diagnosis and management of myeloproliferative neoplasms

DIAGNOSIS AND MANAGEMENT OF MYELOPROLIFERATIVE

NEOPLASMS (MPN)Dr. Natalia Curto Garcia

Haematology ConsultantRoyal Free London NHS

April 2016

Index

• Introduction• Diagnosis MPN • Management MPN• Future • Summary

INTRODUCTION (I)

• MPN- rare disorders of the bone marrow that cause an increase in the number of blood cells.

• Median age 60y, also in young, rare in children• Incidence varied: ET 0.6-2.3/105,MF 0.5-1/105

PV is more prevalent in Europe 1.05/100000. G J. Titmarsh et al. American Journal of Hematology, 2014

• Progression to acute leukaemia .

The history of myeloproliferative disorders: before and after DameshekA Tefferi Leukemia 2008.

1845:Bennett- CML 1879:Heuck- PMF 1892: Vaquez- PV

1934: Estein & Goedel-

ET

1951:Dameshek- MPD1953: DNA structure

1960: Nowel- Crom.Ph1967: PVGS. Stem cell

origin

1982-1990 Molecular and oncogenic

characterization ofBCR-ABL

1996: Imatinib

2005: JAK2 V617F exon 14.2006: MPL

2007: JAK2 exon12. 2013: CALRPresent: Molecular therapy

INTRODUCTION (II):a little of history

INTRODUCTION (III): WHO classification

INTRODUCTION (IV): Aetiology• Genetic mutation, familiar predisposition, exposure to toxins.

R.Jager et al. Haematologica 2010

• Increase proliferation and survival

• Cytokine activation

• Signalling immune system

Mutations affecting the JAK-STAT

signalling

• MPL• LNK• c-CBL• SOCS1-3

Mutations affecting the epigenetic

regulation

• TET2• EZH2• ASXL1• IDH1/2• DNMT3A

Mutations associated with Leukemic transformation

• IDH1/2• IKZF1• TP53• NF1• RUNX1• NRAS• KRAS• DNMT3A

INTRODUCTION (V): Aetiology• Other mutations beyond JAK2

Image modified from Genetic and epigenetic complexity in MPD. Nicholas C.P. Cross, Hematology 2011.

INTRODUCTION (VI): Aetiology

Charles G Mullighan, Nature Genetics 2009

INTRODUCTION (VII): Aetiology

Kazuhiko Ikeda, Fukushima J Med Sci. 2012

INTRODUCTION (VIII): Aetiology• Dec ´13: CALR Exon 9 mutation described in: ET, PMF, MDS/MPN overlap

disorder, and RARS-T. • Mutually exclusive of JAK2 and MPL. Longest survival in MF. • Triple negative patients identified.

DIAGNOSIS: when suspect MPN?

• Erythrocytosis or thrombocytosis without other causes---- think in PV & ET.

• Unusual thrombosis ( portal or hepatic vein thrombosis)--- think in PV.

• Leucoerythroblastic blood film, splenomegaly, anemia--- think in MF.

• Aquagenic pruritus, extramedullar haematopoiesis and bone marrow fibrosis--- think in MPN.

Polycythaemia Vera –PV • Raised Htc >0.52 M, > 0.48 F for> 2 months*• Incidence 0.2-28/106, median age 60y, youngest

(5% < 50yo**)• Median survival >10y• RF survival: advanced age, leucocytosis,

thrombosis and abnormal karyotype. • Leukaemia progression 10% in 20y. Fibrotic

transformation is slightly higher.• JAK2 V617F presents over 95%, exon 12 mutation

~ 3%, exon14 mutation ~ 3%.*BSH guidelines , **Passamonti et al. Haematologica

2003

PV Diagnosis (I)• Clinical presentation:

– Recurrent headaches, blurred vision- hyperviscosity– Dyspnoea, gout– Aquagenic pruritus, Erythromelalgia, Plethoric

appearances, – Splenomegaly- 70% – Haemorrhage or thrombosis ( arterial or venous):

• first manifestation (MI, stroke, DVT)• 20%,• unusual places: mesenteric, portal or splenic• causes of dead

– Asymptomatic

Guidelines for the diagnosis, investigation and management of PV/erythocytois, BSH, 2005

PV Diagnosis (II) ABSOLUTE

Congenital :• High oxygen affinity Hb,• 2,3- BPG deficiency, • EPO receptor mediated,• Chuvash erythrocytosis (VHL mutation).

Acquired:• EPO mediated Hypoxia- driven: chronic lung diseases,

cardiopulmonary shunts, smoking, hypoventilation syndromes

Local renal hypoxia: renal artery stenosis, renal cysts, etc.

Pathological EPO production: tumours ( hepatocellular, renal cancer, parathyroid carcinoma, etc)

• Exogenous EPO : androgen, postrenal transplant erythrocytois, idiopathic.

RELATIVEHaemoconcentration ( dehydration, smoking)

SECO

NDA

RY

ERYT

HRO

CYTO

SIS

Congenital :• Congenital

erythropoietin receptor mutation- EPOR exon 8

Acquired:• PV – JAK2 mutation

PRIM

ARY

ERYT

HRO

CYTO

SIS

FBC • Raised Hb, htc, red cell count and red cell volume• Thrombocytosis 50% , neutrophilia 2/3 patients –

smokers have neutrophilia ( upper limit 12.5x109/L).

Ferritin & Vit B12 • Low serum ferritin• Absence iron stores in BM• Elevated B12 ( transcobalamin release from

increased granulocytic mass)

Red cell mass • Increased ( >25% for age, sex and weight- less usage now)

U&E, LFT´s and Ca profile • Essential to exclude secondary causes.

Sat O2 • Indicator of tissue hypoxia • Measure can be misleading in high affinity Hb,

SAS, carbon monoxide poisoning---- measure COHb, p50

• Consider respiratory tests

EPO • Reduce, also in idiopathic erythrocytosis

Adapted for the Guidelines for the diagnosis, investigation and management of PV/ erythrocytosis, BSH, 2005

PV Diagnosis (III): laboratory findings

BM Aspirate • Dense particles and cellular trials• Marked erythroid hyperplasia with moderate

hyperplasia of granulopoiesis and megakaryopoesis.

• Wide MK size ( large with hyperlobated nuclei)• Iron stores absent.

BM trephine • Hypercellular for age and panmyelosis ( trilineage proliferation)

• Erythroid maturation maintained and normoblastic

• Erythroid nests abnormally located trabeculae• Granulocyte maturation maintained• Increased MK, large size , reduce lobulation• Clusters MK pleomorphic• Mild to moderate stromal reticulin ( gr 2-3)

PV Diagnosis (IV): laboratory findings

Adapted for the Guidelines for the diagnosis, investigation and management of PV/ erythrocytosis, BSH, 2005

BM Aspirate BM Trephine

PostPV-MF

PV Diagnosis (V): laboratory findings

PV Diagnosis (VI): laboratory findingsMolecular studies • JAK2 V617F, Exon 12 and exon 14

• Less frequency MPL, CALR

Karyotype • 10-20% pat: trisomy in chr8 and 9, del (20q), del (13q) and del (1p).

Culture studies of BFU-E • Not usually found in normal individuals• Expensive not standardised

EPO receptor, VHL gene mutation analysis, PRV-1 & other genes

• Unexplained erythrocytosis and low serum EPO levels

• VHL gene mutation related Chuvash disorder • PRV-1 ( novel cell surface receptor)- overexpressed

in granulocytes in PV• c-MPL protein found in platelets of PV

Adapted from the Guidelines for the diagnosis, investigation and management of PV/erythrocytosis, BSH, 2005

PV diagnosis (VII) Masked PV• JAK2+ with PV-characteristic BM morphology

despite lower Hb levels ( <16-18.5g/l men and 15-16.5g/l women).

• Distinguish to ET– Hb optimal cutoff level: 16.5g/L and htc 49% for men and Hb 16g/L and htc 48% women.

• Therapeutic implication- risk of thrombotic complications associated with borderline increased Htc

• ? Modified WHO criteria diagnosis

A.Tefferi and T.Barbui, AJH 2015.

2008 WHO criteria 2014 Proposed revisionEither both major criteria and one minor criterion or the first major criterion and two minor criteria.

Requires meeting either all three major criteria or the first two major criteria and one minor criterion.

Major criteria Major criteria

• Hb ＞ 18.5 g/dL (men), ＞ 16.5 g/dL (women)

• Presence of JAK2V617F or JAK2 exon 12 mutation .

• Hb ＞ 16.5 g/dL (men), ＞ 16 g/dL (women) or Hct ＞ 49% (men), ＞ 48% (women)

• BM trilineage myeloproliferation with pleomorphic MK

• Presence of JAK2 mutation.

Minor criteria Minor criteria• BM trilineage myeloproliferation • Subnormal serum EPO level • Endogenous erythroid colony

growth

• Subnormal serum EPO

Table adapted from Bhee-Jin Kim et al, Blood Research 2014

PV criteria diagnosis

Essential Thrombocythaemia- ET• Raised platelets > 450x109/L• Discard secondary causes. • Median survival ~ 20y, pat >60 y increases to 33 y. • RF survival: advanced age, leucocytosis and

thrombosis. • Causes of dead: haemorrhage and/or thrombosis• Leukaemia progression 5% in 20y, higher rates

for fibrotic transformation • JAK2 V617F presents over 60%, CALR 20%, MPL

3%, triple negative 20%

ET diagnosis (I)• Clinical presentation:

– Thrombosis ( venous and arterial) – Haemorrhage event: nosebleeding, mucosa bleeds,

blood stool, bruising. – Asymptomatic – 25-33%– Mild splenomegaly ( 50%) and hepatomegaly 15-20%.

Splenic atrophy due to infarction. – Erythromelalgia , microvascular occlusion, numbness

and tingling in hands/feet, headache, dizziness, weakness, vision changes.

– Pregnancy complications: spontaneous abortions, placental infarctions,

ET diagnosis (II)

THRO

MBO

CYTO

SISIron deficiency,

Haemolysis. Infection/inflammation HaemorrhageTraumaPost surgery, Splenectomy,Connective tissue diseasesSolid cancer, Other MPN or MDS

Guidelines for the diagnosis, investigation and management of PV/erythocytois, BSH, 2005

ASH imagebank

FBC • Raised plat.• Marked anisocytosis in platelets and atypical

granulation, occ MK fragments , • Features of iron deficiency ( haemorrhage

episodes)• WBC can be elevated. Leucoerythroblastic film

and tear drops are unusual.

Clotting screening and platelets aggregation study

• Usually normal • Bleeding time may or may not be prolonged. • Abnormal platelets aggregation, acquired Von-

WillebrandFerritin and vit b12 • Low serum ferritin if iron deficiency associated.

• Increased vitamin b12 -25% U&E, LFT´s, CRP,ESRLDH

• Essential to exclude secondary causes. • Elevated LDH correlation with fibrotic

transformation

Adapted from the Guidelines for diagnosis and management of thrombocytosis , BSH, 2010 and P.Beer Blood, 2011

ET Diagnosis (III): laboratory findings

BM Aspirate • Normocellular for age or mildly hypercellular. • MK increased in number, spectrum morphology:

large or giants with hyperlobulated ( staghorn), occ small forms and normal MK.

• No significant hyperplasia in erythroid and myeloid series.

• Iron stores may be reduced. Siderotic granulation is normal,

BM trephine • MK similar description as in aspirate.• MK distribution is disperse, may occur in loose

clusters within the interstitium.• Reticulin generally no increased ( gr 0-2/4 or 0/3).• Proliferation of erythroid is haemorrhages.

ET Diagnosis (IV): laboratory findings


ET diagnosis (V)morphology featuresBlood film

Hyperlobulated MK in BM

Hypercellular BM

Clusters MK in BM

ASH imagebank

ET Diagnosis (VI): laboratory and radiology findings

Molecular studies • JAK2 V617F, CALR, MPL.• Triple negative 20%• BCR-ABL

Karyotype • No required in routine test, useful as marker of disease progression.

Radiology tests • Splenomegaly and/or hepatomegaly• Thrombosis• To discard other causes of thrombocytosis


2008 WHO criteria 2014 Proposed revisionMeeting all four major criteria. Meeting all four major criteria or first three

major criteria and one minor criterion.Major criteria Major criteria

• Platelet count ≥450×109/L • MK proliferation with large and

mature morphology.• Not meeting WHO criteria for CML, PV,

PMF, MDS or other myeloid neoplasm • Demonstration of JAK2V617F or other

clonal marker or no evidence of reactive thrombocytosis

• Platelet count ≥450×109/L • MK proliferation with large and mature

morphology. • Not meeting WHO criteria for CML, PV, PMF,

MDS or other Myeloid neoplasm • Presence of JAK2, CALR or MPL mutation

Minor criteria Minor criteria No minor criteria. • Presence of a clonal marker (e.g. abnormal

karyotype) or absence of evidence for reactive thrombocytosis.

ET Criteria diagnosis


Myelofibrosis (MF)• Characterized by marked reticulin fibrosis and

osteosclerosis with extramedullary hematopoiesis and organomegaly.

• Primary MF or secondary to PV ( PPV-MF) and ET ( PET-MF).

• Median age 65y, incidence 0.5-1.5 /100,000 per year.

• Median survival in pat<60y is 15y. Leukaemia transformation 10-20%.

• JAK2 +60%, CALR 25% ( superior survival) and MPL 7%

MF diagnosis (I)• Clinical presentation:

– Anemia– Constitutional symptoms – Symptomatic splenomegaly ( palpable up 90%) – hemorrhage and thrombosis events– Infections,– Bone pain– Extramedullar haematopoiesis,– 30% Asymptomatic

MF diagnosis (II)

MYE

LOFI

BRO

SISSplenomegaly

• Haematology diseases: • Lymphoma, leukaemia, myeloma

• Portal hypertension• Autoimmune disorders:

• SLE, RA• InfectionsLeucoerithrobalastic film• Bone marrow infiltration

• AL, Lymphoma, MPN, MDS• Solid cancer

• Hematopathologies• Sepsis• Massive haemolysisFatigueWeight loss

FBC • Anemia, WBC and plat higher at initial diagnosis and pancytopenia is common at advance stages.

• Leucoerythroblastic film and tear drops.

LDH • Elevated

Radiology tests(US, CT) • Splenomegaly and other organomegalies.

Molecular and cytogenetic studies

• JAK2 V617F, CALR, MPL.• Triple negative~ 10% • BCR-ABL • ASXL1 ( associated to inferior survival)• Abnormal karyotype 50-60% : +8, -7/7q, inv (3),

etc.

Adapted from the Guidelines for diagnosis and management of myelofibrosis , BSH, 2012 and Cervantes F, Blood, 2014

MF Diagnosis (III): laboratory and radiology findings

BM Aspirate • Dry ( 50%)• Hypocellular

BM trephine • Prefibrotic phase: - hypercellular with increased neutrophils and atypical MK( enlarged). Erythroid is reduced.- MK dense clusters of variable size and

adjacent to vascular sinuses and bone trabecule.

- Reticulin fibrosis is reduce.• Fibrotic phase:

- Normo or hypocelluar with patches of active haematopoiesis.

- Atypical MK large clusters. - Dense reticulin or collagen fibrosis. - 10-19% blasts detected by cytometry.

MF Diagnosis (IV): laboratory findings

Adapted from the Guidelines for diagnosis and management of myelofibrosis , BSH, 2012 and Cervantes F, Blood, 2014

MF diagnosis (V) morphology features

Hypercelular BM

Clusters MK Reduce reticulin

Increase neutrophilis

MK clusters

Marked reticulin

2008 WHO criteria 2014 Proposed revisionMeeting all three major criteria and two minor criteria.

Meeting all three major criteria or the first two major criteria and all three minor criteria

Major criteria Major criteria • MK proliferation and atypia, accompanied

by either reticulin and/or collagen fibrosis.• Not meeting WHO criteria for CML, PV, MDS

or other myeloid neoplasm.• Demonstration of JAK2V617F or other

clonal marker or no evidence of reactive BM fibrosis.

• MK proliferation and atypia, accompanied by either reticulin and/or collagen fibrosis.

• Not meeting WHO criteria for CML, PV, MDS or other myeloid neoplasm

• Presence of JAK2, CALR or MPL mutation

Minor criteria Minor criteria• Leukoerythroblastosis • Increased serum LDH level • Anemia • Palpable splenomegaly

• Presence of a clonal marker (e.g. abnormal karyotype) or absence of evidence for reactive BM fibrosis

• Presence of anemia or palpable splenomegaly

• Presence of leukoerythroblastosis or increased LDH level.

MF Criteria diagnosis


Practical Algorithm for Diagnosis of MPN

JAMA Oncol. 2015;1(1):97-105. doi:10.1001/jamaoncol.2015.89

MK IN MPN PV ET MF• Mk varied size ( mostly

large ) and hypolobulated• Loose clusters or adjacent

to endosteum

• MK large to giants and deep lobulated – staghorn like nuclei

• Loose clusters or dispersed

Prefibrotic phase:• Atypical MK –cloud like

or hyperchromatic nuclei• Dense clusters adjacent

to endosteum or sinosidsFibrotic phase:• Atypical MK mostly small

MK• Large clusters or sheets

No reticulin increased No reticulin increased Reticulin increased

MANAGEMENT OF MPN: OBJECTIVES

• Reduce the risk of thrombosis and haemorrhage.• Reduce the risk of transformation to MF and/or

AL.• Manage constitutional symptoms and

complications associated ( thrombosis, haemorrhage, pruritus, infections).

• Manage cardiovascular risk factors• Manage MPN in special situations like pregnancy

Conventional risk stratification International polycythemia vera study stratification.1

High risk PV - ANY ONE of the following: Risk factors (weight) • Age >60 years • Previous documented thrombosis,• Erythromelagia (if refractory to aspirin)

Platelets > 1000x109/L* • Diabetes or hypertension requiring

pharmacological therapy* • Significant (i.e. >5 cm below costal margin

on palpation) or symptomatic (pain, early satiety) splenomegaly

• Age ≥67 years (5 points)• Age 57-66 years (2 points) • Leukocyte count ≥15x109/L (1 point)• Venous thrombosis (1 point), • Abnormal karyotype (identified but no

weight)

Low-risk PV Risk categories• Patients not having any of the above risk

factors. • Low-risk (sum of scores 0 points)• Intermediate-risk (sum of scores 1 or 2

points) • High-risk (sum of scores ≥3 points

Table adapted from C.Harrison EHA 2014

Risk stratification in MPN: PV

Risk stratification in MPN: ETConventional risk stratification2 Intermediate

risk ET**International Prognostic Score for ET – ( IPSET A novel risk stratification based upon histopathologically defined ET3)

High risk ET- ANY ONE of the following: • Patients 40-60 years lacking any of the above markers of high risk disease

Risk factors (weight)

• Age ≥60 years (2 points)• Leukocyte count ≥11x109/L (1 point)• Prior thrombosis (1 point)

• Age >60 years • Platelet count >1500x109/L • Previous thrombosis, • Erythromelagia (if refractory to

aspirin)• Previous hemorrhage related to ET • Diabetes or hypertension requiring

pharmacological therapy*

Low-risk ET** Risk categories• Patients under 40 years lacking any of

the above markers of high-risk disease

• Low-risk (sum of scores 0 points)• Intermediate-risk (sum of scores 1 or

2 points) • High-risk (sum of scores ≥3 points


Risk stratification in MPN: MF (I)IPSS prognostic score DIPSS

Prognostic variables 0 1 Prognostic variables 0 1 2

• Age in years <65 >65 • Age in years <65 >65

• WBC count x109/L

<25 >25• WBC count x109/L <25 >25

• Hemoglobin g/l - <10 • Hemoglobin g/l - - <10

• Peripheral blasts% <1 >1 • Peripheral blood %

<1 >1

• Constitutional symptoms

No Yes • Constitutional symptoms

No Yes

Risk assignment: Low = 0, Intermediate 1 = 1, Intermediate 2 = 2 High = 3+. Median survivals are 135, 95, 48 and 27 months, respectively.

Risk assignment: Low = 0; Intermediate 1 = 1 or 2; Intermediate 2 = 3 or 4; High = 5 or 6. Median survival: not reached, 14.2, 4, and 1.5 years, respectively


DIPSS plus prognostic score

Points for DIPPS 0 1 2 3

DIPSS prognositic group points Low risk 0 Intermidate-1 Intermidate-2 High risk

To the DIPSS prognostic group add one point for:

• Platelets count x109/L • - • <100 • - • -

• Red cell trasnfusion required • No • Yes • - • -

• Unfavorable karyotype (includes +8, -7/7q-, i(17q), inv(3), -5/5q-, 12p-. 11q23 rearrangements and complex karyotypes. )

• No • yes

Risk assignment number of points Low = 0; Intermediate 1 = 1; Intermediate 2 = 2 or 3; High = 4 to 6. Corresponding median survival estimates: 185, 78, 35 and 16m.

Risk stratification in MPN: MF (II)


Risk stratification in MPN: MF (III)

Tefferi A. et al, JAMA network, 2015

• CALR mutations associated favourable survival (10.4y), ASXL1 unfavourable survival (2.3y) independent of DIPSS-plus risk

• New prognostic models:– MIPSS- mutation enhanced international prognostic

scoring system. – GPSS- genetics based prognostic system.

Recommendation of Treatment in PV (I)ALL PATIENTS HIGH RISK ( age>60y and/or

presence thrombosis)PV in pregnacy

• Assess and manage CV risk • Assess and manage CV risk • Low risk: Aspirin low dose and Phlebotomy

• Cytoreductive treatment no recommended in low risk patients

• >60y: • Hydroxyurea, • Second line: Ruxolitinib,

Interferon , Busulfan ( >75y), clinical trial.

• <60y :• Interferon, Anagrelide,

clinical trial

• Cytoreduction therapy if High risk : Interferon and phlebotomy

• Aspirin low dose, unless CI, • If Jak2+ and CV risk:

Aspirin bd.• Determinate ristocetin

cofactor activity >30% if high platetets

• Monitor closely pat with abnormal bleeding diathesis.

• Low dose of aspirin

• Phlebotomy hto target<0.45 • Phlebotomy hto target<0.45

Table adapted from C.Harrison EHA 2014 and A.Tefferi AJH 2015

Recommendation of Treatment in PV (II)• Ruxolitinib- Indicate in patients inadequate response to or are intolerant

of hydroxyurea.• Approved in Europe in 2015. • Control hematocrit and PV-related symptoms• Reduce spleen volume

Verstovsek s et all. ASCO meeting 2011

Recommendation of Treatment in ETALL PATIENTS HIGH RISK ( age>60y and/or presence

thrombosis)ET in pregnacy

• Assess and manage CV risk • Assess and manage CV risk • Low risk: Aspirin low dose

• Cytoreductive treatment no recommended in low risk patients

• >60y: • Hydroxyurea, • Second line: Interferon, anagrelide

, Busulfan ( >65y), clinical trial.• <60y :

• Hydroxyurea or Interferon, • Second line: clinical trial,

interferon, Anagrelide, combination

• Cytoreduction therapy if High risk : Interferon

• Observation or • Aspirin low dose unless CI,

• If Jak2+ and CV risk: Aspirin bd.

• Determinate ristocetin cofactor activity >30% if high platetets

• Monitor closely pat with abnormal bleeding diathesis.

• Low dose of aspirin

Table adapted from C.Harrison EHA 2014 and A.Tefferi AJH 2015

Recommendation of Treatment in MF (I)Intermediate 2 and high-risk patients• AlloHSCT DIPSS-plus high or int-2 risk pat.

High mort-morb ( 50%pat) 5y survival 37% SCTmatched Graft-vs-host 43% SCT matched ? Cord blood transplatation

• Cytoreductive agents Hydroxiurea Interferon (early phase)

• Mangement of anemia Transfusion if symptomatic anaemia Erythropoiesis-stimulating agents Androgens Immunomodulatory agents Prednisolone Danazol

• Splenomegaly Splenectomy Radiotherapy HU Ruxolitinib

Table adapted from Guidelines BSH 2012, C.Harrison EHA 2014 and A.Tefferi AJH 2015

Recommendation of Treatment in MF (II)Ruxolitinib High risk and/or int-2 risk pat.

COMFORT studies:• reduced splenomegaly • increased in volume spleen in 5dl, increase risk of death

9%,• improve constitutional symptoms and QOL• Survival benefit- response maintaned after 3yFU (hazard

ratio, 0.48; 95% CI, 0.28-0.85; log-rank test, P = .009) Heam toxicities: anemia and thrombocytopenia. Increase risk of infections

Other JAK inhibitors & combination therapies

Fedratinib – halted due to Wernicke´s encephalopathy Pacrinitib- JAK2 and FTL3 inh. Momelotinib- ph3, improve in anaemia, symptoms and

splenomegaly. Imetelstat- telomerase inhibitor Pomalidomide & Rux LDE225 & Rux Panobinostat & Rux Buparlisib, Everolimus, PRM-151….

Table adapted from Guidelines BSH 2012, C.Harrison EHA 2014 and A.Tefferi AJH 2015

SUMMARY• Knowledge of MPN pathogenesis has rapidly changed in

last decade and continues evolving. • New molecular markers to be included in criteria diagnosis

and risk factor prognosis.• ? WHO criteria diagnosis to be reviewed. • Consider ongoing clinical trials as option for high risk pat or

resistance/intolerance to previous conventional therapies.• Future target therapies focus on new molecular pathways.• Further clinical trials are required for promising agents to

clarify adverse events and molecular and histopathology response.

What is past is prologue. The best is yet to be...

Thanks

diagnosis and management of myeloproliferative neoplasms

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