Man, 38 jaar

Anamnese:

Blanco voorgeschiedenis, geen medicatie, sinds 4 weken progressieve

vermoeidheid, dyspneu d’effort.

Lichamelijk onderzoek:

Geen afwijkingen hart/longen, geen hepato/splenomegalie, geen

lymfadenopathie, geen hematomen.

Laboratorium onderzoek:

Hb 2.4 mmol/L, Trombocyten 19 x 109/L, Leukocyten 2.7 x 109/L

Granulocyten 0.23 x 109/L, Bilirubine 10, haptoglobine <0.1, LDH 508,

Reticulocyten 10 * 10e9/L

PNH onderzoek in bloed:

Glycosylphosphatidylinositol (GPI)-deficiënte cellen:

41% van de granulocyten, 52% van de monocyten, 5% van de erytrocyten

Diagnose?

A) Verworven Aplastische Anemie B) PNH C) Anders

Laboratorium onderzoek:

Hb 2.4 mmol/L, Trombocyten 19 x 109/L, Leukocyten 2.7 x 109/L

Granulocyten 0.23 x 109/L, Bilirubine 10, haptoglobine <0.1, LDH 508,

Reticulocyten 10 * 10e9/L

PNH onderzoek in bloed:

Glycosylphosphatidylinositol (GPI)-deficiënte cellen:

41% van de granulocyten, 52% van de monocyten, 5% van de erytrocyten

Beenmerg analyse:

•Crista biopsie: aplasie (celrijkdom < 1%)

• Beenmerg aspiraat: celarm, geen myelodysplastische afwijkingen, geen

cytogenetische afwijkingen

Mitomycine gevoeligheid test:

Geen verhoogde chromosomale gevoeligheid voor mitomycine

A) Verworven Aplastische Anemie B) PNH C) Anders

Dus mengbeeld AA/PNH bij 38 jarige man

Gezien het verlaagde aantal reticulocyten en aplasie van het beenmerg is het

beenmergfalen nu de behandel indicatie en daarom behandeling gericht op AA

1 gezonde zus

Wat zou u doen?

1. HLA typering zus afwachten

2. Onverwante search inzetten

3. Zo snel mogelijk starten met ATG

4. Anders

Dutch guidelines 2013

ATG behandeling:

Welk ATG?

2013:

The NVvH guideline on aplastic anemia advises horse-ATG as the preferable type of

ATG in first-line treatment.

ATGAM* 40 mg/kg/day i.v. day 1-4

Ciclosporine** 5 mg/kg/dag p.o day 1-180

Prednisolone 1 mg/kg/day i.v. day 1-4

Prednisolone 1 mg/kg/day p.o day 5-14, after that tapered

down to stop in 14 days

* Horse derived ATG (Pfizer)

** Dosage based on serumlevels (200-300 ng/ml)

However, the only available horse-ATG is ATGAM which has no registration in Europe

This means that there is no reimbursement for ATGAM

Vervolg:

•2 maanden na diagnose: start behandeling met paard-ATG en

ciclosporine

•6 maanden na start behandeling complete remissie, start

afbouwen ciclosporine

•2 jaar na start behandeling hb 9.1, neutrofielen 2.0, trombocyten

158 met 2dd 25 mg ciclosporine.

• January 2014: the NVvH started a national registry for aplastic

anemia for registration of base-line characteristics and follow up

after treatment

• Study purpose: evaluation of efficacy and safety of horse-ATG

in Dutch aplastic anemia patients (non-registered drug)

• Patients: ≥18 yrs, treated with h-ATG (ATGAM) as first-line

treatment. Consecutive enrollment of all patients in the LUMC,

UMCG, AMC, UMCU, VU-MC, Erasmus-MC, Medisch

Spectrum Twente and Antonius Ziekenhuis Nieuwegein

• Based on manufacturer’s data this cohort comprises >80% of

all adult aplastic anemia patients treated with ATGAM as first-

line treatment in the Netherlands

*Disease severity: Non-severe aplastic anemia (NSAA): BM cellularity <25% Blood values below normal, not meeting criteria for SAA Severe aplastic anemia (SAA): BM cellularity <25% and ≥2 of the following: - Neutrophils <0.5 x 10*9/L - Platelets or reticulocytes <20 x 10*9/L Very severe aplastic anemia (VSAA): As for SAA with neutrophils <0.2 x 10*9/L

Baseline characteristics (n = 48)

8 20-01-2016

Age (years; median, range) 53 (18-77)

Follow-up (months; median, range) 13 (1-45)

Disease severity*: Non-severe

Severe Very severe

16 (33%) 19 (40%) 13 (27%)

Indication for ATG treatment: (V)SAA or NSAA with transfusion dependency

Response at 6 months (N=43)

N(%) 95% confidence interval

Response* 24 (56%) 41-71%

PR 21 (49%)

CR 3 (7%)

No response NR 19 (44%) 29-59%

* Definition of response: CR = normalization of blood values, PR =

neutrophil count > 0.5 x 109/L and transfusion independent 9 20-01-2016

• Two patients died before reaching 6 months follow up

(1 at 1 month due to hemorrhagic stroke, 1 at 3

months due to concomitant DLBCL)

• Overall survival up to 6 months is 96% (95% CI 90-

100%)

Supportive care* 9

HSCT 6

Rabbit-ATG 3

Sirolimus, epoeitine, androgens 1

* 3 patients became transfusion independent at

respectively 8, 10 and 18 months after start of ATGAM

Second line treatment if NR (n = 19)

10 20-01-2016

Overall survival after 6 months (N=40)

Response at 6 months (CR+PR) • 1 death due to subarachnoidal

bleeding at 8 months

• 1 death due to complications of

HSCT at 10 months (relapse at 7

months)

11 20-01-

2016

No response at 6 months • 2 deaths due to complications of

HSCT at 7 and 12 months

respectively

• 1 death due to multi-organfailure

at 15 months (second line

treatment a.o sirolimus,

erytropoeitine, androgens)

• 1 death due to secondary AML at

44 months (also treated with r-

ATG)

Conclusion

• At 6 months, overall survival of adults with aplastic anemia after

treatment with ATGAM is 96% (95% CI 90-100%)

• Transfusion-independence is reached in 56% of the patients

within 6 months (95% CI 41-71%) which is comparable to

previously published data

• Based on this analysis, ATGAM (horse-ATG) is confirmed as the

recommended first-line immune-suppressive therapy in adults

with acquired aplastic anemia

12

NVvH Registry In collaboration with:

S. Sypkens Smit L. de Wreede (statistics) C. Halkes F. Falkenburg J. Schreurs M. de Groot S. Zeerleder R. Raymakers R. Fijnheer N. Schaap H. Koene

M. Raaijmakers E. Meijer T. Snijders

Supported by:

13 20-01-

2016

14

Casus: en de PNH clone?

0 1 3 6 9 12 24

granulocyten GPIdeficient

27 41 47 6 5 4 3

monocyten GPIdeficient

43 52 46 13 13 9 5

0

10

20

30

40

50

60

pe

rce

nta

ge

0 1 3 6 9 12 24

trombocyten 16 13 103 144 133 149 154

0

20

40

60

80

100

120

140

160

180

X 1

09/L

28-10-2015

Hematological improvement and decrease in PNH clone size

Issues in AA/PNH

• Why this combination of rare disease?

• If a patient has both PNH and aplastic anemia, which

should you treat?

• Should all aplastic anemia patients be tested for PNH?

If so, how often?

PNH: a stem cell disease characterized by PIGA mutation

Mutation in the PIGA gen is associated to loss of

Glycosylphosphatidylinositol (GPI)-anchor but

is not sufficient to induce PNH:

• Healthy subjects: circulating ‘PNH’ PMNs (10 in 106

cells)

Permissive environment for PNH clone expansion Mutation in PIGA gen is quite common-in the presence of a normal

bone marrow no chance to expand for PNH cells

Araten et al. 1999; Hu et al. 2005; Hertenstein et al. 1995; Rosti et al. 1997; Keller et al. 2001; Jasinski et al. 2001; Maciejewski et al. 1997; Rosse et al. 1966; Rotoli et al. 1984; van der Schoot et al. 1990; Endo et al. 1996; Risitano et al. 2007

PNH: “Escape” or “relative advantage” theory

Antigen-driven immune response against BM-tissue antigens (e.g. epitopes on GPI?)

PIGA-gene mutation: common phenomenon No biological consequences-

no expansion in the presence of otherwise healthy cells

Healthy individual External conditions permissive for PNH-clone expansion

Rotoli &Luzzato 1989; Dunn et al 2000; Karadimitris et al. 2000; Plasilova et al. 2004; Chen et al. 2000; Chen et al. 2005; Nagakura et al. 2002; Murakami et al. 2002; Nachbur et al. 2006; Risitano et al. 2007

GPI+

GPI-

Development of AA or PNH

18

PNH AA

19

PNH AA

Aplastic Bone marrow

Low reticulocyte count

Hemolysis -/+

Very low platelet and neutrophil counts

Increased reticulocyte count

Hemolysis +++

Development of AA or PNH

Hypothesis:

AA is caused by an auto-immune reaction to the normal hematopoiesis

PNH cells can escape from this

In patients responding to Immune suppressive treatment the PNH clone size will decrease

PNH clone size after treatment with ATG

Scheinberg Haematologica 2010:

In 207 AA patients treated with ATGAM in NIH, follow-up of 2 years

60% without PNH clone at diagnosis:

20% had PNH clone at one or more occasions in this period

40% had PNH clone at diagnosis

10% PNH clone had gone after ATG

50% decrease of clone size after ATG

40% increase of clone size after ATG

In this cohort, complications of PNH (thrombosis, transfusions needed for

hemolysis, hemolytic crises) were only seen if clone size was >50% (9% of

total cohort)

Issues in AA/PNH

• Why this combination of rare disease? • Hypothesis: PNH clones escape auto-immune attack

• If a patient has both PNH and aplastic anemia, which

should you treat? • Look at bone marrow cellularity

• Look at reticulocyte count

• Should all aplastic anemia patients be tested for PNH?

If so, how often? • Yes: at diagnosis, after ATG at a yearly base

• If PNH clone present at least once per three months

Diagnostiek en behandeling ernstige aplastische anemie bij volwassenen

• Hoe verder met niet-responderende patiënten?

• Konijn ATG na falen paard ATG (respons 27-77%)

• Alemtuzumab (respons 37%)

• AlloSCT

• Eltrombopag?

Diagnostiek en behandeling ernstige aplastische anemie bij volwassenen

• Hoe verder met niet-responderende patiënten?

• Konijn ATG na falen paard ATG (respons 27-77%)

• Alemtuzumab (respons 37%)

• AlloSCT

• Eltrombopag?

AlloSCT bij AA

Socié Hematology 2013 Bacigalupo Haematol 2012

28-10-2015 25

AlloSCT: GVHD en late effecten

• GVHD voorkomen:

• T cel depletie van het transplantaat

• Indien mogelijk beenmerg als stamcelbron

• Post transplantatie maximale immuunsupressie

• Beperken late effecten (mn secundaire maligniteiten):

• Zo mogelijk geen total body irradiation in conditionering

NB gebasseerd op cohorten met alleen maar of veel kinderen

Eltrombopag in AA

Eltrombopag and Improved Hematopoiesis in Refractory Aplastic Anemia. Olnes , N Engl J Med 2012: 367(11-19)

Eltrombopag = agonist of thrombopoetin receptor

Eltrombopag in AA

Eltrombopag and Improved Hematopoiesis in Refractory Aplastic Anemia. Olnes , N Engl J Med 2012: 367(11-19)

Refractory AA patients: 11 from 25 showed responses (44%)

Eltrombopag in AA

Eltrombopag restores trilineage hematopoiesis in refractory severe aplastic anemia that can be sustained on

discontinuation of drug. Desmon ,Blood 2014: 123(1818-25)

• In part of responding patients eltrombopag can be stopped

• 20% of patients developed new cytogenetic abnormalities (especially

chromosome 7 loss)

• Combination ATGAM, CsA and eltrombopag as first line treatment AA: 85-

90% responses at 6 months (ASH 2014, Young)

Eltrombopag in AA after ATG

• Registration in the Netherlands (Nov 2015): patients with severe

aplastic anemia who are relapsing after or refractory for ATG

• Procedure for reimbursement has been started in December 2015,

answer from ZIN expected in June 2016

Eltrombopag in first line? EBMT Race Study

First line treatment

Open in LUMC (January 2016)

Soon in AMC, UMCG, UMCU

2016 revisie van Nederlandse richtlijnen

Issues:

Diagnostiek

• Welk diagnostisch onderzoek dient te worden gedaan bij verdenking verworven aplastische

anemie?

Behandeling

• Algemeen:

• Wat is de optimale antibiotische profylaxe in patiënten met neutropenie in het kader van

ernstige aplastische anemie?

• Wanneer is er een behandel indicatie?

• Wanneer dient de behandeling gericht te zijn op PNH en wanneer op AA?

• Wat is de indicatie voor allogene SCT als eerste lijn behandeling?

• Wat is een geschikte tweede lijn behandeling indien een patiënt niet respondeert op ATG?

2016 revisie van Nederlandse richtlijnen Issues:

Behandeling

• ATG specifiek:

• Tot welke leeftijd kan ATG gegeven worden?

• Hoe lang moet het effect van ATG worden afgewacht alvorens over te gaan op tweede lijn

behandeling?

• Indien er respons op de combinatie ATG en cyclosporine is, hoe moet dan omgegaan worden

met de cyclosporine: kan dit meteen gestaakt worden of dient er langzaam afgebouwd te

worden?

• Is het effectief om bij een responderende patiënt die na staken of tijdens afbouwen van

cyclosporine een achteruitgang in het bloedbeeld heeft de cyclosporine te hervatten of op te

hogen?

• Hoe is lange termijn follow up van AA patiënten na ATG?

• Hoe moet worden omgegaan met een zwangerschapswens bij vrouwelijke AA patiënten die

geen allogene stam cel transplantatie hebben ondergaan?

2016 revisie van Nederlandse richtlijnen Issues:

Behandeling

• Stamceltransplantatie specifiek:

• Wat is een geschikt conditionering schema voor AA patiënten boven de 55?

• Wat is een geschikt conditionering schema voor AA patiënten onder de 55?