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Nadiminti K, Silverman M, Bhagavathi S, Vikas P. t(15; 17) associated with primary myelofibrosis: a case report of an unusual clinical presentation and diagnostic dilemma. Onco Targets Ther 2019; 12:5449-5455. [PMID: 31371984 PMCID: PMC6633400 DOI: 10.2147/ott.s208290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/21/2019] [Indexed: 01/09/2023] Open
Abstract
Background primary myelofibrosis (PMF) is a myeloproliferative neoplasm which is associated with clonal molecular and cytogenetic abnormalities (CA) and varied clinical manifestations. While various CA have been previously described, t(15; 17) has not been reported in association with this condition. Case presentation A 69-year-old male presented with constitutional symptoms, cytopenias and bone marrow biopsy revealed immature blasts with fibrosis. Cytogenetic analysis showed a t(15;17) which initially suggested a diagnosis of acute promyelocytic leukemia (APL). However, flourescence in situ hybridization (FISH) and reverse transcriptase polymerase chain reaction (RT-PCR) studies were negative for transcripts promyelocytic leukemia (PML) gene and retinoic acid receptor alpha (RARA) or PML-RARA fusion. Along with these results, a second review of bone marrow histology, flowcytometry and the detection of a calreticulin gene (CALR) mutation helped with the correct diagnosis of PMF. Patient was then treated with ruxolitinib, a JAK (Janus kinase) 1 and 2 inhibitor, and eventually proceeded to receive a matched unrelated reduced intensity conditioning (RIC) allogeneic stem cell transplantation (ASCT) and has been doing well at the 6-month follow up. Conclusions Our case highlights two points, that the t(15;17) is diagnostic of Acute Promyelocytic Leukemia (APL) in most cases, there are exceptions and it can be associated with other malignancies without causing any APL like features, as noted in this case. Also, that t(15; 17) by itself is never sufficient to diagnose APL without confirmation by other methods and relying solely on cytogenetics without timely confirmatory tests can lead to risks of delay in diagnosis and appropriate management.
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Affiliation(s)
- Kalyan Nadiminti
- Division of Hematology and Blood and Marrow Transplantation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Margarida Silverman
- Division of Hematology and Blood and Marrow Transplantation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | | | - Praveen Vikas
- Division of Hematology and Blood and Marrow Transplantation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
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102
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Palumbo GA, Stella S, Pennisi MS, Pirosa C, Fermo E, Fabris S, Cattaneo D, Iurlo A. The Role of New Technologies in Myeloproliferative Neoplasms. Front Oncol 2019; 9:321. [PMID: 31106152 PMCID: PMC6498877 DOI: 10.3389/fonc.2019.00321] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/09/2019] [Indexed: 12/17/2022] Open
Abstract
The hallmark of BCR-ABL1-negative myeloproliferative neoplasms (MPNs) is the presence of a driver mutation in JAK2, CALR, or MPL gene. These genetic alterations represent a key feature, useful for diagnostic, prognostic and therapeutical approaches. Molecular biology tests are now widely available with different specificity and sensitivity. Recently, the allele burden quantification of driver mutations has become a useful tool, both for prognostication and efficacy evaluation of therapies. Moreover, other sub-clonal mutations have been reported in MPN patients, which are associated with poorer prognosis. ASXL1 mutation appears to be the worst amongst them. Both driver and sub-clonal mutations are now taken into consideration in new prognostic scoring systems and may be better investigated using next generation sequence (NGS) technology. In this review we summarize the value of NGS and its contribution in providing a comprehensive picture of mutational landscape to guide treatment decisions. Finally, discussing the role that NGS has in defining the potential risk of disease development, we forecast NGS as the standard molecular biology technique for evaluating these patients.
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Affiliation(s)
- Giuseppe A Palumbo
- Department of Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia," University of Catania, Catania, Italy
| | - Stefania Stella
- Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania, Italy.,Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Maria Stella Pennisi
- Center of Experimental Oncology and Hematology, A.O.U. Policlinico-Vittorio Emanuele, Catania, Italy.,Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Cristina Pirosa
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Elisa Fermo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sonia Fabris
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Myeloproliferative Syndromes Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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103
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Iurlo A, Cattaneo D, Gianelli U. Blast Transformation in Myeloproliferative Neoplasms: Risk Factors, Biological Findings, and Targeted Therapeutic Options. Int J Mol Sci 2019; 20:ijms20081839. [PMID: 31013941 PMCID: PMC6514804 DOI: 10.3390/ijms20081839] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 01/24/2023] Open
Abstract
Myeloproliferative neoplasms represent a heterogenous group of disorders of the hematopoietic stem cell, with an intrinsic risk of evolution into acute myeloid leukemia. The frequency of leukemic evolution varies according to myeloproliferative neoplasms subtype. It is highest in primary myelofibrosis, where it is estimated to be approximately 10–20% at 10 years, following by polycythemia vera, with a risk of 2.3% at 10 years and 7.9% at 20 years. In essential thrombocythemia, however, transformation to acute myeloid leukemia is considered relatively uncommon. Different factors are associated with leukemic evolution in myeloproliferative neoplasms, but generally include advanced age, leukocytosis, exposure to myelosuppressive therapy, cytogenetic abnormalities, as well as increased number of mutations in genes associated with myeloid neoplasms. The prognosis of these patients is dismal, with a medium overall survival ranging from 2.6–7.0 months. Currently, there is no standard of care for managing the blast phase of these diseases, and no treatment to date has consistently led to prolonged survival and/or hematological remission apart from an allogeneic stem cell transplant. Nevertheless, new targeted agents are currently under development. In this review, we present the current evidence regarding risk factors, molecular characterization, and treatment options for this critical subset of myeloproliferative neoplasms patients.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
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104
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Bucelli C, Cattaneo D, Valli VB, Levati GV, Lonati S, Gianelli U, Iurlo A. Osteolytic Lesions in Primary Myelofibrosis and Effect of Ruxolitinib Therapy: Report of a Case and Literature Review. Chemotherapy 2019; 63:340-344. [PMID: 30965327 DOI: 10.1159/000497246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/18/2019] [Indexed: 11/19/2022]
Abstract
Here, we report the case of a young female affected by primary myelofibrosis (PMF) who developed an osteolytic lesion of the humerus during the follow-up, and the possible efficacy of ruxolitinib in controlling this rare event. After 26 years of follow-up, the patient reported onset of acute pain at the proximal region of the left upper limb. An X-ray revealed an osteolytic bone lesion in the proximal third of the humeral shaft, which was then confirmed by magnetic resonance imaging. A biopsy of the lytic lesion was done, revealing hypercellular bone marrow with hyperplastic granulopoiesis associated with megakaryocytic proliferation and atypia, accompanied by a diffuse and dense increase in reticulin fibrosis with extensive intersections and coarse bundles of thick fibers, consistent with a grade 3 collagen fibrosis. No new therapeutic intervention was initially required; however, 2 years later, the patient reported symptomatic splenomegaly and drenching night sweats, so ruxolitinib therapy was started. By week 8, the patient had near resolution of constitutional symptoms and a reduction of > 50% of the spleen size that normalized by 6 months; in addition, a repeat bone marrow biopsy showed a decrease in reticulin fibrosis grade. Interestingly, after 9 months of ruxolitinib therapy, further magnetic resonance imaging of the left upper limb showed the absence of bone lytic lesions and a substantial normalization of the bone tissue. In conclusion, with the present case report, we confirm ruxolitinib efficacy in reducing bone marrow fibrosis grade and assume its possible role in the resolution of osteolytic lesions in PMF. Obviously, further studies with a greater number of patients are needed to document the exact frequency of these unusual findings and the possible role of ruxolitinib in their treatment.
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Affiliation(s)
- Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Viviana Beatrice Valli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Giorgia Virginia Levati
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Silvia Lonati
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, Milan, Italy
| | - Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan, and Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy,
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105
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Xiao ZJ. [How I treat primary myelofibrosis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:179-181. [PMID: 30929381 PMCID: PMC7342540 DOI: 10.3760/cma.j.issn.0253-2727.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Z J Xiao
- Blood Diseases Hospital and Institute of Hematology, CAMS & PUMC, Tianjin 300020, China
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106
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Penna D, Lasho TL, Finke CM, Vallapureddy RR, Hanson CA, Ketterling RP, Pardanani A, Gangat N, Tefferi A. 20+ Years and alive with primary myelofibrosis: Phenotypic signature of very long-lived patients. Am J Hematol 2019; 94:286-290. [PMID: 30516867 DOI: 10.1002/ajh.25351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/01/2018] [Accepted: 11/08/2018] [Indexed: 01/09/2023]
Abstract
In the last decade, several prognostic models for primary myelofibrosis (PMF) have been introduced and shown to be effective in predicting overall survival. The main objective for this study was to identify clinical and genetic markers of very long (20+ years) survival in PMF. A total of 1282 patients with PMF were considered (median age 65 years, range 19-92; 63% males); 26 (2%) patients (median age 51 years, range 28-71; 38% males) survived their disease for at least 20 years (long-lived patients) and 626 (49%) patients (median age 68 years, range 27-92; 66% males) died within 5 years of their diagnosis (short-lived patients). Multivariable logistic regression analysis identified 7 variables that were associated with survival beyond 20 years: age ≤ 70 years (P = .002); female sex (P = .03); hemoglobin level ≥ 10 g/dL for women and ≥ 11 g/dL for men (P = .03), leukocyte count ≤25 × 109 /L (P = .009), platelet count ≥100 × 109 /L (P = .002), circulating blasts <2% (P = .03) and absence of constitutional symptoms (P = .04). Five-year mortality was independently predicted by high-molecular risk mutations (P < .001); unfavorable or very high risk karyotype (P < .001); absence of type 1/like CALR mutation (P < .001); age > 70 years (P < .001); constitutional symptoms (P < .001); hemoglobin level < 10 g/dL for women and < 11 g/dL for men (P < .001); leukocyte count >25 × 109 /L (P = .004); and circulating blasts ≥2% (P = .001). This study suggests that genetic risk factors in PMF are associated with early mortality while survival beyond 20 years could be predicted by easily accessible clinical variables, including age, sex, blood counts, and symptoms.
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Affiliation(s)
- Domenico Penna
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Terra L. Lasho
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | | | - Rhett P. Ketterling
- Laboratory Genetics and Genomics, Departments of Internal Medicine and Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Naseema Gangat
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Ayalew Tefferi
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
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107
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Leukemic transformation among 1306 patients with primary myelofibrosis: risk factors and development of a predictive model. Blood Cancer J 2019; 9:12. [PMID: 30683837 PMCID: PMC6347609 DOI: 10.1038/s41408-019-0175-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/13/2018] [Indexed: 11/08/2022] Open
Abstract
Among 1306 patients with primary myelofibrosis (PMF), we sought to identify risk factors that predicted leukemic transformation (LT) in the first 5 years of disease and also over the course of the disease. 149 (11%) LT were documented; patients who subsequently developed LT (n = 149), compared to those who remained in chronic phase disease (n = 1,157), were more likely to be males (p = 0.02) and display higher circulating blasts (p = 0.03), ASXL1 (p = 0.01), SRSF2 (p = 0.001) and IDH1 (p = 0.02) mutations. Logistic regression analysis identified IDH1, ASXL1 and SRSF2 mutations, very high-risk karyotype, age > 70 years, male sex, circulating blasts ≥ 3%, presence of moderate or severe anemia and constitutional symptoms, as predictors of LT in the first 5 years of diagnosis. Time-to-event Cox analysis confirmed LT prediction for IDH1 mutation (HR 4.3), circulating blasts ≥ 3% (HR 3.3), SRSF2 mutation (HR 3.0), age > 70 years (HR 2.1), ASXL1 mutation (HR 2.0) and presence of moderate or severe anemia (HR 1.9). HR-based risk point allocation resulted in a three-tiered LT risk model: high-risk (LT incidence 57%; HR 39.3, 95% CI 10.8-114), intermediate-risk (LT incidence 17%; HR 4.1, 95% CI 2.4-7.3) and low-risk (LT incidence 8%). The current study provides a highly discriminating LT predictive model for PMF.
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108
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Gill H, Ip HW, Yim R, Tang WF, Pang HH, Lee P, Leung GMK, Li J, Tang K, So JCC, Leung RYY, Li J, Panagioutou G, Lam CCK, Kwong YL. Next-generation sequencing with a 54-gene panel identified unique mutational profile and prognostic markers in Chinese patients with myelofibrosis. Ann Hematol 2018; 98:869-879. [PMID: 30515541 DOI: 10.1007/s00277-018-3563-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 11/19/2018] [Indexed: 01/01/2023]
Abstract
Current prognostication in myelofibrosis (MF) is based on clinicopathological features and mutations in a limited number of driver genes. The impact of other genetic mutations remains unclear. We evaluated for mutations in a myeloid panel of 54 genes using next-generation sequencing. Multivariate Cox regression analysis was used to determine prognostic factors for overall survival (OS) and leukaemia-free survival (LFS), based on mutations of these genes and relevant clinical and haematological features. One hundred and one patients (primary MF, N = 70; secondary MF, N = 31) with a median follow-up of 49 (1-256) months were studied. For the entire cohort, inferior OS was associated with male gender (P = 0.04), age > 65 years (P = 0.04), haemoglobin < 10 g/dL (P = 0.001), CUX1 mutation (P = 0.003) and TP53 mutation (P = 0.049); and inferior LFS was associated with male gender (P = 0.03), haemoglobin < 10 g/dL (P = 0.04) and SRSF2 mutations (P = 0.008). In primary MF, inferior OS was associated with male gender (P = 0.03), haemoglobin < 10 g/dL (P = 0.002), platelet count < 100 × 109/L (P = 0.02), TET2 mutation (P = 0.01) and CUX1 mutation (P = 0.01); and inferior LFS was associated with haemoglobin < 10 g/dL (P = 0.02), platelet count < 100 × 109/L (P = 0.02), TET2 mutations (P = 0.01) and CUX1 mutations (P = 0.04). These results showed that clinical and haematological features and genetic mutations should be considered in MF prognostication.
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Affiliation(s)
- Harinder Gill
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ho-Wan Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Rita Yim
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wing-Fai Tang
- Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Herbert H Pang
- School of Public Health, The University of Hong Kong, Hong Kong, China
| | - Paul Lee
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Garret M K Leung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jamilla Li
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Karen Tang
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jason C C So
- Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Rock Y Y Leung
- Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Jun Li
- The Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong, China
| | - Gianni Panagioutou
- Systems Biology Group, School of Biological Sciences, The University of Hong Kong, Hong Kong, China.,Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, Jena, Germany
| | | | - Yok-Lam Kwong
- Department of Medicine, The University of Hong Kong, Hong Kong, China. .,Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong, China.
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109
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Prefibrotic myelofibrosis: treatment algorithm 2018. Blood Cancer J 2018; 8:104. [PMID: 30405096 PMCID: PMC6221891 DOI: 10.1038/s41408-018-0142-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/18/2018] [Accepted: 09/27/2018] [Indexed: 01/06/2023] Open
Abstract
Prefibrotic myelofibrosis (pre-PMF) is a distinct entity among chronic myeloproliferative neoplasm diagnosed according to the revised 2016 WHO classification. The clinical picture is heterogeneous, ranging from isolated thrombocytosis, mimicking essential thrombocythemia (ET), to symptoms of high-risk PMF. Retrospective studies showed that survival of patients with pre-PMF is worse than that of ET and better than overt PMF. Whilst a specific prognostic score is lacking, the International Prognostic Scoring System is able to predict survival in pre-PMF patients, yet failing to separate intermediate-1 and -2 groups, and can be used in clinical practice. Each patient should be evaluated for, and interventions adapted to, both life-expectancy and the risk of bleeding and thrombosis. In low-risk patients with expected long survival, observation only is recommended; in cumulated intermediate-1 and -2 risk cases, whose median survival is projected at more than 10 years, treatment is based on symptoms; in high risk cases, with median survival lower than 5 years, intensive management is required. A pragmatic approach to address the risk of bleeding and thrombosis includes: no treatment or low-dose aspirin in asymptomatic patients; aspirin or oral anticoagulation if previous arterial or venous thrombosis, and hydroxyurea as first-line cytoreduction in case of thrombocytosis or leukocytosis.
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