Cases Of Essential Thrombocythemia Research Articles

Platelet Factor 4 and Longevity of Patients with Essential Thromobocythemia: An Example of Antagonistic Pathogenic Pleiotropy.

This paper presents the concept of Antagonistic Pathogenic Pleiotropy (APaP), in which an abnormality that causes a specific pathology can simultaneously reduce other morbidities through unrelated mechanisms, resulting in the pathology causing less morbidity or mortality than expected. The concept is illustrated by the case of Essential Thrombocythaemia (ET). ET patients have substantially elevated platelets, and are therefore expected to have increased thrombotic events leading to reduced life expectancy. However ET patients do not have reduced life expectancy. A possible explanation is that elevated platelets produce higher levels of Platelet Factor 4 (PF4), which has been found to reduce age-associated decline in immune and cognitive function in mice, and has been suggested as a treatment for age-associated illness. The benefit of elevated PF4 is hypothesised to balance the increased morbidity from hematological causes. Searches for other indications where a well-defined pathology is not associated with concomitant reduction in overall mortality may be a route to identifying factors that could protect against, prevent or treat chronic disease.

A germline JAK2 exon12 mutation and a late somatic CALR mutation in a patient with essential thrombocythemia.

It has been discovered that Janus kinase 2 (JAK2) exon12 mutations lead to the polycythemia vera (PV) phenotype, while somatic mutations of calreticulin (CALR) are associated with essential thrombocythemia (ET) or primary myelofibrosis. In this article, we report a case of ET with coexistence of JAK2 exon12 and CALR mutations. The objective of this study was to elucidate the pathogenicity mechanism of a JAK2 exon12 mutation (JAK2N533S) and the role of the coexistence of mutations on the hematological phenotype. We designed a colony analysis of tumor cells obtained from this patient, and attempted to identify mutant genes using DNA from hair follicles. Mutation impairment prediction and conservative analysis were conducted to predict the mutation impairment and structure of JAK2N533S. In addition, we conducted a functional analysis of JAK2N533S by constructing Ba/F3 cell models. Three distinct tumor subclones, namely JAK2N533Shet+/CALRtype1het +, JAK2N533Shet+/CALR wt, and JAK2N533Shet+/CALRtype1hom +, were identified from the 17 selected erythroid and 21 selected granulocyte colonies. The analysis of hair follicles yielded positive results for JAK2N533S. According to the bioinformatics analysis, JAK2N533S may exert only a minor effect on protein function. Functional studies showed that JAK2N533S did not have a significant effect on the proliferation of Ba/F3 cells in the absence of interleukin-3 (IL-3), similar to wild-type JAK2. Notably, there were no increased phosphorylation levels of JAK2-downstream signaling proteins, including signal transducer and activator of transcription 3 (STAT3) and STAT5, in Ba/F3 cells harboring the JAK2N533S. Our study revealed that the JAK2N533Shet+/CALRtype1het+ subclone was linked to a significant expansion advantage in this patient, indicating that it may contribute to the development of the ET phenotype. We further demonstrated that JAK2N533S, as a noncanonical JAK2 exon12 mutation, is a germline mutation that may not exert an effect on cell proliferation and protein function. These results and the present body of available data imply that certain noncanonical JAK2 mutations are not gain-of-function mutations leading to the development of myeloproliferative neoplasms.

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.

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.

The Epidemiology of Cardiovascular Disease in African American Patients with Myeloid Neoplasms: A SEER Data Analysis

Introduction: Cardiovascular disease (CVD) mortality rates are higher in cancer survivors compared to the general population. Numerous studies have reported racial disparities in CVD mortality among cancer survivors. However, there is a lack of research exploring CVD mortality specifically in African American (AA) patients (pts) with myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN). To address this gap, we conducted a comprehensive population-based study to analyze cardiovascular mortality in the AA population with MDS and MPN. Methods and Statistical analysis: In Surveillance, Epidemiology, and End Results (SEER) database using the 17 registries, we identified cases of essential thrombocythemia (ET), Polycythemia Vera (PV), Primary Myelofibrosis (PMF), and Myelodysplastic syndromes (MDS) in AA population diagnosed between 2001-2020, with the diagnosis age >=20. CVD deaths included deaths from heart diseases, hypertension without heart disease, cerebrovascular diseases, atherosclerosis, and diabetes mellitus, based on the SEER Causes of Death Register and International Classification of Diseases (10th Revision, ICD10). Death rates were calculated by dividing the number of deaths over person-years of follow-up. We also estimated the standardized mortality ratios (SMR by dividing the observed cardiovascular deaths rates in our sample over expected CVD death rates of general population with no cancer, matched to age, gender and ethnicity. All analyses were performed by SEER*Stat 8.4.1.2 and R 4.2.2. Results: The study included 8135 patients, with following diagnoses: ET (n= 2317), PV (n= 1231), PMF (n= 377) and MDS (n= 4210). Overall, 2640 of the total study population (32.45%) died, of which 39.5% were CVD deaths. The mean follow up for PV, ET, PMF and MDS cohorts was 6.44, 5.95, 3.67 and 3.82 years, respectively (Table 1). The CVD mortality rate per 1,000 person-years in PV, ET and PMF subgroups were 17.9, 14.95, and 29.6, respectively. Notably, the rate was highest in the MDS subgroup, 40.37 compared to other subgroups (P<0.01). Comparing the CVD mortality of each risk group to the general US AA population, we observed significantly increased CVD SMRs. These were highest in PMF and MDS (SMR, 3.07; 95% CI, 2.2-4.16 and 2.25; 95% CI, 2.08-2.43, respectively), followed by PV (SMR, 1.75; 95% CI, 1.47-2.06) and ET (SMR, 1.67; 95% CI, 1.45-1.92).When comparing CVD mortality to the general CVD mortality rate in the AA population, we found higher rates across all age groups, including SMR, 13.16; 95% CI, 4.27- 30.72 in 20-29 yrs, SMR, 5.4; 95% CI, 2.95- 9.06 in 30-39 yrs, (SMR, 2.20; 95% CI, 1.92- 2.52) in 60-69 yrs, (SMR, 1.87; 95% CI, 1.67- 2.1) in 70-79 yrs (Figure 1). Conclusion: Our analysis highlights the magnitude of CVD-related deaths in the AA population with MDS and MPN. Among studied subgroups, the impact was highest in patients with MDS. This could be explained by a shared mechanism of CVD pathogenesis with MDS and clonal hematopoiesis of indeterminate potential (CHIP). In addition, we report a higher risk of CVD mortality at younger ages in AA pts relative to older age group. Because CVD-related mortality is high in AA with MDS and MPN, introduction of preventative cardiology services after diagnosis might be warranted to improve survival.

A Rare Case of Essential Thrombocythemia Revealed by an Acute Coronary Syndrome: Management Difficulties and Therapeutic Challenges

Essential thrombocythemia is a clonal abnormality of the multipotent hematopoietic stem cell and results in an increased number of platelets. Patients are at risk of microvascular thrombosis and hemorrhage. The occurrence of an acute coronary syndrome may be a rare revealing mode of discovery of essential thrombocythemia. We report the case of a 67-year-old patient admitted for management of an acute coronary syndrome with the discovery during his assessment of a thrombocythemia reaching up to 966,000/mm3. in the context of the etiological assessment of the thrombocytosis, the diagnosis of essential thrombocythemia was retained. Acute coronary syndrome occurs in 9.4% of patients with essential thrombocytosis. In patients with ET, there is a vicious cycle in which the marked increase of activated platelets causes vascular endothelial damage, induces the instability of coronary plaque, evokes the rupture or erosion of the plaque, and consequently activates other resting platelet. The diagnosis of ACS in patients with essential thrombocythemia is similar to that of the general population, nevertheless in terms of treatment, Antithrombotic treatment remains a difficult decision to take. It is necessary to balance the risk of thrombosis and hemorrhage. the optimal long-term treatment of acute coronary syndrome is a dual antiplatelet therapy (DAT) with clopidogrel and Aspirin and adding Hydroxyurea to the DAPT makes the treatment optimal.

Identification of putative noncanonical driver mutations in patients with essential thrombocythemia.

Essential thrombocythemia (ET) cases without canonical JAK2, CALR, or MPL mutations, that is, triple-negative (TN) ET, have been found in 10%-20% of ET cases. Owing to the limited number of TN ET cases, its clinical significance remains unclear. This study evaluated TN ET's clinical characteristics and identified novel driver mutations. Among 119 patients with ET, 20 (16.8%) had no canonical JAK2/CALR/MPL mutations. Patients with TN ET tended to be younger and had lower white blood cell counts and lactate dehydrogenase values. We identified putative driver mutations in 7 (35%): MPL S204P, MPL L265F, JAK2 R683G, and JAK2 T875N were previously reported as candidate driver mutations in ET. Moreover, we identified a THPO splicing site mutation, MPL*636Wext*12, and MPL E237K. Four of the seven identified driver mutations were germline. Functional studies on MPL*636Wext*12 and MPL E237K revealed that they are gain-of-function mutants that increase MPL signaling and confer thrombopoietin hypersensitivity with very low efficiency. Patients with TN ET tended to be younger, although this was thought to be due to the inclusion of germline mutations, hereditary thrombocytosis. Accumulating the genetic and clinical characteristics of noncanonical mutations may help future clinical interventions in TN ET and hereditary thrombocytosis.

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.

A retrospective review of myeloproliferative neoplasms and correlation of bone marrow morphological results with next generation sequencing profiles

Background: Classification of Philadelphia negative (Ph-) myeloproliferative neoplasms (MPN) relies on the integration of peripheral blood counts, demonstration of driver mutations where possible and the interpretation of bone marrow aspirate and trephine morphology. Of these disorders, the distinction between essential thrombocythemia and prefibrotic myelofibrosis can be challenging. Objectives and methods: To assess reproducibility of the WHO classification for this group of MPNs and to assess the potential of utilising next generation sequencing (NGS) to assist with the diagnosis. This retrospective study was conducted at Pathwest QEII, Western Australia. Twenty cases of MPNs from 2017–2021 with an initial diagnosis or differential diagnosis of essential thrombocythaemia (ET), prefibrotic myelofibrosis (prePMF) and primary myelofibrosis (PMF) were centrally reviewed using a standardised proforma for the FBP parameters and defined morphologic criteria based on the WHO classification. NGS was performed to assess the variant allele frequencies (VAF) of driver mutations and the presence of additional mutations. Results: Fifteen cases were concordant with the initial morphological review. ET cases had a lower JAK2V617F VAF compared to PMF and fewer number of additional mutations. NGS was of limited use in the differentiation between ET and prePMF in the other five cases that were difficult to classify on morphological grounds. Conclusions: This study is limited by the small sample size but reflects practice in a diagnostic laboratory. In this study, the application of NGS was of limited use in further assisting the diagnosis of ET or prePMF where the strict WHO criteria are applied.

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

Restless Legs Syndrome (RLS) in Patients (pts) with Polycythemia Vera (PV): Is Iron Deficiency (ID) the Only Culprit?

Background: RLS is a sensorimotor disorder that causes discomfort in the legs and the urge to move them. In its etiology, there are many conditions including ID. PV is a myeloproliferative neoplasia (MPN), and in pts with PV, ID may develop during the course of the disease. In one study, 29.6% of PV pts had RLS, which was thought to be associated with phlebotomy and ID (Med Oncol. 2010;27(1):105-7). Essential thrombocythemia (ET) is another MPN, in which ID is not typically observed. In our study, we sought to evaluate the frequency of RLS in PV and to search for possible factors other than ID that might have a role in the etiology of RLS among MPN pts. Methods: Previously diagnosed pts with PV and ET, who admitted to our clinic between August and December 2021 were included. All PV pts were evaluated for the study regardless of their iron status. ET pts with ID were not included, since ET cases formed the non-ID MPN control group. Pts with a transferrin saturation below 20% and ferritin level below 20 µg/L were considered as cases with ID. Pts with comorbidities that may lead to RLS generation were excluded. Fasting plasma glucose, HbA1c values, urea, creatinine, thyroid function tests, vitamin B12, and magnesium values were measured. According to these parameters, pts with biochemical disorders that may affect the development of RLS were also excluded (Figure 1). In accordance with the PV and ET groups, pts with ID and healthy subjects (HS) were included as the positive and negative controls, respectively. Demographic characteristics, treatments, complete blood count (CBC) parameters, iron studies, and biochemical tests of the subjects were recorded. Neurological examination was performed in all cases, electromyography (EMG) was taken and evaluated for polyneuropathy. All subjects were questioned according to the RLS diagnostic criteria, and all subjects underwent Pittsburgh Sleep Quality Index (PSQI) tests. Results: In the final analysis, 27 PV, 23 ET, and 22 ID pts and 23 HS were included (Figure 1). Pts in the ID group were significantly younger than other groups (p=0.025) (Table 1). The median follow-up duration of the ET pts was significantly higher than those of others (p=0.011). Other demographic features were comparable between groups (Table 1). No significant pathology was detected in the neurological examination in all subjects. RLS was detected in 25.9%, 34.8%, and 45.5% of PV, ET, and ID pts, respectively. While there was no difference between these groups in terms of the presence of RLS, RLS was not detected in HS. In pts with PV 66% had ID, and there were no significant differences in terms of CBC parameters, iron studies, biochemical parameters, and the JAK2V617F mutational status in PV and ET pts with and without RLS. In addition, polyneuropathy was detected in one ET patient by EMG and RLS was not detected in this patient. There was no significant difference between these groups regarding median PSQI scores, but the median PSQI score was found to be significantly higher in pts with RLS (p=0.001) (Table 1). When we investigated the relationship between cytoreductive treatments and RLS in PV and ET pts, we found that the frequency of RLS was higher in pts receiving interferon-alfa (IFN-a) and anagrelide (Table 2). In pts with PV and ET, IFN-a and anagrelide usage, and magnesium (Mg) levels were found to have an impact on RLS in univariate analysis, but only Mg levels was associated with RLS in multivariate analysis (Table 3). Conclusion: In our study, the high prevalence of RLS in pts with ID and the absence of RLS among HS both indicate that our RLS questionnaire results are reliable. Although not all PV pts had ID, the prevalence of RLS was higher when compared to HS as was described previously (Med Oncol. 2010;27(1):105-7). In addition, although not significantly different, the frequency of RLS was higher in ET pts than that observed in PV cases. These results suggest that, RLS may occur during the course of the disease in MPN pts, due to factors independent of ID and other known RLS triggering conditions. In light of all these, further studies are needed to elucidate the etiology of RLS developing in pts with PV and ET. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

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

Essential Thrombocythemia Associated with Plasma Cell Neoplasm

Abstract Introduction/Objective The co-occurrence of essential thrombocythemia (ET) and multiple myeloma (MM), two distinct entities with distinct cellular origin, is rare, with a limited number of cases reported. Methods/Case Report We report a case of a 63-year-old male who initially presented with thrombocytosis, splenomegaly and elevated LDH. A bone marrow examination showed hypercellularity (90%) with increased abnormal megakaryocytes, as well as a JAK2 V617F mutation, with overall features consistent with involvement by a myeloproliferative neoplasm (MPN), consistent with ET (versus early primary myelofibrosis (PMF)). Additionally, 6% kappa-restricted plasma cells were identified, consistent with involvement by a monoclonal gammopathy of undetermined significance (MGUS). The patient was subsequently treated with hydroxyurea. Four years later, he presented with evidence of paraproteinemia. IgG kappa monoclonal paraprotein was elevated at 3.4 g/dL. A repeat bone marrow examination showed hyper-cellularity (60%), including clusters of abnormal megakaryocytes and mild to moderate reticulin fibrosis. The previously identified kappa-restricted plasma cell population increased to approximately 40% of the total cellularity. Cytogenetic analysis showed a normal male karyotype (46,XY[20]), and a prognostic myeloma-FISH panel including 13q-/-13, 1q32/1q21, p53/NF1, CCND1/IgH t(11;14), FGFR3/IgH t(4;14), IgH/MAF t(14;16) and IgH/MAFB t(14;20) was negative for all tested abnormalities. The overall features were again consistent with involvement by an MPN and progression of the previously identified MGUS. Results (if a Case Study enter NA) NA. Conclusion Only a few cases of concurrent ET and MM have been previously reported in the literature, with most of these cases having a temporal association with alkylating agent therapy. However, MM development has also been reported in a patient with non-cytotoxic treatment of ET. In contrast, our patient was diagnosed with ET associated with MGUS at the initial diagnosis. Notably, the co-existence of early PMF with MM appears to be relatively more established. A large study showed that previous PMF was strongly associated with MM development (OR 24.3; 95% CI:2.9-201.5).

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.

Ischemic Stroke in a patient with Essential Thrombocythemia: Case Report

Essential thrombocythemia represents a rare risk factor for ischemic stroke. Uncontrolled proliferation of megakaryocytes sustained increases circulating platelet count and thrombotic risk. Many patients suffering from the disease may have no symptoms for a long time. We present a case of 60 year old lady with ischemic stroke who was a known case of essential thrombocythemia. And the cerebrovascular event was the complication of essential thrombocythemia as she quit treatment. J MEDICINE 2022; 23: 169-172

Clinical Analysis of Gene Mutation and Vascular Events in Patients with BCR/ABL Negative Myeloproliferative Neoplasms

To explore the relationship between clinical features, peripheral blood cell count, coagulation function, gene mutation and hemorrhagic events and thrombotic events in essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis(PMF) patients. Clinical data of 78 patients with ET, PV, and PMF who were admitted to the Second Affiliated Hospital of Chongqing Medical University between September 2019 and August 2020 were retrospectively analyzed. Information about sex, age, gene mutation, peripheral blood cell count, coagulation function, and hemorrhagic and thrombotic events was included, and the influence of these data on the occurrence of hemorrhagic and thrombotic events was estimated. Among the 78 patients with myeloproliferative neoplasms, there were 47 cases of ET, 15 cases of PV, and 16 cases of PMF.A total of 10 patients (12.82%) experienced hemorrhagic events and 27 (34.62%) experienced thrombotic events. Male,patients aged ≥ 60 years, and patients with a JAK2V617F mutation were more likely to experience thrombotic events (P<0.05). Patients with thrombotic events had higher platelet (PLT) counts and fibrinogen (FIB) levels than patients without hemorrhagic-thrombotic events (P<0.05).White blood cell (WBC) count, red blood cell (RBC) count, hemoglobin (HGB) level, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT) and international normalized ratio (INR) showed no statistical difference between patients with thrombotic events and patients without hemorrhagic-thrombotic events (P>0.05). There was also no significant difference in the above-mentioned indexes between patients with hemorrhagic events and patients without hemorrhagic-thrombotic events (P>0.05). Among JAK2V617F positive myeloproliferative neoplasm patients, male patients were more likely to have thrombotic events (P<0.05), and patients with thrombotic events had higher platelet counts than those without hemorrhagic-thrombotic events (P<0.05). There was no significant difference in age, white blood cell count, red blood cell count, hemoglobin level, PT, APTT, FIB, TT or INR between patients with thrombotic events and patients without hemorrhagic-thrombotic events (P>0.05). Sex, age, JAK2V617F mutation and platelet count have a certain value for predicting thrombosis in patients with myeloproliferative neoplasms.

Analysis of DNA Methylation Gene Mutations and Clinical Features in Patients with Myeloproliferative Neoplasm

Next-generation sequencing technology was used to detect 31 MPN-related genes in 105 cases of MPN patients ［40 cases of polycythaemia vera (PV), 65 cases of essential thrombocythemia (ET)］, and to analyze the relationship between DNA methylation gene mutations and clinical features. 15 mutation types were detected in 105 patients (88 mutations in total), and the total mutation detection rate was 87.6% (92/105). A total of 23 mutations in 4 DNA methylation genes (TET2, DNMT3A, IDH1, IDH2) were detected in 22 patients. The mutation rate of DNA methylation genes was 21.0%, mainly in the form of double mutations, including JAK2 V617F and TET2 (n=10), JAK2 V617F and DNMT3A (n=4), CALR and TET2 (n=2), JAK2 V617F and IDH1 (n=1). Compared with MPN patients without DNA methylation gene mutations, the proportion of women with DNA methylation gene mutations and the white blood cell count (WBC) were significantly higher (P<0.05). Compared with MPN patients with triple-negative driver genes, the proportion of women with DNA methylation gene mutations, age, WBC, platelet count (PLT), and neutrophil-to-lymphocyte ratio (NLR) were significantly higher (P<0.05). The remaining difference was not statistically significant (P>0.05). The MPN10 score, the incidence of thrombotic events, and the proportion of medium-risk and high-risk patients with DNA methylation gene mutations were significantly higher than those of MPN patients without DNA methylation gene mutations (P<0.05). The mutation rate of DNA methylation genes was 21.0%, mainly coexisting in the form of double mutations. The proportion of women with DNA methylation gene mutations in MPN patients and WBC is high, the symptom load is heavy, the incidence of thrombosis is high, and the proportion of medium-high-risk patients is high, suggesting that their prognosis may be poor.

An unusual case of Essential Thrombocythemia in coexistence with Breast cancer

Essential thrombocythemia (ET) is an extremely rare myeloproliferative neoplasm (MPN) which is characterized by persistent, non-reactive thrombocytosis (&gt; 450 X 109/L) and an increased risk for thrombotic events.These patients have an increased risk of both hematological and non-hematological malignancies however the risk of breast cancer in MPN is not increased in comparison to general population. We hereby present an extremely unusual case of ET in a 38 years old female (diagnosed with breast cancer), which came to light on routine pre-surgical work up of the patient.Diagnosis was confirmed on bone marrow aspiration clubbed with JAK 2 mutation. Patients with ET have an increased risk of thrombosis thereby it becomes challenging for the clinician to operate on a coexistent solid tumor. On extensive literary search, there was a single case of coexistent Breast Cancer and Essential Thrombocythemia and we are reporting second such coexistence to the best of our knowledge. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 463-466

Essential Thrombocythemia in Children and Adolescents.

Simple SummaryAmong chronic Ph-negative myeloproliferative neoplasms, essential thrombocythemia is found in children with low but increasing incidence. The diagnostic and clinical features do not completely overlap with ET of adult age. A significant number of cases, in fact, do not meet the criteria of clonality, and many cases require extensive clinical evaluation to exclude secondary, reactive forms. Therefore, histological analysis of bone marrow biopsy is necessary, and its use should be enforced. The clinical course appears to be more benign, at least within the first decades of observation, with the incidence of thrombotic events being much lower than in adults (4 % vs. 30%). Hemorrhages are mostly irrelevant. Therefore, the management should be carefully adapted to the individual patient, balancing the risk of future complications with long-term collateral effects of any drug. This review analyzes the peculiarities of the disease facing similarities and differences with adult scenarios.This paper reviews the features of pediatric essential thrombocythemia (ET). ET is a rare disease in children, challenging pediatric and adult hematologists alike. The current WHO classification acknowledges classical Philadelphia-negative MPNs and defines diagnostic criteria, mainly encompassing adult cases. The presence of one of three driver mutations (JAK2V617F, CALR, and MPL mutations) represent the proof of clonality typical of ET. Pediatric ET cases are thus usually confronted by adult approaches. These can fit only some patients, because only 25–40% of cases present one of the driver mutations. The diagnosis of hereditary, familial thrombocytosis and the exclusion of reactive/secondary thrombocytosis must be part of the diagnostic process in children and can clarify most of the negative cases. Still, many children present a clinical, histological picture of ET, with a molecular triple wild-type status. Moreover, prognosis seems more benign, at least within the first few decades of follow-up. Thrombotic events are rare, and only minor hemorrhages are ordinarily observed. As per the management, the need to control symptoms must be balanced with the collateral effects of lifelong drug therapy. We conclude that these differences concert a compelling case for a very careful therapeutic approach and advocate for the importance of further cooperative studies.

Clonal Dynamics of JAK2V617F and Non-Driver Mutations in Polycythemia Vera and Essential Thrombocythemia Patients Receiving Hydroxyurea Therapy

▪Introduction:Hydroxyurea (HU) is the most widely used cytoreductive treatment for patients with essential thrombocythemia (ET) and polycythemia vera (PV) at high risk of thrombosis. It remains unknown whether long-term HU therapy modulates or promotes the acquisition of mutations in non-driver (ND) genes, especially, when assessing hematological (HR) and molecular (MR) response. The objective of the study was to analyze the clonal dynamics of ND genes in HR and MR with HU in a cohort of JAK2V617F-mutated PV and ET patients.Methods:The study included 144 JAK2V617F positive patients (PV n = 73, TE n = 71) receiving HU as first-line cytoreductive treatment. The baseline sample (before HU treatment) and at the timepoint of best molecular response to JAK2V617F were analyzed. The allelic burden of J AK2V617F was assessed by allele-specific PCR and the mutational profile of ND genes was analyzed by next generation sequencing with a custom panel including 27 myeloid-associated genes. HR was defined according to the criteria of the European LeukemiaNet 2009 and MR of JAK2V617F was defined as complete, major, partial and no response (Table I).Results:Median molecular follow-up was 54.1 months for PV and 55.5 months for ET. Patients with PV were more likely to be males (p<0.001), and displayed higher leukocyte count (p<0.001) compared to those with ET. The respective numbers of deaths, leukemic transformations and fibrotic progressions were: 22 (30%), 4 (5%), 6 (8%) for PV cases, and 19 (27%), 1 (1%), 0 (0%) for ET patients.At baseline, a total of 62 somatic mutations in ND genes were detected in 42/73 (57%) PV patients while 58 were detected in 36/71 (51%) ET patients.Complete HR was observed in 102 patients: 44 (60%) PV and 58 (81%) ET. Partial MR in 67 cases: 35 (48%) PV and 32 (45%) ET and major or complete MR in 21 cases: 8 (11%) PV and 13 (18%) ET. The median duration of HU treatment was 45.8 months (range: 17.5-189.5) for PV and 45.6 months (range: 14.6-168.6) for ET.The most frequently mutated genes detected at pre-therapy samples were TET2 (34%), ASXL1 (12%), SF3B1 (7%) and EZH2 (5%) in PV patients, and TET2 (34%), ASXL1 (13%), DNMT3A (13 %) and SRSF2 (5%) in ET patients. No significant differences were observed in the MR (p=0.358) or HR (p=0.917) according to the presence or absence of mutations in ND genes at baseline.Clonal dynamics of DNMT3A, ASXL1, and TET2 (DAT) genes were not modulated by HU therapy to the same extent as JAK2V617F. Disappearance and emergence of additional mutations in DAT genes were observed independently of the molecular response achieved by the JAK2V617F clone. These findings suggest the existence of clones with mutations in ND genes independent from the pathogenic driver clone, and the lack of modulation by HU treatment.Finally, an increase of allelic burden or the appearance of mutations in TP53, a gene related to progression, and in other DNA repair genes (PPM1D and CHEK2) was observed in 14 (19.1%) PV patients and 9 (12.6%) ET cases during HU treatment. However, no increased risk of myelofibrotic transformation or progression to acute myeloid leukemia was observed in these patients.Conclusions: 1.Pre-treatment ND mutations are not associated with HR and MR to HU in JAK2V617F-mutated patients. 2. The clonal dynamics of ND mutations (decrease, increase, appearance, disappearance) are not related to the evolutionary dynamics of JAK2V617F. 3. An increase or appearance of progression-related mutations in TP53 and/or other genes of the DNA repair pathway such as CHEK2 and PPM1D is observed during HU treatment.Acknowledgments: Instituto de Salud Carlos III-FEDER, PI16/0153, PI19/0005, 2017SGR205, PT20/00023 and XBTC. [Display omitted] DisclosuresSalar: Janssen: Consultancy, Speakers Bureau; Roche: Consultancy, Speakers Bureau; Gilead: Research Funding; Celgene: Consultancy, Speakers Bureau. Besses: Gilead: Research Funding. Bellosillo: Thermofisher Scientific: Consultancy, Speakers Bureau; Qiagen: Consultancy, Speakers Bureau; Roche: Research Funding, Speakers Bureau.