Basics to Brilliance: Haematology Podcast

Polycythaemia- red cell #
Erythrocytosis – in red cell mass
Absolute Erythrocytosis
- M: Hct >0.60 or >0.52 + RCM >25% of mean
- F: Hct >0.56 or >0.48 + RCM >25% of mean

Apparent Erythrocytosis
- Men: Hct >0.52 + normal RCM
- Women: Hct >0.48 + normal RCM

Relative erythrocytosis
-Normal RCM + Reduced plasma volume (pathological dehydration)

M>F
Median >60yo

2' PRV: treat underlying cause +/- venesection (higher hct threshold)

Classification of Absolute:
EPO dependent
- Appropriate: High altitude, chronic hypoxia, localised hypoxia, congenital
- Inappropriate: Tumors, EPO doping, Testosterone replacement, diabetic meds
EPO independent:
- Acquired: Primary PRV (low EPO level, feedback)
- Congential Polycythemia= mutations in EPO receptors

Inv:
- Tumor Hunt
- Hx + Exam: ?True vs. Apparent
- FBC, U+E, LFTs, Ca2+
- Blood film
- Ferritin: low in 1’ PRV
- EPO
- Imaging
- NB: Normal Hct + High Red Cell # + Low MCV + Low ferritin –> Masked PRV
- Molecular Testing:
JAK2 (V617F)(96-97%)...SAMURAI JACK=BLOODY)
EXXON 12 (3%)
Del (13q), Del (20q), Del (1q), Tris. 8/9
- *SV thrombus 50% chance MPN
- BMBx: Tri-lineage myeloid expansion
- Familial screen for congenital(young)

Sx of primary PRV:
- Arterial*+ Venous clot (splanchnic*)
- Hyperviscosity sx
- Splenic sx
- Gout

Indications for urgent venesection...Hyperviscosity sx

BSH diagnostic:
JAK2 Pos
- Hct M >0.52, F > 0.48. Or RCM >25% above baseline OR Splanchnic vein thrombus
- JAK2 positive
JAK2 Neg= A1-4 + either ≥ 1 A or 2 B’s
A1: Hct M >0.60, F > 0.56. Or RCM >25% above baseline
A2: No JAK2
A3: No 2' cause
A4: BMBx pos
A5: Palpable splenomegaly
A5: Acq. genetics in BM cells
B’s: Plt >450, Neut >10 (>12.5 in smokers), Radiological splenomegaly, Low EPO

Congenital testing

Risk Stratification:
- Thrombi..
ECLAP study
High Risk:>65 + prev clots
Low Risk: <65 + no prev clot
- Malignant Transformation to MF (5-15% in 10 years), AML (2% at 10 year) markers:
Splenomegaly, LDH, HVAF burden >50% at diagnosis

Management:
- Lifestyle...CV factors decrease
- Aspirin +PPI for all (after confirmed)- decrease CV events 60% (ECLAP)
- Venesection first line (?isovolemic)- sx***
CYTO-PV trial: Hct aim <0.45, make iron def.
400-450ml off
Weekly -> 3-4x/year
- If previous clots: Lifelong anticoag (w/out aspirin)
- NB: if plt>1000 (acq. VWF) bleeding risk, 1st cytoreduce

Cytoreduction: (once confirmed primary PRV)
- High risk
- Progressive Hepatosplenomegaly
- Plts >1500
- WCC >15
- Constitutional Sx
- Poor tolerance of venesection

1st line: (OHC then/or IFN)
OHC
- Risk: Macrocytosis, ulcers, SCC, Malignant transformation
NB: pregnancy
Peg IFN-A
Young + fertile
Lowers HVAF
PROUD PV study (2020)
Continuation PV study (2022)
SE: flu like sx, AI disease (*thyroid), mood disturbances

2nd line
Rux: JAK2i (works for EXXON)
RESPONSE + RESPONSE 2 trial
MAJIC PV study
SE: immunosuppression, skin cancer, wean dont stop

Older
Busulfan: 1 dose (w monitoring) vs intermittent
Risk: leuk transformation, pneumonitis**

Pregnancy: inc. DVT
OHC not safe (stop 3 months prior)
IFN 1st
Aspirin
Uterine Doppler from 20wks of gestation?flow
LMWH 6 wks postpartum

Synchronous CNS and systemic lymphoma at initial presentation (treatment-naïve; TN-SCNSL)
- CNS relapse without recurrent systemic lymphoma (relapsed isolated CNS lymphoma; RI-SCNSL)
- Relapsed concomitant systemic and CNS disease following treatment for systemic lymphoma (RC-SCNSL)

Generally hybrid disease

Investigations
- MRI Head w gadolinium
- PET-CT
- Testicular US (blood testes barrier influences treatment)
- Opthalmoscopy/fundoscopy +/- Vitreal biopsy +/- subretinal aspirate – could need RT
- Lymph node Biopsy
NB: Worthwhile to remember patient hx re relapses
- ?Stereotactic Brain Biopsy w/ Intraoperative rapid cytology and rv of frozen sections......NB: Steroids pre-biopsy may yield non-diagnostic results (1/3 if 7 days steroids)
- Correlate with imaging and timescale
- LP
o Good for leptomeningeal (15%) which can be missed on MRI
o CSF protein levels are prognostic
o Flow cytometry
o Cytospin
o PCR for IGHV rearrangement: sens.

Trial: MARIETTA study, or also known as the IE LSG 42
- Single arm prospective trial, 75 patients
- +/- Steroid pre-phase –>MATRIX + RICE alternating induction x3–>CR/PR ->Carmustine-Thiotepa AutoSCT
- Pre-morbid performance status <=3
- 2-year overall survival for all of those patients included in the trial just under 50%
- NB: cytaribin omissions if poor performance status
- RICE (Ritux isophosphamide, carboplatin and etoposide)...NB, peripheral neuropathy and neurotoxicitiy
- TN-SCNSL best 70% 2 year PFS
- RI-SCNSL 40% 2 year PFS... can also be given just MATRIX
- RC-SCNSL 14% 2 year PFS
- NB if frail elderly, change MATRIX to MARTA
Response assessment :
- TN-SCNSL and RC-SCNSL
o Brain MRI +/- Spine every 2 cycles
o PET scan every 2-3 cycles
o PET and MRI pre-auto, determine least partial response
o End of treatment PET (6-8 weeks post) and MRI

RI-SCNSL : MRI brain +/- spine every 2 cycles...PET only if suspicion of progression elsewhere

Relapse post MARIETTA :

-BTKi ?compassionate access vs Trial
-ZUMA7 trial: CAR-T (anti CD19) NB : ICANS/CRS....Approved for DLBCL 12 relapse within 12 months and primary refractory disease that hasn’t responded
- PALLIATIVE CARE

NB Immuno-privileged sites :

- Primary Intraocular Lymphoma :
o Stage w PET, MRI head, US Testes
o MATRIX vs MARTA vs PREMAINE as frailty allows (like 1’ CNS) –> AutoSCT
o +/- Occular RT
o Frail++ +-> Intravitreal MTX
- Primary Testicular Lymphoma
o If 1 testicle involved 1/3 of patients have the other involved too
o US Testes –> Orchidectomy + histopathology...if lymphoma ->imaging and investigations as above
o LP with above investigations as 1/3 have CNS involvement
o ?skin lesions sometimes in testicular lymphoma
o RCHOP vs RPolaChP + CNS prophylaxis w MTX
o Radiotherapy (30gy) to contralateral testes to reduce contralateral Relapse risk and/or BL orchidectomy- fertility discussion
o Systemic chemotherapy because of microspread to nodes

CNS Lymphomas

1% of all NHL
3% of all Brain tumours
Most common subtype (90%) is DLBCL

Clinical division:
1. 1* CNS lymphoma,
2. 2* CNS lymphoma
- TN-SCNSL
- RI-SCNSL
- RC-SCNSL
3. Immune deficiency assoc- HIV; better prog.

Presentation:
- SOL Sx
- Raised ICP: morning headaches w N+V
- Neuropsych, Behavioural, Memory, Language
- Focal motor + Stroke Sx
- Seizures
- Visual Sx and uveitis

Investigations:
- FBC + Blood film (exclude 2* CNS lymphoma and BM), GFR, U&Es
- LDH (prog.)
- Virology (Hep+HIV)
- IGs, SPEp (paraprotein)
- Stereotactic Brain Bx w/ IO rapid cytology and rv of frozen sections
NB: Steroids pre-biopsy ?non-diagnostic results
- LP:
.Leptomeningeal*
.CSF protein- prognostic
.Flow
.Cytospin
.PCR for IGHV r.
- CT Head
- MRI H (w gadolinium) +/- spine

Staging:
-R/O systemic lymphoma
-PET/CT
-US Testes
-Opthalmoscopy/fundoscopy +/- Vitreal biopsy +/- subretinal aspirate
-?BMBx

Pre-treatment:
-Baseline neuropsych + cognitive ax
-Premorbid performance status: ECOG, Echo, GFR, PMHx

Dx w/o Bx
-MRI
-Clinical features
-Clonal B cells in CSF/Vitreous fluid and/or PCR IGHV rearrangement
Treatment:
Induction main:
- MATRIX- younger <70
- MARTA- older >65
Consolidation:
- Whole brain RT
- BCNU Thiotepa AutoSCT- gold standard if fit...Within 6-8 weeks of the 1st day of final induction: consider for all patients with non-progressive disease (EOT MRI)

Trials:
IELSG32 study (Leukemia, 2022)- induction + consolidation choices for < 70
Induction: 3 arms, MTX + Cyt main
- MATRIX- MTX +Cyt + Thiotepa + Ritux -> AutoSCT.....best choice (4 cycles)...7yr 70%survival
Consolidation: efficacy equal AutoSCT and WB-RT, favoured AutoSCT for Sx.
...MATRIX regimen available on NSSG:
- Dose ++ to cross BBB
- Folinic Acid rescue*
- IVF till MTX levels <0.1 umol/L (1st lvl 48hrs after MTX)
- EF >45%
- GFR >50
NB: stop co-trimoxazole, penicillins, aspirin, NSAIDs, PPIs (inhibit MTX clearance)
- MTX build up in 3rd spaces
- Stem cell harvest post #2
- Treatment related mortality 4-7% mostly in #1
- Dose reduce Cytaribin (2/3instead of 4 cycles) if pre-morbid, 25-50% total

MARTA study (Blood, Nov 22): fit for autosct and >65
- 2x MTX, cytarabin and rituximab ->AutoSCT

PRIMAIN study(2017): not fit for autosct >= 65
1. 4x MTX, Ritux + PO procarbazine
2. 6mo of PO procarbazine as maintenance
?WB-RT for residual disease

Palliative if unfit and older:
Dex
Temozolomide
WB-RT
?IT Chemo in leptomeningeal

IELSG43 study... favoured AutoSCT PFS and OS to de-escalation consol.

Follow Up:
- Response Ax with contrast enhanced MRI scan: 1-2mo after consol.
- Rpt MRI every 3-4mo for 2 years ++-
- CR: MRI NAD, normal eye, clear CSF
- Stable: <50% decrease, <25% increase
- PR: 50% tumor reduction ?persistent CSF
- Progressive: >25% increase and/or new lesions
- Relapse/Refractory
25% asymptomatic
OS 3-5mo
?Trial
Re-Bx and r/o other brain tumors
Restaging
Re-induction w/ salvage chemo
.MATRix if remission > 2 years +/- WB-RT if post auto
.Ifosfamide based: RICE or RIE

Future:
2nd gen BTKis- Ibrutinib or Zanibrutinib

Chronic MyeloMonocytic Leukemia (not CML)
Persistently high monocyte count- 3 months
Most frequent MDS/Myeloproliferative neoplasms – a cross between the two
Median age 72
Median survival 20-40 months
Transformation to AML (15-30%)

WHO definition of CMML:
1. Excess monocytes- persistent over 3 months, ≥ 1

Monocytes 10% of total WC count
2. Dysplasia: morphological difference (blood film on BMBx)
OR
3. Genetic abnormalites ( on cytogenetics or molecular)

WHO Addition in 2022:
Persistent 3 months Monocytes ≥ 0.5 over 10% of WC count
AND Dysplasia
AND Genetic Abnormalities

No single diagnostic test

Exclude MPNs: CML, MF, pre-fibrotic MF, PRV and ET
- Exclude Genetics: PDFGR A and B, FGFR 1, JAK-2 rearrangement
- Ensure less than 20% blasts

Common Presentation:
- Constitutional Sx
- Cytopenias and sequelae
- Effusions pericardial or pleural (inflammation and infiltration)
- Skin deposits
- Autoimmune disorders (higher incidence of CMML)

Classification:
-Myelodysplastic CMML- WC<13
o Cytopenias**

- Myeloproliferative CMML – WC ≥ 13
o Activate RAS pathway mutations
o Leukostasis**(*brain and lung*)
o More adverse clinical outcomes
o More splenomegaly and extra-medullary (infiltrative)

PROGNOSTIC CLASSIFICATION: Blast Count
- CMML-1: BMBx <10% blasts
- CMML-2: BMBx <20% blasts OR Presence of Auer Rods (trumps blast %)

OTHER:
o CPSS-Mol: cytogenetics, "NARS”, blast count, WBC count, transfusion dependence

Investigations
- R/O infection
- FBC and trend
- Blood film
- Flow of Peripheral blood (immunophenotyping): Chronic Panel
o Classical Monocyte MO1: CD14 +ve and CD16 -ve
- If >=94% MO1 on flow specific and sensitive for malignant
- Can help differentiate reactive monocytes MO3 (CD14 weak +ve, CD16 +ve)
-BMBx if appropriate as per age and fitness
o Aspirate: Dysplasia, Excess monocytes
o Flow: Acute panel (check blasts percentage)
o Cytogenetics:
- Poor cytogenetics: Trisomy 8, Chrom. 7 abnormalities, complex cytogenetics (3 or more cytogenetic abnormalities)
-Good cytogenetics: Isolated loss of chromosome Y
o Molecular: PCR in EDTA- “NARS”.....NRAS, ASXL1, RUNX1, SETBP1

Treatment decisions:
- High risk (AML risk) + Tx eligible -> Intensive chemo (AML style) and Tx
- Transplant outcomes: Overall survival approx. 30% but curable

Low risk and not transplant eligible: QOL improvement
o Watch and wait
o Cytopenia supportive treatment w/ transfusions

o CMML-1 with raised WC count:
->Hydroxycarbimide as long as it provides benefit but can worsen cytopenias in patients with stable counts

o CMML-1 with significant cytopenias MML-2 with WC <13 with high risk of AML
-> Azacytidine (hypomethylating agent) Subcutaneous

Chronic Lymphocytic Leukemia (CLL)- Chronic Relapsing Remitting
Most common leukemia in adults
Incurable but treatable
*Remember Supportive Care*
Median age of 72
M > F
80% incidental
SLL: lymphocytes in lymph nodes and spleen instead of blood

Presentation:
1) Fatigue
2) B symptoms
3) High WC
4) Cytopenias (Marrow infiltrate, AIHA, ITP, Hyposplenism)

Rule out: Reactive (viral serology)- Hepatitis, HIV

Investigate:
1) FBC + blood film (mature lymphocytes) w/ trend
2) Haemolysis screen + Coombs test
3) B2 Microglobulin (prognostic marker)
4) IGs + serum electrophoresis
5) Flow cytometry (immunophenotyping)
6) LN Bx (core) especially if lymphadenopathy (*SLL)
7) BMBx
8) Tp53 (17p del or mut)
9) CTNTAP if treatment indicated

Confirm :
1) Lymphocyte morphology (blood film)- monomorphic mature small w/out nucleolous r/o aggressive pro-lymphocytes r/o prominent nucleoli in reactive lymphocytosis
2) 5x10^9 / L circulating clonal B cells for over 3 months on Flow...if below, need annual FBC monitoring
3) Immunophenotype scoring out of 5 (1 point each): +ve CD5, +ve CD23, weak IG expression, absent/weak CD22, absence of FMC-7...need 4 or 5/5

Staging :
1) BINIT A/B/C
2) RAI 0-4
Prognosis: CLL International Prognostic Index
1) Age
2) B2 Microglobulin
3) TP53 status- continuous therapy better if TP53 mut
4) IGHV mutation- better if present
5) RAI or BINIT

The International Working Group for CLL (iwCLL) treatment- Risk vs. Benefit
1) Cytopenias Hb <100, Plts <100
2) Bulky disease >10cm LN length
3) Constitutional sx disease related
4) AIHA (10-20%) and ITP (2-5%)
5) Symptomatic or fnxnal extranodal involvement
6) Massive Splenomegaly >6cm from costal margin or progressive SM + Sx
7) Lymphocyte doubling time < 6 months or > 50 percent rise in 2 months

WATCH and WAIT if not reaching criteria

Infection risk (bacterial):
1) Vaccination (NB: NO LIVE VACCINES)
2) IVIG in immune paresis
3) Prophylactic Abx (azithromycin)
4) PCP prophylaxis while on treatment

Need IRRAD blood products

Trials for Traditional treatments vs. BTK1 and BCL2
1) Alliance
2) Mayo clinic study
3) FLARE
4) CLL14 (German) and Illuminate trials

Treatment:
1) Traditional: FCR
2) Targeted:
a. 1st gen BTK1- Ibrutinib 420mg OD (continuous)
b. 2nd gen BTK1- Acalabrutonib 100mg BD (continuous)
c. BCL-2 inhibitor- Venetoclax 400mg OD
i. Frontline : OVen.. Ven + Obinutuzumab (CD20 mAb) - 1 yr
ii. Relapse: VenR... Ven + Rituximab (CD20 mAb)- 2 yrs

d. PI3K inhibitor- Idelalisib - 3rd line as bridging for 2x refractory/2x exposed
*High Risk*: Doublet therapy (targeted combined)
i. Jain et al. – Phase 2 trial
ii. CAPTIVATE trial: Ibru + Ven <65, TP53 mut/del OR unmutated IGHV

TRIPLET Therapy trials

-ALLO SCT- early referrals in high risk with first progression
· Primary Progression: <6m of response
· Relapse: >6m response and then....look at iwCLL for treatment...class switching....

FUTURE :
- Zanibrutinib
- Time limited therapies – STATIC trial
- MRD for CLL
NOTE:
- AIHA treatment algorithm 1st THEN CLL treatment
- Richters transformation to DLBCL