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Chen K, Zhang Y, Zou J, Wang D, Yu X, Sun Y, Li Y, Niu J, Chen Y, Zhao P, Liu W, Lv Y, Wang M, Hu X. Comparative efficacy and hematologic safety of different dosages of JAK inhibitors in the treatment of myelofibrosis: a network meta-analysis. Front Oncol 2024; 14:1403967. [PMID: 39281381 PMCID: PMC11392783 DOI: 10.3389/fonc.2024.1403967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 08/13/2024] [Indexed: 09/18/2024] Open
Abstract
Background Myelofibrosis (MF) is a myeloproliferative neoplasm characterized by bone marrow fibrosis associated with substantial morbidity and mortality. The therapeutic landscape for MF has advanced with the development of Janus kinase inhibitors (JAKis) like ruxolitinib (RUX), fedratinib (FED), pacritinib (PAC), and momelotinib (MMB), aiming to alleviate symptoms and enhance patient comfort. Methods A network meta-analysis was conducted to assess the efficacy and safety of eleven JAKi treatment regimens across nine randomized controlled trials (RCTs) with a total of 2340 participants. Outcomes were evaluated in terms of spleen volume reduction (SVR), total symptom score reduction (TSSR), hematological safety profiles, and overall survival (OS). Results RUX and MMB were superior in achieving SVR and TSSR, with significant dose-response relationships observed. PAC and MMB were associated with a decreased risk of grade 3/4 anemia and thrombocytopenia compared to other JAKis. However, no substantial benefits in OS were observed with newer JAKis compared to RUX. The poorer OS outcomes with certain PAC dosages were likely influenced by baseline patient characteristics, particularly severe cytopenias. Conclusion The introduction of JAKis significantly changed the treatment of MF. This meta-analysis reaffirms the core role of RUX and positions MMB as a potentially powerful alternative for treating symptoms and reducing spleen size. Meanwhile, MMB and PAC have a positive effect on anemia in MF while FED is more tolerable for patients with thrombocytopenia. However, it should be noted that these results are influenced by baseline patient characteristics, particularly cytopenias, which affects both management and overall survival. Therefore, there is an urgent need for personalized dosing strategies to optimize the balance between efficacy and safety, with careful consideration of patient-specific factors. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023424179.
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Affiliation(s)
- Ke Chen
- Postdoctoral Research Station of China Academy of Chinese Medical Sciences, Beijing, China
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanyu Zhang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jixuan Zou
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Dehao Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xinyue Yu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Sun
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yumeng Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jicong Niu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Chen
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Pei Zhao
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Lv
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mingjing Wang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Baek DW, Cho HJ, Lee JM, Kim J, Moon JH, Sohn SK. Light and shade of ruxolitinib: positive role of early treatment with ruxolitinib and ruxolitinib withdrawal syndrome in patients with myelofibrosis. Expert Rev Hematol 2022; 15:573-581. [PMID: 35679520 DOI: 10.1080/17474086.2022.2088499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myelofibrosis (MF) is characterized by ineffective and hepatosplenic extramedullary hematopoiesis due to fibrotic changes in the bone marrow and systemic manifestations due to aberrant cytokine release. Ruxolitinib (RUX) is the first JAK1/JAK2 inhibitor that is clinically approved to treat splenomegaly by ameliorating inflammatory cytokines and myeloproliferation in MF. AREAS COVERED Patients with less advanced MF may also achieve better outcome and successful treatment with RUX. However, approximately 40% of the patients failed to achieve a stable response or have shown to be intolerant to RUX, and most of them discontinued RUX. In patients who need to discontinue or reduce the dose of RUX for any reason, RUX is known to induce a paradoxical accumulation of JAK activation loop phosphorylation that is causing RUX discontinuation syndrome (RDS). To review the topic of MF and RUX, we searched relevant literatures using PubMed. EXPERT OPINION RUX treatment in lower IPSS risk patients who present with splenomegaly and disease-associated symptoms can be helpful. A careful discontinuation strategy with steroids may reduce the probability of RDS, and the recognition of RDS with early re-introduction of RUX is important in the treatment of severe cases of RDS.
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Affiliation(s)
- Dong Won Baek
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Hee Jeong Cho
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jung Min Lee
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Juhyung Kim
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Joon Ho Moon
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sang Kyun Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
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Meckstroth S, Wang R, Ma X, Podoltsev N. Patterns of Care for Older Patients With Myelofibrosis: A Population-based Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e551-e558. [PMID: 33648884 DOI: 10.1016/j.clml.2021.01.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current treatments for myelofibrosis (MF) are largely palliative, with the JAK inhibitor ruxolitinib being the breakthrough approved for higher-risk patients by the United States Food and Drug Administration in November 2011. There are limited data on the "real-world" clinical experiences among patients with MF who are treated in the JAK inhibitor era. PATIENTS AND METHODS We evaluated patterns of care for older patients with MF before and after ruxolitinib approval, using the Surveillance, Epidemiology, and End Results-Medicare database. Treatment patterns were assessed using Medicare part B and D claims. RESULTS This study included 528 patients diagnosed during 2007 to 2015, with a median age at diagnosis of 76 years. Among 298 patients diagnosed in the ruxolitinib era (2012-2015), 113 (37.9%) were ruxolitinib users. Similar numbers of users started ruxolitinib at 5, 10, 15, or 20 milligrams twice a day (BID). Among 31 patients starting at 5 milligrams BID or less, 48.4% were unable to escalate the dose, and < 11 users could increase the dose to the maximum 25 mg BID. Approximately one-half of ruxolitinib users took hydroxyurea and/or prednisone simultaneously with ruxolitinib. The median time on ruxolitinib was 11.9 months (interquartile range, 4.2-21.7 months). CONCLUSION It would be important to optimize the use of ruxolitinib and develop new drugs that may be administered together with or after ruxolitinib to accomplish better outcomes in older patients with MF.
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Affiliation(s)
- Shelby Meckstroth
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Rong Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Nikolai Podoltsev
- Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, New Haven, CT.
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Ladwig MA, Sciamanna CN, Rovniak LS, Conroy DE, Gottschall JS, Silvis ML, Smyth JM, Wang M, Auer BJ. Comparative effectiveness of an adult social physical play versus traditional group exercise program for adherence and fitness: Protocol for a randomized-controlled trial. Contemp Clin Trials Commun 2021; 21:100736. [PMID: 33659762 PMCID: PMC7896146 DOI: 10.1016/j.conctc.2021.100736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 01/06/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Despite the myriad benefits associated with regular physical activity (PA), few American adults accrue sufficient weekly PA. Although "lack of time" is often cited as a correlate of physical inactivity, a growing body of evidence suggests that, perhaps more importantly, people allocate their leisure-time to activities they find more enjoyable than PA. These findings underscore the need to devise physical activities that will be chosen over other enjoyable, but less healthy, behavioral alternatives. As a first step in this direction, we designed a group social PA play program for adults, known as PlayFit. The overarching philosophy of PlayFit is that fun and enjoyment are among the most important influences on PA adherence. In PlayFit, traditional sport games are modified to fulfill basic psychological needs, in a non-competitive, and non-contact environment. We will randomize 280 sedentary adults 18-50 years of age to 12-months of PlayFit or traditional group exercise, matching the groups on intensity, frequency, and duration. The primary outcomes include cardiorespiratory fitness (VO2peak), group adherence, and group enjoyment. We hypothesize that, at 6 months, cardiorespiratory fitness will have increased to the same extent in both groups, but at 12 months, only those randomized to PlayFit will have maintained their fitness through better adherence than Group Exercise - and this outcome will be mediated by enjoyment of the assigned group. Findings from this study could provide evidence that a focus on providing fun and enjoyable PA experiences for adults may be a viable route toward improving PA adherence. A simple, inexpensive PA intervention, such as PlayFit, may represent one such approach to do so.
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Affiliation(s)
| | | | | | | | | | | | | | - Ming Wang
- Penn State University, State College, PA, USA
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Quality of patient-reported outcome reporting in randomised controlled trials of haematological malignancies according to international quality standards: a systematic review. LANCET HAEMATOLOGY 2020; 7:e892-e901. [DOI: 10.1016/s2352-3026(20)30292-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
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6
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Colafigli G, Scalzulli E, Pepe S, Di Prima A, Efficace F, Martelli M, Foà R, Breccia M. The advantages and risks of ruxolitinib for the treatment of polycythemia vera. Expert Rev Hematol 2020; 13:1067-1072. [DOI: 10.1080/17474086.2020.1816819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Gioia Colafigli
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Emilia Scalzulli
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Sara Pepe
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Alessio Di Prima
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases [GIMEMA], Health Outcomes Research Unit, Rome, Italy
| | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Sapienza University Azienda Policlinico Umberto 1, Rome, Italy
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7
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Hobbs G. Case Presentation: A Young Man with Polycythemia Vera and Fatigue. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20 Suppl 1:S18. [PMID: 32862852 DOI: 10.1016/s2152-2650(20)30446-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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8
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Lysenko V, Wildner-Verhey van Wijk N, Zimmermann K, Weller MC, Bühler M, Wildschut MHE, Schürch P, Fritz C, Wagner U, Calabresi L, Psaila B, Flavell RA, Vannucchi AM, Mead AJ, Wild PJ, Dirnhofer S, Manz MG, Theocharides APA. Enhanced engraftment of human myelofibrosis stem and progenitor cells in MISTRG mice. Blood Adv 2020; 4:2477-2488. [PMID: 32502268 PMCID: PMC7284099 DOI: 10.1182/bloodadvances.2019001364] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
The engraftment potential of myeloproliferative neoplasms in immunodeficient mice is low. We hypothesized that the physiological expression of human cytokines (macrophage colony-stimulating factor, interleukin-3, granulocyte-macrophage colony-stimulating factor, and thrombopoietin) combined with human signal regulatory protein α expression in Rag2-/-Il2rγ-/- (MISTRG) mice might provide a supportive microenvironment for the development and maintenance of hematopoietic stem and progenitor cells (HSPC) from patients with primary, post-polycythemia or post-essential thrombocythemia myelofibrosis (MF). We show that MISTRG mice, in contrast to standard immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ and Rag2-/-Il2rγ-/- mice, supported engraftment of all patient samples investigated independent of MF disease stage or risk category. Moreover, MISTRG mice exhibited significantly higher human MF engraftment levels in the bone marrow, peripheral blood, and spleen and supported secondary repopulation. Bone marrow fibrosis development was limited to 3 of 14 patient samples investigated in MISTRG mice. Disease-driving mutations were identified in all xenografts, and targeted sequencing revealed maintenance of the primary patient sample clonal composition in 7 of 8 cases. Treatment of engrafted mice with the current standard-of-care Janus kinase inhibitor ruxolitinib led to a reduction in human chimerism. In conclusion, the established MF patient-derived xenograft model supports robust engraftment of MF HSPCs and maintains the genetic complexity observed in patients. The model is suited for further testing of novel therapeutic agents to expedite their transition into clinical trials.
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Affiliation(s)
- Veronika Lysenko
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | | | - Kathrin Zimmermann
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Marie-Christine Weller
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Marco Bühler
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Mattheus H E Wildschut
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Institute of Molecular Systems Biology, ETH Zurich, Zurich, Switzerland
| | - Patrick Schürch
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Christine Fritz
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Ulrich Wagner
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Laura Calabresi
- Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero, Universitaria Careggi, University of Florence, Florence, Italy
| | - Bethan Psaila
- Haematopoietic Stem Cell Biology Laboratory, Medical Research Council Weatherall Institute of Molecular Medicine
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, and
- National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | | | - Alessandro M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliero, Universitaria Careggi, University of Florence, Florence, Italy
| | - Adam J Mead
- Haematopoietic Stem Cell Biology Laboratory, Medical Research Council Weatherall Institute of Molecular Medicine
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, and
- National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Peter J Wild
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany; and
| | - Stefan Dirnhofer
- Institute of Pathology, University Hospital, University of Basel, Basel, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alexandre P A Theocharides
- Department of Medical Oncology and Hematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Sakiyama E, Chinen Y, Tsukamoto T, Takimoto-Shimomura T, Kuwahara-Ota S, Matsumura-Kimoto Y, Shimura Y, Kobayashi T, Horiike S, Kuroda J. Tuberculosis Peritonitis During Treatment of Polycythemia Vera with Ruxolitinib. Infect Drug Resist 2020; 13:1017-1021. [PMID: 32308443 PMCID: PMC7152536 DOI: 10.2147/idr.s249030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 03/31/2020] [Indexed: 01/11/2023] Open
Abstract
Ruxolitinib is a selective JAK1/2 inhibitor that is widely used for the treatment of myeloproliferative neoplasms (MPNs), including myelofibrosis and polycythemia vera (PV). Despite its clinical efficacy for MPNs, ruxolitinib possesses immunosuppressive properties that potentially increase the risks for opportunistic infection, such as mycobacterium tuberculosis (MTB) infection, and reactivation of occult viral infection. Herein, we report the case of a 76-year-old male with PV who developed tuberculosis peritonitis under ruxolitinib therapy for 28 weeks. While previous studies and case reports have suggested an increased risk of MTB infection of various organs during ruxolitinib treatment of MPNs, this case is apparently the first of tuberculosis peritonitis in a patient with MPN treated with ruxolitinib. A review of previous case reports suggests the need for careful observation for MTB from the relatively early phase of ruxolitinib treatment, given that the median duration from the start of ruxolitinib treatment to the emergence of MTB was 20 weeks (range: 3-88 weeks). Clinicians should consider tuberculosis peritonitis as a differential diagnosis when patients with MPN treated with ruxolitinib develop infectious abdominal symptoms.
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Affiliation(s)
- Emiko Sakiyama
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshiaki Chinen
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Tsukamoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoko Takimoto-Shimomura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saeko Kuwahara-Ota
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yayoi Matsumura-Kimoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigeo Horiike
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Spivak JL. Polycythaemia vera, ruxolitinib, and hydroxyurea: where do we go now? LANCET HAEMATOLOGY 2020; 7:e184-e185. [PMID: 31982040 DOI: 10.1016/s2352-3026(19)30262-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jerry L Spivak
- Hematology Division, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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11
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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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Sciamanna C, Ballentine NH, Bopp M, Brach JS, Chinchilli VM, Ciccolo JT, Conroy MB, Fisher A, Fox EJ, Greenspan SL, Jan De Beur Suzanne M, Kearcher K, Kraschnewski JL, McTigue KM, McAuley E, Morone NE, Paranjape A, Rodriguez-Colon S, Rosenzweig A, Smyth JM, Stewart KJ, Stuckey HL. Working to Increase Stability through Exercise (WISE): Study protocol for a pragmatic randomized controlled trial of a coached exercise program to reduce serious fall-related injuries. Contemp Clin Trials 2018; 74:1-10. [PMID: 30261294 PMCID: PMC6333097 DOI: 10.1016/j.cct.2018.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
Abstract
Approximately one-third of older adults fall each year and fall-related injuries are a leading cause of death and disability among this rapidly expanding age group. Despite the availability of bisphosphonates to reduce fractures, concerns over side effects have dramatically reduced use, suggesting that other treatment options are needed. Though many smaller studies have shown that physical activity programs can reduce falls, no study has been adequately powered to detect a reduction in fall-related injuries. We present the design of a three-year randomized controlled clinical trial of 1130 adults age 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The main aim is to determine the impact of a community-based multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers (or delivered via DVD) and accompanied by coaching and oversight, by telephone and in-person, by a fitness professional. The main outcome measure is serious fall-related injuries. Secondary outcomes include health care utilization, bone and muscle mass, loneliness, health-related quality of life and mood. The study represents the first large clinical trial of a comprehensive physical activity program to reduce secondary injuries among patients with a history of fragility fracture.
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Abstract
PURPOSE OF REVIEW The purpose of the review was to provide a contemporary update of novel agents and targets under investigation in myelofibrosis in the Janus kinase (JAK) inhibitor era. RECENT FINDINGS Myelofibrosis (MF) is a clonal stem cell disease characterized by marrow fibrosis and a heterogeneous disease phenotype with a variable degree of splenomegaly, cytopenias, and constitutional symptoms that significantly impact quality of life and survival. Overactive JAK/STAT signaling is a hallmark of MF. The only approved therapy for MF, JAK1/2 inhibitor ruxolitinib, can ameliorate splenomegaly, improve symptoms, and prolong survival in some patients. Therapeutic challenges remain, however. Myelosuppression limits the use of ruxolitinib in some patients, eventual drug resistance is common, and the underlying malignant clone persists despite therapy. A deeper understanding of the pathogenesis of MF has informed the development of additional agents. Promising targets under investigation include JAK1 and JAK2 and downstream intermediates in related signaling pathways, epigenetic modifiers, pro-inflammatory cytokines, and immune regulators.
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Affiliation(s)
- Kristen Pettit
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, 5841 S. Maryland Ave, MC2115, Chicago, IL, 60637, USA
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, 5841 S. Maryland Ave, MC2115, Chicago, IL, 60637, USA.
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Bose P, Verstovsek S. JAK2 inhibitors for myeloproliferative neoplasms: what is next? Blood 2017; 130:115-125. [PMID: 28500170 PMCID: PMC5510786 DOI: 10.1182/blood-2017-04-742288] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/06/2017] [Indexed: 12/11/2022] Open
Abstract
Since its approval in 2011, the Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib has evolved to become the centerpiece of therapy for myelofibrosis (MF), and its use in patients with hydroxyurea resistant or intolerant polycythemia vera (PV) is steadily increasing. Several other JAK2 inhibitors have entered clinical testing, but none have been approved and many have been discontinued. Importantly, the activity of these agents is not restricted to patients with JAK2 V617F or exon 12 mutations. Although JAK2 inhibitors provide substantial clinical benefit, their disease-modifying activity is limited, and rational combinations with other targeted agents are needed, particularly in MF, in which survival is short. Many such combinations are being explored, as are other novel agents, some of which could successfully be combined with JAK2 inhibitors in the future. In addition, new JAK2 inhibitors with the potential for less myelosuppression continue to be investigated. Given the proven safety and efficacy of ruxolitinib, it is likely that ruxolitinib-based combinations will be a major way forward in drug development for MF. If approved, less myelosuppressive JAK2 inhibitors such as pacritinib or NS-018 could prove to be very useful additions to the therapeutic armamentarium in MF. In PV, inhibitors of histone deacetylases and human double minute 2 have activity, but their role, if any, in the future treatment algorithm is uncertain, given the availability of ruxolitinib and renewed interest in interferons. Ruxolitinib is in late-phase clinical trials in essential thrombocythemia, in which it could fill an important void for patients with troublesome symptoms.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
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15
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Lv K, Jiang J, Donaghy R, Riling CR, Cheng Y, Chandra V, Rozenova K, An W, Mohapatra BC, Goetz BT, Pillai V, Han X, Todd EA, Jeschke GR, Langdon WY, Kumar S, Hexner EO, Band H, Tong W. CBL family E3 ubiquitin ligases control JAK2 ubiquitination and stability in hematopoietic stem cells and myeloid malignancies. Genes Dev 2017; 31:1007-1023. [PMID: 28611190 PMCID: PMC5495118 DOI: 10.1101/gad.297135.117] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 05/23/2017] [Indexed: 01/08/2023]
Abstract
Here, Lv et al. report that the CBL family E3 ubiquitin ligases down-regulate JAK2 stability and signaling via the adaptor protein LNK/SH2B3. Their results reveal a novel signaling axis that regulates JAK2 in normal and malignant HSPCs and suggest new therapeutic strategies for treating CBLmut myeloid malignancies. Janus kinase 2 (JAK2) is a central kinase in hematopoietic stem/progenitor cells (HSPCs), and its uncontrolled activation is a prominent oncogenic driver of hematopoietic neoplasms. However, molecular mechanisms underlying the regulation of JAK2 have remained elusive. Here we report that the Casitas B-cell lymphoma (CBL) family E3 ubiquitin ligases down-regulate JAK2 stability and signaling via the adaptor protein LNK/SH2B3. We demonstrated that depletion of CBL/CBL-B or LNK abrogated JAK2 ubiquitination, extended JAK2 half-life, and enhanced JAK2 signaling and cell growth in human cell lines as well as primary murine HSPCs. Built on these findings, we showed that JAK inhibitor (JAKi) significantly reduced aberrant HSPCs and mitigated leukemia development in a mouse model of aggressive myeloid leukemia driven by loss of Cbl and Cbl-b. Importantly, primary human CBL mutated (CBLmut) leukemias exhibited increased JAK2 protein levels and signaling and were hypersensitive to JAKi. Loss-of-function mutations in CBL E3 ubiquitin ligases are found in a wide range of myeloid malignancies, which are diseases without effective treatment options. Hence, our studies reveal a novel signaling axis that regulates JAK2 in normal and malignant HSPCs and suggest new therapeutic strategies for treating CBLmut myeloid malignancies.
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Affiliation(s)
- Kaosheng Lv
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Jing Jiang
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Ryan Donaghy
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | | | - Ying Cheng
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Vemika Chandra
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Krasimira Rozenova
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Wei An
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA.,Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA
| | - Bhopal C Mohapatra
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA.,Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA
| | - Benjamin T Goetz
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA.,Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA
| | - Vinodh Pillai
- Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
| | - Xu Han
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Emily A Todd
- Progenra, Inc., Malvern, Pennsylvania 19355, USA
| | - Grace R Jeschke
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Wallace Y Langdon
- School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Suresh Kumar
- Progenra, Inc., Malvern, Pennsylvania 19355, USA
| | - Elizabeth O Hexner
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Hamid Band
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA.,Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska 6819, USA
| | - Wei Tong
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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16
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Alimam S, Harrison C. Experience with ruxolitinib in the treatment of polycythaemia vera. Ther Adv Hematol 2017; 8:139-151. [PMID: 28491265 PMCID: PMC5405900 DOI: 10.1177/2040620717693972] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Polycythaemia vera (PV) is a myeloproliferative neoplasm classically characterized by an erythrocytosis and is associated with a high risk of thromboembolic events, constitutional symptoms burden and risk of transformation to myelofibrosis and acute myeloid leukaemia. Therapy is directed at the haematocrit (HCT) to reduce the risk of thrombotic events and usually comprises low-dose aspirin and phlebotomy to maintain HCT at >45%. Frequently in addition, cytoreductive therapy is indicated in high-risk patients for normalizing haematological parameters to mitigate the occurrence of thromboembolic events. Unfortunately, there is no clear evidence that current therapies reduce the risk of transformation to myelofibrosis and for some a risk of a therapy related complication is unknown for example leukaemia due to hydroxycarbamide (HC). First-line therapy for treating PV remains HC or interferon, the latter most often in younger patients, especially those of childbearing age. However, therapy related intolerance or resistance is a common feature and results in limited treatment options for such patients. The discovery of the JAK2 V617F mutation and consequently targeted therapy with Janus kinase inhibitors, in particular ruxolitinib, has extended the spectrum of agents that can be used as second or third line in PV. The findings of the phase II trial RESPONSE and the preliminary data from RESPONSE 2 trial have identified a role for ruxolitinib in PV patients who are resistant or intolerant to HC. In this article, using clinical cases we demonstrate our experience with ruxolitinib highlighting the clinical benefits and limitations we encountered in clinical practice.
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Affiliation(s)
- Samah Alimam
- Guy’s and St Thomas’s NHS Foundation Trust, London, UK
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17
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Emerging treatments for classical myeloproliferative neoplasms. Blood 2016; 129:693-703. [PMID: 28028027 DOI: 10.1182/blood-2016-10-695965] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/03/2016] [Indexed: 12/17/2022] Open
Abstract
There has been a major revolution in the management of patients with myeloproliferative neoplasms (MPN), and in particular those with myelofibrosis and extensive splenomegaly and symptomatic burden, after the introduction of the JAK1 and JAK2 inhibitor ruxolitinib. The drug also has been approved as second-line therapy for polycythemia vera (PV). However, the therapeutic armamentarium for MPN is still largely inadequate for coping with patients' major unmet needs, which include normalization of life span (myelofibrosis and some patients with PV), reduction of cardiovascular complications (mainly PV and essential thrombocythemia), prevention of hematological progression, and improved quality of life (all MPN). In fact, none of the available drugs has shown clear evidence of disease-modifying activity, even if some patients treated with interferon and ruxolitinib showed reduction of mutated allele burden, and ruxolitinib might extend survival of patients with higher-risk myelofibrosis. Raised awareness of the molecular abnormalities and cellular pathways involved in the pathogenesis of MPN is facilitating the development of clinical trials with novel target drugs, either alone or in combination with ruxolitinib. Although for most of these molecules a convincing preclinical rationale was provided, the results of early phase 1 and 2 clinical trials have been quite disappointing to date, and toxicities sometimes have been limiting. In this review, we critically illustrate the current landscape of novel therapies that are under evaluation for patients with MPN on the basis of current guidelines, patient risk stratification criteria, and previous experience, looking ahead to the chance of a cure for these disorders.
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18
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Marchetti M, Barosi G, Cervantes F, Birgegård G, Griesshammer M, Harrison C, Hehlmann R, Kiladjian JJ, Kröger N, McMullin MF, Passamonti F, Vannucchi A, Barbui T. Which patients with myelofibrosis should receive ruxolitinib therapy? ELN-SIE evidence-based recommendations. Leukemia 2016; 31:882-888. [DOI: 10.1038/leu.2016.283] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 08/27/2016] [Accepted: 09/14/2016] [Indexed: 12/11/2022]
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19
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Overcoming treatment challenges in myelofibrosis and polycythemia vera: the role of ruxolitinib. Cancer Chemother Pharmacol 2016; 77:1125-42. [PMID: 27017614 PMCID: PMC4882345 DOI: 10.1007/s00280-016-3012-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 03/15/2016] [Indexed: 01/14/2023]
Abstract
Myelofibrosis (MF) and polycythemia vera (PV) are BCR-ABL1-negative myeloproliferative neoplasms associated with somatic hematopoietic stem cell mutations leading to over activation of JAK-STAT signaling. MF and PV are pathogenically related and share specific clinical features such as splenomegaly and constitutional symptoms. The MF phenotype is dominated by the effects of progressive bone marrow fibrosis resulting in shortened survival. In contrast, elevated thrombosis risk due to erythrocytosis is the primary clinical concern in PV. Ruxolitinib, an oral JAK1/JAK2 inhibitor, is approved in the USA for the treatment of patients with intermediate- or high-risk MF and patients with PV who have had an inadequate response to or are intolerant of hydroxyurea. For MF, results of two phase III studies demonstrated that ruxolitinib therapy reduced spleen volume and MF-related symptom burden, improved quality-of-life measures, and was associated with prolonged overall survival. Treatment benefits were generally sustained with continued therapy. Dose-dependent cytopenias were common but generally manageable with transfusions (for anemia), dose reduction, or treatment interruption. Optimal dosing management is critical to maintain long-term treatment benefit, because cessation of therapy resulted in rapid return of symptoms to baseline levels. Results of the phase III PV trial showed that ruxolitinib was significantly more effective than standard therapy in controlling hematocrit levels and improving splenomegaly and PV-related symptoms. Only 1 of 110 patients in the ruxolitinib arm compared with 6 of 112 patients in the control arm experienced a thromboembolic event through week 32. Grade ≥3 cytopenias were uncommon.
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20
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Knight EA, Osunsuyi-Fagbemi S, Neely J. Managing Patients With Myelofibrosis in the Era of Janus Kinase Inhibitors. J Adv Pract Oncol 2015; 6:532-50. [PMID: 27648344 PMCID: PMC5017545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Emily A Knight
- 1Mayo Clinic, Scottsdale, Arizona; 2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Sylvia Osunsuyi-Fagbemi
- 1Mayo Clinic, Scottsdale, Arizona; 2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Jessica Neely
- 1Mayo Clinic, Scottsdale, Arizona; 2Winship Cancer Institute at Emory University, Atlanta, Georgia
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21
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Jamieson C, Hasserjian R, Gotlib J, Cortes J, Stone R, Talpaz M, Thiele J, Rodig S, Pozdnyakova O. Effect of treatment with a JAK2-selective inhibitor, fedratinib, on bone marrow fibrosis in patients with myelofibrosis. J Transl Med 2015; 13:294. [PMID: 26357842 PMCID: PMC4566296 DOI: 10.1186/s12967-015-0644-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/18/2015] [Indexed: 11/16/2022] Open
Abstract
Background Progressive bone marrow fibrosis (BMF) is a cardinal feature of many myeloproliferative neoplasms (MPNs) and there is a documented association between the severity of BMF and overall prognosis. We conducted an exploratory analysis of sequential BMF data from two phase I studies of long-term treatment with the Janus kinase 2 (JAK2) inhibitor fedratinib in patients with myelofibrosis. Methods Bone marrow samples were obtained at baseline and after every six cycles (24 weeks) of daily fedratinib treatment. Fibrosis was centrally assessed by three independent haematopathologists, who were blinded to the patients’ data, and graded according to European Consensus Myelofibrosis Grading Criteria. The analysis population comprised patients with a baseline BMF grade ≥1, and at least one post-baseline BMF grade assessment. Changes in BMF grade compared with baseline were classified as improvement (≥1 grade reduction), stabilisation (no change in any baseline BMF grade <3) or worsening (≥1 grade increase). Results Twenty-one patients were included in the analysis. A total of 153 bone marrow samples were analysed. Improvement or stabilisation of BMF from baseline was recorded in 15 of 18 (83 %) evaluable patients at cycle 6 and in four of nine (44 %) evaluable patients at cycle 30. Two patients achieved resolution of their BMF (grade = 0) by cycle 12. Conclusions This exploratory analysis indicates that improvement or even resolution of BMF may be achievable with JAK2 inhibitor therapy in some patients with MPNs and myelofibrosis. Electronic supplementary material The online version of this article (doi:10.1186/s12967-015-0644-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catriona Jamieson
- Moores UC San Diego Cancer Centre, 3855 Health Sciences Drive, La Jolla, CA, 92093-0820, USA.
| | - Robert Hasserjian
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Jason Gotlib
- Division of Hematology, Stanford University School of Medicine/Stanford Cancer Institute, 875 Blake Wilbur Drive, Room 2324, Stanford, CA, 94305, USA.
| | - Jorge Cortes
- Division of Cancer Medicine, Department of Leukemia, University of Texas MD Anderson Cancer Center, Faculty Center Building on Floors 3 and 4, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Richard Stone
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Moshe Talpaz
- The University of Michigan Hospital and Health Systems, Comprehensive Cancer Center, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Jürgen Thiele
- Institute of Pathology, University of Cologne, Kerpener Str. 62, 50924, Cologne, Germany.
| | - Scott Rodig
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Olga Pozdnyakova
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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22
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Abstract
Background The JAK/STAT pathway transduces signals from multiple cytokines and controls haematopoiesis, immunity and inflammation. In addition, pathological activation is seen in multiple malignancies including the myeloproliferative neoplasms (MPNs). Given this, drug development efforts have targeted the pathway with JAK inhibitors such as ruxolitinib. Although effective, high costs and side effects have limited its adoption. Thus, a need for effective low cost treatments remains. Methods & Findings We used the low-complexity Drosophila melanogaster pathway to screen for small molecules that modulate JAK/STAT signalling. This screen identified methotrexate and the closely related aminopterin as potent suppressors of STAT activation. We show that methotrexate suppresses human JAK/STAT signalling without affecting other phosphorylation-dependent pathways. Furthermore, methotrexate significantly reduces STAT5 phosphorylation in cells expressing JAK2 V617F, a mutation associated with most human MPNs. Methotrexate acts independently of dihydrofolate reductase (DHFR) and is comparable to the JAK1/2 inhibitor ruxolitinib. However, cells treated with methotrexate still retain their ability to respond to physiological levels of the ligand erythropoietin. Conclusions Aminopterin and methotrexate represent the first chemotherapy agents developed and act as competitive inhibitors of DHFR. Methotrexate is also widely used at low doses to treat inflammatory and immune-mediated conditions including rheumatoid arthritis. In this low-dose regime, folate supplements are given to mitigate side effects by bypassing the biochemical requirement for DHFR. Although independent of DHFR, the mechanism-of-action underlying the low-dose effects of methotrexate is unknown. Given that multiple pro-inflammatory cytokines signal through the pathway, we suggest that suppression of the JAK/STAT pathway is likely to be the principal anti-inflammatory and immunosuppressive mechanism-of-action of low-dose methotrexate. In addition, we suggest that patients with JAK/STAT-associated haematological malignancies may benefit from low-dose methotrexate treatments. While the JAK1/2 inhibitor ruxolitinib is effective, a £43,200 annual cost precludes widespread adoption. With an annual methotrexate cost of around £32, our findings represent an important development with significant future potential.
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23
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Vannucchi AM, Kantarjian HM, Kiladjian JJ, Gotlib J, Cervantes F, Mesa RA, Sarlis NJ, Peng W, Sandor V, Gopalakrishna P, Hmissi A, Stalbovskaya V, Gupta V, Harrison C, Verstovsek S. A pooled analysis of overall survival in COMFORT-I and COMFORT-II, 2 randomized phase III trials of ruxolitinib for the treatment of myelofibrosis. Haematologica 2015; 100:1139-45. [PMID: 26069290 DOI: 10.3324/haematol.2014.119545] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/05/2015] [Indexed: 11/09/2022] Open
Abstract
Ruxolitinib, a potent Janus kinase 1/2 inhibitor, resulted in rapid and durable improvements in splenomegaly and disease-related symptoms in the 2 phase III COMFORT studies. In addition, ruxolitinib was associated with prolonged survival compared with placebo (COMFORT-I) and best available therapy (COMFORT-II). We present a pooled analysis of overall survival in the COMFORT studies using an intent-to-treat analysis and an analysis correcting for crossover in the control arms. Overall, 301 patients received ruxolitinib (COMFORT-I, n=155; COMFORT-II, n=146) and 227 patients received placebo (n=154) or best available therapy (n=73). After a median three years of follow up, intent-to-treat analysis showed that patients who received ruxolitinib had prolonged survival compared with patients who received placebo or best available therapy [hazard ratio=0.65; 95% confidence interval (95%CI): 0.46-0.90; P=0.01]; the crossover-corrected hazard ratio was 0.29 (95%CI: 0.13-0.63). Both patients with intermediate-2- or high-risk disease showed prolonged survival, and patients with high-risk disease in the ruxolitinib group had survival similar to that of patients with intermediate-2-risk disease in the control group. The Kaplan-Meier estimate of overall survival at week 144 was 78% in the ruxolitinib arm, 61% in the intent-to-treat control arm, and 31% in the crossover-adjusted control arm. While larger spleen size at baseline was prognostic for shortened survival, reductions in spleen size with ruxolitinib treatment correlated with longer survival. These findings are consistent with previous reports and support that ruxolitinib offers a survival benefit for patients with myelofibrosis compared with conventional therapies. (clinicaltrials.gov identifiers: COMFORT-I, NCT00952289; COMFORT-II, NCT00934544).
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Affiliation(s)
| | | | | | | | - Francisco Cervantes
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | | | - Wei Peng
- Incyte Corporation, Wilmington, DE, USA
| | | | | | | | | | - Vikas Gupta
- Princess Margaret Cancer Center, University of Toronto, Ontario, Canada
| | - Claire Harrison
- Guy's and St. Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Srdan Verstovsek
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Abstract
Myelofibrosis (MF), including primary, post-essential thrombocythemia and post-polycythemia vera MF, associates with a reduced quality of life and shortened life expectancy. Dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway is prominent, even in the absence of the JAK2(V617F) mutation. Therefore, all symptomatic MF patients may potentially derive benefit from JAK inhibitors. Despite the efficacy of JAK inhibitors in controlling signs and symptoms of MF, they do not eradicate the disease. Therefore, JAK inhibitors are currently being tested in combination with other novel therapies, a strategy which may be more effective in reducing disease burden, either by overcoming JAK inhibitor resistance or targeting additional mechanisms of pathogenesis. Additional targets include modulators of epigenetic regulation, pathways that work downstream from JAK/STAT (i.e. mammalian target of rapamycin/AKT/phosphoinositide 3-kinase) heat shock protein 90, hedgehog signaling, pro-fibrotic factors, abnormal megakaryocytes and telomerase. In this review, we discuss novel MF therapeutic strategies.
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Affiliation(s)
- Brady L Stein
- a Northwestern University Feinberg School of Medicine , Chicago , IL , USA
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Francisco Cervantes
- c Hospital Clínic, Hematology Department, Institut d'Investigació Biomédica August Pi i Sunyer , University of Barcelona , Barcelona , Spain
| | - Francis Giles
- b Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago , IL , USA
| | - Claire N Harrison
- d Department of Haematology , Guy's and St. Thomas' National Health Service Foundation Trust , London , UK
| | - Srdan Verstovsek
- e Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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25
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Abstract
BACKGROUND Myelofibrosis is a bone marrow disorder characterized by excessive production of reticulin and collagen fiber deposition caused by hematological and non-hematological disorders. The prognosis of myelofibrosis is poor and treatment is mainly palliative. Janus kinase inhibitors are a novel strategy to treat people with myelofibrosis. OBJECTIVES To determine the clinical benefits and harms of Janus kinase-1 and Janus kinase-2 inhibitors for treating myelofibrosis secondary to hematological or non-hematological conditions. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2014, Issue 11), Ovid MEDLINE (from 1946 to 13 November 2014), EMBASE (from 1980 to 12 January 2013), and LILACS (from 1982 to 20 November 2014). We searched WHO International Clinical Trials Registry Platform and The metaRegister of Controlled Trials. We also searched for conference proceedings of the American Society of Hematology (from 2009 to October 2013), European Hematology Association (from 2009 to October 2013), American Society of Clinical Oncology (from 2009 to October 2013), and European Society of Medical Oncology (from 2009 to October 2013). We included searches in FDA, European Medicines Agency, and Epistemonikos. We handsearched the references of all identified included trials, and relevant review articles. We did not apply any language restrictions. Two review authors independently screened search results. SELECTION CRITERIA We included randomized clinical trials comparing Janus kinase-1 and Janus kinase-2 inhibitors with placebo or other treatments. Both previously treated and treatment naive patients were included. DATA COLLECTION AND ANALYSIS We used the hazard ratio (HR) and 95% confidence interval (95% CI) for overall survival, progression-free survival and leukemia-free survival, risk ratio (RR) and 95% CI for reduction in spleen size and adverse events binary data, and standardized mean differences (SMD) and 95% CI for continuous data (health-related quality of life). Two review authors independently extracted data and assessed the risk of bias of included trials. Primary outcomes were overall survival, progression-free survival and adverse events. MAIN RESULTS We included two trials involving 528 participants, comparing ruxolitinib with placebo or best available therapy (BAT). As the two included trials had different comparators we did not pool the data. The confidence in the results estimates of these trials was low due to the bias in their design, and their limited sample sizes that resulted in imprecise results.There is low quality evidence for the effect of ruxolitinib on survival when compared with placebo at 51 weeks of follow-up (HR 0.51, 95% CI 0.27 to 0.98) and compared with BAT at 48 weeks of follow-up (HR 0.70, 95% CI 0.20 to 2.47). Similarly there was very low quality evidence for the effect of ruxolitinib on progression free survival compared with BAT (HR 0.81, 95% CI 0.47 to 1.39).There is low quality evidence for the effect of ruxolitinib in terms of quality of life. Compared with placebo, the drug achieved a greater proportion of patients with a significant reduction of symptom scores (RR 8.82, 95% CI 4.40 to 17.69), and treated patients with ruxolitinib obtained greater MFSAF scores at the end of follow-up (MD -87.90, 95% CI -139.58 to -36.22). An additional trial showed significant differences in EORTC QLQ-C30 scores when compared ruxolitinib with best available therapy (MD 7.60, 95% CI 0.35 to 14.85).The effect of ruxolitinib on reduction in the spleen size of participants compared with placebo or BAT was uncertain (versus placebo: RR 64.58, 95% CI 9.08 to 459.56, low quality evidence; versus BAT: RR 41.78, 95% CI 2.61 to 669.75, low quality evidence).There is low quality evidence for the effect of the drug compared with placebo on anemia (RR 2.35, 95% CI 1.62 to 3.41), neutropenia (RR 3.57, 95% CI 1.02 to 12.55) and thrombocytopenia (RR 9.74, 95% CI 2.32 to 40.96). Ruxolitinib did not result in differences versus BAT in the risk of anemia (RR 1.35, 95% CI 0.91 to 1.99, low quality evidence) or thrombocytopenia (RR 1.20; 95% CI 0.44 to 3.28, low quality evidence). The risk of non-hematologic grade 3 or 4 adverse events (including fatigue, arthralgia, nausea, diarrhea, extremity pain and pyrexia) was similar when ruxolitinib was compared with placebo or BAT. The rate of neutropenia comparing ruxolitinib with standard medical treatment was not reported by the trial. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence to allow any conclusions regarding the efficacy and safety of ruxolitinib for treating myelofibrosis. The findings of this Cochrane review should be interpreted with caution as they are based on trials sponsored by industry, and include a small number of patients. Unless powered randomized clinical trials provide strong evidence of a treatment effect, and the trade-off between potential benefits and harms is established, clinicians should be cautious when administering ruxolitinib for treating patients with myelofibrosis.
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Affiliation(s)
| | - Vidhu Anand
- University of MinnesotaDepartment of Medicine420 Delaware Street SEMayo Mail Code 195MinneapolisMNUSA55455
| | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Twa DDW, Steidl C. Structural genomic alterations in primary mediastinal large B-cell lymphoma. Leuk Lymphoma 2015; 56:2239-50. [DOI: 10.3109/10428194.2014.985673] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Gravina GL, Senapedis W, McCauley D, Baloglu E, Shacham S, Festuccia C. Nucleo-cytoplasmic transport as a therapeutic target of cancer. J Hematol Oncol 2014; 7:85. [PMID: 25476752 PMCID: PMC4272779 DOI: 10.1186/s13045-014-0085-1] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 11/09/2014] [Indexed: 12/19/2022] Open
Abstract
Shuttling of specific proteins out of the nucleus is essential for the regulation of the cell cycle and proliferation of both normal and malignant tissues. Dysregulation of this fundamental process may affect many other important cellular processes such as tumor growth, inflammatory response, cell cycle, and apoptosis. It is known that XPO1 (Exportin-1/Chromosome Region Maintenance 1/CRM1) is the main mediator of nuclear export in many cell types. Nuclear proteins exported to the cytoplasm by XPO1 include the drug targets topoisomerase IIα (topo IIα) and BCR-ABL and tumor suppressor proteins such as Rb, APC, p53, p21, and p27. XPO1 can mediate cell proliferation through several pathways: (i) the sub-cellular localization of NES-containing oncogenes and tumor suppressor proteins, (ii) the control of the mitotic apparatus and chromosome segregation, and (iii) the maintenance of nuclear and chromosomal structures. The XPO1 protein is elevated in ovarian carcinoma, glioma, osteosarcoma, pancreatic and cervical cancer. There is a growing body of research indicating that XPO1 may have an important role as a prognostic marker in solid tumors. Because of this, nuclear export inhibition through XPO1 is a potential target for therapeutic intervention in many cancers. The best understood XPO1 inhibitors are the small molecule nuclear export inhibitors (NEIs; Leptomycin B and derivatives, ratjadones, PKF050-638, valtrate, ACA, CBS9106, selinexor/KPT-330, and verdinexor/KPT-335). Selinexor and verdinexor are orally bioavailable, highly potent, small molecules that are classified as Selective Inhibitors of Nuclear Export (SINE). KPT-330 is the only NEI currently in Phase I/II human clinical trials in hematological and solid cancers. Of all the potential targets in nuclear cytoplasmic transport, the nuclear export receptor XPO1 remains the best understood and most advanced therapeutic target for the treatment of cancer.
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Affiliation(s)
- Giovanni Luca Gravina
- />Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Dilara McCauley
- />Karyopharm Therapeutics, Inc., 85 Wells Avenue, Newton, MA USA
| | - Erkan Baloglu
- />Karyopharm Therapeutics, Inc., 85 Wells Avenue, Newton, MA USA
| | - Sharon Shacham
- />Karyopharm Therapeutics, Inc., 85 Wells Avenue, Newton, MA USA
| | - Claudio Festuccia
- />Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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Liew E, Lipton JH. Ruxolitinib for the treatment of disease-related splenomegaly or symptoms in adult patients with myelofibrosis. Int J Hematol Oncol 2014. [DOI: 10.2217/ijh.14.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Myelofibrosis is characterized by progressive splenomegaly, cytopenias and debilitating constitutional symptoms. It has the worst prognosis and poorest quality of life of all the chronic myeloproliferative neoplasms. Allogeneic stem cell transplantation is the only curative therapy, but it carries high treatment-related risks and is thus available to only a small subset of patients. All other interventions merely palliate either anemia or splenomegaly. Ruxolitinib, a JAK1/2 inhibitor, has recently been shown to be effective in reducing splenomegaly and improving constitutional symptoms to a degree that has not been achieved with conventional therapy. However, treatment with ruxolitinib can often worsen anemia, and its ability to change the natural history of myelofibrosis has not been definitively established.
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Affiliation(s)
- Elena Liew
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Maffioli M, Caramazza D, Mora B, Merli M, Passamonti F. Myelofibrosis: Prognostication and cytoreductive treatment. World J Hematol 2014; 3:85-92. [DOI: 10.5315/wjh.v3.i3.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 06/11/2014] [Indexed: 02/05/2023] Open
Abstract
Myeloproliferative neoplasms include three diseases: polycythemia vera, essential thrombocythemia and primary myelofibrosis (PMF), currently diagnosed according to the 2008 World Health Organization criteria. Patients with PMF may encounter many complications, and, among these, disease progression is the most severe. Concerning prognostication of Myelofibrosis (MF), the International Prognostic scoring system (IPSS) (International Prognostic Scoring System) model at diagnosis and the Dynamic IPSS (DIPSS) anytime during the course of the disease may be useful to define survival of MF patients. The IPSS and the DIPSS are based on age greater than 65 years, presence of constitutional symptoms, hemoglobin level less than 10 g/dL, leukocyte count greater than 25 × 109/L, and circulating blast cells 1% or greater. Cytogenetic profile and mutational analysis seem to be the next step to implement MF prognostication. Concerning treatments, hydroxyurea has been considered until now the drug of choice when an anti-myeloproliferative effect is needed, but recent data on JAK inhibitors demonstrated a significant effect of these drugs on splenomegaly and symptoms.
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Padrnos L, Mesa RA. A closer look at pacritinib: a JAK2/FLT3 inhibitor for the treatment of myelofibrosis. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.927761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Galli S, McLornan D, Harrison C. Safety evaluation of ruxolitinib for treating myelofibrosis. Expert Opin Drug Saf 2014; 13:967-76. [PMID: 24896661 DOI: 10.1517/14740338.2014.916273] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION In 2005, the JAK2 V617F mutation was identified and found to be highly prevalent in the 'Philadephia Chromosome-negative' Myeloproliferative neoplasms (MPN). This led to new diagnostic criteria for MPN in addition to the development of the first targeted therapy for myelofibrosis (MF), ruxolitinib . AREAS COVERED Ruxolitinib was approved within 5 years of 'first-in-man' trials; it has been assessed in two large Phase III trials, and to date, several thousand patients have been prescribed this drug. This article reviews the latest data from the Phase III trials concerning efficacy and safety in addition to post-authorisation data for this agent. Ruxolitinib is an extremely well-tolerated drug; it is associated with bruising, headaches, dizziness, anaemia and thrombocytopaenia. In addition, an augmented risk of infections has been documented. EXPERT OPINION Ruxolitinib has radically altered the therapeutic landscape for MF with demonstrated advantages over standard therapy, irrespective of JAK2 mutational status and a signal suggesting survival benefit. Other JAK inhibitors are also in late stages of development, although the furthest advanced has just been withdrawn due to cases of encephalopathy (not documented with ruxolitinib). This reminds the clinical community of the need for post-marketing surveillance of safety for these agents. Challenges ahead are identification of appropriate surrogates for survival benefit and perhaps how to best use ruxolitinib either alone or in combination with other therapies.
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Affiliation(s)
- Sofia Galli
- Guy's and St Thomas' NHS Foundation Trust , London , UK
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Novel myelofibrosis treatment strategies: potential partners for combination therapies. Leukemia 2014; 28:2139-47. [PMID: 24888274 DOI: 10.1038/leu.2014.176] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/25/2014] [Accepted: 05/07/2014] [Indexed: 12/15/2022]
Abstract
Of the myeloproliferative neoplasms (MPNs), myelofibrosis (MF) is associated with the greatest symptom burden and poorest prognosis and is characterized by constitutional symptoms, cytopenias, splenomegaly and bone marrow fibrosis. A hallmark of MF is dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway that has led to the development of JAK inhibitors targeting this pathway. Calreticulin gene mutations have recently been identified in JAK2 mutation-negative patients with MF. Identification of JAK inhibitor resistance and broad contributions to MF disease pathogenesis from epigenetic deregulators, pathways that work in concert with JAK/STAT (that is, mammalian target of rapamycin/AKT/phosphoinositide 3-kinase, RAS/RAF/MEK, PIM kinase), fibrosis-promoting factors and the MF megakaryocyte, suggest that numerous options may be partnered with a JAK inhibitor. Therefore, we will discuss logical and potential partners for combination therapies for the treatment of patients with MF.
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Iurlo A, Gianelli U, Rapezzi D, Cattaneo D, Fermo E, Binda F, Santambrogio E, Bucelli C, Cortelezzi A. Imatinib and ruxolitinib association: first experience in two patients. Haematologica 2014; 99:e76-7. [PMID: 24633869 DOI: 10.3324/haematol.2013.102525] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Alessandra Iurlo
- Oncohematology Unit of the Elderly, Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Milan, Italy Hematopathology Service, Division of Pathology, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Milan, Italy Division of Hematology, Santa Croce e Carle Hospital, Cuneo, Italy Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Umberto Gianelli
- Hematopathology Service, Division of Pathology, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Milan, Italy
| | - Davide Rapezzi
- Division of Hematology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Daniele Cattaneo
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Elisa Fermo
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Francesca Binda
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Elisa Santambrogio
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Cristina Bucelli
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
| | - Agostino Cortelezzi
- Oncohematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan Medical School, Italy
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Mughal TI, Girnius S, Rosen ST, Kumar S, Wiestner A, Abdel-Wahab O, Kiladjian JJ, Wilson WH, Van Etten RA. Emerging therapeutic paradigms to target the dysregulated Janus kinase/signal transducer and activator of transcription pathway in hematological malignancies. Leuk Lymphoma 2014; 55:1968-79. [PMID: 24206094 DOI: 10.3109/10428194.2013.863307] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Over the past decade, there has been increasing biochemical evidence that the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway is aberrantly activated in malignant cells from patients with a wide spectrum of cancers of the blood and immune systems. The emerging availability of small molecule inhibitors of JAK and other signaling molecules in the JAK/STAT pathway has allowed preclinical studies validating an important role of this pathway in the pathogenesis of many hematologic malignancies, and provided motivation for new strategies for treatment of these diseases. Here, a round-table panel of experts review the current preclinical and clinical landscape of the JAK/STAT pathway in acute lymphoid and myeloid leukemias, lymphomas and myeloma, and chronic myeloid neoplasms.
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Abstract
Myelofibrosis (MF) is a BCR-ABL1-negative myeloproliferative neoplasm diagnosed de novo or developed from essential thrombocythemia (ET) or polycythemia vera (PV). Average survival of a patient with MF is 5-7 years. Disease complications include fatigue, early satiety, pruritus, painful splenic infarcts, infections and leukemic transformation. Allogeneic hematopoietic stem cell transplant (HSCT) is the only potentially curative option for MF, but carries a risk of treatment-related mortality and is reserved for the few high-risk patients fit enough to endure the procedure. Other traditional therapies are palliative and supported by few randomized, controlled trials; thus, novel treatment strategies are needed. Discovery of the Janus kinase 2 (JAK2) gain-of-function mutation, JAK2V617F, in the majority (50-60%) of patients with MF led to increased understanding of the biology underlying MF and the development of JAK2 inhibitors to treat MF. Recent Food and Drug Administration (FDA) approval of the first JAK2 inhibitor, ruxolitinib, signaled a new era for treatment of MF. Additional JAK2 inhibitors, such as SAR302503, may become commercially available in the near future, and their distinct pharmacologic and efficacy profiles will help determine their use across the patient population. Data on JAK2 inhibitors, their role in an evolving treatment paradigm, and future directions for treatment of MF are discussed.
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Affiliation(s)
- Ruben A Mesa
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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