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Loutsou M, Georgakopoulou VE, Roussakis N, Chadia K, Steiropoulos P. Miliary TB and COVID-19 Coinfection in a Patient With a History of Post-polycythemia Vera Myelofibrosis Treated With Ruxolitinib: A Case Report. Cureus 2024; 16:e63791. [PMID: 39100065 PMCID: PMC11297589 DOI: 10.7759/cureus.63791] [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] [Accepted: 07/03/2024] [Indexed: 08/06/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the diagnosis and management of tuberculosis (TB), a major public health issue. This case report discusses a 70-year-old female with post-polycythemia vera myelofibrosis (post-PV MF) treated with ruxolitinib who developed miliary TB amidst a COVID-19 infection. The patient presented with a flu-like syndrome over the past week with fatigue and weight loss the last month. When she was admitted to the hospital, the real-time polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. Despite the typical COVID-19 presentation, her clinical and radiographic features raised suspicion for disseminated TB. Diagnostic tests, including bronchoscopy and PCR for Mycobacterium tuberculosis, confirmed miliary TB. She was treated with a standard antitubercular regimen, leading to symptomatic improvement. The interplay between COVID-19 and TB is complex, with COVID-19-induced immunosuppression, particularly lymphocytopenia, facilitating TB reactivation. Additionally, ruxolitinib, a Janus kinase (JAK) inhibitor used for myelofibrosis, impairs immune defense mechanisms, increasing infection risk, including TB. Prompt and accurate diagnosis of TB in the context of COVID-19 is crucial for effective management and improved patient outcomes. Clinicians should remain vigilant for TB reactivation in patients undergoing treatments such as ruxolitinib and consider alternative diagnoses despite positive SARS-CoV-2 tests. This report highlights the necessity for a comprehensive evaluation and timely intervention to mitigate the compounded risks of COVID-19 and TB.
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Affiliation(s)
- Maria Loutsou
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, GRC
| | | | - Nikolaos Roussakis
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, GRC
| | - Konstantina Chadia
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, GRC
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, GRC
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Shyam Sunder S, Sharma UC, Pokharel S. Adverse effects of tyrosine kinase inhibitors in cancer therapy: pathophysiology, mechanisms and clinical management. Signal Transduct Target Ther 2023; 8:262. [PMID: 37414756 PMCID: PMC10326056 DOI: 10.1038/s41392-023-01469-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/06/2023] [Accepted: 04/23/2023] [Indexed: 07/08/2023] Open
Abstract
Since their invention in the early 2000s, tyrosine kinase inhibitors (TKIs) have gained prominence as the most effective pathway-directed anti-cancer agents. TKIs have shown significant utility in the treatment of multiple hematological malignancies and solid tumors, including chronic myelogenous leukemia, non-small cell lung cancers, gastrointestinal stromal tumors, and HER2-positive breast cancers. Given their widespread applications, an increasing frequency of TKI-induced adverse effects has been reported. Although TKIs are known to affect multiple organs in the body including the lungs, liver, gastrointestinal tract, kidneys, thyroid, blood, and skin, cardiac involvement accounts for some of the most serious complications. The most frequently reported cardiovascular side effects range from hypertension, atrial fibrillation, reduced cardiac function, and heart failure to sudden death. The potential mechanisms of these side effects are unclear, leading to critical knowledge gaps in the development of effective therapy and treatment guidelines. There are limited data to infer the best clinical approaches for the early detection and therapeutic modulation of TKI-induced side effects, and universal consensus regarding various management guidelines is yet to be reached. In this state-of-the-art review, we examine multiple pre-clinical and clinical studies and curate evidence on the pathophysiology, mechanisms, and clinical management of these adverse reactions. We expect that this review will provide researchers and allied healthcare providers with the most up-to-date information on the pathophysiology, natural history, risk stratification, and management of emerging TKI-induced side effects in cancer patients.
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Affiliation(s)
- Sunitha Shyam Sunder
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Umesh C Sharma
- Division of Cardiovascular Medicine, Jacob's School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Saraswati Pokharel
- Cardio-Oncology Research Group, Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
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La Spina E, Giallongo S, Giallongo C, Vicario N, Duminuco A, Parenti R, Giuffrida R, Longhitano L, Li Volti G, Cambria D, Di Raimondo F, Musumeci G, Romano A, Palumbo GA, Tibullo D. Mesenchymal stromal cells in tumor microenvironment remodeling of BCR-ABL negative myeloproliferative diseases. Front Oncol 2023; 13:1141610. [PMID: 36910610 PMCID: PMC9996158 DOI: 10.3389/fonc.2023.1141610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Chronic myeloproliferative neoplasms encompass the BCR-ABL1-negative neoplasms polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). These are characterized by calreticulin (CALR), myeloproliferative leukemia virus proto-oncogene (MPL) and the tyrosine kinase Janus kinase 2 (JAK2) mutations, eventually establishing a hyperinflammatory tumor microenvironment (TME). Several reports have come to describe how constitutive activation of JAK-STAT and NFκB signaling pathways lead to uncontrolled myeloproliferation and pro-inflammatory cytokines secretion. In such a highly oxidative TME, the balance between Hematopoietic Stem Cells (HSCs) and Mesenchymal Stromal Cells (MSCs) has a crucial role in MPN development. For this reason, we sought to review the current literature concerning the interplay between HSCs and MSCs. The latter have been reported to play an outstanding role in establishing of the typical bone marrow (BM) fibrotic TME as a consequence of the upregulation of different fibrosis-associated genes including PDGF- β upon their exposure to the hyperoxidative TME characterizing MPNs. Therefore, MSCs might turn to be valuable candidates for niche-targeted targeting the synthesis of cytokines and oxidative stress in association with drugs eradicating the hematopoietic clone.
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Affiliation(s)
- Enrico La Spina
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Sebastiano Giallongo
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Cesarina Giallongo
- Department of Medical-Surgical Science and Advanced Technologies "Ingrassia", University of Catania, Catania, Italy
| | - Nunzio Vicario
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Andrea Duminuco
- Department of General Surgery and Medical-Surgical Specialties, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Rosalba Parenti
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Rosario Giuffrida
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Lucia Longhitano
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Giovanni Li Volti
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Daniela Cambria
- Department of General Surgery and Medical-Surgical Specialties, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Francesco Di Raimondo
- Department of General Surgery and Medical-Surgical Specialties, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Giuseppe Musumeci
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Alessandra Romano
- Department of General Surgery and Medical-Surgical Specialties, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Department of Medical-Surgical Science and Advanced Technologies "Ingrassia", University of Catania, Catania, Italy
| | - Daniele Tibullo
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
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Hongjin Zhai, Zhang S, Ampomah-Wireko M, Wang H, Cao Y, Yang P, Yang Y, Frejat FOA, Wang L, Zhao B, Ren C, Wu C. Pyrazole: An Important Core in Many Marketed and Clinical Drugs. RUSSIAN JOURNAL OF BIOORGANIC CHEMISTRY 2022. [DOI: 10.1134/s1068162022060280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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5
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Ogai A, Yagi K, Ito F, Domoto H, Shiomi T, Chin K. Fatal Disseminated Tuberculosis and Concurrent Disseminated Cryptococcosis in a Ruxolitinib-treated Patient with Primary Myelofibrosis: A Case Report and Literature Review. Intern Med 2022; 61:1271-1278. [PMID: 34565769 PMCID: PMC9107979 DOI: 10.2169/internalmedicine.6436-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Ruxolitinib, a Janus kinase inhibitor, improves symptoms in patients with myelofibrosis. However, its association with the development of opportunistic infections has been a concern. We herein report a 71-year-old man with primary myelofibrosis who developed disseminated tuberculosis and concurrent disseminated cryptococcosis during ruxolitinib treatment. We also reviewed the literature on disseminated tuberculosis and/or cryptococcosis associated with ruxolitinib treatment. This is the first case of disseminated tuberculosis and concurrent disseminated cryptococcosis during treatment with ruxolitinib. We therefore suggest considering not only disseminated tuberculosis but also cryptococcosis in the differential diagnosis of patients with abnormal pulmonary shadows during ruxolitinib treatment.
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Affiliation(s)
- Asuka Ogai
- Department of Hematology, Department of Medicine, Keiyu Hospital, Japan
| | - Kazuma Yagi
- Department of Pulmonary Medicine, Department of Medicine, Keiyu Hospital, Japan
| | - Fumimaro Ito
- Department of Pulmonary Medicine, Department of Medicine, Keiyu Hospital, Japan
| | | | - Tetsuya Shiomi
- Department of Pulmonary Medicine, Department of Medicine, Keiyu Hospital, Japan
| | - Kenko Chin
- Department of Hematology, Department of Medicine, Keiyu Hospital, Japan
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Torralba M, Farra R, Maddaloni M, Grassi M, Dapas B, Grassi G. Drugs Repurposing in High-Grade Serous Ovarian Cancer. Curr Med Chem 2021; 27:7222-7233. [PMID: 32660396 DOI: 10.2174/0929867327666200713190520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ovary Carcinoma (OC) is the most lethal gynecological neoplasm due to the late diagnoses and to the common development of resistance to platinum-based chemotherapy. Thus, novel therapeutic approaches are urgently required. In this regard, the strategy of drug repurposing is becoming attractive. By this approach, the effectiveness of a drug originally developed for another indication is tested in a different pathology. The advantage is that data about pharmacokinetic properties and toxicity are already available. Thus, in principle, it is possible to reduce research costs and to speed up drug usage/marketing. RESULTS Here, some noticeable examples of repurposed drugs for OC, such as amiodarone, ruxolitinib, statins, disulfiram, ormeloxifenem, and Quinacrine, are reported. Amiodarone, an antiarrhythmic agent, has shown promising anti-OC activity, although the systemic toxicity should not be neglected. The JAK inhibitor, Ruxolitinib, may be employed particularly in coadministration with standard OC therapy as it synergistically interacts with platinum-based drugs. Particularly interesting is the use of statin which represent one of the most commonly administered drugs in aged population to treat hypercholesterolemia. Disulfiram, employed in the treatment of chronic alcoholism, has shown anti-OC properties. Ormeloxifene, commonly used for contraception, seems to be promising, especially due to the negligible side effects. Finally, Quinacrine used as an antimicrobial and anti-inflammatory drug, is able to downregulate OC cell growth and promote cell death. CONCLUSION Whereas further testing in patients are necessary to better clarify the therapeutic potential of repurposed drugs for OC, it is believed that their use, better if combined with OC targeted delivery systems, can significantly contribute to the development of novel and effective anti-OC treatments.
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Affiliation(s)
- Manuel Torralba
- Department of Life Sciences, University of Trieste, Via Giorgeri 1, 34127 Trieste, Italy
| | - Rossella Farra
- Department of Medical, Surgical and Health Sciences, University of Trieste, Cattinara Hospital, Strada di Fiume 447,
34149 Trieste, Italy
| | - Marianna Maddaloni
- Department of Life Sciences, University of Trieste, Via Giorgeri 1, 34127 Trieste, Italy
| | - Mario Grassi
- Department of Engineering and Architecture, University of Trieste, Via Alfonso Valerio
6/A, I-34127 Trieste, Italy
| | - Barbara Dapas
- Department of Life Sciences, University of Trieste, Via Giorgeri 1, 34127 Trieste, Italy
| | - Gabriele Grassi
- Department of Life Sciences, University of Trieste, Via Giorgeri 1, 34127 Trieste, Italy,Department of Medical, Surgical and Health Sciences, University of Trieste, Cattinara Hospital, Strada di Fiume 447,
34149 Trieste, Italy
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Pugliese N, Giordano C, Nappi D, Luciano L, Cerchione C, Annunziata M, Casale B, Crisà E, Villa MR, Pezzullo L, Iovine M, Picardi M, Grimaldi F, Pane F, Martinelli V. Adding hydroxyurea in combination with ruxolitinib improves clinical responses in hyperproliferative forms of myelofibrosis. Cancer Med 2019; 8:2802-2809. [PMID: 30997748 PMCID: PMC6558489 DOI: 10.1002/cam4.2147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/11/2019] [Accepted: 03/20/2019] [Indexed: 12/21/2022] Open
Abstract
Ruxolitinib, an orally bioavailable and selective inhibitor of Janus kinase 1 (JAK1) and JAK2, significantly reduces splenomegaly and disease‐related symptoms in patients with myelofibrosis (MF). However, no clear survival benefit has been demonstrated, which may in part reflect suboptimal drug exposure related to lower dosages needed to minimize hematological toxicity, specifically cytopenias. Furthermore, the optimal management of specific conditions such as leukocytosis or thrombocytosis in patients under ruxolitinib therapy is still undefined. In these cases, combining ruxolitinib with a cytoreductive agent like hydroxyurea might improve hematological response. This observational multi‐center study enrolled 20 adult patients with intermediate‐ or high‐risk primary MF, post‐ polycythemia vera MF, or postessential thrombocythemia MF with hyperproliferative manifestations of the disease and WBC and/or platelet counts not controlled by ruxolitinib therapy. The patients received treatment with a combination of ruxolitinib and hydroxyurea. A clinical response of any type was obtained in 8 patients (40%) during ruxolitinib monotherapy and in 17 patients (85%) during ruxolitinib‐hydroxyurea combination (P = 0.003). After a median duration of 12.4 months of combination therapy, 16/20 patients had a hematological response; 14/17 patients who had started combination therapy to control WBC count and 2/3 who started in order to reduce platelets count. The number of patients requiring ruxolitinib dosage reduction or discontinuations was lower during combination therapy and, at the end of follow‐up the median ruxolitinib dose was increased in 50% of patients. In conclusion, the combination of hydroxyurea with ruxolitinib yielded a high clinical response rate and increased ruxolitinib exposure in patients with hyperproliferative forms of MF.
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Affiliation(s)
- Novella Pugliese
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Claudia Giordano
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Davide Nappi
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Luigiana Luciano
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Claudio Cerchione
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy.,Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Mario Annunziata
- Hematology Unit, A.O.R.N. Antonio Cardarelli Hospital, Naples, Italy
| | - Beniamino Casale
- Hematology Unit, AO Ospedali dei Colli Napoli, PO Monaldi, Naples, Italy
| | - Elena Crisà
- Hematology Division, Università degli Studi di Torino, Turin, Italy
| | | | - Luca Pezzullo
- Hematology and Hematopoietic Stem Cell Transplant Center, A.U.O. San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Maria Iovine
- Hematology Unit, AORN Sant'Anna e San Sebastiano Caserta, Caserta, Italy
| | - Marco Picardi
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Francesco Grimaldi
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Fabrizio Pane
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
| | - Vincenzo Martinelli
- Department of Medicine and Surgery, Hematology and Hematopoietic Stem Cell Transplant Center, University of Naples Federico II, Naples, Italy
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Mesa RA, Su Y, Woolfson A, Prchal JT, Turnbull K, Jabbour E, Scherber R, Shields AL, Krohe M, Ojo F, Pompilus F, Cappelleri JC, Harrison C. Development of a symptom assessment in patients with myelofibrosis: qualitative study findings. Health Qual Life Outcomes 2019; 17:61. [PMID: 30975150 PMCID: PMC6460742 DOI: 10.1186/s12955-019-1121-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/14/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The goal of the research reported here was to understand the patient experience of living with myelofibrosis (MF) and establish content validity of the Modified Myeloproliferative Neoplasm Symptom Assessment Diary (MPN-SD). METHODS Qualitative interviews were performed in patients with MF, including both concept elicitation and cognitive debriefing. Patients with MF were asked to spontaneously report on their signs, symptoms, and impacts of MF, as well as their understanding of the MPN-SD content, and use of the tool on an electronic platform. A supplementary literature review and meetings with MF experts were also performed. RESULTS Twenty-three patients with MF participated in qualitative interviews. Signs and symptoms most commonly reported by ruxolitinib-experienced patients (n = 16) were: fatigue and/or tiredness (n = 16, 100%), shortness of breath (n = 11, 69%), pain below the ribs on the left side and/or stomach pain and/or abdominal pain (n = 9, 56%), and enlarged spleen (n = 9, 56%) and for ruxolitinib-naïve patients (n = 7) were: fatigue and/or tiredness (n = 6, 86%), pain below the ribs on the left side (n = 6, 86%), enlarged spleen (n = 4, 57%), full quickly/filling up quickly (n = 4, 57%), night sweats and/or general sweats (n = 4, 57%), and itching (n = 4, 57%). Patients demonstrated that they were able to read, understand, and provide meaningful responses to the MPN-SD. The final version of the MPN-SD includes the 10 most commonly reported concepts from the MF patient interviews. CONCLUSIONS The findings demonstrate the comprehensiveness of the MPN-SD in assessing MF symptoms in both ruxolitinib-experienced and ruxolitinib-naïve patients, while remaining easy for patients to understand and complete.
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Affiliation(s)
- Ruben A. Mesa
- University of Texas Health San Antonio Cancer Care Center, 7979 Wurzbach Rd, San Antonio, TX 78229 USA
| | - Yun Su
- Pfizer Inc., 235 E 42nd St., New York, NY 10017 USA
| | | | - Josef T. Prchal
- University of Utah School of Medicine, 201 Presidents Cir., Salt Lake City, UT 84112 USA
| | | | - Elias Jabbour
- MD Anderson Cancer Center, 1230 Holcombe Blvd., Houston, TX 77030 USA
| | - Robyn Scherber
- Mayo Clinic Cancer Center, 5881 E Mayo Blvd., Phoenix, AZ 85054 USA
| | - Alan L. Shields
- Adelphi Values, 290 Congress St. 7th Floor, Boston, MA 02210 USA
| | - Meaghan Krohe
- Adelphi Values, 290 Congress St. 7th Floor, Boston, MA 02210 USA
| | - Funke Ojo
- Adelphi Values, 290 Congress St. 7th Floor, Boston, MA 02210 USA
| | - Farrah Pompilus
- Adelphi Values, 290 Congress St. 7th Floor, Boston, MA 02210 USA
| | | | - Claire Harrison
- Guy’s and St. Thomas’ NHS Foundation Trust, St. Thomas Hospital, Westminster Bridge Rd. Lambeth, London, SE1 7EH UK
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Fogelman D, Cubillo A, García-Alfonso P, Mirón MLL, Nemunaitis J, Flora D, Borg C, Mineur L, Vieitez JM, Cohn A, Saylors G, Assad A, Switzky J, Zhou L, Bendell J. Randomized, double-blind, phase two study of ruxolitinib plus regorafenib in patients with relapsed/refractory metastatic colorectal cancer. Cancer Med 2018; 7:5382-5393. [PMID: 30123970 PMCID: PMC6246927 DOI: 10.1002/cam4.1703] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Janus kinase/signal transducer and activator of transcription (JAK-STAT) signaling pathway plays a key role in the systemic inflammatory response in many cancers, including colorectal cancer (CRC). This study evaluated the addition of ruxolitinib, a potent JAK1/2 inhibitor, to regorafenib in patients with relapsed/refractory metastatic CRC. METHODS In this two-part, multicenter, phase 2 study, eligible adult patients had metastatic adenocarcinoma of the colon or rectum; an Eastern Cooperative Oncology Group performance status of 0-2; received fluoropyrimidine, oxaliplatin, and irinotecan-based chemotherapy, an anti-vascular endothelial growth factor therapy (if no contraindication); and if KRAS wild-type (and no contraindication), an anti-epidermal growth factor receptor therapy; and progressed following the last administration of approved therapy. Patients who received previous treatment with regorafenib, had an established cardiac or gastrointestinal disease, or had an active infection requiring treatment were excluded. The study was conducted in 95 sites in North America, European Union, Asia Pacific, and Israel. After an open-label, safety run-in phase (part 1; ruxolitinib 20 mg twice daily [BID] plus regorafenib 160 mg once daily [QD]), the double-blind, randomized phase (part 2) was conducted wherein patients were randomized 1:1 to receive ruxolitinib 15 mg BID plus regorafenib 160 mg QD [ruxolitinib group] or placebo plus regorafenib 160 mg QD [placebo group]. Part 2 included substudy 1 (patients with high systemic inflammation, ie, C-reactive protein [CRP] >10 mg/L) and substudy 2 (patients with low systemic inflammation, ie, CRP ≤10 mg/L); the primary endpoint was overall survival (OS). RESULTS The study was terminated early; substudy 1 was terminated for futility at interim analysis and substudy 2 was terminated per sponsor decision. Ruxolitinib 20 mg BID was well tolerated in the safety run-in (n = 11). Overall, 396 patients were randomized (substudy 1: n = 175 [ruxolitinib group, n = 87; placebo group, n = 88]; substudy 2: n = 221 [ruxolitinib group, n = 110; placebo group, n = 111]). There was no significant difference in OS or progression-free survival (PFS) between treatments in substudy 1 (OS: hazard ratio [HR] = 1.040 [95% confidence interval: 0.725-1.492]; PFS: HR = 1.004 [0.724-1.391]) and substudy 2 (OS: HR = 0.767 [0.478-1.231]; PFS: HR = 0.787 [0.576-1.074]). The most common hematologic adverse event was anemia. No new safety signals with ruxolitinib were identified. CONCLUSIONS Although addition of ruxolitinib to regorafenib did not show increased safety concerns in patients with relapsed/refractory metastatic CRC, this combination did not improve OS/PFS vs. regorafenib plus placebo.
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Affiliation(s)
- David Fogelman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - John Nemunaitis
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | | | | | | - Jose M Vieitez
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Allen Cohn
- Rocky Mountain Cancer Centers, Denver, Colorado
| | - Gene Saylors
- Charleston Hematology Oncology Associates, Charleston, South Carolina
| | | | | | - Li Zhou
- Incyte Corporation, Wilmington, Delaware
| | - Johanna Bendell
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, Tennessee
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10
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Hurwitz H, Van Cutsem E, Bendell J, Hidalgo M, Li CP, Salvo MG, Macarulla T, Sahai V, Sama A, Greeno E, Yu KH, Verslype C, Dawkins F, Walker C, Clark J, O'Reilly EM. Ruxolitinib + capecitabine in advanced/metastatic pancreatic cancer after disease progression/intolerance to first-line therapy: JANUS 1 and 2 randomized phase III studies. Invest New Drugs 2018; 36:683-695. [PMID: 29508247 PMCID: PMC6752723 DOI: 10.1007/s10637-018-0580-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/20/2018] [Indexed: 12/18/2022]
Abstract
Background Ruxolitinib, a Janus kinase 1 (JAK1)/JAK2 inhibitor, plus capecitabine improved overall survival (OS) vs capecitabine in a subgroup analysis of patients with metastatic pancreatic cancer and systemic inflammation (C-reactive protein [CRP] >13 mg/dL) in the randomized phase II RECAP study. We report results from two randomized phase III studies, JANUS 1 (NCT02117479) and JANUS 2 (NCT02119663). Patients and Methods Adults with advanced/metastatic pancreatic cancer, one prior chemotherapy regimen and CRP >10 mg/L were randomized 1:1 (stratified by modified Glasgow Prognostic Score [1 vs 2] and Eastern Cooperative Oncology Group performance status [0/1 vs 2]) to 21-day cycles of ruxolitinib 15 mg twice daily plus capecitabine 2000 mg/m2/day (Days 1-14) or placebo plus capecitabine. The primary endpoint was OS. Results Both studies were terminated following a planned interim futility/efficacy analysis of JANUS 1. Overall, 321 and 86 patients were randomized in JANUS 1 (ruxolitinib: n = 161; placebo: n = 160) and JANUS 2 (ruxolitinib: n = 43; placebo: n = 43). There was no significant difference in OS or progression-free survival (PFS) between treatments in JANUS 1 (OS: hazard ratio [HR], 0.969, 95% confidence interval [CI], 0.747-1.256; PFS: HR, 1.056; 95% CI, 0.827-1.348) or JANUS 2 (OS: HR, 1.584; 95% CI, 0.886-2.830; PFS: HR, 1.166; 95% CI, 0.687-1.978). The most common hematologic adverse event was anemia. No new safety signals with ruxolitinib or capecitabine were identified. Conclusions Ruxolitinib plus capecitabine was well tolerated in refractory pancreatic cancer patients; this combination did not improve survival.
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Affiliation(s)
- Herbert Hurwitz
- Duke University Medical Center, Campus mail 439 Seeley-mudd Bldg, 10 Bryan Searle Drive, Duke University M, Durham, NC, 27710, USA
| | - Eric Van Cutsem
- Clinical Digestive Oncology, University Hospitals Leuven and KU Leuven, UZ Herestraat 49, 3000, Leuven, Belgium
| | - Johanna Bendell
- Sarah Cannon Research Institute/Tennessee Oncology, 250 25th Ave N, Nashville, TN, 37203, USA
| | - Manuel Hidalgo
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Chung-Pin Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei, 11217, Taiwan
- School of Medicine, National Yang-Ming University, No. 155, Sec. 2, Li-Nong Street, Beitou District, Taipei, 112, Taiwan
| | - Marcelo Garrido Salvo
- Pontificia Universidad Católica de Chile, Av Libertador Bernardo O'Higgins, 340, Santiago, Región Metropolitana, Chile
| | - Teresa Macarulla
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital (HUVH), Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Vaibhav Sahai
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Cancer Center Floor B1 Reception E, 1500 E Medical Center Dr SPC 5912, Ann Arbor, MI, 48109-5912, USA
| | - Ashwin Sama
- Thomas Jefferson University Hospital, 925 Chestnut Street, Suite 320A, Philadelphia, PA, 19107, USA
| | - Edward Greeno
- Division of Hematology, Oncology and Transplantation, University of Minnesota, 420 Delaware Street SE, MMC 480, Minneapolis, MN, 55455, USA
| | - Kenneth H Yu
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA
| | - Chris Verslype
- Clinical Digestive Oncology, University Hospitals Leuven and KU Leuven, UZ Herestraat 49, 3000, Leuven, Belgium
| | - Fitzroy Dawkins
- Incyte Corporation, 1801 Augustine Cut-off, Wilmington, DE, 19803, USA
| | - Chris Walker
- Incyte Corporation, 1801 Augustine Cut-off, Wilmington, DE, 19803, USA
| | - Jason Clark
- Incyte Corporation, 1801 Augustine Cut-off, Wilmington, DE, 19803, USA
| | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10065, USA.
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11
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Pulmonary cryptococcosis in a ruxolitinib-treated patient with primary myelofibrosis. Respir Med Case Rep 2017; 22:87-90. [PMID: 28721333 PMCID: PMC5499110 DOI: 10.1016/j.rmcr.2017.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 12/01/2022] Open
Abstract
We present the case of a 79-year-old man who showed multiple pulmonary nodules on chest computed tomography (CT) after being treated for 6 months with ruxolitinib, an inhibitor of Janus kinase (JAK) 1 and 2, to treat primary myelofibrosis. We examined the lesions by bronchoscopy, and the biopsy specimen revealed fungus bodies of Cryptococcus with granulomatous inflammation. As a result, the patient was diagnosed with pulmonary cryptococcosis. The patient was treated with fluconazole (200 mg daily for 2 weeks) with concomitant ruxolitinib administration, but the pulmonary lesions progressed. Subsequently, the patient was treated with voriconazole (300 mg daily for 3 weeks), but the lesions worsened further. The administration of ruxolitinib was therefore discontinued, and the dosage of voriconazole was increased to 400 mg daily. Three months later, the pulmonary lesions diminished in size. The present case of pulmonary cryptococcosis occurred in a patient treated with ruxolitinib. Treatment of pulmonary cryptococcosis with concomitant JAK inhibitor administration may result in poor treatment efficacy. It might be better to stop administration of JAK inhibitors, if possible, in patients being treated for pulmonary cryptococcosis.
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12
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Patel JN, Ersek JL, Kim ES. Lung cancer biomarkers, targeted therapies and clinical assays. Transl Lung Cancer Res 2015; 4:503-14. [PMID: 26629419 DOI: 10.3978/j.issn.2218-6751.2015.06.02] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Until recently, the majority of genomic cancer research has been in discovery and validation; however, as our knowledge of tumor molecular profiling improves, the idea of genomic application in the clinic becomes increasingly tangible, paralleled with the drug development of newer targeted therapies. A number of profiling methodologies exist to identify biomarkers found within the patient (germ-line DNA) and tumor (somatic DNA). Subsequently, commercially available clinical assays to test for both germ-line and somatic alterations that are prognostic and/or predictive of disease outcome, toxicity or treatment response have significantly increased. This review aims to summarize clinically relevant cancer biomarkers that serve as targets for therapy and their potential relationship to lung cancer. In order to realize the full potential of genomic cancer medicine, it is imperative that clinicians understand these intricate molecular pathways, the therapeutic implication of mutations within these pathways, and the availability of clinical assays to identify such biomarkers.
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Affiliation(s)
- Jai N Patel
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Jennifer L Ersek
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Edward S Kim
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
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13
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The Role of Reactive Oxygen Species in Myelofibrosis and Related Neoplasms. Mediators Inflamm 2015; 2015:648090. [PMID: 26538833 PMCID: PMC4619981 DOI: 10.1155/2015/648090] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/09/2015] [Indexed: 12/13/2022] Open
Abstract
Reactive oxygen species (ROS) have been implicated in a wide variety of disorders ranging between traumatic, infectious, inflammatory, and malignant diseases. ROS are involved in inflammation-induced oxidative damage to cellular components including regulatory proteins and DNA. Furthermore, ROS have a major role in carcinogenesis and disease progression in the myeloproliferative neoplasms (MPNs), where the malignant clone itself produces excess of ROS thereby creating a vicious self-perpetuating circle in which ROS activate proinflammatory pathways (NF-κB) which in turn create more ROS. Targeting ROS may be a therapeutic option, which could possibly prevent genomic instability and ultimately myelofibrotic and leukemic transformation. In regard to the potent efficacy of the ROS-scavenger N-acetyl-cysteine (NAC) in decreasing ROS levels, it is intriguing to consider if NAC treatment might benefit patients with MPN. The encouraging results from studies in cystic fibrosis, systemic lupus erythematosus, and chronic obstructive pulmonary disease warrant such studies. In addition, the antioxidative potential of the widely used agents, interferon-alpha2, statins, and JAK inhibitors, should be investigated as well. A combinatorial approach using old agents with anticancer properties together with novel JAK1/2 inhibitors may open a new era for patients with MPNs, the outlook not only being “minimal residual disease” and potential cure but also a marked improvement in inflammation-mediated comorbidities.
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14
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Gupta M, Jafri K, Sharim R, Silverman S, Sindher SB, Shahane A, Kwan M. Immune reconstitution inflammatory syndrome associated with biologic therapy. Curr Allergy Asthma Rep 2015; 15:499. [PMID: 25504263 DOI: 10.1007/s11882-014-0499-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of biologics in the treatment of autoimmune disease, cancer, and other immune conditions has revolutionized medical care in these areas. However, there are drawbacks to the use of these medications including increased susceptibility to opportunistic infections. One unforeseen risk once opportunistic infection has occurred with biologic use is the onset of immune reconstitution inflammatory syndrome (IRIS) upon drug withdrawal. Although originally described in human immunodeficiency virus (HIV) patients receiving highly active antiretroviral therapy, it has become clear that IRIS may occur when recovery of immune function follows opportunistic infection in the setting of previous immune compromise/suppression. In this review, we draw attention to this potential pitfall on the use of biologic drugs.
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Affiliation(s)
- Malika Gupta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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15
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Nakaya Y, Shide K, Naito H, Niwa T, Horio T, Miyake J, Shimoda K. Effect of NS-018, a selective JAK2V617F inhibitor, in a murine model of myelofibrosis. Blood Cancer J 2014; 4:e174. [PMID: 24413068 PMCID: PMC3913942 DOI: 10.1038/bcj.2013.73] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 11/14/2013] [Accepted: 12/05/2013] [Indexed: 12/21/2022] Open
Abstract
A single somatic mutation, V617F, in Janus kinase 2 (JAK2) is one of the causes of myeloproliferative neoplasms (MPNs), including primary myelofibrosis, and the JAK2V617F mutant kinase is a therapeutic target in MPN. However, inhibition of wild-type (WT) JAK2 can decrease the erythrocyte or platelet (PLT) count. Our selective JAK2 inhibitor, NS-018, suppressed the growth of Ba/F3 cells harboring JAK2V617F more strongly than that of cells harboring WT JAK2. The 4.3-fold JAK2V617F selectivity of NS-018 is higher than the 1.0- to 2.9-fold selectivity of seven existing JAK2 inhibitors. NS-018 also inhibited erythroid colony formation in JAK2V617F transgenic mice at significantly lower concentrations than in WT mice. In keeping with the above results, in a JAK2V617F bone marrow transplantation mouse model with a myelofibrosis-like disease, NS-018 reduced leukocytosis and splenomegaly, improved bone marrow fibrosis and prolonged survival without decreasing the erythrocyte or PLT count in the peripheral blood. By exploring the X-ray co-crystal structure of NS-018 bound to JAK2, we identified unique hydrogen-bonding interactions between NS-018 and Gly993 as a plausible explanation for its JAK2V617F selectivity. These results suggest that NS-018 will have therapeutic benefit for MPN patients through both its efficacy and its reduced hematologic adverse effects.
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Affiliation(s)
- Y Nakaya
- 1] Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Osaka, Japan [2] Discovery Research Laboratories, Nippon Shinyaku Co. Ltd, Kyoto, Japan
| | - K Shide
- Department of Gastroenterology and Hematology, Faculty of Medicine, Miyazaki University, Miyazaki, Japan
| | - H Naito
- Discovery Research Laboratories, Nippon Shinyaku Co. Ltd, Kyoto, Japan
| | - T Niwa
- Discovery Research Laboratories, Nippon Shinyaku Co. Ltd, Kyoto, Japan
| | - T Horio
- Discovery Research Laboratories, Nippon Shinyaku Co. Ltd, Kyoto, Japan
| | - J Miyake
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Osaka, Japan
| | - K Shimoda
- Department of Gastroenterology and Hematology, Faculty of Medicine, Miyazaki University, Miyazaki, Japan
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16
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Gu L, Su L, Chen Q, Xie J, Wu G, Yan Y, Liang B, Tan J, Tang N. Ruxolitinib for myelofibrosis. Exp Ther Med 2013; 5:927-931. [PMID: 23408184 PMCID: PMC3570263 DOI: 10.3892/etm.2013.886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/24/2012] [Indexed: 01/02/2023] Open
Abstract
The aim of the present study was to assess the beneficial and harmful effects of ruxolitinib in patients with myelofibrosis (MF). The Cochrane databases, PubMed and Embase were searched for studies published up to October 2012. Randomised controlled trials assessing ruxolitinib versus a placebo or the best available therapy in patients with MF were included. Two trials randomised 528 patients with MF to ruxolitinib versus a placebo or ruxolitinib versus the best available therapy. Compared with the placebo, ruxolitinib had a significant beneficial effect on the proportion of patients that had a reduction in spleen volume of ≥35% at 24 weeks [odds ratio (OR), 109.78; 95% confidence interval (CI), 14.97–804.78] or an increased overall survival rate (OR, 2.02; 95% CI, 0.99–4.12). Ruxolitinib significantly increased the risk of several non-haematological or haematological adverse events, but not the risk of treatment discontinuations (OR, 1.04; 95% CI, 0.50–2.14). Compared with the best available therapy, ruxolitinib had a significant beneficial effect on the proportion of patients that had a reduction in spleen volume of ≥35% at 24 (OR, 68.45; 95% CI, 4.15–1129.19) or 48 weeks (OR, 56.20; 95%CI, 3.40–928.67). Ruxolitinib once again significantly increased the risk of several non-haematological adverse events, serious adverse events and dose reductions or interruptions (OR, 9.60; 95% CI, 4.66–19.81), but not the risk of treatment discontinuations (OR, 1.54; 95% CI, 0.48–4.97). In conclusion, based on the trials included in the present study, the use of ruxolitinib is beneficial in the treatment of MF.
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Affiliation(s)
- Lian Gu
- Department of Internal Neurology, First Affiliated Hospital, Guangxi University of Chinese Medicine; Nanning, Guangxi, P.R. China
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Colomba C, Rubino R, Siracusa L, Lalicata F, Trizzino M, Titone L, Tolomeo M. Disseminated tuberculosis in a patient treated with a JAK2 selective inhibitor: a case report. BMC Res Notes 2012; 5:552. [PMID: 23039051 PMCID: PMC3515333 DOI: 10.1186/1756-0500-5-552] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 09/22/2012] [Indexed: 11/25/2022] Open
Abstract
Background Primary myelofibrosis is a myeloproliferative disorder characterized by bone marrow fibrosis, abnormal cytokine expression, splenomegaly and anemia. The activation of JAK2 and the increased levels of circulating proinflammatory cytokines seem to play an important role in the pathogenesis of myelofibrosis. Novel therapeutic agents targeting JAKs have been developed for the treatment of myeloproliferative disorders. Ruxolitinib (INCB018424) is the most recent among them. Case presentation To our knowledge, there is no evidence from clinical trials of an increased risk of tuberculosis during treatment with JAK inhibitors. Here we describe the first case of tuberculosis in a patient treated with Ruxolitinib, a male with a 12-year history of chronic idiopathic myelofibrosis admitted to our Institute because of fever, night sweats, weight loss and an enlarging mass in the left inguinal area for two months. Conclusion Treatment with Ruxolitinib may have triggered the reactivation of latent tuberculosis because of an inhibition of Th1 response. Our case highlights the importance of an accurate screening for latent tuberculosis before starting an anti-JAK 2 treatment.
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Affiliation(s)
- Claudia Colomba
- Dipartimento di Scienze per la promozione della salute - Sezione di Malattie infettive, Università di Palermo, Via del Vespro, 129-90127 Palermo, Italy.
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