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Chifotides HT, Bose P, Verstovsek S. Givinostat: an emerging treatment for polycythemia vera. Expert Opin Investig Drugs 2020; 29:525-536. [PMID: 32693648 PMCID: PMC7534842 DOI: 10.1080/13543784.2020.1761323] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Polycythemia vera (PV), a Philadelphia chromosome-negative myeloproliferative neoplasm, is characterized by panmyelosis, pancytosis, and a JAK2 mutation. Patients are at increased risk of thrombohemorrhagic events, and progression to myelofibrosis or acute leukemia. Current treatments include aspirin, phlebotomy, and cytoreductive drugs (most commonly hydroxyurea). Givinostat is a potent, class I/II histone deacetylase (HDAC) inhibitor that is in phase I/II clinical trials in PV. Givinostat was well tolerated and yielded promising clinico-hematological responses. A phase III study of givinostat versus hydroxyurea in high-risk PV patients is planned. AREAS COVERED We present an overview of PV, current treatment guidelines, and the putative mechanism(s) of action of givinostat. We discuss the preclinical and clinical studies of givinostat in PV and briefly review approved and investigational competitor compounds. EXPERT OPINION HDAC inhibitors have long been known to be active in PV, but chronic toxicities can be challenging. Givinostat, however, is active and well tolerated, and is entering a pivotal Phase III randomized trial. Givinostat offers the possibility of replacing hydroxyurea as the standard first-line cytoreductive choice for PV patients. This would completely change the current therapeutic paradigm and guidelines for PV management. Although surrogate clinical study endpoints may suffice for regulatory purposes, thrombosis reduction and prevention of disease progression remain most important to patients and clinicians.
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Affiliation(s)
- Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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202
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Hasselbalch HC. Time for revival of the red blood cell count and red cell mass in the differential diagnosis between essential thrombocythemia and polycythemia vera? Haematologica 2020; 104:2119-2125. [PMID: 31666340 DOI: 10.3324/haematol.2019.229039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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203
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Martins TD, Annichino-Bizzacchi JM, Romano AVC, Filho RM. Principal Component Analysis on Recurrent Venous Thromboembolism. Clin Appl Thromb Hemost 2020; 25:1076029619895323. [PMID: 31858829 PMCID: PMC7058370 DOI: 10.1177/1076029619895323] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The rates of recurrent venous thromboembolism (RVTE) vary widely, and its causes still need to be elucidated. Statistical multivariate methods can be used to determine disease predictors and improve current methods for risk calculation. The objective of this study was to apply principal component analysis to a set of data containing clinical records of patients with previous venous thromboembolism and extract the main factors that predict recurrent thrombosis. Records of 39 factors including blood and lipid parameters, hereditary thrombophilia, antiphospholipid syndrome, clinical data regarding previous thrombosis and treatment, and Doppler ultrasound results were collected from 235 patients. The results showed that 13 principal components were associated with RVTE and that 18 of 39 factors are the important for the analysis. These factors include red blood cell, white blood cell, hematocrit, red cell distribution width, glucose, lipids, natural anticoagulant, creatinine, age, as well as first deep vein thrombosis data (distal/proximal, d-dimer, and time of anticoagulation). The results demonstrated that simple clinical parameters easy to be collected can be used to predict rates of recurrence and to develop new clinical decision support systems to predict the rates of RVTE.
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Affiliation(s)
- Tiago D Martins
- School of Chemical Engineering, University of Campinas, Campinas, Brazil.,Departamento de Engenharia Química, Universidade Federal de São Paulo, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Diadema, São Paulo, Brazil
| | - Joyce M Annichino-Bizzacchi
- Hematology and Hemotherapy Center, University of Campinas/Hemocentro-Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, Campinas, São Paulo, Brazil
| | - Anna V C Romano
- Hematology and Hemotherapy Center, University of Campinas/Hemocentro-Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, Campinas, São Paulo, Brazil
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204
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Lilienthal P, Tetschke M, Schalk E, Fischer T, Sager S. Optimized and Personalized Phlebotomy Schedules for Patients Suffering From Polycythemia Vera. Front Physiol 2020; 11:328. [PMID: 32362837 PMCID: PMC7180210 DOI: 10.3389/fphys.2020.00328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/20/2020] [Indexed: 11/13/2022] Open
Abstract
Polycythemia vera (PV) is a slow-growing type of blood cancer, where the production of red blood cells (RBCs) increase considerably. The principal treatment for targeting the symptoms of PV is bloodletting (phlebotomy) at regular intervals based on data derived from blood counts and physician assessments based on experience. Model-based decision support can help to identify optimal and individualized phlebotomy schedules to improve the treatment success and reduce the number of phlebotomies and thus negative side effects of the therapy. We present an extension of a simple compartment model of the production of RBCs in adults to capture patients suffering from PV. We analyze the model's properties to show the plausibility of its assumptions. We complement this with numerical results using exemplary PV patient data. The model is then used to simulate the dynamics of the disease and to compute optimal treatment plans. We discuss heuristics and solution approaches for different settings, which include constraints arising in real-world applications, where the scheduling of phlebotomies depends on appointments between patients and treating physicians. We expect that this research can support personalized clinical decisions in cases of PV.
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Affiliation(s)
- Patrick Lilienthal
- Institute for Mathematical Optimization, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Manuel Tetschke
- Institute for Mathematical Optimization, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Enrico Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Thomas Fischer
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Sebastian Sager
- Institute for Mathematical Optimization, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
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206
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Faille D, Lamrani L, Loyau S, Huisse MG, Bourrienne MC, Alkhaier S, Cassinat B, Boulaftali Y, Debus J, Jandrot-Perrus M, Chomienne C, Dosquet C, Ajzenberg N. Interferon Alpha Therapy Increases Pro-Thrombotic Biomarkers in Patients with Myeloproliferative Neoplasms. Cancers (Basel) 2020; 12:cancers12040992. [PMID: 32316612 PMCID: PMC7226618 DOI: 10.3390/cancers12040992] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/06/2020] [Accepted: 04/11/2020] [Indexed: 01/01/2023] Open
Abstract
Myeloproliferative neoplasms (MPN) are associated with an increased risk of arterial and venous thrombosis. Pegylated-interferon alpha (IFN) and hydroxyurea (HU) are commonly used to treat MPN, but their effect on hemostasis has not yet been studied. The aim of our study was to determine whether IFN and HU impact the biological hemostatic profile of MPN patients by studying markers of endothelial, platelet, and coagulation activation. A total of 85 patients (50 polycythemia vera and 35 essential thrombocythemia) were included: 28 treated with IFN, 35 with HU, and 22 with no cytoreductive drug (non-treated, NT). Von Willebrand factor, shear-induced platelet aggregation, factor VIII coagulant activity (FVIII:C), fibrinogen, and thrombin generation with and without exogenous thrombomodulin were significantly higher in IFN-treated patients compared to NT patients, while protein S anticoagulant activity was lower. In 10 patients in whom IFN therapy was discontinued, these hemostatic biomarkers returned to the values observed in NT patients, strongly suggesting an impact of IFN therapy on endothelial and coagulation activation. Overall, our study shows that treatment with IFN is associated with significant and reversible effects on the biological hemostatic profile of MPN patients. Whether they could be associated with an increased thrombotic risk remains to be determined in further randomized clinical studies.
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Affiliation(s)
- Dorothée Faille
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat, CEDEX 18, F-75877 Paris, France;
- Correspondence:
| | - Lamia Lamrani
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
| | - Stéphane Loyau
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
| | - Marie-Geneviève Huisse
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat, CEDEX 18, F-75877 Paris, France;
| | - Marie-Charlotte Bourrienne
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat, CEDEX 18, F-75877 Paris, France;
| | - Sawsaneh Alkhaier
- Service de Biologie Cellulaire, AP-HP, Hôpital Saint Louis, CEDEX 10, F-75475 Paris, France; (S.A.); (B.C.); (C.C.); (C.D.)
| | - Bruno Cassinat
- Service de Biologie Cellulaire, AP-HP, Hôpital Saint Louis, CEDEX 10, F-75475 Paris, France; (S.A.); (B.C.); (C.C.); (C.D.)
- INSERM UMR_S1131, Université de Paris, F-75010 Paris, France
| | - Yacine Boulaftali
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
| | - Jérôme Debus
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat, CEDEX 18, F-75877 Paris, France;
- Laboratoire d’Hématologie, AP-HP, Hôpital Louis Mourier, CEDEX, F-92701 Colombes, France
| | - Martine Jandrot-Perrus
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
| | - Christine Chomienne
- Service de Biologie Cellulaire, AP-HP, Hôpital Saint Louis, CEDEX 10, F-75475 Paris, France; (S.A.); (B.C.); (C.C.); (C.D.)
- INSERM UMR_S1131, Université de Paris, F-75010 Paris, France
| | - Christine Dosquet
- Service de Biologie Cellulaire, AP-HP, Hôpital Saint Louis, CEDEX 10, F-75475 Paris, France; (S.A.); (B.C.); (C.C.); (C.D.)
- INSERM UMR_S1131, Université de Paris, F-75010 Paris, France
| | - Nadine Ajzenberg
- INSERM UMR_S1148, Université de Paris, CEDEX 18, F-75877 Paris, France; (L.L.); (S.L.); (M.-G.H.); (M.-C.B.); (Y.B.); (M.J.-P.); (N.A.)
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat, CEDEX 18, F-75877 Paris, France;
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207
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Argalious MY, Steib J, Daskalakis N, Mao G, Li M, Armanyous S, Roselli E. Association of Testosterone Replacement Therapy and the Incidence of a Composite of Postoperative In-Hospital Mortality and Cardiovascular Events in Men Undergoing Cardiac Surgery. Anesth Analg 2020; 130:890-898. [DOI: 10.1213/ane.0000000000004115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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208
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Treatment Patterns and Blood Counts in Patients With Polycythemia Vera Treated With Hydroxyurea in the United States: An Analysis From the REVEAL Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:219-225. [PMID: 32063527 PMCID: PMC8895348 DOI: 10.1016/j.clml.2019.09.601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/21/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022]
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209
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Gangaraju R, Song J, Kim SJ, Tashi T, Reeves BN, Sundar KM, Thiagarajan P, Prchal JT. Thrombotic, inflammatory, and HIF-regulated genes and thrombosis risk in polycythemia vera and essential thrombocythemia. Blood Adv 2020; 4:1115-1130. [PMID: 32203583 PMCID: PMC7094018 DOI: 10.1182/bloodadvances.2019001379] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
Thrombosis is a major cause of morbidity and mortality in polycythemia vera (PV) and essential thrombocythemia (ET). The pathophysiology of thrombosis in these disorders remains unclear, and we hypothesized that upregulation of thrombotic, inflammatory, and hypoxia-inducible factor (HIF)-regulated genes may play a role in it. We performed unbiased RNA sequencing in granulocytes and platelets of PV patients and found differential expression of several thrombotic, inflammatory, and HIF-regulated genes. The expression of many of these genes positively correlated with JAK2 expression and JAK2V617F allelic burden. We then validated these findings by quantitative polymerase chain reaction analyses of selected gene transcripts in a larger number of PV and ET granulocytes and platelets (58 patients) and in 28 controls, and we compared these findings in patients with and without thrombosis. The study included 29 females and 29 males; of these, 28 had a history of thrombosis. We found that transcripts of several selected genes were upregulated in patients with PV or ET compared with controls. In granulocytes, the expression levels of F3, SELP, VEGFA, and SLC2A1 were significantly higher in patients with a history of thrombosis compared with those who did not have thrombosis. Patients with a history of thrombosis have significantly higher expression of IL1RAP (P < .05) in platelets compared with those without thrombosis. Our study confirms the presence of a thrombo-inflammatory state and augmented HIF activity in PV and ET and its role in thrombosis. These data may provide the background for targeted therapies in PV and ET.
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Affiliation(s)
- Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Jihyun Song
- Division of Hematology, School of Medicine, University of Utah, Salt Lake City, UT
| | - Soo Jin Kim
- Division of Hematology, School of Medicine, University of Utah, Salt Lake City, UT
| | - Tsewang Tashi
- Division of Hematology, School of Medicine, University of Utah, Salt Lake City, UT
| | - Brandi N Reeves
- Division of Hematology-Oncology, University of North Carolina, Chapel Hill, NC
| | - Krishna M Sundar
- Division of Pulmonology, Critical Care and Sleep Medicine, School of Medicine, University of Utah, Salt Lake City, UT
| | - Perumal Thiagarajan
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Department of Medicine and Pathology, Baylor College of Medicine, Houston, TX; and
| | - Josef T Prchal
- Division of Hematology, School of Medicine, University of Utah, Salt Lake City, UT
- Veterans Administration Medical Center, Salt Lake City, UT
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210
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From Budd-Chiari syndrome to acquired von Willebrand syndrome: thrombosis and bleeding complications in the myeloproliferative neoplasms. Blood 2020; 134:1902-1911. [PMID: 31778549 DOI: 10.1182/blood.2019001318] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/08/2019] [Indexed: 12/14/2022] Open
Abstract
Thrombotic and hemorrhagic complications are prevalent in patients with essential thrombocythemia, polycythemia vera, and myelofibrosis. Given the impact on morbidity and mortality, reducing the risk of thrombosis and/or hemorrhage is a major therapeutic goal. Historically, patients have been risk stratified on the basis of traditional factors, such as advanced age and thrombosis history. However, multiple factors contribute to the thrombotic tendency, including gender, mutational profile, inflammatory stress, and abnormal cell adhesion. Management includes cardiovascular risk reduction and use of antiplatelet therapy, depending on myeloproliferative neoplasm subtype and mutational status. Anticoagulation is a mainstay of therapy for those with venous thrombosis, but practice patterns remain heterogeneous. Cytoreduction is indicated for higher-risk patients, but efficacy may depend on the involved vascular bed. Management of special situations, such as unusual site thrombosis, bleeding, the perioperative period, and pregnancy, are especially challenging. In this article, risk factors and treatment strategies for myeloproliferative neoplasm thrombosis and bleeding, including special situations, are reviewed. Insights gained from recent studies may lead to the development of a more precise risk classification and tailored therapy.
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211
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Sacco M, Ranalli P, Lancellotti S, Petrucci G, Dragani A, Rocca B, De Cristofaro R. Increased von Willebrand factor levels in polycythemia vera and phenotypic differences with essential thrombocythemia. Res Pract Thromb Haemost 2020; 4:413-421. [PMID: 32211575 PMCID: PMC7086469 DOI: 10.1002/rth2.12315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acquired von Willebrand factor (VWF) deficiency was described in Philadelphia-negative myeloproliferative neoplasms, especially in essential thrombocythemia (ET). VWF phenotype in contemporary patients with polycythemia vera (PV) remains less explored. OBJECTIVES To characterize the VWF phenotype in PV and to compare VWF phenotype in PV with matched healthy subjects and ET patients. PATIENTS/METHODS We studied 48 PV patients, treated according to current recommendations (hematocrit ≤ 45%, on low-dose aspirin prophylaxis); 48 healthy and 41 subjects with ET, all sex, age, and blood group matched. We measured VWF antigen, activity, multimeric pattern, ADAMTS-13, and factor VIII (FVIII) antigen. RESULTS In patients with PV, VWF antigen and activity were significantly higher than in healthy subjects (antigen: 119[96-137] vs 93[79-107] IU/dL; activity: 114[95-128] vs 90[79-107] IU/dL, respectively, medians and interquartile, P < 0.01), with normal multimeric distribution. ADAMTS-13 levels were similar between patients with PV and healthy subjects. FVIII levels were higher in PV than in healthy subjects (141[119-169] versus 98[88-123] IU/dL, respectively, P < 0.01). By multivariable analysis, JAK2-p.V617F allelic burden, erythrocyte count, and male sex significantly predicted VWF antigen and activity levels. As compared to patients with ET, patients with PV showed similar VWF antigen levels but approximately 40% higher activity (79[49-104] vs 112[93-125] IU/dL, respectively, P < 0.01). CONCLUSIONS Patients with PV show increased VWF and FVIII levels, predicted by JAK2-p.V617F burden and erythrocyte count. At variance with ET, acquired VWF defect was not observed in PV. High VWF/FVIII levels may sustain the thrombotic diathesis of PV and may be investigated as biomarkers for risk stratification.
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Affiliation(s)
- Monica Sacco
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
| | - Paola Ranalli
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | | | - Giovanna Petrucci
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Alfredo Dragani
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | - Bianca Rocca
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
- Dipartimento di EmatologiaOspedale S. SpiritoPescaraItaly
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212
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Schukraft S, Puricel S, Togni M, Attinger-Toller A, Cook S. Spontaneous Recanalization of Coronary Thrombus in a Patient With Polycythemia Vera. JACC Case Rep 2020; 2:497-498. [PMID: 34317274 PMCID: PMC8311606 DOI: 10.1016/j.jaccas.2019.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022]
Abstract
Spontaneous recanalized coronary thrombi (SRCT), a rare and under-diagnosed entity, are old thrombus formations characterized by multiple communicating channels. We report the case of a 72-year-old female patient who presented with SRCT in the context of polycythemia vera. Optical coherence tomography (OCT) is the diagnostic method of choice. (Level of Difficulty: Intermediate.)
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Affiliation(s)
| | | | | | | | - Stéphane Cook
- Address for correspondence: Prof. Stéphane Cook, Cardiology, University and Hospital Fribourg, Chemin des Pensionnats 2-6, Fribourg, Switzerland.
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213
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Folsom AR, Wang W, Parikh R, Lutsey PL, Beckman JD, Cushman M. Hematocrit and incidence of venous thromboembolism. Res Pract Thromb Haemost 2020; 4:422-428. [PMID: 32211576 PMCID: PMC7086464 DOI: 10.1002/rth2.12325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/14/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with polycythemia vera with high hematocrit have increased risk of venous thromboembolism (VTE). OBJECTIVE To determine whether high hematocrit in the general population is also associated with elevated VTE risk. METHODS The prospective Atherosclerosis Risk in Communities Study performed a complete blood count in 13 891 adults aged 45 to 64 in 1987 to 1989. We identified incident hospitalized VTEs through 2015 and performed proportional hazards regression analyses using race-sex-specific categorization of hematocrit percentiles (ie, <5th, 5th to <25th, 25th to <75th, 75th to <95th, and 95th-100th percentiles, with the 25th to <75th percentile serving as the reference). RESULTS Over a median follow-up of 26 years, 800 participants had an incident venous thrombosis of the leg and/or a pulmonary embolism. There was a nonlinear association of hematocrit with VTE incidence, with risk elevated 72% for participants above the 95th percentile of hematocrit compared with the reference. Specifically, hazard ratios (95% confidence intervals) of incident VTE were 1.27 (0.91-1.76), 1.06 (0.87-1.28), 1 (reference), 1.17 (0.98-1.40) and 1.72 (1.30-2.27) across the 5 hematocrit percentiles, adjusted for age, race, sex, body mass index, smoking status and pack-years, and other confounding variables. The association of high hematocrit with VTE was limited to provoked VTE, with little evidence for unprovoked VTE. Hemoglobin above the 95th percentile also was associated with an increased risk of VTE. In contrast, there were no significant associations of platelet, leukocyte, neutrophil, or lymphocyte counts with VTE incidence. CONCLUSION High hematocrit and hemoglobin in a general middle-aged population sample were associated with increased long-term risk of VTE, particularly provoked VTE.
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Affiliation(s)
- Aaron R. Folsom
- Division of Epidemiology & Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Wendy Wang
- Division of Epidemiology & Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Romil Parikh
- Division of Epidemiology & Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Pamela L. Lutsey
- Division of Epidemiology & Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Joan D. Beckman
- Division of Hematology, Oncology and TransplantationDepartment of MedicineUniversity of MinnesotaMinneapolisMNUSA
| | - Mary Cushman
- Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVTUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVTUSA
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214
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Alvarez-Larrán A, Pereira A, Magaz M, Hernández-Boluda JC, Garrote M, Cuevas B, Ferrer-Marín F, Gómez-Casares MT, García-Gutiérrez V, Mata-Vázquez MI, Turon F, Hernandez-Gea V, Arellano-Rodrigo E, Cervantes F, García-Pagán JC. Natural history of polycythemia vera and essential thrombocythemia presenting with splanchnic vein thrombosis. Ann Hematol 2020; 99:791-798. [PMID: 32086587 DOI: 10.1007/s00277-020-03965-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/13/2020] [Indexed: 11/28/2022]
Abstract
Patients with polycythemia vera (PV) or essential thrombocythemia (ET) presenting with splanchnic vein thrombosis (SVT) might have a specific clinico-biological profile. To investigate this hypothesis, 3705 PV/ET patients from three national registers, 118 of them presenting with SVT, were reviewed. After correction for age and sex, PV/ET patients with SVT showed an increased risk of death (HR 2.47, 95% CI 1.5-4.01, p < 0.001), venous thrombosis (IRR 3.4, 95%CI 2.1-5.5, p < 0.001), major bleeding (IRR 3.6, 95%CI 2.3-5.5, p < 0.001), and second cancer (IRR 2.37, 95%CI 1.4-4.1, p = 0.002). No case of acute leukemia was documented among patients with PV/ET presenting with SVT and seven of them (6%) progressed to myelofibrosis. SVT was not associated with lower risk of MF after correction by age and sex. Patients with SVT more frequently died from complications related to hepatic disease, major bleeding, or second cancer, resulting in a 5-year reduction of age- and sex-adjusted median survival. In conclusion, PV and ET patients presenting with SVT have shorter survival than patients with PV and ET of the same age and sex. This excess mortality is related to liver disease, major bleeding, and second cancer rather than to the natural evolution of the MPN.
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Affiliation(s)
- Alberto Alvarez-Larrán
- Hematology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain.
| | - Arturo Pereira
- Hemotherapy Department, Hospital Clínic, IDIBAPS, Barcelona, Spain
| | - Marta Magaz
- Barcelona Hepatic Haemodynamic Lab, Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Marta Garrote
- Hematology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Beatriz Cuevas
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | | | | | | | | | - Fanny Turon
- Barcelona Hepatic Haemodynamic Lab, Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Haemodynamic Lab, Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Francisco Cervantes
- Hematology Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Villarroel 170, 08036, Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Haemodynamic Lab, Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
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215
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Kondo H, Watanabe R, Okazaki S, Kuriyama K, Ochi T, Yamada G, Sugiura A, Chiba H, Tsukada A, Taniuchi S, Igarashi T, Kudo M, Harigae H, Fujii H. JAK2 mutation-positive polycythaemia vera associated with IgA vasculitis and nephrotic syndrome: a case report. Mod Rheumatol Case Rep 2020; 4:289-295. [PMID: 33087019 DOI: 10.1080/24725625.2020.1728061] [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: 10/25/2022]
Abstract
We report a case of polycythaemia vera (PV) associated with IgA vasculitis. A 45-year-old man was admitted for evaluation of abdominal pain and palpable purpura. IgA vasculitis was diagnosed, and oral prednisolone therapy (30 mg/day) was initiated. On day 6, the patient developed left hemiparesis, and magnetic resonance imaging revealed acute cerebral infarction. Bone marrow biopsy results and the identification of a Janus kinase 2 (JAK2) mutation led to the diagnosis of PV. Despite steroid therapy, urine protein levels increased to 15 g/g・Cre. Renal biopsy demonstrated mild mesangial proliferation with IgA deposits, but immunosuppressive therapy was partially effective. This case suggests that PV can be a complication of IgA vasculitis and that preventive measures for thrombosis should be taken in such cases.
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Affiliation(s)
- Hinako Kondo
- Department of Rheumatology, Osaki Citizen Hospital, Osaki, Japan
| | - Ryu Watanabe
- Department of Rheumatology, Osaki Citizen Hospital, Osaki, Japan.,Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Soshi Okazaki
- Department of Rheumatology, Osaki Citizen Hospital, Osaki, Japan
| | - Kaori Kuriyama
- Department of Rheumatology, Osaki Citizen Hospital, Osaki, Japan
| | - Tetsuro Ochi
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Gen Yamada
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Japan
| | - Hiromu Chiba
- Department of Dermatology, Osaki Citizen Hospital, Osaki, Japan
| | - Akira Tsukada
- Department of Dermatology, Osaki Citizen Hospital, Osaki, Japan
| | - Shinji Taniuchi
- Department of Pathology, Osaki Citizen Hospital, Osaki, Japan
| | - Takehiko Igarashi
- Department of Gastroenterology, Osaki Citizen Hospital, Osaki, Japan
| | - Masataka Kudo
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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216
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The impact of statins on the intensity of phlebotomies in polycythemia vera. Ann Hematol 2020; 99:911-912. [DOI: 10.1007/s00277-020-03950-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
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217
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Zhang Y, Zhou Y, Wang Y, Teng G, Li D, Wang Y, Du C, Chen Y, Zhang H, Li Y, Fu L, Chen K, Bai J. Thrombosis among 1537 patients with JAK2 V617F -mutated myeloproliferative neoplasms: Risk factors and development of a predictive model. Cancer Med 2020; 9:2096-2105. [PMID: 31994332 PMCID: PMC7064115 DOI: 10.1002/cam4.2886] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/20/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022] Open
Abstract
To explore the risk factors of thrombosis in patients with JAK2V617F‐mutated myeloproliferative neoplasms (MPNs), a cohort of 1537 Chinese patients with JAK2V617F‐mutated MPN was retrospectively analyzed. The Kaplan‐Meier method and multivariate Cox analysis were used to study the risk factors of thrombosis in patients with JAK2V617F‐mutated MPN. Among the 1537 MPN patients, 931, 468, and 138 had polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), respectively. The median follow‐up time was 7 years (range 1‐47), and 12.8% of patients (197/1537) died during this period. A total of 16.8% (259/1399) of PV and ET patients had secondary myelofibrosis, and 2.5% (38/1537) of patients developed acute myeloid leukemia (AML). Thrombotic events occurred in 43.9% (675/1537) of patients, among which 91.4% (617/675) were arterial thrombosis and 16.6% (112/675) were venous thrombosis. The number of thrombotic events in PV, ET, and PMF patients was 439 (47.2%), 197 (42.1%) and 39 (28.2%), respectively. The multivariate analysis indicated that age ≥60 years old, HCT ≥48%, at least one cardiovascular risk factor, a history of thrombosis, and JAK2V617F allele burden (V617F%) ≥50% are risk factors for thrombosis in JAK2V617F‐mutated MPN. According to the results of the multivariate analysis, a risk model of thrombosis was established and comprised low‐risk (0 points), intermediate‐risk (1 points) and high‐risk (≥2 points) groups, among which the incidence of thrombosis was 9.1%, 33.7% and 72.9%. For elderly patients with JAK2V617F‐mutated MPN and a history of thrombosis, reducing the V617F%, controlling HCT and preventing cardiovascular risk factors are necessary measures to prevent thrombosis.
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Affiliation(s)
- Yuhui Zhang
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yuan Zhou
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yingshao Wang
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China.,State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guangshuai Teng
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Dapeng Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yan Wang
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Chenxiao Du
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yafang Chen
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Huiqin Zhang
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yanqi Li
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Lixia Fu
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Kangyin Chen
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Jie Bai
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
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218
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Parra Salinas I, Recasens Flores V, Montañés MÁ, García-Erce JA. Therapeutic erythroapheresis: Experience in patients with polycythemia vera and secondary erythrocytosis. Med Clin (Barc) 2020; 154:16-19. [PMID: 30795904 DOI: 10.1016/j.medcli.2018.12.016] [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: 07/23/2018] [Revised: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
Therapeutic erythrocytapheresis (TE) is a more efficient strategy compared to phlebotomy to deplete levels of haematocrit in primary and secondary erythrocytosis. OBJECTIVE To analyse response rate and safety profile of TE in polycythemia vera (PV) and secondary erythrocytosis (SE). PATIENTS AND METHOD Retrospective review of all patients with PV or SE treated with TE, due to phlebotomy failure, or comorbidities that prevented changes of blood volumen. RESULTS 217 TE sessions (48 PV and 79 SE) corresponding to 20 patients (12 ES and 8 PV). Response were achieved in 87.5% of PV patients and in 50% of SE patients. Adverse effects related to TE performance occurred in 7.08%. CONCLUSION Despite our small sample size and the heterogeneous nature of the patients included, we can postulate that TE is a secure strategy that can achieve haematocrit depletion in a shorter time than phlebotomy, specifically in PV patients and in selected cases of SE with expected haemodynamic intolerance to phlebotomies or in patients who fail to respond to phlebotomies.
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Affiliation(s)
| | | | | | - José Antonio García-Erce
- Banco de Sangre y Tejidos de Navarra, Pamplona, España; Grupo de Trabajo de la Sociedad Española de Transfusión Sanguínea «Hemoterapia basada en sentido común», España.
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219
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Hamdan F, Mahmood I, Al-Tameemi W. Heat-shock protein 70 and pentraxin-3 inflammatory biomarkers: Implication for thrombosis in polycythemia vera. IRAQI JOURNAL OF HEMATOLOGY 2020. [DOI: 10.4103/ijh.ijh_3_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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220
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Bar-Natan M, Hoffman R. New insights into the causes of thrombotic events in patients with myeloproliferative neoplasms raise the possibility of novel therapeutic approaches. Haematologica 2019; 104:3-6. [PMID: 30598493 DOI: 10.3324/haematol.2018.205989] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Michal Bar-Natan
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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221
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Ahlstrand E, Samuelsson J, Lindgren M, Pettersson H, Liljeholm M, Ravn-Landtblom A, Scheding S, Andréasson B. Highly reduced survival in essential thrombocythemia and polycythemia vera patients with vascular complications during follow-up. Eur J Haematol 2019; 104:271-278. [PMID: 31863513 DOI: 10.1111/ejh.13373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To explore the relative importance of risk factors, treatments, and blood counts for the occurrence of vascular complications and their impact on life expectancy in essential thrombocythemia (ET) and polycythemia vera (PV). METHODS Nested case-control study within the Swedish MPN registry. From a cohort of 922 ET patients and 763 PV patients, 71 ET and 81 PV cases with vascular complications were compared with matched controls. RESULTS Incidence of vascular complications was 2.0 and 3.4 events per 100 patient-years in ET and PV, respectively. At diagnosis, no significant risk factor differences were observed between cases and controls in neither of the diseases. At the time of vascular event, ET complication cases did not differ significantly from controls but in PV, cases had significantly higher WBCs and were to a lesser extent treated with anti-thrombotic and cytoreductive therapy. Life expectancy was significantly decreased in both ET and PV cases compared with controls. CONCLUSIONS The risk of vascular complications is high in both ET and PV, and these complications have a considerable impact on life expectancy. The protective effect of anti-thrombotic and cytoreductive therapy for vascular complications in PV underscores the importance of avoiding undertreatment.
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Affiliation(s)
- Erik Ahlstrand
- Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jan Samuelsson
- Department of Hematology, University Hospital Linköping, Linköping, Sweden
| | | | - Helna Pettersson
- Division of Hematology, Specialist Medicine, NU Hospital Group, Uddevalla, Sweden
| | - Maria Liljeholm
- Department of Hematology, University Hospital of Northern Sweden, Umeå, Sweden
| | - Anna Ravn-Landtblom
- Department of Medicine, Karolinska Institute, Solna, Sweden.,Division of Hematology, Department of Medicine, Stockholm South Hospital, Stockholm, Sweden
| | - Stefan Scheding
- Division of Molecular Hematology, Department of Laboratory Medicine, Lund Stem Cell Center, Lund University, Lund, Sweden.,Department of Hematology, Skåne University Hospital, Lund, Sweden
| | - Björn Andréasson
- Division of Hematology, Specialist Medicine, NU Hospital Group, Uddevalla, Sweden
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222
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Hultcrantz M, Modlitba A, Vasan SK, Sjölander A, Rostgaard K, Landgren O, Hjalgrim H, Ullum H, Erikstrup C, Kristinsson SY, Edgren G. Hemoglobin concentration and risk of arterial and venous thrombosis in 1.5 million Swedish and Danish blood donors. Thromb Res 2019; 186:86-92. [PMID: 31927271 DOI: 10.1016/j.thromres.2019.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION There are conflicting results whether elevated hematocrit is associated with an increased risk of thromboembolic events in individuals without polycythemia vera. To assess the risk of vascular events in relation to hemoglobin concentration, we conducted a large population-based cohort study based on Scandinavian health registers. MATERIALS AND METHODS We included 1,538,019 Swedish and Danish blood donors between 1987 and 2012. Hazard ratios (HRs) of arterial and venous thrombosis were estimated using Cox regression. Additionally, we fitted person-stratified models where each donor was compared only to him-/herself. RESULTS The risk of myocardial infarction and ischemic stroke increased with higher hemoglobin concentration in both men and women. The HRs for myocardial infarction and ischemic stroke in men with hemoglobin concentration ≥ 17.5 g/dL were 3.52 (95% confidence interval [CI], 2.85-4.36) and 2.36 (95% CI, 1.63-3.43), respectively, compared to the reference group. The corresponding HRs for women with hemoglobin concentration ≥ 16.0 g/dL were 3.22 (2.12-4.89) and 2.35 (1.37-4.02) for myocardial infarction and ischemic stroke, respectively. The risk of venous thrombosis was highest in men with subnormal hemoglobin concentration (<13.0 g/dL), HR 1.69 (95% CI, 1.40-2.04). In the person-stratified model, the association between elevated hemoglobin concentration and risk of myocardial infarction was attenuated but remained significant. CONCLUSIONS In this large cohort of Scandinavian blood donors, elevated hemoglobin concentration was associated with an increased risk of vascular events, primarily arterial events. Even though associations were weakened when each person served as their own control, a high hemoglobin concentration may serve as a cardiovascular risk marker.
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Affiliation(s)
- Malin Hultcrantz
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | - Anton Modlitba
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Senthil K Vasan
- Oxford Center for Diabetes, Endocrinology, and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Henrik Hjalgrim
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Ullum
- Department of Clinical Immunology, the Blood Bank, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Sigurdur Y Kristinsson
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Faculty of Medicine, University of Iceland and Department of Hematology, Landspitali National University Hospital, Reykjavik, Iceland
| | - Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
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223
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Stein BL, Martin K. From Budd-Chiari syndrome to acquired von Willebrand syndrome: thrombosis and bleeding complications in the myeloproliferative neoplasms. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:397-406. [PMID: 31808903 PMCID: PMC6913438 DOI: 10.1182/hematology.2019001318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Thrombotic and hemorrhagic complications are prevalent in patients with essential thrombocythemia, polycythemia vera, and myelofibrosis. Given the impact on morbidity and mortality, reducing the risk of thrombosis and/or hemorrhage is a major therapeutic goal. Historically, patients have been risk stratified on the basis of traditional factors, such as advanced age and thrombosis history. However, multiple factors contribute to the thrombotic tendency, including gender, mutational profile, inflammatory stress, and abnormal cell adhesion. Management includes cardiovascular risk reduction and use of antiplatelet therapy, depending on myeloproliferative neoplasm subtype and mutational status. Anticoagulation is a mainstay of therapy for those with venous thrombosis, but practice patterns remain heterogeneous. Cytoreduction is indicated for higher-risk patients, but efficacy may depend on the involved vascular bed. Management of special situations, such as unusual site thrombosis, bleeding, the perioperative period, and pregnancy, are especially challenging. In this article, risk factors and treatment strategies for myeloproliferative neoplasm thrombosis and bleeding, including special situations, are reviewed. Insights gained from recent studies may lead to the development of a more precise risk classification and tailored therapy.
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Affiliation(s)
- Brady L Stein
- Division of Hematology/Oncology and Robert H. Lurie Comprehensive Cancer Center, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karlyn Martin
- Division of Hematology/Oncology and Robert H. Lurie Comprehensive Cancer Center, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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224
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Sobieralski P, Leszczyńska A, Bieniaszewska M. Late polycythemic transformation in JAK2-mutated essential thrombocythemia patients-characteristics along with a validation of 2016 WHO criteria. Eur J Haematol 2019; 103:558-563. [PMID: 31449697 DOI: 10.1111/ejh.13320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 05/24/2023]
Abstract
INTRODUCTION AND OBJECTIVES The most common mutation within the spectrum of myeloproliferative neoplasms (MPNs) is a mutation in Janus kinase 2 gene (JAK2V617F). It has been observed that, during a course of disease, transformation from JAK2-mutated essential thrombocythemia (ET) to overt polycythemia vera (PV) can occur. Primary objective of this study was to show the incidence of mentioned phenomenon. METHODS In this study, we analyzed data of 136 patients diagnosed with JAK2-positive ET observed for a median time of 9 years. We examined blood count of each patient at the time of diagnosis and confronted it with 2008 and 2016 WHO criteria for PV and mPV. Additionally, we analyzed JAK2V617F allele burden in two separate time points among selected cases. RESULTS Confrontation with new criteria resulted in change of diagnosis to PV and mPV in 10% and 9% cases, respectively. Within remaining patients, 14 showed increasing hemoglobin concentration over several months during late course of disease, resulting in change of diagnosis to overt PV. We did not find suggested increase in JAK2 allele burden among transforming patients. CONCLUSIONS Phenotype transformation to polycythemia was proven to be possible within the group of JAK2-mutated ET; however, cause of this effect remains uncertain.
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Affiliation(s)
- Patryk Sobieralski
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | - Aleksandra Leszczyńska
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | - Maria Bieniaszewska
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
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225
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Stussi G, Buser A, Holbro A. Red Blood Cells: Exchange, Transfuse, or Deplete. Transfus Med Hemother 2019; 46:407-416. [PMID: 31933570 DOI: 10.1159/000504144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
Erythrocytapheresis, red blood cell (RBC) depletion, and RBC exchange transfusions are apheresis techniques used to rapidly lower the circulating RBC mass or to exchange the patient erythrocyte mass with donor RBC. Automated RBC exchange is performed using an apheresis device, while manual RBC exchange is based on sequential phlebotomies and isovolemic replacement. Compared to simple RBC transfusions, RBC exchange offers several advantages, e.g., a lower risk for iron accumulation and efficient control of pathological erythrocyte populations. Disadvantages are the higher costs of the procedure, the increased use of donor RBC, and the requirement of apheresis devices and trained hospital staff. The most frequent indication for RBC exchange is sickle cell disease (SCD). RBC exchange transfusions are standard treatment in SCD patients with a history of or a risk for acute stroke and are clinical options for other acute complications of SCD. The most common indication for RBC depletion is the removal of donor RBC from the bone marrow grafts in major ABO-incompatible allogeneic hematopoietic stem cell transplantation to avoid immediate hemolysis. Rare indications for RBC exchange are severe infections with intraerythrocytic pathogens such as malaria or babesiosis and severe erythrocytosis or hereditary hemochromatosis where the aim is to rapidly decrease RBC populations or the iron content. However, only few high-quality studies are available looking at the efficacy of RBC exchange in the different disease entities, and treatment is often based on low levels of evidence and should therefore be decided in close collaboration with a transfusion medicine specialist.
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Affiliation(s)
- Georg Stussi
- Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Andreas Buser
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Holbro
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
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226
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 747] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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227
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Frederiksen H, Szépligeti S, Bak M, Ghanima W, Hasselbalch HC, Christiansen CF. Vascular Diseases In Patients With Chronic Myeloproliferative Neoplasms - Impact Of Comorbidity. Clin Epidemiol 2019; 11:955-967. [PMID: 31807079 PMCID: PMC6830370 DOI: 10.2147/clep.s216787] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022] Open
Abstract
Background Patients with chronic myeloproliferative neoplasms (MPNs), including essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF), are at high risk of vascular complications. However, the magnitude of this is risk not well known and the possible effect of comorbidity is poorly understood. Aim Our aim was to compare the risk of vascular diseases in patients with MPNs and matched comparisons from the general population and to study the effect modification of comorbidity. Methods We followed 3087 patients with ET, 6076 with PV, 3719 with PMF or unspecified MPN, and age- and sex-matched general population comparisons to estimate the risks of cardiovascular diseases such as myocardial infarction and stroke. We computed 5-year cumulative incidences (risks) for vascular disease in patients with MPNs and comparisons as well as 1-year and 5-year risks, risk differences, and hazard ratios (HRs) for vascular diseases comparing rates in each group of patients with their comparison cohort by level of comorbidity based on the Charlson Comorbidity Index (CCI) [score of 0 (low comorbidity), of 1–2 (moderate comorbidity), and of >2 (severe comorbidity)], as well as other comorbid conditions. Results The overall 5-year risk of vascular disease ranged from 0.5% to 7.7% in patients with MPNs, which was higher than the risk in the general population. In the same period, the adjusted HRs for vascular disease were 1.3 to 3.7 folds higher in patients with MPNs compared to the general population. An increase in CCI score was associated with an equally increased rate of most types of vascular diseases during the first 5 years of follow-up in both MPN and comparisons. Conclusion Patients with MPNs have a higher risk of vascular diseases during the first 5 years than that of the general population; however, comorbidity modifies the rates similarly in MPN and in the general population.
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Affiliation(s)
- Henrik Frederiksen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Haematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Marie Bak
- Department of Haematology, Zealand University Hospital, Roskilde, Denmark
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway.,Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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228
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Warny M, Helby J, Birgens HS, Bojesen SE, Nordestgaard BG. Arterial and venous thrombosis by high platelet count and high hematocrit: 108 521 individuals from the Copenhagen General Population Study. J Thromb Haemost 2019; 17:1898-1911. [PMID: 31309714 DOI: 10.1111/jth.14574] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/11/2019] [Indexed: 08/31/2023]
Abstract
BACKGROUND It is unclear whether high platelet count or high hematocrit predict risk of thrombosis in individuals from the general population. OBJECTIVES We tested the hypothesis that individuals from the general population with high platelet count or high hematocrit have high risk of arterial and venous thrombosis. METHODS We prospectively followed 108 521 individuals from The Copenhagen General Population Study for a median of 8 years. Platelet count and blood hematocrit were measured at study entry. RESULTS AND CONCLUSION Multivariable adjusted hazard ratios for individuals with platelet counts in the top 5 percentiles (>398 × 109 /L) vs in the 25th-75th percentiles (231-316 × 109 /L) were 1.77 (95% confidence interval [CI], 1.38-2.24) for arterial thrombosis in the brain (38 and 26 events/10 000 person-years) and 0.82 (95%, 0.61-1.11) for arterial thrombosis in the heart (23 and 28 events/10 000 person-years). For individuals with hematocrit values in the top 5 percentiles (women/men: >45/>48%) vs the 25th-75th percentiles (women/men: 38.1-42/41.1-45%), hazard ratios were 1.27 (95% CI, 0.91-1.75) for arterial thrombosis in the brain (40 and 26 events/10 000 person-years) and 1.46 (95% CI, 1.06-2.00) for arterial thrombosis in the heart (43 and 25 events/10 000 person-years). Neither high platelet count nor high hematocrit was associated with risk of venous thromboembolism. When excluding individuals with myeloproliferative neoplasia from the main analyses, results on risk of thrombosis were similar. In this prospective study, high platelet counts were associated with 1.8-fold risk of arterial thrombosis in the brain, whereas high hematocrit was associated with 1.5-fold risk of arterial thrombosis in the heart.
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Affiliation(s)
- Marie Warny
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Jens Helby
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Internal Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Henrik S Birgens
- Department of Hematology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stig E Bojesen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Børge G Nordestgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
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229
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Nersesjan V, Zervides KA, Sørensen AL, Kjaer L, Skov V, Hasselbalch HC. The red blood cell count and the erythrocyte sedimentation rate in the diagnosis of polycythaemia vera. Eur J Haematol 2019; 104:46-54. [PMID: 31584701 DOI: 10.1111/ejh.13334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Iron deficiency in polycythaemia vera (PV) may impact the validity of the haematocrit (HCT), since HCT is red blood cell count (RBC) × mean corpuscular volume (MCV). OBJECTIVES To investigate (a) the effect of microcytosis on HCT, (b) the erythrocyte sedimentation rate (ESR) as a possible additional diagnostic marker for PV. MATERIAL AND METHODS This study included 182 subjects: 39 with PV, 27 with essential thrombocythemia (ET) and 116 suspected of myeloproliferative neoplasm (MPN) with a secondary cause for either thrombocytosis or erythrocytosis. RESULTS Patients with PV had significantly lower ratio of MCV and serum ferritin compared to MPN suspects. A good correlation of RBC versus HCT was found for PV and MPN subjects when individuals with microcytosis were excluded (R2 = .87 in PV and R2 = .82 in MPN suspects). We found a specificity of 98% and a sensitivity of 37% for ESR <2 mm in the diagnosis of PV. CONCLUSION The RBC may more precisely reflect the total red cell mass and accordingly the hypercoagulable state of the PV patient, which is integrated in the ESR. A combination of RBC and ESR is proposed as a novel tool to substitute the Hb concentration and the HCT in the diagnosis of PV.
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Affiliation(s)
- Vardan Nersesjan
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kristoffer A Zervides
- Department of Clinical Sciences, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders L Sørensen
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark.,Institute for Inflammation Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lasse Kjaer
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Vibe Skov
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Hans C Hasselbalch
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
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230
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Wang N, Liu L, Jiang X, Li D, Chen X. Acute multiple cerebral infarction combined with cerebral microhemorrhage in Polycythemia vera: A case report. Exp Ther Med 2019; 18:2949-2955. [PMID: 31572537 PMCID: PMC6755484 DOI: 10.3892/etm.2019.7926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 05/02/2019] [Indexed: 11/06/2022] Open
Abstract
Polycythemia vera (PV) is one of the rare causes of cerebrovascular disease, whose common manifestations in the nervous system are cerebral infarction and transient ischemic attack. A number of cases of PV patients with bleeding complicated with subdural hemorrhage or cerebral hemorrhage have been previously reported. However, sometimes PV patient with complicated cerebral hemorrhage and lower extremity venous thrombosis have been admitted to the People's Hospital of Liaoning Province. The present case study reports on a patient with acute multiple cerebral infarction with cerebral micro-hemorrhage associated with PV, who was not treated with anti-thrombosis treatment. After bloodletting treatment and hydroxyurea treatment, the patients condition was stable and they were discharged. A possible mechanism of infarction is that PV may cause abnormal proliferation of red blood cells, white blood cells and platelets in the circulation, resulting in an increase of blood viscosity and reduction of blood flow velocity. Platelet deficiency may cause abnormal blood coagulation function, which may be the reason for the blood and thrombotic diseases in patients with PV.
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Affiliation(s)
- Nan Wang
- Department of Neurology Inspection, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, P.R. China.,Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 132000, P.R. China
| | - Liyang Liu
- Department of Neurology Inspection, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, P.R. China
| | - Xin Jiang
- Department of Neurology Inspection, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, P.R. China
| | - Daowei Li
- Department of Neurology Inspection, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, P.R. China
| | - Xiaohong Chen
- Department of Neurology Inspection, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, P.R. China
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231
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Hematocrit levels and thrombotic events in patients with polycythemia vera: an analysis of Veterans Health Administration data. Ann Hematol 2019; 98:2533-2539. [PMID: 31552445 PMCID: PMC6848033 DOI: 10.1007/s00277-019-03793-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/29/2019] [Indexed: 01/14/2023]
Abstract
Patients with polycythemia vera (PV) have a high incidence of thrombotic events (TEs), contributing to a greater mortality risk than the general population. The relationship between hematocrit (HCT) levels and TE occurrence among patients with PV from the Veterans Health Administration (VHA) was evaluated to replicate findings of the CYTO-PV trial with a real-world patient population. This retrospective study used VHA medical record and claims data from the first claim with a PV diagnosis (index) until death, disenrollment, or end of study, collected between October 1, 2005, and September 30, 2012. Patients were aged ≥ 18 years at index, had ≥ 2 claims for PV (ICD-9-CM code, 238.4) ≥ 30 days apart during the identification period, continuous health plan enrollment from 12 months pre-index until end of study, and ≥ 3 HCT measurements per year during follow-up. This analysis focused on patients with no pre-index TE, and with all HCT values either < 45% or ≥ 45% during the follow-up period. The difference in TE risk between HCT groups was assessed using unadjusted Cox regression models based on time to first TE. Patients (N = 213) were mean (SD) age 68.9 (11.5) years, 98.6% male, and 61.5% white. TE rates for patients with HCT values < 45% versus ≥ 45% were 40.3% and 54.2%, respectively. Among patients with ≥ 1 HCT before TE, TE risk hazard ratio was 1.61 (95% CI, 1.03–2.51; P = 0.036). This analysis of the VHA population further supports effective monitoring and control of HCT levels < 45% to reduce TE risk in patients with PV.
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232
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Wang W, Liu W, Fidler T, Wang Y, Tang Y, Woods B, Welch C, Cai B, Silvestre-Roig C, Ai D, Yang YG, Hidalgo A, Soehnlein O, Tabas I, Levine RL, Tall AR, Wang N. Macrophage Inflammation, Erythrophagocytosis, and Accelerated Atherosclerosis in Jak2 V617F Mice. Circ Res 2019; 123:e35-e47. [PMID: 30571460 DOI: 10.1161/circresaha.118.313283] [Citation(s) in RCA: 155] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
RATIONALE The mechanisms driving atherothrombotic risk in individuals with JAK2 V617F ( Jak2 VF) positive clonal hematopoiesis or myeloproliferative neoplasms are poorly understood. OBJECTIVE The goal of this study was to assess atherosclerosis and underlying mechanisms in hypercholesterolemic mice with hematopoietic Jak2 VF expression. METHODS AND RESULTS Irradiated low-density lipoprotein receptor knockout ( Ldlr-/-) mice were transplanted with bone marrow from wild-type or Jak2 VF mice and fed a high-fat high-cholesterol Western diet. Hematopoietic functions and atherosclerosis were characterized. After 7 weeks of Western diet, Jak2 VF mice showed increased atherosclerosis. Early atherosclerotic lesions showed increased neutrophil adhesion and content, correlating with lesion size. After 12 weeks of Western diet, Jak2 VF lesions showed increased complexity, with larger necrotic cores, defective efferocytosis, prominent iron deposition, and costaining of erythrocytes and macrophages, suggesting erythrophagocytosis. Jak2 VF erythrocytes were more susceptible to phagocytosis by wild-type macrophages and showed decreased surface expression of CD47, a "don't-eat-me" signal. Human JAK2VF erythrocytes were also more susceptible to erythrophagocytosis. Jak2 VF macrophages displayed increased expression and production of proinflammatory cytokines and chemokines, prominent inflammasome activation, increased p38 MAPK (mitogen-activated protein kinase) signaling, and reduced levels of MerTK (c-Mer tyrosine kinase), a key molecule mediating efferocytosis. Increased erythrophagocytosis also suppressed efferocytosis. CONCLUSIONS Hematopoietic Jak2 VF expression promotes early lesion formation and increased complexity in advanced atherosclerosis. In addition to increasing hematopoiesis and neutrophil infiltration in early lesions, Jak2 VF caused cellular defects in erythrocytes and macrophages, leading to increased erythrophagocytosis but defective efferocytosis. These changes promote accumulation of iron in plaques and increased necrotic core formation which, together with exacerbated proinflammatory responses, likely contribute to plaque instability.
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Affiliation(s)
- Wei Wang
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Wenli Liu
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY.,Tianjin Key Laboratory of Metabolic Diseases, Department of Physiology and Pathophysiology, Tianjin Medical University, China (W.L., D.A.)
| | - Trevor Fidler
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Ying Wang
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Yang Tang
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Brittany Woods
- Human Oncology and Pathogenesis Program (B.W., R.L.L.), Memorial Sloan Kettering Cancer Center, New York, NY.,Leukemia Service, Department of Medicine (B.W., R.L.L.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carrie Welch
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Bishuang Cai
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Carlos Silvestre-Roig
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-University, Munich, Germany (C.S.-R., A.H., O.S.)
| | - Ding Ai
- Tianjin Key Laboratory of Metabolic Diseases, Department of Physiology and Pathophysiology, Tianjin Medical University, China (W.L., D.A.)
| | - Yong-Guang Yang
- Columbia Center for Translational Immunology (Y.-G.Y.), Columbia University Medical Center, New York, NY
| | - Andres Hidalgo
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-University, Munich, Germany (C.S.-R., A.H., O.S.).,Area of Developmental and Cell Biology, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (A.H.)
| | - Oliver Soehnlein
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-University, Munich, Germany (C.S.-R., A.H., O.S.).,Department of Physiology and Pharmacology (FyFa), Karolinska Institutet, Stockholm, Sweden (O.S.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany (O.S.)
| | - Ira Tabas
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Ross L Levine
- Human Oncology and Pathogenesis Program (B.W., R.L.L.), Memorial Sloan Kettering Cancer Center, New York, NY.,Leukemia Service, Department of Medicine (B.W., R.L.L.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alan R Tall
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
| | - Nan Wang
- From the Division of Molecular Medicine, Department of Medicine (W.W., W.L., T.F., Y.W., Y.T., C.W., B.C., I.T., A.R.T., N.W.), Columbia University Medical Center, New York, NY
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233
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Bakalov V, Tang A, Yellala A, Kaplan R, Lister J, Sadashiv S. Risk factors for venous thromboembolism in hospitalized patients with hematological malignancy: an analysis of the National Inpatient Sample, 2011–2015. Leuk Lymphoma 2019; 61:370-376. [DOI: 10.1080/10428194.2019.1666380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Veli Bakalov
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Amy Tang
- Department of Public Health, Henry Ford Health System, Detroit, MI, USA
| | - Amulya Yellala
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Robert Kaplan
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - John Lister
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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234
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Guy A, James C. [Pathogenesis of thrombosis in JAK2V617F myeloproliferative neoplasms]. Med Sci (Paris) 2019; 35:651-658. [PMID: 31532377 DOI: 10.1051/medsci/2019133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BCR-ABL negative myeloproliferative neoplasms are acquired hematologic diseases characterized by blood cell proliferation and that include polycythemia vera (PV), essential thrombocytemia (ET) and primary myelofibrosis (PMF). Occurring of venous and arterial thrombosis is the main complication of these diseases. Risk factors for thrombosis are individuals older than 60 and history of thrombosis. The mechanisms leading to thrombosis are complex and involve several blood compartments, plasmatic factors and endothelial cells. Over the last years, new actors of thrombosis have been discovered.
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Affiliation(s)
- Alexandre Guy
- CHU de Bordeaux, Laboratoire d'hématologie, 1, avenue de Magellan, F-33600, Pessac, France. - Univ. Bordeaux, Inserm, UMR 1034, Biologie des maladies cardio-vasculaires, 1, avenue de Magellan, F-33600, Pessac, France
| | - Chloé James
- CHU de Bordeaux, Laboratoire d'hématologie, 1, avenue de Magellan, F-33600, Pessac, France. - Univ. Bordeaux, Inserm, UMR 1034, Biologie des maladies cardio-vasculaires, 1, avenue de Magellan, F-33600, Pessac, France
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235
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The impact of phlebotomy and hydroxyurea on survival and risk of thrombosis among older patients with polycythemia vera. Blood Adv 2019; 2:2681-2690. [PMID: 30333100 DOI: 10.1182/bloodadvances.2018021436] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/19/2018] [Indexed: 01/12/2023] Open
Abstract
Current guidelines recommend therapeutic phlebotomy for all polycythemia vera (PV) patients and additional cytoreductive therapy (eg, hydroxyurea [HU]) for high-risk PV patients. Little is known about the impact of these therapies in the real-world setting. We conducted a retrospective cohort study of older adults diagnosed with PV from 2007 to 2013 using the linked Surveillance, Epidemiology, and End Results-Medicare database. Multivariable Cox proportional hazards models were used to assess the effect of phlebotomy and HU on overall survival (OS) and the occurrence of thrombotic events. Of 820 PV patients (median age = 77 years), 16.3% received neither phlebotomy nor HU, 23.0% were managed with phlebotomy only, 19.6% with HU only, and 41.1% with both treatments. After a median follow-up of 2.83 years, 37.2% (n = 305) of the patients died. Phlebotomy (yes/no; hazard ratio [HR] = 0.65; 95% confidence interval [CI], 0.51-0.81; P < .01), increasing phlebotomy intensity (HR = 0.71; 95% CI, 0.65-0.79; P < .01), and a higher proportion of days covered (PDC) by HU were all significantly associated with lower mortality. When thrombosis was the outcome of interest, phlebotomy (yes/no; HR = 0.52; 95% CI, 0.42-0.66; P < .01) and increasing phlebotomy intensity (HR = 0.46; 95% CI, 0.29-0.74; P < .01) were significantly associated with a lower risk of thrombotic events, so was a higher HU PDC. In this population-based study of older adults with PV reflecting contemporary clinical practice, phlebotomy and HU were associated with improved OS and decreased risk of thrombosis. However, both treatment modalities were underused in this cohort of older PV patients.
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236
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Loo SY, Azoulay L, Nie R, Dell'Aniello S, Yu OHY, Renoux C. Cardiovascular and Cerebrovascular Safety of Testosterone Replacement Therapy Among Aging Men with Low Testosterone Levels: A Cohort Study. Am J Med 2019; 132:1069-1077.e4. [PMID: 30953635 DOI: 10.1016/j.amjmed.2019.03.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE We assessed the risk of ischemic stroke, transient ischemic attack, and myocardial infarction associated with testosterone replacement therapy (TRT) among aging men with low testosterone levels. METHODS Using the UK Clinical Practice Research Datalink, we formed a cohort of men aged 45 years or older with low testosterone levels and no evidence of hypogonadotropic or testicular disease, between 1995 and 2017. Hazard ratios (HRs) and 95% confidence intervals (CIs) of a composite of ischemic stroke/transient ischemic attack and myocardial infarction were estimated using time-dependent Cox proportional hazards models, comparing current use of TRT with nonuse. RESULTS The cohort included 15,401 men. During 71,541 person-years of follow-up, 850 patients experienced an ischemic stroke/transient ischemic attack/myocardial infarction (crude incidence rate 1.19 [95% confidence interval (CI), 1.11-1.27] per 100 persons per year). Compared with nonuse, current use of TRT was associated with an increased risk of the composite outcome (HR 1.21; 95% CI, 1.00-1.46). This risk was highest in the first 6 months to 2 years of continuous TRT use (HR 1.35; 95% CI, 1.01-1.79), as well as among men aged 45-59 years (HR 1.44; 95% CI, 1.07-1.92). CONCLUSIONS TRT may increase the risk of cardiovascular events in aging men with low testosterone levels, particularly in the first 2 years of use. In the absence of identifiable causes of hypogonadism, TRT should be initiated with caution among aging men with low testosterone levels.
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Affiliation(s)
- Simone Y Loo
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
| | - Rui Nie
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Division of Endocrinology, Jewish General Hospital, Montreal, Québec, Canada
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada.
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237
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Bose P, Verstovsek S. Updates in the management of polycythemia vera and essential thrombocythemia. Ther Adv Hematol 2019; 10:2040620719870052. [PMID: 31516686 PMCID: PMC6719465 DOI: 10.1177/2040620719870052] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 12/25/2022] Open
Abstract
Polycythemia vera (PV) and essential thrombocythemia (ET) are both classic, relatively indolent, chronic Philadelphia-chromosome-negative (Ph-) myeloproliferative neoplasms (MPNs) characterized by elevated blood counts, thrombotic as well as hemorrhagic tendencies, a variety of symptoms, cumulative risks of progression to myelofibrosis and transformation to acute myeloid leukemia over time, and long survival. Molecularly, PV is more homogenous, being driven by JAK2 mutations in virtually all cases, while ET can be JAK2-, CALR-, or MPL-mutated, as well as 'triple negative'. Recent targeted next-generation sequencing efforts have identified other, nondriver gene mutations, some with prognostic relevance. Prevention of thrombotic and hemorrhagic complications continues to be the major focus of management, although symptoms are increasingly being recognized as a relatively unmet need, particularly in ET. Thrombotic risk stratification in PV is still based on age and history of thrombosis, while in ET, the additional contribution of JAK2 V617F to thrombotic risk is now well established. The associations of leukocytosis with clotting risk (in both conditions) and mortality (in PV) have drawn increased attention with the availability of ruxolitinib as a second-line treatment in PV. Similarly, there is a renewed interest in interferons with the emergence of ropeginterferon alfa-2b as a potential new frontline treatment option in PV. Drug development is more difficult in ET, the most indolent of the classic Ph- MPNs, but ruxolitinib is being studied. Triggering apoptosis via the p53 pathway through pharmacologic inhibition of human double minute 2 (and synergism with interferon) is a new, promising therapeutic strategy.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, FC4.3062 (Unit 428), Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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238
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Barbui T, De Stefano V, Falanga A, Finazzi G, Martinelli I, Rodeghiero F, Vannucchi AM, Barosi G. Addressing and proposing solutions for unmet clinical needs in the management of myeloproliferative neoplasm-associated thrombosis: A consensus-based position paper. Blood Cancer J 2019; 9:61. [PMID: 31395856 PMCID: PMC6687826 DOI: 10.1038/s41408-019-0225-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
This article presents the results of a group discussion among an ad hoc constituted Panel of experts aimed at highlighting unmet clinical needs (UCNs) in the management of thrombotic risk and thrombotic events associated with Philadelphia-negative myeloproliferative neoplasms (Ph-neg MPNs). With the Delphi technique, the challenges in Ph-neg MPN-associated thrombosis were selected. The most clinically relevant UCNs resulted in: (1) providing evidence of the benefits and risks of direct oral anticoagulants, (2) providing evidence of the benefits and risks of cytoreduction in patients with splanchnic vein thrombosis without hypercythemia, (3) improving knowledge of the role of the mutated endothelium in the pathogenesis of thrombosis, (4) improving aspirin dosing regimens in essential thrombocythemia, (5) improving antithrombotic management of Ph-neg MPN-associated pregnancy, (6) providing evidence for the optimal duration of anticoagulation for prophylaxis of recurrent VTE, (7) improving knowledge of the association between somatic gene mutations and risk factors for thrombosis, and (8) improving the grading system of thrombosis risk in polycythemia vera. For each of these issues, proposals for advancement in research and clinical practice were addressed. Hopefully, this comprehensive overview will serve to inform the design and implementation of new studies in the field.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Ematologia, Università Cattolica, Roma, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and the Haemostasis and Thrombosis Center, Papa Giovanni XXIII Hospital, Bergamo, Italy.,University of Milan Bicocca, Milan, Italy
| | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, Dept Experimental and Clinical medicine, and Denothe Center, University of Florence, Florence, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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239
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Perner F, Perner C, Ernst T, Heidel FH. Roles of JAK2 in Aging, Inflammation, Hematopoiesis and Malignant Transformation. Cells 2019; 8:cells8080854. [PMID: 31398915 PMCID: PMC6721738 DOI: 10.3390/cells8080854] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/22/2022] Open
Abstract
Clonal alterations in hematopoietic cells occur during aging and are often associated with the establishment of a subclinical inflammatory environment. Several age-related conditions and diseases may be initiated or promoted by these alterations. JAK2 mutations are among the most frequently mutated genes in blood cells during aging. The most common mutation within the JAK2 gene is JAK2-V617F that leads to constitutive activation of the kinase and thereby aberrant engagement of downstream signaling pathways. JAK2 mutations can act as central drivers of myeloproliferative neoplasia, a pre-leukemic and age-related malignancy. Likewise, hyperactive JAK-signaling is a hallmark of immune diseases and critically influences inflammation, coagulation and thrombosis. In this review we aim to summarize the current knowledge on JAK2 in clonal hematopoiesis during aging, the role of JAK-signaling in inflammation and lymphocyte biology and JAK2 function in age-related diseases and malignant transformation.
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Affiliation(s)
- Florian Perner
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany
- Leibniz-Institute on Aging-Fritz Lipmann Institute (FLI), 07745 Jena, Germany
- Dana-Farber Cancer Institute, Department of Pediatric Oncology, Harvard University, Boston, MA 02467, USA
| | - Caroline Perner
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, 02129 MA, USA
| | - Thomas Ernst
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany
| | - Florian H Heidel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany.
- Leibniz-Institute on Aging-Fritz Lipmann Institute (FLI), 07745 Jena, Germany.
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240
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Foltz L, Pica GM, Zerazhi H, Van Droogenbroeck J, Visanica S, Báez de la Fuente E, Leber B, de Almeida AM, Ranta D, Kiladjian JJ, Chrit L, Kandra A, Morando J, Devos T. Safety and efficacy findings from the open-label, multicenter, phase 3b, expanded treatment protocol study of ruxolitinib for treatment of patients with polycythemia vera who are resistant/intolerant to hydroxyurea and for whom no alternative treatments are available. Leuk Lymphoma 2019; 60:3493-3502. [DOI: 10.1080/10428194.2019.1636985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Lynda Foltz
- St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
| | - Gian-Matteo Pica
- Service of Hematology, Centre Hospitalier Métropole Savoie, Chambery, France
| | | | | | - Sorin Visanica
- Service Hématologie, Hôpital Belle Isle, HP Metz, France
| | | | - Brian Leber
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Dana Ranta
- Centre Hospitalier Universitaire, Nancy, France
| | - Jean-Jacques Kiladjian
- Centre d’Investigations Cliniques, AP-HP, Hôpital Saint-Louis, Université Paris Diderot, INSERM CIC 1427, Paris, France
| | | | | | | | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Experimental Transplantation, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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241
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van de Ree-Pellikaan C, de Kreuk A, Schaar CG, Beeker A, Dompeling EC, Gerrits CJH, van Houten AA, Schipperus MR, Strobbe L, Posthuma EFM, Klauke K, Westerweel PE. Treatment strategies for polycythemia vera: Observations in a Dutch "real-world" cohort study. Eur J Haematol 2019; 103:453-459. [PMID: 31298768 DOI: 10.1111/ejh.13291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Assessment of "real-world" treatment strategies and outcome in Dutch polycythemia vera (PV) patients. METHODS Retrospective chart review in 150 patients with PV (WHO 2008 diagnostic criteria) from 10 major non-academic hospitals in the Netherlands. RESULTS Patients (median age 64 years, 49% male) frequently had cardiovascular risk factors (56%) and prior vascular events (31%). About 70% of patients were high-risk, based on ELN criteria. However, the majority of patients were treated with phlebotomies alone (55%). Cytoreduction with hydroxyurea (HU) was received by 44% as part of their initial therapy, with or without phlebotomies. The time to achieve the 45% hematocrit target was shortest in patients treated with phlebotomies with or without HU (125 ± 99 and 197 ± 249 days, respectively) compared to patients treated with only HU (232 ± 216 days). Leukocyte and platelet levels were lower in HU-treated patients, and ELN response targets were more often reached. During the median follow-up period of 4.1 years, 14 patients (9%) suffered a thrombotic vascular event. CONCLUSIONS In Dutch clinical practice, there is major clinical variation in treatment strategies for PV. Phlebotomizing patients shorten the time to achieve hematocrit control, while HU better controls platelet and leukocyte levels. The thrombotic vascular event rate remains clinically significant.
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Affiliation(s)
| | - Arne de Kreuk
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
| | - Cees G Schaar
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
| | - Aart Beeker
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Ellen C Dompeling
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Cees J H Gerrits
- Department of Internal Medicine, Ziekenhuisgroep Twente, Hengelo, The Netherlands
| | - Anja A van Houten
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Martin R Schipperus
- Department of Hematology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Leonie Strobbe
- Department of Internal Medicine, Gelre Hospital, Zutphen, The Netherlands
| | | | | | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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242
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A Man with Seizures and Refractory Hypoxemia. Ann Am Thorac Soc 2019; 14:448-451. [PMID: 28248573 DOI: 10.1513/annalsats.201604-291cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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243
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Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
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244
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Riekki TR, Ling E, Cordovani D. Laparoscopic hepatectomy in a patient with uncontrolled polycythaemia vera. Anaesth Rep 2019; 7:92-95. [PMID: 32051960 DOI: 10.1002/anr3.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 11/06/2022] Open
Abstract
This case report describes the peri-operative course of a patient with uncontrolled polycythaemia vera who underwent a laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. Polycythaemia vera is a chronic condition that results in erythrocytosis and puts patients at risk of peri-operative complications including thrombotic events and paradoxical haemorrhage. Little evidence exists on the ideal peri-operative management of uncontrolled polycythaemia vera when the proposed procedure carries a high risk of haemorrhage. Our patient presented with a pre-operative haemoglobin of 197 g.l-1 (haematocrit 65%) and was not phlebotomised pre-operatively. Intra-operatively he lost 2700 ml of blood, reducing his haematocrit to 48%, and then suffered fatal thrombotic complications postoperatively. The patient did not receive any blood product transfusions during his peri-operative course. We review the available evidence to guide the peri-operative management of patients with polycythaemia vera. The inherent risks of thrombosis and haemorrhage associated with polycythaemia vera need to be weighed against the specific surgical and transfusion-related risks. Phlebotomy to achieve a pre-operative haematocrit under 45% is recommended and intra-operative phlebotomy shows promise for reducing blood loss during hepatectomies. Management of postoperative erythrocytosis may be an important and underappreciated aspect of reducing the peri-operative risk of thrombosis in patients with polycythaemia vera.
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Affiliation(s)
| | - E Ling
- McMaster University Hamilton ON Canada
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245
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Grunwald MR, Burke JM, Kuter DJ, Gerds AT, Stein B, Walshauser MA, Parasuraman S, Colucci P, Paranagama D, Savona MR, Mesa R. Symptom Burden and Blood Counts in Patients With Polycythemia Vera in the United States: An Analysis From the REVEAL Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:579-584.e1. [PMID: 31303457 PMCID: PMC8148986 DOI: 10.1016/j.clml.2019.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Approximately 50% of patients with polycythemia vera (PV) have PV-related symptoms at diagnosis; these symptoms might develop or worsen with time. Symptoms have been shown to negatively affect quality of life and interfere with daily activities. To our knowledge, an analysis to evaluate the relationship between blood count control and symptoms has not been published. PATIENTS AND METHODS The Prospective Observational Study of Patients with Polycythemia Vera in US Clinical Practices (REVEAL; NCT02252159) is a multicenter, noninterventional, nonrandomized prospective observational study of patients with PV in the United States. Patients included were required to have a complete blood count result within 30 days before completing the at-enrollment Myeloproliferative Neoplasm Self-Assessment Form Total Symptom Score (MPN-SAF TSS). Symptom severity was compared between those who had blood count control versus those who did not. RESULTS At the time of enrollment, 1714 patients (94.5%) were being managed with cytoreductive therapy; 468 patients (25.8%) had complete hematologic remission (CHR), 1614 patients (89.0%) had ≥1 controlled blood count, and 1122 patients (61.9%) had ≥2 controlled blood counts. Mean MPN-SAF TSSs were similar across patients in different blood count control groups. Fatigue was the most frequently reported symptom. The severity of individual symptoms, except those of pruritus and night sweats, was not affected by CHR or the number of blood counts that were controlled. CONCLUSION Symptom burden in patients with PV can persist despite control of blood counts, which suggests some discordance between laboratory values and symptom burden. Consequently, regular monitoring of symptom burden should be factored into the assessment of disease control.
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Affiliation(s)
- Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC.
| | - John M Burke
- US Oncology Hematology Research Program, Rocky Mountain Cancer Centers, Aurora, CO
| | - David J Kuter
- Center for Hematology, Massachusetts General Hospital, Boston, MA
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Brady Stein
- Department of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Mark A Walshauser
- Department of Medical Oncology and Hematology, Cancer Care Specialists of Illinois, Swansea, IL
| | | | | | | | - Michael R Savona
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Ruben Mesa
- Department of Hematology and Oncology, The University of Texas Health Science Center, San Antonio, TX
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246
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Abstract
Since its discovery, polycythemia vera (PV) has challenged clinicians responsible for its diagnosis and management and scientists investigating its pathogenesis. As a clonal hematopoietic stem cell (HSC) disorder, PV is a neoplasm but its driver mutations result in overproduction of morphologically and functionally normal blood cells. PV arises in an HSC but it can present initially as isolated erythrocytosis, leukocytosis, thrombocytosis, or any combination of these together with splenomegaly or myelofibrosis, and it can take years for a true panmyelopathy to appear. PV shares the same JAK2 mutation as essential thrombocytosis and primary myelofibrosis, but erythrocytosis only occurs in PV. However, unlike secondary causes of erythrocytosis, in PV, the plasma volume is frequently expanded, masking the erythrocytosis and making diagnosis difficult if this essential fact is ignored. PV is not a monolithic disorder: female patients deregulate fewer genes and clinically behave differently than their male counterparts, while some PV patients are genetically predisposed to an aggressive clinical course. Nevertheless, based on what we have learned over the past century, most PV patients can lead long and productive lives. In this review, using clinical examples, I describe how I diagnose and manage PV in an evidence-based manner without relying on chemotherapy.
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247
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Gordon B, Fischbeck T, Salamo R, Schroff S. Treating Myomatous Erythrocytosis Syndrome With Uterine Artery Embolization. Obstet Gynecol 2019; 133:1274-1277. [PMID: 31135745 DOI: 10.1097/aog.0000000000003289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Myomatous erythrocytosis syndrome, a form of secondary polycythemia associated with uterine leiomyomas, increases the risk of thrombosis and traditionally has been treated with hysterectomy. CASE The patient is a 68-year-old woman with 7-year history of polycythemia initially thought to be secondary to a gastrointestinal stromal tumor that persisted after resection. A subsequent search for an alternative etiology led to the discovery of an 11.2-cm submucosal leiomyoma and likelihood of myomatous erythrocytosis syndrome. The patient declined surgical management and continued to undergo recurrent phlebotomy to maintain a hematocrit of less than 45% until consultation with an interventional radiology specialist. She underwent uterine artery embolization in July 2017, and her hematocrit has remained within normal limits through 17 months of follow-up. CONCLUSION Uterine artery embolization is an effective alternative treatment modality for myomatous erythrocytosis syndrome.
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Affiliation(s)
- Brian Gordon
- Department of Obstetrics and Gynecology and the Department of Radiology, Division of Vascular and Interventional Radiology, University of Southern California, Los Angeles, California
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248
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Ferrari A, Carobbio A, Masciulli A, Ghirardi A, Finazzi G, De Stefano V, Vannucchi AM, Barbui T. Clinical outcomes under hydroxyurea treatment in polycythemia vera: a systematic review and meta-analysis. Haematologica 2019; 104:2391-2399. [PMID: 31123026 PMCID: PMC6959178 DOI: 10.3324/haematol.2019.221234] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/20/2019] [Indexed: 12/29/2022] Open
Abstract
Hydroxyurea is the standard treatment in high-risk patients with polycythemia vera. However, estimates of its effect in terms of clinical outcomes (thrombosis, bleeding, hematologic transformations and mortality) are lacking. We performed a meta-analysis to determine the absolute risk of events in recent cases of patients under hydroxyurea treatment. We searched for relevant articles or abstracts in the following databases: Medline, EMBASE, clinicaltrials.gov, WHO International Clinical Trials Registry, LILACS. Sixteen studies published from 2008 to 2018 reporting number of events using World Health Organization diagnosis for polycythemia vera were selected. Through a random effect logistic model, incidences, study heterogeneity and confounder effects were estimated for each outcome at different follow ups. Overall, 3,236 patients were analyzed. While incidences of thrombosis and acute myeloid leukemia were stable over time, mortality and myelofibrosis varied depending on follow-up duration. Thrombosis rates were 1.9%, 3.6% and 6.8% persons/year at median ages 60, 70 and 80 years, respectively. Higher incidence of arterial events was predicted by previous cardiovascular complication. Leukemic transformation incidence was 0.4% persons/year. Incidence of transformation to myelofibrosis and mortality were significantly dependent on age and follow-up duration. For myelofibrosis, rates were 5.0 at five years and 33.7% at ten years; overall mortality was 12.6% and 56.2% at five and ten years, respectively. In conclusion, we provide reliable risk estimates for the main outcomes in polycythemia vera patients under hydroxyurea treatment. These findings can help design comparative clinical trials with new cytoreductive drugs and prove the feasibility of using critical end points for efficacy, such as major thrombosis.
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Affiliation(s)
| | | | | | | | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII Hospital, Bergamo
| | - Valerio De Stefano
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Alessandro Maria Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tiziano Barbui
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo
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249
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Mochizuki T, Tanabe K, Saito R, Ota H, Yamamoto Y, Saeki Y, Ohdan H. Perioperative management of polycythemia vera with advanced gastric cancer: A case report. Int J Surg Case Rep 2019; 58:224-227. [PMID: 31112910 PMCID: PMC6527945 DOI: 10.1016/j.ijscr.2019.04.022] [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: 01/30/2019] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 11/11/2022] Open
Abstract
We report a case involving operation for gastric cancer after treatment for PV. Control of WBC and Plt counts during the perioperative period led to good results. Perioperative management for PV is important for complication-free surgery. Careful follow up should be performed for gastric cancer and PV recurrence.
Introduction Polycythemia vera (PV) is a chronic myeloproliferative disorder with generally good prognosis. However, thrombotic and cardiovascular complications are among the leading causes of death in patients with PV and sufficiently effective management strategies are yet to be established. We report a case involving operation for gastric cancer in a patient being treated for PV. Presentation of case A 73-year-old man was diagnosed as PV on the basis of abnormal laboratory data eight years previously. Three months ago, he was referred to our department for anorexia and melena. The preoperative diagnosis was advanced gastric cancer, Stage IIB. To avoid perioperative thrombotic and hemorrhagic events, low-dose aspirin administration was continued with an additional dose of hydroxyurea. Emergent control was necessary because of the severity of gastric cancer symptoms, including pyloric stenosis and anemia. Distal gastrectomy with D2 lymph node resection was performed. The postoperative course was satisfactory, and the patient is currently doing well without any signs of recurrence or hematological complications. Discussion We described the successful management of a patient being treated for PV who underwent gastrectomy. As mentioned earlier, thrombotic complications and hemorrhage during the perioperative period are the major risk factors in patients with PV. In this case, control of white blood cell and platelet counts during the perioperative period led to good results. Conclusions Perioperative management for PV is important for complication-free surgery. Careful follow up should be performed for gastric cancer and PV recurrence.
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Affiliation(s)
- Tetsuya Mochizuki
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazuaki Tanabe
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Ryusuke Saito
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroshi Ota
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yuji Yamamoto
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yoshihiro Saeki
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biochemical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Tavares RS, Nonino A, Pagnano KBB, Nascimento ACKVD, Conchon M, Fogliatto LM, Funke VAM, Bendit I, Clementino NCD, Chauffaille MDLLF, Bernardo WM, Santos FPDS. Guideline on myeloproliferative neoplasms: Associacão Brasileira de Hematologia, Hemoterapia e Terapia Cellular: Project guidelines: Associação Médica Brasileira - 2019. Hematol Transfus Cell Ther 2019; 41 Suppl 1:1-73. [PMID: 31248788 PMCID: PMC6630088 DOI: 10.1016/j.htct.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Alexandre Nonino
- Instituto Hospital de Base do Distrito Federal (IHBDF), Brasília, DF, Brazil
| | | | | | | | | | | | - Israel Bendit
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Hospital Das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
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