Tag Archives: mpn

Hypomethylating Agents Show Promise in Myelofibrosis Progression After alloHCT

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Andrea S. Blevins Primeau, PhD, MBA

Donor chimerism was restored with hypomethylating agent (HMA) treatment among some patients with myelofibrosis (MF) who relapsed after allogeneic hematopoietic cell transplantation (alloHCT), according to a small retrospective published in the journal Transplantation and Cellular Therapy.

These data suggest that HMA “is an option for patients in the future,” the researchers wrote in their report. “By promoting restoration of donor chimerism and clearance of pre-alloHCT somatic mutations, HMAs offer a capable therapeutic strategy for improving outcomes in this challenging patient population.”

In the single-center, retrospective study, the researchers analyzed data from the electronic health records of 12 patients with MF who relapsed after alloHCT between 2020 and 2023 and were subsequently treated with an HMA.

The median age of the cohort was 61 years and 33% of patients had primary MF, 41.7% had post-essential thrombocythemia MF, and 25.0% had post-polycythemia vera MF.

There were 92% of patients with disease classified as intermediate-2/high-risk by the Dynamic International Prognostic Scoring System (DIPSS) and 83% were considered high or very high risk by the Molecular International Prognostic Scoring System (MIPSS70+). There were 66.7%, 25.0%, and 16.7% of patients with JAK2, MPL, or CALR driver mutations, respectively, at diagnosis.

After transplantation, 99.9% of patients achieved donor chimerism at day 30 and 96.6% at day 100. Patients relapsed after alloHCT within a median of 282.5 days (range, 96-2388 days). The median donor chimerism before initiating an HMA was 57.82%.

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Shear Wave Elastography Distinguishes Myelofibrosis From Other MPNs

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Sep 25, 2024

 

Liver and spleen shear-wave elastography helped distinguish patients with myelofibrosis from healthy controls and those with essential thrombocytopenia, according to findings published in the Journal of Ultrasound. This suggests that the technique may help diagnose myeloproliferative neoplasms.

Researchers added that liver stiffness and spleen stiffness appeared to be linked with bone marrow fibrosis.

“Vibration-controlled transient elastography (VCTE) has proven to be a valuable tool in providing prognostic and staging information in patients with liver disease, greatly reducing the need for liver biopsy,” Vito Sansone, MD, Student, and colleagues wrote. “Spleen stiffness, similarly, has proven useful as a surrogate marker of portal hypertension. To date, however, the role of any of these techniques in the work-up of MPNs has not been established. …This study aims to investigate if values of liver and spleen stiffness measured with shear-wave elastography could help to differentiate MPNs from healthy controls and if there are significant differences in values of liver stiffness and spleen stiffness.”

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HTR1B Expression and Thrombosis in Patients With Myeloproliferative Neoplasms

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Vicki Moore, PhD

In this retrospective study, the researchers evaluated expression levels of HTR1B based on messenger RNA from peripheral blood mononuclear cells obtained from patients with newly diagnosed MPN, in addition to conducting other analyses. The researchers had a goal of evaluating possible differences in expression of this gene across MPN subtypes.

There were 85 patients with newly diagnosed MPN included in the analysis, with a median age of 57 years (range, 23-80). Among these patients, 28 had polycythemia vera (PV), 25 had essential thrombocythemia (ET), and 32 had primary myelofibrosis (PMF). Additionally, comparisons of HTR1B expression included 6 healthy volunteers.

Across MPN subtypes and control individuals, the expression of HTR1B did not significantly differ (P =.3089). However, there was large variation observed in expression levels. The researchers further examined expression levels in the context of other patient factors, including based on whether patients had a thrombotic or non-thrombotic history.

A total of 32 patients were considered to have thrombotic MPNs and 53 patients were considered to have nonthrombotic MPN, with median ages of 57 years in each group. Levels of HTR1B expression were significantly different when analyzed across groups organized by thrombotic MPN, nonthrombotic MPN, or status as control individuals.

The level of HTR1B expression appeared highest among patients with thrombotic MPNs, while levels appeared to not be significantly different between patients with nonthrombotic MPNs and control individuals. Among patients with thrombotic MPNs, there was no statistically significant difference observed in the level of fold-change in HTR1B expression by MPN subtype.

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Researchers Identify INCA033989 as a Potential Treatment for Myeloproliferative Neoplasms

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By Alexandra Gerlach, Associate Editor

Data from a study published in Blood demonstrates the therapeutic potential of INCA033989 as the first targeted therapy for myeloproliferative neoplasms (MPNs) that does not interfere with normal blood cell production. Existing therapeutic options for MPNs are effective at symptom management but have high discontinuation rates due to resistance and inadequate drug tolerability. The development of INCA033989 opens pathways to more effective, targeted options with disease-modifying potential without any negative impact on surrounding blood cells.1

The development of INCA033989 has positive implications for the evolving treatment landscape of patients with MPNs. Image Credit: © Anna – stock.adobe.com

MPNs are a group of malignancies characterized by the overproduction of red and white blood cells and is an umbrella for 6 different disease types: myelofibrosis (MF), essential thrombocythemia, chronic myelogenous leukemia, polycythemia vera, chronic neutrophilic leukemia, and chronic eosinophilic leukemia. Calreticulin (CALR) mutations are responsible for disease development in 20% to 30% of patients with MPNs, which can be either insertions or deletions in exon 9 of CALR. The mutated CALRprotein (mutCALR) is responsible for the stable interaction with thrombopoietin receptors (TPO-R), which are crucial for controlling blood cell production.2,3

Janus kinase (JAK) inhibitors, such as ruxolitinib (Jakafi; Incyte Corp), are the recommended treatment options for patients with MF or other MPNs; however, they are associated with adverse effects (AEs), namely grade 3 or 4 anemia. INCA033989 is a high affinity, fully human immunoglobulin G1 selective monoclonal antibody targeting mutCALR-driven oncogenesis to suppress TPO-R signaling, thereby preventing the proliferation and progression of disease. According to data from the original study announcing the development of this agent, there was an observed synergism between INCA033989 and ruxolitinib which resulted in the inhibition of cell proliferation and indicated the ability of INCA033989 to enhance the efficacy of ruxolitinib.3,4

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New Trial Sets Out to Test Treatment for Early Primary MF

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Özge Özkaya, MSc, PhD

A new randomized, double-blind, placebo-controlled, phase 3 clinical trial assessing the safety and efficacy of ropeginterferon alfa-2b, a new-generation pegylated interferon-based therapy, in patients with early and lower-risk primary myelofibrosis (MF) is now open.

The trial aims to recruit 150 such patients who are at least 18 years of age and will receive either up to 500 μg of subcutaneous ropeginterferon alfa-2b or a placebo every 2 weeks until 56 weeks.

The primary endpoints of the trial include clinically relevant complete hematologic response as measured by platelet count, white blood cell count, hemoglobin levels in peripheral blood, absence of thrombotic events, and no progression to acute myeloid leukemia, and symptom endpoint.

Secondary endpoints include bone marrow response, event-free survival or progression-free survival, molecular response in driver or relevant coexisting gene mutations, and safety.

“The study will provide important data for the treatment of early/lower-risk [primary] MF for which an anti-clonal, disease-modifying agent is highly needed,” the researchers wrote in an article that they published in the journal Annals of Hematology, which contains the details of the trial design.

The trial is not yet recruiting participants. It is estimated to start in October 2024 and be completed in August 2027.

Previous research has shown that ropeginterferon alfa-2b has favorable pharmacokinetics and safety profiles and requires less frequent injections than previous formulations of pegylated interferon alfa, the researchers noted.

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Korean Study Finds DOAC Use “Seems Effective” in Patients With MPNs

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September 25, 2024

Author(s): Mary Caffrey

A study based on a decade’s worth of Korean insurance data found that use of direct oral anticoagulants (DOACs) to address atrial fibrillation and venous thromboembolism in patients with myeloproliferative neoplasms (MPNs) is effective, with acceptable bleeding risk.

Patients with Philadelphia chromosome–negative myeloproliferative neoplasms (MPNs) face an elevated risk of arterial and venous thrombosis, due to the increased production of mature myeloid blood cells caused by their condition.1 The increased morbidity and mortality caused by atrial fibrillation (AF) and venous thromboembolism (VTE) among patients with MPNs has led the American College of Cardiology and the American Heart Association, among others, to recommend direct oral anticoagulants (DOACs) to prevent blood clots and reduce the risk of major cardiovascular events in patients with MPNs.2

However, a group of authors from Korea, writing in Cancer Research and Treatment, note that the actual amount of evidence regarding the use of DOACs in patients with MPNs is limited. This week, they published a study based on a decade’s worth of Korean insurance data. Based on an analysis of records from 368 patients with MPNs, they concluded that use of DOACs in this population “seems effective with an acceptable bleeding risk.”3

The authors write that a prior study, with very limited data, found the 1-year cumulative incidence of thrombosis was 5.5% and bleeding was 12.3% among patients with MPNs taking DOACs.3 They note their study population involved patients who were somewhat older (average age, 74 years) and had a higher CHA2DS2-VASc score, which evaluates a patient’s risk based on the presence of congestive heart failure, hypertension, age, diabetes status, history of stroke or transient ischemic attack, and vascular disease; risk is doubled if the patient is 75 years or older.

The Korean study was based on data from the Health Insurance Review and Assessment Service, which has information on inpatient and outpatient care for 50 million Koreans. Investigators pulled patient data from the period of January 1, 2011, to January 1, 2021. The cohort of 368 patients had the following characteristics:3

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Bose’s Guide to Ruxolitinib, Fedratinib, Pacritinib, and Momelotinib

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By Prithviraj Bose, MD

Prithviraj Bose, MD, professor in the Department of Leukemia at MD Anderson Cancer Center, provides an overview of the different JAK inhibitors currently available for patients with myeloproliferative neoplasms.

Transcription:

0:09 | We have 4 JAK inhibitors approved for the treatment of myelofibrosis in the US. Important to note, pacritinib [Vonjo] is not approved outside the US. There is obviously a lot to say on this topic, especially, ruxolitinib [Jakafi] was approved in 2011, fedratinib [Inrebic] in 2019 and then pacritinib and momelotinib [Ojjaara], more recently, 2022 and 2023. But I think I will just hit some high points.

0:36 | So for ruxolitinib, the first thing I would say about that is that it is the JAK inhibitor with the most clearly demonstrated survival benefit in myelofibrosis. Now, is that an effect just of ruxolitinib and not of the others? We do not know that. It could be a class effect, but the data are the data and the data are that ruxolitinib is the one that has a clearly shown survival benefit. I think that needs to be considered as we use it, and it is usually the most frequently used frontline drug. Now, where you can get into trouble with ruxolitinib is with cytopenias, low blood counts, and this is a drug that you need to be able to dose well in order to get the benefit that you are seeking. The dose can get compromised by cytopenias.

1:29 | That is where I will tie that into the entry of pacritinib and momelotinib. These are easier to use in the setting of cytopenias. In fact, pacritinib has a label for platelets than 50, and momelotinib is for patients with anemia in myelofibrosis. So right there, you can see that they sort of have their place more in that cytopenic population, which could be frontline, or, more commonly, second-line, after ruxolitinib. I think those are great additions in the sense that you can give them at good doses despite low blood counts, which becomes difficult with ruxolitinib, like I just said. [They are] certainly very welcome additions to the arsenal.

2:12 | I will just say 1 last thing about fedratinib, which was the second one approved. This is a good drug, perhaps as good as ruxolitinib from an efficacy stand point, but really with no clear advantage over ruxolitinib. So, I do not use it in the frontline. I do use it, however, in post-ruxolitinib settings, where the blood counts are good. In those proliferative scenarios, as opposed to the cytopenic scenarios, in second-line and beyond, I do find fedratinib to be a useful drug. It has some toxicities that one has to pay attention to. All patients should get thiamine supplementation, stuff like that, but overall, I would say those are the kind of very high level points about the 4 drugs.

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Dr Amanam on Criteria for Selecting a JAK Inhibitor in Myelofibrosis

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September 23, 2024

Author(s): Idoroenyi Amanam, MD

Idoroenyi Amanam, MD, assistant professor, Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, discusses the criteria for selecting JAK inhibitors in the treatment of patients with myelofibrosis.

Ruxolitinib (Jakafi) was the first JAK inhibitor approved for the treatment of myelofibrosis by the FDA in 2011. Amanam notes that this approval was initially based on the agent’s demonstrated benefits in reducing splenomegaly and improving symptom burden, two critical factors that influence treatment outcomes in myelofibrosis. Since then, 3 additional JAK inhibitors have received FDA approval for the treatment of select patients with myelofibrosis: fedratinib (Inrebic) in 2019, pacritinib (Vonjo) in 2022, and momelotinib (Ojjaara) in 2023.

Amanam emphasizes that the ideal candidates for JAK inhibitors are patients experiencing significant symptom burden and splenomegaly. Patients presenting with myelofibrosis, particularly those with moderate to severe spleen enlargement and a high burden of disease-related symptoms, are likely to derive the most benefit from JAK inhibition, he continues.

Conversely, patients who are not experiencing splenomegaly or any symptom burden may have limited therapeutic gain from JAK inhibitors, and the use of these agents in these patients may expose them to unnecessary risks of adverse effects (AEs), he says. The most commonly reported AEs from JAK inhibitor treatment are cytopenias, such as anemia, thrombocytopenia, and leukopenia, Amanam notes.

To avoid these potential toxicities, Amanam stresses the importance of thorough patient evaluation and symptom assessment when considering JAK inhibitors, as the absence of these key criteria can reduce the overall efficacy of treatment and increase the potential for unnecessary AEs.

In clinical practice, Amanam explains the importance of personalized treatment strategies based on individual patient characteristics and risk profiles, prioritizing those who meet the established clinical benchmarks for symptom relief and splenic volume reduction.

Although JAK inhibitors can offer significant symptomatic relief for appropriately selected patients, they are not universally beneficial for all patients with myelofibrosis and should be used judiciously to optimize clinical outcomes, he concludes.

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Can Vaccines Be Developed for MPNs? Study Examines the Challenges

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September 18, 2024

Author(s): Mary Caffrey

Researchers from Bulgaria conduct an analysis of the potential for therapeutic vaccines in by comparing testing results for patients from their country with an international data set.

Despite their status as myeloid malignancies, myeloproliferative neoplasms (MPNs) have drawn interest from researchers as candidates for therapeutic vaccines. Giroux et al drew attention in Science in 2022 by investigating MPNs with calreticulin (CALR) mutations, which lack T cells to target this antigen.1 Specifically, Giroux’s team pursued the major histocompatibility complex (MHC-1) allele frequences they observed and developed a heteroclitic peptide vaccine to activate T cells against tumors.

Now, a team from Bulgaria follows Giroux with a statistical approach, with results appearing in Frontiers in Immunology.2 The group first made comparisons between patients with MPNs and healthy controls within the homogenous population of Bulgaria before completing a meta-analysis involving patients and healthy controls from the 1000 Genomes Project, an international effort to collect human genome samples.3

To start, the team established that human leukocyte antigen class I (HLA-I) and class II (HLA-II) alleles alter how JAK2 V617F and CALR mutations create cancer cells in MPNs, but that the role of immune response in MPNs is not well known. Thus, the team sought to explore the role of HLA genes in MPNs with CALR mutations. They conducted analyses involving 42 patients with CALR mutations and 158 with JAK2 V6127F mutations, as well as 1083 healthy controls.2

As the authors explained, mutations in 3 genes drive all MPNs; they are JAK2, CALR, and MPL. “These mutations originate at the level of hematopoietic stem cells, but, depending on the intrinsic and extrinsic factors, can lead to differential skewing of hematopoiesis predominantly into one of the myeloid lineages presenting clinically with 1 of the 3 phenotypes,” which they noted are essential thrombocythemia, polycythemia vera, and primary myelofibrosis.2

Mutations may appear just as cancer cells form but also before symptoms appear, in a status called clonal hematopoiesis of indeterminate potential, or CHIP; it may take a long time for CHIP to convert to malignancy, and different mutations follow different paths.

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Rovadicitinib Bests Hydroxyurea in Myelofibrosis

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Erin Clancy

The JAK2 inhibitor rovadicitinib proved more effective than hydroxyurea in patients with JAK inhibitor-naïve, intermediate-2 or high-risk myelofibrosis in a phase 2 trial presented at the ESMO Congress 2024.

These results “support the use of rovadicitinib as a new treatment option” for these patients, said study presenter Ling Pan, of West China Hospital, Sichuan University, in Chengdu, China.

The trial (NCT05020652) enrolled 105 patients with intermediate-2 or high-risk primary, post-polycythemia vera, or post-essential thrombocythemia myelofibrosis. All patients had received no prior JAK inhibitor treatment and had palpable splenomegaly.

Patients were randomly assigned 2:1 to receive rovadicitinib at 15 mg twice daily plus placebo (n=72) or hydroxyurea at 0.5 g twice daily plus placebo (n=35). Baseline characteristics were well balanced between the arms.

Treatment continued for 24 weeks, at which point patients who achieved a spleen volume reduction of 35% or greater (SVR35) maintained treatment as assigned. Those who had not achieved SVR35 by week 24 received open-label rovadicitinib at 15 mg twice daily until treatment termination criteria were met.

At week 24, the SVR35 rate was 58.33% in the rovadicitinib arm and 22.86% in the hydroxyurea arm (P =.0006). The best spleen response rate during the study period was 63.89% with rovadicitinib and 31.43% with hydroxyurea (P =.0017).

The proportion of patients who achieved a 50% or greater reduction in total symptom score at week 24 was 61.11% with rovadicitinib and 45.71% with hydroxyurea (P =.136). The best symptom response rate during the study period was 77.78% with rovadicitinib and 54.29% with hydroxyurea (P =.0136).

Eighteen patients who initially received hydroxyurea but switched to rovadicitinib after week 24 were included in the safety analysis, so 90 patients were evaluable in the rovadicitinib arm and 35 patients were evaluable in the hydroxyurea arm.

The rate of treatment-emergent adverse events (TEAEs) was 97.78% in the rovadicitinib arm and 100% in the hydroxyurea arm. The rate of grade 3 or higher TEAEs was 51.11% and 77.14%, respectively. The rate of serious TEAEs was 31.11% and 40.00%, respectively.

The most common grade 3 or higher hematologic TEAEs (in the rovadicitinib and hydroxyurea arms, respectively) were platelet count decrease (20.00% and 17.14%) and anemia (28.89% and 60.00%). The most common grade 3 or higher non-hematologic TEAE was hyperkalemia (6.67%) in the rovadicitinib arm and weight gain (2.86%) in the hydroxyurea arm.

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