101
|
Bose P, Masarova L, Verstovsek S. Novel Concepts of Treatment for Patients with Myelofibrosis and Related Neoplasms. Cancers (Basel) 2020; 12:cancers12102891. [PMID: 33050168 PMCID: PMC7599937 DOI: 10.3390/cancers12102891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Myelofibrosis (MF) is an advanced form of a group of rare, related bone marrow cancers termed myeloproliferative neoplasms (MPNs). Some patients develop myelofibrosis from the outset, while in others, it occurs as a complication of the more indolent MPNs, polycythemia vera (PV) or essential thrombocythemia (ET). Patients with PV or ET who require drug treatment are typically treated with the chemotherapy drug hydroxyurea, while in MF, the targeted therapies termed Janus kinase (JAK) inhibitors form the mainstay of treatment. However, these and other drugs (e.g., interferons) have important limitations. No drug has been shown to reliably prevent the progression of PV or ET to MF or transformation of MPNs to acute myeloid leukemia. In PV, it is not conclusively known if JAK inhibitors reduce the risk of blood clots, and in MF, these drugs do not improve low blood counts. New approaches to treating MF and related MPNs are, therefore, necessary. Abstract Janus kinase (JAK) inhibition forms the cornerstone of the treatment of myelofibrosis (MF), and the JAK inhibitor ruxolitinib is often used as a second-line agent in patients with polycythemia vera (PV) who fail hydroxyurea (HU). In addition, ruxolitinib continues to be studied in patients with essential thrombocythemia (ET). The benefits of JAK inhibition in terms of splenomegaly and symptoms in patients with MF are undeniable, and ruxolitinib prolongs the survival of persons with higher risk MF. Despite this, however, “disease-modifying” effects of JAK inhibitors in MF, i.e., bone marrow fibrosis and mutant allele burden reduction, are limited. Similarly, in HU-resistant/intolerant PV, while ruxolitinib provides excellent control of the hematocrit, symptoms and splenomegaly, reduction in the rate of thromboembolic events has not been convincingly demonstrated. Furthermore, JAK inhibitors do not prevent disease evolution to MF or acute myeloid leukemia (AML). Frontline cytoreductive therapy for PV generally comprises HU and interferons, which have their own limitations. Numerous novel agents, representing diverse mechanisms of action, are in development for the treatment of these three classic myeloproliferative neoplasms (MPNs). JAK inhibitor-based combinations, all of which are currently under study for MF, have been covered elsewhere in this issue. In this article, we focus on agents that have been studied as monotherapy in patients with MF, generally after JAK inhibitor resistance/intolerance, as well as several novel compounds in development for PV/ET.
Collapse
|
102
|
Buxhofer-Ausch V, Wolf D, Sormann S, Forjan E, Schimetta W, Gisslinger B, Heibl S, Krauth MT, Thiele J, Ruckser R, Gisslinger H. Impact of platelets on major thrombosis in patients with a normal white blood cell count in essential thrombocythemia. Eur J Haematol 2020; 106:58-63. [PMID: 32909297 PMCID: PMC7756407 DOI: 10.1111/ejh.13516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
Objectives Cell counts have a significant impact on the complex mechanism of thrombosis in patients with essential thrombocythemia (ET). We recently demonstrated a considerable impact of white blood cell (WBC) counts on thrombotic risk in patients with optimized platelet counts by analysing a large anagrelide registry. In contrast, the current analysis of the registry aimed to estimate the influence of platelet counts on thrombotic risk in patients with optimized WBC counts. Methods Cox regression analysis and Kaplan‐Meier plot were applied on all patients in the registry with optimized WBC counts. Results By using the calculated cut‐off of 593 G/L for platelets, Cox regression analysis revealed a clear influence of elevated platelet counts on the occurrence of a major thrombotic event (P < .001). A Kaplan‐Meier plot revealed a markedly shorter time to a major thrombotic event for patients with platelet counts above the cut‐off (P < .001). Conclusions The data show clear impact of platelet lowering on the thrombotic risk in ET patients with normal WBC counts. Therefore, selective platelet lowering with anagrelide appears sufficient for thrombotic risk reduction in WHO‐diagnosed ET patients lacking leukocytosis.
Collapse
Affiliation(s)
- Veronika Buxhofer-Ausch
- Department of Internal Medicine I for Haematology with Stem Cell Transplantation, Haemostasis and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Dominik Wolf
- Division of Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Siegfried Sormann
- Department of Haematology, Medical University of Graz, Graz, Austria
| | - Ernst Forjan
- Department of Internal Medicine 3, Hanusch Hospital, Vienna, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research and Statistics, Johannes Kepler University, Linz, Austria
| | - Bettina Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Maria Theresa Krauth
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thiele
- Department of Pathology, University of Cologne, Cologne, Germany
| | | | - Heinz Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
103
|
Kellner A, Dombi P, Illes A, Demeter J, Homor L, Ercsei I, Simon Z, Karadi E, Herczeg J, Gy Korom V, Gasztonyi Z, Szerafin L, Udvardy M, Egyed M. Anagrelide influences thrombotic risk, and prolongs progression-free and overall survival in essential thrombocythaemia vs hydroxyurea plus aspirin. Eur J Haematol 2020; 105:408-418. [PMID: 32557810 DOI: 10.1111/ejh.13459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE We report an extension study of patients with essential thrombocythaemia (ET) in the Hungarian Myeloproliferative Neoplasm (HUMYPRON) Registry, which demonstrated that over 6 years anagrelide significantly decreased the number of patients experiencing minor arterial and minor venous thrombotic events (TEs) vs hydroxyurea+aspirin. METHODS Data on patients with ET were collected through completion of a questionnaire developed according to 2008 WHO diagnostic criteria and with regard to Landolfi, Tefferi and IPSET criteria for thrombotic risk. Data were entered into the registry from 14 haematological centres. TEs, secondary malignancies, disease progression and survival were compared between patients with ET treated with anagrelide (n = 116) and with hydroxyurea+aspirin (n = 121). RESULTS Patients were followed for (median) 10 years. A between-group difference in the number of patients with TEs was observed (25.9% anagrelide vs 38.0% hydroxyurea+aspirin; P = .052). Minor arterial events were more frequently reported in the hydroxyurea+aspirin group (P < .001); there were marginally more reports of major arterial events in the anagrelide group (P = .049). TE prior to diagnosis was found to significantly influence TE incidence (P > .001). Progression-free survival (P = .004) and survival (P = .001) were significantly increased for the anagrelide group vs hydroxyurea+aspirin. CONCLUSIONS Anagrelide reduced TEs, and increased progression-free and overall survival vs hydroxyurea+aspirin over (median) 10 years.
Collapse
Affiliation(s)
- Adam Kellner
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Peter Dombi
- Szent Borbala County Hospital, Tatabánya, Hungary
| | - Arpad Illes
- Department of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Demeter
- First Department of Internal Medicine, Division of Haematology, Semmelweis University of Budapest, Budapest, Hungary
| | - Lajos Homor
- Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
| | - Ibolya Ercsei
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Zsofia Simon
- Department of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Eva Karadi
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Jozsef Herczeg
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Viktoria Gy Korom
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Zoltan Gasztonyi
- Karolina General Hospital Mosonmagyarovar, Mosonmagyarovar, Hungary
| | | | - Miklos Udvardy
- Department of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Egyed
- Department of Haematology, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| |
Collapse
|
104
|
Abstract
The diagnostic approach to thrombocytosis involves consideration of reactive, hereditary, and neoplastic causes. Once reactive causes of thrombocytosis, such as iron deficiency, infections, solid tumors, and other obvious causes such as post-splenectomy thrombocytosis, have been ruled out, the focus shifts to myeloid malignancies, such as chronic myeloid leukemia (CML), the classic Philadelphia chromosome-negative (Ph-) myeloproliferative neoplasms (MPNs), essential thrombocythemia (ET), primary myelofibrosis (PMF), polycythemia vera (PV), myelodysplastic syndrome (MDS) with isolated deletion 5q and the rare MDS/MPN "overlap" syndrome, MDS/MPN with ring sideroblasts, and thrombocytosis (MDS/MPN-RS-T).
Collapse
Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
105
|
Skov V. Next Generation Sequencing in MPNs. Lessons from the Past and Prospects for Use as Predictors of Prognosis and Treatment Responses. Cancers (Basel) 2020; 12:E2194. [PMID: 32781570 PMCID: PMC7464861 DOI: 10.3390/cancers12082194] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022] Open
Abstract
The myeloproliferative neoplasms (MPNs) are acquired hematological stem cell neoplasms characterized by driver mutations in JAK2, CALR, or MPL. Additive mutations may appear in predominantly epigenetic regulator, RNA splicing and signaling pathway genes. These molecular mutations are a hallmark of diagnostic, prognostic, and therapeutic assessment in patients with MPNs. Over the past decade, next generation sequencing (NGS) has identified multiple somatic mutations in MPNs and has contributed substantially to our understanding of the disease pathogenesis highlighting the role of clonal evolution in disease progression. In addition, disease prognostication has expanded from encompassing only clinical decision making to include genomics in prognostic scoring systems. Taking into account the decreasing costs and increasing speed and availability of high throughput technologies, the integration of NGS into a diagnostic, prognostic and therapeutic pipeline is within reach. In this review, these aspects will be discussed highlighting their role regarding disease outcome and treatment modalities in patients with MPNs.
Collapse
Affiliation(s)
- Vibe Skov
- Department of Hematology, Zealand University Hospital, Vestermarksvej 7-9, 4000 Roskilde, Denmark
| |
Collapse
|
106
|
Alvarez-Larrán A, Angona A, Andrade-Campos M, Soledad Noya M, Teresa Gómez-Casares M, Cuevas B, Caballero G, García-Hernández C, García-Gutiérrez V, Palomino A, Ferrer-Marín F, Isabel Mata-Vázquez M, Moretó A, Magro E, Murillo I, Manuel Alonso-Domínguez J, María Guerra J, Guerrero L, María Raya J, Pérez-Encinas M, Carreño-Tarragona G, Fox L, Pastor-Galán I, Bellosillo B, Hernández-Boluda JC. Cytoreductive treatment in patients with CALR-mutated essential thrombocythaemia: a study comparing indications and efficacy among genotypes from the Spanish Registry of Essential Thrombocythaemia. Br J Haematol 2020; 192:988-996. [PMID: 32745264 DOI: 10.1111/bjh.16988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
The present study assessed the criteria for initiating cytoreduction and response to conventional therapies in 1446 patients with essential thrombocythemia (ET), 267 (17%) of which were CALR-mutated. In low risk patients, time from diagnosis to cytoreduction was shorter in CALR-positive than in the other genotypes (2·8, 3·2, 7·4 and 12·5 years for CALR, MPL, JAK2V617F and TN, respectively, P < 0·0001). A total of 1104 (76%) patients received cytoreductive treatment with hydroxycarbamide (HC) (n = 977), anagrelide (n = 113), or others (n = 14). The estimated cumulative rates of complete haematological response (CR) at 12 months were 40 % and 67% in CALR and JAK2V617F genotypes, respectively. Median time to CR was 192 days for JAK2V617F, 343 for TN, 433 for MPL, and 705 for CALR genotypes (P < 0·0001). Duration of CR was shorter in CALR-mutated ET than in the remaining patients (P = 0·003). In CALR-positive patients, HC and anagrelide had similar efficacy in terms of response rates and duration. CALR-mutated patients developed resistance/intolerance to HC more frequently (5%, 23%, 27% and 15% for JAK2V617F, CALR, MPL and TN, respectively; P < 0·0001). In conclusion, conventional cytoreductive agents are less effective in CALR-mutated ET, highlighting the need for new treatment modalities and redefinition of haematologic targets for patients with this genotype.
Collapse
Affiliation(s)
| | - Anna Angona
- Hospital Josep Trueta, ICO-Girona, Girona, Spain
| | - Marcio Andrade-Campos
- Hospital del Mar- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Ana Moretó
- Hospital Universitario de Cruces, Bilbao, Spain
| | - Elena Magro
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | | | | | | | | | - José María Raya
- Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | | | - Laura Fox
- Hospital Vall d'Hebron, VHIO, Barcelona, Spain
| | | | - Beatriz Bellosillo
- Hospital del Mar- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | | | | |
Collapse
|
107
|
Foong TW, Tan PS, Thampi S, Balakrishnan A. Anesthesia for pulmonary veno-occlusive disease: the dilemma and what we should know as anesthesiologists: A case report. Medicine (Baltimore) 2020; 99:e21517. [PMID: 32791767 PMCID: PMC7386984 DOI: 10.1097/md.0000000000021517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary hypertension. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension (PAH). Inappropriate treatment may cause worsening of symptoms which may lead to fatal outcomes. Anesthetic considerations and management for pulmonary hypertension are well described, but few anesthesiologists are aware of the entity of PVOD and its management. PATIENT CONCERNS We report a case of PVOD in a 73-year-old female who was on concurrent aspirin and anagrelide, requiring emergent open femoral hernia repair. DIAGNOSIS PVOD and incarcerated femoral hernia INTERVENTION:: Combined spinal-epidural (CSE) was performed to enable the surgery. OUTCOME Surgery was completed successfully under central neuraxial anesthesia and the patient remained stable and comfortable throughout, avoiding the need for general anesthesia. Due to the concurrent aspirin and anagrelide therapy, significant bleeding from the CSE puncture site was observed immediately post-operatively. This was resolved with external manual compression and withholding the aspirin and anagrelide. Patient remained well without neurological deficit and was discharged postoperative day seven. LESSONS It is important to differentiate PVOD from PAH due to the controversial use of pulmonary vasodilators in PVOD. Pulmonary vasodilator is commonly used to treat acute pulmonary hypertension in PAH but its usage may lead to pulmonary edema in patients with PVOD. Hence, with no ideal treatment available, the avoidance of general anesthesia is crucial to prevent acute pulmonary hypertensive crisis in patient with PVOD. However, this needs to be weighed against the elevated risk of central neuraxial bleeding when performing a CSE in a patient on concurrent aspirin and anagrelide therapy. Calculated decision-making considering the risks and benefits of all alternatives should be carried out in such a scenario, and measures should be taken in anticipation of the potential consequences of the eventual decision. CONCLUSION It is important to differentiate PVOD from PAH. PVOD has unique anesthetic considerations due to the controversial use of pulmonary vasodilators. This case also emphasizes the importance of active anticipation of potential issues and adequate follow up.
Collapse
Affiliation(s)
- Theng Wai Foong
- Department of Anesthesia and Surgical Intensive Care, National University Hospital
- Yong Loo Lin School of Medicine
| | - Pei Shan Tan
- Department of Anesthesia and Surgical Intensive Care, National University Hospital
| | - Swapna Thampi
- Department of Anesthesia and Surgical Intensive Care, National University Hospital
- Yong Loo Lin School of Medicine
| | - Ashokka Balakrishnan
- Department of Anesthesia and Surgical Intensive Care, National University Hospital
- Yong Loo Lin School of Medicine
- Centre For Medical Education, National University of Singapore, Singapore
| |
Collapse
|
108
|
Guidelines for therapy of patients with chronic myeloproliferative neoplasms during the novel coronavirus SARS-CoV2 pandemic. Hematol Transfus Cell Ther 2020; 42:195-199. [PMID: 32654986 PMCID: PMC7303601 DOI: 10.1016/j.htct.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 12/15/2022] Open
Abstract
The novel coronavirus has swept across the world in 2020 and ushered a new era. In the current scenario, it is not clear how patients with myeloproliferative neoplasms (including chronic myelogenous leukemia) should be managed, considering the risk of therapy, the need for social distancing and the risk of untimely therapy discontinuation of delay. This guideline aims to give providers a sense of direction in order to better take care of patients and prioritize care.
Collapse
|
109
|
Significant association of cutaneous adverse events with hydroxyurea: results from a prospective non-interventional study in BCR-ABL1-negative myeloproliferative neoplasms (MPN) - on behalf of the German Study Group-MPN. Leukemia 2020; 35:628-631. [PMID: 32616864 PMCID: PMC8318877 DOI: 10.1038/s41375-020-0945-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 11/22/2022]
|
110
|
Grinfeld J. Prognostic models in the myeloproliferative neoplasms. Blood Rev 2020; 42:100713. [DOI: 10.1016/j.blre.2020.100713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/25/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023]
|
111
|
Current management strategies for polycythemia vera and essential thrombocythemia. Blood Rev 2020; 42:100714. [DOI: 10.1016/j.blre.2020.100714] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/02/2019] [Accepted: 05/11/2020] [Indexed: 02/06/2023]
|
112
|
Awada H, Voso MT, Guglielmelli P, Gurnari C. Essential Thrombocythemia and Acquired von Willebrand Syndrome: The Shadowlands between Thrombosis and Bleeding. Cancers (Basel) 2020; 12:cancers12071746. [PMID: 32629973 PMCID: PMC7407619 DOI: 10.3390/cancers12071746] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, new insights have emerged on the pathophysiology of essential thrombocythemia (ET), its clinical management, and associated thrombohemostatic disturbances. Here, we review the latest diagnostic and risk stratification modalities of ET and its therapeutics. Moreover, we discuss the clinical evidence-based benefits, deriving from major clinical trials, of using cytoreductive therapy and antiplatelet agents to lower the risk of fatal vascular events. Also, we focus on the condition of extreme thrombocytosis (>1000 × 109/L) and bleeding risk, the development and pathogenesis of acquired von Willebrand syndrome, and the clinical approach to this paradoxical scenario in ET.
Collapse
Affiliation(s)
- Hassan Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Correspondence: ; Tel.: +1-216-666-0640
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Fondazione Santa Lucia, Laboratorio di Neuro-Oncoematologia, 00143 Roma, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, 50139 Florence, Italy;
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
| |
Collapse
|
113
|
Barbui T, Vannucchi AM, Guglielmelli P, De Stefano V, Rambaldi A. An agenda for future research projects in polycythemia vera and essential thrombocythemia. Haematologica 2020; 105:1999-2003. [PMID: 32467140 PMCID: PMC7395271 DOI: 10.3324/haematol.2019.246207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/14/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo
| | - Alessandro Maria Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University and Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan, Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
114
|
Mazzucconi MG, Baldacci E, Latagliata R, Breccia M, Paoloni F, Di Veroli A, Cedrone M, Anaclerico B, Villivà N, Porrini R, Montefusco E, Andriani A, Montanaro M, Scaramucci L, Spadea A, Rago A, Cimino G, Spirito F, Santoro C. Anagrelide in Essential Thrombocythemia (ET): Results from 150 patients over 25 years by the "Ph1-negative Myeloproliferative Neoplasms Latium Group". Eur J Haematol 2020; 105:335-343. [PMID: 32441419 DOI: 10.1111/ejh.13454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Anagrelide is a drug effective in reducing platelet counts in essential thrombocythemia (ET) and Ph1-negative myeloproliferative neoplasms. The aim of this study was to evaluate the real-life use of anagrelide in patients with ET followed over 25 years at the Haematological Institutes belonging to "Ph1-negative Myeloproliferative Neoplasms Latium Group." PATIENTS AND METHODS Eligibility criteria were diagnosis of ET and treatment with anagrelide. Data were collected through an ad hoc case report form. RESULTS One hundred and fifty patients received anagrelide for a median time of 7.4 years (0.1-23.2). Anagrelide was administered as first-line therapy in 34.7% of patients, as second-line in 52% and as third-line in 13.3%: 85.4% responded to therapy. Sixty-eight/136 evaluable patients reported side effects: palpitations, peripheral vasodilation, anaemia, diarrhoea and gastric distress. Fourteen thrombotic (arterial 10, venous 4) and 51 bleeding events (minor 48, major 3) occurred. Sixteen/150 (10.6%) patients developed secondary myelofibrosis and 3/150 (2%) an acute myeloid leukaemia. CONCLUSIONS In our experience, anagrelide is an effective drug in reducing platelet levels in a high percentage of patients with ET. It is especially addressed to younger people. A careful assessment of the thrombotic risk and monitoring of cardiac function, at diagnosis and during follow-up, is mandatory.
Collapse
Affiliation(s)
| | - Ermina Baldacci
- Ematologia, Azienda Ospedaliera Universitaria Policlinico Umberto I, Roma, Italia
| | - Roberto Latagliata
- Ematologia, Azienda Ospedaliera Universitaria Policlinico Umberto I, Roma, Italia
| | - Massimo Breccia
- Ematologia, Azienda Ospedaliera Universitaria Policlinico Umberto I, Roma, Italia
| | | | | | | | | | | | | | | | | | | | | | - Antonio Spadea
- Unità di Ematologia e Trapianto di Midollo Osseo, Istituto Nazionale Tumori Regina Elena, Roma, Italia
| | | | | | | | - Cristina Santoro
- Ematologia, Azienda Ospedaliera Universitaria Policlinico Umberto I, Roma, Italia
| |
Collapse
|
115
|
Atypical Myocardial Infarction with Apical Thrombus and Systemic Embolism: A Rare Presentation of Likely JAK2 V617F-Positive Myeloproliferative Neoplasm. Case Rep Oncol Med 2020; 2020:9654048. [PMID: 32685224 PMCID: PMC7338968 DOI: 10.1155/2020/9654048] [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: 01/23/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022] Open
Abstract
A few types of myeloproliferative neoplasms may be significant for Janus-associated kinase 2 mutation, JAK2 V617F, including polycythemia vera, essential thrombocythemia, and primary myelofibrosis. The prevalence of JAK2 mutation is low in the general population but higher in patients with myeloproliferative neoplasms. Some patients with JAK2 V617F-positive essential thrombocythemia are asymptomatic, but others may develop hemorrhagic or thromboembolic complications. Thromboembolism may occur in vessels of high flow organs like the heart and, thereby, present as myocardial infarction. Nonetheless, these patients are usually symptomatic with complaints of chest pain, for example. Atypical (asymptomatic) myocardial infarction with mild thrombocytosis may be the first clue for possible essential thrombocythemia with JAK2 V617F. In this report, we discuss a case of atypical (asymptomatic) myocardial infarction with secondary thromboembolism in a patient positive for JAK2 V617F with a likely myeloproliferative neoplasm.
Collapse
|
116
|
Comparison of starting doses of anagrelide as a first-line therapy in patients with cytoreductive therapy-naïve essential thrombocythemia: difference between starting at 0.5 and 1.0 mg/day. Int J Hematol 2020; 112:33-40. [PMID: 32328973 DOI: 10.1007/s12185-020-02876-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022]
Abstract
Anagrelide is widely used for cytoreductive therapy in patients with essential thrombocythemia who are at high risk for thrombosis. The recommended starting dose in the package insert of anagrelide varies by country. A high starting dose leads to an early onset of action, but causes a higher incidence of adverse events. This relationship indicates that both the onset of action and side effects of anagrelide are dose dependent. We retrospectively compared the efficacy and safety of anagrelide as a first-line drug between patients with essential thrombocythemia who started at 0.5 or 1.0 mg/day. Incidence of total adverse events and anagrelide-related palpitation, discontinuation rates, and the median daily dose of anagrelide were lower in the 0.5 mg/day group than in the 1.0 mg/day group; however, comparable platelet-lowering effects were achieved in both groups. These data suggest that a low starting dose of anagrelide followed by dose escalation may result in fewer adverse events and lower discontinuation rates, while providing desirable platelet-lowering effects. Initiating anagrelide at a lower dose may be a useful approach in actual clinical practice.
Collapse
|
117
|
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.
Collapse
|
118
|
Barbui T, Thiele J, Ferrari A, Vannucchi AM, Tefferi A. The new WHO classification for essential thrombocythemia calls for revision of available evidences. Blood Cancer J 2020; 10:22. [PMID: 32098949 PMCID: PMC7042222 DOI: 10.1038/s41408-020-0290-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/27/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022] Open
Abstract
In the 2016 revised classification of myeloproliferative neoplasms pre-fibrotic primary myelofibrosis (pre-PMF) was recognized as a separate entity, distinct from essential thrombocythemia (ET). Owing that the majority of cases falling in the pre-PMF category were previously diagnosed as ET, one may question about the need to re-evaluate the results of epidemiologic, clinical, and molecular studies, and the results of clinical trials in the two entities. Based on a critical review of recently published studies, pre-PMF usually presents with a distinct clinical and hematological presentation and higher frequency of constitutional symptoms. JAK2V617F and CALR mutations in pre-PMF patients are superimposable to ET, whereas non-driver high-risk mutations are enriched in pre-PMF compared with ET. Thrombosis is not significantly different, whereas bleeding is more frequent in pre-PMF. Median survival is significantly shorter in pre-PMF and 10-year cumulative rates progression to overt myelofibrosis is 0-1% vs. 10-12%, and leukemic transformation is 1-2% vs. 2-6%, in ET and pre-fibrotic-PMF, respectively. Most patients fall in the lower prognostic IPSS group in which observation alone can be recommended. Patients at intermediate risk may require a symptom-driven treatment for anemia, splenomegaly or constitutional symptoms while cytoreductive drugs are indicated in the high-risk category.
Collapse
Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - Alberto Ferrari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, Department Experimental and Clinical medicine, and Denothe Center, University of Florence, Florence, Italy
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
119
|
Spivak JL. Polycythaemia vera, ruxolitinib, and hydroxyurea: where do we go now? LANCET HAEMATOLOGY 2020; 7:e184-e185. [PMID: 31982040 DOI: 10.1016/s2352-3026(19)30262-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jerry L Spivak
- Hematology Division, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| |
Collapse
|
120
|
Mutant Calreticulin in the Myeloproliferative Neoplasms. Hemasphere 2020; 4:e333. [PMID: 32382708 PMCID: PMC7000472 DOI: 10.1097/hs9.0000000000000333] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 12/17/2022] Open
Abstract
Mutations in the gene for calreticulin (CALR) were identified in the myeloproliferative neoplasms (MPNs) essential thrombocythaemia (ET) and primary myelofibrosis (MF) in 2013; in combination with previously described mutations in JAK2 and MPL, driver mutations have now been described for the majority of MPN patients. In subsequent years, researchers have begun to unravel the mechanisms by which mutant CALR drives transformation and to understand their clinical implications. Mutant CALR activates the thrombopoietin receptor (MPL), causing constitutive activation of Janus kinase 2 (JAK2) signaling and cytokine independent growth in vitro. Mouse models show increased numbers of hematopoietic stem cells (HSCs) and overproduction of megakaryocytic lineage cells with associated thrombocytosis. In the clinic, detection of CALR mutations has been embedded in World Health Organization and other international diagnostic guidelines. Distinct clinical and laboratory associations of CALR mutations have been identified together with their prognostic significance, with CALR mutant patients showing increased overall survival. The discovery and subsequent study of CALR mutations have illuminated novel aspects of megakaryopoiesis and raised the possibility of new therapeutic approaches.
Collapse
|
121
|
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.
Collapse
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
| |
Collapse
|
122
|
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.
Collapse
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
| |
Collapse
|
123
|
Affiliation(s)
- Ayalew Tefferi
- From the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Animesh Pardanani
- From the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
124
|
Miyashita N, Onozawa M, Yokoyama S, Hidaka D, Hayasaka K, Kunishima S, Teshima T. Anagrelide Modulates Proplatelet Formation Resulting in Decreased Number and Increased Size of Platelets. Hemasphere 2019; 3:e268. [PMID: 31723843 PMCID: PMC6745917 DOI: 10.1097/hs9.0000000000000268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/15/2019] [Accepted: 05/16/2019] [Indexed: 11/25/2022] Open
Abstract
We retrospectively evaluated 48 essential thrombocythemia (ET) patients who were treated in our institute (male/female, 14/34, median age, 61.5 years). In 14 patients treated with anagrelide (ANA), the degree of platelet count reduction (median, -56.6%) was strongly correlated with increase of mean platelet volume (MPV) (median, +11.7%) (R = 0.777). This correlation was not observed in ET patients treated with hydroxycarbamide alone (R = 0.245). The change in size of platelets strongly suggested that ANA affected the final process of platelet production. Thus, we hypothesized that ANA modifies the process by which platelets are released from proplatelets. To verify the association in an in vitro setting, we compared MEG-01 cells treated with PMA ± ANA. The number of platelet-like particles (PLPs) was decreased (P < 0.05) and the size of PLPs estimated by using flow cytometry was significantly increased when MEG-01 cells were treated with PMA + ANA (P < 0.05 vs PMA alone), recapitulating the clinical findings. The cytoplasmic protrusions extending from MEG-01 cells were shorter and thicker and the number of proplatelets was decreased when MEG-01 cells were treated with PMA + ANA (P < 0.01 vs PMA alone). Western blotting analysis showed that ANA treatment resulted in increased phosphorylation of MLC2 and reduced phosphorylation of focal adhesion kinase (FAK). The morphological change of proplatelets were reversed by blebbistatin, a specific inhibitor of myosin II. These findings indicated that ANA modulates the FAK-RhoA-ROCK-MLC2-myosine IIA pathway and suppresses proplatelet maturation, leading to a decrease in platelet count and increase in MPV.
Collapse
Affiliation(s)
- Naohiro Miyashita
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Masahiro Onozawa
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Shota Yokoyama
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Daisuke Hidaka
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan
| | - Koji Hayasaka
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Shinji Kunishima
- Department of Medical Technology, Gifu University of Medical Science, Seki, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Sapporo, Japan.,Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| |
Collapse
|
125
|
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
| | | |
Collapse
|
126
|
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.
Collapse
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
| |
Collapse
|
127
|
Regan S, Yang X, Finnberg NK, El-Deiry WS, Pu JJ. Occurrence of acute myeloid leukemia in hydroxyurea-treated sickle cell disease patient. Cancer Biol Ther 2019; 20:1389-1397. [PMID: 31423878 DOI: 10.1080/15384047.2019.1647055] [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] [Indexed: 10/26/2022] Open
Abstract
Hydroxyurea (HU) has been widely used in sickle cell disease. Its potential long-term risk for carcinogenesis or leukemogenic risk remains undefined. Here, we report a 26 y old African-American female with Sickle Cell Disease (SCD) who developed refractory/relapsed acute myeloid leukemia (AML) 6 months after 26 months of HU use. That patient's cytogenetics and molecular genetics analyses demonstrated a complex mutation profile with 5q deletion, trisomy 8, and P53 deletion (deletion of 17p13.1). P53 gene sequence studies revealed a multitude of somatic mutations that most suggest a treatment-related etiology. The above-mentioned data indicates that the patient may have developed acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) as a direct result of HU exposure.
Collapse
Affiliation(s)
- Samuel Regan
- Department of Medicine, College of Medicine, SUNY Upstate Medical University , Syracuse , New York , USA
| | - Xuebin Yang
- Department of Pathology, Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | | | - Wafik S El-Deiry
- Department of Pathology, Warren Alpert Medical School, Brown University , Providence , Rhode Island , USA
| | - Jeffrey J Pu
- Department of Medicine, College of Medicine, SUNY Upstate Medical University , Syracuse , New York , USA.,Upstate Cancer Center, Departments of Medicine, Pathology, and Pharmacology, SUNY Upstate Medical University , Syracuse , New York , USA.,Syracuse VA Medical Center, SUNY Upstate Medical University , Syracuse , New York , USA
| |
Collapse
|
128
|
Lu SY, Shelton KT, Fitzsimons MG. Pulmonary Artery Catheter Thrombus in a Patient With Essential Thrombocytosis: A Case Report. A A Pract 2019; 12:292-294. [PMID: 30312177 DOI: 10.1213/xaa.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Essential thrombocytosis (ET) is a rare chronic myeloproliferative disorder characterized by elevated platelet counts. The management of patients with ET undergoing coronary artery bypass graft remains unclear. Often, patients who are deemed "high risk" for thrombotic events receive cytoreductive therapy before surgery, while patients deemed "low risk" do not receive cytoreductive therapy. Here, we present a case of a patient with ET with only a mild elevation in platelets deemed "low risk" for thrombotic complications who was found to have a small intracardiac thrombus around the pulmonary artery catheter before initiation of cardiopulmonary bypass.
Collapse
Affiliation(s)
- Shu Y Lu
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | |
Collapse
|
129
|
Appleby N, Angelov D. Clinical and laboratory assessment of a patient with thrombocytosis. Br J Hosp Med (Lond) 2019; 78:558-564. [PMID: 29019736 DOI: 10.12968/hmed.2017.78.10.558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Elevated platelet counts are frequently encountered in hospital medicine and arise from both physiological and pathological mechanisms. Thrombocytosis may be secondary, reflecting an inflammatory state, iron deficiency, recent surgery or point towards an underlying neoplasm. Thrombocytosis may be the presenting sign of solid tumours and haematological conditions. The discovery of the activating mutations affecting thrombopoiesis led to greater understanding of the pathobiology of essential thrombocythaemia and other myeloproliferative neoplasms. The investigation of suspected primary thrombocytosis has evolved to include testing for these disease-associated mutations. Therapy for patients with essential thrombocythaemia aims to reduce their risk of thrombotic complications by addressing cardiovascular risk factors, and using antiplatelet agents and, in selected patients, cytoreductive therapy. This article provides a logical approach to distinguishing reactive or secondary thrombocytosis from thrombocytosis associated with an underlying myeloproliferative neoplasm and gives an overview of the management of essential thrombocythaemia.
Collapse
Affiliation(s)
- Niamh Appleby
- Molecular Haematology Fellow, Molecular Haematology Laboratory, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU
| | - Daniel Angelov
- Core Medical Trainee, Department of Haematology, Mater Misercordiae University Hospital, Dublin
| |
Collapse
|
130
|
Ito T, Hashimoto Y, Tanaka Y, Nakaya A, Fujita S, Satake A, Nakanishi T, Konishi A, Hotta M, Yoshimura H, Ishii K, Hashimoto A, Kondo T, Omura H, Shinzato I, Tanaka T, Nomura S. Efficacy and safety of anagrelide as a first-line drug in cytoreductive treatment-naïve essential thrombocythemia patients in a real-world setting. Eur J Haematol 2019; 103:116-123. [PMID: 31107982 PMCID: PMC6851998 DOI: 10.1111/ejh.13265] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/31/2022]
Abstract
Objective This study aimed to retrospectively assess the efficacy and safety of anagrelide in cytoreduction therapy‐naïve essential thrombocythemia (ET) patients in a real‐world setting. Method Data from 53 ET patients who received anagrelide as a first‐line therapy were reviewed for patient characteristics, antiplatelet status, cytoreduction status, therapeutic effects, adverse events, thrombohemorrhagic event development, progression to myelofibrosis or acute leukemia, and cause of death. Results The rate of achieving a platelet count of <600 × 109/L during anagrelide monotherapy was 83.0%. Adverse events occurred in 32 of 53 patients, and tended to be slightly more severe in patients with cardiac failure; however, they were mostly tolerable. The therapeutic effect of anagrelide was consistent, regardless of genetic mutation profiles. The incidence of anemia as an adverse event was significantly higher in the CALR mutation‐positive group. Favorable platelet counts were also achieved in patients for whom hydroxyurea was introduced as a replacement for anagrelide or in addition to anagrelide because of unresponsiveness or intolerance to treatment. Conclusion In Japanese cytoreduction therapy‐naïve ET patients, anagrelide administration as a first‐line therapy demonstrated favorable effects in reducing platelet counts, and its safety profile that was generally consistent with those in previous reports.
Collapse
Affiliation(s)
- Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Yoshinori Hashimoto
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Yasuhiro Tanaka
- Department of Hematology and Clinical Immunology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Aya Nakaya
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Takahisa Nakanishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Kazuyoshi Ishii
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Akiko Hashimoto
- Department of Hematology and Clinical Immunology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Toshinori Kondo
- Department of Hematology, Kawasaki Medical School, Kurashiki, Japan
| | - Hiromi Omura
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Isaku Shinzato
- Department of Hematology and Clinical Immunology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Takayuki Tanaka
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| |
Collapse
|
131
|
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.
Collapse
|
132
|
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: 27] [Impact Index Per Article: 5.4] [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.
Collapse
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
| |
Collapse
|
133
|
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.
Collapse
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
| |
Collapse
|
134
|
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
| | | |
Collapse
|
135
|
Masarova L, Verstovsek S. Emerging drugs for essential thrombocythemia. Expert Opin Emerg Drugs 2019; 24:93-105. [PMID: 31050912 DOI: 10.1080/14728214.2019.1615437] [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: 10/26/2022]
Abstract
Introduction: Despite our recent progress in the understanding of essential thrombocythemia (ET) pathogenesis, the therapeutic management of this disease has remained largely unchanged in the past decades. Treatment has mostly focused on decreasing the risk of complications, especially prevention of thrombotic or hemorrhagic events. Areas covered: Over recent years, the treatment options of ET have been expanding with some novel agents on the horizon. The classes of agents described in this review include targeted and immunomodulatory agents, such as JAK1/2 inhibitors, interferon-α, histone deacetylase inhibitors, telomerase inhibitors and human double minute 2 inhibitors. These compounds entered various stages of development, albeit the only portion of them is currently actively undergoing evaluation in clinical trials. In this review, we look at the current therapies and discuss novel agents available in the management of ET. Expert opinion: The drug development in ET possesses several challenges stemming from its relatively benign and prolonged disease course. Therapy focused on reducing the risk of thrombotic and hemorrhagic complications and symptom management needs to be chosen wisely as a vast majority of these patients have a near-normal life expectancy. To date, no therapy has shown effective and definitive alteration of the disease behavior. Although novel agents are in development and hopefully some of them will extend treatment armamentarium of ET, their exact role remains to be determined.
Collapse
Affiliation(s)
- Lucia Masarova
- a MD Anderson Cancer Center , The University of Texas , Houston , TX , USA
| | - Srdan Verstovsek
- a MD Anderson Cancer Center , The University of Texas , Houston , TX , USA
| |
Collapse
|
136
|
Szuber N, Mudireddy M, Nicolosi M, Penna D, Vallapureddy RR, Lasho TL, Finke C, Begna KH, Elliott MA, Hook CC, Wolanskyj AP, Patnaik MM, Hanson CA, Ketterling RP, Sirhan S, Pardanani A, Gangat N, Busque L, Tefferi A. 3023 Mayo Clinic Patients With Myeloproliferative Neoplasms: Risk-Stratified Comparison of Survival and Outcomes Data Among Disease Subgroups. Mayo Clin Proc 2019; 94:599-610. [PMID: 30824279 DOI: 10.1016/j.mayocp.2018.08.022] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/16/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To document the Mayo Clinic decades-long experience with myeloproliferative neoplasms (MPNs) and provide mature risk-stratified survival data and disease complication estimates. PATIENTS AND METHODS All Mayo Clinic patients with World Health Organization-defined MPNs constituted the core study group and included those with polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). RESULTS A total of 3023 consecutive patients (median age, 62 years; range, 18-96 years) were considered: 665 PV, 1076 ET, and 1282 PMF. From October 27, 1967, through December 29, 2017, 1631 deaths (54%), 183 leukemic transformations (6%), 244 fibrotic progressions (14%), and 516 thrombotic events (17%) were recorded. Median overall survival (OS) was 18 years for ET, 15 years for PV, and 4.4 years for PMF (P<.05 for all intergroup comparisons). Inferior survival was documented in patients with ET diagnosed more recently (post-1990) (P<.001), whereas survival data were time independent in PV and PMF. After conventional risk stratification, OS in low-risk ET and low-risk PV were superimposed (P=.89) but each differed significantly from that of age- and sex-matched controls (P<.001). Leukemia-free survival was similar for ET and PV (P=.22) and significantly worse with PMF (P<.001). Compared with ET, PV was associated with higher risk of fibrotic progression (P<.001). Thrombosis risk after diagnosis was highest in PV and lowest in PMF (P=.002 for PV vs ET; P=.56 for ET vs PMF; and P=.001 for PV vs PMF). CONCLUSION This study provides the most mature survival and outcomes data in MPNs and highlights MPN subgroup risk categorization as key in appraising disease natural history. The OS was only marginally better in ET compared with PV, and PV displayed a higher risk of thrombosis and fibrotic progression.
Collapse
Affiliation(s)
- Natasha Szuber
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Mythri Mudireddy
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Maura Nicolosi
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Domenico Penna
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Rangit R Vallapureddy
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Terra L Lasho
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Christy Finke
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Kebede H Begna
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Michelle A Elliott
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - C Christopher Hook
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Alexandra P Wolanskyj
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Curtis A Hanson
- Division of Hematopathology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Rhett P Ketterling
- Division of Laboratory Genetics and Genomics, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Shireen Sirhan
- Division of Hematology, Jewish General Hospital, Montréal, Québec, Canada; Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group
| | - Animesh Pardanani
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Lambert Busque
- Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group; Department of Laboratory Hematology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
137
|
Drexler B, Passweg JR, Tzankov A, Bigler M, Theocharides AP, Cantoni N, Keller P, Stussi G, Ruefer A, Benz R, Favre G, Lundberg P, Nienhold R, Fuhrer A, Biaggi C, Manz MG, Bargetzi M, Mendez-Ferrer S, Skoda RC. The sympathomimetic agonist mirabegron did not lower JAK2-V617F allele burden, but restored nestin-positive cells and reduced reticulin fibrosis in patients with myeloproliferative neoplasms: results of phase II study SAKK 33/14. Haematologica 2019; 104:710-716. [PMID: 30409796 PMCID: PMC6442970 DOI: 10.3324/haematol.2018.200014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/08/2018] [Indexed: 01/20/2023] Open
Abstract
The β-3 sympathomimetic agonist BRL37344 restored nestin-positive cells within the stem cell niche, and thereby normalized blood counts and improved myelofibrosis in a mouse model of JAK2-V617F-positive myeloproliferative neoplasms. We therefore tested the effectiveness of mirabegron, a β-3 sympathomimetic agonist, in a phase II trial including 39 JAK2-V617F-positive patients with myeloproliferative neoplasms and a mutant allele burden more than 20%. Treatment consisted of mirabegron 50 mg daily for 24 weeks. The primary end point was reduction of JAK2-V617F allele burden of 50% or over, but this was not reached in any of the patients. One patient achieved a 25% reduction in JAK2-V617F allele burden by 24 weeks. A small subgroup of patients showed hematologic improvement. As a side study, bone marrow biopsies were evaluated in 20 patients. We found an increase in the nestin+ cells from a median of 1.09 (interquartile range 0.38-3.27)/mm2 to 3.95 (interquartile range 1.98-8.79)/mm2 (P<0.0001) and a slight decrease of reticulin fibrosis from a median grade of 1.0 (interquartile range 0-3) to 0.5 (interquartile range 0-2) (P=0.01) between start and end of mirabegron treatment. Despite the fact that the primary end point of reducing JAK2-V617F allele burden was not reached, the observed effects on nestin+ mesenchymal stem cells and reticulin fibrosis is encouraging, and shows that mirabegron can modify the microenvironment where the JAK2-mutant stem cells are maintained. (Registered at clinicaltrials.gov identifier: 02311569).
Collapse
Affiliation(s)
- Beatrice Drexler
- Division of Hematology, University Hospital Basel and University of Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, University Hospital Basel and University of Basel, Switzerland
| | - Alexandar Tzankov
- Institute of Pathology, University Hospital Basel and University of Basel, Switzerland
| | - Martin Bigler
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Nathan Cantoni
- Oncology, Hematology & Transfusion Medicine, Kantonsspital Aarau AG, Switzerland
| | - Peter Keller
- University Clinic of Hematology and Central Hematology Laboratory, University Hospital Bern, Switzerland
| | - Georg Stussi
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Axel Ruefer
- Departement Medizin, Luzerner Kantonsspital, Switzerland
| | | | | | - Pontus Lundberg
- Division of Hematology, University Hospital Basel and University of Basel, Switzerland
| | - Ronny Nienhold
- Department of Biomedicine, Experimental Hematology, University Hospital Basel and University of Basel, Switzerland
| | - Andrea Fuhrer
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Markus G Manz
- Hematology and Oncology, University Hospital Zurich and University of Zurich, Switzerland
| | - Mario Bargetzi
- Oncology, Hematology & Transfusion Medicine, Kantonsspital Aarau AG, Switzerland
| | - Simon Mendez-Ferrer
- Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Department of Haematology, University of Cambridge, and National Health Service Blood and Transplant, Cambridge, UK
| | - Radek C Skoda
- Department of Biomedicine, Experimental Hematology, University Hospital Basel and University of Basel, Switzerland
| |
Collapse
|
138
|
Randi ML, Bertozzi I, Putti MC. Contemporary management of essential thrombocythemia in children. Expert Rev Hematol 2019; 12:367-373. [PMID: 30925843 DOI: 10.1080/17474086.2019.1602034] [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] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Essential thrombocythemia (ET) is a disease which is extremely rare in children. Only recently, data on pediatric ET have become available. Areas covered: In children with sustained platelet count over 450 x 109/L, secondary thrombocytosis must be ruled out. ET workup comprehends research of JAK2V617F, CALR and MPL mutations and bone marrow biopsy (BM). In asymptomatic children wait and watch is the best option. Aspirin controls headache and other microvascular disturbances. Patients with venous thrombosis need anticoagulation. Cytoreductive drugs in children with ET should be prescribed as a last choice. Hydroxyurea and IFN-a are first-line therapy at any age including children; Anagrelide is not licensed as first-line therapy for ET in Europe. New JAK2-inhibitors are not clearly useful in ET and hence not approved for ET. Expert opinion: The most challenging problem is to understand if a child with prolonged not secondary thrombocytosis really has ET. Diagnostic workup requires molecular and histological studies. The rare children with clonal ET have features like those of adults. Patients with ET have long expected survival and the treatment in children must be long-term efficacious and well tolerated.
Collapse
Affiliation(s)
- Maria Luigia Randi
- a Department of Medicine - DIMED, First Medical Clinic , University of Padua , Padova , Italy
| | - Irene Bertozzi
- a Department of Medicine - DIMED, First Medical Clinic , University of Padua , Padova , Italy
| | - Maria Caterina Putti
- b Department of Women's and Children's Health, Pediatric Hemato-Oncology , University of Padova , Padova , Italy
| |
Collapse
|
139
|
Podoltsev NA, Zhu M, Zeidan AM, Wang R, Wang X, Davidoff AJ, Huntington SF, Giri S, Gore SD, Ma X. Impact of Hydroxyurea on Survival and Risk of Thrombosis Among Older Patients With Essential Thrombocythemia. J Natl Compr Canc Netw 2019; 17:211-219. [DOI: 10.6004/jnccn.2018.7095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/11/2019] [Indexed: 11/17/2022]
Abstract
ABSTRACTBackground: Current guidelines recommend hydroxyurea (HU) as frontline therapy for patients with high-risk essential thrombocythemia (ET) to prevent thrombosis. However, little is known about the impact of HU on thrombosis or survival among these patients in the real-world setting. Patients and Methods: A retrospective cohort study was conducted of older adults (aged ≥66 years) diagnosed with ET from 2007 through 2013 using the linked SEER-Medicare database. Multivariable Cox proportional hazards regression models were used to assess the effect of HU on overall survival, and multivariable competing risk models were used to assess the effect of HU on the occurrence of thrombotic events. Results: Of 1,010 patients, 745 (73.8%) received HU. Treatment with HU was associated with a significantly lower risk of death (hazard ratio [HR], 0.52; 95% CI, 0.43–0.64; P<.01). Every 10% increase in HU proportion of days covered was associated with a 12% decreased risk of death (HR, 0.88; 95% CI, 0.86–0.91; P<.01). Compared with nonusers, HU users also had a significantly lower risk of thrombotic events (HR, 0.51; 95% CI, 0.41–0.64; P<.01). Conclusions: Although underused in our study population, HU was associated with a reduced incidence of thrombotic events and improved overall survival in older patients with ET.
Collapse
Affiliation(s)
- Nikolai A. Podoltsev
- aDepartment of Internal Medicine, Section of Hematology, Yale School of Medicine
| | - Mengxin Zhu
- bDepartment of Chronic Disease Epidemiology, Yale School of Public Health
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
| | - Amer M. Zeidan
- aDepartment of Internal Medicine, Section of Hematology, Yale School of Medicine
| | - Rong Wang
- bDepartment of Chronic Disease Epidemiology, Yale School of Public Health
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
| | - Xiaoyi Wang
- bDepartment of Chronic Disease Epidemiology, Yale School of Public Health
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
| | - Amy J. Davidoff
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
- dDepartment of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Scott F. Huntington
- aDepartment of Internal Medicine, Section of Hematology, Yale School of Medicine
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
| | - Smith Giri
- aDepartment of Internal Medicine, Section of Hematology, Yale School of Medicine
| | - Steven D. Gore
- aDepartment of Internal Medicine, Section of Hematology, Yale School of Medicine
| | - Xiaomei Ma
- bDepartment of Chronic Disease Epidemiology, Yale School of Public Health
- cYale Cancer Outcomes, Public Policy, and Effectiveness Research Center; and
| |
Collapse
|
140
|
Griesshammer M, Kiladjian JJ, Besses C. Thromboembolic events in polycythemia vera. Ann Hematol 2019; 98:1071-1082. [PMID: 30848334 PMCID: PMC6469649 DOI: 10.1007/s00277-019-03625-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/28/2019] [Indexed: 12/19/2022]
Abstract
Thromboembolic events and cardiovascular disease are the most prevalent complications in patients with polycythemia vera (PV) compared with other myeloproliferative disorders and are the major cause of morbidity and mortality in this population. Moreover, a vascular complication such as arterial or venous thrombosis often leads to the diagnosis of PV. The highest rates of thrombosis typically occur shortly before or at diagnosis and decrease over time, probably due to the effects of treatment. Important risk factors include age (≥ 60 years old) and a history of thrombosis; elevated hematocrit and leukocytosis are also associated with an increased risk of thrombosis. The goal of therapy is to reduce the risk of thrombosis by controlling hematocrit to < 45%, a target associated with reduced rates of cardiovascular death and major thrombosis. Low-risk patients (< 60 years old with no history of thrombosis) are managed with phlebotomy and low-dose aspirin, whereas high-risk patients (≥ 60 years old and/or with a history of thrombosis) should be treated with cytoreductive agents. Interferon and ruxolitinib are considered second-line therapies for patients who are intolerant of or have an inadequate response to hydroxyurea, which is typically used as first-line therapy. In this review, we discuss factors associated with thrombosis and recent data on current treatments, including anticoagulation, highlighting the need for more controlled studies to determine the most effective cytoreductive therapies for reducing the risk of thrombosis in patients with PV.
Collapse
Affiliation(s)
- Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
| | - Jean-Jacques Kiladjian
- Hôpital Saint-Louis, AP-HP, Centre d'Investigations Cliniques (CIC 1427), Université Paris Diderot, INSERM UMRS 1131, 1 Avenue Claude Vellefaux, Paris, France
| | - Carlos Besses
- Hospital del Mar-IMIM, Passeig Marítim 25-29, 08003, Barcelona, Spain
| |
Collapse
|
141
|
Mora B, Passamonti F. Developments in diagnosis and treatment of essential thrombocythemia. Expert Rev Hematol 2019; 12:159-171. [PMID: 30793984 DOI: 10.1080/17474086.2019.1585239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by thrombocytosis, increased risk of thrombotic/hemorrhagic events and clonal evolution into blast phase or myelofibrosis. Areas covered: The authors will discuss biology, diagnosis, prognosis, therapy, and outcome of ET. An accurate molecular-morphologic assessment is necessary in order to properly establish diagnosis and prognosis of ET. Stratification for thrombosis prediction is essential, and IPSET-t model is widely applied. The current treatment strategy is directed to lower the rate of vascular events using cytoreduction in patients at high risk. Prophylactic low dose aspirin indication is more uncertain. To date, therapies for patients who are resistant or intolerant to first-line treatments are scarce. Overall, life expectancy indicates an indolent disease, but IPSET model helps in predicting survival at the time of diagnosis. Expert opinion: Challenging for the future will be to share criteria for ET diagnosis with the community. New insights into the molecular pathogenesis of the disease will improve the prediction of clonal evolution and outcome, and lead to the use of disease-modifying treatments.
Collapse
Affiliation(s)
- Barbara Mora
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy
| | - Francesco Passamonti
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy.,b Department of Medicine and Surgery , Universita degli Studi dell'Insubria , Varese , Italy
| |
Collapse
|
142
|
Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2019 update on diagnosis, risk-stratification and management. Am J Hematol 2019; 94:133-143. [PMID: 30281843 DOI: 10.1002/ajh.25303] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 12/15/2022]
Abstract
Disease Overview: Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms respectively characterized by erythrocytosis and thrombocytosis; other disease features include leukocytosis, splenomegaly, thrombosis, bleeding, microcirculatory symptoms, pruritus, and risk of leukemic or fibrotic transformation. Diagnosis: Bone marrow morphology remains the cornerstone of diagnosis. In addition, the presence of JAK2 mutation is expected in PV while approximately 90% of patients with ET express mutually exclusive JAK2, CALR, or myeloproliferative leukemia mutations. In ET, it is most important to exclude the possibility of prefibrotic myelofibrosis. Survival: Median survivals are 14 years for PV and 20 years for ET; the corresponding values for younger patients are 24 and 33 years. Certain mutations (mostly spliceosome) and abnormal karyotype might compromise survival in PV and ET. Life-expectancy in ET is inferior to the control population. Driver mutations have not been shown to affect survival in ET. Risk of thrombosis is higher in JAK2-mutated ET. Leukemic transformation rates at 10 years are estimated at <1% for ET and 3% for PV. Thrombosis Risk: In PV, 2 risk categories are considered: high (age > 60 years or thrombosis history present) and low (absence of both risk factors); in ET, 4 risk categories are considered: very low (age ≤ 60 years, no thrombosis history, JAK2 wild-type), low (same as very low but JAK2 mutation present), intermediate (age > 60 years, no thrombosis history, JAK2 wild-type) and high (thrombosis history present or age > 60 years with JAK2 mutation). Risk-Adapted Therapy: The main goal of therapy in both PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once- or twice-daily aspirin (81 mg), in the absence of contraindications. Very low-risk ET might not require therapy while aspirin therapy is advised for low-risk disease. Cytoreductive therapy is recommended for high-risk ET and PV but it is not mandatory for intermediate-risk ET. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon-α and busulfan. We do not recommend treatment with ruxolutinib in PV, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs.
Collapse
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
| |
Collapse
|
143
|
Tefferi A, Szuber N, Vallapureddy RR, Begna KH, Patnaik MM, Elliott MA, Christopher Hook C, Wolanskyj AP, Hanson CA, Ketterling RP, Pardanani A, Gangat N. Decreased survival and increased rate of fibrotic progression in essential thrombocythemia chronicled after the FDA approval date of anagrelide. Am J Hematol 2019; 94:5-9. [PMID: 30252953 DOI: 10.1002/ajh.25294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 01/01/2023]
Abstract
First-line cytoreductive drug of choice in high risk essential thrombocythemia (ET) is currently hydroxyurea, a practice based on the results of a randomized study; second-line drugs of choice include pegylated interferon-α, busulfan and anagrelide. Anagrelide clinical trials were pioneered by the late Murray N. Silverstein (1928-1998) of the Mayo Clinic whose studies led to FDA approval in March 1997. The current study represents a retrospective examination of the potential impact of anagrelide therapy on survival and disease complications in ET. 1076 patients with ET were considered (median age 58 years; females 63%); risk distribution, according to the international prognostic score for ET (IPSET), was 28% high, 42% intermediate, and 30% low. Overall (OS), myelofibrosis-free (MFFS) and thrombosis-free survival data were compared for ET patients diagnosed before and after the 1997 FDA approval date for anagrelide; a significant difference was apparent in OS (P = .006; HR 1.4, 95% CI 1.1-1.7) and MFFS (P < .001; HR 4.2, 95% CI 2.7-6.5), in favor of patients diagnosed prior to 1997; the difference was sustained during multivariable analysis that included IPSET. Similarly stratified survival data in polycythemia vera (n = 665) and primary myelofibrosis (n = 1282) showed no similar impact on survival (P = .3 and .17, respectively). The current study represents a retrospective analysis and suggests significantly decreased OS and MFFS in ET patients diagnosed after the FDA approval date of anagrelide. Whether or not anagrelide therapy was to blame for the worsening of OS and MFFS over time cannot be assumed and requires validation in a prospective study.
Collapse
Affiliation(s)
- Ayalew Tefferi
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Natasha Szuber
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | | | | | | | | | | | - Rhett P. Ketterling
- Departments of Internal and Laboratory Medicine, Laboratory Genetics and Genomics; Mayo Clinic; Rochester Minnesota
| | | | - Naseema Gangat
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| |
Collapse
|
144
|
Scharf RE. Acquired Disorders of Platelet Function. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00049-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
145
|
Sankar K, Stein BL, Rampal RK. Thrombosis in the Philadelphia Chromosome-Negative Myeloproliferative Neoplasms. Cancer Treat Res 2019; 179:159-178. [PMID: 31317487 DOI: 10.1007/978-3-030-20315-3_11] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The myeloproliferative neoplasms (MPNs) are clonal stem cell-derived diseases. This chapter focuses on the subcategory of Philadelphia (Ph) chromosome-negative classical MPNs, polycythemia vera (PV), essential thrombocythemia (ET), primary myelofibrosis (PMF). These MPNs are associated with both microvascular and macrovascular thrombosis, which may occur in the venous and arterial circulation. Erythrocytosis, leukocytosis, and increased JAK2V617F allele burden are known to be risk factors. In this chapter, we review the thrombotic and hemostatic manifestations of the Philadelphia (Ph) chromosome-negative classical MPNs, including the clinical manifestations, the pathophysiology, as well as management.
Collapse
Affiliation(s)
- Kamya Sankar
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brady L Stein
- Department of Medicine/Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Raajit K Rampal
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
146
|
|
147
|
Efficacy of a Chinese Herbal Medicine Compound Zhangpi Ointment against Hydroxyurea-Induced Leg Ulcers: A Prospective, Randomized, Open-Label, Controlled Clinical Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:9329465. [PMID: 30643539 PMCID: PMC6311290 DOI: 10.1155/2018/9329465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/23/2018] [Indexed: 02/03/2023]
Abstract
Objective. The randomized controlled trial was to evaluate the efficacy of topical Chinese herbal Zhangpi Ointment for hydroxyurea-induced leg ulcers in patients with myeloproliferative neoplasms. Patients and Methods. This single-center, prospective, randomized, open-label, controlled clinical trial conducted at Shanghai Ninth People's Hospital enrolled 54 patients with hydroxyurea-induced leg ulcers. Patients were randomly assigned to the control group (n = 27) treated with chlorhexidine dressing or the intervention group (n = 27) treated with the Zhangpi Ointment. Finally, 26 patients in the control group and 23 patients in the intervention group completed 8 weeks of observation. Results. The rate of complete healing was 100% for the intervention group, which was significantly higher than that of the control group (96.15%) (P<0.05). Furthermore, the intervention group achieved a significantly higher rate of wound healing (95.56%) than the control group (69.02%) at week 4 (P<0.01). The intervention group took 34 ± 5 days to achieve complete healing while the control group took 41 ± 7 days (P < 0.01). Moreover, grade 3/4 side effects were observed in neither group. Conclusion. The Zhangpi Ointment is effective in promoting the healing of hydroxyurea-induced leg ulcers in patients with myeloproliferative neoplasms, providing a therapeutic option for a condition that is recalcitrant to conventional therapy.
Collapse
|
148
|
Pulkka OP, Gebreyohannes YK, Wozniak A, Mpindi JP, Tynninen O, Icay K, Cervera A, Keskitalo S, Murumägi A, Kulesskiy E, Laaksonen M, Wennerberg K, Varjosalo M, Laakkonen P, Lehtonen R, Hautaniemi S, Kallioniemi O, Schöffski P, Sihto H, Joensuu H. Anagrelide for Gastrointestinal Stromal Tumor. Clin Cancer Res 2018; 25:1676-1687. [DOI: 10.1158/1078-0432.ccr-18-0815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/23/2018] [Accepted: 12/04/2018] [Indexed: 11/16/2022]
|
149
|
Godfrey AL, Campbell PJ, MacLean C, Buck G, Cook J, Temple J, Wilkins BS, Wheatley K, Nangalia J, Grinfeld J, McMullin MF, Forsyth C, Kiladjian JJ, Green AR, Harrison CN. Hydroxycarbamide Plus Aspirin Versus Aspirin Alone in Patients With Essential Thrombocythemia Age 40 to 59 Years Without High-Risk Features. J Clin Oncol 2018; 36:3361-3369. [PMID: 30153096 PMCID: PMC6269131 DOI: 10.1200/jco.2018.78.8414] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Cytoreductive therapy is beneficial in patients with essential thrombocythemia (ET) at high risk of thrombosis. However, its value in those lacking high-risk features remains unknown. This open-label, randomized trial compared hydroxycarbamide plus aspirin with aspirin alone in patients with ET age 40 to 59 years and without high-risk factors or extreme thrombocytosis. PATIENTS AND METHODS Patients were age 40 to 59 years and lacked a history of ischemia, thrombosis, embolism, hemorrhage, extreme thrombocytosis (platelet count ≥ 1,500 × 109/L), hypertension, or diabetes requiring therapy. In all, 382 patients were randomly assigned 1:1 to hydroxycarbamide plus aspirin or aspirin alone. The composite primary end point was time to arterial or venous thrombosis, serious hemorrhage, or death from vascular causes. Secondary end points were time to first arterial or venous thrombosis, first serious hemorrhage, death, incidence of transformation, and patient-reported quality of life. RESULTS After a median follow-up of 73 months and a total follow-up of 2,373 patient-years, there was no significant difference between the arms in the likelihood of patients reaching the primary end point (hazard ratio, 0.98; 95% CI, 0.42 to 2.25; P = 1.0). The incidence of significant vascular events was low, at 0.93 per 100 patient-years (95% CI, 0.61 to 1.41). There were also no differences in overall survival; in the composite end point of transformation to myelofibrosis, acute myeloid leukemia, or myelodysplasia; in adverse events; or in patient-reported quality of life. CONCLUSION In patients with ET age 40 to 59 years and lacking high-risk factors for thrombosis or extreme thrombocytosis, preemptive addition of hydroxycarbamide to aspirin did not reduce vascular events, myelofibrotic transformation, or leukemic transformation. Patients age 40 to 59 years without other clinical indications for treatment (such as previous thrombosis or hemorrhage) who have a platelet count < 1,500 × 109/L should not receive cytoreductive therapy.
Collapse
Affiliation(s)
- Anna L. Godfrey
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Peter J. Campbell
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Cathy MacLean
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Georgina Buck
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Julia Cook
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Julie Temple
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Bridget S. Wilkins
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Keith Wheatley
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Jyoti Nangalia
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Jacob Grinfeld
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Mary Frances McMullin
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Cecily Forsyth
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Jean-Jacques Kiladjian
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Anthony R. Green
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - Claire N. Harrison
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - on behalf of the United Kingdom Medical Research Council Primary Thrombocythemia-1 Study
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - the United Kingdom National Cancer Research Institute Myeloproliferative Neoplasms Subgroup
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - the French Intergroup of Myeloproliferative Neoplasms
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| | - and the Australasian Leukaemia and Lymphoma Group.
- Anna L. Godfrey, Jacob Grinfeld, and Anthony R. Green, Cambridge University Hospitals National Health Service (NHS) Foundation Trust; Peter J. Campbell and Jyoti Nangalia, Wellcome Trust Sanger Institute, Hinxton; Cathy MacLean, Julia Cook, Julie Temple, and Anthony R. Green, University of Cambridge; Anthony R. Green, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, Cambridge; Georgina Buck, University of Oxford, Oxford; Bridget S. Wilkins and Claire N. Harrison, Guy’s and St Thomas’ NHS Foundation Trust, London; Keith Wheatley, University of Birmingham, Birmingham; Mary Frances McMullin, Queen’s University Belfast, Belfast, United Kingdom; Cecily Forsyth, Gosford Hospital, Gosford, and Australasian Leukaemia and Lymphoma Group, Australia; and Jean-Jacques Kiladjian, Hôpital Saint-Louis, Paris, France
| |
Collapse
|
150
|
De Stefano V, Rossi E, Carobbio A, Ghirardi A, Betti S, Finazzi G, Vannucchi AM, Barbui T. Hydroxyurea prevents arterial and late venous thrombotic recurrences in patients with myeloproliferative neoplasms but fails in the splanchnic venous district. Pooled analysis of 1500 cases. Blood Cancer J 2018; 8:112. [PMID: 30420642 PMCID: PMC6232117 DOI: 10.1038/s41408-018-0151-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/19/2018] [Accepted: 10/25/2018] [Indexed: 12/25/2022] Open
Abstract
We collected 1500 patients with myeloproliferative neoplasms (MPN) and arterial or venous thrombosis (935/565), pooling three independent cohorts previously reported. Long-term treatment with antiplatelet drugs or vitamin K-antagonists (VKA) was given to 1391 (92.7%) patients; 975 (65%) patients received hydroxyurea (HU). We recorded 348 recurrences (venous in 142 cases) over 6075 patient-years, with an incidence rate of 5.7 per 100 pt-years (95% CI 5.1-6.4). The site of the first thrombosis predicted the site of recurrence. Independent factors influencing the rate of novel arterial thrombosis were HU (HR 0.67, 95% CI 0.46-0.98), antiplatelet treatment (HR 0.54, 95% CI 0.35-0.82), and VKA (HR 0.58, 95% CI 0.35-0.96). On the contrary, the recurrence of venous thromboses was significantly diminished only by VKA (HR 0.60, 95% CI 0.37-0.95), while HU prevented late but not early recurrences after venous thrombosis at common sites. Of note, we failed to demonstrate a positive effect of HU in the prevention of recurrent splanchnic vein thrombosis. In conclusion, in MPN patients, HU plays a role in the prevention of arterial thrombosis, together with aspirin and VKA, whereas its action in the prevention of recurrent venous thrombosis is uncertain. Such findings call for future studies to optimize and personalize secondary prophylaxis after MPN-related thrombosis.
Collapse
Affiliation(s)
- Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elena Rossi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Arianna Ghirardi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Silvia Betti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Guido Finazzi
- Division of Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Department Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| |
Collapse
|