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Although not a malignant neoplasm like other cancers, MPNs are classified within the hematological neoplasms. There are four main myeloproliferative diseases, which can be further categorized by the presence of the Philadelphia chromosome:
In 2008, the World Health Organization listed these diagnoses as types of MPD:
- Chronic myelogenous leukemia (BCR-ABL1–positive)
- Chronic neutrophilic leukemia
- Polycythemia vera
- Primary myelofibrosis
- Essential thrombocythemia
- Chronic eosinophilic leukemia (not otherwise specified)
- Mastocytosis
The myeloproliferative neoplasms (MPNs), previously myeloproliferative diseases (MPDs), are a group of diseases of the bone marrow in which excess cells are produced. They are related to, and may evolve into, myelodysplastic syndrome and acute myeloid leukemia, although the myeloproliferative diseases on the whole have a much better prognosis than these conditions. The concept of myeloproliferative disease was first proposed in 1951 by the hematologist William Dameshek. In the most recent World Health Organization classification of hematologic malignancies, this group of diseases was renamed from "myeloproliferative diseases" to "myeloproliferative neoplasms". This reflects the underlying clonal genetic changes that are a salient feature of this group of disease.
The increased numbers of blood cells may not cause any symptoms, but a number of medical problems or symptoms may occur. The risk of thrombosis is increased in some types of MPN.
The following symptoms are typical ones which lead to testing for JMML, though children with JMML may exhibit any combination of them: pallor, fever, infection, bleeding, cough, poor weight gain, a maculopapular rash (discolored but not raised, or small and raised but not containing pus), lymphadenopathy (enlarged lymph nodes), moderate hepatomegaly (enlarged liver), marked splenomegaly (enlarged spleen), leukocytosis (high white blood cell count in blood), absolute monocytosis (high monocyte count in blood), anemia (low red blood cell count in blood), and thrombocytopenia (low platelet count in blood). Most of these conditions are common, nonspecific signs and symptoms.
Children with JMML and neurofibromatosis 1 (NF1) (about 14% of children with JMML are also clinically diagnosed with NF1, though up to 30% carry the NF1 gene mutation) may also exhibit any of the following symptoms associated with NF1 (in general, only young children with NF1 are at an increased risk of developing JMML):
- 6 or more café-au-lait (flat, coffee-colored) spots on the skin
- 2 or more neurofibromas (pea-size bumps that are noncancerous tumors) on or under the skin
- Plexiform neurofibromas (larger areas on skin that appear swollen)
- Optic glioma (a tumor on the optic nerve that affects vision)
- Freckles under the arms or in the groin
- 2 or more Lisch nodules (tiny tan or brown-colored spots on the iris of the eye)
- Various bone deformations including bowing of the legs below the knee, scoliosis, or thinning of the shin bone
Noonan syndrome (NS) may predispose to the development of JMML or a myeloproliferative disorder (MPD) associated with NS (MPD/NS) which resembles JMML in the first weeks of life. However, MPD/NS may resolve without treatment. Children with JMML and Noonan's syndrome may also exhibit any of the following most-common symptoms associated with Noonan's syndrome:
- Congenital heart defects, in particular, pulmonic stenosis (a narrowing of the valve from the heart to the lungs)
- Undescended testicles in males
- Excess skin and low hair line on back of neck
- Widely set eyes
- Diamond-shaped eyebrows
- Ears that are low-set, backward-rotated, thick outer rim
- Deeply grooved philtrum (upper lip line)
- Learning delays
BAL has similar symptoms with other types of leukemia, but usually more serious.
Symptoms caused by bone marrow damage
Bruising, spotting: the reason is lack of platelets, it is very common in BAL patients, most of patients die due to the
Anemia: Because the decline of hematopoietic function, need blood transfusion therapy
Persistent fever, infection prolonged healing:
Diffuse hemorrhage: also called Septicemia, which is dangerous and might lead to death.
Symptoms caused by blood cancer cells infiltration into tissues:
Lymphadenopathy
Joint pain
Swelling of the gums
Hepatoslenomegaly
Headache and vomiting: blood cancer infiltration into the wear performance of the central nervous system.
Skin lumps: Because look was slightly green, also known as the "Green tumor."
Pericardial or pleural effusion
Most people with ET are without symptoms referable to ET at the time of diagnosis, which is usually ultimately made after noting an elevated platelet level on a routine complete blood count (CBC). The most common symptoms are bleeding (due to dysfunctional platelets), blood clots (e.g., deep vein thrombosis or pulmonary embolism), headache, nausea, vomiting, abdominal pain, visual disturbances, dizziness, fainting, and numbness in the extremities; the most common signs are increased white blood cell count, reduced red blood cell count, and an enlarged spleen.
The most common symptoms of AEL are related to pancytopenia (a shortage of all types of blood cells), including fatigue, infections, and mucocutaneous bleeding. Almost half of people with AEL exhibit weight loss, fever and night sweats at the time of diagnosis. Almost all people with AEL are anemic, and 77% have a hemoglobin level under 10.0 g/dl. Signs of thrombocytopenia are found in about half of people with AEL.
About 90% of JMML patients have some sort of genetic abnormality in their leukemia cells that can be identified with laboratory testing. This includes:
- 15-20% of patients with neurofibromatosis 1 (NF1)
- 25% of patients with mutations in one of the RAS family of oncogenes (only in their leukemia cells)
- Another 35% of patients with a mutation in a gene called PTPN11 (again, only in their leukemia cells).
Acute erythroid leukemia or Di Guglielmo syndrome is a rare form of acute myeloid leukemia (less than 5% of AML cases) where the myeloproliferation is of erythroblastic precursors. It is defined as type "M6" under the FAB classification.
Essential thrombocythemia (ET) is a rare chronic blood condition characterised by the overproduction of platelets by megakaryocytes in the bone marrow. It may, albeit rarely, develop into acute myeloid leukemia or myelofibrosis. It is one of four myeloproliferative neoplasms (blood cancers that occur when the body makes too many white or red blood cells, or platelets).
Acute megakaryoblastic leukemia (AMKL) is a form of leukemia where a majority of the blasts are megakaryoblastic.
It is classified under AML-M7 category of the French-American-British classification.
The latest WHO classification (2008, Lyon), classifies Acute Myeloid Leukemia into distinct subtypes, based on clinico-pathological and molecular features. Acute megakaryoblastic leukemia is placed under the AML-Not Otherwise Specified subcategory.
Diagnosis requires more than 20% Blasts in the marrow/ peripheral blood with more than 50% demonstrating megakaryocytic derivation by morphology, immunophenotypic or electron microscopic studies.
Initial symptoms can be nonspecific, particularly in children. Over 50% of children with leukemia had one or more of five features: a liver one can feel (64%), a spleen one can feel (61%), pale complexion (54%), fever (53%), and bruising (52%). Additionally, recurrent infections, feeling tired, arm or leg pain, and enlarged lymph nodes can be prominent features. The B symptoms, such as fever, night sweats, and weight loss, are often present as well.
Central nervous system (CNS) symptoms such cranial neuropathies due to meningeal infiltration are identified in less than 10% of adults and less than 5% of children, particularly mature B-cell ALL (Burkitt leukemia) at presentation.
The signs and symptoms of ALL are variable and include:
- Generalized weakness and feeling tired
- Anemia
- Dizziness
- Headache, vomiting, lethargy, nuchal rigidity, or cranial nerve palsies (CNS involvement)
- Frequent or unexplained fever and infection
- Weight loss and/or loss of appetite
- Excessive and unexplained bruising
- Bone pain, joint pain (caused by the spread of "blast" cells to the surface of the bone or into the joint from the marrow cavity)
- Breathlessness
- Enlarged lymph nodes, liver and/or spleen
- Pitting edema (swelling) in the lower limbs and/or abdomen
- Petechiae, which are tiny red spots or lines in the skin due to low platelet levels
- Testicular enlargement
- Mediastinal mass
Most initial symptoms of leukemia are similar to symptoms for irregular bone-marrow function. Typically, most symptoms do not occur during the early stages of leukemia, and children may experience different symptoms. The following are symptoms of leukemia that lead doctors to look for different types of juvenile leukemia:
Complete remission and long-term survival are more common in children than adults.
Prognosis depends upon the cause. One third of cases is associated with a t(1;22)(p13;q13) mutation in children. These cases carry a poor prognosis.
Another third of cases is found in Down syndrome. These cases have a reasonably fair prognosis.
The last third of cases may be heterogeneous, and carry a poor prognosis.
This disease is known for an indolent clinical course and incidental discovery. The most common physical finding is moderate splenomegaly. B symptoms are seen in a third of cases, and recurrent infections due to the associated neutropenia are seen in almost half of cases.
Rheumatoid arthritis is commonly observed in people with T-LGLL, leading to a clinical presentation similar to Felty's syndrome. Signs and symptoms of anemia are commonly found, due to the association between T-LGLL and erythroid hypoplasia.
In hairy cell leukemia, the "hairy cells" (malignant B lymphocytes) accumulate in the bone marrow, interfering with the production of normal white blood cells, red blood cells, and platelets. Consequently, patients may develop infections related to low white blood cell count, anemia and fatigue due to a lack of red blood cells, or easy bleeding due to a low platelet count. Leukemic cells may gather in the spleen and cause it to swell; this can have the side effect of making the person feel full even when he or she has not eaten much.
Hairy cell leukemia is commonly diagnosed after a routine blood count shows unexpectedly low numbers of one or more kinds of normal blood cells, or after unexplained bruises or recurrent infections in an otherwise apparently healthy patient.
Platelet function may be somewhat impaired in HCL patients, although this does not appear to have any significant practical effect. It may result in somewhat more mild bruises than would otherwise be expected for a given platelet count or a mildly increased bleeding time for a minor cut. It is likely the result of producing slightly abnormal platelets in the overstressed bone marrow tissue.
Patients with a high tumor burden may also have somewhat reduced levels of cholesterol, especially in patients with an enlarged spleen. Cholesterol levels return to more normal values with successful treatment of HCL.
Acute biphenotypic leukaemia is an uncommon type of leukemia which arises in multipotent progenitor cells which have the ability differentiating into both myeloid and lymphoid lineages. It is a subtype of "leukemia of ambiguous lineage".
The direct reason lead BAL is still not clear. BAL can be de novo or secondary to previous cytotoxic therapy. Many factors, such as virus, hereditary factors, radiation, might have relationship with BAL.
BAL is hard to treat, usually the chemotherapy is chosen according to the morphology of the blast (ALL or AML). The stem cell transplantation is highly recommended.
About 5% of acute leukaemia cases are BAL. BAL could occur in all the age of the people, but more in adults than in children.
The symptoms tend to be similar to AML in general with the following being possible symptoms:
- Anemia
- Fatigue
- Weakness
- Difficulty breathing (dyspnea)
- Low platelets (thrombocytopenia) leading to easy bleeding
- Fever
- Infection as a result of low neutrophils (neutropenia)
- Elevated white blood cells (leukocytosis)
- Coagulopathy (including DIC)
Easy bleeding from low platelets may include:
- Bruising (ecchymosis)
- Gingival bleeding
- Nose bleeds (epistaxis)
- Increased menstrual bleeding (menorrhagia)
The way CML presents depends on the stage of the disease at diagnosis as it has been known to skip stages in some cases.
Most patients (~90%) are diagnosed during the chronic stage which is most often asymptomatic. In these cases it may be diagnosed incidentally with an elevated white blood cell count on a routine laboratory test. It can also present with symptoms indicative of hepatosplenomegaly and the resulting upper quadrant pain this causes. The enlarged spleen may put pressure on the stomach causing a loss of appetite and resulting weight loss. It may also present with mild fever and night sweats due to an elevated basal level of metabolism.
Some (<10%) are diagnosed during the accelerated stage which most often presents bleeding, petechiae and ecchymosis. In these patients fevers are most commonly the result of opportunistic infections.
Some patients are initially diagnosed in the blast phase in which the symptoms are most likely fever, bone pain and an increase in bone marrow fibrosis.
Most signs and symptoms of AML are caused by the replacement of normal blood cells with leukemic cells. A lack of normal white blood cell production makes people more susceptible to infections; while the leukemic cells themselves are derived from white blood cell precursors, they have no infection-fighting capacity. A drop in red blood cell count (anemia) can cause fatigue, paleness, and shortness of breath. A lack of platelets can lead to easy bruising or bleeding with minor trauma.
The early signs of AML are often vague and nonspecific, and may be similar to those of influenza or other common illnesses. Some generalized symptoms include fever, fatigue, weight loss or loss of appetite, shortness of breath, anemia, easy bruising or bleeding, petechiae (flat, pin-head sized spots under the skin caused by bleeding), bone and joint pain, and persistent or frequent infections.
Enlargement of the spleen may occur in AML, but it is typically mild and asymptomatic. Lymph node swelling is rare in AML, in contrast to acute lymphoblastic leukemia. The skin is involved about 10% of the time in the form of leukemia cutis. Rarely, Sweet's syndrome, a paraneoplastic inflammation of the skin, can occur with AML.
Some people with AML may experience swelling of the gums because of infiltration of leukemic cells into the gum tissue. Rarely, the first sign of leukemia may be the development of a solid leukemic mass or tumor outside of the bone marrow, called a chloroma. Occasionally, a person may show no symptoms, and the leukemia may be discovered incidentally during a routine blood test.
A specific histochemical reaction, cyanide-resistant peroxidase, permits identification of leukemic blast cells with eosinophilic differentiation and diagnosis of acute eosinoblastic leukemia in some cases of AML with few identifiable eosinophils in blood or marrow.
Chronic eosinophilic leukemia (CEL) is a disease in which too many eosinophils (a type of white blood cell) are found in the bone marrow, blood, and other tissues. CEL may stay the same for many years, or it may progress quickly to acute leukemia. It is generally caused by overactivation of the oncogene, e.g. PDGFRA through a chromosome translocation or fusion between two genes on the same chromosome, e.g. "FIP1L1-PDGFRA" gene fusion-induced eosinophilic leukemia. Though a highly rare disease, CEL is extremely manageable with the use of Gleevec, which suppresses the oncogenic effects of PDGFRA.
Chronic phase chronic myelogenous leukemia is a phase of chronic myelogenous leukemia in which 5% or fewer of the cells in the blood and bone marrow are blast cells (immature blood cells). This phase may last from several months to several years, and there may be no symptoms of leukemia.
The leukemic cells of T-LGLL can be found in peripheral blood, bone marrow, spleen, and liver. Nodal involvement is rare.
Patients treated with imatinib, dasatinib, and nilotinib have shown meaningful rates of hematologic and cytogenetic response.
Acute eosinophilic leukemia (AEL) is a rare subtype of acute myeloid leukemia with 50 to 80 percent of eosinophilic cells in the blood and marrow. It can arise de novo or may develop in patients having the chronic form of a hypereosinophilic syndrome. Patients with acute eosinophilic leukemia have a propensity for developing bronchospasm and heart failure from endomyocardial fibrosis. Hepatomegaly and splenomegaly are more common than in other variants of AML.