共識(shí) 尋找MDS

10、克隆性造血證據(jù)的手段常規(guī)染色體核型分析、FISH、流式細(xì)胞術(shù)檢測、基因芯片、基因點(diǎn)突變分析中國專家共識(shí) 尋找MDS克隆性造血證據(jù)的手段Chromosomal abnormalities considered presumptive evidence of diseaseMDS克隆證據(jù)染色體核型分析Chromosomal abnormalities cons醫(yī)學(xué)課件再障和低危MDS的鑒別Am J Hematol. 2013 October ; 88(10): 831837Acquisition of Cytogenetic Abnormalities (ACA) in Patients with

11、 IPSSdefined Lower-Risk Myelodysplastic Syndrome Acquisition of cytogenetic abnormalities was detected in 107 patients (29%).Cytopenic patients ( 5% bone marrow blast) will carry less chromosomal abnormality (21%).Cytopenic patients only with dysplasia will rarely carry chromosomal abnormality (?).A

12、m J Hematol. 2013 October ; 8RCC（ refractory cytopenia of childhood ）骨髓細(xì)胞數(shù)和核型異常Interim analysis of studies EWOG-MDS 1998 and 2006.Hematology Am Soc Hematol Educ Program.2011;2011:84-9.RCC（ refractory cytopenia of c+8、20q-、-y不能作為MDS唯一的推定證據(jù)+8、20q-、-y不能作為MDS唯一的推定證據(jù)N Engl J Med.2011 Jun 30;364(26)Blood

13、2013; 112(22)111 genes - 738 patients in Europe104 genes - 944 patients in Japan & GermanLeukemia.2014 Feb;28(2)18 genes - 439 patients in USAMDS克隆證據(jù)基因突變N Engl J Med.2011 Jun 30;364(MDS基因突變頻率Papaemmanuil, et al. Blood. 2013 Nov 21;122(22):3616-27 Hafelach et al. Leukemia. 2013. (e-pub ahead of print

14、) MDS基因突變頻率Papaemmanuil, et al. MDS mutation landscapeMayo Clin Proc. July 2015;90(7):969-983MDS mutation landscapeMayo Cli當(dāng)缺乏特定形態(tài)診斷標(biāo)準(zhǔn)時(shí)，基因突變是否可以替代染色體異常作為MDS證據(jù)？當(dāng)缺乏特定形態(tài)診斷標(biāo)準(zhǔn)時(shí)，基因突變是否可以替代染色體異常作為MDS基因突變的頻率？Frequency-exclusionNo JAK2 mutation- PV is essentially excluded. There is no single gene that is mut

15、ated in the majority of cases of MDS.MDS基因突變的頻率？Frequency-exclusiMDS mutation landscapeMayo Clin Proc. July 2015;90(7):969-983MDS mutation landscapeMayo CliMDS基因突變的特異性？Specificity - presumptive evidenceMDS基因突變的特異性？Specificity - pr醫(yī)學(xué)課件再障和低危MDS的鑒別Metaphase karyotyping & SNP-A karyotypingBLOOD, 23 JUNE

16、 2011 VOLUME 117, NUMBER 25AA的克隆證據(jù)Metaphase karyotyping & SNP-A醫(yī)學(xué)課件再障和低危MDS的鑒別辨別真克隆與假克??？Hematology Am Soc Hematol Educ Program.2011;2011:90-5辨別真克隆與假克??？Hematology Am Soc He基因突變的意義？Highly frequent gene mutation: not specificless frequent gene mutation: may be specific Somatic mutation: BRAF- HCL STAT3

17、/5BT/NK FLT-ITD, IDH1/2, NPM1 AMLgermline mutations: RUNX1, CEBPA, GATA2, ETV6, DDX41, TERT, DKC1-IBMF, secondary MDS 基因突變的意義？Highly frequent gene mAA 與hMDS鑒別診斷1. 形態(tài)2.克隆證據(jù)3.克隆演變AA 與hMDS鑒別診斷1. 形態(tài)非腫瘤患者外周血DNA的全外顯子測序authorNO.compositiongeneGenovese et al12,3806135 (psychiatric disorders),6245(healthy Co

18、ntrols)unselected for cancer or hematologic phenotypesJaiswal et al17,18222 population-based cohorts in three consortia(genomicrisk factors for cardiovascular morbidity and mortality) 160 genes ( known associated with myeloid and lymphoid cancersN Engl J Med. 2014 Dec 25;371(26):2488-98N Engl J Med.

19、 2014 Dec 25;371(26):2477-87非腫瘤患者外周血DNA的全外顯子測序authorNO.comCHIP, Clonal Hematopoiesis of Indeterminate PotenialAbsence of definitive morphological evidence of a hematological neoplasmDoes not meet diagnostic criteria for PNH,MGUS, or MBLPresence of a somatic mutation associated with hematological neo

20、plasia at a variant allele freqency of at least 2%(eg. DNMT3A, TET2, ASXL1, JAK2, SF3B1, TP53, CBL, GNB1, BCOR, U2AF1, CREBBP, CUX1, SRSF2, MLL2, SETD2, SETDB1, GNAS, PPM1D, BCORL1)Odds of progression to overt neoplasia are approximately 0.5-1% per year, similar to MGUSCHIP, Clonal Hematopoiesis of

21、CHIP和年齡相關(guān)110N Engl J Med. 2014 Dec 25;371(26):2488-98N Engl J Med. 2014 Dec 25;371(26):2477-87CHIP和年齡相關(guān)110N Engl J Med. 2014CHIP是髓系腫瘤的前驅(qū)狀態(tài)CHIP是髓系腫瘤的前驅(qū)狀態(tài)從克隆造血到MDS的演變N Engl J Med. 2014 Dec 25;371(26):2477-87從克隆造血到MDS的演變N Engl J Med. 2014克隆發(fā)展模型Nat Med. 2014 December ; 20(12): 14721478. 克隆發(fā)展模型Nat Med. 2

22、014 December ;醫(yī)學(xué)課件再障和低危MDS的鑒別MDS疾病譜CHIPNon-clonal ICUSCHIPCCUSMDS-Ulower risk MDSHigher risk MDScytopenia+-+dysplasia-+ (10%)+(10%)+clonality-+BM blast%5%5%5%5%5%19%Overall riskVery lowVery lowLow (?)Low (?)lowhighAdapted fromClonal cytopeniaMDS by WHO 2008Traditional ICUSMDS疾病譜CHIPNon-clonal ICUSCH

23、IPCAA演變?yōu)镸DS既往觀點(diǎn)MDACC 128名AA患者隨訪10年發(fā)現(xiàn)，9.3%的AA患者轉(zhuǎn)化成MDS。原因1.低增生性MDS 初診AA，6月內(nèi)確診的MDS2.克隆轉(zhuǎn)化 初診AA，6月后確診的MDS（1）免疫抑制劑使用(經(jīng)39月隨訪，AA免疫抑制劑治療患者發(fā)生克隆性疾病幾率是移植患者15倍）（2）AA向MDS的內(nèi)在轉(zhuǎn)化（單獨(dú)接受雄激素治療患者與接受免疫抑制劑患者發(fā)生克隆性疾病幾率相似）可能機(jī)制 AA患者端?？s短起重要作用遺傳不穩(wěn)定Cancer.2007 Oct 1;110(7):1520-6.JAMA. 2010 September 22; 304(12): 13581364.AA演變?yōu)镸D

24、S既往觀點(diǎn)MDACC 128名AA患者隨訪Behavior of SNP-A characterized lesions through the clinical courseBLOOD, 23 JUNE 2011 VOLUME 117, NUMBER 25AA的細(xì)胞遺傳學(xué)演變?nèi)缃馚ehavior of SNP-A characterize一名再障患者的克隆演變N ENGL J MED 373;1 July 2, 2015一名再障患者的克隆演變N ENGL J MED 373;1 AA患者中伴發(fā)PNH的演變(115)(19)(2)(2)Hematology Am Soc Hematol Educ Program.2011;2011:90-5 AA患者中伴發(fā)PNH的演變(115)(2)Hematol167 名重型再障患兒治療及MDS/AML 轉(zhuǎn)化Blood, Vol 90, No 3 (August 1), 1997: pp 1009-1013167 名重型再障患兒治療及MDS/AML 轉(zhuǎn)化Blood,可能機(jī)制：免疫選擇壓力下的克隆轉(zhuǎn)化Hematology Am Soc Hematol Educ Program.2011;2011:90-5可能機(jī)制：免疫選擇壓力下的克隆轉(zhuǎn)化Hematology AmAA和hMDS的免疫機(jī)制AA和hMDS的免疫機(jī)制Overlap in