Cases Of Polycythemia Vera Research Articles

Cardiac hypertrophy in polycythemia vera: A case report and review of literature

BACKGROUND The combination of polycythemia vera (PV) with pathological cardiac hypertrophy is uncommon. In this study, we describe a case of PV accompanied by pathological cardiac hypertrophy. It is hypothesized that the pronounced cardiac hypertrophy in this patient has a strong connection with PV. CASE SUMMARY In 2021, a 34-year-old Chinese man experienced chest constriction, shortness of breath, and palpitations during vigorous activity. Each episode lasted several minutes and resolved spontaneously following cessation of vigorous activity. He occasionally experienced syncope and vertigo without a headache. He underwent cardiac magnetic resonance imaging and was diagnosed with “hypertrophic cardiomyopathy (HCM)”. He was discharged after receiving symptomatic treatment, which resulted in an improvement. He presented to our department with chest constriction, shortness of breath, and respiratory distress for one month while climbing to the second floor in 2023. His blood pressure was 180/100 mmHg at the time of admittance, and he was receiving antihypertensive treatment. He had a history of PV for 2 years without treatment. Symptomatic treatment was implemented concurrently with the administration of hydroxyurea upon admission. Good blood pressure control was observed during the long-term follow-up, and echocardiography did not reveal any progression of myocardial hypertrophy. CONCLUSION Clinicians managing PV patients should remain highly vigilant regarding the risks of thrombosis and cardiovascular complications, particularly in those with refractory hypertension.

Screening for Janus kinase-2 exon 12 mutations among Janus kinase-2 V617F-negative polycythemia vera suspected Iraqi patients

Abstract: BACKGROUND: Diagnosis of myeloproliferative neoplasms including polycythemia vera (PV) has been greatly improved following the identification of driver mutations at exon 12 and exon 14 of the Janus Kinase 2 (JAK2) gene. There are limited academic studies that report the frequency of the JAK2 exon 12 gene with limited number of patients. OBJECTIVES: The aim of this study was to evaluate the frequency of JAK2 exon 12 mutations among JAK2V617F-negative PV-suspected Iraqi patients. PATIENTS’, MATERIALS AND METHODS: This is a retrospective study conducted at the National Center of Hematology/Mustansiriyah University from December 2019 to January 2022; patients with suspicion of PV were enrolled in this study. Screening for JAK2 exon 14 (JAK2V617F) mutations was done for all 323 patients. Out of them, there were 102 patients with JAK2V617F-negative who retrospectively screened for JAK2 exon 12 mutations by direct sequencing (Sanger sequencing). RESULTS: Initial evaluation for the total 323 patients suspected with PV revealed that 84 cases were mutated for the JAK2V617F gene, and 239 were unmutated. The frequency of JAK2 exon 12 was about 1% among JAK2V17F-negative patients. The median age for all patients was 35 years. Among the total cases, 21 cases (20.59%) showed splenomegaly at the time of clinical onset sequencing of these cases revealed only one case mutated with JAK2 exon 12 (E543-D544del). CONCLUSION: The current study showed that the frequency of JAK2 exon 12 mutations in JAK2V617F-negative cases was very low. Despite PV patients with JAK2 exon 12 mutations represent a small proportion of total PV cases, JAK2 exon 12 mutations should be routinely screened in JAK2V617F-negative cases.

Diagnostic Performance of Serum Erythropoietin to Discriminate Polycythemia Vera from Secondary Erythrocytosis through Established Subnormal Limits.

Serum erythropoietin (sEPO) is an initial screening tool for distinguishing polycythemia vera (PV) from secondary erythrocytosis (SE), but defining 'subnormal' sEPO levels for PV diagnosis remains contentious, complicating its clinical utility. This study compares the diagnostic performance of sEPO across established subnormal limits, including reference interval (RI), clinical decision limit (CDL), and functional reference limit. sEPO levels were analyzed in 393 healthy donors (HDs) and 90 patients (41 PV and 49 SE), who underwent bone marrow biopsy and genetic tests due to erythrocytosis. The RI (2.5-97.5 percentile from HDs) of sEPO was 5.3-26.3 IU/L. A CDL of 3.1 IU/L, determined by ROC analysis in erythrocytosis patients, had a sensitivity of 80.5% and specificity of 87.8% for diagnosing PV. A functional reference limit of 7.0 IU/L, estimated based on the relationship between sEPO and hemoglobin, hematocrit, and WBC, increased sensitivity to 97.6% but decreased specificity to 46.7%. Using 5.3 IU/L as a 'subnormal' limit identified all three JAK2-negative PV cases, increasing the sensitivity and negative predictive value to 97.6% and 97.0%, respectively. Combining the RI, CDL, and functional reference limit may improve PV diagnostic accuracy.

Prevalence and clinicopathological features of driver gene mutations profile in BCR: ABL1 negative classical myeloproliferative neoplasm-A single-center study from North India.

Recurrent somatic mutations in the JAK2, CALR, and the MPL genes are noted in BCR: ABL1 negative classic myeloproliferative neoplasms (MPN) that includes polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF). Mutation profile and clinical features of MPN cases diagnosed at a tertiary care center in North India are being described. JAK2V617F mutation was screened using ARMS PCR, and CALR mutation was screened using allele-specific PCR followed by fragment analysis. MPL and JAK2 Exon 12 mutations were screened by Sanger sequencing. Some of the samples were also screened using commercial kits based on single-plex RT PCR. A total of 378 cases (including 124 PV, 121 ET, and 133 PMF cases) were screened over 6.5 years. JAK2V617F mutation was noted in 90.3%, 61.1%, and 69.2% of cases of PV, ET, and PMF, respectively. In PV, JAK2V617F wild-type cases were associated with a significantly lower age (44 yrs vs 54 yrs; P = 0.001), lower TLC (6.3 vs 16.9; P = 0.001), and a lower platelet count (188 × 109/L vs 435 × 109/L; P = 0.009) as compared to the JAK2V617F mutated cases. CALR and MPL mutations were noted in 17.4% and 12% and 0.8% and 5.3% of ET and PMF cases, respectively. Type 1 CALR mutations were commoner in both ET and PMF. The triple negative cases constituted 20.7% and 13.5% cases of ET and PMF, respectively. In ET, the triple negative cases were found to have a significantly lower median age of presentation (42 yrs vs 52 yrs; P = 0.001), lower median TLC (10.2 × 109/L vs 13.2 × 109/L; P = 0.024), and a higher median platelet count (1238 × 109/L vs 906 × 109/L; P = 0.001) as compared to driver genes mutated cases. In PMF, the triple negative cases were found to have a significantly lower hemoglobin level (7.9 g/dl vs 11.0 gl/dl; P = 0.001) and a significant female preponderance (P = 0.05) as compared to the mutated cases. CALR mutations were found to have a significantly lower median age (43 yrs vs 56 yrs; P = 0.001) and lower hemoglobin (9.6 g/dl vs 11.3 g/dl) as compared to the JAK2 mutations. Our data on the driver gene mutational profile of BCR: ABL1 negative MPN is one of the largest patient cohorts. The prevalence and clinicopathological features corroborate with that of other Asian studies.

Impact of Hydroxyurea to Treat Haematological Disorders on Male Fertility: Two Case Reports and a Systematic Review.

Hydroxyurea (HU) is a cytoreductive agent used as standard treatment option for sickle cell anaemia/disease (SCD), essential thrombocythemia (ET), and polycythaemia vera (PV). Despite its overall good safety profile, its use also in relatively young patients raises an interest on its potential impact on spermatogenesis. To perform a systematic review of all published articles investigating fertility in male patients affected by SCD, ET, and PV and treated with HU. Two paradigmatic case reports of patients affected by PV and ET, respectively, have been also reported. PubMed, EMBASE, and Cochrane databases were queried for all the published studies indexed up to November 15th, 2022. A combination of the following keywords was used: "hydroxyurea," "fertility," "male," "sperm," "sickle cell anaemia," "sickle cell disease," "essential thrombocythemia," "polycythaemia vera." Of 48 articles identified, 8 studies, involving 161 patients, were eligible for inclusion. Overall, the number of spermatogonia per round cross section of seminiferous tubule were decreased in patients with SCD compared to healthy males. HU treatment was always associated with a worsening of semen parameters, even up to azoospermia. Notably, treatment discontinuation was associated with an improvement of semen parameters and a trend toward normalization in the case of PV and ET, with a less clear amelioration in men with SCD. In both our patients with either PV or ET, HU discontinuation was associated with a significant improvement of spermatogenesis with successful spontaneous pregnancies. Published evidence do not consistently report normalization of spermatogenesis after HU discontinuation in SCD cases. Conversely, the literature almost consistently reported an improvement of semen parameters at the discontinuation of HU therapy in PV and ET cases. Our real-life two cases confirmed those findings. The willing of fatherhood and the need for effective fertility treatment warrant further research to improve work-up management in men with hematological disorders.

Secondary Erythrocytosis, a Predominant Cause of Polycythemia- Clinical and Laboratory Evaluation of Polycythemia in a Tertiary Care Center

Aims: Polycythemia refers to an increased production of red blood cells from bone marrow. It is one of the frequent reasons for a hematology consultation. The present work aimed to examine the causes, clinical manifestations, prevalence, and diverse patterns in laboratory and clinical parameters among patients with polycythemia attending our outpatient clinics at the Indus Hospital and Health Network.
 Study Design: The present work is retrospective observational study which included all cases of polycythemia.
 Place and Duration of the Study: The study was conducted at a tertiary health care center in Karachi, Pakistan during October 2019 to July 2021.
 Methodology: The data from the patient diagnosed with polycythemia was entered and analyzed by using SPSS version 24.0. Descriptive statistics as per the Gaussian Normality distribution (Sapiro-Wilk) were computed along with frequencies. The association where applicable was calculated via standard statistical methods with the chi square test for categorical while independent sample t-test for the continuous variables. The level of statistical significance will be set at P < 0.05.
 Results: During the investigated period, a total of 33 patients were diagnosed with polycythemia demonstrating a notable male predominance (82%). The majority of the patients exhibited secondary erythrocytosis (85%) with only a minority (15%) diagnosed with polycythemia vera. Of the identified cases of secondary erythrocytosis a significant proportion (46%) was observed in individuals who were smokers while other were found with hypoxic pulmonary disease, hepatitis, and chronic kidney disease. In secondary erythrocytosis 21 patients (75%) required venesection for symptom reduction, while 7 (25%) were closely monitored due to their asymptomatic status. On the contrary all cases of polycythemia vera required a comprehensive treatment approach including venesections, cytoreduction with hydroxyurea and low dose aspirin.

Classification of Philadelphia-Negative MPN As Low Risk and High Risk MPN Based on Peripheral Blood Values and Molecular Genetics Only

Background: Philadelphia-negative myeloproliferative neoplasms (Ph -MPN) are characterized by overproduction of differentiated hematopoietic cells mediated in the majority of cases by mutations in JAK2, MPL or CALR (MPN driver genes). Ph - MPN include polycythemia vera (PV), essential thrombocythemia (ET), primary myelofibrosis (PMF) and MPN, unclassifiable (MPN-U) which differ in clinical presentation, prognosis, fibrosis and leukemic transformation rate as well as therapeutic options. However, WHO based classification requires experienced pathologists, in particular to diagnose prefibrotic PMF as high risk MPN, and thus remains observer dependent. Aim: Observer independent classification of Ph - MPN solely based on molecular genetics and peripheral blood (PB) parameters. Patients and Methods: We analyzed 267 Ph - MPN cases diagnosed as ET (n=76), PV (n=74), PMF (n=68) or MPN-U (n=49) following the WHO4R classification including only patients with an MPN driver mutation (median age: 68 years [22-91]; female: 41%; median follow-up: 5 years). All samples were analyzed by cytomorphology and whole genome sequencing (median coverage 100x). Mutation status of 20 genes associated with myeloid malignancies were analyzed in detail. Results: Genomic landscape of the MPN cohort showed mutations in JAK2 in 222 (83%) (n=132: single mutation; n=90: either mutation and copy neutral loss of heterozygosity or mutation and 9p gain), in CALR in 36 (14%), and in MPL in 9 (3%) patients. The median number of mutations per patient was two (range: 1-6). Within the cohort, 141 patients (53%) harbored MPN driver mutations only, while in 126 (47%) one to 5 additional mutations were found. The most frequent additional mutations were ASXL1 (n=50), TET2 (n=49; thereof 15 biallelic), SRSF2 (n=26), DNMT3A (n=18), U2AF1 (n=11) and TP53 (n=9; thereof 3 biallelic). Regarding PB parameters, high WBC (≥11×10 9/ L) were detected in 127 patients (48%), high PLT (≥450×10 9/ L) in 116 (43%) and anemia (HB <♂12 or ♀11 g/dL) in 50 patients (19%). We then performed Cox regression analyses for overall survival (OS) including only genetic abnormalities and PB values. In univariate analyses, biallelic TET2 inactivation ( TET2bi: hazard ratio/HR: 3.789), RUNX1 (n=4; HR: 13.479), ASXL1 (HR: 1.886), SRSF2 (HR: 3.218) mutations as well as high PLT (HR: 0.440), high WBC (HR: 1.998) and PB blasts >1% (n=57; HR: 1.904) showed significant associations with OS (for all p<0.02), while no effect was observed for MPN driver mutations, DNMT3A and monoallelic TET2 mutations. In addition, anemia showed a trend towards poor prognosis (HR: 1.595; p=0.079). Following this, we determined high and low risk MPN. In the absence of thrombocytosis, high risk MPN was defined if any of the four following risk factors were present: i) mutation in ASXL1 or SRSF2 or RUNX1 or TET2bi, ii) PB blasts >1%, iii) high WBC or iv) anemia. In the presence of thrombocytosis, at least two of these risk factors were required (Figure 1). Survival analysis revealed a significantly worse median OS of high risk (n=137; 51%) compared to low risk MPN (n=130; 49%) (8 years vs. not reached; p<0.001). This proposed novel stratification reflected prognosis better than WHO entities (median OS: MPN-U: 7 years; MF: 8 years; PV/ ET not reached; overall p=0.001) (Figure 1A). All 76 ET cases (100%) and 44/74 PV cases (59%) were classified as low risk MPN, while 63/68 PMF cases (93%) and 44/49 MPN-U cases (90%) were classified as high risk MPN (Figure 1B). Within low risk and high risk MPN, no significant OS differences were observed between the WHO entities ( p=0.114 and p=0.355, respectively). Conclusions: JAK2-pathway mutated Ph - MPN can be categorized into low and high risk MPN based on molecular genetics and PB values only. The presence of these objectively assessable risk factors in a patient with ET or PV warrants for a profound reevaluation of bone marrow histology (eventually by a reference pathologist for MPN) and clinical course before a high risk MPN (including prefibrotic PMF) can be ruled out. Whether the predictive value of low risk MPN based on molecular genetics and PB values only could be sufficient to omit BM biopsy in selected patients, needs to be evaluated in further prospective studies.

Preclinical Evaluation of INCB160058 - a Novel and Potentially Disease-Modifying Therapy for JAK2V617F Mutant Myeloproliferative Neoplasms

The Janus kinase 2 ( JAK2) mutation, JAK2V617F, is the most common oncogenic driver in myeloproliferative neoplasms (MPNs), with nearly all cases of polycythemia vera (PV) and over half of primary myelofibrosis (MF) and essential thrombocythemia (ET) patients positive for the somatic mutation. Approved therapies for MPNs such as ruxolitinib, which act by directly inhibiting activity of the kinase domain (JH1) of JAK2, have demonstrated impressive clinical efficacy and safety in patients with MPNs; however, they do not address JAK2V617F allelic burden or achieve molecular remission of disease. A targeted JAK2V617F selective agent sparing wild-type (WT) JAK2 activity has potential to eliminate mutant cells, induce molecular remission, and theoretically lead to functional cure of MPNs. We report herein the preclinical development of pseudokinase (JH2)-targeting INCB160058, a first-in-class, orally bioavailable small molecule with the ability to selectively target JAK2V617F + cell populations derived from patients with JAK-mutant MPNs. Using structure- and function-guided molecular design, INCB160058 was designed to bind with picomolar affinity to the JH2 domain of JAK2V617F at the canonical ATP-binding site, with high specificity (>2500-fold) relative to binding at the active kinase domain (JH1) targeted by currently approved JAK inhibitors. Live cell single-molecule fluorescence microscopy showed that INCB160058 binding to JAK2V617F blocked ligand-independent thrombopoietin receptor dimerization induced by the mutation, and consequently led to loss of JH1 domain kinase activity. X-ray crystallography analysis indicates that the observed inhibition is likely driven by conformational disruption of the ⍺C helix motif at Phe 594 and Phe 595 in conjunction with a shift of the upstream region from Leu 583 to Asn 589 upon INCB160058 binding to the JH2 domain of JAK2V617F. We utilized both CD34 + human multipotent hematopoietic stem cells derived from patients with JAK2-mutant MF, engineered JAK2-mutant human hematopoietic cancer cell lines (eg, SET2 and UKE-1), and murine BA/F3 cell lines to explore the selective effects of INCB160058 on JAK2V617F compared with WT JAK2. INCB160058 treatment selectively reduced pathogenic phospho-STAT5 levels, decreased abnormal megakaryopoiesis, and suppressed colony formation only in JAK2V617F + CD34 + cells but not in CD34 + cells from healthy volunteers. Importantly, continuous exposure of mutant and WT JAK2 cells to INCB160058 in co-cultures at concentrations below IC 50 resulted in progressive elimination of JAK2V617F + cells without affecting WT cells. At the end of the testing period, the JAK2V617F-harboring population was no longer detectable in the co-culture assay. In NSG mice subcutaneously inoculated with JAK2V617F-expressing SET2 cells, INCB160058 was tolerated and exhibited significant antitumor activity. In addition, following INCB160058 treatment, a significant reduction in the engraftment of total human cells, particularly human erythroid progenitors (hCD45 − mCD45 − Ter119 − hCD71 + hCD235a +), was observed in NSGS mice xenotransplanted with JAK2V617F + CD34 + cells. Moreover, INCB160058 treatment also led to the normalization of various pathogenic cytokines, such as interleukin (IL)-6 and IL-8. Importantly, these observations were absent in NSGS mice engrafted with CD34 + cells from healthy volunteers following INCB160058 treatment, further demonstrating the selectivity of INCB160058 for JAK2V617F. In summary, our results indicate a novel mechanism of action of INCB160058, a high-affinity pseudokinase (JH2) binding inhibitor of JAK2V617F that blocks cytokine-independent activity of JAK2V617F while preserving cytokine-dependent signaling. Extended treatment with INCB160058 at low therapeutic doses results in the specific elimination of mutant JAK2V617F-harboring cells in mouse models and human cancer cells with minimal impact on WT counterparts. Clinical testing of INCB160058 may allow patients with MPNs to achieve molecular remission by eliminating cells with the main genetic aberration and afford an opportunity to overcome the disease.

Genetic Deletion or Pharmacologic Inhibition of PTPN11 Impedes the Development and Progression of Myeloproliferative Neoplasms Induced By JAK2V617F and MPLW515L Mutants

Myeloproliferative neoplasms (MPN) including polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF) are clonal myeloid malignancies derived from mutated hematopoietic stem cells. The JAK2V617F mutation was found in ~95% cases of PV and 50-60% patients with ET and MF. Mutations in MPL and CALR were also detected in ET and MF. The JAK inhibitors, Ruxolitinib and Fedratinib, can reduce splenomegaly and alleviate constitutional symptoms but they are not sufficient to induce remission of MPN. So, there is an unmet need to identify new therapeutic targets and therapies for MPN/MF. The non-receptor protein tyrosine phosphatase 11 (PTPN11), which positively regulates hematopoietic cell signaling, is constitutively hyperphosphorylated in MPN patient cells and in hematopoietic cell lines expressing MPN driver mutants. So, we hypothesize that PTPN11 plays an important role in MPNs. To examine the role of PTPN11 in JAK2V617F-induced MPN, we generated inducible PTPN11-deficient heterozygous JAK2V617F mice by crossing PTPN11 floxed mouse with Mx1Cre and JAK2V617F knock-in mice. While expression of heterozygous JAK2V617F (JAK2 VF/+) induced a PV-like MPN characterized by increased WBC, neutrophil, RBC, hemoglobin and platelet counts in the peripheral blood and enlargement of spleen size, deletion of PTPN11 normalized the blood counts and spleen size in JAK2 VF/+ mice. PTPN11 deletion significantly reduced the expansion of hematopoietic stem/progenitors, erythroid, megakaryocytic, and granulocytic cells in the bone marrow (BM) and spleens of JAK2 VF/+ mice. Furthermore, deletion of PTPN11 abrogated Epo-independent CFU-colonies, a hallmark feature of PV disease, in the BM and spleens of JAK2 VF/+ mice. We also investigated the role of PTPN11 in the development of MF using homozygous JAK2V617F and MPLW515L mouse models. We found that deletion of PTPN11 significantly reduced WBC, neutrophil and platelet counts, normalized spleen size and abrogated BM fibrosis in JAK2V617F and MPLW515L mouse models. These results suggest that PTPN11 plays an important role in the development and progression of PV and MF. Data from our PTPN11 genetic deletion study led us to investigate the effects of PTPN11 inhibition against MPN/MF. We tested the efficacy of an allosteric PTPN11 inhibitor SHP099 in MPN hematopoietic cell lines and mouse models of MPN/MF. We observed that treatment of SHP099 significantly reduced proliferation of hematopoietic cells expressing JAK2V617F and MPLW515L. SHP099 treatment also significantly inhibited hematopoietic progenitor colony growth in PV and MF patient CD34+ cells. Next, we tested the in vivo efficacy of SHP099 against PV using heterozygous JAK2V617F mice. Treatment of SHP099 significantly inhibited the increase in WBC, neutrophil and RBC counts and markedly reduced splenomegaly in JAK2 VF/+ mice. SHP099 treatment also significantly reduced hematopoietic stem/progenitors and myeloid precursors in the BM and spleens of JAK2 VF/+ mice. Furthermore, SHP099 treatment abrogated Epo-independent CFU-E colony formation in the BM and spleens of JAK2 VF/+ mice. We also tested the efficacy of SHP099 alone or in combination with ruxolitinib against myelofibrosis using homozygous JAK2V617F (JAK2 VF/VF) and MPLW515L mouse models. SHP099 treatment alone significantly reduced WBC and neutrophil counts and markedly reduced splenomegaly in JAK2 VF/VF and MPLW515L mice. Combined treatment of SHP099 and ruxolitinib resulted in greater reduction of blood cell counts and spleen size in JAK2 VF/VF and MPLW515Lmice. Histopathologic analyses showed that SHP099 treatment significantly reduced BM fibrosis in JAK2 VF/VF and MPLW515L mice while combined treatment of SHP099and ruxolitinib resulted in greater inhibition of BM fibrosis in these mice. To gain insights into the mechanism of inhibition of MPN/MF by PTPN11 deletion or inhibition, we performed RNA-seq analysis on purified LSK cells from JAK2 VF/+ and PTPN11deleted-JAK2 VF/+ mice as well as from JAK2 VF/VF mice treated with ruxolitinib and SHP099/ruxolitinib. RNA-seq data analysis revealed that genes related to MYC targets, ribosome biogenesis and translation were significantly down-regulated by PTPN11 deletion or SHP099/ruxolitinib combination treatment. Overall, our results suggest that inhibition of PTPN11 alone or in combination with JAK2 inhibition might be useful for treatment of PV and MF.

The utility of testing erythropoietin level in polycythemia diagnosis

ABSTRACTObjectives:Polycythemia vera (PV) is classically thought to be associated with low erythropoietin (EPO) levels. Here, we present a review of the utility of using EPO levels in diagnosing polycythemia.Methods:We conducted a systematic literature review of the Medline data through Pubmed and Google Scholar. We included the articles which described confirmed PV associated with elevated EPO level. Our search strategy included the following terms in Pubmed (((polycythemia vera[MeSH Terms]) OR (jak2 protein tyrosine kinase[MeSH Terms])) OR (Myeloproliferative Disorders[MeSH Terms])) AND (Erythropoietin[MeSH Terms]), and ‘polycythemia vera with erythropoietin’ in Google Scholar.Results:Our research yielded four cases of PV with elevated EPO levels. The most common symptom was a headache. Thrombotic phenomena happened in a single case in the form of Budd-Chiari syndrome. The mean Hb level was 20.2 gm/dl, and the EPO level was 213 mlU/mL.Discussion:Although PV is usually associated with low EPO levels, high levels do not exclude this diagnosis. Workup should include testing for JAK2 mutation and bone marrow biopsy in the presence of suggestive signs and symptoms. Novel biomarkers are also being proposed to aid in the diagnosis.Conclusion:Although elevated EPO levels suggest secondary causes of polycythemia, cases where elevated EPO levels were associated with an underlying PV are reported in the literature, and we have summarized a review of them. Workup for polycythemia should include JAK2 mutation testing if signs and symptoms suggest PV even if EPO is elevated.

A cross-sectional study on restless legs syndrome (RLS) in polycythemia vera (PV): is iron deficiency the only culprit?

ABSTRACT Introduction In polycythemia vera (PV) patients undergoing phlebotomy, iron deficiency (ID) may develop. ID has been linked to restless legs syndrome (RLS), and in one study, 29.6% of PV patients had RLS. We aimed to evaluate the frequency of RLS in PV and to evaluate factors that might play a role in RLS development among PV and essential thrombocythemia (ET) patients. Methods We consecutively included PV cases as the patient group, and ET and ID patients and healthy subjects (HSs) were included as controls. Those with conditions that could lead to RLS were excluded. All subjects were questioned according to the diagnostic criteria of the International Restless Legs Syndrome Study Group. Results Twenty-seven PV, 23 ET, and 22 ID patients and 23 HSs were included. RLS was detected in 25.9%, 34.8%, and 45.5% of PV, ET, and ID patients, respectively. None of the HSs had RLS. In univariate analysis, interferon-α and anagrelide use, magnesium levels, and the Leeds assessment of neuropathic symptoms and signs (LANSS) scores had a significant impact on RLS in PV and ET patients (p = 0.014, p = 0.032, p = 0.036, and p = 0.003, respectively). Conclusion RLS was more common among PV and ET patients than HSs, which was irrespective to the iron status. RLS was more frequent in ET patients than that observed in PV cases, indicating that ID may not be the only causative factor for RLS development in PV. Further prospective studies are needed to determine the prevalence and risk factors of RLS developing in PV and ET.

Clinical Impact of JAK2V617F Allele Burden in Philadelphia-Negative Myeloproliferative Neoplasms

The impact of JAK2V617F allele burden on clinical course in Philadelphia-negative (Ph-negative) myeloproliferative neoplasms (MPNs) is not clear. We analyzed the clinical impact of JAK2V617F allele burden in a relatively large series of patients with Ph-negative MPNs and long-term follow-up. A total of 228 patients with Ph-negative MPNs, including 118 with essential thrombocythemia (ET), 84 with primary myelofibrosis (PMF), and 26 with polycythemia vera (PV), were analyzed. The JAK2 MutaScreen assay was used to quantify JAK2V617F allele burden in genomic DNA. In PV cases, high JAK2V617F allele burden was associated with a trend towards inferior overall survival. In ET, high JAK2V617F allele burden was associated with lower hemoglobin and hematocrit levels, higher lactate dehydrogenase (LDH) levels, larger spleen size, and increased bleeding and mortality rates. In PMF, high JAK2V617F allele burden was associated with higher leukocyte counts and larger spleen size. In the entire cohort, high allele burden was associated with higher leukocyte and lower platelet counts, higher LDH levels, larger spleen size, higher percentage of bleeding events, higher death rate, and inferior overall survival. Our results suggest that high JAK2V617F allele burdens are associated with more severe disease in PV and ET. In PMF, high JAK2V617F allele burdens were associated with more pronounced myeloproliferative phenotypes. In Ph-negative MPNs, high allele burdens were associated with more aggressive phenotypes. Our data with a long follow-up period support the possibility of JAK2V617F allele burden being used as a marker for predicting clinical phenotype in cases of Ph-negative MPNs.

Recurrent Ischemic Stroke In Elderly With Polycythemia Vera: Case Report

<p><strong>Background</strong>: Myeloproliferative disorders can rise a risk of thrombotic events. Ischemic stroke is one of presenting symptoms can be found in such patients. These coexisting conditions can burden patients with more severe complications.</p><p><strong>Objectives</strong>: To discuss a case of polycythemia vera with multiple episodes of ischemic stroke.</p><p><strong>Case description</strong>: The patient was a 70-year-old female with chief complaint of sudden rotatory dizziness with moderate to severe intensity. Nausea, vomiting, slurred speech, and facial muscle weakness were also reported. Onset of symptoms started 3 hours before hospital admission. Medical history including previous ischemic stroke in 2020 and 2015 with remaining right extremity weakness. Physical examination showed weakness, hypertension. Nystagmus horizontal bidirectional and upper motor neuron lesion of left CN VII and XII, weakness in right upper and lower extremities were observed. Physiological reflexes were increased, and pathological reflex was found. Head CT showed hypodense lesion led to her ischemic stroke diagnosis. Blood test showed increased hemoglobin count, leukocytosis but normal platelet count. Increased cell numbers and variations of size, morphology and distribution were found in peripheral smear. This finding was also supported with bone marrow examination which showed hypercellularity, panmyelosis with dysplasia of all hematopoietic lineage. Patient was diagnosed with polycythemia vera and treated accordingly.</p><p><strong>Conclusion</strong>: Further examination of hematology, such as peripheral smear or bone marrow examination should be considered in patients with recurrent episodes of stroke to rule in underlying myeloproliferative disorders.Appropriate treatment and routine hematology<strong> </strong>follow up are in need to increase awareness of future thrombotic events or leukemic transformations.</p>

SOHO State of the Art Updates and Next Questions | Polycythemia Vera: Is It Time to Rethink Treatment?

Polycythemia vera (PV) is a Philadelphia-negative myeloproliferative neoplasm characterized by excessive myeloid cells production, mostly secondary to mutations in the Janus kinase 2 (JAK2) gene. PV natural history might be burdened by thrombotic events (TEs) and evolution into post-PV myelofibrosis (PPV-MF) or blast phase (BP). To date, no treatment strategies have been shown to have disease modifying effects, so therapy is directed at preventing TEs. All patients require phlebotomies (PHLs) to keep hematocrit below 45% and once-daily low dose aspirin (if not contraindicated). Apart from patients at "high risk" because of age over 60 years or a thrombosis history, cytoreductive therapies (CT) should be given to patients with relevant signs of myeloproliferation or intolerance to PHLs. Approved choices both for first and second line CT are hydroxyurea (HU) and pegylated forms of interferon (peg-IFN), the latter probably being better for young patients, and subjects without critical and recent vascular events or massive splenomegaly. The JAK1/2 inhibitor ruxolitinib is the treatment of choice in case of resistance/intolerance to HU, with proved efficacy in terms of thrombotic prevention. Data are too preliminary to consider CT for "low risk" PV cases, but ropeg-IFN is being studied in this setting with a short follow-up. A careful monitoring for signs of evolution into PPV-MF is fundamental for optimizing patient management.

The Role of Bone Marrow Biopsy Morphology and Clinical Characteristics in Facing the Challenges of Diagnosing Primary Myelofibrosis, Polycythemia Vera, and Essential Thrombocythemia at Cipto Mangunkusumo Hospital

BackgroundMyeloproliferative neoplasm (MPN) is a neoplasm characterized by the proliferation of one or more myeloid cells and their derivatives. The limitations of molecular examination in Indonesia make the diagnosis of MPN based on clinical and histopathological examination very crucial. The aim evaluate the clinicopathological profile of primary myelofibrosis (PMF), polycythemia vera (PV), and essential thrombocythemia (ET) and identify the typical morphological characteristics of bone marrow biopsy.MethodsA retrospective study of cases diagnosed with MPN was conducted at the Department of Anatomic Pathology FMUI/RSCM in 2015-2019. Clinical data and evaluation of bone marrow morphology consisting of cellularity, erythroid myeloid ratio, cluster and megakaryocyte morphology, blast cells, fibrosis, osteosclerosis, and sinus dilatation were analyzed.ResultsA total of 172 cases were diagnosed as MPN BCR-ABL1-negative (PMF: 74; ET: 56; PV: 42). On routine blood examination, there was an increase in hemoglobin (Hb) and hematocrit (Ht) in PV, a decrease in Hb in PMF and an increase in platelets in ET (p<0.001). Splenomegaly is mostly found in PMF. Myeloid erythroid ratio was decreased in PV, normal in ET and increased in PMF (p<0.001). Megakaryocytes were arranged in loose clusters in 88.1% of PV cases and 96.4% of ET, dense clusters were found in 91.9% of PMF cases. Staghorn-like megakaryocytes were found in all ET cases and bulbous/cloud-like megakaryocytes were found in 97.3% of PMF cases. Most cases of PV (90.5%) and all cases of ET showed pre-fibrotic bone marrow (grade 0-1), while 77% of PMF cases showed fibrosis grade 2-3.ConclusionIn diagnosing PV, ET, and PMF, correlation between clinical data, laboratory, and bone marrow histomorphological evaluations, especially cellularity, myeloid:erythroid ratio, cluster and megakaryocyte morphology, degree of fibrosis, osteosclerosis, and sinus dilatation is required.

Descriptive study in polycythemia rubra vera and evaluation of management outcome

Background: Polycythemia Vera (PV) is a myeloproliferative neoplastic disorder involving uncontrolled red blood cell production resulting in elevated red blood cell (RBC) mass. There is a signaling defect leading to an abnormal response to growth factors, and the abnormal clonal line interferes with normal lineage proliferation. The Janus kinase-2 (JAK2) gene involved with intracellular signaling is mutated in 90% of cases of PV. It can occur in all age groups, but the median age of diagnosis is 60 years. Thrombosis considered as the most common cause for morbidity and mortality. Aim of study: To review the clinical characteristics of a sample of PV patients and their current treatment in addition to assessment of frequency of development of thrombotic events while on treatment. Patients and method: A hospital based retrospective study was conducted in the hematology outpatient's clinic from different centers in Iraq over a period of 11months (from January 2020 till November 2020). Patient's age more than 18 years old with duration of the disease more than 6 months and all of them were positive for JAKII V617F mutations were included in this study while excluding those who were negative for this mutation. The patients were divided in to low and high risk based on age and leukocyte counts and history of previous thrombosis and presence of cardiovascular risk factors. The response and resistance to treatment with hydroxyurea were evaluated according to ELN definition. Result: Thirty patients were enrolled in this study. The median age was 60.6±11 years, ranging between 35-78 years. The mean duration of disease was 54± 5.5 months. Headache was the predominant symptom observed in 96.7%, pruritus was experienced in 63.3%.Splenomegaly was seen in 46.7% .Thrombosis at time of diagnosis happened in 13.4%of cases. The most common complication that occurred in this study group was thrombosis in 20% of patients ,16.6% progressed to myelofibrosis and 63.3% of patients were controlled by treatment. Conclusion: The demographic and some of characteristic of Iraqi PV patients are similar to those from other countries. A good number of patients were controlled with hydroxyurea. Thrombosis is still the commonest complication in patients with PV and occurred mainly in the first 4 years since diagnosis of polycythemia Vera. Median time for development of myelofibrosis was more than 10 year.

Pediatric Myeloproliferative Neoplasm in Era of Who Classification Systematic Review

Introduction Philadelphia-negative MPNs are most prevalent in the older population (median age at the diagnosis above 60 years) and are rarely diagnosed in pediatrics. It is estimated that the overall incidence of MPNs in pediatric patients is around 0.82 per 100,000 patients yearly, and MPNs are approximately 100 times more common in adults than children. Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. English literature (PubMed, SCOPUS, and Google Scholar) was searched for studies, reviews, case series, and case reports of patients with Philadelphia negative MPNs (including essential thrombocythemia, polycythemia vera, primary myelofibrosis) in the pediatric age group (< 18 years). Only studies that fulfilled WHO-2008 or 2016 criteria for MPN were included. Results: We reviewed 33 articles of available published literature from 2008 to 2022 and collected data on a total of 196 patients in the pediatric population. Among the cohort of patients, 139 had essential thrombocythemia (ET), 20 had polycythemia vera (PV), and 37 had myelofibrosis (MF). Patients' clinical and biological characteristics are addressed in Table 1. The median age at the time of diagnosis for each disease varied, with 8.8 years for ET, 10 years for PV, and 3.6 years for MF. There was a variety in the blood counts at the time of diagnosis between all three diseases (Table 1). Discussion: Based on our review, the presence of splenomegaly pediatrics with PV was not mentioned in most cases, yet around a third of the reported data have splenomegaly, matching the percentage found in adults. On the other hand, hemorrhage was not observed in pediatrics with PV, thrombosis complicated in 2 (10%) cases, and leukemic transformation was documented in 2 (10%) cases. The number of PV cases in this review is small, with only 20 reported cases, so it is challenging to get conclusions, yet the presentation and complications between adults and pediatrics are comparable, apart from a possibly higher chance for AML transformation in the pediatric population. In adults with PV, around 98% of the patients were positive for either JAK2V617F in 95% or other JAK2 mutations in 3%. While in this pediatrics review, JAK2V617F mutation was found in only 45% of the cases and JAK2 exon 12 mutation in 15%. 36% of the ET cases were asymptomatic at presentation, a number lower than that observed in adults (45%). However, thrombosis is less common in pediatrics than in adults (9% versus 21%), and bleeding as a complication from ET in pediatrics was equal to adults (9%). JAK2V617F was the most common mutation (20% of the ET patients). Based on our review, MF cases in pediatrics are more common than PV cases in comparison with adults, in which MF is the least common. Data for pediatric patients with PMF is scarce; based on this sample of 37 patients, the percentage of symptomatic patients is higher than adults, but unlike adults, most pediatrics are presented with symptoms of cytopenia rather than constitutional symptoms, same for palpable splenomegaly where it was more reported compared to adults. The pediatric population with PMF has an entirely different mutation profile, with none of the patients in our data having JAK2V617F or MPL mutations. Interestingly in our collected data, none of the patients with PMF developed thrombosis or leukemic transformation, compared with 7% of adult patients who have documented leukemic transformation. Conclusion: Given the rarity of MPNs in pediatrics and different characteristics compared with adults, international collaborative efforts to study MPNs in this age group are needed to understand these disorders better. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Challenges of Diagnosing Headache in Sickle Cell Disease, a Unique Case of Polycythemia Vera and Essential Thrombocytosis in a Patient with Sickle Cell beta0 Thalassemia

Introduction: Little is known of the relationship between myeloproliferative neoplasm (MPN) and sickle cell disease (SCD), possibly due to under diagnosis from symptom overlap. Few studies exist documenting cases of concomitant MPN in SCD patients, likely because the confounding presence of reactive thrombocytosis in SCD and masking of polycythemia in SCD making the diagnosis of essential thrombosis (ET) and polycythemia vera (PV) difficult. Case Presentation: Here, we report a case of a 38-year-old male with beta 0 thalassemia (HbSB0) SCD who developed a chronic, and unremitting headache of 2 months. Neurological workup of his headache was unremarkable and headache remained unresponsive to various pain medications used by the patient for sickle cell associated pain crises. Laboratory values on presentation were remarkable for WBC 11 k/uL, HgB 10.9 g/dL, platelets 994 k/uL, MCV 72, reticulocyte count 7.0%. A thorough analysis of vasomotor symptoms and laboratory values, when trended over 20 years (table 1), demonstrated that headaches were likely secondary to hyperviscosity, as noted by platelet uptrend and inappropriate hemoglobin elevation for his SCD genotype; in which the expected hemoglobin level is between 6-8g/dL. Laboratory studies demonstrated a JAK2 mutation in peripheral blood with no BCR-ABL mutation detected, excluding chronic myeloid leukemia (CML). Subsequent bone marrow biopsy demonstrated hypercellular marrow (90-95%) with marked erythropoiesis and relatively mild increased granulocytic and megakaryocytic hematopoiesis and mild increase in reticulin fibers, without dysmyelopoiesis; thus excluding myelodysplastic syndrome (MDS). Mutation analysis confirmed JAK2 Val617Phe mutation. Concurrent flow cytometry analysis showed no evidence for leukemia or lymphoproliferative disorder. Together with biopsy data, laboratory data and clinical presentation, the patient was diagnosed with polycythemia vera and essential thrombocytosis. The patient was subsequently managed with Hydroxyurea, with resolution of symptoms presumably due to improvement in blood viscosity due to lowering of platelet levels to 464k/uL. Discussion: Our report highlights a unique association between MPN in a patient with SCD, diagnostic challenges, and its multifaceted treatment. Our patient presented with unremitting headaches, which can be secondary to either SCD or MPN alone. In patients with SCD severe headache can be associated with ischemic stroke due to vaso-occlusion, hemorrhage, venous sinus thrombosis, aneurysms, meningitis, medication withdrawal or tolerance, bony infarcts, and osteomyelitis. The wide differential diagnosis of headaches in SCD complicates the finding of MPN amongst these patients, and without frequent laboratory monitoring, concomitant vasomotor symptoms would likely remain unnoticed in the patient. Furthermore, our report describes the first documented association of a JAK2 Val617Phe mutation in a patient with SCD. Our case also outlines the use of hydroxyurea as a double edged sword. Interestingly in our patient, hydroxyurea initiation acted as a dual therapy for the management of SCD, through reducing pain crisis episodes, and MPN via platelet count reduction, thereby preventing symptoms of hyperviscosity. Overall, this case highlights a distinctive example of PV and ET in a patient with SCD and its diagnostic challenges, and the first case in the literature to describe JAK2 Val617Phe mutation. Further, our case emphasizes the need to consider vasomotor symptoms and perform a critical analysis of laboratory trends in SCD patients. Future studies may consider a multi-institution retrospective analysis of thrombocytosis in SCD patients to determine if MPN is underdiagnosed in SCD patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Efficacy and Safety of Peginterferon Alfa-2b in 95 Patients with Myeloproliferative Neoplasms:a Single Center Retrospective Analysis

Background Polycythemia vera (PV) and essential thrombocythemia (ET) are a common type of Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) driven by the JAK2,CALR or MPL mutation, which are associated with a reduced quality of life, a high rate of vascular events, and an intrinsic risk of disease evolution to myelofibrosis and acute myeloid leukemia. Pegylated interferon has obtained high-level evidence for short-term clinical trial endpoints such as hematocrit control, symptom burden/quality of life, splenomegaly, and JAK2 allele burden lies within the timeline of most studies. Objective To investigate the efficacy and safety of Peginterferon alfa-2b in patients with myeloproliferative neoplasms Methods The clinical data of 95 patients with MPNs treated with Peginterferon alfa-2b in Peking Union Medical College Hospital (Beijing, China) from January 2018 to May 2022 were retrospectively analyzed. Peginterferon alfa-2b was administered subcutaneously once weekly at a starting dose of 180ug, and could be decreased over time to 180ug every 2 to 4 weeks if hematological control was achieved. Hematological control was defined as HCT<45% in the absence of phlebotomy in patients with PV and PLT<400x109/L in patients with ET. Molecular response was defined as JAK2 allele burden decreased＞50% from baseline (partial remission) or undetectable at a lower limit of quantitation at 1% by the central laboratory (complete remission) which was measured by next-generation sequencing Results Among the 95 patients, 48 were male and 47 were female. There were 61 cases of PV and 34 cases of ET. The median age at diagnosis was 45 (17-69) years, and the median time from onset to diagnosis was 5.1 (0-413) months. All patients had next-generation sequencing for the driver mutations, there were 84 cases of JAK2 mutation, 8 cases of CALR mutation, 1 case of MPL mutation, and 2 cases of triple negative. The median duration of Peginterferon alfa-2b exposure was 13.2（2~51）months. 54 (88.5%) of 61 patients with PV achieved hematological control and 24 (70.6%) of 34 patients with ET achieved hematological control. The median onset of action was 1.4 (0.5-6.7) months. 47 patients with JAK2 mutation were detected with JAK2 allele burden for molecular evaluation. A total of 17 (36.2%) patients obtained molecular partial remission by 6 months and 26 (55.3%) patients achieved molecular partial remission by 12 months while no one achieved molecular complete remission. The most common treatment-emergent adverse events were influenza-like symptoms (88.4%), hyperglobulinemia (14.7%), elevated alanine aminotransferase (13.7%), and subclinical hypothyroidism (7.4%). A total of 4 patients (4.2%) discontinued the treatment, 2 due to intolerance of adverse effects, 1 due to disease progression to myelofibrosis, and 1 due to pregnancy. Conclusion This study demonstrates that Peginterferon alfa-2b was safe, well tolerated, and efficacious in patients with PV and ET. Keywords: Peginterferon alfa-2b, myeloproliferative neoplasms, hematological control molecular response

Correlation of Thrombosis and Clinicohematological Parameters with JAK2V617F Mutation in Philadelphia-Negative CMPNs: A Study from India.

Objective Philadelphia-negative chronic myeloproliferative neoplasms (CMPNs), which include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), are characterized by the presence of JAK2V617F (exon 14) mutation, and this occurs in 90 to 95% cases of PV and 50 to 60% cases of ET and PMF. Still, this is a matter of debate regarding the correlation of this mutation with thrombosis and clinicohematological parameters in CMPNs. So, we conducted this study to ascertain the association of JAK2V617F mutation with thrombotic complications and clinicohematological parameters of these patients. Materials and Methods This prospective and retrospective study was conducted during 2018 to 2019 at the Department of Laboratory Sciences and Molecular Medicine of a tertiary care hospital, and 160 CMPN patients were enrolled. Complete hemogram was done and DNA was extracted, followed by real-time qualitative polymerase chain reaction to check for JAK2V617F mutation. This mutation was then correlated with complications, mainly thrombosis, hematological parameters, and clinical parameters such as age and splenomegaly. Results Among 160 CMPN patients, 60 were females and 100 were males, with male to female ratio of 1:0.6, and age range of 27 to 85 years. Total 91 (56.9%) patients were JAK2V617F positive and the remaining 69 (43.1%) were negative for this mutation. We observed statistically significant correlation of leukocyte count, splenomegaly, and thrombosis in JAK2V617F-mutated patients as compared to unmutated patients. Conclusion This study emphasizes the importance of JAK2V617F mutation in CMPNs and stresses on its association with clinical, hematological phenotype, and thrombotic complications, which may open new horizons in prognostication and management protocol.