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review article

Mechanisms of Disease

The Myeloproliferative Disorders

Peter J. Campbell, F.R.A.C.P., F.R.C.P.A.,
and Anthony R. Green, F.R.C.Path., F.Med.Sci.

From the Department of Haematology,

Cambridge Institute for Medical Research,
University of Cambridge, Cambridge, United Kingdom. Address reprint requests to
Dr. Green at the Department of Haematology, Cambridge Institute for Medical
Research, Hills Rd., Cambridge CB2 2XY,
United Kingdom, or at arg1000@cam.
ac.uk.
N Engl J Med 2006;355:2452-66.
Copyright 2006 Massachusetts Medical Society.

he myeloproliferative disorders comprise several clonal hematologic diseases that are thought to arise from a transformation in a hematopoietic stem cell. The main clinical features of these diseases are the
overproduction of mature, functional blood cells and a long clinical course. Chronic myeloid leukemia (not discussed in detail here) is a myeloproliferative disorder
that is defined by its causative molecular lesion, the BCR-ABL fusion gene, which
most commonly results from the Philadelphia translocation (Ph).1 The three main
Ph-negative myeloproliferative disorders polycythemia vera, essential thrombocythemia, and idiopathic myelofibrosis are the focus of this article. Less common
conditions that are also considered myeloproliferative disorders under the classification used by the World Health Organization include systemic mastocytosis, chronic eosinophilic leukemia, chronic myelomonocytic leukemia, and chronic neutrophilic leukemia.2
The cardinal features of the three main myeloproliferative disorders are an increased red-cell mass in polycythemia vera, a high platelet count in essential thrombocythemia, and bone marrow fibrosis in idiopathic myelofibrosis (Fig. 1). These
three disorders share many characteristics, including marrow hypercellularity, a
propensity to thrombosis and hemorrhage, and a risk of leukemic transformation
in the long term. The annual incidences of both polycythemia vera and essential
thrombocythemia are 1 to 3 cases per 100,000 population; myelofibrosis is less
common.3

Patho gene t ic Fe at ur e s
Clues to Molecular Mechanisms

Polycythemia vera, a condition of persistent and excessive hypercellularity accompanied by cyanosis, was recognized by Vaquez in 1892,4 and idiopathic myelofibrosis was described at about the same time (Table 1).23 Essential thrombocythemia
was recognized in the 1930s.24 Dameshek, in 1951, was the first to appreciate the
considerable overlap in the clinical and laboratory features of these conditions and
proposed that they, together with chronic myeloid leukemia and other rarer disorders, constitute a spectrum of related diseases. He coined the term myeloproliferative disorders to embrace these related conditions.5 In 1974, a critical experiment showed that erythroid progenitors from the bone marrow of patients with
polycythemia vera were capable of growing in vitro in the absence of erythropoietin.10 At about the same time, studies based on X-chromosome inactivation were
performed in women with polycythemia vera or essential thrombocythemia who
carried a polymorphic variant of the X-linked G6PD gene. The results suggested that
each of these diseases originated from a clone of hematopoietic stem cells.11,25

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Mechanisms of Disease

Peripheral Blood

Bone Marrow
(hematoxylin and eosin)

Bone Marrow
(reticulin stain)

Polycythemia
Vera

Essential
Thrombocythemia

Idiopathic
Myelofibrosis

Figure 1. Laboratory Features of Polycythemia Vera, Essential Thrombocythemia, and Idiopathic Myelofibrosis.
Polycythemia vera is characterized by an increased hematocrit in the peripheral blood (test tube on left); a hypercellular marrow with increased numbers of erythroid, megakaryocytic, and granulocytic precursor cells; and a variable
increase in the number of reticulin fibers. Essential thrombocythemia is characterized by an increase in the number
of platelets in the peripheral blood and an increased number of megakaryocytes in the marrow, which tend to cluster together and have hyperlobated nuclei. Idiopathic myelofibrosis is characterized by the presence of immature red
and white cells (a so-called leukoerythroblastic blood film) and teardrop red cells, disordered cellular architecture,
dysplastic megakaryocytes, new bone formation in the marrow, and the formation of collagen fibers.

Other clues to the molecular mechanisms responsible for the myeloproliferative disorders have
been accumulating. These include the association
of several chronic myeloid cancers with activated
tyrosine kinases (Table 2)13-18,37 and the recognition of increased signaling through Janus kinases and signal transducers and activators of
transcription (JAKSTAT) and phosphatidylinositol 3-kinase (PI3K) pathways in erythroid and

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myeloid cells.21,22,54 An additional hint came with

the discovery of recurrent mitotic recombination
events affecting chromosome 9p, resulting in the
loss of heterozygosity but a normal DNA copy
number.20
The JAK2 V617F Mutation

In 2005, several groups reported a single, acquired

point mutation in the Janus kinase 2 (JAK2) gene

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Table 1. Milestones in the History of Philadelphia-Negative Myeloproliferative Disorders and Their Relationship
with the V617F Mutation in JAK2.*
Relationship Later Established with V617F
Mutation in JAK2

Year

Historical Milestone

1892

First description of polycythemia vera4

1951

Polycythemia vera, essential thrombocythemia, and idio- Mutation found in all three disorders6-9
pathic myelofibrosis linked as related conditions5

1974

Identification of erythropoietin-independent erythroid

colonies10

Mutation associated with cytokine independence

of primary erythroid progenitors and cell lines6-9

1976

Stem-cell origin of polycythemia vera11

Mutation found in multipotent progenitors and

hematopoietic stem cells6,12

19832003

Dysregulated tyrosine kinases found in chronic myeloid Tyrosine kinase function of JAK2 constitutively
leukemia,13,14 mastocytosis,15 chronic myelomonocyactivated by mutation7-9,19
tic leukemia,16,17 and chronic eosinophilic leukemia18

2002

Description of mitotic recombination involving chromosome 9p as the most common cytogenetic

lesion in polycythemia vera20

Homozygosity of the mutation caused by mitotic

recombination of chromosome 9p6-9

20012004

Erythropoietin-independent growth in polycythemia

vera dependent on JAKSTAT signaling21,22

STAT proteins constitutively activated by mutation7-9,19

2005

Description of the JAK2 V617F mutation6-9,19

* STAT denotes signal transducers and activators of transcription.

in the majority of patients with Ph-negative myeloproliferative disorders.6-9,19 JAK2, a cytoplasmic

tyrosine kinase, is critical for instigating intracellular signaling by the receptors for erythropoietin, thrombopoietin, interleukin-3, granulocyte
colony-stimulating factor (G-CSF), and granulocytemacrophage colony-stimulating factor (GMCSF).55,56 Mice that are deficient in Jak2 die at
embryonic day 12.5, with a complete absence of
definitive erythropoiesis,57,58 a finding that underscores the vital role of JAK2 as a transducer of
signals evoked by the binding of erythropoietin
to its receptor. JAK2 binds to the erythropoietin
receptor in the endoplasmic reticulum and is
required for its cell-surface expression.59 When
erythropoietin binds to its receptor, it provokes
a conformational change in the receptor 60-62 with
consequent phosphorylation and activation of
JAK2.63 The activated JAK2 then phosphorylates
the receptors cytoplasmic domain, thereby promoting the docking of downstream effector proteins and the initiation of intracellular signaling
cascades55,56 (Fig. 2A).
The JAK2 mutation in the myeloproliferative
disorders is not in the germ line but, rather, is
acquired.6-9,19 Sensitive methods demonstrate the
mutation in more than 95% of patients with polycythemia vera6,26 and in 50 to 60% of patients
with essential thrombocythemia6,26-28,31,64 or id-

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iopathic myelofibrosis.6,26,29-31 A substantial proportion of patients with polycythemia vera or

idiopathic myelofibrosis are homozygous for the
JAK2 mutation as a result of mitotic recombination affecting chromosome 9p,6-9 but this phenomenon is rarely detected in essential thrombocythemia.65 The mutation is also found in a
small minority of patients with the hypereosinophilic syndrome, chronic myelomonocytic leukemia, chronic neutrophilic leukemia, myelodysplasia, or acute myeloid leukemia,31-34,66-68 but not
in patients with lymphoid or other cancers or in
those without hematologic disorders.6-9,33,34,67,69
The presence of a mutant JAK2 in some patients
with acute myeloid leukemia,33 especially older
patients, raises the possibility that they may have
had a preceding, undiagnosed myeloproliferative
disorder. The JAK2 mutation is also found in more
than 50% of patients with otherwise unexplained
BuddChiari syndrome,70 which also suggests the
presence of a masked myeloproliferative disorder
in such cases.
The mutation in JAK2 substitutes a bulky phenylalanine for a conserved valine at position 617
of the JAK2 protein (V617F). This residue is located in the JH2, or pseudokinase, domain, which
negatively regulates the kinase domain.71 Biochemical studies have shown that the JAK2 V617F
mutation causes cytokine-independent activa-

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Mechanisms of Disease

Table 2. Molecular Lesions Associated with the Myeloproliferative Disorders.*

Abnormality

Association

Recurrent genetic lesions

BCR-ABL

Chronic myeloid leukemia (100%)1

JAK2 V617F

Polycythemia vera (95%),6,26 essential thrombocythemia (5060%),27,28 idiopathic myelofibrosis

(5060%),29,30 and other myeloid disorders (15%)31-34

MPL W515K/L

Idiopathic myelofibrosis (5%) and essential thrombocythemia (1%)35,36

KIT mutations

Systemic mastocytosis15,37

FIP1L1PDGFRA

Chronic eosinophilic leukemia18,38

PDGFRB fusion genes Chronic myelomonocytic leukemia (rare)16

FGFR fusion genes

Chronic myelomonocytic leukemia (rare)17

Other cytogenetic lesions

Trisomy 9

Amplifies JAK2 gene and associated with JAK2 V617F mutation39

Trisomy 8

Found in myeloproliferative disorders, myelodysplasia, and acute myeloid leukemias; target

genes not identified

Trisomy 1q

Caused by duplication, trisomy, or unbalanced translocations40

20q deletion

Found in myeloproliferative disorders and myelodysplasia41; associated with JAK2 V617F mutation39 and precedes it in some cases42; target genes not identified41

5q and 7q deletions

Thought to reflect changes secondary to cytotoxic therapy40; target genes not identified

13q deletion

Associated with idiopathic myelofibrosis; overlap of commonly deleted region and the region
for chronic lymphocytic leukemia40

Dysregulated genes and proteins

BCL-XL

Overexpressed in polycythemia vera43 as a result of constitutive JAKSTAT signaling; antiapoptotic effects in erythroid cells44,45

NFE2

Up-regulated in JAK2-positive myeloproliferative diseases46,47; may affect erythroid differentiation48,49

PRV1

RNA levels increased in polycythemia vera50,51 but unlikely to play a direct role in disease pathogenesis since protein levels are not increased51

MPL

Surface levels of protein decreased and aberrantly glycosylated in myeloproliferative disorders52,53;

role in disease pathogenesis unclear

* FIP1L1 denotes FH interacting protein 1like 1, PDGFRA platelet-derived growth-factor receptor alpha polypeptide,
PDGFRB platelet-derived growth-factor receptor beta polypeptide, FGFR fibroblast growth-factor receptor, BCL-XL B-cell
leukemia/lymphoma 2like protein X long-transcript variant, NFE2 nuclear factor erythroidderived 2, PRV1 polycythemia
rubra vera 1, and MPL thrombopoietin receptor.

tion of JAKSTAT, PI3K, and AKT (also known

as protein kinase B) pathways, and mitogen-activated protein kinase (MAPK) and extracellular
signal-regulated kinase (ERK),7-9,19 all of which are
implicated in erythropoietin-receptor signaling.22,63,72,73
The JAK2 mutation provides a unifying explanation for many features of the myeloproliferative disorders (Table 1), but other mutations are
probably associated with JAK2 V617F-negative
myeloproliferative disorders. One example is the
presence of an activating mutation in the thrombopoietin receptor (MPL) gene in approximately
10% of patients with V617F-negative idiopathic
myelofibrosis.35,36 This mutation is located in a

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motif that is important for keeping the receptor

inactive.74

Pathoph ysiol o gic a l Fe at ur e s

Genetic Marker

The insights revealed by the foregoing molecular

investigations are reshaping our understanding
of the pathophysiology, classification, diagnosis,
and treatment of these conditions. The JAK2 mutation is the first genetic marker that is directly
associated with the pathogenesis of the myeloproliferative disorders, and for this reason it is a powerful tool for analysis of the molecular and cellular basis of these disorders.

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Mouse Models

Expression of the JAK2 V617F mutation in murine

hematopoietic cells by means of a retroviral vector recapitulates the features of polycythemia
vera.7,75-78 The animals have erythrocytosis and
leukocytosis, and there is evolution to postpolycythemic myelofibrosis.75-78 Thrombocytosis is
not a reproducible feature in these mice, perhaps
because high levels of mutant JAK2 generated by
the retroviral vector inhibit the differentiation
of megakaryocytes.76 Constitutive activation of
signal transducers and activators of transcription 5 (STAT5), erythropoietin hypersensitivity, and
cytokine independence are all present, as in the
human disease. These results provide direct evidence of a causal link between the mutation and
the disease.
Stem-Cell Biology

The myeloproliferative disorders arise from a

mutant multipotent stem cell. Analyses of patterns of X-chromosome inactivation in female
patients11,25,79 show a skewed pattern in myeloid
cells but a balanced pattern in T cells and other
cell types,79 suggesting that some myeloid cells
in these women are clonally derived. However,
skewed patterns of X-chromosome inactivation
in granulocytes have been found in older women
without a myeloproliferative disorder79 and are
thought to reflect polymorphic X-linked genes that
influence hematopoietic stem-cell behavior.80 Agerelated skewing limits the use of the analysis of
X-chromosome inactivation for diagnostic purposes, but such studies remain useful as research
tools. For example, studies of X-chromosome inactivation indicate that in most patients with V617Fnegative essential thrombocythemia or idiopathic
myelofibrosis, there is a dominant clone of blood
cells,26,28,81 implying that these disorders are clonal hematologic diseases.
The presence of the JAK2 mutation in colonies of hematopoietic progenitor cells (grown in
vitro)6,65 and in hematopoietic stem cells isolated by fluorescence-activated cell sorting12,82 provides direct evidence that polycythemia vera and
related myeloproliferative disorders arise in a multipotent progenitor or stem cell. In contrast to the
normal-size myeloid stem-cell compartment in
chronic myeloid leukemia,83 the stem-cell com-

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Figure 2 (facing page). Role of JAK2 in Pathway Signaling and Erythropoietin Binding, Stem-Cell Differentiation, and Development of Homozygosity for the V617F
Mutation.
In Panel A, in the absence of ligand, the erythropoietin
receptor (EPOR) binds JAK2 as an inactive dimer. In cells
with wild-type JAK2 protein, the binding of erythropoietin (Epo) to its receptor induces conformational changes in the receptor, resulting in phosphorylation (P) of
JAK2 and the cytoplasmic tail of the receptor. This leads
to signaling through pathways made up of Janus kinases and signal transducers and activators of transcription (JAKSTAT), phosphatidylinositol 3 kinase (PI3K),
and RAS and mitogen-activated protein kinase (RAS
MAPK). In cells with the V617F mutation, the signaling
is constitutively increased, even in the absence of
erythropoietin. In Panel B, the JAK2 protein binds to
multiple cytokine receptors EPOR, thrombopoietin
receptor (MPL), granulocyte colony-stimulating factor
receptor (G-CSFR), and probably others that are important for hematopoietic stem-cell biology and differentiation. Therefore, the JAK2 protein with the V617F
mutation exerts its effects at various stages of differentiation and in various lineages. In Panel C, the development of homozygosity for the V617F mutation is a
two-step process, with the initial point mutation followed by mitotic recombination of chromosome 9p between the JAK2 locus and the centromere. This results
in the loss of heterozygosity but a diploid DNA copy
number.

partment in polycythemia vera is both expanded

and characterized by preferential erythroid differentiation.12 Taken together, the data suggest
that the JAK2 mutation affects the behavior of
hematopoietic stem cells but probably also acts
at later stages of differentiation, particularly in
the erythroid, granulocytic, and megakaryocytic
lineages (Fig. 2B).
Cooperating Mutations

The JAK2 mutation explains many of the cardinal

features of the myeloproliferative disorders, as
does the BCR-ABL fusion gene in chronic myeloid
leukemia. It seems likely that, as in chronic myeloid
leukemia, leukemic transformation of the myeloproliferative disorders reflects the acquisition of
additional mutations.84,85
Four lines of evidence suggest that cooperating mutations occur at an early stage in V617Fpositive myeloproliferative disorders and can even
predate the JAK2 mutation. First, deletions of 20q
and other cytogenetic abnormalities occur in 5 to

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Mechanisms of Disease

Wild-type JAK2
without erythropoietin

Wild-type JAK2
with erythropoietin

EPOR

JAK2 with V617F mutation

without erythropoietin

Epo

JAK2

No signal

STAT

PI3K

JAK2
V617F
P

STAT

RASMAPK

Progenitor cells

PI3K

RASMAPK

Terminally differentiated cells

EPOR
Red cells

Stem cell
Unknown
receptor
MPL
Megakaryocytes

G-CSFR

Granulocytes

Heterozygous V167F

Wild-type JAK2

V617F

Homozygous V167F
V617F

V617F

Mitotic recombination

Point mutation

Chromosome 9

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10% of patients with a myeloproliferative disorder.40 In one patient with polycythemia vera and
in one with essential thrombocythemia, granulocytes with the 20q deletion outnumbered V617Fpositive granulocytes,42 suggesting that the 20q
deletion occurred before the JAK2 mutation. Patients with molecularly defined 20q deletions are
almost exclusively V617F-positive,39 which is consistent with the presence of a cooperating gene
on 20q. Second, some women with polycythemia
vera or essential thrombocythemia have more
clonally derived granulocytes (estimated by patterns of X-chromosome inactivation) than JAK2positive granulocytes.26,39,42 Although this finding has been interpreted as evidence of a clonal
proliferation that preceded the JAK2 mutation,
such a conclusion remains controversial.39 Third,
in some patients with V617F-positive polycythemia vera or essential thrombocythemia that undergoes leukemic transformation, the leukemic
cells lack the JAK2 mutation.39 This finding is
consistent with the origin of the leukemia in a
mutant clone that preceded the JAK2 mutation,
although other interpretations are possible.39
Fourth, in familial clusters of the myeloproliferative disorders, the JAK2 mutation is acquired,86
which suggests that the inherited predisposition
is unrelated to the JAK2 mutation.
Homozygosity for V617F

Homozygosity for the V617F mutation plays a key

role in the myeloproliferative disorders. Homozygosity results from mitotic recombination (Fig.
2C), with the breakpoints spread along chromosome 9p between the JAK2 locus and the centromere,9 implying that there is no single fragile site
that is prone to recombination. In polycythemia
vera, the prevalence of blood cells that are homozygous for the JAK2 mutation increases with time,65
presumably owing to a proliferative or survival advantage of mutant progenitor cells. Homozygosity for V617F is associated with more marked
changes in the expression of downstream target
genes than is heterozygosity for V617F.46 This reflects increased signaling mediated by a double
dose of V617F, possibly combined with a loss of
inhibition by the wild-type allele.7
Homozygosity in granulocytes can be detected in about 30% of patients with polycythemia
vera.6-9 However, when colonies of hematopoietic progenitor cells derived from such patients

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were studied, approximately 90% of them were

homozygous for the V617F mutation. By contrast,
homozygous progenitor colonies were not found
in essential thrombocythemia.65 This difference
suggests that V617F homozygosity promotes the
development of polycythemia vera. Since there is
substantial variation in the rate of mitotic recombination among persons without a myeloproliferative disorder,87 genetic and environmental factors
that determine susceptibility to mitotic recombination may influence whether essential thrombocythemia or polycythemia vera develops.
Signaling Pathways

The mutant JAK2 protein activates multiple downstream signaling pathways with effects on gene
transcription,46 apoptosis, the cell cycle, and differentiation55,56 (Table 2). Effects on apoptosis
include overexpression of the cell-survival protein
BCL-X in erythroid precursor cells in polycythemia vera,43 probably as a result of enhanced JAK
STAT signaling.44,45,72 There is also a reduction
in apoptosis induced by death receptors in JAK2
V617F-positive erythroid progenitors, an effect mediated through PI3KAKT and MAPKERK pathways.88 With respect to the cell cycle, mutant JAK2
promotes G1/S phase transition in hematopoietic
cell lines, accompanied by up-regulation of cyclin
D2 and down-regulation of the inhibitor p27kip.89
Effects on erythroid differentiation may be mediated by nuclear factor erythroid-derived 2 (NF-E2),
which is up-regulated in polycythemia vera46,47 and
plays an important role in erythroid differentiation.48,49 Hematopoietic cells expressing JAK2
V617F become hypersensitive to insulin-like growth
factor 1 (IGF-1), suggesting that IGF-1-receptor
signaling influences cellular proliferation and differentiation in these diseases.90
Wild-type JAK2 is required for intracellular
processing and cell-surface display of the erythropoietin receptor59 and the thrombopoietin receptor.91 Mutant JAK2 influences the display and
stability of the erythropoietin receptor on the cell
surface92 but reduces levels of cell-surface thrombopoietin receptor (MPL) in cultured cells (Constantinescu S, Vainchenker W: personal communication). The latter may explain the decreased
levels and altered glycosylation of MPL in the myeloproliferative disorders.50,52,53 It has been suggested that, unlike other kinases associated with
hematologic cancers, the V617F protein requires

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Mechanisms of Disease

a type-1 cytokine receptor such as the erythropoietin receptor (EPOR), MPL, or G-CSF receptor to act as a scaffold and docking site for
downstream effector proteins. Such a mechanism
may explain the involvement of the erythroid,
megakaryocyte, and granulocyte lineages in the
myeloproliferative disorders (Fig. 2B),93 but detailed structural and biochemical analyses are
needed to explain why residue 617 is so critical for
JAK2 activation.
Disease Evolution

The evolution of the myeloproliferative disorders into other forms is poorly understood. An
increase in reticulin fibrosis may occur with time
in patients with polycythemia vera94 or essential
thrombocythemia,95,96 and in some of them a
syndrome indistinguishable from idiopathic myelofibrosis develops.97 The stromal cells and fibroblasts responsible for the increased fibrosis, angiogenesis, and formation of new bone do
not derive from the myeloproliferative clone. They
therefore represent a polyclonal reaction to cytokines including transforming growth factor
(TGF-), basic fibroblast growth factor (bFGF),
and vascular endothelial growth factor (VEGF)
produced by megakaryocytes, monocytes, or
both from the myeloproliferative clone.98 Mouse
models of myelofibrosis suggest that excessive
MPL signaling,99 activation of nuclear factor B
(NF-B),100 and low levels of the globin transcription factor 1 (GATA-1)101 also contribute to cytokine secretion and the development of reticulin
fibrosis. In V617F-positive human disease, excessive MPL signaling may be particularly relevant,
since the JAK2 protein is a key component of signal transduction from the MPL receptor.102
Acute myeloid leukemia develops in a small
minority of patients with a myeloproliferative disorder, but transformation to acute lymphoblastic leukemia is extremely rare.94,103 Leukemic
transformation can occur without exposure to
cytoreductive therapy, but the incidence of this
transformation increases after exposure to some
cytoreductive agents103 and probably reflects acquisition of additional genetic lesions. The development of acute myeloid leukemia in the absence
of the JAK2 mutation in patients with a V617Fpositive myeloproliferative disorder demonstrates
that mutant JAK2 is not necessarily involved in
leukemic transformation.39

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Mol ecul a r Cl a s sific at ion

Prospective27,104 and retrospective28,64,105 studies
of essential thrombocythemia have shown that the
V617F mutation divides the disease into biologically distinct subtypes. V617F-positive thrombocythemia resembles polycythemia vera. In contrast
to V617F-negative essential thrombocythemia,
V617F-positive thrombocythemia typically shows
higher levels of hemoglobin and white cells, a
more cellular bone marrow, an increased risk of
venous thrombosis and transformation to polycythemia vera, and greater sensitivity to hydroxyurea.27 These features suggest that V617Fpositive thrombocythemia is a forme fruste of
polycythemia vera, with the degree of erythrocytosis influenced by factors such as low iron
stores, low erythropoietin levels, sex, and homozygosity for V617F.27 V617F-negative patients, who
have a more isolated thrombocytosis, can present with features of a bona fide myeloproliferative disorder, such as splenomegaly, cytogenetic
abnormalities, megakaryocyte dysplasia, a susceptibility to leukemia or myelofibrosis,27 and
clonal hematopoiesis.26,28,81 Fifty patients with
V617F-negative essential thrombocythemia remained V617F-negative for more than 6 years,
indicating that this disorder is distinct from, and
not an early pre-JAK2 phase of, V617F-positive
thrombocythemia.39
V617F-positive patients with idiopathic myelofibrosis had a reduced transfusion requirement
and greater white-cell counts than did patients
without the mutation,29 analogous to the higher
hemoglobin levels and white-cell counts in patients with V617F-positive essential thrombocythemia. In this study, but not in a second,30 the
V617F mutation was independently associated
with poor survival.29
These results lay the foundation for a molecular classification of the myeloproliferative disorders (Fig. 3). This classification is likely to evolve
as additional genetic lesions are identified within the JAK2 V617F-negative category. The similarities between V617F-positive essential thrombocythemia and polycythemia suggest considerable
overlap between these conditions. They may form
a phenotypic continuum in which the degree of
initial erythrocytosis or thrombocytosis depends
on physiological or genetic modifiers.27
The accelerated phase of a myeloproliferative

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Myeloproliferative disorders

BCR-ABL

Chronic myeloid
leukemia

JAK2 V617F

JAK2-positive
thrombocythemia

Unknown mutation

JAK2-positive
polycythemia

Chronic phase

Chronic phase

Accelerated phase

Accelerated phase

Blast crisis

Leukemic
transformation

JAK2-negative
myeloproliferative disorder
Chronic phase

myelofibrosis
cytopenias
increasing blasts
increasing white cells

Accelerated phase

Leukemic
transformation

Figure 3. Classification of the Myeloproliferative Disorders on the Basis of Molecular Pathogenetic Characteristics.
Chronic myeloid leukemia is defined by the BCR-ABL fusion gene and characterized by three stages of disease progression, from the chronic phase through the accelerated phase to blast crisis. Analogously, JAK2-positive thrombocythemia and polycythemia have overlapping phenotypes in the chronic phase and can progress to an accelerated
phase, which is manifested as myelofibrosis or other complications. Leukemic transformation can also occur. JAK2negative disease follows similar patterns of progression. The disorder that is currently called idiopathic myelofibrosis or agnogenic myeloid metaplasia is clinically indistinguishable from the myelofibrotic transformation of polycythemia vera or essential thrombocythemia. Therefore, this disorder may be an accelerated phase of polycythemia
vera or thrombocythemia. Many patients with polycythemia vera who do not have the V617F mutation have other
JAK2 mutations, and therefore truly JAK2-negative polycythemia vera is probably extremely rare.

disorder is analogous to the accelerated phase of

chronic myeloid leukemia and is probably spurred
by the acquisition of additional genetic changes.
In the myeloproliferative disorders, the accelerated phase would encompass not only the transformation of polycythemia vera or essential thrombocythemia into myelofibrosis, but also a rising
white-cell count, increased blasts in the blood,
and neutropenia or thrombocytopenia.94 It is important to distinguish transformation to myelofibrosis from histologic detection of increased
levels of reticulin. The former is a clinical syndrome indicating a biologic change within the

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n engl j med 355;23

myeloproliferative clone, whereas the latter may

accompany chronic-phase polycythemia vera or
essential thrombocythemia, with the degree of
fibrosis reflecting an interplay between the duration of the disease and physiological or genetic
modifiers.
The disorder that is currently termed idiopathic
myelofibrosis is clinically indistinguishable from
the transformation of polycythemia vera or essential thrombocythemia to myelofibrosis,30,95
and the diagnostic criteria for the two conditions
are similar.95,104,106 At least some patients who
receive the diagnosis of idiopathic myelofibrosis

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Mechanisms of Disease

probably are in the accelerated phase of previously unrecognized polycythemia vera or essential thrombocythemia.

Di agnosis

JAK2-positive polycythemia (diagnosis requires the presence of both criteria)*

A1. High hematocrit (>52% in men or >48% in women) or an increased redcell mass (>25% above predicted value)

Until recently, robust tools for the diagnosis of

the myeloproliferative disorders have been lacking. Criteria for the diagnosis of polycythemia
vera are mostly modifications of 20-year-old standards from the Polycythemia Vera Study Group.107
The available tests are expensive, not universally
available, and lacking in sensitivity and specificity. They include a determination of red-cell mass
to distinguish true erythrocytosis from relative
polycythemia, identification of erythropoietinindependent erythroid colonies in vitro, cytogenetic analysis of bone marrow cells, testing of
erythropoietin levels, ultrasonography of the
spleen, and testing for the overexpression of polycythemia rubra vera 1 (PRV1). There are no universally accepted diagnostic tests for essential
thrombocythemia.108,109
Testing for the JAK2 V617F mutation is now
widely available and promises to simplify the
diagnostic workup. Allele-specific polymerasechain-reaction (PCR) assay,6,27,110 pyrosequencing,31,66 restriction-enzyme digestion,6,110 and
real-time PCR26 are all sufficiently sensitive to
detect the presence of a heterozygous mutation
in as few as 5 to 10% of cells. These assays have
low rates of false positive results, making them
useful diagnostic tools.
Proposed diagnostic criteria for V617F-positive and V617-negative myeloproliferative disorders are outlined in Tables 3 and 4, respectively.
The JAK2 mutation is not associated with causes
of an absolute erythrocytosis other than polycythemia vera.7,9,31,111,112 Therefore, in the absence
of a coexisting secondary erythrocytosis, the presence of the JAK2 mutation in a patient with an
increased red-cell mass is sufficient for the diagnosis of polycythemia vera. In this situation,
the role of analysis of the red-cell mass is mainly
to distinguish polycythemia vera from essential
thrombocythemia. However, this distinction is
becoming arbitrary, given the clinical and biologic
similarities between the two conditions.27,28,64,105
Therefore, in patients with the JAK2 mutation,
analysis of the red-cell mass is likely to become
obsolete. Erythropoietin levels do not distinguish
between polycythemia vera and V617F-positive

n engl j med 355;23

Table 3. Proposed Diagnostic Criteria for Myeloproliferative Diseases

with JAK2 Mutation.

A2. Mutation in JAK2

JAK2-positive thrombocythemia (diagnosis requires the presence of all three
criteria)
A1. Platelet count >450109/liter
A2. Mutation in JAK2
A3. No other myeloid cancer, especially JAK2-positive polycythemia, myelofibrosis, or myelodysplasia
JAK2-positive myelofibrosis (diagnosis requires the presence of A1 and A2
and any two B criteria)
A1. Reticulin grade 3 or higher (on a 04 scale)
A2. Mutation in JAK2
B1. Palpable splenomegaly
B2. Otherwise unexplained anemia (hemoglobin <11.5 g/liter for men;
<10 g/ liter for women)
B3. Teardrop red cells on peripheral blood film
B4. Leukoerythroblastic blood film (presence of at least 2 nucleated red cells
or immature myeloid cells in peripheral blood film)
B5. Systemic symptoms (drenching night sweats, weight loss >10% over 6 mo,
or diffuse bone pain)
B6. Histologic evidence of extramedullary hematopoiesis
* Dual pathology (secondary erythrocytosis or relative erythrocytosis) might
rarely coexist with a JAK2-positive myeloproliferative disorder. In this situation, it would be prudent to reduce the hematocrit to the same targets as
those for polycythemia vera.

essential thrombocythemia27 and therefore have

minimal use in patients with the JAK2 mutation.
Cytogenetic studies in patients with the JAK2 mutation generally do not add useful diagnostic or
prognostic information.
V617F-negative polycythemia vera represents
less than 5% of all cases of polycythemia vera.6,26
In these rare cases, apparent erythrocytosis should
be excluded by analysis of the red-cell mass and
secondary erythrocytosis by measurement of erythropoietin levels and oxygen saturation. Abnormal
results on cytogenetic analysis or radiologic evidence of splenomegaly would support the diagnosis of a myeloproliferative disorder.
The presence of a JAK2 mutation in a patient
with thrombocytosis has a high positive predictive value for a myeloproliferative disorder; patients with reactive or secondary thrombocytosis
and persons without a hematologic disorder are
V617F-negative6-9 (Table 3). Other causes of throm-

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2461

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n e w e ng l a n d j o u r na l

bocytosis must be excluded in patients without

the mutation (Table 4). Cytogenetic analysis of
bone marrow is sometimes helpful in JAK2-negative thrombocythemia if it shows a clonal abnormality. Essential thrombocythemia has been divided into histologically distinct subgroups (labeled
true essential thrombocythemia, prefibrotic myTable 4. Proposed Diagnostic Criteria for Myeloproliferative Diseases without
JAK2 Mutation.
JAK2-negative polycythemia vera (diagnosis requires the presence of A1, A2,
and A3, plus either another A criterion or two B criteria)
A1. Increased red-cell mass (>25% above predicted value) or a hematocrit
60% in men or >56% in women

of

m e dic i n e

elofibrosis, and early overt myelofibrosis) that are

thought to have differing prognoses,2,96 but it is
unclear whether this histologic classification is
robust enough to be applied outside specialized
centers.
Diagnostic criteria for idiopathic myelofibrosis are presented in Tables 3 and 4, modified from
the Italian Consensus Conference.113 The criteria
proposed here define a clinical syndrome in which
reticulin fibrosis of the marrow is accompanied
by specific clinical or laboratory features and can
be used for both idiopathic myelofibrosis and
transformation from preceding essential thrombocythemia or polycythemia vera.

A2. Absence of mutation in JAK2

T r e atmen t

A3. No causes of secondary erythrocytosis (normal arterial oxygen saturation

and no elevation of serum erythropoietin)
A4. Palpable splenomegaly
A5. Presence of acquired genetic abnormality (excluding BCR-ABL) in hematopoietic cells
B1. Thrombocytosis (platelets >450109/liter)
B2. Neutrophilia (neutrophils >10109/liter; >12.5109/liter in smokers)
B3. Splenomegaly on radiography
B4. Endogenous erythroid colonies or low serum erythropoietin
JAK2-negative essential thrombocythemia (diagnosis requires the presence
of all five criteria)*
A1. Platelet count >600109/liter on two occasions at least 1 mo apart
A2. Absence of mutation in JAK2
A3. No reactive cause for thrombocytosis
A4. Normal ferritin (>20 g/liter)
A5. No other myeloid disorder, especially chronic myeloid leukemia, myelofibrosis, polycythemia vera, or myelodysplasia
JAK2-negative idiopathic myelofibrosis (diagnosis requires the presence of
A1, A2, A3, and any two B criteria)
A1. Reticulin grade 3 or higher (on a 04 scale)
A2. Absence of mutation in JAK2
A3. Absence of BCR-ABL fusion gene
B1. Palpable splenomegaly
B2. Otherwise unexplained anemia (hemoglobin <11.5 g/liter for men or
<10 g/liter for women)
B3. Teardrop red cells on peripheral blood film
B4. Leukoerythroblastic blood film (presence of at least 2 nucleated red cells
or immature myeloid cells in peripheral blood film)
B5. Systemic symptoms (drenching night sweats, weight loss >10% over
6 mo, or diffuse bone pain)
B6. Histologic evidence of extramedullary hematopoiesis
* The platelet threshold is preferred in patients without the JAK2 mutation,
given the difficulty in ruling out reactive thrombocytosis and the fact that
2.5% of persons without a myeloproliferative disorder have a platelet count
above the normal range.

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n engl j med 355;23

The JAK2 mutation is reshaping how we treat the

myeloproliferative disorders. Moving to a new classification could simplify therapy. In polycythemia vera, the hematocrit is the primary target of
therapy, but the treatment of patients with thrombocytosis is controversial.94,114 By contrast, in essential thrombocythemia, cytoreduction to normalize the platelet count reduces thrombosis in
high-risk patients,115 but the hematocrit is not a
therapeutic target. Given the many similarities between JAK2-positive polycythemia and thrombocythemia, it seems logical to develop target levels
for both the platelet count and the hematocrit in
both conditions. The development of a unified
treatment strategy is consistent with growing evidence that the increased risk of thrombosis is not
exclusively caused by erythrocytosis or thrombocytosis but by interactions among white cells, red
cells, platelets, and the endothelium. Abnormalities in the activation of leukocytes and platelets
occur in both diseases.116,117
The JAK2 mutation also affects response to
treatment. Among patients with essential thrombocythemia, those with the V617F mutation are
more sensitive to hydroxyurea (but not to anagrelide) than are patients without the mutation.27
The response to therapy can now be directly monitored through quantification of JAK2-positive cells
in peripheral blood.118,119
An understanding of the molecular pathogenesis of the myeloproliferative disorders lays the
foundation for the development of novel targeted
therapies. Since JAK2 inhibitors reduce the growth
of JAK2 V617F-positive cell lines and primary cells
in vitro,8,12 there is considerable interest in de-

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Mechanisms of Disease

veloping compounds for clinical use. Such agents eloid leukemia, we hope the next decade will see
hold particular promise for the treatment of pa- the development of well-tolerated, therapeutic
tients whose disease is in the accelerated phase, JAK2 inhibitors.
including myelofibrosis, given the lack of satisfacNo potential conflict of interest relevant to this article was
tory treatments currently available. These agents reported.
We thank Gary Gilliland, William Vainchenker, Radek Skoda,
may also prove to be useful for reducing the risk
Ruben
Mesa, Tiziano Barbui, Wendy Erber, Claire Harrison, and
of vascular events or long-term disease evolution
Mary Frances McMullin for their constructive comments on the
in chronic-phase disease. With an eye to the suc- manuscript, and Wendy Erber for providing some of the light
cess of imatinib in the treatment of chronic my- micrographs in Figure 1.
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