From the Guidelines
A 37-year-old patient with a history of anal cancer, status post resection and flap placement, with thrombocytosis (platelet count of 1141), should be treated with cytoreductive therapy to reduce the risk of thrombotic complications. The patient's age and lack of prior history of thrombosis suggest a low-risk category, but the significantly elevated platelet count indicates the need for intervention 1. According to the NCCN guidelines, symptomatic thrombocytosis is an indication for cytoreductive therapy 1. Given the patient's cancer history and the potential for increased thrombotic risk, it is essential to initiate treatment promptly. The recommended approach would be to start cytoreductive therapy, with the goal of reducing the platelet count to below 400,000/μL to minimize thrombotic risk. Low-dose aspirin (81-100 mg daily) should also be considered unless contraindicated by recent surgery or bleeding risk 1. Regular monitoring of complete blood counts is essential, initially weekly until stable, then monthly. Key considerations in management include:
- Monitoring for new thrombosis, acquired von Willebrand disease, and/or disease-related major bleeding 1
- Managing cardiovascular risk factors 1
- Symptomatic management of thrombocytosis and other disease-related symptoms 1.
From the Research
Patient Assessment
- The patient is a 37-year-old with a history of anal cancer, status post resection and flap placement, presenting with thrombocytosis (platelet count of 1141).
- The elevated platelet count requires careful diagnostic work-up to differentiate between reactive thrombocytosis (RT) and essential thrombocythemia (ET) 2.
Treatment Considerations
- Reactive thrombocytosis (even at platelet counts >1000 x 10^9/l) has never been shown to cause thrombosis or bleeding due to acquired von Willebrand factor defects in association with high platelet counts 2.
- Essential thrombocythemia (ET) and related myeloproliferative neoplasms (MPN) can be associated with thrombosis and/or hemorrhage 2, 3.
- Current recommendations suggest the use of low-dose aspirin in all patients with ET unless contraindicated, but the strength of this recommendation is weak 2.
- Hydroxyurea is effective in preventing thrombosis in high-risk patients with essential thrombocythemia 3.
- Anagrelide is an alternative treatment option for patients with ET who are refractory to hydroxyurea 4.
Risk Stratification
- The patient's age and lack of prior thrombosis suggest a lower risk category 5.
- However, the patient's history of anal cancer and recent surgery may increase the risk of thrombosis 5.
- Low-dose aspirin may be considered for patients with ET and a low risk of thrombosis, but its use should be individualized based on the patient's risk factors 2, 5, 6.