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The 2016 Revision to the World Health Organization Classification of Myeloid Neoplasms and Acute Leukemia

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The 2016 Revision to the World Health Organization Classification of Myeloid Neoplasms and Acute Leukemia From www.bloodjournal.org by guest on January 9, 2019. For personal use only. Review Series THE UPDATED WHO CLASSIFICATION OF HEMATOLOGICAL MALIGNANCIES The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia Daniel A. Arber,1 Attilio Orazi,2 Robert Hasserjian,3 J¨urgen Thiele,4 Michael J. Borowitz,5 Michelle M. Le Beau,6 Clara D. Bloomfield,7 Mario Cazzola,8 and James W. Vardiman9 1Department of Pathology, Stanford University, Stanford, CA; 2Department of Pathology, Weill Cornell Medical College, New York, NY; 3Department of Pathology, Massachusetts General Hospital, Boston, MA; 4Institute of Pathology, University of Cologne, Cologne, Germany; 5Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD; 6Section of Hematology/Oncology, University of Chicago, Chicago, IL; 7Comprehensive Cancer Center, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH; 8Department of Molecular Medicine, University of Pavia, and Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; and 9Department of Pathology, University of Chicago, Chicago, IL The World Health Organization (WHO) the prognostic relevance of entities cur- The 2016 edition represents a revision classification of tumors of the hemato- rently included in the WHO classification of the prior classification rather than poietic and lymphoid tissues was last and that also suggest new entities that an entirely new classification and at- updated in 2008. Since then, there have should be added. Therefore, there is a tempts to incorporate new clinical, prog- been numerous advances in the identifi- clear need for a revision to the current nostic, morphologic, immunophenotypic, cation of unique biomarkers associated classification. The revisions to the cate- and genetic data that have emerged with some myeloid neoplasms and acute gories of myeloid neoplasms and acute since the last edition. The major chan- leukemias, largely derived from gene ex- leukemia will be published in a mono- ges in the classification and their ratio- pression analysis and next-generation graph in 2016 and reflect a consensus of nale are presented here. (Blood. 2016; sequencing that can significantly im- opinion of hematopathologists, hema- 127(20):2391-2405) prove the diagnostic criteria as well as tologists, oncologists, and geneticists. Introduction In collaboration with the Society for Hematopathology and the 2. Improved characterization and standardization of morphological European Association for Haematopathology, the World Health features aiding in the differentiation of disease groups, particularly 2 Organization (WHO) published the third and fourth editions of the of the BCR-ABL1 myeloproliferative neoplasms (MPNs), has WHO Classification of Tumours of Haematopoietic and Lymphoid increased the reliability and reproducibility of di-agnoses. Tissues, in 2001 and 2008, respectively, as part of a series of WHO 3. A number of clinical-pathological studies have now validated the Classification of Tumours “blue book” monographs. In the spring WHO postulate of an integrated approach that includes hemato- of 2014, a clinical advisory committee (CAC) composed of ;100 logic, morphologic, cytogenetic, and molecular genetic findings. pathologists, hematologists, oncologists, and geneticists from around For these reasons, the fourth edition is being updated, but this 2016 the world convened to propose revisions to the fourth edition of the classification is not a major overhaul of the disease categories. Rather, it classification. The revision of the fourth edition follows the philosophy is intended to incorporate new knowledge of these disorders obtained of the third and fourth editions to incorporate clinical features, since the 2008 publication and is a revision of that classification. The morphology, immunophenotyping, cytogenetics, and molecular genetics purpose of this report is to summarize the major changes in the revised to define disease entities of clinical significance. The fourth edition of the WHO classification of myeloid neoplasms and acute leukemia and to classification of hematopoietic and lymphoid tissues was the second provide the rationale for those changes. Table 1 lists the major subtypes volume of the WHO “blue book” tumor series, and the series publication is of myeloid neoplasms and acute leukemias according to the updated still in progress. A fifth edition series cannot begin until the fourth edition (2016) WHO classification. series is completed; but after 8 years of information and experience that have emerged from scientific and clinical studies, a revision of these criteria for hematopoietic and lymphoid neoplasms was felt to be necessary and timely. In relation to myeloid neoplasms and acute leukemia, this revision has been influenced by several factors including the following: Myeloproliferative neoplasms 1. The discovery of recently identified molecular features has The categories of MPNs have not significantly changed since the 2008 yielded new perspectives regarding diagnostic and prognostic fourth edition of the classification, but discoveries of new mutations and markers that provide novel insights for the understanding of the improved understanding of the morphologic features of some entities pathobiology of these disorders. have impacted the diagnostic criteria for the disease entities. Submitted March 16, 2016; accepted April 6, 2016. Prepublished online as © 2016 by The American Society of Hematology Blood First Edition paper, April 11, 2016; DOI 10.1182/blood-2016-03-643544. The online version of this article contains a data supplement. BLOOD, 19 MAY 2016 x VOLUME 127, NUMBER 20 2391 From www.bloodjournal.org by guest on January 9, 2019. For personal use only. 2392 ARBER et al BLOOD, 19 MAY 2016 x VOLUME 127, NUMBER 20 Table 1. WHO classification of myeloid neoplasms and acute Table 1. (continued) leukemia WHO myeloid neoplasm and acute leukemia classification WHO myeloid neoplasm and acute leukemia classification Blastic plasmacytoid dendritic cell neoplasm Myeloproliferative neoplasms (MPN) Acute leukemias of ambiguous lineage 1 Chronic myeloid leukemia (CML), BCR-ABL1 Acute undifferentiated leukemia Chronic neutrophilic leukemia (CNL) Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 Polycythemia vera (PV) MPAL with t(v;11q23.3); KMT2A rearranged Primary myelofibrosis (PMF) MPAL, B/myeloid, NOS PMF, prefibrotic/early stage MPAL, T/myeloid, NOS PMF, overt fibrotic stage B-lymphoblastic leukemia/lymphoma Essential thrombocythemia (ET) B-lymphoblastic leukemia/lymphoma, NOS Chronic eosinophilic leukemia, not otherwise specified (NOS) B-lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities MPN, unclassifiable B-lymphoblastic leukemia/lymphoma with t(9;22)(q34.1;q11.2);BCR-ABL1 Mastocytosis B-lymphoblastic leukemia/lymphoma with t(v;11q23.3);KMT2A rearranged Myeloid/lymphoid neoplasms with eosinophilia and rearrangement of B-lymphoblastic leukemia/lymphoma with t(12;21)(p13.2;q22.1); ETV6-RUNX1 PDGFRA, PDGFRB,orFGFR1, or with PCM1-JAK2 B-lymphoblastic leukemia/lymphoma with hyperdiploidy Myeloid/lymphoid neoplasms with PDGFRA rearrangement B-lymphoblastic leukemia/lymphoma with hypodiploidy Myeloid/lymphoid neoplasms with PDGFRB rearrangement B-lymphoblastic leukemia/lymphoma with t(5;14)(q31.1;q32.3) IL3-IGH Myeloid/lymphoid neoplasms with FGFR1 rearrangement B-lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3);TCF3-PBX1 Provisional entity: Myeloid/lymphoid neoplasms with PCM1-JAK2 Provisional entity: B-lymphoblastic leukemia/lymphoma, BCR-ABL1–like Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) Provisional entity: B-lymphoblastic leukemia/lymphoma with iAMP21 Chronic myelomonocytic leukemia (CMML) T-lymphoblastic leukemia/lymphoma 2 Atypical chronic myeloid leukemia (aCML), BCR-ABL1 Provisional entity: Early T-cell precursor lymphoblastic leukemia Juvenile myelomonocytic leukemia (JMML) Provisional entity: Natural killer (NK) cell lymphoblastic leukemia/lymphoma MDS/MPN with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) MDS/MPN, unclassifiable Mastocytosis, however, is no longer considered a subgroup of the Myelodysplastic syndromes (MDS) MDS with single lineage dysplasia MPNs due to its unique clinical and pathologic features, ranging MDS with ring sideroblasts (MDS-RS) from indolent cutaneous disease to aggressive systemic disease, and MDS-RS and single lineage dysplasia is now a separate disease category in the classification. 1 MDS-RS and multilineage dysplasia With regard to chronic myeloid leukemia (CML), BCR-ABL1 , MDS with multilineage dysplasia most cases of CML in chronic phase can be diagnosed from peripheral MDS with excess blasts blood (PB) findings combined with detection of t(9;22)(q34.1;q11.2) or, MDS with isolated del(5q) more specifically, BCR-ABL1 by molecular genetic techniques. However, MDS, unclassifiable a bone marrow (BM) aspirate is essential to ensure sufficient material for a Provisional entity: Refractory cytopenia of childhood complete karyotype and for morphologic evaluation to confirm the phase Myeloid neoplasms with germ line predisposition of disease.1,2 In the era of tyrosine-kinase inhibitor (TKI) therapy, newly Acute myeloid leukemia (AML) and related neoplasms AML with recurrent genetic abnormalities diagnosed patients may have a nearly normal lifespan, but regular BCR-ABL1 AML with t(8;21)(q22;q22.1);RUNX1-RUNX1T1 monitoring for burden and for evidence of genetic
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