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Stalder G, Grandoni F, Alberio L. Bleeding heralding the diagnosis of essential thrombocythemia. Eur J Intern Med 2024; 123:165-166. [PMID: 38461063 DOI: 10.1016/j.ejim.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Grégoire Stalder
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland; Service of Hematology, Institut Central des Hôpitaux, Hôpital du Valais, Av. du Grand-Champsec 86, CH-1951 Sion, Switzerland
| | - Francesco Grandoni
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
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2
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Kogan L, Price R, Kotchetkov R. Case report: Peri-procedural hydroxyurea helps minimize bleeding in patients with Essential Thrombocythemia associated with acquired von Willebrand syndrome. Front Oncol 2024; 14:1326209. [PMID: 38361779 PMCID: PMC10867169 DOI: 10.3389/fonc.2024.1326209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background Essential Thrombocythemia is a chronic myeloproliferative neoplasm characterized by an isolated excessive production of platelets. Extreme thrombocytosis is defined by having a platelet count greater than or equal to 1,000 x 109/L, which may lead to the development of acquired von Willebrand syndrome and complications of excessive hemorrhage. Case description A 74-year-old female patient was brought in for a bone marrow examination regarding elevated platelet count. She had no history of excessive bleeding. The physical exam was unremarkable with no petechiae or hematomas. Complete blood count showed platelet count 1,491x109/L. Bone marrow aspiration and biopsy were unremarkable, however, the patient developed bleeding from the biopsy site. Local pressure and an ice pack were ineffective, so she received 20 mcg of desmopressin subcutaneously, 1 unit of fresh frozen plasma and was started on tranexamic acid 1,000 mg orally every 8 hours. She was admitted for bleeding control and had another dose of desmopressin. Blood work showed elevated partial thromboplastin time and normal international normalized ratio. Acquired von Willebrand syndrome was suspected and a sample for von Willebrand disease was sent out. The next day her bleeding continued, and her Hb decreased from 145 to 89 g/L, she became symptomatic (tachycardic) and fatigued. The coagulation profile was consistent with acquired von Willebrand syndrome. Since she continued bleeding, she received 1 unit of packed red blood cells. A high dose of hydroxyurea (3g/day) was started urgently; within 24 hours platelet count was halved, and the bleeding resolved. Blood work was repeated 24 hours later and showed normalization of partial thromboplastin time and a normal Von Willebrand profile. Conclusion Patients with extreme thrombocytosis are at high risk of bleeding due to acquired Von Willebrand Syndrome. Initiation of hydroxyurea at the time of bone marrow exam helps to control platelet count and minimizes the risk of peri-procedural hemorrhage in high-risk Essential Thrombocythemia patients with suspected acquired Von Willebrand Syndrome.
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Affiliation(s)
- Leah Kogan
- Department of Medicine, University of Limerick, Limerick, Ireland
| | - Russell Price
- Department of Pathology, Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - Rouslan Kotchetkov
- Simcoe Muskoka Regional Cancer Program, Royal Victoria Regional Health Centre, Barrie, ON, Canada
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Tosoni L, Liberi M, Morelli G, Zannier ME, Lazzarotto D, Filì C, Simeone E, Battaglia G, Callegari C, Fanin M, Damiani D, Fanin R, Tiribelli M. Correlation between IPSET-t risk at diagnosis and subsequent hemorrhage in patients with essential thrombocythemia; a single institution experience. Ann Hematol 2024; 103:443-448. [PMID: 38072850 DOI: 10.1007/s00277-023-05578-8] [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] [Received: 11/12/2023] [Accepted: 11/30/2023] [Indexed: 12/28/2023]
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by an increased risk of thrombotic and hemorrhagic events, that represent the leading causes of mortality and morbidity. Currently, while thrombotic risk is assessed through the IPSET-t and r-IPSET scores, there is no specific prognostic tool used to predict hemorrhagic risk in ET. The aim of the study was to define incidence and risk factors connected to hemorrhagic events by retrospectively analyzing 308 ET patients diagnosed between 1996 and 2022 at the Division of Hematology of Udine and treated according to the current international guidelines. According to molecular status, 193 patients (62.7%) were JAK2 mutated, 66 (21.4%) had a CALR mutation, 14 (4.5%) had a MPL mutation, 21 patients (6.8%) were "triple negative," and 14 patients (4.5%) were not evaluable. According to IPSET-t score, 49.7% patients were at high, 24.3% at intermediate, and 26.0% at low-risk, respectively. Twelve (3.9%) patients experienced bleeding at ET diagnosis, while 24 (7.8%) had at least one hemorrhagic event during follow-up at a median time of 103 months (range: 1-309). Forty hemorrhagic events were totally recorded and defined as minor in 22 cases, moderate in 11 cases, and severe in 7 cases. Cumulative incidence (CI) of hemorrhage at 10 and 20 years was 6.0% and 12.0%, respectively. A statistically significant correlation between hemorrhagic risk and IPSET-t score emerged: 10 years hemorrhage CI was 3.2% for low-risk, 2.9% for intermediate-risk, and 9.8% for high-risk patients, respectively (p=0.002). We found no correlation between hemorrhagic risk and gender or mutational status. Results of our study highlight the validity of IPSET-t score in predicting individual hemorrhagic risk among ET patients, suggesting a possible role of IPSET-t scoring system as a global evaluator for vascular events in ET patients.
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Affiliation(s)
- Luca Tosoni
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Matteo Liberi
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Gianluca Morelli
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Maria Elena Zannier
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Davide Lazzarotto
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Carla Filì
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Erica Simeone
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Giulia Battaglia
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Chiara Callegari
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Matteo Fanin
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
| | - Daniela Damiani
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplant, Azienda Sanitaria Universitaria Friuli Centrale, P.le S. M. Misericordia 15, 33100, Udine, Italy.
- Department of Medicine, University of Udine, Udine, Italy.
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Furuya C, Morishita S, Hashimoto Y, Inano T, Ochiai T, Shirane S, Edahiro Y, Araki M, Ando M, Komatsu N. Impact of non-driver gene mutations on thrombo-haemorrhagic events in ET patients. Br J Haematol 2024; 204:221-228. [PMID: 37920129 DOI: 10.1111/bjh.19177] [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: 08/21/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Risk-adapted therapy is recommended to prevent major clinical complications, such as thrombo-haemorrhagic events, in patients with essential thrombocythaemia (ET). In this study, we analysed the association between non-driver gene mutations and thrombo-haemorrhagic events in 579 patients with ET. ASXL1 and TP53 mutations were frequently identified in patients with ET complicated by thrombosis (22.7% and 23.1%, respectively), and the DNMT3A mutation was frequently identified in patients who experienced haemorrhage (15.2%). Multivariate analyses of thrombosis-free survival (TFS) revealed that ASXL1 and TP53 mutations are associated with thrombosis (hazard ratio [HR] = 3.140 and 3.752 respectively). Patients harbouring the ASXL1 or TP53 mutation had significantly worse TFS rates than those without mutation (p = 0.002 and p < 0.001 respectively). Furthermore, JAK2V617F-mutated patients with accompanying ASXL1 mutations showed significantly shorter TFS compared with those without ASXL1 mutations (p = 0.003). Multivariate analyses of haemorrhage-free survival (HFS) revealed that the DNMT3A mutation (HR = 2.784) is associated with haemorrhage. DNMT3A-mutated patients showed significantly shorter HFS than those without the mutation (p = 0.026). Non-driver gene mutations should be considered in treatment strategies and may provide important information for personalised treatment approaches.
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Affiliation(s)
- Chiho Furuya
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Soji Morishita
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoshinori Hashimoto
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Hematology, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Tadaaki Inano
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomonori Ochiai
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shuichi Shirane
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoko Edahiro
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marito Araki
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Miki Ando
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Advanced Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Laboratory for the Development of Therapies Against MPN, Juntendo University Graduate School of Medicine, Tokyo, Japan
- PharmaEssentia Japan KK, Tokyo, Japan
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Stuckey R, Ianotto JC, Santoro M, Czyż A, Encinas MMP, Gómez-Casares MT, Pereira MSN, de Nałęcz AK, Gołos A, Lewandowski K, Szukalski Ł, González-Martín JM, Sobas MA. Prediction of major bleeding events in 1381 patients with essential thrombocythemia. Int J Hematol 2023; 118:589-595. [PMID: 37660316 PMCID: PMC10615906 DOI: 10.1007/s12185-023-03650-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023]
Abstract
The goal of therapy in essential thrombocythemia (ET) is reducing thrombotic risk. No algorithm to predict hemorrhage risk exists. The impact ofanti-platelet, cytoreductive and anticoagulation therapies on risk of major bleeding (MB) was evaluated. MB events were retrospectively analyzed in 1381 ET from 10 European centers. There were 0.286 MB events/person-year. Neither the International Thrombosis Prognostic Score for thrombosis in essential thrombocythemia (IPSET-t) nor the revised IPSET-t (r-IPSET-t) was predictive for hemorrhage-free survival at 10 years (p = 0.092 vs p = 0.1). Ageand leukocyte count were MB risk factors, while low hemoglobin was protective. For ET with extreme thrombocytosis (ExtT) and leukocytosis cytoreduction was not protective. MB were more frequent in ET with ExtT who received anticoagulation. Antiplatelet therapy was not, while anticoagulation was a risk factor for MB (HR 3.05, p = 0.016, CI 1.23-7.56), in particular vitamin K antagonists (22.6% of those treated had a MB event, HR 2.96, p = 0.004, CI 1.41-6.22). Survival at 10 years was associated with hemorrhage (OR 2.54, p < 0.001) but not thrombosis (HR 0.95, p = 0.829). Hemorrhage has a higher risk of mortality than thrombosis. Improved risk stratification for MB is necessary. The choice of anticoagulation, cytoreduction and antiplatelet therapies is an important area of research in ET.
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Affiliation(s)
- Ruth Stuckey
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Jean-Christophe Ianotto
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, Centre Hospitalier Universitaire de Brest, Brest, France
| | - Marco Santoro
- Hematology Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Anna Czyż
- Department of Hematology and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland
| | - Manuel M Perez Encinas
- Hematology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | | | | | - Krzysztof Lewandowski
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Łukasz Szukalski
- Department of Haematology CM UMK in Bydgoszcz, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | | | - Marta Anna Sobas
- Department of Hematology and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland.
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Herbreteau L, Couturaud F, Hoffmann C, Bressollette L, Pan-Petesch B, Rio L, Lippert E, Ianotto JC. Atrial fibrillation and peripheral arterial disease define MPN patients with very high risk of thrombosis. Thromb Res 2023; 226:93-99. [PMID: 37141796 DOI: 10.1016/j.thromres.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 03/20/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
Myeloproliferative neoplasms (MPNs) are associated with a high risk of thrombotic and hemorrhagic complications, especially in elderly patients. Atrial fibrillation (AF) and peripheral arterial disease (PAD), also frequently discovered in aging patients, are associated with similar complications. We analysed the incidence and complication rates of AF and PAD in a large cohort of MPN patients. In total, 289/1113 patients (26 %) suffered at least one of these diseases as follows: 179 (16.1 %) with AF alone, 81 with PAD alone (7.3 %) and 29 (2.6 %) with both conditions. Postdiagnosis thrombotic events were observed in 31.3 % of AF patients (p = 0.002, OR = 1.80 [1.23;2.61]), 35.8 % of PAD patients (p = 0.002, OR = 2.21[1.31;3.67]) and 62.1 % of AF/PAD patients (p < 0.0001, OR = 6.47 [2.83;15.46]) compared to 20.1 % of no-AF/no-PAD patients. Postdiagnosis hemorrhagic events were also identified in 17.9 %, 16 %, 24.1 % and 10.1 % of AF, PAD, AF/PAD, and no-AF/no-PAD patients, respectively (p = 0.003). This significantly higher risk of thrombosis/bleeding was also observed in patients <60 years old. AF and PAD were significant risk factors for both thrombotic and hemorrhagic risks in multivariate analysis. We identified AF and PAD as criteria for high risk of thrombosis, hemorrhage, and death, emphasizing the interest in early detection and efficient treatment of these conditions.
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Affiliation(s)
- Laura Herbreteau
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHU de Brest, Brest, France
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, CHU de Brest, Brest, France; INSERM, Univ Brest, CHU de Brest, UMR 1304, GETBO, Brest, France
| | - Clément Hoffmann
- Service de Médecine vasculaire, CHU de Brest, Brest, France; INSERM, Univ Brest, CHU de Brest, UMR 1304, GETBO, Brest, France
| | - Luc Bressollette
- Service de Médecine vasculaire, CHU de Brest, Brest, France; INSERM, Univ Brest, CHU de Brest, UMR 1304, GETBO, Brest, France
| | - Brigitte Pan-Petesch
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHU de Brest, Brest, France; INSERM, Univ Brest, CHU de Brest, UMR 1304, GETBO, Brest, France
| | - Laetitia Rio
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHU de Brest, Brest, France
| | - Eric Lippert
- Laboratoire d'Hématologie, CHU de Brest, Brest, France; France Intergroupe des syndromes Myéloprolifératifs (FIM), Paris, France
| | - Jean-Christophe Ianotto
- Service d'Hématologie et d'Hémostase Clinique, Institut de Cancéro-Hématologie, CHU de Brest, Brest, France; INSERM, Univ Brest, CHU de Brest, UMR 1304, GETBO, Brest, France; France Intergroupe des syndromes Myéloprolifératifs (FIM), Paris, France.
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Jones E, Dillon B, Swan D, Thachil J. Practical management of the haemorrhagic complications of myeloproliferative neoplasms. Br J Haematol 2022; 199:313-321. [PMID: 35724983 PMCID: PMC9796684 DOI: 10.1111/bjh.18322] [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: 04/27/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 01/07/2023]
Abstract
Myeloproliferative neoplasms can be associated with bleeding manifestations which can cause significant morbidities. Although haematologists are aware of the likelihood of this complication in the setting of myeloproliferative neoplasms, it may often be overlooked especially in patients with no extreme elevation of blood counts and those with myelofibrosis. Acquired von Willebrand syndrome and platelet dysfunction are the two common diagnoses to be considered in this regard. In this review article, we discuss the mechanisms for the development of these rare bleeding disorders, their diagnosis and practical management.
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Affiliation(s)
- Edward Jones
- Department of HaematologySt James' HospitalDublinIreland
| | - Bryan Dillon
- Department of HaematologySt James' HospitalDublinIreland
| | - Dawn Swan
- National University IrelandGalwayIreland
| | - Jecko Thachil
- Department of HaematologyManchester University Hospitals NHS Foundation TrustManchesterUK
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Gualtierotti R, De Magistris C, Biguzzi E, Acquati Lozej J, Iurlo A, Solimeno LP, Peyvandi F. Successful Chemical Synovectomy in a Patient with Acquired von Willebrand Syndrome with Chronic Synovitis Due to Recurrent Knee Hemarthrosis: A Case Report. Rheumatol Ther 2022; 9:1465-1474. [PMID: 35947268 PMCID: PMC9510071 DOI: 10.1007/s40744-022-00477-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/30/2022] [Indexed: 10/25/2022] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare, non-hereditary bleeding disorder related to heterogeneous medical conditions such as hematological malignancies and cardiovascular and autoimmune diseases. We describe the clinical course of a 62-year-old man with polycythemia vera who experienced post-traumatic knee and leg swelling due to hemarthrosis. He was treated at another center with low molecular weight heparin due to misdiagnosed deep vein thrombosis further exacerbating the ongoing bleeding. At our center, he was diagnosed with AVWS with reduced von Willebrand factor (VWF):GPIbR plasma activity and loss of high molecular weight multimers (HMWM). He was treated with compressive bandages with resolution. Five months later, on clinical recurrence of knee and leg swelling, knee ultrasound scan showed the presence of chronic synovitis and a hemorrhagic Baker's cyst with signs of rupture. The treatment consisted of chemical synovectomy with rifampicin and steroids preceded by systemic replacement therapy using plasma-derived factor VIII-VWF concentrate. At the end of the treatment cycle, our patient reported complete resolution of knee pain and restoration of joint range of motion and function. Ultrasound evaluation confirmed complete resolution of knee capsule distension and Baker's cyst. Hemarthrosis is an anecdotal presentation of AVWS and chemical synovectomy was successful in treating this complication. A multidisciplinary approach allowed an effective management of this rare complication.
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Affiliation(s)
- Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, University of Milan, Via Pace, 9, 20122, Milan, Italy.
- Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Internal Medicine-Hemostasis and Thrombosis, Milan, Italy.
| | - Claudio De Magistris
- Department of Pathophysiology and Transplantation, University of Milan, Via Pace, 9, 20122, Milan, Italy
- Fondazione IRCCS Ca' GrandaOspedale Maggiore PoliclinicoHematology Division, Milan, Italy
| | - Eugenia Biguzzi
- Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Internal Medicine-Hemostasis and Thrombosis, Milan, Italy
| | - Jacopo Acquati Lozej
- Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Internal Medicine-Hemostasis and Thrombosis, Milan, Italy
| | - Alessandra Iurlo
- Fondazione IRCCS Ca' GrandaOspedale Maggiore PoliclinicoHematology Division, Milan, Italy
| | - Luigi Piero Solimeno
- Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Internal Medicine-Hemostasis and Thrombosis, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, University of Milan, Via Pace, 9, 20122, Milan, Italy
- Fondazione IRCCS Ca' GrandaOspedale Maggiore Policlinico, Internal Medicine-Hemostasis and Thrombosis, Milan, Italy
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9
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Real world study of children and young adults with myeloproliferative neoplasms identifying risks and unmet needs. Blood Adv 2022; 6:5171-5183. [PMID: 35802458 PMCID: PMC9631631 DOI: 10.1182/bloodadvances.2022007201] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/06/2022] [Indexed: 11/21/2022] Open
Abstract
In a contemporary cohort of 444 young MPN patients, risks of thrombosis, hemorrhage, and transformation were 1% pt/y. Current risk scores had no utility. Uniquely, we identify that splenomegaly and hyperviscosity symptoms predict thrombosis and transformation.
Myeloproliferative neoplasms (MPNs) are uncommon in children/young adults. Here, we present data on unselected patients diagnosed before 25 years of age included from 38 centers in 15 countries. Sequential patients were included. We identified 444 patients, with median follow-up 9.7 years (0-47.8). Forty-nine (11.1%) had a history of thrombosis at diagnosis, 49 new thrombotic events were recorded (1.16% patient per year [pt/y]), perihepatic vein thromboses were most frequent (47.6% venous events), and logistic regression identified JAK2V617F mutation (P = .016) and hyperviscosity symptoms (visual disturbances, dizziness, vertigo, headache) as risk factors (P = .040). New hemorrhagic events occurred in 44 patients (9.9%, 1.04% pt/y). Disease transformation occurred in 48 patients (10.9%, 1.13% pt/y), usually to myelofibrosis (7.5%) with splenomegaly as a novel risk factor for transformation in essential thrombocythemia (ET) (P= .000) in logistical regression. Eight deaths (1.8%) were recorded, 3 after allogeneic stem cell transplantation. Concerning conventional risk scores: International Prognostic Score for Essential Thrombocythemia-Thrombosis and new International Prognostic Score for Essential Thrombocythemia-Thrombosis differentiated ET patients in terms of thrombotic risk. Both scores identified high-risk patients with the same median thrombosis-free survival of 28.5 years. No contemporary scores were able to predict survival for young ET or polycythemia vera patients. Our data represents the largest real-world study of MPN patients age < 25 years at diagnosis. Rates of thrombotic events and transformation were higher than expected compared with the previous literature. Our study provides new and reliable information as a basis for prospective studies, trials, and development of harmonized international guidelines for the specific management of young patients with MPN.
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10
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Herbreteau L, Papageorgiou L, Le Clech L, Garcia G, James C, Pan-Petesch B, Couturaud F, Gerotziafas G, Lippert E, Ianotto JC. Benefice and pitfall of direct oral anticoagulants in very high-risk myeloproliferative neoplasms. Thromb Res 2022; 216:25-34. [DOI: 10.1016/j.thromres.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/30/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
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Nicol C, Ajzenberg N, Lacut K, Couturaud F, Pan-Petesch B, Lippert E, Ianotto JC. Hemorrhages in polycythemia vera and essential thrombocythemia: epidemiology, description, and risk factors, learnings from a large cohort. Thromb Haemost 2022; 122:1712-1722. [PMID: 35545123 DOI: 10.1055/a-1849-8477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The management of myeloproliferative neoplasms (MPN) is based on the reduction of thrombosis risk. The incidence, impact, and risk factors of bleedings have been less studied. METHOD All patients with polycythemia vera (n=339) or essential thrombocythemia (n=528) treated in our center are included in OBENE cohort (NCT02897297). Major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) occurring after diagnosis were included, except after leukemic transformation. RESULTS With a median follow-up of 8.3 years, incidence of hemorrhages was 1.85% patient/year, with an incidence of MB of 0.95% patient/year. The 10-year bleeding-free survival was 89%. The most frequent locations were digestive tractus, "mouth, nose and throat" and muscular hematoma. The case fatality rate of MB was 25%. The proportion of potentially avoidable iatrogenic bleeding was remarkable (17.6%). In multivariable analysis, eight risk factors of bleeding were identified: leukocytes >20 giga/l at diagnosis (HR=5.13 95%CI [1.77;14.86]), secondary hemopathies (HR=2.99 95%CI [1.27;7.04]), aspirin use at diagnosis (HR=2.11 95%CI [1.24;3.6]), platelet count >1000 giga/l at diagnosis (HR=1.93, 95%CI [1.11;3.36]), history of hemorrhage (HR=1.82 95%CI [1.03;3.24]), secondary cancers (HR=1.71 95%CI [1.01;2.89]), atrial fibrillation (HR=1.66, 95%CI [1.01;2.72]) and male gender (HR=1.54, 95%CI [1.02-2.33]). The majority of patients taking hydroxyurea displayed a non-macrocytic median corpuscular value in the months preceding bleeding (51.4%). DISCUSSION The morbidity and mortality of bleedings in MPN should not be underestimated, and some patients could beneficiate from cytoreduction in order to reducing bleeding risk. Iatrogenic bleedings represent a substantial proportion of bleeding and could be better prevented.
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Affiliation(s)
| | | | - Karine Lacut
- CIC1412, Inserm, Brest, France.,EA 3878, Brest University, Brest, France
| | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | | | - Eric Lippert
- Laboratoire d'Hématologie, CHU de Brest, Brest, France.,Equipe ECLA, INSERM U1078, France
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12
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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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13
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Feng Y, Zhang Y, Shi J. Thrombosis and hemorrhage in myeloproliferative neoplasms: The platelet perspective. Platelets 2022; 33:955-963. [PMID: 35081860 DOI: 10.1080/09537104.2021.2019210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Classical myeloproliferative neoplasm (MPN), also known as BCR-ABL-negative MPN, is a clonal disease characterized by abnormal expansion of hematopoietic stem cells. It has been demonstrated that MPN patients are more susceptible to thrombotic events compared to the general population. Therefore, researchers have been exploring the treatment for MPN thrombosis. However, antithrombotic therapies have brought another concern for the clinical management of MPN because they may cause bleeding events. When thrombosis and bleeding, two seemingly contradictory complications, occur in MPN patients at the same time, they will lead to more serious consequences. Therefore, it is a major challenge to achieving the best antithrombotic effect and minimizing bleeding events simultaneously. To date, there has yet been a perfect strategy to meet this challenge and therefore a new treatment method needs to be established. In this article, we describe the mechanism of thrombosis and bleeding events in MPN from the perspective of platelets for the first time. Based on the double-sided role of platelets in MPN, optimal antithrombotic treatment strategies that can simultaneously control thrombosis and bleeding at the same time may be formulated by adjusting the administration time and dosage of antiplatelet drugs. We argue that more attention should be paid to the critical role of platelets in MPN thrombosis and MPN bleeding in the future, so as to better manage adverse vascular events in MPN.
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Affiliation(s)
- Yiming Feng
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yue Zhang
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jialan Shi
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China.,Departments of Medical Oncology and Research, Dana-Farber Cancer Institute, Va Boston Healthcare System, Harvard Medical School, Boston, MA, USA
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14
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Wille K, Huenerbein K, Jagenberg E, Sadjadian P, Becker T, Kolatzki V, Meixner R, Marchi H, Fuchs C, Griesshammer M. Bleeding complications in bcr-abl-negative myeloproliferative neoplasms (MPN): A retrospective single-center study of 829 MPN patients. Eur J Haematol 2021; 108:154-162. [PMID: 34719056 DOI: 10.1111/ejh.13721] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 12/17/2022]
Abstract
In patients with bcr-abl-negative myeloproliferative neoplasms (MPN), concerns are often raised about the use of anticoagulants because of an increased bleeding risk. However, there are few MPN studies focusing on bleeding. To investigate bleeding complications in MPN, we report our retrospective, single-center study of 829 patients with a median follow-up of 5.5 years (range: 0.1-35.6). A first bleeding event occurred in 143 of 829 patients (17.2%), corresponding to an incidence rate of 2.29% per patient/year. During the follow-up period, one out of 829 patients (0.1%) died due to bleeding. Regarding anticoagulation, most bleeding occurred in patients on antiplatelet therapies (60.1%), followed by patients on anticoagulation therapies (20.3%) and patients not on anticoagulation (19.6%). In multivariate analysis, administration of antiplatelet (HR 2.31 [1.43, 3.71]) and anticoagulation therapies (HR 4.06 [2.32, 7.09]), but not age, gender or mutation status, was associated with an increased bleeding risk. Comparing the "probability of bleeding-free survival" between the MPN subtypes, no significant difference was observed (p = 0.91, log-rank test). Our retrospective study shows that antiplatelet and anticoagulation therapies significantly increase the risk of bleeding in MPN patients without affecting mortality. However, there is no reason to refrain from guideline-conform primary or secondary anticoagulation in MPN patients.
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Affiliation(s)
- Kai Wille
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Karlo Huenerbein
- University Institute for Anesthesiology, Intensive Care and Emergency Medicine, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Ellen Jagenberg
- University Institute for Anesthesiology, Intensive Care and Emergency Medicine, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Parvis Sadjadian
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Tatjana Becker
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Vera Kolatzki
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Raphael Meixner
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany
| | - Hannah Marchi
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany.,Bielefeld University, Bielefeld, Germany
| | - Christiane Fuchs
- Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany.,Bielefeld University, Bielefeld, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
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