What is complex malignant hematology (CMH)?

Complex malignant hematology includes a variety of disorders and cancers of the blood. These conditions start in the bone marrow or in the cells of the immune system.

What are the types of blood cancers?

Complex malignant hematology is divided into two main types: lymphoid and myeloid.

Lymphoid cancers affect the lymphocytes – part of the immune system. It may originate in the bone marrow or the lymph nodes.

Myeloid cancers start in the bone marrow. Bone marrow is a spongy tissue inside some of our bones that contains stem cells. Stem cells are immature cells that can develop into blood cells.

The conditions are further classified as “acute” or “chronic”. Acute conditions mean that the cancer cells are splitting and growing quickly, and affecting the immature cells. Chronic conditions mean the cells are reproducing more slowly, and typically involve more mature cells. Sometimes chronic conditions can transform into acute conditions.

Acute conditions may be life threatening left untreated and generally require the treatments to start within 1 week.

To better understand blood cancers, it is helpful to visualize how they are classified. While not an exhaustive list, the starred conditions would fall under the jurisdiction of Complex Malignant Hematology.

The goal of therapy in most CMH conditions is cure.

Lymphoid Conditions

Acute:
Acute lymphoblastic leukaemia (ALL)*
Lymphoblastic lymphoma (LL)*

Chronic:
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma – many types, including:

• Burkitts lymphomas*
• High grade B-cell lymphomas double hit*
• Primary CNS Lymphomas*

Myeloid Conditions

Acute:
Acute Myeloid Leukemia (AML)*
Granulocytic sarcoma*

Chronic:
Myelodysplastic syndromes (MDS)
Myeloproliferative neoplasms (MPN)
Aplastic Anemia (AA)*
Paroxysmal Nocturnal Hemoglobinuria (PNH)*

What are the symptoms of blood cancers?

The symptoms of blood cancers or conditions can be different because of all the different types of condition.

Some of common symptoms of blood cancer, according to the Canadian Cancer Society, are:

• Unexplained weight loss
• Fatigue
• Shortness of breath
• Easy bruisability or bleeding
• Enlarged lymph nodes in the neck, underarm, groin or above the collarbone
• Swollen stomach or abdominal discomfort
• Frequent and repeated infections
• Fever/night sweats

Why do these conditions require such specialized care?

As a general rule, these conditions require management in specialized cancer centres. Many people require chemotherapy and or immunotherapy, and some may only be cured by a bone marrow transplant. The transplant can come either from ones own stem cells (autologous) or from an external donor’s (allogeneic). These treatments essentially wipe out the immune system, putting patients at risk for infection and at higher risk for needing blood transfusions. So, a very specialized care team and treatment space is needed to deliver the best and safest care.

More resources: 

Lymphoma Canada

Leukemia and Lymphoma Society of Canada

Learn more about Sunnybrook’s facility for treating complex malignant hematology.

This post was reviewed and updated Sept. 15, 2021.

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How big is this news about a second patient having no detectable HIV after a bone marrow transplant?

It’s very big news. We’ve waited so long to see these results replicated after the first patient [American Timothy Ray Brown in 2007]. It really opens up the imagination for what can be done around cure research in HIV.

As exciting as it is, however, we also have to be mindful about what’s realistic for our patients. But it does shine a light on the amazing work going on in HIV research right now.

What does this mean for HIV patients?

There have been other cases of HIV patients who’ve required bone marrow transplants, often for blood cancers, but only one patient had managed to stay off of antiretroviral (ARV) medication until now.

While it’s unlikely that this particular treatment will ever be widely offered due to the risks involved, it’s still good to see things like this happen. The success of the transplant in a second patient has also now identified a potential target for researchers interested in cure, to look at things like gene therapies or specialized antibodies.

It’s important to remember that worldwide, there are 37 million people living with the virus, and 40% of them are still not accessing ARV treatment, which we know works and can keep the virus suppressed. HIV is a chronic disease and it is critical that we don’t take the foot off the gas pedal for resources supporting prevention, testing and treatment programs.

Why can’t a bone marrow transplant be offered as a standard treatment to all patients with HIV?

A bone marrow transplant is a very risky, potentially life-threatening treatment. These two patients needed it because they had severe blood cancers, and they had to go through several rounds of chemotherapy and/or radiation first. It’s a therapy that won’t be readily available or indicated for the vast majority of HIV patients.

What’s next in HIV research?

There is still a lot of work to do in reaching that 40% of people with HIV who aren’t accessing treatment, whether it’s due to cost, location, stigma or other factors.

For example, a study published last week found that community-based testing and getting people on treatment reduces HIV infections by 30%. There are simple solutions that can be used to continue fighting this epidemic.

How far has HIV research come during your career?

With proper treatment, HIV is no longer the “death sentence” it once was. Today, it’s treated as a chronic disease, and we have readily available treatment that can lead to life expectancy that’s just as good as someone who doesn’t have HIV.

I started working as a student on HIV vaccine research back in the early 1990s, and to hear that there’s a second functional cure case is pretty amazing. Some of the patients we see at the Anita Rachlis HIV Clinic have been on treatment since the 1980s and are doing remarkably well, so it’s quite inspiring to see how much things have changed.

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