REFRACTORY ANEMIA

1. REFRACTORY ANEMIA

2. • RA defined as part of the heterogeneous group of Myelodysplastic
syndrome that affects the production normal red blood cells from the
bone marrow.
• Anemia is refractory – Non responsiveness to all conventional forms
of therapy.

3. MDS
• Clonal hematopoietic stem cell disorders characterized by
cytopenias, dysplasia in one or more of the major myeloid
cell lines, ineffective hematopoiesis with cellular marrow
and risk for leukemic transformation.

4. PREDISPOSING FACTORS
HEREDITARY
1. Down’s syndrome
2. NF
3. Congenital Neutropenia
4. Fanconi’s anemia
5. Shwachman Diamond syndrome
6. Diamond Blackfan syndrome
ACQUIRED
1. Radiation
2. Mutation
3. Alkylating agents
4. Tabacoo
5. Benzene
6. Aplastic anemia
7. PNH

5. Pathogenesis

6. CLASSIFICATION
1. FAB
2. WHO

7. FAB CLASSIFIACTION
SUB TYPE PS BM
RA Blasts < 1%
Blasts < 5%
RS < 15%
RA – RS Blasts < 1%
Blasts < 5%
RS > 15%
RAEB Blasts < 5% Blasts 5-20%
RAEBT Blasts > 5%
Blasts 20-30%
Auer rods
CMML
Blasts < 5%
Monocyte > 1%
Any of the above
AML Variable Blasts > 30%

8. WHO CLASSIFICATION
SUBTYPE PS BM
RCUD Unicytopenia / No blast
Unilineage dysplasia > 10% of cells
Blasts < 5%
RS < 15%
RARS Anemia
Erythroid hyperplasia with
Dyserythropoiesis
RS > 15%
Blasts < 5%
RCMD
Bi / Pancytopenia
No blast / No Auer rods
Dysplasia >10 % in > 2 lineage
Blast <5%
RS > 15%
RAEB-1
<5% blasts
Bi / Pancytopenia
No Auer Rods
5-9% blasts
No Auer rods
Dysplasia > 1 hematopoietic cell line
RAEB-2
5-9% blasts
Cytopenias
Auer rods
10-19% blasts
Auer rod +
Myelodysplasia > 1 line

9. MDS – U
No blasts
Cytopenias only
< 5% blasts
Cytogenetic abnormalities
Granulocytic or
Megakaryocytic dysplasia
MDS – 5q deletion
< 1% blasts
Anemia
Increased platelets
< 5% blasts
Isolated 5q deletion
No Auer rods
CMDS
< 2 % blasts
Dysplastic changes in > 10 %
of neutrophils
Dysplasia > 10% erythroid
precursors
Dysplasia > 10% granulocytic
precursors

10. EVALUATION OF SUSPECTED MDS
1. History :
• Prior exposure to chemotherapy/ radiation
• Recurrent infections, Bleeding
2. Examination :
• Pallor/ Splenomegaly
3. Blood counts:
• Hb,TLC,Platelet count, Reticulocyte count
4. Peripheral smear:
• Macrocytosis, Cytopenias, Pseudo – Pelger Huet anomaly, Hypogranular Neutrophils
5. BM aspirate / Biopsy
6. Exclusion of reactive causes
• Megaloblastic anemia,HIV infection, Alcoholism

11. PERIPHERAL SMEAR
Erythroid
• Ovalocytosis
• Macrocytosis
• Eliptocytosis
• Tear drop cells
• Nucleated red cells
• Basophilic stippling
• Howell –Jolly bodies
Myeloid
• Pseudo – Pelger
Huet anomaly
• Auer rod
• Hypogranulation
• Hypersegmentation
of nuclei
Megakaryocyte
• Giant platelets
• Hypogranular
platelets
• Agranullar platelets

12. Bone marrow
Erythroid
• Megaloblastic
erythropoiesis
• Nuclear budding
• Ring sideroblast
• Internuclear bridging
• Nuclear fragments
• Multinucleation
Myeloid
• Defective granulation
• Hypolobation
• Auer rods
• Maturation arrest
• ALIP
Megakaryocyte
• Micromegakaryocyte
• Hypogranulation
• Hypolobation
• Multiple small nuclei

13. Clinical presentation
1. Anemia
2. Lethargy
3. Weakness
4. Fainting
5. Palpitation
6. Dizziness
7. Headache
8. Menstrual abnormalities
9. Poor appetite
10.Irritability

14. REFRACTORY CYTOPENIA WITH UNILINEAGE
DYSPLASIA
1. Dysplasia > 10% in one cell lineage
2. Blasts < 5% of marrow nucleated cells
3. 10 to 20% of all cases of MDS
4. 65 - 70 years
5. M : F equal predilection
6. C/F due to cytopenias

15. Refractory anemia
It includes del 20q, Abnormality of 5 /7
Peripheral smear:
Normocytic, Normochromic or Macrocytic picture
Anisiopoikilocytosis
Dysplasia – limited to erythroid lineage
Myeloid & Megakaryocytic lineage normal
Bone marrow:
Hypercellular, Myeloblast < 5%

16. Normocytic Normochromic to
Macrocytic
Mild Anisiopoikilocytosis
Hypercellular marrow with increased
erythroid precursors

17. Refractory neutropenia
• Most important to exclude the secondary causes EX;DRUGS
• > 10 % of the neutrophils showing dysplasia
• Erythroid & Megakaryocytes do not show dysplasia
Dysplasia confined to the granulocytes
With maturation arrest

18. Refractory thrombocytopenia
1. > 10% of the megakaryocyte shows dysplasia
2. Erythroid & Myeloid cells do not shows dysplasia
3. Should evaluate > 30 megakaryocytes
4. D/D – ITP
5. Presence of the micromegakaryocyte is characteristic features

19. Bizarre shaped dysplastic Megakaryocyte

20. Refractory anemia with Ringed sideroblast
• Characterized by Anemia, Erythroid dysplasia, Ringed sideroblast
• 3-11% of MDS cases
• 60-70 years
• M : F
• RS – Erythroid precursors with abnormal accumulation of iron within the
mitochondria
• 1-2 % evolve into AML

21. • Peripheral smear:
• Normocytic , Normochromic
• Dimorphic picture ( Mostly Normochromic)
• Bone marrow:
• Hypercellular
• Erythroblast – Ragged , Poorly hemoglobinized cytoplasm
• Coarse stippling
• Hemosiderin laden macrophages – Abundant
• Prussian blue reaction :
• Demonstrate > 15% of ringed sideroblast
• 5 or more iron granules encirculing > 1/3 rd or more of the nucleus

22. Dimorphic blood picture Perl’s stain – Ringed sideroblast encircling
the entire nucleus

23. Refractory cytopenias with Multilineage dysplasia
• One or more cytopenias
• Dysplasia > 2 cell lineage
• < 1% blast in PS , < 5% in BM
• 30% of cases of MDS
• Slight male predominance
• 70-80 years
• More aggressive than RA
• More likely progress to AML
• Cytogenetic abnormalities include Trisomy 8,Monosomy 7,del 7q,20q

24. • Peripheral smear:
• Anemia
• Neutropenia
• Thrombocytopenia
To assess dysplasia:
At least 200 Neutrophilic precursors, 200 Red cell precursors, 30
Megakaryocytes should be evaluated

25. Erythroid precursors
• Markedly increased
• Nuclear irregularities
• Internuclear bridging
• Multilobation
• Multinucleation
• Megaloblastoid
chromatin
• PAS positivity
Myeloid precursors
• Cytoplasmic
Hypogranulation
• Nuclear
hyposegmentation
• Binucleated myelocytes
• Clumping of chromatin
Megakaryocyte
• Micromegakaryocyte
• Non lobated
• Hypolobated nuclei
• Lack of cytoplasmic
granules.

26. Dyserythropoiesis &
Dysmyelopoiesis
Dysmegakaryopoiesis –
Hypolobated nuclei

27. Refractory anemia with excess blasts
• More aggressive and poor prognosis
• Blasts are increased number
• But not sufficient to fulfil the criteria for acute leukemia's(> 20%)
• 40% of all MDS
• More than 50 years
• Cytogenetic abnormality – del 5q, del7q, del20q

28. Based on the blast percentage :
• RAEB-1
• 5-9% of blast in BM
• 2-4% in PS
• RAEB-2
• 10-19% blast in BM
• 5-19% in PS
• Presence of the Auer Rods is mandates a diagnosis for RAEB-2 irrespective of
the blast percentage.

29. Bone marrow:
• Hypercellular
• Increased Erythroid precursors
• Myeloid cell line – Increased with Pseudo Pelger Huet cells( small
neutrophil with nuclear Hypolobation)
• Abnormal forms of Megakaryocytic cells

31. • Alteration of normal location of hematopoietic cells
• Myeloblast – normally located paratrabacular areas , dislocated to the
central portion
• Erythroid & Megakaryocyte dislocated to the Paratrabacular area
• When 3 of such foci seen – indicates increased risk of transformation to AML
• Flow cytometry – CD 34 useful in identification of the blast cells
• CD 61,CD42b – identification of the micromegakaryocyte

32. RAEB-1
Blast – Large , High N/C ratio,
Prominent Nucleoli
Increased blast cells

33. RAEB-2

34. MDS WITH ISOLATED 5q DELETION
• Refractory anemia with or without other cytopenias / thrombocytosis due to
deletion of long arm of chromosome 5
• Seen in older women
• Blast < 1% in blood
< 5% in marrow
• Auer rods absent
• F > M
• Median age group 67 years
• 10% progress to AML
• Loss of tumour suppressor gene in the deleted region is responsible
( EGR1,CTNNA1)

35. • Some patient show concomitant JAK2 V617F mutation
Bone marrow :
Hypercellular or Normocellular
Dysplasia uncommon in Erythroid & Myeloid line
Increased megakaryocytes – Non lobated, Hypolobated nuclei
Clinical outcome is mild and good prognosis

37. Childhood MDS
• Rare ( < 5%)
• Aggressive clinical course
• Transform to AML in short period
• Respond to therapy is poor
• Survival 9-10 months
• 60 – 70 % have cytogenetic abnormalities
Associated with:
• Kostmann’s syndrome
• Diamond Blackfan anemia
• Fanconi’s anemia
• Down’s syndrome
• Neurofibromatosis 1

38. Diagnostic criteria
At least two of the following:
• Sustained unexplained cytopenias
• At least bilineage morphologic dysplasia
• Acquired clonal cytogenetic abnormality
• Increased blast > 5%

39. Hypoplastic mds
• 10-15% of MDS are hypoplastic
• F>M
• Severe cytopenias
• Most of them have Refractory anemia
• BM is Hypocellular
• D/D – Aplastic anemia and Hypocellular AML

40. Mds –f (Myelofibrosis)
• Significant marrow fibrosis seen in 10 -15% of MDS
• Most cases : Excessive blasts , aggressive course
• Blast % from aspirate itself may under stage the disease
• CD 34 on BMB may help
• JAK2 - Negative

41. Congenital dyserythropoietic anemia
• Characterized by ineffective Erythropoiesis, Erythroid multinuclearity,
Secondary tissue siderosis.
• Anemia first noted in infancy
• Ineffective erythropoiesis
• Increased plasma iron turnover
• Diminished incorporation of iron
• Erythroid hyperplasia

42. CDA I
• Rare disorder
• Autosomal recessive
• First manifest in infancy
• Characterized by Hyperbilirubinemia , Moderate anemia, Splenomegaly.
• Serum haptoglobin low
• Iron – Normal or high
• Rbc ‘s – Anisiopoikilocytosis, moderate Macrocytosis
• Marrow- Megaloblastoid features
• No effective treatment is available

43. Nuclei joined by chromatin bridge Internuclear bridges between two nuclei

44. CDA II - HEMPAS
• Hereditary Erythroblastic Multinuclearity with Positive Acidified
Serum test
• Defect – N acetylglucosaminyltransferase II – Initially
• Now – Alpha mannosidase II defect
• Lysing of the red cells at PH 6.8 resembling PNH
• Difference is
• Sucrose hemolysis test is negative

45. • Anemia from mild to severe
• Anisiopoikilocytosis
• Irregularly contracted spherocytes
• Reticulocyte count normal
• Body iron and stores increased
• Gaucher like cells are seen
• No satisfactory treatment

46. Large numbers of binucleated normoblasts

47. CDS III
• All patients are asymptomatic or minimal anemia
• Giant erythroblasts with coarse basophilic stippling
• Reticulocyte count < 3%
• Precipitation of beta chains

48. Large numbers of multinucleated
normoblasts / Gigantoblasts

49. TYPE I TYPE II TYPE III
AR AR
AD
AR
CDAN1 mutation SEC 23.3 mutation 15q22 gene not found
Macrocytes Normocytes Macrocytes
Megaloblastic Normoblastic Megaloblastic
HAM’s test- Negative Positive Negative
Anti – i Normal/Strong Strong Normal/ Strong

51. Conclusion
• RA is heterogeneous group of MDS
• Affect the red cell production
• Non responsive to the conventional treatment
• Clinical course is varies and they carry increased risk to transformation of AML
• Transforming AML is more likely in RAMD
• Childhood MDS have short span of AML transformation
• Diagnosis is made by blood and bone marrow morphology and cytogenetic analysis
• The prognosis may be estimated using the revised International Prognostic Scoring System