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Rottenstreich A. Controversies and Clarifications Regarding the Role of Aspirin in Preeclampsia Prevention: A Focused Review. J Clin Med 2024; 13:4427. [PMID: 39124694 PMCID: PMC11312818 DOI: 10.3390/jcm13154427] [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: 06/16/2024] [Revised: 07/23/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. In recent decades, many studies have evaluated different interventions in order to prevent the occurrence of preeclampsia. Among these, administration of low-dose aspirin from early pregnancy showed consistent evidence of its prophylactic role. In this article, we review the scientific literature on this topic, highlighting the rationale for aspirin use, who should be treated, the timing of initiation and cessation of therapy, the importance of proper dosing, and its role in the prevention of other adverse outcomes.
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Affiliation(s)
- Amihai Rottenstreich
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, NY 10065, USA; ; Tel.: +1-212-327-7494; Fax: +1-212-327-7493
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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2
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Landtblom AR, Andersson TML, Johansson ALV, Lundberg FE, Samuelsson J, Björkholm M, Hultcrantz M. Childbirth rates in women with myeloproliferative neoplasms. Leukemia 2024; 38:1081-1085. [PMID: 38461191 DOI: 10.1038/s41375-024-02216-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 03/11/2024]
Abstract
Myeloproliferative neoplasms (MPN) are associated with inferior pregnancy outcome, however, little is known about fertility and childbearing potential in women with MPN. In this study we aimed to describe reproductive patterns, as well as to quantify risk of miscarriage and stillbirth. Women aged 15-44 years with an MPN diagnosis 1973-2018, were identified in Swedish health care registers, and age-matched 1:4 to population controls. We identified 1141 women with MPN and 4564 controls. Women with MPN had a lower rate of childbirth (hazard ratio [HR] with 95% confidence interval was 0.78 (0.68-0.90)). Subgroup analysis showed that the rate was not significantly reduced in essential thrombocythemia, HR 1.02 (0.86-1.22) while the HR was 0.50 (0.33-0.76) in PV and 0.45 (0.28-0.74) in PMF. The risk of miscarriage was not significantly increased before MPN diagnosis, the HR during follow-up after diagnosis was 1.25 (0.89-1.76). Women with MPN were more likely to have had a previous stillbirth. Women with MPN had fewer children at diagnosis, and fewer children in total. In conclusion, the childbirth rate was lower among women with MPN than controls, but not among women with essential thrombocythemia.
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Affiliation(s)
- Anna Ravn Landtblom
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.
| | - Therese M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Cancer Registry of Norway, Oslo, Norway
| | - Frida E Lundberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jan Samuelsson
- Department of Hematology, University Hospital Linköping, Linköping, Sweden
| | - Magnus Björkholm
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hultcrantz
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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3
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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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Wille K, Brouka M, Bernhardt J, Rüfer A, Niculescu-Mizil E, Gotic M, Isfort S, Koschmieder S, Barbui T, Sadjadian P, Becker T, Kolatzki V, Meixner R, Marchi H, Fuchs C, Stegelmann F, Döhner K, Kiladjian JJ, Griesshammer M. Outcome of 129 Pregnancies in Polycythemia Vera Patients: A Report of the European LeukemiaNET. Hemasphere 2023; 7:e882. [PMID: 37153877 PMCID: PMC10155895 DOI: 10.1097/hs9.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/30/2023] [Indexed: 05/10/2023] Open
Affiliation(s)
- Kai Wille
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Maja Brouka
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Johannes Bernhardt
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Axel Rüfer
- Luzerner Kantonsspital, Division of Hematology, Luzern, Switzerland
| | | | - Mirjana Gotic
- Clinic for Hematology Clinical Center of Serbia, Medical Faculty University of Belgrade, Serbia
| | - Susanne Isfort
- Department of Medicine (Hematology, Oncology, Hemostaseology and SCT), Faculty of Medicine, RWTH Aachen University, Germany
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Steffen Koschmieder
- Department of Medicine (Hematology, Oncology, Hemostaseology and SCT), Faculty of Medicine, RWTH Aachen University, Germany
- Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Germany
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Parvis Sadjadian
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Tatjana Becker
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Vera Kolatzki
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
| | - Raphael Meixner
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
| | - Hannah Marchi
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
- Faculty of Business Administration and Economics, Bielefeld University, Germany
| | - Christiane Fuchs
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
- Faculty of Business Administration and Economics, Bielefeld University, Germany
| | - Frank Stegelmann
- Department of Internal Medicine III, University Hospital of Ulm, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Germany
| | - Jean-Jacques Kiladjian
- Université Paris Cité, AP-HP, Hôpital Saint-Louis, Centre d’Investigations Cliniques, Paris, France
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Germany
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Krayem B, Brenner B, Horowitz NA. Thrombosis in Pregnant Women with Hematological Malignancies: A Case-Based Review. Semin Thromb Hemost 2022; 49:348-354. [PMID: 36535649 DOI: 10.1055/s-0042-1759683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractCancer and pregnancy induce a procoagulant environment which may lead to maternal and fetal complications, such as venous thromboembolism, fetal growth restriction, and fetal loss. The incidence of hematological malignancies diagnosed during pregnancy is rising, and thrombotic events in such malignancies are not rare. Management of thrombosis during pregnancy poses a therapeutic challenge, that is further exacerbated by the impact of cancer. The available data on managing pregnant women with hematological malignancies are limited to those with myeloproliferative neoplasms, mainly essential thrombocythemia, and, to a lesser extent, polycythemia vera. Low-dose aspirin is recommended throughout pregnancy, and considering treatment with low-molecular-weight heparin and interferon formulations is advised for high-risk patients. Currently, guidelines for handling thrombotic events in pregnant women with lymphoma or leukemia are lacking, and their management is based on data extrapolated from retrospective studies, and guidelines for prevention and treatment of cancer-associated thrombosis. The present case-based review will focus on the complex issue of thrombotic risk in pregnant women with hematological malignancies, specifically myeloproliferative neoplasms, lymphomas, and leukemias.
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Affiliation(s)
- Baher Krayem
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Netanel A. Horowitz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Ntounis T, Zioutos KA, Koutras A, Prokopakis I, Fasoulakis Z, Sapantzoglou I, Perros P, Samara AA, Spanoudakis E, Valsamaki A, Krouskou SE, Nikolettos K, Palios VC, Mousios P, Goula K, Konis K, Chionis A, Kontomanolis EN. Portal Vein Thrombosis after C-Section in a Patient with Polycythemia Vera (PV) Due to Pregnancy and Iron Deficiency Anemia (IDA). Clin Pract 2022; 12:1069-1077. [PMID: 36547117 PMCID: PMC9776423 DOI: 10.3390/clinpract12060109] [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: 09/27/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
Polycythemia vera (PV) is one of the three main classic disorders of Philadelphia-negative myeloproliferative neoplasms (MPNs), with the other two being essential thrombocythemia (ET) and primary myelofibrosis (PMF). PV may develop (15%) in women of childbearing age (15-45 years), with an anticipated rate of roughly 0.3 per 100,000 people, although maintaining a male to female ratio predominance of about 2:1 and a peak prevalence in the sixth and seventh decades of life. Without always being presented with its actual clinical manifestations due to pregnancy itself, and most commonly due to iron deficiency, PV can be frequently missed and therefore belatedly diagnosed. We describe the case of a primipara woman in her 40s, without risk factors for thrombosis, who developed a portal vein occlusion 1.5 month postpartum after C-section and who had a delayed diagnosis of PV.
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Affiliation(s)
- Thomas Ntounis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
| | - Konstantinos A. Zioutos
- Department of Obstetrics and Gynecology-Kastoria General Hospital, Mavriotissis 33, 52100 Kastoria, Greece
| | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
- Correspondence:
| | - Ioannis Prokopakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
| | - Zacharias Fasoulakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
| | - Ioakeim Sapantzoglou
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
| | - Paraskevas Perros
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens ‘ALEXANDRA’, Lourou and Vasilissis Sofias Ave, 11528 Athens, Greece
| | - Athina A. Samara
- Department of Embryology, University General Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Emmanouil Spanoudakis
- Department of Hematology, Democritus University of Thrace, University General Hospital of Alexandroupolis, 6th km Alexandroupolis–Makris, Dragana, 68100 Alexandroupolis, Greece
| | - Asimina Valsamaki
- Department of Internal Medicine, General Hospital of Larisa, Tsakalof 1, 41221 Larisa, Greece
| | - Sevasti-Effraimia Krouskou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 6th km Alexandroupolis–Makris, 68100 Alexandroupolis, Greece
| | - Konstantinos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 6th km Alexandroupolis–Makris, 68100 Alexandroupolis, Greece
| | | | - Paschalis Mousios
- Department of Obstetrics and Gynecology, University General Hospital of Larissa, Mezourlo, 41110 Larissa, Greece
| | - Kallirroi Goula
- Department of Pathology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Kyriakos Konis
- Department of Obstetrics and Gynecology, General Hospital of Arta, 47100 Arta, Greece
| | - Athanasios Chionis
- Department of Gynecology, Laiko General Hospital of Athens, Agiou Thoma 17, 11527 Athens, Greece
| | - Emmanuel N. Kontomanolis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 6th km Alexandroupolis–Makris, 68100 Alexandroupolis, Greece
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7
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Landtblom AR, Andersson TML, Johansson ALV, Wendel SB, Lundberg FE, Samuelsson J, Björkholm M, Hultcrantz M. Pregnancy and childbirth outcomes in women with myeloproliferative neoplasms-a nationwide population-based study of 342 pregnancies in Sweden. Leukemia 2022; 36:2461-2467. [PMID: 36071101 PMCID: PMC9522578 DOI: 10.1038/s41375-022-01688-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 12/02/2022]
Abstract
Pregnancy and childbirth in women with myeloproliferative neoplasms (MPN) are reported to be associated with maternal thrombosis, hemorrhage, and placental dysfunction. To assess the risks of adverse events in pregnancy in women with MPN, we performed a large population-based study using Swedish health care registers, and included all pregnancies that had reached gestational week 22 (prior to 2008, week 28) during the years 1973-2017 in women with MPN. Control pregnancies were matched 1:1 for age, calendar year, and parity. We identified 342 pregnancies in 229 women with MPN. Preterm birth was significantly increased in pregnancies in MPN, 14% compared to 4% of pregnancies in controls (p < 0.001). Correspondingly, low birth weight (<2500 g) was also significantly increased in MPN pregnancies (p = 0.042). Stillbirth was rare, with two events (0.6%) in MPN, none in controls. Maternal thrombotic complications occurred in three (1%) of the pregnancies in MPN patients, compared to none in controls. Pregnancy-related bleeding affected 14% of pregnancies in MPN and 9% in controls (p < 0.110). Cesarean section was significantly more common in pregnancies in MPN. Incidence was 12.2 per 100.000 pregnancies. In summary, preterm birth was an important complication in MPN pregnancies, while maternal complications were less common than previously reported.
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Affiliation(s)
- Anna Ravn Landtblom
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.
| | - Therese M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Cancer Registry of Norway, Oslo, Norway
| | - Sophia Brismar Wendel
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Frida E Lundberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jan Samuelsson
- Department of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Magnus Björkholm
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Malin Hultcrantz
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
- Department of Medicine, Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Amerikanou R, Lambert J, Alimam S. Myeloproliferative neoplasms in adolescents and young adults. Best Pract Res Clin Haematol 2022; 35:101374. [DOI: 10.1016/j.beha.2022.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/02/2022]
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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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Chronic Myeloid Leukemia and Pregnancy: When Dreams Meet Reality. State of the Art, Management and Outcome of 41 Cases, Nilotinib Placental Transfer. J Clin Med 2022; 11:jcm11071801. [PMID: 35407407 PMCID: PMC8999799 DOI: 10.3390/jcm11071801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/26/2022] [Accepted: 03/11/2022] [Indexed: 02/06/2023] Open
Abstract
The overwhelming success of tyrosine kinase inhibitor (TKI) therapy in chronic myeloid leukemia (CML) patients has opened a discussion among medical practitioners and the lay public on the real possibility of pregnancy and conception in females and males with CML. In the past 10 years this subject has acquired growing interest in the scientific community and specific knowledge has been obtained “from bench to bedside”. Embryological, pharmacological, and pathophysiological studies have merged with worldwide patient databases to provide a roadmap to a successful pregnancy and birth in CML patients. Male conception does not seem to be affected by TKI therapy, since this class of drugs is neither genotoxic nor mutagenic, however, caution should be used specially with newer drugs for which little or no data are available. In contrast, female patients should avoid TKI therapy specifically during the embryonic stage of organogenesis (5–12 weeks) because TKIs can be teratogenic. In the last 15 years, 41 pregnancies have been followed in our center. A total of 11 male conceptions and 30 female pregnancies are described. TKI treatment was generally terminated as soon as the pregnancy was discovered (3–5 weeks), to avoid exposure during embryonic period and to reduce the risk of needing treatment in the first trimester. Eleven pregnancies were treated with interferon, imatinib or nilotinib during gestation. Nilotinib plasma levels in cord blood and maternal blood at delivery were studied in 2 patients and reduced or absent placental crossing of nilotinib was observed. All of the patients were managed by a multidisciplinary team of physicians with obligatory hematological and obgyn consultations. This work provides an update on the state of the art and detailed description of pregnancy management and outcomes in CML patients.
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11
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Wang Y, Jiang L, Li B, Zhao Y. Management of Chronic Myeloid Leukemia and Pregnancy: A Bibliometric Analysis (2000-2020). Front Oncol 2022; 12:826703. [PMID: 35321439 PMCID: PMC8934933 DOI: 10.3389/fonc.2022.826703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Given the increasing number and survival rates of reproductive-age patients with chronic myeloid leukemia (CML), several studies aimed to elucidate optimum disease management in pregnancy. This study aimed to use bibliometric analysis to assess focus and reported insights, as well as future trends, in CML and pregnancy research. Methods We extracted all studies related to CML and pregnancy from the Web of Science database from 2001 to 2020. VOS Viewer, CiteSpace, Python, and R-bibliometrix were used for bibliometric analysis, revealing the leading research countries, institutions, and authors, as well as distribution of keywords (frequency greater than five). Results A total of 196 records, published in 137 journals by 1,105 authors from 421 research institutes in 50 countries, were identified for analysis. The United States was the leader in the number of publications. Imperial College London and National Research Center for Hematology were the most influential institutions. In addition, Apperley J, Cortes J, Abruzzese E and Kantarjian H were the leading authors in the field. Keyword analysis identified four research hotspot clusters. Conclusions This study systematically analyzed the progress in CML and pregnancy research in the last 20 years. The present findings suggest that the management of planned and unplanned pregnancies in patients with CML will remain a research focus, as further evidence is required for the development of treatment guidelines.
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Affiliation(s)
- Yue Wang
- Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Liqing Jiang
- Department of Medical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Baoxuan Li
- Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yan Zhao
- Department of Obstetrics and Gynaecology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Yan Zhao,
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12
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Papageorgiou L, Elalamy I, Vandreden P, Gerotziafas GT. Thrombotic and Hemorrhagic Issues Associated with Myeloproliferative Neoplasms. Clin Appl Thromb Hemost 2022; 28:10760296221097969. [PMID: 35733370 PMCID: PMC9234921 DOI: 10.1177/10760296221097969] [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] [Indexed: 12/04/2022] Open
Abstract
Thrombotic and hemorrhagic complications are related to a significant rate of
morbidity and mortality in patients with myeloproliferative neoplasms (MPNs),
they are therefore called “thrombohemorrhagic” syndromes. Several clinical
factors, such as age and presence of cardiovascular comorbidities are
responsible for thrombotic complications. High blood counts, platelet
alterations, presence of JAK2 mutation and possibly of other CHIP mutations such
as TET2, DNMT3A, and ASXL1, procoagulant microparticles, NETs formation,
endothelial activation and neo-angiogenesis are some of the parameters
accounting for hypercoagulability in patients with myeloproliferative neoplasms.
Bleeding complications emerge as a result of platelet exhaustion. They can be
also linked to a functional deficiency of von Willebrand factor, when platelet
counts rise above 1000G/L. The mainstay of management consists on preventing
hemostatic complications, by antiplatelet and/or anticoagulant treatment and
myelosuppressive agents in high-risk patients.Circumstances related to a high
thrombohemorrhagic risk, such as pregnancy and the perioperative period, prompt
for specific management with regards to anticoagulation and myelosuppression
treatment type. In order to apply a patient-specific treatment strategy, there
is a need for a risk score assessment tool encompassing clinical parameters and
hemostasis biomarkers.
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Affiliation(s)
- Loula Papageorgiou
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France
| | - Ismail Elalamy
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France.,The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Patrick Vandreden
- Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France.,Clinical Research Department, Diagnostica Stago, Gennevilliers, France
| | - Grigoris T Gerotziafas
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France
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13
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Al-Mashdali AF, Yassin MA. Rebound of platelet count in a patient with type 2 calreticulin-mutant essential thrombocythemia in the postpartum period: A case report. Medicine (Baltimore) 2021; 100:e27725. [PMID: 34871269 PMCID: PMC8568366 DOI: 10.1097/md.0000000000027725] [Citation(s) in RCA: 1] [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] [Received: 09/02/2021] [Accepted: 10/22/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Essential thrombocythemia (ET) is an uncommon myeloproliferative neoplasm. It is more common in females; 20% of them are below 40 years old. The optimal management of ET during pregnancy and postpartum periods is still not well established. PATIENT CONCERN We report a case of a young lady with type 2 calreticulin-mutant ET who developed a marked rebound in her platelet count (reaching 2030 × 103/μL) 2 weeks after premature delivery of her baby (24th week of gestation). She was on Pegylated Interferon alfa 2-a during pregnancy (her platelet was around 500 × 103/μL during the second trimester), but she had stopped it on her own from the 20th week of gestation. DIAGNOSIS Postpartum rebound of platelet count due to medication non-compliance. INTERVENTION AND OUTCOME We resumed her regular Pegylated Interferon, and subsequently, her platelet count reduced dramatically within 4 weeks to an acceptable level (684 × 103 /μL). CONCLUSION The guideline is still not well-established regarding the optimal approach for postpartum rebound of platelet count in patients with ET. It is still unclear if the platelet count will fall spontaneously without intervention after the rebound phase. Further research is required to establish the optimal management of ET during the postpartum phase. This case emphasizes the importance of platelet count follow-up during the postpartum period and outlines our management approach in such cases.
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Affiliation(s)
| | - Mohamed A. Yassin
- National Center for Cancer Care and Research, Department of Oncology, Hematology and BMT Section, Hamad Medical Corporation, Doha, Qatar
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14
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Sant'Antonio E, Borsani O, Camerini C, Botta C, Santoro M, Allegra A, Siragusa S. Philadelphia chromosome-negative myeloproliferative neoplasms in younger adults: A critical discussion of unmet medical needs, with a focus on pregnancy. Blood Rev 2021; 52:100903. [PMID: 34742614 DOI: 10.1016/j.blre.2021.100903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 11/02/2022]
Abstract
Myeloproliferative neoplasms (MPN) are traditionally regarded as a disease of older adults, though a not negligible fraction of cases occurs at a younger age, including women of childbearing potential. MPN in younger patients, indeed, offer several challenges for the clinical hematologist, that goes from difficulties in reaching a timely and accurate diagnosis to a peculiar thrombotic risk, with a relatively high incidence of thromboses in unusual sites (as the splanchnic veins or the cerebral ones). Moreover, the issue of pregnancy is recently gaining more attention as maternal age is rising and molecular screening are widely implemented, leading to a better recognition of these cases, both before and during pregnancy. In the present work we aim at discussing four clinical topic that we identified as areas of uncertainty or true unmet medical needs in the management of younger patients with MPN, with a particular focus on the topic of pregnancy. For each of these topics, we critically reviewed the available evidence that support treatment decisions, though acknowledging that recommendations in this field are mostly based on expert opinion or derived from guidelines of other clinical conditions that share with MPN a high vascular risk, as antiphospholipid syndrome. Taking into consideration both the lack of evidence-based data and the clinical heterogeneity of MPN, we support an individualized strategy of counseling and management for both young patients and for expectant mother with MPN.
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Affiliation(s)
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Chiara Camerini
- Division of Hematology, Azienda USL Toscana Nord Ovest, Ospedale San Luca, Lucca, Italy
| | - Cirino Botta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marco Santoro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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15
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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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16
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Integrated bioinformatics analysis reveals novel key biomarkers and potential candidate small molecule drugs in gestational diabetes mellitus. Biosci Rep 2021; 41:228450. [PMID: 33890634 PMCID: PMC8145272 DOI: 10.1042/bsr20210617] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 02/08/2023] Open
Abstract
Gestational diabetes mellitus (GDM) is the metabolic disorder that appears during pregnancy. The current investigation aimed to identify central differentially expressed genes (DEGs) in GDM. The transcription profiling by array data (E-MTAB-6418) was obtained from the ArrayExpress database. The DEGs between GDM samples and non-GDM samples were analyzed. Functional enrichment analysis were performed using ToppGene. Then we constructed the protein–protein interaction (PPI) network of DEGs by the Search Tool for the Retrieval of Interacting Genes database (STRING) and module analysis was performed. Subsequently, we constructed the miRNA–hub gene network and TF–hub gene regulatory network. The validation of hub genes was performed through receiver operating characteristic curve (ROC). Finally, the candidate small molecules as potential drugs to treat GDM were predicted by using molecular docking. Through transcription profiling by array data, a total of 869 DEGs were detected including 439 up-regulated and 430 down-regulated genes. Functional enrichment analysis showed these DEGs were mainly enriched in reproduction, cell adhesion, cell surface interactions at the vascular wall and extracellular matrix organization. Ten genes, HSP90AA1, EGFR, RPS13, RBX1, PAK1, FYN, ABL1, SMAD3, STAT3 and PRKCA were associated with GDM, according to ROC analysis. Finally, the most significant small molecules were predicted based on molecular docking. This investigation identified hub genes, signal pathways and therapeutic agents, which might help us, enhance our understanding of the mechanisms of GDM and find some novel therapeutic agents for GDM.
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17
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Wille K, Bernhardt J, Sadjadian P, Becker T, Kolatzki V, Huenerbein K, Griesshammer M. The management, outcome, and postpartum disease course of 41 pregnancies in 20 women with polycythemia vera. Eur J Haematol 2021; 107:122-128. [PMID: 33763907 DOI: 10.1111/ejh.13627] [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] [Received: 01/21/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Pregnancies in women with polycythemia vera (PV) are associated with an increased risk of PV-related maternal complications and often result in miscarriage. Recommendations for the management of PV pregnancies are mainly based on studies with a small number of patients. A correlation between pregnancy outcome and postpartum course has been reported for essential thrombocythemia, but corresponding data for PV are lacking so far. METHODS In 41 PV pregnancies, the pregnancy outcome, the use of PV-specific therapies (ie, acetylsalicylic acid, low-molecular weight heparin and/or interferon-alpha), and the postpartum PV course were investigated. RESULTS A live birth rate of 51.2% (21/41 pregnancies) was observed. 43.9% of pregnancies ended in spontaneous abortion and 4.9% in stillbirth. A significantly increased live birth rate occurred in pregnancies with PV-specific therapies compared to standard antenatal care (69.0% vs. 8.3%; P < .0019). The use of PV-specific therapy significantly increased the number of maternal hemorrhages (P = .021) without increasing the risk of fetal complications. During the median postpartum follow-up period of 1.2 years (range 0.1-13.7), complicated postpartum PV occurred significantly more often after miscarriages (P = .035). CONCLUSIONS According to our analysis, PV-specific therapy improved the live birth rate. Significantly more complicated postpartum PV courses were observed after miscarriages.
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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
| | - Johannes Bernhardt
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, 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
| | - Karlo Huenerbein
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, 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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18
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Gangat N, Tefferi A. Myeloproliferative neoplasms and pregnancy: Overview and practice recommendations. Am J Hematol 2021; 96:354-366. [PMID: 33296529 DOI: 10.1002/ajh.26067] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 01/08/2023]
Abstract
Pregnancy in the context of myeloproliferative neoplasms (MPN) poses unique fetal and maternal challenges. Current literature in this regard mostly involves essential thrombocythemia (ET) and less so polycythemia vera (PV) or myelofibrosis. In ET, live birth rate is estimated at 70% with first trimester fetal loss (˜ 30%) as the major complication. Risk of pregnancy-associated complications is higher in PV, thus mandating a more aggressive treatment approach. Herein, we appraise the relevant literature, share our own experience and propose management recommendations. Aspirin therapy may offer protection against fetal loss; however the additive benefit of systemic anticoagulation or cytoreductive therapy, in the absence of high risk disease, is unclear. We recommend cytoreductive therapy in the form of interferon alpha in all high risk and select low-risk ET and PV patients with history of recurrent fetal loss, prominent splenomegaly or suboptimal hematocrit control with phlebotomy. In addition, all women with PV should maintain strict hematocrit control <45% with the aid of phlebotomy. Systemic anticoagulation with low molecular weight heparin is advised in patients with history of venous thrombosis. Further clarification awaits prospective clinical trials that implement risk adapted therapeutic interventions.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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19
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Marked Rebound of Platelet Count in the Early Postpartum Period in a Patient with Essential Thrombocythemia. Case Rep Hematol 2021; 2021:6633790. [PMID: 33614173 PMCID: PMC7875641 DOI: 10.1155/2021/6633790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 11/17/2022] Open
Abstract
Essential thrombocythemia (ET) occurs predominantly in the elderly, but approximately 20% of patients are <40 years old. Unlike other myeloproliferative neoplasms, ET occurs more commonly in women. We encountered a 38-year-old women diagnosed with ET who exhibited elevated platelet count in early pregnancy. Her platelet count exceeded 1500 × 109/L by late pregnancy; interferon α was administered but failed to induce an adequate response. She underwent emergency cesarean delivery at 37 weeks of gestation. Although her platelet count was 1000 × 109/L immediately after delivery, it markedly increased to 3271 × 109/L approximately 2 weeks later. Cytoreductive therapy was resumed; the subsequent course was free from complications. Several review articles have indicated that because platelet counts of patients may again increase to the pregnancy level or rebound after delivery, cytoreductive therapy should be administered if necessary. However, there is insufficient information on when therapeutic interventions are necessary and how they should be performed. It remains unknown whether the platelet count will decrease after some time without treatment if it rebounds. We hope management guidelines will be established by collecting detailed data on the postpartum course as well as during pregnancy.
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20
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Burbury K, Panigrahi A. Esssential thrombocythaemia and pregnancy-A need for prospective study and a consensus on its management. Leuk Res 2021; 102:106500. [PMID: 33556743 DOI: 10.1016/j.leukres.2021.106500] [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: 10/25/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
MPN are rare diseases, however young women with ET are increasingly being recognised. Management during pregnancy is often a recognised issue with no clear guidelines for management. Pregnancy is associated with considerable risk of complications and therefore warrants a multidisciplinary approach and early identification of high-risk pregnancies. Robust data is limited and therefore we advocate for more prospective (cohort and registry), multicentre, collaborative efforts to gather meaningful information about risk, and risk-adapted therapy, to guide management. The commentary reviews the study by How et al and compares the observations to other studies around the world. It recognises that previous pregnancies with complications increase the risk of further complications during future pregnancies. It is important to recognise the high-risk pregnancies and have a risk adapted approach to the same. The use of low dose aspirin is recommended throughout the pregnancy. The use of LMWH prophylaxis antepartum should be individualised to the thrombotic risk status and applied post-partum for at least 6 weeks. Interferon a remains the safest and effective approach for cytoreductive therapy. Collaborative expert efforts world-wide, as well as larger prospective trials and registry data, will enhance our knowledge to formulate standard guidelines for these group of patients.
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Affiliation(s)
- Kate Burbury
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, 3000, Australia
| | - Ashish Panigrahi
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, 3000, Australia.
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21
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Buxhofer-Ausch V, Heibl S, Sliwa T, Beham-Schmid C, Wolf D, Geissler K, Krauth MT, Krippl P, Petzer A, Wölfler A, Melchardt T, Gisslinger H. Austrian recommendations for the management of essential thrombocythemia. Wien Klin Wochenschr 2020; 133:52-61. [PMID: 33215234 DOI: 10.1007/s00508-020-01761-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/19/2020] [Indexed: 12/22/2022]
Abstract
According to the World Health Organization (WHO) classification, essential (primary) thrombocythemia (ET) is one of several Bcr-Abl negative chronic myeloproliferative neoplasms (MPN). The classical term MPN covers the subcategories of MPN: ET, polycythemia vera (PV), primary myelofibrosis (PMF), and prefibrotic PMF (pPMF). ET is marked by clonal proliferation of hematopoietic stem cells, leading to a chronic overproduction of platelets. At the molecular level a JAK2 (Janus Kinase 2), calreticulin, or MPL mutation is found in the majority of patients. Typical ongoing complications of the disease include thrombosis and hemorrhage. Primary and secondary prevention of these complications can be achieved with platelet function inhibitors and various cytoreductive drugs including anagrelide, hydroxyurea and interferon. After a long follow up, in a minority of ET patients the disease transforms into post-ET myelofibrosis or secondary leukemia. Overall, life expectancy with ET is only slightly decreased.
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Affiliation(s)
- Veronika Buxhofer-Ausch
- Department of Internal Medicine I for Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen, Fadingerstraße 1, 4020, Linz, Austria. .,Medizinische Fakultät, Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Austria.
| | - Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Thamer Sliwa
- 3rd Medical Department, Hanusch Hospital, Vienna, Austria
| | | | - Dominik Wolf
- Division of Hematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Klaus Geissler
- 5th Medical Department with Hematology, Oncology and Palliative Medicine, Hospital Hietzing, Vienna, Austria
| | - Maria Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Blood Coagulation, Medical University of Vienna, Vienna, Austria
| | - Peter Krippl
- Department of Internal Medicine with Hematology and Oncology, Steiermärkische Krankenanstaltengesellschaft m. b. H. Krankenhausverbund Feldbach-Fürstenfeld, Fürstenfeld, Austria
| | - Andreas Petzer
- Medizinische Fakultät, Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Austria.,Departments of Internal Medicine I for Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz, Linz, Austria
| | - Albert Wölfler
- Division of Hematology, Medical University of Graz, Graz, Austria
| | - Thomas Melchardt
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectiology, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Blood Coagulation, Medical University of Vienna, Vienna, Austria
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22
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Schrickel L, Heidel FH, Sadjadian P, Becker T, Kolatzki V, Hochhaus A, Griesshammer M, Wille K. Interferon alpha for essential thrombocythemia during 34 high-risk pregnancies: outcome and safety. J Cancer Res Clin Oncol 2020; 147:1481-1491. [PMID: 33140210 DOI: 10.1007/s00432-020-03430-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/08/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Pregnancies in women with essential thrombocythemia (ET) are at a higher risk for obstetrical complications. Acetylsalicylic acid (ASA) and low-molecular weight heparin (LMWH) are common options to prevent miscarriages and maternal complications, whereas interferon alpha (IFN) seems to be the cytoreductive therapy of choice. This retrospective study analyzes the largest number of IFN pregnancies to date in terms of outcome and safety. METHODS Data of 34 high-risk pregnancies in 23 women presenting at the University hospitals of Minden and Jena from 01-Jun-2007 to 01-Jun-2020 were collected. Reasons defining high-risk ET pregnancy in all 23 patients were: Thrombosis (n = 9) or severe hemorrhage (n = 2) in history, platelet count ≥ 1500 × 103/µl (n = 8) or severe microcirculatory disturbances not completely responding to ASA (n = 4). RESULTS Without the use of IFN, live birth rate was 60% (6/10), however, after the use of IFN live birth rate increased to 73.5% (25/34 pregnancies). Nine pregnancies ended in miscarriages (9/34; 26.5%); all of them spontaneous abortions. Live birth rate significantly improved with ASA (90% versus 50%, p = 0.0168), however, if ASA and LMWH was added (n = 14), live birth rate was 100%. IFN compound (PEGylated versus standard IFN) and JAK2-driver mutation had no impact on pregnancy outcome. One major maternal complication occurred as a major peripartal bleeding after abortion curettage. CONCLUSION IFN was associated with an encouraging live birth rate of 73.5% with no fatal maternal events and manageable side effects.
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Affiliation(s)
- Lukas Schrickel
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany.
| | - Florian H Heidel
- Department of Internal Medicine 2, Haematology and Oncology, University Hospital Jena, Jena, Germany.,Internal Medicine C, University Medicine Greifswald, Greifswald, Germany
| | - Parvis Sadjadian
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany
| | - Tatjana Becker
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany
| | - Vera Kolatzki
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany
| | - Andreas Hochhaus
- Department of Internal Medicine 2, Haematology and Oncology, University Hospital Jena, Jena, Germany
| | - Martin Griesshammer
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany
| | - Kai Wille
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, Ruhr-University Bochum, Minden, Germany
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23
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Abruzzese E, Mauro M, Apperley J, Chelysheva E. Tyrosine kinase inhibitors and pregnancy in chronic myeloid leukemia: opinion, evidence, and recommendations. Ther Adv Hematol 2020; 11:2040620720966120. [PMID: 33194164 PMCID: PMC7607785 DOI: 10.1177/2040620720966120] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022] Open
Abstract
With survival expectation that of age-matched controls and given excellent response and worldwide access to tyrosine kinase inhibitors (TKI), family planning is increasingly important for a considerable fraction of patients with chronic myeloid leukemia (CML). The potential for therapy discontinuation ("treatment free remission") can afford the opportunity for a CML patient in deep response to plan and carry a pregnancy to full term without any therapeutic interventions. However, the reality of pregnancy desired or occurring when patients are not eligible for treatment-free remission raises the discussion of therapy choices during pregnancy. To date there are no official guidelines available to assist patients and clinicians with these decisions. This first position paper aims to analyze information published and presented surrounding this challenging area, with focus on different scenarios of disease burden and time from CML diagnosis, including CML discovered during pregnancy and pregnancy during CML treatment. An updated review, supported by data and presented together with authors' joint recommendations, is aimed to counsel the practical management of CML patients and pregnancy.
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Affiliation(s)
- Elisabetta Abruzzese
- S. Eugenio Hospital, Tor Vergata University, Piazzale dell’Umanesimo 10, Roma, Roma 00144, Italy
| | - Michael Mauro
- Memorial Sloan-Kettering Cancer Center, New York, USA
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Buxhofer-Ausch V, Wolf D, Sormann S, Forjan E, Schimetta W, Gisslinger B, Heibl S, Krauth MT, Thiele J, Ruckser R, Gisslinger H. Impact of platelets on major thrombosis in patients with a normal white blood cell count in essential thrombocythemia. Eur J Haematol 2020; 106:58-63. [PMID: 32909297 PMCID: PMC7756407 DOI: 10.1111/ejh.13516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
Objectives Cell counts have a significant impact on the complex mechanism of thrombosis in patients with essential thrombocythemia (ET). We recently demonstrated a considerable impact of white blood cell (WBC) counts on thrombotic risk in patients with optimized platelet counts by analysing a large anagrelide registry. In contrast, the current analysis of the registry aimed to estimate the influence of platelet counts on thrombotic risk in patients with optimized WBC counts. Methods Cox regression analysis and Kaplan‐Meier plot were applied on all patients in the registry with optimized WBC counts. Results By using the calculated cut‐off of 593 G/L for platelets, Cox regression analysis revealed a clear influence of elevated platelet counts on the occurrence of a major thrombotic event (P < .001). A Kaplan‐Meier plot revealed a markedly shorter time to a major thrombotic event for patients with platelet counts above the cut‐off (P < .001). Conclusions The data show clear impact of platelet lowering on the thrombotic risk in ET patients with normal WBC counts. Therefore, selective platelet lowering with anagrelide appears sufficient for thrombotic risk reduction in WHO‐diagnosed ET patients lacking leukocytosis.
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Affiliation(s)
- Veronika Buxhofer-Ausch
- Department of Internal Medicine I for Haematology with Stem Cell Transplantation, Haemostasis and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Dominik Wolf
- Division of Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Siegfried Sormann
- Department of Haematology, Medical University of Graz, Graz, Austria
| | - Ernst Forjan
- Department of Internal Medicine 3, Hanusch Hospital, Vienna, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research and Statistics, Johannes Kepler University, Linz, Austria
| | - Bettina Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Maria Theresa Krauth
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thiele
- Department of Pathology, University of Cologne, Cologne, Germany
| | | | - Heinz Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
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25
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How J, Leiva O, Bogue T, Fell GG, Bustoros MW, Connell NT, Connors JM, Ghobrial IM, Kuter DJ, Mullally A, Neuberg D, Zwicker JI, Fogerty AE, Hobbs GS. Pregnancy outcomes, risk factors, and cell count trends in pregnant women with essential thrombocythemia. Leuk Res 2020; 98:106459. [PMID: 33022566 DOI: 10.1016/j.leukres.2020.106459] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/21/2020] [Accepted: 09/27/2020] [Indexed: 01/26/2023]
Abstract
Pregnancy in essential thrombocythemia (ET) is associated with increased risk of obstetric complications. We retrospectively evaluated risk factors in 121 pregnancies in 52 ET women seen at 3 affiliate hospitals. Univariable and multivariable analyses were performed at the α = 0.10 level. Cell counts were characterized throughout pregnancy and correlated with outcomes using logistic modeling. The overall live birth rate was 69 %. 48.7 % of all women experienced a pregnancy complication, the most common being spontaneous abortion, which occurred in 26 % of all pregnancies. Maternal thrombosis and hemorrhage rates were 2.5 % and 5.8 %. On multivariable analysis, aspirin use (OR 0.29, p = 0.014, 90 % CI 0.118-0.658) and history of prior pregnancy loss (OR 3.86, p = 0.011, CI 1.49-9.15) were associated with decreased and increased pregnancy complications, respectively. A Markov model was used to analyze the probability of a future pregnancy complication based on initial pregnancy outcome. An ET woman who suffers a pregnancy complication has a 0.594 probability of a subsequent pregnancy complication, compared to a 0.367 probability if she didn't suffer a complication. However, despite this elevated risk, overall prognosis is good, with a >50 % probability of a successful pregnancy by the third attempt. Platelet counts decreased by 43 % in ET during pregnancy, with nadir at delivery and prompt recovery in the postpartum period. Women with larger declines in gestational platelet counts were less likely to suffer complications (p = 0.083). Our study provides important guidance to physicians treating ET women during pregnancy, including counseling information regarding risk assessment and expected trajectory of platelet levels.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA; Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Orly Leiva
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Thomas Bogue
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA
| | - Geoffrey G Fell
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, 02115, USA
| | - Mark W Bustoros
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA
| | - Nathan T Connell
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Jean M Connors
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Irene M Ghobrial
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Ann Mullally
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, 02115, USA
| | - Jeffrey I Zwicker
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA
| | - Annemarie E Fogerty
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
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26
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How J, Hobbs G. Use of Interferon Alfa in the Treatment of Myeloproliferative Neoplasms: Perspectives and Review of the Literature. Cancers (Basel) 2020; 12:E1954. [PMID: 32708474 PMCID: PMC7409021 DOI: 10.3390/cancers12071954] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/13/2023] Open
Abstract
Interferon alfa was first used in the treatment of myeloproliferative neoplasms (MPNs) over 30 years ago. However, its initial use was hampered by its side effect profile and lack of official regulatory approval for MPN treatment. Recently, there has been renewed interest in the use of interferon in MPNs, given its potential disease-modifying effects, with associated molecular and histopathological responses. The development of pegylated formulations and, more recently, ropeginterferon alfa-2b has resulted in improved tolerability and further expansion of interferon's use. We review the evolving clinical use of interferon in essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF). We discuss interferon's place in MPN treatment in the context of the most recent clinical trial results evaluating interferon and its pegylated formulations, and its role in special populations such as young and pregnant MPN patients. Interferon has re-emerged as an important option in MPN patients, with future studies seeking to re-establish its place in the existing treatment algorithm for MPN, and potentially expanding its use for novel indications and combination therapies.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, 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, Boston, MA 02114, USA;
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27
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Robinson SE, Harrison CN. How we manage Philadelphia-negative myeloproliferative neoplasms in pregnancy. Br J Haematol 2020; 189:625-634. [PMID: 32150650 DOI: 10.1111/bjh.16453] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 11/26/2019] [Indexed: 11/29/2022]
Abstract
The combined incidence of classical Philadelphia-negative myeloproliferative neoplasm (MPN) is 6-9/100 000 with a peak frequency between 50 and 70 years. MPN is less frequent in women of reproductive age. However, for essential thrombocythaemia (ET) in particular there is a second peak in women of reproductive age and 15% of polycythaemia vera (PV) patients are less than 40 years of age at the time of diagnosis. Thus these diseases are encountered in women of reproductive potential and may be diagnosed in pregnancy or in women being investigated for recurrent pregnancy loss. The incidence of MPN pregnancies is 3·2/100 000 maternities per year in the UK. The majority of data regarding Philadelphia-negative MPNs relates to patients with ET, for which the literature suggests significant maternal morbidity and poor fetal outcome; specifically maternal thrombosis and haemorrhage, miscarriage, pre-eclampsia, intrauterine growth restriction (IUGR), stillbirth and premature delivery as summarised in the recent systematic review and meta-analysis in Blood, 2018, 132, 3046. The literature for PV is more sparse but increasing and is concordant with ET pregnancy outcomes. The literature regarding primary myelofibrosis (PMF) is even more scarce. Treatment options include aspirin, venesection, low molecular weight heparin (LMWH) and cytoreductive therapy. Data and management recommendations are often extrapolated from other pro-thrombotic conditions or from ET to PV and PMF. Women of reproductive age with a diagnosis of MPN should receive information and assurance regarding management and outcome of future pregnancies. From pre-conceptual planning to the post-partum period, women should have access to joint care from an obstetrician with experience of high-risk pregnancies and a haematologist in a multidisciplinary setting. This paper provides an update with regards to Philadelphia-negative MPN in pregnancy, details local practise in an internationally recognised centre for patients with MPN and outlines a future research strategy.
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Affiliation(s)
- Susan E Robinson
- Haematology Department, Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Claire N Harrison
- Haematology Department, Guys and St. Thomas' NHS Foundation Trust, London, UK
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28
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Maze D, Kazi S, Gupta V, Malinowski AK, Fazelzad R, Shah PS, Shehata N. Association of Treatments for Myeloproliferative Neoplasms During Pregnancy With Birth Rates and Maternal Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e1912666. [PMID: 31584685 PMCID: PMC6784750 DOI: 10.1001/jamanetworkopen.2019.12666] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/16/2019] [Indexed: 12/15/2022] Open
Abstract
Importance Myeloproliferative neoplasms (MPNs) are increasingly being identified in women of childbearing potential. Pregnancy in women with MPNs is associated with maternal thrombosis, hemorrhage, and placental dysfunction leading to fetal growth restriction or loss. Objective To evaluate the association between the use of aspirin, heparin, interferon, or combinations and live birth rate and adverse maternal outcomes in pregnant women with MPNs. Data Sources Systematic searches of MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the MEDLINE Epub Ahead of Print and In-Process and Other Non-Indexed Citations from inception to July 19, 2018, with no language restrictions, was conducted. Key search terms included myeloproliferative disorders, polycythemia vera, essential thrombocythemia, and primary myelofibrosis. Study Selection A study was eligible if it included pregnant patients with MPNs; interventions included aspirin, heparin, and/or interferon; there was a comparison group in which patients did not receive the intervention; the study reported on at least 1 of the study outcomes; and it was a randomized, case-control, or cohort study or series of at least 10 pregnancies. Data were extracted in duplicate; 0.5% of identified studies met selection criteria. Data Extraction and Synthesis The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and reported in accordance with Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Data were pooled using the Mantel-Haenszel approach. Main Outcomes and Measures Outcomes were the number of live births and maternal complications, specifically, arterial or venous thrombosis, hemorrhage, and preeclampsia. Results Twenty-two studies reporting on 1210 pregnancies were included. The live birth rate was 71.3% (95% CI, 65.1%-77.6%). Use of aspirin (11 studies, 227 patients; unadjusted odds ratio, 8.6; 95% CI, 4.0-18.1) and interferon (6 studies, 90 patients; unadjusted odds ratio, 9.7; 95% CI, 2.3-41.0) were associated with higher odds of live birth. Addition of heparin to aspirin was not associated with higher odds of live birth (6 studies, 96 patients; unadjusted odds ratio, 2.1; 95% CI, 0.5-9.0). The most common adverse maternal event was preeclampsia, with an incidence of 3.1% (95% CI, 1.7%-4.5%). Conclusions and Relevance Most studies reported on pregnancy with essential thrombocythemia. Few studies reported on pregnancy with polycythemia vera and none with myelofibrosis met the inclusion criteria. Most studies were retrospective and early pregnancy losses may have been underreported. Moderate-quality evidence suggests that aspirin or interferon is associated with higher odds of live birth in pregnant women with MPN.
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Affiliation(s)
- Dawn Maze
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Sajida Kazi
- University of Toronto, Toronto, Ontario, Canada
- Division of Hematology, University Health Network, Toronto, Ontario, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Ann Kinga Malinowski
- University of Toronto, Toronto, Ontario, Canada
- Division of Maternal–Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Rouhi Fazelzad
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Prakesh S. Shah
- University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nadine Shehata
- University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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29
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Barbui T, De Stefano V, Falanga A, Finazzi G, Martinelli I, Rodeghiero F, Vannucchi AM, Barosi G. Addressing and proposing solutions for unmet clinical needs in the management of myeloproliferative neoplasm-associated thrombosis: A consensus-based position paper. Blood Cancer J 2019; 9:61. [PMID: 31395856 PMCID: PMC6687826 DOI: 10.1038/s41408-019-0225-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
This article presents the results of a group discussion among an ad hoc constituted Panel of experts aimed at highlighting unmet clinical needs (UCNs) in the management of thrombotic risk and thrombotic events associated with Philadelphia-negative myeloproliferative neoplasms (Ph-neg MPNs). With the Delphi technique, the challenges in Ph-neg MPN-associated thrombosis were selected. The most clinically relevant UCNs resulted in: (1) providing evidence of the benefits and risks of direct oral anticoagulants, (2) providing evidence of the benefits and risks of cytoreduction in patients with splanchnic vein thrombosis without hypercythemia, (3) improving knowledge of the role of the mutated endothelium in the pathogenesis of thrombosis, (4) improving aspirin dosing regimens in essential thrombocythemia, (5) improving antithrombotic management of Ph-neg MPN-associated pregnancy, (6) providing evidence for the optimal duration of anticoagulation for prophylaxis of recurrent VTE, (7) improving knowledge of the association between somatic gene mutations and risk factors for thrombosis, and (8) improving the grading system of thrombosis risk in polycythemia vera. For each of these issues, proposals for advancement in research and clinical practice were addressed. Hopefully, this comprehensive overview will serve to inform the design and implementation of new studies in the field.
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Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Istituto di Ematologia, Università Cattolica, Roma, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and the Haemostasis and Thrombosis Center, Papa Giovanni XXIII Hospital, Bergamo, Italy.,University of Milan Bicocca, Milan, Italy
| | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, Dept Experimental and Clinical medicine, and Denothe Center, University of Florence, Florence, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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30
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Dewarrat N, Kaiser J, Baud D, Alberio L, Gavillet M. Pregnancy with Chuvash Polycythaemia and Other Congenital Erythrocytosis. Acta Haematol 2019; 143:69-72. [PMID: 31167179 DOI: 10.1159/000499861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/22/2019] [Indexed: 11/19/2022]
Abstract
This original report describes the management of a pregnant woman with congenital erythrocytosis (Chuvash polycythaemia) and reviews the scarce data available in the literature. Therapy consisted of low-dose aspirin and phlebotomies to maintain haematocrit <50% while monitoring iron stores to avoid severe deficiency detrimental to the foetus. Despite normal initial foetal growth, the pregnancy was complicated by preterm birth due to chorioamnionitis. The placenta showed no signs of thrombotic events. The published reports cover 13 pregnancies in 8 patients, showing 1 first-trimester miscarriage, 5 infants with intrauterine growth restriction and/or preterm birth and 1 maternal thrombotic event. These cases were managed with phlebotomies, low-dose aspirin and/or low-molecular-weight heparin, although inconsistently.
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Affiliation(s)
- Natacha Dewarrat
- Service and Central Laboratory of Haematology, Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Julie Kaiser
- Service and Central Laboratory of Haematology, Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- Haematology Department, Institute Central des Hôpitaux (ICH), Sion, Switzerland
| | - David Baud
- Materno-Foetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant," University Hospital, Lausanne, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Haematology, Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Haematology, Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland,
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31
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Elli EM, Diral E, Gambacorti-Passerini C, Calori R, Carmosino I, Breccia M, Latagliata R, Di Veroli A. Management and outcome of 11 pregnancies in women with polycythemia vera. Leuk Res 2019; 81:25-26. [PMID: 30986630 DOI: 10.1016/j.leukres.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022]
Affiliation(s)
- E M Elli
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy.
| | - E Diral
- Hematology Division and Bone Marrow Unit, Ospedale San Gerardo, Monza, Italy
| | | | - R Calori
- Oncology Department, Ospedale Civile, Vimercate, Italy
| | - I Carmosino
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Rome, Italy
| | - M Breccia
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Rome, Italy
| | - R Latagliata
- Dipartimento di Biotecnologie Cellulari ed Ematologia, Università Sapienza, Rome, Italy
| | - A Di Veroli
- Hematology Division, Ospedale Belcolle, Viterbo, Italy
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