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Tahiraj X, Bakalli A, Krasniqi X, Çitaku H, Krasniqi F, Koçinaj D. Acute myocardial infarction and polycythemia rubra vera: The double effect of treatment with hydroxyurea. Radiol Case Rep 2024; 19:3386-3389. [PMID: 38827039 PMCID: PMC11140144 DOI: 10.1016/j.radcr.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 06/04/2024] Open
Abstract
We report a case of acute myocardial infarction in a patient with polycythemia rubra vera, who has been treated with hydroxyurea. The patient presented with chest pain extending to both arms accompanied by nausea and sweating. Hemoglobin was 18.1 mg/dL, hematocrit 53.2%, white blood cells 9600/mm³, and platelets 745,000/mm³. The levels of specific cardiac injury markers were increased, troponin I increased to 110 ng/mL and creatine kinase-MB to 361 U/l, respectively. Electrocardiography showed sinus rhythm with ST-segment elevation in leads V2-6, D1, and aVL as well as ST depression in D2, D3 and aVF. Echocardiography demonstrated hypokinesis of the interventricular septum and lateral wall with mildly reduced left ventricle (LV) ejection fraction (EF≈45%). Coronary angiography revealed proximal-LAD subtotal occlusion and 80% mid-LAD stenosis with distal-LAD vasospasm. Percutaneous coronary intervention was performed with a drug-eluting stent in mid- and proximal-LAD. Hypercoagulable state of polycythemia rubra vera may be complicated with acute myocardial infarction, in addition to the vasospastic effect and endothelium lesions of hydroxyurea regardless its favorable effect as a standard therapy.
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Affiliation(s)
| | - Aurora Bakalli
- Medical Faculty, University of Prishtina “Hasan Prishtina”, Republic of kosova
- University Clinical Center of Kosova, Republic of kosova
| | - Xhevdet Krasniqi
- Medical Faculty, University of Prishtina “Hasan Prishtina”, Republic of kosova
- University Clinical Center of Kosova, Republic of kosova
| | - Hajdin Çitaku
- University Clinical Center of Kosova, Republic of kosova
| | - Flora Krasniqi
- University Clinical Center of Kosova, Republic of kosova
| | - Dardan Koçinaj
- University Clinical Center of Kosova, Republic of kosova
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2
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Segura-Díaz A, Stuckey R, Florido Y, Sobas M, Álvarez-Larrán A, Ferrer-Marín F, Pérez-Encinas M, Carreño-Tarragona G, Fox ML, Tazón Vega B, Cuevas B, López Rodríguez JF, Sánchez-Farías N, González-Martín JM, Gómez-Casares MT, Bilbao-Sieyro C. DNMT3A/TET2/ASXL1 Mutations are an Age-independent Thrombotic Risk Factor in Polycythemia Vera Patients: An Observational Study. Thromb Haemost 2024; 124:669-675. [PMID: 38190984 PMCID: PMC11199052 DOI: 10.1055/a-2239-9265] [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: 09/11/2023] [Accepted: 12/23/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Polycythemia vera (PV) patients are classified as high or low thrombotic risk based on age and prior history of thrombosis. Despite adherence to treatment recommendations, vascular events remain frequent, leading us to question whether thrombotic risk stratification could be improved. We previously reported an association between thrombotic events and mutations in DTA genes (DNMT3A, TET2, and ASXL1). The objective of this study was to confirm this observation in a larger series of PV patients. METHODS PV patients with a minimum follow-up of 3 years were recruited from 8 European centers. Medical history was searched for thrombotic event recorded at any time and next-generation sequencing carried out with a myeloid panel. Multivariable logistic regression evaluated the impact of variables on thrombotic risk. Kaplan-Meier thrombosis-free survival curves were compared by the log rank test. Associations in the total cohort were confirmed in a case-control study to exclude selection bias. RESULTS Of the 136 patients recruited, 74 (56.1%) had a thrombotic event, with an incidence density of 2.83/100 person-years. In multivariable analysis, DTA mutation was a risk factor for thrombotic event, being predictive for shorter thrombosis-free survival in the whole cohort (p = 0.007), as well as in low-risk patients (p = 0.039) and older patients (p = 0.009), but not for patients with a prediagnostic event. A gender- and age-matched case-control study confirmed the increased risk of thrombotic event for PV patients with a DTA mutation. CONCLUSION Our results support the use of molecular testing at diagnosis to help predict which PV patients are at higher risk of developing thrombosis.
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Affiliation(s)
- Adrián Segura-Díaz
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Ruth Stuckey
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Yanira Florido
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Marta Sobas
- Department of Hematology and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | | | - Francisca Ferrer-Marín
- Hematology Department, Hospital Morales Messeguer, Instituto Murciano de Investigación Biosanitaria, Centro de Investigación Biomédica en Red de Enfermedades Raras, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Manuel Pérez-Encinas
- Hematology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - María L. Fox
- Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Beatriz Cuevas
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Juan F. López Rodríguez
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Nuria Sánchez-Farías
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - María T. Gómez-Casares
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Cristina Bilbao-Sieyro
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Morphology Department, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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3
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Fukatsu M, Ikezoe T. Cancer-associated thrombosis in hematologic malignancies. Int J Hematol 2024; 119:516-525. [PMID: 38270784 DOI: 10.1007/s12185-023-03690-z] [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: 11/01/2023] [Revised: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024]
Abstract
Patients with hematologic malignancies are often complicated not only by severe bleeding due to thrombocytopenia and disseminated intravascular coagulation but also by thromboembolic events, just like in patients with solid cancers, and these events can negatively impact patient outcomes. Nevertheless, the prevention and treatment of cancer-associated thrombosis (CAT) in hematologic malignancies has not been adequately investigated due to the limited size, heterogeneity, and unique pathophysiology of the patient population. This article summarizes the current understanding, risk factors, prediction models, and optimal prevention and treatment strategies of CAT in hematologic malignancies on a disease-by-disease basis, including acute leukemia, lymphoma, myeloma, and myeloproliferative neoplasms. Specific considerations of novel molecular targeted therapeutics introduced in recent years, such as immunomodulatory drugs and tyrosine kinase inhibitors, are also discussed based on the latest clinical trials.
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Affiliation(s)
- Masahiko Fukatsu
- Department of Hematology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Ferrer-Marín F, Hernández-Boluda JC, Alvarez-Larrán A. Essential thrombocythaemia: A contemporary approach with new drugs on the horizon. Br J Haematol 2024; 204:1605-1616. [PMID: 38586911 DOI: 10.1111/bjh.19403] [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: 12/28/2023] [Revised: 03/02/2024] [Accepted: 03/03/2024] [Indexed: 04/09/2024]
Abstract
Essential thrombocythaemia (ET) is a myeloproliferative neoplasm characterized by an increased risk of vascular complications and a tendency to progress to myelofibrosis and acute leukaemia. ET patients have traditionally been stratified into two thrombosis risk categories based on age older than 60 years and a history of thrombosis. More recently, the revised IPSET-thrombosis scoring system, which accounts for the increased risk linked to the JAK2 mutation, has been incorporated into most expert recommendations. However, there is increasing evidence that the term ET encompasses different genomic entities, each with a distinct clinical course and prognosis. Moreover, the effectiveness and toxicity of cytoreductive and anti-platelet treatments differ depending on the molecular genotype. While anti-platelets and conventional cytoreductive agents, mainly hydroxycarbamide (hydroxyurea), anagrelide and pegylated interferon, remain the cornerstone of treatment, recent research has shed light on the effectiveness of novel therapies that may help improve outcomes. This comprehensive review focuses on the evolving landscape of treatment strategies in ET, with an emphasis on the role of molecular profiling in guiding therapeutic decisions. Besides evidence-based management according to revised IPSET-thrombosis stratification, we also provide specific observations for those patients with CALR-, MPL-mutated and triple-negative ET, as well as cases with high-risk mutations.
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Affiliation(s)
- Francisca Ferrer-Marín
- Hematology Service, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISC III, Universidad Católica San Antonio (UCAM), Murcia, Spain
| | - Juan Carlos Hernández-Boluda
- Department of Hematology, Hospital Clínico Universitario de Valencia, INCLIVA, University of Valencia, Valencia, Spain
| | - Alberto Alvarez-Larrán
- Department of Hematology, Hospital Clínic, Barcelona, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
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Castelli R, Berzuini A, Manetti R, Delitala AP, Castro D, Sanna G, Sircana MC, Profili NI, Bartoli A, La Cava L, Lambertenghi Deliliers G, Donadoni M, Gidaro A. ADAMTS13, von Willebrand Factor, Platelet Microparticles, Factor VIII, and Impact of Somatic Mutations in the Pathogenesis of Splanchnic Vein Thrombosis Associated with BCR-ABL-Negative Myeloproliferative Neoplasms. Life (Basel) 2024; 14:486. [PMID: 38672756 PMCID: PMC11051276 DOI: 10.3390/life14040486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) are often associated with splanchnic vein thrombosis (SVT). Not all the factors involved in the thrombotic tendency are currently known. OBJECTIVES This study aims to evaluate a possible association between ADAMTS13, von Willebrand factor (VWF), platelet microvesicles (MV), and factor VIII activity (FVIII:C) with thrombotic events in MPN patients. MATERIALS AND METHODS In total, 36 consecutive MPN patients with SVT were enrolled. The MPNs were diagnosed based on clinical characteristics and one or more gene mutations among JAK-2, CALR, and MPL. As controls, 50 randomly selected patients with MPN without thrombosis, 50 patients with deep vein thrombosis without MPNs, and 50 healthy blood donors were evaluated. Complete blood count, ADAMTS13, VWF, MV, and FVIII:C in plasma were measured in all the subjects. RESULTS The JAK-2 mutation was found in 94% of the patients with SVT, but none were triple-negative for genetic mutations (JAK2 V617F, CALR, MPL, and exon 12). Compared to the normal subjects, in all the MPN patients (with or without SVT), the levels of ADAMTS13 were found to be significantly lower (p < 0.001) and the MV concentrations were significantly higher (p < 0.001). Among the MPN patients, the VWF and FVIII:C levels were significantly higher in the patients with SVT than those without thrombosis (p = 0.007 and p = 0.04, respectively). Splenomegaly was present in 78% of MPN patients with SVT and in 30% of those without SVT (p < 0.001). The ADAMTS13/VWF ratio was reduced in all the patients, but not in the healthy blood donors (p < 0.001). CONCLUSIONS The significant increase in circulating MV, VWF, and FVIII:C in the MPN patients and in the patients with thrombosis supports the role of endothelium damage in promoting thrombotic events. In particular, a significant increase in VWF and FVIII:C levels was found in the MPN patients with SVT.
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Affiliation(s)
- Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | | | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Alessandro Palmerio Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Marta Chiara Sircana
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Nicia Isabella Profili
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Arianna Bartoli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | | | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
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Morsia E, Torre E, Martini F, Morè S, Poloni A, Olivieri A, Rupoli S. Exploring the Molecular Aspects of Myeloproliferative Neoplasms Associated with Unusual Site Vein Thrombosis: Review of the Literature and Latest Insights. Int J Mol Sci 2024; 25:1524. [PMID: 38338802 PMCID: PMC10855502 DOI: 10.3390/ijms25031524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Myeloproliferative neoplasms (MPNs) are the leading causes of unusual site thrombosis, affecting nearly 40% of individuals with conditions like Budd-Chiari syndrome or portal vein thrombosis. Diagnosing MPNs in these cases is challenging because common indicators, such as spleen enlargement and elevated blood cell counts, can be obscured by portal hypertension or bleeding issues. Recent advancements in diagnostic tools have enhanced the accuracy of MPN diagnosis and classification. While bone marrow biopsies remain significant diagnostic criteria, molecular markers now play a pivotal role in both diagnosis and prognosis assessment. Hence, it is essential to initiate the diagnostic process for splanchnic vein thrombosis with a JAK2 V617F mutation screening, but a comprehensive approach is necessary. A multidisciplinary strategy is vital to accurately determine the specific subtype of MPNs, recommend additional tests, and propose the most effective treatment plan. Establishing specialized care pathways for patients with splanchnic vein thrombosis and underlying MPNs is crucial to tailor management approaches that reduce the risk of hematological outcomes and hepatic complications.
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Affiliation(s)
- Erika Morsia
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Elena Torre
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Francesco Martini
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
- Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Sonia Morè
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Antonella Poloni
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Attilio Olivieri
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
- Department of Clinical and Molecular Sciences (DISCLIMO), Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Serena Rupoli
- Hematology Clinic, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Duminuco A, Harrington P, Harrison C, Curto-Garcia N. Polycythemia Vera: Barriers to and Strategies for Optimal Management. Blood Lymphat Cancer 2023; 13:77-90. [PMID: 38146420 PMCID: PMC10749566 DOI: 10.2147/blctt.s409443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/16/2023] [Indexed: 12/27/2023]
Abstract
Polycythemia vera (PV) is a subtype of myeloproliferative neoplasms characterized by impaired quality of life and severe complications. Despite the increasingly in-depth knowledge of this condition, it necessitates a multifaceted management approach to mitigate symptoms and prevent thrombotic and hemorrhagic events, ensuring prolonged survival. The therapeutic landscape has been revolutionized in recent years, where venesection and hydroxycarbamide associated with antiplatelet therapy have a central role and are now accompanied by other drugs, such as interferon and Janus kinase inhibitors. Ongoing research and advancements in targeted therapies hold promise for further enhancing the therapeutic choice for PV management.
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Affiliation(s)
- Andrea Duminuco
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Haematology with BMT Unit, A.O.U. Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Patrick Harrington
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Claire Harrison
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Natalia Curto-Garcia
- Department of Haematology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Manan MR, Kipkorir V, Nawaz I, Waithaka MW, Srichawla BS, Găman AM, Diaconu CC, Găman MA. Acute myocardial infarction in myeloproliferative neoplasms. World J Cardiol 2023; 15:571-581. [PMID: 38058401 PMCID: PMC10696206 DOI: 10.4330/wjc.v15.i11.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/21/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are a heterogeneous group of hematologic malignancies characterized by an abnormal proliferation of cells of the myeloid lineage. Affected individuals are at increased risk for cardiovascular and thrombotic events. Myocardial infarction (MI) may be one of the earliest clinical manifestations of MPNs or may be a thrombotic complication that develops during the natural course of the disease. In the present review, we examine the epidemiology, pathogenesis, clinical presentation, and management of MI in MPNs based on the available literature. Moreover, we review potential biomarkers that could mediate the MI-MPNs crosstalk, from classical biochemical tests, e.g., lactate dehydrogenase, creatine kinase and troponins, to pro-inflammatory cytokines, oxidative stress markers, and clonal hematopoiesis.
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Affiliation(s)
| | - Vincent Kipkorir
- Department of Human Anatomy and Physiology, University of Nairobi, Nairobi 00100, Kenya
| | - Iqra Nawaz
- Quaid-e-Azam Medical College, Bahawalpur 63100, Pakistan
| | | | - Bahadar Singh Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
| | - Amelia Maria Găman
- Department of Pathophysiology, University of Medicine and Pharmacy of Craiova, Craiova 200143, Romania
- Clinic of Hematology, Filantropia City Hospital, Craiova 200143, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest 050474, Romania
- Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, Bucharest 105402, Romania
| | - Mihnea-Alexandru Găman
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Cellular and Molecular Pathology, Stefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest 030304, Romania.
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Benevolo G, Marchetti M, Melchio R, Beggiato E, Sartori C, Biolé CA, Rapezzi D, Bruno B, Milan A. Diagnosis and Management of Cardiovascular Risk in Patients with Polycythemia Vera. Vasc Health Risk Manag 2023; 19:765-778. [PMID: 38025519 PMCID: PMC10676644 DOI: 10.2147/vhrm.s429995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by aberrant myeloid lineage hematopoiesis with excessive red blood cell and pro-inflammatory cytokine production. Patients with PV present with a range of thrombotic and hemorrhagic symptoms that affect quality of life and reduce overall survival expectancy. Thrombotic events, transformation into acute myeloid leukemia, and myelofibrosis are largely responsible for the observed mortality. Treatment of PV is thus primarily focused on symptom control and survival extension through the prevention of thrombosis and leukemic transformation. Patients with PV frequently experience thrombotic events and have elevated cardiovascular risk, including hypertension, dyslipidemias, obesity, and smoking, all of which negatively affect survival. To reduce the risk of thrombotic complications, PV therapy should aim to normalize hemoglobin, hematocrit, and leukocytosis and, in addition, identify and modify cardiovascular risk factors. Herein, we review what is currently known about the associated cardiovascular risk and propose strategies for diagnosing and managing patients with PV.
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Affiliation(s)
- Giulia Benevolo
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Monia Marchetti
- Hematology and Transplant Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Remo Melchio
- Division of Internal Medicine, A.O. S. Croce E Carle, Cuneo, Italy
| | - Eloise Beggiato
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Sartori
- Cardiology, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | - Benedetto Bruno
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Molecular Biotechnolgies and Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Milan
- Department of Medical Sciences, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
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Duran Luciano P, Sabella-Jiménez V. ST-Segment Elevation Myocardial Infarction and Bleeding Complications in JAK2-Negative Polycythemia. Tex Heart Inst J 2023; 50:e238148. [PMID: 37872693 PMCID: PMC10658142 DOI: 10.14503/thij-23-8148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Thrombotic and bleeding complications are major causes of morbidity and mortality in patients with polycythemia vera, who predominantly present with an alteration in the JAK2 gene. Because of their hypercoagulable state and risk of hemorrhage, patients with polycythemia vera who present with an acute myocardial infarction pose a challenge to physicians. This case report describes the presentation and treatment of a Hispanic patient with JAK2 V617F-negative primary polycythemia who developed cardiac arrest and ST-segment elevation myocardial infarction owing to complete occlusion of the left anterior descending artery as well as bleeding complications and postmyocardial pericarditis.
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Affiliation(s)
- Priscilla Duran Luciano
- Department of Cardiology, Albert Einstein College of Medicine, Bronx, New York
- The William J. Harrington Medical Training Program for Latin America and the Caribbean, Miller School of Medicine, University of Miami, Miami, Florida
| | - Vanessa Sabella-Jiménez
- The William J. Harrington Medical Training Program for Latin America and the Caribbean, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Public Health, Universidad del Norte, Barranquilla, Colombia
- Department of Medicine, Universidad del Norte, Barranquilla, Colombia
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Wille K, Deventer E, Sadjadian P, Becker T, Kolatzki V, Hünerbein K, Meixner R, Jiménez-Muñoz M, Fuchs C, Griesshammer M. Arterial and Venous Thromboembolic Complications in 832 Patients with BCR-ABL-Negative Myeloproliferative Neoplasms. Hamostaseologie 2023. [PMID: 37813367 DOI: 10.1055/a-2159-8767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Arterial (ATE) and venous (VTE) thromboembolic complications are common causes of morbidity and mortality in BCR-ABL-negative myeloproliferative neoplasms (MPNs). However, there are few studies that include all MPN subtypes and focus on both MPN-associated ATE and VTE. In our single-center retrospective study of 832 MPN patients, a total of 180 first thromboembolic events occurred during a median follow-up of 6.6 years (range: 0-37.6 years), of which 105 were VTE and 75 were ATE. The probability of a vascular event at the end of the follow-up period was 36.2%, and the incidence rate for all first ATE/VTE was 2.43% patient/year. The most frequent VTE localizations were deep vein thrombosis with or without pulmonary embolism (incidence rate: 0.59% patient/year), while strokes were the most frequent ATE with an incidence rate of 0.32% patient/year. When comparing the group of patients with ATE/VTE (n = 180) and the group without such an event (n = 652) using multivariate Cox regression analyses, patients with polycythemia vera (hazard ratio [HR]: 1.660; [95% confidence interval [CI] 1.206, 2.286]) had a significantly higher risk of a thromboembolic event than the other MPN subtypes. In contrast, patients with a CALR mutation had a significantly lower risk of thromboembolism compared with JAK2-mutated MPN patients (HR: 0.346; [95% CI: 0.172, 0.699]). In summary, a high incidence of MPN-associated VTE and ATE was observed in our retrospective study. While PV patients or generally JAK2-mutated MPN patients had a significantly increased risk of such vascular events, this risk was reduced in CALR-mutated 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, Bochum, Germany
| | - Eva Deventer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Parvis Sadjadian
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Tatjana Becker
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Vera Kolatzki
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Karlo Hünerbein
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
| | - Raphael Meixner
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
| | - Marina Jiménez-Muñoz
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
| | - Christiane Fuchs
- Core Facility Statistical Consulting, Helmholtz Zentrum München, Munich, Germany
- Faculty of Business Administration and Economics, Bielefeld University, Bielefeld, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Bochum, Germany
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12
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Kuipers RS, Kok L, Virmani R, Tefferi A. Essential thrombocytosis: diagnosis, differential diagnosis, complications and treatment considerations of relevance for a cardiologist. Neth Heart J 2023; 31:371-378. [PMID: 36757576 PMCID: PMC10516821 DOI: 10.1007/s12471-023-01757-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 02/10/2023] Open
Abstract
Essential thrombocytosis (ET) is a rare haematological malignancy, with an incidence rate of 1.5-2.5/100,000 per year. For many patients with ET the first manifestation of their underlying disease is a thrombotic or haemorrhagic complication. A recent retrospective study revealed an incidence rate of at least 2.1% in people under 40 years presenting with an acute coronary syndrome, although the diagnosis was initially missed in all cases. Thus, cardiologists face a much higher than average incidence rate of ET in their daily practice, but seem insufficiently aware of the disease. The current review summarises symptoms, (differential) diagnosis, complications and treatment considerations of ET of relevance for a cardiologist. Typical symptoms, besides thrombosis and haemorrhage, include erythromelalgia and aquagenic pruritus, while platelets > 450 × 109/l are a diagnostic for ET once other myeloproliferative neoplasms, secondary and spurious thrombocytosis have been excluded. With regard to treatment, timing of revascularisation depends on the presence of ischaemia and concurrent platelet counts. In the presence of ischaemia, revascularisation should not be delayed and adequate platelet counts can be achieved by platelet apheresis. In the absence of ischaemia, revascularisation can be delayed until adequate platelet counts have been achieved by cytoreductive therapies. Cardiologists should be aware of/screen for possible ET.
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Affiliation(s)
- R S Kuipers
- OLVG Heart Centre, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
- Department of Cardiology, Dijklander Hospital, Purmerend/Hoorn, The Netherlands.
| | - L Kok
- OLVG Heart Centre, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Cardiology, Spaarne Hospital, Haarlem, The Netherlands
| | - R Virmani
- CVPath Institute, Gaithersburg, MD, USA
| | - A Tefferi
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
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13
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Arai M, Nakase K, Nishimura F, Nakagawa I, Nakase H. Late In-Stent Thrombosis After Carotid Artery Stenting for Symptomatic Internal Carotid Artery Stenosis in a Patient With JAK2 V617F-Positive Essential Thrombocythemia: An Illustrative Case Report. Cureus 2023; 15:e47688. [PMID: 38021556 PMCID: PMC10674047 DOI: 10.7759/cureus.47688] [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] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Essential thrombocythemia (ET) is a myeloproliferative disorder complicated by thrombosis in 13% of cases. The Janus kinase 2 (JAK2) V617Fmutation is present in 60% of ET cases, and it has recently been reported that the mutation itself is a significant contributor to ischemic stroke. Here, we present an illustrative case of late in-stent thrombosis following carotid artery stenting (CAS) in a patient with ET and the JAK2 V617F mutation presenting with symptomatic internal carotid artery (ICA) stenosis. An 80-year-old man with a history of JAK2 V617F-positive ET suffered from left upper motor weakness and numbness. Magnetic resonance imaging/magnetic resonance angiography revealed multiple acute cerebral infarctions scattered in the right frontal and parietal lobes and right ICA stenosis. Despite continued antiplatelet therapy, plaque size did not decrease. CAS was performed one month later; however, five months after the procedure, in-stent thrombus growth was observed, leading to severe stenosis despite administering antiplatelet or anticoagulant drugs. The thrombus was eventually resolved with increased doses of hydroxyurea and aspirin administration. In conclusion, controlling platelets and inflammation with hydroxyurea and aspirin may help improve the condition in case of rapid thrombosis due to the JAK2 V617F mutation, unlike other thromboses. This case highlights the importance of careful follow-up after CAS.
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Affiliation(s)
- Mika Arai
- Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Kenta Nakase
- Neurosurgery, Nara Medical University, Kashihara, JPN
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14
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Tefferi A, Barbui T. Polycythemia vera: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1465-1487. [PMID: 37357958 DOI: 10.1002/ajh.27002] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) is a JAK2-mutated myeloproliferative neoplasm characterized by clonal erythrocytosis; other features include leukocytosis, thrombocytosis, splenomegaly, pruritus, constitutional symptoms, microcirculatory disturbances, and increased risk of thrombosis and progression into myelofibrosis (post-PV MF) or acute myeloid leukemia (AML). DIAGNOSIS A working diagnosis is considered in the presence of a JAK2 mutation associated with hemoglobin/hematocrit levels of >16.5 g/dL/49% in men or 16 g/dL/48% in women; morphologic confirmation by bone marrow examination is advised but not mandated. CYTOGENETICS Abnormal karyotype is seen in 15%-20% of patients with the most frequent sole abnormalities being +9 (5%), loss of chromosome Y (4%), +8 (3%), and 20q- (3%). MUTATIONS Over 50% of patients harbor DNA sequence variants/mutations other than JAK2, with the most frequent being TET2 (18%) and ASXL1 (15%). Prognostically adverse mutations include SRSF2, IDH2, RUNX1, and U2AF1, with a combined incidence of 5%-10%. SURVIVAL AND PROGNOSIS Median survival is ⁓15 years but exceeds 35 years for patients aged ≤40 years. Risk factors for survival include older age, leukocytosis, abnormal karyotype, and the presence of adverse mutations. Twenty-year risk for thrombosis, post-PV MF, or AML are ⁓26%, 16% and 4%, respectively. RISK FACTORS FOR THROMBOSIS Two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). Additional predictors for arterial thrombosis include cardiovascular risk factors and for venous thrombosis higher absolute neutrophil count and JAK2V617F allele burden. TREATMENT Current goal of therapy is to prevent thrombosis. Periodic phlebotomy, with a hematocrit target of <45%, combined with once- or twice-daily aspirin (81 mg) therapy, absent contraindications, is the backbone of treatment in all patients, regardless of risk category. Cytoreductive therapy is reserved for high-risk disease with first-line drugs of choice being hydroxyurea and pegylated interferon-α and second-line busulfan and ruxolitinib. In addition, systemic anticoagulation is advised in patients with venous thrombosis history. ADDITIONAL TREATMENT CONSIDERATIONS At the present time, we do not consider a drug-induced reduction in JAK2V617F allele burden, which is often incomplete and seen not only with peg-IFN but also with ruxolitinib and busulfan, as an indicator of disease-modifying activity, unless accompanied by cytogenetic and independently-verified morphologic remission. Accordingly, we do not use the specific parameter to influence treatment choices. The current review also includes specific treatment strategies in the context of pregnancy, splanchnic vein thrombosis, pruritus, perioperative care, and post-PV MF.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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15
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Yao Y, He L, Mei L, Weng Y, Huang J, Wei S, Li R, Tian S, Liu P, Ruan X, Wang D, Zhou F, Lei C. Cell damage evaluation by intelligent imaging flow cytometry. Cytometry A 2023; 103:646-654. [PMID: 36966466 DOI: 10.1002/cyto.a.24731] [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: 11/29/2022] [Revised: 02/22/2023] [Accepted: 03/21/2023] [Indexed: 03/27/2023]
Abstract
Essential thrombocythemia (ET) is an uncommon situation in which the body produces too many platelets. This can cause blood clots anywhere in the body and results in various symptoms and even strokes or heart attacks. Removing excessive platelets using acoustofluidic methods receives extensive attention due to their high efficiency and high yield. While the damage to the remaining cells, such as erythrocytes and leukocytes is yet evaluated. Existing cell damage evaluation methods usually require cell staining, which are time-consuming and labor-intensive. In this paper, we investigate cell damage by optical time-stretch (OTS) imaging flow cytometry with high throughput and in a label-free manner. Specifically, we first image the erythrocytes and leukocytes sorted by acoustofluidic sorting chip with different acoustic wave powers and flowing speed using OTS imaging flow cytometry at a flowing speed up to 1 m/s. Then, we employ machine learning algorithms to extract biophysical phenotypic features from the cellular images, as well as to cluster and identify images. The results show that both the errors of the biophysical phenotypic features and the proportion of abnormal cells are within 10% in the undamaged cell groups, while the errors are much greater than 10% in the damaged cell groups, indicating that acoustofluidic sorting causes little damage to the cells within the appropriate acoustic power, agreeing well with clinical assays. Our method provides a novel approach for high-throughput and label-free cell damage evaluation in scientific research and clinical settings.
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Affiliation(s)
- Yifan Yao
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Li He
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Liye Mei
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Yueyun Weng
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
- The Key Laboratory of Transients in Hydraulic Machinery of Ministry of Education, School of Power and Mechanical Engineering, Wuhan University, Wuhan, China
| | - Jin Huang
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Shubin Wei
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Rubing Li
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Sheng Tian
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Pan Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaolan Ruan
- Department of Hematology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Du Wang
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Cheng Lei
- The Institute of Technological Sciences, Wuhan University, Wuhan, China
- Suzhou Institute of Wuhan University, Suzhou, China
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16
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Chen J, Dong H, Fu R, Liu X, Xue F, Liu W, Chen Y, Sun T, Ju M, Dai X, Li H, Wang W, Chi Y, Yang R, Zhang L. Machine learning analyses constructed a novel model to predict recurrent thrombosis in adults with essential thrombocythemia. J Thromb Thrombolysis 2023:10.1007/s11239-023-02833-7. [PMID: 37249742 DOI: 10.1007/s11239-023-02833-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 05/31/2023]
Abstract
The current study involving 318 essential thrombocythemia (ET) patients with prior thrombosis was designed to identify risk factors that were predictive of recurrent thrombosis. The whole cohort was randomly split into derivation and validation cohorts. The random forest method, support vector machine with built-in recursive feature elimination model, and logistic multivariable analysis were performed in the derivation cohort, and cardiovascular risk factor (CVF) and RBC distribution width with standard deviation (RDW-SD) were finally selected as independent predictors. Subsequently we devise a 3-tiered model (low risk: 0 points; intermediate risk: 1-1.5 points; and high risk: 2.5 points) and it showed good discrimination in all cohorts. Moreover, the model was significantly correlated with rethrombosis-free survival (rTFS) (p = 0.0007 in the derivation cohort; p = 0.0019 in the validation cohort). In the whole cohort, cytoreductive therapy was more effective than antiplatelet agents alone for 10-year rTFS (p = 0.0336). No significant difference in 10-year rTFS was observed among interferon (IFN), hydroxyurea (HU), and IFN + HU therapy (p = 0.444). The present study helps identify individuals who need close monitoring and provides valuable risk signals for recurrence in ET patients with prior thrombosis.
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Affiliation(s)
- Jia Chen
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huiyuan Li
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wentian Wang
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ying Chi
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
- Tianjin Institutes of Health Science, Tianjin, 301600, China.
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17
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Găman MA, Cozma MA, Manan MR, Srichawla BS, Dhali A, Ali S, Nahian A, Elton AC, Simhachalam Kutikuppala LV, Suteja RC, Diebel S, Găman AM, Diaconu CC. Budd-Chiari syndrome in myeloproliferative neoplasms: A review of literature. World J Clin Oncol 2023; 14:99-116. [PMID: 37009527 PMCID: PMC10052333 DOI: 10.5306/wjco.v14.i3.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/10/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs. Classical, Philadelphia-negative MPNs, i.e., polycythemia vera, essential thrombocythemia and primary myelofibrosis, exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites, e.g., portal, splanchnic or hepatic veins, the placenta or cerebral sinuses. The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury, stasis, elevated leukocyte adhesion, integrins, neutrophil extracellular traps, somatic mutations (e.g., the V617F point mutation in the JAK2 gene), microparticles, circulating endothelial cells, and other factors, to name a few. Herein, we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs, with a particular focus on its epidemiology, pathogenesis, histopathology, risk factors, classification, clinical presentation, diagnosis, and management.
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Affiliation(s)
- Mihnea-Alexandru Găman
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Matei-Alexandru Cozma
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
| | | | - Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts 01655, United States
| | - Arkadeep Dhali
- Department of Internal Medicine, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, United Kingdom
| | - Sajjad Ali
- Department of Medicine, Ziauddin University, Karachi 75600, Pakistan
| | - Ahmed Nahian
- California Baptist University-Lake Erie College of Osteopathic Medicine, Riverside, CA 92504, United States
| | - Andrew C Elton
- University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - L V Simhachalam Kutikuppala
- Department of General Surgery, Dr NTR University of Health Sciences, Andhra Pradesh, Vijayawada 520008, India
| | - Richard Christian Suteja
- Department of Undergraduate Medicine, Faculty of Medicine, Udayana University Denpasar, Bali 80232, Indonesia
| | - Sebastian Diebel
- Department of Family Medicine, Northern Ontario School of Medicine Timmins, Ontario 91762, Canada
| | - Amelia Maria Găman
- Department of Pathophysiology, University of Medicine and Pharmacy of Craiova, Romania & Clinic of Hematology, Filantropia City Hospital, Craiova 200143, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Romania & Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, Bucharest 105402, Romania
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18
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Dural Venous Sinus Thrombosis and Papilledema Related to JAK2 Mutation: A Case Series. Can J Neurol Sci 2023; 50:194-200. [PMID: 34906267 DOI: 10.1017/cjn.2021.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Dural venous sinus thrombosis (DVST) is an important cause of papilledema. Patients diagnosed with DVST should undergo work-up for underlying hypercoagulable state, including genetic causes. One important prothrombotic mutation is in the JAK2 gene, which is a driver of myeloproliferative neoplasms including polycythemia vera (PV). We aimed to determine the prevalence of JAK2 mutation in patients in presenting to neuro-ophthalmology clinic with DVST and papilledema. METHODS Retrospective case series of patients seen in a tertiary neuro-ophthalmology practice who presented with papilledema due to DVST and were investigated for presence of JAK2 mutation. RESULTS Four out of 15 patients with DVST (26%) were found to have JAK2 V617F mutation which led to subsequent diagnosis of PV in 2. One additional patient had a known diagnosis of essential thrombocytosis. We describe the clinical presentation of these four patients with papilledema and JAK2 mutation. CONCLUSIONS A significant proportion of patients with papilledema secondary to DVST will harbor mutations in the JAK2 gene. Clinicians should be aware of this mutation as early testing will facilitate timely diagnosis and treatment of myeloproliferative disease to improve prognosis and reduce risk of recurrent thrombotic events.
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19
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Baysal M, Bayrak M, Eşkazan AE. Current evidence on the use of direct oral anticoagulants in patients with myeloproliferative neoplasm: a systematic review. Expert Rev Hematol 2023; 16:131-140. [PMID: 36709432 DOI: 10.1080/17474086.2023.2174515] [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: 01/30/2023]
Abstract
INTRODUCTION Thromboembolic events in myeloproliferative neoplasms (MPNs) are one of the most important causes of mortality and morbidity, in which vitamin K antagonists (VKAs) have been used mostly. Recently, direct oral anticoagulants (DOACs) are used in venous thromboembolism (VTE) and cancer-associated thrombosis (CAT). With the adoption of data from CAT and VTE, the usage of DOACs in MPNs is increasing. AREAS COVERED In this paper, we performed a systematic review to the current literature regarding the usage of DOACs in MPNs. Eleven studies involving 944 patients were included. The reasons for initiating DOACs were secondary prophylaxis for thrombosis (arterial or venous) and atrial fibrillation (AF) in 562 and 382 patients, respectively. A total of 84 (8.9%) recurrent thrombotic (arterial or venous) events recorded. Forty-six (8.1%) events occurred in the thrombosis group (arterial or venous) and 38 (9.9%) events occurred in patients with AF. EXPERT OPINION Ease of management and patient comfort should be regarded as benefits of DOACs compared to VKAs. However, it would be appropriate to bring an individualized approach until we obtain high-quality data with prospectively designed studies involving more patients and longer follow-up time concerning the use of DOACs in patients with MPNs.
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Affiliation(s)
- Mehmet Baysal
- Division of Hematology, Ali Osman Sönmez Oncology Hospital, Bursa, Turkey
| | - Meltem Bayrak
- Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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20
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Chia YC, Siti Asmaa MJ, Ramli M, Woon PY, Johan MF, Hassan R, Islam MA. Molecular Genetics of Thrombotic Myeloproliferative Neoplasms: Implications in Precision Oncology. Diagnostics (Basel) 2023; 13:163. [PMID: 36611455 PMCID: PMC9818412 DOI: 10.3390/diagnostics13010163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 01/06/2023] Open
Abstract
Classical BCR-ABL-negative myeloproliferative neoplasms (MPN) include polycythaemia vera, essential thrombocythaemia, and primary myelofibrosis. Unlike monogenic disorders, a more complicated series of genetic mutations are believed to be responsible for MPN with various degrees of thromboembolic and bleeding complications. Thrombosis is one of the early manifestations in patients with MPN. To date, the driver genes responsible for MPN include JAK2, CALR, MPL, TET2, ASXL1, and MTHFR. Affords have been done to elucidate these mutations and the incidence of thromboembolic events. Several lines of evidence indicate that mutations in JAK2, MPL, TET2 and ASXL1 gene and polymorphisms in several clotting factors (GPIa, GPIIa, and GPIIIa) are associated with the occurrence and prevalence of thrombosis in MPN patients. Some polymorphisms within XRCC1, FBG, F2, F5, F7, F12, MMP9, HPA5, MTHFR, SDF-1, FAS, FASL, TERT, ACE, and TLR4 genes may also play a role in MPN manifestation. This review aims to provide an insightful overview on the genetic perspective of thrombotic complications in patients with MPN.
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Affiliation(s)
- Yuh Cai Chia
- Department Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Mat Jusoh Siti Asmaa
- School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Marini Ramli
- Department Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Peng Yeong Woon
- Department of Molecular Biology and Human Genetics, Tzu Chi University, Hualien 97004, Taiwan
| | - Muhammad Farid Johan
- Department Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Rosline Hassan
- Department Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
| | - Md Asiful Islam
- Department Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
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21
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Splanchnic Vein Thrombosis in Myeloproliferative Neoplasms: Treatment Considerations and Unmet Needs. Cancers (Basel) 2022; 15:cancers15010011. [PMID: 36612008 PMCID: PMC9817858 DOI: 10.3390/cancers15010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Patients who develop splanchnic vein thrombosis (SVT) in the setting of a myeloproliferative neoplasm (MPN) are at risk for complications including portal hypertension, bleeding, thrombosis, and death. Prompt multidisciplinary treatment is thus necessary to prevent long-term sequelae. However, optimal management strategies are not well established due to a paucity of data. In this review, we very briefly discuss the epidemiology, pathophysiology, and prognosis of MPN-SVT and then more comprehensively explore treatment considerations of MPN-SVT, including anticoagulation, endovascular/surgical intervention, and cytoreductive therapy. We will also highlight current gaps in our knowledge of MPN-SVT and conclude by suggesting future directions to optimize the treatment of MPN-SVT and improve outcomes.
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22
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Akanuma H, Matsuda N, Itagaki Y, Yoshida K, Kanai K. [A case of recurrent cerebral infarction in an adult patient with false Taussig-Bing anomaly]. Rinsho Shinkeigaku 2022; 62:940-945. [PMID: 36450491 DOI: 10.5692/clinicalneurol.cn-001795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The case was a 53-year-old woman. At birth, she was diagnosed with a false Taussig-Bing anomaly with pulmonary artery stenosis and a single ventricle. However, no cardiac surgery was performed, and conservative treatment was continued by a cardiovascular surgeon even after adulthood. Because of secondary polycythemia and a history of multiple cerebral infarctions, she took anti-platelet drugs and anti-coagulants. However, she was admitted with the diagnosis of cerebral infarction for the fourth time. It was considered that the patient was at high risk of paradoxical cerebral embolism due to cardiac malformation with cyanotic congenital heart disease accompanied by coagulation abnormalities. Considering the pathophysiology, we decided to use aspirin in combination with warfarin.
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Affiliation(s)
| | | | - Yuya Itagaki
- Department of Neurology, Fukushima Medical University
| | - Kenji Yoshida
- Department of Neurology, Fukushima Medical University
- Department of General Practice, Shirakawa Kosei General Hospital
| | - Kazuaki Kanai
- Department of Neurology, Fukushima Medical University
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23
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Muacevic A, Adler JR, Verbeek EC, van de Wetering M, Voogel AJ, Oosterom L, Herrman JPR, Kuipers RS. Essential Thrombocytosis in Patients <40 Years Old With Acute Coronary Syndromes: A Not So Uncommon Underlying Diagnosis Often Overlooked. Cureus 2022; 14:e32638. [PMID: 36654555 PMCID: PMC9842111 DOI: 10.7759/cureus.32638] [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] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In patients under <40 years, traditional cardiovascular (CV)-risk factors are a less likely cause of acute coronary syndromes (ACS) compared to older counterparts. AIMS To estimate the prevalence of essential thrombocytosis (ET), a hematological disorder and less-prevalent risk factor, in young patients presenting with ACS. METHODS We constructed a retrospective database of all patients <40 years (n=271) that had consecutively undergone coronary angiography (CAG) after their first ACS within our hospital within the last ten years (2010-2020) and had known thrombocyte counts (n=241). Patients with thrombocytes >450x10*9/L were screened for this hematological disorder. RESULTS In our database, we identified 15 subjects with thrombocytosis. One was previously known as ET. Of the remaining 14 patients, five were considered reactive/secondary thrombocytosis, and four were lost to follow-up, four were eventually diagnosed with ET, one remains uncertain. The diagnosis was newly established before the initiation of this study in two patients (average delay: six years). Two patients were identified as a result of this study. Conclusion: With a prevalence of at least 2.1%, ET appears not uncommon in patients <40 years with ACS. Moreover, screening patients with ACS and elevated thrombocytes yielded a novel diagnosis of ET in 27% of patients. The diagnosis was initially missed in all cases. Since the timing of revascularization should be adjusted to thrombocyte count/initiation of ET therapy to prevent thrombotic complications, cardiologists should know, recognize and screen for this pathology in ACS-patients, notably in those with absent traditional CV-risk factors: an 'ACS-protocol' aimed at less-prevalent risk factors could support this.
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24
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Wang Z, Liu W, Wang D, Yang E, Li Y, Li Y, Sun Y, Wang M, Lv Y, Hu X. TET2 Mutation May Be More Valuable in Predicting Thrombosis in ET Patients Compared to PV Patients: A Preliminary Report. J Clin Med 2022; 11:jcm11226615. [PMID: 36431092 PMCID: PMC9699342 DOI: 10.3390/jcm11226615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
Thrombosis is a common complication of myeloproliferative neoplasm (MPN), and it is a major cause of disability and death. With the development of next-generation gene-sequencing technology, the relationship between non-driver mutations and thrombotic risk factors has also attracted considerable attention. To analyze the risk factors of thrombosis in patients with essential thrombocythemia (ET) and polycythemia vera (PV), we retrospectively analyzed the clinical data of 125 MPN patients (75 ET and 50 PV) and performed a multivariate analysis of the risk factors of thrombosis using a Cox proportional risk model. Among the 125 patients, 35 (28.0%) had thrombotic events, and the incidence of thrombotic events was 21.3% and 38.0% in ET and PV patients, respectively. In ET patients, the multivariate analysis showed that a TET2 mutation and history of remote thrombosis were independent risk factors for thrombosis in ET patients, with an HR of 4.1 (95% CI: 1.40-12.01; p = 0.01) for TET2 mutation and 6.89 (95% CI: 1.45-32.68; p = 0.015) for a history of remote thrombosis. In PV patients, the multivariate analysis presented the neutrophil-to-lymphocyte ratio (NLR) (HR: 4.77, 95% CI: 1.33-17.16; p = 0.017) and a history of remote thrombosis (HR: 1.67, 95% CI: 1.03-1.32; p = 0.014) as independent risk factors for thrombosis, with no significant change in the risk of thrombosis in patients with TET2 mutations. A further analysis of the clinical characteristics and coagulation occurring in ET patients with a TET2 mutation revealed that the values of age and D-dimer were significantly higher and antithrombin III was significantly lower in TET2-mutated ET patients compared to TET2-unmutated patients. In summary, TET2 mutation may be more valuable in predicting thrombosis in ET patients than in PV patients. ET patients with a TET2 mutation are older and present differences in coagulation compared to TET2-unmutated patients.
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Affiliation(s)
- Ziqing Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Dehao Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Erpeng Yang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yujin Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yumeng Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yan Sun
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Graduate School, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Mingjing Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yan Lv
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Correspondence: (Y.L.); (X.H.)
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
- Correspondence: (Y.L.); (X.H.)
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25
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Gangat N, Singh A, Szuber N, Begna K, Elliott M, Wolanskyj‐Spinner A, Hanson CA, Pardanani A, De Stefano V, Barbui T, Vannucchi AM, Tefferi A. Site-specific venous thrombosis in essential thrombocythemia: Impact on subsequent vascular events and survival. J Thromb Haemost 2022; 20:2439-2443. [PMID: 35894106 PMCID: PMC9804406 DOI: 10.1111/jth.15834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/08/2022] [Accepted: 07/19/2022] [Indexed: 01/05/2023]
Affiliation(s)
| | | | - Natasha Szuber
- Department of HematologyUniversité de MontréalMontréalQuebecCanada
| | - Kebede Begna
- Division of HematologyMayo ClinicRochesterMinnesotaUSA
| | | | | | | | | | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological SciencesCatholic University, Fondazione Policlinico A. Gemelli IRCCSRomeItaly
| | - Tiziano Barbui
- Research FoundationPapa Giovanni XXIII HospitalBergamoItaly
| | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria CareggiUniversity of FlorenceFlorenceItaly
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26
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Ganta N, Prasad A, Kochhar S, Ghodasara K, Pavuluri S, Cheriyath P. A Young Adult With Essential Thrombocythemia Presenting as Myocardial Infarction. Cureus 2022; 14:e28883. [PMID: 36225436 PMCID: PMC9541478 DOI: 10.7759/cureus.28883] [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] [Accepted: 09/07/2022] [Indexed: 11/30/2022] Open
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm involving the clonal proliferation of platelets. It is Philadelphia negative and is associated with Janus kinase 2 (JAK2), calreticulin (CALR), or myeloproliferative leukemia virus oncogene (MPL) mutations. The resultant platelets have quantitative and qualitative defects, making them more sticky and prone to thromboembolism. However, ET does not only affect platelet survival, it also has a low leukemogenic potential. It's more common in the elderly, 60 years or more, but can be seen in all age groups, including children. Patients with ET have an increased risk of vascular events like hemorrhage and thromboses like cerebrovascular events, myocardial infarction, superficial thrombophlebitis, deep vein thrombosis, and pulmonary embolism. Cardiovascular risk factors like hypertension, diabetes, and smoking can lead to increased thromboembolism and atherosclerosis. The management of ET focuses primarily on the prevention of thrombosis and hemorrhage. It involves cardiovascular risk management and antiplatelet and cytoreductive therapy according to the risk stratification. Low-risk ET patients are treated with low-dose aspirin, and high-risk ET patients are treated with cytoreductive therapy with hydroxyurea. Interferon (IFN) and anagrelide are reserved for young patients or pregnant women. This case report discusses a 40-year-old male, a known smoker presenting with myocardial infarction and left anterior descending artery (LAD) blockage without any prior history. His high platelets and the relative absence of cardiovascular risk factors helped reach the diagnosis, and bone marrow analysis and mutation analysis confirmed the diagnosis. The patient was started on hydroxyurea, which decreased the total platelet count.
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27
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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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28
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Contemporary and future strategies in polycythemia vera. Best Pract Res Clin Haematol 2022; 35:101370. [DOI: 10.1016/j.beha.2022.101370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/22/2022]
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29
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Pedersen OB, Grove EL, Pasalic L, Ommen HB, Kristensen SD, Hvas AM. Cytoreductive treatment and association with platelet function and maturity in patients with essential thrombocythaemia. Br J Haematol 2022; 198:693-702. [PMID: 35675970 PMCID: PMC9540443 DOI: 10.1111/bjh.18303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/21/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022]
Abstract
Patients with essential thrombocythaemia (ET) have an increased risk of thromboembolic events, which may differ according to different cytoreductive drugs. We investigated the effect of cytoreductive treatment on platelet function and turnover in ET patients. Blood samples were obtained at 1 and 24 h after aspirin intake. Platelet function was evaluated by platelet aggregation and flow cytometry. Platelet turnover was assessed by immature platelet count, immature platelet fraction (IPF) and mean platelet volume (MPV). A total of 47 ET patients were included and grouped into 21 patients not receiving cytoreductive treatment, 15 patients receiving hydroxycarbamide and 11 patients receiving pegylated interferon alpha (peg‐IFN). Patients receiving peg‐IFN had significantly higher IPF and MPV than the other ET groups. Patients not receiving cytoreductive treatment had significantly higher platelet aggregation 24 h after aspirin intake than the other ET groups (p‐values from 0.03 to 0.0002). Patients receiving hydroxycarbamide had significantly higher expression of platelet granule makers, P‐selectin and CD63, than patients receiving peg‐IFN (p‐values ≤0.003). Cytoreduction provides more consistent platelet inhibition compared with no cytoreductive treatment. Moreover, peg‐IFN provides superior inhibition of platelet activation markers than hydroxycarbamide, which in part may explain differences in risk of thromboembolic events in ET patients.
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Affiliation(s)
- Oliver Buchhave Pedersen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research and the Departments of Clinical and Laboratory Haematology, Westmead Hospital, Sydney, Australia.,Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hans Beier Ommen
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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30
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Khan Z, Besis G. A Case Report of Large Bilateral Pulmonary Embolism in a Patient With Janus Kinase 2 (JAK2) Positive Mutation. Cureus 2022; 14:e25482. [PMID: 35800822 PMCID: PMC9246470 DOI: 10.7759/cureus.25482] [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] [Accepted: 05/29/2022] [Indexed: 11/28/2022] Open
Abstract
Venous thromboembolism may be the primary presentation in patients with polycythaemia vera (PV) and essential thrombocythemia. Most patients get diagnosed with polycythaemia vera after presenting with venous or arterial thromboembolism in the first place. Most patients tend to develop thrombosis just before or at the time of diagnosis, and this risk decreases over time. Patients aged >60 years with a history of previous thrombosis, elevated haematocrit, and leukocytosis are most at risk of thrombosis. We report a case of a 74-year-old patient presenting with shortness of breath for three days. A computerized tomography pulmonary angiogram showed bilateral pulmonary emboli with right heart strain. He underwent emergency EkoSonic™ endovascular system-directed thrombolysis (EKOS™, Boston Scientific, Marlborough, MA). The patient tested positive for the Janus kinase 2 gene mutation (JAK2), met two major and one minor criterion for PV, and was discharged home on oral anticoagulation. The Janus kinase 2 (JAK2V617F) mutation is quite common in patients with polycythaemia vera, thrombocythemia, and myelofibrosis, and these patients are at risk of both arterial and venous thrombosis, hence they require long-term follow-up.
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31
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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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32
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Impact of Anti-Endothelial Cell Antibodies (AECAs) in Patients with Polycythemia Vera and Thrombosis. Diagnostics (Basel) 2022; 12:diagnostics12051077. [PMID: 35626232 PMCID: PMC9139835 DOI: 10.3390/diagnostics12051077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/24/2022] [Accepted: 04/24/2022] [Indexed: 11/16/2022] Open
Abstract
Polycythemia vera (PV) causes thrombosis. Erythrocytosis and cell adhesiveness are responsible for thrombosis. JAK2V617F causes inflammation and autoimmunity; however, whether or not autoimmunity or inflammation causes thrombosis has yet to be proven. In 60 PV patients, we analyzed JAK2V671F and its allele burden, autoimmune Th17 cells, interleukin-17 (IL-17), anti-endothelial cell antibodies (AECAs), endothelial leukocyte adhesion molecule-1 (ELAM-1), intercellular adhesion molecule-1 (ICAM-1), and von Willebrand factor antigen (VWF: Ag). Fifty blood donors were used as the controls. All patients were on phlebotomy-maintaining hematocrit <45% and aspirin. Of the 60 patients, 40 had thrombosis. Those patients with thrombosis had a higher JAK2V617F allele burden than those without thrombosis, andTh17 cells and IL-17 were also higher in patients with thrombosis. Interestingly, we observed a high AECA IgG ELISA ratio (ER) in patients with thrombosis, which was normal in patients without thrombosis. We found high ELAM-1 and ICAM-1 as well as high VWF:Ag in patients with thrombosis compared to patients without thrombosis. AECA-positive sera from patients with thrombosis showed enhanced binding to cytokine-treated HUVEC and a positive antibody-dependent cellular cytotoxicity, suggesting that AECA may contribute to vascular injury. A positive correlation between AECAs, allele burden, and thrombosis was found. These results suggest that autoimmunity may be an additional mechanism in PV thrombogenesis.
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33
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Mantovani F, Paolini A, Barbieri A, Boriani G. Case Report: Free-Floating Intracoronary Thrombus: Who Is the Convict? Front Oncol 2022; 12:825711. [PMID: 35350576 PMCID: PMC8957839 DOI: 10.3389/fonc.2022.825711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/08/2022] [Indexed: 02/02/2023] Open
Abstract
In young patients, especially with no traditional coronary risk factors, hypercoagulable states may always be considered as an alternative cause of acute coronary syndromes. The concomitant thrombotic and bleeding risk associated with myeloproliferative disorders complicates the decision-making, particularly regarding long-term dual antiplatelet therapy. The chosen therapy may need to be frequently revisited, depending on the patient's bleeding complications. We reported the case of a 49-year-old woman with acute myocardial infarction with no traditional risk factors for coronary artery disease where a myeloproliferative neoplasm was diagnosed.
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Affiliation(s)
- Francesca Mantovani
- Dipartimento di Medicine Specialistiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ambra Paolini
- Department of Medical and Surgical Sciences, Haematology Unit, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Andrea Barbieri
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Giuseppe Boriani
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
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34
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Pemmaraju N, Gerds AT, Yu J, Parasuraman S, Shah A, Xi A, Kumar S, Scherber RM, Verstovsek S. Thrombotic events and mortality risk in patients with newly diagnosed polycythemia vera or essential thrombocythemia. Leuk Res 2022; 115:106809. [DOI: 10.1016/j.leukres.2022.106809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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35
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Hematologic Disorders and Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Barbui T, Carobbio A, De Stefano V. Thrombosis in myeloproliferative neoplasms during cytoreductive and antithrombotic drug treatment. Res Pract Thromb Haemost 2022; 6:e12657. [PMID: 35155976 PMCID: PMC8822262 DOI: 10.1002/rth2.12657] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/31/2021] [Accepted: 01/12/2022] [Indexed: 12/16/2022] Open
Abstract
A state-of-the-art lecture titled "Myeloproliferative Neoplasm-associated Thrombosis" was presented at the ISTH congress in 2021. We summarize here the main points of the lecture with two purposes: to report the incidence rates of major thrombosis in polycythemia vera and essential thrombocythemia and to discuss to what extent cytoreductive therapy and antithrombotic drugs have reduced the incidence of these events. Unfortunately, the incidence rate of thrombosis remains high, ranging between 2 and 5/100 person-years. It is likely that new drugs such as interferon and ruxolitinib can be more efficacious given their cytoreductive and anti-inflammatory activities. Despite prophylaxis with vitamin K antagonists and direct oral anticoagulants after venous thrombosis in either common sites or splanchnic or cerebral sites, the incidence rate is still elevated, as high as 4 to 5/100 person-years. Future studies with new drugs or new strategies should consider thrombosis as the primary endpoint or surrogate biomarkers only if previously validated.
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Affiliation(s)
- Tiziano Barbui
- FROM Research FoundationPapa Giovanni XXIII HospitalBergamoItaly
| | | | - Valerio De Stefano
- Section of HematologyDepartment of Radiological and Hematological SciencesCatholic UniversityFondazione Policlinico A. Gemelli IRCCSRomeItaly
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Schieppati F. Evidence-Based Minireview: Are DOACs an alternative to vitamin K antagonists for treatment of venous thromboembolism in patients with MPN? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:448-452. [PMID: 34889434 PMCID: PMC8791160 DOI: 10.1182/hematology.2021000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Francesca Schieppati
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Giannotta JA, Fattizzo B, Barcellini W. Paroxysmal Nocturnal Hemoglobinuria in the Context of a Myeloproliferative Neoplasm: A Case Report and Review of the Literature. Front Oncol 2021; 11:756589. [PMID: 34858830 PMCID: PMC8632248 DOI: 10.3389/fonc.2021.756589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolytic anemia and thrombosis and is notoriously associated with aplastic anemia and myelodysplastic syndromes. Rarer associations include myeloproliferative neoplasms (MPNs), which are also burdened by increased thrombotic tendency. The therapeutic management of this rare combination has not been defined so far. Here, we describe a 62-year-old man who developed a highly hemolytic PNH more than 10 years after the diagnosis of MPN. The patient started eculizumab, obtaining good control of intravascular hemolysis but without amelioration of transfusion-dependent anemia. Moreover, we performed a review of the literature regarding the clinical and pathogenetic significance of the association of PNH and MPN. The prevalence of PNH clones in MPN patients is about 10%, mostly in association with JAK2V617F-positive myelofibrosis. Thrombotic events were a common clinical presentation (35% of subjects), sometimes refractory to combined treatment with cytoreductive agents, anticoagulants, and complement inhibitors. The latter showed only partial effectiveness in controlling hemolytic anemia and, due to the paucity of data, should be taken in consideration after a careful risk/benefit evaluation in this peculiar setting.
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Affiliation(s)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera: historical oversights, diagnostic details, and therapeutic views. Leukemia 2021; 35:3339-3351. [PMID: 34480106 PMCID: PMC8632660 DOI: 10.1038/s41375-021-01401-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Polycythemia vera (PV) is a relatively indolent myeloid neoplasm with median survival that exceeds 35 years in young patients, but its natural history might be interrupted by thrombotic, fibrotic, or leukemic events, with respective 20-year rates of 26%, 16%, and 4%. Current treatment strategies in PV have not been shown to prolong survival or lessen the risk of leukemic or fibrotic progression and instead are directed at preventing thrombotic complications. In the latter regard, two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). All patients require phlebotomy to keep hematocrit below 45% and once-daily low-dose aspirin, in the absence of contraindications. Cytoreductive therapy is recommended for high-risk or symptomatic low-risk disease; our first-line drug of choice in this regard is hydroxyurea but we consider pegylated interferon as an alternative in certain situations, including in young women of reproductive age, in patients manifesting intolerance or resistance to hydroxyurea therapy, and in situations where treatment is indicated for curbing phlebotomy requirement rather than preventing thrombosis. Additional treatment options include busulfan and ruxolitinib; the former is preferred in older patients and the latter in the presence of symptoms reminiscent of post-PV myelofibrosis or protracted pruritus. Our drug choices reflect our appreciation for long-term track record of safety, evidence for reduction of thrombosis risk, and broader suppression of myeloproliferation. Controlled studies are needed to clarify the added value of twice- vs once-daily aspirin dosing and direct oral anticoagulants. In this invited review, we discuss our current approach to diagnosis, prognostication, and treatment of PV in general, as well as during specific situations, including pregnancy and splanchnic vein thrombosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Thrombosis in myeloproliferative neoplasms: A clinical and pathophysiological perspective. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Crodel CC, Jentsch-Ullrich K, Reiser M, Jacobasch L, Sauer A, Tesch H, Ulshöfer T, Wunschel R, Palandri F, Heidel FH. Cytoreductive treatment in real life: a chart review analysis on 1440 patients with polycythemia vera. J Cancer Res Clin Oncol 2021; 148:2693-2705. [PMID: 34807311 PMCID: PMC8607972 DOI: 10.1007/s00432-021-03855-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022]
Abstract
Purpose Patients with polycythemia vera (PV) show an elevated incidence of thromboembolic complications and decreased survival when compared to age-matched healthy individuals. Hypercellularity as indicated by elevated hematocrit, pathophysiological changes induced by the JAK2 driver mutation and cardiovascular risk factors contribute to the increased incidence of thromboembolic events. Higher age and a history of thromboembolic events define a high-risk population of PV patients. Depending on the individual risk profile, phlebotomy or pharmacologic cytoreduction is recommended in combination with low-dose acetylsalicylic acid. Stringent cytoreduction is required for effective risk reduction. However, in recent reports, the rate of thromboembolic complications in PV patients under cytoreductive therapy appears still elevated compared to healthy individuals. This study reports on a chart review to assess for cytoreductive therapy of 1440 PV patients in real life. Methods Forty-two eligible hematologists/oncologists in private practice treating patients with MPN were recruited to participate in a paper–pencil-based survey conducted between January 2019 and March 2020 in Germany. Physicians were asked to report primary documented data obtained from patient charts. Descriptive analyses were conducted to assess for patient characteristics, treatment modalities, risk factors and thromboembolic complications. Results Data were collected from the patient charts of 1440 individuals diagnosed with PV. The patient population was older than those reported in multicenter trials with a median age of 72.2 years at the time of reporting and 63.5 years at diagnosis. Age was the main factor accounting for high-risk status with 84.7% of patients being above the age of 60 followed by thromboembolic complications reported in 21.3% of patients. The use of pharmacologic cytoreduction was highly variable between participating centers with an average of 60.7% and a range of 10.1–100%. Hydroxyurea was the most frequently used drug followed by ruxolitinib, while interferons were reported for a minority of patients. For 35.4% of patients a persistent need for phlebotomy in addition to cytoreductive treatment was reported. Although presence of high-risk criteria and insufficient disease control were reported as main triggers to initiate pharmacologic cytoreduction, 28.1% had elevated hematocrit values (> 45%) and 38.6% showed persistence of elevated leukocyte count (> 109/l) while on cytoreductive treatment. In contrast, physician-reported symptom burden was lower than published in clinical trials and patient-reported outcomes. The rate of patients experiencing thromboembolic complications was 32.2% at any time and 14.3% after diagnosis with most patients receiving acetylsalicylic acid and 10.8% remaining on oral anticoagulants or heparin. Conclusions Cytoreductive treatment of high-risk PV in real life is highly variable regarding indication for cytoreduction and definition of therapy resistance. This study highlights the need for (i) improved risk stratification for thromboembolic events, (ii) consequent indication of pharmacologic cytoreduction in high-risk PV and (iii) attention to signs of therapy resistance that can trigger an earlier and stringent switch to second line agents.
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Affiliation(s)
- Carl C Crodel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany
| | | | | | - Lutz Jacobasch
- Gemeinschaftspraxis Hämatologie und Onkologie, Dresden, Germany
| | - Annette Sauer
- MVZ für Blut-und Krebserkrankungen, Potsdam, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie, Frankfurt, Germany
| | | | | | - Francesca Palandri
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Hematology L. and A. Seràgnoli, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Florian H Heidel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.
- Innere Medizin C, Hämatologie und Onkologie, Universitätsmedizin Greifswald, Sauerbruchstrasse, 17475, Greifswald, Germany.
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Bhat V, Gs T, Rao SS, Sarma GRK, Deepalam SK. Clinical and Radiological Profile of Cerebrovascular Disease in Polycythemia: Analysis of Neurologic Manifestations from a Tertiary Center in South India. J Stroke Cerebrovasc Dis 2021; 31:106167. [PMID: 34785446 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106167] [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: 09/03/2021] [Revised: 10/01/2021] [Accepted: 10/06/2021] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Patients with polycythemia, either primary or secondary, are at elevated risk for thrombotic complications, including stroke. We aimed to investigate the clinical and radiological characteristics of cerebrovascular disease (CVD) in polycythemia, and describe other neurologic manifestations. METHODOLOGY We conducted a cross-sectional study of patients diagnosed with polycythemia between 2014 and 2019 at a tertiary care center and collected relevant medical data with a special focus on cerebrovascular disease and neurologic manifestations. We performed descriptive and inferential analyses. We have also described and analyzed the available neuroimaging features. RESULTS We analyzed data from 56 patients. 20 patients (35.7%) had ischemic stroke. The incidence of CVD was higher in those with primary polycythemia (43%) than in those with secondary polycythemia (8%). The most common subtype of stroke was large vessel disease, and the most common arterial territory was the anterior circulation. There was no statistically significant difference in the hematocrit level between those with or without CVD. Neuroimaging revealed multiple large vessel intracranial stenoses on MR Angiography, and hyperdense vessels on plain CT. Other neurologic manifestations included headache, seizures, dizziness, visual symptoms and papilledema, and these were significantly more common in primary polycythemia. CONCLUSIONS CVD is common in patients with polycythemia. The most common type observed was large vessel occlusion, predominantly in the anterior circulation. In stroke patients, multiple vessel stenosis and hyperdense vessels may be clues to polycythemia.
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Affiliation(s)
- Vivek Bhat
- Faculty of Medicine, St. John's Medical College, India
| | - Thanmayi Gs
- Faculty of Medicine, St. John's Medical College, India
| | - Sanjukta S Rao
- Department of Internal Medicine & Hematology, St. John's Medical College, India.
| | - G R K Sarma
- Department of Neurology, St. John's Medical College, India
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Practice patterns and outcomes of direct oral anticoagulant use in myeloproliferative neoplasm patients. Blood Cancer J 2021; 11:176. [PMID: 34741012 PMCID: PMC8571422 DOI: 10.1038/s41408-021-00566-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are characterized by an increased risk of thrombosis and bleeding. Vitamin K antagonists (VKAs) are the historic anticoagulant recommended for use in MPNs. Direct oral anticoagulants (DOACs) are being increasingly used in general and cancer populations. However, DOAC safety and efficacy in MPN patients remains unclear. We characterized real-world practice patterns of DOAC use in MPN patients and evaluated thrombosis and bleeding risk. We conducted a retrospective cohort study of 133 MPN patients prescribed DOACs for venous thromboembolism (VTE), atrial fibrillation, or arterial thromboembolism (ATE). Practice patterns including duration of anticoagulation, dosing, and concomitant use of antiplatelet/cytoreductive agents, were heterogeneous among MPN patients. The 1-year cumulative incidence of thrombosis and bleeding on DOAC was 5.5% (1.5–9.5%) and 12.3% (6.4–18.2%) respectively. In comparison, reported bleeding rates in MPN patients on DOAC and VKAs are 1–3%. On multivariable analysis, prior history of thrombosis, use of dabigatran or edoxaban, and younger age were significantly associated with a higher risk of recurrent thrombosis, while leukocytosis was associated with a higher risk of bleeding on DOAC. The higher-than-expected bleeding rate found in our study indicates the continued need for rigorous evaluation of DOACs in this population.
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Penna D. New Horizons in Myeloproliferative Neoplasms Treatment: A Review of Current and Future Therapeutic Options. Medicina (B Aires) 2021; 57:medicina57111181. [PMID: 34833399 PMCID: PMC8619471 DOI: 10.3390/medicina57111181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
Philadelphia-negative myeloproliferative neoplasms (MPN) are aggressive diseases characterized by clonal proliferation of myeloid stem cells. The clonal process leads to excessive red cells production, platelets production, and bone marrow fibrosis. According to the phenotype, MPN can be classified as polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). MPN patients have shortened survival due to the increased risk of thrombosis, hemorrhages, and transformation to acute myeloid leukemia (AML). Prognosis is variable, with a shorter life expectancy in myelofibrosis. Currently, drug therapy can reduce symptoms, splenomegaly, and risk of thrombosis. Still, some patients can be resistant or intolerant to the treatment. At the same time, allogeneic stem cell transplant (ASCT) is the only treatment modality with the potential to cure the disease. Nevertheless, the ASCT is reserved for high-risk leukemic progression patients due to the risk of treatment-related death and comorbidity. Therefore, there is a need for new drugs that can eradicate clonal hematopoiesis and prevent progression to more aggressive myeloid neoplasms. Thanks to the better understanding of the disease’s molecular pathogenesis, many new potentially disease-modifying drugs have been developed and are currently in clinical trials. This review explores the most promising new drugs currently in clinical trials.
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Affiliation(s)
- Domenico Penna
- Hematology Unit, Azienda Unità Sanitaria Locale—IRCCS, 42123 Reggio Emilia, Italy; ; Tel.: +39-522-296-623
- Ph.D. Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 42121 Modena, Italy
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Burattini M, Falsetti L, Potente E, Rinaldi C, Bartolini M, Buratti L, Silvestrini M, Viticchi G. Ischemic stroke as a presenting manifestation of polycythemia vera: a narrative review. Rev Neurosci 2021; 33:303-311. [PMID: 34508650 DOI: 10.1515/revneuro-2021-0066] [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: 05/13/2021] [Accepted: 08/19/2021] [Indexed: 11/15/2022]
Abstract
Polycythemia vera (PV) is a myeloproliferative disorder associated with an increased risk of cerebrovascular diseases. In this narrative review, we aimed to analyze the relationships between acute ischemic stroke and PV. We conducted a PubMed/Medline and Web of Sciences Database search using MeSH major terms. We found 75 articles and finally considered 12 case reports and 11 cohort studies. The ischemic stroke resulted as the first manifestation of PV in up to 16.2% of cases; the cumulative rate of cerebrovascular events was up to 5.5 per 100 persons per year and stroke accounted for 8.8% of all PV-related deaths; age, mutations, and a previous history of thrombosis were the main risk factors. The best approach to reduce stroke recurrence risk is unclear, even if some evidence suggests a potential role of lowering hematocrit below 45%. Ischemic stroke represents one of the most common PV manifestations but, despite their relationship, patients with both diseases have a very heterogeneous clinical course and management. PV-related strokes often remain underdiagnosed, especially for the low prevalence of PV. An early diagnosis could lead to prompt treatment with phlebotomy, cytoreduction, and low-dose aspirin to decrease the risk of recurrences. Clinicians should be aware of PV as a risk factor for stroke when approaching the differential diagnosis of cryptogenic strokes. An early diagnosis could positively influence patients' management and clinical outcomes. Further studies are required to evaluate the role of PV treatments in the prevention of cerebrovascular disease.
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Affiliation(s)
- Marco Burattini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Ospedali Riuniti Ancona, via Conca n.1, 60020, Ancona, Italy
| | - Eleonora Potente
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Claudia Rinaldi
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Laura Buratti
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
| | - Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, via Conca n.1, 60020, Ancona, Italy
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Improving the investigative approach to polycythaemia vera: a critical assessment of current evidence and vision for the future. LANCET HAEMATOLOGY 2021; 8:e605-e612. [PMID: 34329580 DOI: 10.1016/s2352-3026(21)00171-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
Polycythaemia vera is a challenging disease to study given its low prevalence and prolonged time-to-event for important clinical endpoints such as thrombosis, progression, and mortality. Although researchers in this space often rise to meet these challenges, there is considerable room for improvement in the analysis of retrospective data, the development of risk-stratification tools, and the design of randomised controlled trials. In this Viewpoint, we review the evidence behind the contemporary approach to risk stratification and treatment of polycythaemia vera. Frameworks for using data more efficiently, constructing more nuanced prognostic models, and overcoming challenges in clinical trial design are discussed.
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Baldini C, Moriconi FR, Galimberti S, Libby P, De Caterina R. The JAK-STAT pathway: an emerging target for cardiovascular disease in rheumatoid arthritis and myeloproliferative neoplasms. Eur Heart J 2021; 42:4389-4400. [PMID: 34343257 DOI: 10.1093/eurheartj/ehab447] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/21/2021] [Accepted: 07/31/2021] [Indexed: 01/07/2023] Open
Abstract
Inflammation contributes centrally to cardiovascular diseases, and anti-inflammatory treatments can reduce cardiovascular events. The JAK-STAT pathway is an emerging target in inflammation, mainly in rheumatoid arthritis (RA) and chronic myeloproliferative neoplasms (MPNs), disorders that heighten cardiovascular risk. The aim of this study was to review the international literature on the relationship between dysregulation of the JAK-STAT pathway in RA/MPNs and cardiovascular risk and on the potential cardiovascular effects of JAK-STAT inhibitors. The JAK-STAT pathway sustains inflammatory and thrombotic events in autoimmune disorders such as RA and MPNs. Here, an imbalance exists between pro- and anti-inflammatory cytokines [increased levels of interleukin (IL)-6, IL-1-β, tumour necrosis factor-α, decreased levels of IL-10] and the over-expression of some prothrombotic proteins, such as protein kinase Cε, on the surface of activated platelets. This pathway also operates in atherosclerotic cardiovascular disease. JAK-STAT inhibitors may reduce cardiovascular events and related deaths in such conditions, but the potential of these agents requires more studies, especially with regard to cardiovascular safety, and particularly for potential prothrombotic effects. JAK-STAT inhibitors merit consideration to curb heightened cardiovascular risk in patients with RA and MPNs, with rigorous assessment of the potential benefits and risks.
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Affiliation(s)
- Chiara Baldini
- Division of Rheumatology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Francesca Romana Moriconi
- Division of Rheumatology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy.,Division of Cardiology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Sara Galimberti
- Division of Hematology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital-Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Raffaele De Caterina
- Division of Cardiology, University of Pisa and Pisa University Hospital, Via Paradisa, 2, Pisa 56124, Italy
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Huenerbein K, Sadjadian P, Becker T, Kolatzki V, Deventer E, Engelhardt C, Griesshammer M, Wille K. Direct oral anticoagulants (DOAC) for prevention of recurrent arterial or venous thromboembolic events (ATE/VTE) in myeloproliferative neoplasms. Ann Hematol 2021; 100:2015-2022. [PMID: 33216197 PMCID: PMC8285319 DOI: 10.1007/s00277-020-04350-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
In patients with BCR-ABL-negative myeloproliferative neoplasms (MPN), arterial or venous thromboembolic events (ATE/VTE) are a major burden. In order to control these complications, vitamin K antagonists (VKA) are widely used. There is no robust evidence supporting the use of direct oral anticoagulants (DOAC) in MPN patients. We therefore compared the efficacy and safety of both anticoagulants in 71 cases from a cohort of 782 MPN patients. Seventy-one of 782 MPN patients (9.1%) had ATE/VTE with nine ATE (12.7%) and 62 VTE (87.3%). Forty-five of 71 ATE/VTE (63.4%) were treated with VKA and 26 (36.6%) with DOAC. The duration of anticoagulation therapy (p = 0.984), the number of patients receiving additional aspirin (p = 1.0), and the proportion of patients receiving cytoreductive therapy (p = 0.807) did not differ significantly between the VKA and DOAC groups. During anticoagulation therapy, significantly more relapses occurred under VKA (n = 16) compared to DOAC treatment (n = 0, p = 0.0003). However, during the entire observation period of median 3.2 years (0.1-20.4), ATE/VTE relapse-free survival (p = 0.2) did not differ significantly between the two anticoagulants. For all bleeding events (p = 0.516) or major bleeding (p = 1.0), no significant differences were observed between VKA and DOAC. In our experience, the use of DOAC was as effective and safe as VKA, possibly even potentially beneficial with a lower number of recurrences and no increased risk for bleedings. However, further and larger studies are required before DOAC can be routinely used in MPN patients.
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Affiliation(s)
- Karlo Huenerbein
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | - Parvis Sadjadian
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | - Tatjana Becker
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | - Vera Kolatzki
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | - Eva Deventer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | | | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
| | - Kai Wille
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, UKRUB, University of Bochum, Hans-Nolte-Straße 1, D-32429 Minden, Germany
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Sayar Z, Nallamilli S, Efthymiou M, Lambert J, Cohen H. Coexistent antiphospholipid syndrome and myeloproliferative neoplasm. Lupus 2021; 30:1502-1508. [PMID: 34192956 DOI: 10.1177/09612033211021154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiphospholipid syndrome (APS) and myeloproliferative neoplasms (MPN) are associated with an increased risk of thrombosis. The optimal management of patients with coexistent APS and MPN has not been defined. A single centre and systematic literature review of patients with coexistent APS and MPN was performed. Cases were divided into two groups based on whether they met international consensus criteria for APS. Of the 12 studies identified, eight were excluded (leaving five of a total 54 patients), as although antiphospholipid antibodies (aPL) were documented, the diagnosis of APS was not conclusively demonstrated. Another ten patients with definite APS were identified at our centre. Fifteen patients (ten females, five males) were therefore included in this analysis (eleven definite APS and four highly likely), median age 44 (range: 13-71) years. Nine had polycythaemia vera and six, essential thrombocythaemia. Thirteen of the 15 patients (86.7%) had thrombotic APS (seven with initial venous events and six arterial) and two (13.3%) had obstetric APS. Nine patients were single-positive, and six double-positive for aPL. None were triple aPL-positive. Four patients at our centre had recurrent thrombotic/obstetric events, including while on anticoagulation/antiplatelet treatment.
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Affiliation(s)
- Zara Sayar
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Susanna Nallamilli
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK.,Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Cohen O, Caiano LM, Tufano A, Ageno W. Cancer-Associated Splanchnic Vein Thrombosis. Semin Thromb Hemost 2021; 47:931-941. [PMID: 34116580 DOI: 10.1055/s-0040-1722607] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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