UAEU - CMHS - Hematology-Oncology Course - MMH 302 - HONC 320. Education material for medical students - It cover basic principles of hematology and oncology, including CAR-T and gene editing. It can be used for study and review. It illustrates main principles of hematology and oncology.

1. Bone Marrow Failure Syndromes
Idiopathic Aplastic Anemia
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Myelodysplastic Syndrome (MDS)
Constitutional (Congenital/ Inherited) Aplastic Anemia
Abdul-Kader Souid
Peripheral blood showing
pancytopenia
Normal peripheral blood
Fatty bone marrow in
aplastic anemia
Normal cellular bone
marrow
http://www.healthsystem.virginia.edu/internet/hematology/HessImages/Aplastic-Anemia-Pancytopenia-and-macrocytes-40x-website.jpg
moon.ouhsc.edu/kfung/JTY1/Com05/Com509-1-Diss.htm

2. • Idiopathic aplastic anemia as a result of autoreactive T-cells that
destroy the hematopoietic cells (anhematopiesis).
• Paroxysmal nocturnal hemoglobinuria (PNH) as a result of
complement-mediated intravascular hemolysis (clonal disease).
• Myelodysplastic Syndrome (MDS) = Cytopenia + oligoblastic
leukemia (clonal disease).
• Constitutional/ congenital/ inherited: Diamond-Blackfan anemia
(DBA, ribosomopathy); Fanconi anemia (FA, defect in DNA
repair); dyskeratosis congenita (DC, short telomere).
• Viruses: Epstein-Barr virus, HIV, seronegative hepatitis.
• Toxic exposure: Radiation, benzene, pesticides (organophosphates), chlorinated
solvents (e.g., chloroform), anticancer drugs (cyclophosphamide, etoposide).
• Idiosyncratic (peculiar): Chloramphenicol, NSAID, sulfonamides, anti-epileptic drugs,
psychotropics.
Bone Marrow Failure Syndromes: Etiology

3. Bone Marrow Failure Syndromes: Definition
• These disorders are characterized by “near absence of hematopoietic
cells”. The marrow is replaced by fat cells (“fatty marrow”).
• Clinical manifestations include various severities of anemia,
neutropenia, lymphopenia, and thrombocytopenia.
• In most cases, the disease occurs without a known precipitating
cause (termed “idiopathic aplastic anemia”), resulting from
“autoreactive T-cells” that destroy the hematopoietic cells.
• Severe aplastic anemia is defined as “bone marrow cellularity <25% with 2
of the following cytopenias: neutrophil count <0.5 x109/L, platelet counts
<20 x109/L, and reticulocyte count <40 x109/L.
• All patients need bone marrow biopsy, cytogenetic studies for clonal abnormalities,
chromosome breakage for Fanconi anemia by diepoxybutane [DEB] test, flow
cytometry for CD55/59 for paroxysmal nocturnal hemoglobinuria (PNH), and
telomere length study for dyskeratosis congenita (DC).

4. • Mutations in telomere repair genes, e.g.,
TERT (OMIM#187270), the gene for
telomerase reverse transcriptase (a
ribonucleoprotein polymerase that
maintains telomere ends by adding the
telomere repeat TTAGGG); NEJM
2005;352:1413-1424. (OMIM#614742)
• Inheritance of such mutations results in
short telomeres in the hematopoietic
cells, which predispose to apoptosis.
Genetic Susceptibility to Marrow Failure
A telomere is a region of repetitive nucleotide sequences (TTAGGG) at each end of a
chromatid, which protects the end of the chromosome from deterioration. The telomere is
short in dyskeratosis congenita (DC; OMIM#613989).
NaildystrophyinDC

5. Case Presentation
• A 9-year-old boy presents with pallor and bruises. He has increased fatigue and
bleeding from his gum. His examination reveals fever (38.6oC), tonsillitis,
pallor, and ecchymoses. The liver, spleen, and lymph nodes are not palpable.
– WBC count 0.8 x109/L; neutrophil 0.3 x109/L; lymphocyte 0.5 x109/L.
– Hemoglobin 73 g/L; RBC count 2.1 x1012/L; reticulocyte count 7 x109/L; MCV
110 fL, RDW 14%.
– Platelet count 13 x109/L.
– Blood film shows pancytopenia without abnormal cells.
5
Problem list = Leukopenia + Neutropenia + Lymphopenia
+ Macrocytic anemia + Reticulocytopenia +
Thrombocytopenia

6. Idiopathic Aplastic Anemia: Treatment
• Supportive care include blood and platelet transfusions, antibiotics,
and growth factors [granulocyte colony-stimulating factor (G-CSF),
thrombopoietin, erythropoietin].
• The disease is curable with hematopoietic stem-cell transplantation
from allogeneic HLA-matched (usually sibling) donor.
• About 80% of patients with no HLA-matched donor show
hematopoietic recovery after transient T-cell depletion by anti-
thymocyte immunoglobulins (ATG, cytolytic antibodies) +
cyclosporine (an immunosuppressant that reduces T-cell function);
relapse usually responds to repetitive treatment.
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7. Complement-mediated Hemolysis
CD59 (terminal complement inhibitor) is tethered to the membrane
by GPI anchor (glycosylphosphatidylinositol).
PNH (paroxysmal nocturnal hemoglobinuria) cells lack GPI and
CD59. Consequently, complement activation creates numerous
pores in the membrane.
J Cell Biochem 1986;30:133-170
7
Paroxysmal Nocturnal Hemoglobinuria (PNH)
(OMIM#300818; intravascular hemolysis + cytopenia + venous thrombosis)

8. • PNH is a clonal hematopoietic stem cell disorder caused by somatic
de novo (neither transmitted nor parent possessed) mutation in the
phosphatidylinositol glycan class A (PIGA) gene (OMIM#311770) on
the X chromosome.
• PIGA protein is required for formation of the phosphatidylinositol
(GPI) anchor. Its absence results in missing many membrane
proteins, including inhibitors of the complement cascade. Red cells
are especially sensitive to the hemolytic effect of complements.
• The disease usually evolves as an abnormal clone in the milieu of a
bone marrow failure syndrome.
8
Paroxysmal Nocturnal Hemoglobinuria (PNH)
(OMIM#300818; intravascular hemolysis + cytopenia + venous thrombosis)

9. • The clinical presentation includes chronic intravascular hemolytic anemia,
venous and arterial thrombosis (commonly in abdominal and cerebral
vessels; leading cause of death), abdominal pain and esophageal spasm.
– Depletion of nitric oxide (NO) from increased free hemoglobin leads to smooth
muscle dystonias (abdominal pain, dysphagia, pulmonary hypertension, erectile
dysfunction).
– The most common severe complication is thrombosis. Testing for PNH when patients
present with unprovoked thrombus, particularly if they have hemolysis or cytopenia.
• Diagnosis is by flow cytometry using anti-CD59 (granulocytes missing the
terminal complement inhibitor, CD59).
• Treatment is supportive with transfusion, folate/B12/iron, and anticipatory
guidance about ↑bacterial infection and ↑thrombosis.
– Therapeutic options also include stem-cell transplantation and eculizumab (Soliris™,
monoclonal antibodies to the complement protein C5). Eculizumab blocks
cleavage of C5, thus, halting complement-mediated cell destruction. It
deceases the hemolysis, transfusion requirement, and debilitating fatigue.
Paroxysmal Nocturnal Hemoglobinuria (PNH)
(OMIM#300818; intravascular hemolysis + cytopenia + venous thrombosis)

10. 9/26/2018
Brodsky RA. Paroxysmal nocturnal hemoglobinuria. Blood 2014;124:2804-11. doi: 10.1182/blood-2014-02-522128.

11. • A 17-year-old male presents with fatigue, pallor (anemia), abdominal
pain, dysphagia, and red urine (hematuria). He is icteric (jaundice =
hemolysis).
• Hemoglobin is 84 g/L, reticulocytes 322 x109/L (hemolysis), platelets 96
x109/L (bone marrow disease).
• Lactate dehydrogenase (↑LDH = hemolysis) is 2,950 units/L (normal,
<200).
• Urinalysis reveals hemoglobinuria (+hemoglobin with no red cells = free
hemoglobin in the blood = intravascular hemolysis).
• Flow cytometry using anti-CD59 reveals granulocytes missing the
glycosylphosphatidylinositol–(GPI) anchored protein.
• He is being treated with weekly eculizumab.
Problem list = Anemia + Intravascular Hemolysis +
Thrombocytopenia (bone marrow disease) + GI complaints
Case Presentation

12. Myelodysplastic Syndrome (OMIM#614286):
“Clonal Cytopenia + Oligoblastic Leukemia”
• MDS (myelodysplasia) is ineffective hematopoiesis (cellular bone
marrow + pancytopenia) resulting from an evolving clone of
genetically injured hematopoietic stem cells.
– Cytogenetic abnormalities exist in most patients; most commonly involving
chromosomes 5, 7 and 8.
• Cases could be sporadic (de novo) or result from stem cell injuries, e.g.,
– Cyclophosphamide (AML-associated with monosomy 5 or 7; (del)5q or (del)7q)
– Etoposide (AML-associated with rearrangements involving the mixed lineage
leukemia, MLL [MIM#602409], gene on chromosome 11q23)
• Patients present with uni-lineage, bi-lineage or tri-lineage
(pancytopenia), progressing to acute myelogenous leukemia in many
of the cases.

13. Myelodysplastic Syndrome:
“Clonal Cytopenias and Oligoblastic Leukemia”
A 16-y-old girl is treated for Hodgkin lymphoma at 10 y of age. She
received standard chemotherapy and radiation. She now presents
with fatigue and pallor. CBC reveals pancytopenia. Bone marrow
examination shows myelodysplasia with 30% myeloblasts possessing
a deletion of chromosome 7.
Which of the following is the most likely cause of her disease?
A. Bleomycin
B. Cyclophosphamide
C. Etoposide
D. Vincristine
E. Radiation

14. • Refractory anemia
• Refractory anemia with ringed sideroblasts
• Refractory anemia with multi-lineage dysplasia (cytopenias)
• Refractory anemia with excess myeloblasts (oligoblastic leukemia)
• 5q- syndrome
Myelodysplastic Syndrome: WHO Classification
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pathy.med.nagoya-u.ac.jp/ atlas/doc/node71.htm
Karyotype showing 5q-
www.scielo.br/img/revistas/
rbhh/v26n3/3a19f02.jpg
Blasts and a mono-
lobed neutrophil
Myeloblast with
auer rods
Ringed sideroblast

15. • It primarily affects older females. It presents with anemia and dysmorphic
hematopoiesis (lobulated erythroblast nuclei and hypolobulated
micromegakaryocytes). The platelet count is normal or high. The disease is
indolent and has low propensity to evolve into AML.
• It requires supportive care (erythropoietin, granulocyte–colony stimulating
factor, transfusions and antibiotics).
• Allogeneic stem cell transplantation is curative.
Chromosome 5q Deletion Syndrome (OMIM#153550)
[Macrocytic anemia, refractory, due to 5q deletion, somatic]
Hypolobulated micromegakaryocytes
PEIR Digital Library (Pathology image database
Lobulated erythroblast nuclei
pathologyoutlines.com/images/marrow/048.jpg
15

16. • DBS is characterized by isolated anemia (↑MCV, ↑erythrocyte adenosine deaminase
[eADA], and ↑hemoglobin F) with severe reticulocytopenia and absence of marrow
erythroid precursors. The neutrophil, lymphocyte and platelet counts are normal.
– It appears in early life and may improve with glucocorticoids.
– Congenital malformations occur in 50% of the patients (e.g., cleft palate, thumb defect).
• Patients have mutations in RPS19 [ribosomal protein S19; OMIM#603474;
autosomal dominant], RPL11 [ribosomal protein L11; OMIM#604175], or GATA1
[OMIM#305371; encodes a zinc finger DNA-binding transcription factor that is
critical for the development of hematopoiesis).
Acquired red cell aplasia:
− Parvovirus infection (cytotoxic to erythroid progenitors)
− “Transient erythrocytopenia of childhood” (TEC, a short-lived suppression of
erythropoiesis due to viral infection).
Diamond-Blackfan Anemia (DBA, OMIM#105650) - Ribosomopathy
DBA in a 3-y-old boy from Pakistan Dr. Diamond

17. Fanconi Anemia (OMIM#227650) - A defect in DNA repair
• This entity was first reported in 1927 by Guido Fanconi, who
described 3 siblings with progressive pancytopenia, physical
anomalies and predisposition to malignancy (particularly acute
myelogenous leukemia).
• The disease is autosomal recessive involving one of the 13 FA
genes (OMIM#607139; FANC-A, B, C, D1, D2, E, F, G, I, J, L,
M and N), which regulate DNA repair and cell cycle.
• The disorder is heterogeneous, characterized by hypersensitivity
to chromosome-breaking agents (diepoxybutane, DEB).
• Heterozygotes for FA genes (e.g., FANCD1/BRCA2) have an
increased risk of breast and other cancers.
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18. Fanconi Anemia: Natural History and Treatment
[A defect in DNA repair]
• Bone marrow failure occurs in childhood with petechiae, bruising
and hemorrhage from thrombocytopenia; pallor and fatigue from
anemia; and infection from neutropenia.
• The major cause of death is bone marrow failure, followed by
leukemia (AML) and solid tumors (most commonly liver
adenomas and hepatomas in patients treated with oral
androgens). The projected median survival is ~20 years.
• Treatment: Supportive care (transfusions, antibiotics, growth
factors), androgen therapy and stem-cell transplantation. [Blood
2003;101:1249-1256]
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19. Fanconi Anemia: Birth Defects
• Skeletal anomalies (short stature, abnormal thumbs,
abnormal thumbs and radi, microcephaly).
• Altered skin pigmentation (café au lait spots,
hyperpigmentation, hypopigmentation).
• Other congenital malformations (abnormal gonads,
eye anomalies, renal defects, low birth weight,
developmental delay, abnormal ears or hearing).
Café au lait spot Bifurcated thumb Absent thumb & radius

20. Fanconi Anemia: Chromosome Breaks
Arleen D. Auerbach: Diagnosis of Fanconi Anemia by Diepoxybutane
Analysis. Rockefeller University, New York. Current Protocols in Human
Genetics , UNIT 8.7, 10.1002/0471142905.hg0807s37 , April, 2003.
untreated
treated with 0.1 mg/mL DEB
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Increased chromosome breaks with
diepoxybutane (DEB).
Molecular diagnosis has improved
the diagnosis of Fanconi anemia.

21. 1. Exposure to alkylating agents
2. Complement-mediated hemolysis
3. Autoreactive T-cells destroying bone marrow
4. Thumb terminal defects
5. Blood cells lacking CD59
6. Treatment with anti-thymocyte globulins
7. Hypersensitivity to diepoxybutane (DEB)
8. Chromosome 5q Deletion Syndrome
9. Parvovirus
10. Mutation in phosphatidylinositol glycan gene
11. Treatment with eculizumab
12. Ringed sideroblasts
13. Hemoglobinuria
14. Predisposition to solid tumors
15. Defect in DNA repair
16. Short telomere
17. Ribosomopathy
18. Café au lait spots
19. Abnormal thumbs
20. Cyclophosphamide
21. Anti-thymocyte immunoglobulins (ATG)9/26/2018
A. Idiopathic aplastic anemia
B. Paroxysmal nocturnal
hemoglobinuria
C. Myelodysplastic syndrome
D. Diamond-Blackfan anemia
E. Fanconi anemia
F. Acquired red cell aplasia
G. Dyskeratosis congenita
“Must Know Pearls”

22. Required Reading
• Scheinberg P, Wu CO, Nunez O, Young NS. Long-term outcome of
pediatric patients with severe aplastic anemia treated with antithymocyte
globulin and cyclosporine. J Pediatr 2008;153:814.
• Young NS, Bacigalupo A, Marsh JC. Aplastic anemia: pathophysiology
and treatment. Biol Blood Marrow Transplant 2010;16:S119.
• Korthof ET, Békássy AN, Hussein AA. Management of acquired
aplastic anemia in children. Bone Marrow Transplant 2013;48:191.
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