1
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McLornan DP, Psaila B, Ewing J, Innes A, Arami S, Brady J, Butt NM, Cargo C, Cross NCP, Francis S, Frewin R, Garg M, Godfrey AL, Green A, Khan A, Knapper S, Lambert J, McGregor A, McMullin MF, Nangalia J, Neelakantan P, Woodley C, Mead A, Somervaille TCP, Harrison CN. The management of myelofibrosis: A British Society for Haematology Guideline. Br J Haematol 2024; 204:136-150. [PMID: 38037886 DOI: 10.1111/bjh.19186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Donal P McLornan
- Department of Haematology, University College London Hospitals, London, UK
| | - Bethan Psaila
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Joanne Ewing
- Department of Haematology, University Hospitals Birmingham Trust, London, UK
| | - Andrew Innes
- Department of Haematology, Imperial College, London, UK
| | - Siamak Arami
- Department of Haematology, London Northwest Healthcare University NHS Trust, London, UK
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Nauman M Butt
- Department of Haematology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine Cargo
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | | | - Sebastian Francis
- Department of Haematology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Rebecca Frewin
- Department of Haematology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Mamta Garg
- Department of Haematology, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Anna L Godfrey
- Haematopathology & Oncology Diagnostics Service, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Green
- Department of Histopathology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Alesia Khan
- Department of Haematology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Steve Knapper
- Department of Haematology, Cardiff University, Cardiff, UK
| | - Jonathan Lambert
- Department of Haematology, University College London Hospitals, London, UK
| | | | | | - Jyoti Nangalia
- Wellcome Sanger Institute, University of Cambridge, Cambridge, UK
| | - Pratap Neelakantan
- Department of Haematology, Royal Berkshire NHS Foundation Trust, London, UK
| | - Claire Woodley
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Adam Mead
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Haematology, Churchill Hospital, Oxford University NHS Trust, Oxford, UK
| | - Tim C P Somervaille
- Cancer Research UK Manchester Institute & The Christie NHS Foundation Trust, Manchester, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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2
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Mahdi D, Spiers J, Rampotas A, Polverelli N, McLornan DP. Updates on accelerated and blast phase myeloproliferative neoplasms: Are we making progress? Br J Haematol 2023; 203:169-181. [PMID: 37527977 DOI: 10.1111/bjh.19010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
Management approaches for accelerated and blast phase myeloproliferative neoplasms remain challenging for clinicians and patients alike. Despite many therapeutic advances, outcomes for those patients who are not allogeneic haematopoietic cell transplant eligible remain, in general, very poor. Estimated survival rates for such blast phase patients is frequently reported as less than 6 months. No specific immunological, genomic or clinicopathological signature currently exists that accurately predicts the risk and timing of transformation, which frequently induces a high degree of anxiety among patients and clinicians alike. Within this review article, we provide an up-to-date summary of current understanding of the underlying pathogenesis of accelerated and blast phase disease and discuss current therapeutic approaches and realistic outcomes. Finally, we discuss how the horizon may look with the introduction of more novel agents into the clinical arena.
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Affiliation(s)
- Dina Mahdi
- Department of Haematology, University College Hospital, London, UK
| | - Jessica Spiers
- Department of Haematology, University College Hospital, London, UK
| | | | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, Brescia, Italy
| | - Donal P McLornan
- Department of Haematology, University College Hospital, London, UK
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3
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Saha C, Attwell L, Harrison CN, McLornan DP. Addressing the challenges of accelerated and blast phase myeloproliferative neoplasms in 2022 and beyond. Blood Rev 2022; 55:100947. [DOI: 10.1016/j.blre.2022.100947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 02/08/2023]
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4
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Guidance on changing therapy choice in myelofibrosis. Blood Adv 2021; 4:607-610. [PMID: 32074274 DOI: 10.1182/bloodadvances.2019001426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022] Open
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5
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Kuykendall AT, Horvat NP, Pandey G, Komrokji R, Reuther GW. Finding a Jill for JAK: Assessing Past, Present, and Future JAK Inhibitor Combination Approaches in Myelofibrosis. Cancers (Basel) 2020; 12:E2278. [PMID: 32823910 PMCID: PMC7464183 DOI: 10.3390/cancers12082278] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022] Open
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm hallmarked by the upregulation of the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway with associated extramedullary hematopoiesis and a high burden of disease-related symptoms. While JAK inhibitor therapy is central to the management of MF, it is not without limitations. In an effort to improve treatment for MF patients, there have been significant efforts to identify combination strategies that build upon the substantial benefits of JAK inhibition. Early efforts to combine agents with additive therapeutic profiles have given way to rationally designed combinations hoping to demonstrate clinical synergism and modify the underlying disease. In this article, we review the preclinical basis and existing clinical data for JAK inhibitor combination strategies while highlighting emerging strategies of particular interest.
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Affiliation(s)
- Andrew T. Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Nathan P. Horvat
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612 USA;
| | - Garima Pandey
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (G.P.); (G.W.R.)
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Gary W. Reuther
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (G.P.); (G.W.R.)
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6
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Scherber RM, Mesa RA. Management of challenging myelofibrosis after JAK inhibitor failure and/or progression. Blood Rev 2020; 42:100716. [PMID: 32593470 PMCID: PMC8895349 DOI: 10.1016/j.blre.2020.100716] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/21/2019] [Accepted: 05/13/2020] [Indexed: 11/20/2022]
Abstract
The myeloproliferative neoplasms (MPNs) encompass a heterogenous set of diseases that have variable survival, but in the setting of treatment refractory and progressive disease, prognosis has been characteristically poor. JAK inhibition with ruxolitinib or fedratinib therapy has become the first line treatment for symptomatic or intermediate to high risk myelofibrosis. However, after three years of ruxolitinib therapy, approximately half of all patients with myelofibrosis will likely have stopped treatment. JAK inhibition failure represents a mixture of etiologies, including drug intolerance, suboptimal dosing, drug resistance, or progression of disease. JAK inhibition failure and accelerated/blast phase have now become the primary clinical challenges in the treatment of myelofibrosis and high risk polycythemia vera, and no phase III trials or clear treatment guidelines exist to guide management strategies in this setting. On the other hand, this represents an exciting time in treatment of JAK inhibitor failure and accelerated phase MPNs due to the advent of recently approved drugs as well as new targeted agents currently under investigation. In this article, we review the management options for these challenging clinical scenarios. We discuss the options for JAK inhibitor dose optimization and overcoming resistance by utilizing combinations of JAK inhibition, primarily ruxolitinib, with alternative commercially available therapies. For patients who have progressed, we discuss recent data regarding targeted therapy options approved for AML that represent potentially efficacious options in the progressive MPN setting. We also discuss the new clinical agents under development in MF and accelerated MPNs that may offer new therapeutic options in the years to come.
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Affiliation(s)
- Robyn M Scherber
- Department of Hematology and Oncology, University of Texas Health Science Center San Antonio, San Antonio, TX 78249, USA.
| | - Ruben A Mesa
- UT Health San Antonio MD Anderson Cancer Center, University of Texas Health Science Center San Antonio, San Antonio, TX 78249, USA.
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7
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Cruz NM, Gergis U, Silver RT. Myelofibrosis: best practices, controversies and 2019 update. Expert Rev Hematol 2019; 13:71-84. [PMID: 31709843 DOI: 10.1080/17474086.2020.1691519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Recent advances in the prognostic scheme and treatment of primary and secondary myelofibrosis (MF) have resulted in an overwhelming amount of clinical information to assimilate. The authors believe a comprehensive review that summarizes the most recent published literature, could serve as guidelines for the practicing hematologist.Areas covered: The authors provide a summary of landmark articles regarding epidemiology, symptoms, and pathogenesis of disease. The authors conducted a systematic literature review to answer questions regarding differences between primary myelofibrosis (PMF) and secondary myelofibrosis (SMF), appropriate use and selection of the current risk-stratification models, early versus late treatment of MF and current practices in allogeneic hematopoietic stem cell transplantation (allo-HCT) for MF. The authors conclude the article with their clinical opinion based on their experience and literature review. The purpose of this article is to identify current practices, address any variation, identify and investigate conflicting results and produce statements to guide decision-making.Expert opinion: In this section, the authors advocate for and provide examples of a standardized way of incorporating future discoveries in the pathogenesis and risk-stratification models of MF. They also discuss the importance of using only one risk-stratification model for PMF and one for SMF and their reasoning for early instead of late treatment of MF.
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Affiliation(s)
- Nicole M Cruz
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Usama Gergis
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Richard T Silver
- Division of Hematology & Medical Oncology, Weill Cornell Medicine, New York, NY, USA.,Richard T. Silver, M.D. Myeloproliferative Neoplasms (MPN) Center, Weill Cornell Medical College, New York, NY, USA
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Safety and efficacy of combined ruxolitinib and decitabine in accelerated and blast-phase myeloproliferative neoplasms. Blood Adv 2019; 2:3572-3580. [PMID: 30563881 DOI: 10.1182/bloodadvances.2018019661] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022] Open
Abstract
Myeloproliferative neoplasms (MPN), including polycythemia vera, essential thrombocythemia, and primary myelofibrosis, have a propensity to evolve into accelerated and blast-phase disease (MPN-AP/BP), carrying a dismal prognosis. Conventional antileukemia therapy has limited efficacy in this setting. Thus, MPN-AP/BP is an urgent unmet clinical need. Modest responses to hypomethylating agents and single-agent ruxolitinib have been reported. More recently, combination of ruxolitinib and decitabine has demonstrated synergistic in vitro activity in human and murine systems. These observations led us to conduct a phase 1 study to explore the safety of combined decitabine and dose-escalated ruxolitinib in patients with MPN-AP/BP. A total of 21 patients were accrued to this multicenter study. Ruxolitinib was administered at doses of 10, 15, 25, or 50 mg twice daily in combination with decitabine (20 mg/m2 per day for 5 days) in 28-day cycles. The maximum tolerated dose was not reached. The most common reasons for study discontinuation were toxicity/adverse events (37%) and disease progression (21%). Fourteen patients died during study treatment period or follow-up. The median overall survival for patients on study was 7.9 months (95% confidence interval, 4.1-not reached). Among evaluable patients, the overall response rate by protocol-defined criteria (complete remission with incomplete count recovery + partial remission) was 9/17 (53%) and by intention-to-treat analysis was 9/21 (42.9%). The combination of decitabine and ruxolitinib was generally well tolerated by patients with MPN-AP/BP and demonstrates potentially promising clinical activity. A phase 2 trial evaluating the efficacy of this combination regimen is ongoing within the Myeloproliferative Disorder Research Consortium.
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Diamantopoulos P, Giannakopoulou N, Hatzidavid S, Viniou NA. Post-Myelofibrosis Acute Myeloid Leukemia Effectively Treated with a Combination of Ruxolitinib and 5-Azacytidine. Oncol Res Treat 2019; 42:532-535. [DOI: 10.1159/000502121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/13/2019] [Indexed: 11/19/2022]
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10
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Leukemic Transformation of Myeloproliferative Neoplasms: Therapeutic and Genomic Considerations. Curr Hematol Malig Rep 2019; 13:588-595. [PMID: 30353413 DOI: 10.1007/s11899-018-0491-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Although BCR-ABL1-negative myeloproliferative neoplasms (MPN) are chronic, clonal hematopoietic stem cell (HSC) disorders marked by proliferation of one or more myeloid lineages, a substantial proportion of patients transform to acute myeloid leukemia. Leukemic transformation (LT) from a pre-existing MPN carries a dismal prognosis. Here, we review recent genetic, biological, and clinical data regarding LT. RECENT FINDINGS In the last decade, DNA sequencing has revolutionized our understanding of the genomic landscape of LT. Mutations in TP53, ASXL1, EZH2, IDH1/2, and SRSF2 are significantly associated with increased risk of LT of MPNs. Preclinical modeling of these mutations is underway and has yielded important biological insights, some of which have therapeutic implications. Recent progress has led to the identification of recurrent genomic alterations in patients with LT. This has allowed mechanistic and therapeutic insight into the process of LT. In turn, this may lead to more mechanism-based therapeutic strategies that may improve patient outcomes.
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Greenfield G, McPherson S, Mills K, McMullin MF. The ruxolitinib effect: understanding how molecular pathogenesis and epigenetic dysregulation impact therapeutic efficacy in myeloproliferative neoplasms. J Transl Med 2018; 16:360. [PMID: 30558676 PMCID: PMC6296062 DOI: 10.1186/s12967-018-1729-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022] Open
Abstract
The myeloproliferative neoplasms (MPN), polycythaemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) are linked by a propensity to thrombosis formation and a risk of leukaemic transformation. Activation of cytokine independent signalling through the JAK/STAT cascade is a feature of these disorders. A point mutation in exon 14 of the JAK2 gene resulting in the formation of the JAK2 V617F transcript occurs in 95% of PV patients and around 50% of ET and PMF patients driving constitutive activation of the JAK/STAT pathway. Mutations in CALR or MPL are present as driving mutations in the majority of remaining ET and PMF patients. Ruxolitinib is a tyrosine kinase inhibitor which inhibits JAK1 and JAK2. It is approved for use in intermediate and high risk PMF, and in PV patients who are resistant or intolerant to hydroxycarbamide. In randomised controlled trials it has demonstrated efficacy in spleen volume reduction and symptom burden reduction with a moderate improvement in overall survival in PMF. In PV, there is demonstrated benefit in haematocrit control and spleen volume. Despite these benefits, there is limited impact to induce complete haematological remission with normalisation of blood counts, reduce the mutant allele burden or reverse bone marrow fibrosis. Clonal evolution has been observed on ruxolitinib therapy and transformation to acute leukaemia can still occur. This review will concentrate on understanding the clinical and molecular effects of ruxolitinib in MPN. We will focus on understanding the limitations of JAK inhibition and the challenges to improving therapeutic efficacy in these disorders. We will explore the demonstrated benefits and disadvantages of ruxolitinib in the clinic, the role of genomic and clonal variability in pathogenesis and response to JAK inhibition, epigenetic changes which impact on response to therapy, the role of DNA damage and the role of inflammation in these disorders. Finally, we will summarise the future prospects for improving therapy in MPN in the JAK inhibition era.
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Affiliation(s)
- Graeme Greenfield
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | - Suzanne McPherson
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | - Ken Mills
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
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Scherber RM, Mesa RA. Managing myelofibrosis (MF) that "blasts" through: advancements in the treatment of relapsed/refractory and blast-phase MF. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:118-126. [PMID: 30504300 PMCID: PMC6245993 DOI: 10.1182/asheducation-2018.1.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Myelofibrosis (MF) is the most aggressive form of Philadelphia chromosome-negative myeloproliferative neoplasm, and it is complicated by severe symptom burden, thrombotic events, infections, cytopenias, and transformation to acute myeloid leukemia (AML). Ruxolitinib, the first-line therapy for symptomatic or intermediate- and high-prognostic risk MF, has improved overall survival for this population. However, approximately one-half of MF patients will discontinue ruxolitinib by the first few years of therapy due to a spectrum of resistance, intolerance, relapse, or progression to blast phase disease. Danazol, erythropoietin-stimulating agents, and spleen-directed therapies can be useful in the ruxolitinib-resistant setting. In the ruxolitinib-refractory or -intolerant setting, commercial and novel therapies, either alone or in combination with ruxolitinib, have shown clinical utility. For blast-phase MF, the recent advancements in available AML therapies have increased the options with targeted and more tolerable therapies. In this article, we will discuss our paradigm for the management of relapsed/refractory and blast-phase MF in the context of therapeutic advancements in both AML and MF.
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Affiliation(s)
- Robyn M. Scherber
- Department of Hematology and Oncology, Mays Cancer Center, University of Texas MD Anderson, University of Texas, San Antonio, TX; and
| | - Ruben A. Mesa
- Mays Cancer Center, University of Texas MD Anderson, University of Texas, San Antonio, TX
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13
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How I treat myelofibrosis after failure of JAK inhibitors. Blood 2018; 132:492-500. [PMID: 29866811 DOI: 10.1182/blood-2018-02-785923] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022] Open
Abstract
The introduction of JAK inhibitors, leading to regulatory approval of ruxolitinib, represents a major therapeutic advance in myelofibrosis (MF). Most patients experience reduction in splenomegaly and improved quality of life from symptom improvement. It is a paradox, however, that, despite inhibition of signaling downstream of disease-related driver mutations, JAK inhibitor treatment is not associated with consistent molecular or pathologic responses in MF. Furthermore, there are important limitations to JAK inhibitor therapy including development of dose-limiting cytopenias and/or nonhematological toxicities such as neuropathy or opportunistic infections. Over half of the patients discontinue treatment within 3 years of starting treatment. Although data are sparse, clinical outcome after JAK inhibitor "failure" is likely poor; consequently, it is important to understand patterns of failure to select appropriate salvage treatment(s). An algorithmic approach, particularly one that incorporates cytogenetics/molecular data, is most helpful in selecting stem cell transplant candidates. Treatment of transplant-ineligible patients relies on a problem-based approach that includes use of investigational drugs, or consideration of splenectomy or radiotherapy. Data from early phase ruxolitinib combination studies, despite promising preclinical data, have not shown clear benefit over monotherapy thus far. Development of effective treatment strategies for MF patients failing JAK inhibitors remains a major unmet need.
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Kuykendall A, Duployez N, Boissel N, Lancet JE, Welch JS. Acute Myeloid Leukemia: The Good, the Bad, and the Ugly. Am Soc Clin Oncol Educ Book 2018; 38:555-573. [PMID: 30231330 DOI: 10.1200/edbk_199519] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Acute myeloid leukemia (AML) was initially subdivided according to morphology (the French-American-British system), which proved helpful in pathologic categorization. Subsequently, clinical and genomic factors were found to correlate with response to chemotherapy and with overall survival. These included a history of antecedent hematologic disease, a history of chemotherapy or radiation therapy, the presence of various recurrent cytogenetic abnormalities, and, more recently, the presence of specific point mutations. This article reviews the biology and responses of one AML subgroup with consistent response and good outcomes following chemotherapy (core-binding factor leukemia), and two subgroups with persistently bad, and even ugly, outcomes (secondary AML and TP53-mutated AML).
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MESH Headings
- Alleles
- Biomarkers, Tumor
- Chromosome Aberrations
- Combined Modality Therapy
- Core Binding Factors/genetics
- Core Binding Factors/metabolism
- Gene Frequency
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Mutation
- Neoplasm, Residual/diagnosis
- Neoplasms, Second Primary/diagnosis
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/etiology
- Neoplasms, Second Primary/therapy
- Signal Transduction
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Andrew Kuykendall
- From the Moffitt Cancer Center, Tampa, FL; CHU Lille, INSERM, Laboratory of Hematology, University of Lille, Lille, France; Hematology Department, Saint-Louis Hospital, Paris Diderot University, Paris, France; Washington University School of Medicine, St. Louis, MO
| | - Nicolas Duployez
- From the Moffitt Cancer Center, Tampa, FL; CHU Lille, INSERM, Laboratory of Hematology, University of Lille, Lille, France; Hematology Department, Saint-Louis Hospital, Paris Diderot University, Paris, France; Washington University School of Medicine, St. Louis, MO
| | - Nicolas Boissel
- From the Moffitt Cancer Center, Tampa, FL; CHU Lille, INSERM, Laboratory of Hematology, University of Lille, Lille, France; Hematology Department, Saint-Louis Hospital, Paris Diderot University, Paris, France; Washington University School of Medicine, St. Louis, MO
| | - Jeffrey E Lancet
- From the Moffitt Cancer Center, Tampa, FL; CHU Lille, INSERM, Laboratory of Hematology, University of Lille, Lille, France; Hematology Department, Saint-Louis Hospital, Paris Diderot University, Paris, France; Washington University School of Medicine, St. Louis, MO
| | - John S Welch
- From the Moffitt Cancer Center, Tampa, FL; CHU Lille, INSERM, Laboratory of Hematology, University of Lille, Lille, France; Hematology Department, Saint-Louis Hospital, Paris Diderot University, Paris, France; Washington University School of Medicine, St. Louis, MO
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15
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Mollard LM, Chauveau A, Boyer-Perrard F, Douet-Guilbert N, Houot R, Quintin-Roué I, Couturier MA, Dagorne A, Malou M, Le Calloch R, Luycx O, Thepot S, Hunault M, Guillerm G, Berthou C, Ugo V, Lippert É, Ianotto JC. Outcome of Ph negative myeloproliferative neoplasms transforming to accelerated or leukemic phase. Leuk Lymphoma 2018; 59:2812-2820. [PMID: 29616837 DOI: 10.1080/10428194.2018.1441408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Myeloproliferative neoplasms (MPN) are chronic disorders that can sometimes evolve into accelerated or leukemic phases. We retrospectively identified 122 patients with such blastic phases. The overall median survival was four months: 10.2 months for patients treated with intensive treatments compared to three months for best supportive care (p = .005). Azacytidine, intensive chemotherapies, or allogeneic stem cell transplantation gave the highest median survivals with 9, 10.2, and 19.4 months, respectively. Accelerated phases (AP) had a longer median survival compared to acute leukemia (4.8 months vs. 3.1 months; p = .02). In this retrospective and observational study, we observe that the longest survivals are seen in patients eligible for intensive treatments. Azacytidine shows interesting results in patients non-fit for intensive chemotherapy. Supportive care should probably be restricted to elderly patients and those with unfavorable karyotype. An early diagnosis of AP could also result in a better survival rate.
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Affiliation(s)
- Lise-Marie Mollard
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | | | | | | | - Roch Houot
- e Laboratoire d'Anatomo-Pathologie, CHRU Brest , Brest , France
| | | | | | - Anaig Dagorne
- h Service d'Hématologie Clinique, CH de Morlaix , Brest , France
| | - Mohamed Malou
- i Service de Médecine Interne, CH de Quimper , Brest , France
| | | | - Odile Luycx
- k Laboratoire d'Hématologie, CHU d'Angers , Brest , France
| | - Sylvain Thepot
- c Service des Maladies du Sang, CHU d'Angers , Brest , France
| | | | - Gaelle Guillerm
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | - Christian Berthou
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | - Valérie Ugo
- i Service de Médecine Interne, CH de Quimper , Brest , France
| | - Éric Lippert
- b Laboratoire d'Hématologie, CHRU de Brest , Brest , France
| | - Jean-Christophe Ianotto
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
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16
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Mascarenhas J. A Concise Update on Risk Factors, Therapy, and Outcome of Leukemic Transformation of Myeloproliferative Neoplasms. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 16 Suppl:S124-9. [PMID: 27521308 DOI: 10.1016/j.clml.2016.02.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 12/28/2022]
Abstract
Myeloproliferative neoplasms (MPN) in chronic phase that evolve into blast phase (BP) hold a dismal prognosis and represent an urgent unmet clinical need. The mutational landscape of MPN-BP is distinct from de novo acute myeloid leukemia and offers insight into molecular mechanisms contributing to clonal evolution providing potential novel drug targets. A number of retrospective studies have identified patient- and disease-specific variables associated with increased risk of leukemic transformation (LT) of an underlying MPN. Several prognostic models have been developed to identify those MPN patients at highest risk for LT that may warrant early aggressive therapeutic intervention. Acute myeloid leukemia-type induction chemotherapy does not offer a significant survival benefit for MPN-BP unless followed by hematopoietic stem-cell transplantation. Unfortunately, most patients with MPN-BP are not candidates for hematopoietic stem-cell transplantation as a result of advanced age, competing comorbid conditions, or lack of an acceptable donor graft option. JAK2 inhibitor monotherapy is effective in reducing splenomegaly and symptom burden in the majority of treated patients with myelofibrosis, but LT can still occur. High-dose JAK2 inhibitor monotherapy appears tolerable but only modestly active in the treatment of MPN-BP. Current JAK2 inhibitor-based combination therapy approaches are supported by preclinical investigation and are currently being tested in multicenter clinical trials.
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Affiliation(s)
- John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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17
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Emerging treatments for classical myeloproliferative neoplasms. Blood 2016; 129:693-703. [PMID: 28028027 DOI: 10.1182/blood-2016-10-695965] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/03/2016] [Indexed: 12/17/2022] Open
Abstract
There has been a major revolution in the management of patients with myeloproliferative neoplasms (MPN), and in particular those with myelofibrosis and extensive splenomegaly and symptomatic burden, after the introduction of the JAK1 and JAK2 inhibitor ruxolitinib. The drug also has been approved as second-line therapy for polycythemia vera (PV). However, the therapeutic armamentarium for MPN is still largely inadequate for coping with patients' major unmet needs, which include normalization of life span (myelofibrosis and some patients with PV), reduction of cardiovascular complications (mainly PV and essential thrombocythemia), prevention of hematological progression, and improved quality of life (all MPN). In fact, none of the available drugs has shown clear evidence of disease-modifying activity, even if some patients treated with interferon and ruxolitinib showed reduction of mutated allele burden, and ruxolitinib might extend survival of patients with higher-risk myelofibrosis. Raised awareness of the molecular abnormalities and cellular pathways involved in the pathogenesis of MPN is facilitating the development of clinical trials with novel target drugs, either alone or in combination with ruxolitinib. Although for most of these molecules a convincing preclinical rationale was provided, the results of early phase 1 and 2 clinical trials have been quite disappointing to date, and toxicities sometimes have been limiting. In this review, we critically illustrate the current landscape of novel therapies that are under evaluation for patients with MPN on the basis of current guidelines, patient risk stratification criteria, and previous experience, looking ahead to the chance of a cure for these disorders.
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18
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Naqvi K, Daver N, Pemmaraju N, Bose P, Garcia-Manero G, Cortes J, Kantarjian HM, Verstovsek S. Clinical use of ruxolitinib in an academic medical center in unselected patients with myeloproliferative neoplasms not on clinical study. Leuk Lymphoma 2016; 58:866-871. [PMID: 27494751 DOI: 10.1080/10428194.2016.1217528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ruxolitinib is the only approved therapy for myelofibrosis (MF). However, its use in patients with myeloproliferative neoplasms (MPN) not participating in clinical studies has been poorly described. We reviewed the medical records of 45 patients (35 MF, 10 others) treated with ruxolitinib at our center, off clinical study, during the year after its approval. Patients had advanced features and were refractory to multiple therapies. Ruxolitinib was effective in reducing splenomegaly (51% response rate) and constitutional symptoms (42% response rate). It controlled blood counts in patients with polycythemia and thrombocythemia but was not effective in patients with non-classic MPNs. Ruxolitinib was an active therapy in patients previously treated with a JAK inhibitor and was safely combined with hypomethylating agents in patients with elevated blasts. Median overall survival was 24 months; 10 patients transformed to acute leukemia. Its use in combination with other active agents should be further explored in clinical studies.
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Affiliation(s)
- Kiran Naqvi
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Naval Daver
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Naveen Pemmaraju
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Prithviraj Bose
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Guillermo Garcia-Manero
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jorge Cortes
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Hagop M Kantarjian
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Srdan Verstovsek
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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19
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Fominykh M, Shuvaev V, Martynkevich I, Polushkina L, Udaleva V, Abdulkadyrov K. The combination treatment regimen of ruxolitinib with low-dose mercaptopurine or cytarabine in frail patients with blast-phase myelofibrosis. Br J Haematol 2016; 178:645-646. [PMID: 27291991 DOI: 10.1111/bjh.14162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mikhail Fominykh
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
| | - Vasily Shuvaev
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
| | - Irina Martynkevich
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
| | - Lyubov Polushkina
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
| | - Vera Udaleva
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
| | - Kudrat Abdulkadyrov
- Russian Research Institute of Hematology and Transfusiology, Saint Petersburg, Russia
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20
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Alimam S, Harrison C. Is there a role for pomalidomide in the treatment of myelofibrosis? Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1171139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Alimam S, Wilkins BS, Harrison CN. How we diagnose and treat essential thrombocythaemia. Br J Haematol 2015; 171:306-21. [DOI: 10.1111/bjh.13605] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Samah Alimam
- Department of Haematology; Guy's & St Thomas’ Hospitals NHS Foundation Trust; Guy's Hospital; London UK
| | - Bridget S. Wilkins
- Department of Cellular Pathology; Guy's & St Thomas’ Hospitals NHS Foundation Trust; St Thomas’ Hospital; London UK
| | - Claire N. Harrison
- Department of Haematology; Guy's & St Thomas’ Hospitals NHS Foundation Trust; Guy's Hospital; London UK
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22
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Devillier R, Raffoux E, Rey J, Lengline E, Ronchetti AM, Sebert M, Boissel N, Robin M, Vey N, Kiladjian JJ, Dombret H, Cluzeau T. Combination therapy with ruxolitinib plus intensive treatment strategy is feasible in patients with blast-phase myeloproliferative neoplasms. Br J Haematol 2015; 172:628-30. [PMID: 26061174 DOI: 10.1111/bjh.13516] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Raynier Devillier
- Haematology Department, Institut Paoli Calmettes, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Emmanuel Raffoux
- Adult Haematology Department, Saint Louis Hospital, Paris, France
| | - Jérôme Rey
- Haematology Department, Institut Paoli Calmettes, Marseille, France
| | - Etienne Lengline
- Adult Haematology Department, Saint Louis Hospital, Paris, France
| | | | - Marie Sebert
- Senior Haematology Department, Saint Louis Hospital, Paris, France
| | - Nicolas Boissel
- Adolescents and Young Adults Haematology Department, Saint Louis Hospital, Paris, France.,EA3518, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
| | - Marie Robin
- Allo Stem Cell Transplantation Department, Saint Louis Hospital, Paris, France
| | - Norbert Vey
- Haematology Department, Institut Paoli Calmettes, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Jean-Jacques Kiladjian
- Adult Haematology Department, Saint Louis Hospital, Paris, France.,EA3518, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France.,Centre d'Investigation Clinique (CIC), Saint Louis Hospital, Paris, France
| | - Herve Dombret
- Adult Haematology Department, Saint Louis Hospital, Paris, France.,EA3518, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
| | - Thomas Cluzeau
- Adult Haematology Department, Saint Louis Hospital, Paris, France. .,EA3518, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France. .,INSERM U1065, Centre mediterraneen de Medecine Moleculaire, Nice, France.
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