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Bourrienne MC, Le Cam Duchez V, Faille D, Farkh C, Solo Nomenjanahary M, Gay J, Loyau S, Journé C, Dupont S, Ollivier V, Villeval JL, Plo I, Edmond V, Jandrot-Perrus M, Labrouche-Colomer S, Cassinat B, Verger E, Desilles JP, Ho-Tin-Noé B, Triquenot Bagan A, Mazighi M, Ajzenberg N. Exacerbation of thromboinflammation by JAK2V617F mutation worsens the prognosis of cerebral venous sinus thrombosis. Blood Adv 2024; 8:3330-3343. [PMID: 38386979 PMCID: PMC11258627 DOI: 10.1182/bloodadvances.2023011692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
ABSTRACT Cerebral venous sinus thrombosis (CVST) is an uncommon venous thromboembolic event accounting for <1% of strokes resulting in brain parenchymal injuries. JAK2V617F mutation, the most frequent driving mutation of myeloproliferative neoplasms, has been reported to be associated with worse clinical outcomes in patients with CVST. We investigated whether hematopoietic JAK2V617F expression predisposes to specific pathophysiological processes and/or worse prognosis after CVST. Using an in vivo mouse model of CVST, we analyzed clinical, biological, and imaging outcomes in mice with hematopoietic-restricted Jak2V617F expression, compared with wild-type Jak2 mice. In parallel, we studied a human cohort of JAK2V617F-positive or -negative CVST. Early after CVST, mice with hematopoietic Jak2V617F expression had increased adhesion of platelets and neutrophils in cerebral veins located in the vicinity of CVST. On day 1, Jak2V617F mice had a worse outcome characterized by significantly more frequent and severe intracranial hemorrhages (ICHs) and higher mortality rates. Peripheral neutrophil activation was enhanced, as indicated by higher circulating platelet-neutrophil aggregates, upregulated CD11b expression, and higher myeloperoxydase plasma level. Concurrently, immunohistological and brain homogenate analysis showed higher neutrophil infiltration and increased blood-brain barrier disruption. Similarly, patients with JAK2V617F-positive CVST tended to present higher thrombotic burden and had significantly higher systemic immune-inflammation index, a systemic thromboinflammatory marker, than patients who were JAK2V617F-negative. In mice with CVST, our study corroborates that Jak2V617F mutation leads to a specific pattern including increased thrombotic burden, ICH, and mortality. The exacerbated thromboinflammatory response, observed both in mice and patients positive for JAK2V617F, could contribute to hemorrhagic complications.
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Affiliation(s)
- Marie-Charlotte Bourrienne
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Véronique Le Cam Duchez
- UNIROUEN, INSERM U1096, Normandie University, Rouen University Hospital, Hemostasis Unit and INSERM CIC-CRB 1404, Rouen, France
| | - Dorothée Faille
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Carine Farkh
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | | | - Juliette Gay
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Stéphane Loyau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
| | - Clément Journé
- Université Paris Cité, INSERM UMS34, Fédération de Recherche en Imagerie Multimodalités, Faculté de Médecine X. Bichat, Paris, France
| | - Sébastien Dupont
- Université Paris Cité, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Véronique Ollivier
- Université Paris Cité, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Luc Villeval
- INSERM U1287, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Isabelle Plo
- INSERM U1287, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Valérie Edmond
- INSERM U1287, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Martine Jandrot-Perrus
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
| | - Sylvie Labrouche-Colomer
- Université de Bordeaux, INSERM U1034, Biologie des maladies cardio-vasculaires & Laboratoire d’hématologie, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
| | - Bruno Cassinat
- Laboratoire de Biologie Cellulaire, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Emmanuelle Verger
- Laboratoire de Biologie Cellulaire, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Département de Neuroradiologie interventionnelle, Hôpital Fondation Rothschild, Paris, France
| | - Benoît Ho-Tin-Noé
- Université Paris Cité, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Aude Triquenot Bagan
- Department of Neurology and INSERM CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Mikaël Mazighi
- Université Paris Cité, Inserm, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Département de Neurologie, AP-HP, Hôpital Lariboisière, FHU NeuroVasc, Paris, France
| | - Nadine Ajzenberg
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM UMRS-1148, Laboratory for Vascular Translational Science, Paris, France
- Laboratoire d’Hématologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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Cattaneo D, Bucelli C, Marchetti A, Lionetti M, Fermo E, Bellani V, De Magistris C, Maeda A, Marella A, Primignani M, Consonni D, Gianelli U, Neri A, Baldini L, Bolli N, Iurlo A. Pathological and genomic features of myeloproliferative neoplasms associated with splanchnic vein thrombosis in a single-center cohort. Ann Hematol 2023; 102:1409-1420. [PMID: 37079068 DOI: 10.1007/s00277-023-05217-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
Here, we reviewed clinical-morphological data and investigated mutational profiles by NGS in a single-center series of 58 consecutive MPN-SVT patients admitted to our hospital between January 1979 and November 2021. We identified 15.5% of PV, 13.8% of ET, 34.5% of PMF, 8.6% of SMF and 27.6% of MPN-U. Most cases (84.5%) carried JAK2V617F mutation, while seven patients were characterized by other molecular markers, namely MPL in four and CALR mutations in three cases. NGS was performed in 54 (93.1%) cases: the most frequent additional mutations were found in TET2 (27.8%) and DNMT3A (16.7%) genes, whereas 25 (46.3%) patients had no additional mutation. Cases with JAK2V617F homozygosity had a higher median number of additional mutations than those with low allele burden. More importantly, all cases of leukemic evolution were characterized by a higher median number of co-mutations, and a co-mutational pattern of high-risk lesions, such as truncating mutations of ASXL1, bi-allelic TP53 loss, and CSMD1 mutations. Nevertheless, no difference was found between cases with and without additional somatic mutations regarding fibrotic progression, SVT recurrence, other thrombo-hemorrhagic complications, or death. After a median follow-up of 7.1 years, ten deaths were recorded; fibrotic progression/leukemic evolution was ascertained in one (1.7%) and six (10.3%) patients, respectively, while 22 (37.9%) patients suffered from recurrent thrombosis. In conclusion, our data underline the importance of using NGS analysis in the management of MPN-related SVT as it can support the MPN diagnosis, particularly in "triple-negative" cases, and provide additional information with potential consequences on prognosis and therapeutic strategies.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Alfredo Marchetti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marta Lionetti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Elisa Fermo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Valentina Bellani
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Claudio De Magistris
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Akihiro Maeda
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessio Marella
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Massimo Primignani
- Gastroenterology and Hepatology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Umberto Gianelli
- Division of Pathology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Antonino Neri
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Niccolò Bolli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
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Dural Venous Sinus Thrombosis and Papilledema Related to JAK2 Mutation: A Case Series. Can J Neurol Sci 2023; 50:194-200. [PMID: 34906267 DOI: 10.1017/cjn.2021.512] [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: 11/06/2022]
Abstract
BACKGROUND Dural venous sinus thrombosis (DVST) is an important cause of papilledema. Patients diagnosed with DVST should undergo work-up for underlying hypercoagulable state, including genetic causes. One important prothrombotic mutation is in the JAK2 gene, which is a driver of myeloproliferative neoplasms including polycythemia vera (PV). We aimed to determine the prevalence of JAK2 mutation in patients in presenting to neuro-ophthalmology clinic with DVST and papilledema. METHODS Retrospective case series of patients seen in a tertiary neuro-ophthalmology practice who presented with papilledema due to DVST and were investigated for presence of JAK2 mutation. RESULTS Four out of 15 patients with DVST (26%) were found to have JAK2 V617F mutation which led to subsequent diagnosis of PV in 2. One additional patient had a known diagnosis of essential thrombocytosis. We describe the clinical presentation of these four patients with papilledema and JAK2 mutation. CONCLUSIONS A significant proportion of patients with papilledema secondary to DVST will harbor mutations in the JAK2 gene. Clinicians should be aware of this mutation as early testing will facilitate timely diagnosis and treatment of myeloproliferative disease to improve prognosis and reduce risk of recurrent thrombotic events.
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Barbui T, Carobbio A, De Stefano V. Thrombosis in myeloproliferative neoplasms during cytoreductive and antithrombotic drug treatment. Res Pract Thromb Haemost 2022; 6:e12657. [PMID: 35155976 PMCID: PMC8822262 DOI: 10.1002/rth2.12657] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/31/2021] [Accepted: 01/12/2022] [Indexed: 12/16/2022] Open
Abstract
A state-of-the-art lecture titled "Myeloproliferative Neoplasm-associated Thrombosis" was presented at the ISTH congress in 2021. We summarize here the main points of the lecture with two purposes: to report the incidence rates of major thrombosis in polycythemia vera and essential thrombocythemia and to discuss to what extent cytoreductive therapy and antithrombotic drugs have reduced the incidence of these events. Unfortunately, the incidence rate of thrombosis remains high, ranging between 2 and 5/100 person-years. It is likely that new drugs such as interferon and ruxolitinib can be more efficacious given their cytoreductive and anti-inflammatory activities. Despite prophylaxis with vitamin K antagonists and direct oral anticoagulants after venous thrombosis in either common sites or splanchnic or cerebral sites, the incidence rate is still elevated, as high as 4 to 5/100 person-years. Future studies with new drugs or new strategies should consider thrombosis as the primary endpoint or surrogate biomarkers only if previously validated.
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Affiliation(s)
- Tiziano Barbui
- FROM Research FoundationPapa Giovanni XXIII HospitalBergamoItaly
| | | | - Valerio De Stefano
- Section of HematologyDepartment of Radiological and Hematological SciencesCatholic UniversityFondazione Policlinico A. Gemelli IRCCSRomeItaly
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6
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Ferro JM, de Sousa DA, Canhão P. Cerebral Venous Thrombosis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Giannotta JA, Fattizzo B, Barcellini W. Paroxysmal Nocturnal Hemoglobinuria in the Context of a Myeloproliferative Neoplasm: A Case Report and Review of the Literature. Front Oncol 2021; 11:756589. [PMID: 34858830 PMCID: PMC8632248 DOI: 10.3389/fonc.2021.756589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolytic anemia and thrombosis and is notoriously associated with aplastic anemia and myelodysplastic syndromes. Rarer associations include myeloproliferative neoplasms (MPNs), which are also burdened by increased thrombotic tendency. The therapeutic management of this rare combination has not been defined so far. Here, we describe a 62-year-old man who developed a highly hemolytic PNH more than 10 years after the diagnosis of MPN. The patient started eculizumab, obtaining good control of intravascular hemolysis but without amelioration of transfusion-dependent anemia. Moreover, we performed a review of the literature regarding the clinical and pathogenetic significance of the association of PNH and MPN. The prevalence of PNH clones in MPN patients is about 10%, mostly in association with JAK2V617F-positive myelofibrosis. Thrombotic events were a common clinical presentation (35% of subjects), sometimes refractory to combined treatment with cytoreductive agents, anticoagulants, and complement inhibitors. The latter showed only partial effectiveness in controlling hemolytic anemia and, due to the paucity of data, should be taken in consideration after a careful risk/benefit evaluation in this peculiar setting.
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Affiliation(s)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Gangat N, Guglielmelli P, Betti S, Farrukh F, Carobbio A, Barbui T, Vannucchi AM, De Stefano V, Tefferi A. Cerebral venous thrombosis and myeloproliferative neoplasms: A three-center study of 74 consecutive cases. Am J Hematol 2021; 96:1580-1586. [PMID: 34453762 PMCID: PMC9293093 DOI: 10.1002/ajh.26336] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/22/2022]
Abstract
The recent association of cerebral venous thrombosis (CVT) with COVID‐19 vaccinations prompted the current retrospective review of 74 cases of CVT (median age = 44 years, range 15–85; 61% females) associated with myeloproliferative neoplasms (MPNs), seen at the Mayo Clinic, Catholic University of Rome, and University of Florence, between 1991 and 2021. Disease‐specific frequencies were 1.3% (39/2893), 1.2% (21/1811) and 0.2% (3/1888) for essential thrombocythemia, polycythemia vera and primary myelofibrosis, respectively. Cerebral venous thrombosis occurred either prior to (n = 20, 27%), at (n = 32, 44%) or after (n = 22) MPN diagnosis. A total of 72% of patients presented with headaches. Transverse (51%), sagittal (43%) and sigmoid sinuses (35%) were involved with central nervous system hemorrhage noted in 10 (14%) patients. In all, 91% of tested patients harbored JAK2V617F. An underlying thrombophilic condition was identified in 19 (31%) cases and history of thrombosis in 10 (14%). Treatment for CVT included systemic anticoagulation alone (n = 27) or in conjunction with aspirin (n = 24), cytoreductive therapy (n = 14), or both (n = 9). At a median follow‐up of 5.1 years (range 0.1–28.6), recurrent CVT was documented in three (4%) patients while recurrent arterial and venous thromboses and major hemorrhage were recorded in 11%, 9% and 14%, respectively. Follow‐up neurological assessment revealed headaches (n = 9), vision loss (n = 1) and cognitive impairment (n = 1). The current study lends clarity to MPN‐associated CVT and highlights its close association with JAK2V617F, younger age and female gender. Clinical features that distinguish COVID vaccine‐related CVT from MPN‐associated CVT include, in the latter, lower likelihood of concurrent venous thromboses and intracerebral hemorrhage; as a result, MPN‐associated CVT was not fatal.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Paola Guglielmelli
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi University of Florence Florence Italy
| | - Silvia Betti
- Section of Hematology, Department of Radiological and Hematological Sciences Catholic University, Fondazione Policlinico A. Gemelli IRCCS Rome Italy
| | - Faiqa Farrukh
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Alessandra Carobbio
- Foundation of Clinical Research‐FROM Ospedale Papa Giovanni XXIII Bergamo Italy
| | - Tiziano Barbui
- Foundation of Clinical Research‐FROM Ospedale Papa Giovanni XXIII Bergamo Italy
| | - 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
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences Catholic University, Fondazione Policlinico A. Gemelli IRCCS Rome Italy
| | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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Xie JS, Donaldson L, Margolin E. Papilledema: A review of etiology, pathophysiology, diagnosis, and management. Surv Ophthalmol 2021; 67:1135-1159. [PMID: 34813854 DOI: 10.1016/j.survophthal.2021.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023]
Abstract
Papilledema is optic nerve head edema secondary to raised intracranial pressure (ICP). It is distinct from other causes of optic disk edema in that visual function is usually normal in the acute phase. Papilledema is caused by transmission of elevated ICP to the subarachnoid space surrounding the optic nerve that hinders axoplasmic transport within ganglion cell axons. There is ongoing controversy as to whether axoplasmic flow stasis is produced by physical compression of axons or microvascular ischemia. The most common cause of papilledema, especially in patients under the age of 50, is idiopathic intracranial hypertension (IIH); however, conditions that decrease cerebrospinal fluid (CSF) outflow by either causing CSF derangements or mechanically blocking CSF outflow channels, and rarely conditions that increase CSF production, can be the culprit. When papilledema is suspected clinically, blood pressure should be measured, and pseudopapilledema should be ruled out. Magnetic resonance imaging of the brain and orbits with venography sequences is the preferred neuroimaging modality that should be performed next to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes. Lumbar puncture with measurement of opening pressure and evaluation of CSF composition should then be performed. In patients not in a typical demographic group for IIH, further investigations should be conducted to assess for underlying causes of increased ICP. Magnetic resonance imaging of the neck and spine, magnetic resonance angiography of the brain, computed tomography of the chest, complete blood count, and creatinine testing should be able to identify most secondary causes of intracranial hypertension. Treatment for patients with papilledema should be targeted toward the underlying etiology. Most patients with IIH respond to weight loss and oral acetazolamide. For patients with decreased central acuity and constricted visual fields at presentation, as well as patients who do not respond to treatment with acetazolamide, surgical treatments should be considered, with ventriculoperitoneal shunting being the typical procedure of choice.
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Affiliation(s)
- Jim Shenchu Xie
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Laura Donaldson
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward Margolin
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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10
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Sant'Antonio E, Borsani O, Camerini C, Botta C, Santoro M, Allegra A, Siragusa S. Philadelphia chromosome-negative myeloproliferative neoplasms in younger adults: A critical discussion of unmet medical needs, with a focus on pregnancy. Blood Rev 2021; 52:100903. [PMID: 34742614 DOI: 10.1016/j.blre.2021.100903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 11/02/2022]
Abstract
Myeloproliferative neoplasms (MPN) are traditionally regarded as a disease of older adults, though a not negligible fraction of cases occurs at a younger age, including women of childbearing potential. MPN in younger patients, indeed, offer several challenges for the clinical hematologist, that goes from difficulties in reaching a timely and accurate diagnosis to a peculiar thrombotic risk, with a relatively high incidence of thromboses in unusual sites (as the splanchnic veins or the cerebral ones). Moreover, the issue of pregnancy is recently gaining more attention as maternal age is rising and molecular screening are widely implemented, leading to a better recognition of these cases, both before and during pregnancy. In the present work we aim at discussing four clinical topic that we identified as areas of uncertainty or true unmet medical needs in the management of younger patients with MPN, with a particular focus on the topic of pregnancy. For each of these topics, we critically reviewed the available evidence that support treatment decisions, though acknowledging that recommendations in this field are mostly based on expert opinion or derived from guidelines of other clinical conditions that share with MPN a high vascular risk, as antiphospholipid syndrome. Taking into consideration both the lack of evidence-based data and the clinical heterogeneity of MPN, we support an individualized strategy of counseling and management for both young patients and for expectant mother with MPN.
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Affiliation(s)
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Chiara Camerini
- Division of Hematology, Azienda USL Toscana Nord Ovest, Ospedale San Luca, Lucca, Italy
| | - Cirino Botta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marco Santoro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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11
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Coltro G, Loscocco GG, Vannucchi AM. Classical Philadelphia-negative myeloproliferative neoplasms (MPNs): A continuum of different disease entities. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:1-69. [PMID: 34756241 DOI: 10.1016/bs.ircmb.2021.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Classical Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells and close pathobiologic and clinical features. According to the 2016 World Health Organization (WHO) classification, MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision aimed in particular at strengthening the distinction between masked PV and JAK2-mutated ET, and between prefibrotic/early (pre-PMF) and overt PMF. Clinical manifestations in MPNs include constitutional symptoms, microvascular disorders, thrombosis and bleeding, splenomegaly secondary to extramedullary hematopoiesis, cytopenia-related symptoms, and progression to overt MF and acute leukemia. A dysregulation of the JAK/STAT pathway is the unifying mechanistic hallmark of MPNs, and is guided by somatic mutations in driver genes including JAK2, CALR and MPL. Additional mutations in myeloid neoplasm-associated genes have been also identified, with established prognostic relevance, particularly in PMF. Prognostication of MPN patients relies on disease-specific clinical models. The increasing knowledge of MPN biology led to the development of integrated clinical and molecular prognostic scores that allow a more refined stratification. Recently, the therapeutic landscape of MPNs has been revolutionized by the introduction of potent, selective JAK inhibitors (ruxolitinib, fedratinib), that proved effective in controlling disease-related symptoms and splenomegaly, yet leaving unmet critical needs, owing the lack of disease-modifying activity. In this review, we will deal with molecular, clinical, and therapeutic aspects of the three classical MPNs aiming at highlighting either shared characteristics, that overall define a continuum within a single disease family, and uniqueness, at the same time.
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Affiliation(s)
- Giacomo Coltro
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe G Loscocco
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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12
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Kisilevsky E, Yu E, Margolin E. Papilledema and Extensive Dural Sinus Thrombosis Due to JAK2 Mutation. J Neuroophthalmol 2021; 41:e307-e308. [PMID: 33105413 DOI: 10.1097/wno.0000000000001096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Eli Kisilevsky
- Department of Ophthalmology and Vision Science (EK, EM), and Medical Imaging (EY), University of Toronto, Toronto, Canada ; and Division of Neurology (EM), Department of Medicine, Toronto, Canada
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13
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Das S, Deb A, Pal T. Antithrombotic Management in Ischemic Stroke with Essential Thrombocythemia: Current Evidence and Dilemmas. Med Princ Pract 2021; 30:412-421. [PMID: 33849034 PMCID: PMC8562054 DOI: 10.1159/000516471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 04/10/2021] [Indexed: 12/11/2022] Open
Abstract
Thrombotic diseases like ischemic stroke are common complications of essential thrombocythemia (ET) due to abnormal megakaryopoiesis and platelet dysfunction. Ischemic stroke in ET can occur as a result of both cerebral arterial and venous thrombosis. Management of ET is aimed at preventing vascular complications including thrombosis. Acute management of ischemic stroke in ET is the same as that in the general population without myeloproliferative disorders. However, an ET patient with ischemic stroke is at high risk for rethrombosis and is therefore additionally managed with cytoreductive therapy and antithrombotic agents. Given abnormal platelet production in ET, there is suboptimal suppression of platelets with the standard recommended dose of aspirin for cardiovascular (CV) prevention. Hence, for optimal CV protection in ET, low-dose aspirin is recommended twice daily in an arterial thrombotic disease like atherothrombotic ischemic stroke in presence of the following risk factors: age >60 years, Janus kinase2 V617F gene mutation, and presence of CV risk factors. In the presence of the same risk factors, concurrent antiplatelet and anticoagulant therapy is suggested for venous thrombosis. However, increased risk of bleeding with dual antithrombotic agents poses a significant challenge in their use in cerebral venous thromboembolism or atrial fibrillation in presence of the above-mentioned risk factors. We discuss these dilemmas regarding antithrombotic management in ischemic stroke in ET in this case-based review of literature in the light of current evidence.
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Affiliation(s)
- Shubhabrata Das
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Tanmoy Pal
- Department of Neurology, Neotia Getwel Healthcare Centre, Siliguri, India
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14
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Schafer AI. Thrombotic, Vascular, and Bleeding Complications of the Myeloproliferative Neoplasms. Hematol Oncol Clin North Am 2021; 35:305-324. [PMID: 33641871 DOI: 10.1016/j.hoc.2020.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Thrombotic, vascular, and bleeding complications are the most frequent causes of morbidity and mortality in myeloproliferative neoplasms (MPNs). The interplay and reciprocal amplification between two factors are considered to lead to thrombosis in MPNs: (1) circulating blood cell-intrinsic abnormalities caused by an MPN driver mutation in their hematopoietic progenitor/stem cells, interacting with vascular endothelial cells, show prothrombotic and proadhesive phenotypes; and (2) a state of usually subclinical systemic inflammation that fuels the thrombotic tendency. Prevention and treatment require maintenance of hematocrit less than 45% and cytoreductive therapy in patients with a high risk for thrombotic and vascular complications.
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Affiliation(s)
- Andrew I Schafer
- Weill Cornell Medicine, 1305 York Avenue, 8th Floor, Room Y-811, New York, NY 10021, USA.
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15
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How J, Story C, Connors JM. Prevention of recurrent thromboembolism in myeloproliferative neoplasms: review of literature and focus on direct oral anticoagulants. Postgrad Med 2021; 133:508-516. [PMID: 33480813 DOI: 10.1080/00325481.2021.1880844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (MF) are stem cell clonal neoplasms characterized by expansion of late myeloid cells. Thrombosis risk is elevated in MPNs and contributes significantly to morbidity and mortality. Current consensus guidelines make no specific recommendations regarding anticoagulant choice for the treatment of venous thromboembolism (VTE) in MPNs, with most evidence supporting the use of vitamin K antagonists (VKAs) for secondary prophylaxis. However, direct oral anticoagulants (DOACs) are now increasingly being used, although with limited data on safety and efficacy in MPNs specifically. The widespread adoption of DOACs is based on new, high-quality evidence demonstrating safety and efficacy of DOAC treatment for cancer-associated VTE. However, these studies include few if any MPN patients, and MPNs have disease-specific considerations that may elevate thrombosis and bleeding risk. The purpose of this review is to discuss evidence behind current treatment recommendations for thrombosis in MPNs, with special attention to the use of DOACs.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Charlotte Story
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Marie Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Hamulyák EN, Daams JG, Leebeek FWG, Biemond BJ, Te Boekhorst PAW, Middeldorp S, Lauw MN. A systematic review of antithrombotic treatment of venous thromboembolism in patients with myeloproliferative neoplasms. Blood Adv 2021; 5:113-121. [PMID: 33570633 PMCID: PMC7805324 DOI: 10.1182/bloodadvances.2020003628] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/25/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with myeloproliferative neoplasms (MPNs), polycythemia vera, essential thrombocythemia, and primary myelofibrosis, have an increased risk of thrombosis. Risk of recurrent thrombosis can be reduced with antithrombotic therapy and/or cytoreduction, but the optimal long-term management in patients with MPN with a history of venous thromboembolism (VTE) is unknown, and clinical practice is heterogeneous. We performed a systematic review and meta-analysis of randomized trials and observational studies evaluating anticoagulant and/or antiplatelet therapy, with or without cytoreduction, in MPN patients with a history of VTE. A total of 5675 unique citations were screened for eligibility. No randomized trials were identified. Ten observational studies involving 1295 patients with MPN were included in the analysis. Overall, 23% had an arterial or recurrent venous thrombotic event on follow-up. The recurrence risk was lowest for patients on oral anticoagulation plus cytoreduction (16%); 55 of 313 (18%) with vitamin K antagonists (VKA) and 5 of 63 (8%) with direct oral anticoagulants (DOACs). In 746 analyzed patients, the risk of recurrent VTE ranged up to 33% (median 13%) and was low in 63 DOAC plus cytoreduction-treated patients (3.2%). All types of antithrombotic treatments were associated with a lower risk of recurrent VTE when combined with cytoreduction. Most studies had a high risk of bias, whereas clinical and statistical heterogeneity led to inconsistent and imprecise findings. In summary, evidence on the optimal antithrombotic treatment of VTE in patients with MPN is based on observational studies only with low certainty for all strategies. Our data suggest that a combination of anticoagulation and cytoreduction may provide the lowest recurrence risk.
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Affiliation(s)
| | - Joost G Daams
- Medical Library, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center (Erasmus MC) Rotterdam, Rotterdam, The Netherlands; and
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter A W Te Boekhorst
- Department of Hematology, Erasmus University Medical Center (Erasmus MC) Rotterdam, Rotterdam, The Netherlands; and
| | | | - Mandy N Lauw
- Department of Vascular Medicine and
- Department of Hematology, Erasmus University Medical Center (Erasmus MC) Rotterdam, Rotterdam, The Netherlands; and
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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17
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Gutwein O, Lavi N, Barzilai M, Shacham-Abulafia A, Leader A, Chubar E, Dally N, Shapira S, Mishchenko E, Ellis M, Koren-Michowitz M. Management and Outcome of Venous Thrombosis in Patients with Myeloproliferative Neoplasms: Data from the Israeli MPN Working Group. Acta Haematol 2020; 144:438-445. [PMID: 33316809 DOI: 10.1159/000511426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022]
Abstract
The BCR-ABL-negative myeloproliferative neoplasms (MPN) are associated with high incidence of venous thrombosis and a significant rate of recurrent events, but there is no consensus regarding their management. In this retrospective study, we analyzed 96 patients with MPN-related venous thrombosis. The index venous thrombosis occurred at a median age of 58 years (IQR 37-71), with 58% of the events involving unusual sites. Patients who were on antiplatelet agents at the time of index thrombosis tended to be older than patients who were not receiving antiplatelets at the time of index thrombosis. The majority of index thromboses occurring after the diagnosis of MPN had uncontrolled blood counts at the time of event and were not receiving antithrombotic agents. Following the thrombotic episode, 75% of patients received long-term anticoagulation. At a median follow-up of 3.4 years, the recurrence rate was 14%. Thrombophilia was significantly more prevalent among patients with recurrent thrombosis compared to patients without recurrence (p < 0.01). Patients who developed a recurrent event early were more likely to have thrombophilia (either inherited or antiphospholipid antibodies), and controlled blood counts, and were likely to receive anticoagulation at the time of recurrence compared to patients with later recurrences. Thrombophilia may contribute to venous thrombosis recurrence, especially early after the index venous thrombosis. Suboptimal anticoagulation and blood count control are factors associated with late venous thrombosis recurrence.
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Affiliation(s)
- Odit Gutwein
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Noa Lavi
- Division of Hematology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Merav Barzilai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Sourasky Medical Center, Tel Aviv, Israel
| | - Adi Shacham-Abulafia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tiqva, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tiqva, Israel
| | - Evgeni Chubar
- Hematology Unit, HaEmek Medical Center, Afula, Israel
| | - Najib Dally
- Division of Hematology, Ziv Medical Center, Safed, Israel
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shirley Shapira
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Elena Mishchenko
- Institute of Hematology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Martin Ellis
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Maya Koren-Michowitz
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Current management strategies for polycythemia vera and essential thrombocythemia. Blood Rev 2020; 42:100714. [DOI: 10.1016/j.blre.2020.100714] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/02/2019] [Accepted: 05/11/2020] [Indexed: 02/06/2023]
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19
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Awada H, Voso MT, Guglielmelli P, Gurnari C. Essential Thrombocythemia and Acquired von Willebrand Syndrome: The Shadowlands between Thrombosis and Bleeding. Cancers (Basel) 2020; 12:cancers12071746. [PMID: 32629973 PMCID: PMC7407619 DOI: 10.3390/cancers12071746] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, new insights have emerged on the pathophysiology of essential thrombocythemia (ET), its clinical management, and associated thrombohemostatic disturbances. Here, we review the latest diagnostic and risk stratification modalities of ET and its therapeutics. Moreover, we discuss the clinical evidence-based benefits, deriving from major clinical trials, of using cytoreductive therapy and antiplatelet agents to lower the risk of fatal vascular events. Also, we focus on the condition of extreme thrombocytosis (>1000 × 109/L) and bleeding risk, the development and pathogenesis of acquired von Willebrand syndrome, and the clinical approach to this paradoxical scenario in ET.
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Affiliation(s)
- Hassan Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Correspondence: ; Tel.: +1-216-666-0640
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Fondazione Santa Lucia, Laboratorio di Neuro-Oncoematologia, 00143 Roma, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, 50139 Florence, Italy;
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
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20
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Prefibrotic Myelofibrosis Presenting with Multiple Cerebral Embolic Infarcts and the Rare MPL W515S Mutation. Case Rep Hematol 2020; 2020:8375986. [PMID: 32637179 PMCID: PMC7322597 DOI: 10.1155/2020/8375986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/24/2020] [Accepted: 06/04/2020] [Indexed: 11/17/2022] Open
Abstract
Acquired, activating mutations of MPL W515 are recognised driver mutations of the myeloproliferative neoplasms (MPN), namely, essential thrombocythemia and primary myelofibrosis. The most common mutation at this codon is W515L with several other mutations also described at a lower frequency. Of these less common mutations, MPL W515S has only been reported sporadically with limited information on clinicopathological associations. We describe the case of an elderly man with persistent thrombocytosis presenting with an ischemic cerebral event. Bone marrow biopsy showed evidence of prefibrotic myelofibrosis with targeted sequencing demonstrating the presence of the rare MPL W515S mutation. Thrombolytic and cytoreductive therapies resulted in a favorable outcome and follow-up. This case provides additional, necessary, and phenotypic data for the rare MPN-associated MPL W515S mutation.
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21
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Sant'Antonio E, Guglielmelli P, Pieri L, Primignani M, Randi ML, Santarossa C, Rumi E, Cervantes F, Delaini F, Carobbio A, Betti S, Rossi E, Lavi N, Harrison CN, Curto‐Garcia N, Gisslinger H, Gisslinger B, Specchia G, Ricco A, Vianelli N, Polverelli N, Koren‐Michowitz M, Ruggeri M, Girodon F, Ellis M, Iurlo A, Mannelli F, Mannelli L, Sordi B, Loscocco GG, Cazzola M, De Stefano V, Barbui T, Tefferi A, Vannucchi AM. Splanchnic vein thromboses associated with myeloproliferative neoplasms: An international, retrospective study on 518 cases. Am J Hematol 2020; 95:156-166. [PMID: 31721282 DOI: 10.1002/ajh.25677] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 12/22/2022]
Abstract
Myeloproliferative Neoplasms (MPN) course can be complicated by thrombosis involving unusual sites as the splanchnic veins (SVT). Their management is challenging, given their composite vascular risk. We performed a retrospective, cohort study in the framework of the International Working Group for MPN Research and Treatment (IWG-MRT), and AIRC-Gruppo Italiano Malattie Mieloproliferative (AGIMM). A total of 518 MPN-SVT cases were collected and compared with 1628 unselected, control MPN population, matched for disease subtype. Those with MPN-SVT were younger (median 44 years) and enriched in females compared to controls; PV (37.1%) and ET (34.4%) were the most frequent diagnoses. JAK2V617F mutation was highly prevalent (90.2%), and 38.6% of cases had an additional hypercoagulable disorder. SVT recurrence rate was 1.6 per 100 patient-years. Vitamin K-antagonists (VKA) halved the incidence of recurrence (OR 0.48), unlike cytoreduction (OR 0.96), and were not associated with overall or gastrointestinal bleeding in multivariable analysis. Esophageal varices were the only independent predictor for major bleeding (OR 17.4). Among MPN-SVT, risk of subsequent vascular events was skewed towards venous thromboses compared to controls. However, MPN-SVT clinical course was overall benign: SVT were enriched in PMF with lower IPSS, resulting in significantly longer survival than controls; survival was not affected in PV and slightly reduced in ET. MPN-U with SVT (n = 55) showed a particularly indolent phenotype, with no signs of disease evolution. In the to-date largest, contemporary cohort of MPN-SVT, VKA were confirmed effective in preventing recurrence, unlike cytoreduction, and safe; the major risk factor for bleeding was esophageal varices that therefore represent a major therapeutic target.
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Affiliation(s)
- Emanuela Sant'Antonio
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
- Medical Genetics, University of Siena Siena Italy
| | - Paola Guglielmelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
| | - Lisa Pieri
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
| | - Massimo Primignani
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Foundation IRCCS Cà Granda Maggiore Policlinico Hospital, University of Milan Milan Italy
| | - Maria Luigia Randi
- Department of Medicine – DIMEDUniversity of Padova Medical School Padova Italy
| | - Claudia Santarossa
- Department of Medicine – DIMEDUniversity of Padova Medical School Padova Italy
| | - Elisa Rumi
- Department of Hematology OncologyIRCCS Policlinico S. Matteo Foundation and University of Pavia Pavia Italy
| | | | - Federica Delaini
- Hematology and Bone Marrow Transplant UnitAzienda Ospedaliera Papa Giovanni XXIII Bergamo Italy
| | - Alessandra Carobbio
- Hematology and Bone Marrow Transplant UnitAzienda Ospedaliera Papa Giovanni XXIII Bergamo Italy
| | - Silvia Betti
- Institute of HematologyCatholic University, Fondazione Policlinico A. Gemelli IRCCS Rome Italy
| | - Elena Rossi
- Institute of HematologyCatholic University, Fondazione Policlinico A. Gemelli IRCCS Rome Italy
| | - Noa Lavi
- Department of Hematology and Bone Marrow TransplantationRambam Health Care Campus Haifa Israel
| | - Claire N. Harrison
- Department of HaematologyGuy's and St. Thomas NHS Foundation Trust London UK
| | | | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Blood CoagulationMedical University of Vienna Vienna Austria
| | - Bettina Gisslinger
- Department of Internal Medicine I, Division of Hematology and Blood CoagulationMedical University of Vienna Vienna Austria
| | - Giorgina Specchia
- Department of Emergency and Organ TransplantationSection of Hematology with Transplantation, Medical School, University of Bari Bari Italy
| | - Alessandra Ricco
- Department of Emergency and Organ TransplantationSection of Hematology with Transplantation, Medical School, University of Bari Bari Italy
| | - Nicola Vianelli
- Department of Hematology and Clinical Oncology “L. and A. Seràgnoli” S. Orsola‐Malpighi Hospital Bologna Italy
| | - Nicola Polverelli
- Department of Hematology and Clinical Oncology “L. and A. Seràgnoli” S. Orsola‐Malpighi Hospital Bologna Italy
| | - Maya Koren‐Michowitz
- Department of HematologyShamir Medical Center (Assaf Harofeh), Zerifin, Israel and Sackler school of Medicine, Tel Aviv University Tel Aviv Israel
| | | | | | - Martin Ellis
- The Hematology Institute and Blood Bank and Translational Hemato‐Oncology, Meir Hospital Kfar‐Saba Israel
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda‐Ospedale Maggiore Policlinico Milan Italy
| | - Francesco Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
| | - Lara Mannelli
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
- Medical Genetics, University of Siena Siena Italy
| | - Benedetta Sordi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
| | - Giuseppe Gaetano Loscocco
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
| | - Mario Cazzola
- Department of Hematology OncologyIRCCS Policlinico S. Matteo Foundation and University of Pavia Pavia Italy
| | - Valerio De Stefano
- Institute of HematologyCatholic University, Fondazione Policlinico A. Gemelli IRCCS Rome Italy
| | - Tiziano Barbui
- Research Foundation, Azienda Ospedaliera Papa Giovanni XXIII Bergamo Italy
| | | | - Alessandro Maria Vannucchi
- CRIMM, Centro di Ricerca e Innovazione per le Malattie MieloproliferativeAzienda Ospedaliera Universitaria Careggi Florence Italy
- Dipartimento di Medicina Sperimentale e ClinicaUniversità degli Studi, Firenze, DENOTHE Excellence Center Florence Italy
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Barbui T, De Stefano V, Falanga A, Finazzi G, Martinelli I, Rodeghiero F, Vannucchi AM, Barosi G. Addressing and proposing solutions for unmet clinical needs in the management of myeloproliferative neoplasm-associated thrombosis: A consensus-based position paper. Blood Cancer J 2019; 9:61. [PMID: 31395856 PMCID: PMC6687826 DOI: 10.1038/s41408-019-0225-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
This article presents the results of a group discussion among an ad hoc constituted Panel of experts aimed at highlighting unmet clinical needs (UCNs) in the management of thrombotic risk and thrombotic events associated with Philadelphia-negative myeloproliferative neoplasms (Ph-neg MPNs). With the Delphi technique, the challenges in Ph-neg MPN-associated thrombosis were selected. The most clinically relevant UCNs resulted in: (1) providing evidence of the benefits and risks of direct oral anticoagulants, (2) providing evidence of the benefits and risks of cytoreduction in patients with splanchnic vein thrombosis without hypercythemia, (3) improving knowledge of the role of the mutated endothelium in the pathogenesis of thrombosis, (4) improving aspirin dosing regimens in essential thrombocythemia, (5) improving antithrombotic management of Ph-neg MPN-associated pregnancy, (6) providing evidence for the optimal duration of anticoagulation for prophylaxis of recurrent VTE, (7) improving knowledge of the association between somatic gene mutations and risk factors for thrombosis, and (8) improving the grading system of thrombosis risk in polycythemia vera. For each of these issues, proposals for advancement in research and clinical practice were addressed. Hopefully, this comprehensive overview will serve to inform the design and implementation of new studies in the field.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Ematologia, Università Cattolica, Roma, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and the Haemostasis and Thrombosis Center, Papa Giovanni XXIII Hospital, Bergamo, Italy.,University of Milan Bicocca, Milan, Italy
| | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, Dept Experimental and Clinical medicine, and Denothe Center, University of Florence, Florence, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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24
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McMullin MFF, Mead AJ, Ali S, Cargo C, Chen F, Ewing J, Garg M, Godfrey A, Knapper S, McLornan DP, Nangalia J, Sekhar M, Wadelin F, Harrison CN. A guideline for the management of specific situations in polycythaemia vera and secondary erythrocytosis: A British Society for Haematology Guideline. Br J Haematol 2019; 184:161-175. [PMID: 30426472 PMCID: PMC6519221 DOI: 10.1111/bjh.15647] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Adam J. Mead
- MRC Molecular Haematology UnitMRC Weatherall Institute of Molecular MedicineRadcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Sahra Ali
- Castle Hill HospitalHull and East Yorkshire Hospitals NHS TrustHullUK
| | | | - Frederick Chen
- The Royal London HospitalBart's Health NHS TrustLondonUK
| | - Joanne Ewing
- Birmingham Heart of England NHS Foundation TrustBirminghamUK
| | - Mamta Garg
- University Hospital of Leicester NHS TrustLeicester (BSH representative)UK
| | - Anna Godfrey
- Department of Haematology and Haematopathology and Oncology Diagnostic ServiceCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | | | | | | | - Mallika Sekhar
- Royal Free London NHS Foundation TrustUniversity College London HospitalLondonUK
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25
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Capecchi M, Abbattista M, Martinelli I. Cerebral venous sinus thrombosis. J Thromb Haemost 2018; 16:1918-1931. [PMID: 29923367 DOI: 10.1111/jth.14210] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 01/25/2023]
Abstract
The cerebral venous system is an unusual site of thrombosis, with a particularly high incidence in young adults. This incidence has increased in past decades because of the improvement of neuroradiological techniques. Risk factors for cerebral venous sinus thrombosis overlap with those of other venous thromboembolism sites; however, some are specific for this particular anatomical district. Prognosis is favorable in most cases if diagnosis is made rapidly and treatment is promptly initiated, even if acute complications or chronic invalidity still occur in a quarter of patients. The mainstay of treatment is anticoagulation, which is necessary in order to block clot propagation and obtain recanalization. Intracranial bleeding does not contraindicate anticoagulation. Endovascular procedures are reserved for patients with a particularly severe presentation or rapidly declining neurological symptoms despite appropriate anticoagulation, although data from clinical trials are lacking. Specifically, this review addresses the epidemiology, clinical presentation and course, risk factors, and treatment of cerebral venous sinus thrombosis, with a special focus on the pediatric population.
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Affiliation(s)
- M Capecchi
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - M Abbattista
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - I Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
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26
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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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27
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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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28
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Lamy M, Palazzo P, Agius P, Chomel JC, Ciron J, Berthomet A, Cantagrel P, Prigent J, Ingrand P, Puyade M, Neau JP. Should We Screen for Janus Kinase 2 V617F Mutation in Cerebral Venous Thrombosis? Cerebrovasc Dis 2017; 44:97-104. [PMID: 28609766 DOI: 10.1159/000471891] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/20/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The presence of Janus Kinase 2 (JAK2) V617F mutation represents a major diagnostic criterion for detecting myeloproliferative neoplasms (MPN) and even in the absence of overt MPN, JAK2 V617F mutation is associated with splanchnic vein thrombosis. However, the actual prevalence and diagnostic value of the JAK2 V617F mutation in patients with cerebral venous thrombosis (CVT) are not known. The aims of this study were to assess the prevalence of JAK2 V617F mutation in a large group of consecutive CVT patients, to detect clinical, biological, and radiological features associated with the mutation, and to determine the long-term venous thrombosis recurrence rate in CVT patients with JAK2 mutation but without overt MPN in order to recommend the best preventive treatment. METHODS This was a prospective study conducted on consecutive patients with a first-ever radiologically confirmed CVT. JAK2 V617F mutation analysis was assessed in all the study subjects. JAK2 V617F-positive patients were followed up to detect new venous thrombotic events. RESULTS Of the 125 included subjects, 7 were found to have JAK2 V617F mutation (5.6%; 95% CI 2.3-11.2). Older age (p = 0.039) and higher platelet count (p = 0.004) were independently associated with JAK2 V617F positivity in patients without overt MPN. During a mean follow-up period of 59 (SD 46) months, 2 JAK2 V617F-positive patients presented with 4 new venous thromboembolic events. CONCLUSIONS Screening for the JAK2 V617F mutation in CVT patients seems to be useful even in the absence of overt MPN and/or in the presence of other risk factors for CVT because of its relatively high prevalence and the risk of thrombosis recurrence.
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Affiliation(s)
- Matthias Lamy
- Department of Neurology, S. Giovanni Calibita-Fatebenefratelli Hospital, Rome, Italy
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29
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Lim HY, Ng C, Donnan G, Nandurkar H, Ho P. Ten years of cerebral venous thrombosis: male gender and myeloproliferative neoplasm is associated with thrombotic recurrence in unprovoked events. J Thromb Thrombolysis 2017; 42:423-31. [PMID: 27085541 DOI: 10.1007/s11239-016-1362-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cerebral venous thrombosis (CVT) is a rare venous thrombotic event. We review our local experience in the management of CVT in comparison to other venous thromboembolism (VTE) with specific focus on risk factors for thrombotic recurrence. Retrospective evaluation of consecutive CVT presentations from January 2005 to June 2015, at two major tertiary hospitals in Northeast Melbourne, Australia. This population was compared to a separate audit of 1003 consecutive patients with DVT and PE. Fifty-two patients (30 female, 22 male) with a median age of 40 (18-83) years, presented with 53 episodes of CVT. Twenty-nine episodes (55 %) were associated with an underlying risk factor, with hormonal risk factors in females being most common. The median duration of anticoagulation was 6 months with 11 receiving life-long anticoagulation. Eighty-one percent had residual thrombosis on repeat imaging, which was not associated with recurrence at the same or distant site. Nine (17 %) had CVT-related haemorrhagic transformation with two resultant CVT-related deaths (RR 22.5; p = 0.04). All three VTE recurrences occured in males with unprovoked events (RR 18.2; p = 0.05) who were subsequently diagnosed with myeloproliferative neoplasm (MPN). Compared to the non-cancer VTE population, non-cancer CVT patients were younger, had similar rate of provoked events and VTE recurrence, although with significantly higher rate of MPN diagnosis (RR 9.30 (2.29-37.76); p = 0.002) CVT is a rare thrombotic disorder. All recurrences in this audit occurred in male patients with unprovoked events and subsequent diagnosis of MPN, suggesting further evaluation for MPN may be warranted in patients with unprovoked CVT.
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Affiliation(s)
- H Y Lim
- Department of Haematology, Northern Health, 185 Cooper Street, Epping, Melbourne, VIC, Australia
- Austin Health, Heidelberg, Melbourne, VIC, Australia
| | - C Ng
- Austin Health, Heidelberg, Melbourne, VIC, Australia
| | - G Donnan
- Florey Institute of Neurosciences and Mental Health, Parkville, VIC, Australia
| | - H Nandurkar
- Australian Centre for Blood Diseases, Prahran, VIC, Australia
- Monash University, Clayton, VIC, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Health, 185 Cooper Street, Epping, Melbourne, VIC, Australia.
- Austin Health, Heidelberg, Melbourne, VIC, Australia.
- Florey Institute of Neurosciences and Mental Health, Parkville, VIC, Australia.
- University of Melbourne, Parkville, VIC, Australia.
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30
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Maino A, Abbattista M, Bucciarelli P, Artoni A, Passamonti SM, Lanfranconi S, Martinelli I. Red cell distribution width and the risk of cerebral vein thrombosis: A case-control study. Eur J Intern Med 2017; 38:46-51. [PMID: 27823855 DOI: 10.1016/j.ejim.2016.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 10/02/2016] [Accepted: 10/20/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Red cell distribution width (RDW) is a marker of cardiovascular diseases and venous thromboembolism, but its role in cerebral vein thrombosis (CVT) is unknown. AIMS To investigate whether high values of RDW are associated with an increased risk of CVT. METHODS A case-control study of CVT patients (≥18years-old) referred to our center contrasted with healthy individuals. Odds ratios (ORs) were calculated for RDW values >90th percentile by multivariable logistic regression and adjusted for demographic characteristics, hemorheological parameters, renal function, fibrinogen and CRP. Quartiles based on the distribution of RDW values were used in an additional model to assess a dose-response relationship. The risk of CVT associated with the combined presence of high RDW and either thrombophilia abnormalities or oral contraceptive use was also estimated. RESULTS 143 cases (median age 36years, 18-79) and 352 controls (42years, 18-80) were investigated. RDW values >90th percentile (>14.6%) were associated with an increased risk of CVT (OR 2.44, 95% CI 1.39-4.28). The association remained after further adjustment for hemorheological parameters (OR 3.73, 95% CI 1.72-8.09), inflammatory markers (OR 3.77, 95% CI 1.72-8.25) and renal function (OR 3.62, 95% CI 1.53-8.55). The risk appeared restricted to these extreme levels (>14.6%), as there was no graded association between values of RDW and CVT risk over quartiles. There was a synergistic effect on the risk of CVT for the combination of high RDW and thrombophilia abnormalities (OR 33.20, 95% CI 6.95-158.55) or oral contraceptive use (OR 37.99, 95% CI 8.78-164.45). CONCLUSIONS Values of RDW >90th percentile are associated with CVT.
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Affiliation(s)
- Alberto Maino
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Abbattista
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Bucciarelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena M Passamonti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Lanfranconi
- Department of Neurological Sciences, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
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31
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De Stefano V, Vannucchi AM, Ruggeri M, Cervantes F, Alvarez-Larrán A, Iurlo A, Randi ML, Pieri L, Rossi E, Guglielmelli P, Betti S, Elli E, Finazzi MC, Finazzi G, Zetterberg E, Vianelli N, Gaidano G, Nichele I, Cattaneo D, Palova M, Ellis MH, Cacciola E, Tieghi A, Hernandez-Boluda JC, Pungolino E, Specchia G, Rapezzi D, Forcina A, Musolino C, Carobbio A, Griesshammer M, Barbui T. Splanchnic vein thrombosis in myeloproliferative neoplasms: risk factors for recurrences in a cohort of 181 patients. Blood Cancer J 2016; 6:e493. [PMID: 27813534 PMCID: PMC5148051 DOI: 10.1038/bcj.2016.103] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/16/2016] [Indexed: 12/13/2022] Open
Abstract
We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd–Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.
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Affiliation(s)
- V De Stefano
- Institute of Hematology, Catholic University, Roma, Italy
| | - A M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - M Ruggeri
- Ospedale San Bortolo, Vicenza, Italy
| | | | - A Alvarez-Larrán
- Department of Hematology, Hospital del Mar-IMIM, Barcelona, Spain
| | - A Iurlo
- Oncohematology Division, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - M L Randi
- Clinica Medica 1, Università di Padova, Padova, Italy
| | - L Pieri
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - E Rossi
- Institute of Hematology, Catholic University, Roma, Italy
| | - P Guglielmelli
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - S Betti
- Institute of Hematology, Catholic University, Roma, Italy
| | - E Elli
- Divisione di Ematologia, Ospedale San Gerardo, ASST Monza, Italy
| | - M C Finazzi
- Hematology Division, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - G Finazzi
- Hematology Division, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - N Vianelli
- Institute of Hematology and Medical Oncology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - G Gaidano
- Department of Translational Medicine, Università del Piemonte Orientale, Vercelli, Italy
| | - I Nichele
- Ospedale San Bortolo, Vicenza, Italy
| | - D Cattaneo
- Oncohematology Division, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - M Palova
- University Hospital of Olomouc, Olomouc, Czech Republic
| | - M H Ellis
- Department of Hematology, Institute Meir Medical Center, Kfar Saba, Israel
| | - E Cacciola
- Haemostasis Unit, Department of Medical, Surgical and Advanced Technologies Sciences 'G.F. Ingrassia', University of Catania, Catania, Italy
| | - A Tieghi
- Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - E Pungolino
- A.O. Ospedale Niguarda Ca' Granda, Milano, Italy
| | - G Specchia
- A.O. Universitaria, Policlinico di Bari, Italy
| | - D Rapezzi
- A.O. Santa Croce e Carle, Cuneo, Italy
| | - A Forcina
- IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - A Carobbio
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - M Griesshammer
- Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - T Barbui
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
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32
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Parashar Y, Kushwaha R, Kumar A, Agarwal K, Singh US, Jain M, Verma SP, Tripathi AK. Haemostatic Profile in Patients of Myeloproliferative Neoplasms-A Tertiary Care Centre Experience. J Clin Diagn Res 2016; 10:EC01-EC04. [PMID: 28050371 DOI: 10.7860/jcdr/2016/19985.8840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 08/10/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Patients of MPN commonly present with abnormalities in laboratory coagulation tests that are consistent with hypercoagulable state. Some individuals with MPN exhibit a pattern of exclusive bleeding or thrombotic events; many others have both bleeding and thrombosis during the course of the disease. AIM This study was undertaken to assess the haemostatic defects and platelet functions in patients of MPN. MATERIALS AND METHODS One year prospective study was conducted at a tertiary care centre in North India in Department of Pathology in collaboration with Department of Clinical Haematology. All recently diagnosed cases of MPN along with 30 age and sex matched controls were included. Patients on antiplatelet drugs, antimyeloproliferative treatment, vitamin K agonists or antagonists, OCPs, Platelet count <1,00,000/μl, high grade fever, liver disease, pregnancy were excluded from this study. All the patients underwent screening investigations like CBC, peripheral smear evaluation, BT, PT, aPTT, Protein C and S measurement (clot based assay) and aggregation studies with ADP (5μM) (Optical Aggregometry with AGGRO/LINK 8 software and CHRONOLOG 700 aggregometer). RESULTS In present study, 50 cases were included. There was an occult prothrombotic state, suggested by significantly (p<0.001) reduced levels of Protein C and Protein S, but no patient presented with frank thrombosis while 8 out of 50 patients had haemorrhagic manifestations ranging from subdural haematoma to pin point petechial haemorrhages. Patients of CML-CP, ET, PV, PMF, MPN-NOS showed significantly reduced maximal aggregation with ADP (5μM) when compared to control (p<0.001). MPV also showed a statistically significant increase in these patients. CONCLUSION Thrombohaemorrhagic complications significantly affect the morbidity and mortality of MPN patients. This can be assessed by the use of platelet aggregation studies, Protein C and S activities and other coagulation studies. Timely diagnosis of these prothrombotic/haemorrhagic states can decrease the morbidity in these patients.
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Affiliation(s)
- Yatendra Parashar
- Junior Resident, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - Rashmi Kushwaha
- Associate Professor, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - Ashutosh Kumar
- Professor and Head, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - Kamal Agarwal
- Professor, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - U S Singh
- Professor, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - Mili Jain
- Assistant Professor, Department of Pathology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - S P Verma
- Assistant Professor, Department of Clinical Hematology, King George's Medical University , Lucknow, Uttar Pradesh, India
| | - A K Tripathi
- Head of Department of Clinical Hematology, King George's Medical University , Lucknow, Uttar Pradesh, India
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33
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Atypical venous thromboses in myeloproliferative neoplasias. PHLEBOLOGIE 2015. [DOI: 10.12687/phleb2292-6-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryWe describe two patients who developed an extensive catheter-related upper extremity deep vein thrombosis and a cerebral venous sinus thrombosis, respectively. Both thrombotic complications occurred in the presence of an elevated platelet count. Subsequent detection of the JAK2 V617F and MPL mutations led to the diagnosis of a myeloproliferative neoplasia.
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34
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Artoni A, Bucciarelli P, Martinelli I. Cerebral thrombosis and myeloproliferative neoplasms. Curr Neurol Neurosci Rep 2015; 14:496. [PMID: 25217248 DOI: 10.1007/s11910-014-0496-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Myeloproliferative neoplasms (MPN) are acquired clonal disorders characterized by the proliferation of bone marrow myeloid cells. Different somatic mutations have been recently associated with MPN, the most common being JAK-2 V617F. Among MPN, polycythemia vera and essential thrombocythemia are particularly associated with an increased risk to develop thrombotic complications, either arterial or venous. Cerebrovascular events (stroke and transient ischemic attacks) are prevalent, accounting for approximately two-thirds of all events. Also cerebral vein thrombosis can complicate MPN and can be the first manifestation of the disease. Risk factors for thrombosis in patients with MPN are related or unrelated to the disease. Among the former there are cellular risk factors, such as increased white blood cell counts, vascular cell activation, endothelial dysfunction, and plasmatic risk factors, such as increased plasma viscosity, reduced levels of protein S, increased thrombin generation. The latter include increased age and previous thrombotic events. In addition, common cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, obesity) contribute to the pathogenesis of arterial events, whereas circumstantial risk factors (particularly oral contraceptive use and pregnancy/puerperium) to that of venous events. Primary prevention of arterial thrombosis with antiplatelet therapy is warranted in the majority of patients with MPN, whereas primary prevention of venous thrombosis is limited to anticoagulant prophylaxis during high-risk situations. Secondary prevention includes long-term antiplatelet therapy for arterial and short- or long-term anticoagulant therapy for venous thrombosis, depending on the risk factors present at the first event.
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Affiliation(s)
- Andrea Artoni
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
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Gianelli U, Iurlo A, Cattaneo D, Bossi A, Cortinovis I, Augello C, Moro A, Savi F, Castelli R, Brambilla C, Bianchi P, Primignani M, Cortelezzi A, Bosari S. Discrepancies between bone marrow histopathology and clinical phenotype in BCR-ABL1-negative myeloproliferative neoplasms associated with splanchnic vein thrombosis. Leuk Res 2015; 39:525-9. [PMID: 25840747 DOI: 10.1016/j.leukres.2015.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 02/17/2015] [Accepted: 03/05/2015] [Indexed: 01/30/2023]
Abstract
We examined a consecutive series of 29 patients with myeloproliferative neoplasms (MPNs) associated with splanchnic vein thrombosis (SVT) in order to evaluate their bone marrow morphology and identify possible associations between histological findings and clinical features. Eleven patients showed the morphological features of polycythemia vera (PV), 11 of primary myelofibrosis (PMF) and six of essential thrombocythemia (ET). Molecular analyses identified the JAK2 V617F mutation in 27 patients; one of the JAK2-negative patients carried the MPL W515K mutation, the other was "triple-negative" (no JAK2, MPL or CALR mutation). On the basis of the WHO classification, three patients were classified as having PV, 11 as having PMF, and two as having ET; the remaining 13 cases fell into the MPN-unclassifiable category as there were discrepancies between their morphological and clinical features. In conclusion, our findings suggest that bone marrow histology should always be considered a key component of the diagnostic algorithm in patients with SVT, but that it is not enough to distinguish the different entities. This is particularly important because diagnoses of PV, PMF or ET have very different prognoses and obviously imply different therapies. It is therefore necessary to adopt a comprehensive approach that considers morphological, clinical and molecular data.
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Affiliation(s)
- Umberto Gianelli
- Hematopathology Service, Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Alessandra Iurlo
- Oncohematology of the Elderly Unit, Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Anna Bossi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Ivan Cortinovis
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Claudia Augello
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Alessia Moro
- Division of Pathology, San Paolo Hospital, Milan, Italy.
| | - Federica Savi
- Division of Pathology, San Paolo Hospital, Milan, Italy.
| | - Roberto Castelli
- Department of Medicine and Medical Specialities, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Cecilia Brambilla
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Paola Bianchi
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Massimo Primignani
- First Division of Gastroenterology, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
| | - Agostino Cortelezzi
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation and University of Milan, Milan, Italy.
| | - Silvano Bosari
- Division of Pathology, Department of Pathophysiology and Transplantation, University of Milan and IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, Milan, Italy.
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Iurlo A, Cattaneo D, Gianelli U, Fermo E, Augello C, Cortelezzi A. Molecular analyses in the diagnosis of myeloproliferative neoplasm-related splanchnic vein thrombosis. Ann Hematol 2014; 94:881-2. [DOI: 10.1007/s00277-014-2249-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 10/27/2014] [Indexed: 12/22/2022]
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Abstract
Polycythemia vera (PV) is a chronic myeloproliferative neoplasm associated with JAK2 mutations (V617F or exon 12) in almost all cases. The World Health Organization has defined the criteria for diagnosis, but it is still unclear which parameter (hemoglobin or hematocrit) is the most reliable for demonstrating increased red cell volume and for monitoring response to therapy; also, the role of bone marrow biopsy is being revisited. PV is associated with reduced survival because of cardiovascular complications and progression to post-PV myelofibrosis or leukemia. Criteria for risk-adapted treatment rely on the likelihood of thrombosis. Controlled trials have demonstrated that incidence of cardiovascular events is reduced by sustained control of hematocrit with phlebotomies (low-risk patients) and/or cytotoxic agents (high-risk patients) and antiplatelet therapy with aspirin. Hydroxyurea and interferon may be used as first-line treatments, whereas busulfan is reserved for patients that are refractory or resistant to first-line agents. However, there is no evidence that therapy improves survival, and the significance of reduction of JAK2 mutated allele burden produced by interferon is unknown. PV is also associated with a plethora of symptoms that are poorly controlled by conventional therapy. This article summarizes my approach to the management of PV in daily clinical practice.
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