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Slowley A, Weinmann S, d'Estrube T, Phiri K, Karl FM, Gleißner E, Mueller S, Junker S, Göthert JR. Myelofibrosis and anemia: A German claims data analysis to describe epidemiology and current treatment. Eur J Haematol 2024. [PMID: 39101601 DOI: 10.1111/ejh.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES There is limited data on the incidence, prevalence, and treatments for myelofibrosis (MF) in Germany. This retrospective study examined claims data from 3.3 million insured individuals, spanning from 2010 to 2021. METHODS Four sensitivity scenarios were explored to identify cases of MF. Point prevalence and cumulative incidence of MF were determined as of December 31, 2021, and within 2021, respectively. A cross-sectional analysis used the main scenario definition of MF to identify cases and evaluate the period prevalence of patients receiving treatment for symptoms and/or splenomegaly, including first-line (1L) Janus kinase inhibitor (JAKi), second-line, or further (2L+) MF-related treatment therapies during 2021. The prevalence of anemia treatment was also reported. RESULTS The estimated standardized point prevalence of MF on December 31, 2021, was 9.9-12.4 cases per 100 000 persons, and cumulative incidence in 2021 was 1.2-1.8 cases per 100 000 persons. Standardized period prevalence in 2021 for MF patients receiving 1L JAKi and/or 2L+ MF-related treatment was 4.0 cases per 100 000. Among these patients, 47.1%-53.7% required treatment for anemia, resulting in a period prevalence of 1.9-2.2 cases per 100 000 individuals. CONCLUSION The data reveal gaps in MF treatments and the need to improve patient quality of life.
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Affiliation(s)
| | | | - Tim d'Estrube
- GSK, Value, Evidence and Outcomes Europe, London, UK
| | | | | | | | | | - Sophia Junker
- Ingress-Health HWM GmbH, a Cytel Company, Berlin, Germany
| | - Joachim R Göthert
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center (WTZ), University Hospital Essen, Germany
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Cattaneo D, Galli N, Bucelli C, Fidanza CA, Bellani V, Artuso S, Bianchi P, Consonni D, Passamonti F, Iurlo A. Red cell distribution width and prognosis in myelofibrosis patients treated with ruxolitinib. Ann Hematol 2024; 103:2787-2795. [PMID: 38864904 DOI: 10.1007/s00277-024-05801-0] [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: 02/17/2024] [Accepted: 05/10/2024] [Indexed: 06/13/2024]
Abstract
We evaluated RDW in a single-center series of 61 consecutive patients with primary and secondary MF at diagnosis and during treatment with ruxolitinib (RUX) and examined any possible prognostic impact. Elevated RDW values were present in all but 4 patients at diagnosis with a median RDW of 18.9%. RDW was higher in subjects with palpable splenomegaly (p = 0.02), higher ferritin, as well as among those cases who did not receive any cytoreduction before RUX (p = 0.04). Interestingly, higher RDW at diagnosis also correlated with a shorter time from MF diagnosis to RUX start (-4.1 months per one RDW unit; p = 0.03). We observed a modest increase (< 1%) in RDW during the first 6 months of RUX treatment. In a multivariable random-intercept model that considered all time points and contained the covariates time and RUX dose, we also observed a clear decrease in RDW with increasing hemoglobin (Hb) during RUX (slope: -0.4% per g/dL of Hb; p < 0.001). The median RDW at diagnosis of 18.9% was used as a cut-off to identify two subgroups of patients [Group 1: RDW 19.0-25.7%; Group 2: RDW 13.1-18.7%], showing a difference in mortality [Group 1 vs. 2: crude HR 2.88; p = 0.01]. Using continuous RDW at diagnosis, the crude HR was 1.21 per RDW unit (p = 0.002). In a Cox model adjusted for gender, age and Hb at diagnosis, the HR was 1.13 per RDW unit (p = 0.07). RDW may have prognostic significance at MF diagnosis and during RUX, helping in the rapid detection of patients with poor prognosis.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Nicole Galli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
| | - Cecilia Anna Fidanza
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Valentina Bellani
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
| | - Silvia Artuso
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
| | - Paola Bianchi
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Passamonti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Myeloproliferative Syndromes Unit, Via Francesco Sforza 35, Milan, 20122, Italy.
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3
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Masarova L, Verstovsek S, Liu T, Rao S, Sajeev G, Fillbrunn M, Simpson R, Li W, Yang J, Lorier YL, Gorsh B, Signorovitch J. Transfusion-related cost offsets and time burden in patients with myelofibrosis on momelotinib vs. danazol from MOMENTUM. Future Oncol 2024:1-12. [PMID: 39072442 DOI: 10.1080/14796694.2024.2368450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/12/2024] [Indexed: 07/30/2024] Open
Abstract
Aim: To estimate projected US-based cost and time burden for patients with myelofibrosis and anemia treated with momelotinib compared with danazol. Methods: Cost and time burden were calculated based on the transfusion status of patients in the MOMENTUM trial and estimates extracted from previous studies. Results: Reductions in transfusion associated with momelotinib are projected to result in cost and time savings compared with danazol in transfusion-dependent and transfusion-independent/requiring patients with myelofibrosis, respectively: annual medical costs ($53,143 and $46,455 per person), outpatient transfusion costs ($42,021 and $8,370 per person) and annual time savings (173 and 35 h per person). Conclusion: Fewer transfusions with momelotinib are projected to result in cost and time savings in patients with myelofibrosis and anemia compared with danazol.
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Affiliation(s)
- Lucia Masarova
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Srdan Verstovsek
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer, Houston, TX 77030, USA
| | - Tom Liu
- GSK plc, Philadelphia, PA 19104, USA
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4
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Jilg S, Schwaab J, Sockel K, Crodel CC, Brueckl V, Stegelmann F, Jentzsch M, Sasca D, Moyses M, Fuhrmann S, Gundel D, Caduc M, Teichmann LL, Heidel F, Al-Ali HK, Petrides PE. MoReLife - real-life data support the potential of momelotinib as a safe and effective treatment option for cytopenic myelofibrosis patients. Ann Hematol 2024:10.1007/s00277-024-05908-4. [PMID: 39073589 DOI: 10.1007/s00277-024-05908-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
Recurrent problems of patients with myelofibrosis (MF) are cytopenias, debiliating disease-related symptoms and splenomegaly. Whereas the latter are usually addressed by the JAK1/2 inhibitors ruxolitinib and fedratinib, cytopenias often remain critical. Momelotinib, a JAK1/2 inhibitor recently approved for the treatment of anemic MF patients, was shown to improve anemia via a direct inhibition of activin A receptor type I. In this German-wide, multicenter, retrospective analysis the safety and efficacy profile of momelotinib was evaluated in a real world setting within a cohort of 60 MF patients independent of pre-treatment. The median duration of treatment was 12 weeks. As a new, but manageable safety finding, creatinine increase (CTC°1-2) was detected in 10/60 patients (17%). Interestingly, not only hemoglobin levels increased in 84% of patients, but also platelet values (67%). In the cohort of transfusion-dependent individuals (n = 38), transfusion requirement improved in 15 patients (39%) with 8 reaching transfusion independency (21%). Transfusion independency was achieved within a median of 4 weeks (range 2-12). Spleen size decreased in 13/53 individuals (25%) with a median response time of 6 weeks. Thereof, 11 patients had been pre-treated with JAK inhibitor(s) (85%). Clinical improvement was detected in 24/51 symptomatic individuals (47%) with a median response time of 4 weeks. 5 patients stopped treatment due to side effects (8%), 6 patients due to a worsening of clinical symptoms (10%). Taken together, the MoReLife analysis identifies momelotinib as potent and safe therapeutic option also for heavily pre-treated cytopenic MF patients under real world conditions.
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Affiliation(s)
- Stefanie Jilg
- Onkologie Erding, Bajuwarenstr.3, Erding, Germany.
- Department of Medicine III, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Juliana Schwaab
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Carl C Crodel
- Abteilung Hämatologie und Internistische Onkologie, Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Valeska Brueckl
- Department of Hematology and Oncology, University Hospital Erlangen, Friedrich- Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Stegelmann
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Madlen Jentzsch
- Medizinische Klinik I - Hämatologie, Hämostaseologie und Infektiologie, Zelltherapie, Leipzig, Germany
| | - Daniel Sasca
- Department of Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Margarete Moyses
- Department of Internal Medicine II, Medical University Hospital, Tübingen, Germany
| | | | - Daniel Gundel
- Hämatologisch-Onkologische Praxis Würzburg, Würzburg, Germany
| | - Madlen Caduc
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Lino L Teichmann
- Department of Medicine III, University Hospital Bonn, Bonn, Germany
| | - Florian Heidel
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School (MHH), Hannover, Germany
| | - Haifa K Al-Ali
- Krukenberg Cancer Center, University Hospital of Halle, Halle, Germany
| | - Petro E Petrides
- Hematology Oncology Center Munich, Munich, Germany
- Ludwig Maximilians University Munich, Munich, Germany
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5
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Harrison CN, Vannucchi AM, Recher C, Passamonti F, Gerds AT, Hernandez-Boluda JC, Yacoub A, Sirhan S, Ellis C, Patel B, Strouse B, Platzbecker U. Momelotinib versus Continued Ruxolitinib or Best Available Therapy in JAK Inhibitor-Experienced Patients with Myelofibrosis and Anemia: Subgroup Analysis of SIMPLIFY-2. Adv Ther 2024:10.1007/s12325-024-02928-4. [PMID: 38990433 DOI: 10.1007/s12325-024-02928-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Some Janus kinase (JAK) inhibitors such as ruxolitinib and fedratinib do not address and may worsen anemia in patients with myelofibrosis. In these cases, the JAK inhibitor may be continued at a reduced dose in an effort to maintain splenic and symptom control, with supportive therapy and/or red blood cell (RBC) transfusions added to manage anemia. This post hoc descriptive analysis of the phase 3 SIMPLIFY-2 trial evaluated the relative benefits of this approach versus switching to the JAK1/JAK2/activin A receptor type 1 inhibitor momelotinib in patients for whom anemia management is a key consideration. METHODS SIMPLIFY-2 was a randomized (2:1), open-label, phase 3 trial of momelotinib versus best available therapy (BAT; 88.5% continued ruxolitinib) in JAK inhibitor-experienced patients with myelofibrosis (n = 156). Patient subgroups (n = 105 each) were defined by either baseline (1) hemoglobin (Hb) of < 100 g/L or (2) non-transfusion independence (not meeting the criteria of no transfusions and no Hb of < 80 g/L for the previous 12 weeks); outcomes have been summarized descriptively. RESULTS In both subgroups of interest, week 24 transfusion independence rates were higher with momelotinib versus BAT/ruxolitinib: baseline Hb of < 100 g/L, 22 (33.3%) versus 5 (12.8%); baseline non-transfusion independent, 25 (34.7%) versus 1 (3.0%). Mean Hb levels over time were also generally higher in both subgroups with momelotinib, despite median transfusion rates through week 24 with momelotinib being comparable to or lower than with BAT/ruxolitinib. Spleen and symptom response rates with momelotinib in these subgroups were comparable to the intent-to-treat population, while rates with BAT/ruxolitinib were lower. CONCLUSION In patients with moderate-to-severe anemia and/or in need of RBC transfusions, outcomes were improved by switching to momelotinib rather than continuing ruxolitinib and using anemia supportive therapies. TRIAL REGISTRATION ClinicalTrials.gov: NCT02101268.
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Affiliation(s)
- Claire N Harrison
- Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK.
| | | | | | - Francesco Passamonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Dipartimento di Oncologia ed Onco-Ematologia, Università degli Studi di Milano, Milan, Italy
| | - Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | | | | | - Shireen Sirhan
- Jewish General Hospital, McGill University, Montreal, QC, Canada
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6
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Gupta V, Oh S, Devos T, Dubruille V, Catalano J, Somervaille TCP, Platzbecker U, Giraldo P, Kosugi H, Sacha T, Mayer J, Illes A, Ellis C, Wang Z, Gonzalez Carreras FJ, Strouse B, Mesa R. Momelotinib vs. ruxolitinib in myelofibrosis patient subgroups by baseline hemoglobin levels in the SIMPLIFY-1 trial. Leuk Lymphoma 2024; 65:965-977. [PMID: 38501751 DOI: 10.1080/10428194.2024.2328800] [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: 01/31/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
A key hallmark of myelofibrosis is anemia, which ranges from mild to severe based on hemoglobin levels. To more clearly define outcomes with the Janus kinase (JAK) 1/JAK2/activin A receptor type 1 inhibitor momelotinib by anemia severity, we performed a descriptive post hoc exploratory analysis of the double-blind, randomized, phase 3 SIMPLIFY-1 study (NCT01969838; N = 432, JAK inhibitor naive, momelotinib vs. ruxolitinib); subgroups were defined by baseline hemoglobin: <10 (moderate/severe), ≥10 to <12 (mild), or ≥12 g/dL (nonanemic). Spleen and symptom results were generally consistent with those previously reported for the intent-to-treat population. In anemic subgroups, momelotinib was associated with higher rates of transfusion independence and reduced/stable transfusion intensity vs. ruxolitinib. No new or unexpected safety signals were identified. Overall, momelotinib provides spleen, symptom, and anemia benefits to JAK inhibitor-naive patients with myelofibrosis regardless of baseline hemoglobin level, and greater anemia-related benefits vs. ruxolitinib in patients with hemoglobin <12 g/dL.
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Affiliation(s)
- Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, Canada
| | - Stephen Oh
- Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, Belgium
| | | | - John Catalano
- Monash University & Frankston Hospital, Frankston, Australia
| | - Tim C P Somervaille
- The Christie NHS Foundation Trust & Cancer Research UK Manchester Institute, Manchester, UK
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Pilar Giraldo
- Department of Hematology, Hospital Quironsalud, Zaragoza, Spain
| | - Hiroshi Kosugi
- Department of Hematology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tomasz Sacha
- Jagiellonian University Hospital, Kraków, Poland
| | - Jiri Mayer
- University Hospital Brno, Brno, Czech Republic
| | - Arpad Illes
- Department of Internal Medicine, Division of Haematology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | - Ruben Mesa
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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7
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Furqan M, Oduoye MO. Momelotinib - a promising advancement in the management of myelofibrosis in adults with anemia. Front Oncol 2024; 14:1411972. [PMID: 38983933 PMCID: PMC11231182 DOI: 10.3389/fonc.2024.1411972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
Myelofibrosis (MF) is a rare BCR-ABL negative myeloproliferative neoplasm characterized by clonal proliferation of stem cells, with mutations in JAK2, CALR, or MPL genes. MF presents in primary and secondary forms, with common symptoms including splenomegaly, anemia, and thrombocytopenia. Diagnostic criteria involve bone marrow examination and mutation studies. Current treatments are limited, with allogeneic stem cell transplant as the only curative option. Recent FDA approval of Momelotinib (MMB) offers new promise for MF patients with anemia. MMB, a JAK1/2 and ACVR1 inhibitor, effectively reduces spleen size, improves hemoglobin levels, and decreases transfusion dependency. The MOMENTUM trial compared MMB to danazol in JAK inhibitor-treated MF patients with anemia, showing MMB's superior symptom relief and transfusion independence rates. Additionally, the SIMPLIFY-1 and SIMPLIFY-2 trials evaluated MMB in JAK inhibitor-naïve and experienced patients, respectively, confirming MMB's non-inferiority to ruxolitinib in spleen volume reduction and highlighting its benefits in transfusion requirements. MMB's unique dual inhibition mechanism addresses anemia by suppressing hepcidin production, thus enhancing erythropoiesis. These trials collectively suggest MMB as an effective treatment for MF, improving quality of life and offering a survival advantage for patients with anemia. Despite challenges, such as trial design limitations and adverse events, MMB represents a significant advancement in MF management, providing a new therapeutic option for a previously underserved patient population.
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Affiliation(s)
- Muhammad Furqan
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Malik O. Oduoye
- Department of Research and Education, Medical Research Circle, Goma, Democratic Republic of Congo
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Verstovsek S, Talpaz M, Wadleigh M, Isidori A, Te Boekhorst P, Savona MR, Bose P, Pozdnyakova O, Mesa R, El-Galaly TC, O'Sullivan J, Gamel K, Higgins B, Katakam S, Todorov B, Trunzer K, Harrison CN. A randomized, double-blind study of zinpentraxin alfa in patients with myelofibrosis who were previously treated with or ineligible for ruxolitinib: stage 2 of a phase II trial. Haematologica 2024; 109:1977-1983. [PMID: 38268448 PMCID: PMC11141656 DOI: 10.3324/haematol.2023.284410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/18/2024] [Indexed: 01/26/2024] Open
Abstract
Not available.
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Affiliation(s)
| | - Moshe Talpaz
- Michigan Medicine - The University of Michigan, Ann Arbor, MI
| | | | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, AORMN Hospital, Pesaro, Italy
| | | | - Michael R Savona
- Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olga Pozdnyakova
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ruben Mesa
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
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9
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Palandri F, Palumbo GA, Benevolo G, Iurlo A, Elli EM, Abruzzese E, Polverelli N, Tiribelli M, Auteri G, Tieghi A, Caocci G, Binotto G, Cavazzini F, Branzanti F, Beggiato E, Miglino M, Bosi C, Crugnola M, Bocchia M, Martino B, Pugliese N, Scaffidi L, Venturi M, Duminuco A, Isidori A, Cattaneo D, Krampera M, Pane F, Cilloni D, Semenzato G, Lemoli RM, Cuneo A, Trawinska MM, Vianelli N, Cavo M, Bonifacio M, Breccia M. Incidence of blast phase in myelofibrosis patients according to anemia severity at ruxolitinib start and during therapy. Cancer 2024; 130:1270-1280. [PMID: 38153814 DOI: 10.1002/cncr.35156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Anemia is frequently present in patients with myelofibrosis (MF), and it may be exacerbated by treatment with the JAK2-inhibitor ruxolitinib (RUX). Recently, a relevant blast phase (BP) incidence has been reported in anemic MF patients unexposed to RUX. METHODS The authors investigated the incidence of BP in 886 RUX-treated MF patients, included in the "RUX-MF" retrospective study. RESULTS The BP incidence rate ratio (IRR) was 3.74 per 100 patient-years (3.74 %p-y). At therapy start, Common Terminology Criteria for Adverse Events grade 3-4 anemia (hemoglobin [Hb] <8 g/dL) and severe sex/severity-adjusted anemia (Hb <8/<9 g/dL in women/men) were present in 22.5% and 25% patients, respectively. IRR of BP was 2.34 in patients with no baseline anemia and reached respectively 4.22, 4.89, and 4.93 %p-y in patients with grade 1, 2, and 3-4 anemia. Considering the sex/severity-adjusted Hb thresholds, IRR of BP was 2.85, 4.97, and 4.89 %p-y in patients with mild/no anemia, moderate, and severe anemia. Transfusion-dependent patients had the highest IRR (5.03 %p-y). Progression-free survival at 5 years was 70%, 52%, 43%, and 27% in patients with no, grade 1, 2, and 3-4 anemia, respectively (p < .001). At 6 months, 260 of 289 patients with no baseline anemia were receiving ruxolitinib, and 9.2% had developed a grade 3-4 anemia. By 6-month landmark analysis, BP-free survival was significantly worse in patients acquiring grade 3-4 anemia (69.3% vs. 88.1% at 5 years, p < .001). CONCLUSIONS This study highlights that anemia correlates with an increased risk of evolution into BP, both when present at baseline and when acquired during RUX monotherapy. Innovative anemia therapies and disease-modifying agents are warranted in these patients.
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Affiliation(s)
- Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Giuseppe A Palumbo
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", Università di Catania, Catania, Italy
| | - Giulia Benevolo
- Division of Hematology, Città della Salute e della Scienza Hospital, Torino, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena M Elli
- IRCCS San Gerardo dei Tintori, Divisione di Ematologia e Unità Trapianto di Midollo, Monza, Italy
| | | | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mario Tiribelli
- Division of Hematology and BMT, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Alessia Tieghi
- Department of Hematology, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Caocci
- Hematology Unit, Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - Gianni Binotto
- Unit of Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | | | - Filippo Branzanti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Eloise Beggiato
- Division of Hematology, Città della Salute e della Scienza Hospital, Torino, Italy
| | - Maurizio Miglino
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Genova, Genova, Italy
| | - Costanza Bosi
- Division of Hematology, AUSL di Piacenza, Piacenza, Italy
| | - Monica Crugnola
- Division of Hematology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Bruno Martino
- Division of Hematology, Azienda Ospedaliera 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, Hematology Section, University of Naples "Federico II", Naples, Italy
| | - Luigi Scaffidi
- Hematology and Bone Marrow Transplant Unit, Section of Biomedicine of Innovation, Department of Engineering for Innovative Medicine, University of Verona, Verona, Italy
| | - Marta Venturi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Andrea Duminuco
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, AORMN Hospital, Pesaro, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Krampera
- Hematology and Bone Marrow Transplant Unit, Section of Biomedicine of Innovation, Department of Engineering for Innovative Medicine, University of Verona, Verona, Italy
| | - Fabrizio Pane
- Department of Clinical Medicine and Surgery, Hematology Section, University of Naples "Federico II", Naples, Italy
| | - Daniela Cilloni
- Haematology Division, Department of Clinical and Biological Sciences, Ospedale San Luigi di Orbassano, University of Turin, Orbassano, Italy
| | | | - Roberto M Lemoli
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Genova, Genova, Italy
| | - Antonio Cuneo
- Division of Hematology, University of Ferrara, Ferrara, Italy
| | | | - Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Massimiliano Bonifacio
- Hematology and Bone Marrow Transplant Unit, Section of Biomedicine of Innovation, Department of Engineering for Innovative Medicine, University of Verona, Verona, Italy
| | - Massimo Breccia
- A.O.U. Policlinico Umberto I, Università degli Studi di Roma "La Sapienza", Rome, Italy
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10
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Stein EM, Fathi AT, Harb WA, Colak G, Fusco A, Mangan JK. Results from phase 1 of the MANIFEST clinical trial to evaluate the safety and tolerability of pelabresib in patients with myeloid malignancies. Leuk Lymphoma 2024; 65:503-510. [PMID: 38259250 DOI: 10.1080/10428194.2023.2300710] [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: 09/26/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Pelabresib (CPI-0610), a BET protein inhibitor, is in clinical development for hematologic malignancies, given its ability to target NF-κB gene expression. The MANIFEST phase 1 study assessed pelabresib in patients with acute leukemia, high-risk myelodysplastic (MDS) syndrome, or MDS/myeloproliferative neoplasms (MDS/MPNs) (NCT02158858). Forty-four patients received pelabresib orally once daily (QD) at various doses (24-400 mg capsule or 225-275 mg tablet) on cycles of 14 d on and 7 d off. The most frequent drug-related adverse events were nausea, decreased appetite, and fatigue. The maximum tolerated dose (MTD) was 225 mg tablet QD. One patient with chronic myelomonocytic leukemia (CMML) showed partial remission. In total, 25.8% of acute myeloid leukemia (AML) patients and 38.5% of high-risk MDS patients had stable disease. One AML patient and one CMML patient showed peripheral hematologic response. The favorable safety profile supports the ongoing pivotal study of pelabresib in patients with myelofibrosis using the recommended phase 2 dose of 125 mg tablet QD.CLINICAL TRIAL REGISTRATION: NCT02158858.
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Affiliation(s)
- Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amir T Fathi
- Leukemia Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wael A Harb
- Horizon Oncology and Research Center, Lafayette, IN, USA
| | - Gozde Colak
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA, USA
| | - Andrea Fusco
- Constellation Pharmaceuticals, Inc., a MorphoSys Company, Boston, MA, USA
| | - James K Mangan
- Department of Medicine, Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, CA, USA
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11
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Ho YL, Gorycki P, Ferron‐Brady G, Martin P, Vlasakakis G. Clinical assessment of momelotinib drug-drug interactions via CYP3A metabolism and transporters. Clin Transl Sci 2024; 17:e13799. [PMID: 38634429 PMCID: PMC11024956 DOI: 10.1111/cts.13799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Momelotinib-approved for treatment of myelofibrosis in adults with anemia-and its major active metabolite, M21, were assessed as drug-drug interaction (DDI) victims with a strong cytochrome P450 (CYP) 3A4 inhibitor (multiple-dose ritonavir), an organic anion transporting polypeptide (OATP) 1B1/1B3 inhibitor (single-dose rifampin), and a strong CYP3A4 inducer (multiple-dose rifampin). Momelotinib DDI perpetrator potential (multiple-dose) was evaluated with CYP3A4 and breast cancer resistance protein (BCRP) substrates (midazolam and rosuvastatin, respectively). DDI was assessed from changes in maximum plasma concentration (Cmax), area under the concentration-time curve (AUC), time to reach Cmax, and half-life. The increase in momelotinib (23% Cmax, 14% AUC) or M21 (30% Cmax, 24% AUC) exposure with ritonavir coadministration was not clinically relevant. A moderate increase in momelotinib (40% Cmax, 57% AUC) and minimal change in M21 was observed with single-dose rifampin. A moderate decrease in momelotinib (29% Cmax, 46% AUC) and increase in M21 (31% Cmax, 15% AUC) were observed with multiple-dose rifampin compared with single-dose rifampin. Due to potentially counteracting effects of OATP1B1/1B3 inhibition and CYP3A4 induction, multiple-dose rifampin did not significantly change momelotinib pharmacokinetics compared with momelotinib alone (Cmax no change, 15% AUC decrease). Momelotinib did not alter the pharmacokinetics of midazolam (8% Cmax, 16% AUC decreases) or 1'-hydroxymidazolam (14% Cmax, 16% AUC decreases) but increased rosuvastatin Cmax by 220% and AUC by 170%. Safety findings were mild in this short-term study in healthy volunteers. This analysis suggests that momelotinib interactions with OATP1B1/1B3 inhibitors and BCRP substrates may warrant monitoring for adverse reactions or dose adjustments.
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12
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Klencke BJ, Donahue R, Gorsh B, Ellis C, Kawashima J, Strouse B. Anemia-related response end points in myelofibrosis clinical trials: current trends and need for renewed consensus. Future Oncol 2024; 20:703-715. [PMID: 38318719 DOI: 10.2217/fon-2023-0964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
JAK inhibitors are the current standard of care in myelofibrosis, but many do not address and may worsen anemia; thus, anemia-related responses have traditionally been overlooked as efficacy end points in pivotal clinical trials, leading to a lack of consistency and analytic detail in their reporting. Here we apply our experiences in the phase III trials of momelotinib, a JAK1/JAK2/ACVR1 inhibitor and the first therapy indicated by the US FDA for myelofibrosis patients with anemia, to highlight how application of different criteria impacts the anemia-related benefits reported for any potential treatment in myelofibrosis. We advocate for a convention of a new expert consensus panel to bring consistency and transparency to the definition of anemia-related response in myelofibrosis.
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Affiliation(s)
| | - Rafe Donahue
- Sierra Oncology, a GSK company, San Mateo, CA 94404, USA
| | | | | | - Jun Kawashima
- Sierra Oncology, a GSK company, San Mateo, CA 94404, USA
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13
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Bruzzese A, Martino EA, Labanca C, Mendicino F, Lucia E, Olivito V, Zimbo A, Fragliasso V, Neri A, Morabito F, Vigna E, Gentile M. Momelotinib in myelofibrosis. Expert Opin Pharmacother 2024; 25:521-528. [PMID: 38623844 DOI: 10.1080/14656566.2024.2343780] [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: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Myelofibrosis (MF) is a hematologic disease characterized by bone marrow fibrosis, cytopenias, splenomegaly, and constitutional symptoms. Recent years have seen the emergence of novel therapeutic agents, notably ruxolitinib and fedratinib, which target the Janus kinases (JAK) pathway. However, their myelosuppressive effect coupled with the persistence, and even worsening anemia remains a significant challenge, leading usually to treatment discontinuation. AREAS COVERED This review focuses on Momelotinib (MMB), a unique JAK inhibitor that has shown promise in MF treatment, particularly in improving anemia. MMB inhibits type 1 kinase activin A receptor or activin receptor-like kinase-2 (ACVR1/ALK2), with consequent rebalancing of the SMAD pathways and reduced transcription of hepcidin. Moreover, it seems that MMB could reduce the serum levels of several inflammatory cytokines responsible for anemia. Clinical trials have demonstrated MMB's efficacy in reducing spleen size, alleviating symptoms, and improving anemia, with a favorable safety profile compared to other JAK inhibitors, both in treatment-naïve and in pre-treated patients. EXPERT OPINION Due to its mechanism of action, MMB represents a valuable therapeutic option in MF, addressing the clinical challenge of anemia and potentially improving outcomes for patients with hematologic malignancies. Ongoing research explores MMB's potential in acute myeloid leukemia and combination therapies.
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Affiliation(s)
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Valentina Fragliasso
- Laboratorio di Ricerca Traslazionale Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, Reggio Emilia, EmiliaRomagna, Italy
| | | | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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14
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Duminuco A, Chifotides HT, Giallongo S, Giallongo C, Tibullo D, Palumbo GA. ACVR1: A Novel Therapeutic Target to Treat Anemia in Myelofibrosis. Cancers (Basel) 2023; 16:154. [PMID: 38201581 PMCID: PMC10778144 DOI: 10.3390/cancers16010154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Activin receptor type I (ACVR1) is a transmembrane kinase receptor belonging to bone morphogenic protein receptors (BMPs). ACVR1 plays an important role in hematopoiesis and anemia via the BMP6/ACVR1/SMAD pathway, which regulates expression of hepcidin, the master regulator of iron homeostasis. Elevated hepcidin levels are inversely associated with plasma iron levels, and chronic hepcidin expression leads to iron-restricted anemia. Anemia is one of the hallmarks of myelofibrosis (MF), a bone marrow (BM) malignancy characterized by BM scarring resulting in impaired hematopoiesis, splenomegaly, and systemic symptoms. Anemia and red blood cell transfusions negatively impact MF prognosis. Among the approved JAK inhibitors (ruxolitinib, fedratinib, momelotinib, and pacritinib) for MF, momelotinib and pacritinib are preferably used in cytopenic patients; both agents are potent ACVR1 inhibitors that suppress hepcidin expression via the BMP6/ACVR1/SMAD pathway and restore iron homeostasis/erythropoiesis. In September 2023, momelotinib was approved as a treatment for patients with MF and anemia. Zilurgisertib (ACVR1 inhibitor) and DISC-0974 (anti-hemojuvelin monoclonal antibody) are evaluated in early phase clinical trials in patients with MF and anemia. Luspatercept (ACVR2B ligand trap) is assessed in transfusion-dependent MF patients in a registrational phase 3 trial. Approved ACVR1 inhibitors and novel agents in development are poised to improve the outcomes of anemic MF patients.
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Affiliation(s)
- Andrea Duminuco
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
| | - Helen T. Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd., Houston, TX 77030, USA;
| | - Sebastiano Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Cesarina Giallongo
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
| | - Daniele Tibullo
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy;
| | - Giuseppe A. Palumbo
- Hematology Unit with BMT, A.O.U. Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy;
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy; (S.G.); (C.G.)
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15
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Gill H, Leung GMK, Ooi MGM, Teo WZY, Wong CL, Choi CW, Wong GC, Lao Z, Rojnuckarin P, Castillo MRID, Xiao Z, Hou HA, Kuo MC, Shih LY, Gan GG, Lin CC, Chng WJ, Kwong YL. Management of classical Philadelphia chromosome-negative myeloproliferative neoplasms in Asia: consensus of the Asian Myeloid Working Group. Clin Exp Med 2023; 23:4199-4217. [PMID: 37747591 DOI: 10.1007/s10238-023-01189-9] [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: 03/18/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Myeloproliferative neoplasms (MPN) are a heterogeneous group of clonal hematopoietic stem cell disorders characterized clinically by the proliferation of one or more hematopoietic lineage(s). The classical Philadelphia-chromosome (Ph)-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). The Asian Myeloid Working Group (AMWG) comprises representatives from fifteen Asian centers experienced in the management of MPN. This consensus from the AMWG aims to review the current evidence in the risk stratification and treatment of Ph-negative MPN, to identify management gaps for future improvement, and to offer pragmatic approaches for treatment commensurate with different levels of resources, drug availabilities and reimbursement policies in its constituent regions. The management of MPN should be patient-specific and based on accurate diagnostic and prognostic tools. In patients with PV, ET and early/prefibrotic PMF, symptoms and risk stratification will guide the need for early cytoreduction. In younger patients requiring cytoreduction and in those experiencing resistance or intolerance to hydroxyurea, recombinant interferon-α preparations (pegylated interferon-α 2A or ropeginterferon-α 2b) should be considered. In myelofibrosis, continuous risk assessment and symptom burden assessment are essential in guiding treatment selection. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) in MF should always be based on accurate risk stratification for disease-risk and post-HSCT outcome. Management of classical Ph-negative MPN entails accurate diagnosis, cytogenetic and molecular evaluation, risk stratification, and treatment strategies that are outcome-oriented (curative, disease modification, improvement of quality-of-life).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China.
- Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Pok Fu Lam, Hong Kong, China.
| | - Garret M K Leung
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
| | - Melissa G M Ooi
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Winnie Z Y Teo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Fast and Chronic Program, Alexandra Hospital, Singapore, Singapore
| | - Chieh-Lee Wong
- Department of Medicine, Sunway Medical Centre, Shah Alam, Selangor, Malaysia
| | - Chul Won Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gee-Chuan Wong
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Zhentang Lao
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Ponlapat Rojnuckarin
- King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | | | - Zhijian Xiao
- Blood Disease Hospital and Institute of Hematology, Chinese Academy of Medical Sciences Peking Union Medical College, Tianjin, China
| | - Hsin-An Hou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chung Kuo
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Lee-Yung Shih
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Gin-Gin Gan
- University of Malaya, Kuala Lumpur, Malaysia
| | - Chien-Chin Lin
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wee-Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Yok-Lam Kwong
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
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16
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Oh ST, Mesa RA, Harrison CN, Bose P, Gerds AT, Gupta V, Scott BL, Kiladjian JJ, Lucchesi A, Kong T, Buckley SA, Tyavanagimatt S, Harder BG, Roman-Torres K, Smith J, Craig AR, Mascarenhas J, Verstovsek S. Pacritinib is a potent ACVR1 inhibitor with significant anemia benefit in patients with myelofibrosis. Blood Adv 2023; 7:5835-5842. [PMID: 37552106 PMCID: PMC10561048 DOI: 10.1182/bloodadvances.2023010151] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023] Open
Abstract
In patients with cytopenic myelofibrosis, treatment with the JAK2/IRAK1 inhibitor pacritinib was associated with anemia benefit in the phase 3 PERSIST-2 study. The impact of pacritinib on transfusion independence (TI) has not been previously described, nor has the mechanism by which pacritinib improves anemia been elucidated. Because it has been previously postulated that inhibition of activin A receptor, type 1 (ACVR1)/activin receptor-like kinase-2 improves anemia in patients with myelofibrosis via suppression of hepcidin production, we assessed the relative inhibitory potency of pacritinib compared with other JAK2 inhibitors against ACVR1. Pacritinib inhibited ACVR1 with greater potency (half-maximal inhibitory concentration [IC50] = 16.7 nM; Cmax:IC50 = 12.7) than momelotinib (IC50 = 52.5 nM; Cmax:IC50 = 3.2), fedratinib (IC50 = 273 nM; Cmax:IC50 = 1.0), or ruxolitinib (IC50 > 1000; Cmax:IC50 < 0.01). Pacritinib's inhibitory activity against ACVR1 was corroborated via inhibition of downstream SMAD signaling in conjunction with marked suppression of hepcidin production. Among patients on PERSIST-2 who were not transfusion independent at baseline based on Gale criteria, a significantly greater proportion achieved TI on pacritinib compared with those treated on best available therapy (37% vs 7%, P = .001), and significantly more had a ≥50% reduction in transfusion burden (49% vs 9%, P < .0001). These data indicate that the anemia benefit of the JAK2/IRAK1 inhibitor pacritinib may be a function of potent ACVR1 inhibition.
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Affiliation(s)
- Stephen T. Oh
- Washington University School of Medicine, St. Louis, MO
| | - Ruben A. Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Prithviraj Bose
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori,” Meldola, Italy
| | - Tim Kong
- Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | | | | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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17
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Amé S, Barraco F, Ianotto J, Jourdan E, Rey J, Viallard J, Wémeau M, Kiladjian J. Advances in management of primary myelofibrosis and polycythaemia vera: Implications in clinical practice. EJHAEM 2023; 4:779-791. [PMID: 37601853 PMCID: PMC10435696 DOI: 10.1002/jha2.734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Primary myelofibrosis (PMF) and polycythaemia vera (PV) are rare BCR-ABL1-negative myeloproliferative neoplasms, associated with an increased risk of thrombosis, haemorrhagic complications and progression to fibrosis or leukaemia or fibrosis for PV. Both diseases are characterised by biological and clinical heterogeneity, leading to great variability in their management in routine clinical practice. In this review, we present an updated overview of the diagnosis, prognosis and treatment of PMF and PV, and we discuss how our multidisciplinary expert group based across France translates this evidence-based knowledge into routine clinical practice.
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Affiliation(s)
- Shanti Amé
- Department of HaematologyInstitut de Cancérologie Strasbourg Europe (ICANS)StrasbourgFrance
| | - Fiorenza Barraco
- Department of HaematologyLyon Sud Hospital CentrePierre‐BéniteFrance
| | | | - Eric Jourdan
- Department of Clinical HaematologyUniversity Hospital of NimesNimesFrance
| | - Jérôme Rey
- Department of HaematologyInstitute Paoli‐CalmettesMarseilleFrance
| | | | - Mathieu Wémeau
- Department of HaematologyHospital Centre of RoubaixRoubaixFrance
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18
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Verstovsek S, Mesa R, Gupta V, Lavie D, Dubruille V, Cambier N, Platzbecker U, Hus M, Xicoy B, Oh ST, Kiladjian JJ, Vannucchi AM, Gerds A, Egyed M, Mayer J, Sacha T, Kawashima J, Morris M, Huang M, Harrison C. Momelotinib long-term safety and survival in myelofibrosis: integrated analysis of phase 3 randomized controlled trials. Blood Adv 2023; 7:3582-3591. [PMID: 37042865 PMCID: PMC10368854 DOI: 10.1182/bloodadvances.2022009311] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/08/2023] [Accepted: 03/06/2023] [Indexed: 04/13/2023] Open
Abstract
Momelotinib is the first inhibitor of Janus kinase 1 (JAK1) and JAK2 shown to also inhibit activin A receptor type 1 (ACVR1), a key regulator of iron homeostasis, and has demonstrated improvements in splenomegaly, constitutional symptoms, and anemia in myelofibrosis (MF). This long-term analysis pooled data from 3 randomized phase 3 studies of momelotinib (MOMENTUM, SIMPLIFY-1, and SIMPLIFY-2), representing MF disease from early (JAK inhibitor-naive) to late (JAK inhibitor-experienced) stages. Patients in the control arms (danazol in MOMENTUM, ruxolitinib in SIMPLIFY-1, and best available therapy in SIMPLIFY-2) could cross over to receive momelotinib at the end of the 24-week randomized period, and all patients could continue momelotinib treatment after the completion of these studies via an extended access protocol (XAP). Across these studies, 725 patients with MF received momelotinib; 12% remained on therapy for ≥5 years, with a median treatment exposure of 11.3 months (range, 0.1-90.4 months). The most common nonhematologic treatment-emergent adverse event (AE) occurring in ≥20% of patients was diarrhea (any grade, 27% and grade ≥3, 3%). Any-grade thrombocytopenia, anemia, and neutropenia occurred in 25%, 23%, and 7% of patients, respectively. The most common reason for momelotinib discontinuation was thrombocytopenia (4% discontinuation rate). The incidence of AEs of clinical importance (eg, infections, malignant transformation, peripheral neuropathy, and hemorrhage) did not increase over time. This analysis of one of the largest randomized trial databases for a JAK inhibitor to date in MF demonstrated a consistent safety profile of momelotinib without long-term or cumulative toxicity. These trials were registered at www.clinicaltrials.gov as: MOMENTUM (#NCT04173494), SIMPLIFY-1 (#NCT01969838), SIMPLIFY-2 (#NCT02101268), and XAP (#NCT03441113).
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Affiliation(s)
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David Lavie
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Viviane Dubruille
- Centre Hospitalier Universitaire de Nantes (CHU de Nantes), Nantes, France
| | - Nathalie Cambier
- Service d’hématologie, Centre hospitalier régional universitaire de Lille (CHRU Lille), Lille, France
| | - Uwe Platzbecker
- Clinic of Hematology, Cellular Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Marek Hus
- Uniwersytet Medyczny w Lublinie, Lublin, Poland
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Stephen T. Oh
- Division of Hematology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jean-Jacques Kiladjian
- Université de Paris, Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, Paris, France
| | - Alessandro M. Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms (CRIMM), Department of Experimental and Clinical Medicine, University of Florence, Careggi University Hospital, Florence, Italy
| | | | | | - Jiří Mayer
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomasz Sacha
- Uniwersytet Jagielloński Collegium Medicum, Krakow, Poland
| | | | | | | | - Claire Harrison
- Guy's and St Thomas' National Health Services (NHS) Foundation Trust, London, United Kingdom
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Chifotides HT, Verstovsek S, Bose P. Association of Myelofibrosis Phenotypes with Clinical Manifestations, Molecular Profiles, and Treatments. Cancers (Basel) 2023; 15:3331. [PMID: 37444441 PMCID: PMC10340291 DOI: 10.3390/cancers15133331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023] Open
Abstract
Myelofibrosis (MF) presents an array of clinical manifestations and molecular profiles. The two distinct phenotypes- myeloproliferative and myelodepletive or cytopenic- are situated at the two poles of the disease spectrum and are largely defined by different degrees of cytopenias, splenomegaly, and distinct molecular profiles. The myeloproliferative phenotype is characterized by normal/higher peripheral blood counts or mildly decreased hemoglobin, progressive splenomegaly, and constitutional symptoms. The myeloproliferative phenotype is typically associated with secondary MF, higher JAK2 V617F burden, fewer mutations, and superior overall survival (OS). The myelodepletive phenotype is usually associated with primary MF, ≥2 cytopenias, modest splenomegaly, lower JAK2 V617F burden, higher fibrosis, greater genomic complexity, and inferior OS. Cytopenias are associated with mutations in epigenetic regulators/splicing factors, clonal evolution, disease progression, and shorter OS. Clinical variables, in conjunction with the molecular profiles, inform integrated prognostication and disease management. Ruxolitinib/fedratinib and pacritinib/momelotinib may be more suitable to treat patients with the myeloproliferative and myelodepletive phenotypes, respectively. Appreciation of MF heterogeneity and two distinct phenotypes, the different clinical manifestations and molecular profiles associated with each phenotype alongside the growing treatment expertise, the development of non-myelosuppressive JAK inhibitors, and integrated prognostication are leading to a new era in patient management. Physicians can increasingly tailor personalized treatments that will address the unique unmet needs of MF patients, including those presenting with the myelodepletive phenotype, to elicit optimal outcomes and extended OS across the disease spectrum.
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Affiliation(s)
| | | | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (H.T.C.); (S.V.)
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20
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Chifotides HT, Masarova L, Verstovsek S. SOHO State of the Art Updates and Next Questions: Novel Therapeutic Strategies in Development for Myelofibrosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:219-231. [PMID: 36797153 PMCID: PMC10378306 DOI: 10.1016/j.clml.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023]
Abstract
Development of myelofibrosis (MF) therapeutics has reached fruition as the transformative impact of JAK2 inhibitors in the MPN landscape is complemented/expanded by a profusion of novel monotherapies and rational combinations in the frontline and second line settings. Agents in advanced clinical development span various mechanisms of action (eg, epigenetic or apoptotic regulation), may address urgent unmet clinical needs (cytopenias), increase the depth/duration of spleen and symptom responses elicited by ruxolitinib, improve other aspects of the disease besides splenomegaly/constitutional symptoms (eg, resistance to ruxolitinib, bone marrow fibrosis or disease course), provide personalized strategies, and extend overall survival (OS). Ruxolitinib had a dramatic impact on the quality of life and OS of MF patients. Recently, pacritinib received regulatory approval for severely thrombocytopenic MF patients. Momelotinib is advantageously poised among JAK inhibitors given its differentiated mode of action (suppression of hepcidin expression). Momelotinib demonstrated significant improvements in anemia measures, spleen responses, and MF-associated symptoms in MF patients with anemia; and will likely receive regulatory approval in 2023. An array of other novel agents combined with ruxolitinib, such as pelabresib, navitoclax, parsaclisib, or as monotherapies (navtemadlin) are evaluated in pivotal phase 3 trials. Imetelstat (telomerase inhibitor) is currently evaluated in the second line setting; OS was set as the primary endpoint, marking an unprecedented goal in MF trials, wherein SVR35 and TSS50 at 24 weeks have been typical endpoints heretofore. Transfusion independence may be considered another clinically meaningful endpoint in MF trials given its correlation with OS. Overall, therapeutics are at the cusp of an exponential expansion and advancements that will likely lead to the golden era in treatment of MF.
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Affiliation(s)
- Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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21
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Abstract
OPINION STATEMENT Currently approved therapies for myelofibrosis (MF) consist of JAK inhibitors, which produce meaningful improvements in spleen size and symptom burden but do not significantly impact leukemic progression. In addition, many patients develop resistance or intolerance to existing therapies and are left without meaningful therapeutic options. There has been recent rapid development of agents in MF that may be able to fill these unmet needs. Importantly, most treatments currently in clinical development have targets outside the JAK-STAT pathway, including BET, BCL-2/BCL-xL, PI3k, HDM2, PIM-1, SINE, telomerase, LSD1, and CD123. These therapies are being tested in combination with JAK inhibitors in the front-line setting and in patients with a suboptimal response, as well as a single agent after JAK inhibitor failure. This next generation of agents is likely to produce a paradigm shift in MF treatment with a focus on combination treatment targeting multiple areas of MF pathophysiology.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX, USA.
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX, USA.
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22
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Verstovsek S, Gerds AT, Vannucchi AM, Al-Ali HK, Lavie D, Kuykendall AT, Grosicki S, Iurlo A, Goh YT, Lazaroiu MC, Egyed M, Fox ML, McLornan D, Perkins A, Yoon SS, Gupta V, Kiladjian JJ, Granacher N, Lee SE, Ocroteala L, Passamonti F, Harrison CN, Klencke BJ, Ro S, Donahue R, Kawashima J, Mesa R. Momelotinib versus danazol in symptomatic patients with anaemia and myelofibrosis (MOMENTUM): results from an international, double-blind, randomised, controlled, phase 3 study. Lancet 2023; 401:269-280. [PMID: 36709073 DOI: 10.1016/s0140-6736(22)02036-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Janus kinase (JAK) inhibitors approved for myelofibrosis provide spleen and symptom improvements but do not meaningfully improve anaemia. Momelotinib, a first-in-class inhibitor of activin A receptor type 1 as well as JAK1 and JAK2, has shown symptom, spleen, and anaemia benefits in myelofibrosis. We aimed to confirm the differentiated clinical benefits of momelotinib versus the active comparator danazol in JAK-inhibitor-exposed, symptomatic patients with anaemia and intermediate-risk or high-risk myelofibrosis. METHODS MOMENTUM is an international, double-blind, randomised, controlled, phase 3 study that enrolled patients at 107 sites across 21 countries worldwide. Eligible patients were 18 years or older with a confirmed diagnosis of primary myelofibrosis or post-polycythaemia vera or post-essential thrombocythaemia myelofibrosis. Patients were randomly assigned (2:1) to receive momelotinib (200 mg orally once per day) plus danazol placebo (ie, the momelotinib group) or danazol (300 mg orally twice per day) plus momelotinib placebo (ie, the danazol group), stratified by total symptom score (TSS; <22 vs ≥22), spleen size (<12 cm vs ≥12 cm), red blood cell or whole blood units transfused in the 8 weeks before randomisation (0 units vs 1-4 units vs ≥5 units), and study site. The primary endpoint was the Myelofibrosis Symptom Assessment Form (MFSAF) TSS response rate at week 24 (defined as ≥50% reduction in mean MFSAF TSS over the 28 days immediately before the end of week 24 compared with baseline). MOMENTUM is registered with ClinicalTrials.gov, number NCT04173494, and is active but not recruiting. FINDINGS 195 patients were randomly assigned to either the momelotinib group (130 [67%]) or danazol group (65 [33%]) and received study treatment in the 24-week randomised treatment period between April 24, 2020, and Dec 3, 2021. A significantly greater proportion of patients in the momelotinib group reported a 50% or more reduction in TSS than in the danazol group (32 [25%] of 130 vs six [9%] of 65; proportion difference 16% [95% CI 6-26], p=0·0095). The most frequent grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were haematological abnormalities by laboratory values: anaemia (79 [61%] of 130 vs 49 [75%] of 65) and thrombocytopenia (36 [28%] vs 17 [26%]). The most frequent non-haematological grade 3 or higher treatment-emergent adverse events with momelotinib and danazol were acute kidney injury (four [3%] of 130 vs six [9%] of 65) and pneumonia (three [2%] vs six [9%]). INTERPRETATION Treatment with momelotinib, compared with danazol, resulted in clinically significant improvements in myelofibrosis-associated symptoms, anaemia measures, and spleen response, with favourable safety. These findings support the future use of momelotinib as an effective treatment in patients with myelofibrosis, especially in those with anaemia. FUNDING Sierra Oncology.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Aaron T Gerds
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Alessandro M Vannucchi
- Department of Hematology, University of Florence, Florence, Italy; Center of Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy
| | | | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Medical University of Silesia, Katowice, Poland
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Mihaela C Lazaroiu
- Department of Hematology, Policlinica de Diagnostic Rapid Brasov, Brasov, Romania
| | - Miklos Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, Hungary
| | - Maria Laura Fox
- Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Perkins
- Department of Haematology, Alfred Hospital, Monash University, Melbourne, Australia
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hoôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, CIC1427, Paris, France
| | - Nikki Granacher
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Sung-Eun Lee
- Department of Laboratory Medicine, Seoul St Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | | | | | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | | | - Ruben Mesa
- Mays Cancer Center, UT Health San Antonio MD Anderson, San Antonio, TX, USA
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23
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Yacoub A, Mesa RA, Oh ST. Long-Term Hematologic Improvement in a Patient With Cytopenic Myelofibrosis Treated With Pacritinib. JCO Precis Oncol 2023; 7:e2200523. [PMID: 36634298 PMCID: PMC9929105 DOI: 10.1200/po.22.00523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Ruben A. Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX
| | - Stephen T. Oh
- Washington University School of Medicine, St Louis, MO
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24
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Thrombocytopenia in Patients With Myelofibrosis: A Practical Management Guide. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1067-e1074. [PMID: 36117043 DOI: 10.1016/j.clml.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 01/26/2023]
Abstract
Patients with myelofibrosis (MF) frequently develop thrombocytopenia as a consequence of bone marrow fibrosis, splenic sequestration, and myelosuppression from an inflammatory microenvironmental milieu. Thrombocytopenia occurs frequently at diagnosis, worsens with disease progression, is an independent adverse prognostic factor, and limits effective dosing of JAK2 inhibitors. Recently, pacritinib was approved for patients with MF and extreme thrombocytopenia. However, this JAK2/IRAK1 inhibitor is not primarily used to attain improvement in platelet count. In this narrative review, we discuss strategies to specifically address thrombocytopenia in MF patients including immunomodulatory drugs, synthetic androgens, hypomethylating agents and splenectomy, all of which have only modest efficacy in alleviating thrombocytopenia. We also detail transfusion approaches, including diagnostic and therapeutic consideration for platelet transfusion refractoriness. We end by discussing novel therapies, including TGFβ traps and recombinant pentraxin-2, which may increase platelet counts in MF patients. Despite recent therapeutic advancements in MF, there remains a near paucity of agents that can effectively alleviate thrombocytopenia.
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25
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Passamonti F, Harrison CN, Mesa RA, Kiladjian JJ, Vannucchi AM, Verstovsek S. Anemia in myelofibrosis: current and emerging treatment options. Crit Rev Oncol Hematol 2022; 180:103862. [DOI: 10.1016/j.critrevonc.2022.103862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/17/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
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26
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Palmer J. EXABS-163-MPN Myelofibrosis with Cytopenia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22 Suppl 2:S70-S71. [PMID: 36164237 DOI: 10.1016/s2152-2650(22)00667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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27
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Mascarenhas J. Pacritinib for the treatment of patients with myelofibrosis and thrombocytopenia. Expert Rev Hematol 2022; 15:671-684. [PMID: 35983661 DOI: 10.1080/17474086.2022.2112565] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Myelofibrosis (MF) is a rare myeloproliferative neoplasm characterized by a complex symptom profile, cytopenias, splenomegaly, and potential for leukemic progression. Severe thrombocytopenia is common in patients with MF and correlates with poor prognosis; however, until recently, treatment options for these patients were limited. Pacritinib, a potent Janus kinase (JAK) 2/interleukin-1 receptor-associated kinase 1 (IRAK1) inhibitor, has demonstrated significant reduction in splenomegaly, improved symptom control, and a manageable safety profile in patients with MF regardless of the severity of thrombocytopenia. AREAS COVERED : This review will outline the pacritinib drug profile and summarize key efficacy and safety data, focusing on the 200 mg twice daily dose from phase 2 and 3 studies that formed the basis for the recent US Food and Drug Administration approval of pacritinib in patients with MF and severe thrombocytopenia (platelet counts <50 x 109/L). EXPERT OPINION Pacritinib, with its unique mechanism of action targeting both JAK2 and IRAK1, offers patients with MF and severe thrombocytopenia a new treatment option, providing consistent disease and symptom control. Adverse events are easily manageable. Further analyses to identify ideal patient characteristics for pacritinib and other JAK inhibitors along with studies of pacritinib combinations are warranted, including in related myeloid malignancies.
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Affiliation(s)
- John Mascarenhas
- Tisch Cancer Institute, Division of Hematology/Oncology Icahn School of Medicine at Mount Sinai, New York, USA
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28
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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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29
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Mesa R, Oh ST, Gerds AT, Gupta V, Catalano J, Cervantes F, Devos T, Hus M, Kiladjian JJ, Lech-Maranda E, McLornan D, Palmer J, Platzbecker U, Treliński J, Shimoda K, Donahue R, D'Hollander K, Kowalski M, Verstovsek S. Momelotinib reduces transfusion requirements in patients with myelofibrosis. Leuk Lymphoma 2022; 63:1718-1722. [PMID: 35255234 DOI: 10.1080/10428194.2022.2043304] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ruben Mesa
- Mays Cancer Center, UT Health San Antonio Cancer Center, San Antonio, TX, USA
| | - Stephen T Oh
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Aaron T Gerds
- Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Vikas Gupta
- Department of Medicine, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - John Catalano
- Haematology Department, Monash University & Frankston Hospital, Frankston, Australia
| | - Francisco Cervantes
- Hematology Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven and Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, Belgium
| | - Marek Hus
- Hematooncology Department, Medical University of Lublin, Lublin, Poland
| | - Jean-Jacques Kiladjian
- Université de Paris, AP-HP, Hôpital Saint-Louis, Centre d'Investigations Cliniques, INSERM, Paris, France
| | - Ewa Lech-Maranda
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Donal McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jeanne Palmer
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | - Jacek Treliński
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Kazuya Shimoda
- Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan
| | - Rafe Donahue
- Biometrics, Sierra Oncology Inc, San Mateo, CA, USA
| | - Koenraad D'Hollander
- Biostatistics, International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Mark Kowalski
- Research and Early Development, Sierra Oncology Inc, San Mateo, CA, USA
| | - Srdan Verstovsek
- Leukemia Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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30
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Abstract
Myelofibrosis is a myeloproliferative neoplasm characterized by splenomegaly, debilitating constitutional symptoms and bone marrow failure. Disease-related anemia is common and associated with an inferior quality of life and survival. Unfortunately, few therapies exist to improve hemoglobin in myelofibrosis patients. Momelotinib is a JAK1/JAK2 inhibitor that also antagonizes ACVR1, leading to downregulation of hepcidin expression and increased availability of iron for erythropoiesis. In clinical testing, momelotinib has demonstrated a unique ability to improve hemoglobin and reduce transfusion burden in myelofibrosis patients with baseline anemia, while producing reductions in spleen size and symptom burden. This review explores the preclinical rationale, clinical trial data and future role of momelotinib in the evolving therapeutic landscape of myelofibrosis.
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Affiliation(s)
- Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, TX, USA
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31
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Novel Usefulness of Krebs von den Lungen 6 (KL-6) with Hemoglobin and Lactate Dehydrogenase for Assessing Bone Marrow Fibrosis. Diagnostics (Basel) 2022; 12:diagnostics12030628. [PMID: 35328181 PMCID: PMC8946956 DOI: 10.3390/diagnostics12030628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
Bone marrow fibrosis (BMF) is manually assessed by reticulin and trichrome stain of bone marrow (BM) biopsy and graded on a semi-quantitative scale. Krebs von den Lungen 6 (KL-6) and Mac-2 binding protein glycosylation isomer (M2BPGi) are known to be associated with lung and liver fibrosis, respectively. We explored the usefulness of KL-6 and M2BPGi to assess BMF. A total of 250 patients who underwent BM biopsy with hematologic or non-hematologic diseases were included, and 42 patients with lung and liver diseases were excluded. The patients’ data, including age, sex, diagnosis, white blood cell, hemoglobin (Hb), platelet, and lactate dehydrogenase (LDH) were collected. Measured KL-6 and M2BPGi levels were compared with reticulin grade (RG) (grade 0–3). KL-6 levels were significantly elevated with an increase in RG, but M2BPGi did not show a significant difference. Hb, LDH, or KL-6 were independent predictors for BMF (odds ratio: 1.96, 2.26, 2.91, respectively), but showed poor predictive ability (area under the curve [AUC] 0.62, 0.61, 0.60, respectively). The combination of Hb, LDH, and KL-6 showed a significantly improved predictive ability for BMF (AUC 0.73; integrated discrimination improvement 0.057; category-free net reclassification improvement 0.625). This is the first study to evaluate the usefulness of KL-6 for assessing BMF. The combination of Hb, LDH, and KL-6 would be an objective and relevant biomarker approach and be applied to risk stratification for BMF.
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32
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Chifotides HT, Bose P, Verstovsek S. Momelotinib: an emerging treatment for myelofibrosis patients with anemia. J Hematol Oncol 2022; 15:7. [PMID: 35045875 PMCID: PMC8772195 DOI: 10.1186/s13045-021-01157-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022] Open
Abstract
The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib’s unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.
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33
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Tremblay D, Hoffman R. Emerging drugs for the treatment of myelofibrosis: phase II & III clinical trials. Expert Opin Emerg Drugs 2021; 26:351-362. [PMID: 34875179 DOI: 10.1080/14728214.2021.2015320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Myelofibrosis is a clonal hematologic malignancy with clinical manifestations that include cytopenias, debilitating constitutional symptoms, splenomegaly, bone marrow fibrosis and a propensity toward leukemic progression. While allogeneic hematopoietic stem cell transplantation can be curative, this therapy is not available for the majority of patients. Ruxolitinib and fedratinib are approved JAK2 inhibitors that have produced meaningful benefits in terms of spleen reduction and symptom improvement, but there remain several unmet needs. AREAS COVERED We discuss novel therapies based upon published data from phase II or III clinical trials. Specifically, we cover novel JAK inhibitors (momelotinib and pacritinib), and agents that target bromodomain and extra-terminal domain (pelabresib), the antiapoptotic proteins BCL-2/BCL-xL (navitoclax), MDM2 (navtemadlin), phosphatidylinositol 3-kinase (parsaclisib), or telomerase (imetelstat). EXPERT OPINION Patients with disease related cytopenias are ineligible for currently approved JAK2 inhibitors. However, momelotinib and pacritinib may be able to fill this void. Novel therapies are being evaluated in the upfront setting to improve the depth and duration of responses with ruxolitinib. Future evaluation of agents must be judged on their potential to modify disease progression, which current JAK2 inhibitors lack. Combination therapy, possibly with an immunotherapeutic agent might serve as key components of future myelofibrosis treatment options.
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Affiliation(s)
- Douglas Tremblay
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA10029
| | - Ronald Hoffman
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA10029
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Palumbo GA, Galimberti S, Barcellini W, Cilloni D, Di Renzo N, Elli EM, Finelli C, Maurillo L, Ricco A, Musto P, Russo R, Latagliata R. From Biology to Clinical Practice: Iron Chelation Therapy With Deferasirox. Front Oncol 2021; 11:752192. [PMID: 34692534 PMCID: PMC8527180 DOI: 10.3389/fonc.2021.752192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 01/19/2023] Open
Abstract
Iron chelation therapy (ICT) has become a mainstay in heavily transfused hematological patients, with the aim to reduce iron overload (IOL) and prevent organ damage. This therapeutic approach is already widely used in thalassemic patients and in low-risk Myelodysplastic Syndrome (MDS) patients. More recently, ICT has been proposed for high-risk MDS, especially when an allogeneic bone marrow transplantation has been planned. Furthermore, other hematological and hereditary disorders, characterized by considerable transfusion support to manage anemia, could benefit from this therapy. Meanwhile, data accumulated on how iron toxicity could exacerbate anemia and other clinical comorbidities due to oxidative stress radical oxygen species (ROS) mediated by free iron species. Taking all into consideration, together with the availability of approved oral iron chelators, we envision a larger use of ICT in the near future. The aim of this review is to better identify those non-thalassemic patients who can benefit from ICT and give practical tips for management of this therapeutic strategy.
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Affiliation(s)
- Giuseppe A Palumbo
- Department of Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia, " University of Catania, Catania, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Wilma Barcellini
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico di Milano and University of Milan, Milan, Italy
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Nicola Di Renzo
- Hematology and Transplant Unit, Ospedale Vito Fazzi, Lecce, Italy
| | - Elena Maria Elli
- Division of Hematology and Bone Marrow Unit, Ospedale San Gerardo, Aziende Socio Sanitarie Territoriali (ASST), Monza, Italy
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Luca Maurillo
- Department of Onco-hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alessandra Ricco
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy
| | - Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Universitaria (AOU) Consorziale Policlinico, Bari, Italy.,Department of Emergency and Organ Transplantation, "Aldo Moro" University School of Medicine, Bari, Italy
| | - Rodolfo Russo
- Clinica Nefrologica, Dialisi e Trapianto, Department of Integrated Medicine with the Territory, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberto Latagliata
- Unità Operativa Complessa (UOC) Ematologia, Ospedale Belcolle, Viterbo and Division of Cellular Biotechnology and Hematology, Sapienza University, Rome, Italy
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Soyfer EM, Fleischman AG. Inflammation in Myeloid Malignancies: From Bench to Bedside. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:160-167. [PMID: 35663100 PMCID: PMC9138438 DOI: 10.36401/jipo-21-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/21/2021] [Accepted: 05/21/2021] [Indexed: 12/19/2022]
Abstract
Myeloid malignancies, stemming from a somatically mutated hematopoietic clone, can cause a wide variety of clinical consequences, including pancytopenia in myelodysplastic syndrome, overproduction of three myeloid lineages in myeloproliferative neoplasm, and the rapid growth of immature hematopoietic cells in acute myeloid leukemia (AML). It is becoming clear that inflammation is a hallmark feature of clonal myeloid conditions, ranging from clonal hematopoiesis of indeterminate potential to AML. Fundamental findings from laboratory research on inflammation in myeloid malignancies has potential implications for diagnosis, prognostication, and treatment in these diseases. In this review, we highlighted some pertinent basic science findings regarding the role of inflammation in myeloid malignancies and speculated how these findings could impact the clinical care of patients.
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Affiliation(s)
- Eli M Soyfer
- School of Medicine, University of California, Irvine, CA, USA
| | - Angela G Fleischman
- Division of Hematology/Oncology, UC Irvine Health, Irvine, CA, USA
- Chao Family Comprehensive Cancer Center, University of California, Irvine, USA
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Verstovsek S, Chen CC, Egyed M, Ellis M, Fox L, Goh YT, Gupta V, Harrison C, Kiladjian JJ, Lazaroiu MC, Mead A, McLornan D, McMullin MF, Oh ST, Perkins A, Platzbecker U, Scheid C, Vannucchi A, Yoon SS, Kowalski MM, Mesa RA. MOMENTUM: momelotinib vs danazol in patients with myelofibrosis previously treated with JAKi who are symptomatic and anemic. Future Oncol 2021; 17:1449-1458. [PMID: 33423550 DOI: 10.2217/fon-2020-1048] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hallmark features of myelofibrosis (MF) are cytopenias, constitutional symptoms and splenomegaly. Anemia and transfusion dependency are among the most important negative prognostic factors and are exacerbated by many JAK inhibitors (JAKi). Momelotinib (MMB) has been investigated in over 820 patients with MF and possesses a pharmacological and clinical profile differentiated from other JAKi by inhibition of JAK1, JAK2 and ACVR1. MMB is designed to address the complex drivers of iron-restricted anemia and chronic inflammation in MF and should improve constitutional symptoms and splenomegaly while maintaining or improving hemoglobin in JAKi-naive and previously JAKi-treated patients. The MOMENTUM Phase III study is designed to confirm and extend observations of safety and clinical activity of MMB.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia at The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chih-Cheng Chen
- Division of Hematology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Miklós Egyed
- Department of Hematology, Somogy County Mór Kaposi General Hospital, Kaposvár, 7400, Hungary
| | - Martin Ellis
- Hematology Institute & Blood Bank, Meir Medical Center, Kfar Saba & Sackler School of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Laura Fox
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, 08035, Spain
| | - Yeow T Goh
- Singapore General Hospital, 169608, Singapore
| | - Vikas Gupta
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, M5G 2C1, Canada
| | - Claire Harrison
- Guy's & St. Thomas' NHS Foundation Trust, London, SE1 9RS, UK
| | - Jean-Jacques Kiladjian
- Centre d'Investigations Cliniques (INSERM CIC 1427), AP-HP, Hopital Saint-Louis, Université de Paris, Paris, 75010, France
| | | | - Adam Mead
- Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | | | | | - Stephen T Oh
- Hematology Division, Washington University, St. Louis, MO 63110, USA
| | - Andrew Perkins
- The Alfred Hospital & Monash University, Melbourne 3004, Australia
| | | | - Christof Scheid
- Department of Internal Medicine & Center of Integrated Oncology Cologne Bonn, University of Cologne, Köln, 50923, Germany
| | - Alessandro Vannucchi
- Center Research & Innovation of Myeloproliferative Neoplasms, AOU Careggi, University of Florence, Firenze, 50139, Italy
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | | | - Ruben A Mesa
- Mays Cancer Center, UT Health San Antonio Cancer Center, San Antonio, TX 78229, USA
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Nasillo V, Riva G, Paolini A, Forghieri F, Roncati L, Lusenti B, Maccaferri M, Messerotti A, Pioli V, Gilioli A, Bettelli F, Giusti D, Barozzi P, Lagreca I, Maffei R, Marasca R, Potenza L, Comoli P, Manfredini R, Maiorana A, Tagliafico E, Luppi M, Trenti T. Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies. Int J Mol Sci 2021; 22:ijms22041906. [PMID: 33672997 PMCID: PMC7918142 DOI: 10.3390/ijms22041906] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.
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Affiliation(s)
- Vincenzo Nasillo
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
- Correspondence: ; Tel.: +39-059-422-2173
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Ambra Paolini
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Luca Roncati
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (L.R.); (A.M.)
| | - Beatrice Lusenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Monica Maccaferri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Rossana Maffei
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, 27100 Pavia, Italy;
| | - Rossella Manfredini
- Centre for Regenerative Medicine “S. Ferrari”, University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Antonino Maiorana
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (L.R.); (A.M.)
| | - Enrico Tagliafico
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy; (A.P.); (F.F.); (M.M.); (A.M.); (V.P.); (A.G.); (F.B.); (D.G.); (P.B.); (I.L.); (R.M.); (R.M.); (L.P.); (M.L.)
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy; (G.R.); (B.L.); (E.T.); (T.T.)
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Nasillo V, Riva G, Paolini A, Forghieri F, Roncati L, Lusenti B, Maccaferri M, Messerotti A, Pioli V, Gilioli A, Bettelli F, Giusti D, Barozzi P, Lagreca I, Maffei R, Marasca R, Potenza L, Comoli P, Manfredini R, Maiorana A, Tagliafico E, Luppi M, Trenti T. Inflammatory Microenvironment and Specific T Cells in Myeloproliferative Neoplasms: Immunopathogenesis and Novel Immunotherapies. Int J Mol Sci 2021. [PMID: 33672997 DOI: 10.3390/ijms22041906.pmid:33672997;pmcid:pmc7918142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
The Philadelphia-negative myeloproliferative neoplasms (MPNs) are malignancies of the hematopoietic stem cell (HSC) arising as a consequence of clonal proliferation driven by somatically acquired driver mutations in discrete genes (JAK2, CALR, MPL). In recent years, along with the advances in molecular characterization, the role of immune dysregulation has been achieving increasing relevance in the pathogenesis and evolution of MPNs. In particular, a growing number of studies have shown that MPNs are often associated with detrimental cytokine milieu, expansion of the monocyte/macrophage compartment and myeloid-derived suppressor cells, as well as altered functions of T cells, dendritic cells and NK cells. Moreover, akin to solid tumors and other hematological malignancies, MPNs are able to evade T cell immune surveillance by engaging the PD-1/PD-L1 axis, whose pharmacological blockade with checkpoint inhibitors can successfully restore effective antitumor responses. A further interesting cue is provided by the recent discovery of the high immunogenic potential of JAK2V617F and CALR exon 9 mutations, that could be harnessed as intriguing targets for innovative adoptive immunotherapies. This review focuses on the recent insights in the immunological dysfunctions contributing to the pathogenesis of MPNs and outlines the potential impact of related immunotherapeutic approaches.
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Affiliation(s)
- Vincenzo Nasillo
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Giovanni Riva
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Ambra Paolini
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Luca Roncati
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Beatrice Lusenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Monica Maccaferri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Rossana Maffei
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, 27100 Pavia, Italy
| | - Rossella Manfredini
- Centre for Regenerative Medicine "S. Ferrari", University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Antonino Maiorana
- Institute of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Enrico Tagliafico
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, 41124 Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, AUSL/AOU Policlinico, 41124 Modena, Italy
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Yokus O, Yigit B, Goze H, Serin I. The relationship between serum ferritin level and fibrosis and splenomegaly in myelofibrosis. AMERICAN JOURNAL OF BLOOD RESEARCH 2020; 10:345-350. [PMID: 33489443 PMCID: PMC7811910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/27/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Myelofibrosis (MF) is a disease in which the grade of bone marrow fibrosis increases in proportion to the degree of extramedullary hematopoiesis and splenomegaly. Associated with increased cytokines and inflammation, anemia deepens and an increase in serum ferritin levels is also expected. There are no studies addressing the relationship between ferritin and splenomegaly or fibrosis. In this study, the relationship between serum ferritin level and splenomegaly and bone marrow fibrosis was examined. MATERIAL AND METHOD The study was performed retrospectively in 46 MF cases diagnosed between 2012 and 2020. MF was divided into 3 separate subgroups: Primary myelofibrosis, secondary myelofibrosis and myeloproliferative neoplasms (MDS/MPN) with myelodsplastic syndrome. RESULTS Thirty (28.3%) of cases were PMF, 26 (56.5%) were SMF and 7 (15.2%) were MDS/MPN. There was no relation found between serum ferritin and splenomegaly in none of the cases or subgroup analysis (for PMF p: 0.564, for SMF p: 0.192, for MDS/MPN p: 0.364). There was a statistically significant relationship between serum ferritin and marrow fibrosis within the group of ages 60 years and older (p: 0.016). DISCUSSION AND CONCLUSION Disruption of hematopoiesis and progressive splenomegaly causes an increase in iron stores associated with an increased need for transfusion. This causes iron-related organ toxicity and bone marrow hematopoiesis disruption, leading to an increase in morbidity. We see that a significant relationship between ferritin and fibrosis has been revealed in the group aged 60 years and older. It is an unprecedented study in the literature in terms of both examining the relationship ferritin and fibrosis or splenomegaly and its results.
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Affiliation(s)
- Osman Yokus
- Department of Hematology, University of Health Sciences, Istanbul Training and Research HospitalIstanbul, Turkey
| | - Betul Yigit
- Department of Internal Medicine, University of Health Sciences, Istanbul Training and Research HospitalIstanbul, Turkey
| | - Hasan Goze
- Department of Hematology, University of Health Sciences, Istanbul Training and Research HospitalIstanbul, Turkey
| | - Istemi Serin
- Department of Hematology, University of Health Sciences, Istanbul Training and Research HospitalIstanbul, Turkey
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Bassiony S, Harrison CN, McLornan DP. Evaluating the Safety, Efficacy, and Therapeutic Potential of Momelotinib in the Treatment of Intermediate/High-Risk Myelofibrosis: Evidence to Date. Ther Clin Risk Manag 2020; 16:889-901. [PMID: 33061394 PMCID: PMC7524184 DOI: 10.2147/tcrm.s258704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022] Open
Abstract
Myelofibrosis is a heterogeneous disorder with regard to both molecular pathogenesis and clinical phenotype, ranging from an initial fairly indolent condition in some through to an aggressive and debilitating scenario with profound constitutional symptoms, cytopenia frequently requiring transfusional support, and massive splenomegaly. Many advances have been made within the therapeutic arena, and an increasing array of novel agents are now available for disease management. Within this review, we focus on the current and predicted role of the JAK inhibitor momelotinib (Sierra Oncology) in myelofibrosis, with an emphasis on clinical trial evaluation, drug efficacyand safety, and discuss the suggested place in the therapeutic paradigm of myelofibrosis in 2020 and beyond.
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Affiliation(s)
- Sarah Bassiony
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
| | - Donal P McLornan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
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Mughal TI, Deininger MW, Kucine N, Saglio G, Van Etten RA. Children and Adolescents with Chronic Myeloproliferative Neoplasms: Still an Unmet Biological and Clinical Need? Hemasphere 2019; 3:e283. [PMID: 31942538 PMCID: PMC6919464 DOI: 10.1097/hs9.0000000000000283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 12/20/2022] Open
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