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Wille K, Sadjadian P, Becker T, Kolatzki V, Horstmann A, Fuchs C, Griesshammer M. High risk of recurrent venous thromboembolism in BCR-ABL-negative myeloproliferative neoplasms after termination of anticoagulation. Ann Hematol 2018; 98:93-100. [PMID: 30155552 DOI: 10.1007/s00277-018-3483-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/20/2018] [Indexed: 12/30/2022]
Abstract
Venous thromboembolism (VTE) is a major burden in patients with BCR-ABL-negative myeloproliferative neoplasms (MPN). In addition to cytoreductive treatment anticoagulation is mandatory, but optimal duration of anticoagulation is a matter of debate. In our single center study, we retrospectively included 526 MPN patients. In total, 78 of 526 MPN patients (14.8%) had 99 MPN-associated VTE. Median age at first VTE was 52.5 years (range 23-81). During a study period of 3497 years, a VTE event rate of 1.7% per patient/year was detected. 38.4% (38/99) of all VTEs appeared before or at MPN diagnosis and 55.6% (55/99) occurred at "uncommon" sites like splanchnic or cerebral veins. MPN patients with VTEs were significantly more female (p = 0.028), JAK2 positive (p = 0.018), or had a polycythemia vera (p = 0.009). MPN patients without VTEs were more often CALR positive (p = 0.023). Total study period after first VTE was 336 years with 20 VTE recurrences accounting for a recurrence rate of 6% per patient/year. In 36 of 71 MPN patients with anticoagulation therapy after first VTE event (50.7%), prophylactic anticoagulation was terminated after a median time of 6 months (range 1-61); 13 of those 36 patients (36.1%) had a VTE recurrence after a median of 13 months (range 4-168). In contrast, only three of 35 (8.6%) patients with ongoing anticoagulation had a VTE recurrence (p = 0.0127). Thus, termination of prophylactic anticoagulation was associated with a significantly higher risk of VTE recurrence. Our data suggest that in MPN patients with VTE, a prolonged duration of anticoagulation may be beneficial.
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Affiliation(s)
- Kai Wille
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
| | - Parvis Sadjadian
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Tatjana Becker
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Vera Kolatzki
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Anette Horstmann
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Christiane Fuchs
- Faculty of Business Administration and Economics, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.,Institute of Computational Biology, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
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152
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Kanakura Y, Shirasugi Y, Yamaguchi H, Koike M, Chou T, Okamoto S, Achenbach H, Wu J, Nakaseko C. A phase 3b, multicenter, open-label extension study of the long-term safety of anagrelide in Japanese adults with essential thrombocythemia. Int J Hematol 2018; 108:491-498. [PMID: 30121892 DOI: 10.1007/s12185-018-2510-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/25/2018] [Accepted: 07/30/2018] [Indexed: 12/25/2022]
Abstract
Cytoreductive therapy is used in high-risk essential thrombocythemia (ET) to reduce risk of thrombohemorrhagic complications. Anagrelide is an orally active, quinazolone-derived platelet-lowering agent approved for first-line treatment of high-risk ET in Japan. Long-term safety and efficacy data were collected from 53 Japanese high-risk ET patients (Study 308); 41 patients who completed Study 308 entered this phase 3b, open-label extension (Study 309; NCT01467661). Reductions in mean platelet counts occurred throughout the study, from 1021.6 × 109/L (at Study 308 baseline) to 675.4 × 109/L at final assessment. At month 48 (since Study 308 enrollment), mean platelet count was 444.5 × 109/L in the 10 patients who completed 4 years of therapy. Overall, platelet counts decreased from 1088.3 × 109/L at Study 308 baseline (n = 33) to 473.5 × 109/L at final assessment (n = 31). Long-term platelet count reductions were maintained without marked changes in mean anagrelide dose. Anagrelide was generally well tolerated, with anemia (54.7%) and headache (49.1%) as the most frequent adverse events. These findings indicate that anagrelide effectively reduces platelet counts in high-risk Japanese ET patients, with titration resulting in a well-tolerated, effective and sustainable dose. In conclusion, these results support anagrelide administration to high-risk Japanese ET patients using individualized dosing strategies defined in instructions previously approved in Europe and the USA.
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Affiliation(s)
- Yuzuru Kanakura
- Graduate School of Medicine, Osaka University, Osaka University Hospital, C9, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | | | | | | | | | | | | | - Jingyang Wu
- Global Biometrics, Shire Pharmaceuticals, Lexington, MA, USA
| | - Chiaki Nakaseko
- Chiba University Hospital, Chiba, Japan.,International University of Health and Welfare School of Medicine, Narita, Japan
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153
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Trifan G, Shafi N, Testai FD. Implications of Janus Kinase 2 Mutation in Embolic Stroke of Unknown Source. J Stroke Cerebrovasc Dis 2018; 27:2572-2578. [PMID: 30056970 DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/15/2018] [Accepted: 05/28/2018] [Indexed: 12/19/2022] Open
Abstract
The role of genetic mutations in cerebral ischemia is not completely understood. Among these genetic variations, Philadelphia-negative gain-of-function mutation in the janus kinase 2 (JAK2) protein leads to overexpression of the genes involved in cell growth and proliferation, and has been linked to development of hematological malignancies, specifically, myeloproliferative neoplasms (MPNs; essential thrombocythemia [ET], polycythemia vera [PV], and primary myelofibrosis). Overt ET and PV are known to induce a prothrombotic state that leads to development of vascular complications, including cerebral arterial or venous thrombosis. Thromboembolism can precede overt presentation of an MPN by 2-3 years. As such, for the selected cases of embolic stroke or cerebrovascular sinus thrombosis with otherwise undetermined source and persistent thrombocytosis or polycythemia, in the absence of a confirmed MPN diagnosis, screening for JAK2 mutation may be reasonable, as early diagnosis and appropriate treatment can influence outcome by preventing recurrent thrombotic events. In this article, we review the literature on the genetics, pathogenesis, clinical manifestations, and treatment of JAK2-associated thrombosis, and present 2 cases of JAK2-associated cerebral arterial infarction and cerebral and systemic venous thromboembolism with otherwise negative etiology workup for stroke.
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Affiliation(s)
- Gabriela Trifan
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, Illinois.
| | - Neelofer Shafi
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, Illinois
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154
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Ruxolitinib for the Treatment of Essential Thrombocythemia. Hemasphere 2018; 2:e56. [PMID: 31723782 PMCID: PMC6746005 DOI: 10.1097/hs9.0000000000000056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 12/21/2022] Open
Abstract
Deregulated Janus Kinase 2 (JAK2) activation is central to the pathogenesis of most myeloproliferative neoplasms (MPNs), of which essential thrombocythemia (ET) is the most common entity. Patients with ET are risk-stratified according to their risk of thrombo-hemorrhagic complications. High-risk patients are offered treatments to reduce their platelet count using cytoreductive therapy. The disease course is often long and therapy intolerance is not infrequent. Ruxolitinib, a Janus Kinase (JAK) 1/JAK2 inhibitor, has demonstrated efficacy in patients with both myelofibrosis (MF) and polycythemia vera and is well tolerated. Side effects include predictable cytopenias and an augmented risk of infections. Ruxolitinib has been investigated in a small group of ET patients who were refractory/intolerant to hydroxycarbamide (HC) and demonstrated improvements in both symptoms and splenomegaly. Of note, a proportion of treated patients (13.2%) also had a significant reduction in platelet counts. However, these results require further validation in comparison with conventional therapy. Recently, a randomized-controlled phase 2 study (MAJIC-ET) assessed the role of Ruxolitinib in patients refractory or intolerant to HC. This study revealed that Ruxolitinib demonstrated some clinical efficacy but was only superior in terms of symptom control. In clinical practice, some individuals with ET do exhaust all potential treatment options and there may well be a role for Ruxolitinib in such patients or those with a significant symptom burden. However, in the wider context the goal of therapy with the use of JAK inhibitor therapy in ET needs to be defined carefully and we explore this within this timely review article.
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155
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Buxhofer-Ausch V, Steurer M, Sormann S, Schloegl E, Schimetta W, Gisslinger B, Schalling M, Krauth MT, Thiele J, Ruckser R, Gastl G, Gisslinger H. Impact of white blood cells on thrombotic risk in patients with optimized platelet count in essential thrombocythemia. Eur J Haematol 2018; 101:131-135. [PMID: 29603799 DOI: 10.1111/ejh.13070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Risk of thrombosis is significantly enhanced by both elevated platelet (PLT) and white blood cell (WBC) counts according to a retrospective analysis of a large anagrelide registry in thrombocythemic MPN patients. We were interested in the impact of elevated WBC counts on thrombosis risk in patients where PLT counts were reduced below the calculated cutoff of 574.5 G/L by treatment with anagrelide. METHODS Cox regression analysis and Kaplan-Meier plot were applied on all patients in the registry with optimized PLT counts. RESULTS Using the calculated cutoff of 9.66 G/L for WBC, Cox regression analysis revealed a clear influence of elevated WBC counts on the occurrence of a major thrombotic event (P = .012). A Kaplan-Meier plot revealed a markedly shorter time to a major thrombotic event for patients with WBC counts above the cutoff (P = .001). CONCLUSIONS These data suggest that additional correction of elevated WBC counts is mandatory in patients with optimally managed PLT counts to reduce thrombotic risk. This study is the first investigation in a prospectively observed large patient cohort which was treated homogenously allowing for evaluation of single parameters for an effect on thrombophilia.
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Affiliation(s)
- Veronika Buxhofer-Ausch
- Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
- Department of Internal Medicine I, Ordensklinikum Linz, Elisabethinen Hospital, Linz, Austria
| | - Michael Steurer
- Division of Hematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | | | - Ernst Schloegl
- 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
- Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Martin Schalling
- Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Maria Theresa Krauth
- Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thiele
- Department of Pathology, University of Cologne, Cologne, Germany
| | | | - Günther Gastl
- Division of Hematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Heinz Gisslinger
- Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
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156
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Xiong N, Gao W, Pan J, Luo X, Shi H, Li J. Essential thrombocythemia presenting as acute coronary syndrome: case reports and literature review. J Thromb Thrombolysis 2018; 44:57-62. [PMID: 28285408 DOI: 10.1007/s11239-017-1490-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
For the patients with essential thrombocythemia (ET), systemic thrombosis presents as one of the most dangerous complications. It's been widely accepted that acute coronary syndrome (ACS) is a kind of thrombotic diseases. However, there are very few case reports about ET first presenting as ACS. For some patients diagnosed as ACS, but without markedly elevated platelet, underlying ET was missed. And there are some controversies in the principles and target of treatment in those patients. We reported three cases of ACS, in which the patients who did not have common risk factors for coronary artery diseases and presented only mild atherosclerotic stenosis during coronary angiography, one of which had recurrent coronary artery thrombosis. Noticing their elevated blood platelet level and characteristics in angiography, diagnosis of ET was made according to bone marrow morphology and genetic tests. Although they had only mild thrombocytosis, we applied intensive treatment with dual anti-platelet therapy combined with cytoreduction in addition to early coronary intervention, having satisfying outcomes. During the diagnosis and treatment of ACS, if patients present thrombocytosis, but lack common coronary disease risk factors and thrombotic coronary artery occlusion, cardiologists should search for possible ET as an underlying cause of thrombotic coronary event. All those patients were high-risk according to ET risk stratification. Treatment of cytoreduction in combination with anti-thrombosis therapy and revascularization are beneficial. Treatment aims at the target of complete response with platelet count below 400 × 109/L.
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Affiliation(s)
- Nanqing Xiong
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China
| | - Wen Gao
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China
| | - Junjie Pan
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China
| | - Haiming Shi
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital, Fudan University, 12 Wulumuqizhong Road, Shanghai, China.
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157
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Hultcrantz M, Björkholm M, Dickman PW, Landgren O, Derolf ÅR, Kristinsson SY, Andersson TML. Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms: A Population-Based Cohort Study. Ann Intern Med 2018; 168:317-325. [PMID: 29335713 PMCID: PMC7533681 DOI: 10.7326/m17-0028] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients with myeloproliferative neoplasms (MPNs) are reported to be at increased risk for thrombotic events. However, no population-based study has estimated this excess risk compared with matched control participants. OBJECTIVE To assess risk for arterial and venous thrombosis in patients with MPNs compared with matched control participants. DESIGN Matched cohort study. SETTING Population-based setting in Sweden from 1987 to 2009, with follow-up to 2010. PATIENTS 9429 patients with MPNs and 35 820 matched control participants. MEASUREMENTS The primary outcomes were rates of arterial and venous thrombosis. Flexible parametric models were used to calculate hazard ratios (HRs) and cumulative incidence with 95% CIs. RESULTS The HRs for arterial thrombosis among patients with MPNs compared with control participants at 3 months, 1 year, and 5 years were 3.0 (95% CI, 2.7 to 3.4), 2.0 (CI, 1.8 to 2.2), and 1.5 (CI, 1.4 to 1.6), respectively. The corresponding HRs for venous thrombosis were 9.7 (CI, 7.8 to 12.0), 4.7 (CI, 4.0 to 5.4), and 3.2 (CI, 2.9 to 3.6). The rate was significantly elevated across all age groups and was similar among MPN subtypes. The 5-year cumulative incidence of thrombosis in patients with MPNs showed an initial rapid increase followed by gentler increases during follow-up. The HR for venous thrombosis decreased during more recent calendar periods. LIMITATION No information on individual laboratory results or treatment. CONCLUSION Patients with MPNs across all age groups have a significantly increased rate of arterial and venous thrombosis compared with matched control participants, with the highest rates at and shortly after diagnosis. Decreases in the rate of venous thrombosis over time likely reflect advances in clinical management. PRIMARY FUNDING SOURCE The Cancer Research Foundations of Radiumhemmet, Blodcancerfonden, the Swedish Research Council, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, the Adolf H. Lundin Charitable Foundation, and Memorial Sloan Kettering Cancer Center.
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Affiliation(s)
- Malin Hultcrantz
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden, and Memorial Sloan Kettering Cancer Center, New York, New York (M.H.)
| | - Magnus Björkholm
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden (M.B., Å.R.D.)
| | - Paul W Dickman
- Karolinska Institutet, Stockholm, Sweden (P.W.D., T.M.A.)
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, New York (O.L.)
| | - Åsa R Derolf
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden (M.B., Å.R.D.)
| | - Sigurdur Y Kristinsson
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden, and University of Iceland and Landspítali National University Hospital, Reykjavik, Iceland (S.Y.K.)
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159
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De Stefano V, Carobbio A, Di Lazzaro V, Guglielmelli P, Iurlo A, Finazzi MC, Rumi E, Cervantes F, Elli EM, Randi ML, Griesshammer M, Palandri F, Bonifacio M, Hernandez-Boluda JC, Cacciola R, Miroslava P, Carli G, Beggiato E, Ellis MH, Musolino C, Gaidano G, Rapezzi D, Tieghi A, Lunghi F, Loscocco GG, Cattaneo D, Cortelezzi A, Betti S, Rossi E, Finazzi G, Censori B, Cazzola M, Bellini M, Arellano-Rodrigo E, Bertozzi I, Sadjadian P, Vianelli N, Scaffidi L, Gomez M, Cacciola E, Vannucchi AM, Barbui T. Benefit-risk profile of cytoreductive drugs along with antiplatelet and antithrombotic therapy after transient ischemic attack or ischemic stroke in myeloproliferative neoplasms. Blood Cancer J 2018. [PMID: 29535299 PMCID: PMC5849668 DOI: 10.1038/s41408-018-0048-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We analyzed 597 patients with myeloproliferative neoplasms (MPN) who presented transient ischemic attacks (TIA, n = 270) or ischemic stroke (IS, n = 327). Treatment included aspirin, oral anticoagulants, and cytoreductive drugs. The composite incidence of recurrent TIA and IS, acute myocardial infarction (AMI), and cardiovascular (CV) death was 4.21 and 19.2%, respectively at one and five years after the index event, an estimate unexpectedly lower than reported in the general population. Patients tended to replicate the first clinical manifestation (hazard ratio, HR: 2.41 and 4.41 for recurrent TIA and IS, respectively); additional factors for recurrent TIA were previous TIA (HR: 3.40) and microvascular disturbances (HR: 2.30); for recurrent IS arterial hypertension (HR: 4.24) and IS occurrence after MPN diagnosis (HR: 4.47). CV mortality was predicted by age over 60 years (HR: 3.98), an index IS (HR: 3.61), and the occurrence of index events after MPN diagnosis (HR: 2.62). Cytoreductive therapy was a strong protective factor (HR: 0.24). The rate of major bleeding was similar to the general population (0.90 per 100 patient-years). In conclusion, the long-term clinical outcome after TIA and IS in MPN appears even more favorable than in the general population, suggesting an advantageous benefit-risk profile of antithrombotic and cytoreductive treatment.
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Affiliation(s)
- Valerio De Stefano
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | | | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Biomedico di Roma, Rome, Italy
| | - Paola Guglielmelli
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Alessandra Iurlo
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | | | - Elisa Rumi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Elena Maria Elli
- Hematology Division, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | | | - Martin Griesshammer
- University Clinic for Hematology and Oncology Minden, University of Bochum, Bochum, Germany
| | - Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | | | - Rossella Cacciola
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Palova Miroslava
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Giuseppe Carli
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Eloise Beggiato
- Unit of Hematology, Department of Oncology, University of Torino, Torino, Italy
| | - Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, and Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Caterina Musolino
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Davide Rapezzi
- S.C. Ematologia, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
| | - Alessia Tieghi
- Divisione di Ematologia, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giuseppe Gaetano Loscocco
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Daniele Cattaneo
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | - Agostino Cortelezzi
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | - Silvia Betti
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Elena Rossi
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII hospital, Bergamo, Italy
| | - Bruno Censori
- Neurology Division, Papa Giovanni XXIII hospital, Bergamo, Italy
| | - Mario Cazzola
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marta Bellini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Irene Bertozzi
- Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Parvis Sadjadian
- University Clinic for Hematology and Oncology Minden, University of Bochum, Bochum, Germany
| | - Nicola Vianelli
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Montse Gomez
- Hematology Department, Hospital Clínico Universitario, Valencia, Spain
| | - Emma Cacciola
- Department of Medical, Surgical and Advanced Technologies Sciences "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII hospital, Bergamo, Italy.
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160
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Philadelphia chromosome-negative classical myeloproliferative neoplasms: revised management recommendations from European LeukemiaNet. Leukemia 2018. [PMID: 29515238 DOI: 10.1038/s41375-018-0077-1] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This document updates the recommendations on the management of Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-neg MPNs) published in 2011 by the European LeukemiaNet (ELN) consortium. Recommendations were produced by multiple-step formalized procedures of group discussion. A critical appraisal of evidence by using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was performed in the areas where at least one randomized clinical trial was published. Seven randomized controlled trials provided the evidence base; earlier phase trials also informed recommendation development. Key differences from the 2011 diagnostic recommendations included: lower threshold values for hemoglobin and hematocrit and bone marrow examination for diagnosis of polycythemia vera (PV), according to the revised WHO criteria; the search for complementary clonal markers, such as ASXL1, EZH2, IDH1/IDH2, and SRSF2 for the diagnosis of myelofibrosis (MF) in patients who test negative for JAK2V617, CALR or MPL driver mutations. Regarding key differences of therapy recommendations, both recombinant interferon alpha and the JAK1/JAK2 inhibitor ruxolitinib are recommended as second-line therapies for PV patients who are intolerant or have inadequate response to hydroxyurea. Ruxolitinib is recommended as first-line approach for MF-associated splenomegaly in patients with intermediate-2 or high-risk disease; in case of intermediate-1 disease, ruxolitinib is recommended in highly symptomatic splenomegaly. Allogeneic stem cell transplantation is recommended for transplant-eligible MF patients with high or intermediate-2 risk score. Allogeneic stem cell transplantation is also recommended for transplant-eligible MF patients with intermediate-1 risk score who present with either refractory, transfusion-dependent anemia, blasts in peripheral blood > 2%, adverse cytogenetics, or high-risk mutations. In these situations, the transplant procedure should be performed in a controlled setting.
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161
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Martin K. Risk Factors for and Management of MPN-Associated Bleeding and Thrombosis. Curr Hematol Malig Rep 2018; 12:389-396. [PMID: 28948496 DOI: 10.1007/s11899-017-0400-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF THE REVIEW The Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) are characterized by both thrombotic and bleeding complications. The purpose of this review is to describe the risk factors associated with bleeding and thrombosis in MPN, as well as to review prevention strategies and management of these complications. RECENT FINDINGS Well-described risk factors for thrombotic complications include older age and history of prior thrombosis, along with traditional cardiovascular and venous thromboembolic risk factors. More recently, JAK2 V617F mutation has been found to carry an increased risk of thrombotic complications, whereas CALR has a lower risk than JAK2 mutation. Factors associated with an increased risk of bleeding in MPN include a prior history of bleeding, acquired von Willebrand syndrome, and primary myelofibrosis. Recent findings suggest that thrombocytosis carries a higher risk of bleeding than thrombosis in MPN, and aspirin may exacerbate this risk of bleeding, particularly in CALR-mutated ET. Much of the management of MPN focuses on predicting risk of bleeding and thrombosis and initiating prophylaxis to prevent complications in those at high risk of thrombosis. Emerging evidence suggests that sub-populations may have bleeding risk that outweighs thrombotic risk, particularly in setting of antiplatelet therapy. Future work is needed to better characterize this balance. At present, a thorough assessment of the risks of bleeding and thrombosis should be undertaken for each patient, and herein, we review risk factors for and management of these complications.
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Affiliation(s)
- Karlyn Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Suite 1020, Chicago, IL, 60611, USA.
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162
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018. [PMID: 29426921 DOI: 10.1038/s41408-018-0054-y.pmid:29426921;pmcid:pmc5807384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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163
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Barbui T, Thiele J, Gisslinger H, Kvasnicka HM, Vannucchi AM, Guglielmelli P, Orazi A, Tefferi A. The 2016 WHO classification and diagnostic criteria for myeloproliferative neoplasms: document summary and in-depth discussion. Blood Cancer J 2018; 8:15. [PMID: 29426921 PMCID: PMC5807384 DOI: 10.1038/s41408-018-0054-y] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 12/17/2022] Open
Abstract
The new edition of the 2016 World Health Organization (WHO) classification system for tumors of the hematopoietic and lymphoid tissues was published in September 2017. Under the category of myeloproliferative neoplasms (MPNs), the revised document includes seven subcategories: chronic myeloid leukemia, chronic neutrophilic leukemia, polycythemia vera (PV), primary myelofibrosis (PMF), essential thrombocythemia (ET), chronic eosinophilic leukemia-not otherwise specified and MPN, unclassifiable (MPN-U); of note, mastocytosis is no longer classified under the MPN category. In the current review, we focus on the diagnostic criteria for JAK2/CALR/MPL mutation-related MPNs: PV, ET, and PMF. In this regard, the 2016 changes were aimed at facilitating the distinction between masked PV and JAK2-mutated ET and between prefibrotic/early and overtly fibrotic PMF. In the current communication, we (i) provide practically useful resource tables and graphs on the new diagnostic criteria including outcome, (ii) elaborate on the rationale for the 2016 changes, (iii) discuss the complementary role of mutation screening, (iv) address ongoing controversies and propose solutions, (v) attend to the challenges of applying WHO criteria in routine clinical practice, and (vi) outline future directions from the perspectives of the clinical pathologist.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Cologne, Germany
| | | | | | | | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Azienda Ospedaliera-Universitaria Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Attilio Orazi
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
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164
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Annibali O, Napolitano M, Avvisati G, Siragusa S. Incidence of venous thromboembolism and use of anticoagulation in hematological malignancies: Critical review of the literature. Crit Rev Oncol Hematol 2018; 124:41-50. [PMID: 29548485 DOI: 10.1016/j.critrevonc.2018.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/04/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022] Open
Abstract
Venous Thromboembolism (VTE) frequently complicates the course of hematologic malignancies (HM) and its incidence is similar to that observed in high-risk solid tumors. Despite that, pharmacologic prophylaxis and treatment of VTE in patients with HM is challenging, mainly because a severe thrombocytopenia frequently complicates the course of treatments or may be present since diagnosis, thus increasing the risk of bleeding. Therefore, in this setting, safe and effective methods of VTE prophylaxis and treatment have not been well defined and hematologists generally refer to guidelines produced for cancer patients that give indications on anticoagulation in patients with thrombocytopenia. In this review, besides to summarize the incidence and the available data on prophylaxis and treatment of VTE in HM, we give some advices on how to use antithrombotic drugs in patients with HM according to platelets count.
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Affiliation(s)
- Ombretta Annibali
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Mariasanta Napolitano
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy.
| | - Giuseppe Avvisati
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Sergio Siragusa
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
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165
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Rodriguez-Ziccardi M, Rubio M, Lu M, Greenspan A. Ventricular tachyarrhythmia in a 78-year-old woman with essential thrombocythaemia. BMJ Case Rep 2018; 2018:bcr-2017-220723. [PMID: 29437800 DOI: 10.1136/bcr-2017-220723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Anagrelide is a phosphodiesterase-3 inhibitor used in the treatment of essential thrombocythaemia. Cardiovascular side effects such as ventricular tachycardia and cardiomyopathy are rare but potentially fatal and should be made known to patients before starting the medication. It usually arises within the first 6 months after initiation of therapy and may be dose related. The elderly population are particularly susceptible. These cardiotoxicities result from an increase in cyclic AMP that induces positive inotropic and chronotropic effects and are often reversible with cessation of use. We report a case of a 78-year-old woman with essential thrombocythaemia and recently started on anagrelide who presented with syncope and multiple bruises and facial trauma and found to have developed ventricular tachyarrhythmia.
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Affiliation(s)
| | - Manolo Rubio
- Internal Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Marvin Lu
- Internal Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Allan Greenspan
- Division of Cardiac Electrophysiology, Einstein Medical Center, Philadelphia, Pennsylvania, USA
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166
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Petrides PE, Schoergenhofer C, Widmann R, Jilma B, Klade CS. Pharmacokinetics of a Novel Anagrelide Extended-Release Formulation in Healthy Subjects: Food Intake and Comparison With a Reference Product. Clin Pharmacol Drug Dev 2018; 7:123-131. [PMID: 28301098 PMCID: PMC5811889 DOI: 10.1002/cpdd.340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/18/2017] [Indexed: 11/10/2022]
Abstract
Anagrelide is an established therapy for essential thrombocythemia. Common adverse effects have been linked to peak plasma concentrations of anagrelide and its 3OH metabolite. Our study was performed to investigate the pharmacokinetics (PK) of a novel anagrelide extended-release (AER) formulation and its active metabolites. Thirty healthy volunteers were randomized to receive either 2 mg AER (under fasting and fed conditions) or 2 mg commercially available reference product (CARP) in an open-label, 3-way crossover trial with washout periods of 6 days. Plasma concentrations of anagrelide and its active metabolites were assessed by tandem mass spectrometry. The PK differed significantly between all treatment periods. Bioavailability of AER was 55% of the CARP under fasting conditions and 60% under fed conditions. Cmax , AUCt, and AUC∞ were significantly higher and Tmax and T1/2 were significantly shorter after the CARP compared with AER. Food had a significant impact on the PK of AER, increasing the Cmax and AUCt while reducing the T1/2 , plateau, and mean residence time. Both formulations were well tolerated, with a trend toward more frequently occurring adverse events after the CARP. The PK of AER and the CARP differed significantly in all parameters. Food enhanced the bioavailability of AER.
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Affiliation(s)
- Petro E. Petrides
- Hematology Oncology Center and Ludwig Maximilians University of Munich Medical SchoolMunichGermany
| | | | | | - Bernd Jilma
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
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167
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Phosphatidylserine-exposing blood and endothelial cells contribute to the hypercoagulable state in essential thrombocythemia patients. Ann Hematol 2018; 97:605-616. [PMID: 29332224 DOI: 10.1007/s00277-018-3228-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/28/2017] [Indexed: 12/27/2022]
Abstract
The mechanisms of thrombogenicity in essential thrombocythemia (ET) are complex and not well defined. Our objective was to explore whether phosphatidylserine (PS) exposure on blood cells and endothelial cells (ECs) can account for the increased thrombosis and distinct thrombotic risks among mutational subtypes in ET. Using flow cytometry and confocal microscopy, we found that the levels of PS-exposing erythrocytes, platelets, leukocytes, and serum-cultured ECs were significantly higher in each ET group [JAK2, CALR, and triple-negative (TN) (all P < 0.001)] than those in controls. Among ET patients, those with JAK2 mutations showed higher levels of PS-positive erythrocytes, platelets, neutrophils, and serum-cultured ECs than TN patients or those with CALR mutations, which show similar levels. Coagulation function assays showed that higher levels of PS-positive blood cells and serum-cultured ECs led to markedly shortened coagulation time and dramatically increased levels of FXa, thrombin, and fibrin production. This procoagulant activity could be largely blocked by addition of lactadherin (approx. 70% inhibition). Confocal microscopy showed that the FVa/FXa complex and fibrin fibrils colocalized with PS on ET serum-cultured ECs. Additionally, we found a relationship between D-dimer, prothrombin fragment F1 + 2, and PS exposure. Our study reveals a previously unrecognized link between hypercoagulability and exposed PS on cells, which might also be associated with distinct thrombotic risks among mutational subtypes in ET. Thus, blocking PS-binding sites may represent a new therapeutic target for preventing thrombosis in ET.
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168
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Abstract
Current drug therapy for myeloproliferative neoplasms, including essential thrombocythemia (ET) and polycythemia vera (PV), is neither curative nor has it been shown to prolong survival. Fortunately, prognosis in ET and PV is relatively good, with median survivals in younger patients estimated at 33 and 24 years, respectively. Therefore, when it comes to treatment in ET or PV, less is more and one should avoid exposing patients to new drugs that have not been shown to be disease-modifying, and whose long-term consequences are suspect (e.g., ruxolitinib). Furthermore, the main indication for treatment in ET and PV is to prevent thrombosis and, in that regard, none of the newer drugs have been shown to be superior to the time-tested older drugs (e.g., hydroxyurea). We currently consider three major risk factors for thrombosis (history of thrombosis, JAK2/MPL mutations, and advanced age), in order to group ET patients into four risk categories: "very low risk" (absence of all three risk factors); "low risk" (presence of JAK2/MPL mutations); "intermediate-risk" (presence of advanced age); and "high-risk" (presence of thrombosis history or presence of both JAK2/MPL mutations and advanced age). Herein, we provide a point-of-care treatment algorithm that is risk-adapted and based on evidence and decades of experience.
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169
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera treatment algorithm 2018. Blood Cancer J 2018; 8:3. [PMID: 29321547 PMCID: PMC5802495 DOI: 10.1038/s41408-017-0042-7] [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: 07/12/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 12/18/2022] Open
Abstract
Recently reported mature survival data have confirmed the favorable prognosis in polycythemia vera (PV), with an estimated median survival of 24 years, in patients younger than age 60 years old. Currently available drugs for PV have not been shown to prolong survival or alter the natural history of the disease and are instead indicated primarily for prevention of thrombosis. Unfortunately, study endpoints that are being utilized in currently ongoing clinical trials in PV do not necessarily target clinically or biologically relevant outcomes, such as thrombosis, survival, or morphologic remission, and are instead focused on components of disease palliation. Even more discouraging has been the lack of critical appraisal from "opinion leaders", on the added value of newly approved drugs. Keeping these issues in mind, at present, we continue to advocate conservative management in low-risk PV (phlebotomy combined with once- or twice-daily aspirin therapy) and include cytoreductive therapy in "high-risk" patients; in the latter regard, our first, second, and third line drugs of choice are hydroxyurea, pegylated interferon-α and busulfan, respectively. In addition, it is reasonable to consider JAK2 inhibitor therapy, in the presence of protracted pruritus or markedly enlarged splenomegaly shown to be refractory to the aforementioned drugs.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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170
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Mascarenhas J, Iancu-Rubin C, Kremyanskaya M, Najfeld V, Hoffman R. Essential Thrombocythemia. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00069-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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171
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Bose P, Gotlib J, Harrison CN, Verstovsek S. SOHO State-of-the-Art Update and Next Questions: MPN. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2018; 18:1-12. [PMID: 29277359 PMCID: PMC5915302 DOI: 10.1016/j.clml.2017.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022]
Abstract
The discovery of the activating Janus kinase (JAK)2V617F mutation in 2005 in most patients with the classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) spurred intense interest in research into these disorders, culminating in the identification of activating mutations in MPL in 2006 and indels in the gene encoding calreticulin (CALR) in 2013, thus providing additional mechanistic explanations for the universal activation of JAK-signal transducer and activator of transcription (JAK-STAT) observed in these conditions, and the success of the JAK1/2 inhibitor ruxolitinib, which first received regulatory approval in 2011. The field has continued to advance rapidly since then, and the past 2 years have witnessed important changes to the classification of MPN and diagnostic criteria for polycythemia vera (PV), novel insights into the mechanisms of bone marrow fibrosis in primary myelofibrosis (PMF), increasing appreciation of the biologic differences between essential thrombocythemia (ET), prefibrotic and overt PMF, and between primary and post-PV/ET myelofibrosis (MF). Additionally, the mechanisms through which mutant CALR drives JAK-STAT pathway activation and oncogenic transformation are now better understood. Although mastocytosis is no longer included under the broad heading of MPN in the 2016 revision to the World Health Organization classification, an important milestone in mastocytosis research was reached in 2017 with the regulatory approval of midostaurin for patients with advanced systemic mastocytosis (AdvSM). In this article, we review the major recent developments in the areas of PV, ET, and MF, and also briefly summarize the literature on midostaurin and other KIT inhibitors for patients with AdvSM.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Jason Gotlib
- Department of Medicine - Hematology, Stanford University, Palo Alto, CA
| | | | - Srdan Verstovsek
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX
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172
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Vannucchi AM, Guglielmelli P. What are the current treatment approaches for patients with polycythemia vera and essential thrombocythemia? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:480-488. [PMID: 29222296 PMCID: PMC6142598 DOI: 10.1182/asheducation-2017.1.480] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Polycythemia vera (PV) and essential thrombocythemia (ET) are chronic myeloproliferative neoplasms that are characterized by thrombohemorrhagic complications, symptom burden, and impaired survival mainly due to thrombosis, progression to myelofibrosis, and transformation to acute leukemia. In this manuscript, we will review the most recent changes in diagnostic criteria, the improvements in risk stratification, and the "state of the art" in the daily management of these disorders. The role of conventional therapies and novel agents, interferon α and the JAK2 inhibitor ruxolitinib, is critically discussed based on the results of a few basic randomized clinical studies. Several unmet needs remain, above all, the lack of a curative approach that might overcome the still burdensome morbidity and mortality of these hematologic neoplasms, as well as the toxicities associated with therapeutic agents.
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Affiliation(s)
- Alessandro M Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Careggi University Hospital/University of Florence, Florence, Italy
| | - Paola Guglielmelli
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Careggi University Hospital/University of Florence, Florence, Italy
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173
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Greenfield G, McMullin MF. A spotlight on the management of complications associated with myeloproliferative neoplasms: a clinician's perspective. Expert Rev Hematol 2017; 11:25-35. [PMID: 29183180 DOI: 10.1080/17474086.2018.1410433] [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: 10/18/2022]
Abstract
INTRODUCTION Myeloproliferative neoplasms (MPNs) are associated with a variety of symptoms and signs which cause major morbidity for the patients. The disorders are associated with increased incidence of thromboembolic and hemorrhagic events which can lead to complications and shortened life expectancy. Areas covered: Using systematic literature review and expert clinical and research experience the authors discuss strategies for the management of symptoms and signs including pruritus, fatigue, splenomegaly, and cytopenia. Cytoreduction including treatments to inhibit the JAK/STAT pathway are considered. Pathogenesis and prevention and treatment of thrombotic and hemorrhagic events and their management is addressed and the suggested management of the special situations such as surgery and pregnancy are discussed. Expert commentary: Management of disease has traditionally focused on symptom treatment and complication prevention but the discovery of driver mutations has led to treatments aiming to eliminate the clone, which should be the ultimate goal of therapy. A future challenge is to develop safe and effective MPN therapy and to personalize therapy.
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174
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Incidence and impact of atrial arrhythmias on thrombotic events in MPNs. Ann Hematol 2017; 97:101-107. [PMID: 29164292 DOI: 10.1007/s00277-017-3164-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
Atrial arrhythmias (AA) induce a high rate of thromboses and require vitamin K antagonists (VKA) or direct anticoagulants (DOAC) prescriptions. Essential thrombocythemia (ET) and polycythemia vera (PV) are also pro-thrombotic diseases. The prevention of thromboses is based on the association of cytoreductive drug and low-dose aspirin (LDA). We studied the incidence and complications of AA among patients with ET or PV. We identified 96/713 patients (13.5%) carrying AA. These patients were older (median 72.1 vs. 61.3 years old, p < 0.0001). In a case-control analysis, we observed that patients with AA had a higher frequency of cardiovascular risk factors (77/96, 80% vs. 61/96, 61%; p = 0.01). A higher incidence of thromboses before and after myeloproliferative neoplasm (MPN) diagnosis was seen in this group: 26/96, 27.1% vs. 14/96, 14.6% (p = 0.03) and 34/96, 35% vs. 18/96, 18.8% (p = 0.009). Most of the events were arterial (82 vs. 61%, p = 0.09). This translates into a shorter thrombosis-free survival (11.0 vs. 21.6 years, p = 0.01). Continuation of LDA in this situation exposed patients to more thrombotic events (p = 0.04) but VKA did not seem to be good anticoagulant drugs either. The association of AA and MPN is more frequent than expected. AA clearly increased the thrombotic risk of these patients. Anticoagulant drugs should be carefully managed between cardiologists and hematologists. Association of LDA and VKA or the role of DOAC in such population should be rapidly discussed to reduce the thrombotic rate.
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175
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Patient characteristics and outcomes in adolescents and young adults with classical Philadelphia chromosome-negative myeloproliferative neoplasms. Ann Hematol 2017; 97:109-121. [DOI: 10.1007/s00277-017-3165-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/30/2017] [Indexed: 02/01/2023]
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176
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Khan M, Siddiqi R, Gangat N. Therapeutic options for leukemic transformation in patients with myeloproliferative neoplasms. Leuk Res 2017; 63:78-84. [PMID: 29121538 DOI: 10.1016/j.leukres.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/12/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
Approximately 5-10% of patients with Philadelphia chromosome negative myeloproliferative neoplasms (MPN) comprising of essential thrombocythemia, polycythemia vera and primary myelofibrosis) experience transformation to acute myeloid leukemia (AML, ≥20% blasts). Treatment options for post-MPN AML patients are limited, as conventional approaches like standard chemotherapy, fail to offer long-term benefit. Median survival for secondary AML is ∼2.4 months. Post-MPN AML therefore represents an area of urgent clinical need. At present, allogeneic stem cell transplant (ASCT) following induction therapy is the best therapeutic option. Patients ineligible for ASCT are treated with hypomethylating agents. New agents under investigation include histone deacetylase inhibitors, JAKinhibitors and agents targeting the BRD4 protein. Combined treatment strategies involving these novel agents are being tested. In this review we present the current evidence regarding treatment options for post-MPN AML patients.
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Affiliation(s)
- Maliha Khan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rabbia Siddiqi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, MN, United States.
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177
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Birgegård G, Besses C, Griesshammer M, Gugliotta L, Harrison CN, Hamdani M, Wu J, Achenbach H, Kiladjian JJ. Treatment of essential thrombocythemia in Europe: a prospective long-term observational study of 3649 high-risk patients in the Evaluation of Anagrelide Efficacy and Long-term Safety study. Haematologica 2017; 103:51-60. [PMID: 29079600 PMCID: PMC5777190 DOI: 10.3324/haematol.2017.174672] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/25/2017] [Indexed: 01/01/2023] Open
Abstract
Evaluation of Anagrelide (Xagrid®) Efficacy and Long-term Safety, a phase IV, prospective, non-interventional study performed in 13 European countries enrolled high-risk essential thrombocythemia patients treated with cytoreductive therapy. The primary objectives were safety and pregnancy outcomes. Of 3721 registered patients, 3649 received cytoreductive therapy. At registration, 3611 were receiving: anagrelide (Xagrid®) (n=804), other cytoreductive therapy (n=2666), or anagrelide + other cytoreductive therapy (n=141). The median age was 56 vs. 70 years for anagrelide vs. other cytoreductive therapy. Event rates (patients with events/100 patient-years) were 1.62 vs. 2.06 for total thrombosis and 0.15 vs. 0.53 for venous thrombosis. Anagrelide was more commonly associated with hemorrhage (0.89 vs. 0.43), especially with anti-aggregatory therapy (1.35 vs. 0.33) and myelofibrosis (1.04 vs. 0.30). Other cytoreductive therapies were more associated with acute leukemia (0.28 vs. 0.07) and other malignancies (1.29 vs. 0.44). Post hoc multivariate analyses identified increased risk for thrombosis with prior thrombohemorrhagic events, age ≥65, cardiovascular risk factors, or hypertension. Risk factors for transformation were prior thrombohemorrhagic events, age ≥65, time since diagnosis, and platelet count increase. Safety analysis reflected published data, and no new safety concerns for anagrelide were found. Live births occurred in 41/54 pregnancies (76%). clinicaltrials.gov Identifier: 00567502.
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Affiliation(s)
- Gunnar Birgegård
- Department of Haematology, Institute for Medical Sciences, Uppsala University, Sweden
| | - Carlos Besses
- Department of Hematology, Hospital del Mar-IMIM, Barcelona, Spain
| | | | - Luigi Gugliotta
- Department of Haematology, 'L e A Seragnoli', Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mohamed Hamdani
- Global Biometrics, Shire Pharmaceuticals, Lexington, MA, USA
| | - Jingyang Wu
- Global Biometrics, Shire Pharmaceuticals, Lexington, MA, USA
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Harrison CN, Mead AJ, Panchal A, Fox S, Yap C, Gbandi E, Houlton A, Alimam S, Ewing J, Wood M, Chen F, Coppell J, Panoskaltsis N, Knapper S, Ali S, Hamblin A, Scherber R, Dueck AC, Cross NCP, Mesa R, McMullin MF. Ruxolitinib vs best available therapy for ET intolerant or resistant to hydroxycarbamide. Blood 2017; 130:1889-1897. [PMID: 29074595 PMCID: PMC6410531 DOI: 10.1182/blood-2017-05-785790] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/24/2017] [Indexed: 01/11/2023] Open
Abstract
Treatments for high-risk essential thrombocythemia (ET) address thrombocytosis, disease-related symptoms, as well as risks of thrombosis, hemorrhage, transformation to myelofibrosis, and leukemia. Patients resistant/intolerant to hydroxycarbamide (HC) have a poor outlook. MAJIC (ISRCTN61925716) is a randomized phase 2 trial of ruxolitinib (JAK1/2 inhibitor) vs best available therapy (BAT) in ET and polycythemia vera patients resistant or intolerant to HC. Here, findings of MAJIC-ET are reported, where the modified intention-to-treat population included 58 and 52 patients randomized to receive ruxolitinib or BAT, respectively. There was no evidence of improvement in complete response within 1 year reported in 27 (46.6%) patients treated with ruxolitinib vs 23 (44.2%) with BAT (P = .40). At 2 years, rates of thrombosis, hemorrhage, and transformation were not significantly different; however, some disease-related symptoms improved in patients receiving ruxolitinib relative to BAT. Molecular responses were uncommon; there were 2 complete molecular responses (CMR) and 1 partial molecular response in CALR-positive ruxolitinib-treated patients. Transformation to myelofibrosis occurred in 1 CMR patient, presumably because of the emergence of a different clone, raising questions about the relevance of CMR in ET patients. Grade 3 and 4 anemia occurred in 19% and 0% of ruxolitinib vs 0% (both grades) in the BAT arm, and grade 3 and 4 thrombocytopenia in 5.2% and 1.7% of ruxolitinib vs 0% (both grades) of BAT-treated patients. Rates of discontinuation or treatment switching did not differ between the 2 trial arms. The MAJIC-ET trial suggests that ruxolitinib is not superior to current second-line treatments for ET. This trial was registered at www.isrctn.com as #ISRCTN61925716.
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Affiliation(s)
| | - Adam J Mead
- Weatherall Institute of Molecular Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Anesh Panchal
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Sonia Fox
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Emmanouela Gbandi
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Aimee Houlton
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Samah Alimam
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Joanne Ewing
- Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Marion Wood
- Colchester Hospital University NHS Foundation Trust, Colchester, United Kingdom
| | - Frederick Chen
- Centre for Clinical Hematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jason Coppell
- Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Nicki Panoskaltsis
- Department of Hematology, London North West Healthcare NHS Trust, London, United Kingdom
| | - Steven Knapper
- Department of Hematology, Cardiff University, Cardiff, United Kingdom
| | - Sahra Ali
- Castle Hill Hospital, Hull, United Kingdom
| | - Angela Hamblin
- NIHR Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Robyn Scherber
- Department of Hematology and Oncology, Oregon Health and Sciences University, Portland, OR
- Mayo Clinic, Phoenix, AZ
| | - Amylou C Dueck
- Division of Health Sciences Research, Mayo Clinic, Scottsdale, AZ
| | - Nicholas C P Cross
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; and
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179
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Abstract
PURPOSE OF REVIEW Venous thromboembolism is frequent in chronic myeloproliferative neoplasms (MPN). The current strategy for its management includes cytoreductive therapy and antithrombotic prophylaxis, but many issues remain uncertain. In this review, the risk factors and prevention of recurrences will be discussed. RECENT FINDINGS Around one-third of patients with polycythemia vera and essential thrombocythemia experience a major thrombosis at diagnosis or during follow-up. According to the European Leukemia Net guidelines, these patients must be included in the high-risk group for thrombotic recurrence and should be treated with cytoreduction and antiplatelet or anticoagulant drugs in the presence of arterial or venous thrombosis, respectively. Despite this treatment, the annual incidence of recurrence after the first venous thrombosis varies from 4.2 to 6.5% on vitamin K-antagonists and is doubled after discontinuation. The highest incidence of recurrence occurs after cerebral and hepatic vein thrombosis (8.8 and 8 per 100 pt-years, respectively). The occurrence of major bleeding on vitamin K-antagonists is similar to a non-MPN population and accounts for a rate of 1.8-2.4 per 100 pt-years. SUMMARY After venous thrombosis, the incidence of recurrence in MPN remains elevated, which suggested there was a need to review the current recommendations of primary and secondary prophylaxis.
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180
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The Use of Anagrelide in Myeloproliferative Neoplasms, with Focus on Essential Thrombocythemia. Curr Hematol Malig Rep 2017; 11:348-55. [PMID: 27497846 PMCID: PMC5031713 DOI: 10.1007/s11899-016-0335-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anagrelide (ANA) is a drug with specific platelet-lowering activity, used primarily in ET, registered as a second-line drug in essential thrombocythemia (ET) in Europe and in some countries as first-line therapy, in USA licensed by FDA for thrombocythemia in myeloproliferative neoplasms (MPN). The platelet-lowering efficacy is similar to that of hydroxycarbamide (HC), around 70 % complete response and 90 % partial response. Side effects are common, especially headache and tachycardia, but usually subside or disappear within a few weeks. Around 20 % of patients stop ANA therapy due to side effects or insufficient response. Studies of treatment patterns in Europe show that ANA is preferentially given to younger patients, probably because of the concern for a possible leukemogenic effect of the common first-line drug, HC. Only two randomized studies have compared the efficacy of ANA and HC in preventing thrombosis and haemorrhage, the larger of them showing a slightly better efficacy of HC, the other showing non-inferiority of ANA to HC. A recent observational 5-year study of 3600 patients shows a low and basically similar efficacy of ANA and other cytoreductive therapies in ET. ANA does not appear to inhibit fibrosis development, and probably due to its anticoagulation properties, the combination of ASA and ANA produces an increased rate of haemorrhage. Combination of ANA with HC or interferon (IFN) is feasible and effective in patients with insufficient platelet response to mono-therapy.
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181
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. Blood Lymphat Cancer 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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182
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Ruxolitinib for essential thrombocythemia refractory to or intolerant of hydroxyurea: long-term phase 2 study results. Blood 2017; 130:1768-1771. [PMID: 28827411 DOI: 10.1182/blood-2017-02-765032] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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183
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Fatal pulmonary embolism following splenectomy in a patient with Evan's syndrome: case report and review of the literature. Thromb J 2017; 15:18. [PMID: 28680366 PMCID: PMC5496165 DOI: 10.1186/s12959-017-0141-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/26/2017] [Indexed: 12/19/2022] Open
Abstract
Background Evans syndrome (ES) is a rare disease characterized by simultaneous or sequential development of autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) with or without immune neutropenia. Splenectomy is one of the treatment options for disease refractory to medical therapy. Venous thromboembolism (VTE) following splenectomy for hematological diseases has an incidence of 10%. Case presentation Here we describe a case report of a young patient hospitalized with severe hemolytic anemia with Hgb 4.8 g/dl. He developed thrombocytopenia with platelet nadir of 52,000/mm3, thus formally diagnosed with ES. He failed standard medical therapy. He underwent splenectomy and had a fatal outcome. Autopsy confirmed the cause of death as pulmonary embolism (PE). Conclusions This case report and review of the literature highlight important aspects of the association between VTE, splenectomy, and hemolytic syndromes including the presence of thrombocytopenia. The burden of the disease is reviewed as well as various pathophysiologic mechanisms contributing to thromboembolic events in these patients and current perioperative prophylactic anticoagulation strategies. Despite an advancing body of literature increasing awareness of VTE following splenectomy, morbidity and mortality remains high. Identifying high risk individuals for thromboembolic complications from splenectomy remains a challenge. There are no consensus guidelines for proper perioperative and post-operative anti-coagulation. We encourage future research to determine which factors might be playing a role in increasing the risk for VTE in real time with hope of forming a consensus to guide management.
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184
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Mannargudi MB, Deb S. Clinical pharmacology and clinical trials of ribonucleotide reductase inhibitors: is it a viable cancer therapy? J Cancer Res Clin Oncol 2017. [PMID: 28624910 DOI: 10.1007/s00432-017-2457-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Ribonucleotide reductase (RR) enzymes (RR1 and RR2) play an important role in the reduction of ribonucleotides to deoxyribonucleotides which is involved in DNA replication and repair. Augmented RR activity has been ascribed to uncontrolled cell growth and tumorigenic transformation. METHODS This review mainly focuses on several biological and chemical RR inhibitors (e.g., siRNA, GTI-2040, GTI-2501, triapine, gemcitabine, and clofarabine) that have been evaluated in clinical trials with promising anticancer activity from 1960's till 2016. A summary on whether their monotherapy or combination is still effective for further use is discussed. RESULTS Among the RR2 inhibitors evaluated, GTI-2040, siRNA, gallium nitrate and didox were more efficacious as a monotherapy, whereas triapine was found to be more efficacious as combination agent. Hydroxyurea is currently used more in combination therapy, even though it is efficacious as a monotherapy. Gallium nitrate showed mixed results in combination therapy, while the combination activity of didox is yet to be evaluated. RR1 inhibitors that have long been used in chemotherapy such as gemcitabine, cladribine, fludarabine and clofarabine are currently used mostly as a combination therapy, but are equally efficacious as a monotherapy, except tezacitabine which did not progress beyond phase I trials. CONCLUSIONS Based on the results of clinical trials, we conclude that RR inhibitors are viable treatment options, either as a monotherapy or as a combination in cancer chemotherapy. With the recent advances made in cancer biology, further development of RR inhibitors with improved efficacy and reduced toxicity is possible for treatment of variety of cancers.
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Affiliation(s)
- Mukundan Baskar Mannargudi
- Clinical Pharmacology Program, Medical Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Subrata Deb
- Department of Biopharmaceutical Sciences, Roosevelt University College of Pharmacy, 1400 N. Roosevelt Blvd., Schaumburg, IL, 60173, USA.
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185
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Ianotto JC, Couturier MA, Galinat H, Mottier D, Berthou C, Guillerm G, Lippert E, Delluc A. Administration of direct oral anticoagulants in patients with myeloproliferative neoplasms. Int J Hematol 2017. [PMID: 28623609 DOI: 10.1007/s12185-017-2282-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Direct oral anticoagulants (DOACs) have been approved to treat and prevent thrombotic events. However, they are not yet labeled for use in patients with active cancers. Myeloproliferative neoplasms (MPNs) are clonal chronic disorders with a high incidence of thrombotic events, for which low-dose aspirin (LDA) is the standard drug treatment. We analyzed efficacy and safety of DOACs prescription in patients treated for MPNs. An MPN database, the OBENE registry, was established at our institution. We collected biological and clinical data from diagnosis to last follow-up for every patient included in this study. Thrombotic and hemorrhagic events and hematologic evolutions were categorized as major events in the database. Of the 760 MPN patients in the OBENE registry, 25 (3.3%) were treated with a DOAC. Median follow-up duration was 2.1 years (0.12-4.3 years). The reasons for prescribing DOACs were atrial fibrillation and thrombotic events for 13 and 12 patients, respectively. We only observed one thrombotic event (4%) and three major hemorrhagic events (12%). A case-control study did not detect a significant difference in thrombotic or hemorrhagic events in patients treated with LDA and DOACs. These preliminary results suggest that DOACs may be highly efficient and safe for use in MPN patients.
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Affiliation(s)
- Jean-Christophe Ianotto
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France.
- INSERM EA-3878, GETBO (Groupe d'étude de la thrombose en Bretagne occidentale), CHRU de Brest, Brest, France.
| | - Marie-Anne Couturier
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France
| | | | - Dominique Mottier
- INSERM EA-3878, GETBO (Groupe d'étude de la thrombose en Bretagne occidentale), CHRU de Brest, Brest, France
- Département de Médecine Interne et de Pneumologie, CHRU de Brest, Brest, France
| | - Christian Berthou
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France
| | - Gaëlle Guillerm
- Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest, Brest, France
| | - Eric Lippert
- Laboratoire d'Hématologie, CHRU de Brest, Brest, France
| | - Aurélien Delluc
- INSERM EA-3878, GETBO (Groupe d'étude de la thrombose en Bretagne occidentale), CHRU de Brest, Brest, France
- Département de Médecine Interne et de Pneumologie, CHRU de Brest, Brest, France
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186
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Thromboses and hemorrhages are common in MPN patients with high JAK2V617F allele burden. Ann Hematol 2017; 96:1297-1302. [DOI: 10.1007/s00277-017-3040-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/27/2017] [Indexed: 12/30/2022]
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187
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Affiliation(s)
- Jerry L Spivak
- From the Hematology Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
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188
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Chuzi S, Stein BL. Essential thrombocythemia: a review of the clinical features, diagnostic challenges, and treatment modalities in the era of molecular discovery. Leuk Lymphoma 2017; 58:2786-2798. [DOI: 10.1080/10428194.2017.1312371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sarah Chuzi
- Department of Medicine, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
| | - Brady L. Stein
- Department of Medicine, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern Feinberg University School of Medicine, Chicago, IL, USA
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189
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Grinfeld J, Godfrey AL. After 10 years of JAK2V617F: Disease biology and current management strategies in polycythaemia vera. Blood Rev 2017; 31:101-118. [DOI: 10.1016/j.blre.2016.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 11/08/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022]
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190
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Abstract
Myeloproliferative neoplasms (MPNs) are diseases of excess cell proliferation from bone marrow precursors. Two classic MPNs, polycythemia vera (PV) and essential thrombocytosis (ET), are conditions of excess proliferation of red blood cells and platelets, respectively. Although PV and ET involve different cells in the myeloid lineage, their clinical presentations have shared features, consistent with overlapping mutations in growth factor signaling. The management of both diseases involves minimizing the risk of thrombotic and hemorrhagic complications. Both PV and ET can progress to myelofibrosis or acute myeloid leukemia, portending a poor prognosis. MPNs can also present as primary myelofibrosis.
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Affiliation(s)
- Aric Parnes
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA.
| | - Arvind Ravi
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
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191
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Kiladjian JJ. Long-term treatment with interferon alfa for myeloproliferative neoplasms. LANCET HAEMATOLOGY 2017; 4:e150-e151. [PMID: 28291641 DOI: 10.1016/s2352-3026(17)30039-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Jean-Jacques Kiladjian
- Assistance Publique-Hopitaux de Paris, Hopital Saint-Louis, Université Paris Diderot, INSERM CIC 1427, Paris, France; Centre d'Investigations Cliniques, Hopital Saint-Louis, Paris 75010, France.
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192
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Sokolova MA, Turkina AG, Melikian AL, Sudarikov AB, Treglazova SA, Shukhov OA, Gemdzhian EG, Abdullaev AО, Kovrigina AM, Misyurin AV, Pliskunova YV, Ivanova VL, Moiseeva TN. [Efficiency of interferon therapy in patients with essential thrombocythemia or polycythemia vera]. TERAPEVT ARKH 2017; 88:69-77. [PMID: 28139563 DOI: 10.17116/terarkh2016881269-77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficiency of interferon (IFN) therapy in patients with essential thrombocythemia (ET) and polycythemia vera (PV). SUBJECTS AND METHODS A total of 61 patients (41 with ET and 20 with PV) were examined. Prior to study enrolment, 44 (72%) patients with ET or PV received one or other therapy (aspirin was not taken into account). The mean Jak2V617F mutant allele at baseline was 23% (6-54%) in the patients with ET and 40% (11-88%) in those with PV. The median time from diagnosis to enrollment was 49 months. RESULTS The paper presents the clinical and molecular findings of long-term INF-α therapy in patients with ET or PV. The median follow-up was 52 months. Recombinant IFN-α2 showed its ability to induce complete hematologic remission (ET (76%), PV (70%)) and a complete molecular response. 22 (69%) out of 32 patients were noted to have a smaller number of cells with the Jak2V617F mutation. In the patients with PV and in those with ET, the relative reduction in the proportion of cells with the Jak2V617F mutant gene averaged 85% and 56% of the baseline values, respectively. There was a reduction in the proportion of cells expressing the Jak2V617F mutation in both the ET (from 12 to 2.2%; p=0.001) and PV (from 32.7% to 3.2%) groups (р=0.001). Ten (31%) patients achieved a deep molecular remission (≤2% Jak2V617F allele); among them, 5 patients were not found to have Jak2V617F mutation. The obtained molecular response remained in 7 of the 10 patients untreated for 11 to 86 months. The long-term treatment with IFN-α led to normalization of the morphological pattern of bone marrow in 5 of the 7 PV or ET patients. CONCLUSION Significant molecular remissions achieved by therapy with recombinant interferon-α2 confirm the appropriateness of this treatment option in in the majority of patients with ET or PV.
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Affiliation(s)
- M A Sokolova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A G Turkina
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A L Melikian
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A B Sudarikov
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - S A Treglazova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - O A Shukhov
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - E G Gemdzhian
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A О Abdullaev
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A M Kovrigina
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A V Misyurin
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - Yu V Pliskunova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - V L Ivanova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - T N Moiseeva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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193
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Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2017; 92:94-108. [PMID: 27991718 DOI: 10.1002/ajh.24607] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
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 PV is defined by a JAK2 mutation, whose absence, combined with normal or increased serum erythropoietin level, makes the diagnosis unlikely. JAK2, CALR, and MPL mutations are the mutually exclusive "driver" mutations in ET with respective incidences of 55%, 25%, and 3%; approximately 17% are triple-negative. However, the same molecular markers might also be present in prefibrotic myelofibrosis, whose morphological distinction from ET is prognostically relevant. SURVIVAL AND LEUKEMIC/FIBROTIC TRANSFORMATION Median survivals are approximately 14 years for PV and 20 years for ET; the corresponding values for younger patients (age <60 years) are 24 and 33 years. Life-expectancy in ET is inferior to the control population. Driver mutational status has not been shown to affect survival in ET whereas the presence of JAK2/MPL mutations has been associated with higher risk of arterial thrombosis and that of MPL with higher risk of fibrotic progression. Risk factors for overall survival in both ET and PV include advanced age, leukocytosis and thrombosis. Leukemic transformation rates at 20 years are estimated at <10% for PV and 5% for ET; fibrotic transformation rates are slightly higher. Most recently, ASXL1, SRSF2, and IDH2 mutations have been associated with inferior overall, leukemia-free or fibrosis-free survival in PV; similarly adverse mutations in ET included SH2B3, SF3B1, U2AF1, TP53, IDH2, and EZH2. THROMBOSIS RISK STRATIFICATION Current risk stratification in PV and ET is designed to estimate the likelihood of recurrent thrombosis. Accordingly, PV includes two risk categories: high-risk (age >60 years or thrombosis history) and low-risk (absence of both risk factors). In ET, risk stratification includes four categories: very low risk (age ≤60 years, no thrombosis history, JAK2/MPL un-mutated), low risk (age ≤60 years, no thrombosis history, JAK2/MPL mutated), intermediate risk (age >60 years, no thrombosis history, JAK2/MPL un-mutated), and high risk (thrombosis history or age >60 years with JAK2/MPL mutation). In addition, presence of extreme thrombocytosis (platelets >1000 × 10(9)/L) might be associated with acquired von Willebrand syndrome (AvWS) and, therefore, risk of bleeding. RISK-ADAPTED THERAPY The main goal of therapy in PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once-daily aspirin (81 mg). In addition, high-risk patients with PV require cytoreductive therapy. Very low risk ET patients might not require any form of therapy while low-risk patients require at least once-daily aspirin therapy. Cytoreductive therapy is also recommended for high-risk ET patients but it is not mandatory for intermediate-risk patients. 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 currently do not recommend treatment with ruxolutinib or other JAK2 inhibitors in PV or ET, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs. Screening for AvWS is recommended before administrating aspirin, in the presence of extreme thrombocytosis. Am. J. Hematol. 92:95-108, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
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Emerging treatments for classical myeloproliferative neoplasms. Blood 2016; 129:693-703. [PMID: 28028027 DOI: 10.1182/blood-2016-10-695965] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/03/2016] [Indexed: 12/17/2022] Open
Abstract
There has been a major revolution in the management of patients with myeloproliferative neoplasms (MPN), and in particular those with myelofibrosis and extensive splenomegaly and symptomatic burden, after the introduction of the JAK1 and JAK2 inhibitor ruxolitinib. The drug also has been approved as second-line therapy for polycythemia vera (PV). However, the therapeutic armamentarium for MPN is still largely inadequate for coping with patients' major unmet needs, which include normalization of life span (myelofibrosis and some patients with PV), reduction of cardiovascular complications (mainly PV and essential thrombocythemia), prevention of hematological progression, and improved quality of life (all MPN). In fact, none of the available drugs has shown clear evidence of disease-modifying activity, even if some patients treated with interferon and ruxolitinib showed reduction of mutated allele burden, and ruxolitinib might extend survival of patients with higher-risk myelofibrosis. Raised awareness of the molecular abnormalities and cellular pathways involved in the pathogenesis of MPN is facilitating the development of clinical trials with novel target drugs, either alone or in combination with ruxolitinib. Although for most of these molecules a convincing preclinical rationale was provided, the results of early phase 1 and 2 clinical trials have been quite disappointing to date, and toxicities sometimes have been limiting. In this review, we critically illustrate the current landscape of novel therapies that are under evaluation for patients with MPN on the basis of current guidelines, patient risk stratification criteria, and previous experience, looking ahead to the chance of a cure for these disorders.
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195
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Falchi L, Bose P, Newberry KJ, Verstovsek S. Approach to patients with essential thrombocythaemia and very high platelet counts: what is the evidence for treatment? Br J Haematol 2016; 176:352-364. [DOI: 10.1111/bjh.14443] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Lorenzo Falchi
- Division of Hematology/Oncology; Columbia University Medical Center; New York NY USA
| | - Prithviraj Bose
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Kate J. Newberry
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Srdan Verstovsek
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston TX USA
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196
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Abstract
Abstract
Essential thrombocythemia (ET) is an indolent myeloproliferative neoplasm that may be complicated by vascular events, including both thrombosis and bleeding. This disorder may also transform into more aggressive myeloid neoplasms, in particular into myelofibrosis. The identification of somatic mutations of JAK2, CALR, or MPL, found in about 90% of patients, has considerably improved the diagnostic approach to this disorder. Genomic profiling also holds the potential to improve prognostication and, more generally, clinical decision-making because the different driver mutations are associated with distinct clinical features. Prevention of vascular events has been so far the main objective of therapy, and continues to be extremely important in the management of patients with ET. Low-dose aspirin and cytoreductive drugs can be administered to this purpose, with cytoreductive treatment being primarily given to patients at high risk of vascular complications. Currently used cytoreductive drugs include hydroxyurea, mainly used in older patients, and interferon α, primarily given to younger patients. There is a need for disease-modifying drugs that can eradicate clonal hematopoiesis and/or prevent progression to more aggressive myeloid neoplasms, especially in younger patients. In this article, we use a case-based discussion format to illustrate our approach to diagnosis and treatment of ET.
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197
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Evaluation of thrombin generation in classical Philadelphianegative myeloproliferative neoplasms / Evaluarea generării trombinei în neoplasmele mieloproliferative Philadelphia- negative. REV ROMANA MED LAB 2016. [DOI: 10.1515/rrlm-2016-0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Introduction: Patients with Philadelphia-negative chronic myeloproliferative neoplasms (Ph-MPN), polycytemia vera (PV), essential thrombocythaemia (ET) and primary myelofibrosis (PMF), are prone to develop thrombotic events. We aimed to investigate the coagulation status in their plasma using thrombin generation assay (TGA), a functional global assay, on Ceveron® Alpha.
Materials and methods: The samples were collected from 89 consecutive Ph-negative MPN patients and from 78 controls into K2EDTA and CTAD tubes for blood cell counts, TGA and coagulation screening tests. Thrombin generation was analysed in platelet-poor plasma using Technothrombin® TGA assay kit.
Results: We found a significantly increased peak thrombin generation (p=0.049) and velocity index (VI) (p=0.012) in patients in comparison with controls, especially in ET patients, and a significantly higher values for peak thrombin (p=0.043) and VI (p=0.042) in patients receiving anagrelide in comparison with those treated with hydroxyurea. We also noticed an inverse correlation between the length of cytoreductive therapy and TGA parameters, (peak thrombin R=-0.25, p=0.018, AUC R=-0.257, p=0.015, and VI R=-0.21, p=0.048).
Conclusion: Our results suggest that Ph-MPN patients, and especially those with ET, are predisposed to thrombotic events due to their higher peak thrombin and VI values and their risk may decreases as treatment is longer. Patients treated with hydroxyurea generate less thrombin and could be less prone to develop thrombotic events in comparison with those treated with anagrelide.
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198
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[Chinese expert consensus on the diagnosis and treatment of essential thrombcythaemia(2016)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:833-836. [PMID: 27801309 PMCID: PMC7364880 DOI: 10.3760/cma.j.issn.0253-2727.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Indexed: 01/17/2023]
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Chong BK, Mun D, Kang CH, Park CB, Cho WC. Essential Thrombocytosis-Associated Thromboembolism in the Abdominal Aorta. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:397-400. [PMID: 27734003 PMCID: PMC5059129 DOI: 10.5090/kjtcs.2016.49.5.397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 11/24/2022]
Abstract
Essential thrombocytosis (ET) is a myeloproliferative disorder characterized by an anomalous increase in platelet production. Many patients with ET are asymptomatic. Few studies have reported ET-associated thromboembolism in large vessels such as the aorta. We report a patient with ET who presented with peripheral embolism from an abdominal aortic thrombus and developed acute limb ischemia. The patient underwent aortic replacement successfully. The patient’s platelet count was controlled with hydroxyurea, and no recurrence was noted over 2 years of follow-up.
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Affiliation(s)
- Byung Kwon Chong
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Dana Mun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Chae Hoon Kang
- Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Chong-Bin Park
- Department of Thoracic and Cardiovascular Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine
| | - Won Chul Cho
- Department of Thoracic and Cardiovascular Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine
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Tamaru S, Tono Y, Matsumoto T, Oda H, Sugimoto Y, Mizuno T, Katayama N, Nishikawa M. Successful treatment by prednisolone for interstitial pneumonia associated with anagrelide in a patient with essential thrombocythemia. Int Cancer Conf J 2016; 6:22-24. [PMID: 31149463 DOI: 10.1007/s13691-016-0265-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022] Open
Abstract
Anagrelide is a cytoreductive agent for essential thrombocythemia and its common side effects are anemia, headache, palpitation, diarrhea, and fluid retention. However, severe pulmonary adverse effects are rare. A 66-year-old Japanese man with essential thrombocythemia presented with hemoptysis 2 months after starting anagrelide treatment. Interstitial pneumonia was diagnosed based on physical and radiographic findings. Discontinuation of anagrelide and institution of corticosteroids resulted in the improvement of interstitial pneumonia. Severe lung injury associated with anagrelide is a rare but an important adverse event that must be addressed when treating interstitial pneumonia.
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Affiliation(s)
- Satoshi Tamaru
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan.,2Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
| | - Yasutaka Tono
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Takeshi Matsumoto
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan.,3Division of Blood Transfusion Service, Mie University Hospital, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Hiroyasu Oda
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Yuka Sugimoto
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Toshiro Mizuno
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Naoyuki Katayama
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan
| | - Masakatsu Nishikawa
- 1Department of Hematology and Oncology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507 Japan.,2Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu City, Mie 514-8507 Japan
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