scholarly journals Predictors of Response to Erythropoietin in Autoimmune Hemolytic Anemia

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3516-3516 ◽  
Author(s):  
Bruno Fattizzo ◽  
Marc Michel ◽  
Laetitia Languille ◽  
Juri Giannotta ◽  
Henrik Frederiksen ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Hemolytic Anemia ◽  
Autoimmune Hemolytic Anemia ◽  
Research Funding ◽  
Specific Treatment ◽  
Advisory Board ◽  
Recombinant Erythropoietin ◽  
Severe Anemia ◽  
Predictors Of Response ◽  
Small Series

BACKGROUND AND AIM Bone marrow compensation in autoimmune hemolytic anemia (AIHA) is an emerging predictor of clinical outcome. It is measured by reticulocytosis that may be inadequate in a proportion of cases, particularly in chronic refractory ones. Moreover, reticulocytosis may be masked by constant destruction, particularly in cold forms. Recombinant erythropoietin (EPO), has been anecdotally used off-label in AIHA to improve anemia, but only case reports and small series have been described. Here we evaluate EPO efficacy and predictors of response in a multicentric cohort of primary and secondary AIHA patients. METHODS Hematological data, hemolytic markers (LDH, reticulocytes), and concomitant treatments were retrospectively and prospectively collected. Efficacy was evaluated at 15 and 30 days, and then at 3,6 and 12 months after EPO start. Response was considered as partial (PR, >2 g/dL Hb increase or >10 g/dL) or complete (CR, >12g/dL and normalization of hemolytic markers). Forty-six AIHA cases followed from June 2007 to June 2019 at 9 centers in Italy, France, Norway, Austria, Denmark, and UK were included. RESULTS Table 1 shows patients characteristics: all AIHA types (warm, cold, mixed, and DAT negative) were present, and 5 cases were secondary to a lymphoproliferative disorder (not active and without specific treatment at the time of EPO start). Bone marrow evaluation pre-EPO (N=24) showed hypercellularity in 14 cases, dyserythropoiesis in 11, and reticulin fibrosis in 3; a lymphoid infiltrate was found in 19 patients (T-cell in 6, B-cell in 10, mixed in 3), greater than 10% in the 5 secondary cases only. Forty-one cases (89%) had been previously treated, with a mean of 1.8+1 lines of therapy including steroids, rituximab, splenectomy, immunosuppressors and sutimlimab (1 case, where the drug completely abolished hemolysis). The majority (67%) started EPO due to non-response to ongoing treatment (18 steroids, 6 immunosuppressors, 1 sutimlimab) or within 3 months from rituximab course (7). At EPO initiation, 30% of cases displayed severe anemia, 71% had inadequate reticulocytosis (bone marrow responsiveness index<121), and 73% showed inappropriately low endogenous EPO levels. Of note, 2 patients had concomitant renal impairment, possibly contributing to this finding. Most cases received epoetin alpha 40,000 UI/week (45%), followed by darbopoetin alpha (34% of cases, median dose 102 mcg/week) and epoetin zeta (14% of cases, 30,000 UI/week). EPO was administered for a median of 6 months and responses were observed in 68% and 70% of cases at month+1 and +3. Comparable response rates were recorded at month+6 (70%, 13 CR and 1 PR, N=20) and +12 (72%, 8 CR and 5 PR, N=18), although evaluable cases were fewer. Median Hb increase from baseline was 2.5 g/dL (0.2-7.6) at month+1 (p<0.001), and 3.1 g/dL (0-9.4) at month+3 (p<0.001). Consistently, reticulocytes increased by 23 x109/L (0-217) at month+1, and 33 x109/L (0-353) at month+3. No EPO-related adverse events occurred (particularly no thrombosis). At last follow up, 23 cases had discontinued EPO: 13 for long lasting CR and 10 because of NR. Considering predictors of response, a better efficacy was observed in primary versus secondary AIHA (71 vs 40%) and in patients with shorter time from diagnosis to EPO treatment (52% of responders started EPO within 1 year from diagnosis vs 8% of NR, p=0.01). Moreover, responders had received a lower number of previous treatments (p=0.04), particularly rituximab (p=0.05) and immunosuppressors (p=0.08). Remarkably, responders more frequently showed severe anemia (86% vs 62%) and lower endogenous EPO (91% vs 50% with a cut-off of <60 UI/L, p=0.05) at baseline. CONCLUSIONS EPO is effective in roughly 70% of chronic refractory AIHA cases, independently from antibody thermal characteristics/isotype and underlying disease. Concomitant treatments may partially affect response evaluation, although EPO treatment has been introduced because of their partial or complete inefficacy. Further limitations are the retrospective nature of the study and a possible selection bias (i.e. most of patients had inadequate reticulocytosis). Predictors of response were severe anemia and low levels of endogenous EPO, as well as, shorter disease duration and a lower burden of previous treatments. These data suggest an early use of EPO in this setting in order to overcome inadequate bone marrow compensatory ability. Table Disclosures Fattizzo: Apellis: Consultancy. Michel:Novartis: Consultancy; Amgen: Consultancy; Rigel: Consultancy. Frederiksen:Novartis: Research Funding; Janssen Pharmaceuticals: Research Funding; Abbvie: Research Funding; Alexion: Research Funding; Gilead: Research Funding. Mauro:Gilead: Consultancy, Research Funding; Shire: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Jannsen: Consultancy, Research Funding; Roche: Consultancy, Research Funding. Jilma:TrueNorth a Bioverativ company, a Sanofi company: Consultancy, Research Funding. Hill:Regeneron: Honoraria; Roche: Honoraria; Ra Pharma: Honoraria; Bioverativ: Honoraria; Novartis: Honoraria; Akari: Honoraria; Alexion: Honoraria; Apellis: Honoraria. Berentsen:Mundipharma: Research Funding; Apellis, Bioverativ (a Sanofi company), Momenta Pharmaceuticals, and True North Therapeutics: Consultancy; Alexion, Apellis, and Janssen-Cilag: Honoraria. Barcellini:Agios: Other: Advisory board; Bioverativ: Other: Advisory board; Alexion: Other: Invited Speaker, Research Funding; Novartis: Other: Invited Speaker, Research Funding; Incyte: Other: Advisory board. OffLabel Disclosure: Erythropoietin (EPO) is not yet indicated for the use in autoimmune hemolytic anemia. Here we report retrospective data on a large cohort of cases treated with EPO as a support to bone marrow compensation.

scholarly journals Effective Treatment of Cold Agglutinin Disease/Cold Agglutinin Syndrome with Ibrutinib: An International Case Series

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 29-30
Author(s):  
Marit Jalink ◽  
Sigbjørn Berentsen ◽  
Jorge J. Castillo ◽  
Steven Treon ◽  
Bruno Fattizzo ◽  
...  
Keyword(s):  
Bone Marrow ◽  
B Cell ◽  
Hemolytic Anemia ◽  
Median Duration ◽  
Autoimmune Hemolytic Anemia ◽  
Research Funding ◽  
Cold Agglutinin ◽  
Cold Agglutinin Disease ◽  
Btk Inhibitor

Background In cold agglutinin mediated autoimmune hemolytic anemia (cAIHA), anti-red blood cell autoantibodies lead to complement-mediated hemolysis with or without symptoms of acrocyanosis after exposure at low temperatures. cAIHA can be divided into cold agglutinin disease (primary CAD) and cold agglutinin syndrome (CAS). The latter is secondary to diseases such as B-cell malignancies including CLL, infections or autoimmune disorders. In primary CAD, more than 90% of patients have a monoclonal IgM (mostly low level) and often a small bone marrow B-cell clone. There is no approved treatment. For patients with significant hemolytic anemia or acrocyanosis despite thermal protection, rituximab is the most accepted first line treatment with an overall response rate of 50% and median duration of response <1 year. Cytotoxic combinations such as rituximab-bendamustine produce more sustained remissions, although with concerns for long-term adverse effects and stem cell toxicity. Studies involving complement inhibitors are showing promising results on hemolysis, although cold induced peripheral symptoms (IgM mediated rather than complement-mediated) will not improve. Recent international guidelines on cAIHA suggest treatment with the Bruton tyrosine kinase (BTK)-inhibitor ibrutinib in refractory patients with cAIHA (Jäger et al Blood Rev 2020). Indeed, the underlying pathophysiology of cAIHA suggest that BTK inhibition could be effective. Aims To evaluate the efficacy of ibrutinib on anemia, hemolysis and acrocyanosis in patients with cold agglutinin-mediated AIHA (CAD/CAS). Methods An international retrospective study was undertaken of cAIHA patients (CAD/CAS) treated with BTK inhibition using a preformed questionnaire. For eligible patients, laboratory and clinical data regarding underlying disease, bone marrow pathology, hemolytic parameters and patient-reported acrocyanosis were collected at diagnosis, 30 days, 3 months, 6 months and 12 months and last date of follow up. Hemoglobin (Hb) response was considered none (NR), partial (PR, >2 g/dL Hb increase or >10g/dL) or complete (CR, >12g/dL). Adverse events were graded according to the Common Terminology Criteria, version-5.0 (2017). Results So far, 10 patients with cAIHA treated with a BTK-inhibitor (all involving ibrutinib) could be included in the study. Patients were followed from April 2014 until June 2020 at 5 centers (Italy (2), Norway, The United Kingdom and The United States). Median duration of follow up was 20 months (1-74 months). The main findings are summarized in table 1. The indication to start treatment was cAIHA based in all but 1 case (CLL). Median previous number of therapies was 2. All patients had a complement-mediated hemolytic anemia, 7 were transfusion-dependent, and 7 reported symptoms of acrocyanosis at the initiation of ibrutinib. After initiation of ibrutinib, all patients showed an improvement in hemoglobin (Median rise: 4.4 g/dL) resulting in 1 PR and 9 CR. All 7 transfusion-dependent patients became transfusion independent (5 within 30 days). In all but 1 patient, markers of hemolysis (LDH, bilirubin) improved after initiation of ibrutinib (see Figure 1). All 7 patients with acrocyanosis reported clear clinical improvement, with complete resolution of symptoms in 5. There was 1 adverse event (grade 1 bleeding). Data collection is still ongoing and future updates are expected. Conclusion Data show that ibrutinib is effective in the treatment of cAIHA with a notable and brisk improvement of both the hemolytic anemia as well as the cold induced peripheral symptoms. Although preliminary, these promising data support further research of BTK-inhibitor based treatment of cAIHA (CAD/CAS) in a prospective study. Disclosures Berentsen: Alexion, Apellis, Bioverativ and Janssen-Cilag: Other: Travel grants ; Alexion, Apellis, Bioverativ, Janssen-Cilag, True North Therapeutics: Honoraria; Apellis, Bioverativ, Momenta Pharmaceuticals and True North Therapeutics: Consultancy; Mundipharma: Research Funding. Castillo:TG Therapeutics: Research Funding; Pharmacyclics: Consultancy, Research Funding; Beigene: Consultancy, Research Funding; Kymera: Consultancy; Abbvie: Research Funding; Janssen: Consultancy, Research Funding. Treon:Bristol-Meyer-Squibb: Honoraria, Research Funding; Pharmacyclics: Honoraria, Research Funding. D'Sa:Sanofi: Honoraria; BeiGene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding. OffLabel Disclosure: BTK-inhibitors (ibrutinib/acalabrutinib) are not yet indicated for the use in (primairy) cold autoimmune hemolytic anemia (cAIHA). However it is indicated for use in Waldenstrom macroglobulinemia (WM) and chronic lymphatic leukemia (CLL). Here we report retrospective data on a cohort of cases treated with ibrutinib for cAIHA mostly secondary to WM or CLL.

scholarly journals Alemtuzumab Plus Cyclosporine Treatment of the Autoimmune Hemolytic Anemia in an Adult Bowel Transplant

2014 ◽  
Vol 2014 ◽  
pp. 1-4
Author(s):  
A. Lauro ◽  
M. Stanzani ◽  
C. Finelli ◽  
C. Zanfi ◽  
M. C. Morelli ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Hemolytic Anemia ◽  
Bone Marrow Biopsy ◽  
Autoimmune Hemolytic Anemia ◽  
Leukocyte Count ◽  
Pure Red Cell Aplasia ◽  
Febrile Episode ◽  
High Dose ◽  
Laboratory Findings ◽  
Transfusion Requirements

An adult male underwent a bowel transplant for tufting enteropathy, receiving alemtuzumab, tacrolimus, and steroids as immunosuppressants. Five years later, he developed an autoimmune hemolytic anemia (AIHA), anti-IgG positive, with reduced reticulocyte count, leukopenia, and thrombocytopenia with antiplatelet antibodies. After an unsuccessful initial treatment with high dose steroids, reduction in tacrolimus dose, and intravenous immunoglobulin (IVIG), a bone marrow biopsy revealed absence of erythroid maturation with precursor hyperplasia. The patient was switched to sirolimus and received four doses of rituximab plus two courses of plasmapheresis, which decreased his transfusion requirements. After a febrile episode one month later, the AIHA relapsed with corresponding decreases in platelet and leukocyte count: cyclosporine A (CsA) was started with a second course of rituximab and IVIG without response, even though repeat bone marrow biopsy did not reveal morphology correlated to an acquired pure red cell aplasia (APRCA). Considering the similarity in his clinical and laboratory findings to APRCA, alemtuzumab was added (three doses over a week) with CsA followed by steroids. The patient was eventually discharged transfusion-independent, with increasing hemoglobin (Hb) levels and normal platelet and leukocyte count. One year later he is still disease-free with functioning graft.

scholarly journals Clinical Patterns and Hematological Spectrum in Autoimmune Hemolytic Anemia

2010 ◽  
Vol 2 (01) ◽  
pp. 017-020 ◽  
Author(s):  
Vanamala Alwar ◽  
Shanthala Devi A M. ◽  
Sitalakshmi S. ◽  
Karuna R K.
Keyword(s):  
Connective Tissue ◽  
Hemolytic Anemia ◽  
Autoimmune Hemolytic Anemia ◽  
Severe Anemia ◽  
Red Cell ◽  
Connective Tissue Disorders ◽  
Red Cell Membrane ◽  
Antiglobulin Test ◽  
Circulating Autoantibodies ◽  
Positive Direct

ABSTRACT Background: Autoimmune hemolytic anemia (AIHA) results from red cell destruction due to circulating autoantibodies against red cell membrane antigens. They are classified etiologically into primary and secondary AIHAs. A positive direct antiglobulin test (DAT) is the hallmark of diagnosis for AIHA. Methods and Results: One hundred and seventy-five AIHA cases diagnosed based on positive DAT were included in the study. The cases showed a female predilection (M: F = 1:2.2) and a peak incidence in the third decade. Forty cases were found to be due to primary AIHA, while a majority (n = 135) had AIHA secondary to other causes. The primary AIHA cases had severe anemia at presentation (65%) and more often showed a blood picture indicative of hemolysis (48%). Forty-five percent of primary AIHAs showed positivity for both DAT and indirect antiglobulin test (IAT). Connective tissue disorders were the most common associated etiology in secondary AIHA (n = 63). Conclusion: AIHAs have a female predilection and commonly present with symptoms of anemia. AIHA secondary to other diseases (especially connective tissue disorders) is more common. Primary AIHAs presented with severe anemia and laboratory evidence of marked hemolysis.

Microrna-Dependent Modulation Of Osteogenesis In a 3D In Vitro Bone Marrow Model System Of Multiple Myeloma

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 3093-3093
Author(s):  
Michaela R Reagan ◽  
Yuji Mishima ◽  
Yong Zhang ◽  
Patricia Maiso ◽  
Salomon Manier ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Research Funding ◽  
3D Model ◽  
Human Cancer ◽  
Model System ◽  
Advisory Board ◽  
Alizarin Red ◽  
Non Destructive

Abstract Introduction Recent evidence indicates that tumor cells are not only influenced by their microenvironment, but are also able to drastically alter their surroundings leading to cancer progression. Multiple Myeloma (MM) involves clonal proliferation of malignant plasma cells within the bone marrow, inhibition of osteoblast function, and increased osteoclast activity leading to osteolytic lesions. Our work aims to understand the bi-directional interactions between MM cells and mesenchymal stromal cells (MSCs), using both 2D and 3D in vitro co-culture bone marrow models. Methods We developed a 3D in vitro model system to better mimic myeloma growth within the bone marrow using human MSCs (hMSCs) and fluorescent-, luciferase-labeled MM cell lines seeded into porous, autofluorescent silk scaffolds. Proliferation and osteogenic differentiation of myeloma patient (MM-) and normal donor (ND-) MSCs cultured with or without MM.1S cells were characterized in 2D culture and 3D scaffolds. Non-destructive bioluminescent imaging and fluorescent confocal imaging were used to observe cell growth and cell-cell interactions within scaffolds. Histology was performed to confirm changes in extracellular matrix (ECM) production and bone tissue formation. microRNA (miRNA) profiling was performed on primary ND- (n=3) and MM-MSCs (n=7) using Nanostring technologies. We analyzed 800 human miRNAs from miRBase v.18 and 230 human cancer-related genes using the nCounter® Human Cancer Reference Kit. Gain-of function studies (miRvana mimics) were performed for miRNAs that were down-modulated in MM vs ND-MSCs, and in the 3D model MSCs co-cultured with MM.1S vs MSCs alone, using lipofectamine. Modulation of osteogenesis was evaluated using alizarin red staining and qRT-PCR for the osteogenic markers: IBSP (integrin-binding sialoprotein), Col1a1 (collagen, type I, alpha 1), RUNX2 (runt related transcription factor 2), ALPL (alkaline phosphatase), OPN (secreted phosphoprotein 1), and BGLAP (bone gamma-carboxyglutamate (gla) protein). Results MM-MSCs presented with a lower proliferation rate compared to ND-MSCs and this phenotype was also observed in ND-MSCs co-cultured in the presence of MM.1S cells compared to ND-MSCs alone. Moreover, significant inhibition of MSC growth was evident when co-cultured with MM.1S cells, using a 3D model (Figure 1), where inhibition of osteogenesis, and ECM production were also documented. Alizarin red staining demonstrated inhibited ability for MM-MSCs to undergo osteogenic differentiation. In addition, MM-MSCs differed from ND-MSCs at the gene and miRNA level. Specifically, CDKN1A and CDKN2A were over-expressed in MM vs. ND-MSCs, (P<0.05; fold change >1.2), thus explaining, at least in part, the decreased proliferation of MM-MSCs vs ND-MSCs. Moreover, down-regulation of specific miRNAs (miRNA-199a, -24-3p, -199a, -15a-5p, -16-5p) was demonstrated in MM- vs ND-MSCs, as well as in ND-MSCs vs ND-MSCs co-cultured with MM.1S, using the 3D model. By over-expressing miRNA-199a, -15a-5p and -16-5p, we were able to increase the osteogenic potential, thus suggesting their role in modulating osteogenesis in MM-MSCs. Conclusions Our 3D platform provides a simple, non-destructive, flexible, and clinically relevant tool to spatially and temporally model myeloma growth within bone. It recapitulates decreased bone formation as seen in MM patients and suggests miR-199a-3p, 15a-5p and 16-5p as novel bone anabolic targets. Disclosures: Tai: Onyx: Consultancy. Ghobrial:Onyx: Advisoryboard Other; BMS: Advisory board, Advisory board Other, Research Funding; Noxxon: Research Funding; Sanofi: Research Funding.

Silencing The Sialyltransferase Gene ST3GAL6 Inhibits Adhesion and Migration Of Myeloma Cells In Vitro and Reduces The Homing and Proliferation Of Tumor Cells In Vivo

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 275-275
Author(s):  
Siobhan Glavey ◽  
Salomon Manier ◽  
Antonio Sacco ◽  
Michaela R Reagan ◽  
Yuji Mishima ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Cell Lines ◽  
Research Funding ◽  
Advisory Board ◽  
Myeloma Cells ◽  
Sialyl Lewis ◽  
And Migration ◽  
Rpmi 8226

Abstract Background Glycosylation is a stepwise procedure of covalent attachment of oligosaccharide chains to proteins or lipids, and alterations in this process, especially increased sialylation, have been associated with malignant transformation and metastasis. The adhesion and trafficking of multiple myeloma (MM) cells is strongly influenced by glycosylation and multiple myeloma cells express a variety of adhesion molecules, including selectin ligands and integrins, which are typically dependent on glycosylation for their function. We have previously reported that the sialyltransferase ST3GAL6 is up-regulated in plasma cells from MM patients and that increased expression is associated with inferior overall survival (OS) in MM gene expression profiling (GEP) datasets. The functional significance of increased sialylation of MM cells has not previously been reported. Methods MM cell lines MM1s and RPMI-8226 were confirmed to have high expression levels of ST3GAL6 at the gene and protein level compared to healthy controls. Knockdown of ST3GAL6 was confirmed in MM cell lines RPMI-8226 and MM1s using lentiviral shRNAs targeting different regions in the ST3GAL6 mRNA. Specific ST3GAL6 knockdown was confirmed by reduced ST3GAL6 mRNA and protein expression in comparison to a scrambled control. In a calcein-AM fluorescence based adhesion assay we next evaluated the effects of ST3GAL6 knockdown on MM-cell adhesion to bone marrow stromal cells (BMSC’s) and fibronectin coated plates. Migration to 30nM SDF1-α was assessed using transwell plates comparing ST3GAL6 knockdown cells to scrambled controls. The commercially available sialyltransferase inhibitor 3Fax-Neu5Ac was used to pre-treat MM cells in vitro prior to assessment of apoptosis by flow cytometry. shST3GAL6 MM1s cells positive for green fluorescent protein and luciferin (GFP-Luc+) were injected into tail veins of SCID-Bg mice (5x106 cells, n=5/group) and mice were followed weekly using bioluminescent imaging (BLI) for tumor development. Bone marrow homing of tumor cells was assessed using in vivoconfocal imaging of the skull vasculature (n=3/group). Results Knockdown of ST3GAL6 in MM cell lines resulted in a 50% reduction in cell surface staining with the monoclonal antibody HECA-452. This indicated reduced expression of cutaneous lymphocyte associated antigen (CLA), a carbohydrate domain shared by sialyl Lewis X (sLex) and sialyl Lewis a (sLea) antigens, confirming suppression of ST3GAL6 activity. There was a significant reduction in the ability of knockdown cells to adhere to BMSC’s and fibronectin in-vitro compared to scrambled controls (P=0.016, 0.032 respectively). Migration ability of these cells in response to SDF1-α was also reduced (P=0.01). In vivo in a xenograft SCID-Bg mouse model shST3GAL6 cells demonstrated a reduced tumor burden as assessed by weekly BLI (P=0.017 at week 4). A consolidated map of the skull bone marrow niche in mice injected with shST3GAL6 MM1s GFP-Luc+ cells revealed a reduced homing ability of these cells in comparison to mice injected with scrambled control cells. Treatment of the MM cell lines MM1s and RPMI-8226 with a sialyltransferase inhibitor 3Fax-Neu5Ac resulted in almost complete elimination of cell surface sLex and/or sLea expression as determined by HECA-452 staining. Following pre-treatment with 3Fax-Neu5Ac, MM1S cells grown in co-culture with BMSC’s cells showed increased sensitivity to Bortezomib compared to cells treated with bortezomib alone. Conclusions shRNA knockdown of ST3GAL6 in MM cells significantly inhibits adhesion and migration in vitro with reduced homing and proliferation potential in vivo. In conjunction with the results of enzymatic inhibition this indicates that sialylation may play an important role in the malignant behavior of MM cells. Studies are ongoing to address the potential role of altered glycosylation in MM. Disclosures: Ghobrial: Onyx: Advisoryboard Other; BMS: Advisory board, Advisory board Other, Research Funding; Noxxon: Research Funding; Sanofi: Research Funding.

Examination of Phosphoprotein Targets in Timed Samples from Patients with RAS-Mutated AML during Concurrent Treatment with Alpelisib and Binimetinib on the Phase Ib Clinical Trial CMEK162X2109

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2749-2749
Author(s):  
Kira Gritsman ◽  
Robert P. Hasserjian ◽  
Taneisha Sinclair ◽  
David M. Weinstock ◽  
Britta Will ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Bone Marrow ◽  
Peripheral Blood ◽  
Clinical Benefit ◽  
Research Funding ◽  
Mapk Signaling ◽  
Advisory Board ◽  
Post Treatment ◽  
Blood Samples ◽  
Phase Ib

Abstract Activation of MAPK signaling is characteristic of many cancers, and approximately 15% of AML patients carry activating RAS mutations. The PI3K pathway is also constitutively activated in AML. Both pathways interact with each other extensively and provide compensatory signaling when one pathway is inhibited. It has been demonstrated in vitro that concurrent inhibition of both pathways is effective in blocking the proliferation of AML cell lines through an immediate decrease in pAkt and pErk, leading to inhibition of pS6 (Gritsman et al, J Clin Invest, 2014, 124(4):1794-1809). The combination of alpelisib (BYL-719), which inhibits PI3K (p110alpha), and binimetinib (MEK-162), which inhibits MEK (MAPK pathway), was tested in various tumor types in the Phase Ib Clinical Trial CMEK162x2109. We present here the clinical data and correlative phosphoprotein analysis of 6 patients with relapsed refractory RAS-mutated AML treated at Massachusetts General Hospital on Extension Arm 4A of this trial. Entry to this trial was restricted to adult patients with RAS-mutated AML previously treated with 1 or 2 prior chemotherapy regimens or for whom there was no known effective therapy. Patients received 200mg QD of alpelisib and 45mg BID of binimetinib concurrently and continuously with adjustments for toxicities. Hematologic toxicity could not be determined in these patients with active AML causing myelosuppression. There were responses in blood and/or bone marrow (BM) in 3 patients, but none made partial response criteria by IWG guidelines, mainly due to platelet counts <100,000/ul. Blast clearance from blood in the first month were seen in 2 patients, with a >50% reduction in a third patient. A rise in absolute neutrophil count was seen in 3 patients, 2 from below 100/ul to above 500/ul, and in 1 from 5,320/ul to 12,797/ul during the first month. BM partial responses were seen in 2 patients, with blast percentages dropping from 39% to 10% in 1 patient and from 12% to 5% in another. We analyzed the effects of this drug combination on signaling targets by collecting peripheral blood samples on day 1 pre-treatment and at 6 and 24 hours post-initiation of treatment. In 4 patients, we performed analysis of the phosphorylation of Akt, ribosomal protein S6, Erk, STAT5, and STAT3 on timed peripheral blood samples by immunoblotting. In all 4 cases at baseline, pAkt, pErk, and pS6 were detectable, while pSTAT5 and pSTAT3 levels were variable. In 3 of 4 cases, we observed a transient decrease in pAkt at 6 hours, but then a rebound at 24 hours. In 3 of 4 cases, we observed a lack of sustained pS6 inhibition. We observed sustained pErk inhibition at 24 hours in 2 cases. One patient who had blood blast clearance, improvement in ANC, and a drop in bone marrow blasts, showed strong inhibition of pAkt and pERK at 6 hours, although pS6 did not decrease. In another case we performed phospho-flow cytometry on timed whole blood samples. We observed an increase in pAkt, pS6, and pErk from baseline at 24 hours, both in CD34+38+blasts, and in the primitive CD34+38- cells. This second patient showed no clinical benefit from the treatment in terms of blood blast count, ANC, or platelets. We also performed immunohistochemistry for pS6, pErk, pAkt, pSTAT5, pSTAT3, p-eIF4E, and Caspase 3 on BM sections obtained at diagnosis and at one month and two months post-initiation of treatment, when available. These studies generally showed either persistence or an increase in the pS6 and p-eIF4E signals, both indicators of mTORC1 activity, in post-treatment BM samples. Levels of pAkt, pErk, pSTAT5 and pSTAT3 were highly variable in the post-treatment bone marrow samples. In conclusion, we demonstrated some initial target inhibition with the concurrent use of alpelisib and binimetinib in a subset of patients. However, inhibition of late downstream targets was not sufficiently sustained to achieve consistent clinical benefit in our patients with RAS-mutated AML. While the strategy of concurrent inhibition of various critical signaling pathways remains interesting, sustained inhibition of downstream signaling may require a different dosing schedule of the two drugs. Given the incomplete inhibition of mTORC1 targets pS6 and p-eIF4E in most cases, the addition of a third agent to inhibit pathways causing cross-activation downstream of mTORC1 may be required. Disclosures Weinstock: Novartis: Consultancy, Research Funding. Fathi:Bexalata: Other: Advisory Board participation; Merck: Other: Advisory Board participation; Celgene: Consultancy, Research Funding; Seattle Genetics: Consultancy, Other: Advisory Board participation, Research Funding; Agios Pharmaceuticals: Other: Advisory Board participation.

Combination of Oral Rigosertib and Injectable Azacitidine in Patients with Myelodysplastic Syndromes (MDS): Results from a Phase II Study

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3167-3167 ◽  
Author(s):  
Shyamala C. Navada ◽  
Guillermo Garcia-Manero ◽  
Katherine P. Hearn ◽  
Rosalie Odchimar-Reissig ◽  
Erin P. Demakos ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Median Time ◽  
Phase Ii ◽  
Median Duration ◽  
Clinical Benefit ◽  
Research Funding ◽  
Standard Dose ◽  
Advisory Board ◽  
Treatment Naïve ◽  
Clinical Benefit Response

Abstract Background: Based on a model suggesting leukemia can be driven by combined effect of mutations in an epigenetic gene (DNMT3) and Ras, the combination of a hypomethylating agent (HMA) such as azacitidine (AZA) and a Ras mimetic such as rigosertib (RIG) may have enhanced activity in both MDS and AML. The mechanism of action for RIG (Athuluri-Divakar et al, Cell 2016) documents its interference with the RAS-binding domains of RAF kinases and inhibition of the RAS-RAF-MEK and the PI3Ks pathways. In vitro, the combination of RIG with AZA was found to act synergistically to inhibit growth and to induce apoptosis of leukemic cells in a sequence-dependent manner (exposure to RIG first, followed by AZA) (Skidan et al, AACR 2006). Rigosertib's low bone marrow toxicity in pre-clinical assays, effective inhibition of human hematopoietic tumor cell lines, and its synergy with AZA suggests the potential value of combination treatment for patients (pts) with MDS. Phase I results of the current clinical study in pts with MDS or AML showed the combination of oral RIG and standard-dose AZA to be well-tolerated with evidence of efficacy (Navada et al, Blood 2014). The phase II portion of the study was initiated to further evaluate the combination in pts with MDS. Methods: Phase II results are presented for HMA-treatment-naïve MDS pts and for those with MDS failing to respond to or progressed on a prior HMA. Oral RIG was administered twice daily on Day 1-21 of a 28-day cycle at the recommended Phase II dose (RPTD: 560 mg qAM and 280 mg qPM). AZA 75 mg/m2/d SC or IV was administered for 7 days starting on Day 8. A CBC was performed weekly and a bone marrow aspirate and/or biopsy were performed at baseline, D29, and then every 8 weeks thereafter. Results: The combination of oral RIG and injectable AZA has been administered to a total of 54 pts, of whom 40 were pts with MDS including HMA-treatment-naïve (N=23) and previously HMA treated pts (N=17). Median age was 66 years (range 25-85); 73% of pts were male; and ECOG performance status was 0, 1, and 2 in 23%, 73%, and 5%, respectively. 17 pts received prior HMA therapy: 12 AZA, 4 decitabine, and 1 both. Patients have received 1-36+ cycles of treatment (median, 6 cycles), with a median duration of treatment of 25 weeks (range 4 to 145+ weeks). 8 (20%) and 2 (5%) of pts have been treated for more than 1 and 2 years, respectively. Table 1 shows the response per IWG 2006 criteria (Cheson, Blood 2006) among 33 evaluable patients. The response per IWG 2006 was complete remission (CR) in 8 (24%), concurrent marrow CR and hematologic improvement (HI) in 9 (27%), marrow CR alone in 7 (21%), and HI alone in 1 (3%). When overall response is defined as CR plus PR plus HI - responses with improvement in marrow function and thus either normalization of the peripheral blood count or lineage improvement - defined here as Clinical Benefit Response - 55% of all evaluable pts and 70% of the evaluable HMA-treatment-naïve patients showed responses meeting these criteria. Median time to initial response was 2 cycles (2.2 months), and median time to best response was 3 cycles (3.3 months). Median duration of response was 8 months for CR, 14.3 months for marrow CR, 7.4 months for erythroid response, 8 months for platelet response, and 6.2 months for neutrophil response. Clinical response is classified by IPSS-R risk categories below. The most frequently reported adverse events are nausea (41%), fatigue (39%), diarrhoea (37%), constipation (37%), dysuria (28%), decreased appetite (28%), haematuria (24%, 8% Grade 3), pyrexia (24%), dizziness (22%), thrombocytopenia (20%), back pain (20%), dyspnoea (20%), and cough (20%). Eight deaths were reported on study with most common causes including infection and progression of disease. Conclusions: The combination oforalRIG and standard-dose AZA was well tolerated in repetitive cycles in pts with MDS. Response per IWG 2006 criteria was observed both in HMA-treatment-naïve patients (85%) and in patients after failure of prior HMA therapy (62%); employing Clinical Benefit Response as the criteria, these groups had 70% and 31% response, respectively. These clinical results confirm the preclinical synergistic interaction with the combination of RIG and AZA reported by Skidan et al, and suggest that the combination can overcome clinical resistance to HMAs. Based on these results, a Phase III study of the combination of oral RIG and AZA in patients with MDS is planned. Disclosures Navada: Onconova Therapeutics, Inc.: Research Funding. Daver:Karyopharm: Honoraria, Research Funding; Pfizer: Consultancy, Research Funding; Sunesis: Consultancy, Research Funding; Ariad: Research Funding; Otsuka: Consultancy, Honoraria; Kiromic: Research Funding; BMS: Research Funding. DiNardo:Agios: Other: advisory board, Research Funding; Novartis: Other: advisory board, Research Funding; Celgene: Research Funding; Abbvie: Research Funding; Daiichi Sankyo: Other: advisory board, Research Funding. Konopleva:Reata Pharmaceuticals: Equity Ownership; Abbvie: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Stemline: Consultancy, Research Funding; Eli Lilly: Research Funding; Cellectis: Research Funding; Calithera: Research Funding. Fenaux:Celgene, Janssen,Novartis, Astex, Teva: Honoraria, Research Funding. Petrone:Onconova Therapeutics, Inc.: Employment. Zbyszewski:Onconova Therapeutics, Inc.: Employment. Fruchtman:Onconova: Employment. Silverman:Onconova Therapeutics, Inc.: Patents & Royalties: Co-Patent holder for the combination of azacitidine and rigosertib, Research Funding.

scholarly journals Autoimmune myelofibrosis associated with autoimmune hemolytic anemia successfully treated with ruxolitinib

2021 ◽  
Author(s):  
Shuku Sato ◽  
Wataru Kamata ◽  
Yotaro Tamai
Keyword(s):  
Bone Marrow ◽  
Hemolytic Anemia ◽  
Autoimmune Hemolytic Anemia ◽  
Transforming Growth Factor ◽  
Myeloproliferative Neoplasms ◽  
Bone Marrow Examination ◽  
Coombs Test ◽  
Bone Marrow Fibrosis ◽  
Cytokine Levels ◽  
Antiglobulin Test

Abstract A 55-year-old man suffered from dyspnea, general malaise, and jaundice. His laboratory date showed pancytopenia and hemolytic anemia, and computed tomography showed splenomegaly. Bone marrow examination revealed myelofibrosis (MF)-1. The hemolytic anemia was diagnosed as IgM autoimmune hemolytic anemia (AIHA) with negative direct and indirect Coombs test but positive IgM-direct antiglobulin test. We started ruxolitinib 20 mg, which improved not only bone marrow fibrosis, symptoms related to myeloproliferative neoplasms and splenomegaly, but also AIHA. AIHA may be associated with Autoimmune MF (AIMF), and cytokines such as transforming growth factor (TGF)-β are thought to be involved in such cases. This case suggests that ruxolitinib may improve the cytokine levels and may lead to the treatment of AIHA as well as AIMF.

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