ASH Hematology Review Series

Bone Marrow Failure

Timothy Olson, MD, PhD

Summer, 2022
Disclosures (past 2 years)
• Bluebird bio – Consultant
• Vertex Pharmaceuticals- Advisory Board
• Medexus Pharmaceuticals- Consultant
• Elixirgen Therapeutics- DSMB
What Defines a Stem Cell?
➢ Totipotency or multipotency
➢ Self-renewal
➢ Asymmetric Cell Division

Embryonic Adult (HSC)

✓ Give rise to all cells in ✓ Ableto reconstitute
an organism one specific tissue
✓ Exhaust following ✓ Must persist through
development entire life of organism
 Hematopoietic Stem Cell Fun Facts!

➢ Humans have ~10,000 to 20,000 true HSCs

➢ Each HSC only divides once every 50 weeks

➢ Origin of the 100 Billion new blood cells produced daily

➢ We can live a lifetime with <10% of this HSC pool (BMT recipients)
Abkowitz, et al Blood 2002,
Rufer ,et al. J Exp Med, 1999
Domen, Wagers, and Weissman, http://stemcells.nih.gov
Definition of Bone Marrow Failure:
Intrinsic disorder of the BM, resulting in:
1. Disrupted hematopoietic stem and progenitor cell homeostasis
and function
2. Inadequate production of white blood cells, red blood cells,
and/or platelets.
Immunology Genetics

Bone Marrow
Failure Syndromes

Cancer
Pancytopenia: Differential Diagnosis
Acquired or Inherited Bone Marrow Failure Malignancy: leukemia, lymphoma,
(least common cause!) metastatic tumors, myelofibrosis

Autoimmune: HLH, TTP, Infection: viruses,

Evan’s syndrome, lupus mycobacteria, sepsis

Metabolic/Toxins: B12, Folate, or copper deficiency; excess zinc intake; anorexia, Images from ASH
storage diseases (Gaucher), alcoholism, solvents Image Bank
 First Step in Bone Marrow Failure Diagnosis:
Is it Acquired or Inherited

Acquired Inherited
Acquired Aplastic Anemia Diamond-Blackfan Anemia
Acquired Pure Red Cell Aplasia Fanconi Anemia
Hypocellular MDS GATA2 Haploinsufficiency
Paroxysmal Nocturnal Hemoglobinuria SAMD9/SAMD9L syndromes
Transient Drug Suppression Severe Congenital Neutropenia
Transient Infection Shwachman-Diamond Syndrome
Vitamin/Mineral Deficiency Short Telomere Syndromes
Thrombocytopenia Syndromes
Why determine whether cause of aplasia is inherited or acquired?

➢ Treatment approaches are different!

 Acquired Aplastic Anemia can be treated with immune suppression
 Inherited causes:
 Stem Cell Transplant (SCT) is the only cure
 Other organ systems affected!

➢ Implications of inherited causes for other family members

 Family genetic counseling and testing
 Many BMF diseases have incomplete penetrance or variable disease onset
 Family donors for bone marrow transplant
Why determine whether cause of aplasia is inherited or acquired?

➢ Because inherited BMF is common in some scenarios

➢ Ex #1: >70% of Adolescent/Young Adult patients with

Monosomy 7 MDS had germline GATA2 mutation*

➢ Ex #2: ~66% of a BMF NOS/MDS cohort had a causal or

contributing germline variant^

*Wlodarski et al. Blood 2016

^Bluteau et al. Blood 2018
 Clues to Etiology of Bone Marrow Failure from Medical History

Acquired Inherited
✓ Rapid symptom onset ✓ Slow symptom onset

✓ Prior normal blood counts ✓ Longer history/variably low blood

counts
✓ No family history
✓ Family history of blood disorders
✓ Preceding viral illness
✓ Developmental or other organ
✓ Associated with other autoimmune system abnormalities
diseases (particularly thyroid disease,
Eczema/psoriasis)
***Note exceptions to these trends can
and do occur
➢ BMF Evaluation: Initial
For All Patients:
➢ History and Physical: infections, medications, toxin exposure, family history, height/weight,
congenital anomalies.

➢ Blood testing: CBC, differential, blood smear review, Hgb F%, Liver function tests, BUN/Cr, type
and screen, DAT, PT/PTT.

➢ BM aspirate and biopsy: assessment for cellularity, dyspoiesis, M:E ratio, presence and
morphology of megakaryocytes, iron stain, +/- reticulin stain and immunostains (eg. CD34).

➢ Cytogenetics: metaphase karyotype + FISH for 5, 7, 8, 13. NGS panel for somatic mutations
(becoming standard?). Single nucleotide polymorphism array used in some centers.

➢ Skin/buccal fibroblasts?: (germ-line genetic testing)

➢ HLA typing: patient/siblings

➢ BMF Evaluation: Secondary
Screen for Associated/Causative Conditions:

➢ Viral studies: HIV, hepatitis viruses, parvovirus, EBV, CMV

➢ Metabolic Deficiencies: Serum folate/B12/Cu/Zn

➢ Assess for other autoimmune conditions and immune deficiency: Immune

globulins, B/T cell panels, ANA, thyroid function studies, anti-neutrophil/platelet Ab’s

➢ Paroxysmal Nocturnal Hemoglobinuria (PNH) testing

➢ Testing for inherited causes of bone marrow aplasia
Functional Screens:
➢ Should be done in all patients for two types of genetic conditions:
➢ Fanconi Anemia: Chromosomal Breakage Testing
➢ Short Telomere Diseases (“Dyskeratosis congenita”): Telomere length analysis (6-panel)

Sequencing for Germline Genetic Mutations:

➢ Note: Use in cases that present as classic acquired BMF is controversial.

Strategy Advantages Limitation

Individual Gene • Fastest in cases where a specific disorder caused by • Only rule out one gene at a time
Sequencing mutations in one gene is suspected • Costs can add up

Next Generation • Covers a broad panel of genes linked to BMF • Won’t discover new genes, and
Sequencing Panel • Reasonably fast and designed to capture most known panels need ongoing updates
mutations in these genes • Somewhat expensive

Whole Exome • Best for discovering new causes of bone marrow failure • Expensive and takes long time
Sequencing • Can be reanalyzed in future without new sample • May miss some mutations
 Genes Currently Implicated in Hereditary Predisposition to Bone
Marrow Aplasia, MDS, Leukemia

Primary DNA Repair/ Breakage Syndromes Telomere Disorders Diamond-Blackfan

MDS/Leukemia ATM FANCM ACD RTEL1 Anemia
Predisposition BLM (RECQL3) LIG4 CTC1 TERC RPL11 RPS17
ANKRD26 BRCA1 MLH1 DKC1 TERT RPL15 RPS19
CDKN2A BRCA2 MSH2 NHP2 TINF2 RPL19 RPS24
CEBPA BRIP1 (FANCJ) MSH6 RPL26 RPS26
NOP10 WRAP53
CHEK2 ERCC4 NBN RPL27 RPS27
PARN
DDX41 FANCA PALB2 (FANC-N) RPL35A RPS29
ERBB3 FANCB PMS2 RPL5 RPS7
ETV6
Noonan/JMML RPS10
FANCC RAD51 (FANC-R)
GATA1 CBL
FANCD2 RAD51C (FANC-O)
GATA2 KRAS Miscellaneous BMF
FANCE REV7 (FANC-V)
IKZF1 NF1
FANCF SLX4 (FANC-P) DNAJC21 RMRP
PAX5 NRAS
FANCG UBET2 (FANC-T) ERCC6L2 SBDS
RUNX1 PTPN11
FANCI XRCC2 (FANC-U) MECOM SRP72
SAMD9 RAF1
FANCL MPL WAS
SAMD9L SOS1
SH2B3 RECQL4 WIPF1
TP53
*More genes being identified each year
Case: An 8 year-old male develops several weeks of increased
bruising and fatigue, followed by 1 day of fever

• PMH: No previous medical problems, except for recent viral gastroenteritis

(stomach bug)

• Family hx: significant for psoriasis, thyroid disease. No history of cancer

• Exam: No distress. Temp 100.3° F. No lymphadenopathy or

hepatosplenomegaly. Multiple petechiae and bruises. No abnormal
developmental features.

• CBC: Severe pancytopenia

– White blood cells: Absolute Neutrophil Count 60/μL
– Red blood cells: Hemoglobin 5.1 g/dL
– Platelets: 12 k/μL Marrow
– No blasts Aplasia
Bone Marrow Aspirate/Biopsy →
 Acquired Aplastic Anemia

➢ Incidence 2-8 cases per

■ Idiopathic/Immune Mediated
million/year with two peaks:
(75-80%) ➢ Mid-childhood
■ Drug/chemical Effect (3-5%): ➢ Older adults
chemotherapy, anti-epileptics, ➢ (Can occur at any age)
benzene exposure

■ Hepatitis Associated (10- Incidence

15%): Non-typeable, (per million per year)
autoimmune? 50
40
■ Viral Infection (5-10%): EBV, 30
HIV, parvovirus 20
10
0
Leukemia Aplastic Anemia
 What Causes Acquired Aplastic Anemia

An exposure (virus, chemical) T cell activation, expansion, Bone marrow suppression

triggers an autoimmune T cell and migration to bone marrow due to both direct T cell killing
response in a susceptible of marrow stem cells and by
individual production of cytokines that
inhibit blood production

***Distinct from inherited causes of aplastic anemia that are due to gene
mutations causing early exhaustion of stem cells without autoimmunity
Adapted from Hartung, Olson, and Bessler, 2013
Classification of Acquired Aplastic Anemia
Definition of Aplastic Anemia Severity

Moderate or non-severe Decreased bone marrow cellularity and peripheral

(NSAA) blood cytopenia, NOT fulfilling criteria for SAA

Bone marrow cellularity <25% of age normal

And at least 2 of the following:
Severe (SAA) a. Neutrophil count <500 x 106/L
b. Platelet count <20,000 x 106/L
c. Reticulocyte count <60,000 x 106/L

Fulfilling criteria for SAA

Very severe (vSAA) PLUS
Neutrophil count < 200 x 106/L

➢ Only patients with severe or very severe acquired

aplastic anemia are typically eligible for transplant
Treatment for Severe Aplastic Anemia (age 40 and under…)

Acquired Should upfront URD/haplo

Aplastic HLA Identical SCT be an option?
Anemia Sibling? Haploidentical
Diagnosis or Unrelated
Yes No
Donor SCT

Only 15-30% of MSD Immune

U.S.A. patients will Refractory, Relapse, MDS
have a MSD
BMT Suppression

Historical
Count recovery and no Treatment
clonal evolution: wean Algorithm
IST and observe
(since 1990’s)
Where did this treatment algorithm come from?
Overall Survival by Treatment for Aplastic Anemia

Late 80’s to Late 1990’s 2000’s Data derived from

CHOP, NAPAAC,
Early 90’s and from Young NS,
BBMT, 2010
MSD-BMT 70-75% 80% 90-95% Dufour et al., Br J
Hematol 2015
IST 60-65% 70-75% ~80-90%
EFS in 2010’s
URD-BMT 35-40% 65-70% 90-95%* *Pediatric

1950 1960 1970 1980 1990 2000 2010 2020

Matched Sibling BMT
Matched Unrelated BMT
Cord Blood Transplantation
Haploidentical BMT
Gene
Therapy
Outline of Immune Suppression Therapy (IST) for SAA: Part 1
➢ Timing:
➢ May start once:
➢ Fanconi Anemia and Telomere disease functional screening complete
➢ HLA typing complete and shows no matched sibling donor
➢ Goal: start within 3-4 weeks of diagnostic bone marrow studies
➢ Supportive care prior to and during IST
➢ Infectious disease prophylaxis:
➢ Antifungals if ANC consistently < 500
➢ HSV prophylaxis x 1 month (some centers)
➢ Pneumocystis pneumonia prophylaxis: at least 3 months once IST starts
➢ G-CSF: No proven benefit other than reduction of hospitalization.
➢ Blood products:
➢ Use leukoreduced and irradiated blood products
➢ Maintain platelet count > 10 thou/μL (higher during ATG), hemoglobin > 7-8 g/dL
➢ Setting up inpatient admission for ATG
➢ We always give ATG through central venous catheter
➢ Plan for approximately 1 week admission
Outline of Immune Suppression Therapy (IST) for SAA: Part 2
➢ Equine ATG: 4-8 hour IV infusions x 4 days (requires hospitalization with close monitoring)
➢ Equine (Atgam) superior to Rabbit (thymoglobulin), but Equine not available in some countries
➢ Rabbit ATG often used as 2nd line IST if patients not a candidate for transplant.
➢ Side effects: severe allergic reactions/anaphylaxis/serum sickness

➢ Prednisone: Starts with ATG, IV or oral

➢ Used to prevent serum sickness: full dose for 7-10 days, followed by a taper over 2 weeks.
➢ Side effects: many (hypertension, high blood sugar), but only using short-term

➢ Cyclosporine A: Twice daily oral medication, starts with ATG

➢Levels need monitoring
➢Dose adjusted to maintain trough level 200-350 ng/ml
➢ Duration of full treatment dosing: varies by center (6-12 months- we use 12 months).
➢ Side effects: hair growth, gum overgrowth, kidney dysfunction, hypertension and rarely seizures.

➢ Eltrombopag: more later…

Monitoring of IST response:
➢Response assessments- based on blood count recovery

Goal: gradual blood count recovery over the first 6-9 months
Complete Response: Normal blood counts (some use platelets > 100 μL)
Partial Response: Transfusion independent, ANC> 500
Treatment Failure: definitions vary across centers with respect to timing. Our approach:
➢ No ANC recovery (ANC < 200) by 3 months
➢ Still transfusion dependent (with no signs of improvement) by 6 months
➢ Pursue alternative therapy

➢Repeat BM Aspirate/Biopsy Evaluations:

➢ Goal of follow-up assessments primarily to screen for MDS, but also to assess cellularity.
➢ Routine monitoring varies by center
➢ Most centers agree to recheck BM with:
➢ Any significant decline in blood counts after initial recovery
➢ Before alternative treatments initiated if IST fails to improve counts.
Weaning IST and Long-term Monitoring
➢ Weaning cyclosporine
➢ Timing varies across centers
➢ Wean starts 6-12 months after initiation (may delay wean based on degree of responses)
➢ Wean by 10%/month or 20-25% every 3 months
➢ If evidence of falling counts during wean- you have a choice
➢ Resume full dose cyclosporine
➢ Pursue alternative treatment (SCT)

➢ Long-term follow-up:
➢ CBC’s every 1-3 months for first year after stopping IST
➢ Slowly decrease to yearly follow-up visits (indefinite as late relapse can occur)
➢ Remember to check for PNH clones yearly.
 Eltrombopag for Acquired AA
➢ Synthetic non-peptide TPO mimetic, TPO receptor agonist

In Refractory Patients: Desmond et al. Blood, 2014

• 40% overall response rate, bi- or trilineage ➢ Eltrombopag has become

standard addition to IST for SAA in
• 10-12% CR rate adults
• 19% rate of clonal evolution ( most common- monosomy 7) ➢ Start with IST initiation

➢ Rx for up to 6 months if
Added To Upfront IST: Townsley et al. New Eng J Med, 2017 tolerated
• Added to ATG/CsA for up to 6 months ➢ May restart if counts decline
• ~85-90% overall response, 35-40% CR at 6 months ➢ Dosing needs adjustment for
(compared to 10% historical CR rate) certain populations
• Long-term relapse continues to be an issue?

• Lower risk of clonal evolution when used upfront (5-10%)

 Outcomes of IST in Pediatric Severe Aplastic Anemia
North American Pediatric Aplastic No Benefit of
Anemia Consortium (NAPAAC) Eltrombopag in Children?
(Rogers, Nakano, Olson et al., Haematologica 2019)
➢ Retrospective multicenter study of 314 patients NHLBI Sub-analysis: Outcomes of IST with
treated with IST (most ATG/CsA) from 2002 to 2014 Eltrombopag in Pediatric SAA

➢ Complete response: 60% (Groarke et al., Br J. Hematol, 2021)

➢ Overall survival: 92% ➢ Overall response not better with (70%) than
without (72%) eltrombopag
➢ Failure-free survival
Age < 12 Age ≥ 12
➢ At 5 years: 62%
IST IST+EPAG IST IST+EPAG
➢ But doesn’t plateau
Overall Response 78% 63% 68% 75%
➢ Clonal complications
Complete response 24% 6% 21% 46%
➢ MDS/Leukemia: ~2-7%
Partial response 53% 56% 45% 29%
➢ PNH: not assessed
 Aplastic Anemia and Failed 1st IST: What Comes Next?
➢ 2nd Course of IST ineffective in most cases
➢ Failure Free Survival ~10% (Kosaka, et al. Blood, 2008)

➢ Alternative donor transplant should be considered if young

patient
➢ Unrelated donor if 9/10 or 10/10 match
➢ Haploidentical with post-transplant cyclophosphamide
UK Pediatric SAA Working Party Experience
Timing of URD- n Failure-free Overall
BMT survival Survival
1st therapy 24 95% 95%
After Failed IST* 24 74% 74%
Data from Dufour et al., Br J Hematol 2015
 • Multicenter PI’s (Pulsipher,
Shimamura, Williams)
• 9 centers
• Pilot study

Pulsipher et al Pediatr Blood Cancer 2020:

• 23 patients randomized (40% of screened)
• 12 to BMT
• 11 to IST
• 10 of 12 randomized to BMT received it
• Average of 35 days from randomization
• All alive, no severe GVHD
• 22% with mild GVHD
• 6 of 11 patients (55%) randomized to IST
failed therapy (5 refractory; 1 relapse)
• Phase III trial in planning stages
➢ Hopkins Approach: Haploidentical Donor SCT with Post-Transplant
Cyclophosphamide
(Dezern et al, Blood 2020)
Relapsed/ Treatment-Naïve
Refractory Patients Patients
(n=20) (n=17)
Median age 29 (5-69) 22 (3-63)
(range) (Nearly all adult)
DFS/OS 95%/100% 76%/88%
Deaths 0 2 (at 200 cGy)
EBV (1) CMV (1)

10/20 Graft 1/0 1/2

Failure
>= Grade 3
None None
GHVD
Chronic GHVD 2 Limited, 1 None
Extensive
Rejection more of a concern in
pediatric patients? ** After initial 7 treatment-naïve patients treated at
200 cGy, increase TBI to 400 cGy
 70% of Patients with Acquired Aplastic Anemia Will
Develop Clonal Hematopoiesis

No clear leukemia Others = “CHIP” Suspicious for Aggressive

disposition Disease (10-20%)
20q
13q deletion Monosomy 7
Trisomy 8 Complex Cytogenetics
PNH (PIGA mutations)
Rare translocations DNMT3A
HLA mutations ASXL1
BCOR
6p CN-LOH TP53
BCORL1
RUNX1
CSMD1
 In children with SAA, patterns of
clonal hematopoiesis are distinct
Associated
Type Frequency
Disease
PIGA 40-50% PNH
HLA Class I Loss 15-25% none
Chromosome changes:
~5-10% MDS
(eg. Monosomy 7)
Other Gene Mutations:
~5-10% MDS?
(eg. BCOR, ASXL1)
Aplastic Anemia versus Hypocellular MDS
Feature AA MDS
Marrow cellularity <10% >10%
Excess blasts - +
Single lineage dysplasia +/- +/-
Multilineage dysplasia - +
Ringed sideroblasts - +
Reticulin fibrosis - +
Copy # abnormalities in chromosome 5 and 7 rare +
PNH or 6p CN-LOH as only somatic change + -
Somatic Mutations in aging related genes + +
Paroxysmal Nocturnal Hemoglobinuria (PNH)
GPI- PNH
GPI linked
Anchor protein
Cause: Acquired mutations in PIGA
gene (Xp22.2) → Loss of GPI
anchored cell surface proteins
Cytoplasm

Immune Restored
Escape Blood Cell ➢ Typically only develop symptoms or
Acquired Clonal PNH Production
Aplastic HSPC
require treatment with clones > 30%
Anemia of blood cells.
Intravascular
RBC’s lacking Complement Hemolysis &
➢ Up to 50% of SAA patients will have
CD55/CD59 Activation Thrombosis PNH clones: most are small (<1%)

French Registry Study presented at 2019 ASH annual meeting (Garff-Tavernier, et al. )
➢ Patients who already have hemolysis: clones will always increase with time
➢ Patients with subclinical clones: clones may increase, decrease, or remain stable; but clones will
not resolve with IST
Paroxysmal Nocturnal Hemoglobinuria (PNH)
➢ Bone marrow transplant is the only definitive cure
➢ If concurrent aplastic anemia: transplant and outcomes are similar to patients with AA without PNH
➢ If PNH progresses and restores marrow cellularity:
➢ More intensive transplant regimen is needed
➢ Success somewhat decreased: only ~70% survival (Hill et al, Nat Rev Dis Prim 2017)

➢ Complement inhibition
➢ Eculizumab first approved drug. Others now available (ravulizumab-cwvz).
➢ Infusion q2-8 week for life.
➢ Prevents blood cell breakdown and blood clot complications
➢ Does not affect course of BM failure
➢ Quite expensive → insurance concerns
 Inherited Bone Marrow Failure Disorders
Quick guide to testing
➢ Inability to maintain Condition
#
Screening Tests
Genes
rapidly dividing cells: Chromosome breakage
Fanconi Anemia >21
to DEB/MMC
1. Defective DNA repair Dyskeratosis Lymphocyte telomere
>14
Congenita length
2. Defective chromosome
GATA2 GATA2 Low monocytes/B cells
maintenance
Diamond Blackfan Elevated Hgb F% and
3. Defective ribosome and Anemia
>20
RBC ADA
protein synthesis Severe Congenital
>10 ANC always < 200/L
Neutropenia
Shwachman Decreased pancreatic
>90%
Diamond enzymes, fatty pancreas,
SBDS
Syndrome metaphyseal dysplasia
Inherited Bone Marrow Failure Disorders

High Risk of Cancer

Extra-hematopoietic
Manifestations of BMF/MDS
Predisposition Disorders

Needs Non-hematologic Cancer Screening x x x x

Infection/Immunodeficiency x x x x
Pituitary/Thyroid Function x x x x x
Pulmonary x x x
Cardiovascular/AVM x x x x
Hepatic/Enteropathy x x x
Pancreatic x
Adrenal x x
Renal x x x
Musculoskeletal x x x x
Neurologic x x x x
 Fanconi Anemia
➢ Most Common iBMF FA core complex

➢ Etiology of BMF: B
Damaged DNA
Crosslink recognition,
A G
1. Defective DNA repair E L activation of ID complex
F C T
2. Oxidative stress M
I D2
➢ >23 genes
➢ Most autosomal recessive (except FANCB) P Q Crosslink unhooking

➢ FANCA, FANCC, FANCG are most common

mutated genes (~80%)
D1 S J Homologous
➢ BRCA2 = FANCD1 Recombination Repair
➢ Mutations vary by ethnicity O N R
Fanconi Anemia: Clinical Presentation
➢ Severe: 5-9 years old with macrocytosis,
Diagnosis:
low platelets or pancytopenia, and BM aplasia
1. Chromosomal breakage
➢ Mild: MDS/AML in adolescence/young study in response to
adulthood DEB/MMC

➢ Congenital malformations (>75%) 2. confirm with gene

sequencing (NGS)
➢ Short stature (45%)
➢ Café au lait (40%) 3. Complementation testing
➢ Hypoplastic thumbs (35%) now rarely used
➢ Microcephaly (20%)
➢ VACTERL abnormalities (2-10%)
➢ Hypogonadism/hypospadias (males 25%) *Lymphocyte mosaicism
➢ Cognitive delays (10%) and somatic reversion can
➢ Pituitary dysfunction occur
 Fanconi Anemia – Treating BMF and MDS/Leukemia
➢ BM Failure
➢ Androgens (Danazol): improves blood counts in ~50%
➢ Can work for weeks to years

➢ Side effects: Peliosis Hepatis, hepatic tumors

➢ SCT only curative option: low doses of TBI, alkylators

➢ MSD-BMT OS >80% MUD-SCT OS 60-70%

➢ MDS/Leukemia
➢ MDS/AML: SCT still only cure. Pre-SCT chemotherapy controversial.

➢ T-ALL: may occur in FANCD1 (biallelic BRCA2), dismal prognosis.

 Telomere Biology Diseases
(formerly Dyskeratosis Congenita)
➢ Etiology: abnormal aging of BM stem cells through defective
telomere maintenance
Telomeres
• Long TTAGGG repeats at
chromosome ends
• Shorten with each cell
division
• Many pathways maintain
telomere length

Dyskeratosis Congenita: 2015 Guidelines

 Telomere Biology Diseases- Presentations
Dyskeratosis Congenita
(Classic Presentation) Other Presentations
➢ Most common: BM failure in
adolescence/young adulthood
➢ Cancer: squamous cell carcinoma
(head/neck), leukemia
➢ Late onset: liver cirrhosis,
pulmonary fibrosis (TERT/RTEL1)
➢ Dyskeratotic nails/hair
➢ Leukoplakia ➢ New: Variant of Unknown
➢ reticular rash, skin hypertrophy on hands/feet Significance on genomic testing
➢ Severe form (Hoyeraal Hreidarsson): failure to
thrive, ataxia, esophageal stricture, enteropathy, GU
anomalies, immune deficiency Dyskeratosis Congenita: 2015 Guidelines
 Telomere Biology Diseases- Diagnosis And Treatment

➢ Screen: 2 or 6 panel telomere length

study • SCT can cure BM failure: but high rates
➢ Gene testing: NGS panel +/- of complications
deletion/duplication ➢ Beware silent carrier as donor!

Most Frequent Others • Cancer Screening: head/neck (1000x

Gene Mode Gene Mode
risk), derm, anorectal
DKC1 XL ACD AD/AR • GI/Hepatic/Pulmonary AVM: Difficult to
TERC AD CTC1 AR manage
NHP2 AR
TERT AD /AR • Pulmonary fibrosis: no known effective
NOP10 AR
treatment other than lung transplant
TINF2 AD PARN AD/AR
RTEL1 AD/AR WRAP53 AR
 Diamond Blackfan Anemia Gene % cases
RPS19 ~25%
➢ A Ribosomopathy Caused by Mutations in Ribosomal Proteins RPL5 ~6.6%
RPS10 ~6.4%
➢ 5-7 cases per million births Mutated Ribosomal
Protein RPL11 ~4.8%
➢ Hypo-productive anemia meeting 4 RPL35A ~3%
criteria: Ribosome RPS26 ~2.6%
➢ 90% < 1 year old (mild cases may be older) Stress RPS24 ~2%
➢ Macrocytic Anemia Free RP’s RPS17 ~1%
➢ Reticulocytopenia HDM2 RPS7 ~1%
➢ BM: paucity of RBC precursors p53 RPL26 <1%
GATA1 <1%
➢ Supportive labs: ↑ eADA (>80%), Hgb F HDM2 p53 RPL15 <1%
➢ Diff Dx: TEC, Fanconi Anemia Apoptosis RPS29 <1%

➢ Congenital anomalies (30- 50%) ➢ 40% respond to corticosteroids ➢ Most autosomal dominant
(except GATA1)
➢ Short stature (30%) ➢ Others require chronic transfusions
➢ Cardiac/renal/GU (15-30%) ➢ Mutations can be “de novo”
➢ hand/limb (~40%) ➢ SCT an option for this subset in affected patient or can be
➢ Craniofacial/neck (50%) incompletely penetrant
➢ Cancer risks: Lower GI, osteosarcoma
Severe Congenital Neutropenia (SCN)

➢Classic presentation:
➢ Infants/toddlers: delayed
cord separation, recurrent
infections
➢ ANC: < 200 /µL. CBC
otherwise normal.
➢ BM: Neutrophil arrest at
promyelocyte stage
 ELANE Mutations in Neutropenia
SCN and Cyclic Neutropenia (CyN)
Caused by ELANE Mutations

➢ Misfolded Neutrophil Elastase:

apoptotic death of neutrophil
precursors
➢ Site of mutation → extent of
ER stress/death
Why transplant patients with SCN?
➢ G-CSF therapy can normalize ANC,
but at a cost:
➢ Much worse SCT outcome
➢ Severe osteopenia and
splenomegaly
after MDS/AML develops

➢ High risk of progression to ➢ ELANE Gly185Arg mutation:

MDS/AML high leukemia risk and G-CSF
resistance!
Risk of MDS by 15 years
G-CSF Dose
on G-CSF Therapy
≤8 g/kg/day 10-20%
>8 g/kg/day 35-40%
Data derived from Rosenberg et al, Br. J. Haematol. 2010
 Shwachman-Diamond Syndrome (SDS)
Ribosome disorder caused by Clinical Manifestations
mutations in SBDS (7q11) ➢ GI: pancreatic insufficiency,
steatorrhea, FTT, infections
28S rRNA 5.8S rRNA
➢ Skeletal deformities: thoracic
dystrophy, metaphyseal dysplasia
60S
>45 RPL proteins ➢ Immune, endocrine, cognitive
SBDS
dysfunction
18S rRNA
Mature Ribosome ➢ Hematology: variable neutropenia, with
40S & milder ↓↓ in Hgb, PLT, occasional
Protein Synthesis
>30 RPS proteins panycytopenia
➢ Malignancy: high risk of MDS/AML but:
➢ Baseline bone marrow
Autosomal recessive, dysmorphology
combination of null and ➢ Some cytogenetic changes frequent
hypomorphic mutations and benign (20q-, isochrom 7)
GATA2-related Bone Marrow Failure

Treatment → HSCT
Pre-HSCT: Laboratory and
Radiologic Screening for:
➢ Lung disease (PAP, MAI,
bronchiectasis)
➢ Immune Deficiency (may
need prophylaxis pre-SCT)
➢ Many syndromic features more likely with null mutation ➢ Lymphedema
or large chromosomal deletion

➢ Most common cause of Monosomy 7 MDS in AYA (> 70%)

 Thrombocytopenia Syndromes
➢ Collection of disorders characterized by chronic platelet transfusion dependence
➢ Often misdiagnosed as chronic ITP

Severe thrombocytopenia presenting in childhood

➢ Congenital Amegakaryocytic Thrombocytopenia:
➢ >70% due to mutations in thrombopoietin receptor (c-MPL)
➢ Most develop aplastic anemia by age 5 and need SCT
➢ Thrombocytopenia and Absent Radii Syndrome
➢ MECOM Syndomes: thrombocytopenia and radioulnar synostosis
➢ Wiskott-Aldrich Syndrome: Low Ig’s, eczema
➢ SAMD9/SAMD9L: newly described, often syndromic
 Thrombocytopenia Syndromes with Adult Presentation
 FPD-AML: RUNX1-associated familial  Familial AML with mutated CEBPA
platelet disorder with propensity to ◦ Autosomal dominant, nearly complete
myeloid malignancy penetrance (altered Transcription)
◦ 1 copy Runx1 loss → thrombocytopenia, ◦ Somatic 2nd mutation in CEBPA required
variable penetrance for MDS/AML in AYA age group
◦ MDS/AML transformation in 20-60%
 ETV6-associated familial
 ANKRD26-related thrombocytopenia thrombocytopenia and malignancy
◦ Autosomal dominant gain of function ◦ Autosomal dominant, Often misdiagnosed
mutations (unclear mechanism) with ITP, also have macrocytic anemia

◦ moderate thrombocytopenia, 10% risk of ◦ ALL in young; MDS in AYA, CMML, mixed
myeloid malignancy (all in adults) phenotype in adults
Summary Slide: Board Pearls for Bone Marrow Failure
• Diagnostics: key is to determine whether a patient has acquired or inherited BMF
– Inherited BMF is associated with congenital anomalies, slow cytopenia onset, non-hematologic cancer and
organ failure risk.
– Critical for determining treatment, including family donor selection for stem cell transplant
• Acquired aplastic anemia
– Treatment with immune suppression therapy (ATG, cyclosporine, eltrombopag) or stem cell transplant (MSD-
BMT generally considered first line)
– 20-30% risk of clinically significant clonal evolution: PNH and 6p CNLOH are specific to acquired AA; MDS is
not.
• Inherited bone marrow failure
Condition # Genes Screening Tests Physical features
Fanconi Anemia >21 Abnormal chromosome breakage to DEB/MMC VACTERL-H; short stature, microcephaly
Telomere Biology Diseases >23 Lymphocyte telomere length Nail dystrophy, dyskeratosis, leukoplakia, thin/gray hair
GATA2 GATA2 Low monocytes/B cells Lymphedema (subset)
Diamond Blackfan Anemia >20 Elevated Hgb F% and RBC ADA VACTERL-H
Severe Congenital >10 (ELANE
ANC always < 200/L Variable
Neutropenia most common)
Shwachman Diamond
>90% SBDS Decreased pancreatic enzymes; metaphyseal dysplasia Distinct facies, short stature, failure to thrive
Syndrome
Thank you!

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