Idiopathic myelofibrosis--an update with particular reference to clinical aspects and prognosis

Increasing the Role of Phenomenology in Psychiatric Diagnosis-The Clinical Staging Approach

Recent editions of diagnostic manuals in psychiatry have focused on providing quick and efficient operationalized criteria. Notwithstanding the genuine value of these classifications, many psychiatrists have argued that the operationalization approach does not sufficiently accommodate the rich and complex domain of patients’ experiences that is crucial for clinical reasoning in psychiatry. How can we increase the role of phenomenology in the process of diagnostic reasoning in psychiatry? I argue that this could be done by adopting a clinical staging approach in diagnostic reasoning in psychiatry. The approach has the resources to include the progressive nature of patients’ experiences to a much greater degree than is currently practiced. It can address the recent plea for increasing the role of phenomenology in psychiatric diagnosis by offering a model for clinical reasoning that goes beyond the operationalized, static criteria of diagnostic manuals, without depriving us of their benefits.

Bone marrow fibrosis in primary myelofibrosis: pathogenic mechanisms and the role of TGF-β

Primary myelofibrosis (PMF) is a Philadelphia chromosome negative myeloproliferative neoplasm (MPN) with adverse prognosis and is associated with bone marrow fibrosis and extramedullary hematopoiesis. Even though the discovery of the Janus kinase 2 (JAK2), thrombopoietin receptor (MPL) and calreticulin (CALR) mutations have brought new insights into the complex pathogenesis of MPNs, the etiology of fibrosis is not well understood. Furthermore, since JAK2 inhibitors do not lead to reversal of fibrosis further understanding of the biology of fibrotic process is needed for future therapeutic discovery. Transforming growth factor beta (TGF-β) is implicated as an important cytokine in pathogenesis of bone marrow fibrosis. Various mouse models have been developed and have established the role of TGF-β in the pathogenesis of fibrosis. Understanding the molecular alterations that lead to TGF-β mediated effects on bone marrow microenvironment can uncover newer therapeutic targets against myelofibrosis. Inhibition of the TGF-β pathway in conjunction with other therapies might prove useful in the reversal of bone marrow fibrosis in PMF.

The differential diagnosis and bone marrow evaluation of new-onset pancytopenia

New-onset pancytopenia can be caused by a wide variety of etiologies, leading to a diagnostic dilemma. These etiologies range from congenital bone marrow failure to marrow space-occupying lesions, infection, and peripheral destruction, to name a few. Bone marrow examination, in addition to a detailed clinical history, is often required for an accurate diagnosis. The purpose of this review is to provide a brief overview of many of the causes of new-onset pancytopenia in adults and children, with emphasis on bone marrow findings and recommendations of additional testing and clinical evaluation when needed, with the overall aim of aiding the pathologist's role as a consultant to the patient's treating physician.

Clinical staging: a heuristic model for psychiatry and youth mental health

Diagnosis in psychiatry continues to struggle to fulfil its key purposes, namely to guide treatment and to predict outcome. A clinical staging model, widely used in clinical medicine, could improve the utility of diagnosis in psychiatry, especially in young people with emerging disorders. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry, as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of a disorder, and selected by consumers and clinicians on the basis of clear-cut risk-benefit criteria. This would ensure that, as treatments are offered earlier, they remain safe, acceptable and affordable, and potentially more effective. Biological variables and a range of candidate risk and protective factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorders clarified. In this way, a clinicopathological framework could be progressively constructed. Clinical staging, with restructuring across and within diagnostic boundaries and explicit operational criteria for extent and progression of disorder, should be actively explored in psychiatry as a heuristic strategy for developing and evaluating earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders. Young people with emerging mental and substance use disorders could be the main beneficiaries.

Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions

Diagnosis in psychiatry increasingly struggles to fulfil its key purposes, namely, to guide treatment and to predict outcome. The clinical staging model, widely used in clinical medicine yet virtually ignored in psychiatry, is proposed as a more refined form of diagnosis which could restore the utility of diagnosis, promote early intervention and also make more sense of the confusing array of biological research findings in psychiatry by organizing data into a coherent clinicopathological framework. A selective review of key papers in clinical medicine and psychiatry which describe clinical and clinicopathological staging, and a range of related issues. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry just as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of disorder, and they could be selected on clear-cut risk/benefit criteria. Biological variables and a range of candidate risk factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorder could be greatly clarified. A clinicopathological framework could be progressively constructed. Clinical staging with a restructure across and within diagnostic boundaries with the explicit operationalization of criteria for extent and progression of disorder should be actively explored in psychiatry as a heuristic strategy for the development and evaluation of earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders.

Grade of bone marrow fibrosis is associated with relevant hematological findings-a clinicopathological study on 865 patients with chronic idiopathic myelofibrosis

Controversy continues to exist regarding not only the exact definition and grading of myelofibrosis (MF), but also whether, and to what extent, this feature may be correlated with clinical findings. A retrospective study was performed involving 865 bone marrow (BM) biopsies together with the clinical records from patients with chronic idiopathic myelofibrosis (CIMF). Diagnosis was established according to the World Health Organization criteria, and assessment of MF followed a consensus scoring system that included four grades (MF-0 to MF-3). Histopathological and clinical evaluations were carried out in an independent fashion. Prefibrotic and early CIMF (MF-0/-1) were presented by 565 patients showing borderline to mild anemia and no or slight splenomegaly, but frequently, thrombocytosis exceeding 500x10(9)/l was shown. In 300 patients, manifest reticulin and collagen fibrosis (MF-2/-3) were characterized by marked anemia, gross splenomegaly, peripheral blasts, and normal to decreased platelet and leukocyte counts. The latter cohort was consistent with findings generally in keeping with MF with myeloid metaplasia. Regarding the stepwise evolution of disease, sequential BM examinations showed that in 103 patients, prefibrotic and early CIMF transformed into advanced stages accompanied by correspondingly developing clinical and histomorphological features. Survival analysis (univariate calculation) revealed a significantly more favorable prognosis in prefibrotic vs advanced stages of CIMF. On the other hand, higher classes of MF also exerted a higher clinical risk profile (Lille score). In conclusion, the dynamics of the disease process in CIMF are characterized by evolving MF in the BM and closely associated changes of relevant hematological findings.

Bone marrow histopathology following cytoreductive therapy in chronic idiopathic myelofibrosis

AIMS

To analyse systematically therapy-induced lesions of haematopoiesis in chronic idiopathic myelofibrosis (IMF).

METHODS AND RESULTS

A total of 759 sequential bone marrow (BM) biopsies (median interval 32 months) were performed in 261 patients with IMF. Besides a control group (symptomatic treatment), monotherapies included busulfan, hydroxyurea and interferon. In all therapy groups hypoplasia of varying degree was a frequent finding and often accompanied by a patchy distribution of haematopoiesis. Most conspicuous was gelatinous oedema showing a tendency to develop discrete reticulin fibrosis (scleroedema). Minimal to moderate maturation defects of megakaryopoiesis and erythroid precursors occurred, but overt myelodysplastic features were most prominent following hydroxyurea and busulfan therapy. Acceleration and blastic crisis were characterized by the appearance of immature and CD34+ progenitor cells. Concerning the dynamics of fibrosis, no differences were observed between controls and the various therapy groups. In 143 patients (55%) without or with little reticulin at onset, an increase in myelofibrosis was detectable that progressed to overt collagen fibrosis.

CONCLUSIONS

Therapy-related bone marrow lesions in IMF comprise a strikingly variable spectrum that may include aplasia with scleroedema and a patchy distribution of myelodysplastic haematopoiesis associated with progressive myelofibrosis.

Dynamics of fibrosis in chronic idiopathic (primary) myelofibrosis during therapy: a follow-up study on 309 patients

Controversial issues in chronic idiopathic myelofibrosis (IMP) are amongst others the evolution of the disease process and the influence of therapy on the dynamics of fibrosis. For this reason, a multicenter observational study was performed on 309 patients with IMF that had a long follow-up including 822 bone marrow biopsies at a median interval of 32 months. In addition to a control group (156 patients) with symptomatic treatment, monotherapy consisted of busulfan (30 patients), hydroxyurea (52 patients), interferon (26 patients) and various combinations (48 patients). Density and quality (reticulin/collagen) of fibers was determined by a semiquantitative scoring system. Independent of therapeutic regimens at the time of the last bone marrow biopsy 67% of the patients with grades 0-2 fibrosis revealed a progression, 42% stable state and 6% regression of myelofibrosis. Because of significant differences concerning frequencies of biopsies and endpoints of examinations, individual changes in the grades of fibrosis were evaluated with regard to treatment applied at standardized intervals of 20 months. According to this calculation no relevant differences in the dynamics of myelofibrosis (progression, stable state) was detectable in the control group compared to the other therapeutic modalities. The few patients with a regression of myelofibrosis usually presented with severe hypoplasia compatible with a myelo-ablative effect by aggressive chemotherapy. In conclusion, persuasive evidence has been produced that myelofibrosis in IMF is characterized by a stepwise progression and that this process is not significantly influenced by current treatment strategies.

Melphalan treatment in patients with myelofibrosis with myeloid metaplasia

Between January 1985 and December 1992, 104 consecutive patients with symptomatic myelofibrosis with myeloid metaplasia (MMM) [splenic enlargement >5 cm and/or transfusional requirement or Hb < 10 g/dl and/or white blood cell (WBC) count >20 x 10(9)/l and/or platelets >1.0 x 10(9)/l] received low-dose Melphalan (2.5 mg/3 times/week) to evaluate the efficacy and toxicity of this approach. Among 99 evaluable patients, 66 (66.7%) achieved a response after a median time of 6.7 months: 26 (26.3%) had a normalization of all clinical and haematological parameters (complete response, CR) and 40 (40.4%) showed an improvement >50% (partial response, PR). Thirty-three patients (33.3%) were resistant. Reversible haematological toxicity was the most common complication. Median durations of CR and PR were 28.4 and 26 months respectively: median survival of CR + PR patients was 71.2 months (95%CI: 33.8-108.7) versus 36.5 months (95%CI: 24.5-48.5) for the non-responders (log-rank test, P =0.002). In the multivariate analysis, the following variables were significantly associated with a shorter survival: anaemia [hazard risk (HR) = 2.7], WBC count >20 x 10(9)/l (HR = 2.4) and not achieving any type of response, either partial or complete (HR = 3.9). In conclusion, Melphalan could be a promising first-line option for MMM patients with clinical or haematological symptoms requiring treatment.

Myelofibrosis in systemic lupus erythematosus

In this study we present a case of coexisting systemic lupus erythematosus (SLE) and myelofibrosis. Literature review supports the fact that the two diseases rarely occur together in the same patient. The young female patient studied was admitted with pancytopenia and a clinical picture which met the criteria of SLE. Histological examination of the bone marrow biopsy revealed severe myelofibrosis with hypocellularity of the myeloid cell lines. Treatment with immunosuppressive and colony stimulating factor led to slow but complete regeneration of the bone marrow and subsequently to an improved haematological status, and the patient was spared bone marrow transplantation.

Matrix metalloproteinase and tissue inhibitor of metalloproteinase in human bone marrow tissues-an immunohistochemical study

Unlike other tissues, bone marrow (BM) seldom displays fibrosis after injury, suggesting a possible suppressive mechanism against secondary myelofibrosis in BM tissues. We investigated if fibrosis-related factors, such as matrix metalloproteinase (MMP) and tissue inhibitor of metalloproteinase (TIMP), were expressed in BM tissues in vivo. We attempted immunohistochemical studies on specimens of 16 BM aspiration materials with normal hematological findings and 21 BM tissues from autopsy cases who had succumbed to acute heart failure or cerebrovascular diseases without any BM injuries. Identification of immunohistochemically reactive MMP-2, MMP-9 and TIMP-2 in BM tissue samples revealed for the first time that MMP-2 was localized in the myeloid cells, erythroblasts and megakaryocytes, MMP-9 in the myeloid cells and megakaryocytes. In addition, expression of TIMP-2 in the megakaryocytes as well as in the histiocytes within the stroma was verified. In the non-pathological condition, MMP/TIMP expressions were not encountered in BM stromal cells, such as fibroblasts, vascular endothelial cells, reticulum cells on adipocytes, except for TIMP-2 identification in stromal histiocytes. It is highly possible that these MMP and TIMP expressions in the BM hematopoietic cells and stromal histiocytes are significantly associated with suppression or induction of myelofibrosis.

Expression of c-myb and B-myb oncogenes on myelofibrotic marrow fibroblasts

The term IMF (Idiopathic Myelofibrosis) refers to a primary bone marrow disease in which the normal haematopoietic bone marrow cells are for unknown reasons replaced by connective tissue. The pathogenesis of the disease has not been clarified yet. We have speculated that the increment of proliferation of bone marrow fibroblasts in IMF may be the consequence of the over-expression of some oncogenes, leading or contributing to the fibrosis via a cell amplification. Thus, we investigated the possible role of the c-myb and B-myb genes in IMF and control bone marrow fibroblasts in different culture conditions to evaluate proliferation parameters in the absence or presence of serum. Using the reverse transcriptase polymerase chain reaction technique, we demonstrated that the kinetics of induction was similar for both c-myb and B-myb during the proliferation of normal bone marrow fibroblasts. When compared to normal controls, cultured IMF fibroblasts showed more elevated values of c-myb and B-myb RNA; furthermore, after a 72 hours stimulation with serum, c-myb and B-myb messages remained relatively high in myelofibrotic fibroblasts. Finally, after serum starvation, c-myb and to a lesser extent B-myb RNA levels remained unusually high in IMF fibroblasts, while under the same experimental conditions c-myb and B-myb messages became virtually undetectable in normal bone marrow fibroblasts. To our knowledge this work represents the first description of an abnormal behavior of these genes in IMF fibroblasts.

[Splenic irradiation in myeloid hemopathies: evaluation and toxicity]

PURPOSE

Splenomegaly occurs frequently in patients with myelofibrosis (MF) or chronic myelogenous leukemia (CML), indicating significant splenic metaplasia. Symptomatic radiation therapy can be delivered, but the best irradiation scheme is still unknown. Results of splenic irradiation in patients with myelofibrosis or chronic leukemia were retrospectively analyzed.

PATIENTS AND METHODS

There were 24 patients: 15 presented with MF and 9 with CML. Median irradiation doses were 9.8 and 7.7 Gy, respectively. The hematologic toxicity was moderate (except for platelets in the acute phase of the disease).

RESULTS

No toxicity was observed. Various factors predictive of the response to radiation therapy are described. While high (around 14 Gy) radiation therapy dose appears necessary for MF and should be started before the increase in transfusion need, huge splenomegalies should be excluded in regard to CML. As for other cases, the optimal dose is still unclear, but should probably be high enough, ie, around 10 Gy.

CONCLUSION

To further study and better understand biological mechanisms underlying response to radiotherapy in patients with MF, prospective radio-chemotherapy phase II trials should be conducted in both CML and MF patients.

Prognostic factors in idiopathic (primary) osteomyelofibrosis

BACKGROUND

Prognostic variables for idiopathic (primary) osteomyelofibrosis (IMF) are ill-defined because of the lack of large control studies based on uniform diagnostic criteria.

METHODS

A retrospective clinicopathologic study was performed on 250 consecutively recruited patients (115 males and 135 females) with an established diagnosis of IMF. In contrast to previous studies, the current study cohort encompassed the full spectrum of initial to advanced stages of the disease process according to laboratory data and particularly histology. Because of the relatively high patient age on admission (median, 66.5 years), relative survival rates with corresponding life expectancies and disease specific life loss were calculated. Moreover, a classification and regression tree (CART) analysis was performed to segregate the study patients into subgroups with significantly different prognosis.

RESULTS

Analysis of the life expectancy and the proportion of deaths attributable to IMF showed a global reduction in life expectancy of 31%. Further calculation disclosed a consistently greater impact of disease in older patients. Age, hemoglobin level on admission, and leukocyte and thrombocyte counts remained as the most relevant parameters for prognosis in multivariate consideration (CART analysis) and facilitated a clear-cut separation into three risk groups. The life expectancy of low risk patients was approximately 10 times higher than that of high risk patients (22.07 years vs. 2.25 years).

CONCLUSIONS

These results are in keeping with the assumption that features signaling bone marrow insufficiency are associated with a worsening of survival. Generalization, indicated by myeloid metaplasia, can occur at every stage, even in so-called hypercellular phases of IMF. Conversely, myelofibrosis alone is not necessarily predictive of poor survival.