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Differenzialdiagnose myelproliferativer Neoplasien

Quantitative NF-E2-Immunhistochemie zur Unterscheidung zwischen essenzieller Thrombozythämie und primärer Myelofibrose

Differential diagnosis of myeloproliferative neoplasms

Quantitative NF-E2 immunohistochemistry for differentiating between essential thrombocythemia and primary myelofibrosis

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Zusammenfassung

Hintergrund

Die WHO-definierten myeloproliferativen Neoplasien (MPN) umfassen neben der essenziellen Thrombozythämie (ET), der Polycythaemia vera (PV) und der primären Myelofibrose (PMF) auch die Entität der unklassifizierbaren MPN (MPN, U). Tatsächlich ist die exakte Differenzialdiagnose zwischen den MPN-Entitäten v. a. in der frühen Erkrankungsphase eine Herausforderung. Dem Pathologen stehen bislang neben der histomorphologischen Evaluation von Knochenmarktrepanaten im Kontext mit klinischen Daten wie z. B. Laborwerten keine hilfreichen Zusatzuntersuchungen zur Verfügung. In der Unterscheidung zwischen ET und PMF ist selbst die molekularpathologische JAK2-Mutationsanalyse nicht weiterführend, da beide Erkrankungen zu 50 % mit der V617F-Mutation assoziiert sind. Kürzlich wurde in MPN die Überexpression des Transkriptionsfaktors NF-E2 beschrieben

Materialien und Methoden

Ein Kollektiv aus 163 Knochenmarkbiopsien, darunter 139 MPN-Fälle, wurde immunhistochemisch NF-E2-gefärbt und hinsichtlich der subzellulären Lokalisation von NF-E2 in erythroiden Vorläuferzellen analysiert. Die Ergebnisse der MPN-Fälle und Kontrollen wurden miteinander verglichen und statistisch ausgewertet.

Ergebnisse und Diskussion

In dieser Arbeit konnte gezeigt werden, dass die immunhistochemische NF-E2-Färbung mit quantitativer Auswertung des Anteils der nukleär positiven Erythroblasten an der Gesamtheit aller erythroiden Vorläuferzellen eine zuverlässige Unterscheidung zwischen ET und PMF bereits in frühen Stadien zulässt. Ein MPN-U-Fall mit einem Anteil mehr als 20 % nukleär positiver Erythroblasten kann mit einer Genauigkeit von 92 % der PMF zugeordnet werden.

Abstract

Background

Besides essential thrombocythemia (ET), polycythemia vera (PV) and primary myelofibrosis (PMF) the myeloproliferative neoplasms (MPN) defined by the World Health Organization (WHO) comprise the entity of unclassifiable MPNs (MPN, U). The exact differential diagnosis of the specific MPN entities can be challenging particularly at early stages of the diseases. So far, pathologists have had to rely only on histomorphological evaluation of bone marrow biopsies in combination with laboratory data because helpful ancillary tests are not yet available. Even molecular tests, such as JAK2 mutation analysis are not helpful particularly in the differential diagnosis of ET and PMF because both entities are associated with the V617F mutation in 50 % of the cases. Recently overexpression of the transcription factor NF-E2 in MPN was described.

Materials and methods

A collective of samples consisting of 163 bone marrow biopsies including 139 MPN cases was stained immunohistochemically for NF-E2 and analyzed regarding the subcellular localization of NF-E2 in erythroid progenitor cells. The results were compared between the MPN entities as well as the controls and statistical analyses were conducted.

Results and discussion

This study showed that NF-E2 immunohistochemistry and analysis of the proportion of nuclear positive erythroblasts of all erythroid precursor cells can help to distinguish between ET and PMF even in early stages of the diseases. An MPN, U case showing a proportion of more than 20 % nuclear positive erythroblasts can be classified as a PMF with 92 % accuracy.

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Danksagung

Die Autoren bedanken sich herzlich bei Theresa Lowka und Katja Thurig für hervorragende technische Assistenz sowie bei Dr. Heiko Becker und Dr. Jonas Jutzi für kritische Kommentare. Diese Arbeit wurde finanziell unterstützt durch die Medizinische Fakultät der Albert-Ludwigs-Universität Freiburg (AUM843/11, KA), die Deutsche Gesellschaft für Pathologie (KA), The National Cancer Institute (1 PO1 CA108671, HLP) und die Deutsche Forschungsgemeinschaft (Pa 611/6-1, HLP).

Einhaltung ethischer Richtlinien

Interessenkonflikt. K. Aumann, A.-V. Frey, A.M. May, D. Hauschke, C. Kreutz, J.P. Marx, M. Werner, H.L. Pahl geben an, dass kein Interessenkonflikt besteht. Alle angewandten Verfahren stehen im Einklang mit den ethischen Normen der verantwortlichen Kommission für Forschung am Menschen (institutionell und national) und mit der Deklaration von Helsinki von 1975 in der revidierten Fassung von 2008. Alle Patienten wurden erst nach erfolgter Aufklärung und Einwilligung in die Studie eingeschlossen.

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Authors and Affiliations

  1. Institut für Pathologie, Universitätsklinikum Freiburg, Breisacher Str. 115a, 79106, Freiburg, Deutschland

    K. Aumann MD, A.-V. Frey, A.M. May & M. Werner

  2. Institut für medizinische Biometrie und Informatik, Universitätsklinikum Freiburg, Freiburg, Deutschland

    D. Hauschke

  3. Physikalisches Institut und Zentrum für Biosystemanalyse (ZBSA), Universität Freiburg, Freiburg, Deutschland

    C. Kreutz & J. Timmer

  4. Abteilung für molekulare Hämatologie, Zentrum für klinische Forschung, Universitätsklinikum Freiburg, Freiburg, Deutschland

    J.P. Marx & H.L. Pahl

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  1. K. Aumann MD
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  2. A.-V. Frey
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  3. A.M. May
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  4. D. Hauschke
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  5. C. Kreutz
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  6. J.P. Marx
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  7. J. Timmer
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  8. M. Werner
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  9. H.L. Pahl
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Correspondence to K. Aumann MD.

Additional information

The supplement this article is part of is not sponsored by the industry.

This research was originally published in Blood. Aumann K, Werner M, Pahl HL et al. (2013) Subcellular mislocalization of the transcription factor NF-E2 in erythroid cells discriminates pre-fibrotic primary myelofibrosis from essential thrombocythemia. Blood 122:93–99. Reprinted with permission from the American Society of Hematology, which does not endorse any particular uses of this document. The American Society of Hematology is not responsible for the completeness or the accuracy of the translation. © American Society of Hematology.

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Aumann, K., Frey, AV., May, A. et al. Differenzialdiagnose myelproliferativer Neoplasien. Pathologe 34 (Suppl 2), 201–209 (2013). https://doi.org/10.1007/s00292-013-1824-8

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