1、骨髓增生异常综合骨髓增生异常综合征征（Myelodysplastic syndromes,MDS）12一组起源于造血干细胞(HSC)的异质性的克隆性疾病,以外周血一系或多系减少骨髓增生正常或亢进伴病态造血和高风险向急性白血病转化为特征。A group of clonal neoplasms;heterogeneous;Hematopoietic stem cells(HSC)or progenitors;Cytopenia Myelodysplasia;ineffective hematopoiesis Increased risk of blastic transformation:-pre
2、leukemia,smouldering leukemia定义定义3MDS vs AMLBlood.2013;121:3811发病情况发病情况 发病年龄：成人发病为主，老年更多见，轻微男性发病优势 发病率：美国报告为2-12/10万；70岁以上者50/10万(Int J Hematol 2001,73:405)5 高龄，外因；高龄，外因；原发性、继发性原发性、继发性MDS：tMDS（烷化剂、表鬼臼毒素类）（烷化剂、表鬼臼毒素类）先天先天/家族性家族性MDS HSC增生失控、分化受阻、细胞凋亡增加增生失控、分化受阻、细胞凋亡增加 细胞遗传学异常：细胞遗传学异常：-5/5q-，-7/7q-基因水平
3、的改变；基因水平的改变；AML1-MDS1-EVI1融合基因融合基因 表观遗传学调控异常表观遗传学调控异常6分类分类 FAB:1976;1982 中国1986 WHO:2000;2008;20167FAB 1976Dysmyelopoietic syndromes RA RAEBBr J Haematol 1976,33:4518MDS(FAB 1982)MDS(FAB 1982)9FABWHO 2000 与AML界限：骨髓原始细胞降为20%RAEB-t归入AML；但有t(8;21)、t(15;17)、inv(16)/t(16;16)等核型异常者即使小于20%也应诊断为白血病CMML:MDS/
4、MPD10WHO 2000WHO 20002008 增加RN、RT，与RA一起组成RCUD;重新定义MDS-U（不再包括RN和RT）增加Childhood MDS（RCC）RCMD与RCMD-RS合并t-MDS/t-AML不再区分原因（烷化剂or鬼臼毒素类）12WHO 2008WHO 2008WHO 2016WHO 20161.MDS with single lineage dysplasia(MDS-SLD)2.MDS with multilineage dysplasia(MDS-MLD)3.MDS with ring sideroblasts(MDS-RS)MDS-RS and sing
5、le lineage dysplasia(MDS-RSSLD)MDS-RS and multilineage dysplasia(MDS-RSMLD)4.MDS with excess blasts(MDS-EB1,MDS-EB2)5.MDS with isolated del(5q)(5q-syndrome)6.MDS,unclassifiable(MDS-U)7.Provisional entity:Refractory cytopenia of childhood(RCC)1415CHIP&ICUS16 Clonal hematopoiesis of indeterminate pote
6、ntial(CHIP):acquired clonal mutations identical to those seen in MDS can occur in the hematopoietic cells of apparently healthy older individuals without MDS.Provisional category：idiopathic cytopenia of undetermined significance(ICUS)171.Myeloproliferative neoplasms(MPN)2.Mastocytosis3.Myeloid/lymph
7、oid neoplasms with eosinophilia and rearrangement of PDGFRA,PDGFRB,or FGFR1,or with PCM1-JAK24.Myelodysplastic/myeloproliferative neoplasms(MDS/MPN)5.Myelodysplastic syndromes(MDS)6.Myeloid neoplasms with germ line predisposition7.Acute myeloid leukemia(AML)and related neoplasms1.AML with recurrent
8、genetic abnormalities2.AML with myelodysplasia-related changes3.Therapy-related myeloid neoplasms4.AML,NOS5.Myeloid sarcoma6.Myeloid proliferations related to Down syndrome7.Transient abnormal myelopoiesis(TAM)8.Myeloid leukemia associated with Down syndrome8.Acute leukemias of ambiguous lineage9.B-
9、lymphoblastic leukemia/lymphoma10.T-lymphoblastic leukemia/lymphoma11.Provisional entity:Natural killer(NK)cell lymphoblastic leukemia/lymphomaWHO myeloid neoplasm and acute leukemia classification18Myeloproliferative neoplasms(MPN)(JAK2,MPL,CALR mutations)Chronic myeloid leukemia(CML),BCR-ABL11 Chr
10、onic neutrophilic leukemia(CNL)(CSF3R mutation)Polycythemia vera(PV)Primary myelofibrosis(PMF)PMF,prefibrotic/early stage PMF,overt fibrotic stage Essential thrombocythemia(ET)Chronic eosinophilic leukemia,not otherwise specified(NOS)MPN,unclassifiable 191.Chronic myelomonocytic leukemia(CMML)2.Atyp
11、ical chronic myeloid leukemia(aCML),BCR-ABL1(-)3.Juvenile myelomonocytic leukemia(JMML)4.MDS/MPN with ring sideroblasts and thrombocytosis(MDS/MPN-RS-T)5.MDS/MPN,unclassifiable20临床表现临床表现 差异大、早期低危患者无症状差异大、早期低危患者无症状 贫血贫血 发热、感染发热、感染 出血出血 一般无肝脾淋巴结肿大一般无肝脾淋巴结肿大 转化为急性白血病转化为急性白血病 老年患者多有合并症老年患者多有合并症Recommend
12、ations and Definitions in MDS Recommendations Differential:500 in BM,200 cells in PB Number:200 for G and E,30 cells for meg.Ring sideroblasts:5 iron granules encircling 1/3 of the nucleus Minimal dysplastic changes(good quality of smear)10%in one single cell line*or 10%with recurrent abnormal cytog
13、enetics Cytopenia(6 month),Transfusion-dependent,macrocytic anemia Hgb 10g/dL ANC 1.5 x 109/L PLT 50%MDS with hypocellular marrow MDS with fibrosisMDS with thrombocytosisPNHMPNAAMDSAML28Minimal Diagnostic Criteria in MDS(A)Prerequisite criteriaConstant cytopenia in one or more of the following cell
14、lineages:erythroid(hemoglobulin 11 g dL-1);or neutrophilic(ANC1500-1);or megakaryocytic(platelets 15%ringed sideroblasts5-19%Blast cells in bone marrow smearsTypical chromosomal abnormality:conventional karyotyping or FISHValent P,et al.Leukemia Research 2007:727-73629Minimal Diagnostic Criteria in
15、MDS Contd.(C)Co-criteria(for patients fulfilling A but not B”):Typical clinical features,macrocytic transfusion-dependent anemia.典型临床特征，输血依赖大细胞贫血Abnormal phenotype of BM cells indicative of a monoclonal population determined by flow cytometry 单克隆表型-流式Molecular:Monoclonal cell population in HUMARA as
16、say,gene chip profiling,or point mutation analysis(e.g.RAS mutations)单克隆表型-基因异常Markedly and persistently reduced colony-formation of BM or/and circulating progenitor cells(CFU-assay)骨髓集落培养减低Valent P,et al.Leukemia Research 2007:727-73630MDSMDS治疗原则治疗原则治疗方案设计要求个体化、分层治疗方案设计要求个体化、分层personalization strat
17、ification;支持、对症治疗仍是主要措施（支持、对症治疗仍是主要措施（Best supportive care)：红细胞、血小板输注，红细胞、血小板输注，CSFs,EPO 抗感染抗感染 去铁治疗去铁治疗FDA批准的药物（批准的药物（3个）：个）：去甲基化药物去甲基化药物:-阿扎胞苷（阿扎胞苷（5-azacytidine 2004）-地西他滨（地西他滨（decitabine,2006;中国中国2009）来那度胺（来那度胺（lenalidomide，2005）：）：del(5q)首选首选造血干细胞移植造血干细胞移植31Hypomethylating Cytosine Analogues地西他
18、宾地西他宾FDA2006阿扎胞苷阿扎胞苷FDA200432地西他滨地西他滨（Decitabine，Dacogen)15-30 mg/m2(10-50mg)intravenously daily 3-5 days/cycle.33Decitabine Pharmacology Mechanism of ActionDecitabine is an S-phase specific agent Antineoplastic activity attributed to Inhibition of cell proliferation at higher doses incorporation in
19、to DNA blocking of DNA synthesis cytotoxicity nonreversible covalent linking with DNA methyltransferase Induction of hypomethylation at lower doses promoting cell differentiation re-expression of tumor suppressor genes stimulation of immune mechanisms suppression of tumor growth 34Hypomethylators vs
20、 Intensive Chemo Rx in MDS with 10-30%Blasts 330 pts:93(28%)Rx with HMA and 237(72%)with chemo Rx MVA:worse survival with chemo RxNazha.Blood 122:abst 2788:201335来那度胺来那度胺(Lenalidomide,瑞复美瑞复美)Antiangiogenic Immunomodulatory imide drugs(IMiDs)5q-syndrome 10 mg/day orally Multiple myeloma36Thalidomide（
21、沙利度胺（沙利度胺、反应停）、反应停）developed by German pharmaceutical company Grnenthal sold from 1957 to 1961 to pregnant women,as an antiemetic to combat morning sickness and as an aid to help them sleep approximately 10,000 children were born with severe malformities,including phocomelia（Seal Baby)1991 Dr.Gilla
22、Kaplan at Rockefeller University showed that thalidomide worked in leprosy by inhibiting tumor necrosis factor alpha 37其它治疗选择其它治疗选择1.免疫抑制剂：免疫抑制剂：ATG,CsA,Dexamethasone2.小剂量化疗：小剂量化疗：Low-dose cytarabine；DA3.亚砷酸亚砷酸4.ATRA5.Amifostine 阿米福汀阿米福汀(氨磷汀氨磷汀)6.Clinical trials38预后预后3940Prognostic models IPSS IPSS-
23、R WPSS Others:Global MDACC model;MDACC lower risk model;Impact of comorbidities41发病机制及分子治疗细胞遗传学异常分子遗传学（基因结构）异常表观遗传学调控紊乱Nybakken&Bagg.Journal of Molecular Diagnostics,2014;16:145-158 Cytogenetic findings in MDSCytogenetic findings in MDS4344Distribution of recurrent mutations andkaryotypic abnormalit
24、ies in MDS45Mutational landscape in MDSHaferlach et al.Leukemia 201346Targeted sequencing of a limited number of genes can detectmutations in 80%to 90%of MDS patients;the most commonly mutated genes in MDS are SF3B1,TET2,SRSF2,ASXL1,DNMT3A,RUNX1,U2AF1,TP53,and EZH2Mutations of TP53&SF3B1 TP53 mutati
25、on is associated with aggressive disease in MDS in general and appears to predict poorer response to lenalidomide in patients with del(5q).With regard to MDS with ring sideroblasts(MDS-RS),recurrent mutations in the spliceosome gene SF3B1 are frequent in MDS and are associated with the presence of r
26、ing sideroblasts.So,if an SF3B1 mutation is identified,a diagnosis of MDS-RS may bemade if ring sideroblasts comprise as few as 5%of nucleated erythroid cells47Impact of mutation of p53 or DNMT3A on survival of MDS pts w/HSC 48表观遗传学调控异常表观遗传学调控异常epigenetics不涉及基因一级结构改变的表达调控机制，即基因DNA序列不发生改变的情况下，基因的表达水平
27、与功能发生改变，并产生可遗传的表型三大特征：DNA序列本身不变、可遗传、可逆性Regulation of transcriptionnDNA methylation 甲基化nHistone modifications 组蛋白修饰nChromatin remodeling nPseudogenes Regulation of post-transcriptionnNon-coding RNA：microRNA,siRNA,lncRNAnRiboswitch49DNA甲基化的基本作用：抑制基因表达50DNA+histones=Nucleosome（转录单位）（转录单位）n Acetylation/
28、deacetylation乙酰化乙酰化-去乙酰化去乙酰化n Methylation/demethylation甲基化甲基化-去甲基化去甲基化n Phosphorylation/dephosphorylation磷酸化状态磷酸化状态组蛋白修饰Histone modifications “histone code”51Epigenetic Alterationsmmm mmethylationacetylationphosphorylationDNA methylationHistone modificationsH3 AC K9 +H4 AC K8 +H3 Ser10P +H3Met K4 +H
29、3 Met K9 Histone residue Effect52Examples of DNA methylation DNA replication X chromosome inactivation Genomic imprinting(基因组印记):亲代基因在子代中表达状况取决于基因来自母本还是父本的现象。即来自父方和母方的等位基因在传递给子代时发生了修饰，使带有亲代印记的等位基因具有不同的表达特性。CancerDNA Methylation vs Cancer5455Methylation of LINE-1 before and after Decitabine treatment
30、 Line-1:long interspersed nucleotide elements 56Fold changes of gene expression after DAC treatment(D8/D0)0.000.010.101.0010.00100.001000.0010000.00#5#6#7#8#9#10#11#12#13#14#15#18#19#20#21#24#26#27#28#29#30#31#32#33#34#36#37#38#39#40#42#43#44#45#47#48#50#51#53#55#56#59#60#61#63#64#65CalcitoninIRF-12,5-OASp15p16p21RARbeta57DNMTi58SAHA(Zolinza)was the first HDACi approved by the FDA for the treatment of cutaneous T cell lymphoma(CTCL)on October 6,2006HDACi5960Clinical trials61Luspatercept对SF3B1突变阳性者有效率60%阴性者11%6263
