101
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Boulos R, Turner K, Saklayen S, Perez W, Iyer MH. Cefazolin-Induced Thrombocytopenia in a Patient with Polycythemia Vera Following Coronary Artery Bypass. Semin Cardiothorac Vasc Anesth 2021; 26:83-85. [PMID: 34965170 DOI: 10.1177/10892532211065234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cefazolin is an antibiotic that is commonly administered perioperatively to reduce the risk of surgical site infections. Cephalosporins have a well-established safety profile, but have been associated with thrombocytopenia and neutropenia due to their myelosuppressive effects. While this effect may be benign in healthy patients undergoing minor surgery, it can be detrimental in patients with underlying hematologic disorders presenting for open-heart surgery. Herein, we discuss the first case in the literature of cefazolin-induced thrombocytopenia and severe coagulopathy in a patient with polycythemia vera (PCV) during a coronary artery bypass-grafting surgery.
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Affiliation(s)
- Racha Boulos
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
| | - Katja Turner
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
| | - Samiya Saklayen
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
| | - William Perez
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
| | - Manoj H Iyer
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
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102
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MDM2 antagonist idasanutlin in patients with polycythemia vera: results from a single-arm phase 2 study. Blood Adv 2021; 6:1162-1174. [PMID: 34933330 PMCID: PMC8864654 DOI: 10.1182/bloodadvances.2021006043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/19/2021] [Indexed: 12/01/2022] Open
Abstract
Idasanutlin showed clinical activity in patients with HU-resistant/-intolerant PV, but chronic toxicity led to a high discontinuation rate. Significant reductions in JAK2 allele burden occurred after 3 treatment cycles and were greatest in patients with clinical response.
Idasanutlin, an MDM2 antagonist, showed clinical activity and a rapid reduction in JAK2 V617F allele burden in patients with polycythemia vera (PV) in a phase 1 study. This open-label phase 2 study evaluated idasanutlin in patients with hydroxyurea (HU)-resistant/-intolerant PV, per the European LeukemiaNet criteria, and phlebotomy dependence; prior ruxolitinib exposure was permitted. Idasanutlin was administered once daily on days 1 through 5 of each 28-day cycle. The primary end point was composite response (hematocrit control and spleen volume reduction > 35%) in patients with splenomegaly and hematocrit control in patients without splenomegaly at week 32. Key secondary end points included safety, complete hematologic response (CHR), patient-reported outcomes, and molecular responses. All patients (n = 27) received idasanutlin; 16 had response assessment (week 32). Among responders with baseline splenomegaly (n = 13), 9 (69%) attained any spleen volume reduction, and 1 achieved composite response. Nine patients (56%) achieved hematocrit control, and 8 patients (50%) achieved CHR. Overall, 43% of evaluable patients (6/14) showed a ≥50% reduction in the Myeloproliferative Neoplasm Symptom Assessment Form Total Symptom Score (week 32). Nausea (93%), diarrhea (78%), and vomiting (41%) were the most common adverse events, with grade ≥ 3 nausea or vomiting experienced by 3 patients (11%) and 1 patient (4%), respectively. Reduced JAK2 V617F allele burden occurred early (after 3 cycles), with a median reduction of 76%, and was associated with achieving CHR and hematocrit control. Overall, the idasanutlin dosing regimen showed clinical activity and rapidly reduced JAK2 allele burden in patients with HU-resistant/- intolerant PV but was associated with low-grade gastrointestinal toxicity, leading to poor long-term tolerability. This trial was registered at www.clinincaltrials.gov as #NCT03287245.
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103
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Casu C, Liu A, De Rosa G, Low A, Suzuki A, Sinha S, Ginzburg YZ, Abrams C, Aghajan M, Guo S, Rivella S. Tmprss6-ASO as a tool for the treatment of Polycythemia Vera mice. PLoS One 2021; 16:e0251995. [PMID: 34890402 PMCID: PMC8664179 DOI: 10.1371/journal.pone.0251995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/22/2021] [Indexed: 11/19/2022] Open
Abstract
Polycythemia Vera (PV) is a chronic myeloproliferative neoplasm resulting from an acquired driver mutation in the JAK2 gene of hematopoietic stem and progenitor cells resulting in the overproduction of mature erythrocytes and abnormally high hematocrit, in turn leading to thromboembolic complications. Therapeutic phlebotomy is the most common treatment to reduce the hematocrit levels and consequently decrease thromboembolic risk. Here we demonstrate that, by using the iron restrictive properties of the antisense oligonucleotides against Tmprss6 mRNA, we can increase hepcidin to achieve effects equivalent to therapeutic phlebotomy. We provide evidence that this less invasive approach could represent an additional therapeutic tool for the treatment of PV patients.
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Affiliation(s)
- Carla Casu
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, United States of America
- * E-mail:
| | - Alison Liu
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, United States of America
| | - Gianluca De Rosa
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, United States of America
| | - Audrey Low
- Ionis Pharmaceuticals, Inc., Carlsbad, CA, United States of America
| | - Aae Suzuki
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Sayantani Sinha
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, United States of America
| | - Yelena Z. Ginzburg
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Charles Abrams
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Mariam Aghajan
- Ionis Pharmaceuticals, Inc., Carlsbad, CA, United States of America
| | - Shuling Guo
- Ionis Pharmaceuticals, Inc., Carlsbad, CA, United States of America
| | - Stefano Rivella
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, United States of America
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States of America
- Cell and Molecular Biology affinity group (CAMB), University of Pennsylvania, Philadelphia, PA, United States of America
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics-CHOP, Philadelphia, PA, United States of America
- Penn Center for Musculoskeletal Disorders, CHOP, Philadelphia, PA, United States of America
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104
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JAK2V617F variant allele frequency >50% identifies patients with polycythemia vera at high risk for venous thrombosis. Blood Cancer J 2021; 11:199. [PMID: 34897288 PMCID: PMC8665926 DOI: 10.1038/s41408-021-00581-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 12/22/2022] Open
Abstract
Arterial (AT) and venous (VT) thrombotic events are the most common complications in patients with polycythemia vera (PV) and are the leading causes of morbidity and mortality. In this regard, the impact of JAK2V617F variant allele frequency (VAF) is still debated. The purpose of the current study was to analyze the impact of JAK2V617F VAF in the context of other established risk factors for thrombosis in a total of 865 2016 WHO-defined PV patients utilizing two independent cohorts: University of Florence (n = 576) as a training cohort and Policlinico Gemelli, Catholic University, Rome (n = 289) as a validation cohort. In the training cohort VT free-survival was significantly shorter in the presence of a JAK2V617F VAF > 50% (HR 4; p < 0.0001), whereas no difference was found for AT (HR 0.9; p = 0.8). Multivariable analysis identified JAK2V617F VAF > 50% (HR 3.8, p = 0.001) and previous VT (HR 2.2; p = 0.04) as independent risk factors for future VT whereas diabetes (HR 2.4; p = 0.02), hyperlipidemia (HR 2.3; p = 0.01) and previous AT (HR 2; p = 0.04) were independent risk factors for future AT. Similarly, JAK2V617F VAF > 50% (HR 2.4; p = 0.01) and previous VT (HR 2.8; p = 0.005) were confirmed as independent predictors of future VT in the validation cohort. Impact of JAK2V617F VAF > 50% on VT was particularly significant in conventional low-risk patients, both in Florence (HR 10.6, p = 0.005) and Rome cohort (HR 4; p = 0.02). In conclusion, we identified JAK2V617F VAF > 50% as an independent strong predictor of VT, supporting that AT and VT are different entities which might require distinct management.
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105
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Running interferon interference in treating PV/ET: meeting unmet needs. Hematology 2021; 2021:463-468. [DOI: 10.1182/hematology.2021000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Enthusiasm about interferons for the treatment of myeloproliferative neoplasms has recently arisen. How does a nontargeted therapy selectively target the malignant clone? Many foundational questions about interferon treatment are unanswered, including who, when, and for how long do we treat. Using an individual case, this review touches on gaps in risk assessment in polycythemia vera (PV) and essential thrombocythemia (ET) and the history of treatment with interferons. How is it that this proinflammatory cytokine effectively treats ET and PV, themselves proinflammatory states? We summarize existing mechanistic and clinical data, the molecular context as a modifier for treatment response, the establishment of treatment goals, and the challenges that lie ahead.
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106
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Schieppati F. Evidence-Based Minireview: Are DOACs an alternative to vitamin K antagonists for treatment of venous thromboembolism in patients with MPN? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:448-452. [PMID: 34889434 PMCID: PMC8791160 DOI: 10.1182/hematology.2021000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Francesca Schieppati
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
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107
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MPN and thrombosis was hard enough . . . now there's COVID-19 thrombosis too. Hematology 2021; 2021:710-717. [DOI: 10.1182/hematology.2021000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Both myeloproliferative neoplasms (MPNs) and coronavirus disease 2019 (COVID-19) are characterized by an intrinsic thrombotic risk. Little is known about the incidence and the outcome of thrombotic events in patients with MPN infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but common mechanisms of coagulation activation, typical of both disorders, suggest that these patients can be at particularly high risk. To define the best thromboprophylaxis and treatment regimens in both MPN and COVID-19, individual- and disease-specific thrombotic risk factors, bleeding risk, and concomitant specific treatments need to be considered. In this case-based review, an individualized approach is presented in a case of SARS-CoV-2 infection occurring in a man with polycythemia vera (PV). A primary anticoagulant thromboprophylaxis strategy and adjustment of his PV treatment were implemented. However, during the hospital stay, he experienced pulmonary embolism and therapeutic anticoagulation had to be set. Then his condition improved, and discharge was planned. Postdischarge decisions had to be made about the type and duration of venous thromboembolism treatment as well as the management of PV-specific drugs. The steps of our decisions and recommendations are presented.
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108
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera: historical oversights, diagnostic details, and therapeutic views. Leukemia 2021; 35:3339-3351. [PMID: 34480106 PMCID: PMC8632660 DOI: 10.1038/s41375-021-01401-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Polycythemia vera (PV) is a relatively indolent myeloid neoplasm with median survival that exceeds 35 years in young patients, but its natural history might be interrupted by thrombotic, fibrotic, or leukemic events, with respective 20-year rates of 26%, 16%, and 4%. Current treatment strategies in PV have not been shown to prolong survival or lessen the risk of leukemic or fibrotic progression and instead are directed at preventing thrombotic complications. In the latter regard, two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). All patients require phlebotomy to keep hematocrit below 45% and once-daily low-dose aspirin, in the absence of contraindications. Cytoreductive therapy is recommended for high-risk or symptomatic low-risk disease; our first-line drug of choice in this regard is hydroxyurea but we consider pegylated interferon as an alternative in certain situations, including in young women of reproductive age, in patients manifesting intolerance or resistance to hydroxyurea therapy, and in situations where treatment is indicated for curbing phlebotomy requirement rather than preventing thrombosis. Additional treatment options include busulfan and ruxolitinib; the former is preferred in older patients and the latter in the presence of symptoms reminiscent of post-PV myelofibrosis or protracted pruritus. Our drug choices reflect our appreciation for long-term track record of safety, evidence for reduction of thrombosis risk, and broader suppression of myeloproliferation. Controlled studies are needed to clarify the added value of twice- vs once-daily aspirin dosing and direct oral anticoagulants. In this invited review, we discuss our current approach to diagnosis, prognostication, and treatment of PV in general, as well as during specific situations, including pregnancy and splanchnic vein thrombosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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109
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Thrombosis in myeloproliferative neoplasms: A clinical and pathophysiological perspective. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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110
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Prevention of venous thromboembolism in hematologic neoplasms: an expert consensus from SEHH-SETH. Clin Transl Oncol 2021; 24:770-783. [PMID: 34850351 DOI: 10.1007/s12094-021-02735-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
Venous thromboembolism (VTE) is a serious complication in hematologic neoplasms, so finding adequate prevention strategies is an urgent requirement. However, prospective studies with large enough cohorts are scarce, limiting the development of evidence-based thromboprophylaxis guidelines. The present position paper is addressed to all hematologists treating patients affected by hematologic neoplasms with the aim to provide clinicians with a useful tool for the prevention of VTE.
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111
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Crodel CC, Jentsch-Ullrich K, Reiser M, Jacobasch L, Sauer A, Tesch H, Ulshöfer T, Wunschel R, Palandri F, Heidel FH. Cytoreductive treatment in real life: a chart review analysis on 1440 patients with polycythemia vera. J Cancer Res Clin Oncol 2021; 148:2693-2705. [PMID: 34807311 PMCID: PMC8607972 DOI: 10.1007/s00432-021-03855-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022]
Abstract
Purpose Patients with polycythemia vera (PV) show an elevated incidence of thromboembolic complications and decreased survival when compared to age-matched healthy individuals. Hypercellularity as indicated by elevated hematocrit, pathophysiological changes induced by the JAK2 driver mutation and cardiovascular risk factors contribute to the increased incidence of thromboembolic events. Higher age and a history of thromboembolic events define a high-risk population of PV patients. Depending on the individual risk profile, phlebotomy or pharmacologic cytoreduction is recommended in combination with low-dose acetylsalicylic acid. Stringent cytoreduction is required for effective risk reduction. However, in recent reports, the rate of thromboembolic complications in PV patients under cytoreductive therapy appears still elevated compared to healthy individuals. This study reports on a chart review to assess for cytoreductive therapy of 1440 PV patients in real life. Methods Forty-two eligible hematologists/oncologists in private practice treating patients with MPN were recruited to participate in a paper–pencil-based survey conducted between January 2019 and March 2020 in Germany. Physicians were asked to report primary documented data obtained from patient charts. Descriptive analyses were conducted to assess for patient characteristics, treatment modalities, risk factors and thromboembolic complications. Results Data were collected from the patient charts of 1440 individuals diagnosed with PV. The patient population was older than those reported in multicenter trials with a median age of 72.2 years at the time of reporting and 63.5 years at diagnosis. Age was the main factor accounting for high-risk status with 84.7% of patients being above the age of 60 followed by thromboembolic complications reported in 21.3% of patients. The use of pharmacologic cytoreduction was highly variable between participating centers with an average of 60.7% and a range of 10.1–100%. Hydroxyurea was the most frequently used drug followed by ruxolitinib, while interferons were reported for a minority of patients. For 35.4% of patients a persistent need for phlebotomy in addition to cytoreductive treatment was reported. Although presence of high-risk criteria and insufficient disease control were reported as main triggers to initiate pharmacologic cytoreduction, 28.1% had elevated hematocrit values (> 45%) and 38.6% showed persistence of elevated leukocyte count (> 109/l) while on cytoreductive treatment. In contrast, physician-reported symptom burden was lower than published in clinical trials and patient-reported outcomes. The rate of patients experiencing thromboembolic complications was 32.2% at any time and 14.3% after diagnosis with most patients receiving acetylsalicylic acid and 10.8% remaining on oral anticoagulants or heparin. Conclusions Cytoreductive treatment of high-risk PV in real life is highly variable regarding indication for cytoreduction and definition of therapy resistance. This study highlights the need for (i) improved risk stratification for thromboembolic events, (ii) consequent indication of pharmacologic cytoreduction in high-risk PV and (iii) attention to signs of therapy resistance that can trigger an earlier and stringent switch to second line agents.
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Affiliation(s)
- Carl C Crodel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany
| | | | | | - Lutz Jacobasch
- Gemeinschaftspraxis Hämatologie und Onkologie, Dresden, Germany
| | - Annette Sauer
- MVZ für Blut-und Krebserkrankungen, Potsdam, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie, Frankfurt, Germany
| | | | | | - Francesca Palandri
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology L. and A. Seràgnoli, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Florian H Heidel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.
- Innere Medizin C, Hämatologie und Onkologie, Universitätsmedizin Greifswald, Sauerbruchstrasse, 17475, Greifswald, Germany.
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112
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Oz O, Gonel A. The Association Between Parameters of Erythrocytes Morphology and Thrombophilia-Related Mutations. Rev Recent Clin Trials 2021; 17:40-45. [PMID: 34814821 DOI: 10.2174/1574887116666211123092603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/21/2021] [Accepted: 10/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Alterations in erythrocyte morphology parameters have been identified and associated with hematological disorders and other chronic and cardiovascular diseases. Erythrocytes are abundant in thrombus content. Their hemoglobin density and differences in the ratio of macrocytic and microcytic cells may be associated with hypercoagulopathy in those with a history of thrombosis. OBJECTIVE This cross-sectional study aimed to investigate the relationship between hemogram parameters and thrombophilia genetic parameters. METHOD A total of 55 patients whose thrombophilia panel was reviewed due to the diagnosis of thrombosis were included in the study. %MIC, %MAC, %HPO, %HPR and all hemogram parameters were measured using Abbott Alinity HQ. Prothrombin G20210A, MTHFR C677T, MTHFR A1298C, Factor V Leiden G169A and PAI-1 4G/5G mutations were studied using Real Time-PCR. RESULTS The MTHFR C677T mutation was detected in 58.2% of the patients. The Factor V Leiden mutation was detected in 5.5% of the patients. The MTHFR A1298C mutation was detected in 58.2%, The PAI mutation was detected in 74.5%, and the Factor 13 mutation was detected in 29% of the patients. Prothrombin G20210A mutation was not detected in any of the patients. Red blood cell (RBC) and Hct values were higher in Factor 13 mutant group; the Hgb and Htc values were higher in the MTHFR C677T mutant group. CONCLUSION The MTHFR C677T and Factor 13 mutations may be associated with high Hct and RBC, Hgb, and Htc values, respectively and coagulation tendency in patients with a history of thrombosis.
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Affiliation(s)
- Ozlem Oz
- Department of Medical Genetics, Harran University. Turkey
| | - Ataman Gonel
- Department of Medicinal Biochemistry, Harran University. Turkey
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113
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Janmohamed IK, Sondh RS, Ahmed H, Afzal MB, Tyson N, Harky A. Polycythaemia Vera and Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature. Heart Lung Circ 2021; 31:304-312. [PMID: 34794873 DOI: 10.1016/j.hlc.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/15/2021] [Accepted: 10/14/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Polycythaemia vera (PV) is a condition that may potentially put patients undergoing cardiac surgery at an increased risk of bleeding and thrombosis; however, there is currently a paucity of literature regarding the management of these patients. We aim to examine the literature in this systematic review to indicate the interventions that may be considered to minimise complications. METHODS We conducted a literature search using keywords and MeSH terms to identify articles discussing PV and cardiac surgery. The studies were identified and qualitatively analysed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. RESULTS In total, 10 case reports representing 11 patients were identified for this systematic review and were included in qualitative analysis. 63.6% of patients had preoperative intermittent phlebotomy, and the majority of patients received postoperative therapy that involved one antiplatelet and one anticoagulant. Generous perioperative fluid management, phlebotomy, preservation of core body temperature, early extubation, monitoring of myocardial ischaemia, infarction and vascular events, intense chest physiotherapy and patient mobilisation are important to consider to reduce the risk of complications arising from surgery. CONCLUSION These considerations should be systematically discussed in a multidisciplinary team, where the acute surgical need can be balanced appropriately against the risk of haemorrhage and thrombosis.
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Affiliation(s)
| | - Rajan Singh Sondh
- St George's Hospital Medical School, University of London, London, UK
| | - Hasan Ahmed
- Imperial College London, Department of Medicine, London, UK
| | | | - Nathan Tyson
- Nottingham University Hospitals, Department of Cardiac Surgery, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, UK.
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114
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Zaman MO, Kim K, Yousafzai OK, Umer M, Jones RG, Shah R, Kim B. Heart failure with reduced ejection fraction due topolycythemia vera. Oxf Med Case Reports 2021; 2021:omab104. [PMID: 34729202 PMCID: PMC8557432 DOI: 10.1093/omcr/omab104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/11/2021] [Accepted: 08/31/2021] [Indexed: 02/02/2023] Open
Abstract
Polycythemia vera is a rare hematological disorder that can cause heart failure with reduced ejection fraction from chronic micro-vascular ischemia. Appropriately recognizing the underlying cause of cardiomyopathy is essential to decrease morbidity and mortality. Patients can present with elevated troponin level and have patent epicardial coronary arteries on coronary angiogram, hence presenting a diagnostic challenge for health care professionals. Furthermore, the presentation can mimic myocarditis. Herein, we report a case of a 61-year-old female who presented with heart failure due to microvascular thrombotic complication associated with polycythemia vera. Laboratory investigation and coronary angiogram were inconclusive. A high degree of clinical suspicion and utilizing non-invasive techniques, such as cardiac imaging, can describe myocardial pathology and aid with the diagnosis.
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Affiliation(s)
- Muhammad Omer Zaman
- Department of Advanced Heart Failure and Pulmonary Hypertension, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Kevin Kim
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Osman K Yousafzai
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Muhammad Umer
- Department of Cardiac Diagnostic Imaging, St. Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Riley G Jones
- Department of Internal Medicine, University of Florida Health, Gainesville, FL 32608, USA
| | - Roshan Shah
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Bernard Kim
- Department of Advanced Heart Failure and Pulmonary Hypertension, Hackensack University Medical Center, Hackensack, NJ, USA
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115
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Hematocrit to hemoglobin ratio as a prognostic marker in polycythemia vera. Wien Klin Wochenschr 2021; 134:110-117. [PMID: 34738212 DOI: 10.1007/s00508-021-01967-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hematocrit to hemoglobin ratio (HHR) is frequently used in everyday practice to measure hemoconcentration; however, clinical associations of HHR in the context of polycythemia vera (PV) have not been investigated so far. PATIENTS AND METHODS We retrospectively assessed HHR at the time of diagnosis in 107 PV and 40 secondary polycythemia (SP) patients from three community hospitals. RESULTS Median HHR was higher in PV than in SP patients (3.131 vs. 2.975, p = 0.041). Among PV patients, higher HHR correlated with splenomegaly, higher total leukocyte and absolute granulocyte counts, higher red blood cell counts, lower hemoglobin, higher red blood cell distribution width, lower mean corpuscular hemoglobin and lower ferritin levels, whereas in SP patients higher HHR correlated with older age, female sex and lower hemoglobin (p < 0.050 for all analyses). Using the receiver operating curve analysis-defined cut-off points, higher HHR in PV was associated with a shorter time to thrombosis (hazard ratio-HR 5.20, p = 0.022) independently of high-risk disease status (HR 4.48, p = 0.034) and shorter overall survival (HR 6.69, p = 0.009) independently of leukocytosis (HR 4.48, P = 0.034) and the absence of aspirin use (HR 15.53, p < 0.001). CONCLUSION Higher HHR may represent iron deficiency and a stronger clonal myeloproliferation in PV and could provide additional prognostic information to the classical risk assessment.
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Thomas S, Krishnan A. Platelet Heterogeneity in Myeloproliferative Neoplasms. Arterioscler Thromb Vasc Biol 2021; 41:2661-2670. [PMID: 34615371 PMCID: PMC8551046 DOI: 10.1161/atvbaha.121.316373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
Myeloproliferative neoplasms (MPNs) are a group of malignant disorders of the bone marrow where a dysregulated balance between proliferation and differentiation gives rise to abnormal numbers of mature blood cells. MPNs encompass a spectrum of disease entities with progressively more severe clinical features, including complications with thrombosis and hemostasis and an increased propensity for transformation to acute myeloid leukemia. There is an unmet clinical need for markers of disease progression. Our understanding of the precise mechanisms that influence pathogenesis and disease progression has been limited by access to disease-specific cells as biosources. Here, we review the landscape of MPN pathology and present blood platelets as potential candidates for disease-specific understanding. We conclude with our recent work discovering progressive platelet heterogeneity by subtype in a large clinical cohort of patients with MPN.
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Affiliation(s)
- Sally Thomas
- Department of Oncology and Metabolism, University of Sheffield and Department of Haematology, Royal Hallamshire Hospital, United Kingdom (S.T.)
| | - Anandi Krishnan
- Department of Pathology, Stanford University School of Medicine, CA (A.K.)
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Sharda AV, Bogue T, Barr A, Mendez LM, Flaumenhaft R, Zwicker JI. Circulating Protein Disulfide Isomerase Is Associated with Increased Risk of Thrombosis in JAK2-Mutated Myeloproliferative Neoplasms. Clin Cancer Res 2021; 27:5708-5717. [PMID: 34400417 DOI: 10.1158/1078-0432.ccr-21-1140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/07/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Thromboembolic events (TE) are the most common complications of myeloproliferative neoplasms (MPN). Clinical parameters, including patient age and mutation status, are used to risk-stratify patients with MPN, but a true biomarker of TE risk is lacking. Protein disulfide isomerase (PDI), an endoplasmic reticulum protein vital for protein folding, also possesses essential extracellular functions, including regulation of thrombus formation. Pharmacologic PDI inhibition prevents thrombus formation, but whether pathologic increases in PDI increase TE risk remains unknown. EXPERIMENTAL DESIGN We evaluated the association of plasma PDI levels and risk of TE in a cohort of patients with MPN with established diagnosis of polycythemia vera (PV) or essential thrombocythemia (ET), compared with healthy controls. Plasma PDI was measured at enrollment and subjects followed prospectively for development of TE. RESULTS A subset of patients, primarily those with JAK2-mutated MPN, had significantly elevated plasma PDI levels as compared with controls. Plasma PDI was functionally active. There was no association between PDI levels and clinical parameters typically used to risk-stratify patients with MPN. The risk of TE was 8-fold greater in those with PDI levels above 2.5 ng/mL. Circulating endothelial cells from JAK2-mutated MPN patients, but not platelets, demonstrated augmented PDI release, suggesting endothelial activation as a source of increased plasma PDI in MPN. CONCLUSIONS The observed association between plasma PDI levels and increased risk of TE in patients with JAK2-mutated MPN has both prognostic and therapeutic implications.
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Affiliation(s)
- Anish V Sharda
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical School and Harvard Medical School, Boston, Massachusetts
| | - Thomas Bogue
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Alexandra Barr
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical School and Harvard Medical School, Boston, Massachusetts
| | - Lourdes M Mendez
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Robert Flaumenhaft
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical School and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey I Zwicker
- Division of Hematology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts. .,Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical School and Harvard Medical School, Boston, Massachusetts
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Stivala S, Meyer SC. Recent Advances in Molecular Diagnostics and Targeted Therapy of Myeloproliferative Neoplasms. Cancers (Basel) 2021; 13:cancers13205035. [PMID: 34680185 PMCID: PMC8534234 DOI: 10.3390/cancers13205035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/24/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Myeloproliferative neoplasms (MPN) are clonal hematologic malignancies with dysregulated myeloid blood cell production driven by JAK2, calreticulin, and MPL gene mutations. Technological advances have revealed a heterogeneous genomic landscape with additional mutations mainly in epigenetic regulators and splicing factors, which are of diagnostic and prognostic value and may inform treatment decisions. Thus, genetic testing has become an integral part of the state-of-the-art work-up for MPN. The finding that JAK2, CALR, and MPL mutations activate JAK2 signaling has promoted the development of targeted JAK2 inhibitor therapies. However, their disease-modifying potential remains limited and investigations of additional molecular vulnerabilities in MPN are imperative to advance the development of new therapeutic options. Here, we summarize the current insights into the genetic basis of MPN, its use as diagnostic and prognostic tool in clinical settings, and recent advances in targeted therapies for MPN. Abstract Somatic mutations in JAK2, calreticulin, and MPL genes drive myeloproliferative neoplasms (MPN), and recent technological advances have revealed a heterogeneous genomic landscape with additional mutations in MPN. These mainly affect genes involved in epigenetic regulation and splicing and are of diagnostic and prognostic value, predicting the risk of progression and informing decisions on therapeutic management. Thus, genetic testing has become an integral part of the current state-of-the-art laboratory work-up for MPN patients and has been implemented in current guidelines for disease classification, tools for prognostic risk assessment, and recommendations for therapy. The finding that JAK2, CALR, and MPL driver mutations activate JAK2 signaling has provided a rational basis for the development of targeted JAK2 inhibitor therapies and has fueled their translation into clinical practice. However, the disease-modifying potential of JAK2 inhibitors remains limited and is further impeded by loss of therapeutic responses in a substantial proportion of patients over time. Therefore, the investigation of additional molecular vulnerabilities involved in MPN pathogenesis is imperative to advance the development of new therapeutic options. Combination of novel compounds with JAK2 inhibitors are of specific interest to enhance therapeutic efficacy of molecularly targeted treatment approaches. Here, we summarize the current insights into the genetic basis of MPN, its use as a diagnostic and prognostic tool in clinical settings, and the most recent advances in targeted therapies for MPN.
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Affiliation(s)
- Simona Stivala
- Department of Biomedicine, University Hospital Basel and University of Basel, 4031 Basel, Switzerland;
| | - Sara C. Meyer
- Department of Biomedicine, University Hospital Basel and University of Basel, 4031 Basel, Switzerland;
- Division of Hematology, University Hospital Basel, 4031 Basel, Switzerland
- Correspondence: ; Tel.: +41-61-556-5965; Fax: +41-61-265-4568
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Abu-Zeinah G, Silver RT, Abu-Zeinah K, Scandura JM. Normal life expectancy for polycythemia vera (PV) patients is possible. Leukemia 2021; 36:569-572. [PMID: 34625712 DOI: 10.1038/s41375-021-01447-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Ghaith Abu-Zeinah
- Myeloproliferative Neoplasms (MPN) Center, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY, USA.
| | - Richard T Silver
- Myeloproliferative Neoplasms (MPN) Center, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY, USA
| | | | - Joseph M Scandura
- Myeloproliferative Neoplasms (MPN) Center, Division of Hematology and Oncology, Weill Cornell Medicine, New York, NY, USA
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Barbui T, De Stefano V. Philadelphia-Negative Myeloproliferative Neoplasms Around the COVID-19 Pandemic. Curr Hematol Malig Rep 2021; 16:455-463. [PMID: 34586561 PMCID: PMC8480119 DOI: 10.1007/s11899-021-00647-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) is associated with a high rate of respiratory failure, thromboembolism, bleeding, and death. Patients with myeloproliferative neoplasms (MPNs) are prone to both thrombosis and bleeding, calling for special care during COVID-19. We reviewed the clinical features of MPN patients with COVID-19, suggesting guidance for treatment. RECENT FINDINGS One study by the European LeukemiaNet collected 175 MPN patients with COVID-19 during the first wave of the pandemic, from February to May 2020. Patients with primary myelofibrosis (PMF) were at higher risk of mortality (48%) in comparison with essential thrombocythemia (ET) (25%) and polycythemia vera (19%); the risk of death was higher in those patients who abruptly discontinued ruxolitinib. In patients followed at home, in regular wards, or in ICU, the thrombosis rate was 1.0%, 2.8%, and 18.4%, respectively. Independent risk factors for thrombosis were ET phenotype, transfer to ICU, and neutrophil/lymphocyte ratio; major bleeding occurred in 4.3% of patients, particularly those with PMF. MPN patients with non-severe COVID-19 treated at home should continue their primary or secondary antithrombotic prophylaxis with aspirin or oral anticoagulants. In the case of hospitalization, patients assuming aspirin should add low molecular weight heparin (LMWH) at standard doses. In contrast, LMWH at intermediate/therapeutic doses should replace oral anticoagulants prescribed for atrial fibrillation or previous venous thromboembolism. Intermediate/high doses of LMWH can also be considered in ICU patients with ET, particularly in the case of a rapid decline in the number of platelets and progressive respiratory failure.
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MESH Headings
- Anticoagulants/therapeutic use
- COVID-19/complications
- COVID-19/diagnosis
- COVID-19/epidemiology
- COVID-19/therapy
- Hemorrhage/epidemiology
- Heparin, Low-Molecular-Weight/therapeutic use
- Humans
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/complications
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/diagnosis
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/epidemiology
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/therapy
- Myeloproliferative Disorders/complications
- Myeloproliferative Disorders/diagnosis
- Myeloproliferative Disorders/epidemiology
- Myeloproliferative Disorders/therapy
- Pandemics
- SARS-CoV-2/physiology
- Thrombosis/epidemiology
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Piazza OMS n. 1, 24127 Bergamo, Italy
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
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Kundal SV, Lee J, Khalid M, Shani J, Hollander GM, Ping Z, Maung C, Shetty VS. Lemierre's Syndrome in an Elderly Female Patient with Polycythemia Vera: Does Polycythemia Vera Predispose to Lemierre's Syndrome? AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933587. [PMID: 34587148 PMCID: PMC8488186 DOI: 10.12659/ajcr.933587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 66-year-old
Final Diagnosis: Lemierre’s syndrome
Symptoms: Chills • neck pain • odynophagia • rigors • trismus
Medication: —
Clinical Procedure: Computed tomography
Specialty: Cardiology • Hematology • Infectious Diseases • General and Internal Medicine
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Affiliation(s)
- Sanchit V Kundal
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jasmine Lee
- Department of Internal Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Mazin Khalid
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jacob Shani
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Zhou Ping
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Chun Maung
- Department of Internal Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Vijay S Shetty
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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Coltro G, Loscocco GG, Vannucchi AM. Classical Philadelphia-negative myeloproliferative neoplasms (MPNs): A continuum of different disease entities. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:1-69. [PMID: 34756241 DOI: 10.1016/bs.ircmb.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Classical Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells and close pathobiologic and clinical features. According to the 2016 World Health Organization (WHO) classification, MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision aimed in particular at strengthening the distinction between masked PV and JAK2-mutated ET, and between prefibrotic/early (pre-PMF) and overt PMF. Clinical manifestations in MPNs include constitutional symptoms, microvascular disorders, thrombosis and bleeding, splenomegaly secondary to extramedullary hematopoiesis, cytopenia-related symptoms, and progression to overt MF and acute leukemia. A dysregulation of the JAK/STAT pathway is the unifying mechanistic hallmark of MPNs, and is guided by somatic mutations in driver genes including JAK2, CALR and MPL. Additional mutations in myeloid neoplasm-associated genes have been also identified, with established prognostic relevance, particularly in PMF. Prognostication of MPN patients relies on disease-specific clinical models. The increasing knowledge of MPN biology led to the development of integrated clinical and molecular prognostic scores that allow a more refined stratification. Recently, the therapeutic landscape of MPNs has been revolutionized by the introduction of potent, selective JAK inhibitors (ruxolitinib, fedratinib), that proved effective in controlling disease-related symptoms and splenomegaly, yet leaving unmet critical needs, owing the lack of disease-modifying activity. In this review, we will deal with molecular, clinical, and therapeutic aspects of the three classical MPNs aiming at highlighting either shared characteristics, that overall define a continuum within a single disease family, and uniqueness, at the same time.
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Affiliation(s)
- Giacomo Coltro
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe G Loscocco
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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Philadelphia-Negative Chronic Myeloproliferative Neoplasms during the COVID-19 Pandemic: Challenges and Future Scenarios. Cancers (Basel) 2021; 13:cancers13194750. [PMID: 34638236 PMCID: PMC8507529 DOI: 10.3390/cancers13194750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 09/17/2021] [Indexed: 12/30/2022] Open
Abstract
An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) started in December 2019 in China and then become pandemic in February 2020. Several publications investigated the possible increased rate of COVID-19 infection in hematological malignancies. Based on the published data, strategies for the management of chronic Philadelphia-negative chronic myeloproliferative neoplasms (MPNs) are provided. The risk of severe COVID-19 seems high in MPN, particularly in patients with essential thrombocythemia, but not negligible in myelofibrosis. MPN patients are at high risk of both thrombotic and hemorrhagic complications and this must be accounted in the case of COVID-19 deciding on a case-by-case basis. There are currently no data to suggest that hydroxyurea or interferon may influence the risk or severity of COVID-19 infection. Conversely, while the immunosuppressive activity of ruxolitinib might pose increased risk of infection, its abrupt discontinuation during COVID-19 syndrome is associated with worse outcome. All MPN patients should receive vaccine against COVID-19; reassuring data are available on efficacy of mRNA vaccines in MPNs.
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Dang S, Mady LJ, Tarfa R, Li JC, Bontempo F, Chibisov I, Kubik MW, Solari MG, Sridharan S. Head and Neck Reconstruction in Patients with Polycythemia Vera: Case Series and Literature Review. J Hand Microsurg 2021; 15:67-74. [PMID: 36761055 PMCID: PMC9904977 DOI: 10.1055/s-0041-1734398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background Polycythemia vera (PV) is a myeloproliferative disease with overproduction of erythrocytes, leukocytes, and platelets causing an increased risk of both thrombosis and hemorrhage. There are limited reports and no established guidelines for managing such patients undergoing reconstructive surgery. Methods We present four patients with PV and head and neck cancer who required reconstruction after resection and provide a review of the current literature. Results Preoperatively, patients on cytoreductive therapy continued with their treatment throughout their hospital course and had hematologic parameters normalized with phlebotomy or transfusions if needed. Two patients who underwent free flap surgery (cases 1 and 2) had postoperative courses complicated by hematoma formation and persistent anemia, requiring multiple transfusions. Cases 3 and 4 (JAK2+ PV and JAK2- PV, respectively) underwent locoregional flap without postoperative complications. Conclusion Concomitant presentation of PV and head and neck cancer is uncommon and presents unique challenges for the reconstructive surgeon. Overall, we recommend that patients should have hematologic parameters optimized prior to surgery, continue ruxolitinib or hydroxyurea, and hold antiplatelet/anticoagulation per established department protocols. It is essential to engage a multidisciplinary team involving hematology, head and neck and reconstructive surgery, anesthesia, and critical care to develop a standardized approach for managing this unique subset of patients.
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Affiliation(s)
- Sophia Dang
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Leila J. Mady
- Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Rahilla Tarfa
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Jonathan C. Li
- Combined Internal Medicine–Pediatrics Residency Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Frank Bontempo
- Department of Internal Medicine, The Institute of Transfusion Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Irina Chibisov
- Department of Internal Medicine, The Institute of Transfusion Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Mark W. Kubik
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States,Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Mario G. Solari
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States,Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Shaum Sridharan
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States,Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States,Address for correspondence Shaum Sridharan, MD Department of Otolaryngology–Head and Neck Surgery and Department of Plastic Surgery, Eye and Ear Institute, Suite 500203 Lothrop Street, Pittsburgh, PA 15213United States
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Huang YC, Wang CY. Telomere Attrition and Clonal Hematopoiesis of Indeterminate Potential in Cardiovascular Disease. Int J Mol Sci 2021; 22:9867. [PMID: 34576030 PMCID: PMC8467562 DOI: 10.3390/ijms22189867] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/31/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022] Open
Abstract
Clinical evidence suggests that conventional cardiovascular disease (CVD) risk factors cannot explain all CVD incidences. Recent studies have shown that telomere attrition, clonal hematopoiesis of indeterminate potential (CHIP), and atherosclerosis (telomere-CHIP-atherosclerosis, TCA) evolve to play a crucial role in CVD. Telomere dynamics and telomerase have an important relationship with age-related CVD. Telomere attrition is associated with CHIP. CHIP is commonly observed in elderly patients. It is characterized by an increase in blood cell clones with somatic mutations, resulting in an increased risk of hematological cancer and atherosclerotic CVD. The most common gene mutations are DNA methyltransferase 3 alpha (DNMT3A), Tet methylcytosine dioxygenase 2 (TET2), and additional sex combs-like 1 (ASXL1). Telomeres, CHIP, and atherosclerosis increase chronic inflammation and proinflammatory cytokine expression. Currently, their epidemiology and detailed mechanisms related to the TCA axis remain incompletely understood. In this article, we reviewed recent research results regarding the development of telomeres and CHIP and their relationship with atherosclerotic CVD.
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Affiliation(s)
- Yi-Chun Huang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City 33305, Taiwan;
| | - Chao-Yung Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City 33305, Taiwan;
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan 35053, Taiwan
- Department of Medical Science, National Tsing Hua University, Hsinchu 30013, Taiwan
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Burattini M, Falsetti L, Potente E, Rinaldi C, Bartolini M, Buratti L, Silvestrini M, Viticchi G. Ischemic stroke as a presenting manifestation of polycythemia vera: a narrative review. Rev Neurosci 2021; 33:303-311. [PMID: 34508650 DOI: 10.1515/revneuro-2021-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/19/2021] [Indexed: 11/15/2022]
Abstract
Polycythemia vera (PV) is a myeloproliferative disorder associated with an increased risk of cerebrovascular diseases. In this narrative review, we aimed to analyze the relationships between acute ischemic stroke and PV. We conducted a PubMed/Medline and Web of Sciences Database search using MeSH major terms. We found 75 articles and finally considered 12 case reports and 11 cohort studies. The ischemic stroke resulted as the first manifestation of PV in up to 16.2% of cases; the cumulative rate of cerebrovascular events was up to 5.5 per 100 persons per year and stroke accounted for 8.8% of all PV-related deaths; age, mutations, and a previous history of thrombosis were the main risk factors. The best approach to reduce stroke recurrence risk is unclear, even if some evidence suggests a potential role of lowering hematocrit below 45%. Ischemic stroke represents one of the most common PV manifestations but, despite their relationship, patients with both diseases have a very heterogeneous clinical course and management. PV-related strokes often remain underdiagnosed, especially for the low prevalence of PV. An early diagnosis could lead to prompt treatment with phlebotomy, cytoreduction, and low-dose aspirin to decrease the risk of recurrences. Clinicians should be aware of PV as a risk factor for stroke when approaching the differential diagnosis of cryptogenic strokes. An early diagnosis could positively influence patients' management and clinical outcomes. Further studies are required to evaluate the role of PV treatments in the prevention of cerebrovascular disease.
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Affiliation(s)
- Marco Burattini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Ospedali Riuniti Ancona, via Conca n.1, 60020, Ancona, Italy
| | - Eleonora Potente
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Claudia Rinaldi
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
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Cao YY, Cao J, Bi ZJ, Xu SB, Liu CC. Hemorrhagic transformation after acute ischemic stroke caused by polycythemia vera: Report of two case. World J Clin Cases 2021; 9:7551-7557. [PMID: 34616825 PMCID: PMC8464450 DOI: 10.12998/wjcc.v9.i25.7551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Polycythemia vera (PV) is a chronic myeloproliferative disorder characterized by an increase in red blood cells in the peripheral blood. Previous work has reported the occurrence of thrombosis or hemorrhage arising in the cerebral vasculature secondary to PV. However, hemorrhagic transformation after PV-associated acute ischemic stroke has not been previously described.
CASE SUMMARY We herein present two cases of PV where hemorrhagic transformation occurred after an acute ischemic stroke. Case 1 was a 57-year-old woman with a history of hypertension who was admitted for left-sided weakness. Case 2 was a 68-year-old man who was admitted for a 10-d sudden left arm weakness. Imaging examinations for the two patients revealed hemorrhagic transformation after acute ischemic stroke. Both patients had JAK-2-V617F mutation and received antiplatelet therapy. Both of them had a good prognosis during the follow-up.
CONCLUSION This report suggested that hemorrhagic transformation may occur in acute ischemic stroke caused by PV. Antiplatelet drugs do not seem to influence the long-term outcomes in such patients. Future research should focus on establishing a standard antiplatelet treatment strategy for this condition.
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Affiliation(s)
- Ya-Yun Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Jie Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Zhua-Jin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Sha-Bei Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Chen-Chen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
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How J, Hobbs G. Management Issues and Controversies in Low-Risk Patients with Essential Thrombocythemia and Polycythemia Vera. Curr Hematol Malig Rep 2021; 16:473-482. [PMID: 34478054 DOI: 10.1007/s11899-021-00649-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Essential thrombocythemia (ET) and polycythemia vera (PV) are the most common myeloproliferative neoplasms (MPNs). Treatment of ET and PV is based on the risk for subsequent thrombosis. High-risk patients, defined as older than 60, JAK2 V617F-positive patients, or patients with a history of prior thrombosis, merit cytoreduction to control blood counts, whereas a watchful waiting paradigm is utilized in low-risk patients. However, low-risk patients have a host of other specific management issues that arise during their disease course. This review will discuss the most common management issues specific to the care of low-risk patients, including anti-platelet therapy dosing, pregnancy, and indications for early cytoreduction. RECENT FINDINGS Although low-dose aspirin is well established in PV, its indications and dosing regimens are less clear in ET. Recent evidence has supported twice daily low-dose aspirin in ET and observation alone in very low-risk ET patients. Pregnancy is not contraindicated in MPNs, and we recommend aspirin throughout pregnancy with consideration for prophylactic postpartum anticoagulation. High phlebotomy needs, symptom burden, and extreme thrombocytosis are common reasons for initiation of cytoreduction in low-risk patients, although we typically do not start cytoreduction for an isolated high platelet count alone. Recent data has also demonstrated a potential disease-modifying effect of interferons in MPNs, with some experts now advocating the early use of interferon in low-risk patients, although more mature data is needed before practice guidelines change. We evaluate the literature to inform clinical decision-making regarding these controversies, including most recent data that has challenged the "watchful waiting" paradigm. Our discussion provides guidance on common clinical scenarios seen in low-risk ET and PV patients, who face a myriad of complex management decisions in their care.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson, Office 138, Boston, MA, 02114, USA.,Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Gabriela Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson, Office 138, Boston, MA, 02114, USA.
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Kiem D, Wagner S, Magnes T, Egle A, Greil R, Melchardt T. The Role of Neutrophilic Granulocytes in Philadelphia Chromosome Negative Myeloproliferative Neoplasms. Int J Mol Sci 2021; 22:ijms22179555. [PMID: 34502471 PMCID: PMC8431305 DOI: 10.3390/ijms22179555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022] Open
Abstract
Philadelphia chromosome negative myeloproliferative neoplasms (MPN) are composed of polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF). The clinical picture is determined by constitutional symptoms and complications, including arterial and venous thromboembolic or hemorrhagic events. MPNs are characterized by mutations in JAK2, MPL, or CALR, with additional mutations leading to an expansion of myeloid cell lineages and, in PMF, to marrow fibrosis and cytopenias. Chronic inflammation impacting the initiation and expansion of disease in a major way has been described. Neutrophilic granulocytes play a major role in the pathogenesis of thromboembolic events via the secretion of inflammatory markers, as well as via interaction with thrombocytes and the endothelium. In this review, we discuss the molecular biology underlying myeloproliferative neoplasms and point out the central role of leukocytosis and, specifically, neutrophilic granulocytes in this group of disorders.
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Affiliation(s)
- Dominik Kiem
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
| | - Sandro Wagner
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
| | - Teresa Magnes
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
| | - Alexander Egle
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
- Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), 5020 Salzburg, Austria
| | - Richard Greil
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
- Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), 5020 Salzburg, Austria
| | - Thomas Melchardt
- Oncologic Center, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Paracelsus Medical University, 5020 Salzburg, Austria; (D.K.); (S.W.); (T.M.); (A.E.); (R.G.)
- Cancer Cluster Salzburg, 5020 Salzburg, Austria
- Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), 5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-57255-25801
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Chattopadhyay S, Ram R, Sarkar A, Dutta G, Chakraborty S. Reagent-free hemoglobin estimation on a spinning disc. Microchem J 2021. [DOI: 10.1016/j.microc.2021.106463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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NK Cells in Myeloproliferative Neoplasms (MPN). Cancers (Basel) 2021; 13:cancers13174400. [PMID: 34503210 PMCID: PMC8431564 DOI: 10.3390/cancers13174400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary NK cells are important innate immune effectors that contribute substantially to tumor control, however the role of NK cells in haematological cancers is not as well understood. The aim of this review is to highlight the importance of the role of NK cells in the management of Ph+ Myeloproliferative Neoplasms, and emphasize the need and possible benefits of a more in-depth investigation into their role in classical MPNs and show potential strategies to harness the anti-tumoral capacities of NK cells. Abstract Myeloproliferative neoplasms (MPNs) comprise a heterogenous group of hematologic neoplasms which are divided into Philadelphia positive (Ph+), and Philadelphia negative (Ph−) or classical MPNs. A variety of immunological factors including inflammatory, as well as immunomodulatory processes, closely interact with the disease phenotypes in MPNs. NK cells are important innate immune effectors and substantially contribute to tumor control. Changes to the absolute and proportionate numbers of NK cell, as well as phenotypical and functional alterations are seen in MPNs. In addition to the disease itself, a variety of therapeutic options in MPNs may modify NK cell characteristics. Reports of suppressive effects of MPN treatment strategies on NK cell activity have led to intensive investigations into the respective compounds, to elucidate the possible negative effects of MPN therapy on control of the leukemic clones. We hereby review the available literature on NK cells in Ph+ and Ph− MPNs and summarize today’s knowledge on disease-related alterations in this cell compartment with particular focus on known therapy-associated changes. Furthermore, we critically evaluate conflicting data with possible implications for future projects. We also aim to highlight the relevance of full NK cell functionality for disease control in MPNs and the importance of considering specific changes related to therapy in order to avoid suppressive effects on immune surveillance.
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Shalaby K, Correia Lima J, Szulawski R. Subdural Hemorrhage Due to Acquired Von Willebrand Syndrome in a Patient With Polycythemia Vera. Cureus 2021; 13:e16625. [PMID: 34458036 PMCID: PMC8384727 DOI: 10.7759/cureus.16625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/05/2022] Open
Abstract
Polycythemia vera (PV) is a chronic myeloproliferative neoplasm associated with thrombosis. A 48-year-old female with PV presented with right eye pain following a low-impact head trauma. She consumed aspirin for analgesia and took preparations of Chinese herbs. CT head revealed right-sided subdural hematoma. She had reduced Von Willebrand activity to 26%. Direct angiographic imaging showed an aneurysm arising from a right middle cerebral atery (MCA) branch. The patient was given 1-deamino-8-D-arginine vasopressin (DDAVP) prior to the craniotomy. Intra-operative examination revealed that the aneurysm-like structure was a small grape-like structure of the fibrinous part of the subdural membrane that had formed from the subdural hematoma. Acquired von Willebrand syndrome (AVWS) is an important risk factor for bleeding in PV. DDAVP may be useful to increase levels of Von Willebrand Factor (VWF) and decrease the risk of bleeding perioperatively. Exogenous substances such as ginseng should be investigated as possible contributors to bleeding tendency and discontinued.
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Affiliation(s)
- Khalid Shalaby
- Internal Medicine, University of Connecticut Health, Farmington, USA
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Aylan Gelen S, Sarper N, Zengin E, Tahsin İ, Azizoğlu M. Clinical Characteristics of Pediatric Patients with Congenital Erythrocytosis: A Single-Center Study. Indian J Hematol Blood Transfus 2021; 38:366-372. [PMID: 35496967 PMCID: PMC9001768 DOI: 10.1007/s12288-021-01484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/19/2021] [Indexed: 11/29/2022] Open
Abstract
Although congenital erythrocytosis (CE), an inherited disorder, impairs pediatric quality of life, physicians often overlook high hemoglobin (Hgb) levels and its symptoms due to lack of knowledge of age-adjusted pediatric Hgb levels and CE's rarity. In a retrospective, single-center study, data from hospital records of pediatric patients diagnosed with CE were evaluated. Twenty-six patients from 25 families (80.8% male) had been diagnosed with CE in 20 years, at a mean age of 14.9 ± 2.8 years (8.3-17.8) and with a mean Hgb level of 17.36 ± 1.44 g/dL (14.63-22.1). No serum erythropoietin levels exceeded the reference levels. Although the most common symptom was headache (85%), 38% of patients presented with at least one gastrointestinal symptom (e.g., nausea, vomiting, abdominal pain, and rectal bleeding), and 54% exhibited plethora. No patient had leukocytosis, thrombocytosis, JAK2 mutation; capillary oxygen saturation, venous blood gas analysis, and Hgb electrophoresis revealed no abnormalities. While 34.6% of patients had family histories of CE, 42.3% had 15-45-year-old relatives who had experienced myocardial infarction, stroke, and/or sudden death. Aspirin was routinely prescribed, and phlebotomy was performed when hyperviscosity symptoms were present. To detect CE, physicians should consider age-adjusted normal Hgb levels in children. Pediatric patients with CE may also present with gastrointestinal symptoms. Although no thrombotic episode occurred among the patients, their family histories included life-threatening thrombotic episodes, even in adolescents.
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Affiliation(s)
- Sema Aylan Gelen
- Division of Pediatric Hematology, Department of Pediatrics, Kocaeli University, Umuttepe, 41380 Kocaeli, Turkey
| | - Nazan Sarper
- Division of Pediatric Hematology, Department of Pediatrics, Kocaeli University, Umuttepe, 41380 Kocaeli, Turkey
| | - Emine Zengin
- Division of Pediatric Hematology, Department of Pediatrics, Kocaeli University, Umuttepe, 41380 Kocaeli, Turkey
| | - İnci Tahsin
- Division of Pediatric Hematology, Department of Pediatrics, Kocaeli University, Umuttepe, 41380 Kocaeli, Turkey
| | - Mehmet Azizoğlu
- Division of Pediatric Hematology, Department of Pediatrics, Kocaeli University, Umuttepe, 41380 Kocaeli, Turkey
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Patino-Alonso C, Gómez-Sánchez M, Hernández-Rivas JM, González-Porras JR, Bastida-Bermejo JM, Martín AA, Rodríguez-Sánchez E, Recio-Rodríguez JI, González-Sánchez J, Maderuelo-Fernández JA, García-Ortiz L, Gómez-Marcos MA. Vascular target organ damage in patients with Philadelphia negative myeloproliferative syndrome: A propensity score analysis. Med Clin (Barc) 2021; 158:503-508. [PMID: 34399987 DOI: 10.1016/j.medcli.2021.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess whether subjects with Philadelphia negative myeloproliferative neoplasms (Ph-MPNs) show differences in the presence of vascular, cardiac or renal target organ damage (TOD) and other vascular function parameters as compared to individuals without this condition. METHODS An observational study was conducted. Fifty-seven subjects diagnosed with Ph-MPNs used as cases and 114 subjects without Ph-MPNs as controls. We matched the subjects with and without Ph-MPNs using the propensity scores in a 1:2 ratio using the variables gender, type 2 diabetes mellitus, high blood pressure, hyperlipidaemia and smoking. Vascular, cardiac and renal TOD were established according to the criteria of the European Society of Hypertension and Cardiology guidelines. Arterial stiffness was also assessed using the cardio-ankle vascular index (CAVI). RESULTS Mean age was 63.50±11.70 and 62.90±8.32 years in subjects with and without Ph-MPNs, 32 females (56%) in the first group and 62 (54%) in the second. Subjects with Ph-MPNs have a higher percentage of carotid injury than subjects without Ph-MPNs (35.1% vs. 21.1%) and higher albumin/creatinine ratio. In the logistic regression analysis, subjects with Ph-MPNs had an OR=2.382 (IC95% 1.066-5.323) for carotid injury versus those without haematological disease. CONCLUSIONS Subjects with Ph-MPNs have twice the risk of by carotid injury than those without haematological disease.
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Affiliation(s)
- Carmen Patino-Alonso
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Statistics, University of Salamanca, Salamanca, Spain.
| | - Marta Gómez-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain
| | - Jesús M Hernández-Rivas
- Department of Medicine, University of Salamanca, Salamanca, Spain; Department of Hematology, Hospital Clínico Universitario, Salamanca, Spain; Center of Cancer Research, Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | - José R González-Porras
- Department of Hematology, Hospital Clínico Universitario, Salamanca, Spain; Center of Cancer Research, Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | - José M Bastida-Bermejo
- Department of Hematology, Hospital Clínico Universitario, Salamanca, Spain; Center of Cancer Research, Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Ana-Africa Martín
- Department of Hematology, Hospital Clínico Universitario, Salamanca, Spain; Center of Cancer Research, Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Emiliano Rodríguez-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Medicine, University of Salamanca, Salamanca, Spain
| | - José I Recio-Rodríguez
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Nurse and Physiotherapy, University of Salamanca, Salamanca, Spain
| | - Jesús González-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Nurse and Physiotherapy, University of Salamanca, Salamanca, Spain
| | - José A Maderuelo-Fernández
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain
| | - Luis García-Ortiz
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - Manuel A Gómez-Marcos
- Primary Care Research Unit of Salamanca (APISAL), Biomedical Research Institute of Salamanca (IBSAL), 37005 Salamanca, Spain; Department of Medicine, University of Salamanca, Salamanca, Spain
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Improving the investigative approach to polycythaemia vera: a critical assessment of current evidence and vision for the future. LANCET HAEMATOLOGY 2021; 8:e605-e612. [PMID: 34329580 DOI: 10.1016/s2352-3026(21)00171-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
Polycythaemia vera is a challenging disease to study given its low prevalence and prolonged time-to-event for important clinical endpoints such as thrombosis, progression, and mortality. Although researchers in this space often rise to meet these challenges, there is considerable room for improvement in the analysis of retrospective data, the development of risk-stratification tools, and the design of randomised controlled trials. In this Viewpoint, we review the evidence behind the contemporary approach to risk stratification and treatment of polycythaemia vera. Frameworks for using data more efficiently, constructing more nuanced prognostic models, and overcoming challenges in clinical trial design are discussed.
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Balagopal K, Mathew A, Koshy AG, Jacob JP. Polycythemia Vera Presenting as Hemorrhagic Stroke. J Neurosci Rural Pract 2021; 12:601-602. [PMID: 34295120 PMCID: PMC8289499 DOI: 10.1055/s-0041-1729478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Patients with polycythemia vera are at high risk for vaso-occlusive events including cerebral ischemia and hemorrhage. Cerebral ischemic events are due to increased blood viscosity and platelet activation within the central nervous system arterial vessels. We present a case of a 65-year-old woman who presented to the emergency department with seizures followed by left-sided weakness. Hematologic investigations revealed a hyperviscous state, and magnetic resonance imaging (MRI) was consistent with bilateral hemorrhagic infarction. Genetic studies were positive for polycythemia vera mutation. Symptoms improved with phlebotomy and antiplatelet agents. Through this case, we aim to highlight polycythemia vera as a cause of hemorrhagic stroke and the importance of blood counts in the routine evaluation of the same.
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Affiliation(s)
- Krishnan Balagopal
- Department of Neurology, MOSC Medical College, Kolenchery, Kochi, Kerala, India
| | - Aju Mathew
- Department of Hemato-Oncology, MOSC Medical College, Kolenchery, Kochi, Kerala, India
| | - Ansa Grace Koshy
- Department of Neurology, MOSC Medical College, Kolenchery, Kochi, Kerala, India
| | - Jerin Peter Jacob
- Department of Neurology, MOSC Medical College, Kolenchery, Kochi, Kerala, India
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Melikyan AL, Subortseva IN, Gilyazitdinova EA, Koloshejnova TI, Shashkina KS, Egorova EK, Kovrigina AM, Sudarikov AB, Gorgidze LA. Thrombosis in patients with myeloproliferative neoplasms. Case report. TERAPEVT ARKH 2021; 93:800-804. [DOI: 10.26442/00403660.2021.07.200925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
Thrombotic complications are the most significant factors determining the prognosis in myeloproliferative neoplasms. Markers for assessing the risk of thrombosis are the number of leukocytes, platelets, hemoglobin level, hematocrit, age, molecular status, history of thrombosis, obesity, arterial hypertension, hyperlipidemia, hereditary or acquired thrombophilia. The pathogenesis of thrombosis in patients with myeloproliferative neoplasms is complex and multifactorial. In most cases, the etiological factor remains unknown. Currently, antiplatelet and anticoagulant therapy is carried out on an individual basis. The algorithm for primary and secondary (after thrombosis) prevention requires development and testing. We present a clinical case of repeated arterial and venous thrombotic complications in a patient with primary myelofibrosis.
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138
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Clinical insights into the origins of thrombosis in myeloproliferative neoplasms. Blood 2021; 137:1145-1153. [PMID: 33237986 DOI: 10.1182/blood.2020008043] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs), polycythemia vera, essential thrombocythemia, and primary myelofibrosis, are hematopoietic stem cell disorders that are defined by activating mutations in signal transduction pathways and are characterized clinically by the overproduction of platelets, red blood cells, and neutrophils, significant burden of disease-specific symptoms, and high rates of vascular events. The focus of this review is to critically reevaluate the clinical burden of thrombosis in MPNs, to review the clinical associations among clonal hematopoiesis, JAK2V617F burden, inflammation, and thrombosis, and to provide insights into novel primary and secondary thrombosis-prevention strategies.
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Barosi G, Rosti V, Massa M, Campanelli R, Villani L, Catarsi P, Carolei A, Abbà C, Lodigiani C, Primignani M, Gregato G, Bertolini F, Magrini U, Gale RP. Clonal Megakaryocyte Dysplasia with Normal Blood Values Is a Distinct Myeloproliferative Neoplasm. Acta Haematol 2021; 145:30-37. [PMID: 34280924 DOI: 10.1159/000517207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In 1991, we reported 18 persons with a clinical-pathologic entity and termed atypical myeloproliferative disorder because they did not meet the contemporary diagnostic criteria for a myeloproliferative neoplasm. We sought to gain further knowledge on this disease entity. METHODS This retrospective cohort study included consecutive subjects registered in the database of the Center for the Study of Myelofibrosis in Pavia, Italy, from 1998 to 2020 (June), and diagnosed with atypical myeloproliferative disorder according to our adjudicated criteria. We studied clinical, histological, cytogenetic, and molecular covariates and risks of thrombosis, disease progression, and death. Data were compared with those of concurrent subjects with prefibrotic myelofibrosis. RESULTS Fifteen new subjects with atypical myeloproliferative disorder were identified. Seven were male. Median age was 50 years (IQR, 41-54 years). Thirteen were diagnosed with a synchronous symptomatic or incidentally detected thrombotic event. The bone marrow showed megakaryocyte hyperplasia with dysplasia. JAK2V617F was present in 10 subjects and CALR mutation in one. No other somatic mutations were identified in next generation sequencing. After a median follow-up of 101 months (IQR, 40-160 months), no subject had disease progression or blast transformation. Incidence of post-diagnosis or recurrent thrombosis was 3.9 events (95% confidence interval, 3.5-4.0) and 5.0 events (4.6-5.6) per 100 person-years. Features of subjects with atypical myeloproliferative disorder differed markedly from those of 546 subjects with prefibrotic myelofibrosis. CONCLUSION Our data indicate that these 15 persons have a distinct myeloproliferative neoplasm. We propose naming this new disorder clonal megakaryocyte dysplasia with normal blood values.
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Affiliation(s)
- Giovanni Barosi
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Vittorio Rosti
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Margherita Massa
- Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Foundation, Pavia, Italy
| | - Rita Campanelli
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Laura Villani
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Paolo Catarsi
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Adriana Carolei
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Carlotta Abbà
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | | | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Giuliana Gregato
- Laboratory of Hematology-Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesco Bertolini
- Laboratory of Hematology-Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Umberto Magrini
- Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnostics, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo Foundation, Pavia, Italy
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Center for Haematology Research, Imperial College London, London, United Kingdom
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Altomare I, Parasuraman S, Paranagama D, Kish J, Lord K, Yu J, Colucci P. Real-World Dosing Patterns of Ruxolitinib in Patients With Polycythemia Vera Who Are Resistant to or Intolerant of Hydroxyurea. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e915-e921. [PMID: 34353779 DOI: 10.1016/j.clml.2021.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Approximately one-quarter of patients with polycythemia vera become resistant to and/or intolerant of hydroxyurea. This analysis characterizes reasons patients were switched from hydroxyurea to ruxolitinib and describes ruxolitinib dosing patterns and outcomes in real-world clinical practice. PATIENTS AND METHODS This medical chart review of United States community hematology/oncology practices in the Cardinal Health Oncology Provider Extended Network included patients with polycythemia vera who were ≥18 years old, received hydroxyurea for ≥3 months, started ruxolitinib between January 1, 2015 and December 31, 2016, and had ≥2 visits during the subsequent 6 months. Clinical data were collected at predefined intervals from diagnosis to last provider visit. RESULTS Providers identified 249 patients for inclusion. jcauses of hydroxyurea discontinuation were resistance (78%; frequently for hematocrit ≥45% [79%]) and intolerance (28%; frequently for nausea/vomiting [50%]). Initial ruxolitinib dosing was 10 mg twice daily (recommended dose) in 131 patients (53%). Among these patients, median treatment duration was 29.2 months, 35 (27%) had dose modification (increase, n = 24; decrease, n = 11) and 4 had interruptions within 6 months. The most common reason for dose increase was continued need for phlebotomy (46%); 6 patients had dose reductions owing to reduced platelets. Hematocrit control at initiation and during the first 6 months of ruxolitinib treatment was 15% and 63%, respectively. CONCLUSION Most patients initiated ruxolitinib upon hydroxyurea resistance. Approximately half initiated ruxolitinib at the recommended dose, 27% of whom experienced dosing modifications within the first 6 months. After switching to ruxolitinib, most patients achieved hematocrit control and continued treatment for extended time frames.
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Affiliation(s)
| | | | | | | | - Kevin Lord
- Cardinal Health Specialty Solutions, Dublin, OH
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141
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Castillo Tokumori F, Komrokji R, Kuykendall AT. Stepping out of antiquity: An update on emerging drugs for the treatment of polycythemia vera. Expert Opin Emerg Drugs 2021; 26:209-218. [PMID: 34139920 DOI: 10.1080/14728214.2021.1945579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Polycythemia vera is a chronic hematologic malignancy frequently presented with constitutional symptoms and associated with an increased risk of thrombosis, hemorrhage, and progression to myelofibrosis or acute myeloid leukemia. Current treatment strategies reduce thrombohemorrhagic risk by controlling blood counts and inhibiting platelets, but often fail to address disease-related symptoms or biologically modify the disease.Areas covered: We review the current paradigm for treating polycythemia vera, highlight areas of unmet need, review therapeutic agents in late stage clinical development, and provide an overarching view of how these emerging agent may fit into the future armamentarium of polycythemia vera treatments.Expert opinion: The shift from focusing solely on secondary prevention of thrombohemorrhagic events to a comprehensive treatment strategy that additionally aims to improve quality of life and prevent disease progression has resulted in a rapidly evolving therapeutic landscape that promises to move the treatment of polycythemia vera out of antiquity into the modern age.
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Affiliation(s)
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA
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142
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Zeeh FC, Meyer SC. Current Concepts of Pathogenesis and Treatment of Philadelphia Chromosome-Negative Myeloproliferative Neoplasms. Hamostaseologie 2021; 41:197-205. [PMID: 34192778 DOI: 10.1055/a-1447-6667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms are hematopoietic stem cell disorders characterized by dysregulated proliferation of mature myeloid blood cells. They can present as polycythemia vera, essential thrombocythemia, or myelofibrosis and are characterized by constitutive activation of JAK2 signaling. They share a propensity for thrombo-hemorrhagic complications and the risk of progression to acute myeloid leukemia. Attention has also been drawn to JAK2 mutant clonal hematopoiesis of indeterminate potential as a possible precursor state of MPN. Insight into the pathogenesis as well as options for the treatment of MPN has increased in the last years thanks to modern sequencing technologies and functional studies. Mutational analysis provides information on the oncogenic driver mutations in JAK2, CALR, or MPL in the majority of MPN patients. In addition, molecular markers enable more detailed prognostication and provide guidance for therapeutic decisions. While JAK2 inhibitors represent a standard of care for MF and resistant/refractory PV, allogeneic hematopoietic stem cell transplantation remains the only therapy with a curative potential in MPN so far but is reserved to a subset of patients. Thus, novel concepts for therapy are an important need, particularly in MF. Novel JAK2 inhibitors, combination therapy approaches with ruxolitinib, as well as therapeutic approaches addressing new molecular targets are in development. Current standards and recent advantages are discussed in this review.
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Affiliation(s)
- Franziska C Zeeh
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sara C Meyer
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Division of Hematology and Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
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143
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Hasse S, Duchez AC, Fortin P, Boilard E, Bourgoin SG. Interplay between LPA2 and LPA3 in LPA-mediated phosphatidylserine cell surface exposure and extracellular vesicles release by erythrocytes. Biochem Pharmacol 2021; 192:114667. [PMID: 34216604 DOI: 10.1016/j.bcp.2021.114667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/10/2021] [Accepted: 06/28/2021] [Indexed: 11/27/2022]
Abstract
Evidence is growing for the role of red blood cells (RBCs) in vascular homeostasis, including thrombogenic events and inflammation. Lysophosphatidic acid (LPA) is known to induce phosphatidylserine (PS) exposure and the release of RBC Extracellular Vesicles (REVs). Using high sensitivity flow cytometry, we examined the effects and the mechanisms by which the LPA species commonly found in human plasma could activate RBCs. We report that LPA 16:0, 18:0 and 18:1, but not LPA 20:4, induced PS exposure and the release of small PS- and large PS+ REVs through LPA3 receptor signalling in RBCs. The release of large PS+ REVs required higher concentrations of LPA. RBCs were not activated by LPA 20:4. Interestingly, blockade of LPA2 enhanced LPA-mediated PS- REV release in RBCs. Furthermore, LPA receptor agonists and antagonists highlighted that LPA 20:4 inhibited LPA3-dependent PS exposure and, through the LPA2 receptor, inhibited PS- REV production. Activation of RBCs with LPA 18:1 in normal plasma stimulated the release of PS- and PS+ REVs. REVs released in response to LPA were similar to those found in the plasma of systemic lupus erythematosus patients. Our results suggest that LPA species exhibit different biological activities in RBCs through targeting LPA2 and/or LPA3 receptors.
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Affiliation(s)
- Stephan Hasse
- Centre de recherche du CHU de Québec-Université Laval, Centre ARThrite de l'Université Laval, Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, QC G1V 4G2, Canada.
| | - Anne-Claire Duchez
- Centre de recherche du CHU de Québec-Université Laval, Centre ARThrite de l'Université Laval, Département de médecine, Faculté de médecine, Université Laval, QC G1V 4G2, Canada
| | - Paul Fortin
- Centre de recherche du CHU de Québec-Université Laval, Centre ARThrite de l'Université Laval, Département de médecine, Faculté de médecine, Université Laval, QC G1V 4G2, Canada.
| | - Eric Boilard
- Centre de recherche du CHU de Québec-Université Laval, Centre ARThrite de l'Université Laval, Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, QC G1V 4G2, Canada.
| | - Sylvain G Bourgoin
- Centre de recherche du CHU de Québec-Université Laval, Centre ARThrite de l'Université Laval, Département de microbiologie-infectiologie et d'immunologie, Université Laval, Québec, QC G1V 4G2, Canada.
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144
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Fuqua J, Reece J, Sofka S. Successful use of phlebotomy to treat severe secondary polycythemia due to chronic lung disease. Hematol Rep 2021; 13:8961. [PMID: 34221292 PMCID: PMC8215527 DOI: 10.4081/hr.2021.8961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/30/2021] [Indexed: 11/23/2022] Open
Abstract
Secondary polycythemia (SP) occurs as a result of increase erythropoietin levels most commonly as a result of tissue hypoxia. Symptoms such as erythromelalgia, pruritis, and bleeding, which are frequently seen in polycythemia vera (PV), do not commonly occur in SP. Phlebotomy is considered one of the mainstays of therapy for PV but is rarely used for treatment of SP due to concern about worsening tissue hypoxia. We present the case of a patient with severe SP due to chronic hypoxic lung disease who presented with erythromelalgia, pruritis, and bleeding and was treated successfully with therapeutic phlebotomy. This case illustrates the importance of considering the use of therapeutic phlebotomy in symptomatic patients with severe SP.
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Affiliation(s)
- Jacob Fuqua
- Department of Medicine, West Virginia University, Morgantown, WV, USA
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145
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Bewersdorf JP, Giri S, Wang R, Podoltsev N, Williams RT, Tallman MS, Rampal RK, Zeidan AM, Stahl M. Interferon alpha therapy in essential thrombocythemia and polycythemia vera-a systematic review and meta-analysis. Leukemia 2021; 35:1643-1660. [PMID: 32868875 PMCID: PMC7917159 DOI: 10.1038/s41375-020-01020-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 01/28/2023]
Abstract
Data on the efficacy and safety of interferon (IFN)-α for the treatment of essential thrombocythemia (ET) and polycythemia vera (PV) are inconsistent. We conducted a systematic review and meta-analysis and searched MEDLINE and EMBASE via Ovid, Scopus, COCHRANE registry of clinical trials, and Web of Science from inception through 03/2019 for studies of pegylated IFN (peg-IFN) and non-pegylated IFN (non-peg-IFN) in PV and ET patients. Random-effects models were used to pool response rates for the primary outcome of overall response rate (ORR) defined as a composite of complete response, partial response, complete hematologic response (CHR) and partial hematologic response. Peg-IFN and non-peg-IFN were compared by meta-regression analyses. In total, 44 studies with 1359 patients (730 ET, 629 PV) were included. ORR were 80.6% (95% confidence interval: 76.6-84.1%, CHR: 59.0% [51.5%-66.1%]) and 76.7% (67.4-84.0%; CHR: 48.5% [37.8-59.4%]) for ET and PV patients, respectively. In meta-regression analyses results did not differ significantly for non-peg-IFN vs. peg-IFN. Annualized rates of thromboembolic complications and treatment discontinuation due to adverse events were low at 1.2% and 8.8% for ET and 0.5% and 6.5% for PV patients, respectively. Both peg-IFN and non-peg-IFN can be effective and safe long-term treatments for ET and PV.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Nikolai Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | | | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raajit K Rampal
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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146
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Arish N, Mackay T, Frangulyan R, Riha RL. Haematocrit level in obesity hypoventilation syndrome: a predictor of mortality? Sleep Breath 2021; 26:355-358. [PMID: 34047903 DOI: 10.1007/s11325-021-02395-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 04/28/2021] [Accepted: 05/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The connection between obstructive sleep apnea and secondary erythrocytosis is controversial. We hypothesised that there may be a higher prevalence of erythrocytosis in patients with obesity hypoventilation syndrome (OHS) due to persistent hypoxemia. METHODS The study was a retrospective, cross-sectional review of patients with OHS derived from an established cohort of "non-invasive ventilation" patients at the Department of Sleep Medicine at the Royal Infirmary Medical Centre, Edinburgh (2004-2017). Relevant clinical data were obtained from patient records. RESULTS The cohort comprised 74 patients with OHS, 44 men (60%), mean age at diagnosis 54 ± 10 years. The mean haematocrit level for the group overall was 0.44, in men 0.45, and in women 0.41. Of 11 patients with erythrocytosis (15%), 7 were men. Thirteen patients (18%) died during follow-up (2004-2017). There was a statistically significant increase in risk of death in patients with higher and lower haematocrit levels compared to that in patients with OHS who had normal haematocrits. CONCLUSIONS This is the first study showing increased prevalence of erythrocytosis in OHS patients. There was a "U"-shaped correlation with mortality according to haematocrit levels.
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Affiliation(s)
- Nissim Arish
- Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Tom Mackay
- The Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, EH16 4SA
| | - Ruzanna Frangulyan
- The Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, EH16 4SA
| | - Renata L Riha
- The Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, EH16 4SA
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147
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Shallis RM, Podoltsev NA. Emerging agents and regimens for polycythemia vera and essential thrombocythemia. Biomark Res 2021; 9:40. [PMID: 34049597 PMCID: PMC8161993 DOI: 10.1186/s40364-021-00298-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022] Open
Abstract
Polycythemia vera (PV) and essential thrombocythemia (ET) are both driven by JAK-STAT pathway activation and consequently much of the recent research efforts to improve the management and outcomes of patients with these neoplasms have centered around inhibition of this pathway. In addition to newer JAK inhibitors and improved interferons, promising novel agents exploiting a growing understanding of PV and ET pathogenesis and disease evolution mechanisms are being developed. These agents may modify the disease course in addition to cytoreduction. Histone deacetylase, MDM2 and telomerase inhibitors in patients with PV/ET have demonstrated clinically efficacy and serve as chief examples. Hepcidin mimetics, limiting iron availability to red blood cell precursors, offer an exciting alternative to therapeutic phlebotomy and have the potential to revolutionize management for patients with PV. Many of these newer agents are found to improve hematologic parameters and symptom burden, but their role in thrombotic risk reduction and disease progression control is currently unknown. The results of larger, randomized studies to confirm the early efficacy signals observed in phase 1/2 trials are eagerly awaited.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA
| | - Nikolai A Podoltsev
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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148
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Mithoowani S, Laureano M, Crowther MA, Hillis CM. Investigation and management of erythrocytosis. CMAJ 2021; 192:E913-E918. [PMID: 32778603 DOI: 10.1503/cmaj.191587] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Siraj Mithoowani
- Departments of Medicine (Mithoowani, Laureano, Crowther) and Oncology (Hillis), McMaster University, Hamilton, Ont
| | - Marissa Laureano
- Departments of Medicine (Mithoowani, Laureano, Crowther) and Oncology (Hillis), McMaster University, Hamilton, Ont
| | - Mark A Crowther
- Departments of Medicine (Mithoowani, Laureano, Crowther) and Oncology (Hillis), McMaster University, Hamilton, Ont
| | - Christopher M Hillis
- Departments of Medicine (Mithoowani, Laureano, Crowther) and Oncology (Hillis), McMaster University, Hamilton, Ont.
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149
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Clinical, laboratory, and genetic risk factors for thrombosis in sickle cell disease. Blood Adv 2021; 4:1978-1986. [PMID: 32384541 DOI: 10.1182/bloodadvances.2019001384] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022] Open
Abstract
Sickle cell disease (SCD) patients are at a four- to 100-fold increased risk for thrombosis compared with the general population, although the mechanisms and risk factors are not clear. We investigated the incidence and predictors for thrombosis in a retrospective, longitudinal cohort of 1193 pediatric and adult SCD patients treated at our institution between January 2008 and December 2017. SCD diagnosis and thrombotic complications were identified using International Classification of Diseases coding and verified through medical chart review. Clinical and laboratory data were extracted from the medical records. With a median follow-up of 6.4 years, 208 (17.4%) SCD patients experienced 352 thrombotic events (64 strokes, 288 venous thromboembolisms [VTE]). Risk factors for stroke included older age and HbSS/Sβ0-genotype and a lower hemoglobin (Hb) F% in the subset of HbSS/Sβ0-genotype patients (P < .05). VTE risk was independently associated with lower estimated glomerular filtration rate, hydroxyurea (HU) use, HbSS/Sβ0 genotype, and higher white blood cell (WBC) counts and Hb (P ≤ .03). Two thrombomodulin gene variants previously associated with thrombosis in the general African American population, THBD rs2567617 (minor allele frequency [MAF] 0.25; odds ratio [OR], 1.5; P = .049) and THBD rs1998081 (MAF, 0.24; OR, 1.5; P = .059), were associated with thrombosis in this cohort. In summary, thrombotic complications are common, and several traditional and SCD-specific risk factors are associated with thrombotic risk. Future studies integrating clinical, laboratory, and genetic risk factors may improve our understanding of thrombosis and guide intervention practices in SCD.
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150
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Raman I, Pasricha SR, Prince HM, Yannakou CK. Management of hydroxyurea resistant or intolerant polycythemia vera. Leuk Lymphoma 2021; 62:2310-2319. [PMID: 33949918 DOI: 10.1080/10428194.2021.1901092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Polycythemia vera is a Philadelphia negative myeloproliferative neoplasm characterized by erythrocytosis in which the major cause of morbidity and mortality is thrombosis. Aspirin and hematocrit reduction by venesection or cytoreductive therapy are at the cornerstone of management. First line cytoreductive therapy in high-risk patients is hydroxyurea; however, its use is associated with toxicities and resistance in a significant proportion of patients. In a disease with a long overall survival with appropriate treatment, it is imperative that other treatment options do not accelerate the risk of progression to acute leukemia. The following review will appraise the evidence of interferon, ruxolitinib, and other agents in management of hydroxyurea resistant or intolerant polycythemia vera.
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Affiliation(s)
- Indu Raman
- Molecular Oncology and Cancer Immunology, Epworth Healthcare, Melbourne, Australia.,Walter and Eliza Hall Institute, Melbourne, Australia
| | | | - H Miles Prince
- Molecular Oncology and Cancer Immunology, Epworth Healthcare, Melbourne, Australia.,Peter MacCallum Cancer Institute, Melbourne, Australia
| | - Costas K Yannakou
- Molecular Oncology and Cancer Immunology, Epworth Healthcare, Melbourne, Australia
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