Bone Marrow Failure/ Aplastic

Anemia
Anca Colita
 What is Aplastic Anemia?
Aplastic anemia is a bone marrow failure syndrome characterized by
peripheral pancytopenia and marrow hypoplasia.

Bone marrow is a
Factory of Blood Cells

Red Blood Cell Platelets

White Blood Cell
 Aplastic Anemia

• Aplastic Anemia patients have decreased

amounts of:
- Red Blood Cells
- White Blood Cells
- Platelets
 Functions of Blood Cells
Red Blood Cells
Carry oxygen to all body organs
White Blood Cells
Fight infection and keep you healthy
Platelets
Help control bleeding
 Symptoms

Low Red Blood Cell

Fatigue, Headache, Inability to Concentrate
Low White Blood Cell
Viral Infections, Bacterial Infections, …
Low Platelets
Easy Bruising, Nosebleeds, Petechiae, …
 DEFINITION
A disorder of the hemtopoietic system
characterized by:
Bone marrow - marked reduction of all 3 cell lines
Peripheral blood - pancytopenia
 PATHOGENESIS
Stem cell failure resulting from:
1-An acquired intrinsic stem cell defect
2-An environmental cause
Direct toxic injury
Immune mechanisms
Growth factor deficiency
Defects in the microenvironment
 Epidemiology
Incidence: 5-10:106 per year
Age:
15 –30 years
> 60 years
Sex: M = F
 Clinical manifestations
Insidious onset
Manifestations caused by pancytopenia
Anemia - weakness, fatigue
Thrombocytopenia – bleeding
Neutropenia - infections
 Classification
• Inherited
– Fanconi’s anemia, dyskeratosis congenita, Shwachman-Diamond Syndrome,
Reticular dysgenesis, Amegakaryocytic thrombocytopenia, familial aplastic
anemia, preleukemia (monosomy 7) and nonhematologic disease (Down,
Dubowitz, Seckel)
• Acquired
– Irradiation
– drugs and chemicals: cytotoxic agents, benzene, idiosyncratic reaction,
chloramphenicol, NSAIDS, antiepileptics, Gold
– viruses: EBV, Hepatitis virus (non-A,non-B, non-C, non-G), Parvovirus
(transient aplastic crisis or pure red cell aplasia), HIV
– Immune diseases: eosinophilic fasciitis, hyperimmunoglobulinemia,
thymoma and thymic carcinoma, GvHD in immunodeficiency
– PNH
– Pregnancy
– Idiopathic
 Diagnosis

Peripheral blood Bone marrow biopsy

*Pancytopenia *Empty fatty spaces
*Normocytic- *Few hematopoietic
normochromic cells
anemia *Lymphocytes and
*Low reticulocyte index plasma cells
BM Aspiration BM Biopsy
 BM biopsy
hypocellular ,increased fat spaces
 Bone Marrow Failure
Congenital/ Syndromic
Acquired
Acquired Aplastic Anemia
 Acquired Aplastic Anemia

**Secondary

**Idiopathic
 Secondary AA
1-Meds/ toxins
Chemotherapy
Chloramphenicol, benzene,
carbamazapine, indomethacin, cimetidine,
sulfas, acetazolamide, lithium
2- Radiation
3- Viruses - EBV, HIV, parvo B19, hepatitis
4-Paroxysmal Nocturnal Hemoglobinurea
5-Malnutrition
6-Myelodysplastic syndromes
7-Thymoma
 PATHOPHYSIOLOGY
1. Direct toxic injury to hematopoietic stem cells can
be induced by exposure to ionizing radiation,
cytotoxic chemotherapy, or benzene.

These agents can crosslink DNA and induce DNA

strand breaks leading to inhibition of DNA and RNA
synthesis.
2-Immune-mediated destruction of hematopoietic
stem cells
-- Direct killing of the stem cells has been
hypothesized to occur via interations between
Fas ligand expressed on the T-cells and Fas
(CD95) present on the stem cells, which triggers
programmed cell death (apoptosis).
-- T-lymphocytes also may suppress stem cell
proliferation by elaborating soluble factors
including interferon-γ.
 Idiopathic AA
*70% or more of cases
Higher in SE Asia
M=F
 AA - Clinical
** Symptoms are due to pancytopenia:
pallor, mucosal bleeding, ecchymoses, or petechiae and
bacterial or fungal infections..
** Hepatosplenomegaly and lymphadenopathy do not
occur; their presence suggests an underlying
leukemia.
** Hyperplastic gingivitis is also a symptom of aplastic
anemia.
 AA - Labs
↓ RBC = pale, tachycardic
↓ Plt = bruising, bleeding
↓ WBC = infection
↓ Retic < 1%
↓Plt < 20,000
↓ ANC < 500
 AA - Labs
Marrow : < 25% cellularity
• Marrow is profoundly
hypocellular with decrease
in all elements.
• Residual hematopoietic cells
are morphologically normal.
• Malignant infiltrates and
fibrosis is absent.
• Hematopoiesis is non-
megaloblastic.
 AA - Evaluation

*CBC w/ diff and retic

*Bone marrow
*Send DEB (Fanconi’s test)
*Send Hep A, B, C, D titers HIV
*Test for PNH (CD55, CD59)
*HLA typing
*Fetal hemoglobin
*Liver and renal function chemistries
*Quantitative immunoglobulins, C3, C4, and
complement.
* Autoimmune disease evaluation:
Antinuclear antibody (ANA), total
hemolytic complement (CH50), Coombs’
test.
* HLA typing: Patient and family done at the
time of diagnosis of severe aplastic anemia
to ensure a timely transplant.
 Classification of aplastic anemia
1. Severe aplastic anemia is defined if at last two of
the following criteria are present:
- ANC < 0.5 x109/L
- PLT < 20 x109/L
- RTC < 1% (20 x109/L)
Hypoplastic bone marrow (less than 25%) on
biopsy
2. Very severe aplastic anemia
- criteria as above but ANC < 0.2 x109/L
3. Non-severe aplastic anemia.
 Differential Diagnosis
• Pancytopenia with hypocellular bone marrow
– Acquired aplastic anemia - Inherited aplastic anemia
– Hypoplastic MDS - Hypoplastic AML
• Pancytopenia with cellular bone marrow
– Primary bone marrow diseases -MDS
– PNH - Myelofibrosis
– Myelophthisis - Bone marrow lymphoma
– Hairy cell leukemia - SLE, Sjogren’s disease
– Hypersplenism - Vitamin B12 and folate deficiency
– Overwhelming infection - Alcoholism
– Brucellosis - Ehrlichiosis
– Sarcoidosis - tuberculosis
• Hypocellular bone marrow with or without cytopenia
– Q fever - Legionaires disease
– Mycobacteria - Tuberculosis
– Hypothyroidism - Anorexia nervosa
 Treatment Options

Bone Marrow
Transplant
Other

Immune Suppressive Supportive Care

Therapy
 TREATMENT
1-Withdrawal of the etiologic agent
2-Supportive treatment
Blood and platelet transfusion used with caution- sensitization
(filtered)
3-Allogeneic BMT
-Preferably from sibling
-Curative in 60-90% of patients
-Applicable only for a third of patients
*Immunosuppression
Cyclosporin + ATG
Corticosteroids
High dose cyclophosphamide
*G-CSF/ GM-CSF/ EPO - maybe
**Response rate 50-70% occurs 2-3 months
post Rx.
 Hematopoietic stem cell transplatation in
severe aplastic anemia
1. Advantages
- correction of hematopoietic defect
- long-term survival: 80% - 90% (HLA-matched sibling donor)
- majority of the patients appear to be cured
2. Restrictions
- age below 40
- suitable donor available in less than 30% (sibling)
- 25-40% risk of GVHD
- 5-15% risk of graft failure in multitransfused patients
- high mortality after MUD-HSCT
- solid tumors (12%)
 Immunosuppressive therapy
• Indicated for children without familial
donor and for patients > 40 years
• Anti-Thymocyte Globulin (ATG) from horse
or rabbit, cyclosporin, methylprednisolone.
• Best results are for combination therapy.
• Response is slow, 4-12 weeks to see early
improvement.
 AA - Outcomes
Age, Younger is better
BMT
< 20 yr with a sib… 75%
20 - 40 yr with a sib…60%
< 20 yr unrelated BMT… 40%
20 - 40 yr unrelated BMT…35%
Immunosuppression - 60 - 80%
But for how long and consequences…
Inherited bone marrow syndromes
(Inherited aplastic anemia)

1. Fanconi Anemia
 History: Guido Fanconi
Fanconi Anemia (Fanconi
pancytopenia syndrome):
1927 - 3 brothers with
pancytopenia and physical
abnormalities,
“perniziosiforme”
Fanconi Syndrome (renal
Fanconi syndrome): 1936 –
Ricketts, growth retardation,
proteinuria, glucosuria, and
proximal renal tubular
acidosis
 Fanconi Anemia (FA)
Rare (< 1/ 100,000 births)
Autosomal recessive
Many physical features
But up to 20-25% will have no physical findings
Mean age at dx 7.8 yrs
Autosomal Recessive Inheritance
 FA- Clinical
Abnormality % of FA Patients
Skin 60%
Short Stature 57%
Upper Limb Abnl 48%
Head/ Microcephaly 27%
Renal 23%
Dev. Delay 13%
Short Stature Only 1%
Skin Only 3%
 Clinical Features
Progressive bone marrow failure
Most common etiology of inherited bone marrow
failure
Others include dykeratosis congenita, amegakaryocytic
thrombocytopenia, Schwachman-Diamond syndrome
Increased risk of MDS and AML (15,000x)
Many have monosomy 7, or duplication of 1q
(Auerbach et al., Cancer Genet Cytogenet 1991)
 Clinical Features
Increased risk of solid tumor formation (hepatic,
esophageal, oropharyngeal, vulvar)
Average age at diagnosis is 23*
Cumulative incidence ~30% by age 45**
 FA - genetics
Identification of subtypes (compliment groups)
A, B, C, D1, D2, E, F, G
Identical clinically
Sub-units of a common protein/ common pathway
Protein modifies FANCD2
FANCD2 interacts with BRCA1 and 2
BRCA1 and 2 needed for DNA repair
 PATHOPHYSIOLOGY
DNA damage activates a complex consisting of
Fanconi proteins A, C, G, and F. This in turn
leads to the modification of the FANCD2
protein. This protein interacts, for example,
with the breast cancer susceptibility gene
BRCA1.
*Fanconi anemia cells are characterized by
hypersensitivity to chromosomal breakage as
well as hypersensitivity to G2/M cell cycle arrest
induced by DNA cross-linking agents.
*In addition there is sensitivity to oxygen-free
radicals and to ionizing radiation.
 Diagnosis
*Pts. with congenital abnormalities are often
diagnosed as neonates/infants
*Others may be diagnosed when hematological
problems occur
*Median age of onset of pancytopenia is 7
Usually normal CBC at birth
*First develop macrocytosis, then thrombocytopenia,
and eventually neutropenia
 Diagnosis
Based on chromosomal hypersensitivity to cross-
linking agents
Chromosome fragility test: Mitomycin C (MMC) or
diepoxybutane (DEB) added to lymphoctyes –
increases the number of chromosome breaks and
radial structures
Very specific for FA, regardless of severity of
disease
Can do chromosome breakage analysis on
amniotic cells, chorionic villus cells or fetal
blood
FA cells were treated with mitomycin C and harvested in metaphase. Typical
abnormalities include radial formation (green circle) and chromosome breaks (red
arrows).
 Initial management
Refer for genetic counseling
Testing of siblings
Renal ultrasound, hearing test, eye exam
Endocrine evaluation if evidence of growth failure
(check growth hormone levels, TSH)
Referral to hand surgeon for radial ray defects
Bone marrow biopsy
 Management
• Bone marrow failure
– Transfusions
– Androgens (e.g. oral oxymethalone) – can improve blood
counts in 50% of pts.
• Side effects: Masculinization, acne, hyperactivity,
premature closure of epiphyses, liver toxicity, hepatic
adenomas
– Growth factors (G-CSF, CM-CSF) – should not be used in
patients with clonal cytogenetic abnormalities
– Bone marrow transplantation
• FA cells are very sensitive to radiation and alkylating
agents – can use greatly reduced doses
• 2-yr. survival 70% for allo;* 20-40% for MUD**
 Other Congenital Marrow Failures
Dystkeratosis Congenita
Rare
Different modes of inheritance
-short stature, leukoplakia, skin hiperpigmentation,
ungheal dysplasia
50% develop aplastic anemia after 10 y
Schwachman-Diamond
Cartilage-Hair Hypoplasia
Familial Marrow Dysfunction
…….