Myeloproliferative Neoplasms
(MPN)
1
Objectives
1. classify MPNs; Ph chromosome negative and Ph chromosome positive.
2. understand the pathogenesis of MPNs and its clinical manifestations.
3. describe the molecular techniques used in the diagnosis and monitoring of
treatment
response of MPNs.
2
Introduction
• Group of conditions arising from marrow
stem cells
• Characterised by clonal proliferation of one or
more haemopoietic components in the BM
• Can progress to acute leukaemia
• Can progress to severe BM fibrosis
4
MPN
• Granulopoiesis –CML ( Chronic Myeloid leukaemia)
• Erythropoiesis- PV (Polycythaemia Vera)
• Thrombopoiesis- ET (Essential Thrombocythaemia)
• Primary Myelofibrosis - MF
5
MPN-Classification
Philadelphia ( +) Philadelphia( -)
• Granulopoiesis Erythropoiesis- PV
CML Thrombopoiesis- ET
Primary Myelofibrosis - MF
6
7
Signal Transducers and Activation of Transcription
8
9
JAK 2 and MPN
Frequency
PV 95%
ET 50%
MF 50%
10
Other Genetic abnormalities
11
Polycythaemia
• Raised Hb
• What is next?
• True/spurious
• Repeat on a non tourniquet sample after good
hydration
• Still elevated
Male Female
Hct .49 .48
Hb 16.5g/dl 16.0g/dl
Absolute erythrocytosis
Primary Secondary
Congenital Acquired(PV) Congenital Acquired
PV
Polycythaemia vera
• Clonal stem cell disorder
• (Val 617 Phe)/V617F- JAK 2 mutation-95%
• Exon 12 mutation-some
• excessive production of all myeloid cell
lines
• predominantly red cells - RCV
Clinical features
• Old age- 6 th decade
• CF Hyperviscosity
Hypermetabolism
Clinical features
1. Headache, dyspnoea, blurred vision
2. Plethoric appearance, conjunctival suffusion
3. Night sweats
4. Pruritus
5. Splenomegaly in 75%
6. Haemorrhages
7. Thrombosis-arterial/venous
8. Hypertension
9. Gout
Lab findings
• FBC-Hb/Hct/RCC increased
• Neutrophil leucocytosis & thrombocytosis-
50%
• Eosinophilia/ Basophilia
• BP-Crowded RBC
• BM-Hypercellular,panmyelosis
• Erythropoietin-Low
• Uric acid-Increased
• LDH-NL/Slightly raised
PRV - typical blood count
WBC x 109/L 18.0 [4-11]
Hb g/dl 20 [13-18]
HCt 0.62[.42-.51]
MCV fl 75 [80-100]
Platelets x 109/L 850 [150-450]
Neuts x 109/L 14.6[2-7.5]
Lymphs x 109/L 2.0 [1.5-4]
Monos x 109/L 0.8 [0.2-0.8]
Eos x 109/L 0.1 [0-0.7]
Basos x 109/L 0.5 [0-0.1]
PV-BM
WHO PV criteria
• Major criteria
1.Hemoglobin .16.5 g/dL in men
• Hemoglobin .16.0 g/dL in women
or,
• Hematocrit .49% in men
• Hematocrit .48% in women
or
• increased red cell mass (RCM)*
2. BM biopsy showing hypercellularity for age with trilineage growth (panmyelosis)
including prominent erythroid, granulocytic, and megakaryocytic proliferation with
pleomorphic, mature megakaryocytes (differences in size)
3. Presence of JAK2V617F or JAK2 exon 12mutation
• Minor criterion
• Subnormal serum erythropoietin level
Diagnosis of PV requires meeting either all 3 major criteria, or the first 2 major criteria and the minor
criterion†
*More than 25% above mean normal predicted value.
MPN – Classification
Philadelphia ( +) Philadelphia( -)
• Granulopoiesis-CML ➢ Erythropoiesis- PV(Polycythaemia Vera)
➢ Thrombopoiesis- ET(Essential Thrombocythaemia)
➢ Primary Myelofibrosis - MF
ESSENTIAL THROMBOCYTHAEMIA
• MPN of Megakaryocytes
• Sustained thrombocytosis
• Mutations-
JAK 2 mutation –positive in 50%
MPL gene mutation
New- Calreticulin mutation
Thrombocytosis
Primary Secondary/reactive Spurious
ET
Clinical features
• Age – 50 – 60 yrs, 2 nd peak at 30 yrs in
females
• >1/2 – Asymptomatic
• Thrombosis
• Hemorrhage
• Splenomegaly – 50%
• Hepatomegaly – 15-20%
• Splenic atrophy
Laboratory features
• FBC – Thrombocytosis
• BP – Platelet anisocytosis, small- large bizarre forms
megakaryocyte fragments
sometimes HC/MC
• BM – Marked increase in megakaryocytes
large, giant forms; hyperlobulated ‘stag horn’ nuclei
Reticulin – not increased
• JAK 2 mutation positive in 50%
• Calreticulin mutation-1/3rd
• Platelet function tests-Abnormal
Normal
Essential Thrombocythemia
BM-ET
Increased megakaryocytes
2. Essential Thrombocythemia (ET) Key Diagnostic Criteria (WHO 2016/2022)
• Major Criteria:
• Platelet Count: ≥450 × 10⁹/L.2
• Bone Marrow Biopsy Findings: Increased megakaryocytes with hyperlobulated
nuclei. No significant fibrosis or other myeloid neoplasms
• Exclusion of Other MPNs :Rule out PV, CML, PMF, or MDS.4. Mutations in JAK2,
CALR, or MPL.
• Minor Criterion:
• Absence of reactive causes for thrombocytosis.
• Diagnosis: Requires all 4 major criteria or the first 3 major criteria and the minor
criterion.
Primary Myelofibrosis (MF)
• Clonal Stem Cell disease
• Mutations-
JAK 2 mutation-50%
Calreticulin-30-40% TET 2
mutation-15%
• 1/3-previous Hx of PV/ET
• 10-20% transform to leukaemia
• Increased Megakaryocytes
• Progressive reactive BM fibrosis
• Caused by fibroblast stimulation by PDGF
• Myeloid metaplasia - Haemopoiesis in liver & Spleen
Massive Splenomegaly
Clinical features
Laboratory findings
• Anaemia
• WBC/Platelets-could be initially high but later leucopenia &
thrombocytopenia
• Leucoerthroblatic blood film with tear drop poikilocytosis
• BMA-dry tap
• Trephine Biopsy-Increased megakaryocytes , Fibrosis,
osteosclerosis
• Reticulin stain-confirms increased fibrosis
• JAK 2 mutation- + in 50%
• Raised LDH/Uric acid
MF - typical blood count
WBC x 109/L 2.4 [4-11]
Hb g/L 88 [140-
180]
MCV fl 85 [80-
100]
Platelets x 109/L 60 [150-
450]
Neuts x 109/L 1.0 [2-7.5]
Lymphs x 109/L 1.0 [1.5-4]
Monos x 109/L 0.2 [0.2-
0.8]
Eos x 109/L 0.1 [0-0.7]
Basos x 109/L 0.1 [0-0.1]
Nucleated red cells
Myelocyte
Tear drop poikilocytes
Clustering of Atypical
Megakaryocytes
in prefibrotic/early
PMF
WHO diagnostic criteria for PMF- all 3 major criteria and >2 minor criteria
Major Criteria:
1. Bone Marrow Biopsy Findings:Fibrosis (grade 2 or 3) with atypical
megakaryocyte clusters.
2. JAK2, CALR, or MPL Mutation or absence of reactive marrow fibrosis.
3. Peripheral Blood Features:Leukoerythroblastosis, tear-drop-shaped RBCs,
anemia.
Minor Criteria: (≥2 required):Splenomegaly.Elevated
LDH.Anemia.Constitutional symptoms (fever, weight loss, night sweats).
Chronic Leukaemia
What are chronic Leukemias?
• Neoplasms of either the myeloid or
lymphoid lineage which are capable of
differentiation to mature cells.
Types of Leukemia
Acute – no Chronic –
maturation maturation
beyond blast beyond blast
Lymphocytic - T or B
lineage ALL CLL
Myeloid –
(granulocytes,
AML CML
monocytes,
erythrocytes, platelets)
CML
• Clonal disorder of pluripotent stem cells
• Characterized by Philadelphia chromosome
Philadelphia chromosome
The bcr/abl fusion protein
❑ Uncontrolled kinase activity
❑ Deregulated cellular proliferation
❑ Decreased adherence of leukemia
cells to the bone marrow stroma
❑ Leukemic cells are protected from
normal programmed cell death
(apoptosis)
Clinical features
• Male : Female=1.4:1
• 40-60y
• Symptoms related to hypermetabolism
• Massive splenomegaly
• Features of anaemia
• Bleeding manifestations
• Hyperuricaemis-Gout/Renal impairment
• Rare-visual disturbances/priapism
• Incidental finding – 50%
Laboratory findings
1.FBC+BP
Leucocytosis
Complete spectrum of myeloid cells in the
peripheral blood(left shift)
Neutrophil and myelocyte peaks
Increased basophils/eosinophils
NC/NC anaemia
Platelets-increased/NL/decreased
CML - blood count
WBC x 109/L 122 [4-11]
Hb g/dL 9.85 [12.0-16.0]
MCV fl 87 [79-98]
Platelets x 109/L 843 [150-450]
Neuts x 109/L 80 [2-7.5]
Lymphs x 109/L 2.0 [1.5-4]
Monos x 109/L 2.0 [0.2-0.8]
Eos x 109/L 1.0 [0-0.7]
Basos x 109/L 5.0 [0-0.1]
Metamyelocytes x 109/L 4.0 [0]
Myelocytes x 109/L 20.0 [0]
Promyelocytes x 109/L 4.0 [0]
Blasts x 109/L 2.0 [0]
Nucleated red cells x 109/L 2.0 [0]
CML -BP
CML -BP
CML -BP
2.Demonstration of underlying genetic
abnormality
Philadelphia chromosome- Karyotyping
BCR-ABL fusion gene-FISH
PCR
• BM Biopsy-Hypercellular,granulocytic
hyperplasia
• USS-abdomen-Splenomegaly
• Serum-Uric acid raised
