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Tefferi A, Vannucchi AM, Barbui T. Essential thrombocythemia: 2024 update on diagnosis, risk stratification, and management. Am J Hematol 2024; 99:697-718. [PMID: 38269572 DOI: 10.1002/ajh.27216] [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: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
OVERVIEW Essential thrombocythemia is a Janus kinase 2 (JAK2) mutation-prevalent myeloproliferative neoplasm characterized by clonal thrombocytosis; clinical course is often indolent but might be interrupted by thrombotic or hemorrhagic complications, microcirculatory symptoms (e.g., headaches, lightheadedness, and acral paresthesias), and, less frequently, by disease transformation into myelofibrosis (MF) or acute myeloid leukemia. DIAGNOSIS In addition to thrombocytosis (platelets ≥450 × 109 /L), formal diagnosis requires the exclusion of other myeloid neoplasms, including prefibrotic MF, polycythemia vera, chronic myeloid leukemia, and myelodysplastic syndromes with ring sideroblasts and thrombocytosis. Bone marrow morphology typically shows increased number of mature-appearing megakaryocytes distributed in loose clusters. GENETICS Approximately 80% of patients express myeloproliferative neoplasm driver mutations (JAK2, CALR, MPL), in a mutually exclusive manner; in addition, about 50% harbor other mutations, the most frequent being TET2 (9%-11%), ASXL1 (7%-20%), DNMT3A (7%), and SF3B1 (5%). Abnormal karyotype is seen in <10% of patients and includes +9/20q-/13q-. SURVIVAL AND PROGNOSIS Life expectancy is less than that of the control population. Median survival is approximately 18 years but exceeds >35 years in younger patients. The triple A survival risk model, based on Age, Absolute neutrophil count, and Absolute lymphocyte count, effectively delineates high-, intermediate-1-, intermediate-2-, and low-risk disease with corresponding median survivals of 8, 14, 21, and 47 years. RISK FACTORS FOR THROMBOSIS Four risk categories are considered: very low (age ≤60 years, no thrombosis history, JAK2 wild-type), low (same as very low but JAK2 mutation present), intermediate (same as low but age >60 years), and high (thrombosis history or age >60 years with JAK2 mutation). MUTATIONS AND PROGNOSIS MPL and CALR-1 mutations have been associated with increased risk of MF transformation; spliceosome with inferior overall and MF-free survival; TP53 with leukemic transformation, and JAK2V617F with thrombosis. Leukemic transformation rate at 10 years is <1% but might be higher in JAK2-mutated patients with extreme thrombocytosis and those with abnormal karyotype. TREATMENT The main goal of therapy is to prevent thrombosis. In this regard, once-daily low-dose aspirin is advised for all patients and twice daily for low-risk disease. Cytoreductive therapy is advised for high-risk and optional for intermediate-risk disease. First-line cytoreductive drugs of choice are hydroxyurea and pegylated interferon-α and second-line busulfan. ADDITIONAL CONTENT The current review includes specific treatment strategies in the context of extreme thrombocytosis, pregnancy, splanchnic vein thrombosis, perioperative care, and post-essential thrombocythemia MF, as well as new investigational drugs.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro Maria Vannucchi
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Garrote M, López-Guerra M, García-Pagán JC, Arellano-Rodrigo E, Ferrer-Marín F, Hernández-Boluda JC, Bellosillo B, Nomdedeu M, Hernández-Gea V, Triguero A, Guijarro F, Álamo J, Baiges A, Turon F, Colomer D, Cervantes F, Alvarez-Larrán A. Genomic classification and outcomes of young patients with polycythemia vera and essential thrombocythemia according to the presence of splanchnic vein thrombosis and its chronology. Ann Hematol 2024; 103:737-747. [PMID: 38263537 PMCID: PMC10866782 DOI: 10.1007/s00277-023-05610-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/23/2023] [Indexed: 01/25/2024]
Abstract
To elucidate the role of splanchnic vein thrombosis (SVT) and genomic characteristics in prognosis and survival, we compared patients with polycythemia vera (PV) or essential thrombocythemia (ET) presenting SVT at diagnosis (n = 69, median age 43 years) or during follow-up (n = 21, median age 46 years) to a sex- and age-matched control group of PV/ET without SVT (n = 165, median age 48 years). The majority of patients presenting with SVT at diagnosis were classified as myeloproliferative neoplasm with heterozygous JAK2 mutation (87% of cases vs. 69% in PV/ET control group, p < 0.05), characterized by low JAK2 allele burden and no high-risk mutations. Despite this lower molecular complexity, patients presenting with SVT showed a higher risk of death (HR 3.0, 95% CI 1.5-6.0, p = 0.003) and lower event-free survival (HR 3.0, 95% CI 1.9-4.8, p < 0.001) than age- and sex-matched PV/ET controls. In patients presenting with SVT, molecular high-risk was associated with increased risk of venous re-thrombosis (HR 5.8, 95% CI 1.4-24.0, p = 0.01). Patients developing SVT during follow-up were more frequently allocated in molecular high-risk than those with SVT at diagnosis (52% versus 13%, p < 0.05). In the whole cohort of patients, molecular classification identified PV/ET patients at higher risk of disease progression whereas DNMT3A/TET2/ASXL1 mutations were associated with higher risk of arterial thrombosis. In conclusion, clinical and molecular characteristics are different in PV/ET patients with SVT, depending on whether it occurs at diagnosis or at follow-up. Molecular characterization by NGS is useful for assessing the risk of thrombosis and disease progression in young patients with PV/ET.
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Affiliation(s)
- Marta Garrote
- Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain.
- Hematopathology Unit, Pathology Department, Hospital Clínic, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Mónica López-Guerra
- Hematopathology Unit, Pathology Department, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
| | - Juan Carlos García-Pagán
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
| | | | | | | | - Beatriz Bellosillo
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
- Pathology Department, Hospital del Mar, Barcelona, Spain
| | - Meritxell Nomdedeu
- Hemotherapy and Hemostasis Department, Hospital Clínic, Barcelona, Spain
| | - Virginia Hernández-Gea
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Ana Triguero
- Hematology Department, Hospital Clínic, Barcelona, Spain
| | - Francesca Guijarro
- Hematopathology Unit, Pathology Department, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Álamo
- Hematopathology Unit, Pathology Department, Hospital Clínic, Barcelona, Spain
| | - Anna Baiges
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Fanny Turon
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Dolors Colomer
- Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
- Hematopathology Unit, Pathology Department, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro Investigación Biomédica en Red (CIBER) Oncología (CIBERONC) y Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
| | - Francisco Cervantes
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alberto Alvarez-Larrán
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Hematology Department, Hospital Clínic, Barcelona, Spain
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Morsia E, Torre E, Martini F, Morè S, Poloni A, Olivieri A, Rupoli S. Exploring the Molecular Aspects of Myeloproliferative Neoplasms Associated with Unusual Site Vein Thrombosis: Review of the Literature and Latest Insights. Int J Mol Sci 2024; 25:1524. [PMID: 38338802 PMCID: PMC10855502 DOI: 10.3390/ijms25031524] [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: 12/18/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Myeloproliferative neoplasms (MPNs) are the leading causes of unusual site thrombosis, affecting nearly 40% of individuals with conditions like Budd-Chiari syndrome or portal vein thrombosis. Diagnosing MPNs in these cases is challenging because common indicators, such as spleen enlargement and elevated blood cell counts, can be obscured by portal hypertension or bleeding issues. Recent advancements in diagnostic tools have enhanced the accuracy of MPN diagnosis and classification. While bone marrow biopsies remain significant diagnostic criteria, molecular markers now play a pivotal role in both diagnosis and prognosis assessment. Hence, it is essential to initiate the diagnostic process for splanchnic vein thrombosis with a JAK2 V617F mutation screening, but a comprehensive approach is necessary. A multidisciplinary strategy is vital to accurately determine the specific subtype of MPNs, recommend additional tests, and propose the most effective treatment plan. Establishing specialized care pathways for patients with splanchnic vein thrombosis and underlying MPNs is crucial to tailor management approaches that reduce the risk of hematological outcomes and hepatic complications.
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Affiliation(s)
- Erika Morsia
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Elena Torre
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Francesco Martini
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
- Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Sonia Morè
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Antonella Poloni
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Attilio Olivieri
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Serena Rupoli
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Henze L, Grunwald L, Felser S, Witte M, Grosse-Thie C, Roolf C, Murua Escobar H, Junghanss C. Abdominal venous thromboses: detection of the JAK2 p.V617F mutation by next-generation ultradeep sequencing-A prevalence study of patients in Mecklenburg-West Pomerania (2017-2021). Front Med (Lausanne) 2024; 10:1344769. [PMID: 38274463 PMCID: PMC10808308 DOI: 10.3389/fmed.2023.1344769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/15/2023] [Indexed: 01/27/2024] Open
Abstract
Background Abdominal venous thromboses are rare thrombotic events with heterogeneous etiologies. They are related to myeloproliferative neoplasms (MPNs) in some patients and can occur as first signs of the disease. MPNs are characterized by mutations in the genes of Janus kinase 2 (JAK2), myeloproliferative leukemia virus oncogene (MPL), and calreticulin (CALR). Methods Within the prospective trial "Prevalence of JAK2 mutations in patients with abdominal venous thromboses" (JAK2 MV study; German Clinical Trials Register: DRKS00026943), the peripheral blood of patients with abdominal venous thromboses in Mecklenburg-West Pomerania, a federal state located in north-east Germany, was analyzed by next-generation ultradeep sequencing for MPN-associated mutations. Clinical characteristics and blood cell counts were also of interest. The primary endpoint was the detection of the mutation JAK2 p.V617F. Secondary endpoints were the detection of other acquired variants of JAK2, as well as MPL and CALR. Results A total of 68 patients with abdominal venous thromboses were included from February 2017 to January 2021, with splanchnic veins affected in 65 patients. The mutation JAK2 p.V617F was present in 13 patients (19%), with four patients showing low variant allele frequencies (VAF 0.1% to 1.9%). The time interval from the thrombotic event to analysis was longer for patients with the mutation. The mutation MPL p.W515R was detected in three cases, all of them with low VAF. One patient among them had a concurrent mutation of JAK2 p.V617F. The mutations CALR type I or type II were not found. Discussion By analyzing peripheral blood for the mutation JAK2 p.V617F, an important cause of these rare thrombotic events can be identified. The development of a diagnostic workup with next-generation ultradeep sequencing for the analysis of the JAK2 p.V617F mutation and further mutations has the potential to better understand the etiology of abdominal venous thromboses in individual patients in regional clinical care, as abdominal venous thromboses are diagnosed by various medical disciplines.
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Affiliation(s)
- Larissa Henze
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Luise Grunwald
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Sabine Felser
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Maria Witte
- Department of General, Visceral, Thoracic, Vascular, and Transplant Surgery, Rostock University Medical Center, Rostock, Germany
| | - Christina Grosse-Thie
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Catrin Roolf
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Hugo Murua Escobar
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Christian Junghanss
- Department of Medicine, Clinic III—Hematology, Oncology, and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
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Pescia C, Lopez G, Cattaneo D, Bucelli C, Gianelli U, Iurlo A. The molecular landscape of myeloproliferative neoplasms associated with splanchnic vein thrombosis: Current perspective. Leuk Res 2024; 136:107420. [PMID: 38016412 DOI: 10.1016/j.leukres.2023.107420] [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: 06/26/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
BCR::ABL1-negative myeloproliferative neoplasms (MPNs) are classically represented by polycythemia vera, essential thrombocythemia, and primary myelofibrosis. BCR::ABL1-negative MPNs are significantly associated with morbidity and mortality related to an increased risk of thrombo-hemorrhagic events. They show a consistent association with splanchnic vein thrombosis (SVT), either represented by the portal, mesenteric or splenic vein thrombosis, or Budd-Chiari Syndrome. SVT is also a frequent presenting manifestation of MPN. MPNs associated with SVT show a predilection for younger women, high association with JAK2V617F mutation, low JAK2V617F variant allele frequency (generally <10 %), and low rates of CALR, MPL, or JAK2 exon 12 mutations. Next-Generation Sequencing techniques have contributed to deepening our knowledge of the molecular landscape of such cases, with potential diagnostic and prognostic implications. In this narrative review, we analyze the current perspective on the molecular background of MPN associated with SVT, pointing as well future directions in this field.
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Affiliation(s)
- Carlo Pescia
- Unit of Anatomic Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Gianluca Lopez
- Unit of Anatomic Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Umberto Gianelli
- Department of Health Sciences, University of Milan, Milan, Italy; Unit of Anatomic Pathology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Tefferi A, Barbui T. Polycythemia vera: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1465-1487. [PMID: 37357958 DOI: 10.1002/ajh.27002] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) is a JAK2-mutated myeloproliferative neoplasm characterized by clonal erythrocytosis; other features include leukocytosis, thrombocytosis, splenomegaly, pruritus, constitutional symptoms, microcirculatory disturbances, and increased risk of thrombosis and progression into myelofibrosis (post-PV MF) or acute myeloid leukemia (AML). DIAGNOSIS A working diagnosis is considered in the presence of a JAK2 mutation associated with hemoglobin/hematocrit levels of >16.5 g/dL/49% in men or 16 g/dL/48% in women; morphologic confirmation by bone marrow examination is advised but not mandated. CYTOGENETICS Abnormal karyotype is seen in 15%-20% of patients with the most frequent sole abnormalities being +9 (5%), loss of chromosome Y (4%), +8 (3%), and 20q- (3%). MUTATIONS Over 50% of patients harbor DNA sequence variants/mutations other than JAK2, with the most frequent being TET2 (18%) and ASXL1 (15%). Prognostically adverse mutations include SRSF2, IDH2, RUNX1, and U2AF1, with a combined incidence of 5%-10%. SURVIVAL AND PROGNOSIS Median survival is ⁓15 years but exceeds 35 years for patients aged ≤40 years. Risk factors for survival include older age, leukocytosis, abnormal karyotype, and the presence of adverse mutations. Twenty-year risk for thrombosis, post-PV MF, or AML are ⁓26%, 16% and 4%, respectively. RISK FACTORS FOR THROMBOSIS Two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). Additional predictors for arterial thrombosis include cardiovascular risk factors and for venous thrombosis higher absolute neutrophil count and JAK2V617F allele burden. TREATMENT Current goal of therapy is to prevent thrombosis. Periodic phlebotomy, with a hematocrit target of <45%, combined with once- or twice-daily aspirin (81 mg) therapy, absent contraindications, is the backbone of treatment in all patients, regardless of risk category. Cytoreductive therapy is reserved for high-risk disease with first-line drugs of choice being hydroxyurea and pegylated interferon-α and second-line busulfan and ruxolitinib. In addition, systemic anticoagulation is advised in patients with venous thrombosis history. ADDITIONAL TREATMENT CONSIDERATIONS At the present time, we do not consider a drug-induced reduction in JAK2V617F allele burden, which is often incomplete and seen not only with peg-IFN but also with ruxolitinib and busulfan, as an indicator of disease-modifying activity, unless accompanied by cytogenetic and independently-verified morphologic remission. Accordingly, we do not use the specific parameter to influence treatment choices. The current review also includes specific treatment strategies in the context of pregnancy, splanchnic vein thrombosis, pruritus, perioperative care, and post-PV MF.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Agrawal S, Rayamajhi S, Rayamajhi A, Karki S, Deo A, Kharel KK, Lamsal M, Hamal R. Spontaneous bacterial peritonitis complicating extensive splanchnic vein thrombosis, a rare manifestation of essential thrombocythemia: A case report. Clin Case Rep 2023; 11:e7634. [PMID: 37405042 PMCID: PMC10315444 DOI: 10.1002/ccr3.7634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/10/2023] [Accepted: 06/19/2023] [Indexed: 07/06/2023] Open
Abstract
Key Clinical Message Clinicians should be mindful of the rare occurrence of spontaneous bacterial peritonitis in essential thrombocythemia with extensive splanchnic vein thrombosis, especially when patients with ascites exhibit fever and abdominal pain. Abstract Spontaneous bacterial peritonitis (SBP) complicating extensive splanchnic vein thrombosis (SVT) is a rare manifestation of essential thrombocythemia (ET). In the absence of any hypercoagulable state, JAK2 mutation can be an important risk factor for extensive SVT. Evaluation for SBP is crucial when non-cirrhotic patient exhibits fever, abdominal pain and tenderness in the background of ascites after ruling out common pathologies such as tubercular peritonitis, acute pancreatitis, Budd-Chiari syndrome and ovarian malignancy. We present a case of SBP complicating pre-hepatic portal hypertension with ascites in a 44-years-old female. On further evaluation, extensive SVT with portal cavernoma in the setting of ET was identified. She was managed with cytoreductive therapy and anticoagulation, resulting in symptom resolution.
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Affiliation(s)
- Saurav Agrawal
- Maharajgunj Medical Campus, Institute of MedicineTribhuvan UniversityKathmanduNepal
| | - Sandesh Rayamajhi
- Nepalese Army Institute of Health Sciences College of MedicineKathmanduNepal
| | - Aadesh Rayamajhi
- Maharajgunj Medical Campus, Institute of MedicineTribhuvan UniversityKathmanduNepal
| | - Susmin Karki
- Maharajgunj Medical Campus, Institute of MedicineTribhuvan UniversityKathmanduNepal
| | - Anand Deo
- Department of Internal MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | | | - Manoj Lamsal
- Department of GastroenterologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Rabin Hamal
- Department of GastroenterologyTribhuvan University Teaching HospitalKathmanduNepal
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Splanchnic Vein Thrombosis in Myeloproliferative Neoplasms: Treatment Considerations and Unmet Needs. Cancers (Basel) 2022; 15:cancers15010011. [PMID: 36612008 PMCID: PMC9817858 DOI: 10.3390/cancers15010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Patients who develop splanchnic vein thrombosis (SVT) in the setting of a myeloproliferative neoplasm (MPN) are at risk for complications including portal hypertension, bleeding, thrombosis, and death. Prompt multidisciplinary treatment is thus necessary to prevent long-term sequelae. However, optimal management strategies are not well established due to a paucity of data. In this review, we very briefly discuss the epidemiology, pathophysiology, and prognosis of MPN-SVT and then more comprehensively explore treatment considerations of MPN-SVT, including anticoagulation, endovascular/surgical intervention, and cytoreductive therapy. We will also highlight current gaps in our knowledge of MPN-SVT and conclude by suggesting future directions to optimize the treatment of MPN-SVT and improve outcomes.
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Splanchnic vein thrombosis associated with myeloproliferative neoplasms. Thromb Res 2022; 218:8-16. [DOI: 10.1016/j.thromres.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/30/2022] [Accepted: 08/03/2022] [Indexed: 11/22/2022]
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Turatti G, Fedeli U, Valerio L, Klok FA, Cohen AT, Hunt BJ, Simioni P, Middeldorp S, Ageno W, Kucher N, Konstantinides SV, Schievano E, Barco S. Splanchnic vein thrombosis-related mortality in the Veneto region (Italy), 2008-2019: Retrospective analysis of epidemiological data. Thromb Res 2021; 209:41-46. [PMID: 34856495 DOI: 10.1016/j.thromres.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/31/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is an uncommon manifestation of venous thromboembolism. Epidemiological data on SVT-related mortality rate is not available to date. METHODS We investigated time trends in SVT-related mortality rate, 2008-2019, in Veneto, an Italian high-income region of approximatively 5,000,000 inhabitants. SVT-related deaths were identified by the following ICD-10 codes: I81 (portal vein thrombosis), K75.1 (phlebitis of portal vein), K76.3 (liver infarction), K76.5 (hepatic veno-occlusive disease) or I82.0 (Budd-Chiari syndrome). RESULTS During the study period, a total of 557,932 deaths were recorded. SVT was reported in 823 cases; 776 (94%) consisted of portal vein thrombosis. The age-standardized SVT-related mortality rate varied from 1.47 (year 2008) to 1.52 (year 2019) per 100,000 person-years. An increase in the cause-specific annual mortality rate was observed in women (0.56 in 2008 to 1.04 per 100,000 person-years in 2019; average annual percent change +5.7%, 95%CI +3.1; +8.3%). In men, the cause-specific mortality rate moved from 2.53 in 2008 to 2.03 per 100,000 person-years in 2019 (average annual percent change -1.2%, 95%CI -4.0; +1.6%). After conditioning for age and sex, the odds of having a concomitant liver disease were higher for SVT-related deaths (OR 31.6; 95%CI 17.1-37.0) compared with non-SVT-related deaths. This also applies to gastrointestinal cancers (OR 1.28; 95%CI 1.07-1.55), although to a lesser extent. CONCLUSIONS We report first epidemiological estimates of SVT-related mortality in a Western country. These values will serve as a reference to weight novel potential factors associated with SVT-related death and interpret them from an epidemiological perspective.
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Affiliation(s)
- Giacomo Turatti
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Ugo Fedeli
- Epidemiological Department, Azienda Zero, Padova, Veneto Region, Italy
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander T Cohen
- Department of Haematology, Thrombosis & Haemophilia Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guys & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elena Schievano
- Epidemiological Department, Azienda Zero, Padova, Veneto Region, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera: historical oversights, diagnostic details, and therapeutic views. Leukemia 2021; 35:3339-3351. [PMID: 34480106 PMCID: PMC8632660 DOI: 10.1038/s41375-021-01401-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Polycythemia vera (PV) is a relatively indolent myeloid neoplasm with median survival that exceeds 35 years in young patients, but its natural history might be interrupted by thrombotic, fibrotic, or leukemic events, with respective 20-year rates of 26%, 16%, and 4%. Current treatment strategies in PV have not been shown to prolong survival or lessen the risk of leukemic or fibrotic progression and instead are directed at preventing thrombotic complications. In the latter regard, two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). All patients require phlebotomy to keep hematocrit below 45% and once-daily low-dose aspirin, in the absence of contraindications. Cytoreductive therapy is recommended for high-risk or symptomatic low-risk disease; our first-line drug of choice in this regard is hydroxyurea but we consider pegylated interferon as an alternative in certain situations, including in young women of reproductive age, in patients manifesting intolerance or resistance to hydroxyurea therapy, and in situations where treatment is indicated for curbing phlebotomy requirement rather than preventing thrombosis. Additional treatment options include busulfan and ruxolitinib; the former is preferred in older patients and the latter in the presence of symptoms reminiscent of post-PV myelofibrosis or protracted pruritus. Our drug choices reflect our appreciation for long-term track record of safety, evidence for reduction of thrombosis risk, and broader suppression of myeloproliferation. Controlled studies are needed to clarify the added value of twice- vs once-daily aspirin dosing and direct oral anticoagulants. In this invited review, we discuss our current approach to diagnosis, prognostication, and treatment of PV in general, as well as during specific situations, including pregnancy and splanchnic vein thrombosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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12
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Palandri F, Mora B, Gangat N, Catani L. Is there a gender effect in polycythemia vera? Ann Hematol 2021; 100:11-25. [PMID: 33006021 PMCID: PMC7782364 DOI: 10.1007/s00277-020-04287-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
In recent times, there has been a growing interest in understanding the impact of gender on disease biology and clinical outcomes in Philadelphia-negative chronic myeloproliferative neoplasms. Among those, polycythemia vera (PV) is characterized by increased thrombotic risk, systemic symptoms, and overall reduced survival. Here, we aim to summarize data on whether and to what extent female sex can affect PV biology and outcome. To this end, we will discuss the latest acquisitions in terms of pathogenesis, diagnosis, epidemiology, clinical presentation and symptoms burden, thrombotic risk and related treatment strategies, and prognosis in female patients affected by PV.
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Affiliation(s)
- Francesca Palandri
- Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Barbara Mora
- Hematology, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy
| | | | - Lucia Catani
- Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
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13
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Magaz M, Alvarez-Larrán A, Colomer D, López-Guerra M, García-Criado MÁ, Mezzano G, Belmonte E, Olivas P, Soy G, Cervantes F, Darnell A, Ferrusquía-Acosta J, Baiges A, Turon F, Hernández-Gea V, García-Pagán JC. Next-generation sequencing in the diagnosis of non-cirrhotic splanchnic vein thrombosis. J Hepatol 2021; 74:89-95. [PMID: 32679300 DOI: 10.1016/j.jhep.2020.06.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Myeloproliferative neoplasms (MPNs) are the most frequent cause of non-tumoural non-cirrhotic splanchnic vein thrombosis (NC-SVT). Diagnosis of MPN is based on blood cell count alterations, bone marrow histology, and detection of specific gene mutations. Next-generation sequencing (NGS) allows the simultaneous evaluation of multiple genes implicated in myeloid clonal pathology. The aim of this study was to evaluate the potential role of NGS in elucidating the aetiology of NC-SVT. METHODS DNA samples from 80 patients (75 with idiopathic or exclusively local factor [Idiop/loc-NC-SVT] and 5 with MPN and NC-SVT [SVT-MPN] negative for Janus kinase 2 gene [JAK2] [V617F and exon 12], calreticulin gene [CALR], and thrombopoietin gene [MPL] mutations by classic techniques) were analysed by NGS. Mutations involved in myeloid disorders different from JAK2, CALR, and MPL genes were categorised as high-molecular-risk (HMR) variants or variants of unknown significance. RESULTS In 2/5 triple-negative SVT-MPN cases (40%), a mutation in exon 12 of JAK2 was identified. JAK2-exon 12 mutation was also identified in 1/75 patients with Idiop/loc-NC-SVT. Moreover, 28/74 (37.8%) of the remaining Idiop/loc-NC-SVT had at least 1 HMR variant. Sixty-two patients with Idiop/loc-NC-SVT were not receiving long-term anticoagulation and 5 of them (8.1%) had recurrent NC-SVT. This cumulative incidence was significantly higher in patients with HMR variants than in those without. CONCLUSIONS NGS identified JAK2-exon12 mutations not previously detected by conventional techniques. In addition, NGS detected HMR variants in approximately one-third of patients with Idiop/loc-NC-SVT. These patients seem to have a higher risk of splanchnic rethrombosis. NGS might be a useful diagnostic tool in NC-SVT. LAY SUMMARY Next-generation sequencing (NGS) performs massive sequencing of DNA allowing the simultaneous evaluation of multiple genes even at very low mutational levels. Application of this technique in a cohort of patients with non-cirrhotic non-tumoral portal vein thrombosis (NC-SVT) and a negative study for thrombophilic disorders was able to identify patients with a mutation in exon 12 not previously detected by conventional techniques. Moreover, NGS detected High Molecular Risk (HMR)-variants (Mutations involved in myeloid disorders different from JAK2, CALR and MPL genes) in approximately one third of patients. These patients appear to be at increased risk of rethrombosis. All these findings supports NGS as a potential useful tool in the management of NC-SVT.
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Affiliation(s)
- Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Alberto Alvarez-Larrán
- Hematology Department, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Dolors Colomer
- Hematopathology Section, Pathology Department, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red en Cancer, University of Barcelona, Barcelona, Spain
| | - Mónica López-Guerra
- Hematopathology Section, Pathology Department, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red en Cancer, University of Barcelona, Barcelona, Spain
| | - M Ángeles García-Criado
- Abdominal Radiology Section, Radiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gabriel Mezzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Ernest Belmonte
- Abdominal Radiology Section, Radiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Guillem Soy
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Francisco Cervantes
- Hematology Department, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Anna Darnell
- Abdominal Radiology Section, Radiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - José Ferrusquía-Acosta
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Health Care Provider of the European Reference Network on Rare Liver Disorders, Barcelona, Spain.
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