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Puli'uvea C, Immanuel T, Green TN, Tsai P, Shepherd PR, Kalev-Zylinska ML. Insights into the role of JAK2-I724T variant in myeloproliferative neoplasms from a unique cohort of New Zealand patients. Hematology 2024; 29:2297597. [PMID: 38197452 DOI: 10.1080/16078454.2023.2297597] [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: 08/20/2023] [Accepted: 12/12/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVES This study aimed to compile bioinformatic and experimental information for JAK2 missense variants previously reported in myeloproliferative neoplasms (MPN) and determine if germline JAK2-I724T, recently found to be common in New Zealand Polynesians, associates with MPN. METHODS For all JAK2 variants found in the literature, gnomAD_exome allele frequencies were extracted and REVEL scores were calculated using the dbNSFP database. We investigated the prevalence of JAK2-I724T in a cohort of 111 New Zealand MPN patients using a TaqMan assay, examined its allelic co-occurrence with JAK2-V617F using Oxford Nanopore sequencing, and modelled the impact of I724T on JAK2 using I-Mutant and ChimeraX software. RESULTS Several non-V617F JAK2 variants previously reported in MPN had REVEL scores greater than 0.5, suggesting pathogenicity. JAK2-I724T (REVEL score 0.753) was more common in New Zealand Polynesian MPN patients (n = 2/27; 7.4%) than in other New Zealand patients (n = 0/84; 0%) but less common than expected for healthy Polynesians (n = 56/377; 14.9%). Patients carrying I724T (n = 2), one with polycythaemia vera and one with essential thrombocythaemia, had high-risk MPN. Both patients with JAK2-I724T were also positive for JAK2-V617F, found on the same allele as I724T, as well as separately. In silico modelling did not identify noticeable structural changes that would give JAK2-I724T a gain-of-function. CONCLUSION Several non-canonical JAK2 variants with high REVEL scores have been reported in MPN, highlighting the need to further understand their relationship with disease. The JAK2-I724T variant does not drive MPN, but additional investigations are required to exclude any potential modulatory effect on the MPN phenotype.
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Affiliation(s)
- Christopher Puli'uvea
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, Hosted by the University of Auckland, Auckland, New Zealand
| | - Tracey Immanuel
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Taryn N Green
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Tsai
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, Hosted by the University of Auckland, Auckland, New Zealand
| | - Peter R Shepherd
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, Hosted by the University of Auckland, Auckland, New Zealand
| | - Maggie L Kalev-Zylinska
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Pathology and Laboratory Medicine, Auckland City Hospital, Auckland, New Zealand
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Tripodi J, Hoffman R, Tremblay D, Ahire D, Mascarenhas J, Kremyanskaya M, Najfeld V. Conventional Cytogenetic Analysis and Array CGH + SNP Identify Essential Thrombocythemia and Prefibrotic Primary Myelofibrosis Patients Who Are at Risk for Disease Progression. Int J Mol Sci 2024; 25:4061. [PMID: 38612873 PMCID: PMC11012420 DOI: 10.3390/ijms25074061] [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: 02/26/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
The Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-MPNs) are a heterogeneous group of clonal hematopoietic malignancies that include polycythemia vera (PV), essential thrombocythemia (ET), and the prefibrotic form of primary myelofibrosis (prePMF). In this study, we retrospectively reviewed the karyotypes from conventional cytogenetics (CC) and array Comparative Genomic Hybridization + Single Nucleotide Polymorphism (aCGH + SNP) in patients with ET or prePMF to determine whether the combined analysis of both methodologies can identify patients who may be at a higher risk of disease progression. We performed a comprehensive genomic review on 169 patients with a clinical diagnosis of ET (154 patients) or prePMF (15 patients). Genomic alterations detected by CC or array-CGH + SNP were detected in 36% of patients. In patients who progressed, 68% had an abnormal genomic finding by either technology. There was a shorter progression-free survival (PFS) among patients who were cytogenetically abnormal or who were cytogenetically normal but had an abnormal aCGH + SNP result. Leveraging the ability to detect submicroscopic copy number alterations and regions of copy neutral-loss of heterozygosity, we identified a higher number of patients harboring genomic abnormalities than previously reported. These results underscore the importance of genomic analysis in prognostication and provide valuable information for clinical management and treatment decisions.
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Affiliation(s)
- Joseph Tripodi
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daiva Ahire
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Vesna Najfeld
- Tumor CytoGenomics Laboratory, Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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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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Mulas O, Mola B, Costa A, Pittau F, Mantovani D, Dessì S, Fronteddu A, La Nasa G, Caocci G. Renin-angiotensin inhibitors reduce thrombotic complications in Essential Thrombocythemia and Polycythemia Vera patients with arterial hypertension. Ann Hematol 2023; 102:2717-2723. [PMID: 37603060 PMCID: PMC10492873 DOI: 10.1007/s00277-023-05417-w] [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: 08/02/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
Essential Thrombocythemia (ET) and Polycythemia Vera (PV) are chronic myeloproliferative neoplasms (MPNs) characterized by thrombotic and hemorrhagic complications, leading to a high risk of disability and mortality. Although arterial hypertension was found to be the most significant modifiable cardiovascular (CV) risk factor in the general population, little is known about its role in MPNs as well as a possible role of renin-angiotensin system inhibitors (RASi) in comparison with other anti-hypertensive treatments. We investigated a large cohort of 404 MPN adult patients, 133 diagnosed with PV and 271 with ET. Over half of the patients (53.7%) reported hypertension at MPN diagnosis. The 15-year cumulative incidence of thrombotic-adverse events (TAEs) was significantly higher in patients with hypertension (66.8 ± 10.3% vs 38.5 ± 8.4%; HR = 1.83; 95%CI 1.08-3.1). Multivariate analysis showed that PV diagnosis and hypertension were independently associated with a higher risk of developing TAEs (HR = 3.5; 95%CI 1.928-6.451, p < 0.001 and HR = 1.8; 95%CI 0.983-3.550, p = 0.05, respectively). In multivariate analysis, the diagnosis of PV confirmed a significant predictive role in developing TAEs (HR = 4.4; 95%CI 1.92-10.09, p < 0.01), also considering only MPN patients with hypertension. In addition, we found that the use of RASi showed a protective effect from TAEs both in the whole cohort of MPN with hypertension (HR = 0.46; 95%CI 0.21-0.98, p = 0.04) and in the subgroup of thrombotic high-risk score patients (HR = 0.49; 95%CI 0.24-1.01, p = 0.04). In particular, patients with ET and a high risk of thrombosis seem to benefit most from RASi treatment (HR = 0.27; 95%CI 0.07-1.01, p = 0.03). Hypertension in MPN patients represents a significant risk factor for TAEs and should be adequately treated.
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Affiliation(s)
- Olga Mulas
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Brunella Mola
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Alessandro Costa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesca Pittau
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniela Mantovani
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Samuele Dessì
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonella Fronteddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giorgio La Nasa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy.
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5
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Mahdi D, Spiers J, Rampotas A, Polverelli N, McLornan DP. Updates on accelerated and blast phase myeloproliferative neoplasms: Are we making progress? Br J Haematol 2023; 203:169-181. [PMID: 37527977 DOI: 10.1111/bjh.19010] [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: 04/30/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
Management approaches for accelerated and blast phase myeloproliferative neoplasms remain challenging for clinicians and patients alike. Despite many therapeutic advances, outcomes for those patients who are not allogeneic haematopoietic cell transplant eligible remain, in general, very poor. Estimated survival rates for such blast phase patients is frequently reported as less than 6 months. No specific immunological, genomic or clinicopathological signature currently exists that accurately predicts the risk and timing of transformation, which frequently induces a high degree of anxiety among patients and clinicians alike. Within this review article, we provide an up-to-date summary of current understanding of the underlying pathogenesis of accelerated and blast phase disease and discuss current therapeutic approaches and realistic outcomes. Finally, we discuss how the horizon may look with the introduction of more novel agents into the clinical arena.
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Affiliation(s)
- Dina Mahdi
- Department of Haematology, University College Hospital, London, UK
| | - Jessica Spiers
- Department of Haematology, University College Hospital, London, UK
| | | | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, Brescia, Italy
| | - Donal P McLornan
- Department of Haematology, University College Hospital, London, UK
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6
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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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Alvarez-Larrán A, Cuevas B, Velez P, Noya S, Caballero-Navarro G, Ferrer-Marín F, Carbonell S, Pérez-Encinas M, Gómez-Casares MT, Pérez-López R, Magro E, Moretó A, Pastor-Galán I, Angona A, Mata-Vázquez MI, Guerrero-Fernández L, Guerra JM, Carreño-Tarragona G, Fox L, Murillo I, García-Gutiérrez V, Mora E, Stuckey R, Arellano-Rodrigo E, Hernández-Boluda JC, Pereira A. Application of IPSET-thrombosis in 1366 Patients Prospectively Followed From the Spanish Registry of Essential Thrombocythemia. Hemasphere 2023; 7:e936. [PMID: 37476303 PMCID: PMC10356121 DOI: 10.1097/hs9.0000000000000936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 07/22/2023] Open
Abstract
The International Prognostic Score of thrombosis in Essential Thrombocythemia (IPSET-thrombosis) and its revised version have been proposed to guide thrombosis prevention strategies. We evaluated both classifications to prognosticate thrombosis in 1366 contemporary essential thrombocythemia (ET) patients prospectively followed from the Spanish Registry of ET. The cumulative incidence of thrombosis at 10 years, taking death as a competing risk, was 11.4%. The risk of thrombosis was significantly higher in the high-risk IPSET-thrombosis and high-risk revised IPSET-thrombosis, but no differences were observed among the lower risk categories. Patients allocated in high-risk IPSET-thrombosis (subdistribution hazard ratios [SHR], 3.7 [95% confidence interval, CI, 1.6-8.7]) and high-risk revised IPSET-thrombosis (SHR, 3.2 [95% CI, 1.4-7.45]) showed an increased risk of arterial thrombosis, whereas both scoring systems failed to predict venous thrombosis. The incidence rate of thrombosis in intermediate risk revised IPSET-thrombosis (aged >60 years, JAK2-negative, and no history of thrombosis) was very low regardless of the treatment administered (0.9% and 0% per year with and without cytoreduction, respectively). Dynamic application of the revised IPSET-thrombosis showed a low rate of thrombosis when patients without history of prior thrombosis switched to a higher risk category after reaching 60 years of age. In conclusion, IPSET-thrombosis scores are useful for identifying patients at high risk of arterial thrombosis, whereas they fail to predict venous thrombosis. Controlled studies are needed to determine the appropriate treatment of ET patients assigned to the non-high-risk categories.
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Affiliation(s)
| | | | | | - Soledad Noya
- Complexo Hospitalario Universitario de A Coruña, Spain
| | | | | | | | | | | | | | - Elena Magro
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | | | | | | | | | | | | | | | - Laura Fox
- Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | | | | | - Elvira Mora
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
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8
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Tefferi A, Alkhateeb H, Gangat N. Blast phase myeloproliferative neoplasm: contemporary review and 2024 treatment algorithm. Blood Cancer J 2023; 13:108. [PMID: 37460550 DOI: 10.1038/s41408-023-00878-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 07/20/2023] Open
Abstract
Leukemic transformation in myeloproliferative neoplasms (MPN), also referred to as "blast-phase MPN", is the most feared disease complication, with incidence estimates of 1-4% for essential thrombocythemia, 3-7% for polycythemia vera, and 9-13% for primary myelofibrosis. Diagnosis of MPN-BP requires the presence of ≥20% circulating or bone marrow blasts; a lower level of excess blasts (10-19%) constitutes "accelerated phase" disease (MPN-AP). Neither "intensive" nor "less intensive" chemotherapy, by itself, secures long-term survival in MPN-BP. Large-scale retrospective series have consistently shown a dismal prognosis in MPN-BP, with 1- and 3-year survival estimates of <20% and <5%, respectively. Allogeneic hematopoietic stem cell transplant (AHSCT) offers the possibility of a >30% 3-year survival rate and should be pursued, ideally, while the patient is still in chronic phase disease. The value of pre-transplant bridging chemotherapy is uncertain in MPN-AP while it is advised in MPN-BP; in this regard, we currently favor combination chemotherapy with venetoclax (Ven) and hypomethylating agent (HMA); response is more likely in the absence of complex/monosomal karyotype and presence of TET2 mutation. Furthermore, in the presence of an IDH mutation, the use of IDH inhibitors, either alone or in combination with Ven-HMA, can be considered. Pre-transplant clearance of excess blasts is desired but not mandated; in this regard, additional salvage chemotherapy is more likely to compromise transplant eligibility rather than improve post-transplant survival. Controlled studies are needed to determine the optimal pre- and post-transplant measures that target transplant-associated morbidity and post-transplant relapse.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Hassan Alkhateeb
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Naseema Gangat
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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9
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Iurlo A, Bucelli C, Cattaneo D. Essential Thrombocythemia in Adolescents and Young Adults: Clinical Aspects, Treatment Options and Unmet Medical Needs. Curr Treat Options Oncol 2023; 24:802-820. [PMID: 37195587 DOI: 10.1007/s11864-023-01099-8] [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] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
OPINION STATEMENT Current treatment of essential thrombocythemia (ET) should primarily prevent thrombo-hemorrhagic events, without increasing the rate of fibrotic progression or leukemic evolution, and secondarily control microvascular symptoms. Unlike other classic BCR::ABL1-negative myeloproliferative neoplasms, ET is frequently diagnosed in adolescents and young adults (AYA), defined as individuals aged 15 to 39 years, in up to 20% of patients. However, since the current risk stratification of this disease is based on models, including that of ELN, IPSET-Thrombosis and its revised version, mainly applied to an older patients' population, international guidelines are needed that specifically consider how to evaluate the prognosis of AYAs with ET. Furthermore, although ET is the most frequent MPN among AYA subjects, there is a lack of specific recommendations on how to treat it in this subgroup of patients, as management decisions are typically extrapolated from those for the elderly. Accordingly, since AYAs with ET represent a unique disease subset defined by attenuated genetic risk, more indolent phenotype, and longer survival than their older counterparts, treatment selection requires special attention to specific issues such as the risk of fibrotic/leukemic transformation, carcinogenicity, and fertility. This review article will provide a comprehensive overview of the diagnosis, prognostic stratification, and possible therapeutic approaches for AYA patients with ET, including antiplatelets/anticoagulants and cytoreductive agents, with a focus on pregnancy management in real-life clinical practice.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - 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
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10
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Tefferi A, Bacigalup A. Blast phase myeloproliferative neoplasm: Transplant to the rescue. Am J Hematol 2023; 98:553-555. [PMID: 36655312 DOI: 10.1002/ajh.26849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Bacigalup
- Istituto di Ematologia, Policlinico Universitario A Gemelli, Rome, Italy
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Abstract
The Philadelphia-negative myeloproliferative neoplasms (MPNs)-essential thrombocythemia (ET), polycythemia vera (PV) and myelofibrosis (MF), are characterized by a propensity for thrombotic events and variable risks for transformation to MF (for ET and PV) and acute leukemia. Leukocytosis, which serves a minor criterion for the diagnosis of MF, is present in a significant portion of patients with MPNs. The relation and impact of leukocytosis on disease course and outcomes of patients with MPNs has been studied in multiple, large retrospective and prospective studies. Despite this, the association of leukocytosis and thrombosis, fibrosis and leukemic transformation remains unclear. This article details the published investigations regarding the impact of leukocytosis in MPNs and explores the changing role of leukocytosis in disease prognostication as increasing emphasis is placed on molecular and genetic studies.
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Affiliation(s)
- Alexander Coltoff
- Department of Hematology/Oncology, Medical University of South Carolina, Charleston, SC, USA
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12
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McKinnell Z, Karel D, Tuerff D, SH Abrahim M, Nassereddine S. Acute Myeloid Leukemia Following Myeloproliferative Neoplasms: A Review of What We Know, What We Do Not Know, and Emerging Treatment Strategies. J Hematol 2022; 11:197-209. [PMID: 36632576 PMCID: PMC9822656 DOI: 10.14740/jh1042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/15/2022] [Indexed: 01/04/2023] Open
Abstract
Acute myeloid leukemia (AML) arising from myeloproliferative neoplasms (MPNs) represents a small subtype of secondary AML (sAML). This entity is well known to be associated with poor responses to available treatment options and dismal outcomes. To date, there are no standardized treatment options and there has been very little therapeutic advancement in recent years. This is a stark contrast to other subsets of AML for which there have been significant advances in therapeutic approaches, especially for patients with targetable mutations. We aim to focus our review on the incidence, risk factors for leukemogenesis, pathogenesis, molecular landscape, and emerging therapeutic options in post-myeloproliferative neoplasm acute myeloid leukemia (post-MPN AML).
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Affiliation(s)
- Zoe McKinnell
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Daniel Karel
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Daniel Tuerff
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Marwa SH Abrahim
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA
| | - Samah Nassereddine
- Department of Hematology and Oncology, George Washington University Hospital, Washington, DC, USA,Corresponding Author: Samah Nassereddine, Department of Hematology and Oncology, George Washington University and George Washington Cancer Center, Washington, DC, USA.
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13
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Tekin TO, Karis D, Ates Alkan F, Cetin G, Ercan AM. Evaluation of trace elements in essential thrombocytosis and reactive thrombocytosis. J Trace Elem Med Biol 2022; 73:127034. [PMID: 35839560 DOI: 10.1016/j.jtemb.2022.127034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 03/15/2022] [Accepted: 07/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trace elements (TE) are vital for cellular mechanisms at biological, chemical and molecular levels. The effects of TE in diagnosis, progression and treatment of essential thrombocytosis (ET), which is one of the chronic myeloproliferative neoplasms is a rare clonal stem cell disease characterized by increased thrombocyte numbers with impaired function, have not been elucidated in detail yet. The aim of the present study was to investigate the effects of TE alterations in an ET model and the efficacy of TE in ET treatment protocol by means of a vast number of TE. METHODS Study groups were categorized as patients with ET diagnosis (ET group, n:30), patients with reactive thrombocytosis secondary to iron deficiency anemia (IDA-RT) (IDA-RT group, n:30) and healthy controls (HC group, n:30). Serum levels of copper (Cu), iron (Fe), cobalt (Co), chromium (Cr), aluminum (Al), silicon (Si), nickel (Ni), zinc (Zn), selenium (Se), manganese (Mn), boron (B) and magnesium (Mg) were analyzed utilizing inductively coupled plasma-optical emission spectrophotometer instrument (ICP-OES). Statistical analysis was evaluated using SPSS 23.0. RESULTS ET group had statistically higher serum levels of Co and Mg (p < 0.05), Ni and Mn (p < 0.001), and lower Si (p < 0.05) than IDA-RT group. ET group had statistically higher serum levels of Co and Mn (p < 0.05), and Ni (p < 0.001), and lower Al, Si and Se (p < 0.001) than HC group. Serum levels of Fe, Al and Se (p < 0.001), and Mg (p < 0.01), and Zn (p < 0.05) in IDA-RT group were significantly lower than HC group. CONCLUSION This novel study pointed out that alterations of many serum TE by means of both increment or decrement might have close relationship with mechanisms and complications of ET onset and follow-up. We consider that further research of TE would elucidate ethiopathogenesis and prognosis of ET. Thus, analysis of serum trace elements in essential thrombocytosis patients may be an important protocol by means of diagnosis, treatment and follow-up intervals.
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Affiliation(s)
- Tuba Ozkan Tekin
- Department of Hematology, Department of Internal Medicine, Faculty of Medicine, Bezmialem University, Fatih, Istanbul, Turkey
| | - Denizhan Karis
- Department of Biophysics, Faculty of Medicine, İstanbul University-Cerrahpasa, Fatih, Istanbul, Turkey.
| | - Fatma Ates Alkan
- Department of Biophysics, Faculty of Medicine, İstanbul University-Cerrahpasa, Fatih, Istanbul, Turkey
| | - Guven Cetin
- Department of Hematology, Department of Internal Medicine, Faculty of Medicine, Bezmialem University, Fatih, Istanbul, Turkey
| | - Alev Meltem Ercan
- Department of Biophysics, Faculty of Medicine, İstanbul University-Cerrahpasa, Fatih, Istanbul, Turkey
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14
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Goulart H, Mascarenhas J, Tremblay D. Low-risk polycythemia vera and essential thrombocythemia: management considerations and future directions. Ann Hematol 2022; 101:935-951. [PMID: 35344066 DOI: 10.1007/s00277-022-04826-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/21/2022] [Indexed: 01/06/2023]
Abstract
Thrombotic events are a distinctive feature of the myeloproliferative neoplasms (MPNs) polycythemia vera (PV) and essential thrombocythemia (ET). Patients with these MPNs may also experience a poor quality of life secondary to symptom burden, as well as progression of disease to acute leukemia or myelofibrosis. Over the years, various risk stratification methods have evolved in order to attempt to predict thrombotic risk, which is the largest contributor of morbidity and mortality in these patients. More than half of PV and ET patients are low- or intermediate-risk disease status at the time of diagnosis. While therapeutic development is presently focused on high-risk patients, there is a paucity of therapies, outside of aspirin and therapeutic phlebotomy, which can reduce the thrombotic risk or delay disease progression in low-risk patients. In this review, we first describe the various complications that patients with PV and ET experience, and then detail our evolving understanding of risk stratification in these diseases. We then highlight the available evidence on the management of low-risk PV and ET and include a description of novel therapies currently under investigation in this space. We conclude with recommendations for future directions to advance our understanding and improve the treatment of low-risk PV and ET.
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Affiliation(s)
- Hannah Goulart
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA
| | - Douglas Tremblay
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA.
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15
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Nalluru S, Efe O, Chen Y, Trivedi N. Acute myeloid leukemia and myelofibrosis: Simultaneous transformation of essential thrombocythemia during treatment with hydroxyurea. J Cancer Res Ther 2022; 18:1180-1182. [DOI: 10.4103/jcrt.jcrt_1107_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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16
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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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17
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Yap YY, Sathar J, Law KB. Mortality outcomes and survival patterns of patients with myeloproliferative neoplasms in Malaysia. Cancer Causes Control 2021; 33:343-351. [PMID: 34846616 DOI: 10.1007/s10552-021-01521-2] [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: 01/07/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prognostication of myeloproliferative neoplasm (MPN) has always been challenging, even with the advent of Janus kinase 2 (JAK2 V617F) molecular studies. The survival pattern of patients diagnosed with MPN in developing countries is still undetermined. MATERIALS AND METHODS The national MPN registry conducted from 2009 to 2015 in Malaysia provided a comprehensive insight into the demographics, clinical characteristics and laboratory parameters of patients diagnosed with MPN nationwide. The study analysed the survival patterns and mortality outcomes and risk among 671 patients diagnosed with essential thrombocythaemia (ET), polycythaemia vera (PV), primary myelofibrosis (PMF) and unclassified MPN (MPN-U). Mortality status was traced and confirmed until the end of December 2018, with right censoring applied to patients alive beyond that. RESULTS The analysed cohort consisted of 283 (42.2%) ET, 269 (40.1%) PV, 62 (9.2%) PMF and 57 (8.5%) MPN-U incident cases with diagnosis made between 2007 and 2015. The majority of patients were male (52.3%) and Malay (48.9%), except for ET, in which the majority of patients were female (60.1%) and of Chinese origin (47.0%). Female patients were found to have significantly better overall survival (OS) rates in ET (p = 0.0285) and MPN-U (p = 0.0070). Patients with JAK2 V617F mutation were found to have marginally inferior OS over time. Multivariable Cox regression identified patients with increased age [hazard ratio (HR) 1.055, 95% CI 1.031; 1.064], reduced haemoglobin (HB) level (HR 0.886, 95% CI 0.831; 0.945, p = 0.0002), being male (HR 1.545, 95% CI 1.077; 2.217, p = 0.0182), and having MPN-U (HR 2.383, 95% CI 1.261; 4.503, p = 0.0075) and PMF (HR 1.975, 95% CI 1.054; 3.701, p = 0.0335) at increased risk for worse mortality outcomes. CONCLUSION Myeloproliferative neoplasm reduces patient survival. The degree of impact on survival varies according to sub-type, sex, bone marrow fibrosis and HB levels. The JAK2 V617F mutation was not found to affect the survival pattern or mortality outcome significantly.
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Affiliation(s)
- Yee Yee Yap
- Department of Haematology, Ampang Hospital, Jalan Mewah Utara, Pandan Mewah, 68000, Ampang, Selangor, Malaysia.
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Jalan Mewah Utara, Pandan Mewah, 68000, Ampang, Selangor, Malaysia
| | - Kian Boon Law
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Kompleks Institut Kesihatan Negara, Jalan Setia Murni U13/52 Seksyen U13, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
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18
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How J, Hobbs G. Management Issues and Controversies in Low-Risk Patients with Essential Thrombocythemia and Polycythemia Vera. Curr Hematol Malig Rep 2021; 16:473-482. [PMID: 34478054 DOI: 10.1007/s11899-021-00649-x] [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] [Accepted: 06/02/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Essential thrombocythemia (ET) and polycythemia vera (PV) are the most common myeloproliferative neoplasms (MPNs). Treatment of ET and PV is based on the risk for subsequent thrombosis. High-risk patients, defined as older than 60, JAK2 V617F-positive patients, or patients with a history of prior thrombosis, merit cytoreduction to control blood counts, whereas a watchful waiting paradigm is utilized in low-risk patients. However, low-risk patients have a host of other specific management issues that arise during their disease course. This review will discuss the most common management issues specific to the care of low-risk patients, including anti-platelet therapy dosing, pregnancy, and indications for early cytoreduction. RECENT FINDINGS Although low-dose aspirin is well established in PV, its indications and dosing regimens are less clear in ET. Recent evidence has supported twice daily low-dose aspirin in ET and observation alone in very low-risk ET patients. Pregnancy is not contraindicated in MPNs, and we recommend aspirin throughout pregnancy with consideration for prophylactic postpartum anticoagulation. High phlebotomy needs, symptom burden, and extreme thrombocytosis are common reasons for initiation of cytoreduction in low-risk patients, although we typically do not start cytoreduction for an isolated high platelet count alone. Recent data has also demonstrated a potential disease-modifying effect of interferons in MPNs, with some experts now advocating the early use of interferon in low-risk patients, although more mature data is needed before practice guidelines change. We evaluate the literature to inform clinical decision-making regarding these controversies, including most recent data that has challenged the "watchful waiting" paradigm. Our discussion provides guidance on common clinical scenarios seen in low-risk ET and PV patients, who face a myriad of complex management decisions in their care.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson, Office 138, Boston, MA, 02114, USA.,Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Gabriela Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson, Office 138, Boston, MA, 02114, USA.
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19
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Medawar G, Ackula H, Weinberg O, Roberts T, Meleveedu K. T-cell Acute Lymphoblastic Leukemia in a Patient with Pre-existing Essential Thrombocythemia: A Case Report and Literature Review. Leuk Res Rep 2021; 16:100264. [PMID: 34430196 PMCID: PMC8367827 DOI: 10.1016/j.lrr.2021.100264] [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: 05/14/2021] [Revised: 07/25/2021] [Accepted: 08/06/2021] [Indexed: 11/05/2022] Open
Abstract
The occurrence of T–cell acute lymphoblastic leukemia (T–ALL), on a background of preexisting Philadelphia–negative Myeloproliferative neoplasm is rare. Among the few reported cases where no deep molecular sequencing was performed, it was difficult to ascertain whether these leukemia's occurred de-novo or were due to the clonal progression of underlying MPN. We present a case of a 49–year-old man with a history of essential thrombocythemia who subsequently developed T–ALL. By utilizing next generation sequencing we were able to determine that these two entities originated from two distinct clones and were likely random events. We report the outcome and review the literature.
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Affiliation(s)
- Georgio Medawar
- Department of Internal Medicine, Roger Williams Medical Center, 825 Chalkstone Ave, Providence, RI 02908, United States
| | - Haritha Ackula
- Department of Hematology and Oncology, Roger Williams Medical Center, 825 Chalkstone Ave, Providence, RI 02908, United States
| | - Olga Weinberg
- Department of Pathology, Roger Williams Medical Center, 825 Chalkstone Ave, Providence, RI 02908, United States
| | - Todd Roberts
- Department of Hematology and Oncology, Bone Marrow Transplant, Roger Williams Medical Center, 825 Chalkstone Ave, Providence, RI 02908, United States
| | - Kapil Meleveedu
- Department of Hematology and Oncology, Bone Marrow Transplant, Roger Williams Medical Center, 825 Chalkstone Ave, Providence, RI 02908, United States
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20
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Acute promyelocyte leukemia arose from CALR 1 mutated post essential thrombocythemia- myelofibrosis with splanchnic vein thrombosis: A case report. Leuk Res Rep 2021; 15:100243. [PMID: 34040959 PMCID: PMC8142272 DOI: 10.1016/j.lrr.2021.100243] [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: 03/10/2021] [Revised: 04/19/2021] [Accepted: 05/02/2021] [Indexed: 11/23/2022] Open
Abstract
Major disease complications for patients with essential thrombocythemia (ET) include thrombosis and fibrotic or leukemic transformation. Calreticulin (CALR) mutation type 1 frequencies in ET are estimated between 7% and 11% and ET patients carrying CALR type 1 mutation are associated with lower risk of thrombosis but higher risk of myelofibrosis transformation compared to ET patients with JAK2 mutation. Leukemic transformation rates at 20 years are estimated at less than 5% for ET and risk factors for leukemic transformation are advanced age, thrombosis history, leukocytosis, and anemia. Amongst the subtypes of blast phase myeloproliferative neoplasms, acute promyelocytic leukemia is extremely rare. Herein, we present a case of a promyelocytic blast crisis of post-ET myelofibrosis with associated life-threatening splanchnic vein thrombosis. This case suggests that inflammation plays a key role in thrombotic events and fibrotic/leukemic transformation in ET patients, regardless the molecular landscape.
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21
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Leukemic evolution of polycythemia vera and essential thrombocythemia: genomic profiles predict time to transformation. Blood Adv 2021; 4:4887-4897. [PMID: 33035330 DOI: 10.1182/bloodadvances.2020002271] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023] Open
Abstract
Among myeloproliferative neoplasms, polycythemia vera (PV) and essential thrombocythemia (ET) are the 2 entities associated with the most chronic disease course. Leukemic evolution occurs rarely but has a grim prognosis. The interval between diagnosis and leukemic evolution is highly variable, from a few years to >20 years. We performed a molecular evaluation of 49 leukemic transformations of PV and ET by targeted next-generation sequencing. Using a hierarchical classification, we identified 3 molecular groups associated with a distinct time to leukemic transformation. Short-term transformations were mostly characterized by a complex molecular landscape and mutations in IDH1/2, RUNX1, and U2AF1 genes, whereas long-term transformations were associated with mutations in TP53, NRAS, and BCORL1 genes. Studying paired samples from chronic phase and transformation, we detected some mutations already present during the chronic phase, either with a significant allele burden (short-term transformation) or with a very low allele burden (especially TP53 mutations). However, other mutations were not detected even 1 year before leukemic transformation. Our results suggest that the leukemic transformation of PV and ET may be driven by distinct time-dependent molecular mechanisms.
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22
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Gangat N, Szuber N, Jawaid T, Hanson CA, Pardanani A, Tefferi A. Young platelet millionaires with essential thrombocythemia. Am J Hematol 2021; 96:E93-E95. [PMID: 33524176 DOI: 10.1002/ajh.26114] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Naseema Gangat
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
| | - Natasha Szuber
- Department of Hematology Université de Montréal Montréal Quebec Canada
| | - Tabinda Jawaid
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
| | - Curtis A. Hanson
- Division of Hematopathology, Department of Laboratory Medicine Mayo Clinic Rochester Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota
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23
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Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2021 update on diagnosis, risk-stratification and management. Am J Hematol 2020; 95:1599-1613. [PMID: 32974939 DOI: 10.1002/ajh.26008] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms (MPN) respectively characterized by clonal erythrocytosis and thrombocytosis; other disease features include leukocytosis, splenomegaly, thrombosis, bleeding, microcirculatory symptoms, pruritus and risk of leukemic or fibrotic transformation. DIAGNOSIS Bone marrow morphology remains the cornerstone of diagnosis. In addition, the presence of JAK2 mutation is expected in PV while approximately 90% of patients with ET express mutually exclusive JAK2, CALR or MPL mutations (so called driver mutations). In ET, it is most important to exclude the possibility of prefibrotic myelofibrosis. SURVIVAL Median survivals are approximately 15 years for PV and 18 years for ET; the corresponding values for patients age 40 or younger were 37 and 35 years. Certain mutations (mostly spliceosome) and abnormal karyotype might compromise survival in PV and ET. Life-expectancy in ET is inferior to the control population. Driver mutations have not been shown to affect survival in ET but risk of thrombosis is higher in JAK2 mutated cases. Leukemic transformation rates at 10 years are estimated at <1% for ET and 3% for PV. THROMBOSIS RISK In PV, two risk categories are considered: high (age > 60 years or thrombosis history present) and low (absence of both risk factors). In ET, 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 (age > 60 years, no thrombosis history, JAK2 wild-type) and high (thrombosis history present or age > 60 years with JAK2 mutation). RISK-ADAPTED THERAPY The main goal of therapy in both PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once-daily or twice-daily aspirin (81 mg), in the absence of contraindications. Very low risk ET might not require therapy while aspirin therapy is advised for low risk disease. Cytoreductive therapy is recommended for high-risk ET and PV, but it is not mandatory for intermediate-risk ET. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon-α and busulfan. We do not recommend treatment with ruxolutinib in PV, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs. NEW TREATMENT DIRECTIONS Controlled studies are needed to confirm the clinical outcome value of twice-daily vs once-daily aspirin dosing and the therapeutic role of pegylated interferons and direct oral anticoagulants.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota
| | - Tiziano Barbui
- Research Foundation Papa Giovanni XXIII Hospital Bergamo Italy
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24
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Dunbar AJ, Rampal RK, Levine R. Leukemia secondary to myeloproliferative neoplasms. Blood 2020; 136:61-70. [PMID: 32430500 PMCID: PMC7332899 DOI: 10.1182/blood.2019000943] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/23/2020] [Indexed: 12/11/2022] Open
Abstract
Secondary acute myeloid leukemias (AMLs) evolving from an antecedent myeloproliferative neoplasm (MPN) are characterized by a unique set of cytogenetic and molecular features distinct from de novo AML. Given the high frequency of poor-risk cytogenetic and molecular features, malignant clones are frequently insensitive to traditional AML chemotherapeutic agents. Allogeneic stem cell transplant, the only treatment modality shown to have any beneficial long-term outcome, is often not possible given the advanced age of patients at time of diagnosis and frequent presence of competing comorbidities. Even in this setting, relapse rates remain high. As a result, outcomes are generally poor and there remains a significant unmet need for novel therapeutic strategies. Although advances in cancer genomics have dramatically enhanced our understanding of the molecular events governing clonal evolution in MPNs, the cell-intrinsic and -extrinsic mechanisms driving leukemic transformation at this level remain poorly understood. Here, we review known risk factors for the development of leukemic transformation in MPNs, recent progress made in our understanding of the molecular features associated with leukemic transformation, current treatment strategies, and emerging therapeutic options for this high-risk myeloid malignancy.
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MESH Headings
- Abnormal Karyotype
- Allografts
- Antineoplastic Agents/therapeutic use
- Cell Transformation, Neoplastic
- Chromosome Aberrations
- Clonal Evolution
- Combined Modality Therapy
- Comorbidity
- Disease Progression
- Drug Resistance, Neoplasm
- Drugs, Investigational/therapeutic use
- Genes, Neoplasm
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Models, Biological
- Mutation
- Myeloproliferative Disorders/genetics
- Myeloproliferative Disorders/pathology
- Neoplasm Proteins/genetics
- Recurrence
- Risk Factors
- Single-Cell Analysis
- Therapies, Investigational
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Affiliation(s)
- Andrew J Dunbar
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
| | - Raajit K Rampal
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
| | - Ross Levine
- Leukemia Service, Department of Medicine
- Center for Hematologic Malignancies
- Human Oncology and Pathogenesis Program, and
- Center for Epigenetics Research, Memorial Sloan Kettering Cancer Center, New York, NY
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Ishida H, Miyajima Y, Hyakuna N, Hamada S, Sarashina T, Matsumura R, Umeda K, Mitsui T, Fujita N, Tomizawa D, Urayama KY, Ishida Y, Taga T, Takagi M, Adachi S, Manabe A, Imamura T, Koh K, Shimada A. Clinical features of children with polycythemia vera, essential thrombocythemia, and primary myelofibrosis in Japan: A retrospective nationwide survey. EJHAEM 2020; 1:86-93. [PMID: 35847744 PMCID: PMC9175656 DOI: 10.1002/jha2.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Abstract
Background Philadelphia-negative (Ph-negative) myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are exceptionally rare during childhood. Thus, clinical features of pediatric Ph-negative MPNs remain largely unknown. This study was therefore performed to address this. Methods We performed a retrospective study to collect clinical information of children diagnosed with Ph-negative MPNs from 2000 to 2016 using questionnaires in qualified institutions in Japan. The results obtained from the questionnaire survey were then combined with those from the national registry data. Results Among 50 children identified, five had PV, 44 had ET, and one had PMF. Median age at diagnosis was 14.0, 9.0, and 0 years, respectively. Male to female ratio was 4:1, 21:23, and 1:0, respectively. Detection rates of the JAK2 V617F variant were 0/5 in PV and 9/39 in ET. Frequencies of complications, such as thrombosis and subsequent leukemia, were lower than complication frequencies in adults. We identified two children who developed subsequent leukemia, which has not been reported previously, and one of them died. Conclusion This is the first nationally representative survey of pediatric Ph-negative MPNs. Given its rarity, an international collaboration with comprehensive genetic analyses might be needed to fully elucidate the clinical and genetic features.
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Affiliation(s)
- Hisashi Ishida
- Department of PediatricsOkayama University HospitalOkayamaJapan
| | - Yuji Miyajima
- Department of PediatricsAnjo Kosei HospitalAnjoJapan
| | - Nobuyuki Hyakuna
- Department of PediatricsUniversity of the Ryukyus HospitalNishiharaJapan
| | - Satoru Hamada
- Department of PediatricsUniversity of the Ryukyus HospitalNishiharaJapan
| | - Takeo Sarashina
- Department of PediatricsAsahikawa Medical UniversityAsahikawaJapan
| | - Risa Matsumura
- Department of PediatricsHiroshima University HospitalHiroshimaJapan
| | - Katsutsugu Umeda
- Department of PediatricsGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Tetsuo Mitsui
- Department of PediatricsYamagata University HospitalYamagataJapan
| | - Naoto Fujita
- Department of PediatricsHiroshima Red Cross Hospital and Atomic‐bomb Survivors HospitalHiroshimaJapan
| | - Daisuke Tomizawa
- Children's Cancer CentreNational Centre for Child Health and DevelopmentTokyoJapan
| | - Kevin Y. Urayama
- Department of Social MedicineNational Centre for Child Health and DevelopmentTokyoJapan
- Graduate School of Public HealthSt. Luke's International UniversityTokyoJapan
| | - Yasushi Ishida
- Pediatric Medical CentreEhime Prefectural Central HospitalMatsuyamaJapan
| | - Takashi Taga
- Department of PediatricsShiga University of Medical ScienceOtsuJapan
| | - Masatoshi Takagi
- Department of Pediatrics and Developmental BiologyTokyo Medical and Dental UniversityTokyoJapan
| | - Souichi Adachi
- Department of Human Health ScienceKyoto UniversityKyotoJapan
| | - Atsushi Manabe
- Department of PediatricsHokkaido University HospitalSapporoJapan
| | - Toshihiko Imamura
- Department of PediatricsGraduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Katsuyoshi Koh
- Department of Hematology/OncologySaitama Children's Medical CentreSaitamaJapan
| | - Akira Shimada
- Department of PediatricsOkayama University HospitalOkayamaJapan
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Zhou S, Tremblay D, Hoffman R, Kremyanskaya M, Najfeld V, Li L, Moshier E, Mascarenhas J. Clinical Benefit Derived from Decitabine Therapy for Advanced Phases of Myeloproliferative Neoplasms. Acta Haematol 2020; 144:48-57. [PMID: 32160610 DOI: 10.1159/000506146] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/18/2020] [Indexed: 12/30/2022]
Abstract
Treatment options are limited for patients with advanced forms of myeloproliferative neoplasms (MPN) including blast-phase disease (MPN-BP). Decitabine has frequently been deployed but its efficacy and safety profile are not well described in this population. We retrospectively reviewed 42 patients treated with decitabine either alone or in combination with ruxolitinib at our institution: 16 with MPN-BP, 14 with MPN accelerated-phase (MPN-AP), and 12 with myelofibrosis with high-risk features (MF-HR). The median overall survival (OS) for the MPN-BP patients was 2.6 months, and for those who received ≥2 cycles of decitabine therapy, it was 6.7 months (3.8-29.8). MPN-BP patients with a poor performance status and who required hospitalization at the time of the initiation of decitabine had a dismal prognosis. After a median follow-up of 12.4 months for MPN-AP patients, and 38.7 months for MF-HR patients, the median OS was not reached for either cohort, with 1 and 2 patients alive at 60 months, respectively. The probability of spleen length reduction and transfusion independence within 12 months of initiating decitabine was 28.6 and 23.5%, respectively. The combination of decitabine and ruxolitinib appeared to improve overall survival versus single-agent decitabine (21 and 12.9 months, respectively). Decitabine, alone or in combination with ruxolitinib, appears to have clinical benefit for patients with advanced phases of MPN when initiated early in the disease course prior to the development of MPN-BP.
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Affiliation(s)
- Selena Zhou
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ronald Hoffman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marina Kremyanskaya
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vesna Najfeld
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lihua Li
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Moshier
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA,
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27
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Appleby N, Angelov D. Clinical and laboratory assessment of a patient with thrombocytosis. Br J Hosp Med (Lond) 2019; 78:558-564. [PMID: 29019736 DOI: 10.12968/hmed.2017.78.10.558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Elevated platelet counts are frequently encountered in hospital medicine and arise from both physiological and pathological mechanisms. Thrombocytosis may be secondary, reflecting an inflammatory state, iron deficiency, recent surgery or point towards an underlying neoplasm. Thrombocytosis may be the presenting sign of solid tumours and haematological conditions. The discovery of the activating mutations affecting thrombopoiesis led to greater understanding of the pathobiology of essential thrombocythaemia and other myeloproliferative neoplasms. The investigation of suspected primary thrombocytosis has evolved to include testing for these disease-associated mutations. Therapy for patients with essential thrombocythaemia aims to reduce their risk of thrombotic complications by addressing cardiovascular risk factors, and using antiplatelet agents and, in selected patients, cytoreductive therapy. This article provides a logical approach to distinguishing reactive or secondary thrombocytosis from thrombocytosis associated with an underlying myeloproliferative neoplasm and gives an overview of the management of essential thrombocythaemia.
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Affiliation(s)
- Niamh Appleby
- Molecular Haematology Fellow, Molecular Haematology Laboratory, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU
| | - Daniel Angelov
- Core Medical Trainee, Department of Haematology, Mater Misercordiae University Hospital, Dublin
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28
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Combination of decitabine, idarubicin, cytarabine, and G-CSF (DIAG) regimen for the treatment of high-risk myelodysplastic syndrome and acute myeloid leukemia. Ann Hematol 2019; 98:2223-2225. [PMID: 30980106 DOI: 10.1007/s00277-019-03674-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/17/2019] [Indexed: 10/27/2022]
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29
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Iurlo A, Cattaneo D, Gianelli U. Blast Transformation in Myeloproliferative Neoplasms: Risk Factors, Biological Findings, and Targeted Therapeutic Options. Int J Mol Sci 2019; 20:ijms20081839. [PMID: 31013941 PMCID: PMC6514804 DOI: 10.3390/ijms20081839] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 01/24/2023] Open
Abstract
Myeloproliferative neoplasms represent a heterogenous group of disorders of the hematopoietic stem cell, with an intrinsic risk of evolution into acute myeloid leukemia. The frequency of leukemic evolution varies according to myeloproliferative neoplasms subtype. It is highest in primary myelofibrosis, where it is estimated to be approximately 10–20% at 10 years, following by polycythemia vera, with a risk of 2.3% at 10 years and 7.9% at 20 years. In essential thrombocythemia, however, transformation to acute myeloid leukemia is considered relatively uncommon. Different factors are associated with leukemic evolution in myeloproliferative neoplasms, but generally include advanced age, leukocytosis, exposure to myelosuppressive therapy, cytogenetic abnormalities, as well as increased number of mutations in genes associated with myeloid neoplasms. The prognosis of these patients is dismal, with a medium overall survival ranging from 2.6–7.0 months. Currently, there is no standard of care for managing the blast phase of these diseases, and no treatment to date has consistently led to prolonged survival and/or hematological remission apart from an allogeneic stem cell transplant. Nevertheless, new targeted agents are currently under development. In this review, we present the current evidence regarding risk factors, molecular characterization, and treatment options for this critical subset of myeloproliferative neoplasms patients.
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Affiliation(s)
- Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
| | - Umberto Gianelli
- Division of Pathology, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, and University of Milan, 20122 Milan, Italy.
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30
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Szuber N, Mudireddy M, Nicolosi M, Penna D, Vallapureddy RR, Lasho TL, Finke C, Begna KH, Elliott MA, Hook CC, Wolanskyj AP, Patnaik MM, Hanson CA, Ketterling RP, Sirhan S, Pardanani A, Gangat N, Busque L, Tefferi A. 3023 Mayo Clinic Patients With Myeloproliferative Neoplasms: Risk-Stratified Comparison of Survival and Outcomes Data Among Disease Subgroups. Mayo Clin Proc 2019; 94:599-610. [PMID: 30824279 DOI: 10.1016/j.mayocp.2018.08.022] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/16/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To document the Mayo Clinic decades-long experience with myeloproliferative neoplasms (MPNs) and provide mature risk-stratified survival data and disease complication estimates. PATIENTS AND METHODS All Mayo Clinic patients with World Health Organization-defined MPNs constituted the core study group and included those with polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). RESULTS A total of 3023 consecutive patients (median age, 62 years; range, 18-96 years) were considered: 665 PV, 1076 ET, and 1282 PMF. From October 27, 1967, through December 29, 2017, 1631 deaths (54%), 183 leukemic transformations (6%), 244 fibrotic progressions (14%), and 516 thrombotic events (17%) were recorded. Median overall survival (OS) was 18 years for ET, 15 years for PV, and 4.4 years for PMF (P<.05 for all intergroup comparisons). Inferior survival was documented in patients with ET diagnosed more recently (post-1990) (P<.001), whereas survival data were time independent in PV and PMF. After conventional risk stratification, OS in low-risk ET and low-risk PV were superimposed (P=.89) but each differed significantly from that of age- and sex-matched controls (P<.001). Leukemia-free survival was similar for ET and PV (P=.22) and significantly worse with PMF (P<.001). Compared with ET, PV was associated with higher risk of fibrotic progression (P<.001). Thrombosis risk after diagnosis was highest in PV and lowest in PMF (P=.002 for PV vs ET; P=.56 for ET vs PMF; and P=.001 for PV vs PMF). CONCLUSION This study provides the most mature survival and outcomes data in MPNs and highlights MPN subgroup risk categorization as key in appraising disease natural history. The OS was only marginally better in ET compared with PV, and PV displayed a higher risk of thrombosis and fibrotic progression.
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Affiliation(s)
- Natasha Szuber
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Mythri Mudireddy
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Maura Nicolosi
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Domenico Penna
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Rangit R Vallapureddy
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Terra L Lasho
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Christy Finke
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Kebede H Begna
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Michelle A Elliott
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - C Christopher Hook
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Alexandra P Wolanskyj
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Curtis A Hanson
- Division of Hematopathology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Rhett P Ketterling
- Division of Laboratory Genetics and Genomics, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Shireen Sirhan
- Division of Hematology, Jewish General Hospital, Montréal, Québec, Canada; Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group
| | - Animesh Pardanani
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Lambert Busque
- Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group; Department of Laboratory Hematology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal and Laboratory Medicine, Mayo Clinic, Rochester, MN.
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31
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Therapy-associated leukemic transformation in myeloproliferative neoplasms – What do we know? Best Pract Res Clin Haematol 2019; 32:65-73. [DOI: 10.1016/j.beha.2019.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 12/22/2022]
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Mora B, Passamonti F. Developments in diagnosis and treatment of essential thrombocythemia. Expert Rev Hematol 2019; 12:159-171. [PMID: 30793984 DOI: 10.1080/17474086.2019.1585239] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by thrombocytosis, increased risk of thrombotic/hemorrhagic events and clonal evolution into blast phase or myelofibrosis. Areas covered: The authors will discuss biology, diagnosis, prognosis, therapy, and outcome of ET. An accurate molecular-morphologic assessment is necessary in order to properly establish diagnosis and prognosis of ET. Stratification for thrombosis prediction is essential, and IPSET-t model is widely applied. The current treatment strategy is directed to lower the rate of vascular events using cytoreduction in patients at high risk. Prophylactic low dose aspirin indication is more uncertain. To date, therapies for patients who are resistant or intolerant to first-line treatments are scarce. Overall, life expectancy indicates an indolent disease, but IPSET model helps in predicting survival at the time of diagnosis. Expert opinion: Challenging for the future will be to share criteria for ET diagnosis with the community. New insights into the molecular pathogenesis of the disease will improve the prediction of clonal evolution and outcome, and lead to the use of disease-modifying treatments.
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Affiliation(s)
- Barbara Mora
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy
| | - Francesco Passamonti
- a Ospedale di Circolo , ASST Sette Laghi, Hematology , Varese , Italy.,b Department of Medicine and Surgery , Universita degli Studi dell'Insubria , Varese , Italy
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33
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Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2019 update on diagnosis, risk-stratification and management. Am J Hematol 2019; 94:133-143. [PMID: 30281843 DOI: 10.1002/ajh.25303] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 12/15/2022]
Abstract
Disease Overview: Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms respectively characterized by erythrocytosis and thrombocytosis; other disease features include leukocytosis, splenomegaly, thrombosis, bleeding, microcirculatory symptoms, pruritus, and risk of leukemic or fibrotic transformation. Diagnosis: Bone marrow morphology remains the cornerstone of diagnosis. In addition, the presence of JAK2 mutation is expected in PV while approximately 90% of patients with ET express mutually exclusive JAK2, CALR, or myeloproliferative leukemia mutations. In ET, it is most important to exclude the possibility of prefibrotic myelofibrosis. Survival: Median survivals are 14 years for PV and 20 years for ET; the corresponding values for younger patients are 24 and 33 years. Certain mutations (mostly spliceosome) and abnormal karyotype might compromise survival in PV and ET. Life-expectancy in ET is inferior to the control population. Driver mutations have not been shown to affect survival in ET. Risk of thrombosis is higher in JAK2-mutated ET. Leukemic transformation rates at 10 years are estimated at <1% for ET and 3% for PV. Thrombosis Risk: In PV, 2 risk categories are considered: high (age > 60 years or thrombosis history present) and low (absence of both risk factors); in ET, 4 risk categories are considered: very low (age ≤ 60 years, no thrombosis history, JAK2 wild-type), low (same as very low but JAK2 mutation present), intermediate (age > 60 years, no thrombosis history, JAK2 wild-type) and high (thrombosis history present or age > 60 years with JAK2 mutation). Risk-Adapted Therapy: The main goal of therapy in both PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once- or twice-daily aspirin (81 mg), in the absence of contraindications. Very low-risk ET might not require therapy while aspirin therapy is advised for low-risk disease. Cytoreductive therapy is recommended for high-risk ET and PV but it is not mandatory for intermediate-risk ET. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon-α and busulfan. We do not recommend treatment with ruxolutinib in PV, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital; Bergamo Italy
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Li Y, Zhang XY, Han J, Wang L. Analysis of clinical characteristics of bone marrow proliferative tumor progression to acute myeloid leukemia. Cancer Biomark 2018; 23:469-472. [PMID: 30452397 DOI: 10.3233/cbm-171145] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aims to analyze Chinese patients who developed acute leukemia after being diagnosed and treated for Philadelphia chromosome (Ph)-negative chronic myeloproliferative neoplasms (MPNs), and compare the findings of this series with similar studies from literature. METHODS Nine patients who progressed to leukemia after being diagnosed with MPN were included into the present study. Clinical data including age, treatment modalities and duration of use in the myeloproliferative phase, latency to leukemic transformation (LT), characteristics of leukemia, chemotherapy administration, and survival after LT were examined. Furthermore, factors associated with leukemia transformation were analyzed. RESULTS Over a 13-year period, nine patients had LT in 192 Ph-negative MPNs. Among these patients, two patients had polycythemia vera (PV), three patients had essential thrombocythemia (ET), and four patients had myelofibrosis (MF). The median age at MPN diagnosis was 51 years old (range: 42-69 years old), and the median age upon reaching LT was 57 years old (range: 46-72 years old). Furthermore, the median latency to LT was 72.8 months (range: 7-144 months). Five patients had cytogenetic abnormalities (62.5%), with abnormalities in chromosomes -5, +8 and -7 being common. Eight patients underwent the JAK2 V617F gene test when diagnosed with MPN. The prognosis of patients with LT was poor, and the average survival time was 6.7 months. This was not correlated with the treatment. CONCLUSION LT in Ph-negative MPNs is rare, and has poor prognosis, which has been consistently reported in a number of studies, However, this needs to be further confirmed through larger studies.
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MESH Headings
- Adult
- Aged
- Bone Marrow Cells/pathology
- Cell Proliferation/genetics
- China
- Chromosome Aberrations
- Disease Progression
- Female
- Humans
- Janus Kinase 2/genetics
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Myeloproliferative Disorders/diagnosis
- Myeloproliferative Disorders/epidemiology
- Myeloproliferative Disorders/pathology
- Primary Myelofibrosis/diagnosis
- Primary Myelofibrosis/epidemiology
- Primary Myelofibrosis/genetics
- Primary Myelofibrosis/pathology
- Prognosis
- Thrombocythemia, Essential/diagnosis
- Thrombocythemia, Essential/epidemiology
- Thrombocythemia, Essential/genetics
- Thrombocythemia, Essential/pathology
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35
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ERSOY E, SOYALTIN UE, PEKER A, ÇOLAK A, CEYLAN C, AKAR H. Ischemia-Modified Albumin Levels in Patients With Essential Thrombocytosis. KONURALP TIP DERGISI 2018. [DOI: 10.18521/ktd.376723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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36
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Masarova L, Verstovsek S. Therapeutic Approach to Young Patients With Low-Risk Essential Thrombocythemia: Primum Non Nocere. J Clin Oncol 2018; 36:JCO2018793497. [PMID: 30346901 DOI: 10.1200/jco.2018.79.3497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 51-year-old woman was diagnosed with essential thrombocythemia (ET) the previous year (April 2016) when she was incidentally found to have increased platelets (747 × 109/L) during a yearly physical examination. Her past medical history was significant only for mild hypertension, which was well controlled with a low dose of a β-blocker. There was no history of thromboembolic events. A JAK2V617F mutation was detected in her peripheral blood. A repeated platelet count 1 month later showed increased platelets of 871 × 109/L and she began hydroxyurea. One year later, she presented to our clinic with a white cell count of 8.9 × 109/L, hemoglobin 14 g/dL, and platelets 846 ×109/L while receiving hydroxyurea 500 mg one day alternating with 1000 mg the next day and aspirin 81 mg once per day. The differential as well as other laboratory findings were within normal limits. She had chronic mild to moderate itching, but otherwise denied symptoms referable to ET. Her physical examination was notable for the absence of palpable hepatosplenomegaly. Bone marrow aspiration and biopsy revealed normocellular marrow with hyperplastic megakaryocytes in clusters, no reticulin fibrosis, and 2% blasts, compatible with ET. Molecular testing confirmed JAK2V617F mutations at a variant allele frequency of 12% without any other mutations (81-gene panel), and her karyotype was diploid. She visited the clinic to discuss the next steps in her treatment.
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Affiliation(s)
- Lucia Masarova
- Lucia Masarova and Srdan Verstovsek, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Lucia Masarova and Srdan Verstovsek, The University of Texas MD Anderson Cancer Center, Houston, TX
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Azevedo AP, Silva SN, Reichert A, Lima F, Júnior E, Rueff J. Effects of polymorphic DNA genes involved in BER and caspase pathways on the clinical outcome of myeloproliferative neoplasms under treatment with hydroxyurea. Mol Med Rep 2018; 18:5243-5255. [PMID: 30320340 DOI: 10.3892/mmr.2018.9535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/01/2018] [Indexed: 11/06/2022] Open
Abstract
Several single nucleotide polymorphisms (SNPs) influencing DNA repair capacity and apoptotic status may confer genetic predisposition to Philadelphia‑chromosome negative myeloproliferative neoplasms (PN‑MPNs), and influence therapeutic response and the clinical course. In the present study, whether SNPs in genes involved in apoptosis and the base excision repair (BER) pathway was evaluated. In addition, some known risk factors in PN‑MPNs that may influence survival and therapeutic response to hydroxyurea (HU) were analyzed, taking into account three items: Disease progression, predisposition to new non‑myeloid neoplasms and thrombotic events. The present study involved a total of 133 Caucasian Portuguese PN‑MPNs patients treated with HU, whereby 17 cases showed progression to myelofibrosis/leukemia, 11 developed new non‑myeloid neoplasms and 22 presented with thrombotic events. Progression to secondary myelofibrosis/leukemia is influenced by exposure to cytoreductive agents, and caspase and BER polymorphisms {globally, CASP8 3'untranslated region [odds ratio (OR)=0.24; 95% confidence interval (CI), 0.08‑0.69], XRCC1 Arg194Trp [OR=3.58; 95% CI, 0.98‑13.01]; for essential thrombocythemia patients CASP9 Arg173His [OR=11.27; 95% CI, 1.13‑112.28], APEX1 Asp148Glu [OR=0.28; 95% CI, 0.74‑1.03], and XRCC1 Arg194Trp [OR=6.60; 95% CI, 1.60‑27.06]}. Moreover, globally caspase and BER polymorphisms influenced the development of new nonmyeloid malignancies [CASP8 Asp270His (OR=5.90; 95% CI, 1.42‑24.62) and XRCC1 Arg399Gln (OR=0.27; 95% CI, 0.07‑1.03)]. On the other hand, only the BER pathway had a role in the presence of thrombotic events [XRCC1 Gln399Arg (OR=0.35; 95% CI, 0.14‑0.88)]. JAK2 mutation had no influence on these complications. Larger studies are required to confirm these results, and to provide conclusive evidence of association between these and other variants with PN‑MPNs therapeutic response and clinical evolution. However, this study may allow the development of drugs more directly targeted to the pathophysiology of the disease, with high efficacy, fewer adverse effects, contributing to compliance of patients with treatments. The clinical indication for classical drugs, including HU, may be guided by variant genes, which may provide additional beneficial effects.
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Affiliation(s)
- Ana P Azevedo
- Centre for Toxicogenomics and Human Health (Toxomics), Genetics, Oncology and Human Toxicology, NOVA Medical School/Faculty of Medical Sciences, Universidade Nova de Lisboa, 1150‑082 Lisbon, Portugal
| | - Susana N Silva
- Centre for Toxicogenomics and Human Health (Toxomics), Genetics, Oncology and Human Toxicology, NOVA Medical School/Faculty of Medical Sciences, Universidade Nova de Lisboa, 1150‑082 Lisbon, Portugal
| | - Alice Reichert
- Department of Clinical Haematology, Hospital of São Francisco Xavier, West Lisbon Hospital Centre, 1449‑005 Lisbon, Portugal
| | - Fernando Lima
- Department of Clinical Haematology, Hospital of São Francisco Xavier, West Lisbon Hospital Centre, 1449‑005 Lisbon, Portugal
| | - Esmeraldina Júnior
- Department of Clinical Pathology, Hospital of São Francisco Xavier, West Lisbon Hospital Centre, 1449‑005 Lisbon, Portugal
| | - José Rueff
- Centre for Toxicogenomics and Human Health (Toxomics), Genetics, Oncology and Human Toxicology, NOVA Medical School/Faculty of Medical Sciences, Universidade Nova de Lisboa, 1150‑082 Lisbon, Portugal
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38
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Guy A, Gourdou-Latyszenok V, Le Lay N, Peghaire C, Kilani B, Dias JV, Duplaa C, Renault MA, Denis C, Villeval JL, Boulaftali Y, Jandrot-Perrus M, Couffinhal T, James C. Vascular endothelial cell expression of JAK2 V617F is sufficient to promote a pro-thrombotic state due to increased P-selectin expression. Haematologica 2018; 104:70-81. [PMID: 30171023 PMCID: PMC6312008 DOI: 10.3324/haematol.2018.195321] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/23/2018] [Indexed: 01/13/2023] Open
Abstract
Thrombosis is the main cause of morbidity and mortality in patients with JAK2V617F myeloproliferative neoplasms. Recent studies have reported the presence of JAK2V617F in endothelial cells of some patients with myeloproliferative neoplasms. We investigated the role of endothelial cells that express JAK2V617F in thrombus formation using an in vitro model of human endothelial cells overexpressing JAK2V617F and an in vivo model of mice with endothelial-specific JAK2V617F expression. Interestingly, these mice displayed a higher propensity for thrombus. When deciphering the mechanisms by which JAK2V617F-expressing endothelial cells promote thrombosis, we observed that they have a pro-adhesive phenotype associated with increased endothelial P-selectin exposure, secondary to degranulation of Weibel-Palade bodies. We demonstrated that P-selectin blockade was sufficient to reduce the increased propensity of thrombosis. Moreover, treatment with hydroxyurea also reduced thrombosis and decreased the pathological interaction between leukocytes and JAK2V617F-expressing endothelial cells through direct reduction of endothelial P-selectin expression. Taken together, our data provide evidence that JAK2V617F-expressing endothelial cells promote thrombosis through induction of endothelial P-selectin expression, which can be reversed by hydroxyurea. Our findings increase our understanding of thrombosis in patients with myeloproliferative neoplasms, at least those with JAK2V617F-positive endothelial cells, and highlight a new role for hydroxyurea. This novel finding provides the proof of concept that an acquired genetic mutation can affect the pro-thrombotic nature of endothelial cells, suggesting that other mutations in endothelial cells could be causal in thrombotic disorders of unknown cause, which account for 50% of recurrent venous thromboses.
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Affiliation(s)
- Alexandre Guy
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac
| | | | | | - Claire Peghaire
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac
| | - Badr Kilani
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac
| | | | - Cécile Duplaa
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac
| | - Marie-Ange Renault
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac
| | - Cécile Denis
- Inserm U1176, Hemostasis Inflammation Thrombosis, Le Kremlin-Bicêtre
| | | | | | | | - Thierry Couffinhal
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac.,CHU de Bordeaux, Service des Maladies Cardiaques et Vasculaires, Pessac
| | - Chloe James
- Univ. Bordeaux, Inserm, UMR1034, Biology of Cardiovascular Diseases, Pessac .,CHU de Bordeaux, Laboratoire d'Hématologie, Pessac, France
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39
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Ding W, Li D, Zhuang C, Wei P, Mou W, Zhang L, Liang H, Liu Y. Essential thrombocythemia during treatment of acute myeloid leukemia with JAK2 V617F mutation: A case report of a CARE-compliant article. Medicine (Baltimore) 2018; 97:e11331. [PMID: 29979407 PMCID: PMC6076173 DOI: 10.1097/md.0000000000011331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The JAK2 V617F mutation is frequently found in ET, while it is rare in de novo AML. ET has a low frequency of leukemic transformation. Both secondary AML (sAML) from ET and AML with JAK2 V617F mutation have poor prognoses. Because of the low incidence of JAK2 mutation in acute myeloid leukemia (AML), the clinical features of AML with JAK2 mutation are rarely reported so far, either transformed from essential thrombocythemia (ET) or de novo AML. PATIENT CONCERNS In this article, we present a pediatric AML patient with the JAK2 V617F mutation. DIAGNOSES A diagnosis of acute megakaryoblastic leukemia was made and sAML was ruled out. INTERVENTIONS The patient underwent chemotherapy. OUTCOMES In the first two complete remission periods, we found significantly increased numbers of platelets and bone marrow megakaryocytes, which are characteristic of ET. After the third chemotherapy phase, the disease relapsed; the platelet count was reduced and continued to decrease. When disease relapsed, her family abandoned treatment. LESSONS These observations of our case raise two possibilities: either transient posttreatment thrombocythemia is a feature of AML with JAK2 V617F mutation, or this was a case of secondary AML. Additional information is required to reach better conclusions on the connection between AML and JAK2 mutations.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Diagnosis, Differential
- Fatal Outcome
- Female
- Humans
- Infant
- Janus Kinase 2/genetics
- Leukemia, Megakaryoblastic, Acute/diagnosis
- Leukemia, Megakaryoblastic, Acute/drug therapy
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Mutation
- Platelet Count
- Thrombocythemia, Essential/diagnosis
- Thrombocythemia, Essential/drug therapy
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Affiliation(s)
| | | | | | | | - Wenfeng Mou
- Department of Laboratory, Qingdao Women and Children's Hospital
| | | | | | - Yong Liu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
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40
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Lancman G, Brunner A, Hoffman R, Mascarenhas J, Hobbs G. Outcomes and predictors of survival in blast phase myeloproliferative neoplasms. Leuk Res 2018; 70:49-55. [PMID: 29807273 DOI: 10.1016/j.leukres.2018.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/13/2018] [Accepted: 05/15/2018] [Indexed: 01/08/2023]
Abstract
We retrospectively reviewed treatment outcomes for 57 patients with myeloproliferative neoplasms in blast phase (MPN-BP). The median overall survival (OS) of the entire cohort was 5.8 months. For patients receiving induction therapy, 67% achieved a complete response (CR) and 75% received stem cell transplantation (SCT). Median OS for all transplanted patients (n = 19) was not reached after a median follow-up of 19.2 months compared with 3.8 months in non-transplanted patients (p < 0.0001); patients who did not receive SCT after induction chemotherapy survived a median of 4.9 months. OS was not improved in patients transplanted after CR (OS not reached after median follow-up of 26.7 months) compared with those transplanted upfront or after suboptimal response to initial therapy (9.0 months; p = .097). Those who were transfusion-dependent during their MPN course and received SCT had a median OS of 4.4 months, with all patients dying from SCT complications. Patients receiving hypomethylating agents (HMA) survived 6.7 months, while those receiving supportive care survived 1.1 months. Although outcomes for MPN-BP remain poor, long-term survival can be achieved in appropriately selected patients utilizing SCT, optimally after attaining a complete response with induction therapy. For patients ineligible for SCT, HMAs can offer similar survival to induction chemotherapy with less toxicity.
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Affiliation(s)
- Guido Lancman
- The Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Andrew Brunner
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronald Hoffman
- The Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Mascarenhas
- The Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Gabriela Hobbs
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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41
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Zhou A, Afzal A, Oh ST. Prognostication in Philadelphia Chromosome Negative Myeloproliferative Neoplasms: a Review of the Recent Literature. Curr Hematol Malig Rep 2018; 12:397-405. [PMID: 28948488 DOI: 10.1007/s11899-017-0401-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW The prognosis for patients with Philadelphia chromosome (Ph)-negative myeloproliferative neoplasms (MPNs) is highly variable. All Ph-negative MPNs carry an increased risk for thrombotic complications, bleeding, and leukemic transformation. Several clinical, biological, and molecular prognostic factors have been identified in recent years, which provide important information in guiding management of patients with Ph-negative MPNs. In this review, we critically evaluate the recent published literature and discuss important new developments in clinical and molecular factors that impact survival, disease transformation, and thrombosis in patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis. RECENT FINDINGS Recent studies have identified several clinical factors and non-driver mutations to have prognostic impact on Ph-negative MPNs independent of conventional risk stratification and prognostic models. In polycythemia vera (PV), leukocytosis, abnormal karyotype, phlebotomy requirement on hydroxyurea, increased bone marrow fibrosis, and mutations in ASXL1, SRSF2, and IDH2 were identified as additional adverse prognostic factors. In essential thrombocythemia (ET), JAK2 V617F mutation, splenomegaly, and mutations in SH2B3, SF3B1, U2AF1, TP53, IDH2, and EZH2 were found to be additional negative prognostic factors. Bone marrow fibrosis and mutations in ASXL1, SRSF2, EZH2, and IDH1/2 have been found to be additional prognostic factors in primary myelofibrosis (PMF). CALR mutations appear to be a favorable prognostic factor in PMF, which has not been clearly demonstrated in ET. The prognosis for patients with PV, ET, and PMF is dependent upon the presence or absence of several clinical, biological, and molecular risk factors. The significance of additional risk factors identified in these recent studies will need further validation in prospective studies to determine how they may be best utilized in the management of these disorders.
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Affiliation(s)
- Amy Zhou
- Division of Hematology, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus Box 8125, St. Louis, MO, 63110, USA
| | - Amber Afzal
- Division of Hematology, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus Box 8125, St. Louis, MO, 63110, USA
| | - Stephen T Oh
- Division of Hematology, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus Box 8125, St. Louis, MO, 63110, USA.
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42
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Tefferi A, Mudireddy M, Mannelli F, Begna KH, Patnaik MM, Hanson CA, Ketterling RP, Gangat N, Yogarajah M, De Stefano V, Passamonti F, Rosti V, Finazzi MC, Rambaldi A, Bosi A, Guglielmelli P, Pardanani A, Vannucchi AM. Blast phase myeloproliferative neoplasm: Mayo-AGIMM study of 410 patients from two separate cohorts. Leukemia 2018; 32:1200-1210. [PMID: 29459662 PMCID: PMC5940634 DOI: 10.1038/s41375-018-0019-y] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/05/2017] [Accepted: 12/21/2017] [Indexed: 12/29/2022]
Abstract
A total of 410 patients with blast phase myeloproliferative neoplasm (MPN-BP) were retrospectively reviewed: 248 from the Mayo Clinic and 162 from Italy. Median survival was 3.6 months, with no improvement over the last 15 years. Multivariable analysis performed on the Mayo cohort identified high risk karyotype, platelet count < 100 × 109/L, age > 65 years and transfusion need as independent risk factors for survival. Also in the Mayo cohort, intensive chemotherapy resulted in complete remission (CR) or CR with incomplete count recovery (CRi) rates of 35 and 24%, respectively; treatment-specified 3-year/5-year survival rates were 32/10% for patients receiving allogeneic stem cell transplant (AlloSCT) (n = 24), 19/13% for patients achieving CR/CRi but were not transplanted (n = 24), and 1/1% in the absence of both AlloSCT and CR/CRi (n = 200) (p < 0.01). The survival impact of AlloSCT (HR 0.2, 95% CI 0.1–0.3), CR/CRi without AlloSCT (HR 0.3, 95% CI 0.2–0.5), high risk karyotype (HR 1.6, 95% CI 1.1–2.2) and platelet count < 100 × 109/L (HR 1.6, 95% CI 1.1–2.2) were confirmed to be inter-independent. Similar observations were made in the Italian cohort. The current study identifies the setting for improved short-term survival in MPN-BP, but also highlights the limited value of current therapy, including AlloSCT, in securing long-term survival.
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Affiliation(s)
| | | | - Francesco Mannelli
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
| | | | | | | | | | | | - Meera Yogarajah
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Valerio De Stefano
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,Institute of Hematology, Catholic University, Roma, Italy
| | - Francesco Passamonti
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,Department of Medicine and Surgery, University of Insubria, ASST Settelaghi, Ospedale di Circolo, Varese, Italy
| | - Vittorio Rosti
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,Center for the Study of Myelofibrosis, Laboratory of Biochemistry, Biotechnology and Advanced Diagnosis, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Chiara Finazzi
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,Department of Oncology and Hemato-oncology University of Milan and Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandro Rambaldi
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,Department of Oncology and Hemato-oncology University of Milan and Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Alberto Bosi
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
| | - Paola Guglielmelli
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
| | | | - Alessandro M Vannucchi
- AGIMM (AIRC-Gruppo Italiano Malattie Mieloproliferative: Rome, Varese, Pavia, Bergamo, Florence, Italy.,CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
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43
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Mangaonkar AA, Hoversten KP, Gangat N. Prognostic risk model for patients with high-risk polycythemia vera and essential thrombocythemia. Expert Rev Hematol 2018; 11:247-252. [PMID: 29313725 DOI: 10.1080/17474086.2018.1426455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Polycythemia Vera (PV) and Essential Thrombocythemia (ET) are the most frequent Philadelphia chromosome-negative myeloproliferative neoplasms, the other entity being myelofibrosis. Management of patients with PV and ET is fraught with difficulties as they have an inherent tendency to cause thrombotic and hemorrhagic events. There are no curative treatment options, therefore it is important that a risk-adapted treatment approach is applied. Areas covered: This review discusses existing literature about prognosis in PV and ET, and addresses critical aspects related to defining 'high-risk' disease. In addition to the traditional risk factors such as age and prior thrombotic history, we discuss the prognostic impact of additional parameters such as cardiovascular risk factors, white blood cell count, karyotype and gene mutations. Expert commentary: We use age>60 years, presence of JAK2 mutation and a prior thrombotic history as the principle determinants of 'high-risk' for thrombosis in PV and ET, dividing the patients into very-low, low, intermediate and high-risk disease. Typically, low-risk patients are treated either with observation or aspirin alone. High-risk patients require cytoreductive therapies, along with aspirin and/or systemic anticoagulation. Intermediate-risk patients are treated on a case-by-case basis. Further, we aim to maintain a hematocrit <45% with aggressive phlebotomy in patients with PV.
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Affiliation(s)
| | | | - Naseema Gangat
- a Department of Hematology , Mayo Clinic , Rochester , MN , USA
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44
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Patient characteristics and outcomes in adolescents and young adults with classical Philadelphia chromosome-negative myeloproliferative neoplasms. Ann Hematol 2017; 97:109-121. [DOI: 10.1007/s00277-017-3165-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/30/2017] [Indexed: 02/01/2023]
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45
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Tefferi A, Betti S, Barraco D, Mudireddy M, Shah S, Hanson CA, Ketterling RP, Pardanani A, Gangat N, Coltro G, Guglielmelli P, Vannucchi AM. Gender and survival in essential thrombocythemia: A two-center study of 1,494 patients. Am J Hematol 2017; 92:1193-1197. [PMID: 28795425 DOI: 10.1002/ajh.24882] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 12/30/2022]
Abstract
Based on suggestive information from recent epidemiologic data and earlier retrospective studies, we revisited the effect of gender on survival in 1,494 patients with essential thrombocythemia (ET). The primary study population included 904 patients from the Mayo Clinic (median age 58 years; 65% females); risk distribution, according to the international prognostic score for ET (IPSET), was 23% high, 42% intermediate and 35% low. Multivariable analysis that included IPSET-relevant risk factors identified male sex (HR 1.6, 95% CI 1.3-2.0), age ≥60 years (HR 4.3, 95% CI 3.4-5.4) and leukocyte count ≥11 × 10(9)/L (HR 1.5, 95% CI 1.3-1.9) as independent predictors of shortened survival. These findings were confirmed by analysis of a separate cohort of 590 ET patients (65% females) from the University of Florence, Italy, with corresponding HRs (95% CI) of 1.6 (1.1-2.5), 4.6 (2.2-9.5) and 1.8 (1.1-2.8). The independent prognostic effect of gender was further corroborated by a separate multivariable analysis against IPSET risk categories; HR (95% CI) for the Mayo Clinic/Florence cohorts were 1.5/1.6 (1.2/1.1-1.8/2.5) for male sex, 6.8/7.5 (5.0/3.1-9.3/18.3) for IPSET high risk and 2.8/4.1 (2.1/1.8-3.8/9.5) for IPSET intermediate risk. Furthermore, the survival disadvantage in men was most apparent in IPSET high risk category and in patients older than 60 years. In both patient cohorts, thrombosis history garnered significance in univariate, but not in multivariable analysis. The observations from the current study suggest that women with ET live longer than their male counterparts and that gender might supersede thrombosis history as a risk variable for overall survival.
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Affiliation(s)
- Ayalew Tefferi
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Silvia Betti
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | - Sahrish Shah
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - Rhett P. Ketterling
- Cytogenetics, Departments of Medicine and Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Naseema Gangat
- Divisions of Hematology; Mayo Clinic; Rochester Minnesota
| | - Giacomo Coltro
- Department of Experimental and Clinical Medicine; CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence; Florence Italy
| | - 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
| | - 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
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46
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Khan M, Siddiqi R, Gangat N. Therapeutic options for leukemic transformation in patients with myeloproliferative neoplasms. Leuk Res 2017; 63:78-84. [PMID: 29121538 DOI: 10.1016/j.leukres.2017.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/12/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
Approximately 5-10% of patients with Philadelphia chromosome negative myeloproliferative neoplasms (MPN) comprising of essential thrombocythemia, polycythemia vera and primary myelofibrosis) experience transformation to acute myeloid leukemia (AML, ≥20% blasts). Treatment options for post-MPN AML patients are limited, as conventional approaches like standard chemotherapy, fail to offer long-term benefit. Median survival for secondary AML is ∼2.4 months. Post-MPN AML therefore represents an area of urgent clinical need. At present, allogeneic stem cell transplant (ASCT) following induction therapy is the best therapeutic option. Patients ineligible for ASCT are treated with hypomethylating agents. New agents under investigation include histone deacetylase inhibitors, JAKinhibitors and agents targeting the BRD4 protein. Combined treatment strategies involving these novel agents are being tested. In this review we present the current evidence regarding treatment options for post-MPN AML patients.
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Affiliation(s)
- Maliha Khan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rabbia Siddiqi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, MN, United States.
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47
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Tefferi A, Vannucchi AM. Genetic Risk Assessment in Myeloproliferative Neoplasms. Mayo Clin Proc 2017; 92:1283-1290. [PMID: 28778261 DOI: 10.1016/j.mayocp.2017.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
Abstract
The World Health Organization classification system recognizes 4 variants of JAK2 mutation-enriched myeloproliferative neoplasms (for expansion of gene symbols, use search tool at www.genenames.org): essential thrombocythemia (ET), polycythemia vera (PV), primary myelofibrosis (PMF), and prefibrotic PMF. All 4 disorders are characterized by stem cell-derived clonal myeloproliferation with mutually exclusive driver mutations, including JAK2, CALR, and MPL. The median survival is approximately 20 years for ET, 14 years for PV, and 6 years for PMF; age is the most important determinant of survival with the corresponding median of 33, 24, and 15 years in patients younger than 60 years. Genetic information is the second most important prognostic tool and includes karyotype, driver mutational status, and presence of specific other mutations. Karyotype has been shown to carry prognostic relevance in PV (abnormal vs normal) and PMF (unfavorable vs favorable abnormalities). Driver mutational status is prognostically most relevant in PMF; type 1/type 1-like CALR vs other driver mutational status has been associated with superior survival. In ET, arterial thrombosis risk is higher in patients with JAK2 or MPL mutations whereas MPL-mutated patients might be at risk for accelerated fibrotic progression. ASXL1 and SRSF2 mutations have been associated with inferior overall, leukemia-free, or fibrosis-free survival in both PV and PMF, and a recent targeted sequencing study has identified additional other adverse mutations in both these disorders, as well as in ET. Further enhancement of genetic risk stratification in myeloproliferative neoplasms is possible by combining cytogenetic and mutation information and developing a prognostic model that is adjusted for age.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
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48
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Yogarajah M, Tefferi A. Leukemic Transformation in Myeloproliferative Neoplasms: A Literature Review on Risk, Characteristics, and Outcome. Mayo Clin Proc 2017; 92:1118-1128. [PMID: 28688466 DOI: 10.1016/j.mayocp.2017.05.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/08/2017] [Accepted: 05/17/2017] [Indexed: 01/01/2023]
Abstract
Myeloproliferative neoplasms (MPNs) operationally include essential thrombocythemia, polycythemia vera, primary myelofibrosis (PMF), and prefibrotic PMF. All 4 MPN variants might progress into blast-phase disease (MPN-BP). For essential thrombocythemia, reported risk factors for leukemic transformation include advanced age, extreme thrombocytosis, anemia, leukocytosis, and sequence variants/mutations involving TP53 and EZH2 (for expansion of gene symbols, see www.genenames.org); for polycythemia vera, advanced age, leukocytosis, abnormal karyotype, mutations involving SRSF2 and IDH2, and treatment with pipobroman, chlorambucil, or P32; and for PMF, increased blast percentage, thrombocytopenia, abnormal karyotype, triple-negative driver mutational status, and sequence variants/mutations involving SRSF2, RUNX1, CEBPA, and SH2B3. The reported median survival figures for MPN-BP range from 1.5 to 2.5 months in patients treated with supportive care only, from 2.5 to 10 months in those receiving hypomethylating agents or low-dose chemotherapy, and from 3.9 to 9.4 months in those receiving induction chemotherapy. Three-year survival after allogeneic stem cell transplant was reported in 16% to 33% of patients. These observations validate the extremely poor prognosis associated with MPN-BP and the lack of effective drug therapy and highlight the need for urgent assessment of therapeutic values of investigational agents. In the meantime, affected patients might be best served with aggressive chemotherapy followed by allogeneic stem cell transplant after adequate blast clearance.
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Affiliation(s)
- Meera Yogarajah
- Division of Hematology and Oncology, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
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49
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Acute megakaryoblastic transformation from essential thrombocythemia. HUMAN PATHOLOGY: CASE REPORTS 2017. [DOI: 10.1016/j.ehpc.2016.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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50
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Alvarez-Larrán A, Senín A, Fernández-Rodríguez C, Pereira A, Arellano-Rodrigo E, Gómez M, Ferrer-Marin F, Martínez-López J, Camacho L, Colomer D, Angona A, Navarro B, Cervantes F, Besses C, Bellosillo B, Hernández-Boluda JC. Impact of genotype on leukaemic transformation in polycythaemia vera and essential thrombocythaemia. Br J Haematol 2017; 178:764-771. [DOI: 10.1111/bjh.14762] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/29/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Alberto Alvarez-Larrán
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Alicia Senín
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | | | - Arturo Pereira
- Haemotherapy and Haemostasis Department; Hospital Clínic-IDIBAPS; Barcelona Spain
| | | | - Montse Gómez
- Haematology Department; Hospital Clínico-INCLIVA; Valencia Spain
| | - Francisca Ferrer-Marin
- Haematology and Medical Oncology; Hospital Morales-Messeguer; CIBERER; UCAM; Murcia Spain
| | | | - Laura Camacho
- Pathology Department-IMIM; Hospital del Mar; Universidad Pompeu Fabra; Barcelona Spain
| | - Dolors Colomer
- Haematopathology Unit; Hospital Clínic-IDIBAPS; Barcelona Spain
| | - Anna Angona
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Blanca Navarro
- Haematology Department; Hospital Clínico-INCLIVA; Valencia Spain
| | | | - Carlos Besses
- Haematology Department; Hospital del Mar-IMIM; Universidad Autónoma de Barcelona; Barcelona Spain
| | - Beatriz Bellosillo
- Pathology Department-IMIM; Hospital del Mar; Universidad Pompeu Fabra; Barcelona Spain
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