review article

The new engl and j ournal o f medicine

n engl j med 355;23 www.nejm.org december 7, 2006 2452
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, Unit-
ed Kingdom. Address reprint requests to
Dr. Green at the Department of Haema-
tology, 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.
T
he myeloproliferative disorders comprise several clonal he-
matologic diseases that are thought to arise from a transformation in a he-
matopoietic stem cell. The main clinical features of these diseases are the
overproduction of mature, functional blood cells and a long clinical course. Chron-
ic 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 thrombocy-
themia, and idiopathic myelofibrosis are the focus of this article. Less common
conditions that are also considered myeloproliferative disorders under the classifi-
cation used by the World Health Organization include systemic mastocytosis, chron-
ic eosinophilic leukemia, chronic myelomonocytic leukemia, and chronic neutro-
philic leukemia.
2
The cardinal features of the three main myeloproliferative disorders are an in-
creased red-cell mass in polycythemia vera, a high platelet count in essential throm-
bocythemia, 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
Pathogenetic Features
Clues to Molecular Mechanisms
Polycythemia vera, a condition of persistent and excessive hypercellularity accom-
panied by cyanosis, was recognized by Vaquez in 1892,
4
and idiopathic myelofibro-
sis 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 disor-
ders, constitute a spectrum of related diseases. He coined the term myeloprolif-
erative disorders to embrace these related conditions.
5
In 1974, a critical experi-
ment showed that erythroid progenitors from the bone marrow of patients with
polycythemia vera were capable of growing in vitro in the absence of erythropoie-
tin.
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
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2453
Other clues to the molecular mechanisms re-
sponsible 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 recog-
nition of increased signaling through Janus ki-
nases and signal transducers and activators of
transcription (JAKSTAT) and phosphatidylino-
sitol 3-kinase (PI3K) pathways in erythroid and
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
Polycythemia
Vera
Peripheral Blood
Bone Marrow
(hematoxylin and eosin)
Bone Marrow
(reticulin stain)
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 hypercel-
lular 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 clus-
ter 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.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2454
in the majority of patients with Ph-negative myelo-
proliferative disorders.
6-9,19
JAK2, a cytoplasmic
tyrosine kinase, is critical for instigating intracel-
lular signaling by the receptors for erythropoi-
etin, thrombopoietin, interleukin-3, granulocyte
colony-stimulating factor (G-CSF), and granulo-
cytemacrophage colony-stimulating factor (GM-
CSF).
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 un-
derscores 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 pro-
moting the docking of downstream effector pro-
teins and the initiation of intracellular signaling
cascades
55,56
(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 poly-
cythemia vera
6,26
and in 50 to 60% of patients
with essential thrombocythemia
6,26-28,31,64
or id-
iopathic myelofibrosis.
6,26,29-31
A substantial pro-
portion of patients with polycythemia vera or
idiopathic myelofibrosis are homozygous for the
JAK2 mutation as a result of mitotic recombina-
tion affecting chromosome 9p,
6-9
but this phe-
nomenon is rarely detected in essential throm-
bocythemia.
65
The mutation is also found in a
small minority of patients with the hypereosino-
philic syndrome, chronic myelomonocytic leuke-
mia, chronic neutrophilic leukemia, myelodyspla-
sia, 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 phe-
nylalanine for a conserved valine at position 617
of the JAK2 protein (V617F). This residue is lo-
cated in the JH2, or pseudokinase, domain, which
negatively regulates the kinase domain.
71
Bio-
chemical studies have shown that the JAK2 V617F
mutation causes cytokine-independent activa-
Table 1. Milestones in the History of Philadelphia-Negative Myeloproliferative Disorders and Their Relationship
with the V617F Mutation in JAK2.*
Year Historical Milestone
Relationship Later Established with V617F
Mutation in JAK2
1892 First description of polycythemia vera
4
1951 Polycythemia vera, essential thrombocythemia, and idio-
pathic myelofibrosis linked as related conditions
5
Mutation found in all three disorders
6-9
1974 Identification of erythropoietin-independent erythroid
colonies
10
Mutation associated with cytokine independence
of primary erythroid progenitors and cell lines
6-9
1976 Stem-cell origin of polycythemia vera
11
Mutation found in multipotent progenitors and
hematopoietic stem cells
6,12
19832003 Dysregulated tyrosine kinases found in chronic myeloid
leukemia,
13,14
mastocytosis,
15
chronic myelomonocy-
tic leukemia,
16,17
and chronic eosinophilic leukemia
18
Tyrosine kinase function of JAK2 constitutively
activated by mutation
7-9,19
2002 Description of mitotic recombination involving chro-
mosome 9p as the most common cytogenetic
lesion in polycythemia vera
20
Homozygosity of the mutation caused by mitotic
recombination of chromosome 9p
6-9
20012004 Erythropoietin-independent growth in poly cythemia
vera dependent on JAKSTAT signaling
21,22
STAT proteins constitutively activated by muta-
tion
7-9,19
2005 Description of the JAK2 V617F mutation
6-9,19
* STAT denotes signal transducers and activators of transcription.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2455
tion of JAKSTAT, PI3K, and AKT (also known
as protein kinase B) pathways, and mitogen-acti-
vated protein kinase (MAPK) and extracellular
signal-regulated kinase (ERK),
7-9,19
all of which are
implicated in erythropoietin-receptor signal-
ing.
22,63,72,73
The JAK2 mutation provides a unifying expla-
nation for many features of the myeloprolifera-
tive 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 throm-
bopoietin receptor (MPL) gene in approximately
10% of patients with V617F-negative idiopathic
myelofibrosis.
35,36
This mutation is located in a
motif that is important for keeping the receptor
inactive.
74
Pathophysiological Features
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 mu-
tation is the first genetic marker that is directly
associated with the pathogenesis of the myelopro-
liferative disorders, and for this reason it is a pow-
erful tool for analysis of the molecular and cel-
lular basis of these disorders.
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 mastocytosis
15,37
FIP1L1PDGFRA Chronic eosinophilic leukemia
18,38

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 mutation
39
Trisomy 8 Found in myeloproliferative disorders, myelodysplasia, and acute myeloid leukemias; target
genes not identified
Trisomy 1q Caused by duplication, trisomy, or unbalanced translocations
40

20q deletion Found in myeloproliferative disorders and myelodysplasia
41
; associated with JAK2 V617F muta-
tion
39
and precedes it in some cases
42
; target genes not identified
41
5q and 7q deletions Thought to reflect changes secondary to cytotoxic therapy
40
; target genes not identified
13q deletion Associated with idiopathic myelofibrosis; overlap of commonly deleted region and the region
for chronic lymphocytic leukemia
40
Dysregulated genes and proteins
BCL-XL Overexpressed in polycythemia vera
43
as a result of constitutive JAKSTAT signaling; antiapop-
totic effects in erythroid cells
44,45
NFE2 Up-regulated in JAK2-positive myeloproliferative diseases
46,47
; may affect erythroid differentiation
48,49
PRV1 RNA levels increased in polycythemia vera
50,51
but unlikely to play a direct role in disease patho-
genesis since protein levels are not increased
51
MPL Surface levels of protein decreased and aberrantly glycosylated in myeloproliferative disorders
52,53
;
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.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2456
Mouse Models
Expression of the JAK2 V617F mutation in murine
hematopoietic cells by means of a retroviral vec-
tor recapitulates the features of polycythemia
vera.
7,75-78
The animals have erythrocytosis and
leukocytosis, and there is evolution to postpoly-
cythemic 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 transcrip-
tion 5 (STAT5), erythropoietin hypersensitivity, and
cytokine independence are all present, as in the
human disease. These results provide direct evi-
dence 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 pat-
terns of X-chromosome inactivation in female
patients
11,25,79
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 disorder
79
and are
thought to reflect polymorphic X-linked genes that
influence hematopoietic stem-cell behavior.
80
Age-
related skewing limits the use of the analysis of
X-chromosome inactivation for diagnostic pur-
poses, but such studies remain useful as research
tools. For example, studies of X-chromosome inac-
tivation indicate that in most patients with V617F-
negative essential thrombocythemia or idiopathic
myelofibrosis, there is a dominant clone of blood
cells,
26,28,81
implying that these disorders are clon-
al hematologic diseases.
The presence of the JAK2 mutation in colo-
nies of hematopoietic progenitor cells (grown in
vitro)
6,65
and in hematopoietic stem cells isolat-
ed by fluorescence-activated cell sorting
12,82
pro-
vides direct evidence that polycythemia vera and
related myeloproliferative disorders arise in a mul-
tipotent progenitor or stem cell. In contrast to the
normal-size myeloid stem-cell compartment in
chronic myeloid leukemia,
83
the stem-cell com-
partment in polycythemia vera is both expanded
and characterized by preferential erythroid dif-
ferentiation.
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 myelo-
proliferative disorders reflects the acquisition of
additional mutations.
84,85
Four lines of evidence suggest that cooperat-
ing mutations occur at an early stage in V617F-
positive myeloproliferative disorders and can even
predate the JAK2 mutation. First, deletions of 20q
and other cytogenetic abnormalities occur in 5 to
Figure 2 (facing page). Role of JAK2 in Pathway Signal-
ing and Erythropoietin Binding, Stem-Cell Differentia-
tion, 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 erythropoi-
etin (Epo) to its receptor induces conformational chang-
es 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 kinas-
es and signal transducers and activators of transcrip-
tion (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 im-
portant for hematopoietic stem-cell biology and differ-
entiation. Therefore, the JAK2 protein with the V617F
mutation exerts its effects at various stages of differ-
entiation and in various lineages. In Panel C, the devel-
opment of homozygosity for the V617F mutation is a
two-step process, with the initial point mutation fol-
lowed by mitotic recombination of chromosome 9p be-
tween the JAK2 locus and the centromere. This results
in the loss of heterozygosity but a diploid DNA copy
number.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2457
A
B
C
Wild-type JAK2
without erythropoietin
Wild-type JAK2
with erythropoietin
JAK2 with V617F mutation
without erythropoietin
Stem cell
Progenitor cells Terminally differentiated cells
Wild-type JAK2
Red cells
Megakaryocytes
Granulocytes
EPOR
MPL
G-CSFR
Heterozygous V167F
V617F
Homozygous V167F
Point mutation Mitotic recombination
No signal
JAK2
EPOR
Epo
P
PI3K
RASMAPK STAT
JAK2
V617F
P
P P
P
P
P
P
Unknown
receptor
Chromosome 9
V617F
PI3K
RASMAPK STAT
V617F
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2458
10% of patients with a myeloproliferative disor-
der.
40
In one patient with polycythemia vera and
in one with essential thrombocythemia, granulo-
cytes with the 20q deletion outnumbered V617F-
positive granulocytes,
42
suggesting that the 20q
deletion occurred before the JAK2 mutation. Pa-
tients with molecularly defined 20q deletions are
almost exclusively V617F-positive,
39
which is con-
sistent 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 pat-
terns of X-chromosome inactivation) than JAK2-
positive granulocytes.
26,39,42
Although this find-
ing 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 polycythe-
mia vera or essential thrombocythemia that un-
dergoes 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 myeloprolifera-
tive 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. Homozy-
gosity results from mitotic recombination (Fig.
2C), with the breakpoints spread along chromo-
some 9p between the JAK2 locus and the centro-
mere,
9
implying that there is no single fragile site
that is prone to recombination. In polycythemia
vera, the prevalence of blood cells that are homo-
zygous for the JAK2 mutation increases with time,
65

presumably owing to a proliferative or survival ad-
vantage of mutant progenitor cells. Homozygos-
ity for V617F is associated with more marked
changes in the expression of downstream target
genes than is heterozygosity for V617F.
46
This re-
flects 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 detect-
ed in about 30% of patients with polycythemia
vera.
6-9
However, when colonies of hematopoi-
etic progenitor cells derived from such patients
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 recom-
bination among persons without a myeloprolifera-
tive disorder,
87
genetic and environmental factors
that determine susceptibility to mitotic recombi-
nation may influence whether essential thrombo-
cythemia or polycythemia vera develops.
Signaling Pathways
The mutant JAK2 protein activates multiple down-
stream signaling pathways with effects on gene
transcription,
46
apoptosis, the cell cycle, and dif-
ferentiation
55,56
(Table 2). Effects on apoptosis
include overexpression of the cell-survival protein
BCL-X in erythroid precursor cells in polycythe-
mia 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 me-
diated through PI3KAKT and MAPKERK path-
ways.
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 p27
kip
.
89

Effects on erythroid differentiation may be medi-
ated by nuclear factor erythroid-derived 2 (NF-E2),
which is up-regulated in polycythemia vera
46,47
and
plays an important role in erythroid differentia-
tion.
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 dif-
ferentiation in these diseases.
90
Wild-type JAK2 is required for intracellular
processing and cell-surface display of the eryth-
ropoietin receptor
59
and the thrombopoietin re-
ceptor.
91
Mutant JAK2 influences the display and
stability of the erythropoietin receptor on the cell
surface
92
but reduces levels of cell-surface throm-
bopoietin receptor (MPL) in cultured cells (Con-
stantinescu S, Vainchenker W: personal communi-
cation). The latter may explain the decreased
levels and altered glycosylation of MPL in the my-
eloproliferative disorders.
50,52,53
It has been sug-
gested that, unlike other kinases associated with
hematologic cancers, the V617F protein requires
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2459
a type-1 cytokine receptor such as the eryth-
ropoietin receptor (EPOR), MPL, or G-CSF recep-
tor 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 de-
tailed structural and biochemical analyses are
needed to explain why residue 617 is so critical for
JAK2 activation.
Disease Evolution
The evolution of the myeloproliferative disor-
ders into other forms is poorly understood. An
increase in reticulin fibrosis may occur with time
in patients with polycythemia vera
94
or essential
thrombocythemia,
95,96
and in some of them a
syndrome indistinguishable from idiopathic my-
elofibrosis develops.
97
The stromal cells and fi-
broblasts responsible for the increased fibro-
sis, angiogenesis, and formation of new bone do
not derive from the myeloproliferative clone. They
therefore represent a polyclonal reaction to cyto-
kines 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 transcrip-
tion factor 1 (GATA-1)
101
also contribute to cyto-
kine secretion and the development of reticulin
fibrosis. In V617F-positive human disease, exces-
sive MPL signaling may be particularly relevant,
since the JAK2 protein is a key component of sig-
nal transduction from the MPL receptor.
102
Acute myeloid leukemia develops in a small
minority of patients with a myeloproliferative dis-
order, but transformation to acute lymphoblas-
tic 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 agents
103
and probably reflects ac-
quisition of additional genetic lesions. The devel-
opment of acute myeloid leukemia in the absence
of the JAK2 mutation in patients with a V617F-
positive myeloproliferative disorder demonstrates
that mutant JAK2 is not necessarily involved in
leukemic transformation.
39
Molecular Classification
Prospective
27,104
and retrospective
28,64,105
studies
of essential thrombocythemia have shown that the
V617F mutation divides the disease into biologi-
cally distinct subtypes. V617F-positive thrombo-
cythemia 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 poly-
cythemia vera, and greater sensitivity to hy-
droxyurea.
27
These features suggest that V617F-
positive thrombocythemia is a forme fruste of
polycythemia vera, with the degree of erythro-
cytosis inf luenced by factors such as low iron
stores, low erythropoietin levels, sex, and homo-
zygosity for V617F.
27
V617F-negative patients, who
have a more isolated thrombocytosis, can pres-
ent with features of a bona fide myeloprolifera-
tive disorder, such as splenomegaly, cytogenetic
abnormalities, megakaryocyte dysplasia, a sus-
ceptibility to leukemia or myelofibrosis,
27
and
clonal hematopoiesis.
26,28,81
Fifty patients with
V617F-negative essential thrombocythemia re-
mained 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 myelo-
fibrosis 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 pa-
tients with V617F-positive essential thrombo-
cythemia. 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 molecu-
lar classification of the myeloproliferative disor-
ders (Fig. 3). This classification is likely to evolve
as additional genetic lesions are identified with-
in the JAK2 V617F-negative category. The similari-
ties between V617F-positive essential thrombo-
cythemia 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
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2460
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 acceler-
ated phase would encompass not only the trans-
formation of polycythemia vera or essential throm-
bocythemia into myelofibrosis, but also a rising
white-cell count, increased blasts in the blood,
and neutropenia or thrombocytopenia.
94
It is im-
portant to distinguish transformation to myelo-
fibrosis from histologic detection of increased
levels of reticulin. The former is a clinical syn-
drome indicating a biologic change within the
myeloproliferative clone, whereas the latter may
accompany chronic-phase polycythemia vera or
essential thrombocythemia, with the degree of
fibrosis reflecting an interplay between the dura-
tion 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 es-
sential 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
Myeloproliferative disorders
Chronic myeloid
leukemia
BCR-ABL JAK2 V617F Unknown mutation
JAK2-positive
thrombocythemia
JAK2-positive
polycythemia
JAK2-negative
myeloproliferative disorder
Accelerated phase
Blast crisis Leukemic
transformation
myelofibrosis
cytopenias
increasing blasts
increasing white cells
Chronic phase Chronic phase Chronic phase
Accelerated phase 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 pro-
gression, from the chronic phase through the accelerated phase to blast crisis. Analogously, JAK2-positive thrombo-
cythemia 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. JAK2-
negative disease follows similar patterns of progression. The disorder that is currently called idiopathic myelofibro-
sis or agnogenic myeloid metaplasia is clinically indistinguishable from the myelofibrotic transformation of polycy-
themia 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.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2461
probably are in the accelerated phase of previ-
ously unrecognized polycythemia vera or essen-
tial thrombocythemia.
Diagnosis
Until recently, robust tools for the diagnosis of
the myeloproliferative disorders have been lack-
ing. Criteria for the diagnosis of polycythemia
vera are mostly modifications of 20-year-old stan-
dards from the Polycythemia Vera Study Group.
107

The available tests are expensive, not universally
available, and lacking in sensitivity and specific-
ity. They include a determination of red-cell mass
to distinguish true erythrocytosis from relative
polycythemia, identification of erythropoietin-
independent erythroid colonies in vitro, cytoge-
netic analysis of bone marrow cells, testing of
erythropoietin levels, ultrasonography of the
spleen, and testing for the overexpression of poly-
cythemia rubra vera 1 (PRV1). There are no uni-
versally 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 polymerase-
chain-reaction (PCR) assay,
6,27,110
pyrosequenc-
ing,
31,66
restriction-enzyme digestion,
6,110
and
real-time PCR
26
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-posi-
tive and V617-negative myeloproliferative disor-
ders are outlined in Tables 3 and 4, respectively.
The JAK2 mutation is not associated with causes
of an absolute erythrocytosis other than polycy-
themia vera.
7,9,31,111,112
Therefore, in the absence
of a coexisting secondary erythrocytosis, the pres-
ence of the JAK2 mutation in a patient with an
increased red-cell mass is sufficient for the di-
agnosis 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
essential thrombocythemia
27
and therefore have
minimal use in patients with the JAK2 mutation.
Cytogenetic studies in patients with the JAK2 mu-
tation 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 eryth-
ropoietin levels and oxygen saturation. Abnormal
results on cytogenetic analysis or radiologic evi-
dence of splenomegaly would support the diag-
nosis of a myeloproliferative disorder.
The presence of a JAK2 mutation in a patient
with thrombocytosis has a high positive predic-
tive value for a myeloproliferative disorder; pa-
tients with reactive or secondary thrombocytosis
and persons without a hematologic disorder are
V617F-negative
6-9
(Table 3). Other causes of throm-
Table 3. Proposed Diagnostic Criteria for Myeloproliferative Diseases
with JAK2 Mutation.
JAK2-positive polycythemia (diagnosis requires the presence of both cri-
teria)*
A1. High hematocrit (>52% in men or >48% in women) or an increased red-
cell mass (>25% above predicted value)
A2. Mutation in JAK2
JAK2-positive thrombocythemia (diagnosis requires the presence of all three
criteria)
A1. Platelet count >45010
9
/liter
A2. Mutation in JAK2
A3. No other myeloid cancer, especially JAK2-positive polycythemia, myelo-
fibrosis, 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 situa-
tion, it would be prudent to reduce the hematocrit to the same targets as
those for polycythemia vera.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2462
bocytosis must be excluded in patients without
the mutation (Table 4). Cytogenetic analysis of
bone marrow is sometimes helpful in JAK2-nega-
tive thrombocythemia if it shows a clonal abnor-
mality. Essential thrombocythemia has been divid-
ed into histologically distinct subgroups (labeled
true essential thrombocythemia, prefibrotic my-
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 myelofibro-
sis 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 throm-
bocythemia or polycythemia vera.
Treatment
The JAK2 mutation is reshaping how we treat the
myeloproliferative disorders. Moving to a new clas-
sification could simplify therapy. In polycythe-
mia vera, the hematocrit is the primary target of
therapy, but the treatment of patients with throm-
bocytosis is controversial.
94,114
By contrast, in es-
sential thrombocythemia, cytoreduction to nor-
malize the platelet count reduces thrombosis in
high-risk patients,
115
but the hematocrit is not a
therapeutic target. Given the many similarities be-
tween JAK2-positive polycythemia and thrombo-
cythemia, 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 evi-
dence that the increased risk of thrombosis is not
exclusively caused by erythrocytosis or thrombo-
cytosis but by interactions among white cells, red
cells, platelets, and the endothelium. Abnormali-
ties 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 throm-
bocythemia, those with the V617F mutation are
more sensitive to hydroxyurea (but not to ana-
grelide) than are patients without the mutation.
27

The response to therapy can now be directly moni-
tored through quantification of JAK2-positive cells
in peripheral blood.
118,119
An understanding of the molecular pathogen-
esis 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-
Table 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
A2. Absence of mutation in JAK2
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 hema-
topoietic cells
B1. Thrombocytosis (platelets >45010
9
/liter)
B2. Neutrophilia (neutrophils >1010
9
/liter; >12.510
9
/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 >60010
9
/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, myelofi-
brosis, 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.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2463
veloping compounds for clinical use. Such agents
hold particular promise for the treatment of pa-
tients whose disease is in the accelerated phase,
including myelofibrosis, given the lack of satisfac-
tory treatments currently available. These agents
may also prove to be useful for reducing the risk
of vascular events or long-term disease evolution
in chronic-phase disease. With an eye to the suc-
cess of imatinib in the treatment of chronic my-
eloid leukemia, we hope the next decade will see
the development of well-tolerated, therapeutic
JAK2 inhibitors.
No potential conflict of interest relevant to this article was
reported.
We thank Gary Gilliland, William Vainchenker, Radek Skoda,
Ruben Mesa, Tiziano Barbui, Wendy Erber, Claire Harrison, and
Mary Frances McMullin for their constructive comments on the
manuscript, and Wendy Erber for providing some of the light
micrographs in Figure 1.
References
Goldman JM, Melo JV. Chronic my-
eloid leukemia advances in biology and
new approaches to treatment. N Engl J Med
2003;349:1451-64.
Pierre R, Imbert M, Thiele J, Vardiman
JW, Brunning RD, Flandrin G. Chronic my-
eloproliferative diseases. In: Jaffe ES, Har-
ris NL, Stein H, Vardiman JW, eds. World
Health Organization classification of tu-
mours: pathology and genetics of tumours
of haemopoietic and lymphoid tissues.
Lyon, France: IARC Press, 2001:61-73.
Johansson P, Kutti J, Andreasson B, et
al. Trends in the incidence of chronic Phila-
delphia chromosome negative (Ph-) myelo-
proliferative disorders in the city of Gote-
borg, Sweden, during 1983-99. J Intern
Med 2004;256:161-5.
Vaquez H. Sur une forme speciale de
cyanose saccompagnant dhyperglobulie
excessive et persistante. C R Soc Biol (Par-
is) 1892;44:384-8.
Dameshek W. Some speculations on
the myeloproliferative syndromes. Blood
1951;6:372-5.
Baxter EJ, Scott LM, Campbell PJ, et al.
Acquired mutation of the tyrosine kinase
JAK2 in human myeloproliferative disor-
ders. Lancet 2005;365:1054-6. [Erratum,
Lancet 2005;366:122.]
James C, Ugo V, Le Couedic JP, et al.
A unique clonal JAK2 mutation leading to
constitutive signaling causes polycythae-
mia vera. Nature 2005;434:1144-8.
Levine RL, Wadleigh M, Cools J, et al.
Activating mutation in the tyrosine kinase
JAK2 in polycythemia vera, essential throm-
bocythemia, and myeloid metaplasia with
myelofibrosis. Cancer Cell 2005;7:387-97.
Kralovics R, Passamonti F, Buser AS,
et al. A gain-of-function mutation of JAK2
in myeloproliferative disorders. N Engl J
Med 2005;352:1779-90.
Prchal JF, Axelrad AA. Bone-marrow
responses in polycythemia vera. N Engl J
Med 1974;290:1382.
Adamson JW, Fialkow PJ, Murphy S,
Prchal JF, Steinmann L. Polycythemia vera:
stem-cell and probable clonal origin of the
disease. N Engl J Med 1976;295:913-6.
Jamieson CH, Gotlib J, Durocher JA,
et al. The JAK2 V617F mutation occurs in
hematopoietic stem cells in polycythemia
vera and predisposes toward erythroid dif-
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
ferentiation. Proc Natl Acad Sci U S A
2006;103:6224-9.
Bartram CR, de Klein A, Hagemeijer
A, et al. Translocation of c-ab1 oncogene
correlates with the presence of a Philadel-
phia chromosome in chronic myelocytic
leukaemia. Nature 1983;306:277-80.
Lugo TG, Pendergast AM, Muller AJ,
Witte ON. Tyrosine kinase activity and
transformation potency of bcr-abl onco-
gene products. Science 1990;247:1079-82.
Buttner C, Henz BM, Welker P, Sepp
NT, Grabbe J. Identification of activating
c-kit mutations in adult-, but not in child-
hood-onset indolent mastocytosis: a pos-
sible explanation for divergent clinical be-
havior. J Invest Dermatol 1998;111:1227-
31.
Golub TR, Barker GF, Lovett M, Gil-
liland DG. Fusion of PDGF receptor beta
to a novel ets-like gene, tel, in chronic my-
elomonocytic leukemia with t(5;12) chro-
mosomal translocation. Cell 1994;77:307-
16.
Xiao S, Nalabolu SR, Aster JC, et al.
FGFR1 is fused with a novel zinc-finger
gene, ZNF198, in the t(8;13) leukaemia/
lymphoma syndrome. Nat Genet 1998;
18:84-7.
Cools J, DeAngelo DJ, Gotlib J, et al.
A tyrosine kinase created by fusion of the
PDGFRA and FIP1L1 genes as a therapeutic
target of imatinib in idiopathic hypereo-
sinophilic syndrome. N Engl J Med 2003;
348:1201-14.
Zhao R, Xing S, Li Z, et al. Identifica-
tion of an acquired JAK2 mutation in
polycythemia vera. J Biol Chem 2005;280:
22788-92.
Kralovics R, Guan Y, Prchal JT. Ac-
quired uniparental disomy of chromo-
some 9p is a frequent stem cell defect in
polycythemia vera. Exp Hematol 2002;30:
229-36.
Roder S, Steimle C, Meinhardt G, Pahl
HL. STAT3 is constitutively active in some
patients with polycythemia rubra vera.
Exp Hematol 2001;29:694-702.
Ugo V, Marzac C, Teyssandier I, et al.
Multiple signaling pathways are involved
in erythropoietin-independent differenti-
ation of erythroid progenitors in polycy-
themia vera. Exp Hematol 2004;32:179-
87.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Heuck G. Falle von Leukaemie mit ei-
genthumlichen Blut-resp. Knockenmarks-
befund. Virchown Archiv 1879;78:475-81.
Epstein E, Goedel A. Haemorrhagische
thrombocythamie bei vascularer schrumpf-
milz. Virchovs Archiv Abteilung 1934;293:
233-47.
Fialkow PJ, Faguet GB, Jacobson RJ,
Vaidya K, Murphy S. Evidence that essen-
tial thrombocythemia is a clonal disor-
der with origin in a multipotent stem cell.
Blood 1981;58:916-9.
Levine RL, Belisle C, Wadleigh M, et
al. X-inactivation-based clonality analysis
and quantitative JAK2V617F assessment
reveals a strong association between clon-
ality and JAK2V617F in PV but not ET/MMM,
and identifies a subset of JAK2V617F-neg-
ative ET and MMM patients with clonal
hematopoiesis. Blood 2006;107:4139-41.
Campbell PJ, Scott LM, Buck G, et al.
Definition of subtypes of essential throm-
bocythaemia and relation to polycythae-
mia vera based on JAK2 V617F mutation
status: a prospective study. Lancet 2005;
366:1945-53.
Antonioli E, Guglielmelli P, Pancrazzi
A, et al. Clinical implications of the JAK2
V617F mutation in essential thrombocy-
themia. Leukemia 2005;19:1847-9.
Campbell PJ, Griesshammer M, Doh-
ner K, et al. V617F mutation in JAK2 is as-
sociated with poorer survival in idiopathic
myelofibrosis. Blood 2006;107:2098-100.
Tefferi A, Lasho TL, Schwager SM, et
al. The JAK2(V617F) tyrosine kinase mu-
tation in myelofibrosis with myeloid meta-
plasia: lineage specificity and clinical cor-
relates. Br J Haematol 2005;131:320-8.
Jones AV, Kreil S, Zoi K, et al. Wide-
spread occurrence of the JAK2 V617F mu-
tation in chronic myeloproliferative disor-
ders. Blood 2005;106:2162-8.
Steensma DP, Dewald GW, Lasho TL,
et al. The JAK2 V617F activating tyrosine
kinase mutation is an infrequent event in
both atypical myeloproliferative disor-
ders and myelodysplastic syndromes. Blood
2005;106:1207-9.
Scott LM, Campbell PJ, Baxter EJ, et al.
The V617F JAK2 mutation is uncommon
in cancers and in myeloid malignancies
other than the classic myeloproliferative
disorders. Blood 2005;106:2920-1.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;23 www.nejm.org december 7, 2006 2464
Levine RL, Loriaux M, Huntly BJ, et al.
The JAK2V617F activating mutation occurs
in chronic myelomonocytic leukemia and
acute myeloid leukemia, but not in acute
lymphoblastic leukemia or chronic lym-
phocytic leukemia. Blood 2005;106:3377-
9.
Pikman Y, Lee BH, Mercher T, et al.
MPLW515L is a novel somatic activating
mutation in myelofibrosis with myeloid
metaplasia. PLoS Med 2006;3:e270.
Pardanani AD, Levine RL, Lasho T, et
al. MPL515 mutations in myeloprolifera-
tive and other myeloid disorders: a study
of 1182 patients. Blood (in press).
Longley BJ Jr, Metcalfe DD, Tharp M,
et al. Activating and dominant inactivat-
ing c-KIT catalytic domain mutations in
distinct clinical forms of human masto-
cytosis. Proc Natl Acad Sci U S A 1999;96:
1609-14.
Pardanani A, Brockman SR, Paternos-
ter SF, et al. FIP1L1-PDGFRA fusion: prev-
alence and clinicopathologic correlates in
89 consecutive patients with moderate to
severe eosinophilia. Blood 2004;104:3038-
45.
Campbell PJ, Baxter EJ, Beer PA, et al.
Mutation of JAK2 in the myeloproliferative
disorders: timing, clonality studies, cyto-
genetic associations and role in leukemic
transformation. Blood (in press).
Bench AJ, Nacheva EP, Champion KM,
Green AR. Molecular genetics and cyto-
genetics of myeloproliferative disorders.
Baillieres Clin Haematol 1998;11:819-48.
Bench AJ, Nacheva EP, Hood TL, et al.
Chromosome 20 deletions in myeloid ma-
lignancies: reduction of the common de-
leted region, generation of a PAC/BAC con-
tig and identification of candidate genes.
Oncogene 2000;19:3902-13.
Kralovics R, Teo SS, Li S, et al. Acquisi-
tion of the V617F mutation of JAK2 is
a late genetic event in a subset of patients
with myeloproliferative disorders. Blood
2006;108:1377-80.
Silva M, Richard C, Benito A, Sanz C,
Olalla I, Fernandez-Luna JL. Expression of
Bcl-x in erythroid precursors from patients
with polycythemia vera. N Engl J Med
1998;338:564-71.
Kieslinger M, Woldman I, Moriggl R,
et al. Antiapoptotic activity of Stat5 re-
quired during terminal stages of myeloid
differentiation. Genes Dev 2000;14:232-
44.
Socolovsky M, Nam H, Fleming MD,
Haase VH, Brugnara C, Lodish HF. Ineffec-
tive erythropoiesis in Stat5a(/)5b(/)
mice due to decreased survival of early
erythroblasts. Blood 2001;98:3261-73.
Kralovics R, Teo SS, Buser AS, et al.
Altered gene expression in myeloprolifer-
ative disorders correlates with activation
of signaling by the V617F mutation of Jak2.
Blood 2005;106:3374-6.
Goerttler PS, Kreutz C, Donauer J, et
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
al. Gene expression profiling in polycy-
thaemia vera: overexpression of transcrip-
tion factor NF-E2. Br J Haematol 2005;129:
138-50.
Labbaye C, Valtieri M, Barberi T, et al.
Differential expression and functional role
of GATA-2, NF-E2, and GATA-1 in normal
adult hematopoiesis. J Clin Invest 1995;95:
2346-58.
Sayer MS, Tilbrook PA, Spadaccini A,
et al. Ectopic expression of transcription
factor NF-E2 alters the phenotype of ery-
throid and monoblastoid cells. J Biol Chem
2000;275:25292-8.
Goerttler PS, Steimle C, Marz E, et al.
The Jak2V617F mutation, PRV-1 overexpres-
sion, and EEC formation define a similar
cohort of MPD patients. Blood 2005;106:
2862-4.
Klippel S, Strunck E, Busse CE, Beh-
ringer D, Pahl HL. Biochemical character-
ization of PRV-1, a novel hematopoietic cell
surface receptor, which is overexpressed
in polycythemia rubra vera. Blood 2002;
100:2441-8.
Moliterno AR, Hankins WD, Spivak
JL. Impaired expression of the thrombo-
poietin receptor by platelets from patients
with polycythemia vera. N Engl J Med
1998;338:572-80.
Moliterno AR, Spivak JL. Posttransla-
tional processing of the thrombopoietin
receptor is impaired in polycythemia vera.
Blood 1999;94:2555-61.
Komura E, Chagraoui H, Mansat de
Mas V, et al. Spontaneous STAT5 activa-
tion induces growth factor independence
in idiopathic myelofibrosis: possible rela-
tionship with FKBP51 overexpression. Exp
Hematol 2003;31:622-30.
Sandberg EM, Wallace TA, Godeny
MD, Vonderlinden D, Sayeski PP. Jak2 ty-
rosine kinase: a true jak of all trades? Cell
Biochem Biophys 2004;41:207-32.
Kisseleva T, Bhattacharya S, Braun-
stein J, Schindler CW. Signaling through
the JAK/STAT pathway, recent advances
and future challenges. Gene 2002;285:1-
24.
Neubauer H, Cumano A, Muller M, Wu
H, Huffstadt U, Pfeffer K. Jak2 deficiency
defines an essential developmental check-
point in definitive hematopoiesis. Cell
1998;93:397-409.
Parganas E, Wang D, Stravopodis D,
et al. Jak2 is essential for signaling through
a variety of cytokine receptors. Cell 1998;
93:385-95.
Huang LJ, Constantinescu SN, Lodish
HF. The N-terminal domain of Janus ki-
nase 2 is required for Golgi processing
and cell surface expression of erythropoi-
etin receptor. Mol Cell 2001;8:1327-38.
Remy I, Wilson IA, Michnick SW. Eryth-
ropoietin receptor activation by a ligand-
induced conformation change. Science
1999;283:990-3.
Lu X, Gross AW, Lodish HF. Active con-
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
formation of the erythropoietin receptor:
random and cysteine-scanning mutagen-
esis of the extracellular juxtamembrane
and transmembrane domains. J Biol Chem
2006;281:7002-11.
Seubert N, Royer Y, Staerk J, et al. Ac-
tive and inactive orientations of the trans-
membrane and cytosolic domains of the
erythropoietin receptor dimer. Mol Cell
2003;12:1239-50.
Witthuhn BA, Quelle FW, Silven-
noinen O, et al. JAK2 associates with the
erythropoietin receptor and is tyrosine
phosphorylated and activated following
stimulation with erythropoietin. Cell 1993;
74:227-36.
Wolanskyj AP, Lasho TL, Schwager SM,
et al. JAK2 mutation in essential throm-
bocythaemia: clinical associations and
long-term prognostic relevance. Br J Hae-
matol 2005;131:208-13.
Scott LM, Scott MA, Campbell PJ,
Green AR. Progenitors homozygous for
the V617F JAK2 mutation occur in most
patients with polycythemia vera but not
essential thrombocythemia. Blood 2006;
108:2435-7.
Jelinek J, Oki Y, Gharibyan V, et al.
JAK2 mutation 1849GT is rare in acute
leukemias but can be found in CMML, Phil-
adelphia chromosome-negative CML, and
megakaryocytic leukemia. Blood 2005;
106:3370-3.
Lee JW, Kim YG, Soung YH, et al. The
JAK2 V617F mutation in de novo acute my-
elogenous leukemias. Oncogene 2006;25:
1434-6.
Frohling S, Lipka DB, Kayser S, et al.
Rare occurrence of the JAK2 V617F muta-
tion in AML subtypes M5, M6, and M7.
Blood 2006;107:1242-3.
Melzner I, Weniger MA, Menz CK,
Moller P. Absence of the JAK2 V617F acti-
vating mutation in classical Hodgkin lym-
phoma and primary mediastinal B-cell
lymphoma. Leukemia 2006;20:157-8.
Patel RK, Lea NC, Heneghan MA, et
al. Prevalence of the activating JAK2 tyro-
sine kinase mutation V617F in the Budd-
Chiari syndrome. Gastroenterology 2006;
130:2031-8.
Saharinen P, Takaluoma K, Silvennoin-
en O. Regulation of the Jak2 tyrosine ki-
nase by its pseudokinase domain. Mol Cell
Biol 2000;20:3387-95.
Socolovsky M, Fallon AE, Wang S,
Brugnara C, Lodish HF. Fetal anemia and
apoptosis of red cell progenitors in
Stat5a/5b/ mice: a direct role for Stat5
in Bcl-X(L) induction. Cell 1999;98:181-91.
Myklebust JH, Blomhoff HK, Rusten
LS, Stokke T, Smeland EB. Activation of
phosphatidylinositol 3-kinase is important
for erythropoietin-induced erythropoiesis
from CD34(+) hematopoietic progenitor
cells. Exp Hematol 2002;30:990-1000.
Staerk J, Lacout C, Sato T, Smith SO,
Vainchenker W, Constantinescu SN. An
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
Mechanisms of Disease
n engl j med 355;23 www.nejm.org december 7, 2006 2465
amphipathic motif at the transmem-
brane-cytoplasmic junction prevents au-
tonomous activation of the thrombopoi-
etin receptor. Blood 2006;107:1864-71.
Wernig G, Mercher T, Okabe R, Levine
RL, Lee BH, Gilliland DG. Expression of
Jak2V617F causes a polycythemia vera-
like disease with associated myelofibrosis
in a murine bone marrow transplant mod-
el. Blood 2006;107:4274-81.
Lacout C, Pisani DF, Tulliez M,
Gachelin FM, Vainchenker W, Villeval JL.
JAK2V617F expression in murine hemato-
poietic cells leads to MPD mimicking hu-
man PV with secondary myelofibrosis.
Blood 2006;108:1652-60.
Zaleskas VM, Krause DS, Lazarides K,
et al. Molecular pathogenesis of polycy-
themia induced in mice by JAK2 V617F.
Blood 2005;106:A116. abstract.
Bumm TGP, Elsea C, Wood LG, et al.
JAK2 V617F mutation induces a myelopro-
liferative disorder in mice. Blood 2005;106:
A116. abstract.
Gale RE. Evaluation of clonality in my-
eloid stem-cell disorders. Semin Hematol
1999;36:361-72.
Abkowitz JL, Taboada M, Shelton GH,
Catlin SN, Guttorp P, Kiklevich JV. An
X chromosome gene regulates hemato-
poietic stem cell kinetics. Proc Natl Acad
Sci U S A 1998;95:3862-6.
Kiladjian JJ, Elkassar N, Cassinat B, et
al. Essential thrombocythemias without
V617F JAK2 mutation are clonal hemato-
poietic stem cell disorders. Leukemia 2006;
20:1181-3.
Lasho TL, Mesa R, Gilliland DG, Tef-
feri A. Mutation studies in CD3+, CD19+
and CD34+ cell fractions in myeloprolif-
erative disorders with homozygous JAK2
(V617F) in granulocytes. Br J Haematol
2005;130:797-9.
Jamieson CH, Ailles LE, Dylla SJ, et al.
Granulocyte-macrophage progenitors as
candidate leukemic stem cells in blast-cri-
sis CML. N Engl J Med 2004;351:657-67.
Mesa RA, Powell H, Lasho T, Dewald
G, McClure R, Tefferi A. JAK2(V617F) and
leukemic transformation in myelofibrosis
with myeloid metaplasia. Leuk Res 2006;
30:1457-60.
Mesa RA, Powell H, Lasho T, DeWald
GW, McClure R, Tefferi A. A longitudinal
study of the JAK2(V617F) mutation in my-
elofibrosis with myeloid metaplasia: analy-
sis at two time points. Haematologica 2006;
91:415-6.
Bellanne-Chantelot C, Chaumarel I,
Labopin M, et al. Genetic and clinical im-
plications of the Val617Phe JAK2 muta-
tion in 72 families with myeloprolifera-
tive disorders. Blood 2006;108:346-52.
Holt D, Dreimanis M, Pfeiffer M, Fir-
gaira F, Morley A, Turner D. Interindivid-
ual variation in mitotic recombination. Am
J Hum Genet 1999;65:1423-7.
Zeuner A, Pedini F, Signore M, et al.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
Increased death receptor resistance and
FLIPshort expression in polycythemia vera
erythroid precursor cells. Blood 2006;107:
3495-502.
Walz C, Crowley BJ, Hudon HE, et al.
Activated JAK2 with the V617F point mu-
tation promotes G1/S-phase transition.
J Biol Chem 2006;281:18177-83.
Staerk J, Kallin A, Demoulin JB, Vain-
chenker W, Constantinescu SN. JAK1 and
Tyk2 activation by the homologous poly-
cythemia vera JAK2 V617F mutation: cross-
talk with IGF1 receptor. J Biol Chem 2005;
280:41893-9.
Royer Y, Staerk J, Costuleanu M, Cour-
toy PJ, Constantinescu SN. Janus kinases
affect thrombopoietin receptor cell sur-
face localization and stability. J Biol Chem
2005;280:27251-61.
Vainchenker W, Constantinescu SN.
A unique activating mutation in JAK2
(V617F) is at the origin of polycythemia
vera and allows a new classification of
myeloproliferative diseases. Hematology
Am Soc Hematol Educ Program 2005;195-
200.
Lu X, Levine R, Tong W, et al. Expres-
sion of a homodimeric type I cytokine
receptor is required for JAK2V617F-medi-
ated transformation. Proc Natl Acad Sci
U S A 2005;102:18962-7.
Spivak JL. Polycythemia vera: myths,
mechanisms, and management. Blood
2002;100:4272-90.
Cervantes F, Alvarez-Larran A, Talarn
C, Gomez M, Montserrat E. Myelofibro-
sis with myeloid metaplasia following
essential thrombocythaemia: actuarial
probability, presenting characteristics and
evolution in a series of 195 patients. Br
J Haematol 2002;118:786-90.
Thiele J, Kvasnicka HM, Zankovich R,
Diehl V. Relevance of bone marrow fea-
tures in the differential diagnosis between
essential thrombocythemia and early stage
idiopathic myelofibrosis. Haematologica
2000;85:1126-34.
Tefferi A. Myelofibrosis with myeloid
metaplasia. N Engl J Med 2000;342:1255-
65.
Idem. Pathogenesis of myelofibrosis
with myeloid metaplasia. J Clin Oncol
2005;23:8520-30.
Villeval JL, Cohen-Solal K, Tulliez M,
et al. High thrombopoietin production by
hematopoietic cells induces a fatal myelo-
proliferative syndrome in mice. Blood 1997;
90:4369-83.
Komura E, Tonetti C, Penard-Lacro-
nique V, et al. Role for the nuclear factor
kappaB pathway in transforming growth
factor-beta1 production in idiopathic my-
elofibrosis: possible relationship with
FK506 binding protein 51 overexpression.
Cancer Res 2005;65:3281-9.
Vannucchi AM, Bianchi L, Paoletti F,
et al. A pathobiologic pathway linking
thrombopoietin, GATA-1, and TGF-beta1
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
in the development of myelofibrosis. Blood
2005;105:3493-501.
James C, Ugo V, Casadevall N, Con-
stantinescu SN, Vainchenker WA. JAK2
mutation in myeloproliferative disorders:
pathogenesis and therapeutic and scien-
tific prospects. Trends Mol Med 2005;11:
46-54.
Barbui T. The leukemia controversy
in myeloproliferative disorders: is it a natu-
ral progression of disease, a secondary
sequela of therapy, or a combination of
both? Semin Hematol 2004;41:Suppl 3:
15-7.
Harrison CN, Campbell PJ, Buck G,
et al. Hydroxyurea compared with ana-
grelide in high-risk essential thrombocy-
themia. N Engl J Med 2005;353:33-45.
Cheung B, Radia D, Pantelidis P, Ya-
degarfar G, Harrison C. The presence of
the JAK2 V617F mutation is associated with
a higher haemoglobin and increased risk
of thrombosis in essential thrombocy-
thaemia. Br J Haematol 2006;132:244-5.
Marchioli R, Finazzi G, Landolfi R,
et al. Vascular and neoplastic risk in
a large cohort of patients with polycythe-
mia vera. J Clin Oncol 2005;23:2224-32.
Berk PD, Goldberg JD, Donovan PB,
Fruchtman SM, Berlin NI, Wasserman LR.
Therapeutic recommendations in polycy-
themia vera based on Polycythemia Vera
Study Group protocols. Semin Hematol
1986;23:132-43.
Campbell PJ, Green AR. Manage-
ment of polycythemia vera and essential
thrombocythemia. Hematology Am Soc
Hematol Educ Program 2005;201-8.
Tefferi A, Murphy S. Current opinion
in essential thrombocythemia: pathogen-
esis, diagnosis, and management. Blood
Rev 2001;15:121-31.
Campbell PJ, Scott LM, Baxter EJ,
Bench AJ, Green AR, Erber WN. Methods
for the detection of the JAK2 V617F muta-
tion in human myeloproliferative disor-
ders. Methods Mol Med 2006;125:253-
64.
Percy MJ, Jones FG, Green AR, Reilly
JT, McMullin MF. The incidence of the
JAK2 V617F mutation in patients with id-
iopathic erythrocytosis. Haematologica
2006;91:413-4.
James C, Delhommeau F, Marzac C,
et al. Detection of JAK2 V617F as a first
intention diagnostic test for erythrocyto-
sis. Leukemia 2006;20:350-3.
Barosi G, Ambrosetti A, Finelli C, et
al. The Italian Consensus Conference on
diagnostic criteria for myelofibrosis with
myeloid metaplasia. Br J Haematol 1999;
104:730-7.
McMullin MF, Bareford D, Campbell
P, et al. Guidelines for the diagnosis, inves-
tigation and management of polycythae-
mia/erythrocytosis. Br J Haematol 2005;
130:174-95.
Cortelazzo S, Finazzi G, Ruggeri M,
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.
n engl j med 355;23 www.nejm.org december 7, 2006 2466
Mechanisms of Disease
et al. Hydroxyurea for patients with es-
sential thrombocythemia and a high risk
of thrombosis. N Engl J Med 1995;332:
1132-6.
Falanga A, Marchetti M, Vignoli A,
Balducci D, Barbui T. Leukocyte-platelet
interaction in patients with essential
thrombocythemia and polycythemia vera.
Exp Hematol 2005;33:523-30.
116.
Arellano-Rodrigo E, Alvarez-Larran
A, Reverter JC, Villamor N, Colomer D,
Cervantes F. Increased platelet and leuko-
cyte activation as contributing mechanisms
for thrombosis in essential thrombocythe-
mia and correlation with the JAK2 muta-
tional status. Haematologica 2006;91:169-
75.
Jones AV, Silver RT, Waghorn K, et al.
117.
118.
Minimal molecular response in polycythe-
mia vera patients treated with imatinib or
interferon alpha. Blood 2006;107:3339-41.
Kiladjian JJ, Cassinat B, Turlure P, et
al. High molecular response rate of poly-
cythemia vera patients treated with pe-
gylated interferon alpha-2a. Blood 2006;
108:2037-40.
Copyright 2006 Massachusetts Medical Society.
119.
The New England Journal of Medicine
Downloaded from nejm.org by LINO F ROJAS L on February 14, 2014. For personal use only. No other uses without permission.
Copyright 2006 Massachusetts Medical Society. All rights reserved.