骨髓衰竭綜合征培訓(xùn)課件

骨髓衰竭綜合征CasePresentation16yearoldmaleSeenbyfamilydoctorbecausetennisinstructornoticedthathewastiringeasilyHistoryoftripoutsidetheUSA5monthsearlierNotedtohavepallorandalargebruiseonarm(wherehitbytennisball)CBC:Hb8.5g/dL,platelets40,000/mL,WBC2000/mL(20%neutrophils)2骨髓衰竭綜合征NextStepLookatbloodsmearR/ocirculatingblastsDoabonemarrowAspirateCelltypesCytogeneticsBiopsyCellularity3骨髓衰竭綜合征PancytopeniawithHypocellularMarrowAcquiredaplasticanemiaInheritedbonemarrowfailuresyndromeHypocellularMyelodysplasticSyndromeAleukemicleukemiaMarrowlymphoma4骨髓衰竭綜合征PancytopeniawithCellularMarrowPrimarymarrowdiseaseLeukemiaMyelodysplasticsyndromeParoxysmalnocturnalhemoglobinuriaSystemicdiseaseLupusHypersplenismInfection,e.g.brucellosis,sarcoidosis,tuberculosis5骨髓衰竭綜合征BoneMarrow(BM)BiopsyNormalAplastic6骨髓衰竭綜合征AplasticAnemia:SignsandSymptomsAnemiafatigue,lassitude,dyspneaThrombocytopeniabruises,petechiaeseriousbleedingNeutropeniainfections7骨髓衰竭綜合征SeverityofAplasticAnemiaSevere2ofthefollowing3:neutrophils<500/mL,platelets<20,000/mL,reticulocytes<20,000/mLBMcellularity<25%with<30%hematopoieticcellsVerysevereNeutrophils<200/mLNon-severe(moderate)Betterthansevere8骨髓衰竭綜合征NosologyofAplasticAnemiaGeneticsAcquiredInheritedCellbiologyStemcellImmune9骨髓衰竭綜合征AcquiredAplasticAnemiaRadiationDrugs(cytotoxics,chloramphenicol,nonsteroidals,anticonvulsants,gold)Chemicals(benzene,insecticides,pesticides,fertilizer)Viruses(Epstein-Barr,hepatitis[non-A,B,C],humanimmunodeficiency)GeneticpolymorphismsindetoxifyingenzymesParoxysmalnocturnalhemoglobinuria(PNH)PregnancyImmunediseases(eosinophilicfasciitis,hypoimmunoglobulinemia,thymoma)IDIOPATHIC10骨髓衰竭綜合征EvidenceforImmuneDiseaseAutologousrecoveryafterimmunosuppressionfortransplantEvensyngeneictransplantsrequireconditioningResponsetoimmunosuppression(ATG/CsA;Cp)OligoclonalexpansionofVbsubfamiliesActivatedTcellsIncreasedfrequencyofHLA-DR2Increasedapoptosis11骨髓衰竭綜合征Copyright?2006AmericanSocietyofHematology.Copyrightrestrictionsmayapply.Young,N.S.etal.Blood2006;108:2509-2519ImmunePathophysiologyofAcquiredAplasticAnemiaIncitingevent(virusordrug),aberrantimmuneresponse,oligoclonalexpansionofcytotoxicTcells,destroysstemcells.BMTorISTeradicateorsuppresspathogenicT-cellclones.Immuneresponserecurs,selectionofPNH,MDS,orAMLcells.PNH,12骨髓衰竭綜合征TreatmentforAcquiredAplasticAnemiaStemcelltransplantATG/CsACyclophosphamideSupportTransfusionsPlatelets?G-CSF13骨髓衰竭綜合征OverlappingSyndromesAATERC,TERT,TINF2OtherFADCMDSAMLPNHAcquired14骨髓衰竭綜合征InheritedBoneMarrowFailureSyndromes(IBMFS):YoungChildren3yoFA4yoDBANBTAR2yoSDS10yoDC1.5yoSCN5yoAmega15骨髓衰竭綜合征IBMFS:AdultsandOlderChildren26FA23FA16SDS21DC32DBA42TAR16骨髓衰竭綜合征

IBMFS:BenignHematologyOncologySyndromeHematologyLeukemiaSolidTumorsFanconiAnemia(FA)AplasticAMLSCCDyskeratosisCongenita(DC)AplasticAMLSCCDiamond-BlackfanAnemia(DBA)PureanemiaAMLSarcomasShwachman-DiamondSyndrome(SD)NeutropeniaAML-SevereCongenitalNeutropenia(SCN)NeutropeniaAML-AmegakaryocyticThrombocytopeniaThrombocytopeniaAML-ThrombocytopeniaAbsentRadii(TAR)ThrombocytopeniaAML-Thesedisordersarethemajor“InheritedBoneMarrowFailureSyndromes.”17骨髓衰竭綜合征History:GuidoFanconiFanconiAnemia

(Fanconipancytopeniasyndrome):1927-3brotherswithpancytopeniaandphysicalabnormalities,“perniziosiforme”FanconiSyndrome

(renalFanconisyndrome):1936-proteinuria,glucosuria,phosphaturia,aminoaciduria,citraturia,andproximalrenaltubularacidosis18骨髓衰竭綜合征FanconiAnemia-ChildrenPhotoswithpermission19骨髓衰竭綜合征FanconiAnemia:AdultsAbsentradius,0Aplasticanemia,5?,6Aplasticanemia,16Cancer,30BMTdonor,5520骨髓衰竭綜合征Literature:PhysicalFindingsFinding%LowBirthWeight52Short45Skinhyperpigmented31Skincaféaulait18Thumbs32Radii7Gonadsmale26Gonadsfemale1Microcephaly22Finding%Eyes20Renal20Developmentaldelay10Ears,deaf8Legs,hips,feet6Cardiopulmonary6Gastrointestinaltract5Brain/pituitary3Shortorskinonly7Allfindingsbiasedbyunder-orover-reporting!21骨髓衰竭綜合征LaboratoryFindingsinFALowbloodcounts(pancytopenia)Largeredcells(macrocytosis)Increasedfetalhemoglobin(HbF)ChromosomebreakageinlymphocytesorfibroblastsculturedwithaDNAcrosslinker,e.g.diepoxybutane(DEB)ormitomycinC(MMC)22骨髓衰竭綜合征FanconiAnemia-DefinitionAutosomalrecessive(1X-linkedrecessivegene)PhysicalfindingsAplasticanemiaLeukemiaSolidtumorsChromosomeinstabilityDNArepairdefect>13genes23骨髓衰竭綜合征FANCGenesAdaptedfromJoenje,2006D1=BRCA2*JandNinteractwithBRCA1andBRCA224骨髓衰竭綜合征FAComplementationGroups/GenesGroupLocuscDNAExonsAA%A16q24.35.5431455~70BXp22.312.810859RareC9q22.34.614558~10D1/BRCA213q12.311.4273418RareD23p25.35441451RareE6p21-222.510536~5F11p151.31374RareG/XRCC99p132.514622~10I/KIAA179415q25-264.5381328RareJ/BACH1/BRIP117q22.34.6201249RareL/PHF9/POG2p15-16.11.714375RareM/Hef14q21.36.5222014RareN/PALB216p12.13.5131186RareBRIP1is“BRCA1interactingprotein”;PALB2is“partnerandlocalizerofBRCA2”25骨髓衰竭綜合征FADNARepairPathwayBD2DNARepairDNADamageCEFIGMLAPCNANBS1RAD51J/BACH1BRCA1D2UbD1/BRCA2D2UbN/PALB226骨髓衰竭綜合征WhoShouldbeTestedforFA?Characteristicbirthdefects(egthumbs,kidneys,poorgrowth,etc)AplasticAnemia(AA)MyelodysplasticSyndrome(MDS)AcuteMyeloidLeukemia(AML)DecreasedfertilityEarlycharacteristiccancerSiblingsofFApatients27骨髓衰竭綜合征WhataretheTestsforFA?Bloodchromosomebreakage(DEBorMMC)SkinfibroblastchromosomebreakageFlowcytometryforG2arrestWesternblotforubiquitinatedD2RetroviralFAgenecorrectionofFAphenotypeFAgenesequencing28骨髓衰竭綜合征D2UbiquitinationShimamuraetal,Blood,2002LIJ(BRIP1)BM29骨髓衰竭綜合征Retrovirus-mediatedCorrectionofTA0252'sT-cellsanalyzedbyflowcytometryafterfivedaysofMMC-Incubation0204060801001101001000c(MMC)[nM]cellsalive[%]S11EGSFAS11FCIEGS11FEIEG2S11FFIEGS11FGFANCARetrovirus-mediatedCorrectionofFACells30骨髓衰竭綜合征FAComplicationsAplasticAnemiaAcuteLeukemiaMyelodysplasticSyndromeSolidTumorsLivertumors31骨髓衰竭綜合征FAAplasticAnemiaAdaptedfromKutleretal,Blood,200380%byage~15,>90%overall32骨髓衰竭綜合征FALiterature:Cancer1927-2007179solidtumorsand163leukemiasin330/1865patients;29had2-4cancersAMLLiverHNSCCBrainVulvaWilmsALLEsophagus33骨髓衰竭綜合征RiskofCancerinFAbyO/ERatioFACohortsParameterNASGEFAISFARNCINumberofPatients145182Person-Years20002818AllCancers52x44xAllSolidTumors51x26xOralCavity/Pharynx706x240xVulvar4317x2411xAML785x868xMDS8559x4559xNorthAmericanSurvey;GermanFARegistry;IsraeliFARegistry;NationalCancerInstitute34骨髓衰竭綜合征NCIFACumulativeIncidenceandCause-specificHazards35骨髓衰竭綜合征CompetingRisksofCancer36骨髓衰竭綜合征FanconiAnemia:Phenotype/OutcomeRosenberg,Huang,Alter,Blood2004Phenotypepredictsageandincidenceofmarrowfailureandsolidtumors.NormalPhenotypeAbnormalPhenotypeAbnormalphenotype=radii,plusabnormaldevelopment,heartorlung,kidney,hearing,andhead.Competingriskanalyses.37骨髓衰竭綜合征TransplantandHeadandNeckCancerinFanconiAnemiaBMTNoBMTDATA:Transplantincreasedcancerby4.4-fold;Shiftedmedianageto16yearsyounger;Allcancerpatientshadgraftvshostdisease.ParisRosenberg,Socie,Gluckman,Alter:Blood,2005;BiolBlood&MarrowTranspl,2005LESSON:Improvetransplantpreparationtoreducegraftvshostdisease.USA38骨髓衰竭綜合征DiagnosisofFAafterCancerTongueSCCage30SkinSCCsage33Short,80lbs,hearingaids,menopauseage30XRTsideeffectsNormalbloodcountsPBchromosomesnobreaks;skinbreaksExon8:790C>T;Q264X;Gln264StopExon27:2585delCT;Frameshift,Cys846fsX20SkinGeneconversion,lossofexon27frameshift2585delCTBloodSomaticMosaicism,FANCAAlter,Joenje,Oostra,Pals,ArchOtolaryngol,200539骨髓衰竭綜合征HematopoieticMosaicism40骨髓衰竭綜合征MosaicismfromRecombinationaAAaaAAaaAAa41骨髓衰竭綜合征FANCD1/BRCA2Proband;AdultFANCAPhotoswithparentalandpatientconsent42骨髓衰竭綜合征

OddsRatiosforComplicationsinFAandFANCD1/BRCA2GeneralPopulationFAFAvsGenlFA-D1FA-D1vsFAFA-D1vsGenlVATER2.6/1065/10019,0005/273.771,000AML1/1059/14580010/278.97,000AnyCancer10/10523/1455025/27663300FANCD1/BRCA2isassociatedwithextremelyhighincidencesofVACTERL-Hassociation,AML,andspecificSolidTumors(Wilms,medulloblastoma).Alter,Brody,Rosenberg:JMedGenet200743骨髓衰竭綜合征Genotype/Phenotype/Outcome:27FAwithBiallelicMutationsinBRCA2Alter:BrJHaematol,2006Alter,Brody,Rosenberg:JMedGenet,200778%byage10(AML,ALL)HR7.7(CI2-29),p=0.00383%byage7(Wilms,Medulloblastoma)97%byage644骨髓衰竭綜合征FANCD1/BRCA2MutationsMutationsUniformity1Cluster2MissenseNo,p=0.01Yes,p=<0.001DeleteriousYes,p=0.6No,p=0.3Whatistheriskofcancerincarriersofthesemissensemutations?1Chisquareofexpectedfrequencyacrossthegene.2Permutationtestofrangebetweentheextremes.Alter,Brody,Rosenberg:JMedGenet,2007Whydopatientswithbiallelicdeleterious/deleteriousordeleterious/missensemutationsinBRCA2bothdevelopFAandcancer?45骨髓衰竭綜合征FA:WhentoTreatCytopeniasHb<8g/dLorsymptomsPlatelets<30,000/mm3WBC<500/mm3MDSMorphologic+cytopeniasNotforclonealoneLeukemiaBlastsinblood>20%blastsinmarrowSolidtumorsorlivertumorsWhendetectedFA:GuidelinesforDiagnosisandManagement,200846骨髓衰竭綜合征FA:HowtoTreatHematologicdisease(benignormalignant)StemcelltransplantAndrogensHematopoieticgrowthfactors(G-CSF,Ep)ChemotherapyFolicacidBloodproducts:notfamily;leukodeplete;irradiateGenetherapy?LivertumorsStopandrogensSolidtumorsConservative/focusedradiationChemotherapythatdoesnotcross-linkDNANewmodalities,e.g.cetuximabFA:GuidelinesforDiagnosisandManagement,200847骨髓衰竭綜合征FASurveillance:CancerHematopoiesis–AA,MDS,aMLBloodcountsevery3-4monthsBonemarrowaspirate,biopsy,cytogeneticsannuallyOralcavityandpharynx-roleofHPVvaccine?Age>10yearsBMT>1yearGynecologic-roleofHPVvaccine?Age>16yearsMenarcheLiverLiverenzymesevery3-4monthsLiverultrasoundevery6-12monthsSkinAnnualexam48骨髓衰竭綜合征CasePresentation16yearoldmaleSeenbyfamilydoctorbecausetennisinstructornoticedthathewastiringeasilyHistoryoftripoutsidetheUSA5monthsearlierNotedtohavepallorandalargebruiseonarm(wherehitbytennisball)CBC:Hb8.5g/dL,platelets40,000/mL,WBC2000/mL(20%neutrophils)Diagnosis:FanconiAnemia,newlydiagnosedinanadolescent49骨髓衰竭綜合征DyskeratosisCongenita50骨髓衰竭綜合征DyskeratosisCongenita-Kids2yo,HH1.5yo,HH6yo,TINF210yo,TINF251骨髓衰竭綜合征DyskeratosisCongenita-Adults22yo,DKC148and16yo,TERC27yo,TINF224yo,TINF252骨髓衰竭綜合征PhysicalFindingsinDCDystrophicnails*Laceypigmentation*Leukoplakia*Epiphora,blepharitisDevelopmentaldelayPulmonarydiseaseShortstatureDentalcariesLiverdiseaseEsophagealstrictureEarlygreyhair,hairloss,sparseeyelashesHyperhidrosisCerebellarhypoplasiaHypogonadismMicrocephalyUrethralstrictureOsteoporosis,avascularnecrosis*DiagnosticTriad(need2/3).Or,1ofthetriad,+hypoplasticbonemarrow,+2oftheotherfindings.53骨髓衰竭綜合征X-linkedrecessive(XLR),Autosomaldominant(AD),Autosomalrecessive(AR)Mutationsintelomeraseandshelterinpathways:DKC1(XLR)TERC(AD)TERT(AD,AR)TINF2(AD)DCInheritanceNOLA2(AR)NOLA3(AR)Others(~50%)54骨髓衰竭綜合征MajorComplicationsinDCHematologicBonemarrowfailureMyelodysplasticsyndromeLeukemiaSolidtumorsHeadandneckAnogenitalPulmonaryfibrosis55骨髓衰竭綜合征44cancersin36/425patientsDCLiterature:Cancer1910-2007HNSCCRectalStomach56骨髓衰竭綜合征WhatistheEndoftheShoelace?Theaglet57骨髓衰竭綜合征TelomeresandChromosomalInstabilityLongTTAGGGrepeatsShortenwitheachcelldivisionManyproteinsinteracttoregulatetelomerelengthandstabilizestructureLackoftelomeremaintenanceleadstoerosionofchromosomeends,genomicinstability,cellcrisisandcelldeathFISH:telomeresCourtesyofPeterLansdorp58骨髓衰竭綜合征TelomereBiologyPathwayArmanios,AnnuRevGenomicsHumGenet,2009KirwanandDokal,BBA,200959骨髓衰竭綜合征LaboratoryDiagnosticTest:

TelomereLengthbyflow-FISHAlter,Baerlocher,Savage,…Lansdorp:Blood,2007AlmostallpatientswithDChaveveryshorttelomeresinbloodcells,including3silentcarriersand6lackingthetriad.

MostpatientswithotherIBMFShavenormaltelomeres.60骨髓衰竭綜合征TelomereLengthinMultiplexFamilyEthics:Dennyetal:AJMG,2008Genediscovery:Savageetal:AJHG,200861骨髓衰竭綜合征TINF2isMutatedinDCArg282SerLys280GluArg282HisHoyeraal-HreidarssonSyndromeReveszSyndromeSavageetal:AJHG,200862骨髓衰竭綜合征NCIIBMFSCohort:

RelativeRiskofCancer(O/ERatio)ParameterFADCNumberPerson-YearsAllCancersAllSolidTumorsTongueAMLMDS63骨髓衰竭綜合征NCIDC

ComparedwithAllFA64骨髓衰竭綜合征DCSurveillanceandTreatmentSimilartoFanconiAnemiaRoleofHPVvaccine?StemcelltransplantcomplicatedbypulmonarydiseaseNoroleforimmunosuppressionFeaturesuniquetoDC:AndrogensensitiveSplenicpeliosisandruptureonandrogens+G-CSFPulmonaryfibrosisHepaticfibrosis,cirrhosisTelomerelengthassay:diagnosisofpatients,silentcarriers;surveillanceandgeneticcounseling65骨髓衰竭綜合征Diamond-BlackfanAnemia66骨髓衰竭綜合征Diamond-BlackfanAnemiaNormochromic,usuallymacrocyticanemia,developingininfancyReticulocytopeniaMarrowerythroblastopeniaNormalorslightlydecreasedleukocytesNormalorincreasedplateletsIncreasedfetalhemoglobin(HbF)Increasedredcelladenosinedeaminase(ADA)25%withphysicalfindings:short,abnormalthumbs,etc67骨髓衰竭綜合征DBALiterature2008:PhysicalFindingsFindingNumber%Anyabnormalityincludingshortstature22425Anyabnormalityotherthanshortstature15321Shortstatureonly354Thumbanomaly576Triphalangealthumb243Cleftpalate243Denominator=~900,butnodatainmanyreports.68骨髓衰竭綜合征DBAInheritanceAutosomaldominant~25%RPS19~2%RPS24~1%RPS1740sribosomebiogenesisHaploinsufficiency~7%RPL5~5%RPL11~2%RPL35a69骨髓衰竭綜合征DBASurveillanceandTreatmentMonitorbloodcountsAnnualbonemarrows(noconsensus)TreatwhenHb<8g/dL,orsymptomsCorticosteroidsTransfuseduringfirstyearandpuberty(noconsensus)CyclosporinA(rare)Metoclopramide(rare)71骨髓衰竭綜合征Shwachman-DiamondSyndromeExocrinepancreaticinsufficiencyDecreasedtrypsinogenandisoamylase(age-dependent)PancreassmallorfattyonimagingBonemarrowfailureNeutropenia:<1500/mLAnemia:MacrocytosisThrombocytopeniaMyelodysplasticsyndrome/acuteleukemiaBonesMetaphysealdysostosisAutosomalrecessiveSBDS=Shwachman-Bodian-DiamondSyndrome60sribosomebiogenesis72骨髓衰竭綜合征SDSLiterature:Leukemia1949-200736leukemiasin36/510patients

AMLALL73骨髓衰竭綜合征SDSSurveillanceandTreatmentSimilartoFanconiAnemiaG-CSF-neutropeniaStemcelltransplant-cardiotoxicityfromcyclophosphamide?FeaturesuniquetoSDS:Malabsorption-pancreaticenzymes,ADEKMetaphysealdysostosis-surgeryasneededCytogeneticclones-monitor74骨髓衰竭綜合征SevereCongenitalNeutropeniaNophysicalphenotypeANC<500/mLPyogenicinfectionsRxG-CSFAutos