Understanding Your Blood Work Results

Carlos Besses, MD, PhD

Hematology Department

Hospital del Mar - IMIM, Barcelona

Carlos Besses – Disclosures

Novartis Honorarium Speaker

Shire Honorarium Speaker

Galena Honorarium Advisory Board

Abnormal blood results

Diagnostic process

History

taking Physical

examination

Additional

tests

Bone marrow

examination

Genetic

tests

Blood Results Leading to Suspicion of MPN

─ Thrombocytosis ( platelets)

─ Erythrocytosis ( red blood cells)

─ Leukocytosis ( white blood cells)

─ Anemia ( red blood cells)

─ Thrombocytopenia ( platelets)

─ Any combination of the above

PV

PMF

ET

Work-up for a Patient with Thrombocytosis

Platalet count ≥450x109/L

Secondary thrombocytosis Persistent unexplained thrombocytosis

History taking Physical

examination

Usually normal

Additional

tests

• Iron deficiency • Infection • Inflammation • Surgery • Cancer • Splenectomy • ……

• Any relative with MPN or excess of blood cells?

• Microvascular symptoms

Genetic

tests

Bone marrow

examination

Normal

ET

Workflow for Molecular Diagnosis of ET

ET Suspicion

JAK2 V617F

Positive 50-60% Negative

CALR

Positive 15-35% Negative

MPL

Positive 3-5% Negative

BCR-ABL1

Triple-Negative

5-25%

Negative Positive CML

Essential Thrombocythemia

ET Clinical Case, bone marrow biopsy

ET

A

C

B

Megakaryocyte nuclei:

A. Hyperlobulation: staghorn-like

B. Hypolobulation: bulbous/cloud-like

C. Hyperchromatic

Work-up for a Patient with Erytrocytosis

Increased Hct/Hb

History

taking

Physical

examination

Additional

tests

Splenomegaly JAK2V617F

Erythropoietin level

Thrombocitosis

and/or

Leukocytosis

Red cell mass Bone marrow

examination

• Chronic lung disease • Smoking • Renal disease • Tumors • Androgen/Epo use • Sleep apnea • ……

• Chest X Ray • Abdominal ultrasound • Oxygen saturation • Carboxy hemoglobin • ……

Normal

PV

JAK2 JAK2

NUCLEUS

CYTOPLASM

Type I cytokine receptors

EPOR

TPOR

G-CSF

EPO

TPO

STAT STAT

JAK2 JAK2

P P

NUCLEUS

CYTOPLASM

Type I cytokine receptors

EPOR

TPOR

G-CSF

Gene transcription

EPO

TPO

P

P

P P

P

P

P P

STAT STAT

JAK2 JAK2

P P

NUCLEUS

CYTOPLASM

Gene transcription

EPO

TPO

P

P

P P

P

P

P P

G>T

GTC TTC

Val (V) Phe (F)

Type I cytokine receptors

EPOR

TPOR

G-CSF

PV

Increased leukocyte count

History

taking

Physical

examination Additional

tests

Splenomegaly

and/or

lymphadenopathy

Blood

film

Secondary

leukocytosis

Myeloid cells Lymphoid cells

• Chromosome and/or

genetic studies

• Cell flow cytometry

• CT scans

• PET, MRI

• ……

• Infections

• Acute

inflammation

• Corticosteroids

• Smoking

• ……

Work-up for a Patient with Leukocytosis

What are the Cells Involved in Myeloid Diseases?

PV

CLL

CML

Work-up for a Patient with Suspicion of Myelofibrosis

Anemia +/-

Other cytopenia +/-

WBC/platelets

Genetic test Peripheral blood Bone marrow biopsy +/-

Cytogenetic study

Mandatory Staining for:

Hematoxylin-eosin

Reticulin

Collagen ASXL1,

SRSF2, EZH2,

IDH1/2

Splenomegaly plus

Optional

JAK2V617F,

CALR, MPL

+/-

BCR-ABL1

Blood film

+/-

Cytogenetic study

PMF

Myelofibrosis: an heterogeneous disease

ET

Staging of Bone Marrow Fibrosis Severity in Myelofibrosis

1. Thiele J, et al. Haematologica. 2005;90:1128

2. Thiele J, Kvasnicka HM. Ann Hematol. 2006;85:226

3. Michiels JJ, Thiele J. Int J Hematol. 2002;76:133

MF0 MF1 MF2 MF3

Scattered linear reticulin,

no intersections1-3

Loose network of

reticulin with many

intersections1-3

Diffuse, dense increase in

reticulin with extensive

intersections and

occasional collagen foci1-3

Diffuse and dense

increase in reticulin with

extensive intersections;

presence of coarse

collagen bundles, often

with significant

osteosclerosis1-3

Bone Marrow Fibrosis Grading According to European Myelofibrosis Network (EUMNET) Consensus Criteria

With kind permission from Springer Science +Business Media:

Annals of Hematology. Ref. 2, Fig. 1.

MF0

MF2 MF3

MF1

Reticulin fibrosis

PMF

Thiele et al, Blood 2011;117(21):5710-5718

WHO-Classification

A

C

B

Megakaryocyte nuclei:

A. Hyperlobulation: staghorn-like

B. Hypolobulation: bulbous/cloud-like

C. Hyperchromatic

Survival and Disease Complications

in ET vs. Early/Prefibrotic PMF

Outcome ET

15-Year Cumulative

Incidence (%)

Early/Prefibrotic PMF 15-Year Cumulative

Incidence (%)

Survival 75% 44%

Leukemic transformation 2% 12%

Transformation to overt myelofibrosis 9% 17%

Thrombosis 22% 25%

Results from 1104 patients; 891 (81%) True ET; 180 (16%) early/prefibrotic PMF; 33 (3%) not evaluable

Median follow-up: 6.2 years for ET; 7 years for early/prefibrotic PMF

Barbui et al, J Clin Oncol 2011;29(23):3179-3184

PV Suspicion ET Suspicion PMF Suspicion

Essential Thrombocythemia

Positive

Primary Myelofibrosis

Positive Negative Negative

Polycythemia Vera

Positive

JAK2 exon 12

Positive

Negative

JAK2V617F JAK2V617F JAK2V617F

Discard BCR-ABL

Negative

MPL

Positive

Negative

MPL

Positive

Positive

CALR

Positive

CALR

Negative

Negative Negative

1. Blood work results are important information but the

diagnosis relies on the whole picture

2. Genetic studies & Bone marrow examination are

essential components of the diagnosis

3. Common-sense and step-based tests are the best

way to reach a well-grounded diagnosis

Please, trust in your doctor!

Conclusions

Thank you for your attention