Polycythemia vera

Primary polycythemia, often called polycythemia vera (PCV), polycythemia rubra vera (PRV), or erythremia, occurs when excess red blood cells are produced as a result of an abnormality of the bone marrow. Often, excess non-lymphoid white blood cells and platelets are also produced. Polycythemia vera is classified as a myeloproliferative disease.

Epidemiology

Polycythemia vera occurs in all age groups (including children), [cite journal | author = Passamonti F, Malabarba L, Orlandi E, Baratè C, Canevari A, Brusamolino E, Bonfichi M, Arcaini L, Caberlon S, Pascutto C, Lazzarino M | title = Polycythemia vera in young patients: a study on the long-term risk of thrombosis, myelofibrosis and leukemia | journal = Haematologica | volume = 88 | issue = 1 | pages = 13–8 | year = 2003 | pmid = 12551821] although the incidence increases with age. One study found the median age at diagnosis to be 60 years,Berlin, NI. (1975). "Diagnosis and classification of polycythemias". "Semin Hematol" 12: 339.] while a study in Olmsted County, Minnesota found that the highest incidence was in people aged 70–79 years.cite journal | author = Anía B, Suman V, Sobell J, Codd M, Silverstein M, Melton L | title = Trends in the incidence of polycythemia vera among Olmsted County, Minnesota residents, 1935-1989 | journal = Am J Hematol | volume = 47 | issue = 2 | pages = 89–93 | year = 1994 | pmid = 8092146 | doi = 10.1002/ajh.2830470205] The overall incidence in the Minnesota population was 1.9 per 100,000 person-years, and the disease was more common in men than women. A cluster around a toxic site was confirmed in northeast Pennsylvania in 2008.cite web | author = MICHAEL RUBINKAM | title = Cancer cluster confirmed in northeast Pennsylvania | journal = Associated Press | url = http://news.yahoo.com/s/ap/20080826/ap_on_sc/toxic_dump_fears | year = 2008]

ymptoms

Patients with polycythemia vera are often asymptomatic. A classic symptom of polycythemia vera is generalized itching, particularly after exposure to warm water, which may be due to abnormal histamine release [cite journal | author = Steinman H, Kobza-Black A, Lotti T, Brunetti L, Panconesi E, Greaves M | title = Polycythaemia rubra vera and water-induced pruritus: blood histamine levels and cutaneous fibrinolytic activity before and after water challenge | journal = Br J Dermatol | volume = 116 | issue = 3 | pages = 329–33 | year = 1987 | pmid = 3567071 | doi = 10.1111/j.1365-2133.1987.tb05846.x] [cite journal | author = Jackson N, Burt D, Crocker J, Boughton B | title = Skin mast cells in polycythaemia vera: relationship to the pathogenesis and treatment of pruritus | journal = Br J Dermatol | volume = 116 | issue = 1 | pages = 21–9 | year = 1987 | pmid = 3814512 | doi = 10.1111/j.1365-2133.1987.tb05787.x] or prostaglandin production. [cite journal | author = Fjellner B, Hägermark O | title = Pruritus in polycythemia vera: treatment with aspirin and possibility of platelet involvement | journal = Acta Derm Venereol | volume = 59 | issue = 6 | pages = 505–12 | year = 1979 | pmid = 94209] Such itching is present in approximately 40% of patients with polycythemia vera. Gouty arthritis may be present in up to 20% of patients. Peptic ulcer disease is also common in patients with polycythemia vera; the reasons for this are unclear, but may be related to an increased susceptibility to infection with the ulcer-causing bacterium "H. pylori". [cite journal | author = Torgano G, Mandelli C, Massaro P, Abbiati C, Ponzetto A, Bertinieri G, Bogetto S, Terruzzi E, de Franchis R | title = Gastroduodenal lesions in polycythaemia vera: frequency and role of Helicobacter pylori | journal = Br J Haematol | volume = 117 | issue = 1 | pages = 198–202 | year = 2002 | pmid = 11918555 | doi = 10.1046/j.1365-2141.2002.03380.x]

A rare but classic symptom of polycythemia vera (and the related myeloproliferative disease essential thrombocythemia) is erythromelalgia. [cite journal | author = van Genderen P, Michiels J | title = Erythromelalgia: a pathognomonic microvascular thrombotic complication in essential thrombocythemia and polycythemia vera | journal = Semin Thromb Hemost | volume = 23 | issue = 4 | pages = 357–63 | year = 1997 | pmid = 9263352] This is a sudden, severe burning pain in the hands or feet, usually accompanied by a reddish or bluish coloration of the skin. Erythromelalgia is caused by an increased platelet count or increased platelet "stickiness", resulting in the formation of tiny blood clots in the vessels of the extremity; it responds rapidly to treatment with aspirin. [cite journal | author = Michiels J | title = Erythromelalgia and vascular complications in polycythemia vera | journal = Semin Thromb Hemost | volume = 23 | issue = 5 | pages = 441–54 | year = 1997 | pmid = 9387203] [cite journal | author = Landolfi R, Ciabattoni G, Patrignani P, Castellana M, Pogliani E, Bizzi B, Patrono C | title = Increased thromboxane biosynthesis in patients with polycythemia vera: evidence for aspirin-suppressible platelet activation in vivo | journal = Blood | volume = 80 | issue = 8 | pages = 1965–71 | year = 1992 | pmid = 1327286]

Patients with polycythemia vera are prone to the development of blood clots (thrombosis). A major thrombotic complication (e.g. heart attack, stroke, deep venous thrombosis, or Budd-Chiari syndrome) may sometimes be the first symptom or indication that a person has polycythemia vera.

Diagnosis

Patients with polycythemia vera may often be asymptomatic. Physical exam findings are non-specific, but may include enlarged liver or spleen, plethora, or gouty nodules. The diagnosis is often suspected on the basis of laboratory tests. Common findings include an elevated hemoglobin level or hematocrit, reflecting the increased number of red blood cells; the platelet count or white blood cell count may also be increased. Because polycythemia vera results from an essential increase in erythrocyte production, patients have a low erythropoietin (EPO) level.

In primary polycythemia, there may be 8 to 9 million and occasionally 11 million erythrocytes cubic millimeter of blood (a normal range for adults is 4-6), and the hematocrit may be as high as 70 to 80%. In addition, the total blood volume sometimes increases to as much as twice normal. The entire vascular system can become markedly engorged with blood, and circulation times for blood throughout the body can increase up to twice the normal value. The increased numbers of erythrocytes can cause the viscosity of the blood to increase as much as five times normal. Capillaries can become plugged by the very viscous blood, and the flow of blood through the vessels tends to be extremely sluggish.

Recently, in 2005, a mutation in the JAK2 kinase (V617F) was found by multiple research groups [cite journal | author=Baxter EJ, Scott LM, Campbell PJ, East C, Fourouclas N, Swanton S, Vassiliou GS, Bench AJ, Boyd EM, Curtin N, Scott MA, Erber WN, Green AR | title=Acquired mutation of the tyrosine kinase JAK2 in human myeloproliferative disorders | journal=Lancet | year=2005 | pages=1054–61 | volume=365 | issue=9464 | pmid=15781101] [cite journal | author=Levine RL, Wadleigh M, Cools J, Ebert BL, Wernig G, Huntly BJ, Boggon TJ, Wlodarska I, Clark JJ, Moore S, Adelsperger J, Koo S, Lee JC, Gabriel S, Mercher T, D'Andrea A, Frohling S, Dohner K, Marynen P, Vandenberghe P, Mesa RA, Tefferi A, Griffin JD, Eck MJ, Sellers WR, Meyerson M, Golub TR, Lee SJ, Gilliland DG | title=Activating mutation in the tyrosine kinase JAK2 in polycythemia vera, essential thrombocythemia, and myeloid metaplasia with myelofibrosis | journal=Cancer Cell | year=2005 | pages=387–97 | volume=7 | issue=4 | pmid=15837627 | doi=10.1016/j.ccr.2005.03.023] to be strongly associated with polycythemia vera. "JAK2" is a member of the Janus kinase family. This mutation may be helpful in making a diagnosis or as a target for future therapy.

As a consequence of the above, people with untreated PV are at a risk of various thrombotic events (deep venous thrombosis, pulmonary embolism), heart attack and stroke, and have a substantial risk of Budd-Chiari syndrome (hepatic vein thrombosis), or Myelofibrosis. The condition is considered chronic; no cure exists. Symptomatic treatment (see below) can normalize the blood count and most patients can live a normal life for years.

Treatment

As the condition cannot be cured, treatment focuses on treating symptoms and reducing thrombotic complications reducing the erythrocyte levels.

Bloodletting or phlebotomy is one form of treatment, which often may be combined with other therapies. The removal of blood from the body reduces the blood volume and brings down the hematocrit levels; in patients with polycythemia vera, this reduces the risk of blood clots. Phlebotomy is typically performed in people with polycythemia vera to bring their hematocrit (red blood cell percentage) down below 45 for men or 42 for women. [cite journal |author=Streiff MB, Smith B, Spivak JL |title=The diagnosis and management of polycythemia vera in the era since the Polycythemia Vera Study Group: a survey of American Society of Hematology members' practice patterns |journal=Blood |volume=99 |issue=4 |pages=1144–9 |year=2002 |pmid=11830459 |doi=10.1182/blood.V99.4.1144] . It has been observed that phlebotomy also improves cognitive impairment. [Di Pollina L, Mulligan R, Juillerat Van der Linden A, Michel JP, Gold G.Eur Neurol. 2000;44(1):57-9. "Cognitive impairment in polycythemia vera: partial reversibility upon lowering of the hematocrit." PMID 10894997]

Low dose aspirin is often prescribed. Research has shown that aspirin reduces the risk for various thrombotic complications.

Chemotherapy for polycythemia may be used sparingly, when the rate of bloodlettings required to maintain normal hematocrit is not acceptable. This is usually with a "cytoreductive agent" (hydroxyurea, also known as hydroxycarbamide).

The tendency to avoid chemotherapy if possible, especially in young patients, is due to research indicating increased risk of transformation to AML, and while hydroxyurea is considered safer in this aspect, there is still some debate about its long-term safety.

In the past, injection of radioactive isotopes [principally Phosphorus-32] was used as another means to suppress the bone marrow. Such treatment is now avoided due to a high rate of AML transformation.

Other therapies include interferon injections, and in cases where secondary thrombocytosis (high platelet count) is present, anagrelide may be prescribed.

Bone marrow transplants are rarely undertaken in polycythemia patients - since this condition is non-fatal if treated and monitored, the benefits rarely outweigh the risks involved in such a procedure.

There are indications that with certain genetic markers, Erlotinib may be an additional treatment option for this condition. . [cite journal |author=Li Z, Xu M, Xing S, Ho W, Ishii T, Li Q, Fu X, Zhao Z |title=Erlotinib effectively inhibits JAK2V617F activity and polycythemia vera cell growth |journal=J Biol Chem |volume=282 |issue=6 |pages=3428–32 |year=2007 |pmid=17178722 |doi=10.1074/jbc.C600277200]

External links

* [http://www.mpdinfo.org/ Myeloproliferative Disorders (CMPD Education Foundation)]
* [http://www.mpdfoundation.org MPD Foundation and Research Alliance]
* [http://www.mpd-rc.org Myelo-Proliferative Disease Research Consortium]
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References