Hypercellular Bone Marrow Research Articles

Olaparib-induced myelodysplasia – A case report

Olaparib is an antineoplastic agent that is a poly ADP ribose polymerase (PARP) inhibitor and is Food and Drug Administration-approved for the treatment of ovarian, breast, pancreatic, and prostate cancer. PARP inhibitors can cause DNA damage and epigenetic changes, leading to hematological transformations and increasing the risk of myelodysplasia. We present a case of a 58-year-old female with malignant breast cancer initiated on Olaparib after failing multiple treatment lines. The patient had persistent declining blood cell counts, and a bone marrow biopsy revealed hypercellular bone marrow with predominant myeloid cells with increasing number of blasts and promyelocytes. Olaparib was stopped. The patient elected for supportive care and hospice.

Idiopathic multicentric Castleman disease with marrow fibrosis and extramedullary hematopoiesis.

Idiopathic multicentric Castleman disease (iMCD) is a rare inflammatory disorder mediated by excessive proinflammatory cytokine signaling, most notably by interleukin 6 (IL-6). IL-6-induced extramedullary hematopoiesis (EMH) has been reported in murine models of iMCD. Herein we present four cases of iMCD with EMH in humans. The index case is a 24-year-old white woman who presented with pancytopenia, hepatosplenomegaly, and diffuse lymphadenopathy (LAD) with EMH in core lymph node biopsies. We then searched ACCELERATE, a Castleman disease (CD) natural history registry, and identified three additional CD cases with EMH reported in biopsies: A 23-year-old Asian man with fatigue, edema, LAD, and splenomegaly; a 20-year-old white man with fever, dyspnea, LAD, and hepatosplenomegaly; and a 50-year-old white man with constitutional symptoms, LAD, and myelodysplastic syndrome in bone marrow with a KRAS mutation. All four patients presented with thrombocytopenia and fever and/or markedly elevated C-reactive protein. Patient 1 had iMCD-NOS (not otherwise specified) with severe thrombocytopenia, reticulin fibrosis in bone marrow, small volume LAD and organomegaly but no anasarca. The other three patients had iMCD-TAFRO (thrombocytopenia, anasarca, reticulin fibrosis, renal dysfunction, organomegaly). Two had mixed CD and two had hypervascular CD in lymph nodes. All four had bone marrow hypercellularity and megakaryocyte hyperplasia and two had reticulin fibrosis. This case series demonstrates that EMH can be seen in CD, particularly in iMCD-TAFRO. Given the similarity of this finding to previous murine models of IL-6-induced marrow and lymph node changes we hypothesize that this is an IL-6-mediated phenomenon.

MPN-123 Complex Clonal Evolution in a Patient with Advanced Myelofibrosis Exhibiting Bone Marrow Hypercellularity and Chromosomal Anomalies

MPN-123 Complex Clonal Evolution in a Patient with Advanced Myelofibrosis Exhibiting Bone Marrow Hypercellularity and Chromosomal Anomalies

Misleading Trails: Uncovering Systemic Mastocytosis Disguised as Eosinophilic Gastrointestinal Disorder - A Case Report

An uncommon class of illnesses known as mastocytosis is defined by aberrant mast cells in different tissues or organs. It encompasses mast cell sarcoma, systemic mastocytosis, and cutaneous mastocytosis. For those without advanced manifestations of the disease, the diagnosis of Systemic Mastocytosis can be protracted due to the high rate of symptom overlap with other illnesses. A 56-year-old female patient was brought to our department for a diagnosis because of her history of eosinophilia, chronic colitis, and skin allergies. The patient's eosinophilia remained in spite of treatment. The patient's blood count revealed persistent eosinophilia even after five months. An examination of the bone marrow aspirate showed a hypercellular bone marrow with a noticeable eosinophilic prominence. To our astonishment, the trephine biopsy showed sheets and nodules of mast cells, expressing strong positivity for CD117 immunostain. A review of the colonic biopsy also showed a significant mast cell presence as highlighted by CD117 immunostain. A definitive diagnosis of systemic mastocytosis was reached, indicating that, in situations of eosinophilia, a low index of suspicion and meticulous morphological examination are necessary to prevent delays in the diagnosis of mastocytosis, particularly in cases where there is no cutaneous involvement.

Chronic neutrophilic leukemia and atypical chronic myeloid leukemia: 2024 update on diagnosis, genetics, risk stratification, and management.

Chronic neutrophilic leukemia (CNL) is a rare BCR::ABL1-negative myeloproliferative neoplasm (MPN) defined by persistent mature neutrophilic leukocytosis and bone marrow granulocyte hyperplasia. Atypical chronic myeloid leukemia (aCML) (myelodysplastic "[MDS]/MPN with neutrophilia" per World Health Organization [WHO]) is a MDS/MPN overlap disorder featuring dysplastic neutrophilia and circulating myeloid precursors. Both manifest with frequent hepatosplenomegaly and less commonly, bleeding, with high rates of leukemic transformation and death. The 2022 revised WHO classification conserved CNL diagnostic criteria of leukocytosis ≥25 × 109/L, neutrophils ≥80% with <10% circulating precursors, absence of dysplasia, and presence of an activating CSF3R mutation. ICC criteria are harmonized with those of other myeloid entities, with a key distinction being lower leukocytosis threshold (≥13 × 109/L) for cases CSF3R-mutated. Criteria for aCML include leukocytosis ≥13 × 109/L, dysgranulopoiesis, circulating myeloid precursors ≥10%, and at least one cytopenia for MDS-thresholds (ICC). In both classifications ASXL1 and SETBP1 (ICC), or SETBP1 ± ETNK1 (WHO) mutations can be used to support the diagnosis. Both diseases show hypercellular bone marrow due to a granulocytic proliferation, aCML distinguished by dysplasia in granulocytes ± other lineages. Absence of monocytosis, rare/no basophilia, or eosinophilia, <20% blasts, and exclusion of other MPN, MDS/MPN, and tyrosine kinase fusions, are mandated. Cytogenetic abnormalities are identified in ~1/3 of CNL and ~15-40% of aCML patients. The molecular signature of CNL is a driver mutation in colony-stimulating factor 3 receptor-classically T618I, documented in >80% of cases. Atypical CML harbors a complex genomic backdrop with high rates of recurrent somatic mutations in ASXL1, SETBP1, TET2, SRSF2, EZH2, and less frequently in ETNK1. Leukemic transformation rates are ~10-25% and 30-40% for CNL and aCML, respectively. Overall survival is poor: 15-31 months in CNL and 12-20 months in aCML. The Mayo Clinic CNL risk model for survival stratifies patients according to platelets <160 × 109/L (2 points), leukocytes >60 × 109/L (1 point), and ASXL1 mutation (1 point); distinguishing low- (0-1 points) versus high-risk (2-4 points) categories. The Mayo Clinic aCML risk model attributes 1 point each for: age >67 years, hemoglobin <10 g/dL, and TET2 mutation, delineating low- (0-1 risk factor) and high-risk (≥2 risk factors) subgroups. Management is risk-driven and symptom-directed, with no current standard of care. Most commonly used agents include hydroxyurea, interferon, Janus kinase inhibitors, and hypomethylating agents, though none are disease-modifying. Hematopoietic stem cell transplant is the only potentially curative modality and should be considered in eligible patients. Recent genetic profiling has disclosed CBL, CEBPA, EZH2, NRAS, TET2, and U2AF1 to represent high-risk mutations in both entities. Actionable mutations (NRAS/KRAS, ETNK1) have also been identified, supporting novel agents targeting involved pathways. Preclinical and clinical studies evaluating new drugs (e.g., fedratinib, phase 2) and combinations are detailed.

Myeloid sarcoma with RBM15::MRTFA (MKL1) mimicking vascular neoplasm.

Extramedullary involvement of acute myeloid leukemia (AML), aka myeloid sarcoma, is a rare phenomenon in acute megakaryoblastic leukemia with RBM15:: MRTFA(MKL1) fusion, which might mimic non-hematologic malignancies. A 7-month-old infant presented with leukocytosis, hepatosplenomegaly, multiple lymphadenopathies, and a solid mass in the right thigh. Initially, the patient was diagnosed with a malignant vascular tumor regarding the expression of vascular markers from the biopsy of the right thigh lesion that was performed after the inconclusive bone marrow biopsy. The second bone marrow biopsy, which was performed due to the partial response to sarcoma treatment, showed hypercellular bone marrow with CD34 and CD61-positive spindle cell infiltration and > 20% basophilic blasts with cytoplasmic blebs. RNA sequencing of soft tissue biopsy revealed the presence of RBM15::MRTFA(MKL1) fusion. Based on these findings, myeloid sarcoma/AML with RBM15::MRTFA(MKL1) fusion diagnosis was made. AML with RBM15::MRTFA(MKL1) fusion can initially present as extramedullary lesions and might cause misdiagnosis of non-hematologic malignancies.

Trombocitopenia primária imune com púrpura palpável: um relato de caso

Immune thrombocytopenia is a relatively common bleeding disorder characterized by isolated destruction of platelets by autoantibodies, with a typically acute onset, benign course and self-limiting in most cases. The aim of this report is to present a rare case of Primary Immune Thrombocytopenia (ITP) with palpable purpura, an uncommon manifestation in this disease and little described in the literature. This is a 12-year-old female adolescent who presented with palpable purpura, ecchymosis and oral cavity bleeding associated with thrombocytopenia and anemia. Initial investigation excluded autoimmune diseases, vasculitis, lymphoproliferative diseases and coagulation disorders, in addition to the myelogram showing typical findings of ITP: hypercellular bone marrow with megakaryocytic hyperplasia and decreased thrombocytogenesis. Due to the diversity of clinical presentation and the possibility of atypical manifestations, the diagnosis is often challenging, as in the case of this patient in which the main finding on physical examination was the presence of palpable purpura.

Seorang Wanita Usia 23 Tahun Dengan Anemia Mikrositik Hipokromik Suspect Systemic Lupus Erythematosus (SLE)

Systemic Lupus Erythematosus (SLE) is an autoimmune inflammatory disease with diverse clinical manifestations, disease course and prognosis, and it is difficult to predict the onset of acute and subtle manifestations, can attack various organs of the body, and can recur. Hematological manifestations in SLE occur frequently and are one of the criteria for ACR. Thrombocytopenia occurs in 25% - 50% of patients, leukopenia occurs in around 50% and hemolytic anemia with positive Coombs test results in around 10%. Cytopenia that occurs is usually the result of peripheral damage mediated by autoantibodies that cause bone marrow hypercellularity. In rare cases, hypocellularity occurs in the bone marrow due to mediation of T cells that inhibit hemopoetic cells, which causes bone marrow failure and causes anemia gravis. A 23 year old woman came with complaints of paleness, fatigue, decreased appetite, joint pain, nausea, vomiting, headaches, dizzy eyes. On laboratory examination on June 12 2023, microcytic hypochromic anemia was found, on June 13 2023, microcytic hypochromic anemia was found, on peripheral blood morphology examination, anemia was suspected due to iron deficiency, and there was a bacterial and parasitic infection process, on June 15 2023, hypokalemia was found. , hyperchloremia, hypocalcemia. On June 16, 2023, microcytic hypochromic anemia was found. On ECG examination, benign Ves arrhythmia was found. On chest examination, the lung showed no abnormalities, the cast size was normal. On ultrasound examination, Nephrolithiasis Dextra was found. So it was found on physical examination, and the patient's supporting examination was confirmed as microcytic hypochromic anemia suspect systemic lupus erythematosus, however in the patient in this case report it could not be established as systemic lupus erythematosus, because the patient was not willing to be referred to Zainal Abidin General Hospital, Banda Aceh for treatment. further examination.

Abstract B030: Intracerebral and intraventricular hemorrhage due to severe thrombocytopenia: A rare case of Evans syndrome

Abstract Introduction: Evans syndrome (ES) is a rare autoimmune disorder characterized by the development of autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and/or immune neutropenia (AIN) without an identifiable cause. It is believed to involve immune system dysregulation, leading to the destruction of red blood cells, platelets, and neutrophils. Case Presentation: A 68-year-old male with a history of coronary artery disease, hypertension, diabetes, and atrial fibrillation presented with abdominal pain and diarrhea. Laboratory tests revealed a platelet count of 3k, suggesting ITP. Initial treatment with dexamethasone and platelet transfusion provided limited improvement. A bone marrow biopsy showed mildly hypercellular bone marrow with trilineage hematopoiesis. However, the patient's condition rapidly deteriorated, and he returned to the emergency department with severe symptoms, including headache, gum bleeding, and lower extremity petechiae. A CT scan revealed a large intraparenchymal hematoma with intraventricular hemorrhage, highlighting the risk of life-threatening bleeding in ES patients. Discussion: The patient was managed with platelet transfusions, high-dose steroids, and intravenous immunoglobulin (IVIG), which provided temporary relief but failed to maintain stable platelet levels. Further investigations revealed a positive antinuclear antibody (ANA), suggesting an underlying rheumatological condition and confirming the diagnosis of secondary ES. This finding necessitated the exploration of treatment options. Of interest is Romiplostim (Promacta), a thrombopoietin receptor agonist, which has shown promise in increasing platelet counts and reducing bleeding episodes in refractory ITP. Considering the positive ANA and the suspected rheumatological etiology, Romiplostim may serve as a viable long-term treatment option to stabilize platelet levels and mitigate bleeding risks in this case. Conclusion: This case highlights the complexity of Evans syndrome and emphasizes the need to promptly recognize and manage life-threatening bleeding complications, particularly in older patients. The presence of a positive ANA suggests an underlying rheumatological condition, necessitating comprehensive evaluation, and tailored therapeutic approaches. Although further research is needed to understand the pathogenesis and optimal management strategies for ES, Romiplostim holds promise as a potential treatment for patients with secondary ES who are unresponsive to conventional therapies. Citation Format: Kiersten R. Patterson, Aliya M. Khan, Raj Patel. Intracerebral and intraventricular hemorrhage due to severe thrombocytopenia: A rare case of Evans syndrome [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B030.

Bone Marrow Cellularity at Diagnosis Predicts Outcomes of Patients with Myelodysplastic Syndrome with Allogeneic Hematopoietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only known curative therapy for myelodysplastic syndromes (MDS). The decision of allo-HSCT depends on prognostic scoring models such as revised international prognostic scoring system (IPSS-R) which include cytogenetic abnormalities, cytopenia, and % of bone marrow (BM) blasts. Recently, the prognostic role of genomic profile in MDS patients is arising. However, it is hard to conduct the next generation sequencing to all MDS patients in the real-world. Therefore, we aimed to evaluate the prognostic impact of BM cellularity at diagnosis as a new clinical prognostic factor of MDS with allo-HSCT. A total of 122 patients with MDS patients who underwent allo-HSCT between July 2009 to August 2022 in single center were analyzed retrospectively. Overall survival (OS) was analyzed using the Kaplan-Meier survival curves according to the BM cellularity at diagnosis. The potential prognostic parameters were evaluated for OS by uni-and multivariate cox-regression analysis. All patients were eligible for allo-HSCT and median age of 61.5 years (range: 19-71). Median follow-up duration was 36.9 (IQR 17.6-72.4) months. The 3-year and 5-year OS were 60.1% (95% CI 51.6-69.0) and 52.5% (95% CI 42.8-61.3), respectively. IPSS-R risk group was classified as very low (6, 4.9%), low (15, 12.2%), intermediate (40, 32.8%), high (37, 30.3%) and very high (24, 19.7%). Seventeen patients (13.9%) had complex karyotype at diagnosis. Seventy-seven patients (63.1%) were treated with hypomethylating agents before allo-HSCT. Most patients (70, 57.4%) had less than 5% BM blasts at allo-HSCT. The majority (74, 60.7%) received reduced intensity conditioning. OS significantly differed between patients with hypercellular BM and normo- to hypocellular BM at diagnosis by the log-rank test ( P &amp;lt;0.001) (Figure 1). In multivariate analysis for OS, complex karyotype at diagnosis ( P&amp;lt;0.001; HR 6.00; 95% CI 3.08-11.66), age ( P=0.04; HR 1.03; 95% CI 1.00-1.06) and hypercellular BM at diagnosis ( P=0.005; HR 2.16; 95% CI 1.26-3.72) were associated with worse outcome (Table 1). In this study, we demonstrated the BM hypercellularity at diagnosis independently predicts the inferior outcome of MDS patients with allo-HSCT. Although further validation with a larger cohort would be needed, it could be helpful to decide the treatment strategy of transplantation eligible MDS patients.

Calr+ Myelofibrosis/BCR-ABL Chronic Myeloid Leukemia Overlap Syndrome Treated with Asciminib

Introduction Myeloproliferative neoplasms are considered mutually exclusive, and reports of co-occurring mutations are rare. Over the past 10 years, approximately two dozen case reports have been published of co-occurring BCR-ABL positive and CALR positive patients. Here we present the case of a patient who was reported to have myelofibrosis (MF)/myeloproliferative neoplasm (MPN), later developed chronic myeloid leukemia (CML), and ultimately progressed to acute myeloid leukemia (AML). This is unique in the literature reviewed, and may be the first reported case of this overlap syndrome being treated with asciminib. Case presentation A 40-year old male was diagnosed in 2018 with MF/MPN based upon a hypercellular bone marrow biopsy with diffuse reticulin fibrosis. He was negative for JAK2, but was not tested for CALR or MPL mutations. Treatment was ruxolitinib and hydroxyurea. Two years later, the patient was diagnosed with CML after being admitted for recurrent fevers, headache, and shortness of breath. At that time, a type 2 CALR mutation (CALR K385Nfs*47) was noted. He started dasatinib and decitabine, which resulted in a drop from 28.31% BCR-ABL to 0.0196% (Table 1A). However, hyperuricemia and renal failure led to a change in regimen and the patient was started on asciminib and ropeginterferon alfa-2b-njft in January 2022. By December, the patient's BCR-ABL PCR dropped below quantification, but he received a diagnosis of AML based on a bone marrow biopsy which showed 43% blasts. He received cladribine and cytarabine, but was found to have leukemic infiltration of the spinal cord five months later. The patient was referred to hospice and passed away in June 2023. Discussion To our knowledge, this is the first MPN-CML patient reported to have been treated with asciminib. This case illustrates its effectiveness in treating CML, but highlights the need for improved treatments for CALR+ MPN. Moreover, this case illustrates the importance of testing for CALR, MPL, and BCR-ABL in addition to JAK2 immediately when a patient presents with an MPN. It is unknown whether this patient's CALR mutation preceded the BCR-ABL translocation, and there is debate in the literature with respect to mutation chronology. The patient's BCR-ABL burden dropped from 28.31% to 0.0196% while the CALR burden remained around 94% over the same period (Table 1B). Thus, it is unlikely that the BCR-ABL mutation preceded the CALR mutation within the same clone. The patient's &amp;gt;90% CALR allele burden is higher than reported in the other reported cases, where the burden ranged from 10% to 68%. Furthermore, none of the other cases were reported to progress to AML, though follow up data is lacking. The heavy allelic burden in our patient may have been a contributing factor to the development of AML, as has been reported elsewhere. The patient's overall mutational profile is of interest. Type 2 CALR mutations have been reported to have less favorable prognoses than type 1 mutations. In addition to the CALR and BCR-ABL mutations, the patient had ASXL1 A861Hfs*6, EZH2 D730*, and NRAS G12V. All three mutations are associated with unfavorable outcomes in MDS, AML, and/or CML. Genomic instability has been discussed in relation to both CML and JAK2-positive MPN. Our patient's heavy mutational burden suggests CALR-positive neoplasms may also present against a background of inherent genomic instability. Conclusion We reported a case of MPN, followed by CML, and then AML. The patient was positive for CALR and BCR-ABL. He achieved a complete response in CML after targeted treatment, with asciminib consolidating the gains the patient made on earlier therapies. However, he always maintained a high CALR burden. This patient's mutational profile and disease course argue for the importance of early testing for CALR and BCR-ABL in addition to JAK2 and MPL in the setting of an MPN and for further research into the underlying causes of these overlap conditions.

Targeting Complement Inhibition in Cold Hemolysis; A Multifaceted Approach Using Sutimlimab and Washed Red Cell Transfusions

Introduction: Cold agglutinin syndrome (CAS) is a transient disorder mediated by autoantibodies that cause red cell agglutination at cold temperatures. CAS is often associated with infections rather than malignant or autoimmune conditions. Sutimlimab, a monoclonal antibody directed against the complement component C1s, was previously shown to improve anemia and fatigue in cold agglutinin disease (CAD) in single-arm studies. However, its use in CAS has not yet been elucidated. Here, we describe a case where complement inhibition using the novel C1s inhibitor, as well as washed and warmed red cell transfusions, were used to treat CAS in the setting of a rare autoantibody directed toward the Pr antigen Case report: A healthy 46-year-old woman presented with severe acute hemolytic anemia: with nadir hemoglobin of 4.7, hematocrit of 13.4%, 0.2% of reticulocytes, total bilirubin of 9.8 mg/dL, and unconjugated bilirubin of 8.4 mg/dL. A peripheral blood smear review revealed severe anemia with agglutination of red blood cells. An extensive infectious workup was negative including COVID-19, Parvovirus B19, CMV, EBV, CMV, and HIV. Over a period of two weeks, she received three doses of IVIG, prednisone, and 17 transfusions units of warmed red blood cells in the setting of persistent hemolytic anemia. Despite the evidence of severe hemolysis, her reticulocyte count remained very low (&amp;lt;0.5%). A bone marrow biopsy showed trilineage hematopoiesis with erythroid hypoplasia and maturation arrest. A direct Coombs test was intermittently positive but probably confused by IgG infusions, with anti-I and anti-i titers of 1:64, and positive for C3. Thermal amplitude studies showed agglutination at 30°C, 37°C, and room temperature. Red blood cell antibodies were not identified in the eluate. The indirect antiglobulin test was negative for ficin-treated RBCs showing no agglutination. This led the reference laboratory to report that the cold agglutination was directed against the anti-pr antigen and that this patient had clinically significant anti-Pr antibodies. The patient was kept warm and started on Danazol and Sutimlimab. However, the patient continued to have hemolysis after transfusions. After receiving her second dose of Sutimlimab and in the context of persistent hemolytic anemia, she underwent another bone marrow biopsy on day 34 after presentation. The biopsy showed hypercellular bone marrow with erythroid hyperplasia and complete maturation. However, this was not reflected in reticulocytosis until day 44. The patient received her third dose of Sutimlimab, and red blood cell transfusions were washed in addition to being warmed, which resolved hemolysis after transfusion reactions. She received a total of 30 red blood cell transfusions since presentation. The patient's anemia improved, with a hemoglobin level of 8.8 mg/dL and a reticulocyte count of 13%, and she was discharged on Day 51 after presentation (figure 1). She received one more dose of Sutimlimab (total of four doses) with complete resolution of her anemia, a normal reticulocyte count, normal LDH, negative Coombs study, and negative cold agglutinin titers. Conclusion: Here, we describe a challenging case of CAS caused by a rare Pr autoantibody, with a failure of first-line treatments for CAS. This report is the first to describe the use of Sutimlimab as a treatment for CAS. After initiating Sutimlimab, the patient continued to experience significant hemolysis shortly after transfusions, exhibiting hemoglobinuria and an inadequate increase in hematocrit. Only when the red blood cell transfusions were washed to remove complement, the hemolytic reactions ceased and significant increases in hematocrit occurred. This finding may be a consideration in other cases of cold agglutinin anemia. As CAS is a transient disorder, Sutimlimab could ultimately be discontinued once the hemolysis resolved. This case illustrates the role of complement inhibition in CAS and the potential need to warm and wash red blood cells in severe cases of CAS.

A RESPON KEMOTERAPI FLUDARABINE PADA HAIRY CELL LEUKEMIA

HCL is part of a rare B-cell lymphoproliferative disorder and is a subtype of Chronic Lymphocytic Leukemia. It is characterized by progressive pancytopenia, splenomegaly, and bone marrow hypercellularity. Patients often come because of abnormal complete blood count results or complications such as infection. This case report explains a case of a 41-year-old woman who had recurrent shortness of breath and cough as symptoms, where the patient had a history of acute myeloblastic leukemia (AML) with non-routine fludarabine chemotherapy. After receiving treatment and underwent further investigations in the form of peripheral blood smear and bone marrow aspiration examination, it was found that the patient had hairy cell leukemia. Fludarabine was given to the patient and it is reported to give effect partial remission (based on last bone marrow aspiration) along with pancytopenia as a clinical manifestation from myelosuppression as a side effect for long-term used fludarabine.&#x0D; HCL is part of a rare B-cell lymphoproliferative disorder and is a subtype of Chronic Lymphocytic Leukemia. It is characterized by progressive pancytopenia, splenomegaly, and bone marrow hypercellularity. Patients often come because of abnormal complete blood count results or complications such as infection. This case report explains a case of a 41-year-old woman who had recurrent shortness of breath and cough as symptoms, where the patient had a history of acute myeloblastic leukemia (AML) with non-routine fludarabine chemotherapy. After receiving treatment and underwent further investigations in the form of peripheral blood smear and bone marrow aspiration examination, it was found that the patient had hairy cell leukemia. Fludarabine was given to the patient and it is reported to give effect partial remission (based on last bone marrow aspiration) along with pancytopenia as a clinical manifestation from myelosuppression as a side effect for long-term used fludarabine.

TNFα induces Caspase-3 activity in hematopoietic progenitor cells CD34+, CD33+, and CD41 + of myelodysplastic syndromes

BackgroundCytopenia is the primary feature of Myelodysplastic Syndrome, even in the presence of hypercellular bone marrow. TNFα is recognized as both a proinflammatory, and proapoptotic cytokine with a well established role in promoting apoptosis in MDS. Therefore, TNFα has the potential to be a valuable biomarker for predicting the progression of cytopenia in MDS. This study aims to establish the role of TNFα exposure in triggering apoptosis through caspase-3 activity in CD34+, CD33+, and CD41 + cells in MDS.MethodsThis study is an in vitro comparative experimental research. Bone marrow mononuclear cells were isolated as the source of hematopoietic progenitor cells. Subsequently, CD34+, CD33+, and CD41 + cells were exposed to rhTNFα, and the caspase-3 activity was measured using flowcytometry.ResultsIn MDS CD33 + and CD41 + caspase-3 activity of rhTNFα exposed cells was significantly higher than without exposed cells. The opposite result was found in CD34 + cells, where the caspase-3 activity without rhTNFα exposed cells was significantly higher than rhTNFα exposed cells.ConclusionrhTNFα exposure led to an elevation in caspase-3 activity in MDS progenitor cells, especially in those that had differentiated into myeloid cell CD33 + and megakaryocyte cell CD41+, as opposed to the early progenitor cells CD34+.

Mutant p53 Drives the Development of Myelodysplastic Syndromes Via Dysregulating Pre-mRNA Splicing in Hematopoietic Stem and Progenitor Cells

Despite the clinical importance of TP53 mutations, to date there have been no studies on the functional impact of TP53 mutations on the initiation and progression of MDS. We found that heterozygous p53 mutant mice ( p53R248W/+) show extended survival and died within 15-20 months after birth. p53 mutant mice had hypercellular bone marrow and displayed cytopenia, thrombocytopenia, and anemia. Approximately 60% of p53R248W/+ mice developed MDS based upon pathological analysis of bone marrow (BM) and peripheral blood smears, while the remaining p53R248W/+ mice developed lymphoma and sarcoma. We further showed that mutant p53-driven MDS are transplantable. Thus, we have generated a mouse model of MDS that has some features of human MDS with TP53 mutations. To understand how mutant p53 drives MDS development, we performed RNA-seq studies to compare gene expression in hematopoietic stem and progenitor cells (HSPCs). GSEA analysis revealed that spliceosome genes were significantly downregulated in middle-aged p53 R248W/+ HSPCs compared to age-matched p53 +/+ HSPCs. We confirmed that the expression of splicing factors, such as Prpf3 and Prpf4, was significantly downregulated in middle-aged p53 R248W/+ HSPCs. We conducted alternative splicing analysis utilizing MISO (Mixture of Isoforms) algorithm to identify differences in exon inclusion ratio between WT and mutant HSPCs. We observed differential splicing of all classes of alternative splicing events, including Cassette Exons (CE), Competing 5′ and 3′ splice sites (A5' or A3'SS), Mutually Exclusive Exons (MXE), and Retained Introns (RI) in p53 R248W/+ cells compared to that of the WT HSPCs. Notably, we found that murine p53 mutant HSPCs exhibited aberrant splicing of key regulators of NFκBactivation, such as USP15. USP15 overexpression promotes NFκB expression through inhibiting its ubiquitination, whereas NFκB promotes USP15 expression. p53 mutant HSPCs tend to skip exon 7 and express high levels of short isoform of Usp15. The short isoform of Usp15, but not the long isoform of Usp15, activates NFκB in HSPCs, manifested by increased phosphorylation of p65. To determine the impact of mutant p53 on pre-mRNA splicing in human HSPCs, we ectopically expressed GFP or p53 R248W in human cord blood CD34 + cells and performed RNA-seq in transduced cells (GFP +). Human HSPCs expressing mutant p53 displayed alterations in pre-mRNA splicing compared to HSPCs expressing GFP. We found that human HSPCs expressing mutant p53 display aberrant splicing in key regulator of NFκB such as IKBKE (Inhibitor of nuclear factor kappa-B kinase subunit epsilon). Human HSPCs expressing mutant p53 tend to include exon 7 and express high levels of long isoform of IKBKE. The long isoform of IKBKE, but not the short isoform of IKBKE, activates NFκB in human HSPCs. Many proinflammatory cytokine genes are NFκB targets and we observed increased levels of pro-inflammatory cytokines, including IL-1β and IL-6, in the BM of middle-aged p53 mutant mice. Notably, we observed increased levels of IL-1β and IL-6 in the BM of MDS or AML patients with TP53 mutations. TP53 mutations co-occur with splicing factor mutations in MDS. To determine whether TP53 and SRSF2 mutations cooperate in pathogenesis of MDS, we have generated p53 R248W/+SRSF2 P95H/+ mice. We found that the survival of recipient mice repopulated with p53 R248W/+SRSF2 P95H/+ BM cells was significantly decreased compared to recipients repopulated with WT, p53 R248W/+, or SRSF2 P95H/+ BM cells. All recipient mice repopulated with p53 R248W/+SRSF2 P95H/+ BM cells died within 6 months and developed MDS or leukemia. Thus, we demonstrate that TP53 and SRSF2 mutations cooperate in MDS or leukemia development. In summary, we discovered that mutant p53 dysregulates pre-mRNA splicing in key regulators of inflammatory response during aging, thereby generating a chronic inflammatory microenvironment to drive MDS pathogenesis.

Newly Dignosed Early T-Cell Precursor Acute Lymphoblastic Leukemia Successfully Treated with Venetoclax Combined with DA and IA Regime

Abstract Background: Early T-cell precursor acute lymphoblastic leukemia (ETP-ALL) is a distinctive and extremely aggressive subtype of T-ALL. It is characterized by the aberrant expression of myeloid/stem cell antigens and the lack of Tlymphoid antigens including CD1a, CD4, CD5, and CD8. Currently, standard combination chemotherapy is still the mainstay of ETP-ALL treatment. However, the optimal management remains to be determined. ETP-ALL has low response rates to conventional chemotherapy and high relapse rates with a grim prognosis. Although some ETPALL patients achieved morphologic complete remission (CR), a more signifcant proportion maintained MRD positive. Under the traditional induction and intensifcation treatment strategy, the ETP-ALL group had worse long-term outcomes than the non-ETP-ALL group [1]. A recent preclinical study suggested that inhibition of B-cell lymphoma/leukemia-2 (BCL-2) might be a potential treatment option for patients with ETP-ALL [2]. Here, we present two cases of ETP-ALL clinical reactivity to venetoclax in combination with the IA regimen, providing a better bridge to allogeneic hematopoietic stem cell transplantation (allo-HSCT). Case 1 A 47-year-old female was diagnosed with ETPALL in October 2021. Flow cytometry analysis showed CD7,CD117,CD34,CD13,CD2,CD200,cyCD3 positive,suggestive of ETP ALL. Cytogenetic analysis was normal and molecular panel identified aberrations in TET, EP300 and EZH2. She then recived venetoclax plus DA regime（venetoclax, 100 mg d1, 200 mg d2, 400 mg qd d3-14；daunorubicin 40mg d1-3；cytarabine 100mg d1-5). A bone marrow biopsy after the 1st cycle revealed CR with minimum residual disease (MRD) 1.91% by flow cytometry. She then received 2nd cycle of venetoclax plus CAG treatment and got MRD negative. She received 2cycles of the same combination and remained in MRD-negative CR prior to proceeding with a reduced intensity haploidentical allo-transplantation. She is currently 1 years and 4 months post-transplant and in remission. Case 2 A 53-year-old man was diagnosed with ETP-ALL following bone marrow aspiration in August 2022. He presented with Leukopenia and anemia (WBC 2.53× 109 /L, HB 73 g/L, PLT 148 × 109 /L). Bone marrow biopsy revealed a hypercellular bone marrow with 80% lymphoid blasts, negative for MPO staining. The flow cytometry showed the immunophenotype of the lymphoid blasts (CD7+CD34+CD33+CD13+CD200+cyCD3+nTdT+), which were consistent with the immunophenotype of the ETP-leukemic cells. Cytogenetics revealed der(4)(q35).The molecular panel identified aberrations in CSF3R,DNMT3A,CCND3,CSF3R and WT1. Therefore, ETP-ALL was diagnosed. Initially, he received the first cycles of venetoclax combined with IA regimen (venetoclax, 100 mg d1, 200 mg d2, 400 mg qd d3-14;idarubicin 10mg d1-3,cytarabine 100mg d1-5), and CR was achieved this time. Then, he received a 3rd CAG therapy. Subsequently, he underwent hematopoietic stem cell transplantation (HSCT) successfully in December, and CR was still maintained at now 7 months after HSCT. Conclusion Combination therapy of venetoclax with IA regimen is an effective regimen for treating patients with ETP ALL.

Chronic neutrophilic leukemia: A case report

Objectives. We present a case report of a patient with malaise, abdominal pain, and vomiting, later underwent bone marrow biopsy and found to have CNL with no genetic mutation. Case presentation. A 40 years old male came into hospital with malaise, abdominal pain, nausea, and vomiting. Furthermore there were bilateral lymphadenopathy in the neck, hepatomegaly and moderate splenomegaly in abdominal examination. Anemia, leukocytosis and increase of Lactat Dehydrogenase (LDH) were found. Bone marrow aspiration and biopsy was performed and showed predominant neutrophil and the bone marrow biopsy showed hypercellular bone marrow with increased myeloid-neutrophil, increased myeloid erythroid ratio. Outcome. After further investigation this patient was diagnosed with chronic neutrophilic leukemia based on bone marrow aspiration and biopsy result.

CSF3R-mutant chronic myelomonocytic leukemia is a distinct clinically subset with abysmal prognosis: a case report and systematic review of the literature

Chronic myelomonocytic leukemia (CMML) is a myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) chacaterized by persistent peripheral blood monocytosis, hypercellular bone marrow and dysplasia at least in one myeloid lineage. CMML shares much of its molecular landscape with other myeloid neoplasms, while differs from others such as chronic neutrophilic leukemia (CNL), given the high frequency of CSF3R mutations in the latter. In this article, we report a case of CSF3R-mutated CMML and dissect this rare entity by reviewing the medical literature, with the intent to understand how this rare mutation shapes CMML's clinical and morphological phenotype. CSF3R-mutated CMML emerges as a rare entity meeting the ICC/WHO diagnostic criteria for CMML and simultaneously showing clinical-pathological and molecular traits of CNL and atypical chronic myeloid leukemia, rising an important and difficult diagnostic and therapeutical issue.

Association of pre-treatment bone marrow morphology and achievement of BCR-ABL1 transcript milestones in CML

Chronic myeloid leukemia (CML) is characterized by the fusion gene BCR-ABL1 which encodes aberrantly functioning tyrosine kinase. Treatment with tyrosine kinase inhibitors (TKI) is a landmark of CML management and the main goal is to achieve major molecular response (MMR) which is defined as BCR-ABL1IS ≤ 0.1 % at 12 months of therapy. The aim of this study is to analyze histologic features of bone marrow (BM) in CML patients at the time of diagnosis and compare it to the level of BCR-ABL1IS transcript at 3 (BCR-ABL1IS ≤10 % early molecular response; EMR) and 12 months (MMR) as well as to so called molecularly undetectable leukemia (MUL) to see weather bone marrow morphology can be of value in predicting achievement molecular response milestones. Thirty-two bone marrow biopsies of CML patients, prior TKI therapy, were re-evaluated and CD34 immunohistochemistry was performed to examine microvessel density (MVD) and microvessel area (MVA) and subsequently compared it to the level of BCR-ABL1IS transcript. This study showed statistically significant association between BM hypercellularity and EMR (p = 0.048) and MUL (p = 0.034), peri-trabecular adipocyte distribution and EMR and MUL (p = 0.027 and p = 0.011, respectively), MMR and bone marrow fibrosis (p = 0.029), loose megakaryocyte clustering and EMR and MUL (p = 0.004 and p = 0.018, respectively), absence of naked nuclei and MUL (p = 0.033) but there was no statistically significant association with vascular parameters. These results suggest that some bone marrow morphologic features prior TKI therapy might be indicators of favorable molecular response.

A Peculiar Manifestation of Chronic Myelogenous Leukemia in Lymphoid Blast Crisis

A 61-year-old man with a history of factor V Leiden mutation, hypothyroidism, and transient ischemic attacks presented to his physician's office but could not recall the reason for his visit. Initial laboratory test results showed a slight leukocytosis with slight basophilia; neuro-immunologic, infectious, and metabolic work-up was unrevealing. Flow cytometry results showed atypical B lymphoblasts. Bone marrow biopsy results revealed a hypercellular bone marrow with CD10 staining lymphoblasts and Philadelphia chromosomal translocation. Hematologic malignancy fusion panel results revealed BCR/ABL1 fusion with p210 oncoprotein, establishing the diagnosis of chronic myelogenous leukemia in lymphoid blast crisis—a peculiar manifestation of a disease that usually manifests with significant leukocytosis.