The role of thrombocytapheresis in the contemporary management of hyperthrombocytosis in myeloproliferative neoplasms: A case-based review

Abstract

Extreme thrombocytosis induces an acquired thrombotic-hemorrhagic diathesis, and left uncontrolled is a harbinger of potentially fatal vascular complications. Currently, cytoreduction with medical therapy remains the mainstay of hyperthrombocytosis management. However, it offers a less-than-ideal option in situations where a rapid reduction in platelets is urgently needed, as in the presence of vital end-organ ischemia or to ameliorate of life-threatening hemorrhage. The role of thrombocytapheresis, or plateletpheresis, in hyperthrombocytosis has become increasingly obsolete given the proactive titration of cytoreductive therapies and early identification and correction of reversible causes of reactive thrombocytosis. Despite its narrowed indications, plateletpheresis continues to offer a valuable temporizing measure in platelet count reduction before cytoreductive agents exert their maximal effect. In this context, it is important for the treating physician to be aware of the symptoms and risks associated with hyperthrombocytosis to inform best clinical practices. In this review, we discuss the role of plateletpheresis in the modern-day management of hyperthrombocytosis in patients with myeloproliferative neoplasms through a case based review of the literature. It becomes apparent throughout the discussion that the decision to perform plateletpheresis should be individualized based upon the clinical scenario, degree of thrombocytosis, available infrastructure and every patient’s risk profile.

Therapeutic thrombocytapheresis for extreme thrombocytosis after chemotherapy in essential thrombocytosis

“…There is lack of evidence to predict the kinetics of platelet rise in these cases. For this reason, even though he did not present any symptoms or thrombotic event associated with thrombocytosis, and was receiving hydroxyurea and anagrelide, it was decided to perform therapeutic thrombocytapheresis, because the effect of this double pharmacologic cytoreduction is not immediate . In addition, this indication is in line with the recommendation of the Guidelines of the American Society for Apheresis where prophylactic thrombocytapheresis in recommended in thrombocytosis cases although a category III, that is, decision making should be individualized.…”

“…The efficiency platelet reduction with Spectra Optia observed in our case was significantly higher than previously reported. There are a variety of studies comparing this equipment related to platelet donation in healthy individuals, however for therapeutic use is not frequent and the only equipment approved in the United States is COBE Spectra . Spectra Optia has not been yet FDA cleared for therapeutic thrombocytapheresis.…”

“…There are a variety of studies comparing this equipment related to platelet donation in healthy individuals, however for therapeutic use is not frequent and the only equipment approved in the United States is COBE Spectra. 7 Spectra Optia has not been yet FDA cleared for therapeutic thrombocytapheresis. Boddu et al presented a case-based review of four patients treated with therapeutic thrombocytapheresis in which platelet count was reduced 30%-60% after processing 1.5-2 total blood volumes; unfortunately, no information is provided regarding the apheresis separators used.…”

The underappreciated risk of thrombosis and bleeding in patients with myelofibrosis: a review

“…The role of thrombocytapheresis in management of bleeding secondary to extremely high platelet counts is not well defined in MF patients. However, like any other thrombocytosis in general, it may be considered on case by case basis, if urgent platelet reduction is desired in bleeding secondary to acquired von Willebrand’s syndrome [54]. Per current ASFA guidelines, thrombocytapheresis is a category 2 (second line therapy either as a standalone treatment or in conjunction with other modes of treatment), grade 2C recommendation (weak recommendation, low quality or very low quality evidence) for symptomatic thrombocytosis [55].…”

A spotlight on the management of complications associated with myeloproliferative neoplasms: a clinician’s perspective

“…With extreme thrombocytosis in an emergency situation thrombocytopheresis could be considered. In most situations urgent cytoreductive therapies are what is needed but there may be individual cases where thrombocytophersis should be considered as a possible therapeutic option [74].…”