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Kuipers RS, Kok L, Virmani R, Tefferi A. Essential thrombocytosis: diagnosis, differential diagnosis, complications and treatment considerations of relevance for a cardiologist. Neth Heart J 2023; 31:371-378. [PMID: 36757576 PMCID: PMC10516821 DOI: 10.1007/s12471-023-01757-4] [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: 12/06/2022] [Indexed: 02/10/2023] Open
Abstract
Essential thrombocytosis (ET) is a rare haematological malignancy, with an incidence rate of 1.5-2.5/100,000 per year. For many patients with ET the first manifestation of their underlying disease is a thrombotic or haemorrhagic complication. A recent retrospective study revealed an incidence rate of at least 2.1% in people under 40 years presenting with an acute coronary syndrome, although the diagnosis was initially missed in all cases. Thus, cardiologists face a much higher than average incidence rate of ET in their daily practice, but seem insufficiently aware of the disease. The current review summarises symptoms, (differential) diagnosis, complications and treatment considerations of ET of relevance for a cardiologist. Typical symptoms, besides thrombosis and haemorrhage, include erythromelalgia and aquagenic pruritus, while platelets > 450 × 109/l are a diagnostic for ET once other myeloproliferative neoplasms, secondary and spurious thrombocytosis have been excluded. With regard to treatment, timing of revascularisation depends on the presence of ischaemia and concurrent platelet counts. In the presence of ischaemia, revascularisation should not be delayed and adequate platelet counts can be achieved by platelet apheresis. In the absence of ischaemia, revascularisation can be delayed until adequate platelet counts have been achieved by cytoreductive therapies. Cardiologists should be aware of/screen for possible ET.
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Affiliation(s)
- R S Kuipers
- OLVG Heart Centre, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
- Department of Cardiology, Dijklander Hospital, Purmerend/Hoorn, The Netherlands.
| | - L Kok
- OLVG Heart Centre, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Cardiology, Spaarne Hospital, Haarlem, The Netherlands
| | - R Virmani
- CVPath Institute, Gaithersburg, MD, USA
| | - A Tefferi
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
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Le Gall-Ianotto C, Ficheux AS, Lippert E, Herbreteau L, Rio L, Pan-Petesch B, Misery L, Ianotto JC. Differences between aquagenic and non-aquagenic pruritus in myeloproliferative neoplasms: An observational study of 500 patients. J Eur Acad Dermatol Venereol 2023; 37:1175-1183. [PMID: 36808754 DOI: 10.1111/jdv.18990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Pruritus is a frequent symptom experienced by patients with myeloproliferative neoplasms (MPN). Aquagenic pruritus (AP) is the most common type. The Myeloproliferative Neoplasm-Symptom Assessment Form Total Symptom Score (MPN-SAF TSS) self-report questionnaires were distributed to MPN patients before consultations. OBJECTIVES The aim of this study was to assess clinical incidence (phenotypical evolution and response to treatment) of pruritus, especially AP, in MPN patients during their follow-ups. PATIENTS AND METHODS We collected 1444 questionnaires from 504 patients [54.4% essential thrombocythaemia (ET) patients, 37.7% polycythaemia vera (PV) patients, and 7.9% primary myelofibrosis (PMF) patients]. RESULTS Pruritus was reported by 49.8% of the patients, including 44.6% of AP patients, regardless of type of MPN or driver mutations. Patients suffering from pruritus were more symptomatic and had a higher rate of evolution into myelofibrosis/acute myeloid leukaemia (19.5% vs. 9.1%, OR = 2.42 [1.39; 4.32], p = 0.0009) than MPN patients without pruritus. Patients with AP had the highest pruritus intensity values (p = 0.008) and a higher rate of evolution (25.9% vs. 14.4%, p = 0.025, OR = 2.07) than patients with non-AP. Disappearance of pruritus was observed in only 16.7% of AP cases, compared to 31.7% of cases with other types of pruritus (p < 0.0001). Ruxolitinib and hydroxyurea were the most effective drugs to reduce AP intensity. CONCLUSIONS In this study, we demonstrate the global incidence of pruritus across all MPN. Pruritus, especially AP, which is a major constitutional symptom observed in MPN, should be assessed in all MPN patients due to higher symptom burden and higher risk of evolution.
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Affiliation(s)
| | - Anne-Sophie Ficheux
- Service de Dermatologie, CHRU de Brest, Brest, France.,Univ Brest, LIEN, CHRU Brest, Brest, France
| | - Eric Lippert
- Laboratoire d'Hématologie, CHRU de Brest, Brest, France.,France Intergroupe des Néoplasies Myéloprolifératives (FIM), Paris, France
| | - Laura Herbreteau
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France
| | - Laetitia Rio
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France
| | - Brigitte Pan-Petesch
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France.,INSERM, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Laurent Misery
- Service de Dermatologie, CHRU de Brest, Brest, France.,Univ Brest, LIEN, CHRU Brest, Brest, France
| | - Jean-Christophe Ianotto
- France Intergroupe des Néoplasies Myéloprolifératives (FIM), Paris, France.,Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France.,INSERM, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
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Le Gall-Ianotto C, Verdet R, Nowak E, Le Roux L, Gasse A, Fiedler A, Carlhant-Kowalski D, Marcorelles P, Misery L, Ianotto JC. Rationale and design of the multicentric, double-blind, double-placebo, randomized trial APrepitant versus HYdroxyzine in association with cytoreductive treatments for patients with myeloproliferative neoplasia suffering from Persistent Aquagenic Pruritus. Trial acronym: APHYPAP. Trials 2021; 22:938. [PMID: 34923994 PMCID: PMC8686668 DOI: 10.1186/s13063-021-05864-8] [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: 06/30/2021] [Accepted: 11/23/2021] [Indexed: 12/04/2022] Open
Abstract
Background Aquagenic pruritus (AP), an intense sensation of scratching induced after water contact, is the most troublesome aspect of BCR-ABL1-negative myeloproliferative neoplasms (MPNs). Mostly described in polycythemia vera (PV, ~ 40%), it is also present in essential thrombocythemia (ET) and primary myelofibrosis (PMF) (10%). Even if this symptom can decrease or disappear under cytoreductive treatments, 30% of treated MPN patients still persist with a real impact on the quality of life (QoL). Because its pathophysiology is poorly understood, efficient symptomatic treatments of AP are missing. The neuropeptide substance P (SP) plays a crucial role in the induction of pruritus. Several studies showed the efficacy of aprepitant, an antagonist of SP receptor (NK-1R), in the treatment of chronic pruritus but never evaluated in AP. The objectives of APHYPAP are twofold: a clinical aim with the evaluation of the efficacy of two drugs in the treatment of a persistent AP for MPN patients and a biological aim to find clues to elucidate AP pathophysiology. Methods/design A multicentric, double-blind, double-placebo, randomized study will include 80 patients with MPN (PV or ET or PMF) treated since at least 6 months for their hemopathy but suffering from a persistent AP (VAS intensity ≥6/10). Patients will be randomized between aprepitant (80 mg daily) + placebo to match to hydroxyzine OR hydroxyzine (25 mg daily) + placebo to match to aprepitant for 14 days. At D0, baseline information will be collected and drugs dispense. Outcome measures will be assessed at D15, D30, D45, and D60. The primary study endpoint will be the reduction of pruritus intensity below (or equal) at 3/10 on VAS at D15. Secondary outcome measures will include the number of patients with a reduction or cessation of AP at D15 or D60; evaluation of QoL and AP characteristics at D0, D15, D30, D45, and D60 with MPN-SAF and AP questionnaires, respectively; modification of plasmatic concentrations of cytokines and neuropeptides at D0, D15, D30, and D60; and modification of epidermal innervation density and pruriceptor expression at D0 and D15. Discussion The APHYPAP trial will examine the efficacy of aprepitant vs hydroxyzine (reference treatment for AP) to treat persistent AP in MPN patients. The primary objective is to demonstrate the superiority of aprepitant vs hydroxyzine to treat persistent AP of MPN patients. The treatment received will be considered efficient if the AP intensity will be reduced at 3/10 or below on VAS after 14 days of treatment. The results of this study may provide a new treatment option for this troublesome symptom and also give us more insights in the pathophysiology understanding of AP. Trial registration APHYPAP. NCT03808805, first posted: January 18, 2019; last update posted: June 10, 2021. EudraCT 2018-090426-66
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Low-Risk Essential Thrombocythemia: A Comprehensive Review. Hemasphere 2021; 5:e521. [PMID: 33880431 PMCID: PMC8051994 DOI: 10.1097/hs9.0000000000000521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022] Open
Abstract
Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by a persistently elevated platelet count in the absence of a secondary cause. The clinical consequences of uncontrolled thrombocytosis can include both thrombosis and hemorrhage. Patients with features conferring a “high risk” of vascular events benefit from reduction of the platelet count through cytoreductive therapy. The management of patients who lack such high-risk features has until recently been less well defined, but it is now apparent that many require minimal or even no intervention. In this review, we discuss the diagnostic pathway for younger patients with unexplained thrombocytosis, including screening molecular investigations, the role of bone marrow biopsy, and investigations in those patients negative for the classic myeloproliferative neoplasm driver mutations (JAK2, CALR, MPL). We discuss conventional and novel risk stratification methods in essential thrombocythemia and how these can be best applied in clinical practice, particularly in the era of more comprehensive genomic testing. The treatment approach for “low risk” patients is discussed including antiplatelets and the options for cytoreductive therapy, if indicated, together with areas of clinical need for future study.
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Stuckey R, López-Rodríguez JF, Sánchez-Sosa S, Segura-Díaz A, Sánchez-Farías N, Bilbao-Sieyro C, Gómez-Casares MT. Predictive indicators of successful tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia. World J Clin Oncol 2020; 11:996-1007. [PMID: 33437662 PMCID: PMC7769711 DOI: 10.5306/wjco.v11.i12.996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 09/28/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023] Open
Abstract
Clinical trials have demonstrated that some patients with chronic myeloid leukemia (CML) treated for several years with tyrosine kinase inhibitors (TKIs) who have maintained a molecular response can successfully discontinue treatment without relapsing. Treatment free remission (TFR) can be reached by approximately 50% of patients who discontinue. Despite having similar levels of deep molecular response and an identical duration of treatment, the factors that influence the successful discontinuation of CML patients remain to be determined. In this review we will explore the factors identified to date that can help predict whether a patient will successfully achieve TFR. We will also discuss the need for the identification of predictive biomarkers associated with a high probability of achieving TFR for the future personalized identification of patients who are suitable for the discontinuation of TKI treatment.
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Affiliation(s)
- Ruth Stuckey
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | | | - Santiago Sánchez-Sosa
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Adrián Segura-Díaz
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Nuria Sánchez-Farías
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - Cristina Bilbao-Sieyro
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
| | - María Teresa Gómez-Casares
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria 35019, Spain
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