risk factors and mechanisms for the initiation and
TRANSCRIPT
Risk Factors and Mechanisms for the Initiation and Progression of Myeloproliferative Neoplasms:
Will a better understanding yield an Achilles Heel or Penrose Stairs?
Andrew Kuykendall, MDAssistant MemberMoffitt Cancer Center
@KuykendallMD
• Disease Background• MPNs as a Model of Inflammation• MPN Development• MPN Progression• Future Considerations
Outline
MPN Overview
MPN Epidemiology
1. Anderson, L. A., & McMullin, M. F. (2014). Epidemiology of MPN: what do we know? Curr Hematol Malig Rep, 9(4), 340-349. doi:10.1007/s11899-014-0228-z2. Rollison, D. E., Howlader, N., Smith, M. T., Strom, S. S., Merritt, W. D., Ries, L. A., . . . List, A. F. (2008). Epidemiology of myelodysplastic syndromes and chronic myeloproliferative disorders in the United States,
2001-2004, using data from the NAACCR and SEER programs. Blood, 112(1), 45-52. doi:10.1182/blood-2008-01-134858
MPNs are associated with a diverse array of symptoms
Emanuel, R. M., Dueck, A. C., Geyer, H. L., Kiladjian, J. J., Slot, S., Zweegman, S., . . . Mesa, R. A. (2012). Myeloproliferative neoplasm (MPN) symptom assessment form total symptom score: prospective international assessment of an abbreviated symptom burden scoring system among patients with MPNs. J Clin Oncol, 30(33), 4098-4103. doi:10.1200/JCO.2012.42.3863
MPNs are associated with worse survival than age-matched controls
Price, G. L., Davis, K. L., Karve, S., Pohl, G., & Walgren, R. A. (2014). Survival patterns in United States (US) medicare enrollees with non-CML myeloproliferative neoplasms (MPN). PLoS One, 9(3), e90299. doi:10.1371/journal.pone.0090299
MPNs are driven by a mutation in JAK2, CALR, or MPL
Grinfeld, J., Nangalia, J., & Green, A. R. (2017). Molecular determinants of pathogenesis and clinical phenotype in myeloproliferative neoplasms. Haematologica, 102(1), 7-17. doi:10.3324/haematol.2014.113845
There is a familial risk with MPNs that is not linked to driver mutation
1. Landgren, O., Goldin, L. R., Kristinsson, S. Y., Helgadottir, E. A., Samuelsson, J., & Bjorkholm, M. (2008). Increased risks of polycythemia vera, essential thrombocythemia, and myelofibrosis among 24,577 first-degree relatives of 11,039 patients with myeloproliferative neoplasms in Sweden. Blood, 112(6), 2199-2204. doi:10.1182/blood-2008-03-143602
2. Rumi, E., & Cazzola, M. (2017). Diagnosis, risk stratification, and response evaluation in classical myeloproliferative neoplasms. Blood, 129(6), 680-692. doi:10.1182/blood-2016-10-6959573. Sud, A., Chattopadhyay, S., Thomsen, H., Sundquist, K., Sundquist, J., Houlston, R. S., & Hemminki, K. (2018). Familial risks of acute myeloid leukemia, myelodysplastic syndromes, and myeloproliferative
neoplasms. Blood, 132(9), 973-976. doi:10.1182/blood-2018-06-858597
MPNs are driven by a mutation in JAK2, CALR, or MPL
Nangalia, J., & Green, A. R. (2017). Myeloproliferative neoplasms: from origins to outcomes. Blood, 130(23), 2475-2483. doi:10.1182/blood-2017-06-782037
The hallmark of MPN is hyperactive JAK/STAT signaling
Rampal, R., Al-Shahrour, F., Abdel-Wahab, O., Patel, J. P., Brunel, J. P., Mermel, C. H., . . . Levine, R. L. (2014). Integrated genomic analysis illustrates the central role of JAK-STAT pathway activation in myeloproliferative neoplasm pathogenesis. Blood, 123(22), e123-133. doi:10.1182/blood-2014-02-554634
Additional inflammatory pathways beyond JAK/STAT are activated in MPNs
1. Fisher, D. A. C., Malkova, O., Engle, E. K., Miner, C. A., Fulbright, M. C., Behbehani, G. K., . . . Oh, S. T. (2017). Mass cytometry analysis reveals hyperactive NF Kappa B signaling in myelofibrosis and secondary acute myeloid leukemia. Leukemia, 31(9), 1962-1974. doi:10.1038/leu.2016.3772. Fisher, D. A. C., Miner, C. A., Engle, E. K., Hu, H., Collins, T. B., Zhou, A., . . . Oh, S. T. (2019). Cytokine production in myelofibrosis exhibits differential responsiveness to JAK-STAT, MAP kinase, and NFkappaB signaling. Leukemia, 33(8), 1978-1995. doi:10.1038/s41375-019-0379-y
Numerous inflammatory cytokines are increased in PMF
Tefferi, A., Vaidya, R., Caramazza, D., Finke, C., Lasho, T., & Pardanani, A. (2011). Circulating interleukin (IL)-8, IL-2R, IL-12, and IL-15 levels are independently prognostic in primary myelofibrosis: a comprehensive cytokine profiling study. J Clin Oncol, 29(10), 1356-1363. doi:10.1200/JCO.2010.32.9490
Specific Cytokines are Prognostic
Tefferi, A., Vaidya, R., Caramazza, D., Finke, C., Lasho, T., & Pardanani, A. (2011). Circulating interleukin (IL)-8, IL-2R, IL-12, and IL-15 levels are independently prognostic in primary myelofibrosis: a comprehensive cytokine profiling study. J Clin Oncol, 29(10), 1356-1363. doi:10.1200/JCO.2010.32.9490
General Inflammatory Markers are Prognostic
1. Barbui T, Carobbio A, Finazzi G, et al: Elevated C-reactive protein is associated with shortened leukemia-free survival in patients with myelofibrosis. Leukemia 27:2084-6, 20132. Barosi G, Massa M, Campanelli R, et al: Primary myelofibrosis: Older age and high JAK2V617F allele burden are associated with elevated plasma high-sensitivity C-reactive protein levels and a phenotype of progressive disease. Leuk Res 60:18-23, 2017
Numerous Cytokines are Implicated in MPN Progression
Longhitano L, Li Volti G, Giallongo C, et al: The Role of Inflammation and Inflammasome in Myeloproliferative Disease. J Clin Med 9, 2020
Ruxolitinib, a JAK1/2 inhibitor, decreases several cytokine levels
Verstovsek, S., Kantarjian, H., Mesa, R. A., Pardanani, A. D., Cortes-Franco, J., Thomas, D. A., . . . Tefferi, A. (2010). Safety and efficacy of INCB018424, a JAK1 and JAK2 inhibitor, in myelofibrosis. N Engl J Med, 363(12), 1117-1127. doi:10.1056/NEJMoa1002028
Ruxolitinib improves spleen size, symptom score, albumin level and survival in higher risk MF patients
1. Verstovsek, S., Mesa, R. A., Gotlib, J., Levy, R. S., Gupta, V., DiPersio, J. F., . . . Kantarjian, H. M. (2012). A double-blind, placebo-controlled trial of ruxolitinib for myelofibrosis. N Engl J Med, 366(9), 799-807. doi:10.1056/NEJMoa11105572. Mesa, R. A., Verstovsek, S., Gupta, V., Mascarenhas, J. O., Atallah, E., Burn, T., . . . Gotlib, J. (2015). Effects of ruxolitinib treatment on metabolic and nutritional parameters in patients with myelofibrosis from COMFORT-I. Clin Lymphoma Myeloma Leuk, 15(4), 214-221 e211.
doi:10 1016/j clml 2014 12 008
Spleen Symptoms
Albumin Survival
Some MF-upregulated cytokines are not reduced with ruxolitinib
1. Fisher, D. A. C., Miner, C. A., Engle, E. K., Hu, H., Collins, T. B., Zhou, A., . . . Oh, S. T. (2019). Cytokine production in myelofibrosis exhibits differential responsiveness to JAK-STAT, MAP kinase, and NFkappaB signaling. Leukemia, 33(8), 1978-1995. doi:10.1038/s41375-019-0379-
Ruxolitinib has modest impact on mutant allele burden
Deininger, M., Radich, J., Burn, T. C., Huber, R., Paranagama, D., & Verstovsek, S. (2015). The effect of long-term ruxolitinib treatment on JAK2p.V617F allele burden in patients with myelofibrosis. Blood, 126(13), 1551-1554. doi:10.1182/blood-2015-03-635235
So, what do we know?
• MPNs are rare, and their incidence increases with advancing age.
• There is a familial susceptibility to MPNs that is not linked to driver mutation.
• MPNs are driven by phenotype-driving mutations in one of three genes that all lead to activated JAK/STAT signaling; however, other inflammatory pathways are upregulated as well.
• The inflammatory cytokines upregulated in MPNs are linked to disease progression and inferior outcomes.
• Some of this inflammation is mitigated with blocking the JAK/STAT pathway and correlates with symptomatic improvement and prolonged survival, but modest disease modification.
So, what do we need to know?
• MPNs are rare, and their incidence increases with advancing age.• What factors are associated with an increased incidence of MPN?
• There is a familial susceptibility to MPNs that is not linked to driver mutation.• What accounts for this susceptibility?
• MPNs are driven by phenotype-driving mutation in one of three genes that activates JAK/STAT signaling; however, other inflammatory pathways are upregulated as well.
• What is the incidence of these mutations in the general (healthy) population?
• The inflammatory cytokines upregulated in MPNs are linked to disease progression and inferior outcomes.
• What is the role for these cytokines? Are some critical for disease initiation/progression vs mediating clinical symptoms?
• Some of this inflammation is mitigated with blocking the JAK/STAT pathway and correlates with symptomatic improvement and prolonged survival, but modest disease modification.
• Can blocking additional inflammatory pathways induce superior symptomatic improvement?
• Can targeting specific cytokines not inhibited by JAK inhibition lead to disease modification?
JAK2 clonal hematopoiesis is not uncommon and is associated with increased risk of cardiovascular disease
Jaiswal S, Natarajan P, Silver AJ, et al. Clonal Hematopoiesis and Risk of Atherosclerotic Cardiovascular Disease. N Engl J Med. 2017;377(2):111-121.
JAK2 mutations occur in healthy patients and their presence and burden correlates with increasing age.
Cordua S, Kjaer L, Skov V, et al: Prevalence and phenotypes of JAK2 V617F and calreticulin mutations in a Danish general population. Blood 134:469-479, 2019
Population Presence of JAK2mutations: 3.2%
What determines whether a JAK2 mutation
turns into an MPN?
?
Inflammation supports MPN Development
Fleischman AG: Inflammation as a Driver of Clonal Evolution in Myeloproliferative Neoplasm. Mediators Inflamm 2015:606819, 2015Fleischman AG, Aichberger KJ, Luty SB, et al: TNFalpha facilitates clonal expansion of JAK2V617F positive cells in myeloproliferative neoplasms. Blood 118:6392-8, 2011
Chronic Inflammation is Mediated by Cytokines and Fosters MPN Progression
Hasselbalch HC: The role of cytokines in the initiation and progression of myelofibrosis. Cytokine Growth Factor Rev 24:133-45, 2013
MPN is driven by inflammation
Andersen M, Sajid Z, Pedersen RK, et al: Mathematical modelling as a proof of concept for MPNs as a human inflammation model for cancer development. PLoS One 12:e0183620, 2017
MPN Development Can be Mathematically Modeled
Andersen M, Sajid Z, Pedersen RK, et al: Mathematical modelling as a proof of concept for MPNs as a human inflammation model for cancer development. PLoS One 12:e0183620, 2017
Modulation of Inflammation Alters the MPN Timeline
Andersen M, Sajid Z, Pedersen RK, et al: Mathematical modelling as a proof of concept for MPNs as a human inflammation model for cancer development. PLoS One 12:e0183620, 2017
Inflammation supports MPN Development
Craver, B. M., El Alaoui, K., Scherber, R. M., & Fleischman, A. G. (2018). The Critical Role of Inflammation in the Pathogenesis and Progression of Myeloid Malignancies. Cancers (Basel), 10(4). doi:10.3390/cancers10040104
What specific inflammatory pressures promote MPN formation?
• Inflammatory Bowel Disease• Obesity• Smoking• Polymorphisms Altering Inflammatory Balance
• miR-146a• IL-6R polymorphisms
• TNFα / IL-10 axis
There is an increased incidence of inflammatory bowel disease both before and after an MPN diagnosis
1. Bak M, Jess T, Flachs EM, Zwisler AD, Juel K, Frederiksen H. Risk of Inflammatory Bowel Disease in Patients with Chronic Myeloproliferative Neoplasms: A Danish Nationwide Cohort Study. Cancers (Basel). 2020;12(9).
2.4-fold increased risk of developing IBD after MPN diagnosis
40% increased risk of preceding IBD diagnosis prior to MPN
Smoking is associated with MPN Development
Jayasuriya NA, Kjaergaard AD, Pedersen KM, et al. Smoking, blood cells and myeloproliferative neoplasms: meta-analysis and Mendelian randomization of 2.3 million people. Br J Haematol. 2020;189(2):323-334.
Adolescent obesity may be related to increased incidence of MPNs
Leiba A, Duek A, Afek A, Derazne E, Leiba M. Obesity and related risk of myeloproliferative neoplasms among israeli adolescents. Obesity (Silver Spring). 2017;25(7):1187-1190.
miR-146a Expression Linked to Fibrotic Progression
Ferrer-Marin F, Arroyo AB, Bellosillo B, et al: miR-146a rs2431697 identifies myeloproliferative neoplasm patients with higher secondary myelofibrosis progression risk. Leukemia, 2020
• miR-146a is a brake in NF-kB signaling
• rs2431697 genotype is associated with lower levels of miR-146a leading to more active NF-kB activity
miR-146a is a significant brake on autoimmunity, myeloproliferation, and cancer in mice
Boldin, M. P., Taganov, K. D., Rao, D. S., Yang, L., Zhao, J. L., Kalwani, M., . . . Baltimore, D. (2011). miR-146a is a significant brake on autoimmunity, myeloproliferation, and cancer in mice. J Exp Med, 208(6), 1189-1201. doi:10.1084/jem.20101823
miR-146a knockout leads to dysregulated NF-kB and myeloproliferation
Zhou et al., NF-kB dysregulation in microRNA-146a-deficient mice drives the development of myeloid malignancies. Proc Natl Acad Sci U S A. 2011 May 31; 108(22):9184-9189
Loss of Function Polymorphism in IL6R Reduces Risk of MPN Formation
Pedersen KM, Colak Y, Ellervik C, et al: Loss-of-function polymorphism in IL6R reduces risk of JAK2V617F somatic mutation and myeloproliferative neoplasm: A Mendelian randomization study. EClinicalMedicine21:100280, 2020
Loss of Function Polymorphism in IL6R Reduces Risk of MPN Formation
Pedersen KM, Colak Y, Ellervik C, et al: Loss-of-function polymorphism in IL6R reduces risk of JAK2V617F somatic mutation and myeloproliferative neoplasm: A Mendelian randomization study. EClinicalMedicine 21:100280, 2020
Selective pressures may shape clonal expansion
Craver, B. M., El Alaoui, K., Scherber, R. M., & Fleischman, A. G. (2018). The Critical Role of Inflammation in the Pathogenesis and Progression of Myeloid Malignancies. Cancers (Basel), 10(4). doi:10.3390/cancers10040104
MPN monocytes produce more TNFα than normal monocytes
Lai, H. Y., Brooks, S. A., Craver, B. M., Morse, S. J., Nguyen, T. K., Haghighi, N., . . . Fleischman, A. G. (2019). Defective negative regulation of Toll-like receptor signaling leads to excessive TNF-alpha in myeloproliferative neoplasm. Blood Adv, 3(2), 122-131. doi:10.1182/bloodadvances.2018026450
Decreased response to IL-10 leads to high TNFαenvironment
Lai, H. Y., Brooks, S. A., Craver, B. M., Morse, S. J., Nguyen, T. K., Haghighi, N., . . . Fleischman, A. G. (2019). Defective negative regulation of Toll-like receptor signaling leads to excessive TNF-alpha in myeloproliferative neoplasm. Blood Adv, 3(2), 122-131. doi:10.1182/bloodadvances.2018026450
Decreased response to IL-10 seen in affected and unaffected twin – suggesting an inherited susceptibility
Lai, H. Y., Brooks, S. A., Craver, B. M., Morse, S. J., Nguyen, T. K., Haghighi, N., . . . Fleischman, A. G. (2019). Defective negative regulation of Toll-like receptor signaling leads to excessive TNF-alpha in myeloproliferative neoplasm. Blood Adv, 3(2), 122-131. doi:10.1182/bloodadvances.2018026450
IL-1β promotes disease initiation and progression
Rai, S., Hansen, N., Hao-Shen, H., Tata, N. R., & Skoda, R. C. (2019). IL-1B secreted from mutant cells carrying JAK2-V617F favors early clonal expansion and promotes MPN disease initiation and progression. Blood, 134 (Supplement_1), 307.
IL-1β Supports the Mutant HSC
1. Arranz L, Sanchez-Aguilera A, Martin-Perez D, et al: Neuropathy of haematopoietic stem cell niche is essential for myeloproliferative neoplasms. Nature 512:78-81, 20142. Sollazzo D, Forte D, Polverelli N, et al: Crucial factors of the inflammatory microenvironment (IL-1beta/TNF-alpha/TIMP-1) promote the maintenance of the malignant hemopoietic clone of myelofibrosis: an in vitro study. Oncotarget 7:43974-43988, 2016
IL-1β and TNFα support MPN HSC survival, enhance migratory behavior of MF CD34+ cells and increase clonogenic output
1. Arranz L, Sanchez-Aguilera A, Martin-Perez D, et al: Neuropathy of haematopoietic stem cell niche is essential for myeloproliferative neoplasms. Nature 512:78-81, 20142. Sollazzo D, Forte D, Polverelli N, et al: Crucial factors of the inflammatory microenvironment (IL-1beta/TNF-alpha/TIMP-1) promote the maintenance of the malignant hemopoietic clone of myelofibrosis: an in vitro study. Oncotarget 7:43974-43988, 2016
CXCL4 links inflammation and disease progression
Gleitz, H. F. E., Dugourd, A. J. F., Leimkuhler, N. B., Snoeren, I. A. M., Fuchs, S. N. R., Menzel, S., . . . Schneider, R. K. (2020). Increased CXCL4 expression in hematopoietic cells links inflammation and progression of bone marrow fibrosis in MPN. Blood, 136(18), 2051-2064. doi:10.1182/blood.2019004095
CXCL4 knockout in HSPCs ameliorates MPN phenotype
Gleitz, H. F. E., Dugourd, A. J. F., Leimkuhler, N. B., Snoeren, I. A. M., Fuchs, S. N. R., Menzel, S., . . . Schneider, R. K. (2020). Increased CXCL4 expression in hematopoietic cells links inflammation and progression of bone marrow fibrosis in MPN. Blood, 136(18), 2051-2064. doi:10.1182/blood.2019004095
CXCL4 knockout in HSPCs ameliorates MPN phenotype
Gleitz, H. F. E., Dugourd, A. J. F., Leimkuhler, N. B., Snoeren, I. A. M., Fuchs, S. N. R., Menzel, S., . . . Schneider, R. K. (2020). Increased CXCL4 expression in hematopoietic cells links inflammation and progression of bone marrow fibrosis in MPN. Blood, 136(18), 2051-2064. doi:10.1182/blood.2019004095
BET inhibition suppresses NF-kB-mediated inflammation and synergizes with JAK inhibition
Kleppe, M., Koche, R., Zou, L., van Galen, P., Hill, C. E., Dong, L., . . . Levine, R. L. (2018). Dual Targeting of Oncogenic Activation and Inflammatory Signaling Increases Therapeutic Efficacy in Myeloproliferative Neoplasms. Cancer Cell, 33(1), 29-43 e27. doi:10.1016/j.ccell.2017.11.009
Combined BET and JAK inhibition leads to spleen and symptom responses
Mascarenhas et al., CPI-0610, a Bromodomain and Extraterminal Domain Protein (BET) Inhibitor, in Combination with Ruxolitinib, in JAK-Inhibitor-Naïve Myelofibrosis Patients: Update of MANIFEST Phase 2 Study. Presented at ASH 2020.
Add-on of CPI-0610 leads to symptom benefit and transfusion independence
Mascarenhas et al., CPI-0610, a Bromodomain and Extraterminal Domain Protein (BET) Inhibitor, in Combination with Ruxolitinib, in JAK-Inhibitor-Naïve Myelofibrosis Patients: Update of MANIFEST Phase 2 Study. Presented at ASH 2020.
Pacritinib – a selective JAK2 inhibitor – also inhibits IRAK1 at nanomolar concentrations
Singer, J. W., Al-Fayoumi, S., Ma, H., Komrokji, R. S., Mesa, R., & Verstovsek, S. (2016). Comprehensive kinase profile of pacritinib, a nonmyelosuppressive Janus kinase 2 inhibitor. J Exp Pharmacol, 8, 11-19. doi:10.2147/JEP.S110702
Pacritinib is effective in reducing spleen volume in severely thrombocytopenic patients
Mesa RA, Vannucchi AM, Mead A, et al. Pacritinib versus best available therapy for the treatment of myelofibrosis irrespective of baseline cytopenias (PERSIST-1): an international, randomised, phase 3 trial. Lancet Haematol. 2017;4(5):e225-e236.
Summary
• MPNs are inflammatory diseases that are cultivated by and induce inflammation
• Numerous inflammatory pathways/mediators have been implicated in the pathogenesis of
MPNs
• Clinical targeting of these pathways has led to encouraging early clinical results
• Numerous trials are being developed to assess whether targeting the underlying inflammatory
pathways can modify the disease.