Chromosomal Aberrations in Polycythemia Vera

A number of chromosomal aberrations, occurring in polycythemia verapatients are presented, with an emphasis on their nonspecific nature. Amongradiophosphorus-treated patients the frequency of these aberrations was moderately higher. The one finding typical to P³² treated patients was the presenceof dicentric chromosomes, and a dose response curve to the last P³² dose wasdemonstrated. A Philadelphia-like chromosome was observed in two patientswith polycythemia vera and in one with benign erythrocytosis, all post P³²therapy.

A question is raised whether it is possible that the future course of thepolycythemic patient is dependent upon the type and location of chromosomaldamage, and in turn, on the establishment of a clone of cells with a selectivedevelopmental advantage.

Submitted on November 22, 1968 Accepted on August 14, 1969     

Granulocyte Kinetic Studies in Patients with Proliferative Disorders of the Bone Marrow

Granulocyte kinetic studies with DFP³² were done in four patients withchronic myelocytic leukemia, three patients with polycythemia vera, one patient with essential thrombocythemia, and one patient with persistent, unexplained granulocytosis. The increased blood granulocyte concentrationfound in the patients with polycythemia vera, essential thrombocythemia andunexplained granulocytosis was at least in part the result of increased granulocyte production. Precise calculations of granulocyte pool sizes and turnoverrates in the patients with chronic myelocytic leukemia were not possiblebecause of unresolved problems related to the non-uniform population ofmyeloid cells in the blood of these patients. However, within the limitationsof the method, a greater number of myeloid cells were turned over per daythrough blood than in normal subjects. The findings support the conceptthat a widespread disorder of marrow proliferation exists in chronic myelocytic leukemia, polycythemia vera, and essential thrombocythemia.

Submitted on December 20, 1962 Accepted on March 23, 1963     

Allogeneic hematopoietic stem cell transplantation in patients with polycythemia vera or essential thrombocythemia transformed to myelofibrosis or acute myeloid leukemia: a report from the MPN Subcommittee of the Chronic Malignancies Working Party of the European Group for Blood and Marrow Transplantation

The clinical course of polycythemia vera and essential thrombocythemia is potentially associated with long-term severe complications, such as evolution to myelofibrosis or acute myeloid leukemia. Allogeneic stem cell transplantation is currently the only potentially curative treatment for advanced polycythemia vera or essential thrombocythemia. We analyzed 250 consecutive patients with an initial diagnosis of polycythemia vera (n=120) or essential thrombocythemia (n=130), who underwent transplantation due to progression to myelofibrosis (n=193) or acute myeloid leukemia (n=57) and who were reported to the European Group for Blood and Marrow Transplantation registry between 1994 and 2010. Their median age was 56 years (range, 22–75) and in 52% of cases the interval between diagnosis and transplantation was 10 years or more. With a median follow-up from transplantation of 13 months, the 3-year overall survival rate and relapse incidence were 55% and 32%, respectively. In univariate analysis, the main parameters that negatively affected post-transplantation outcomes were older age (>55 years), a diagnosis at transplant of acute myeloid leukemia and the use of an unrelated donor. The overall 3-year cumulative incidence of non-relapse mortality was 28%, but was significantly higher in older patients than in younger ones (>55 years, 35% versus 20%, P=0.032), in those transplanted from an unrelated donor rather than a related donor (34% versus 18%, P=0.034) and in patients with a diagnosis of acute myeloid leukemia compared to myelofibrosis (29% versus 27%, P=0.045). This large retrospective study confirms that transplantation is potentially curative for patients with end-stage polycythemia vera/essential thrombocythemia progressing to myelofibrosis or acute myeloid leukemia. Relapse and non-relapse mortality remain unsolved problems for which innovative treatment approaches need to be assessed.     

Polycythemia Vera with Ph1 Chromosomes in Two Brothers

Two brothers with polycythemia rubra vera have been studied: one beforetreatment and one after many years of treatment. Direct harvests of marrowaspirates from both patients exhibited the presence of the Ph¹ chromosome.Moderately increased LAP levels were present in both. Available data do notindicate whether the disease and the chromosomal aberrations in these twobrothers are familial or fortuitous.

Submitted on October 19, 1966 Accepted on April 24, 1967     

Leukocyte Kinetics in Hematologic Disorders Studied by DNA-Phosphorus Labeling

Leukocyte physiology in the normal and in hematopoietic disease statesin humans has been studied by DNA-P labeling with inorganic P³². In thenormal there is a post-mitotic granulocyte reservoir in marrow about 17times the size of the intravascular compartment. Progress through this reservoir is orderly and requires about 6 days. Some 1-2 x 10¹¹ cells dailyare released from it into the blood. In polycythemia vera there is an increasedproduction of granulocytes. DNA-P labeling in patients with chronic lymphocytic leukemia occurs at a very low level and is compatible with a veryslow rate of cell renewal. In one patient with chronic lymphocytic leukemia,no disturbances in kinetics caused by a dose of 20 µc. of P³²/Kg. weredetected during the time of the study. Although a progressively rising concentration of label in circulating leukocyte DNA was found in patients withchronic granulocytic leukemia, without the lag suggesting a distinct marrow phase, it is concluded that the blood and extravascular leukopoietic compartments cannot be a single compartment. An essentially normal curve isobtained after induction of a complete remission with busulfan.

Submitted on October 1, 1963 Accepted on December 3, 1963     

Studies of the production and life span of erythrocytes in myeloid metaplasia

1. Four patients with agnogenic myeloid metaplasia and one patient withpolycythemia vera and myeloid metaplasia were studied with Fe⁵⁹, Cr⁵¹ andglycine-2-C¹⁴.

2. Three of the patients with agnogenic myeloid metaplasia had activesplenic, hepatic or renal erythropoiesis. One had deficient erythropoiesis.

3. The red cell life span was short in all of the patients with agnogenicmyeloid metaplasia, definite splenic sequestration occurring in two patients.The red cell life span was normal in the patient with polycythemia vera andmyeloid metaplasia.

4. The possible indications for splenectomy were discussed.

Submitted on July 25, 1958 Accepted on October 12, 1958     

Co60 Vitamin B12 Binding Capacity of Human Leukocytes

1. Mature neutrophilic leukocytes show the highest Co⁶⁰B₁₂ binding capacity.

2. Less mature granulocytes, "blast" forms and eosinophils have little or noCo⁶⁰B₁₂ binding capacity.

3. Disintegrated mature leukocytes from chronic myelocytic leukemia andpolycythemia vera show higher B₁₂ binding capacity than intact cells.

4. Mature leukocytes from patients with chronic myelocytic leukemia andpolycythemia vera show a two-phase B₁₂ curve suggesting specific and nonspecificbinding, similar to that observed in human serum.

5. Disintegration products from mature neutrophilic leukocytes probablycontribute largely to increased B₁₂ binding capacity of serum in chronic myelocyticleukemia and polycythemia vera.

Submitted on August 30, 1961 Accepted on October 17, 1961     

Haptoglobin Metabolism in Polycythemia Vera

1. Turnover studies with ¹²⁵I-labeled haptoglobin (Hp) were performed in7 patients with polycythemia vera, 2 patients with erythrocytosis of unknownetiology, and 2 control subjects.

2. The T of plasma radioactivity was shortened in 6 of the 7 patients withpolycythemia vera; 3 of these had diminished plasma Hp levels but lackedother evidence of hemolysis.

3. The fractional catabolic rate exceeded 40 per cent/day in all subjectswith a shortened half-time of plasma radioactivity.

4. Increases in the fractional catabolic rate were not accompanied by increases in Hp turnover (mg./kg./day), suggesting that accelerated Hp catabolism per se does not provide a stimulus to Hp production.

5. It is concluded that patients with polycythemia vera catabolize Hp morerapidly than nonpolycythemic subjects, possibly because of increased formation and removal of the haptoglobin-hemoglobin complex.

Submitted on November 5, 1968 Accepted on January 21, 1969     

The Threshold Dose of P32 for Leukemic Cells of the Lymphocytic and Granulocytic Series

Analyses of the threshold dose of P³² to control 201 chronic lymphocyticleukemia patients and 100 chronic granulocytic leukemia patients and of theP³² dose to maintain 133 chronic lymphocytic leukemia patients for a meanperiod of 50.2 months and 49 chronic granulocytic leukemia patients for amean period of 33.6 months are analyzed. These threshold doses fit the logarithmic probability distributions given in the tables and figures.

See PDF for Figure

See PDF for Figure

When the dose in mc. to control was plotted against the leukocyte count,a straight line was obtained on log log paper. The equation for this curvefor the median dose to control chronic granulocytic leukemia is: log mc. P³²per 12 weeks = 0.33 log L - 0.633, where L is the leukocyte count on theday the first P³² was given. The equation for the log log curve relating mediandose to control chronic lymphocytic leukemia to initial counts above 15,000is: log mc. P³² per 12 weeks = 0.47 log L - 1.420. But the 40 aleukemic orsubleukemic cases with leukocyte counts below 15,000 had a median P³² requirement and standard deviation that did not differ significantly from thatfor the entire group, suggesting that this subleukemic group includes patientsresembling the entire spectrum of cases with elevated initial leukocyte counts.

See PDF for Figure

See PDF for Figure

The median dose of P³² per year to maintain chronic granulocytic leukemiacases fits the equation: log P³² per year = 0.546 log L - 1.506, and the corresponding equation for chronic leukemic lymphocytic leukemia is: log mc.P³² per year = 0.45 log L - 1.22. The group of lymphocytic leukemias withinitial counts below 15,000 again showed a median and distribution similar tothat for the entire leukemic group.

The remarkable fact that the dose requirement years later is related to theinitial leukocyte count is discussed. Revised recommendations on dosageschedule for titrated, regularly spaced P³² therapy of the chronic leukemiasare presented.

For each individual patient with chronic leukemia, there is a thresholddose of intravenously administered P³² below which no effect is observed. Thedose and interval which will maintain a uniform leukocyte count of about15,000 may remain unchanged for years or may show abrupt changes at anytime to either a lower or higher requirement.

Submitted on November 6, 1959 Accepted on January 4, 1960     

Treatment of the myeloproliferative disorders with 32P

Abstract: The use of radioactive phosphorus (³²P) to treat the myeloproliferative disorders (chronic leukemia, polycythemia vera and essential thrombocythemia) began in 1939 when John H. Lawrence treated the first patient on the basis of work done in the laboratory anima that found localization of the radioisotope in the spleen, liver, bone and in leukemic cells sufficient to indicate a therapeutic potential. After World War II when ³²P became widely available, it was used extensively to treat the chronic leukemias and polycythemia vera. Its use in the treatment of essential thrombocythemia began later in 1950. Today it is not widely used in the treatment of the chronic leukemia, if at all, its use in polycythemia vera appears to have decreased substantially and replaced by hydroxyurea, and its use in the management of essential thrombocythemia is not widespread. In each instance it has been replaced by a drug developed for use in cancer chemotherapy, and in some instances by interferon. It probably has wider use in polycythemia vera in the rest of Western Europe than in the UK, and there are cogent reasons to suggest that it may be the best tool for the treatment of polycythemia vera. Thus have we discarded a treatment modality that in polycythemia vera may be the best?     

Trends in the incidence of polycythemia vera among olmsted county,Minnesota residents, 1935–1989

To investigate the suggestion that the incidence of polycythemia vera has increased in recent decades, we ascertained secular trends in the incidence of polycythemia vera in Olmsted County, Minnesota, over the 55-year period, 1935–1989. The inpatient and outpatient medical records of all potential cases of polycythemia vera in Olmsted County residents were reviewed and the diagnostic criteria of the Polycythemia Vera Study Group were applied. We found no indication of an increase in the age- and sex-adjusted incidence of polycythemia vera, which averaged 1.9 per 100,000 person-years (95% C.I., 1.4–2.5) over the study period. Incidence rates increased with age, and age-adjusted incidence rates were greater for men (2.8 per 100,000 person-years; 95% C.I., 1.8–3.9) than for women (1.3 per 100,000 person-years; 95% C.I., 0.7–1.9), with the highest incidence rate (23.5 per 100,000 person-years) among men aged 70–79 years. Survival was reduced in this inception cohort of 50 cases, compared to that expected for individuals of like age and sex (P < 0.0001); median survival following diagnosis was 7.2 years. © 1994 Wiley-Liss, Inc.     

Life span of thrombocytes and erythrocytes in normal and thrombocytopenic calves

1. Bovine thrombocytes and erythrocytes became labeled with P³² following an intramuscular injection of DFP.³²

2. The life span of bovine thrombocytes calculated from survival curves ofDFP³²-labeled thrombocytes was about 10 days.

3. The life span of bovine erythrocytes calculated from the linear portionof the survival curve was about 110 to 120 days.

4. There was no significant difference between the life span of the thrombocytes and erythrocytes from normal calves and those from calves with thrombocytopenia induced by the feeding of trichloroethylene-extracted soybeanoil meal.

Submitted on May 5, 1958 Accepted on June 26, 1958     

A Study of Histamine in Myeloproliferative Disease

1. Whole blood histamine content was measured in 80 patients with myeloproliferative disease. Increased levels were found in 60 per cent of patientswith uncontrolled polycythemia vera, in 7 per cent of patients with polycythemia vera being controlled by myelosuppressive therapy, and in 71 percent of a group with "spent" polycythemia, myeloid metaplasia and myelofibrosis.

2. The excretion of histamine in the urine was measured in 60 patients,30 with elevated blood histamine and 30 with normal blood histamine. Theurine findings paralleled the blood findings in 90 per cent of the cases.

3. Measurements of cell-poor and cell-rich fractions of blood showed thatthe histamine is contained in the white cell fraction. Elevated basophil countswere present in 50 per cent of the patients and occurred with the greatestfrequency in the groups with elevated blood and urine histamine. A roughcorrelation between the basophil count and the histamine content of bloodand white cell fractions was observed in normal subjects and most cases withmyeloproliferative disease. Data obtained in some cases of myeloproliferativedisease suggest that the histamine content of the basophil may be abnormaland that other granulocytes may contribute to the total leukocyte histamine.

4. Myelosuppressive agents produced a reduction in histamine (expressedper 10⁹ myeloid cells) and a decrease in urine histamine as control of themyeloproliferative process was achieved. Treatment with phlebotomy aloneproduced no change in histamine levels.

5. The incidence of pruritus, upper gastrointestinal distress and urticarialmanifestations was increased 7-fold, 4-fold and 12-fold, respectively, in patients with elevated histamine levels as compared with those who had normalhistamine levels.

6. Cyproheptadine, a potent antihistaminic, successfully controlled pruritus,relieved pyrosis and suppressed urticarial eruptions in patients with elevatedhistamine levels. Suppression of the reaction to subcutaneously administeredcodeine (a histamine-releaser) afforded objective evidence that cyproheptadine blocked the effects of histamine release in vivo.

7. The metabolism of histamine and the role of elevated histamine levelsin the clinical manifestations and pathophysiology of myeloproliferative diseaseare discussed.

Submitted on September 23, 1965 Accepted on May 24, 1966     

Comparative Studies of Platelet Survival by Different Methods in the Rabbit

Four methods for measuring the survival of homologous platelets in rabbitswere studied: (1) transfusion of nonradioactive platelet concentrates tothrombocytopenic recipients, (2) transfusion of concentrates of plateletslabeled in vitro with Cr⁵¹-sodium chromate, (3) transfusion of concentratesof platelets labeled in vivo with P³²-orthophosphate and (4) transfusion ofwhole blood labeled in vivo with P³²-orthophosphate. The survival time ofplatelets in normal rabbits was 3-4 days.

From comparison of the 3 methods using platelet concentrates, the followingconclusions were drawn. (1) All the platelets in a platelet concentrate werecapable of recirculating after transfusion. (2) Labeling with P³² or Cr⁵¹ didnot damage platelets. (3) About one-third of the Cr⁵¹ was immediately elutedfrom viable platelets after they were transfused. (4) Further exchange of thelabel in vivo did not occur to a significant degree with either Cr⁵¹ or P³².(5) Cr⁵¹ did not elute from platelets during storage of the platelets. (6) Studiesof rabbit platelets had applicability in predicting the behavior of humanplatelets.

Submitted on April 13, 1964 Accepted on July 2, 1964     

Polycythemia vera in childhood: Case report and review of the literature

A patient presented at 5 years of age with polycythemia vera. He subsequently developed splenic infarctions and died at 20 years of age following cerebral hemorrhage and infarctions. Two months before his death, he developed hypertension and had biochemical evidence of primary hyperparathyroidism and possibly pheochromocytoma. Only nine reported childhood cases of polycythemia vera fulfill the criteria of the Polycythemia Vera Study Group. These cases are summarized and the complications discussed. Although none have progressed to myeloid metaplasia or acute leukemia, these patients are at risk of developing thrombo-hemorrhagic complications; available evidence indicates that they should be managed to keep the hematocrit between 40 and 45%.     

Life expectancy and prognostic factors for survival in patients with polycythemia vera and essential thrombocythemia

PURPOSE: To assess life expectancy and prognostic factors for survival in patients with polycythemia vera and essential thrombocythemia. METHODS: The study sample consisted of 831 consecutive patients with polycythemia vera (n = 396; 4184 person-years of follow-up) or essential thrombocythemia (n = 435; 4304 person-years of follow-up). Mortality in each group was compared with the Italian population using the standardized mortality ratio (SMR) based on life expectancy data obtained from the Italian Institute of Statistics. RESULTS: The 15-year survival was 65% in patients with polycythemia and 73% in those with thrombocythemia. By Cox regression analysis, the independent predictors of death were a history of thrombosis for polycythemia (hazard ratio [HR] = 2.2; P = 0.0002) and thrombocythemia (HR = 2; P = 0.01), and male sex (HR = 1.8; P = 0.03) for thrombocythemia. Mortality compared with the general population was 1.6-fold higher (P <0.001) in patients with polycythemia but was not increased in those with thrombocythemia (SMR = 1; P = 0.8). CONCLUSION: Life expectancy of patients with polycythemia vera (especially if younger than 50 years) was reduced compared with the general population, whereas life expectancy of patients with essential thrombocythemia was not affected significantly by the disease, reflecting the more indolent nature of the proliferation. History of thrombosis was the main predictor of death in both diseases.     

Therapy of polycythemia vera with myleran

Myleran was used in the therapy of nine relapses of polycythemia verain five patients. Clinical examinations, blood studies, and, in three instances,radioisotope tracer tests before and after treatment demonstrated the effectiveness, safety and simplicity of the treatment. Further trial of Mylerantherapy in polycythemia vera seems warranted.

Submitted on September 6, 1957 Accepted on December 16, 1957     

Rate of production of P32-labeled lymphocytes

1. Lymphocytes in dogs have been labeled by means of the DNA-P³² incorporation technic.

2. In the thoracic duct, a high level of lymphocyte DNA-P³² specific activityis reached within two hours. After 24 to 30 hours, the activity falls to alower level which is then maintained for at least 160 hours.

3. Lymphocyte-granulocyte separations on the blood revealed that DNA-P³²specific activity reached a peak on the fourth day for both lymphocytes andgranulocytes.

4. These findings are consistent with a short maturation time for the lymphocyte and a short intravascular time.

Submitted on February 17, 1958 Accepted on April 12, 1958     

Leukocyte Labeling in Rats during and after Continuous Infusion of Tritiated Thymidine: Implications for Lymphocyte Longevity and DNA Reutilization

Leukocyte labeling was studied in rats during and after continuous intravenous infusion of H³-thymidine. The radioisotope was administered forvarying periods up to 271 days. The results permit the following conclusions:

1. The median survival of small lymphocytes is about 1 month. Five to8 per cent of small lymphocytes have a life span of more than 9 months.

2. Following the administration of H³-thymidine, reutilization of the tracermarkedly delays the fall-off of labeled cells in the peripheral blood. Reutilization probably involves H³-thymidine released from labeled DNA during cell death, since suppression occurs with massive infusion of non-labeled thymidine.

3. Unlike granulocytes and large lymphocytes, small lymphocytes labelnonuniformly, and appear to be comprised of at least two populations withdifferent intensities of labeling and different turnover rates. The more heavilylabeled cells have the faster turnover.

4. The complexity of the labeling process indicated by the present observations must be considered in the interpretation of H³-thymidine data.However, the survival of unlabeled cells during continuous H³-thymidineinfusion remains a valid means of measuring the life spans of circulatingblood cells.

Submitted on October 22, 1964 Accepted on January 25, 1965     

Studies of phosphorus metabolism in man; a study of the permeability of the human erythrocyte to inorganic phosphate in vitro by the use of radioactive phosphate (P32)

1. Phosphate exchange in red cells and plasma was studied in vitro using P³²in the form of sodium phosphate as a tracer.

2. No phosphate was added other than the isotopic preparation which was ofhigh specific activity.

3. Inorganic phosphate exchanged freely between the plasma and the erythrocytes at 37.5 C. in a period of four hours. Minimal transfer occurred at 7 C.

4. Most of the added P³² which passed into the erythrocytes during this timeremained in the inorganic fraction, less than 15 per cent being found in the organicacid soluble fraction.

5. The specific activity of the inorganic phosphate of the erythrocytes was equalto or greater than that obtaining for the inorganic phosphate of the plasma at theend of the four hour incubation period at 37.5 C.