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Arslan Davulcu E, Oğuz MB, Kılıç E, Eşkazan AE. Treatment of anemia in myelofibrosis: focusing on novel therapeutic options. Expert Opin Investig Drugs 2024; 33:27-37. [PMID: 38073183 DOI: 10.1080/13543784.2023.2294324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Myelofibrosis is a clonal myeloproliferative neoplasm associated with the proliferation of hematopoietic stem cells, increased bone marrow fibrosis, extramedullary hematopoiesis, hepatosplenomegaly, abnormal cytokine production, and constitutional symptoms. These and many other factors contribute to the development of anemia in myelofibrosis patients. AREAS COVERED This review summarizes novel and promising treatments for anemia in myelofibrosis including transforming growth factor-β inhibitors luspatercept and KER-050, JAK inhibitors momelotinib, pacritinib, and jaktinib, BET inhibitors pelabresib and ABBV-744, antifibrotic PRM-151, BCL2/BCL-XL inhibitor navitoclax, and telomerase inhibitor imetelstat. EXPERT OPINION Standard approaches to treat myelofibrosis-related anemia have limited efficacy and are associated with toxicity. New drugs have shown positive results in myelofibrosis-associated anemia when used alone or in combination.
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Affiliation(s)
- Eren Arslan Davulcu
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, University of Health Sciences, Istanbul, Turkey
| | - Merve Beyza Oğuz
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emre Kılıç
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Sastow D, Mascarenhas J, Tremblay D. Thrombocytopenia in Patients With Myelofibrosis: Pathogenesis, Prevalence, Prognostic Impact, and Treatment. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e507-e520. [PMID: 35221248 DOI: 10.1016/j.clml.2022.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 06/14/2023]
Abstract
Myelofibrosis (MF) is a clonal hematopoietic stem cell neoplasm, characterized by pathologic myeloproliferation associated with inflammatory and pro-angiogenic cytokine release, that results in functional compromise of the bone marrow. Thrombocytopenia is a disease-related feature of MF, which portends a poor prognosis impacting overall survival (OS) and leukemia free survival. Thrombocytopenia in MF has multiple causes including ineffective hematopoiesis, splenic sequestration, and treatment-related effects. Presently, allogeneic hematopoietic stem cell transplantation (HSCT) remains the only curable treatment for MF, which, unfortunately, is only a viable option for a minority of patients. All other currently available therapies are either focused on improving cytopenias or the alleviating systemic symptoms and burdensome splenomegaly. While JAK2 inhibitors have moved to the forefront of MF therapy, available JAK inhibitors are advised against in patients with severe thrombocytopenia (platelets < 50 × 109/L). In this review, we describe the pathogenesis, prevalence, and prognostic significance of thrombocytopenia in MF. We also explore the value and limitations of treatments directed at addressing cytopenias, splenomegaly and symptom burden, and those with potential disease modification. We conclude by proposing a treatment algorithm for patients with MF and severe thrombocytopenia.
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Affiliation(s)
- Dahniel Sastow
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Tisch Cancer Institute Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas Tremblay
- Division of Hematology and Medical Oncology, Tisch Cancer Institute Icahn School of Medicine at Mount Sinai, New York, NY.
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Chernak BJ, Rampal RK. Extramedullary hematopoiesis in myeloproliferative neoplasms: Pathophysiology and treatment strategies. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:97-116. [PMID: 34756246 DOI: 10.1016/bs.ircmb.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Extramedullary hematopoiesis (EMH) is often a physiologic response to ineffective marrow production of hematologic cells. While this can be found incidentally in various physiologic and pathophysiologic states, the myeloproliferative neoplasms (MPNs) are some of the most common underlying conditions found in patients with EMH. Although this process can assist with hematologic production in defective states, the burden of EMH can lead to symptomatic discomfort and mechanical obstructive complications, most commonly in the spleen and liver. Here we describe the pathophysiology of EMH, treatment options, including medical, surgical and radiation-based approaches.
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Affiliation(s)
- Brian J Chernak
- Department of Leukemia, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of Medicine, NewYork-Presbyterian Weill Cornell Medical Center, New York, NY, United States
| | - Raajit K Rampal
- Department of Leukemia, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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Pemmaraju N, Chen NC, Verstovsek S. Immunotherapy and Immunomodulation in Myeloproliferative Neoplasms. Hematol Oncol Clin North Am 2021; 35:409-429. [PMID: 33641877 DOI: 10.1016/j.hoc.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Myeloproliferative neoplasms are characterized by chronic inflammation. The discovery of constitutively active JAK-STAT signaling associated with driver mutations has led to clinical and translational breakthroughs. Insights into the other pathways and novel factors of potential importance are being actively investigated. Various classes of agents with immunomodulating or immunosuppressive properties have been used with varying degrees of success in treating myeloproliferative neoplasms. Early clinical trials are investigating the feasibility, effectiveness, and safety of immune checkpoint inhibitors, cell-based immunotherapies, and SMAC mimetics. The dynamic landscape of immunotherapy and immunomodulation in myeloproliferative neoplasms is the topic of the present review.
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Affiliation(s)
- Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard #3000, Houston, TX 77030, USA.
| | - Natalie C Chen
- Department of Internal Medicine, The University of Texas School of Health Sciences at Houston, 6431 Fannin, MSB 1.150, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard #428, Houston, TX 77030, USA
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Tefferi A. Primary myelofibrosis: 2021 update on diagnosis, risk-stratification and management. Am J Hematol 2021; 96:145-162. [PMID: 33197049 DOI: 10.1002/ajh.26050] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/16/2022]
Abstract
DISEASE OVERVIEW Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR, or MPL mutations. Additional disease features include bone marrow reticulin/collagen fibrosis, aberrant inflammatory cytokine expression, anemia, hepatosplenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression, and shortened survival. DIAGNOSIS Bone marrow morphology is the primary basis for diagnosis. Presence of JAK2, CALR, or MPL mutation, expected in around 90% of the patients, is supportive but not essential for diagnosis; these mutations are also prevalent in the closely related MPNs, namely polycythemia vera (PV) and essential thrombocythemia (ET). The 2016 World Health Organization classification system distinguishes "prefibrotic" from "overtly fibrotic" PMF; the former might mimic ET in its presentation. Furthermore, approximately 15% of patients with ET or PV might progress into a PMF-like phenotype (post-ET/PV MF) during their clinical course. ADVERSE MUTATIONS SRSF2, ASXL1, and U2AF1-Q157 mutations predict inferior survival in PMF, independent of each other and other risk factors. RAS/CBL mutations predicted resistance to ruxolitinib therapy. ADVERSE KARYOTYPE Very high risk abnormalities include -7, inv (3), i(17q), +21, +19, 12p-, and 11q-. RISK STRATIFICATION Two new prognostic systems for PMF have recently been introduced: GIPSS (genetically-inspired prognostic scoring system) and MIPSS70+ version 2.0 (MIPSSv2; mutation- and karyotype-enhanced international prognostic scoring system). GIPSS is based exclusively on mutations and karyotype. MIPSSv2 includes, in addition, clinical risk factors. GIPSS features four and MIPSSv2 five risk categories. RISK-ADAPTED THERAPY Observation alone is advised for MIPSSv2 "low" and "very low" risk disease (estimated 10-year survival 56%-92%); allogeneic hematopoietic stem cell transplant (AHSCT) is the preferred treatment for "very high" and "high" risk disease (estimated 10-year survival 0%-13%); treatment-requiring patients with intermediate-risk disease (estimated 10-year survival 30%) are best served by participating in clinical trials. In non-transplant candidates, conventional treatment for anemia includes androgens, prednisone, thalidomide, and danazol; for symptomatic splenomegaly, hydroxyurea and ruxolitinib; and for constitutional symptoms, ruxolitinib. Fedratinib, another JAK2 inhibitor, has now been FDA-approved for use in ruxolitinib failures. Splenectomy is considered for drug-refractory splenomegaly and involved field radiotherapy for non-hepatosplenic EMH and extremity bone pain. NEW DIRECTIONS A number of new agents, alone or in combination with ruxolitinib, are currently under investigation for MF treatment (ClinicalTrials.gov); preliminary results from some of these clinical trials were presented at the 2020 ASH annual meeting and highlighted in the current document.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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Masarova L, Bose P, Verstovsek S. The Rationale for Immunotherapy in Myeloproliferative Neoplasms. Curr Hematol Malig Rep 2020; 14:310-327. [PMID: 31228096 DOI: 10.1007/s11899-019-00527-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The classic, chronic Philadelphia chromosome negative myeloproliferative neoplasms (MPN)-essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF)-are clonal malignancies of hematopoietic stem cells and are associated with myeloproliferation, organomegaly, and constitutional symptoms. Expanding knowledge that chronic inflammation and a dysregulated immune system are central to the pathogenesis and progression of MPNs serves as a driving force for the development of agents affecting the immune system as therapy for MPN. This review describes the rationale and potential impact of anti-inflammatory, immunomodulatory, and targeted agents in MPNs. RECENT FINDINGS The advances in molecular insights, especially the discovery of the Janus kinase 2 (JAK2) V617F mutation and its role in JAK-STAT pathway dysregulation, led to the development of the JAK inhibitor ruxolitinib, which currently represents the cornerstone of medical therapy in MF and hydroxyurea-resistant/intolerant PV. However, there remain significant unmet needs in the treatment of these patients, and many agents continue to be investigated. Novel, more selective JAK inhibitors might offer reduced myelosuppression or even improvement of blood counts. The recent approval of a novel, long-acting interferon for PV patients in Europe, might eventually lead to its broader clinical use in all MPNs. Targeted immunotherapy involving monoclonal antibodies, checkpoint inhibitors, or therapeutic vaccines against selected MPN epitopes could further enhance tumor-specific immune responses. Immunotherapeutic approaches are expanding and hopefully will extend the therapeutic armamentarium in patients with myeloproliferative neoplasms.
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Affiliation(s)
- Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0428, Houston, TX, 77030, USA.
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0428, Houston, TX, 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0428, Houston, TX, 77030, USA
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Garmezy B, Schaefer JK, Mercer J, Talpaz M. A provider's guide to primary myelofibrosis: pathophysiology, diagnosis, and management. Blood Rev 2020; 45:100691. [PMID: 32354563 DOI: 10.1016/j.blre.2020.100691] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 03/20/2020] [Accepted: 04/02/2020] [Indexed: 12/23/2022]
Abstract
Although understanding of the pathogenesis and molecular biology of primary myelofibrosis continues to improve, treatment options are limited, and several biological features remain unexplained. With an appropriate clinical history, exam, laboratory evaluation, and bone marrow biopsy, the diagnosis can often be established. Recent studies have better characterized prognostic factors and driver mutations in myelofibrosis, facilitated by use of next-generation sequencing. These advances have facilitated development of a management strategy that is based on both risk factors and clinical phenotype. For low-risk patients, treatment will depend on symptom severity. For patients with higher-risk disease, several treatments are available including JAK inhibitors, allogeneic hematopoietic stem cell transplant, and clinical trials using novel molecularly targeted therapies and rational drug combinations. In this review, we outline what is known about the disease pathogenesis, discuss an approach to reaching the diagnosis, review the prognosis of myelofibrosis, and detail current therapeutic strategies.
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Affiliation(s)
- Benjamin Garmezy
- Division of Cancer Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jordan K Schaefer
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Jessica Mercer
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Moshe Talpaz
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI 48109, USA.
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Benevolo G, Elli EM, Guglielmelli P, Ricco A, Maffioli M. Thrombocytopenia in patients with myelofibrosis: management options in the era of JAK inhibitor therapy. Leuk Lymphoma 2020; 61:1535-1547. [PMID: 32093511 DOI: 10.1080/10428194.2020.1728752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Myelofibrosis (MF), either appearing de novo (primary MF, PMF) or after a previous diagnosis of essential thrombocythemia or of polycythemia vera, is a progressive disease burdened by symptomatic splenomegaly, debilitating systemic symptoms, ineffective hematopoiesis, and overall reduced survival. Patients often present worsening cytopenias, including thrombocytopenia, secondary to progression of the disease as well as to cytoreductive treatment. Patients with MF and thrombocytopenia have few therapeutic options and there is limited information regarding the management of disease in these settings. This article reviews current evidence for the management of patients with MF and thrombocytopenia, in the era of JAK inhibitors.
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Affiliation(s)
- Giulia Benevolo
- Hematology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elena M Elli
- Hematology Division and Bone Marrow Unit, San Gerardo Hospital, Monza, Italy
| | - Paola Guglielmelli
- CRIMM-Centro Ricerca e Innovazione delle Malattie Mieloproliferative, Department of Experimental and Clinical Medicine, Azienda ospedaliera-Universitaria Careggi, University of Florence, Florence, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
| | - Margherita Maffioli
- Hematology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Abstract
Myelofibrosis (MF) is a myeloproliferative neoplasm that is pathologically characterized by bone marrow myeloproliferation, reticulin and collagen fibrosis, and extramedullary hematopoiesis. Constitutive activation of the Janus associated kinase (JAK)-signal transducers and activators of transcription signaling pathway with resultant elevation in pro-inflammatory cytokine levels is the pathogenic hallmark of MF. JAK inhibitors, namely ruxolitinib, have been successful in alleviating symptoms and reducing splenomegaly, but therapy-related myelosuppression has led to the further development of highly selective JAK2 inhibitors. Additionally, ruxolitinib does not appear to affect the malignant hematopoietic clone substantially, evidenced by lack of molecular remissions, bone marrow histopathologic responses, and a proportion of treated patients developing progressive disease and leukemic transformation while receiving therapy. A number of other pharmacotherapeutic strategies are currently being explored in the clinic. Non-JAK inhibitor strategies being evaluated in MF include non-JAK signaling pathway inhibitors, epigenetic-directed therapies, immune-modulating agents, anti-fibrotic agents, and telomerase inhibitors. This review highlights the current landscape of MF pharmacotherapy and explores therapeutic advances underway.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA
| | - Bridget Marcellino
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA.
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Abstract
PURPOSE OF REVIEW Cytopenias, particularly anemia, are frequently encountered in patients with myelofibrosis. Management of cytopenias in myelofibrosis can be very challenging because current therapeutic interventions are only of modest efficacy and ruxolitinib, the only approved drug for myelofibrosis, is myelosuppressive. Yet, dose optimization of ruxolitinib is important for its survival benefit in patients with advanced disease. We sought to summarize the data on treatments for cytopenias available at present and review promising agents in development and emerging strategies. RECENT FINDINGS The activin receptor ligand traps hold considerable promise for the treatment of anemia and could represent an attractive combination strategy with ruxolitinib. Low-dose thalidomide, which could offset both anemia and thrombocytopenia caused by ruxolitinib, represents another potential partner for ruxolitinib. The anti-fibrotic agent PRM-151 produced sustained improvements in cytopenias in some patients, and further data on this drug are eagerly awaited. Finally, several preclinical leads with translational potential are worthy of clinical investigation as strategies to halt/reverse bone marrow fibrosis and thereby improve cytopenias. Cytopenias remain a significant hurdle in myelofibrosis management, but several novel investigational agents hold considerable promise for the future.
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Tefferi A. Primary myelofibrosis: 2019 update on diagnosis, risk-stratification and management. Am J Hematol 2018; 93:1551-1560. [PMID: 30039550 DOI: 10.1002/ajh.25230] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR, or MPL mutations; additional disease features include bone marrow stromal reaction including reticulin fibrosis, abnormal cytokine expression, anemia, hepatosplenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression, and shortened survival. DIAGNOSIS Diagnosis of PMF is based on bone marrow morphology. Presence of JAK2, CALR, or MPL mutation, expected in ∼ 90% of the patients, is supportive but not essential for diagnosis. The revised 2016 World Health Organization (WHO) classification system distinguishes "prefibrotic" from "overtly fibrotic" PMF; the former might mimic ET in its presentation and it is prognostically relevant to distinguish the two. RISK STRATIFICATION Two new prognostic systems for PMF have recently been introduced: GIPSS (genetically inspired prognostic scoring system) and MIPSS70+ version 2.0 (mutation- and karyotype-enhanced international prognostic scoring system). GIPSS is based exclusively on mutations and karyotype. MIPSS70+ version 2.0 utilizes both genetic and clinical risk factors. GIPSS features four and MIPSS70+ version 2.0 five risk categories. MIPSS70+ version 2.0 requires an online score calculator (http://www.mipss70score.it) while GIPPS offers a lower complexity prognostic tool. RISK-ADAPTED THERAPY Observation alone is advised for MIPSS70+ version 2.0 "low" and "very low" risk disease (estimated 10-year survival 56%-92%); allogeneic stem cell transplant is the preferred treatment of choice for "very high" and "high" risk disease (estimated 10-year survival 0-13%); treatment-requiring patients with intermediate-risk disease (estimated 10-year survival 30%) are best served by participating in clinical trials. All other treatment approaches, including the use of JAK2 inhibitors, are mostly palliative and should not be used in the absence of clear treatment indications. Conventional treatment for anemia includes androgens, prednisone, thalidomide and danazol, for symptomatic splenomegaly hydroxyurea and ruxolitinib and for constitutional symptoms ruxolitinib. Splenectomy is considered for drug-refractory splenomegaly and involved field radiotherapy for nonhepatosplenic EMH and extremity bone pain.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
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12
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Hijji Y, Benjamin E, Jasinski JP, Butcher RJ. Crystal structure of the thalidomide analog (3a R*,7a S*)-2-(2,6-dioxopiperidin-3-yl)hexa-hydro-1 H-iso-indole-1,3(2 H)-dione. Acta Crystallogr E Crystallogr Commun 2018; 74:1595-1598. [PMID: 30443388 PMCID: PMC6218906 DOI: 10.1107/s2056989018014317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/10/2018] [Indexed: 11/23/2022]
Abstract
The title compound, C13H16N2O4, crystallizes in the monoclinic centrosymmetric space group, P21/c, with four mol-ecules in the asymmetric unit, thus there is no crystallographically imposed symmetry and it is a racemic mixture. The structure consists of a six-membered unsaturated ring bound to a five-membered pyrrolidine-2,5-dione ring N-bound to a six-membered piperidine-2,6-dione ring and thus has the same basic skeleton as thalidomide, except for the six-membered unsaturated ring substituted for the aromatic ring. In the crystal, the mol-ecules are linked into inversion dimers by R 2 2(8) hydrogen bonding involving the N-H group. In addition, there are bifurcated C-H⋯O inter-actions involving one of the O atoms on the pyrrolidine-2,5-dione with graph-set notation R 1 2(5). These inter-actions along with C-H⋯O inter-actions involving one of the O atoms on the piperidine-2,6-dione ring link the mol-ecules into a complex three-dimensional array. There is pseudomerohedral twinning present which results from a 180° rotation about the [100] reciprocal lattice direction and with a twin law of 1 0 0 0 0 0 0 [BASF 0.044 (1)].
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Affiliation(s)
- Yousef Hijji
- Department of Chemistry and Earth Sciences, Qatar University, Doha, Qatar
| | - Ellis Benjamin
- Department of Chemistry, Richard Stockton College of New Jersey, Galloway, NJ 08205, USA
| | - Jerry P Jasinski
- Department of Chemistry, Keene State College, 229 Main Street, Keene NH 03435, USA
| | - Ray J Butcher
- Department of Chemistry, Howard University, 525 College Street NW, Washington, DC 20059, USA
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Philadelphia chromosome-negative classical myeloproliferative neoplasms: revised management recommendations from European LeukemiaNet. Leukemia 2018. [PMID: 29515238 DOI: 10.1038/s41375-018-0077-1] [Citation(s) in RCA: 377] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This document updates the recommendations on the management of Philadelphia chromosome-negative myeloproliferative neoplasms (Ph-neg MPNs) published in 2011 by the European LeukemiaNet (ELN) consortium. Recommendations were produced by multiple-step formalized procedures of group discussion. A critical appraisal of evidence by using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was performed in the areas where at least one randomized clinical trial was published. Seven randomized controlled trials provided the evidence base; earlier phase trials also informed recommendation development. Key differences from the 2011 diagnostic recommendations included: lower threshold values for hemoglobin and hematocrit and bone marrow examination for diagnosis of polycythemia vera (PV), according to the revised WHO criteria; the search for complementary clonal markers, such as ASXL1, EZH2, IDH1/IDH2, and SRSF2 for the diagnosis of myelofibrosis (MF) in patients who test negative for JAK2V617, CALR or MPL driver mutations. Regarding key differences of therapy recommendations, both recombinant interferon alpha and the JAK1/JAK2 inhibitor ruxolitinib are recommended as second-line therapies for PV patients who are intolerant or have inadequate response to hydroxyurea. Ruxolitinib is recommended as first-line approach for MF-associated splenomegaly in patients with intermediate-2 or high-risk disease; in case of intermediate-1 disease, ruxolitinib is recommended in highly symptomatic splenomegaly. Allogeneic stem cell transplantation is recommended for transplant-eligible MF patients with high or intermediate-2 risk score. Allogeneic stem cell transplantation is also recommended for transplant-eligible MF patients with intermediate-1 risk score who present with either refractory, transfusion-dependent anemia, blasts in peripheral blood > 2%, adverse cytogenetics, or high-risk mutations. In these situations, the transplant procedure should be performed in a controlled setting.
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Myelofibrosis-Related Anemia: Current and Emerging Therapeutic Strategies. Hemasphere 2017; 1:e1. [PMID: 31723730 PMCID: PMC6745971 DOI: 10.1097/hs9.0000000000000001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022] Open
Abstract
Myelofibrosis (MF) is a clonal hematopoietic stem cell disorder characterized by pathological myeloproliferation and aberrant cytokine production resulting in progressive fibrosis, inflammation, and functional compromise of the bone marrow niche. Patients with MF develop splenomegaly (due to extramedullary hematopoiesis), hypercatabolic symptoms (due to overexpression of inflammatory cytokines), and anemia (due to bone marrow failure and splenic sequestration). MF remains curable only with allogeneic hematopoietic stem cell transplantation (ASCT), a therapy that few MF patients are deemed fit to undergo. The goals of treatment are thus often palliative. The approval of the JAK inhibitor ruxolitinib has done much to address the burden of splenomegaly and constitutional symptoms of patients with MF; however, therapy-related anemia is often an anticipated downside. Anemia thus remains a challenge in the management of MF and represents a major unmet need. Intractable anemia depresses quality of life, portends poor outcomes, and can act to restrict access to palliative JAK inhibition in some patients. While therapies for MF-related anemia do exist, they are limited in their efficacy, durability, and tolerability. Therapies currently in development promise improved anemia-specific outcomes; however, are still early in the pathway to regulatory approval and regular clinical use. In this review, we will discuss established and emerging treatments for MF-related anemia. We will give particular attention to developmental therapies which herald significant progress in the understanding and management of MF-related anemia.
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Tefferi A. Anemia in myelofibrosis-prevalence, the U2AF1 connection, new treatments. Blood Cancer J 2017; 7:648. [PMID: 29242616 PMCID: PMC5802449 DOI: 10.1038/s41408-017-0032-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/23/2017] [Indexed: 11/09/2022] Open
Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Masarova L, Verstovsek S, Kantarjian H, Daver N. Immunotherapy based approaches in myelofibrosis. Expert Rev Hematol 2017; 10:903-914. [DOI: 10.1080/17474086.2017.1366853] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Lucia Masarova
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Srdan Verstovsek
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Hagop Kantarjian
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Naval Daver
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
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Abstract
INTRODUCTION Primary myelofibrosis (PMF) is the least common but the most aggressive of the classic Philadelphia chromosome-negative myeloproliferative neoplasms. Survival is much shorter in PMF than in polycythemia vera (PV) or essential thrombocythemia (ET). Post-PV/ET myelofibrosis (MF) is clinically indistinguishable from PMF and approached similarly. Areas covered: Current pharmacologic therapy of MF revolves around the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib, which dramatically improves constitutional symptoms and splenomegaly in the majority of patients, and improves overall survival (OS). However, allogeneic stem cell transplantation remains the only potential cure. Other JAK inhibitors continue to be developed for MF, and momelotinib and pacritinib are in phase III clinical trials. Anemia is common in MF, and initially worsened by ruxolitinib. Momelotinib and pacritinib may prove advantageous in this regard. Current strategies for managing anemia of MF include danazol, immunomodulatory drugs and erythroid stimulating agents, either alone or in combination with ruxolitinib. Expert opinion: A number of other agents, representing diverse drug classes, are in various stages of development for MF. These include newer JAK inhibitors, other signaling inhibitors, epigenetic modifiers, anti-fibrotic agents, telomerase inhibitors, and activin receptor ligand traps (for anemia). Hopefully, these novel therapies will further extend the clinical benefits of ruxolitinib.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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Tefferi A. Primary myelofibrosis: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:1262-1271. [PMID: 27870387 DOI: 10.1002/ajh.24592] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 12/13/2022]
Abstract
Disease overview: Primary myelofibrosis (PMF) is a myeloproliferative neoplasm (MPN) characterized by stem cell-derived clonal myeloproliferation that is often but not always accompanied by JAK2, CALR or MPL mutation, abnormal cytokine expression, bone marrow fibrosis, anemia, splenomegaly, extramedullary hematopoiesis (EMH), constitutional symptoms, cachexia, leukemic progression and shortened survival. DIAGNOSIS Diagnosis is based on bone marrow morphology. The presence of JAK2, CALR or MPL mutation is supportive but not essential for diagnosis; approximately 90% of patients carry one of these mutations and 10% are "triple-negative." None of these mutations are specific to PMF and are also seen in essential thrombocythemia (ET). According to the revised 2016 World Health Organization (WHO) classification and diagnostic criteria, "prefibrotic" PMF (pre-PMF) is distinguished from "overtly fibrotic" PMF; the former might mimic ET in its presentation and it is prognostically relevant to distinguish the two. Risk stratification: The Dynamic International Prognostic Scoring System-plus (DIPSS-plus) uses eight predictors of inferior survival: age >65 years, hemoglobin <10 g/dL, leukocytes >25 × 109 /L, circulating blasts ≥1%, constitutional symptoms, red cell transfusion dependency, platelet count <100 × 109 /L and unfavorable karyotype (i.e., complex karyotype or sole or two abnormalities that include +8, -7/7q-, i(17q), inv(3), 5/5q-, 12p-, or 11q23 rearrangement). The presence of 0, 1, "2 or 3" and ≥4 adverse factors defines low, intermediate-1, intermediate-2 and high-risk disease with median survivals of approximately 15.4, 6.5, 2.9 and 1.3 years, respectively. Most recently, DIPSS-plus-independent adverse prognostic relevance has been demonstrated for certain mutations including ASXL1 and SRSF2 whereas patients with type 1/like CALR mutations, compared to their counterparts with other driver mutations, displayed significantly better survival. Risk-adapted therapy: Observation alone is a reasonable treatment strategy for asymptomatic low or intermediate-1 DIPSS-plus risk disease, especially in the absence of high-risk mutations. All other patients with high or intermediate-2 risk disease, or those harboring high-risk mutations such as ASXL1 or SRSF2, should be considered for stem cell transplant, which is currently the only treatment modality with the potential to favorably modify the natural history of the disease. Non-transplant candidates should be encouraged to participate in clinical trials, since the value of conventional drug therapy, including the use of JAK2 inhibitors, is limited to symptoms palliation and reduction in spleen size. Specifically, JAK2 inhibitors have not been shown to induce complete clinical or cytogenetic remissions or significantly affect JAK2/CALR/MPL mutant allele burden. Splenectomy is considered for drug-refractory splenomegaly. Involved field radiotherapy is most useful for post-splenectomy hepatomegaly, non-hepatosplenic EMH, PMF-associated pulmonary hypertension and extremity bone pain. Am. J. Hematol. 91:1262-1271, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of MedicineMayo ClinicRochester Minnesota
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19
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Reuther GW. Myeloproliferative Neoplasms: Molecular Drivers and Therapeutics. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2016; 144:437-484. [PMID: 27865464 DOI: 10.1016/bs.pmbts.2016.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Activating mutations in genes that drive neoplastic cell growth are numerous and widespread in cancer, and specific genetic alterations are associated with certain types of cancer. For example, classic myeloproliferative neoplasms (MPNs) are hematopoietic stem cell disorders that affect cells of the myeloid lineage, including erythrocytes, platelets, and granulocytes. An activating mutation in the JAK2 tyrosine kinase is prevalent in these diseases. In MPN patients that lack such a mutation, other genetic changes that lead to activation of the JAK2 signaling pathway are present, indicating deregulation of JAK2 signaling plays an etiological driving role in MPNs, a concept supported by significant evidence from in vivo experimental MPN systems. Thus, small molecules that inhibit JAK2 activity are ideal drugs to impede the progression of disease in MPN patients. However, even though JAK inhibitors provide significant symptomatic relief, they have failed as a remission-inducing therapy. Nonetheless, the progress made understanding the molecular etiology of MPNs since 2005 is significant and has provided insight for the development and testing of novel molecular targeted therapeutic approaches. The current understanding of driver mutations in MPNs and an overview of current and potential therapeutic strategies for MPN patients will be discussed.
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Affiliation(s)
- G W Reuther
- H. Lee Moffitt Cancer Center, Tampa, FL, United States; University of South Florida, Tampa, FL, United States.
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20
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Leung M, Highsmith K, Rexwinkle A. Pharmacologic management of myelofibrosis. J Oncol Pharm Pract 2016; 23:591-601. [DOI: 10.1177/1078155216670229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Myelofibrosis is a BCR-ABL-negative myeloproliferative neoplasm characterized by abnormal hematopoiesis. Alterations to the Janus kinase-signal transducer and activator of transcription pathway result in dysregulation of gene transcription and cell proliferation. Patients with symptomatic myelofibrosis present with a variety of signs and symptoms including, but not limited to myelosuppression, marked splenomegaly, abdominal discomfort, fatigue, and blood transfusion-dependence. Traditional myelosuppressive therapies including hydroxyurea, azacitidine, and cladribine aim to reduce constitutional symptoms and control the burden of disease. Immunomodulators can potentially reverse anemia associated with myelofibrosis, but are poorly tolerated by most patients. The novel Janus kinase 2 (JAK2) inhibitor, ruxolitinib, has demonstrated marked improvements to constitutional symptoms and splenomegaly. While survival benefit has not yet been demonstrated, continued research into pharmacologic management of myelofibrosis offers the promise of altering the course of disease progression.
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Affiliation(s)
- Michael Leung
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaitlin Highsmith
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amber Rexwinkle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Pinilla-Ibarz J, Sweet KL, Corrales-Yepez GM, Komrokji RS. Role of tyrosine-kinase inhibitors in myeloproliferative neoplasms: comparative lessons learned. Onco Targets Ther 2016; 9:4937-57. [PMID: 27570458 PMCID: PMC4986686 DOI: 10.2147/ott.s102504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
An important pathogenetic distinction in the classification of myeloproliferative neoplasms (MPNs) is the presence or absence of the BCR–ABL fusion gene, which encodes a unique oncogenic tyrosine kinase. The BCR–ABL fusion, caused by the formation of the Philadelphia chromosome (Ph) through translocation, constitutes the disease-initiating event in chronic myeloid leukemia. The development of successive BCR–ABL-targeted tyrosine-kinase inhibitors has led to greatly improved outcomes in patients with chronic myeloid leukemia, including high rates of complete hematologic, cytogenetic, and molecular responses. Such levels of treatment success have long been elusive for patients with Ph-negative MPNs, because of the difficulties in identifying specific driver proteins suitable as drug targets. However, in recent years an improved understanding of the complex pathobiology of classic Ph-negative MPNs, characterized by variable, overlapping multimutation profiles, has prompted the development of better and more broadly targeted (to pathway rather than protein) treatment options, particularly JAK inhibitors. In classic Ph-negative MPNs, overactivation of JAK-dependent signaling pathways is a central pathogenic mechanism, and mutually exclusive mutations in JAK2, MPL, and CALR linked to aberrant JAK activation are now recognized as key drivers of disease progression in myelofibrosis (MF). In clinical trials, the JAK1/JAK2 inhibitor ruxolitinib – the first therapy approved for MF worldwide – improved disease-related splenomegaly and symptoms independent of JAK2V617F mutational status, and prolonged survival compared with placebo or standard therapy in patients with advanced MF. In separate trials, ruxolitinib also provided comprehensive hematologic control in patients with another Ph-negative MPN – polycythemia vera. However, complete cytogenetic or molecular responses with JAK inhibitors alone are normally not observed, underscoring the need for novel combination therapies of JAK inhibitors and complementary agents that better address the complexity of the pathobiology of classic Ph-negative MPNs. Here, we discuss the role of tyrosine-kinase inhibitors in the current MPN-treatment landscape.
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Affiliation(s)
- Javier Pinilla-Ibarz
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kendra L Sweet
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gabriela M Corrales-Yepez
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- Department of Malignant Hematology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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22
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Al-Ali HK, Vannucchi AM. Managing patients with myelofibrosis and low platelet counts. Ann Hematol 2016; 96:537-548. [PMID: 27209535 DOI: 10.1007/s00277-016-2697-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/10/2016] [Indexed: 12/18/2022]
Abstract
Myelofibrosis (MF) is a chronic myeloproliferative neoplasm characterized by bone marrow fibrosis, ineffective hematopoiesis, splenomegaly, constitutional symptoms, and shortened survival. Patients often experience multiple disease-associated, as well as treatment-emergent, cytopenias, including thrombocytopenia. However, patients with MF with thrombocytopenia have few therapeutic options, and there is little information on the management of these patients. Several Janus kinase (JAK) inhibitors have been developed for the treatment of MF, with one (ruxolitinib) having been approved. However, given their mechanism of action, JAK inhibitors are associated with high rates of thrombocytopenia. Patients can be successfully managed with dose modifications, but little is known about the safety and efficacy of these agents in patients with thrombocytopenia. Recent studies of JAK inhibitors in patients with MF who have low platelet counts have had mixed results. This review discusses the prevalence, prognostic implications, and management of thrombocytopenia in MF and the different therapeutic options available for this patient population, with an emphasis on current clinical experience with targeted therapies, as well as recent findings from several clinical studies currently underway.
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Affiliation(s)
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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23
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Alimam S, Harrison C. Is there a role for pomalidomide in the treatment of myelofibrosis? Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1171139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Primary myelofibrosis: current therapeutic options. Rev Bras Hematol Hemoter 2016; 38:257-63. [PMID: 27521865 PMCID: PMC4997889 DOI: 10.1016/j.bjhh.2016.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 12/24/2022] Open
Abstract
Primary myelofibrosis is a Philadelphia-negative myeloproliferative neoplasm characterized by clonal myeloid expansion, followed by progressive fibrous connective tissue deposition in the bone marrow, resulting in bone marrow failure. Clonal evolution can also occur, with an increased risk of transformation to acute myeloid leukemia. In addition, disabling constitutional symptoms secondary to the high circulating levels of proinflammatory cytokines and hepatosplenomegaly frequently impair quality of life. Herein the main current treatment options for primary myelofibrosis patients are discussed, contemplating disease-modifying therapeutics in addition to palliative measures, in an individualized patient-based approach.
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25
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Sochacki AL, Fischer MA, Savona MR. Therapeutic approaches in myelofibrosis and myelodysplastic/myeloproliferative overlap syndromes. Onco Targets Ther 2016; 9:2273-86. [PMID: 27143923 PMCID: PMC4844455 DOI: 10.2147/ott.s83868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The discovery of JAK2 (V617F) a decade ago led to optimism for a rapidly developing treatment revolution in Ph(-) myeloproliferative neoplasms. Unlike BCR-ABL, however, JAK2 was found to have a more heterogeneous role in carcinogenesis. Therefore, for years, development of new therapies was slow, despite standard treatment options that did not address the overwhelming symptom burden in patients with primary myelofibrosis (MF), post-essential thrombocythemia MF, post-polycythemia vera MF, and myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN) syndromes. JAK-STAT inhibitors have changed this, drastically ameliorating symptoms and ultimately beginning to show evidence of impact on survival. Now, the genetic foundations of myelofibrosis and MDS/MPN are rapidly being elucidated and contributing to targeted therapy development. This has been empowered through updated response criteria for MDS/MPN and refined prognostic scoring systems in these diseases. The aim of this article is to summarize concisely the current and rationally designed investigational therapeutics directed at JAK-STAT, hedgehog, PI3K-Akt, bone marrow fibrosis, telomerase, and rogue epigenetic signaling. The revolution in immunotherapy and novel treatments aimed at previously untargeted signaling pathways provides hope for considerable advancement in therapy options for those with chronic myeloid disease.
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Affiliation(s)
- Andrew L Sochacki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa A Fischer
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael R Savona
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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27
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Overcoming treatment challenges in myelofibrosis and polycythemia vera: the role of ruxolitinib. Cancer Chemother Pharmacol 2016; 77:1125-42. [PMID: 27017614 PMCID: PMC4882345 DOI: 10.1007/s00280-016-3012-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 03/15/2016] [Indexed: 01/14/2023]
Abstract
Myelofibrosis (MF) and polycythemia vera (PV) are BCR-ABL1-negative myeloproliferative neoplasms associated with somatic hematopoietic stem cell mutations leading to over activation of JAK-STAT signaling. MF and PV are pathogenically related and share specific clinical features such as splenomegaly and constitutional symptoms. The MF phenotype is dominated by the effects of progressive bone marrow fibrosis resulting in shortened survival. In contrast, elevated thrombosis risk due to erythrocytosis is the primary clinical concern in PV. Ruxolitinib, an oral JAK1/JAK2 inhibitor, is approved in the USA for the treatment of patients with intermediate- or high-risk MF and patients with PV who have had an inadequate response to or are intolerant of hydroxyurea. For MF, results of two phase III studies demonstrated that ruxolitinib therapy reduced spleen volume and MF-related symptom burden, improved quality-of-life measures, and was associated with prolonged overall survival. Treatment benefits were generally sustained with continued therapy. Dose-dependent cytopenias were common but generally manageable with transfusions (for anemia), dose reduction, or treatment interruption. Optimal dosing management is critical to maintain long-term treatment benefit, because cessation of therapy resulted in rapid return of symptoms to baseline levels. Results of the phase III PV trial showed that ruxolitinib was significantly more effective than standard therapy in controlling hematocrit levels and improving splenomegaly and PV-related symptoms. Only 1 of 110 patients in the ruxolitinib arm compared with 6 of 112 patients in the control arm experienced a thromboembolic event through week 32. Grade ≥3 cytopenias were uncommon.
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28
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Tefferi A. Myeloproliferative neoplasms: A decade of discoveries and treatment advances. Am J Hematol 2016; 91:50-8. [PMID: 26492355 DOI: 10.1002/ajh.24221] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 10/19/2015] [Indexed: 12/14/2022]
Abstract
Myeloproliferative neoplasms (MPN) are clonal stem cell diseases, first conceptualized in 1951 by William Dameshek, and historically included chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). In 1960, Nowell and Hungerford discovered an invariable association between the Philadelphia chromosome (subsequently shown to harbor the causal BCR-ABL1 mutation) and CML; accordingly, the term MPN is primarily reserved for PV, ET, and PMF, although it includes other related clinicopathologic entities, according to the World Health Organization (WHO) classification system. In 2005, William Vainchenker and others described a Janus kinase 2 mutation (JAK2V617F) in MPN and this was followed by a series of additional descriptions of mutations that directly or indirectly activate JAK-STAT: JAK2 exon 12, myeloproliferative leukemia virus oncogene (MPL) and calreticulin (CALR) mutations. The discovery of these, mostly mutually exclusive, "driver" mutations has contributed to revisions of the WHO diagnostic criteria and risk stratification in MPN. Mutations other than JAK2, CALR and MPL have also been described in MPN and shown to provide additional prognostic information. From the standpoint of treatment, over the last 50 years, Louis Wasserman from the Unites States and Tiziano Barbui from Italy had skillfully organized and led a number of important clinical trials, whose results form the basis for current treatment strategies in MPN. More recently, allogeneic stem cell transplant, as a potentially curative treatment modality, and JAK inhibitors, as palliative drugs, have been added to the overall therapeutic armamentarium in myelofibrosis. In the current review, I will summarize the important advances made in the last 10 years regarding the science and practice of MPN.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
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29
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Gowin KL, Mesa RA. Profile of pomalidomide and its potential in the treatment of myelofibrosis. Ther Clin Risk Manag 2015; 11:549-56. [PMID: 25897239 PMCID: PMC4397931 DOI: 10.2147/tcrm.s69211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Myelofibrosis, a Philadelphia-negative myeloproliferative neoplasm, is in a new treatment era after the discovery of the JAK2V617F mutation in 2005. JAK inhibitors boast improvements in disease-related symptoms, splenomegaly, and overall survival; however, treatment of myelofibrosis remains a challenge, given the lack of improvement in cytopenias with these agents. Second-generation immunomodulatory agents, such as pomalidomide, have shown efficacy in myelofibrosis-associated anemia within multiple clinical trials. Five major pomalido-mide clinical trials have been completed to date, and demonstrate tolerability and efficacy with low-dose pomalidomide (0.5 mg/day) in the treatment of myelofibrosis, and no clinical benefit of elevated dosing regimens (≥2.5 mg/day). Anemia responses ranged from 17% to 36% as per the International Working Group for Myelofibrosis Research and Treatment consensus guidelines, while improvements in splenomegaly were rare, and observed in <1% of most clinical trials. In comparison with earlier immunomodulatory agents, pomalidomide was associated with an improved toxicity profile, with substantially lower rates of myelosuppression and neuropathy. Given the low overall response rate to pomalidomide as a single agent, combination strategies are of particular interest for future studies. Pomalidomide is currently being tested in combination with ruxolitinib, and other novel combinations are likely on the horizon.
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Affiliation(s)
- Krisstina L Gowin
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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Durable Red Blood Cell Transfusion Independence in a Patient with an MDS/MPN Overlap Syndrome Following Discontinuation of Iron Chelation Therapy. Case Rep Hematol 2015; 2015:253294. [PMID: 25918650 PMCID: PMC4396885 DOI: 10.1155/2015/253294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/11/2015] [Accepted: 03/06/2015] [Indexed: 01/14/2023] Open
Abstract
Background. Hematologic improvement (HI) occurs in some patients with acquired anemias and transfusional iron overload receiving iron chelation therapy (ICT) but there is little information on transfusion status after stopping chelation. Case Report. A patient with low IPSS risk RARS-T evolved to myelofibrosis developed a regular red blood cell (RBC) transfusion requirement. There was no response to a six-month course of study medication or to erythropoietin for three months. At 27 months of transfusion dependence, she started deferasirox and within 6 weeks became RBC transfusion independent, with the hemoglobin normalizing by 10 weeks of chelation. After 12 months of chelation, deferasirox was stopped; she remains RBC transfusion independent with a normal hemoglobin 17 months later. We report the patient's course in detail and review the literature on HI with chelation. Discussion. There are reports of transfusion independence with ICT, but that transfusion independence may be sustained long term after stopping chelation deserves emphasis. This observation suggests that reduction of iron overload may have a lasting favorable effect on bone marrow failure in at least some patients with acquired anemias.
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Birgegård G. Does anything work for anaemia in myelofibrosis? Best Pract Res Clin Haematol 2014; 27:175-85. [PMID: 25189728 DOI: 10.1016/j.beha.2014.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/11/2014] [Indexed: 11/18/2022]
Abstract
Anaemia is a common finding at diagnosis in myelofibrosis, and becomes a symptomatic problem in most patients with time. There are several treatment options for specific anaemia treatment, none of which has been tested in large, randomized, controlled trials. However, as myelofibrosis is not a disease with spontaneous remissions, even non-randomized trials carry weight. In this survey, the existing evidence will be analysed, both for the commonly used treatments like erythropoiesis-stimulating agents, androgens and thalidomide and for the new drugs in the area, and conclusions will be drawn concerning standard clinical anaemia treatment in myelofibrosis, which according to evidence from studies has a 40-50% chance of response in patients with not too advanced disease.
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Andrei M, Sindhu H, Wang JC. Two cases of myelofibrosis with severe thrombocytopenia and symptomatology successfully treated with combination of pomalidomide and ruxolitinib. Leuk Lymphoma 2014; 56:524-6. [PMID: 24893800 DOI: 10.3109/10428194.2014.924121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Mirela Andrei
- Division of Hematology/Oncology, Brookdale Hospital Medical Center , Brooklyn, New York, NY , USA
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Daver N, Shastri A, Kadia T, Newberry K, Pemmaraju N, Jabbour E, Zhou L, Pierce S, Cortes J, Kantarjian H, Verstovsek S. Phase II study of pomalidomide in combination with prednisone in patients with myelofibrosis and significant anemia. Leuk Res 2014; 38:1126-9. [PMID: 25047979 DOI: 10.1016/j.leukres.2014.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/07/2014] [Accepted: 06/28/2014] [Indexed: 01/18/2023]
Abstract
We evaluated pomalidomide with prednisone for myelofibrosis (MF) with significant anemia (hemoglobin < 10 g/dL). Patients (n = 29; 18 RBC-transfusion dependent) received 0.5mg pomalidomide daily in continuous 28-day cycles with prednisone given for the first 3 cycles only. Six (21%) patients responded (median response duration 11.4 months), including four who achieved RBC-transfusion-independence per the Delphi criteria and two who achieved clinical improvement (in platelets and spleen, respectively) per the International Working Group for Myelofibrosis Research and Treatment criteria. Grade 3 toxicity occurred in 1 patient (fatigue). Pomalidomide with prednisone is safe therapy with modest activity in patients with MF and anemia. ClinicalTrials.gov Identifier: NCT00946270.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Aditi Shastri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Kate Newberry
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Linghsa Zhou
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA.
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Angiogenesis in myeloproliferative neoplasms, new markers and future directions. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2014; 7:206-210. [PMID: 25544863 PMCID: PMC4274371 DOI: 10.1007/s12254-014-0142-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/22/2014] [Indexed: 12/11/2022]
Abstract
Tumor angiogenesis has been identified to play a critical role in tumor growth and tumor progression, and is regulated by a balance of angiogenic and antiangiogenic cytokines. This has been documented for solid tumors, and there is emerging evidence suggesting that tumor progression of hematological malignancies also depends on the induction of new blood vessel formation. Data on angiogenesis in the bone marrow of BCR-ABL1-negative myeloproliferative neoplasm patients suggest an increase of the microvessel density and vascular endothelial growth factor (VEGF) expression, and there is a relation to the JAK2-V617F status. The most important proangiogenic agent is VEGF, activating VEGF receptors 1 and 2. Inhibition of VEGF signaling by monoclonal antibodies or small molecules (kinase inhibitors) has already been successfully established for the treatment of different cancer entities, and multiple new drugs are being tested in clinical trials. Most patients with essential thrombocythemia (ET) or primary myelofibrosis (PMF) that was not associated with a JAK2 or MPL alteration carried a somatic mutation in calreticulin (CALR). Thus, CALR mutations should be included in the next classification system for ET/PMF. This review summarizes recent advances in the basic understanding of the role of angiogenesis in myeloproliferative neoplasms and the translation of such basic findings into clinical studies.
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Tibes R, Mesa RA. Targeting hedgehog signaling in myelofibrosis and other hematologic malignancies. J Hematol Oncol 2014; 7:18. [PMID: 24598114 PMCID: PMC3975838 DOI: 10.1186/1756-8722-7-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/20/2014] [Indexed: 01/05/2023] Open
Abstract
Treatment of myelofibrosis (MF), a BCR-ABL-negative myeloproliferative neoplasm, is challenging. The only current potentially curative option, allogeneic hematopoietic stem cell transplant, is recommended for few patients. The remaining patients are treated with palliative therapies to manage MF-related anemia and splenomegaly. Identification of a mutation in the Janus kinase 2 (JAK2) gene (JAK2 V617F) in more than half of all patients with MF has prompted the discovery and clinical development of inhibitors that target JAK2. Although treatment with JAK2 inhibitors has been shown to improve symptom response and quality of life in patients with MF, these drugs do not alter the underlying disease; therefore, novel therapies are needed. The hedgehog (Hh) signaling pathway has been shown to play a role in normal hematopoiesis and in the tumorigenesis of hematologic malignancies. Moreover, inhibitors of the Hh pathway have been shown to inhibit growth and self-renewal capacity in preclinical models of MF. In a mouse model of MF, combined inhibition of the Hh and JAK pathways reduced JAK2 mutant allele burden, reduced bone marrow fibrosis, and reduced white blood cell and platelet counts. Preliminary clinical data also suggest that inhibition of the Hh pathway, alone or in combination with JAK2 inhibition, may enable disease modification in patients with MF. Future studies, including one combining the Hh pathway inhibitor sonidegib and the JAK2 inhibitor ruxolitinib, are underway in patients with MF and will inform whether this combination approach can lead to true disease modification.
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Affiliation(s)
- Raoul Tibes
- Mayo Clinic Cancer Center, NCI Designated Comprehensive Cancer Center, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
| | - Ruben A Mesa
- Mayo Clinic Cancer Center, NCI Designated Comprehensive Cancer Center, 13400 E. Shea Blvd, Scottsdale, AZ 85259, USA
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Abstract
Abstract
Myelofibrosis (MF), including primary MF, postpolycythemia vera MF, and postessential thrombocythemia MF, is a clonal stem cell disorder characterized by BM fibrosis, extramedullary hematopoiesis, and a variable propensity to transform into acute leukemia. Allogeneic stem cell transplantation is the only known cure for MF, but its applicability is limited by the advanced age of most patients and by comorbid conditions. In the past decade, there has been an explosion of information on the molecular-genetic features associated with these diseases, fueled recently by the discovery of the JAK2V617F mutation. The development of JAK inhibitors has represented a significant therapeutic advance for these diseases; however, their use in MF has not yet been associated with eradication or a significant suppression of the malignant clone. In this era, much remains to be understood about MF, but it is likely that the identification of key pathogenetic drivers of the disease, coupled with the availability of novel molecularly targeted agents, will result in the discovery of new agents that significantly alter the natural history of the disease. This review focuses on recent and ongoing efforts in the development of novel agents in MF that go beyond the field of JAK inhibitors.
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Gowin K, Mesa R. Emerging therapies for the treatment of chronic Philadelphia chromosome-negative myeloproliferative neoplasm-associated myelofibrosis. Expert Opin Investig Drugs 2013; 22:1603-11. [PMID: 24066969 DOI: 10.1517/13543784.2013.832199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Chronic Philadelphia chromosome-negative myeloproliferative neoplasm-associated myelofibrosis significantly impacts afflicted patients with cytopenia, splenomegaly, debilitating constitutional symptoms and decreased survival. Approval of the first Janus kinase 2 (JAK2) inhibitor therapy, ruxolitinib, has improved splenomegaly, symptomatic burden, survival and perhaps fibrosis in some treated patients; however, other patients remain symptomatic and are in need of alternate therapeutic strategies. AREAS COVERED A review of recent literature via PubMed and meeting abstracts has revealed many studies investigating new treatment approaches for chronic Philadelphia chromosome-negative myeloproliferative neoplasms. Multiple additional JAK2 inhibitors (fedratinib, pacritinib and momelotinib) are well into single agent development, as well as multiple combination approaches with ruxolitinib. Efforts to combine JAK2 inhibition with agents to improve cytopenia, marrow fibrosis, additional pathway inhibitors and even allogeneic transplant are planned or ongoing. Additionally, Phase III trials of immunomodulation with pomalidomide are ongoing. EXPERT OPINION This article discusses investigational therapies for the treatment of Philadelphia chromosome-negative myeloproliferative neoplasms, particularly those in Phase II clinical trials, employing new JAK2 inhibitors, novel multi-agent therapeutic approaches and innovative new drug targets. Additionally, the future era of Philadelphia chromosome-negative myeloproliferative neoplasms is addressed with potentially expanded niches for JAK2 inhibition.
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Affiliation(s)
- Krisstina Gowin
- Mayo Clinic , 13499E Shea Blvd, Scottsdale, AZ 85259 , USA +480 301 8335 ; +480 301 4675 ;
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Jiang Y, Wang J, Rozewski DM, Kolli S, Wu CH, Chen CS, Yang X, Hofmeister CC, Byrd JC, Johnson AJ, Phelps MA. Sensitive liquid chromatography/mass spectrometry methods for quantification of pomalidomide in mouse plasma and brain tissue. J Pharm Biomed Anal 2013; 88:262-8. [PMID: 24095801 DOI: 10.1016/j.jpba.2013.08.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 08/18/2013] [Accepted: 08/20/2013] [Indexed: 12/23/2022]
Abstract
Pomalidomide was recently approved by the United States Food and Drug Administration for the treatment of patients with relapsed or refractory multiple myeloma who have received at least two prior therapies. As pomalidomide is increasingly evaluated in other diseases and animal disease models, this paper presents development and validation of a sensitive liquid chromatography tandem mass spectrometry assay for quantification of pomalidomide in mouse plasma and brain tissue to fill a gap in published preclinical pharmacokinetic and analytical data with this agent. After acetonitrile protein precipitation, pomalidomide and internal standard, hesperitin, were separated with reverse phase chromatography on a C-18 column with a gradient mobile phase of water and acetonitrile with 0.1% fomic acid. Positive atmospheric pressure chemical ionization mass spectrometry with selected reaction monitoring mode was applied to achieve 0.3-3000nM (0.082-819.73ng/mL) linear range in mouse plasma and 0.6-6000pmol/g in brain tissue. The within- and between-batch accuracy and precision were less than 15% for both plasma and brain tissue. The method was applied to measure pomalidomide concentrations in plasma and brain tissue in a pilot mouse pharmacokinetic study with an intravenous dose of 0.5mg/kg. This assay can be applied for thorough characterization of pomalidomide pharmacokinetics and tissue distribution in mice.
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Affiliation(s)
- Yao Jiang
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH, United States
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Struggling with myelofibrosis-associated anemia. Leuk Res 2013; 37:1429-31. [PMID: 24011697 DOI: 10.1016/j.leukres.2013.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/14/2013] [Indexed: 11/22/2022]
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Daver N, Shastri A, Kadia T, Quintas-Cardama A, Jabbour E, Konopleva M, O'Brien S, Pierce S, Zhou L, Cortes J, Kantarjian H, Verstovsek S. Modest activity of pomalidomide in patients with myelofibrosis and significant anemia. Leuk Res 2013; 37:1440-4. [PMID: 23890523 DOI: 10.1016/j.leukres.2013.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/01/2013] [Indexed: 12/16/2022]
Abstract
We evaluated single agent pomalidomide for myelofibrosis-associated anemia. First, 21 patients received pomalidomide 3.0mg/day on 21-day-on/7-day-off schedule. Due to poor tolerance the study was quickly suspended. Second, 29 patients received pomalidomide 0.5mg/day continuously. Three patients (10%) experienced clinical improvement in hemoglobin per International-Working-Group criteria (median time to response 1.6 months; median response duration 6.7 months). Ten patients were RBC-transfusion-dependent per Delphi criteria; 2 (20%) achieved RBC-transfusion-independence (time to response 0.9 months in both; response duration of 8.3 and 15 months). One grade 3/4 toxicity (neutropenia) occurred. Pomalidomide at low dose is well tolerated but has modest clinical activity in myelofibrosis.
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Affiliation(s)
- Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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A comprehensive review and analysis of the effect of ruxolitinib therapy on the survival of patients with myelofibrosis. Blood 2013; 121:4832-7. [DOI: 10.1182/blood-2013-02-482232] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Myelofibrosis is a hematological malignancy with a median survival of approximately 5 to 7 years. Allogeneic stem cell transplantation is the only therapeutic modality that provides a cure for myelofibrosis patients. Recently, ruxolitinib has been shown in 2 phase 3 studies to be effective in reducing splenomegaly and improving symptoms in myelofibrosis patients. Although conventional markers of disease burden (marrow histopathological features, cytogenetic and molecular markers, and reversal of cytopenias) were not uniformly improved, a survival advantage in favor of ruxolitinib therapy was demonstrated. The use of historical control cohorts to compare survival was implemented in 2 different analyses of patients enrolled in the phase 1/2 studies and has further added fuel to the controversy surrounding the significance of this survival advantage. Ruxolitinib therapy results in a dramatic reduction in circulating proinflammatory cytokine levels, which has been associated with improvement in symptoms and performance status and may provide a link to improved survival. We analyze the various data published and place in perspective the significance of the prolongation of survival associated with ruxolitinib therapy. This critical review of these data may allow physicians to more rationally assess the benefits that can be anticipated with the appropriate use of this therapy.
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Palandri F, Polverelli N, Catani L, Cavo M, Vianelli N. Update on the treatment of Ph-negative myeloproliferative neoplasms. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
SUMMARY Myeloproliferative neoplasms (MPNs) that do not harbor the BCR–ABL rearrangement include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis. All of these diseases are characterized by an increased risk of vascular complications and by the propensity to evolve into acute leukemia. The JAK2V617F mutation determines a gain of function in the gene encoding JAK2 and is the most frequent molecular abnormality in MPNs, with an estimated prevalence of more than 95% in PV and 50% in ET and primary myelofibrosis. Molecular markers, together with marrow histology and cytogenetic data, are increasingly relevant for MPN diagnosis, and their prognostic value is under evaluation. In PV and ET, the use of aspirin, hydroxyurea and phlebotomy remain the mainstay of treatment. In myelofibrosis, conventional therapy (androgens, steroids, chemotherapy and splenectomy) has still only palliative effects. The only potentially curative approach is allogeneic stem cell transplantation, but treatment-related mortality remains high. In the last 2 years, the JAK–STAT pathway has become the target of selective tyrosine kinase inhibitors, which might represent a promising therapeutic option. Their role in future therapy, as single agents and/or in combinatorial approaches, is yet to be determined.
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Affiliation(s)
- Francesca Palandri
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy.
| | - Nicola Polverelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Lucia Catani
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Michele Cavo
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
| | - Nicola Vianelli
- Department of Hematology & Oncology “L. & A. Seràgnoli”, University of Bologna, Italy
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Raza S, Stein BL. Novel therapies in the classical BCR–ABL-negative myeloproliferative neoplasms. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Myeloproliferative neoplasms (MPN) are clonal stem cell disorders that include essential thrombocytosis, polycythemia vera and myelofibrosis. Effective therapy is challenging owing to the heterogeneity of the disease; however, recent advances in our understanding of MPN pathogenesis have led to the evaluation of novel therapies, each with its own distinct contribution and side-effect profile. This review summarizes promising approaches to the treatment of MPN, aiming to improve upon the currently used conventional therapies.
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Affiliation(s)
- Sania Raza
- Department of Medicine, Northwestern University Feinberg School of Medicine & Robert H Lurie Comprehensive Cancer Center, 645 North Michigan Avenue, Suite 1020, Chicago, IL 60611, USA
| | - Brady L Stein
- Department of Medicine, Northwestern University Feinberg School of Medicine & Robert H Lurie Comprehensive Cancer Center, 645 North Michigan Avenue, Suite 1020, Chicago, IL 60611, USA.
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Abstract
INTRODUCTION Myelofibrosis (MF), a Philadelphia chromosome-negative myeloproliferative neoplasm, is a life-threatening heterogeneous disorder characterized by dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling network. The clinical hallmarks of MF are progressive splenomegaly, anemia and debilitating symptoms attributable to ineffective hematopoiesis and excessive production of proinflammatory cytokines. AREAS COVERED This review describes the pathogenesis, clinical features and current treatment of MF, clinical data for ruxolitinib, a potent oral JAK1/JAK2 inhibitor and the only therapy approved for the treatment of MF, and agents in development for the treatment of MF. Information was derived from relevant MF articles identified in the published literature and abstracts of recent congresses. EXPERT OPINION Ruxolitinib reduces spleen size and alleviates MF-related symptoms, thereby improving quality of life. Ruxolitinib may increase the risk of anemia and thrombocytopenia and does not appear to reverse bone marrow fibrosis. Studies are exploring ruxolitinib dosing strategies for patients with low platelet counts and combination therapies. Several other JAK inhibitors and other agents (i.e., immunomodulators, antifibrotic agents, anti-anemia agents, mammalian target of rapamycin [mTOR] inhibitors, epigenetic modifiers, pegylated interferon-α2a) to treat various aspects of MF (i.e., to improve blood counts or forestall marrow fibrosis) are in early clinical development.
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Affiliation(s)
- Ehab Atallah
- Medical College of Wisconsin Cancer Center, Neoplastic Diseases and Related
Disorders, Department of Internal Medicine, Milwaukee, WI, USA
| | - Srdan Verstovsek
- University of Texas MD Anderson Cancer Center, Leukemia Department, 1515
Holcombe Boulevard, Houston, TX 77030-4009, USA
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Ruchelman AL, Man HW, Zhang W, Chen R, Capone L, Kang J, Parton A, Corral L, Schafer PH, Babusis D, Moghaddam MF, Tang Y, Shirley MA, Muller GW. Isosteric analogs of lenalidomide and pomalidomide: synthesis and biological activity. Bioorg Med Chem Lett 2012; 23:360-5. [PMID: 23168019 DOI: 10.1016/j.bmcl.2012.10.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 10/12/2012] [Accepted: 10/15/2012] [Indexed: 11/26/2022]
Abstract
A series of analogs of the immunomodulary drugs lenalidomide (1) and pomalidomide (2), in which the amino group is replaced with various isosteres, was prepared and assayed for immunomodulatory activity and activity against cancer cell lines. The 4-methyl and 4-chloro analogs 4 and 15, respectively, displayed potent inhibition of tumor necrosis factor-α (TNF-α) in LPS-stimulated hPBMC, potent stimulation of IL-2 in a human T cell co-stimulation assay, and anti-proliferative activity against the Namalwa lymphoma cell line. Both of these analogs displayed oral bioavailability in rat.
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Affiliation(s)
- Alexander L Ruchelman
- Drug Discovery Department, Celgene Corporation, 86 Morris Avenue, Summit, NJ 07901, United States.
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Vaddi K, Sarlis NJ, Gupta V. Ruxolitinib, an oral JAK1 and JAK2 inhibitor, in myelofibrosis. Expert Opin Pharmacother 2012; 13:2397-407. [PMID: 23051187 DOI: 10.1517/14656566.2012.732998] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is a debilitating hematologic malignancy characterized by progressive splenomegaly, burdensome symptoms, cytopenias and shortened survival. Chronic alterations in Janus-associated kinase-signal transducer and activator of transcription (JAK-STAT) signaling have been identified in the pathogenesis of MF, making this pathway a target for drug development. Ruxolitinib is the first JAK1 and JAK2 inhibitor to be approved by the US Food and Drug Administration. AREAS COVERED This review describes the characteristics of MF, the current therapeutic options and need for effective therapies, the contribution of aberrant JAK-STAT signaling to various disease-specific manifestations and the pharmacodynamics, pharmacokinetics, efficacy and tolerability of ruxolitinib. Articles describing MF disease burden and results of ruxolitinib pre-clinical and clinical trials were identified and summarized. EXPERT OPINION Conventional MF treatments alleviate some MF symptoms but have limited efficacy, do not modify the natural history of the disease and are not approved for MF. The JAK1 and JAK2 inhibitor ruxolitinib has shown promising results in pre-clinical and clinical trials. In Phase III trials, ruxolitinib was shown to reduce splenomegaly and improve MF-related symptoms. Recent evidence also suggests that ruxolitinib may improve survival. The most common adverse events were anemia and thrombocytopenia, which were managed with dose adjustments (or red blood cell transfusions for anemia).
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Affiliation(s)
- Kris Vaddi
- Pharmacology & Toxicology, Experimental Station, Incyte Corp., Wilmington, DE 19348, USA.
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Lu K, Wang X. Therapeutic advancement of chronic lymphocytic leukemia. J Hematol Oncol 2012; 5:55. [PMID: 22980425 PMCID: PMC3465197 DOI: 10.1186/1756-8722-5-55] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/06/2012] [Indexed: 12/20/2022] Open
Abstract
Despite the combinations of chemotherapy with monoclonal antibodies have further improved response rates, chronic lymphocytic leukemia (CLL) remains an incurable disease with an extremely variable course. This article reviews the ongoing clinical advances in the treatment of CLL in both previously untreated and relapsed disease and focuses on the benefit of different therapeutic strategies, the most effective therapy combinations and the potential activity of novel agents. Novel agents and combination therapies have been investigated by several studies in both the upfront and relapsed setting, particularly for patients with 17p deletion, TP53 mutation and fludarabine-refractory CLL. While these agents and combination therapies have improved initial response rates, ongoing studies are continued to determine and improve the efficacy and safety. Despite advancements in the treatment of CLL have led to high response rates, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative option and reduced-intensity conditioning (RIC) allo-HSCT must be strongly considered whenever feasible. As such, ongoing studies of these agents and other novel approaches in clinical development are needed to expand and improve treatment options for CLL patients.
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Affiliation(s)
- Kang Lu
- Department of Hematology, Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Jinan, Shandong, 250021, P R China
| | - Xin Wang
- Department of Hematology, Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Jinan, Shandong, 250021, P R China
- Department of Diagnostics, Shandong University School of Medicine, Jinan, Shandong, 250012, P. R. China
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Abstract
Polycythemia vera (PV) is a clonal disorder characterized by unwarranted production of red blood cells. In the majority of cases, PV is driven by oncogenic mutations that constitutively activate the JAK-STAT signal transduction pathway, such as JAK2 V617F, or exon 12 mutations or LNK mutations. Diagnosis of PV is based on the WHO criteria. Diagnosis of post-PV myelofibrosis is established according to the International Working Group for Myeloproliferative Neoplasms Research and Treatment criteria. Different clinical presentations of PV are discussed. Prognostication of PV is tailored to the most frequent complication during follow-up, namely, thrombosis. Age older than 60 years and prior history of thrombosis are the 2 main risk factors for disease stratification. Correlations are emerging between leukocytosis, JAK2(V617F) mutation, BM fibrosis, and different outcomes of PV, which need to be confirmed in prospective studies. In my practice, hydroxyurea is still the "gold standard" when cytoreduction is needed, even though pegylated IFN-alfa-2a and ruxolitinib might be useful in particular settings. Results of phase 1 or 2 studies concerning these latter agents should however be confirmed by the ongoing randomized phase 3 clinical trials. In this paper, I discuss the main problems encountered in daily clinical practice with PV patients regarding diagnosis, prognostication, and therapy.
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