Polycythemia vera (PV) is a clonal disorder characterized by unwarranted production of red blood cells. In the majority of cases, PV is driven by oncogenic mutations that constitutively activate the JAK-STAT signal transduction pathway, such as JAK2 V617F, or exon 12 mutations or LNK mutations. Diagnosis of PV is based on the WHO criteria. Diagnosis of post-PV myelofibrosis is established according to the International Working Group for Myeloproliferative Neoplasms Research and Treatment criteria. Different clinical presentations of PV are discussed. Prognostication of PV is tailored to the most frequent complication during follow-up, namely, thrombosis. Age older than 60 years and prior history of thrombosis are the 2 main risk factors for disease stratification. Correlations are emerging between leukocytosis, JAK2(V617F) mutation, BM fibrosis, and different outcomes of PV, which need to be confirmed in prospective studies. In my practice, hydroxyurea is still the "gold standard" when cytoreduction is needed, even though pegylated IFN-alfa-2a and ruxolitinib might be useful in particular settings. Results of phase 1 or 2 studies concerning these latter agents should however be confirmed by the ongoing randomized phase 3 clinical trials. In this paper, I discuss the main problems encountered in daily clinical practice with PV patients regarding diagnosis, prognostication, and therapy. (Blood. 2012;120(2):275-284)
IntroductionPolycythemia vera (PV) is a myeloproliferative neoplasm (MPN). 1 The abnormal myeloproliferation of PV is sustained by a constitutively active JAK-STAT signal transduction pathway, caused by the unique V617F mutation within exon 14 (ϳ 95% of PV) 2-5 and by different mutations within exon 12 (ϳ 4% of PV) of the JAK2 gene. 6,7 With lower prevalence, loss of negative regulation of JAK activation caused by LNK mutations (hot spot between codons 208 and 234), 8 or by SOCS mutations 9 or hypermethylation of CpG islands in SOCS1 and SOCS3, 10 have been implicated in PV pathogenesis. The current view suggests that several other cooperating genetic hits might be required. Among others, mutations involving EZH2 11 or TET2, 12 possibly interfering with epigenetic regulatory mechanisms, have been found in approximately 3% and in approximately 16% of JAK2(V617F)-positive PV, respectively.The course of PV is mainly dominated by thrombosis, with an incidence estimated at 18 ϫ 1000 person-years and accounting for 45% of all deaths, but also evolution to myelofibrosis (post-PV MF) and to acute myeloid leukemia (AML), both occurring with an incidence of 5 ϫ 1000 person-years and accounting for 13% of deaths, 13 highlighting the genetic complexity of AML after PV.In this manuscript, I discuss my approach to patients with PV with a focus on specific issues encountered in daily practice regarding diagnosis, prognosis, and treatment.
DiagnosisThe median age at presentation is in the sixth decade; patients younger than 50 years of age account for one-third of PV patients. 23 Clinical presentation of PV may be rec...