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Vincelette ND, Yu X, Kuykendall AT, Moon J, Su S, Cheng CH, Sammut R, Razabdouski TN, Nguyen HV, Eksioglu EA, Chan O, Al Ali N, Patel PC, Lee DH, Nakanishi S, Ferreira RB, Hyjek E, Mo Q, Cory S, Lawrence HR, Zhang L, Murphy DJ, Komrokji RS, Lee D, Kaufmann SH, Cleveland JL, Yun S. Trisomy 8 Defines a Distinct Subtype of Myeloproliferative Neoplasms Driven by the MYC-Alarmin Axis. Blood Cancer Discov 2024:745193. [PMID: 38713018 DOI: 10.1158/2643-3230.bcd-23-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/16/2024] [Accepted: 05/06/2024] [Indexed: 05/08/2024] Open
Abstract
Despite advances in understanding the genetic abnormalities in myeloproliferative neoplasms (MPNs) and the development of JAK2 inhibitors, there is an urgent need to devise new treatment strategies, particularly for triple negative myelofibrosis (MF) patients who lack mutations in the JAK2 kinase pathway and have very poor clinical outcomes. Here we report that MYC copy number gain and increased MYC expression frequently occur in triple negative MF, and that MYC-directed activation of S100A9, an alarmin protein that plays pivotal roles in inflammation and innate immunity, is necessary and sufficient to drive development and progression of MF. Notably, the MYC-S100A9 circuit provokes a complex network of inflammatory signaling that involves numerous hematopoietic cell types in the bone marrow microenvironment. Accordingly, genetic ablation of S100A9 or treatment with small molecules targeting the MYC-S100A9 pathway effectively ameliorates MF phenotypes, highlighting the MYC-alarmin axis as a novel therapeutic vulnerability for this subgroup of MPNs.
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Affiliation(s)
- Nicole D Vincelette
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, United States
| | - Xiaoqing Yu
- Moffitt Cancer Center, Tampa, FL, United States
| | | | | | - Siyuan Su
- University of Illinois at Chicago, United States
| | - Chia-Ho Cheng
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | | | | | - Hai Vu Nguyen
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | | | - Onyee Chan
- Moffitt Cancer Center, Tampa, United States
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, United States
| | | | - Dae Hyun Lee
- University of South Florida, Tampa, FL, United States
| | | | | | | | - Qianxing Mo
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, United States
| | - Suzanne Cory
- Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | | | - Ling Zhang
- Moffitt Cancer Center, Tampa, Florida, United States
| | | | | | - Daesung Lee
- University of Illinois at Chicago, Chicago, IL, United States
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Pandey G, Mazzacurati L, Rowsell TM, Horvat NP, Amin NE, Zhang G, Akuffo AA, Colin-Leitzinger CM, Haura EB, Kuykendall AT, Zhang L, Epling-Burnette PK, Reuther GW. SHP2 inhibition displays efficacy as a monotherapy and in combination with JAK2 inhibition in preclinical models of myeloproliferative neoplasms. Am J Hematol 2024. [PMID: 38440831 DOI: 10.1002/ajh.27282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/30/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024]
Abstract
Myeloproliferative neoplasms (MPNs), including polycythemia vera, essential thrombocytosis, and primary myelofibrosis, are clonal hematopoietic neoplasms driven by mutationally activated signaling by the JAK2 tyrosine kinase. Although JAK2 inhibitors can improve MPN patients' quality of life, they do not induce complete remission as disease-driving cells persistently survive therapy. ERK activation has been highlighted as contributing to JAK2 inhibitor persistent cell survival. As ERK is a component of signaling by activated RAS proteins and by JAK2 activation, we sought to inhibit RAS activation to enhance responses to JAK2 inhibition in preclinical MPN models. We found the SHP2 inhibitor RMC-4550 significantly enhanced growth inhibition of MPN cell lines in combination with the JAK2 inhibitor ruxolitinib, effectively preventing ruxolitinib persistent growth, and the growth and viability of established ruxolitinib persistent cells remained sensitive to SHP2 inhibition. Both SHP2 and JAK2 inhibition diminished cellular RAS-GTP levels, and their concomitant inhibition enhanced ERK inactivation and increased apoptosis. Inhibition of SHP2 inhibited the neoplastic growth of MPN patient hematopoietic progenitor cells and exhibited synergy with ruxolitinib. RMC-4550 antagonized MPN phenotypes and increased survival of an MPN mouse model driven by MPL-W515L. The combination of RMC-4550 and ruxolitinib, which was safe and tolerated in healthy mice, further inhibited disease compared to ruxolitinib monotherapy, including extending survival. Given SHP2 inhibitors are undergoing clinical evaluation in patients with solid tumors, our preclinical findings suggest that SHP2 is a candidate therapeutic target with potential for rapid translation to clinical assessment to improve current targeted therapies for MPN patients.
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Affiliation(s)
- Garima Pandey
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Lucia Mazzacurati
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Tegan M Rowsell
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Nathan P Horvat
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Narmin E Amin
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Guolin Zhang
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Afua A Akuffo
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Eric B Haura
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Ling Zhang
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Gary W Reuther
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, Florida, USA
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Kuykendall AT, Ball S, Mora B, Mo Q, Al Ali N, Maffioli M, Auteri G, Mazzoni C, Palumbo GA, Duminuco A, Longo A, Elli EM, Passamonti F, Palandri F, Komrokji R. Investigation of Serum Albumin as a Dynamic Treatment-Specific Surrogate for Outcomes in Patients With Myelofibrosis Treated With Ruxolitinib. JCO Precis Oncol 2024; 8:e2300593. [PMID: 38484210 PMCID: PMC10954075 DOI: 10.1200/po.23.00593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/05/2023] [Accepted: 01/12/2024] [Indexed: 03/19/2024] Open
Abstract
PURPOSE Ruxolitinib improves splenomegaly and disease-related symptoms in most patients with myelofibrosis (MF), and it has been associated with a survival benefit in higher-risk patients with splenomegaly. Spleen volume reduction has been associated with a survival benefit in ruxolitinib-treated patients; however, its use as a surrogate is limited. We hypothesized that an anti-inflammatory response to ruxolitinib would correlate with improved patient outcomes. METHODS We interrogated serum albumin, an acute phase reactant and marker of nutritional status in 590 patients with MF and analyzed differential trajectories of albumin on the basis of ruxolitinib treatment. Additionally, we assessed the prognostic role of baseline albumin and change in albumin. RESULTS We found that serum albumin levels tend to decrease in patients with MF; however, this tendency is abrogated by ruxolitinib treatment. To that end, baseline serum albumin level correlates with overall survival (OS) in patients with MF, independent of the variables that comprise the dynamic international prognostic scoring system; however, this correlation is limited to ruxolitinib-naïve patients. In ruxolitinib-treated patients, the change in serum albumin after ruxolitinib treatment, rather than the baseline value, is associated with improved OS, a finding not seen in ruxolitinib-naïve patients. CONCLUSION These findings suggest that serum albumin, a ubiquitously available laboratory value, has specific relevance in patients with MF and reflects therapeutic response to ruxolitinib.
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Affiliation(s)
| | - Somedeb Ball
- Vanderbilt University Medical Center, Nashville, TN
| | | | - Qianxing Mo
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Najla Al Ali
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | | | - Giuseppi Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Camilla Mazzoni
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Giuseppe A. Palumbo
- Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate “G.F.Ingrassia”, University of Catania, Catania, Italy
| | - Andrea Duminuco
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Anna Longo
- Hematology Unity, AOU Policlinico “G.Rodolico”, San Marco, Catania, Italy
| | - Elena M. Elli
- Hematology Division and Bone Marrow Unit, IRCCS San Gerardo Del Tintori Monza, Monza, Italy
| | | | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia “Seràgnoli”, Bologna, Italy
| | - Rami Komrokji
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
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Kremyanskaya M, Kuykendall AT, Pemmaraju N, Ritchie EK, Gotlib J, Gerds A, Palmer J, Pettit K, Nath UK, Yacoub A, Molina A, Saks SR, Modi NB, Valone FH, Khanna S, Gupta S, Verstovsek S, Ginzburg YZ, Hoffman R. Rusfertide, a Hepcidin Mimetic, for Control of Erythrocytosis in Polycythemia Vera. N Engl J Med 2024; 390:723-735. [PMID: 38381675 DOI: 10.1056/nejmoa2308809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Polycythemia vera is a chronic myeloproliferative neoplasm characterized by erythrocytosis. Rusfertide, an injectable peptide mimetic of the master iron regulatory hormone hepcidin, restricts the availability of iron for erythropoiesis. The safety and efficacy of rusfertide in patients with phlebotomy-dependent polycythemia vera are unknown. METHODS In part 1 of the international, phase 2 REVIVE trial, we enrolled patients in a 28-week dose-finding assessment of rusfertide. Part 2 was a double-blind, randomized withdrawal period in which we assigned patients, in a 1:1 ratio, to receive rusfertide or placebo for 12 weeks. The primary efficacy end point was a response, defined by hematocrit control, absence of phlebotomy, and completion of the trial regimen during part 2. Patient-reported outcomes were assessed by means of the modified Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) patient diary (scores range from 0 to 10, with higher scores indicating greater severity of symptoms). RESULTS Seventy patients were enrolled in part 1 of the trial, and 59 were assigned to receive rusfertide (30 patients) or placebo (29 patients) in part 2. The estimated mean (±SD) number of phlebotomies per year was 8.7±2.9 during the 28 weeks before the first dose of rusfertide and 0.6±1.0 during part 1 (estimated difference, 8.1 phlebotomies per year). The mean maximum hematocrit was 44.5±2.2% during part 1 as compared with 50.0±5.8% during the 28 weeks before the first dose of rusfertide. During part 2, a response was observed in 60% of the patients who received rusfertide as compared with 17% of those who received placebo (P = 0.002). Between baseline and the end of part 1, rusfertide treatment was associated with a decrease in individual symptom scores on the MPN-SAF in patients with moderate or severe symptoms at baseline. During parts 1 and 2, grade 3 adverse events occurred in 13% of the patients, and none of the patients had a grade 4 or 5 event. Injection-site reactions of grade 1 or 2 in severity were common. CONCLUSIONS In patients with polycythemia vera, rusfertide treatment was associated with a mean hematocrit of less than 45% during the 28-week dose-finding period, and the percentage of patients with a response during the 12-week randomized withdrawal period was greater with rusfertide than with placebo. (Funded by Protagonist Therapeutics; REVIVE ClinicalTrials.gov number, NCT04057040.).
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Affiliation(s)
- Marina Kremyanskaya
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Andrew T Kuykendall
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Naveen Pemmaraju
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Ellen K Ritchie
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Jason Gotlib
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Aaron Gerds
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Jeanne Palmer
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Kristen Pettit
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Uttam K Nath
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Abdulraheem Yacoub
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Arturo Molina
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Samuel R Saks
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Nishit B Modi
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Frank H Valone
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Sarita Khanna
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Suneel Gupta
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Srdan Verstovsek
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Yelena Z Ginzburg
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
| | - Ronald Hoffman
- From the Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (M.K., Y.Z.G., R.H.), and the Division of Hematology and Medical Oncology, Weill Cornell Medical College (E.K.R.) - both in New York; the Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL (A.T.K.); the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston (N.P., S.V.); the Division of Hematology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford (J.G.), and Clinical Research and Development, Protagonist Therapeutics, Newark (A.M., S.R.S, N.B.M., F.H.V., S.K., S.G.) - both in California; the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland (A.G.); the Mayo Clinic, Phoenix, AZ (J.P.); the Rogel Cancer Center, University of Michigan Health, Ann Arbor (K.P.); All India Institute of Medical Sciences, Rishikesh, India (U.K.N.); and the University of Kansas Cancer Center, Westwood (A.Y.)
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5
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Vachhani P, Mascarenhas J, Bose P, Hobbs G, Yacoub A, Palmer JM, Gerds AT, Masarova L, Kuykendall AT, Rampal RK, Mesa R, Verstovsek S. Interferons in the treatment of myeloproliferative neoplasms. Ther Adv Hematol 2024; 15:20406207241229588. [PMID: 38380373 PMCID: PMC10878223 DOI: 10.1177/20406207241229588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/14/2023] [Indexed: 02/22/2024] Open
Abstract
Interferons are cytokines with immunomodulatory properties and disease-modifying effects that have been used to treat myeloproliferative neoplasms (MPNs) for more than 35 years. The initial use of interferons was limited due to difficulties with administration and a significant toxicity profile. Many of these shortcomings were addressed by covalently binding polyethylene glycol to the interferon structure, which increases the stability, prolongs activity, and reduces immunogenicity of the molecule. In the current therapeutic landscape, pegylated interferons are recommended for use in the treatment of polycythemia vera, essential thrombocythemia, and primary myelofibrosis. We review recent efficacy, molecular response, and safety data for the two available pegylated interferons, peginterferon alfa-2a (Pegasys) and ropeginterferon alfa-2b-njft (BESREMi). The practical management of interferon-based therapies is discussed, along with our opinions on whether to and how to switch from hydroxyurea to one of these therapies. Key topics and questions related to use of interferons, such as their safety and tolerability, the significance of variant allele frequency, advantages of early treatment, and what the future of interferon therapy may look like, will be examined. Pegylated interferons represent an important therapeutic option for patients with MPNs; however, more research is still required to further refine interferon therapy.
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Affiliation(s)
- Pankit Vachhani
- Hematology Oncology at The Kirklin Clinic of UAB Hospital, North Pavilion, Room 2540C, 1720 2 Ave S, Birmingham, AL 35294-3300, USA
| | - John Mascarenhas
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Prithviraj Bose
- Division of Cancer Medicine, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriela Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abdulraheem Yacoub
- Division of Hematologic Malignancies and Cellular Therapeutics, The University of Kansas Cancer Center, Westwood, KS, USA
| | | | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Lucia Masarova
- Division of Cancer Medicine, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew T. Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Raajit K. Rampal
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Srdan Verstovsek
- Division of Cancer Medicine, Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Horvat NP, Abdallah EF, Xie Z, Al Ali N, Yun S, Walker A, Padron E, Sallman D, Chan O, Lancet J, Komrokji R, Kuykendall AT. Young patients with myelofibrosis have distinct clinicomolecular features, favorable prognosis, and commonly exhibit inflammatory comorbidities. Ann Hematol 2024; 103:117-123. [PMID: 38030891 DOI: 10.1007/s00277-023-05564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
Myelofibrosis (MF) is commonly diagnosed in older individuals and has not been extensively studied in young patients. Given the infrequent diagnosis in young patients, analyzing this cohort may identify factors that predict for disease development/progression. We retrospectively analyzed clinical/genomic characteristics, treatments, and outcomes of patients with MF aged 18-50 years (YOUNG) at diagnosis. Sixty-three YOUNG patients were compared to 663 patients diagnosed at 51 or older (OLDER). YOUNG patients were more likely to be female, harbor driving CALR mutations, lack splicing gene mutations, and have low-risk disease by dynamic international prognostic scoring system (DIPSS) at presentation. Thirty-six patients (60%) presented with incidental lab findings and 19 (32%) with symptomatic disease. Median time to first treatment was 9.4 months (mo). Fourteen (22%) YOUNG patients underwent allogeneic hematopoietic stem cell transplant (median 57.4 mo post-diagnosis). Five (8%) developed blast-phase disease (median 99 mo post-diagnosis). Median overall survival (OS) for YOUNG patients was not reached compared to 62.8 mo in OLDER cohort (p < 0.001). The survival advantage for YOUNG patients lost significance when compared to OLDER patients lacking splicing mutations (p = 0.11). Thirty-one (49%) had comorbidities predating MF diagnosis. Presence of a comorbidity correlated with increased disease risk as measured by serial DIPSS (p=0.02). Increased disease risk correlated with decreased OS (p = 0.05). MF is rare in young adults, has distinct clinical/molecular correlates, and a favorable prognosis. The high frequency of inflammatory comorbidities and their correlation with progression of disease risk clinically highlights the role of inflammation in MF pathogenesis.
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Affiliation(s)
- Nathan P Horvat
- University of South Florida Health Morsani College of Medicine, 560 Channelside Dr., Tampa, FL, 33602, USA
| | - Enas F Abdallah
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Seongseok Yun
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Alison Walker
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - David Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Onyee Chan
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Jeffrey Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
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7
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Patel MR, Donnellan W, Byrne M, Asch AS, Zeidan AM, Baer MR, Fathi AT, Kuykendall AT, Zheng F, Walker C, Cheng L, Marando C, Savona MR. Phase 1/2 Study of the Pan-PIM Kinase Inhibitor INCB053914 Alone or in Combination With Standard-of-Care Agents in Patients With Advanced Hematologic Malignancies. Clin Lymphoma Myeloma Leuk 2023; 23:674-686. [PMID: 37290996 DOI: 10.1016/j.clml.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The Proviral Integration site of Moloney murine leukemia virus (PIM) kinases are implicated in tumorigenesis; the pan-PIM kinase inhibitor, INCB053914, demonstrated antitumor activity in hematologic malignancy preclinical models. PATIENTS AND METHODS This phase 1/2 study evaluated oral INCB053914 alone or combined with standard-of-care agents for advanced hematologic malignancies (NCT02587598). In Parts 1/2 (monotherapy), patients (≥18 years) had acute leukemia, high-risk myelodysplastic syndrome (MDS), MDS/myeloproliferative neoplasm, myelofibrosis (MF), multiple myeloma, or lymphoproliferative neoplasms. In Parts 3/4 (combination therapy), patients had relapsed/refractory or newly diagnosed (≥65 years, unfit for intensive chemotherapy) acute myeloid leukemia (AML) or MF with suboptimal ruxolitinib response. RESULTS Parts 1/2 (n = 58): 6 patients experienced dose-limiting toxicities (DLTs), most commonly aspartate aminotransferase/alanine aminotransferase-elevated (AST/ALT; each n = 4). Fifty-seven patients (98.3%) had treatment-emergent adverse events (TEAEs), most commonly ALT-elevated and fatigue (36.2% each); 48 (82.8%) had grade ≥3 TEAEs, most commonly anemia (31.0%); 8 (13.8%) had grade ≥3 ALT/AST-elevated TEAEs. Parts 3/4 (n = 39): for INCB053914 + cytarabine (AML; n = 6), 2 patients experienced DLTs (grade 3 maculopapular rash, n = 1; grade 3 ALT-elevated and grade 4 hypophosphatemia, n = 1); for INCB053914 + azacitidine (AML; n = 16), 1 patient experienced a DLT (grade 3 maculopapular rash). Two complete responses were observed (1 with incomplete count recovery). For INCB053914 + ruxolitinib (MF; n = 17), no DLTs occurred; 3 patients achieved best reduction of >25% spleen volume at week 12 or 24. CONCLUSION INCB053914 was generally well tolerated as monotherapy and in combinations; TEAEs were most commonly ALT/AST-elevated. Limited responses were observed with combinations. Future studies are needed to identify rational, effective combination strategies.
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Affiliation(s)
- Manish R Patel
- Florida Cancer Specialists/Sarah Cannon Research Institute, Sarasota, FL.
| | | | - Michael Byrne
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Adam S Asch
- Stephenson Cancer Center, Oklahoma University, Oklahoma City, OK
| | - Amer M Zeidan
- Yale University and Yale Cancer Center, New Haven, CT
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Amir T Fathi
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | | | | | | | - Michael R Savona
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN
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8
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Gerds AT, Verstovsek S, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Oh S, Klencke BJ, Yu J, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis previously treated with a JAK inhibitor (MOMENTUM): an updated analysis of an international, double-blind, randomised phase 3 study. Lancet Haematol 2023; 10:e735-e746. [PMID: 37517413 DOI: 10.1016/s2352-3026(23)00174-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The MOMENTUM study met all key endpoints at week 24, demonstrating symptom, spleen, and anaemia benefits with momelotinib versus danazol in patients with myelofibrosis. In this updated analysis, we report duration of week 24 responses and new responses with momelotinib through week 48. METHODS MOMENTUM is an international, double-blind, randomised, phase 3 study done at 107 sites across 21 countries. Patients were 18 years or older with primary, post-polycythaemia vera, or post-essential thrombocythaemia myelofibrosis, previously treated with an approved Janus kinase (JAK) inhibitor for 90 days or more (≥28 days with haematological complications), and had an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were randomly assigned (2:1) to either the momelotinib group (200 mg orally once per day) or danazol group (300 mg orally twice per day) through week 24 via non-deterministic biased coin minimisation and an interactive response system. Stratification factors were Total Symptom Score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), transfusion burden (0 units vs 1-4 units vs ≥5 units), and study site. After week 24, all patients initially randomly assigned to either group who remained on the study received open-label momelotinib. The primary endpoint, which has already been reported, was Myelofibrosis Symptom Assessment Form TSS response rate at week 24. Predefined secondary endpoints were duration of week 24 TSS and transfusion independence responses, safety, and survival, which are summarised post hoc at the week 48 data cutoff (May 17, 2022). TSS, transfusion independence, and splenic responses at week 48 were defined post hoc and assessed in all evaluable patients who entered the open-label period and provided sufficient data. The timing of this updated analysis was defined post hoc after all patients had the opportunity to complete their week 48 assessments, as most patients entered an extended access study (NCT03441113) after week 48. This study is registered with ClinicalTrials.gov, number NCT04173494, and is now complete. FINDINGS Between April 24, 2020, and Dec 3, 2021, a total of 195 patients were randomised (130 [67%] in the momelotinib group and 65 [33%] in the danazol group). 93 (72%) of 130 patients in the momelotinib group and 41 (63%) of 65 in the danazol group entered the momelotinib open-label extension period. Median follow-up was 48·4 weeks (IQR 40·6-55·7). Among TSS-evaluable patients at week 48, 30 (45%) of 67 patients in the momelotinib group who continued treatment and 15 (50%) of 30 in the danazol group who crossed over were responders. TSS responders at any time during the open-label period by week 48 were 46 (61%) of 75 evaluable patients in the momelotinib group who continued and 19 (59%) of 32 in the danazol group who crossed over, including most week 24 responders plus new responders after week 24. No new safety signals emerged with long-term follow-up. The most common non-haematological treatment-emergent adverse events in momelotinib-treated patients over the entire study period as of the data cutoff were diarrhoea (45 [26%] of 171) and asthenia (28 [16%]); the most common grades 3-4 treatment-emergent adverse events were thrombocytopenia (33 [19%]) and anaemia (19 [11%]). Serious treatment-emergent adverse events were reported in 79 (46%) of 171 patients, and fatal treatment-emergent adverse events were reported in 30 (18%); two fatal treatment-emergent adverse events were considered possibly related to momelotinib (rotaviral enteritis and Staphylococcus pneumonia). INTERPRETATION Momelotinib was associated with durable symptom, spleen, and anaemia benefits, late responses after week 24, and favourable safety through week 48. These results highlight the potential benefits of treatment with momelotinib in patients with myelofibrosis, particularly those with anaemia. FUNDING Sierra Oncology, a GSK company.
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Affiliation(s)
- Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Department of Haematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Hematology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephen Oh
- Division of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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9
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Gotlib J, Castells M, Elberink HO, Siebenhaar F, Hartmann K, Broesby-Olsen S, George TI, Panse J, Alvarez-Twose I, Radia DH, Tashi T, Bulai Livideanu C, Sabato V, Heaney M, Van Daele P, Cerquozzi S, Dybedal I, Reiter A, Pongdee T, Barete S, Ustun C, Schwartz L, Ward BR, Schafhausen P, Vadas P, Bose P, DeAngelo DJ, Rein L, Vachhani P, Triggiani M, Bonadonna P, Rafferty M, Butt NM, Oh ST, Wortmann F, Ungerstedt J, Guilarte M, Taparia M, Kuykendall AT, Arana Yi C, Ogbogu P, Gaudy-Marqueste C, Mattsson M, Shomali W, Giannetti MP, Bidollari I, Lin HM, Sulllivan E, Mar B, Scherber R, Roche M, Akin C, Maurer M. Avapritinib versus Placebo in Indolent Systemic Mastocytosis. NEJM Evid 2023; 2:EVIDoa2200339. [PMID: 38320129 DOI: 10.1056/evidoa2200339] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Avapritinib in Indolent Systemic MastocytosisIn a randomized trial, patients with indolent systemic mastocytosis were treated with avapritinib or placebo along with supportive care. The trial primary end point was the change in mean total symptom scores at 24 weeks. Avapritinib-treated patients had a decrease in mean total symptom score of 15.6 points compared with 9.2 points in the placebo group.
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Affiliation(s)
- Jason Gotlib
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Mariana Castells
- Department of Medicine, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Hanneke Oude Elberink
- Department of Allergology, University Medical Center, Groningen Research Institute Asthma and COPD, University of Groningen, Groningen, the Netherlands
| | - Frank Siebenhaar
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Tracy I George
- Associated Regional and University Pathologists, Inc. Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology, and Stem Cell Transplantation, University Hospital Aachen, Medical Faculty, Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Iván Alvarez-Twose
- Institute of Mastocytosis Studies of Castilla-La Mancha, Virgen del Valle Hospital, Toledo, Spain
| | - Deepti H Radia
- Guy's & St. Thomas' National Health Service Foundation Trust, London
| | - Tsewang Tashi
- Huntsman Cancer Institute, University of Utah, Salt Lake City
| | - Cristina Bulai Livideanu
- Department of Dermatology, Centre of Reference for Mastocytosis, Toulouse University Hospital, Toulouse, France
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Mark Heaney
- Department of Medicine, Columbia University Medical Center, New York
| | - Paul Van Daele
- Department of Internal Medicine and Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sonia Cerquozzi
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ingunn Dybedal
- Department of Hematology, Oslo University Hospital, Oslo
| | - Andreas Reiter
- Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Thanai Pongdee
- Division of Allergic Diseases, Mayo Clinic, Rochester, MN
| | - Stéphane Barete
- Unit of Dermatology, Centre of Reference for Mastocytosis, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris
| | - Celalettin Ustun
- Department of Internal Medicine, Division of Hematology, Oncology and Cell Therapy, Section of Bone Marrow Transplantation and Cellular Therapy, Rush Medical College, Chicago
| | | | | | - Philippe Schafhausen
- Department of Oncology, Hematology, and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Vadas
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Michael's Hospital, University of Toronto, Toronto
| | - Prithviraj Bose
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Lindsay Rein
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Pankit Vachhani
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Patrizia Bonadonna
- Allergy Unit and Asthma Center, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Mark Rafferty
- The Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - Nauman M Butt
- The Clatterbridge Cancer Centre, Bebington, Wirral, United Kingdom
| | - Stephen T Oh
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, Washington University, St. Louis
| | - Friederike Wortmann
- Oberärztin Hämatologie/Onkologie bei Uksh Campus Lübeck, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Lübeck, Schleswig-Holstein, Germany
| | - Johanna Ungerstedt
- Department of Medicine, Huddinge (H7), Karolinska University Hospitale, Stockholm
| | - Mar Guilarte
- Hospital UniversitariVall d'Hebron, Institut de Recerca Vall d'Hebron (VHIR), Barcelona
| | | | | | - Cecilia Arana Yi
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ
| | - Princess Ogbogu
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland
| | - Caroline Gaudy-Marqueste
- Service de Dermatologie et de cancérologie cutanée, Assistance Publique-Hopitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Mattias Mattsson
- Department of Hematology, Uppsala University Hospital and Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - William Shomali
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston
| | | | - Hui-Min Lin
- Blueprint Medicines Corporation, Cambridge, MA
| | | | - Brenton Mar
- Blueprint Medicines Corporation, Cambridge, MA
| | | | - Maria Roche
- Blueprint Medicines Corporation, Cambridge, MA
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin
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10
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Bose P, Kuykendall AT, Miller C, Kurtin S, Farina K, Harting DM, Mascarenhas JO, Mesa RA. Moving Beyond Ruxolitinib Failure in Myelofibrosis: Evolving Strategies for Second Line Therapy. Expert Opin Pharmacother 2023; 24:1091-1100. [PMID: 37163478 DOI: 10.1080/14656566.2023.2213435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Ruxolitinib has been the cornerstone of pharmacologic therapy for myelofibrosis for over a decade. However, the last several years have witnessed the regulatory approval of other Janus kinase (JAK) inhibitors for myelofibrosis, i.e. fedratinib, pacritinib, and US approval of momelotinib is widely anticipated in 2023. Due to the multifaceted clinical presentation of myelofibrosis, a watertight definition of ruxolitinib failure has remained elusive, as "progression" on ruxolitinib can take many forms and management is highly nuanced. Yet, the availability of other JAK inhibitors and potential future availability of non-JAK inhibitor agents for myelofibrosis make a consensus on management of ruxolitinib failure critically important. This consensus paper summarizes a discussion between multiple academic and community physician experts, a pharmacist and an advanced practice provider around the issues to be considered for the optimal care of patients with myelofibrosis whose disease is refractory to or does not respond adequately to ruxolitinib, or who exhibit intolerance to ruxolitinib. The panel identified several areas of consensus, as well as some areas where more data to inform evidence-based practice are needed. In some situations, maintaining ruxolitinib while adding another agent, e.g. to address anemia, is appropriate, whereas in others, switching to a different drug has merit.
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Affiliation(s)
- Prithviraj Bose
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Sandra Kurtin
- University of Arizona Cancer Center, Tucson, Arizona
| | - Kyle Farina
- The Mount Sinai Hospital, Department of Pharmacy, New York, New York
| | | | | | - Ruben A Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem and Charlotte, North Carolina
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11
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Kuykendall AT. Correction to: Treatment of hydroxyurea-resistant/intolerant polycythemia vera: a discussion of best practices. Ann Hematol 2023:10.1007/s00277-023-05235-0. [PMID: 37088817 DOI: 10.1007/s00277-023-05235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Affiliation(s)
- Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, 33612, USA.
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12
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Komrokji RS, Aguirre LE, Al-Ali N, Chan O, Xie Z, Kuykendall AT, Sweet KL, Lancet JE, Padron E, Sallman DA. Activity of luspatercept and ESAs combination for treatment of anemia in lower-risk myelodysplastic syndromes. Blood Adv 2023:495378. [PMID: 37058483 PMCID: PMC10365940 DOI: 10.1182/bloodadvances.2023009781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023] Open
Affiliation(s)
| | - Luis E Aguirre
- H. Lee Moffitt Cancer Center, Tampa, Florida, United States
| | - Najla Al-Ali
- H. Lee Moffitt Cancer Center, Tampa, Florida, United States
| | - Onyee Chan
- Moffitt Cancer Center, Tampa, Florida, United States
| | - Zhuoer Xie
- Moffitt Cancer Center, Tampa, Florida, United States
| | | | - Kendra L Sweet
- H. Lee Moffitt Cancer Center, Tampa, Florida, United States
| | | | - Eric Padron
- H. Lee Moffitt Cancer Center, Tampa, Florida, United States
| | - David A Sallman
- Moffitt Cancer Center and Research Institute, Tampa, Florida, United States
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13
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Kuykendall AT. Treatment of hydroxyurea-resistant/intolerant polycythemia vera: a discussion of best practices. Ann Hematol 2023; 102:985-993. [PMID: 36944847 PMCID: PMC10113291 DOI: 10.1007/s00277-023-05172-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
Polycythemia vera (PV) is a burdensome, chronic myeloproliferative neoplasm characterized by activating mutations in Janus kinase 2, erythrocytosis, and bone marrow hypercellularity. The goals of treatment are to achieve hematocrit and blood count control to ultimately reduce the risk of thrombohemorrhagic events and improve PV-related symptoms. Treatment is risk-stratified and typically includes cytoreduction with hydroxyurea or interferon formulations in first line for high-risk disease. However, inadequate response, resistance, or intolerance to first-line cytoreductive therapies may warrant introduction of second-line treatments, such as ruxolitinib. In this review, I detail preferred treatment and patient management approaches following inadequate response to or intolerance of first-line treatment for PV.
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Affiliation(s)
- Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, 33612, USA.
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14
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Elmariah H, Kim J, Reid K, Cubitt C, Lancet JE, Kuykendall AT, Komrokji R, Sallman D, Chan O, Sweet K, Ribickas A, Faramand RG, Mishra A, Khimani F, Perez LE, Kirtane K, Dormesy S, Kessler D, Hansen DK, Pidala JA, Anasetti C, Fuchs EJ, Jain MD, Locke FL, Bejanyan N, DeZern AE. Phase I Trial of CD8-Depleted Human Leukocyte Antigen (HLA) Mismatched Unrelated Donor Lymphocyte Infusion (DLI) to Achieve Remissions in Myelodysplastic Syndrome (MDS) and Secondary Acute Myeloid Leukemia (sAML). Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00334-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Verstovsek S, Gerds AT, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Klencke BJ, Ro S, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis (MOMENTUM): results from an international, double-blind, randomised, controlled, phase 3 study. Lancet 2023; 401:269-280. [PMID: 36709073 DOI: 10.1016/s0140-6736(22)02036-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Janus kinase (JAK) inhibitors approved for myelofibrosis provide spleen and symptom improvements but do not meaningfully improve anaemia. Momelotinib, a first-in-class inhibitor of activin A receptor type 1 as well as JAK1 and JAK2, has shown symptom, spleen, and anaemia benefits in myelofibrosis. We aimed to confirm the differentiated clinical benefits of momelotinib versus the active comparator danazol in JAK-inhibitor-exposed, symptomatic patients with anaemia and intermediate-risk or high-risk myelofibrosis. METHODS MOMENTUM is an international, double-blind, randomised, controlled, phase 3 study that enrolled patients at 107 sites across 21 countries worldwide. Eligible patients were 18 years or older with a confirmed diagnosis of primary myelofibrosis or post-polycythaemia vera or post-essential thrombocythaemia myelofibrosis. Patients were randomly assigned (2:1) to receive momelotinib (200 mg orally once per day) plus danazol placebo (ie, the momelotinib group) or danazol (300 mg orally twice per day) plus momelotinib placebo (ie, the danazol group), stratified by total symptom score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), red blood cell or whole blood units transfused in the 8 weeks before randomisation (0 units vs 1-4 units vs ≥5 units), and study site. The primary endpoint was the Myelofibrosis Symptom Assessment Form (MFSAF) TSS response rate at week 24 (defined as ≥50% reduction in mean MFSAF TSS over the 28 days immediately before the end of week 24 compared with baseline). MOMENTUM is registered with ClinicalTrials.gov, number NCT04173494, and is active but not recruiting. FINDINGS 195 patients were randomly assigned to either the momelotinib group (130 [67%]) or danazol group (65 [33%]) and received study treatment in the 24-week randomised treatment period between April 24, 2020, and Dec 3, 2021. A significantly greater proportion of patients in the momelotinib group reported a 50% or more reduction in TSS than in the danazol group (32 [25%] of 130 vs six [9%] of 65; proportion difference 16% [95% CI 6-26], p=0·0095). The most frequent grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were haematological abnormalities by laboratory values: anaemia (79 [61%] of 130 vs 49 [75%] of 65) and thrombocytopenia (36 [28%] vs 17 [26%]). The most frequent non-haematological grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were acute kidney injury (four [3%] of 130 vs six [9%] of 65) and pneumonia (three [2%] vs six [9%]). INTERPRETATION Treatment with momelotinib, compared with danazol, resulted in clinically significant improvements in myelofibrosis-associated symptoms, anaemia measures, and spleen response, with favourable safety. These findings support the future use of momelotinib as an effective treatment in patients with myelofibrosis, especially in those with anaemia. FUNDING Sierra Oncology.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hoôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Laboratory Medicine, Seoul St Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | | | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson, San Antonio, TX, USA
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16
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Ball S, Knepper TC, Deutsch YE, Samra W, Watts JM, Bradley TJ, Chan O, Hussaini MO, Zhang L, Sweet KL, Kuykendall AT, Talati C, Padron E, Komrokji RS, Lancet JE, Sallman DA. Molecular annotation of extramedullary acute myeloid leukemia identifies high prevalence of targetable mutations. Cancer 2022; 128:3880-3887. [DOI: 10.1002/cncr.34459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/05/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Somedeb Ball
- Division of Hematology and Medical Oncology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Todd C. Knepper
- Department of Individualized Cancer Management H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Yehuda E. Deutsch
- Department of Malignant Hematology and Cellular Therapy at Memorial Healthcare System Moffitt Cancer Center Pembroke Pines Florida USA
| | - Wassim Samra
- Sylvester Comprehensive Cancer Center University of Miami Miami Florida USA
| | - Justin M. Watts
- Sylvester Comprehensive Cancer Center University of Miami Miami Florida USA
| | | | - Onyee Chan
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Mohammad Omar Hussaini
- Department of Hematopathology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Ling Zhang
- Department of Hematopathology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Kendra L. Sweet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Andrew T. Kuykendall
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Chetasi Talati
- Abbvie Inc. (formerly affiliated to Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA) North Chicago Illinois USA
| | - Eric Padron
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Rami S. Komrokji
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Jeffrey E. Lancet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - David A. Sallman
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
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17
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Gerds AT, Gotlib J, Ali H, Bose P, Dunbar A, Elshoury A, George TI, Gundabolu K, Hexner E, Hobbs GS, Jain T, Jamieson C, Kaesberg PR, Kuykendall AT, Madanat Y, McMahon B, Mohan SR, Nadiminti KV, Oh S, Pardanani A, Podoltsev N, Rein L, Salit R, Stein BL, Talpaz M, Vachhani P, Wadleigh M, Wall S, Ward DC, Bergman MA, Hochstetler C. Myeloproliferative Neoplasms, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:1033-1062. [PMID: 36075392 DOI: 10.6004/jnccn.2022.0046] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) consist of myelofibrosis, polycythemia vera, and essential thrombocythemia and are a heterogeneous group of clonal blood disorders characterized by an overproduction of blood cells. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MPN were developed as a result of meetings convened by a multidisciplinary panel with expertise in MPN, with the goal of providing recommendations for the management of MPN in adults. The Guidelines include recommendations for the diagnostic workup, risk stratification, treatment, and supportive care strategies for the management of myelofibrosis, polycythemia vera, and essential thrombocythemia. Assessment of symptoms at baseline and monitoring of symptom status during the course of treatment is recommended for all patients. This article focuses on the recommendations as outlined in the NCCN Guidelines for the diagnosis of MPN and the risk stratification, management, and supportive care relevant to MF.
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Affiliation(s)
- Aaron T Gerds
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Haris Ali
- City of Hope National Medical Center
| | | | | | | | | | | | | | | | - Tania Jain
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | | | | | - Stephen Oh
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Brady L Stein
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Sarah Wall
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Dawn C Ward
- UCLA Jonsson Comprehensive Cancer Center; and
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18
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Harrison CN, Gupta VK, Gerds AT, Rampal R, Verstovsek S, Talpaz M, Kiladjian JJ, Mesa R, Kuykendall AT, Vannucchi AM, Palandri F, Grosicki S, Devos T, Jourdan E, Wondergem MJ, Al-Ali HK, Buxhofer-Ausch V, Alvarez-Larrán A, Patriarca A, Kremyanskaya M, Mead AJ, Akhani S, Sheikine Y, Colak G, Mascarenhas J. Phase III MANIFEST-2: pelabresib + ruxolitinib vs placebo + ruxolitinib in JAK inhibitor treatment-naive myelofibrosis. Future Oncol 2022; 18:2987-2997. [PMID: 35950489 DOI: 10.2217/fon-2022-0484] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Myelofibrosis (MF) is a clonal myeloproliferative neoplasm, typically associated with disease-related symptoms, splenomegaly, cytopenias and bone marrow fibrosis. Patients experience a significant symptom burden and a reduced life expectancy. Patients with MF receive ruxolitinib as the current standard of care, but the depth and durability of responses and the percentage of patients achieving clinical outcome measures are limited; thus, a significant unmet medical need exists. Pelabresib is an investigational small-molecule bromodomain and extraterminal domain inhibitor currently in clinical development for MF. The aim of this article is to describe the design of the ongoing, global, phase III, double-blind, placebo-controlled MANIFEST-2 study evaluating the efficacy and safety of pelabresib and ruxolitinib versus placebo and ruxolitinib in patients with JAKi treatment-naive MF. Clinical Trial Registration: NCT04603495 (ClinicalTrials.gov).
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Affiliation(s)
- Claire N Harrison
- Guys & St Thomas' NHS Foundation Trust, Guy's Hospital, London, SE1 9RT, UK
| | - Vikas K Gupta
- Department of Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, M5G 1Z5, Canada
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA
| | - Raajit Rampal
- Leukemia Service, Department of Medicine and Center for Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Moshe Talpaz
- Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI 48109-5936, USA
| | - Jean-Jacques Kiladjian
- Clinical Investigation Center (INSERM CIC 1427), Université Paris Cité and Hôpital Saint-Louis, Paris, 75010, France
| | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio Cancer Center, San Antonio, TX 78229-3900, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Alessandro M Vannucchi
- Department of Hematology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50139, Italy
| | - Francesca Palandri
- Department of Hematology, IRCCS Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, 40138, Italy
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia in Katowice, Katowice, 40-055, Poland
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven & Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, 3000, Belgium
| | - Eric Jourdan
- Department of Hematology, C.H.U., Nîmes, 30029, France
| | - Marielle J Wondergem
- Department of Hematology, Amsterdam University Medical Centers, Amsterdam, 1081 HV, The Netherlands
| | | | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Hematology, Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen & Johannes Kepler University Linz, Linz, 4020, Austria
| | | | - Andrea Patriarca
- Hematology Unit, Azienda Ospedaliero Universitaria Maggiore della Carità di Novara, Novara, 28100, Italy
| | - Marina Kremyanskaya
- Division of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adam J Mead
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DX, UK
| | | | - Yuri Sheikine
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA 02110, USA
| | - Gozde Colak
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA 02110, USA
| | - John Mascarenhas
- Division of Hematology and Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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19
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Kuykendall AT, Mo Q, Sallman DA, Ali NA, Chan O, Yun S, Sweet KL, Padron E, Lancet JE, Komrokji RS. Disease-related thrombocytopenia in myelofibrosis is defined by distinct genetic etiologies and is associated with unique prognostic correlates. Cancer 2022; 128:3495-3501. [PMID: 35942592 DOI: 10.1002/cncr.34414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/24/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Thrombocytopenia in patients with myelofibrosis (MF) is prognostically detrimental and poses a therapeutic challenge. MF patients with thrombocytopenia are considered high-risk by most prognostic models and their distinct phenotype has given rise to the emerging concept of cytopenic MF. Yet, the mechanisms underlying thrombocytopenia in MF are poorly understood. METHODS This study aimed to highlight the genetic mechanisms driving low platelet counts in treatment-naive MF patients, establish their phenotypic correlates, and assess prognostic factors specific to this group of patients. RESULTS The authors found that most patients presenting with low platelets had a clear thrombocytopenia-specific genetic abnormality involving a U2AF1 Q157 mutation, deletion 20q, molecular complexity (three or more mutations), or high-risk karyotype. Etiologic clustering did not correlate with prognosis; however, thrombocytopenic patients were found to have unique prognostic variables including low serum albumin and mutations of SRSF2 and TP53. This led to the proposal of a prognostic model (SRSF2, albumin, TP53 score) that stratifies thrombocytopenic patients as low, intermediate, or high-risk with corresponding median survivals of 93.5, 29.5, and 7.2 months, respectively. CONCLUSIONS This study demonstrates that thrombocytopenia in MF is driven by different genetic mechanisms and is not uniformly high-risk. As novel agents with improved hematologic safety profiles enter the treatment landscape, thoughtful, risk-adapted therapeutic decisions will be required for MF patients with thrombocytopenia. LAY SUMMARY A significant minority of patients with myelofibrosis (MF) present with low platelets. Historically, these patients have been viewed as having "high-risk" disease, but this may not be uniformly true. Our study shows that there are various different causes for low platelets in MF, some of which represent high-risk disease whereas others do not. Additionally, our study shows that genetic mutations affecting the genes SRSF2 and TP53 are uniquely problematic in this group, as is a low serum albumin level. This study helps to risk-stratify MF patients with thrombocytopenia, thereby providing more information to guide informed and individualized treatment decisions.
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Affiliation(s)
| | | | | | | | - Onyee Chan
- Moffitt Cancer Center, Tampa, Florida, USA
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20
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Castillo Tokumori F, Al Ali N, Chan O, Sallman D, Yun S, Sweet K, Padron E, Lancet J, Komrokji R, Kuykendall AT. Comparison of Different Treatment Strategies for Blast-Phase Myeloproliferative Neoplasms. Clin Lymphoma Myeloma Leuk 2022; 22:e521-e525. [PMID: 35241387 PMCID: PMC10766145 DOI: 10.1016/j.clml.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Up to 20% of patients with myeloproliferative neoplasms (MPN) will progress to blast phase (MPN-BP). Outcomes are dismal, with intensive chemotherapy providing little benefit. Low-intensity therapy is preferred due to better tolerability, but the prognosis remains poor. Allogeneic stem cell transplant (AHSCT) is still the only potential for long term survival. PATIENTS AND METHODS To better evaluate the initial treatment approach in MPN-BP, we performed a single-institution retrospective analysis of 75 patients with MPN-BP treated at Moffitt Cancer Center between 2001 and 2021. Patients were stratified by initial treatment: best supportive care (BSC), hypomethylating agent (HMA)-based therapy or intensive chemotherapy (IC). RESULTS Median overall survival (mOS) for the entire cohort was 4.8 months (BSC 0.8 months, HMA 4.7 months, and IC 11.4 months). Among IC patients, improved survival was evident in those that received AHSCT (mOS 40.8 months vs. 4.9 months, p < .01). Most patients that underwent AHSCT were initially treated with IC (p < .01). All patients that underwent AHSCT had achieved complete response (CR) or CR with incomplete hematological recovery (CRi). On multivariate analysis, factors associated with improved survival were receipt of therapy (HMA or IC) (P = .017), CR/CRi (P = .037) and receipt of AHSCT (p < .001). CONCLUSION We show that active treatment with IC improves survival, but it is mostly tied to receipt of AHSCT. IC is a reasonable approach in appropriate patients as it can provide an effective bridge to AHSCT. Other treatment strategies such as molecularly targeted therapy and novel agents are desperately needed.
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Affiliation(s)
- Franco Castillo Tokumori
- University of South Florida, Morsani College of Medicine, Department of Internal Medicine. Tampa, FL; H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL.
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Onyee Chan
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - David Sallman
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Seongseok Yun
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Eric Padron
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Jeffrey Lancet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Andrew T Kuykendall
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
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21
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Mesa RA, Gerds AT, Vannucchi A, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan DP, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Donahue R, Kawashima J, Verstovsek S. MOMENTUM: Phase 3 randomized study of momelotinib (MMB) versus danazol (DAN) in symptomatic and anemic myelofibrosis (MF) patients previously treated with a JAK inhibitor. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.7002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7002 Background: MMB, an oral JAK1/2 and ACVR1/ALK2 inhibitor, showed clinical activity on MF symptoms, RBC transfusion requirements (anemia), and spleen volume in the SIMPLIFY trials. This pivotal phase 3 study of MF patients (pts) previously treated with a JAK inhibitor (JAKi) tested MMB vs DAN on key symptom, anemia, and spleen volume endpoints at 24 weeks (wks). Methods: Eligibility: Primary or post-ET/PV MF; DIPSS high risk, Int-2, or Int-1; MF Symptom Assessment Form Total Symptom Score (MFSAF TSS) ≥10; Hgb <10 g/dL; prior JAKi for ≥90 days, or ≥28 days if RBC transfusions ≥4 units in 8 wks or Gr 3/4 thrombocytopenia, anemia, or hematoma; palpable spleen ≥5 cm. Stratification: TSS, palpable spleen, and RBC units transfused. JAKi taper and washout was ≥21 days. Randomization: 2:1 to MMB 200 mg QD plus DAN placebo or DAN 600 mg QD plus MMB placebo for 24 wks, after which pts could receive open-label MMB. Assessments: Pt reported symptoms using a daily eDiary and spleen volume by MRI or CT. The primary endpoint was TSS response (≥50% reduction from baseline [BL]) rate at wk 24. Secondary endpoints, assessed sequentially at wk 24, were RBC transfusion independence (TI) rate, splenic response rate (SRR; ≥25% reduction in volume from BL), change from BL in TSS, SRR (≥35% reduction from BL) and rate of zero transfusions since BL. Results: 94 of 130 (72%) MMB pts and 38 of 65 (58%) DAN pts completed the 24-wk randomized treatment (RT) phase. Median BL TSS were 28 (MMB) and 26 (DAN), Hgb were 8.1 (MMB) and 7.9 (DAN) g/dL, and platelets were 97 (MMB) and 94 (DAN) x109/L. BL TI was 13% (MMB) and 15% (DAN). Prior JAKi was ruxolitinib in 195 pts (100%) and fedratinib in 9 pts (5%). All primary and key secondary endpoints were met (Table). Most common Gr ≥3 TEAEs in the RT phase of the study were thrombocytopenia (MMB, 22%; DAN, 12%) and anemia (MMB, 8%; DAN, 11%). Gr ≥3 infections occurred in 15% of MMB and 17% of DAN pts. Peripheral neuropathy occurred in 5 (4%) of MMB (all Gr ≤2) and 1 (2%) of DAN (Gr ≤2) pts in the RT phase, and none discontinued study drug. Overall, TEAEs led to study drug discontinuation in 18% of MMB and 23% of DAN pts in RT phase. A trend toward improved OS up to wk 24 was seen with MMB vs DAN (HR=0.506, p=0.0719). Conclusions: In symptomatic and anemic MF pts, MMB was superior to DAN for symptom responses, transfusion requirements, and spleen responses with comparable safety and favorable survival. MMB may address a critical unmet need, particularly in MF pts with anemia. Clinical trial information: NCT04173494. [Table: see text]
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Affiliation(s)
| | - Aaron Thomas Gerds
- Cleveland Clinic Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland, OH
| | | | | | | | | | - Sebastian Grosicki
- Department of Hematology, Independent Public Healthcare Facility Municipal Hospitals, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Yeow Tee Goh
- Singapore General Hospital, Singapore, Singapore
| | | | - Miklos Egyed
- Somogy County Mór Kaposi General Hospital, Kaposvar, Hungary
| | - Maria Laura Fox
- Hematology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Andrew Perkins
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | | | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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22
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Aguirre LE, Ball S, Jain AG, Al Ali N, Sallman DA, Kuykendall AT, Sweet KL, Lancet JE, Padron E, Komrokji RS. Hyperferritinemia as predictive biomarker of poor clinical outcomes in CMML. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.7055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7055 Background: CMML is a heterogenous disease exhibiting features innate to MPN and MDS. Increasing evidence supports a close interplay between systemic inflammation and risk of myeloid malignancies, notably for those with history of infection or autoimmune disease. CMML has been associated with inflammation and end-organ damage related to CKD and CVD. Analysis of gene signatures from CMML-derived monocytes has shown them to be highly proinflammatory. High ferritin may serve as a practical biomarker of disease activity to help identify pts at higher risk of poor outcomes. Methods: Retrospective data was collected from a database of CMML pts treated at Moffitt Cancer Center. Pts were stratified in 2 cohorts based on ferritin levels ( < 1000 or ≥1000 ng/mL). Hyperferritinemia was defined as ferritin > 1000 as seen at diagnosis or during follow-up. Kaplan–Meier was used to estimate OS. Cox regression was used for multivariate analysis. Results: Between August 1995 and October 2020 729 pts with CMML were identified. Median age at diagnosis was 71 (17-95). Out of 571 pts with available ferritin levels 29% (n = 168) developed hyperferritinemia vs 71% (n = 403) who did not. mOS was 32.4 mos (95%CI 30-35 mos). Pts with higher ferritin tended to present with CMML-2 (p = 0.001) and harbor a proliferative phenotype (p = 0.01). They presented with higher marrow cellularity (mean 83%, p = 0.08), PLT (mean 177k, p = 0.038), and lower Hb (mean 9.5, p < 0.05). There was no association with % circulating IMC, monocytes, WBC or ANC at baseline. Hyperferritinemia was associated with more profound fibrosis (p = 0.007), cytopenias (p < 0.05), % peripheral blasts (p < 0.05), RBC and PLT transfusion dependence (p < 0.05). Pts with hyperferritinemia had higher risk disease per IPSS-R, CPSS and all CMML models (p < 0.05); and had higher rates of AML transformation (p < 0.05). Pts were also more likely to require treatment earlier (within 3 yrs of diagnosis) (p < 0.05). ASXL1 (p = 0.002), EZH2 (p = 0.003), and SETBP1 (p = 0.019) mutations were more common among pts with hyperferritinemia. Conversely, TET2 (p = 0.001), CBL (p = 0.028) and SRSF2 (p = 0.003) mutations were less common. mOS for pts with hyperferritinemia was 23.9 mos (95%CI 19.9-27.9 mos), much lower than for those with ferritin < 1000 (mOS 40.5 mos, 95%CI 35.4-45.5 mos) (p < 0.05). In multivariate analysis, hyperferritinemia was a significant independent covariate for OS after adjusting for CPSS, transfusion dependence and disease phenotype (dysplastic vs proliferative) (HR = 0.69; 95%CI 0.53-0.89; p = 0.005). Conclusions: Almost 1/3 of pts with CMML will develop hyperferritinemia. This is associated with more aggressive disease and higher rates of AML transformation leading to dismal outcomes. ASXL1, EZH2, and SETBP1 MTs confer a higher risk of hyperferritinemia. Our findings indicate that hyperferritinemia is an independent prognostic biomarker that may serve as a surrogate representative of disease biology and comorbidities in CMML.
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23
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Gerds AT, Verstovsek S, Vannucchi A, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan DP, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Donahue R, Kawashima J, Mesa RA. Thrombocytopenic myelofibrosis (MF) patients previously treated with a JAK inhibitor in a phase 3 randomized study of momelotinib (MMB) versus danazol (DAN) [MOMENTUM]. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.7061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7061 Background: MMB, an oral JAK1/2 and ACVR1/ALK2 inhibitor, showed clinical activity on MF symptoms, RBC transfusion requirements (anemia), and spleen volume in the SIMPLIFY trials, including in MF patients (pts) with thrombocytopenia. MOMENTUM is a pivotal phase 3 study of symptomatic and anemic MF pts previously treated with a JAK inhibitor (JAKi) testing MMB vs DAN. This analysis evaluated MOMENTUM pts with baseline (BL) platelet counts (PLT) ≤150 x 109/L. Methods: Eligibility: Primary or post-ET/PV MF; DIPSS high risk, Int-2, or Int-1; MF Symptom Assessment Form Total Symptom Score (MFSAF TSS) ≥10; Hgb <10 g/dL; prior JAKi for ≥90 days, or ≥28 days if RBC transfusions ≥4 units in 8 weeks (wks) or Gr 3/4 thrombocytopenia, anemia, or hematoma; palpable spleen ≥5 cm; PLT ≥25 x 109/L. JAKi taper and washout was ≥21 days. Randomization: 2:1 to MMB 200 mg QD plus DAN placebo or DAN 600 mg QD plus MMB placebo for 24 wks. Primary endpoint: TSS response (≥50% reduction from BL) rate at wk 24. Key secondary endpoints, assessed sequentially at wk 24: RBC transfusion independence (TI) rate, splenic response rate (SRR; ≥25% reduction in volume from BL), change from BL in TSS, SRR (≥35% reduction from BL) and rate of zero transfusions since BL. Results: 60 (74%) of 81 MMB pts and 25 (58%) of 43 DAN pts with BL PLT ≤150 x 109/L completed the 24-week randomized treatment (RT) phase. Median BL TSS were 29 (MMB) and 24 (DAN), Hgb were 7.9 (MMB) and 8.0 (DAN) g/dL, and PLT were 67 x 109/L (MMB) and 64 x 109/L (DAN). Prior JAKi was ruxolitinib in 124 pts (100%) and fedratinib in 6 pts (5%). Efficacy results are in Table. These results are consistent with the overall ITT analysis set (N=195). Most common Gr ≥3 TEAEs in the RT phase were thrombocytopenia (MMB, 31%; DAN, 16%) and anemia (MMB, 7%; DAN, 14%); Gr ≥3 bleeding events occurred in 9% of MMB and 5% of DAN pts. TEAEs led to study drug discontinuation in 15% of MMB and 19% of DAN pts in RT phase. A trend toward improved OS up to wk 24 was seen with MMB vs DAN [HR (95% CI)=0.490 (0.195, 1.235)]. Additional analyses of pts with BL PLT <100 x 109/L (N=100) and BL PLT <50 x 109/L (N=31) show similar treatment effects of MMB vs DAN. Conclusions: In thrombocytopenic MF pts who were symptomatic and anemic, MMB was superior to DAN for symptom responses, transfusion requirements, and spleen responses and showed comparable safety and favorable survival. MMB may address a critical unmet need in thrombocytopenic MF pts. Clinical trial information: NCT04173494. [Table: see text]
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Affiliation(s)
- Aaron Thomas Gerds
- Cleveland Clinic Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland, OH
| | | | | | | | | | | | - Sebastian Grosicki
- Department of Hematology, Independent Public Healthcare Facility Municipal Hospitals, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Yeow Tee Goh
- Singapore General Hospital, Singapore, Singapore
| | | | - Miklos Egyed
- Somogy County Mór Kaposi General Hospital, Kaposvar, Hungary
| | - Maria Laura Fox
- Hematology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Andrew Perkins
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | | | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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24
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Ball S, Jain AG, Aguirre LE, Al Ali N, Zhang Y, Chan O, Kuykendall AT, Sweet KL, Lancet JE, Swoboda DM, Padron E, Komrokji RS, Sallman DA. Hypomethylating agent and venetoclax in patients with chronic myelomonocytic leukemia: Is the combination indeed better? Am J Hematol 2022; 97:E185-E188. [PMID: 35179241 DOI: 10.1002/ajh.26504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Somedeb Ball
- Division of Hematology and Medical Oncology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Akriti G. Jain
- Division of Hematology and Medical Oncology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Luis E. Aguirre
- Division of Hematology and Medical Oncology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Najla Al Ali
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Yumeng Zhang
- Division of Hematology and Medical Oncology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Onyee Chan
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Andrew T. Kuykendall
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Kendra L. Sweet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Jeffrey E. Lancet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | | | - Eric Padron
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - Rami S. Komrokji
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
| | - David A. Sallman
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida USA
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25
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Pandey G, Kuykendall AT, Reuther GW. JAK2 inhibitor persistence in MPN: uncovering a central role of ERK activation. Blood Cancer J 2022; 12:13. [PMID: 35082276 PMCID: PMC8792018 DOI: 10.1038/s41408-022-00609-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/22/2022] Open
Abstract
The Philadelphia chromosome negative myeloproliferative neoplasms, including polycythemia vera, essential thrombocytosis, and myelofibrosis, are driven by hyper activation of the JAK2 tyrosine kinase, the result of mutations in three MPN driving genes: JAK2, MPL, and CALR. While the anti-inflammatory effects of JAK2 inhibitors can provide improved quality of life for many MPN patients, the upfront and persistent survival of disease-driving cells in MPN patients undergoing JAK2 inhibitor therapy thwarts potential for remission. Early studies indicated JAK2 inhibitor therapy induces heterodimeric complex formation of JAK2 with other JAK family members leading to sustained JAK2-dependent signaling. Recent work has described novel cell intrinsic details as well as cell extrinsic mechanisms that may contribute to why JAK2 inhibition may be ineffective at targeting MPN driving cells. Diverse experimental strategies aimed at uncovering mechanistic details that contribute to JAK2 inhibitor persistence have each highlighted the role of MEK/ERK activation. These approaches include, among others, phosphoproteomic analyses of JAK2 signaling as well as detailed assessment of JAK2 inhibition in mouse models of MPN. In this focused review, we highlight these and other studies that collectively suggest targeting MEK/ERK in combination with JAK2 inhibition has the potential to improve the efficacy of JAK2 inhibitors in MPN patients. As MPN patients patiently wait for improved therapies, such studies should further strengthen optimism that pre-clinical research is continuing to uncover mechanistic insights regarding the ineffectiveness of JAK2 inhibitors, which may lead to development of improved therapeutic strategies.
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Affiliation(s)
- Garima Pandey
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Gary W Reuther
- Department of Molecular Oncology, Moffitt Cancer Center, Tampa, FL, USA.
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26
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King AC, Weis TM, Derkach A, Ball S, Pandey M, Mauro MJ, Goldberg AD, Stahl M, Famulare C, Tallman MS, Wang ES, Kuykendall AT, Rampal RK. Multicenter evaluation of efficacy and toxicity of venetoclax-based combinations in patients with accelerated and blast phase myeloproliferative neoplasms. Am J Hematol 2022; 97:E7-E10. [PMID: 34674293 DOI: 10.1002/ajh.26381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/07/2021] [Accepted: 10/17/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Amber C. King
- Department of Pharmacy Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Taylor M. Weis
- Department of Pharmacy Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Somedeb Ball
- Department of Malignant Hematology Moffitt Cancer Center Tampa Florida USA
| | - Manu Pandey
- Department of Medicine Leukemia Service, Roswell Park Cancer Center Buffalo New York USA
| | - Michael J. Mauro
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Aaron D. Goldberg
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Maximilian Stahl
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher Famulare
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Martin S. Tallman
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
| | - Eunice S. Wang
- Department of Medicine Leukemia Service, Roswell Park Cancer Center Buffalo New York USA
| | | | - Raajit K. Rampal
- Department of Medicine Leukemia Service, Memorial Sloan Kettering Cancer Center New York New York USA
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27
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Gajzer D, Logothetis CN, Sallman DA, Calon G, Babu A, Chan O, Vincelette ND, Volpe VO, Al Ali NH, Basra P, Talati C, Kuykendall AT, Mo Q, Padron E, Sweet K, Komrokji RS, Lancet JE, Yun S, Zhang L. MYC overexpression is associated with an early disease progression from MDS to AML. Leuk Res 2021; 111:106733. [PMID: 34749168 DOI: 10.1016/j.leukres.2021.106733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
Recent studies demonstrated that MYC epigenetically regulates AML cell survival and differentiation by suppressing IDH1/2-TET2-5hmC signaling and that MYC overexpression is associated with poor survival outcomes in multiple AML patient cohorts. However, the oncogenic roles of MYC in MDS remain to be explored. A total of 41 patients with de novo MDS were retrospectively identified using the Total Cancer Care database at the Moffitt Cancer Center. A total of 61 % of patients had low MYC expression and 39 % of patients had high MYC expression defined as MYC reactivity by immunohistochemical staining in ≥5% of bone marrow (BM) cells at the time of MDS diagnosis. The median MDS-to-AML progression free survival (PFS) was significantly shorter in the high MYC group (median PFS 9.3 vs. 17.7 months, HR = 2.328, p = 0.013). Further, overall survival (OS) was also shorter in the high MYC patients (median OS 19.7 vs. 51.7 months, HR = 2.299, p = 0.053). Multivariate analyses demonstrated that high MYC expression is an independent poor prognostic factor for the MDS-to-AML progression (HR = 2.275, p = 0.046). Our observations indicate that MYC may play a crucial role in MDS transformation to AML and the underlying mechanisms of MYC-driven MDS clonal expansion and leukemic transformation require further investigation.
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Affiliation(s)
- David Gajzer
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | - Abida Babu
- University of South Florida, Internal Medicine, Tampa, FL, USA
| | - Onyee Chan
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Nicole D Vincelette
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Virginia O Volpe
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Najla H Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Pukhraz Basra
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Chetasi Talati
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Qianxing Mo
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Seongseok Yun
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Ling Zhang
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Kuykendall AT, Komrokji RS. JAK Be Nimble: Reviewing the Development of JAK Inhibitors and JAK Inhibitor Combinations for Special Populations of Patients with Myelofibrosis. J Immunother Precis Oncol 2021; 4:129-141. [PMID: 35663107 PMCID: PMC9138443 DOI: 10.36401/jipo-20-36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/16/2021] [Accepted: 04/16/2021] [Indexed: 04/27/2023]
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm hallmarked by uncontrolled blood counts, constitutional symptoms, extramedullary hematopoiesis, and an increased risk of developing acute myeloid leukemia. Janus kinase (JAK) inhibitors are the most common treatment for MF due to their ability to reduce spleen size and improve disease-related symptoms; however, JAK inhibitors are not suitable for every patient and their impact on MF is limited in several respects. Novel JAK inhibitors and JAK inhibitor combinations are emerging that aim to enhance the treatment landscape, providing deeper responses to a broader population of patients with the continued hope of providing disease modification and improving long-term outcomes. In this review, we highlight several specific areas of unmet need within MF. Subsequently, we review agents that target those areas of unmet need, focusing specifically on the JAK inhibitors, momelotinib, pacritinib, itacitinib, and NS-018 as well as JAK inhibitor combination approaches using CPI-0610, navitoclax, parsaclisib, and luspatercept.
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Affiliation(s)
| | - Rami S. Komrokji
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
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Kuykendall AT, Burke L, Lakshminarayanan M, Colucci P. Abstract CT236: A Two-Part Phase 2 Study of Itacitinib Immediate Release in Patients with Primary or Secondary Myelofibrosis Who Have Received Prior Ruxolitinib and/or Fedratinib Monotherapy. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-ct236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Ruxolitinib (JAK1/JAK2 inhibitor) and fedratinib (JAK2/FLT3 inhibitor) are indicated in the US for myelofibrosis (MF); however, some patients fail to achieve adequate/sustained response to initial JAK-inhibitor therapy. Itacitinib is a potent JAK inhibitor selective for JAK1 over JAK2 when administered as a once-daily sustained-release (SR) formulation. In prior clinical trials, the SR formulation improved MF-related symptoms but had less effect with respect to spleen volume reduction. When dosed as a twice-daily (BID) immediate release (IR) formulation, itacitinib may offer increased JAK2 inhibition (in addition to JAK1 inhibition) to better address the JAK2-mediated myeloproliferative features of MF. This open-label phase 2 study is designed to determine a tolerable and safe dose of itacitinib IR that results in clinically significant reductions in symptoms and spleen volume in patients with MF who have previously received ruxolitinib and/or fedratinib monotherapy (INCB 39110-213; NCT04629508). Methods: Eligible patients are aged ≥18 years, diagnosed with at least INT-1 risk (Dynamic International Prognostic Scoring System [Passamonti. Blood. 2010;115:1703-1708]) primary or secondary (post-polycythemia vera or post-essential thrombocythemia) MF and have received ruxolitinib and/or fedratinib monotherapy. Patients must also have palpable splenomegaly and platelets ≥50×109/L at screening. Exclusion criteria include receipt of a JAK inhibitor other than ruxolitinib or fedratinib, ≥10% myeloid blasts in peripheral blood or bone marrow, or inability to taper ruxolitinib/fedratinib over 14 days without use of other agents. Two itacitinib IR dose levels (DLs) will be evaluated in part 1 following a Bayesian optimal interval design algorithm: 3-9 patients will be enrolled at DL1 (300 mg BID) and observed for 28 days for dose-limiting toxicity before enrollment at DL2 (600 mg BID). Part 2 will enroll ~55 patients at the recommended phase 2 dose (RP2D) determined in part 1. Patients may remain on treatment until week 48 if they are receiving clinical benefit and have not met study withdrawal criteria. A safety follow-up will occur 30 days after treatment completion. Primary objectives: part 1 - evaluate safety and tolerability of itacitinib IR and select the RP2D; part 2 - evaluate efficacy of itacitinib IR at the RP2D based on spleen volume reduction at week 24. Secondary objectives (part 2 only): evaluate safety and tolerability of itacitinib IR; evaluate efficacy of itacitinib IR with respect to MF symptom improvement at week 24 in patients with baseline total symptom score ≥10, quality-of-life improvement, and patient global impression of change. Sites are opening in the US and EU.
Citation Format: Andrew T. Kuykendall, Lea Burke, Mani Lakshminarayanan, Philomena Colucci. A Two-Part Phase 2 Study of Itacitinib Immediate Release in Patients with Primary or Secondary Myelofibrosis Who Have Received Prior Ruxolitinib and/or Fedratinib Monotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT236.
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Castillo Tokumori F, Komrokji R, Kuykendall AT. Stepping out of antiquity: An update on emerging drugs for the treatment of polycythemia vera. Expert Opin Emerg Drugs 2021; 26:209-218. [PMID: 34139920 DOI: 10.1080/14728214.2021.1945579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Polycythemia vera is a chronic hematologic malignancy frequently presented with constitutional symptoms and associated with an increased risk of thrombosis, hemorrhage, and progression to myelofibrosis or acute myeloid leukemia. Current treatment strategies reduce thrombohemorrhagic risk by controlling blood counts and inhibiting platelets, but often fail to address disease-related symptoms or biologically modify the disease.Areas covered: We review the current paradigm for treating polycythemia vera, highlight areas of unmet need, review therapeutic agents in late stage clinical development, and provide an overarching view of how these emerging agent may fit into the future armamentarium of polycythemia vera treatments.Expert opinion: The shift from focusing solely on secondary prevention of thrombohemorrhagic events to a comprehensive treatment strategy that additionally aims to improve quality of life and prevent disease progression has resulted in a rapidly evolving therapeutic landscape that promises to move the treatment of polycythemia vera out of antiquity into the modern age.
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Affiliation(s)
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA
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Logothetis CN, Talati C, Calon G, Horvat NP, Volpe VO, Vincelette ND, Kuykendall AT, Chan O, Sallman DA, Padron E, Sweet KL, Komrokji RS, Zhang L, Lancet JE, Yun S. Outcomes of IDH1/2 mutant AML patients treated with IDH1/2 inhibitors: A single institutional experience. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e19010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19010 Background: Recent studies showed that IDH1/2 are frequently mutated in AML and that aberrant 2-HG elevation driven by the mutant IDH1/2 proteins plays a pivotal role in AML development. Subsequent clinical trials of IDH1/2 inhibitors demonstrated promising outcomes in IDH1/2mut AML patients. In this single institutional retrospective study, we explored the efficacy and safety outcomes of IDH1/2mut AML patients treated with Ivosidenib or Enasidenib. Methods: We retrospectively identified AML patients who had IDH1/2 somatic mutations based on NGS assessments. Clinical and demographic data were extracted from the medical records. Statistical analyses were performed using GraphPad Prism (v.7.03) and SPSS (v.24.0). Results: A total of 43 ( IDH1mut, n = 12; IDH2mut, n = 33; both IDH1/2mut, n = 2) patients were included in the study. Median age at AML diagnosis was 67.6 (24.2-83.3) years and 24 (55.8%) patients were male. Eighteen (42%) patients had secondary AML and 13 (34.2%), 17 (44.7%), and 8 (21.1%) patients had favorable, intermediate, and adverse risk, respectively. A total of 23 (53.5%) and 9 (20.9%) patients received intensive chemotherapy and hypomethylating agents as their 1st line therapy. One patient received Enasidenib as the 1st line therapy and the rest of the patients had relapsed/refractory disease prior to IDH1/2 inhibitor therapy. Median number of treatment prior to IDH1/2 inhibitors was 4 (0-8). The median duration of IDH1/2 inhibitor treatment was 3.2 (0.2-31.6) months ( IDH1 mut, 2.5 [0.7-13.5]; IDH2 mut, 3.4 [0.2-31.6]). Treatment response was assessed in 38 patients and 18 had overall response (CR, n = 7 [18.4%]; PR, n = 11 [28.9%]). Among these, 13 patients had concurrent somatic mutations in FLT3, KRAS, NRAS, or PTPN11. The overall response rate in these patients was not statistically different compared to patients who did not have these mutations (38.5% vs. 40%, p > 0.05). The median PFS was 3.9 (0.4-14.7) months ( IDH1 mut, 5.6 [1.7-11.5] vs. IDH2 mut, 3.7 [0.4-14.7], p > 0.05) and median OS was 7.6 (0.4-44.1) months. The most common reason for IDH1/2 inhibitor discontinuation was disease progression (n = 21) followed by adverse events (n = 3) and allogeneic transplant (n = 2). The adverse events were assessed in 41 patients and the most common adverse events were differentiation syndrome ( IDH1 mut, n = 3; IDH2 mut, n = 5) and leukocytosis ( IDH1 mut, n = 4; IDH2 mut, n = 4) followed by hepatic toxicity ( IDH2 mut n = 7), and QTc prolongation ( IDH1 mut, n = 3). Conclusions: Our study indicates that IDH1/2 inhibitors remain a reasonable option for the refractory/relapsed IDH1/2mut AML. However, significant number of patients failed to show any response and many of the patients who showed initial response had short response duration. These findings warrant further studies to identify underlying resistance mechanisms of IDH1/2 inhibitors and the optimal combination therapeutic strategies.
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Affiliation(s)
| | - Chetasi Talati
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Gregoire Calon
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Nathan P Horvat
- University of South Florida Morsani College of Medicine, Tampa, FL
| | | | | | | | - Onyee Chan
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Eric Padron
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra L Sweet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | | | | | - Seongseok Yun
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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Kuykendall AT, Tokumori FC, Komrokji RS. Traipsing Through Muddy Waters: A Critical Review of the Myelodysplastic Syndrome/Myeloproliferative Neoplasm (MDS/MPN) Overlap Syndromes. Hematol Oncol Clin North Am 2021; 35:337-352. [PMID: 33641873 DOI: 10.1016/j.hoc.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Myelodysplastic syndrome/Myeloproliferative neoplasms (MDS/MPNs) are molecularly complex, clinically heterogeneous diseases that exhibit proliferative and dysplastic features. Diagnostic criteria use clinical, pathologic, and genomic features to distinguish between disease entities, though considerable clinical and genetic overlap persists. MDS/MPNs are associated with a poor prognosis, save for MDS/MPN with ring sideroblasts and thrombocytosis, which can behave more indolently. The current treatment approach is risk-adapted and symptom-directed and largely extrapolated from experience in MDS or MPN. Gene sequencing has demonstrated frequent mutations involving signaling, epigenetic, and splicing pathways, which present numerous therapeutic opportunities for clinical investigation.
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Affiliation(s)
- Andrew T Kuykendall
- Moffitt Cancer Center, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL 33612, USA.
| | - Franco Castillo Tokumori
- University of South Florida, 17 Davis Boulevard, Suite 308, Tampa, FL 33606, USA. https://twitter.com/CTFrancoMD
| | - Rami S Komrokji
- Moffitt Cancer Center, 12902 USF Magnolia Drive, CSB 7th Floor, Tampa, FL 33612, USA. https://twitter.com/Ramikomrokji
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Gesiotto QJ, Swoboda DM, Shallis RM, Al Ali N, Padron E, Kuykendall AT, Song J, Talati C, Sweet K, Lancet JE, Zeidan AM, Komrokji RS, Sallman DA. Evaluating Predictors of Immune-Related Adverse Events and Response to Checkpoint Inhibitors in Myeloid Malignancies. Clin Lymphoma Myeloma Leuk 2021; 21:421-424.e2. [PMID: 33583730 DOI: 10.1016/j.clml.2021.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Affiliation(s)
| | - David M Swoboda
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT
| | - Najla Al Ali
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Eric Padron
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Andrew T Kuykendall
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jinming Song
- Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Chetasi Talati
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Kendra Sweet
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jeffrey E Lancet
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT
| | - Rami S Komrokji
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - David A Sallman
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL.
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Schwabkey ZI, Al Ali N, Chan O, Sallman DA, Padron E, Kuykendall AT, Talati C, Sweet K, Lancet JE, Komrokji RS. Fluorescence in Situ Hybridization (FISH) Utility for Risk Score Assessment in Patients With MDS With Normal Metaphase Karyotype. Clin Lymphoma Myeloma Leuk 2020; 21:e52-e56. [PMID: 33093008 DOI: 10.1016/j.clml.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cytogenetic profile is an essential parameter in myelodysplastic syndromes (MDS) risk stratification by both International Prognostic Symptom Score (IPSS) and Revised (R)-IPSS. Almost one-half of patients with MDS have normal cytogenetics by metaphase karyotype. Here we report the yield of MDS fluorescence in situ hybridization (FISH) panel detecting cytogenetic abnormalities in these patients and its impact on risk stratification. PATIENTS AND METHODS Among patients with normal metaphase karyotype, we assessed those patients who had cytogenetic abnormalities detected by an MDS FISH panel, which included probes for del (5), del (7), del (20), trisomy 8, and del (17p). Risk stratification was calculated by both IPSS and R-IPSS. RESULTS Of 1600 patients with MDS with normal metaphase karyotype, 53 (3%) patients had cytogenetic abnormality detected by MDS FISH panel. Integrating the MDS FISH panel cytogenetics (IPSS + FISH restaging) resulted in upstaging the score, where 53% of low-risk IPSS were upstaged to intermediate (int)-1, 56% of int-1 were upstaged to int-2, and 78% of int-2 were upstaged to high risk. Based on the R-IPSS, 61% of very low-risk patients, all low-risk patients, 92% of intermediate-risk patients, and 50% of high-risk patients with FISH abnormalities were upstaged, respectively. CONCLUSION The yield of MDS FISH panel detecting cytogenetic abnormalities in patients with normal karyotype by G-banding is low and may not warrant ordering the panel in all patients. Among the 3% of patients with normal karyotype who had cytogenetic abnormality detected by FISH, the risk score assignment by IPSS and R-IPSS was upstaged.
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Affiliation(s)
- Zaker I Schwabkey
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Onyee Chan
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Chetasi Talati
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL.
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Kuykendall AT, Komrokji R. What's in a Number? Examining the Prognostic and Predictive Importance of Platelet Count in Patients With Essential Thrombocythemia. J Natl Compr Canc Netw 2020; 18:1279-1284. [PMID: 32886905 DOI: 10.6004/jnccn.2020.7595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/21/2020] [Indexed: 11/17/2022]
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by clonal overproduction of platelets and an increased risk of thrombohemorrhagic complications. Patients are risk stratified by driver mutation, age, and thrombotic history and treated to reduce the risk of thrombotic and hemorrhagic events. The significance of platelet number as a risk factor or treatment goal is unclear. Despite the preponderance of data failing to demonstrate an association, there exists a pervasive belief that higher platelet counts correlate with an increased thrombotic risk. In fact, the association between thrombocytosis and bleeding is more clearly supported. Variability in regional consensus guidelines contributes to the uncertainty. This article reviews the data that shed light on the importance of platelet count in patients with ET.
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Affiliation(s)
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Gerds AT, Gotlib J, Bose P, Deininger MW, Dunbar A, Elshoury A, George TI, Gojo I, Gundabolu K, Hexner E, Hobbs G, Jain T, Jamieson C, Kuykendall AT, McMahon B, Mohan SR, Oehler V, Oh S, Pardanani A, Podoltsev N, Ranheim E, Rein L, Salit R, Snyder DS, Stein BL, Talpaz M, Thota S, Vachhani P, Wadleigh M, Walsh K, Ward DC, Bergman MA, Sundar H. Myeloid/Lymphoid Neoplasms with Eosinophilia and TK Fusion Genes, Version 3.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1248-1269. [PMID: 32886902 DOI: 10.6004/jnccn.2020.0042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Eosinophilic disorders and related syndromes represent a heterogeneous group of neoplastic and nonneoplastic conditions, characterized by more eosinophils in the peripheral blood, and may involve eosinophil-induced organ damage. In the WHO classification of myeloid and lymphoid neoplasms, eosinophilic disorders characterized by dysregulated tyrosine kinase (TK) fusion genes are recognized as a new category termed, myeloid/lymphoid neoplasms with eosinophilia and rearrangement of PDGFRA, PDGFRB or FGFR1 or with PCM1-JAK2. In addition to these aforementioned TK fusion genes, rearrangements involving FLT3 and ABL1 genes have also been described. These new NCCN Guidelines include recommendations for the diagnosis, staging, and treatment of any one of the myeloid/lymphoid neoplasms with eosinophilia (MLN-Eo) and a TK fusion gene included in the 2017 WHO Classification, as well as MLN-Eo and a FLT3 or ABL1 rearrangement.
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Affiliation(s)
- Aaron T Gerds
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | - Ivana Gojo
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | - Tania Jain
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Vivian Oehler
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Stephen Oh
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Brady L Stein
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | - Katherine Walsh
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Dawn C Ward
- UCLA Jonsson Comprehensive Cancer Center; and
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Kuykendall AT, Horvat NP, Pandey G, Komrokji R, Reuther GW. Finding a Jill for JAK: Assessing Past, Present, and Future JAK Inhibitor Combination Approaches in Myelofibrosis. Cancers (Basel) 2020; 12:E2278. [PMID: 32823910 PMCID: PMC7464183 DOI: 10.3390/cancers12082278] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022] Open
Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm hallmarked by the upregulation of the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway with associated extramedullary hematopoiesis and a high burden of disease-related symptoms. While JAK inhibitor therapy is central to the management of MF, it is not without limitations. In an effort to improve treatment for MF patients, there have been significant efforts to identify combination strategies that build upon the substantial benefits of JAK inhibition. Early efforts to combine agents with additive therapeutic profiles have given way to rationally designed combinations hoping to demonstrate clinical synergism and modify the underlying disease. In this article, we review the preclinical basis and existing clinical data for JAK inhibitor combination strategies while highlighting emerging strategies of particular interest.
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Affiliation(s)
- Andrew T. Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Nathan P. Horvat
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612 USA;
| | - Garima Pandey
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (G.P.); (G.W.R.)
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Gary W. Reuther
- Department of Molecular Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (G.P.); (G.W.R.)
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Kuykendall AT, Talati C, Padron E, Sweet K, Lancet JE, List AF, Sallman D, Komrokji RS. Driver mutation-specific clinical and genomic correlates differ between primary and secondary myelofibrosis. Am J Hematol 2019; 94:E314-E317. [PMID: 31444809 DOI: 10.1002/ajh.25625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/08/2019] [Accepted: 08/19/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Andrew T. Kuykendall
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Chetasi Talati
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Eric Padron
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Kendra Sweet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Jeffrey E. Lancet
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Alan F. List
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - David Sallman
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
| | - Rami S. Komrokji
- Department of Malignant Hematology H. Lee Moffitt Cancer Center and Research Institute Tampa Florida
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Abstract
PURPOSE OF REVIEW MDS/MPNs comprise a group of rare hematologic malignancies that balance features of myeloproliferation and bone marrow failure. Given overlapping clinical features and rarity of incidence, MDS/MPNs have long posed a diagnostic and therapeutic challenge. Herein, we sought to review recent advances in diagnosis and emerging therapeutic strategies and highlight the upcoming ABNL MARRO study which aims to individualize therapy for patients with MDS/MPN. RECENT FINDINGS Focused study of molecular mutations in MDS/MPNs has provided improved diagnostic clarity. Specific gene mutation or patterns of mutation have been increasingly described and have helped to distinguish between clinically similar diseases. While the current treatment landscape consists largely of therapies that have been co-opted from related disease, the emergence of prospective clinical trials specifically focused on MDS/MPN and the increased use of targeted agents represent progress for patients with MDS/MPN. An improved understanding of the molecular drivers of myeloid diseases has provided diagnostic clarity and renewed hope of targeted therapies for MDS/MPN patients. The upcoming ABNL MARRO study hopes to leverage this knowledge to match patients with targeted therapeutic options specific to molecular drivers of their disease.
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Affiliation(s)
- Andrew T Kuykendall
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
| | - Eric Padron
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
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Kuykendall AT, Talati C, Padron E, Sweet K, Sallman D, List AF, Lancet JE, Komrokji RS. Genetically inspired prognostic scoring system (GIPSS) outperforms dynamic international prognostic scoring system (DIPSS) in myelofibrosis patients. Am J Hematol 2019; 94:87-92. [PMID: 30390311 DOI: 10.1002/ajh.25335] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/16/2018] [Accepted: 10/24/2018] [Indexed: 01/23/2023]
Abstract
A genetically inspired prognostic scoring system (GIPSS) that stratifies primary myelofibrosis (PMF) patients by genetic variants alone was recently proposed. While non-inferior to the dynamic international prognostic scoring system (DIPSS), the lack of overlapping prognostic variables between the models leads to increased risk for disagreement between two valid prognostic models and presents a challenging clinical situation. In an external cohort of 266 molecularly annotated myelofibrosis (MF) patients, we demonstrated that the GIPSS model significantly differentiated between four risk groups (low, int-1, int-2, high) with median OS that was not reached, not reached, 60.5 and 28.9 months, respectively. High-risk patients had significantly inferior leukemia-free survival (LFS) (P < 0.0001). We identified a cohort of prognostically ambiguous patients (n = 39) in which GIPSS and DIPSS models differed by ≥2 risk groups. Among these patients, a similar proportion were up-staged by DIPSS (n = 19) and GIPSS (n = 20). Patients upstaged by GIPSS (genetically high-risk) had a trend toward inferior OS compared with patients upstaged by DIPSS (clinically high-risk) (P = .08) and significantly worse LFS (P = .04). Patients deemed intermediate-2 and high-risk by GIPSS who underwent allogeneic transplant had improved OS compared with those that did not (P = .04). GIPSS is a valid disease-specific prognostic system and outperforms DIPSS in patients where the two models disagree. Additionally, while GIPSS was developed for PMF; the current study shows, however, that the contemporary genetic model performs equally well for both primary and secondary myelofibrosis.
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Affiliation(s)
| | - Chetasi Talati
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Eric Padron
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - David Sallman
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Alan F. List
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | | | - Rami S. Komrokji
- H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
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Kuykendall AT, Shah S, Talati C, Al Ali N, Sweet K, Padron E, Sallman DA, Lancet JE, List AF, Zuckerman KS, Komrokji RS. Between a rux and a hard place: evaluating salvage treatment and outcomes in myelofibrosis after ruxolitinib discontinuation. Ann Hematol 2017; 97:435-441. [PMID: 29189896 DOI: 10.1007/s00277-017-3194-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/20/2017] [Indexed: 11/26/2022]
Abstract
Ruxolitinib is a JAK1/2 inhibitor that is effective in managing symptoms and splenomegaly related to myelofibrosis (MF). Unfortunately, many patients must discontinue ruxolitinib, at which time treatment options are not well defined. In this study, we investigated salvage treatment options and clinical outcomes among MF patients who received and discontinued ruxolitinib outside the context of a clinical trial. Among 145 patients who received ruxolitinib, 23 died while on treatment, 58 remained on treatment at time of analysis, leaving 64 people available for analysis. Development of cytopenias was the most common reason for discontinuation (38%) after median treatment time of 3.8 months (mo). The majority of patients received some form of salvage therapy after ruxolitinib discontinuation (n = 42; 66%), with allogeneic hematopoietic stem cell transplant (alloHSCT) (n = 17), being most commonly employed. Lenalidomide, thalidomide, hydroxyurea, interferon, and danazol were used with similar frequency. The response rate to salvage treatment was 26% (8 responses) and responses were most often seen with lenalidomide or thalidomide. Improved outcomes were observed in patients who underwent alloHSCT or received salvage therapy compared to those who did not receive additional therapy. Median overall survival (OS) after ruxolitinib discontinuation was 13 months. These findings show that salvage therapy can provide clinical responses after ruxolitinib discontinuation; however, these responses are rare and outcomes in this patient population are poor. This represents an area of unmet clinical need in MF.
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Affiliation(s)
- Andrew T Kuykendall
- University of South Florida Morsani College of Medicine at H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, MCC-GME, Tampa, FL, 33612, USA.
| | - Savan Shah
- Morsani College of Medicine, Department of Internal Medicine, University of South Florida, 12902 Magnolia Drive, MCC-GME, Tampa, FL, 33612, USA
| | - Chetasi Talati
- University of South Florida Morsani College of Medicine at H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, MCC-GME, Tampa, FL, 33612, USA
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Alan F List
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Kenneth S Zuckerman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
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Kuykendall AT, Talati C, Al Ali N, Sweet K, Padron E, Sallman DA, Lancet JE, List AF, Zuckerman KS, Komrokji RS. The Treatment Landscape of Myelofibrosis Before and After Ruxolitinib Approval. Clin Lymphoma Myeloma Leuk 2017; 17:e45-e53. [PMID: 28869184 DOI: 10.1016/j.clml.2017.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/01/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION/BACKGROUND Myelofibrosis (MF) is a chronic myeloproliferative neoplasm that presents with a heterogeneous clinical phenotype and prognosis. Before the US Food and Drug Administration approval of ruxolitinib, treatment options were varied and had limited effect. The increased use of ruxolitinib has drastically altered the MF treatment landscape. In this study, we aimed to clarify the clinical situations in which ruxolitinib is being used and analyze its effect on this landscape. PATIENTS AND METHODS We retrospectively assessed treatment choices for MF patients treated at our institution (n = 309). This population was divided into 2 cohorts on the basis of a diagnosis before (cohort BR: n = 174) or after (cohort AR: n = 135) ruxolitinib approval. Cohorts were further stratified for comparison according to presenting clinical factors. RESULTS Expectedly, the first-line use of ruxolitinib markedly increased after its approval. AR patients were less likely to receive erythropoiesis-stimulating agents (ESAs; P = .0003) and thalidomide (P = .003) than BR patients. In patients with MF-related symptoms and/or splenomegaly, increased use of ruxolitinib was associated with decreased use of first-line ESA (P = .03) or thalidomide (P = .03). In anemic patients, increased use of first-line ruxolitinib was associated with a decreased use of thalidomide (P = .007). In patients with severe leukocytosis, ruxolitinib use did not significantly increase and hydroxyurea was the preferred first-line agent. CONCLUSION Overall, the increased use of ruxolitinib appears to have come predominantly at the expense of thalidomide and ESAs, while not having a large effect on the first-line use of hydroxyurea.
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Affiliation(s)
- Andrew T Kuykendall
- Department of Internal Medicine, Hematology & Medical Oncology Fellowship Program at Moffitt Cancer Center, University of South Florida, Tampa, FL.
| | - Chetasi Talati
- Department of Internal Medicine, Hematology & Medical Oncology Fellowship Program at Moffitt Cancer Center, University of South Florida, Tampa, FL
| | - Najla Al Ali
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra Sweet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jeffrey E Lancet
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Alan F List
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kenneth S Zuckerman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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