V 20TH ANNIVERSARY
3 March 1999
CE Refereed Peer Review
FOCAL POINT
★Essential thrombocythemia
(ET) is treated with the same
chemotherapy or radioisotope
protocols used to treat
polycythemia vera and other
myeloproliferative diseases (MPDs).
KEY FACTS
■ A diagnosis of ET can be made
when reactive thrombocytosis is
ruled out and bone marrow or
peripheral blood cytology reveals
morphologically abnormal
platelets or megakaryocytes.
■ Hydroxyurea is considered the
first-line therapy for ET and
several other MPDs.
■ Human recombinant interferon-α
is an adjunctive therapy for many
MPDs, including ET.
■ The ability to provide a prognosis
to owners of animals with ET or
any MPD depends on the ability
to accurately and reliably
distinguish among different
disorders of the hematopoietic
system.
■ Recent efforts to develop positive
criteria for diagnosis have led to
the search for specific markers
for the disease or more reliable
exclusionary data.
Vol. 21, No.
Essential
Thrombocythemia in
Dogs and Cats—Part II*
Auburn University
Alexandra Chisholm-Chait, VMD
ABSTRACT: Essential thrombocythemia is typically diagnosed in middle-aged and geriatric an-
imals. The most common presenting signs are lethargy, inappetence, and weight loss. This ar-
ticle discusses the hematologic and cytologic indications of essential thrombocythemia as well
as current therapeutic recommendations for veterinary patients. Recent advances in diagnos-
tic methods investigated in humans are also reviewed.
E
ssential thrombocythemia (ET) must be differentiated from other myelo-
proliferative diseases (MPDs) and common causes of an elevated platelet
count. A brief review of the classifications and terminology used to de-
scribe MPDs and other causes of thrombocytosis was presented in Part I; diag-
nosis of ET was also discussed. Part II reviews the history, clinicopathologic
findings, and treatment, which is based on the same chemotherapy or radioiso-
tope protocols used for other MPDs; recent advances in diagnostic methods in-
vestigated in human patients are also reviewed.
SIGNALMENT
As with humans, nearly all of the animals diagnosed with ET have been geri-
atric or well into middle age1–4 (Table I), which is in contrast with the broad
range of ages of patients diagnosed with other types of MPDs. There does not
appear to be a sex or breed predilection among the relatively few patients de-
scribed in the veterinary literature; as more cases are reported, however, it may
become evident that certain breeds are more represented than others. Table I
summarizes relevant findings from three case reports and serves as the founda-
tion for the following discussion of recommended strategies for diagnosing and
treating ET in animals.
HISTORY AND PHYSICAL EXAMINATION
The most common presenting clinical signs in all of the reported cases were
lethargy, listlessness, inappetence, and weight loss. Neoplastic disease should always
be high on a rule-out list when older animals are presented with these nonspecific
signs, particularly when they occur with any degree of chronicity (over weeks to
months). Owners should be carefully questioned with respect to vaccination and
*Part I of this two-part presentation appeared in the February 1999 (Vol. 21, No. 2) issue
of Compendium.
Compendium March 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE I
Signalment, History, Physical and Laboratory Examination Findings, Treatment, and
Outcome of Three Reported Cases of Essential Thrombocythemia
Simpson et al 1 Hopper et al 2 Hammer et al 3
Species Dog Dog Cat
Age (yr) 8 11 8
Breed Irish setter Airedale terrier Domestic longhair
Sex/reproductive status Female/? Female/spayed Male/castrated
Subjective signs Progressive lethargy, Listlessness, exercise Lethargy, weight loss,
anorexia, weight loss intolerance, weight loss polyphagia,
intermittent vomiting
Objective signs No splenomegaly,a Splenomegaly b (marked Tachycardia,
regenerative anemia extramedullary hyposplenism,a
hematopoiesis), FIV/FeLV negative,
GI bleeding, GI bleeding
chronic nonregenerative (after onset of
anemia, marked basophilia treatment)
Platelet count (µl) 957,000b 4,190,000–4,950,000b 1,965,000b
Mean platelet volume — Decreased —
Abnormal platelet or Yesb Yesb No,a except slightly
MK morphology? increased MK
cytoplasm in BM and
occasional peripheral
macroplatelets
Abnormal platelet function — Yesb Noa
(by mucosal bleeding time
or aggregation assays)?
MK hyperplasia? Yesb Yesb Yesa
(dysmegakaryocytopoiesis)
BM cytology All other lineages MK hyperplasia,b erythroid Granulocytic hyperplasia,
appeared normal hypoplasia, basophilic normal morphology
hyperplasia, granulocytic of erythroid and
hyperplasia myeloid series,
adequate iron stores
BM fibrosis? Nob Nob Nob
Circulating blasts? Yes No No
PCV (%) 8–23a 15a 30
Leukocyte/µl 11,200–30,000 18,600 ≥ 14,000 (up to 28,400)
Serum iron —a Increasedb Normal
TIBC —a Slightly increasedb Normal
Any possible causes of RT? —a Nob Nob
Any evidence of other Nob Nob Nob
MP thrombocytosis?
Treatment Chemotherapy Radiophosphorus (32P) Melphalan
(COP + cyto-arab)
Outcome Complete remission Partial response, death Death due to sepsis 9
(survival ≥9 mo), due to pancreatitis/DKA days after therapy
euthanatized due to
hemorrhagic cystitis
a
Findings not consistent with the diagnostic criteria for essential thrombocythemia listed by the Polycythemia Vera Study Group.4
b
Findings consistent with the diagnostic criteria for essential thrombocythemia listed by the Polycythemia Vera Study Group4 and
other supportive criteria.
BM = bone marrow; COP = cyclophosphamide, vincristine, prednisone; cyto-arab = cytosine arabinoside; DKA = diabetic ketoacidosis;
FeLV = feline leukemia virus; FIV = feline immunodeficiency virus; GI = gastrointestinal; MK = megakaryocyte; MP = myelopro-
liferative; PCV = packed cell volume; RT = reactive thrombocytosis; TIBC = total iron-binding capacity; — = not reported.
Small Animal/Exotics 20TH ANNIVERSARY Compendium March 1999

deworming history and med- of listlessness and cachexia

ications administered to the (e.g., fungal, protozoal, or rick-
pet, especially heartworm pre- ettsial diseases), many neo-
ventives, antibiotics, steroids, plasias may induce a fever
and nonsteroidal antiinflam- through direct or indirect re-
matory drugs; this informa- lease of cytokines.
tion may be critical to the
correct interpretation of ab- HEMATOLOGY AND
normalities on a hemogram. CYTOLOGY
Owners should also be asked The most compelling evi-
to describe any changes in dence in establishing a diag-
stool and urine color because nosis of ET is a persistently
responses may reveal a histo- elevated platelet count (Fig-
ry of gastrointestinal or uro- Figure 1—Buccal mucosal bleeding time test performed in a ure 2) along with consistent
genital hemorrhage. dog using a Simplate (Organon Teknika Corporation, Dur- bone marrow findings, in-
The physical examination ham, NC) and a loose gauze tie to keep the lip exposed. cluding the presence of
should include a thorough as- megakaryocytic hyperplasia
sessment of mucous mem- (Figure 3) and adequate
branes (including vaginal mem- stores of iron. Most patients
branes if oral membranes are with ET have dramatically
too pigmented for examina- increased platelet counts
tion) for hydration, pallor, compared with the moder-
and any evidence of petechia- ate increases typical of reac-
tion. A rectal examination tive thrombocytosis (RT).
may provide evidence of gas- Nevertheless, any patient
trointestinal bleeding. Pete- with a platelet count above
chiation, ecchymosis, overt 700,000/µl should undergo a
hemorrhage, or a prolonged repeat complete blood count
buccal mucosal bleeding time regardless of whether the
(Figure 1) in the face of throm- sample was drawn from a
bocytosis is strongly suggestive Figure 2—Blood smear (oil immersion field) showing throm- symptomatic patient or an
bocytosis with more than 40 platelets per oil immersion field.
of a platelet function defect. asymptomatic pet presented
This combination of features for routine geriatric screen-
should alert clinicians to the ing or preanesthetic blood
strong possibility of an MPD work. The second sample
as the underlying cause. If should be obtained via the
available, platelet aggregome- minimally traumatic and
try may be useful to confirm “clean” venipuncture tech-
platelet dysfunction. nique and placed quickly
Many animals with MPDs into an ethylenediamine
present with splenomegaly tetraacetic acid or citrate
and occasionally hepato- anticoagulant vacutainer,
megaly as well. Neoplasia, preferably with the needle
particularly lymphosarcoma and rubber tube top re-
or hemangiosarcoma, should moved prior to expelling the
be strongly suspected when blood from the syringe. The
abdominal palpation reveals Figure 3—Bone marrow cytology showing megakaryocytic sample should ideally be an-
multifocal organomegaly. A hyperplasia. Bone marrow particles (a grouping of hemato- alyzed within 20 minutes.
thorough ocular examination poietic cells as shown) normally contain three to four mega- Several blood smear slides
karyocytes; this particle contains at least 12.
should be performed in any should be prepared immedi-
animal with chronic weight ately for the differential and
loss or cachexia. Although the presence of fever should special stains. Examination of a smear is helpful for sev-
prompt clinicians to search carefully for infectious causes eral reasons: The presence of abnormal platelets or dys-

QUESTIONS FOR OWNERS ■ PHYSICAL EXAMINATION ■ MEGAKARYOCYTIC HYPERPLASIA

Compendium March 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE II
Differential Diagnoses Based on Packed Cell Volume and Leukocyte Count
in Reactive versus Myeloproliferative Thrombocytosis
Reactive Thrombocytosis Myeloproliferative Thrombocytosis

Normal PCV Chronic inflammation; infection; Rare cases of polycythemia vera with iron
splenic contraction; widespread deficiency; ET; myeloid leukemia; early
carcinoma or lymphosarcoma stages of myelofibrosis; virus-associated
MPDs in cats
↓ PCV Rebound thrombocytosis following Rare cases of polycythemia vera with iron
hemorrhage or erythrocyte consumption deficiency; ET with hemorrhage secondary
(immune-mediated); renal disease; to platelet dysfunction; myeloid leukemia;
erythrocyte parasitism (Babesia); chronic myelofibrosis; virus-associated MPDs in cats
inflammation; recent hemorrhage; iron
deficiency (severe chronic parasitism);
widespread carcinoma or lymphosarcoma
↑ PCV Secondary polycythemia (cardiac or Polycythemia vera; ET
pulmonary disorders, high altitude);
hemoconcentration and splenic contraction
↑ Leukocyte count Chronic inflammation; infection; rebound ET; myeloid leukemia; early myelofibrosis;
after immune-mediated consumption of virus-associated MPDs in cats
platelets or erythrocytes; carcinoma or
lymphosarcoma; after therapy with G-CSF;
Cushing’s disease
↓ Leukocyte count Sepsis; myelophthisis with significant ET; myeloid leukemia; later stages of
extramedullary hematopoiesis; early G-CSF myelofibrosis; virus-associated MPDs in cats
therapy

ET = essential thrombocythemia; G-CSF = granulocyte–colony-stimulating factor; MPDs = myeloproliferative diseases; PCV = packed
cell volume.

plastic leukocytes may provide evidence of a neoplastic
disorder; the manual estimation of platelet numbers
can be used to verify the platelet count measured by a
cytometer (one platelet per oil immersion field repre-
sents approximately 15,000 platelets/µl of whole
blood); and platelet clumping may give an underesti-
mated count by machine methods, diminishing the sig-
nificance of what may in fact be a dramatic thrombocy-
tosis.
An increased platelet count should always be evaluat-
ed in conjunction with the erythrocyte and leukocyte
counts and differential because important clues impli-
cating reactive causes of thrombocytosis can be appreci-
ated only by such a comprehensive assessment (Table
II). A high platelet count accompanied by a significantly
decreased packed cell volume and a normal or elevated
leukocyte count is strongly suggestive of RT secondary
to immune-mediated hemolytic anemia, a recent severe
hemorrhagic event, chronic hemorrhage or renal disease,
and/or any other cause of iron deficiency. Although oth-
er differentials should be considered, appropriate addi-
tional tests would include a urinalysis, chemistry profile,
reticulocyte count, fecal analysis, Coombs’ test, blood
smear evaluation for hemotrophic parasites, activated
clotting time or coagulogram, and careful examination
for evidence of external parasitism or recent trauma.
An elevated platelet count in the context of mild or
moderate anemia is more representative of a typical he-
mogram from patients with ET; however, RT secondary
to chronic inflammation or renal disease must be ruled
out. A complete blood count dominated by an extreme-
ly elevated leukocyte count or a significant left shift (in
addition to the high platelet count) should prompt sus-
picion of an infectious process and/or immune-mediat-
ed disease; a workup may include an antinuclear anti-
body test, toxoplasma IgM and IgG titers, buffy coat
evaluation for hepatozoon organisms, blood cultures,
and chest radiographs for evidence of fungal disease. Fi-
nally, truncal obesity, alopecia, hepatomegaly, and
polyuria are suggestive of Cushing’s disease as an under-

PLATELET COUNT ■ DIFFERENTIAL DIAGNOSES ■ ADDITIONAL TESTS

Small Animal/Exotics 20TH ANNIVERSARY Compendium March 1999

lying cause of thrombocyto- mately made using criteria

sis. Diagnostic Criteria for Essential recommended by the Poly-
Lack of obvious causes of Thrombocythemia in Humansa cythemia Vera Study Groupa
RT in a patient with persis- (see Diagnostic Criteria for
tently and remarkably ele- ■ Platelet count in excess of 600 x 109/Lb (>700 x Essential Thrombocythemia
vated platelet counts necessi- 10 9/L in veterinary patients) in Humans), modified to
tates examination of bone ■ Normal erythrocyte mass/hematocrit apply more appropriately to
marrow cytology. Early mar- ■ Stainable iron in bone marrow or failure of iron veterinary patients, along
row infiltration by metastat- trial (iron supplementation for 1 month does not with the additional criteria
ic disease is often difficult to of megakaryocytic hyperpla-
result in a significant rise in hemoglobin)
infer from peripheral blood sia 5,6 and morphologically
counts alone; this is because ■ No Philadelphia chromosome or bcr/abl gene abnormal platelets and/or
extramedullary hematopo- rearrangementb MKs (Figure 4). 2,7,8 Other
iesis may mask deteriorating ■ Collagen fibrosis of bone marrow absent; or less supportive findings 4–6,9,10
marrow function. Platelet than one third of bone marrow biopsy area is (which should not be con-
counts may vary significant- fibrosed and there is no evidence of splenomegaly sidered essential for diagno-
ly due to sequestration and sis in animals due to clinical
and leukoerythroblastic reaction
release from enlarged sec- and conformational differ-
ondary hematopoietic or- ■ No cytogenetic or morphologic evidence for a ences from humans) include
gans, such as the spleen or myelodysplastic syndrome splenomegaly and platelet
liver. Similarly, myelofibrosis ■ No known cause for reactive thrombocytosis (no dysfunction. MK ploidy,
is not often discovered in evidence of inflammation, etc.) serum interleukin (IL)-6
earlier stages prior to pancy- aRecommendations from the Polycythemia Vera Study Group,
levels, and spontaneous pro-
topenia without bone mar- 34
1986, updated in 1997. 35 genitor colony growth are
row evaluation. An MPD b These criteria are inappropriate for veterinary patients. not routinely available to
should be suspected when veterinary practitioners (see
multiple cell lines are signifi- the Recent Advances in Di-
cantly elevated or decreased or when immature, blast, agnosis). However, these assays would lend additional
or otherwise morphologically abnormal hematopoietic support to a diagnosis when and if they do become
cells of any lineage are detected on a peripheral blood more accessible.
smear. In patients with remarkably elevated erythro-
cytes, secondary causes of polycythemia (e.g., chronic TREATMENT AND PROGNOSIS
hypoxia or cardiac disease) must be ruled out before a Treatment options for ET are similar to those used
clonal disorder in erythrocyte progenitors can be sus- for PV and other MPDs. Myelosuppressive cytoreduc-
pected. tive drugs remain the mainstay of therapy, with radio-
A diagnosis of ET is made when RT is ruled out and phosphorus (32P); alkylating agents; antimetabolites;
bone marrow or peripheral blood cytology reveals mor- and, more recently, hydroxyurea being used most com-
phologically abnormal platelets or megakaryocytes monly.
(MKs; although one case of suspected ET in a cat was Hydroxyurea is considered a first-line therapy for
reported without meeting the latter criterion).3 Further- symptomatic patients with MPDs. It functions by inac-
more, no evidence of an MPD involving other lineages, tivating the ribonucleotide reductase enzyme, thereby
including myeloid leukemia, myelofibrosis, or poly- inhibiting synthesis of DNA from ribonucleotides. Ef-
cythemia vera (PV), should exist on evaluation of pe- fective dosages in cats and dogs are broad, ranging from
ripheral and marrow cytology and biopsy (in which 25 to 50 mg/kg orally daily for 10 days or until cell
case the elevated platelet count is more consistently counts return to normal, at which point the dose is re-
termed “myeloproliferative thrombocytosis”). PV may duced to 15 mg/kg/day.11,12 For cats, the 500-mg cap-
be particularly difficult to rule out based on peripheral sule can be compounded into quarter-capsule doses by
blood counts alone, and the marrow should be carefully a pharmacist and administered as one 125-mg dose per
assessed for adequate stores of iron. In patients with de- cat orally every 24 to 48 hours.11
pleted marrow iron, failure of the platelet count to nor- A major concern in human medicine is the develop-
malize after an iron challenge (i.e., supplementation for a
The rule-out of chromosomal or genetic aberrations listed
1 month) strongly repudiates iron deficiency or PV-as- herein should not be considered a criterion for diagnosis of
sociated thrombocytosis. The diagnosis of ET is ulti- ET in veterinary patients at this time.

BONE MARROW CYTOLOGY ■ POLYCYTHEMIA VERA STUDY GROUP ■ HYDROXYUREA

Small Animal/Exotics 20TH ANNIVERSARY Compendium March 1999

ment of acute leukemia as- interferon-α and other hu-

sociated with the therapy it- man recombinant cytokines
self. Unlike antimetabolites, in the treatment of MPDs
alkylating agents, and radio- in animals.
active isotopes,13 hydroxyurea A new phosphodiester-
is not typically considered ase inhibitor, anagrelide,
mutagenic in most animals.14 has been shown to induce a
However, late development dose-dependent decrease in
of myelodysplasia and acute circulating platelets in hu-
leukemia has been reported mans with ET and other
following hydroxyurea use myeloproliferative throm-
in humans.15,16 This concern bocytoses without causing
is not particularly relevant to marrow toxicity to other
veterinary patients that have Figure 4A cell lines. 24,25 The mecha-
a relatively short remaining nism of its thrombocy-
life span due to their typical- topenic action is not fully
ly advanced age at diagnosis understood, although it ap-
as well as their underlying pears to be metabolized to a
MPD. substance that delays MK
Alkylating agents (i.e., cell maturation.26 However, pre-
cycle–nonspecific drugs that liminary research suggests
cross-link DNA), such as cy- that the metabolic pathway
clophosphamide, chloram- that potentiates its thera-
bucil, and melphalan, alone or peutic effect is unique to
in combination with other humans. 26 Preliminary in-
agents, have been used with vestigation at Auburn Uni-
varying success.1,3 Antimetab- versity shows no effect in
olites (e.g., cytosine arabino- normal dogs; thus, use of
Figure 4B
side) inhibit nucleic acid syn- other agents is still recom-
thesis and have been used Figure 4—(A and B) Bone marrow cytology showing mega- mended until more data can
in combination protocols.1,11 karyocytic dysplasia. Compared with a normal megakary- be generated on anagrelide.
ocyte, these are morphologically abnormal with a reduced
Other agents, such as 32P, have Other treatment strate-
nuclear:cytoplasmic ratio and abnormal nuclear ploidy.
been successfully used in gies, such as platelet hema-
both human and veterinary pheresis, provide rapid at-
practice to achieve long-term tenuation in circulating
remission of MPDs; however, availability of this treat- platelets and are used in human medicine for patients
ment is limited to institutions that have the facilities to with ET who require surgery or are otherwise predis-
handle radioactive isotopes and the sequelae of their posed to developing microvascular thrombotic le-
use.17 Several resources can provide information on pro- sions.27,28 However, the procedure does not provide
tocols, drug dosages, side effects, and recommended long-term control nor is it readily available to the vet-
strategies for use of these chemotherapy agents to treat erinary community. Finally, medications that decrease
MPDs.11,18 platelet aggregation, such as aspirin, are associated with
Biologic response modifiers have recently received a a lower incidence of both thrombotic and hemorrhagic
great deal of attention in both human and veterinary complications in humans,27,29 but the same definitive
19
oncology. Interferon-α has been used with consider- benefits are not yet proven in animals with ET. Sple-
able success as adjunctive therapy in human patients nectomy only exacerbates the disease and is contraindi-
with ET20 and other MPDs and appears to exert its in- cated.30–32
21,22
hibitory effect on megakaryocytopoiesis. Human re- The ability to provide a prognosis to owners of ani-
combinant interferon-α has been given to cats experi- mals with ET or any other MPD ultimately depends
mentally inoculated with feline leukemia virus; treated on the ability to accurately and reliably distinguish
cats were significantly less likely to develop fatal com- among different disorders of the hematopoietic system.
plications.23 More importantly, studies like this may The prognosis for humans with accurately diagnosed
pave the way to the routine use of human recombinant ET is significantly better than it is for most other non-

ALKYLATING AGENTS ■ ANTIMETABOLITES ■ 32

P ■ INTERFERON-α ■ ANAGRELIDE
Small Animal/Exotics 20TH ANNIVERSARY Compendium March 1999

lymphoid leukemias, par- TABLE III orated as a result of is-

ticularly acute forms. Pre- Percentage of Human Patients from Whom Peripheral chemic necrosis or other
liminary reports in veteri- Blood or Marrow Hematopoietic Progenitors sequelae of these types of
nary medicine suggest Demonstrate Spontaneous (Unstimulated) vascular events.
that this observation may Colony Growth in Culture42,44 Other laboratory param-
apply to animals as well; eters studied in efforts
Essential Reactive
with treatment, many to distinguish between
Thrombocythemia Thrombocytosis Controls
animals may achieve par- ET and RT include plate-
tial or complete remis- CFU-Meg 42
63 0 0 let aggregation responses
sions for many months (n = 60) (n = 10) (n = 21) to collagen, epinephrine,
and possibly years.1,17,30 and ADP and von Wille-
BFU-E42 70 0 0 brand factor antigen lev-
RECENT ADVANCES CFU-Meg 40 0 0 els. 36,37 In general, von
IN DIAGNOSIS and BFU-E42
Willebrand factor anti-
With the exception of gen levels and levels of
the use of anagrelide, ad- CFU-Meg 91 0 0 other acute phase pro-
ditional novel therapies to and/or BFU-E42 teins were elevated in hu-
treat ET in humans have No colony 9 0 0 man patients with RT
not been reported. Many formation42 but not ET, whereas abnor-
investigators continue to mal responses to platelet
engage in active research CFU-Meg44 69 0 0 agonists were observed in
in efforts to improve the (n = 61) (n = 22) (n = 44) patients with ET but not
efficiency and accuracy BFU-E44 59 0 0 RT. 36,37 These tests are
with which the diagnosis not likely to be routinely
is made in the first place. CFU-Meg 51 0 0 helpful in distinguishing
Recent efforts to develop and BFU-E44 between ET and RT in
positive criteria for diag- CFU-Meg only44 18 0 0 companion animals be-
nosis have led to the cause of expense, lack of
search for specific markers BFU-E only44 8 0 0 experimental data in ani-
for the disease or at least CFU-Meg/BFU-E44 77 0 0 mals, and the paucity of
more reliable exclusionary veterinary laboratories
data. IL-6, a cytokine pro- No colony formation44 23 0 0 capable of performing
duced by B and T lymph- BFU-E = burst-forming unit–erythrocyte; CFU-Meg = colony-forming platelet function assays.
ocytes and various tumor unit–megakaryocyte. Nevertheless, where avail-
cell lines, is an acute phase able, platelet aggregomet-
reactant that plays a significant role in immune respons- ry may prove very helpful to support a diagnosis and
es. IL-6 stimulates the hepatic acute phase response and direct therapy.
plays a role in megakaryocytopoiesis.33,34 Several investi- Other investigators have compared the frequency of
gators have measured IL-6 levels in patients with differ- megakaryocytic emperipolesis among patients with dif-
ent causes of thrombocytosis; levels were found to be sig- ferent causes for thrombocytosis.38 Emperipolesis is the
nificantly higher in patients with RT than in those with process of phagocytosis of one cell by another without
ET or in controls.34,35 As serum IL-6 assays become more the subsequent fusion of lysosomal vacuoles. Unlike
readily available to veterinary practitioners, they are like- traditional phagocytosis, which typically ends in diges-
ly to become a helpful test to distinguish between ET tion and eventual elimination of the engulfed cell and
and RT. often in damage to the phagocytic cell as well, em-
Another acute phase reactant, fibrinogen, is also sig- peripolesis rarely results in damage to either cell and is
nificantly elevated in patients with RT compared with responsible for the giant cells often noted on
those with thrombocytosis associated with MPDs.36 histopathology of tumor biopsies. In a fairly recent
However, the ranges of “normal” levels of fibrinogen in study,38 77% of patients with ET, 100% of patients
animals vary among species, limiting its application in with PV, 17% of patients with chronic granulocytic
the differentiation of RT versus ET. Furthermore, be- leukemia, 66% of patients with unclassified MPDs,
cause hemorrhage and thrombosis can accompany ET, and 75% of patients with RT demonstrated em-
fibrinogen and other acute phase reactants may be elab- peripolesis within MKs. With the exception of chronic

SERUM IL-6 ASSAYS ■ FIBRINOGEN ■ PLATELET AGGREGOMETRY ■ EMPERIPOLESIS

Small Animal/Exotics 20TH ANNIVERSARY
TABLE IV
Percentage of Human Patients from Whom Bone
Marrow Megakaryocyte Progenitors Demonstrate
Spontaneous Colony Growth in Culture43
Chronic
Essential Polycythemia Myeloid
Thrombocythemia Vera Leukemia Thrombocytosis Controls
CFU-Meg 100 55 44
(n = 24) (n = 20) (n = 16)
BFU-E 88 100 6 0
BFU-E = burst-forming unit–erythrocyte; CFU-Meg = colony-forming unit–megakaryocyte.
granulocytic leukemia, there were no statistical differ-
ences in the incidence of emperipolesis among the dif-
ferent categories of MPDs nor between myeloprolifera-
tive thrombocytosis and RT.
A somewhat more helpful assay to investigate the dif-
ferential diagnoses for excessive circulating platelets
may be the analysis and comparison of MK ploidy pat-
terns, although observations from different investiga-
tors have not always been consistent.39–41 MKs from un-
fractionated bone marrow aspirates are easily identified
with fluorescein-labeled monoclonal antibody and
thereby efficiently analyzed for labeled DNA content
using two-color flow cytometry. A very recent study
measured MK ploidy in 29 patients with chronic
MPDs with concomitant thrombocytosis (8 with PV,
17 with ET, and 4 with chronic myeloid leukemia), 9
patients with RT, and 12 healthy controls.39 The mean
MK ploidy of controls and patients with RT was 16N,
whereas patients with ET or PV had a mean MK
ploidy of 32N. The mean MK ploidy in patients with
chronic myeloid leukemia was significantly lower than
that observed in the other two MPDs and even lower
than that observed in controls or patients with RT. In 39
humans, the presence of the Philadelphia chromosome
is a helpful marker for chronic myelogenous leukemia;
veterinarians may instead have to rely on ancillary data,
such as MK ploidy, when other findings are equivocal.
The recent discovery of disparate growth patterns of
cultured MK precursors among patients with ET and
RT and “controls” promises to expand the short list of
bona fide positive criteria for the diagnosis of ET. Mul-
tiple studies have now clearly demonstrated that cul-
tured bone marrow and circulating hematopoietic pro-
genitor cells from patients with ET generate
spontaneous or “unstimulated” megakaryocytic and
erythroid colonies (colony-forming unit–megakary-
ocyte and burst-forming unit–erythrocyte, respective-
MK PLOIDY PATTERNS ■ CHRONIC MYELOID LEUKEMIA ■ MK PRECURSORS
Compendium March 1999
ly). 42–44 Although data derived
from serum-free cultures 45 or
cultures incubated in growth
factors (such as erythropoietin
and factors released from phyto-
hemagglutinin-stimulated leuko-
Reactive cytes) 43 are somewhat more
equivocal, there is little doubt
0 0 that unstimulated formation of
(n = 20) (n = 18) colony-forming unit–mega-
karyocyte and/or burst-forming
0 unit–er ythrocyte in culture
eliminates RT as a differential
diagnosis and strongly correlates
with myeloproliferative thrombo-
cytosis (Tables III and IV). 42–44
Furthermore, one study demonstrated that the sponta-
neous formation of colonies is also positively correlated
with an increased risk of thromboembolic or hemor-
rhagic complications.44
There is little doubt that some of these recently devel-
oped assays (MK ploidy, serum IL-6, and spontaneous
progenitor colony growth) will improve diagnostic accu-
racy enough to merit their inclusion in the criteria used
by most clinicians to diagnose ET. Although most of
these assays are currently limited to research or teaching
institutions, the increasing number of veterinarians and
clients who wish to pursue the treatment of MPDs in
animals may create a “market” that may encourage re-
search in this area of veterinary oncology.
REFERENCES
1. Simpson JW, Else RW, Honeyman P: Successful treatment
of suspected essential thrombocythaemia in the dog. J Small
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About the Author
Dr. Chisholm-Chait is affiliated with the Small Animal
Surgery and Medicine Department, College of Veterinary
Medicine, Auburn University, Alabama.