骨髓衰竭综合征培训ppt课件

骨髓衰竭骨髓衰竭综综合征合征骨髓衰竭综合征1Case 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(20%neutrophils)骨髓衰竭综合征2Case Presentation16 year old mNext StepLook at blood smearR/o circulating blastsDo a bone marrowAspirateCell typesCytogeneticsBiopsyCellularity骨髓衰竭综合征3Next StepLook at blood smear骨髓Pancytopenia with Hypocellular MarrowAcquired aplastic anemiaInherited bone marrow failure syndromeHypocellular Myelodysplastic SyndromeAleukemic leukemiaMarrow lymphoma骨髓衰竭综合征4Pancytopenia with HypocellularPancytopenia with Cellular MarrowPrimary marrow diseaseLeukemiaMyelodysplastic syndromeParoxysmal nocturnal hemoglobinuriaSystemic diseaseLupusHypersplenismInfection,e.g.brucellosis,sarcoidosis,tuberculosis骨髓衰竭综合征5Pancytopenia with Cellular MarBone Marrow(BM)BiopsyNormalAplastic骨髓衰竭综合征6Bone Marrow(BM)BiopsyNormalAAplastic Anemia:Signs and SymptomsAnemiafatigue,lassitude,dyspneaThrombocytopeniabruises,petechiaeserious bleedingNeutropeniainfections骨髓衰竭综合征7Aplastic Anemia:Signs and SymSeverity of Aplastic AnemiaSevere2 of the following 3:neutrophils 500/mL,platelets 20,000/mL,reticulocytes 20,000/mLBM cellularity 25%with 30%hematopoietic cellsVery severeNeutrophils 13 genes骨髓衰竭综合征23Fanconi Anemia-DefinitionAutFANC GenesAdapted from Joenje,2006D1=BRCA2*J and N interact with BRCA1 and BRCA2骨髓衰竭综合征24FANC GenesAdapted from Joenje,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/POG2p15-16.11.714375RareM/Hef14q21.36.5222014RareN/PALB216p12.13.5131186RareBRIP1 is“BRCA1 interacting protein”;PALB2 is“partner and localizer of BRCA2”骨髓衰竭综合征25FA Complementation Groups/GeneFA DNA Repair PathwayBD2DNA RepairDNA DamageCEFIGMLAPCNANBS1RAD51J/BACH1BRCA1D2UbUbD1/BRCA2D2UbUbN/PALB2骨髓衰竭综合征26FA DNA Repair PathwayBD2DNA ReWho 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 patients骨髓衰竭综合征27Who Should be Tested for FA?ChWhat are the Tests for FA?Blood chromosome breakage(DEB or MMC)Skin fibroblast chromosome breakageFlow cytometry for G2 arrestWestern blot for ubiquitinated D2Retroviral FA gene correction of FA phenotypeFA gene sequencing骨髓衰竭综合征28What are the Tests for FA?BlooD2 UbiquitinationShimamura et al,Blood,2002LIJ(BRIP1)BM骨髓衰竭综合征29D2 UbiquitinationShimamura 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 Cells骨髓衰竭综合征30Retrovirus-mediated CorrectionFA ComplicationsAplastic AnemiaAcute LeukemiaMyelodysplastic SyndromeSolid TumorsLiver tumors骨髓衰竭综合征31FA Complications骨髓衰竭综合征31FA Aplastic AnemiaAdapted fromKutler et al,Blood,200380%by age 15,90%overall骨髓衰竭综合征32FA Aplastic AnemiaAdapted fromFA Literature:Cancer 1927-2007179 solid tumors and 163 179 solid tumors and 163 leukemias in 330/1865 leukemias in 330/1865 patients;29 had 2-4 cancerspatients;29 had 2-4 cancersAMLLiverHNSCCBrainVulvaWilmsALLEsophagus骨髓衰竭综合征33FA Literature:Cancer 1927-200Risk of Cancer in FA by O/E RatioFA CohortsParameterNASGEFAISFARNCINumber of Patients145182Person-Years20002818All Cancers52x44xAll Solid Tumors51x26xOral Cavity/Pharynx706x240 xVulvar4317x2411xAML785x868xMDS8559x4559xNorth American Survey;German FA Registry;Israeli FA Registry;National Cancer Institute骨髓衰竭综合征34Risk of Cancer in FA by O/E RaNCI FA Cumulative Incidence and Cause-specific Hazards骨髓衰竭综合征35NCI FA Cumulative Incidence anCompeting Risks of Cancer骨髓衰竭综合征36Competing Risks of Cancer骨髓衰竭综Fanconi 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,and head.Competing risk analyses.骨髓衰竭综合征37Fanconi Anemia:Phenotype/OutcTransplant and Head and Neck Cancer in Fanconi AnemiaBMTNo BMTDATA:Transplant increased cancer by 4.4-fold;Shifted median age to 16 years younger;All cancer patients had graft vs host disease.ParisRosenberg,Socie,Gluckman,Alter:Blood,2005;Biol Blood&Marrow Transpl,2005LESSON:Improve transplant preparation to reduce graft vs host disease.USA骨髓衰竭综合征38Transplant 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 breaks;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,2005骨髓衰竭综合征39Diagnosis of FA after CancerToHematopoietic Mosaicism 骨髓衰竭综合征40Hematopoietic Mosaicism 骨髓衰竭综合Mosaicism from RecombinationaAAaaAAaaAAa骨髓衰竭综合征41Mosaicism from RecombinationaAFANCD1/BRCA2 Proband;Adult FANCAPhotos with parental andpatient consent骨髓衰竭综合征42FANCD1/BRCA2 Proband;Adult FAOdds Ratios for Complications in FA and FANCD1/BRCA2General PopulationFAFA vs GenlFA-D1FA-D1 vs FAFA-D1 vs GenlVATER2.6/1065/10019,0005/273.771,000AML1/1059/14580010/278.97,000Any 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 2007骨髓衰竭综合征43Odds Ratios for ComplicationsGenotype/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 6骨髓衰竭综合征44Genotype/Phenotype/Outcome:27FANCD1/BRCA2 MutationsMutationsUniformity1Cluster2MissenseNo,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 patients with biallelic deleterious/deleterious or deleterious/missense mutations in BRCA2 both develop FA and cancer?骨髓衰竭综合征45FANCD1/BRCA2 MutationsMutationFA:When to TreatCytopeniasHb 8 g/dL or symptomsPlatelets 30,000/mm3WBC 20%blasts in marrowSolid tumors or liver tumorsWhen detectedFA:Guidelines for Diagnosis and Management,2008骨髓衰竭综合征46FA: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 tumorsConservative/focused radiationChemotherapy that does not cross-link DNANew modalities,e.g.cetuximabFA:Guidelines for Diagnosis and Management,2008骨髓衰竭综合征47FA:How to TreatHematologic diFA Surveillance:CancerHematopoiesis AA,MDS,aMLBlood counts every 3-4 monthsBone marrow aspirate,biopsy,cytogenetics 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 exam骨髓衰竭综合征48FA Surveillance:CancerHematopCase 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(20%neutrophils)Diagnosis:Fanconi Anemia,newly diagnosed in an adolescent骨髓衰竭综合征49Case Presentation16 year old mDyskeratosis Congenita骨髓衰竭综合征50Dyskeratosis Congenita骨髓衰竭综合征5Dyskeratosis Congenita-Kids2 yo,HH1.5 yo,HH6 yo,TINF210 yo,TINF2骨髓衰竭综合征51Dyskeratosis Congenita-Kids2Dyskeratosis Congenita-Adults22 yo,DKC148 and 16 yo,TERC27 yo,TINF224 yo,TINF2骨髓衰竭综合征52Dyskeratosis Congenita-AdultPhysical Findings in DCDystrophic nails*Lacey pigmentation*Leukoplakia*Epiphora,blepharitisDevelopmental delayPulmonary diseaseShort statureDental cariesLiver diseaseEsophageal strictureEarly grey hair,hair loss,sparse eyelashesHyperhidrosisCerebellar hypoplasiaHypogonadismMicrocephalyUrethral strictureOsteoporosis,avascular necrosis*Diagnostic Triad(need 2/3).Or,1 of the triad,+hypoplastic bone marrow,+2 of the other findings.骨髓衰竭综合征53Physical Findings in DCDystropX-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%)骨髓衰竭综合征54X-linked recessive(XLR),AutoMajor Complications in DCHematologicBone marrow failureMyelodysplastic syndromeLeukemiaSolid tumorsHead and neckAnogenitalPulmonary fibrosis骨髓衰竭综合征55Major Complications in DCHemat44 cancers in 36/425 patients44 cancers in 36/425 patientsDC Literature:Cancer 1910-2007HNSCCRectalStomach骨髓衰竭综合征5644 cancers in 36/425 patientsDWhat is the End of the Shoelace?The aglet骨髓衰竭综合征57What is the End of the ShoelacTelomeres and Chromosomal InstabilityLong TTAGGG repeatsShorten with each cell divisionMany proteins interact to regulate telomere length and stabilize structureLack of telomere maintenance leads to erosion of chromosome ends,genomic instability,cell crisis and cell deathFISH:telomeresCourtesy of Peter Lansdorp骨髓衰竭综合征58Telomeres and Chromosomal InstTelomere Biology PathwayArmanios,Annu Rev Genomics Hum Genet,2009Kirwan and Dokal,BBA,2009骨髓衰竭综合征59Telomere 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.骨髓衰竭综合征60Laboratory Diagnostic Test:TTelomere Length in Multiplex FamilyEthics:Denny et al:AJMG,2008Gene discovery:Savage et al:AJHG,2008骨髓衰竭综合征61Telomere Length in Multiplex FTINF2 is Mutated in DCArg 282 SerArg 282 SerLys 280 GluArg 282 HisArg 282 HisHoyeraal-Hreidarsson Hoyeraal-Hreidarsson SyndromeSyndromeRevesz SyndromeRevesz SyndromeSavage et al:AJHG,2008骨髓衰竭综合征62TINF2 is Mutated in DCArg 282 NCI IBMFS Cohort:Relative Risk of Cancer(O/E Ratio)ParameterFADCNumberPerson-YearsAll CancersAll Solid TumorsTongueAMLMDS骨髓衰竭综合征63NCI IBMFS Cohort:Relative RiNCI DC Compared with All FA骨髓衰竭综合征64NCI DC Compared with All FA骨髓衰DC Surveillance and TreatmentSimilar to Fanconi AnemiaRole of HPV vaccine?Stem cell transplant 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 counseling骨髓衰竭综合征65DC Surveillance and TreatmentSDiamond-Blackfan Anemia骨髓衰竭综合征66Diamond-Blackfan Anemia骨髓衰竭综合征Diamond-Blackfan AnemiaNormochromic,usually macrocytic anemia,developing in infancyReticulocytopeniaMarrow erythroblastopeniaNormal or slightly decreased leukocytesNormal or increased plateletsIncreased fetal hemoglobin(Hb F)Increased red cell adenosine deaminase(ADA)25%with physical findings:short,abnormal thumbs,etc骨髓衰竭综合征67Diamond-Blackfan AnemiaNormochDBA Literature 2008:Physical FindingsFindingNumber%Any abnormality including short stature22425Any abnormality other than short stature15321Short stature only354Thumb anomaly576Triphalangeal thumb243Cleft palate243Denominator=900,but no data in many reports.骨髓衰竭综合征68DBA Literature 2008:Physical DBA InheritanceAutosomal dominant25%RPS192%RPS241%RPS1740s ribosome biogenesisHaploinsufficiency7%RPL55%RPL112%RPL35a骨髓衰竭综合征69DBA InheritanceAutosomal domin骨髓衰竭综合征培训ppt课件70DBA 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)Metoclopramide(rare)骨髓衰竭综合征71DBA 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 leukemiaBonesMetaphyseal dysostosisAutosomal recessiveSBDS=Shwachman-Bodian-Diamond Syndrome60s ribosome biogenesis骨髓衰竭综合征72Shwachman-Diamond SyndromeExocSDS Literature:Leukemia 1949-200736 leukemias in 36/510 patients AMLALL骨髓衰竭综合征73SDS Literature:Leukemia 1949-SDS Surveillance and TreatmentSimilar to Fanconi AnemiaG-CSF-neutropeniaStem cell transplant-cardiotoxicity from cyclophosphamide?Features unique to SDS:Malabsorption-pancreatic enzymes,ADEKMetaphyseal dysostosis-surgery as neededCytogenetic clones-monitor骨髓衰竭综合征74SDS Surveillance and TreatmentSevere Congenital NeutropeniaNo physical phenotypeANC 500/mLPyogenic infectionsRx G-CSFAutosomal dominantELA2GFI1Autosomal recessive(Kostmann Syndrome)HAX1X-linked recessiveWAS骨髓衰竭综合征75Severe 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 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?骨髓衰竭综合征76SCN and Leukemia(Rosenberg,AlAmegakaryocytic ThrombocytopeniaNeonatal thrombocytopeniaDecreased megakaryocytesNo anomaliesEvolution to aplastic anemia and/or leukemiaAR:1p,mpl,thrombopoietin receptorType I:nonsense mutations,severeType II:missense mutations,milder骨髓衰竭综合征77Amegakaryocytic ThrombocytopenThrombocytopenia Absent Radii Neonatal thrombocytopeniaAbsent radii,thumbs presentMegakaryocytes absent,reduced,hypoplastic,immature4 cases of leukemia2 mo;1,5,41 yrsNo gene identifiedMicrodeletion 200 kb at 1q21.1;digenic骨髓衰竭综合征78Thrombocytopenia Absent Radii Treatment and OutcomeInherited BMFSAcquired AASupport(txs,abx)Yes,not familyYesImmunosuppressionNoYesAndrogensYesNoG-CSF,EpoYesAdjunctClonal evolutionMDS,AMLMDS,AML,PNHStem cell transplantYesYesSolid tumorsYes,inc p-BMTp-BMT骨髓衰竭综合征79Treatment and OutcomeInheritedSummary/ConclusionsPatients known to have an IBMFS have a high risk of neoplasiaPatients with atypical presentations of neoplasms may have an undiagnosed IBMFSThe molecular mechanisms depend on the IBMFSThe magnitude of these problems merits further study骨髓衰竭综合征80Summary/ConclusionsPatients knFA chromosome breakageDC telomere lengthDBA red cell ADASD trypsinogen,isoamylaseSCN,Amega,TAR clinical diagnoses Sequence candidate genesScreening Tests for Suspected IBMFS骨髓衰竭综合征81Screening Tests for Suspected And,Next骨髓衰竭综合征82And,Next骨髓衰竭综合征82www.marrowfailure.cancer.gov骨髓衰竭综合征83www.marrowfailure.cancer.gov骨髓