Elevated IPF in Patient with

Myelodisplastic Syndrome
 Database
• Female, 49 y.o
• Chief complain: abdominal pain
• History taking: patient suffered from abdominal
pain, especially in upper right quadran, since a
month ago and getting worse 2 weeks ago,
without nause and vomiting.
• She loss of her appetide and decrease her BW + 5
kg in 5 months.
• She also pale and general weakness since 2
weeks ago, sometimes she suffered subfebris,
gum bleeding (-) and epistaksis (-).
• Past medical history : she got transfusion 1
bag PRC when admitted in other hospital a
week ago.
 Physical Examination
General status Moderately ill, GCS : 4-5-6
Vital sign BP : 130/80 mmHg HR : 86 bpm
RR : 20 tpm T : 36,9°C (axilla)
Head & Neck Anemic conjunctiva +/+, Icteric sclera -/-, cyanosis (-),
gum bleeding (-), hypertrophy gingggiva (-),
lymphadenopathy (-)
JVP : R + 0 cmH2O

Thorax P : symmetrical, Wh -/-, Rh -/-

C : ictus at 5th ICS, left MCL, single S1/S2, murmur –
Abdomen Flat, BS +, liver span 14 cm, spleen schuffner II

Extremities Edema -/-

4
Hematology 12-12 13-12 22-12 Ref. Value
Hb (g/dL) 7,90 8,00 7,80 11,4 – 15,1
RBC (106/μL) 3,37 3,35 3,16 4,0 - 5,0
Hct (%) 24,90 25,00 24,00 38 - 42
MCV (fL) 73,90 74,60 75,90 80 - 93
MCH (pg) 23,40 23,90 24,7 27 - 31
MCHC (g/dL) 31,70 32,00 32,50 32-36
RDW (%) 22,60 23,10 20,30 11,5-14,5
WBC (103/μL) 3,00 3,13 3,09 4,7 - 11,3
Plt (103/μL) 107 118 86 142 - 424
Retic (%) 2,23 0,16 0,5-2,5
IPF (%) 13,1 1,1-6,1
Diff. count 0/0/0/48 0/0/0/56/20/14 0/0/16/48/6/20 0-4/0-1/51-
/24/28 Meta: 6%, myelo: 4% Meta: 4%, myelo: 6% 67/25-33/2-5
Peripheral Blood Smear (13-12):
E: hypocromic anisopoikilocytosis, fragmentocyte (+), makroovalocyte (+)
L: decreased
T: decreased, giant trombocyte (+)
 Bloodsmear evaluation
Bloodsmear 22-12
Erytrocyte Hypochrom microcytic anisopoikilositosis, eliptosit (+)

Leucocyte Decreased, shift to the left, monocyte < 1000/uL

Trombocyte Decreased

Bone Marrow Aspiration

BMA 22-12
Cellularity Hyperceluler
Ratio M:E 5:1
Eritropoeisis activity Good
Granulopoeisis activity Increased, disgranulopoiesis (+), myeloblast 5%
Megakariopoeisis activity Increased, dismegakariopoesis (+)
Iron storage Positive
Others -
Conclution Myelodysplastic Syndrome with excess blasts 1 (MDS-EB-1)
Marrow : hypercelluler Marrow : Dismegakariopoeitik (mikromegakariosit &
hipolobulasi

Marrow : Disgranulopoeitik (hypogranulation)

Marrow: Diseritropoeitik (binucleated).
peripher blood smear: Hypochrom microcytic Marrow : Fe storage positive
anisopoikilositosis, eliptosit (+)
Faal hemostasis
Parameter 13-12 Reference range
PPT
• Patient 11,00 9,4 – 11,3
• Kontrol 10,9
• INR 1,06 < 1,5
APPT
• Patient 49,20 49,20
• Kontrol 25,6
Conclusion: PPT and APTT within normal limit

Electrolyte Result
Parameter 12-12 16-12 Ref
Na (mmol/L) 133 123 136 – 145
K (mmol/L) 3.91 3.56 3.5 – 5.0
Cl (mmol/L) 103 98 98 – 106
Kalsium (Ca) 8.0 7.6 – 11.0
Phospor 3.4 2.7 – 4.5
 Clinical chemistry result
Parameter 12-12 13-12 16-12 Ref

AST/SGOT (mg/dL) 54 0-40

ALT/SGPT (mg/dL) 67 0-41

Ureum (mg/dL) 14.70 15.50 16.6-48.5

Creatin (mg/dL) 0.54 0.55 <1.2

Uric acid (mg/dL) 2.6 2.4-5.7

eGFR (mL/min/1.73m2) > 90

Albumin (g/dL) 2.61 2.67 3.5-5.5

Total Bilirubin 1.01 < 1.0

Direct Bilirubin 0.23 < 0.25

Indirect Bilirubin 0.78 < 0.75

Fe/Iron 96 49-151

TIBC 211 250-350

Transferin saturation 45 10
16 - 45
 Urinalysis
Urinalysis 12-12 Ref.value Micros. 26-10 Ref.value
urine
Clarity Clear
10x
Color Yellow
Epithel
pH 7,0 4.5-8.0
Cilinder Negative
SG 1,010 1.010-1.030
-Hyalin -/lpf ≤2
Glucose Negative Negative -Granule -/lpf Negative
-others -/lpf
Protein Negative Negative
40x
Ketone Trace Negative
Erythrocyte 0,8/hpf ≤2
Bilirubin Negative Negative
Leukocyte 0,2/hpf ≤2
Urobilinogen Negative Negative
Cristal -
Nitrite Negative Negative
Bakteria 9,9 ≤ 23 x 103/mL
Leucocyte Negative Negative
Others -
Blood Negative Negative
11
 Other Examination
• USG abdomen (7-12):
- mild splenomegali
 Data Interpretative
• The laboratory results showed anemia
hypochrom microcytic anisopoikilositosis,
leukopenia, shift to the left, thrombocytopenia,
elevated IPF, BMA: Myelodysplastic Syndrome
with excess blasts 1 (MDS-EB1), and
hypoalbuminemia.
• From history taking, clinical examination,
laboratory and others showed Myelodisplastic
Syndrome (MDS) with excess blasts 1 (MDS-EB1).
• Suggestion : monitoring BMA,
Immunophenotyping, cytogenetics
 Discussion
1. Establisment of the Diagnosis
2. Elevated IPF in this patient
3. Hypoalbuminemia in this patient
Establisment of the Diagnosis
 MYELODYSPLASTIC SYNDROME (MDS)
• Myelodysplastic syndromes (MDS) are a spectrum
of clonal myeloid disorders characterized by
ineffective hematopoiesis, cytopenias, qualitative
disorders of blood cells, clonal chromosomal
abnormalities, and the potential for clonal
evolution to acute myeloid leukemia (AML).
• The major pathogenic mechanism in MDS is
ineffective hematopoiesis, causing defective
maturation and death of marrow precursors.
• The incidence rate of these conditions is about 5
cases per 100 000 persons per year.
Jasleen Randhawa, MD, and Ehab Atallah, MD. Myelodysplastic Syndromes. Hematology Board Review
Manual. 2014
 Clinical Features of Myelodysplastic Syndrome

• Anemic and transfusion dependent

• Neutropenia
• Thrombocitopenia
• Recurrent infection
• Spontaneous bruising and bleeding
• Fatigue, weakness, exercise intolerance, angina, dizziness,
or an altered sense of well-being as a result of
unrecognized anemia
• Morphologic abnormalities in peripheral blood & bone
marrow (dyserythropoiesis, dysmyelopoiesis,
dysmegakaryopoiesis)

Brunning RD, Orazi A, Germing U, Le Beau MM, Porwit A, et al. Myelodysplastic syndromes/neoplasms overwiew.
In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, et al, editors. WHO classification of tumors of
haematopoietic and lymphoid tissues. IARC. 4th ed. Lyon. 2008. p 88-107
THIS PATIENT

• Female, 49 y.o Myelodysplastic

• Anemia Syndrome
• Leukopenia
• Thrombocytopenia With Excess Blast I
• BMA: Myelodysplastic
Syndrome tipe Refractory
anemia with excess blasts
1 (MDS-EB1)
• Clinic: abdominal pain,
Suggestions: monitoring
pale, weakness BMA,
• USG: splenomegali Immunophenotyping
Cytogenetics
Elevated IPF in this patient
 Immature Platelet Fraction
• Immature platelet fraction (IPF) is an index of
thrombopoiesis and can help determine the
mechanism of thrombocytopenia.
• An increased IPF in the presence of
thrombocytopenia is indicative of platelet
destruction or consumption.
• A decreased/low normal IPF in the presence of
thrombocytopenia is indicative of decreased
marrow production.
• The reference range for IPF is 1.1 – 6.1 %
• High IPF% is usually seen in thrombocytopenic
patients whose thrombopoiesis is accelerated
to compensate for low platelet counts.
• some patients with MDS exhibit IPF% above
10% despite the fact that there is no or only
mild thrombocytopenia
• MDS with high IPF%  higher platelet size
variation, MPV and PDW than MDS patients
without high IPF and healthy adults.
• The signs of dysmegakaryopoiesis  seen in
MDS patients with high IPF%. Thus, the
aberrantly high IPF% in MDS patients probably
reflects the presence of dysthrombopoiesis.
• These findings suggest that a high IPF% in
MDS patient may be a marker for karyotypic
abnormalities with a poor prognosis, including
chromosome 7 abnormalities.
Hypoalbuminemia in this patient
 Hypoalbumin in MDS
• Low serum albumin level is known to be an
adverse prognostic factor in patients with
malignancies.
• Kharfan-Dabaja et al: hypoalbumin was an
independent predictor of non-relapse and
overall mortality in patients with acute
myeloid leukemia (AML) and myelodysplastic
syndromes (MDS)
 Conclusion
• It has been discussed a case of 49 y.o female
with Myelodisplastic Syndrome with excess
blasts 1 (MDS-EB1).
• Elevated IPF in this patient caused by
disthrombopoeisis in MDS.
• Hypoalbumin in MDS reflection the poor
prognosis.
• Suggestion: monitoring BMA,
Immunophenotyping, and cytogenetics.
 MDS Subtype
Primary/secondary MDS
In addition to subtype, MDS is called either primary or
secondary MDS. Primary MDS is much more common
than secondary MDS. About 80% of people with MDS
have primary MDS.
• Primary MDS, no apparent risk factors can be found.
This may also be called de novo MDS.
• Secondary MDS occurs because of damage to the
DNA from chemotherapy or radiation therapy
previously given to treat another medical condition.
MDS can develop two to 10 years after such
treatment. Secondary MDS is often associated with
more complex chromosomal abnormalities.

http://www.cancer.net/cancer-types/myelodysplastic-syndromes-mds/subtypes-and-
classification
 Cytogenetics
• Cytogenetic abnormalities have a major role in
the diagnosis of myelodysplastic syndrome
and in risk assessment.
• Common abnormalities include
– an extra chromosome 8
– loss of the long arm of the chromosome 5, 7, 9,
20, or 21
– monosomy for chromosomes 7 and 9
– deletion in 5q is at band 5q31.1
– deletions of 5q32-33.3, 20q, or Y.
 Cytogenetics
• In many instances, cytogenetics is not
informative, and the diagnosis of MDS is
based entirely and exclusively on
morphological criteria.
• Diagnosis of MDS may be particularly difficult
in patients with a normal karyotype or non-
informative cytogenetics who do not have
robust morphological markers, such as ringed
sideroblasts or excess of blasts.
• Flow cytometry immunophenotyping is a
reliable method for quantitative and
qualitative evaluation of hematopoietic cells,
and not surprisingly has been evaluated as a
potential diagnostic tool for myelodysplastic
syndromes.
• Despite many efforts, no one single simple
immunophenotypic parameter has been
proved to be diagnostic of MDS.
 Transfusion in MDS
• Iron overload in MDS, red blood cell (RBC) transfusions are
a major part of the supportive care for anemic MDS
patients. Although the specific therapies patients receive
may alleviate the RBC transfusion need, many MDS patients
may not respond to these treatments and may develop iron
overload as well as its consequences.
• Patients requiring relatively large numbers of RBC
transfusions have experienced adverse effect of chronic
iron overload on liver, heart, endocrine functions. It is
possible that this organ dysfunction may result from iron
overload in patients with MDS and that transfusional iron
overload might be a contributor to increased sickness and
death in early stage MDS.
• For patients requiring many RBC transfusions,
serum ferritin levels, number of RBC
transfusions received, and associated organ
dysfunction (heart, liver, and pancreas) should
be monitored to determine iron levels.
• Monitoring serum ferritin may also be useful,
aiming to decrease ferritin levels to <1000
mcg/L.
 Kelainan kromosom
• Kelainan sitogenetik lebih sering terdapat pd
MDS sekunder dibanding primer & paling sering
terdiri dari hilangnya kromosom 5,7 atau Y
parsial atau total, atau trisomi 8.
• Hilangnya pita q13 sampai q33 kromosom 5 pd
wanita tua dg anemia makrositik, hitung
trombosit normal atau meningkat, serta
mikromegakariosit disebut sindrom 5q- dan
berprognosis baik.
• Mutasi onkogen RAS terjadi pd sekitar 20% kasus
dan mutasi FMS terjadi sekitar 15% kasus.
 Gambaran klinis
Sekitar separuh pasien berusia >70 th dan < 25%
pasien <50 th.
Pria lebih sering terkena.
Evolusinya lambat, dapat ditemukan scr kebetulan
saat pasien diperiksa hitung darah utk alasan lain yg
tdk terkait.
Anemia
Infeksi
Mudah memar atau berdarah
Netrofil, monosit, dan trombosit seringkali terganggu
scr fungsional shg terjadi infeksi spontan pd bbrp
kasus, memar atau perdarahan pd kasus lain yg tdk
sebanding dg beratnya sitopenia.
Limpa biasanya tdk membesar
Hipertrofi gusi & limfadenopati
 Temuan laboratorium
• Pada darah tepi sering ditemukan pansitopenia.
• Eritrosit biasanya makrositik atau dismorfik tetapi
kadang2 hipokrom, mungkin ditemukan normoblas.
• Hitung retikulosit rendah.
• Jmlh granulosit seringkali menurun &
memperlihatkan tdk adanya granulasi.
• Fungsi kemotaktik, fagositik, & adhesi terganggu.
• Kelainan Pelger (inti tunggal atau berlobus dua)
seringkali ditemukan.
Pada CMML monosit > 1,0 x 109/l dlm darah dan
jmlh leukosit total mungkin > 100 x 109/l
Trombosit dapat sangat besar atau kecil dan
biasanya berkurang jumlahnya tetapi meningkat
pada 10% kasus.
Pada kasus yg memiliki prognosis buruk
ditemukan mieloblast dg jumlah yg bervariasi dlm
darah.
Selularitas pd sutul meningkat.
Cincin sideroblast dpt ditemukan pd kelima tipe
FAB tetapi scr definisi mencakup 15% normoblast
pd anemia refrakter dg cincin sideroblas.
• Ditemukan normoblas berinti byk & gambaran
diseritropoiesis lain.
• Prekursor granulosit memperlihatkan adanya
gangguan granulasi primer & sekunder, dan sering
ditemukan sel2 yg sulit diidentifikasi apakah sbg
mielosit agranular, monosit atau promonosit.
• Megakariosit abnormal dg bentuk mikronuklear,
binuklear kecil, atau polinuklear.
• Biopsi sutul memperlihatkan fibrosis pd 10% kasus.
Pathogenesis
The pathogenesis of myelodysplastic syndromes
(MDS) is unclear but is presumed to start following
genetic damage to a multipotent haemopoietic
progenitor cell. This leads to increased stem cell
proliferation but ineffective differentiation and
maturation, leading to the paradox of a hypercellular
bone marrow but a pancytopenia in peripheral
blood. A high rate of apoptosis is present in bone
marrow precw·sors. The immune system may have
a role in suppressing bone marrow fW1ction;
immunosuppression
is sometimes used in treatment
 IPF
• Reticulated or immature platelets (RPs) are undeveloped
platelets recently released from the bone marrow into
circulation, which have high cytoplasmic ribonucleic acid
(mRNA) amounts
• The mRNA is unstable, degrades within 24 h and disappears
in parallel with the platelets age. RPs are similar to
reticulocytes, the undeveloped precursor of the
erythrocytes
• RPs are usually large, dense and more reactive in thrombus
formation process than mature platelets. It is probably due
to a progressive loss of surface glycoprotein required for
aggregation and activation that occur along the maturation
platelet process
• RP count can be an important tool to assess
platelet recovery in several clinical conditions,
especially platelet immunomediated
consumption or in post-chemotherapy
myelosuppression.
• RPs have been described as a marker of
platelet activity not only in thrombopoietic
disorders but also in acute coronary
syndrome, stroke, and in patients on
hemodialysis
• The discrimination between RPs from those
mature platelets can be done by
flowcytometer using a fluorescent dye that
binds to platelet mRNA (acridine orange,
thiazole orange, polymethine, coriphosphine
O, mepacrine and oxazine)
 PLT-F channel
• The PLT-F channel is for accurately measuring platelets,
especially for low platelet counts.
• By flow cytometry method using a semiconductor
laser, a two-dimensional scattergram is plotted, with
the X-axis representing the intensity of the side
fluorescent light (SFL), and the Y-axis representing the
intensity of the forward scattered light (FSC).
• This scattergram displays groups of platelets, part of
red blood cells, part of white blood cells, and debris.
• The IPF is obtained as a ratio of platelet count in the
area with strong fluorescent light intensity in the PLT-F
scattergram (IPFzone), to the total platelet count.
Teknologi pengukuran IPF
Amount of RNA/DNA

Intracellular
structure

Cell size
IPF Scattergram
Larger size

Lower size

Mature Immature
 Measurement Principles
Channels

RET/
RBC/PLT HGB WNR WDF WPC PLT-F
PLT-O

Sheath SLS- Flow Flow Flow Flow Flow

Flow DC Hemoglobin Cytometry Cytometry Cytometry Cytometry Cytometry
method method method method
Technology

Detection Method method

Method
Scattergrams
Histograms/

Hemoglobin
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