Primary myelofibrosis (PMF) is a rare bone marrow blood cancer. It is classified by the World Health Organization (WHO) as a type of myeloproliferative neoplasm, a group of cancers in which there is activation and growth of mutated cells in the bone marrow. This is most often associated with a somatic mutation in the JAK2, CALR, or MPL genes. In PMF, the bony aspects of bone marrow are remodeled in a process called osteosclerosis; in addition, fibroblasts secrete collagen and reticulin proteins that are collectively referred to as fibrosis. These two pathological processes compromise the normal function of bone marrow, resulting in decreased production of blood cells such as erythrocytes (red cells), granulocytes, and megakaryocytes. The latter are responsible for the production of platelets. Signs and symptoms include fever, night sweats, bone pain, fatigue, and abdominal pain. Increased infections, bleeding and an enlarged spleen (splenomegaly) are also hallmarks of the disease. Patients with myelofibrosis have an increased risk of acute meyloid leukemia and frank bone marrow failure. In 2016, prefibrotic primary myelofibrosis was formally classified as a distinct condition that progresses to overt PMF in many patients, the primary diagnostic difference being the grade of fibrosis.
Signs and symptoms The primary feature of primary myelofibrosis is bone marrow fibrosis, but it is often accompanied by:
Abdominal fullness related to an enlarged spleen (splenomegaly). Enlargement of both the liver and spleen Splenomegaly due to extramedullary hematopoiesis (hematopoiesis occurring outside of the bone marrow) Bone pain Bruising and easy bleeding due to inadequate numbers of platelets Increased risk of thrombosis Cachexia (loss of appetite, weight loss, and fatigue) Fatigue Fevers Chills Weight loss Gout and high uric acid levels Increased susceptibility to infection, such as pneumonia Pallor and shortness of breath due to anemia Leukoerythroblastic smear (tear-drop RBCs, nucleated RBCs, and immature granulocytes) In rarer cases, a raised red blood cell volume Cutaneous myelofibrosis is a rare skin condition characterized by dermal and subcutaneous nodules.
Causes The underlying cause of PMF is almost always related to an acquired mutation in JAK2, CALR or MPL in a hematopoietic stem/progenitor cell in the bone marrow. There is an association between mutations to the JAK2, CALR, or MPL genes and myelofibrosis. Approximately 90% of those with myelofibrosis have one of these mutations; 10% do not have mutations in these three genes. These mutations are not specific to myelofibrosis, but are observed in other myeloproliferative neoplasms, specifically polycythemia vera and essential thrombocythemia. The JAK2 protein is mutated giving risk to a variant protein with an amino acid substitution commonly referred to as V617F; the mutation causing this variant is found in approximately half of individuals with primary myelofibrosis. The V617F substitution is an amino acid change of valine to phenylalanine at the 617 position in the JAK2 protein. Janus kinases (JAKs) are non-receptor tyrosine kinase part of the signaling pathway activated by receptors that recognize cytokines and growth factors. These include receptors for erythropoietin, thrombopoietin, most interleukins and interferon. JAK2 mutations play a significant role in the pathogenesis of all the myeloproliferative neoplasms because the recognized mutations all cause constitutive activation of the pathway controlling the production of blood cells arising from hematopoietic stem cells. The V617F subsustition also renders hematopoietic cells more sensitive to growth factors that use JAK2 for signal transduction, which include erythropoietin and thrombopoietin. The MPL gene codes for a protein that acts as a receptor for thrombopoietin, a growth factor that enhances production of platelets. A mutation in that gene, resulting in the substitution W515L, results in thrombopoietin receptor that is constitutively active even in the absence of thrompoietin. Abnormal megakaryocytes predominate in the bone marrow and platelet production is enhanced. The mutant megakaryocytes also release growth factors that stimulate other cells in the bone marrow including fibroblasts, the cells that are stimulated to secrete excess collagen, by secreting PDGF and TGF-β1. Smoking has been associated with the development of MPN, to which PMF belongs, when comparing smokers and never‐smokers.
Mechanism Myelofibrosis is a clonal neoplastic disorder of hematopoiesis, the formation of blood cellular components. It is one of the myeloproliferative disorders, diseases of the bone marrow in which excess cells are produced at some stage. Production of cytokines such as fibroblast growth factor by the abnormal hematopoietic cell clone (particularly by megakaryocytes) leads to replacement of the hematopoietic tissue of the bone marrow by connective tissue via collagen fibrosis. The decrease in hematopoietic tissue impairs the patient's ability to generate new blood cells, resulting in progressive pancytopenia, a shortage of all blood cell types. However, the proliferation of fibroblasts and deposition of collagen is a secondary phenomenon, and the fibroblasts themselves are not part of the abnormal cell clone. In primary myelofibrosis, progressive scarring, or fibrosis, of the bone marrow occurs, for the reasons outlined above. The result is extramedullary hematopoiesis, i.e. blood cell formation occurring in sites other than the bone marrow, as the hemopoietic cells are forced to migrate to other areas, particularly the liver and spleen. This causes an enlargement of these organs. In the liver, the abnormal size is called hepatomegaly. Enlargement of the spleen is called splenomegaly, which also contributes to causing pancytopenia, particularly thrombocytopenia and anemia. Another complication of extramedullary hematopoiesis is poikilocytosis, or the presence of abnormally shaped red blood cells. Myelofibrosis can be a late complication of other myeloproliferative disorders, such as polycythemia vera, and less commonly, essential thrombocythemia. In these cases, myelofibrosis occurs as a result of somatic evolution of the abnormal hematopoietic stem cell clone that caused the original disorder. In some cases, the development of myelofibrosis following these disorders may be accelerated by the oral chemotherapy drug hydroxyurea.
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