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Chen K, Zhang Y, Zou J, Wang D, Yu X, Sun Y, Li Y, Niu J, Chen Y, Zhao P, Liu W, Lv Y, Wang M, Hu X. Comparative efficacy and hematologic safety of different dosages of JAK inhibitors in the treatment of myelofibrosis: a network meta-analysis. Front Oncol 2024; 14:1403967. [PMID: 39281381 PMCID: PMC11392783 DOI: 10.3389/fonc.2024.1403967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 08/13/2024] [Indexed: 09/18/2024] Open
Abstract
Background Myelofibrosis (MF) is a myeloproliferative neoplasm characterized by bone marrow fibrosis associated with substantial morbidity and mortality. The therapeutic landscape for MF has advanced with the development of Janus kinase inhibitors (JAKis) like ruxolitinib (RUX), fedratinib (FED), pacritinib (PAC), and momelotinib (MMB), aiming to alleviate symptoms and enhance patient comfort. Methods A network meta-analysis was conducted to assess the efficacy and safety of eleven JAKi treatment regimens across nine randomized controlled trials (RCTs) with a total of 2340 participants. Outcomes were evaluated in terms of spleen volume reduction (SVR), total symptom score reduction (TSSR), hematological safety profiles, and overall survival (OS). Results RUX and MMB were superior in achieving SVR and TSSR, with significant dose-response relationships observed. PAC and MMB were associated with a decreased risk of grade 3/4 anemia and thrombocytopenia compared to other JAKis. However, no substantial benefits in OS were observed with newer JAKis compared to RUX. The poorer OS outcomes with certain PAC dosages were likely influenced by baseline patient characteristics, particularly severe cytopenias. Conclusion The introduction of JAKis significantly changed the treatment of MF. This meta-analysis reaffirms the core role of RUX and positions MMB as a potentially powerful alternative for treating symptoms and reducing spleen size. Meanwhile, MMB and PAC have a positive effect on anemia in MF while FED is more tolerable for patients with thrombocytopenia. However, it should be noted that these results are influenced by baseline patient characteristics, particularly cytopenias, which affects both management and overall survival. Therefore, there is an urgent need for personalized dosing strategies to optimize the balance between efficacy and safety, with careful consideration of patient-specific factors. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023424179.
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Affiliation(s)
- Ke Chen
- Postdoctoral Research Station of China Academy of Chinese Medical Sciences, Beijing, China
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanyu Zhang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jixuan Zou
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Dehao Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xinyue Yu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Sun
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yumeng Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jicong Niu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Chen
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Pei Zhao
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Lv
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mingjing Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Isfort S, von Bubnoff N, Al-Ali HK, Becker H, Götze T, le Coutre P, Griesshammer M, Moskwa C, Wohn L, Riedel J, Palandri F, Manz K, Hochhaus A, Döhner K, Heidel FH. FRACTION: protocol of a phase II study of Fedratinib and Nivolumab combination in patients with myelofibrosis and resistance or suboptimal response to JAK-inhibitor treatment of the German MPN study group (GSG-MPN). Ann Hematol 2024; 103:2775-2785. [PMID: 38967662 PMCID: PMC11283433 DOI: 10.1007/s00277-024-05867-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Abstract
Development of Janus-kinase (JAK) inhibitors has revolutionized the therapeutic landscape for patients with myeloproliferative neoplasia (MPN). Following approval of the first JAK1/2-inhibitor Ruxolitinib, symptoms of this inflammatory disease, characterized by splenomegaly, release of inflammatory cytokines and appearance of thrombosis, could be effectively reduced for the first time. However, JAK-inhibitor treatment is limited in several aspects: 1) duration of response: 3 years after initiation of therapy more than 50% of patients have discontinued JAK-inhibitor treatment due to lack of efficacy or resistance; 2) reduction of disease burden: while effective in reducing inflammation and constitutional symptoms, JAK-inhibitors fail to reduce the malignant clone in the majority of patients and therefore lack long-term efficacy. Early clinical trials for patients with myelofibrosis (MF) have tried to address these issues for patients with suboptimal response to Ruxolitinib therapy while combination therapies with Fedratinib are rare. Recent reports provided first evidence on how the JAK2-V617F mutated myeloid cells may influence T-cell responses. JAK2-V617F promoted the synthesis of PD-L1 in MPN cells leading to limited anti-neoplastic T-cell responses, metabolic changes in T-cells and eventually JAK2-V617F-driven immune-escape of MPN cells. These findings may facilitate the use of immunotherapeutic approaches for JAK-mutated clones. Immune checkpoints refer to a variety of inhibitory pathways that are crucial for maintaining self-tolerance and modulating the duration and amplitude of physiological immune responses in peripheral tissues in order to minimize collateral tissue damage. The FRACTION study is a single arm, open label Phase II trial investigating the combination of Fedratinib with the PD-1 inhibitor Nivolumab in patients with myelofibrosis and suboptimal or lack of response to JAK-inhibitor therapy. Over a 12 months period the trial assesses longer term outcomes, particularly the effects on clinical outcomes, such as induction of clinical remissions, quality of life and improvement of anemia. No prospective clinical trial data exist for combinations of JAK- and immune-checkpoint-inhibitors in the planned MF study population and this study will provide new findings that may contribute to advancing the treatment landscape for MF patients with suboptimal responses and limited alternatives.
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Affiliation(s)
- Susanne Isfort
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, Hannover, 30625, Germany
| | - Nikolas von Bubnoff
- Department of Hematology and Oncology, University Hospital Lübeck, Lübeck, Germany
| | - Haifa Kathrin Al-Ali
- University Hospital Halle (Saale), Krukenberg Cancer Center Halle, Halle, Germany
| | - Heiko Becker
- Department of Medicine I - Medical Center - University of Freiburg, Faculty of Medicine, University of , Freiburg, Freiburg, Germany
| | - Thorsten Götze
- Krankenhaus Nordwest, University Cancer Center (UCT), Frankfurt, Germany
- Institut für Klinische Krebsforschung IKF Am Krankenhaus Nordwest, Frankfurt, Germany
| | - Philipp le Coutre
- Department of Hematology, Oncology and Stem Cell Transplantation, Charite Berlin, Germany
| | | | - Claudia Moskwa
- Internal Medicine C, Hematology, Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany
| | - Luisa Wohn
- Institut für Klinische Krebsforschung IKF Am Krankenhaus Nordwest, Frankfurt, Germany
| | - Johanna Riedel
- Institut für Klinische Krebsforschung IKF Am Krankenhaus Nordwest, Frankfurt, Germany
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | - Kirsi Manz
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, Hannover, 30625, Germany
- Institute for Community Medicine - SHIP-KEF, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Abteilung Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Florian H Heidel
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, Hannover, 30625, Germany.
- Internal Medicine C, Hematology, Oncology, Stem Cell Transplantation and Palliative Care, University Medicine Greifswald, Greifswald, Germany.
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Hunter AM, Bose P. Advances with janus kinase inhibitors for the treatment of myeloproliferative neoplasms: an update of the literature. Expert Opin Pharmacother 2024; 25:1391-1404. [PMID: 39067001 DOI: 10.1080/14656566.2024.2385729] [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: 06/12/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION The hallmark discovery of hyperactivation of the janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway was a sentinel moment in the history of myeloproliferative neoplasms (MPNs). This finding paved the way for the development of JAK inhibitors, which now represent the foundation of myelofibrosis therapy. With four JAK inhibitors now approved for myelofibrosis, awareness of their clinical efficacy and safety data and recognition of their unique pharmacologic attributes are of critical importance. Additionally, ruxolitinib represents an integral part of the therapeutic arsenal for polycythemia vera. AREAS COVERED This review provides a broad overview of the published literature supporting JAK inhibitor therapy for MPNs. Primarily focusing on myelofibrosis, each of the four available JAK inhibitors is reviewed in detail, including pharmacology, efficacy, and safety data. Failure of JAK inhibitors and future directions in JAK inhibitor therapy are also discussed. EXPERT OPINION JAK inhibitors revolutionized the treatment of MPNs and have dramatically improved patient outcomes. However, data informing selection between currently available JAK inhibitors is limited. These agents are not curative and eventually fail most patients with myelofibrosis. Combining JAK inhibitors with novel targeted agents appears to be the most promising path to further improve outcomes.
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Affiliation(s)
- Anthony M Hunter
- Department of Hematology and Medical oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ranalli P, Natale A, Guardalupi F, Santarone S, Cantò C, La Barba G, Di Ianni M. Myelofibrosis and allogeneic transplantation: critical points and challenges. Front Oncol 2024; 14:1396435. [PMID: 38966064 PMCID: PMC11222377 DOI: 10.3389/fonc.2024.1396435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/23/2024] [Indexed: 07/06/2024] Open
Abstract
New available drugs allow better control of systemic symptoms associated with myelofibrosis (MF) and splenomegaly but they do not modify the natural history of progressive and poor prognosis disease. Thus, hematopoietic stem cell transplantation (HSCT) is still considered the only available curative treatment for patients with MF. Despite the increasing number of procedures worldwide in recent years, HSCT for MF patients remains challenging. An increasingly complex network of the patient, disease, and transplant-related factors should be considered to understand the need for and the benefits of the procedure. Unfortunately, prospective trials are often lacking in this setting, making an evidence-based decision process particularly arduous. In the present review, we will analyze the main controversial points of allogeneic transplantation in MF, that is, the development of more sophisticated models for the identification of eligible patients; the need for tools offering a more precise definition of expected outcomes combining comorbidity assessment and factors related to the procedure; the decision-making process about the best transplantation time; the evaluation of the most appropriate platform for curative treatment; the impact of splenomegaly; and splenectomy on outcomes.
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Affiliation(s)
- Paola Ranalli
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Francesco Guardalupi
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
| | | | - Chiara Cantò
- Hematology Unit, Pescara Hospital, Pescara, Italy
| | | | - Mauro Di Ianni
- Hematology Unit, Pescara Hospital, Pescara, Italy
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy
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Verstovsek S, Mesa R, Gupta V, Lavie D, Dubruille V, Cambier N, Platzbecker U, Hus M, Xicoy B, Oh ST, Kiladjian JJ, Vannucchi AM, Gerds A, Egyed M, Mayer J, Sacha T, Kawashima J, Morris M, Huang M, Harrison C. Momelotinib long-term safety and survival in myelofibrosis: integrated analysis of phase 3 randomized controlled trials. Blood Adv 2023; 7:3582-3591. [PMID: 37042865 PMCID: PMC10368854 DOI: 10.1182/bloodadvances.2022009311] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 03/06/2023] [Indexed: 04/13/2023] Open
Abstract
Momelotinib is the first inhibitor of Janus kinase 1 (JAK1) and JAK2 shown to also inhibit activin A receptor type 1 (ACVR1), a key regulator of iron homeostasis, and has demonstrated improvements in splenomegaly, constitutional symptoms, and anemia in myelofibrosis (MF). This long-term analysis pooled data from 3 randomized phase 3 studies of momelotinib (MOMENTUM, SIMPLIFY-1, and SIMPLIFY-2), representing MF disease from early (JAK inhibitor-naive) to late (JAK inhibitor-experienced) stages. Patients in the control arms (danazol in MOMENTUM, ruxolitinib in SIMPLIFY-1, and best available therapy in SIMPLIFY-2) could cross over to receive momelotinib at the end of the 24-week randomized period, and all patients could continue momelotinib treatment after the completion of these studies via an extended access protocol (XAP). Across these studies, 725 patients with MF received momelotinib; 12% remained on therapy for ≥5 years, with a median treatment exposure of 11.3 months (range, 0.1-90.4 months). The most common nonhematologic treatment-emergent adverse event (AE) occurring in ≥20% of patients was diarrhea (any grade, 27% and grade ≥3, 3%). Any-grade thrombocytopenia, anemia, and neutropenia occurred in 25%, 23%, and 7% of patients, respectively. The most common reason for momelotinib discontinuation was thrombocytopenia (4% discontinuation rate). The incidence of AEs of clinical importance (eg, infections, malignant transformation, peripheral neuropathy, and hemorrhage) did not increase over time. This analysis of one of the largest randomized trial databases for a JAK inhibitor to date in MF demonstrated a consistent safety profile of momelotinib without long-term or cumulative toxicity. These trials were registered at www.clinicaltrials.gov as: MOMENTUM (#NCT04173494), SIMPLIFY-1 (#NCT01969838), SIMPLIFY-2 (#NCT02101268), and XAP (#NCT03441113).
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Affiliation(s)
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David Lavie
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Viviane Dubruille
- Centre Hospitalier Universitaire de Nantes (CHU de Nantes), Nantes, France
| | - Nathalie Cambier
- Service d’hématologie, Centre hospitalier régional universitaire de Lille (CHRU Lille), Lille, France
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Marek Hus
- Uniwersytet Medyczny w Lublinie, Lublin, Poland
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jean-Jacques Kiladjian
- Université de Paris, Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, Paris, France
| | - Alessandro M. Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, University of Florence, Careggi University Hospital, Florence, Italy
| | | | | | - Jiří Mayer
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomasz Sacha
- Uniwersytet Jagielloński Collegium Medicum, Krakow, Poland
| | | | | | | | - Claire Harrison
- Guy's and St Thomas' National Health Services (NHS) Foundation Trust, London, United Kingdom
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Ayala R, Fernández RA, García‐Gutiérrez V, Alvarez‐Larrán A, Osorio S, Sánchez‐Pina JM, Carreño‐Tarragona G, Álvarez N, Gómez‐Casares MT, Duran A, Gorrochategi J, Hernández‐Boluda JC, Martínez‐López J. Janus kinase inhibitor ruxolitinib in combination with nilotinib and prednisone in patients with myelofibrosis (RuNiC study): A phase Ib, multicenter study. EJHAEM 2023; 4:401-409. [PMID: 37206258 PMCID: PMC10188506 DOI: 10.1002/jha2.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 05/21/2023]
Abstract
This phase Ib, non-randomized, open-label study evaluates the safety and tolerability of ruxolitinib in combination with nilotinib and prednisone in patients with naïve or ruxolitinib-resistant myelofibrosis (MF). A total of 15 patients with primary or secondary MF received the study treatment; 13 patients had received prior ruxolitinib treatment (86.7%). Eight patients completed seven cycles (53.3%) and six patients completed twelve cycles of treatment (40%). All the patients experienced at least one adverse event (AE) during the study (the most common AEs were hyperglycemia, asthenia, and thrombocytopenia), and 14 patients registered at least one treatment-related AE (the most common treatment-related AEs were hyperglycemia (22.2%; three grade 3 cases). Five treatment-related serious AEs (SAEs) were reported in two patients (13.3%). No deaths were registered throughout the study. No dose-limiting toxicity was observed. Four out of fifteen (27%) patients experienced a 100% spleen size reduction at Cycle 7, and two additional patients achieved a >50% spleen size reduction, representing an overall response rate of 40% at Cycle 7. In conclusion, the tolerability of this combination was acceptable, and hyperglycemia was the most frequent treatment-related AE. Ruxolitinib in combination with nilotinib and prednisone showed relevant clinical activity in patients with MF. This trial was registered with EudraCT Number 2016-005214-21.
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Affiliation(s)
- Rosa Ayala
- Haematological Malignancies Clinical Research UnitHospital Universitario 12 de Octubre, Universidad Complutense, CNIO, CIBERONCMadridSpain
| | | | | | | | - Santiago Osorio
- Hematology Department Hospital General UGregorio MarañónMadridSpain
| | | | | | - Noemi Álvarez
- Department of Translational HematologyResearch Institute Hospital 12 de Octubre (i+12)MadridSpain
| | | | - Antonia Duran
- Hematology Department Hospital Universitario Son EspasesPalma de MallorcaSpain
| | | | | | - Joaquín Martínez‐López
- Haematological Malignancies Clinical Research UnitHospital Universitario 12 de Octubre, Universidad Complutense, CNIO, CIBERONCMadridSpain
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7
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Does ruxolitinib really prolong survival in peoples with myelofibrosis? The never-ending story. Blood Adv 2022; 6:2331-2333. [PMID: 35240682 PMCID: PMC9006303 DOI: 10.1182/bloodadvances.2022007230] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022] Open
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Thomas JW, Jamy O, Shah MV, Vachhani P, Go RS, Goyal G. Risk of mortality and second malignancies in primary myelofibrosis before and after ruxolitinib approval. Leuk Res 2021; 112:106770. [PMID: 34920340 DOI: 10.1016/j.leukres.2021.106770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Primary myelofibrosis (PMF) is associated with morbidity and mortality. Ruxolitinib gained US FDA approval for treatment of intermediate/high-risk PMF in November 2011. We evaluated differences in survival and second primary malignancy (SPM) incidence among US PMF patients in the years before and after ruxolitinib approval. METHODS We conducted a retrospective study utilizing the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-18 database for PMF patients. We divided patients into five-year cohorts pre- (2007-2011) and post-ruxolitinib (2012-2016) approval and compared relative survival rates (RSRs) to the standard population and standardized incidence rates (SIRs) of SPMs between cohorts. RESULTS We included 2020 patients diagnosed with PMF from 2007-2016 in this study. There was no difference in the four-year RSRs between cohorts (54 % vs. 57 %, p = 0.776). More patients developed SPMs in the post-ruxolitinib cohort (8% vs. 6%, p = 0.041). The majority of SPMs were hematologic with higher incidence of AML transformation in the post-ruxolitinib cohort (SIR 125.29 vs. 70.55). CONCLUSIONS PMF prognosis remains poor in the years following ruxolitinib's approval. SPM incidence including AML transformation is higher in the years after approval. Further studies are needed to determine the true impact of ruxolitnib on population outcomes.
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Affiliation(s)
- John W Thomas
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Omer Jamy
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
| | | | - Pankit Vachhani
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Gaurav Goyal
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
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9
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Cattaneo D, Iurlo A. Immune Dysregulation and Infectious Complications in MPN Patients Treated With JAK Inhibitors. Front Immunol 2021; 12:750346. [PMID: 34867980 PMCID: PMC8639501 DOI: 10.3389/fimmu.2021.750346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022] Open
Abstract
BCR-ABL1-negative myeloproliferative neoplasms are burdened by a reduced life expectancy mostly due to an increased risk of thrombo-hemorrhagic events, fibrotic progression/leukemic evolution, and infectious complications. In these clonal myeloid malignancies, JAK2V617F is the main driver mutation, leading to an aberrant activation of the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling pathway. Therefore, its inhibition represents an attractive therapeutic strategy for these disorders. Several JAK inhibitors have entered clinical trials, including ruxolitinib, the first JAK1/2 inhibitor to become commercially available for the treatment of myelofibrosis and polycythemia vera. Due to interference with the JAK-STAT pathway, JAK inhibitors affect several components of the innate and adaptive immune systems such as dendritic cells, natural killer cells, T helper cells, and regulatory T cells. Therefore, even though the clinical use of these drugs in MPN patients has led to a dramatic improvement of symptoms control, organ involvement, and quality of life, JAK inhibitors–related loss of function in JAK-STAT signaling pathway can be a cause of different adverse events, including those related to a condition of immune suppression or deficiency. This review article will provide a comprehensive overview of the current knowledge on JAK inhibitors’ effects on immune cells as well as their clinical consequences, particularly with regards to infectious complications.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Çorman ME, Cetinkaya A, Ozcelikay G, Özgür E, Atici EB, Uzun L, Ozkan SA. A porous molecularly imprinted nanofilm for selective and sensitive sensing of an anticancer drug ruxolitinib. Anal Chim Acta 2021; 1187:339143. [PMID: 34753569 DOI: 10.1016/j.aca.2021.339143] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/09/2021] [Accepted: 10/01/2021] [Indexed: 01/25/2023]
Abstract
A novel methodology has been applied to generate a porous molecularly imprinted material for highly selective and sensitive recognition of Janus kinase inhibitor ruxolitinib (RUX). The porous material-based nucleobase-derivative functional monomer was developed by a photopolymerization method. The thymine methacrylate (ThyM) as a functional monomer was synthesized and copolymerized with 2-hydroxyethyl methacrylate (HEMA) in the presence of ethylene glycol dimethacrylate (EGDMA) onto the glassy carbon electrode [glassy carbon electrode/molecularly imprinted polymer@poly(2-hydroxyethyl methacrylate-co-thymine methacrylate), (GCE/MIP@PHEMA-ThyM)] for the first time. The presence of ThyM results in the functional groups in imprinting binding sites, while the presence of poly(vinyl alcohol) (PVA) allows to generate porous materials for sensitive sensing. The characterization of GCE/MIP@PHEMA-ThyM was investigated by Fourier transform infrared (FT-IR) spectroscopy, scanning electron microscopy (SEM), and impedance spectroscopy technique. Then, the porous MIP modified glassy carbon electrode was optimized with effecting parameters including removal agent, removal time, and incubation time to get a better response for RUX. Under well-controlled optimum conditions, the GCE/MIP@PHEMA-ThyM linearly responded to the RUX concentration up to 0.01 pM at the limit of detection (LOD) of 0.00191 pM. The non-imprinted polymer (NIP) was also prepared to serve as a control in the same way but without the template. The proposed method improves the accessibility of binding sites by generating the porous material resulting in highly selective and sensitive recognition of drugs in the pharmaceutical dosage form and synthetic human serum samples.
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Affiliation(s)
- M Emin Çorman
- Ankara University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey; Sinop University, Faculty of Science and Arts, Department of Chemistry, Sinop, Turkey.
| | - Ahmet Cetinkaya
- Ankara University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey
| | - Goksu Ozcelikay
- Ankara University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey
| | - Erdoğan Özgür
- Hacettepe University, Advanced Technologies Application and Research Center, Ankara, Turkey
| | | | - Lokman Uzun
- Hacettepe University, Faculty of Science, Department of Chemistry, Ankara, Turkey
| | - Sibel A Ozkan
- Ankara University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey.
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11
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NK Cells in Myeloproliferative Neoplasms (MPN). Cancers (Basel) 2021; 13:cancers13174400. [PMID: 34503210 PMCID: PMC8431564 DOI: 10.3390/cancers13174400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary NK cells are important innate immune effectors that contribute substantially to tumor control, however the role of NK cells in haematological cancers is not as well understood. The aim of this review is to highlight the importance of the role of NK cells in the management of Ph+ Myeloproliferative Neoplasms, and emphasize the need and possible benefits of a more in-depth investigation into their role in classical MPNs and show potential strategies to harness the anti-tumoral capacities of NK cells. Abstract Myeloproliferative neoplasms (MPNs) comprise a heterogenous group of hematologic neoplasms which are divided into Philadelphia positive (Ph+), and Philadelphia negative (Ph−) or classical MPNs. A variety of immunological factors including inflammatory, as well as immunomodulatory processes, closely interact with the disease phenotypes in MPNs. NK cells are important innate immune effectors and substantially contribute to tumor control. Changes to the absolute and proportionate numbers of NK cell, as well as phenotypical and functional alterations are seen in MPNs. In addition to the disease itself, a variety of therapeutic options in MPNs may modify NK cell characteristics. Reports of suppressive effects of MPN treatment strategies on NK cell activity have led to intensive investigations into the respective compounds, to elucidate the possible negative effects of MPN therapy on control of the leukemic clones. We hereby review the available literature on NK cells in Ph+ and Ph− MPNs and summarize today’s knowledge on disease-related alterations in this cell compartment with particular focus on known therapy-associated changes. Furthermore, we critically evaluate conflicting data with possible implications for future projects. We also aim to highlight the relevance of full NK cell functionality for disease control in MPNs and the importance of considering specific changes related to therapy in order to avoid suppressive effects on immune surveillance.
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12
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Bankar A, Alibhai S, Smith E, Yang D, Malik S, Cheung V, Siddiq N, Claudio J, Arruda A, Tsui H, Capo-Chichi JM, Kennedy JA, McNamara C, Sibai H, Maze D, Xu W, Gupta V. Association of frailty with clinical outcomes in myelofibrosis: a retrospective cohort study. Br J Haematol 2021; 194:557-567. [PMID: 34131896 PMCID: PMC8361997 DOI: 10.1111/bjh.17617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/13/2021] [Indexed: 12/17/2022]
Abstract
There is limited understanding of the impact of frailty on clinical outcomes in patients with myelofibrosis (MF). In this retrospective cohort study on 439 chronic phase MF patients [mean age: 68·7 ± 12 years; median follow-up: 3·4 years (IQR 0·4-8·6)] from 2004 till 2018, we used a 35-variable frailty index (FI) to categorise patient's frailty status as fit (FI < 0·2, reference), prefrail (FI 0·2-0·29) or frail (FI ≥ 0·3). The association of frailty with overall survival (OS) and cumulative JAK inhibitor (JAKi) therapy failure was measured using hazard ratio (HR, 95% CI). In multivariable analysis, prefrail (HR 1·7, 1·1-2·5) and frail patients (HR 2·9, 1·6-5·5), those with higher DIPSS score (HR 2·5, 1·6-3·9) and transfusion dependency (HR 1·9, 1·3-2·9) had shorter OS. In a subset analysis of patients on JAKi treatment (n = 222), frail patients (HR 2·5, 1·1-5·7), patients with higher DIPSS score (HR 1·7, 1·0-3·1) and transfusion dependence (HR 1·7, 1·1-2·7) had higher cumulative incidence of JAKi failure. Age, comorbidities, ECOG performance status, and MPN driver mutations did not impact outcomes. Thus, higher frailty scores are associated with worse OS and increased JAKi failure in MF, and is a superior indicator of fitness in comparison to age, comorbidities, and performance status.
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Affiliation(s)
- Aniket Bankar
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Elliot Smith
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dongyang Yang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Sarah Malik
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Verna Cheung
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nancy Siddiq
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jaime Claudio
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andrea Arruda
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hubert Tsui
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | | | - Hassan Sibai
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Wei Xu
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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13
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Savani M, Dulery R, Bazarbachi AH, Mohty R, Brissot E, Malard F, Bazarbachi A, Nagler A, Mohty M. Allogeneic haematopoietic cell transplantation for myelofibrosis: a real-life perspective. Br J Haematol 2021; 195:495-506. [PMID: 33881169 DOI: 10.1111/bjh.17469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 01/12/2023]
Abstract
Myelofibrosis (MF) is a clonal stem cell neoplasm with heterogeneous clinical phenotypes and well-established molecular drivers. Allogeneic haematopoietic stem cell transplantation (HSCT) offers an important curative treatment option for primary MF and post-essential thrombocythaemia/polycythaemia vera MF or secondary MF. With a disease course that varies from indolent to highly progressive, we are now able to stratify risk of mortality through various tools including patient-related clinical characteristics as well as molecular genetic profile. Owing to the high risk of mortality and morbidity associated with HSCT for patients with myelofibrosis, it is important to improve patient selection for transplant. Our primary goal is to comprehensively define our understanding of current practices including the role of Janus Kinase (JAK) inhibitors, to present the data behind transplantation before and after leukaemic transformation, and to introduce novel personalization of MF treatment with a proposed clinical-molecular prognostic model to help elucidate a timepoint optimal for consideration of HSCT.
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Affiliation(s)
- Malvi Savani
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Rémy Dulery
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Abdul Hamid Bazarbachi
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Razan Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.,Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Florent Malard
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Department of Internal Medicine, Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
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14
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The Janus Kinase Inhibitor Ruxolitinib Prevents Terminal Shock in a Mouse Model of Arenavirus Hemorrhagic Fever. Microorganisms 2021; 9:microorganisms9030564. [PMID: 33803310 PMCID: PMC8001354 DOI: 10.3390/microorganisms9030564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 12/20/2022] Open
Abstract
Arenaviruses such as Lassa virus cause arenavirus hemorrhagic fever (AVHF), but protective vaccines and effective antiviral therapy remain unmet medical needs. Our prior work has revealed that inducible nitric oxide synthase (iNOS) induction by IFN-γ represents a key pathway to microvascular leak and terminal shock in AVHF. Here we hypothesized that Ruxolitinib, an FDA-approved JAK inhibitor known to prevent IFN-γ signaling, could be repurposed for host-directed therapy in AVHF. We tested the efficacy of Ruxolitinib in MHC-humanized (HHD) mice, which develop Lassa fever-like disease upon infection with the monkey-pathogenic lymphocytic choriomeningitis virus strain WE. Anti-TNF antibody therapy was tested as an alternative strategy owing to its expected effect on macrophage activation. Ruxolitinib but not anti-TNF antibody prevented hypothermia and terminal disease as well as pleural effusions and skin edema, which served as readouts of microvascular leak. As expected, neither treatment influenced viral loads. Intriguingly, however, and despite its potent disease-modifying activity, Ruxolitinib did not measurably interfere with iNOS expression or systemic NO metabolite levels. These findings suggest that the FDA-approved JAK-inhibitor Ruxolitinib has potential in the treatment of AVHF. Moreover, our observations indicate that besides IFN-γ-induced iNOS additional druggable pathways contribute essentially to AVHF and are amenable to host-directed therapy.
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15
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Skov V. Next Generation Sequencing in MPNs. Lessons from the Past and Prospects for Use as Predictors of Prognosis and Treatment Responses. Cancers (Basel) 2020; 12:E2194. [PMID: 32781570 PMCID: PMC7464861 DOI: 10.3390/cancers12082194] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022] Open
Abstract
The myeloproliferative neoplasms (MPNs) are acquired hematological stem cell neoplasms characterized by driver mutations in JAK2, CALR, or MPL. Additive mutations may appear in predominantly epigenetic regulator, RNA splicing and signaling pathway genes. These molecular mutations are a hallmark of diagnostic, prognostic, and therapeutic assessment in patients with MPNs. Over the past decade, next generation sequencing (NGS) has identified multiple somatic mutations in MPNs and has contributed substantially to our understanding of the disease pathogenesis highlighting the role of clonal evolution in disease progression. In addition, disease prognostication has expanded from encompassing only clinical decision making to include genomics in prognostic scoring systems. Taking into account the decreasing costs and increasing speed and availability of high throughput technologies, the integration of NGS into a diagnostic, prognostic and therapeutic pipeline is within reach. In this review, these aspects will be discussed highlighting their role regarding disease outcome and treatment modalities in patients with MPNs.
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Affiliation(s)
- Vibe Skov
- Department of Hematology, Zealand University Hospital, Vestermarksvej 7-9, 4000 Roskilde, Denmark
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16
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Saraceni F, Scortechini I, Mancini G, Mariani M, Federici I, Gaetani M, Barbatelli P, Minnucci ML, Bagnarelli P, Olivieri A. Severe COVID-19 in a patient with chronic graft-versus-host disease after hematopoietic stem cell transplant successfully treated with ruxolitinib. Transpl Infect Dis 2020; 23:e13401. [PMID: 32629531 PMCID: PMC7361240 DOI: 10.1111/tid.13401] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 01/18/2023]
Abstract
Graft‐versus‐host disease (GVHD) is a common complication of hematopoietic stem cell transplant, which is known to be mediated by cytotoxic T‐cell effectors and dysregulated inflammatory cytokines. Similarly, the lung injury observed in severe COVID‐19 cases appears to be related to a massive production of pro‐inflammatory cytokines. The selective JAK1/2 inhibitor ruxolitinib has shown promising results in the context of GVHD, and different trials are currently underway in patients with severe COVID‐19; nevertheless, no clinical observation of safety or efficacy of treatment with ruxolitinib in this context has been published yet. We describe a first case of severe COVID‐19 developed after hematopoietic stem cell transplantation in a patient with a concomitant chronic GVHD (cGVHD), in which a treatment with ruxolitinib was administered with good tolerance and positive outcome.
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Affiliation(s)
- Francesco Saraceni
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
| | - Ilaria Scortechini
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
| | - Giorgia Mancini
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
| | - Marianna Mariani
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
| | - Irene Federici
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
| | - Mariana Gaetani
- Department of Internal Medicine, Covid-19 Hospital, Civitanova Marche, Italy
| | - Paolo Barbatelli
- Department of Internal Medicine, Covid-19 Hospital, Civitanova Marche, Italy
| | | | | | - Attilio Olivieri
- Hematology and Stem Cell Transplant, Ancona University Hospital, Ancona, Italy
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17
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Giudice V, Pagliano P, Vatrella A, Masullo A, Poto S, Polverino BM, Gammaldi R, Maglio A, Sellitto C, Vitale C, Serio B, Cuffa B, Borrelli A, Vecchione C, Filippelli A, Selleri C. Combination of Ruxolitinib and Eculizumab for Treatment of Severe SARS-CoV-2-Related Acute Respiratory Distress Syndrome: A Controlled Study. Front Pharmacol 2020; 11:857. [PMID: 32581810 PMCID: PMC7291857 DOI: 10.3389/fphar.2020.00857] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/25/2020] [Indexed: 12/23/2022] Open
Abstract
To date, there are no specific therapeutic strategies for treatment of COVID-19. Based on the hypothesis that complement and coagulation cascades are activated by viral infection, and might trigger an acute respiratory distress syndrome (ARDS), we report clinical outcomes of 17 consecutive cases of SARS-CoV-2-related ARDS treated (N = 7) with the novel combination of ruxolitinib, a JAK1/2 inhibitor, 10 mg/twice daily for 14 days and eculizumab, an anti-C5a complement monoclonal antibody, 900 mg IV/weekly for a maximum of three weeks, or with the best available therapy (N = 10). Patients treated with the combination showed significant improvements in respiratory symptoms and radiographic pulmonary lesions and decrease in circulating D-dimer levels compared to the best available therapy group. Our results support the use of combined ruxolitinib and eculizumab for treatment of severe SARS-CoV-2-related ARDS by simultaneously turning off abnormal innate and adaptive immune responses.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Clinical Pharmacology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Pasquale Pagliano
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Infectious Disease Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Alfonso Masullo
- Infectious Disease Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Sergio Poto
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Benedetto Maria Polverino
- Respiratory Disease Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Renato Gammaldi
- Respiratory Endoscopy Unit, Hospital "Giovanni Da Procida", University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Angelantonio Maglio
- Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Carmine Sellitto
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Clinical Pharmacology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Carolina Vitale
- Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Bianca Serio
- Hematology and Transplant Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Bianca Cuffa
- Hematology and Transplant Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Anna Borrelli
- Executive Board, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Clinical Pharmacology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Carmine Selleri
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy.,Hematology and Transplant Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
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18
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Yassin MA, Taher A, Mathews V, Hou HA, Shamsi T, Tuğlular TF, Xiao Z, Kim SJ, Depei W, Li J, Rippin G, Sadek I, Siddiqui A, Wong RS. MERGE: A Multinational, Multicenter Observational Registry for Myeloproliferative Neoplasms in Asia, including Middle East, Turkey, and Algeria. Cancer Med 2020; 9:4512-4526. [PMID: 32351024 PMCID: PMC7333830 DOI: 10.1002/cam4.3004] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/13/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Philadelphia chromosome-negative (Ph-) myeloproliferative neoplasms (MPNs) are a heterogeneous group of clonal disorders of the bone marrow, and are associated with a high disease burden, reduced quality of life (QOL), and shortened survival. This multinational, multicenter, non-interventional registry "MERGE" was initiated with an objective to collect data on the epidemiological indices of classical Ph-MPNs, existing treatment patterns, and impact of MPNs on health-related QOL in various countries/regions in Asia, including the Middle East, Turkey, and Algeria. Of the 884 eligible patients with MPNs, 169 had myelofibrosis (MF), 301 had polycythemia vera (PV), 373 had essential thrombocythemia (ET), and 41 had unclassified MPNs. The median age was 58 years (range, 47-66 years), and 50% of patients were males. The prevalence and incidence of MPNs were estimated to be 57-81 and 12-15 per 100 000 hospital patients per year over the last 4 years, respectively, in these countries. Total symptom score (mean [standard deviation; SD]) at baseline was highest in patients with MF (23.5 [17.47]) compared with patients with ET (14.6 [14.26]) and PV (16.6 [14.84]). Patients with ET had a lower mean (SD) number of inpatient visits (0.9 [0.77] days), and patients with MF had more outpatient visits (5.2 [3.17] days) on an average, compared with the entire MPN group. The study showed that patients with MPNs have a severe disease burden and reduced QOL. A discordance between physician and patient perception of symptom assessment was observed in this study (International clinical trials registry ID: CTRI/2014/05/004598).
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Affiliation(s)
- Mohamed A Yassin
- National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ali Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
| | - Hsin-An Hou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tahir Shamsi
- Research Department, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | | | - Zhijian Xiao
- MDS and MPN Centre, Institute of Hematology & Blood Diseases Hospital, CAMS and PUMC, Tianjin, China
| | | | - Wu Depei
- Department of Hematology, The First Hospital Affiliated to Soochow University, Suzhou, China
| | | | | | - Islam Sadek
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Raymond S Wong
- Sir YK Pao Centre for Cancer & Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, SAR
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19
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Zhang L, Yang F, Feng S. Allogeneic hematopoietic stem-cell transplantation for myelofibrosis. Ther Adv Hematol 2020; 11:2040620720906002. [PMID: 32110286 PMCID: PMC7019406 DOI: 10.1177/2040620720906002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
Myelofibrosis is one of the Philadelphia chromosome (Ph)-negative
myeloproliferative neoplasms with heterogeneous clinical course. Though many
treatment options, including Janus kinase (JAK) inhibitors, have provided
clinical benefits and improved survival, allogeneic hematopoietic stem-cell
transplantation (AHSCT) remains the only potentially curative therapy.
Considering the significant transplant-related morbidity and mortality, it is
crucial to decide who to proceed to AHSCT, and when. In this review, we discuss
recent updates in patient selection, prior splenectomy, conditioning regimen,
donor type, molecular mutation, and other factors affecting AHSCT outcomes.
Relapse is a major cause of treatment failure; we also describe recent data on
minimal residual disease monitoring and management of relapse. In addition,
emerging studies have reported pretransplant therapy with ruxolitinib for
myelofibrosis showing favorable results, and further research is needed to
explore its use in the post-transplant setting.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Fan Yang
- Aerospace Center Hospital, Beijing, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
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20
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Elli EM, Baratè C, Mendicino F, Palandri F, Palumbo GA. Mechanisms Underlying the Anti-inflammatory and Immunosuppressive Activity of Ruxolitinib. Front Oncol 2019; 9:1186. [PMID: 31788449 PMCID: PMC6854013 DOI: 10.3389/fonc.2019.01186] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/21/2019] [Indexed: 12/20/2022] Open
Abstract
The JAK-STAT signaling pathway plays a central role in signal transduction in hematopoietic cells, as well as in cells of the immune system. The occurrence in most patients affected by myeloproliferative neoplasms (MPNs) of driver mutations resulting in the constitutive activation of JAK2-dependent signaling identified the deregulated JAK-STAT signal transduction pathway as the major pathogenic mechanism of MPNs. It also prompted the development of targeted drugs for MPNs. Ruxolitinib is a potent and selective oral inhibitor of both JAK2 and JAK1 protein kinases. Its use in patients with myelofibrosis is associated with a substantial reduction in spleen volume, attenuation of symptoms and decreased mortality. With growing clinical experience, concerns about infectious complications, and increased risk of B-cell lymphoma, presumably caused by the effects of JAK1/2 inhibition on immune response and immunosurveillance, have been raised. Evidence shows that ruxolitinib exerts potent anti-inflammatory and immunosuppressive effects. Cellular targets of ruxolitinib include various components of both the innate and adaptive immune system, such as natural killer cells, dendritic cells, T helper, and regulatory T cells. On the other hand, immunomodulatory properties have proven beneficial in some instances, as highlighted by the successful use of ruxolitinib in corticosteroid-resistant graft vs. host disease. The objective of this article is to provide an overview of published evidence addressing the key question of the mechanisms underlying ruxolitinib-induced immunosuppression.
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Affiliation(s)
- Elena Maria Elli
- Hematology Division and Bone Marrow Transplant Unit, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Francesco Mendicino
- Hematology Unit, Department of Hemato-Oncology, Ospedale Annunziata, Cosenza, Italy
| | - Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giuseppe Alberto Palumbo
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", University of Catania, Catania, Italy
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21
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Perner F, Perner C, Ernst T, Heidel FH. Roles of JAK2 in Aging, Inflammation, Hematopoiesis and Malignant Transformation. Cells 2019; 8:cells8080854. [PMID: 31398915 PMCID: PMC6721738 DOI: 10.3390/cells8080854] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/22/2022] Open
Abstract
Clonal alterations in hematopoietic cells occur during aging and are often associated with the establishment of a subclinical inflammatory environment. Several age-related conditions and diseases may be initiated or promoted by these alterations. JAK2 mutations are among the most frequently mutated genes in blood cells during aging. The most common mutation within the JAK2 gene is JAK2-V617F that leads to constitutive activation of the kinase and thereby aberrant engagement of downstream signaling pathways. JAK2 mutations can act as central drivers of myeloproliferative neoplasia, a pre-leukemic and age-related malignancy. Likewise, hyperactive JAK-signaling is a hallmark of immune diseases and critically influences inflammation, coagulation and thrombosis. In this review we aim to summarize the current knowledge on JAK2 in clonal hematopoiesis during aging, the role of JAK-signaling in inflammation and lymphocyte biology and JAK2 function in age-related diseases and malignant transformation.
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Affiliation(s)
- Florian Perner
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany
- Leibniz-Institute on Aging-Fritz Lipmann Institute (FLI), 07745 Jena, Germany
- Dana-Farber Cancer Institute, Department of Pediatric Oncology, Harvard University, Boston, MA 02467, USA
| | - Caroline Perner
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, 02129 MA, USA
| | - Thomas Ernst
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany
| | - Florian H Heidel
- Innere Medizin 2, Hämatologie und Onkologie, Universitätsklinikum Jena, 07747 Jena, Germany.
- Leibniz-Institute on Aging-Fritz Lipmann Institute (FLI), 07745 Jena, Germany.
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22
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Charlier B, Marino L, Dal Piaz F, Pingeon M, Coglianese A, Izzo B, Serio B, Selleri C, Filippelli A, Izzo V. Development and Validation of a Reverse-Phase High-Performance Liquid Chromatography with Fluorescence Detection (RP-HPLC-FL) Method to Quantify Ruxolitinib in Plasma Samples. ANAL LETT 2019. [DOI: 10.1080/00032719.2018.1537283] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Bruno Charlier
- Postgraduate School in Hospital Pharmacy, University of Salerno, Fisciano, Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | - Luigi Marino
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Fabrizio Dal Piaz
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Marine Pingeon
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Barbara Izzo
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
- CEINGE-Biotecnologie Avanzate, Naples, Italy
| | - Bianca Serio
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | - Carmine Selleri
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Amelia Filippelli
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Viviana Izzo
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
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23
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Stivala S, Codilupi T, Brkic S, Baerenwaldt A, Ghosh N, Hao-Shen H, Dirnhofer S, Dettmer MS, Simillion C, Kaufmann BA, Chiu S, Keller M, Kleppe M, Hilpert M, Buser AS, Passweg JR, Radimerski T, Skoda RC, Levine RL, Meyer SC. Targeting compensatory MEK/ERK activation increases JAK inhibitor efficacy in myeloproliferative neoplasms. J Clin Invest 2019; 129:1596-1611. [PMID: 30730307 DOI: 10.1172/jci98785] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/29/2019] [Indexed: 12/18/2022] Open
Abstract
Constitutive JAK2 signaling is central to myeloproliferative neoplasm (MPN) pathogenesis and results in activation of STAT, PI3K/AKT, and MEK/ERK signaling. However, the therapeutic efficacy of current JAK2 inhibitors is limited. We investigated the role of MEK/ERK signaling in MPN cell survival in the setting of JAK inhibition. Type I and II JAK2 inhibition suppressed MEK/ERK activation in MPN cell lines in vitro, but not in Jak2V617F and MPLW515L mouse models in vivo. JAK2 inhibition ex vivo inhibited MEK/ERK signaling, suggesting that cell-extrinsic factors maintain ERK activation in vivo. We identified PDGFRα as an activated kinase that remains activated upon JAK2 inhibition in vivo, and PDGF-AA/PDGF-BB production persisted in the setting of JAK inhibition. PDGF-BB maintained ERK activation in the presence of ruxolitinib, consistent with its function as a ligand-induced bypass for ERK activation. Combined JAK/MEK inhibition suppressed MEK/ERK activation in Jak2V617F and MPLW515L mice with increased efficacy and reversal of fibrosis to an extent not seen with JAK inhibitors. This demonstrates that compensatory ERK activation limits the efficacy of JAK2 inhibition and dual JAK/MEK inhibition provides an opportunity for improved therapeutic efficacy in MPNs and in other malignancies driven by aberrant JAK-STAT signaling.
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Affiliation(s)
- Simona Stivala
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tamara Codilupi
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sime Brkic
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Anne Baerenwaldt
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Nilabh Ghosh
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Hui Hao-Shen
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stephan Dirnhofer
- Department of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | | | - Cedric Simillion
- Department of BioMedical Research, University of Berne, Berne, Switzerland
| | - Beat A Kaufmann
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sophia Chiu
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Matthew Keller
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Kleppe
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Morgane Hilpert
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas S Buser
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Jakob R Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Radek C Skoda
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ross L Levine
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sara C Meyer
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
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24
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Robin M, de Wreede LC, Wolschke C, Schetelig J, Eikema DJ, Van Lint MT, Knelange NS, Beelen D, Brecht A, Niederwieser D, Vitek A, Bethge W, Arnold R, Finke J, Volin L, Yakoub-Agha I, Nagler A, Poiré X, Einsele H, Chevallier P, Holler E, Ljungman P, Robinson S, Radujkovic A, McLornan D, Chalandon Y, Kröger N. Long-term outcome after allogeneic hematopoietic cell transplantation for myelofibrosis. Haematologica 2019; 104:1782-1788. [PMID: 30733269 PMCID: PMC6717573 DOI: 10.3324/haematol.2018.205211] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/31/2019] [Indexed: 12/25/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant remains the only curative treatment for myelofibrosis. Most post-transplantation events occur during the first two years and hence we aimed to analyze the outcome of 2-year disease-free survivors. A total of 1055 patients with myelofibrosis transplanted between 1995 and 2014 and registered in the registry of the European Society for Blood and Marrow Transplantation were included. Survival was compared to the matched general population to determine excess mortality and the risk factors that are associated. In the 2-year survivors, disease-free survival was 64% (60-68%) and overall survival was 74% (71-78%) at ten years; results were better in younger individuals and in women. Excess mortality was 14% (8-21%) in patients aged <45 years and 33% (13-53%) in patients aged ≥65 years. The main cause of death was relapse of the primary disease. Graft-versus-host disease (GvHD) before two years decreased the risk of relapse. Multivariable analysis of excess mortality showed that age, male sex recipient, secondary myelofibrosis and no GvHD disease prior to the 2-year landmark increased the risk of excess mortality. This is the largest study to date analyzing long-term outcome in patients with myelofibrosis undergoing transplant. Overall it shows a good survival in patients alive and in remission at two years. However, the occurrence of late complications, including late relapses, infectious complications and secondary malignancies, highlights the importance of screening and monitoring of long-term survivors.
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Affiliation(s)
- Marie Robin
- Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, LUMC, Leiden, the Netherlands and DKMS CTU, Dresden, Germany
| | | | - Johannes Schetelig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Dresden, Germany
| | | | | | | | | | | | | | - Antonin Vitek
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | | | | | - Jürgen Finke
- Division of Medicine I, Hematology, Oncology and Stem Cell Transplantation, University of Freiburg, Freiburg, Germany
| | - Liisa Volin
- HUCH Comprehensive Cancer Center, Helsinki, Finland
| | | | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Per Ljungman
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Donal McLornan
- Comprehensive Cancer Centre, Department of Haematology, Kings College, London, UK
| | - Yves Chalandon
- Hôpitaux Universitaires de Genève and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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25
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Vannucchi AM, Te Boekhorst PAW, Harrison CN, He G, Caramella M, Niederwieser D, Boyer-Perrard F, Duan M, Francillard N, Molloy B, Wroclawska M, Gisslinger H. EXPAND, a dose-finding study of ruxolitinib in patients with myelofibrosis and low platelet counts: 48-week follow-up analysis. Haematologica 2018; 104:947-954. [PMID: 30442723 PMCID: PMC6518918 DOI: 10.3324/haematol.2018.204602] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/13/2018] [Indexed: 12/28/2022] Open
Abstract
EEXPAND (phase Ib, dose-finding study) evaluated the starting dose of ruxolitinib in patients with myelofibrosis with baseline platelet counts of 50-99×109/L. The study consisted of dose-escalation and safety-expansion phases. Based on the baseline platelet counts, patients were assigned to stratum 1 (75-99×109/L) or stratum 2 (50-74×109/L), with the primary objective of determining the maximum safe starting dose (MSSD); key secondary objectives included safety and efficacy. At week 48 data cutoff (stratum 1, n=44; stratum 2, n=25), 24.6% (17 out of 69) of patients were still receiving treatment. The MSSD was established as ruxolitinib 10 mg twice daily in both strata. Thrombocytopenia [grade 4 (stratum 1, n=1; stratum 2, n=2)] was the only reported dose-limiting toxicity (study drug related) at 10 mg twice daily. In the MSSD cohort (stratum 1, n=20; stratum 2, n=18), adverse events (regardless of study drug relationship) led to treatment discontinuation in 15.0% and 33.3% of patients in stratum 1 and stratum 2, respectively, and dose adjustment/interruption in 45.0% and 66.7% of patients in stratum 1 and stratum 2, respectively. Three cases of on-treatment deaths were reported at the MSSD. Spleen response was achieved at week 48 in 33.3% and 30.0% of patients in stratum 1 and stratum 2, respectively. Improvements in the Total Symptom Score were also observed. In this study, ruxolitinib demonstrated acceptable tolerability in both the strata at the MSSD of 10 mg twice daily. (Registered at: clinicaltrials.gov identifier: 01317875).
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Affiliation(s)
- Alessandro M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero Universitaria Careggi, University of Florence, Italy
| | | | - Claire N Harrison
- Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | | | | | | | | | - Minghui Duan
- Peking Union Medical College Hospital, Beijing, China
| | | | | | | | - Heinz Gisslinger
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Austria
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26
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Ruxolitinib Rechallenge Can Improve Constitutional Symptoms and Splenomegaly in Patients With Myelofibrosis: A Case Series. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e463-e468. [DOI: 10.1016/j.clml.2018.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 12/26/2022]
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Treating early-stage myelofibrosis. Ann Hematol 2018; 98:241-253. [DOI: 10.1007/s00277-018-3526-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/12/2018] [Indexed: 01/03/2023]
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28
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Menghrajani K, Boonstra PS, Mercer JA, Perkins C, Gowin KL, Weber AA, Mesa R, Gotlib JR, Wang L, Singer JW, Talpaz M. Predictive models for splenic response to JAK-inhibitor therapy in patients with myelofibrosis. Leuk Lymphoma 2018; 60:1036-1042. [PMID: 30234400 DOI: 10.1080/10428194.2018.1509315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
JAK inhibitors for myelofibrosis (MF) reduce spleen size, control constitutional symptoms, and may improve survival. We studied the clinical characteristics of 548 MF patients treated with JAK inhibitors from 2008 to 2016 to better understand predictors of splenic response. Response was defined as a 50% decrease in spleen size at early (3-4 months on therapy) and late (5-12 months) timepoints after therapy initiation. Early response positively correlated with higher doses of JAK inhibitor, baseline spleen size 5-10 cm, and hemoglobin. Early response negatively correlated with baseline spleen size >20 cm and high WBC. The strongest predictor of late response was whether a patient had a response at the earlier timepoint (OR 8.88). Our response models suggest that clinical factors can be used to predict which patients are more likely to respond to JAK inhibitors, and those who do not achieve an early response, i.e. within 3-4 months, should consider alternative treatments.
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Affiliation(s)
- Kamal Menghrajani
- a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Philip S Boonstra
- b Department of Biostatistics , University of Michigan , Ann Arbor , MI , USA
| | - Jessica A Mercer
- a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Cecelia Perkins
- c Medicine/Hematology Stanford Cancer Institute , Stanford , CA , USA
| | - Krisstina L Gowin
- d Division of Hematology and Medical Oncology , Mayo Clinic Cancer Center , Scottsdale , AZ , USA
| | - Alissa A Weber
- a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
| | - Ruben Mesa
- d Division of Hematology and Medical Oncology , Mayo Clinic Cancer Center , Scottsdale , AZ , USA
| | - Jason R Gotlib
- c Medicine/Hematology Stanford Cancer Institute , Stanford , CA , USA
| | - Lixia Wang
- e CTI Biopharmaceuticals , Seattle , WA , USA
| | | | - Moshe Talpaz
- a Department of Internal Medicine , University of Michigan , Ann Arbor , MI , USA
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Talpaz M, Erickson-Viitanen S, Hou K, Hamburg S, Baer MR. Evaluation of an alternative ruxolitinib dosing regimen in patients with myelofibrosis: an open-label phase 2 study. J Hematol Oncol 2018; 11:101. [PMID: 30086777 PMCID: PMC6081850 DOI: 10.1186/s13045-018-0642-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/18/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Ruxolitinib improves splenomegaly and symptoms in patients with intermediate-2 or high-risk myelofibrosis; however, nearly half develop grade 3/4 anemia and/or thrombocytopenia, necessitating dose reductions and/or transfusions. We report findings from an open-label phase 2 study exploring a dose-escalation strategy aimed at preserving clinical benefit while reducing hematological adverse events early in ruxolitinib treatment. METHODS Patients with myelofibrosis received ruxolitinib 10 mg twice daily (BID), with incremental increases of 5 mg BID at weeks 12 and 18 for lack of efficacy (maximum, 20 mg BID). Symptom severity was measured using the Myelofibrosis Symptom Assessment Form Total Symptom Score (MFSAF TSS). RESULTS Forty-five patients were enrolled, 68.9% of whom had a Dynamic International Prognostic Scoring System score of 1 to 2 (i.e., intermediate-1 disease risk). Median percentage change in spleen volume from baseline to week 24 was - 17.3% (≥ 10% reduction achieved by 26 patients [57.8%]), with a clear dose response. Median percentage change in MFSAF TSS from baseline at week 24 was - 45.6%, also with a dose response. The most frequent treatment-emergent adverse events were anemia (26.7%), fatigue (22.2%), and arthralgias (20.0%). Grade 3/4 anemia (20.0%) and dose decreases due to anemia (11.1%) or thrombocytopenia (6.7%) were infrequent. CONCLUSIONS A dose-escalation approach may mitigate worsening anemia during early ruxolitinib therapy in some patients with myelofibrosis. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01445769 . Registered September 23, 2011.
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Affiliation(s)
| | | | - Kevin Hou
- Incyte Corporation, Wilmington, DE, USA
| | - Solomon Hamburg
- Tower Hematology Oncology Medical Group, Beverly Hills, CA, USA
| | - Maria R Baer
- University of Maryland, Greenebaum Comprehensive Cancer Center, 22 S. Greene St, Baltimore, MD, 21201, USA.
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Krauth MT, Burgstaller S, Buxhofer-Ausch V, Gastl G, Geissler K, Keil F, Krippl P, Melchardt T, Petzer A, Rumpold H, Sliwa T, Wöhrer S, Wölfler A, Gisslinger H. Ruxolitinib therapy for myelofibrosis in Austria : Consensus on therapy management. Wien Klin Wochenschr 2018; 130:495-504. [PMID: 30043249 PMCID: PMC6132876 DOI: 10.1007/s00508-018-1365-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/04/2018] [Indexed: 12/19/2022]
Abstract
The oral Janus associated kinase (JAK1/2) inhibitor ruxolitinib has been available for treatment of patients with intermediate or high-risk myelofibrosis in Europe since 2012. Since its introduction, the expertise of prescribing doctors with respect to ruxolitinib function, efficacy and adverse effects has consistently been augmented, resulting in therapy modalities that are better tailored to individual patients as well as in increased safety of the treatment. The present consensus on ruxolitinib therapy management has been elaborated by Austrian experts in myeloproliferative neoplasms in line with international treatment guidelines. Our recommendations aim to contribute to an improved management of patients with myelofibrosis treated with ruxolitinib.
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Affiliation(s)
- Maria-Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria.
| | - Sonja Burgstaller
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | - Günther Gastl
- Department of Internal Medicine V, Division Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Geissler
- Fifth Medical Department, Hospital Hietzing, Vienna, Austria
| | - Felix Keil
- Third Medical Department, Hanusch Hospital, Vienna, Austria
| | - Peter Krippl
- Department of Internal Medicine, LKH Fürstenfeld, Krankenhausverbund Feldbach, Fürstenfeld, Austria
| | - Thomas Melchardt
- Third Medical Department, Division Hematology and Medical Oncology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Andreas Petzer
- Department of Internal Medicine I, Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | - Holger Rumpold
- Internal Medicine II, Medical Oncology, Hematology, Gastroenterology and Rheumatology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Thamer Sliwa
- Third Medical Department, Hanusch Hospital, Vienna, Austria
| | - Stefan Wöhrer
- Permedio Center for Personalized Medicine and Sanatorium Hera Vienna, Vienna, Austria
| | - Albert Wölfler
- Division of Hematology, Medical University of Graz, Graz, Austria
| | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
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Treatment With JAK Inhibitors in Myelofibrosis Patients Nullifies the Prognostic Impact of Unfavorable Cytogenetics. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e201-e210. [PMID: 29574002 DOI: 10.1016/j.clml.2018.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/26/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In the era before Janus kinase (JAK) inhibitors, cytogenetic information was used to predict survival in myelofibrosis patients. However, the prognostic value of cytogenetics in the setting of JAK inhibitor therapy remains unknown. PATIENTS AND METHODS We performed a retrospective analysis of 180 patients with bone marrow biopsy-proven myelofibrosis from 3 US academic medical centers. We fit Cox proportional hazards models for overall survival and transformation-free survival on the bases of 3 factors: JAK inhibitor therapy as a time-dependent covariate, dichotomized cytogenetic status (favorable vs. unfavorable), and statistical interaction between the two. The median follow-up time was 37.1 months. RESULTS Among patients treated with best available therapy, unfavorable cytogenetic status was associated with decreased survival (hazard ratio = 2.31; P = .025). At initiation of JAK inhibitor therapy, unfavorable cytogenetics was (nonsignificantly) associated with increased survival compared to favorable cytogenetics (hazard ratio = 0.292; P = .172). The ratio of hazard ratios was 0.126 (P = .034). These findings were similar after adjusting for standard clinical prognostic factors as well as when measured against transformation-free survival. CONCLUSION The initiation of JAK inhibitor therapy appears to change the association between cytogenetics and overall survival. There was little difference in survival between treatment types in patients with favorable cytogenetics. However, the use of JAK inhibitor therapy among patients with unfavorable cytogenetics was not associated with worse survival compared to favorable cytogenetics. Our analyses suggest that initiation of JAK inhibitor therapy nullifies the negative prognostic implication of unfavorable cytogenetics established in the pre-JAK inhibitor therapy era.
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Jin J, Du X, Zhou DB, Li JM, Li JY, Hou M, Liu T, Wu DP, Hu Y, Xiao ZJ. [Efficacy and safety of JAK inhibitor ruxolitinib in Chinese patients with myelofibrosis: results of a 1-year follow-up of A2202]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 37:858-863. [PMID: 27801315 PMCID: PMC7364878 DOI: 10.3760/cma.j.issn.0253-2727.2016.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
目的 评价芦可替尼在中国骨髓纤维化患者中的疗效和安全性。 方法 63例中国骨髓纤维化患者纳入研究,男32例,女31例,中位年龄55(25~79)岁。芦可替尼起始剂量:基线PLT(100~200)×109/L者(25例)30 mg/d,基线PLT>200×109/L者(38例)40 mg/d。使用MRI/CT、欧洲癌症研究与治疗组织生活质量调查问卷核心30(EORTC QLQ-C30)和骨髓纤维化症状评估表(MFSAF)v2.0对患者进行脾脏体积、生活质量和症状评估。 结果 截至12个月随访结束,47例(74.6%)患者仍在继续治疗,25例(39.7%)患者脾脏体积较基线缩小超过35%,首次达到脾脏体积缩小≥35%的中位时间为12.71(95%CI 12.14~35.00)周。治疗期间,85.7%(54/63)的患者有不同程度的脾脏缩小,中位最佳脾脏体积缩小百分比为35.5%,48周时中位脾脏缩小体积为34.7%。治疗48周时53.1 %(26/49)的患者MFSAF症状评分降低超过50%,生活质量得到改善。最常见的血液学不良事件包括贫血和血小板计数降低,但极少造成停药。非血液学不良事件以1/2级为主。 结论 芦可替尼使中国骨髓纤维化患者的脾脏体积获得持续缩小、症状改善,不良反应可耐受。
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Z J Xiao
- Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, the State Key Laboratory of Experimental Hematology, Tianjin 300020, China
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Kvasnicka HM, Thiele J, Bueso-Ramos CE, Sun W, Cortes J, Kantarjian HM, Verstovsek S. Long-term effects of ruxolitinib versus best available therapy on bone marrow fibrosis in patients with myelofibrosis. J Hematol Oncol 2018; 11:42. [PMID: 29544547 PMCID: PMC5856218 DOI: 10.1186/s13045-018-0585-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myelofibrosis (MF) is a life-shortening complication of myeloproliferative neoplasms associated with ineffective hematopoiesis, splenomegaly, and progressive bone marrow (BM) fibrosis. The oral Janus kinase (JAK) 1/JAK2 inhibitor ruxolitinib has been shown to improve splenomegaly, symptom burden, and overall survival in patients with intermediate-2 or high-risk MF compared with placebo or best available therapy (BAT). METHODS The effects of ruxolitinib therapy for up to 66 months on BM morphology in 68 patients with advanced MF with variable BM fibrosis grade were compared with those in 192 matching patients treated with BAT. Available trephine biopsies underwent independent, blinded review by three hematopathologists for consensus-based adjudication of grades for reticulin fibrosis, collagen deposition, and osteosclerosis. RESULTS Ruxolitinib treatment versus BAT was associated with greater odds of BM fibrosis improvement or stabilization and decreased odds of BM fibrosis worsening based on changes from baseline in reticulin fibrosis grade. Generally, these changes were accompanied by a sustained higher level of individual spleen size reduction and regression of leukoerythroblastosis. Patients with more advanced baseline fibrosis showed lower spleen size response. CONCLUSIONS The finding that long-term ruxolitinib therapy may reverse or markedly delay BM fibrosis progression in advanced MF suggests that sustained JAK inhibition may be disease-modifying. TRIAL REGISTRATION INCB18424-251, ClinicalTrials.gov identifier NCT00509899 .
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Affiliation(s)
- Hans Michael Kvasnicka
- Senckenberg Institute of Pathology, University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | | | - Carlos E Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jorge Cortes
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Rocca S, Carrà G, Poggio P, Morotti A, Brancaccio M. Targeting few to help hundreds: JAK, MAPK and ROCK pathways as druggable targets in atypical chronic myeloid leukemia. Mol Cancer 2018; 17:40. [PMID: 29455651 PMCID: PMC5817721 DOI: 10.1186/s12943-018-0774-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/01/2018] [Indexed: 12/19/2022] Open
Abstract
Atypical Chronic Myeloid Leukemia (aCML) is a myeloproliferative neoplasm characterized by neutrophilic leukocytosis and dysgranulopoiesis. From a genetic point of view, aCML shows a heterogeneous mutational landscape with mutations affecting signal transduction proteins but also broad genetic modifiers and chromatin remodelers, making difficult to understand the molecular mechanisms causing the onset of the disease. The JAK-STAT, MAPK and ROCK pathways are known to be responsible for myeloproliferation in physiological conditions and to be aberrantly activated in myeloproliferative diseases. Furthermore, experimental evidences suggest the efficacy of inhibitors targeting these pathways in repressing myeloproliferation, opening the way to deep clinical investigations. However, the activation status of these pathways is rarely analyzed when genetic mutations do not occur in a component of the signaling cascade. Given that mutations in functionally unrelated genes give rise to the same pathology, it is tempting to speculate that alteration in the few signaling pathways mentioned above might be a common feature of pathological myeloproliferation. If so, targeted therapy would be an option to be considered for aCML patients.
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Affiliation(s)
- Stefania Rocca
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126, Torino, Italy
| | - Giovanna Carrà
- Department of Clinical and Biological Sciences, University of Torino, 10043, Orbassano, Italy
| | - Pietro Poggio
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126, Torino, Italy
| | - Alessandro Morotti
- Department of Clinical and Biological Sciences, University of Torino, 10043, Orbassano, Italy
| | - Mara Brancaccio
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126, Torino, Italy.
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Bose P, Gotlib J, Harrison CN, Verstovsek S. SOHO State-of-the-Art Update and Next Questions: MPN. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2018; 18:1-12. [PMID: 29277359 PMCID: PMC5915302 DOI: 10.1016/j.clml.2017.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022]
Abstract
The discovery of the activating Janus kinase (JAK)2V617F mutation in 2005 in most patients with the classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) spurred intense interest in research into these disorders, culminating in the identification of activating mutations in MPL in 2006 and indels in the gene encoding calreticulin (CALR) in 2013, thus providing additional mechanistic explanations for the universal activation of JAK-signal transducer and activator of transcription (JAK-STAT) observed in these conditions, and the success of the JAK1/2 inhibitor ruxolitinib, which first received regulatory approval in 2011. The field has continued to advance rapidly since then, and the past 2 years have witnessed important changes to the classification of MPN and diagnostic criteria for polycythemia vera (PV), novel insights into the mechanisms of bone marrow fibrosis in primary myelofibrosis (PMF), increasing appreciation of the biologic differences between essential thrombocythemia (ET), prefibrotic and overt PMF, and between primary and post-PV/ET myelofibrosis (MF). Additionally, the mechanisms through which mutant CALR drives JAK-STAT pathway activation and oncogenic transformation are now better understood. Although mastocytosis is no longer included under the broad heading of MPN in the 2016 revision to the World Health Organization classification, an important milestone in mastocytosis research was reached in 2017 with the regulatory approval of midostaurin for patients with advanced systemic mastocytosis (AdvSM). In this article, we review the major recent developments in the areas of PV, ET, and MF, and also briefly summarize the literature on midostaurin and other KIT inhibitors for patients with AdvSM.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Jason Gotlib
- Department of Medicine - Hematology, Stanford University, Palo Alto, CA
| | | | - Srdan Verstovsek
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX
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Dioverti MV, Abu Saleh OM, Tande AJ. Infectious complications in patients on treatment with Ruxolitinib: case report and review of the literature. Infect Dis (Lond) 2017; 50:381-387. [DOI: 10.1080/23744235.2017.1390248] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | | | - Aaron J. Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
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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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Bose P, Verstovsek S. JAK2 inhibitors for myeloproliferative neoplasms: what is next? Blood 2017; 130:115-125. [PMID: 28500170 PMCID: PMC5510786 DOI: 10.1182/blood-2017-04-742288] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/06/2017] [Indexed: 12/11/2022] Open
Abstract
Since its approval in 2011, the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib has evolved to become the centerpiece of therapy for myelofibrosis (MF), and its use in patients with hydroxyurea resistant or intolerant polycythemia vera (PV) is steadily increasing. Several other JAK2 inhibitors have entered clinical testing, but none have been approved and many have been discontinued. Importantly, the activity of these agents is not restricted to patients with JAK2 V617F or exon 12 mutations. Although JAK2 inhibitors provide substantial clinical benefit, their disease-modifying activity is limited, and rational combinations with other targeted agents are needed, particularly in MF, in which survival is short. Many such combinations are being explored, as are other novel agents, some of which could successfully be combined with JAK2 inhibitors in the future. In addition, new JAK2 inhibitors with the potential for less myelosuppression continue to be investigated. Given the proven safety and efficacy of ruxolitinib, it is likely that ruxolitinib-based combinations will be a major way forward in drug development for MF. If approved, less myelosuppressive JAK2 inhibitors such as pacritinib or NS-018 could prove to be very useful additions to the therapeutic armamentarium in MF. In PV, inhibitors of histone deacetylases and human double minute 2 have activity, but their role, if any, in the future treatment algorithm is uncertain, given the availability of ruxolitinib and renewed interest in interferons. Ruxolitinib is in late-phase clinical trials in essential thrombocythemia, in which it could fill an important void for patients with troublesome symptoms.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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Clonal evolution and outcomes in myelofibrosis after ruxolitinib discontinuation. Blood 2017; 130:1125-1131. [PMID: 28674026 DOI: 10.1182/blood-2017-05-783225] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/17/2017] [Indexed: 01/14/2023] Open
Abstract
Despite significant improvements in the signs and symptoms of myelofibrosis (MF), and possible prolongation of patients' survival, some have disease that is refractory to ruxolitinib and many lose their response over time. Furthermore, patients with ≥3 mutations are less likely to respond to ruxolitinib. Here we describe outcomes after ruxolitinib discontinuation in MF patients enrolled in a phase 1/2 study at our center. After a median follow-up of 79 months, 86 patients had discontinued ruxolitinib (30 of whom died while on therapy). The median follow-up after ruxolitinib discontinuation for the remaining 56 patients was 32 months, with median survival after discontinuation of 14 months. Platelets <260 × 109/L at the start of therapy or <100 × 109/L at the time of discontinuation were associated with shorter survival after discontinuation. Of 62 patients with molecular data at baseline and follow-up, 22 (35%) acquired a new mutation while receiving ruxolitinib (14 [61%] in ASXL1). Patients showing clonal evolution had significantly shorter survival after discontinuation (6 vs 16 months). Transfusion dependency was the only clinical variable associated with clonal evolution. These findings underscore the need for novel therapies and suggest that clonal evolution or decreasing platelet counts while on ruxolitinib therapy may be markers of poor prognosis.
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Saeed I, McLornan D, Harrison CN. Managing side effects of JAK inhibitors for myelofibrosis in clinical practice. Expert Rev Hematol 2017; 10:617-625. [PMID: 28571503 DOI: 10.1080/17474086.2017.1337507] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by bone marrow fibrosis, abnormalities in peripheral counts, extramedullary hematopoiesis, splenomegaly and an increased risk of transformation to acute myeloid leukaemia. The disease course is often heterogeneous and management can range from observation alone through to allogeneic stem cell transplantation. As of 2017, the only approved medication for MF remains the JAK Inhibitor (JAKi), ruxolitinib (Novartis Pharmaceuticals, Basel, Switzerland; Incyte, Wilmington, Detroit, USA) although several others have reached advanced stages of clinical trials. Areas covered: In this review, we focus on the management of both common and uncommon side effects arising from the use of currently approved and clinical trial JAKi. Most of the discussion concerns ruxolitinib although we also cover both pacritinib (CTI BioPharma) and momelotinib (Gilead Sciences, Foster City, California) which have been in recent large, multinational phase III trials. The various approaches to management of JAKi-related side effects are discussed - with particular emphasis to anaemia, thrombocytopaenia and infection risk. Expert commentary: JAK inhibitors are effective in many individuals with MF and have revolutionized the current treatment paradigm. The side effect profile, in the most, is predictable and manageable with high degrees of clinical surveillance and dose modifications.
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Affiliation(s)
- Iram Saeed
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
| | - Donal McLornan
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK.,b Department of Haematology , Guy's and St Thomas' NHS Foundation Trust , London , UK
| | - Claire N Harrison
- a Department of Haematological Medicine , King's College Hospital NHS Foundation Trust , London , UK
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Abstract
Myeloproliferative neoplasms are driven by activated JAK2 signaling due to somatic mutations in JAK2, the thrombopoietin receptor MPL or the chaperone calreticulin in hematopoietic stem/progenitor cells. JAK2 inhibitors have been developed, but despite clinical benefits, they do not signficantly reduce the mutant clone. Loss of response to JAK2 inhibitors occurs and several mechanisms of resistance, genetic and functional, have been identified. Resistance mutations have not been reported in MPN patients suggesting incomplete target inhibition. Alternative targeting of JAK2 by HSP90 inhibitors or type II JAK2 inhibition overcomes resistance to current JAK2 inhibitors. Additional combined therapy approaches are currently being evaluated.
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Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by bone marrow fibrosis with subsequent extramedullary hematopoiesis and abnormal cytokine expression leading to splenomegaly, constitutional symptoms and cytopenias. The discovery of the JAK2 V617F mutation in the majority of MF patients has been followed by significant progress in drug development for MF. Areas covered: In this article, we review advances in the understanding of the underlying disease biology, prognostic assessment and therapeutic modalities for MF. We provide clinical trial evidence behind using the JAK2 inhibitor ruxolitinib, erythropoiesis stimulating agents, androgens, immunomodulatory drugs, interferon, cytoreductive drugs and hypomethylating agents in MF. Finally, we review novel therapeutic options for MF including the new JAK1/2 inhibitors, ruxolitinib based combination approaches as well as novel therapeutic agents. Expert commentary: Despite significant reduction of splenomegaly and improvement of symptom burden and a signal for survival improvement, ruxolitinib does not lead to major reductions in JAK2 V617F allele burden and bone marrow fibrosis. No ruxolitinib-based combination approach has so far demonstrated superiority over ruxolitinib monotherapy. The novel JAK2 inhibitors pacritinib and momelotinib, other JAK inhibitors, telomerase inhibitors, anti-fibrosis agents and hsp90 inhibitors are in different stages of development.
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Affiliation(s)
- Maximilian Stahl
- a Yale University School of Medicine , Department of Internal Medicine, Section of Hematology and the Yale Cancer Center , New Haven , CT , USA
| | - Amer M Zeidan
- a Yale University School of Medicine , Department of Internal Medicine, Section of Hematology and the Yale Cancer Center , New Haven , CT , USA
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Vercellino L, Ouvrier MJ, Barré E, Cassinat B, de Beco V, Dosquet C, Chevret S, Meignin V, Chomienne C, Toubert ME, Merlet P, Kiladjian JJ. Assessing Bone Marrow Activity in Patients with Myelofibrosis: Results of a Pilot Study of 18F-FLT PET. J Nucl Med 2017; 58:1603-1608. [PMID: 28360204 DOI: 10.2967/jnumed.116.188508] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/20/2017] [Indexed: 11/16/2022] Open
Abstract
An emerging noninvasive approach to assess tissue proliferation uses the PET tracer 3'-deoxy-3'-18F-fluorothymidine (18F-FLT). To evaluate the diagnostic value of this technique in myelofibrosis, 18F-FLT PET imaging results were compared with bone marrow histology and bone marrow scintigraphy (BMS), the gold standard techniques in this clinical situation. Methods: Fifteen patients with histology-proven myelofibrosis were included consecutively in the study. Tracers' distributions were assessed using a visual grading assessment score of the uptake in the axial skeleton, proximal and distal limbs, liver, and spleen. This visual score was used to define patterns of tracer distribution and to compare the information provided either by PET or by BMS. A semiquantitative analysis with determination of SUVmax in the same localizations was performed for 18F-FLT PET. Results: The histology grade of fibrosis correlated with the SUVmax in the axial skeleton (spine and iliac crests) and proximal limbs. 18F-FLT uptake in these areas was much lower in patients with grade 3 fibrosis than in patients with grade 1 or 2 fibrosis. 18F-FLT PET showed the same distribution of uptake as BMS in 13 of 14 patients (1 patient did not undergo BMS). In 1 patient, 18F-FLT PET clearly showed an intense abnormal splenic uptake, whereas spleen uptake was inconclusive with BMS. Conclusion:18F-FLT PET appears to be a reliable and convenient technique to assess hematopoietic activity in bone marrow. It yields results close to those observed with BMS. In our study population, 18F-FLT uptake in the axial skeleton and proximal limbs assessed by SUVmax correlated with the grade of fibrosis. Thus, 18F-FLT PET may be a useful tool to measure the severity of myelofibrosis, and to monitor noninvasively the patients' status during follow-up. Finally, 18F-FLT PET may be foreseen as an alternative to BMS.
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Affiliation(s)
- Laetitia Vercellino
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Matthieu John Ouvrier
- Service de Médecine Nucléaire, Hôpital Avicenne, Assistance-Publique Hôpitaux de Paris, Bobigny, France
| | - Emmanuelle Barré
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Bruno Cassinat
- Unité de Biologie Cellulaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Virginie de Beco
- Service de Médecine Nucléaire, Hôpital Avicenne, Assistance-Publique Hôpitaux de Paris, Bobigny, France
| | - Christine Dosquet
- Unité de Biologie Cellulaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Sylvie Chevret
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France.,Université Paris-Diderot (Paris 7), Paris, France
| | - Véronique Meignin
- Service d'Anatomo-Pathologie, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France; and
| | - Christine Chomienne
- Unité de Biologie Cellulaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France.,Université Paris-Diderot (Paris 7), Paris, France
| | - Marie-Elisabeth Toubert
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - Pascal Merlet
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris, France.,Université Paris-Diderot (Paris 7), Paris, France
| | - Jean-Jacques Kiladjian
- Université Paris-Diderot (Paris 7), Paris, France.,Centre d'Investigations Cliniques, Hôpital Saint-Louis, Assistance-Publique Hôpitaux de Paris France, Paris, France
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Wade R, Hodgson R, Biswas M, Harden M, Woolacott N. A Review of Ruxolitinib for the Treatment of Myelofibrosis: A Critique of the Evidence. PHARMACOECONOMICS 2017; 35:203-213. [PMID: 27592020 DOI: 10.1007/s40273-016-0447-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
As part of the National Institute for Health and Care Excellence's (NICE) Single Technology Appraisal (STA) process, ruxolitinib was assessed to determine the clinical and cost effectiveness of its use in the treatment of disease-related splenomegaly or symptoms in adults with myelofibrosis. Ruxolitinib had previously been assessed as part of the STA process and was not recommended in NICE guidance issued in June 2013 (TA289). A review of TA289 was commissioned following the availability of new longer-term survival data; a price discount patient access scheme (PAS) was also introduced. The Centre for Reviews and Dissemination (CRD) and Centre for Health Economics (CHE) Technology Appraisal Group at the University of York was commissioned to act as the independent Evidence Review Group (ERG). This article provides a summary of the manufacturer or sponsor of the technology's (referred to as the company) submission, the ERG review and the resulting NICE guidance issued in March 2016. The main clinical effectiveness data were derived from two good-quality multicentre randomised controlled trials (RCTs): COMFORT-II compared ruxolitinib with best available therapy (BAT) and COMFORT-I compared ruxolitinib with placebo. Both RCTs demonstrated a statistically significant reduction in splenomegaly and its associated symptoms in intermediate-2 and high-risk myelofibrosis patients. Overall survival was statistically significantly improved with ruxolitinib compared with BAT at 3.5 years of follow-up in the COMFORT-II trial (hazard ratio 0.58, 95 % CI 0.36-0.93). Grade 3-4 adverse events were more frequent in the ruxolitinib group than in the BAT group; 42 % compared with 25 %. Evidence relating to patients with lower-risk disease or low platelet counts (50-100 × 109/L) was less robust. The company's economic model was well-presented and had an appropriate model structure. The base-case incremental cost-effectiveness ratio (ICER) was estimated to be around £45,000 per quality-adjusted life-year (QALY) gained (including the PAS discount). Extensive sensitivity and scenario analyses were presented, demonstrating that the estimated ICER was robust to a range of input values and assumptions made in the model. Alternative scenarios presented by the ERG showed only modest increases in the estimated ICER, primarily as a result of including an element of drug wastage within the model. Alternative scenarios resulted in estimated ICERs ranging from around £45,000 to £49,000 per QALY gained (including the PAS discount). At the first appraisal meeting, the NICE Appraisal Committee concluded that ruxolitinib was clinically effective and was a cost effective use of National Health Service (NHS) resources for patients with high-risk myelofibrosis who meet NICE's end-of-life criteria. Following the consultation, the company offered a revised PAS, resulting in a revised base-case ICER of £31,229 per QALY gained. The company also presented new evidence on the cost effectiveness of ruxolitinib in intermediate-2 and high-risk subgroups and a revised version of the model. The NICE Appraisal Committee considered the new evidence and recommended ruxolitinib for the treatment of patients with intermediate-2-risk disease as well as patients with high-risk disease, based on International Prognostic Scoring System (IPSS) prognostic factors.
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Affiliation(s)
- Ros Wade
- Centre for Reviews and Dissemination (CRD), University of York, York, YO10 5DD, UK.
| | - Robert Hodgson
- Centre for Reviews and Dissemination (CRD), University of York, York, YO10 5DD, UK
| | - Mousumi Biswas
- Centre for Reviews and Dissemination (CRD), University of York, York, YO10 5DD, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination (CRD), University of York, York, YO10 5DD, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination (CRD), University of York, York, YO10 5DD, UK
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Mesa RA, Passamonti F. Individualizing Care for Patients With Myeloproliferative Neoplasms: Integrating Genetics, Evolving Therapies, and Patient-Specific Disease Burden. Am Soc Clin Oncol Educ Book 2017; 35:e324-35. [PMID: 27249739 DOI: 10.1200/edbk_159322] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Individualized medicine is important for patients with myeloproliferative neoplasms (MPNs), including essential thrombocythemia, polycythemia vera, and myelofibrosis, which are heterogeneous in terms of genetic mutation profile, prognosis, disease burden, and symptoms. Status of MPN driver mutations in JAK2, CALR, and MPL (or lack of one of these mutations) and other myeloid mutations (ASXL1, SRSF2, CBL, and IDH1/2, among others) affects diagnosis and prognosis. Management begins with estimating the prognosis, disease burden including MPN symptoms, and prevention of vascular events. Allogeneic stem cell transplantation is the definitive therapy in a subset of patients with myelofibrosis, the majority of whom receive JAK inhibition with ruxolitinib to relieve splenomegaly and symptoms and to prolong survival. Ruxolitinib is now a second-line therapy in polycythemia vera, with pegylated interferon being evaluated as a potential front-line therapy compared with hydroxyurea. The therapeutic landscape is evolving to include new JAK inhibitors, which may affect cytopenias (pacritinib and momelotinib), combination therapies including ruxolitinib, and novel targets such as pentraxin and telomerase. Assessing the therapeutic efficacy (including symptom impact) and toxicity of these new approaches is necessary to determine longitudinal management of MPNs in clinical practice and is a key component of "individualizing" care for patients with MPNs.
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Affiliation(s)
- Ruben A Mesa
- From the Mayo Clinic Cancer Center, Phoenix, AZ; Division of Hematology, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Francesco Passamonti
- From the Mayo Clinic Cancer Center, Phoenix, AZ; Division of Hematology, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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Ikeda K, Ueda K, Sano T, Ogawa K, Ikezoe T, Hashimoto Y, Morishita S, Komatsu N, Ohto H, Takeishi Y. The Amelioration of Myelofibrosis with Thrombocytopenia by a JAK1/2 Inhibitor, Ruxolitinib, in a Post-polycythemia Vera Myelofibrosis Patient with a JAK2 Exon 12 Mutation. Intern Med 2017; 56:1705-1710. [PMID: 28674362 PMCID: PMC5519475 DOI: 10.2169/internalmedicine.56.7871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Less than 5% of patients with polycythemia vera (PV) show JAK2 exon 12 mutations. Although PV patients with JAK2 exon 12 mutations are known to develop post-PV myelofibrosis (MF) as well as PV with JAK2V617F, the role of JAK inhibitors in post-PV MF patients with JAK2 exon 12 mutations remains unknown. We describe how treatment with a JAK1/2 inhibitor, ruxolitinib, led to the rapid amelioration of marrow fibrosis, erythrocytosis and thrombocytopenia in a 77-year-old man with post-PV MF who carried a JAK2 exon 12 mutation (JAK2H538QK539L). This case suggests that ruxolitinib is a treatment option for post-PV MF in patients with thrombocytopenia or JAK2 exon 12 mutations.
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Affiliation(s)
- Kazuhiko Ikeda
- Department of Hematology, Fukushima Medical University, Japan
- Department of Transfusion and Transplantation Immunology, Fukushima Medical University, Japan
| | - Koki Ueda
- Department of Hematology, Fukushima Medical University, Japan
| | - Takahiro Sano
- Department of Hematology, Fukushima Medical University, Japan
| | - Kazuei Ogawa
- Department of Hematology, Fukushima Medical University, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Japan
| | - Yuko Hashimoto
- Department of Pathology and Diagnostic Pathology, Fukushima Medical University, Japan
| | - Soji Morishita
- Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University Graduate School of Medicine, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Japan
| | - Hitoshi Ohto
- Department of Transfusion and Transplantation Immunology, Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
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Does ruxolitinib prolong the survival of patients with myelofibrosis? Blood 2016; 129:832-837. [PMID: 28031182 DOI: 10.1182/blood-2016-11-731604] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 12/23/2016] [Indexed: 12/16/2022] Open
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Lancman G, Mascarenhas J. Should we be treating lower risk myelofibrosis patients with a JAK2 inhibitor? Expert Rev Hematol 2016; 10:23-28. [DOI: 10.1080/17474086.2017.1264268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Guido Lancman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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Usefulness of Low-Dose Splenic Irradiation prior to Reduced-Intensity Conditioning Regimen for Hematopoietic Stem Cell Transplantation in Elderly Patients with Myelofibrosis. Case Rep Hematol 2016; 2016:8751329. [PMID: 27840748 PMCID: PMC5093251 DOI: 10.1155/2016/8751329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 09/21/2016] [Accepted: 09/29/2016] [Indexed: 01/30/2023] Open
Abstract
The Janus kinase (JAK) 1 and 2 inhibitor, ruxolitinib, was recently approved in Japan and has been effective in many patients with myelofibrosis (MF). Although the inhibitor decreases splenomegaly and relieves MF-related symptoms, allogeneic hematopoietic cell transplantation (HCT) remains as the only curative therapy for MF. The presence of splenomegaly has been reported as a risk factor for graft failure, delayed engraftment, and poor survival. Here, we report two elderly MF patients with massive splenomegaly and a JAK2 V617F mutation. These patients underwent splenic irradiation to decrease splenomegaly prior to HCT with a reduced-intensity conditioning (RIC) regimen. Massive splenomegaly gradually decreased by 4 Gy splenic irradiation. The subsequent RIC regimen involved 4 Gy total body irradiation and fludarabine and intravenous busulfan. In both patients, engraftment failure did not occur, and complete remission was achieved. The splenomegaly decreased, and MF-related symptoms were resolved. Furthermore, the JAK2 V617F mutation disappeared, and fibrosis in the bone marrow regressed. We suggest that splenic irradiation prior to the RIC regimen for HCT in elderly MF patients with massive splenomegaly is safe. Furthermore, the HCT protocols with splenic irradiation should be considered for patients who have not shown clinical benefits to optimal medical management such as treatment with ruxolitinib.
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