Aplastic Anemia

Tissue Conference
1/19/00
Brad Kahl, MD

Pancytopenia
Reduction of counts in all three cell lines
Differential Diagnosis
aplastic anemia
myelodysplasia
marrow replacement
leukemia, lymphoma, carcinoma, myelofibrosis

B12, folate
chemotherapy induced

Pancytopenia
Differential Diagnosis continued

splenomegaly (any cause)

PNH
SLE
Congenital
Fanconis, Schwamann-Diamond, Folate uptake def

Pancytopenia
Presentation varies with degree of cytopenia
anemia fatigue
thrombocytopenia bruising/bleeding
neutropenia infection

Approach
history
constitutional symptoms, pain, early satiety, etc...
diet, EtOH, exposures, occupation

Pancytopenia
Approach
PE
nodes, spleen, sensory, portal htn

Labs
B12, folate, LFTs, PNH, ANA
view smear (macrocytosis, megaloblastosis, tear
drops, nuc RBCs, malignant cells)
abdominal imaging
bone marrow evaluation

Aplastic Anemia
Bone Marrow Failure
WHY??????????
Stem cell defect (seed)
Stromal cell defect (soil)
Growth Factor defect (fertilizer)

Evidence suggests that majority of cases of

idiopathic AA are due to immune suppression
of the hematopoietic stem cell

Aplastic Anemia Classification

Direct Toxicity
Iatrogenic (radiation, chemotherapy)
Benzene
Drug metabolites

Immune Mediated

Drug metabolites
transfusion associated
hepatitis associated
idiopathic

Aplastic Anemia Pathophysiology

Evidence for an immunological basis arose
from observations after BMT
unexpected improvement of pancytopenia in
some patients after allogeneic graft failure
successful BMT of identical twins generally
requires some sort of immunosuppressive
conditioning regimen

Aplastic Anemia Pathophysiology

Evidence for stem cells (seed) as targets
in vitro colony forming assays are used to
define the stem cell compartment
two papers in 1996 showed profound deficits in
the stem cell population in patients with AA
at the time of clinical presentation the absolute
number of stem cells is < 1% of normal

Aplastic Anemia Pathophysiology

What about the stroma (soil) and growth factors
(fertilizer)?
successful BMT implies intact stroma since it is not
replaced in the transplant
laboratory studies have shown the stroma of AA
patients is able to support normal stem cell growth
stromal cells of AA patients tend to make increased
levels of several growth factors (EPO, TPO, G-CSF)
clinical studies using factor replacement havent worked

Aplastic Anemia Pathophysiology

Laboratory Evidence for Immune
Destruction of Hematopoietic Stem Cells
mononuclear cells from blood and marrow of
AA patients suppress hematopoietic colony
formation by normal marrow stem cells
if selectively remove T cells from the sample,
generally improve in vitro colony formation

Aplastic Anemia Pathophysiology

What are the T cells doing?
Direct cellular cytotoxicity
blood and marrow of AA patients contain increased
numbers of activated cytotoxic lymphocytes
the number and activity of these cells decreases after
successful treatment with ATG

Aplastic Anemia Pathophysiology

Cytokines
T cells of AA patients overproduce both IFN-gamma and
TNF-alpha
both of these cytokines inhibit colony formation in vitro
IFN-gamma induces nitric oxide synthase (NOS) and production
of nitric oxide (NO)
both induce expression of Fas receptor on CD34+ cells and
activation of this receptor by its ligand induces apoptosis

both appear to inhibit mitosis

IFN-gamma increases IFN regulatory factor 1 which inhibits
transcription of cellular genes and entry into the cell cycle

Aplastic Anemia Pathophysiology

Aplastic Anemia Pathophysiology

Inciting Events
much less clear, most cases--no clue
a few cases clearly associated with a non-A,
non-B, non-C, non-G hepatitis
severe pancytopenia 1-2 months after an apparent
viral hepatitis
patients tend to have a marked activation of
cytotoxic lymphocytes and tend to respond
favorably to immunosuppressive therapy

Aplastic Anemia Pathophysiology

Drugs

implicated in 15-25% cases (difficult to study)

no animal model
some cases may be a direct toxic effect
some cases appear immune mediated
in general patients have similar characteristics
as idiopathic AA and respond similarly to
immunosuppression

Aplastic Anemia Treatment

Options
BMT from donor vs. immunosuppression with
ATG, CSA, or ATG/CSA combination
steroids, androgens generally ineffective

Trend towards separating severe AA and

non-severe AA in current clinical trials

Aplastic Anemia Treatment

Severe Aplastic Anemia Criteria
blood:
neutrophils < 500/mm3
platelets < 20k
retics < 1% (corrected)

marrow
severe hypocellularity
moderate hypocellularity with hematopoietic cells representing
< 30% of residual cells

need 2/3 blood and one marrow criteria

Aplastic Anemia Treatment

Non-severe AA (Blood, April 99)
patients randomized to CSA vs. ATG/CSA
Overall Response Rate at 6 months
CSA 46%

ATG/CSA 74%

Similar early toxicity/infections

P=.02

Aplastic Anemia Treatment

Severe AA (Ann Int Med 1997)
Allo BMT vs. Immunosuppression
ORR
15 Yr OS
allogeneic BMT
89%
69%
Immunosuppression 44%
38%
40% BMT patients clinically extensive chronic GVHD
1/227 receiving immunosuppression got ATG/CSA
50/227 received ATG + mismatched bone marrow

Aplastic Anemia Treatment

Severe Aplastic Anemia
ORR ATG/Pred 31%
ATG/Pred/CSA
65%
Blood 1992
ATG/LDM/oxymethalone
ATG/HDM/oxymetholone
48%
Blood 1995
ATG/CSA 78%
NEJM 1991

36%

Aplastic Anemia Treatment

Future
High Dose Cyclophosphamide vs. ATG
Addition of MMF to ATG/CSA combinations
? allo BMT vs optimal immunosuppression?

Aplastic Anemia Summary

idiopathic AA appears to be an AI disorder
directed against hematopoietic stem cells
mediated by cytotoxic T cells and cytokines
allo BMT is the gold standard treatment
intensive immunosuppressive therapy has
improved the outlook for patients ineligible for
BMT due to age or lack of a suitable donor
expect further refinements in therapy as the
pathophysiology is further elucidated