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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: myelofibrosis, agnogenic/idiopathic myeloid metaplasia with myelofibrosis.
This is one of the chronic myeloproliferative disorders. It is an acquired, malignant clonal disorder, characterised by expansion of pluripotent stem cells. They show deranged production of one or more myeloid lines and have a variable tendency to transform to leukaemia.
Although this condition is seen at any age, it is most often seen over the age of 50 years. Peak incidence is at 60-70 years.
It is very rare. Approximately 1 case per 300,000 per year. Males and females are equally affected.
- Marrow fibrosis with either greater or decreased cellularity is a constant feature. The fibrosis is thought to be due to platelet-derived growth factor produced by malignant megakaryocytes. This is a known mitogenic agent for fibroblasts.
- Primary myelosclerotic marrow is hypocellular due to extensive fibrosis replacing the myeloid and erythrocytic element.
- Megakaryocytes, which are not always increased in number, are morphologically abnormal.
- Osteosclerosis is a common finding.
- As marrow fibrosis progresses the amount of extramedullary myeloid metaplasia increases.
- The spleen is the primary site of extramedullary metaplasia. The liver, lymph nodes and kidneys can also become involved.
- Patients may be asymptomatic for some time; 2 years is common. There may be incidental finding with anaemia or splenomegaly.
- Fatigue and weakness (secondary to anaemia) are common presenting complaints.
- It may present as unusual bleeding.
- It may present as early satiety, with accompanying weight loss, and abdominal distension due to splenomegaly. Systemic symptoms are also found: bone pain, night sweats and fever.
- Massive splenomegaly
- Portal hypertension and hepatomegaly
- Hyperuricaemia (may show as kidney stones)/gout
- Metastatic neoplasia
- Polycythaemia vera
- Essential thrombocytosis
- FBC reveals moderate-to-severe normochromic, normocytic anaemia.
- There is anisocytosis with marked poikilocytosis, characterised by teardrop shapes - dacrocytes.
- Nucleated red blood cells (RBCs) are present.
- Leukocytosis with immature forms is seen. Leukocyte alkaline phosphatase (LAP) score - a histochemical stain used to identify the neutrophil enzyme in myeloid disease - is normal or unusually high.
- There are abnormal platelets and sometimes megakaryocyte nuclei are seen.
Not all these features are there in early disease.
End-stage disease can be accompanied by haemorrhagic episodes, infection, heart failure, portal hypertension and acute leukaemic transformation.
Transfusion of packed RBCs and platelets may be helpful.
- Glucocorticoids help RBC survival time, which is often reduced.
- Recombinant erythropoetin and hydroxyurea have been used to treat anaemia. Cladribine is particularly useful post-splenectomy with thrombocytopenia and hepatomegaly. Thalidomide was thought to give a good response in 20-60%, but a recent Cochrane review showed that there was no substantial efficacy in anaemic myelosclerotic patients. The placebo group also showed spontaneous periods of remission of anaemia.
- Testosterone also reduces transfusion requirements, but is poorly tolerated by women.
- Chemotherapy with hydroxyurea or interferon alfa 2b can reduce splenomegaly. Interferon reduces spleen size in 30-50% of patients with myeloproliferative disease.
- Painful splenomegaly can be treated with radiation or splenectomy. Decision to operate must balance potential palliative gain with postoperative mortality rate of 9%, and morbidity from infection, thrombosis or bleeding of 30%.
- Allogenic, peripheral bone marrow or stem cell transplant.
Average survival is 5 years, with a range of 1-16 years. The first 2 years are usually asymptomatic. Prognostic factors include:
- Degree of anaemia
- Degree of leukopenia or leukocytosis
- Number of circulating blasts
- Karyotypic abnormalities present and presence of systemic symptoms
If 2 of these are present, median survival is <3 years. If only one factor is present, prognosis is much better - up to 15 years. Patients who present at age <45 years have a survival of <3 years when they present with haemoglobin concentration of 10 g/dL and constitutional symptoms.
Further reading and references
Haematological malignancy - suspected; NICE CKS, 2005
Tavares TS et al; Pediatric Myelofibrosis, Medscape, May 2012
Lal A; Agnogenic Myeloid Metaplasia with Myelofibrosis. eMedicine, October 2008.
Al-Assar O, Ul-Hassan A, Brown R, et al; Gains on 9p are common genomic aberrations in idiopathic myelofibrosis: a comparative genomic hybridization study. Br J Haematol. 2005 Apr129(1):66-71.
Reilly JT; Idiopathic myelofibrosis: pathogenesis to treatment. Hematol Oncol. 2006 Jun24(2):56-63.
Tefferi A, Mesa RA, Nagorney DM, et al; Splenectomy in myelofibrosis with myeloid metaplasia: a single-institution experience with 223 patients. Blood. 2000 Apr 195(7):2226-33.
Giovanni B, Michelle E, Letizia C, et al; Thalidomide in myelofibrosis with myeloid metaplasia: a pooled-analysis of individual patient data from five studies. Leuk Lymphoma. 2002 Dec43(12):2301-7.
Gilbert HS; Long term treatment of myeloproliferative disease with interferon-alpha-2b: feasibility and efficacy. Cancer. 1998 Sep 1583(6):1205-13.
Tefferi A, Huang J, Schwager S, et al; Validation and comparison of contemporary prognostic models in primary myelofibrosis: analysis based on 334 patients from a single institution. Cancer. 2007 May 15109(10):2083-8.
Kroger N, Mesa RA; Choosing between stem cell therapy and drugs in myelofibrosis. Leukemia. 2008 Mar22(3):474-86. Epub 2008 Jan 10.
Cervantes F, Barosi G, Demory JL, et al; Myelofibrosis with myeloid metaplasia in young individuals: disease characteristics, prognostic factors and identification of risk groups. Br J Haematol. 1998 Aug102(3):684-90.
Cervantes F, Pereira A, Esteve J, et al; Identification of 'short-lived' and 'long-lived' patients at presentation of idiopathic myelofibrosis. Br J Haematol. 1997 Jun97(3):635-40.