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Treatment of Patients with Primary Myelofibrosis Using Dasatinib

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Treatment of Patients with Primary Myelofibrosis Using Dasatinib European Review for Medical and Pharmacological Sciences 2017; 21: 3312-3319 Treatment of patients with primary myelofibrosis using dasatinib Q.-L. SONG1, B. ZHANG1, Y. XU1, R.-X. XIA2, X.-H. LU1, Z.-X. PEI1, Q.-W. XU1, W.-Y. LI1, Z.-D. LI1 1Department of Hematology, the People’s Hospital of Jiaozuo City, Jiaozuo, Henan Province, China 2Department of Laboratory Medicine, 266 Hospial of PLA, Chengde, Hebei Province, China Abstract. – OBJECTIVE: Primary myelofibro- of approximately five years. Deaths from PMF are sis (PMF) is a chronic clonal myeloproliferative mainly caused by infection, bleeding, and disease neoplasm. It is associated with a poor progno- progression to acute myeloid leukemia (AML). sis, with a median survival time of approximately Currently, there are no specific targeted drugs five years. Thus far, there are no specific targeted for PMF. Available treatments include immune drugs for PMF. In this study, we evaluated the ef- ficacy and safety of dasatinib, a second-genera- modulators (such as thalidomide, lenalidomide, tion tyrosine kinase inhibitor, in six PMF patients. and interferons), anemia therapies, hydroxy- PATIENTS AND METHODS: From June 1, 2015 urea, JAK2V617F kinase inhibitors, hematopoi- to February 29, 2016, six patients with PMF in etic stem cell transplantation, experimental new our department were enrolled into this trial. The drugs, radiation therapy, and splenectomy2,3. Out efficacy and safety of 100 mg/d (50 mg twice dai- of these, hematopoietic stem cell transplantation ly) dasatinib were investigated in these patients. RESULTS: For patients who experienced ad- is the only curative treatment for PMF. However, verse drug events, the dose was reduced to 70 its application is limited by the fact that only a or 50 mg/d, whereas for those who tolerated few patients are able to receive the treatment and the drug well, the dosage was increased to 140 its high cost. mg/d (70 mg twice a day). Of the six patients, Dasatinib is a second-generation tyrosine ki- two achieved bone marrow histologic remission, nase (TK) inhibitor. Tyrosine kinases regulate a five showed symptomatic improvement, and one wide range of normal cell processes, including reached a stable condition. No severe hemato- logical or non-hematological adverse events metabolism, growth, differentiation, and apopto- were observed thus far. sis. They are key players in various diseases such CONCLUSIONS: Dasatinib treatment may be as cancer, pulmonary arterial hypertension, and beneficial to patients with PMF and resulted in systemic sclerosis4. Using a mouse model of pul- significant improvements in splenomegaly, clini- monary fibrosis, we showed that dasatinib exerted cal symptoms, physical condition, and quality of therapeutic effects in the fibrotic lung. Dasatinib life. Therefore, we regard it as an effective ther- apy for PMF. limited myofibroblast activation and collagen-1 accumulation by inhibiting PDGFR-α (plate- Key Words: let-derived growth factor receptor-α), Src, and Primary myelofibrosis, Dasatinib, Treatment. c-Abl activation5. Moreover, Cruz et al6 reported that dasatinib was effective in inducing macro- phage polarization towards the M2 phenotype Introduction and in reducing lung inflammation and fibrosis. In this study, we evaluated the efficacy and safety Primary myelofibrosis (PMF) is a chronic clon- of dasatinib in six PMF patients. al myeloproliferative neoplasm characterized clinically by anemia, splenomegaly, myelofibro- sis, bone sclerosis, and the presence of immature Patients and Methods granulocytes and teardrop-shaped erythrocytes. Also, it may be accompanied by symptoms such Patients as fever, night sweats, fatigue, and weight loss1. It From June 1, 2015 to February 29, 2016, has a poor prognosis, with a median survival time six patients with PMF in our department were 3312 Corresponding Author: Qing-Lin Song, MD; e-mail: [email protected] Treatment of patients with primary myelofibrosis using dasatinib enrolled into this trial. Bone marrow aspira- Pharmaceutical Group Co, Ltd. (CTTQ: Yinishu, tion, bone marrow biopsy, myeloproliferative produced in Jiangsu Province, China). neoplasm (MPN)-related gene detection, and Evaluation of drug efficacy was based on cri- karyotype analysis was performed. G-banding teria proposed by the European Myelofibrosis was used in cytogenetics for karyotype anal- Network (EUMNET) in 2005. The definition of ysis, and the karyotype was named according the response to treatment in patients was based to the International System for Human Cyto- on hematological, histological, and cytogenetic genetic Nomenclature (ISCN2013). Diagnosis parameters10. The International Working Group criteria were based on the 2008 WHO diagnos- for Myelofibrosis Research and Treatment (IWG- tic criteria for PMF7; the diagnosis met the re- MRT) proposed new efficacy evaluation criteria quirements of three major criteria, as well as in 200611. two minor criteria. The inclusion criteria were: Safety evaluations included assessments of (1) no severe injuries in major organs such as adverse events such as hepatic, renal, and cardi- the heart, liver, and other vital organs; and (2) ac toxicity, monitoring of lung disease, pleural patients and their families gave their informed effusion, gastrointestinal symptoms, vital signs, consent. The exclusion criteria were: (1) pa- weight, and behavioral status, as well as blood, tients with severe concurrent medical condi- metabolic, and urine analyses. Classification of tions and a short predicted survival time, for adverse events was based on the NCI/NIH com- example, due to another malignancy; (2) women mon toxicity criteria. who were pregnant or currently breastfeeding; and (3) patients and their families who chose to withdraw from the clinical trial. Results Dasatinib Treatment Patients’ Details All patients signed the informed consent forms Details of the six enrolled patients are shown in and voluntarily participated in this clinical trial. Tables I and II. One patient discontinued dasati- The study protocol was approved by our institu- nib treatment for personal reasons. Subsequently, tion’s Ethics Committee (approval number: ChiE- the disease progressed and the patient died from CRCT-20150071). Patients were administered 100 cachexia, severe diarrhea, and pleural effusions. mg/d (50 mg twice a day) dasatinib. Prognostic The other five patients continued with the treat- stratification of patients was based on DIPSS Plus ment. before the commencement of treatment8. The My- eloproliferative Neoplasm Symptom Assessment Efficacy Assessment Form (MPN10) was used to assess the symptoms9, At the end of the treatment period, dasatinib which included fatigue, inactivity, concentration, markedly reduced spleen volume in all six pa- early satiety, abdominal discomfort, itching, night tients (100%) who received the treatment, but sweats, bone pain (diffuse, non-arthritis or joint did not induce a significant increase in the pe- pain), unintentional weight loss in the past six ripheral blood count. The reduction in spleen months, and fever (> 37.8 °C). Symptom severity volume is shown in Figure 1, where the sple- was rated on a 0 (absent/as good as it can be) to nomegaly measurement is represented by line 10 (worst imaginable/as bad as it can be) scale. “1”. One patient tested positive for JAK2V617F Patients received the treatment until the appear- mutation before the treatment, which persisted ance of intolerable side effects or until they chose two months after dasatinib treatment. Before to withdraw from the trial. The follow-up period the treatment, another patient tested positive ended on February 29, 2016. During the treat- for JAK2V617F mutation and 20q-; the patient ment period, dosage adjustments or transient sus- had grade 3 bone marrow fibrosis and eryth- pension of treatment was allowed based on drug roid hypoplasia. Ten weeks after dasatinib tolerability or occurrence of adverse events. The treatment, the patient still tested positive for dosage for patients who developed adverse drug the JAK2V617F mutation and 20q-, but a bone reactions was reduced to 70 or 50 mg/d, whereas marrow biopsy showed that the fibrosis had for those who tolerated the drug well, the dosage reduced to grade 1, and that the bone marrow was increased to 140 mg/d (70 mg twice a day). showed erythroid hyperplasia with primary The dasatinib tablets (20 and 50 mg) used in this cells < 5%. Another patient also tested positive study were manufactured by ChiaTai Tian Qing for the JAK2V617F mutation before treatment 3313 Q.-L. Song, B. Zhang, Y. Xu, R.-X. Xia, X.-H. Lu, Z.-X. Pei, Q.-W. Xu, W.-Y. Li, Z.-D. Li Table I. Basic clinical information of patients with PMF. Age ECOG Sokal MPN Prognostic Genetic Treatment No. Sex (year) score score score stratification mutation duration (week) 1 Female 55 3 1.54 50 Intermidate-2 JAK2V617F 16 2 Male 58 2 1.08 28 Intermidate-2 JAK2V617F 10 3 Female 64 2 0.66 38 Intermidate-2 JAK2V617F 10 4 Male 60 2 1.38 39 Intermidate-2 JAK2V617F 10 5 Female 69 3 1.64 31 High risk JAK2V617F 11 6 Female 60 2 1.39 32 Intermidate-2 ASXL1, MPLW515 8 and had grade 3 bone marrow fibrosis; the pa- um, potassium, and magnesium tablets, as well tient tested positive for JAK2V617F mutation as hepatoprotective agents. In the event of edema, 11 weeks after treatment with dasatinib, but the pleural effusion, gastrointestinal reactions, and fibrosis had reduced to grade 1 and the primary other adverse reactions, symptomatic treatment cell count was < 5%. One patient tested positive
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