JAK2V617F Myeloproliferative Neoplasm Research Articles

Effect of Integrin α 4β 1 -VCAM-1 Interactions in JAK2V617F Myeloproliferative Neoplasm Pro-Thrombotic Interactions

Introduction: The JAK2 V617Fmutation, which occurs in up to 95% of polycythemia vera (PV) myeloproliferative neoplasm (MPN) patients, increases thrombosis risk 6-fold. A recent study in PV mice demonstrated that blocking JAK2 V617F+ leukocyte-mediated β1/β2 integrin interactions with anti-VCAM-1 antibodies decreases thrombosis. Interestingly, hydroxyurea (HU), a common PV treatment, reduces leukocyte and red cell α4β1 integrin expression. Overall, JAK2 V617F+ mouse models show inconsistent thrombosis and bleeding phenotype, hindering pre-clinical study reproducibility; therefore, we have developed an in vitro endothelialized microfluidic model to assess MPN-flow behavior. We hypothesized that in our microfluidic model, disrupting α4β1 integrin expression on JAK2 V617F+ leukocytes would reduce pro-adhesive interactions. We tested this hypothesis by assessing JAK2 V617F+ MPN blood flow in untreated and hydroxyurea treated subjects and through addition of a monoclonal antibody against α4β1 integrin, natalizumab. Methods: Primary human umbilical vein endothelial cells (HUVECs) were exposed to venous shear (15 dynes/cm 2) in microfluidics for a 4-day culture period. On day 4, endothelialized microfluidics were treated +/- 10 ng/mL TNFα for 4 hours. Blood samples were obtained from consented JAK2 V617F MPN individuals aged >18 years with ET, PV, or MF as diagnosed by the WHO 2016 Criteria identified in the M Health Fairview Masonic Cancer Center Clinics. Healthy age, race, and sex-matched blood samples served as controls. Clinical data on patients was collected and stored in REDCAP. Platelets and leukocytes were visualized using Calcein AM. Samples were treated +/- 0.25 μg/mL natalizumab for 30 minutes, then perfused through the microfluidic under a microscope to observe blood-endothelial interactions in real-time. Post-experiment, videos were analyzed to quantify velocity and adhesion of platelets and leukocytes for each treatment condition. Results: When perfused over TNF-α activated endothelium, both controls ( JAK2 negative, n=11) and JAK2 V617F MPN (n=20) had a significant reduction in cell velocity. Furthermore, compared to controls, JAK2 V617F MPN individuals exhibited significantly lower cell velocities. In multi-variate analysis, reduction in cell velocity was independent of white blood cell, hemoglobin, hematocrit or platelet counts. Hydroxyurea is a standard therapy in JAK2 V617F MPN and is known to reduce α4β1 expression. Therefore, we performed subgroup analysis in our JAK2 V617F MPN cohort based on treatment. When perfused over TNF-α activated endothelium, individuals with JAK2 V617F MPN (n=9) not on therapy (newly diagnosed) or on phlebotomy/aspirin only had a significant reduction in cell velocity. In the same conditions, HU-treated JAK2 V617F MPN patients (n=9) had no change in cell velocity. There was no difference in complete blood counts between these groups. In a separate subgroup analysis, compared to untreated JAK2 V617F MPN patients (n=9), interferon-treated JAK2 V617F MPN patients (n=5) had a greater reduction in cell velocity. Last, we specifically targeted α4β1 integrin by adding natalizumab to either control (n=7) or untreated JAK2 V617F MPN (n=3) samples. On inactivated endothelium, treatment of either control or JAK2 V617F MPN blood with natalizumab did not significantly change cell velocity. On a TNF-α activated endothelium, treatment of control (n=7) and JAK2 V617F MPN blood (n=3) with natalizumab led to a recovery in cell velocity. Conclusion: Our data suggests that the interaction between integrin α4β1 on JAK2 V617F cell surface and VCAM-1 on activated endothelium is important for initiation of pro-thrombotic interactions. JAK2 V617F MPN individuals treated with HU exhibit decreased adhesion to activated endothelium compared to control; JAK2 V617F MPN individuals treated with interferon exhibit increased adhesion. In the microfluidic system, based on current findings, blockage of integrin α4β1-VCAM-1 interactions using natalizumab is a potential therapeutic strategy. Further mechanistic studies evaluating interferon and cell populations changed by therapies as they pertain to integrin α4β1 are underway.

Polycythemia Vera Molecular Response and Its Correlation with Disease Progression: A Systematic Review and Meta-Analysis

Background: Polycythemia vera (PV) is a chronic myeloproliferative neoplasm (MPN) driven primarily by JAK2V617F and is associated with an excess risk of thrombosis and progression to myelofibrosis (MF) and acute leukemia (AML). Advances in treatment of PV and earlier diagnosis has reduced fatal thrombotic events, but with longer thrombosis-free survival, the natural progression to MF is an increasingly common cause of morbidity. More than 50% of PV patients (pts) have MF after 30 years from diagnosis, independent of age, making this a particularly important issue for young pts1. Because of disease chronicity, short-term monitoring biomarkers are needed to dynamically predict risk of disease progression on the long-term and allow appropriate implementation and modification of therapy. Whole blood (WB) JAK2V617F allele frequency (MAF) is frequently measured in clinical trials to assess molecular response to treatment, yet no study has established whether serial changes in MAF are predictive of progression. Despite limitations of WB MAF monitoring 2, the readily accessible WB samples and feasibility of testing, along with the need for a clinical biomarker in PV, merits a study to determine whether MAF change correlates with disease progression. Objective & Methods: We conducted a systematic review and meta-analysis to examine the correlation of molecular response with thrombosis or progression to MF and AML in PV pts. We searched the main scholarly engines: Pubmed, Scopus and Embase for "Polycythemia vera" and terms including "JAK2V617F" and "molecular response". Title and abstracts were screened by 2 reviewers independently based on predefined criteria and selected for full-text review if criteria are met or further information was required. Studies were included if they reported serial MAF measurements in PV patients, and excluded for other JAK2V617F MPNs or lack of serial MAF assessment. Pearson correlation analysis was conducted on the subset of studies that reported rates of thrombosis, MF and or AML to determine the correlation of MAF reduction with clinical outcomes. Results: The search resulted in 563 abstracts to screen. A total of 59 studies were selected for full-text review and ultimately only 20 studies met inclusion criteria where MAF was serially assessed in PV patients. In all studies, MAF was monitored on cytoreductive therapy, and these included 12 on interferon (IFN), 8 on hydroxyurea (HU), and 2 on ruxolitinib (RUX). The median follow-up times were between 16-116 months. In most studies (n=18, 90%), there was an overall decrease in MAF on cytoreductive treatment (Figure 1). There was a poor correlation between molecular response rates and hematological response rates (n=11 studies, r2=0.20). Of the 20 studies, only 7 reported clinical outcomes of thrombosis and/or progression: 2 were prospective and 5 were retrospective. In our analysis, MAF reduction correlated with decreased rates of MF (n = 7 studies, r2=0.69) (Figure 2), irrespective of treatment (IFN: r2 =0.83, HU: r2 =0.72), but results were not statistically significant (p=0.08). On the other hand, there was no correlation between MAF reduction and progression to AML (n= 3 studies, r2=0.17), or the incidence of thrombotic events (n = 6 studies, r2=0.15), but fewer studies reported these outcomes. Discussion: This systematic review highlights the lack of high-level evidence available to determine if molecular response in PV is associated with reduced risk of progression. The correlation observed between MAF reduction and MF rates requires validation in larger, ideally prospective studies. Until then, reduction in WB MAF should not be the determinant of a treatment's long-term likelihood of success. Alternative biomarkers are needed to capture the biology of malignant MPN stem cells and better predict the long-term outcomes of patients with PV.

Suppression of multiple anti-apoptotic BCL2 family proteins recapitulates the effects of JAK2 inhibitors in JAK2V617F driven myeloproliferative neoplasms.

Several lines of research suggest that Bcl‐xL‐mediated anti‐apoptotic effects may contribute to the pathogenesis of myeloproliferative neoplasms driven by JAK2V617F and serve as therapeutic target. Here, we used a knock‐in JAK2V617F mouse model and confirmed that Bcl‐xL was overexpressed in erythroid progenitors. The myeloproliferative neoplasm (MPN)‐induced phenotype in the peripheral blood by conditional knock‐in of JAK2V617F was abrogated by conditional knockout of Bcl2l1, which presented anemia and thrombocytopenia independently of JAK2 mutation status. Mx1‐Cre Jak2V617W/VF/Bcl2l1f/f mice presented persistent splenomegaly as a result of extramedullary hematopoiesis and pro‐apoptotic stimuli in terminally differentiated erythroid progenitors. The pan‐BH3 mimetic inhibitor obatoclax showed superior cytotoxicity in JAK2V617F cell models, and reduced clonogenic capacity in ex vivo assay using Vav‐Cre Jak2V617F bone marrow cells. Both ruxolitinib and obatoclax significantly reduced spleen weights in a murine Jak2V617F MPN model but did not show additive effect. The tumor burden reduction was observed with either ruxolitinib or obatoclax in terminal differentiation stage neoplastic cells but not in myeloid‐erythroid precursors. Therefore, disrupting the BCL2 balance is not sufficient to treat MPN at the stem cell level, but it is certainly an additional option for controlling the critical myeloid expansion of the disease.

Imbalance between Tolerant and Cytotoxic Functional Subsets of NK Cells in a JAK2V617F Myeloproliferative Neoplasm Model

Natural killer (NK) cells are lymphocytes that play a critical role in both innate and adaptive immune responses. It has been shown that CD27 and CD11b are antigens expressed in the last stage of NK cells development and allow the classification of NK cells into three functional subsets. Tolerant NK cells are double negative (DN) for CD27 and CD11b, have an immature phenotype and present low secretory and cytotoxic potential. The secretory NK cells are CD27 positive, have a great ability to release cytokines, but do not exhibit cytotoxicity properties. The cytotoxic NK cells express CD11b, release granzymes and perforins, but are less capable of secreting cytokines. While cytotoxic NK cells are essential for the natural defenses against infected or malignant cells, secretory NK cells, when activated, produce different cytokines, including IFNγ, TNFα, TGFβ, GM-CSF, MIP1α, MIP1β, IL-10 and others, which may modify the functions or other hematopoietic cells including the hematopoietic stem cells (HSC). We hypothesized that deregulation of the balance between secretory or cytotoxic subtypes of NK cells may favor HSC malignant transformation and contribute to stem cell-derived diseases. In this regard, few studies have shown that NK cells are defective in chronic myeloid leukemia (CML). In contrast to CML, the role of NK cells in BCR-ABL1 negative-myeloproliferative neoplasms (MPN) is currently unexplored. We aimed to study the activity of NK cells and their subsets in murine primary cells from MPN. NK cells subsets were quantified by flow cytometry by the use of spleen cells from a pre-established conditional vavCre knockin Jak2V617F (Jak2VF) murine model. Besides genotyping to identify controls (Jak2 wt/wt vavCre+, or Jak2WT) and Jak2-mutated mice (Jak2 wt/V617F vavCre+, Jak2VF), the presence of polycythemia and splenomegaly was confirmed in the animals with MPN. Mice (n=5 per group) were euthanized between 8-12 weeks of age. For immunophenotyping, spleen cells were isolated, submitted to red cell lyse, and stained with fluorescence-conjugated antibodies against Ter119, CD19, CD4, CD8, CD3, NK1.1 and CD27 and CD11b. All the stainings were performed at 4°C for 20 minutes and acquisition was performed in a FACSCanto™II flow cytometer (BD Biosciences). Data was analyzed by the use of the Flowjo software version X. When compared to Jak2WT controls, the Jak2VF mice had lower numbers of NK cells (1,447 x 106 versus 0,381 x 106 p<0.05) and T cells (0,638 x 106 versus 0,158 x 106 of the spleen; p<0.05) among the total splenocytes. The analysis of NK subsets showed an increase in the percentages of DN NK cells (CD27-CD11b-) in the spleen of Jak2VF mice as compared to controls (14.84% versus 4.97%; p<0.05). CD27+ immature and mature secretory NK (CD27+CD11b-/+) cells also seemed to be increased in Jak2-mutated mice but this data did not reach statistical significance (37.43% versus 17.65%; p=0.1). On the other hand, when compared to Jak2WT controls, the Jak2VF mice presented lower percentages of CD11b+ cytotoxic NK cells (77.07% versus 47.80% of the spleen cells; p<0.05). In agreement, when the expression of NK receptors was analyzed by flow cytometry, the inhibitory NKG2A receptor was found to be higher expressed in Jak2VF NK cells as compared to non-mutated cells, while the expression of the activatory receptors Ly49H and Ly49D was reduced in Jak2-mutated NK cells. Of note, low levels of the Jak2V617F mutation were detected in sorted NK cells isolated from Jak2VF mice as compared to controls by Real Time quantitative RT-PCR, thus suggesting that the distribution between NK cell subtypes observed here is associated with the JAK2 mutational status. In summary, when compared to controls, Jak2-mutated mice presented an increased proportion of tolerant NK cells, previously described as immature cells with low secretory and cytotolytic potential. To date, CD11b-/CD27- tolerant cells have been observed among solid tumor-infiltrating NK cells, but have not been previously associated with MPN. Moreover, an inverted ratio between the secretory and cytotoxic NK subsets was also detected in Jak2VF animals, suggesting that a cytotoxic deficiency occurs and may contribute to the leukemic stem cell expansion. The expansion of the NK secretory potential deserves further elucidation. Our study provided new insights into the distribution of JAK2V617F NK functional subsets that may be used as future therapeutic targets for MPN. DisclosuresKobayashi:Pfizer: Consultancy.

JAK2V617F myeloproliferative neoplasm eradication by a novel interferon/arsenic therapy involves PML

Interferon α (IFNα) is used to treat JAK2V617F-driven myeloproliferative neoplasms (MPNs) but rarely clears the disease. We investigated the IFNα mechanism of action focusing on PML, an interferon target and key senescence gene whose targeting by arsenic trioxide (ATO) drives eradication of acute promyelocytic leukemia. ATO sharply potentiated IFNα-induced growth suppression of JAK2V617F patient or mouse hematopoietic progenitors, which required PML and was associated with features of senescence. In a mouse MPN model, combining ATO with IFNα enhanced and accelerated responses, eradicating MPN in most mice by targeting disease-initiating cells. These results predict potent clinical efficacy of the IFNα+ATO combination in patients and identify PML as a major effector of therapy, even in malignancies with an intact PML gene.

Erythrocyte-derived microvesicles induce arterial spasms in JAK2V617F myeloproliferative neoplasm.

Arterial cardiovascular events are the leading cause of death in patients with JAK2V617F myeloproliferative neoplasms (MPNs). However, their mechanisms are poorly understood. The high prevalence of myocardial infarction without significant coronary stenosis or atherosclerosis in patients with MPNs suggests that vascular function is altered. The consequences of JAK2V617F mutation on vascular reactivity are unknown. We observe here increased responses to vasoconstrictors in arteries from Jak2V617F mice resulting from a disturbed endothelial NO pathway and increased endothelial oxidative stress. This response was reproduced in WT mice by circulating microvesicles isolated from patients carrying JAK2V617F and by erythrocyte-derived microvesicles from transgenic mice. Microvesicles of other cellular origins had no effect. This effect was observed ex vivo on isolated aortas, but also in vivo on femoral arteries. Proteomic analysis of microvesicles derived from JAK2V617F erythrocytes identified increased expression of myeloperoxidase as the likely mechanism accounting for their effect. Myeloperoxidase inhibition in microvesicles derived from JAK2V617F erythrocytes suppressed their effect on oxidative stress. Antioxidants such as simvastatin and N-acetyl cysteine improved arterial dysfunction in Jak2V617F mice. In conclusion, JAK2V617F MPNs are characterized by exacerbated vasoconstrictor responses resulting from increased endothelial oxidative stress caused by circulating erythrocyte-derived microvesicles. Simvastatin appears to be a promising therapeutic strategy in this setting.

Distinct effects of ruxolitinib and interferon-alpha on murine JAK2V617F myeloproliferative neoplasm hematopoietic stem cell populations.

JAK2V617F is the most common mutation in patients with BCR-ABL negative myeloproliferative neoplasms (MPNs). The eradication of JAK2V617F hematopoietic stem cells (HSCs) is critical for achieving molecular remissions and cure. We investigate the distinct effects of two therapies, ruxolitinib (JAK1/2 inhibitor) and interferon-alpha (IFN-α), on the disease-initiating HSC population. Whereas ruxolitinib inhibits Stat5 activation in erythroid progenitor populations, it fails to inhibit this same pathway in HSCs. In contrast, IFN-α has direct effects on HSCs. Furthermore, STAT1 phosphorylation and pathway activation is greater after IFN-α stimulation in Jak2V617F murine HSCs with increased induction of reactive oxygen species, DNA damage and reduction in quiescence after chronic IFN-α treatment. Interestingly, ruxolitinib does not block IFN-α induced reactive oxygen species and DNA damage in Jak2V617F murine HSCs in vivo. This work provides a mechanistic rationale informing how pegylated IFN-α reduces JAK2V617F allelic burden in the clinical setting and may inform future clinical efforts to combine ruxolitinib with pegylated IFN-α in patients with MPN.

Hippo kinase loss contributes to del(20q) hematologic malignancies through chronic innate immune activation

AbstractHeterozygous deletions within chromosome 20q, or del(20q), are frequent cytogenetic abnormalities detected in hematologic malignancies. To date, identification of genes in the del(20q) common deleted region that contribute to disease development have remained elusive. Through assessment of patient gene expression, we have identified STK4 (encoding Hippo kinase MST1) as a 20q gene that is downregulated below haploinsufficient amounts in myelodysplastic syndrome (MDS) and myeloproliferative neoplasm (MPN). Hematopoietic-specific gene inactivation in mice revealed Hippo kinase loss to induce splenomegaly, thrombocytopenia, megakaryocytic dysplasia, and a propensity for chronic granulocytosis; phenotypes that closely resemble those observed in patients harboring del(20q). In a JAK2-V617F model, heterozygous Hippo kinase inactivation led to accelerated development of lethal myelofibrosis, recapitulating adverse MPN disease progression and revealing a novel genetic interaction between these 2 molecular events. Quantitative serum protein profiling showed that myelofibrotic transformation in mice was associated with cooperative effects of JAK2-V617F and Hippo kinase inactivation on innate immune-associated proinflammatory cytokine production, including IL-1β and IL-6. Mechanistically, MST1 interacted with IRAK1, and shRNA-mediated knockdown was sufficient to increase IRAK1-dependent innate immune activation of NF-κB in human myeloid cells. Consistent with this, treatment with a small molecule IRAK1/4 inhibitor rescued the aberrantly elevated IL-1β production in the JAK2-V617F MPN model. This study identified Hippo kinase MST1 (STK4) as having a central role in the biology of del(20q)-associated hematologic malignancies and revealed a novel molecular basis of adverse MPN progression that may be therapeutically exploitable via IRAK1 inhibition.

PS1435 SLAMF7 HIGH CD16 NEGATIVE MONOCYTES INCREASE IN PERIPHERAL BLOOD OF PATIENTS WITH MYELOFIBROSIS IN CORRELATION WITH JAK2V617F MUTATION

Background:Monocyte‐derived fibrocytes are vital in the pathogenesis of primary myelofibrosis (MF) (J Exp Med 2016;213:1723). We established the direct induction of fibrocyte differentiation using TPO receptor activation in a mouse model (Leukemia 2017;31:2709). Moreover, we demonstrated that elotuzumab (Elo; anti‐SLAMF7 antibody) inhibited human fibrocyte differentiation in vitro and relieved MF in the mouse model, determining Elo as a potential therapeutic agent (manuscript in preparation). In the peripheral blood (PB) of patients with MF, SLAMF7high CD16− monocytes were significantly increased than that of healthy controls (HCs). Thus, we hypothesize that SLAMF7high CD16− monocytes reflected fibrocyte activation and were the target of Elo.Aims:Through this cross‐sectional study, we aimed to identify suitable candidates for a clinical trial of Elo by evaluating SLAMF7high CD16− monocyte percentage in the PB of HCs, myeloproliferative neoplasm (MPN) patients with or without MF, and non‐MPN patients with MF.Methods:We enrolled 6 HCs, 12 non‐MPN patients with MF, and 44 patients with MPN (18 without and 26 with MF) and collected their blood samples. All patients with MPN underwent a bone marrow biopsy in 2016–2018 and were diagnosed per the 2016 WHO classification and diagnostic criteria. Non‐MPN patients underwent a bone marrow biopsy in 2015–2018, and MF was established over MF‐1 per the European Consensus Criteria. We evaluated the SLAMF7high CD16– monocyte percentage in PB monocytes of HCs and patients using flow cytometry. All PB samples were tested for JAK2V617F, CALR, or MPL genetic mutations, and the allele burden of the JAK2V617F mutation was measured in PB samples and cultured fibrocytes. Furthermore, we collected SLAMF7high/low CD16– monocytes separately of 2 patients harboring the JAK2V617F mutation and assessed the JAK2V617F allele burden of that fraction and the ratio of fibrocytes in culture.Results:The SLAMF7high CD16− monocyte percentage significantly increased in MPN and non‐MPN patients compared with HCs and MPN patients without MF (P &lt; 0.001 and P &lt; 0.01, respectively). JAK2V617F MPN patients with MF exhibited a significantly higher SLAMF7high CD16− monocyte percentage than those without MF (P &lt; 0.001). We noted a similar trend in patients not harboring the JAK2V617F mutation (P = 0.05). The ROC analysis revealed that &gt;25% of SLAMF7high CD16− monocytes in PB estimates MF in patients with MPN harboring the JAK2V617F mutation (sensitivity: 82.4%, specificity: 87.5%). Moreover, the JAK2V617F allele burden of fibrocytes markedly correlated with the SLAMF7high CD16− monocyte percentage in the PB (P = 0.0003). In CD16– monocytes of 2 patients, the JAK2V617F allele burden of the SLAMF7high fraction was high (87.96% and 94.75%) compared with the SLAMF7low fraction (49.09% and 45.64%, respectively). Furthermore, the culture assay of isolated SLAMF7high/low monocytes revealed that the frequency of fibrocytes derived from SLAMF7high monocytes markedly increased compared with SLAMF7low monocytes.Summary/Conclusion:SLAMF7high CD16– monocytes are neoplastic cells with homozygous JAK2V617F, and the levels closely correlate with MF and a neoplastic clone of fibrocytes harboring the JAK2V617F mutation; this fraction indicates fibrocyte activation and denotes a noninvasive marker of MF progression and a potential target for Elo treatment.

Myeloproliferative Neoplasm (MPN) Driver Mutations Are Enriched during Hematopoietic Stem Cell Differentiation in Patterns That Correlate with Clinical Phenotype and Treatment Response

Introduction. Philadelphia negative (Ph-neg) Myeloproliferative Neoplasms (MPNs) differ in clinical phenotype and outcomes despite harboring identical driver mutations. The biology behind phenotypic heterogeneity has been attributed to mutational burden, co-occurring mutations and mutation order, but remains uncertain. It is known that MPN mutations in JAK2, CALR, and MPL result in augmentation of cytokine signaling at different stages of hematopoietic differentiation towards myeloid lineages. Consistent with this, the JAK2V617F driver mutation is enriched in certain myeloid lineages compared to the hematopoietic stem and progenitor cell (HSPC) compartment (Anand et al. Blood 2011). We therefore hypothesized that the lineage-specific patterns of clonal enrichment that arise during hematopoietic differentiation from stem cells to mature progeny would account for phenotypic heterogeneity in MPNs.Methods. Peripheral blood and/or bone marrow specimens were prospectively collected from 87 MPN patients (pts) providing informed consent between July 2017 and July 2018. Data on age, gender, diagnosis, date of diagnosis, symptoms, spleen size, blood counts, bone marrow findings, mutation profile, and treatment was collected for all pts. Each specimen was deconvoluted into 11 well-defined and strictly validated hematopoietic populations using a combination of density gradient separation (Ficoll), immunomagnetic selection (CD34) and fluorescence-activated cell sorting (FACS). Final purification of specimens was performed by multiparameter FACS to isolate CD15+/CD16+ polymorphonucleated cells (PMNs), CD14+/CD11b+ monocytes, CD3+ T cells, CD19+ B cells, CD71+/CD36+ erythroblasts and 6 well-defined HSPC populations (Manz et al. PNAS. 2002, Majeti et al. Cell Stem Cell 2007). Functional and morphologic characteristics were validated for all populations. DNA was extracted from the sorted populations and the variant allelic frequency (VAF) of the driver mutation in JAK2, CALR, or MPL was quantified by droplet digital PCR. Individual patterns of mutation enrichment were represented by the VAF plotted on a hematopoietic hierarchy (Fig 1). A composite VAF hierarchy was established for each of the WHO defined MPN subtypes of Polycythemia Vera (PV), Essential Thrombocythemia (ET), and Primary Myelofibrosis (PMF) prior to treatment, during course of treatment, and in secondary myelofibrosis. Clustering of individual patterns in relation to composite trees was performed using principal component analysis (PCA), which allowed clinical validation of clustering patterns.Results. A total of 135 samples were collected from 87 pts. Demographic and clinical features of the cohort are shown in Table 1. The composite pattern of MPN mutation enrichment differed in PV, ET and PMF (Fig 1). Pts with untreated PV or ET harbored a small proportion of mutated stem cells. The VAF in PV patients implied clonal dominance in mature myeloid progeny while there was minimal enrichment of the driver mutation in pts with JAK2 ET. In comparison, pts with PMF had a significantly higher VAF in the HSC compartment, but had minimal enrichment of the driver mutation during myeloid differentiation. Using PCA, individual patterns from a sample of 34 JAK2V617F MPN pts were clustered in reference to the pre-established composite patterns (heatmap in Fig. 2). This was done in order to validate consistency of patterns with clinical diagnoses (see example in Fig 2).Finally, we found that interferon treated PV pts had a unique decline in VAF with myeloid differentiation (Fig 3) but persistence of the mutant allele within the stem cell compartment: a finding that potentially explains the persistence of bone marrow abnormalities in pts achieving molecular response determined by whole blood (WB) VAF.Conclusion. The pattern of clonal enrichment of an MPN stem cell during hematopoiesis is unique to individual pts and varies significantly among the 3 major WHO subtypes of PV, ET, and PMF. This pattern also differs in relation to the disease stage, and is informative of treatment effects. WB VAF does not predict the proportion of immature HSPC harboring driver mutation. For these reasons, evaluating the clonal heterogeneity of MPN driver mutations, particularly those in HSPCs, may provide a useful surrogate measure to qualify response to novel agents in pre-clinical and clinical studies in MPNs. This is currently being tested. [Display omitted] DisclosuresRitchie:NS Pharma: Research Funding; Incyte: Consultancy, Speakers Bureau; Bristol-Myers Squibb: Research Funding; ARIAD Pharmaceuticals: Speakers Bureau; Astellas Pharma: Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding, Speakers Bureau; Celgene: Consultancy, Other: Travel, Accommodations, Expenses, Speakers Bureau.

Abnormal Distribution and Function of NK Cells Subsets May Lead to Impaired Tumor Surveillance in a JAK2V617F Myeloproliferative Neoplasm Model

Background: The JAK2V617F mutation is the most common molecular abnormality present in Philadelphia chromosome-negative Classical Myeloproliferative Neoplasms (Ph-neg MPNs), present in approximately 95% of patients with Polycythemia Vera and in almost 50% of patients with primary myelofibrosis and essential thrombocythemia. Besides the genetic mutations, different cells in the bone marrow can modulate the microenvironment and contribute to disease initiation and maintenance. Natural killer (NK) cells are part of innate immunity and are divided into subsets, according the expression of CD27 and CD11b. The immature NK cells, CD27-CD11b- (tolerant), CD27+CD11b-, presenting less cytotoxicity, while the mature NK cells, CD27+CD11b+ and CD27-CD11b+ (cytotoxic), have a great cytotoxic function. Considering that the role of NK cells in Ph-neg MPNs is currently unclear, our hypothesis is that a defect of the NK cells may favor HSC malignant transformation and contribute to MPN development. Aim: We aimed to study their distribution and cytotoxic function in murine primary cells from a MPN transgenic model. Methods: NK cells were quantified by flow cytometry from splenocytes of a pre-established conditional vavCre knockin Jak2V617F (Jak2VF) murine model. Polycythemia and splenomegaly were confirmed in Jak2 wt/V617F vavCre+ (Jak2VF) as compared to Jak2 wt/wt vavCre+ (Jak2WT) control animals. Mice (n= 4 per group) were euthanized between 10-16 weeks of age. For immunophenotyping, spleen was isolated, submitted to red cell lysis, and stained with fluorescence-conjugated antibodies against Ter119, CD19, CD4, CD8 CD3, NK1.1, CD27, CD11b, CD69 and CD107a. All the stainings were performed at 4°C for 20 minutes and acquisition of at least ten thousands events per tube was performed in a FACSCanto™II flow cytometer. For the activation and degranulation assays, splenocytes were cultivated and stimulated with PMA (2.5ug/mL) and ionomicyn (0.7ug/mL) for 3 hours and then submitted to the analysis of CD69and CD107a expression, respectively. The cytotoxicity assay was performed by a co-culture of sorted NK cells with YAC-1 cells previously marked with an impermeable cell tracker, for 3 hours. Then, the target cell death percentage was determined by 7-AAD detection. Results: The analysis of the degranulation marker CD107a in activated NK cells (CD69+) showed that, when compared with the Jak2WT group, the Jak2VF mice presented a decreased frequency of CD107a+ NK cells (87.2% vs 74.1% p=.02). Besides, the ability of Jak2VF NK cells to kill the target cells was reduced when compared to the Jak2WT group (80.1%±17.4 vs 65.5%±8.7 at the 5:1 NK:target cell ratio and 84.9%±11.9 vs 75.3%±0.1 at the 10:1 NK:target cell ratio). The maturation profile showed that, when compared to Jak2WT mice, the frequency of immature NK cells was 4.2-fold increase in Jak2VF animals (8% vs 33% p=.009), and the percentage of these cells that expressed the degranulation marker CD107a was reduced when compared with the Jak2WT group (55.5% vs 42.7% p=.02). In agreement, the frequency of mature NK cells was decreased in Jak2-mutated mice (92% vs 67% p=.009) as compared to controls. Among the mature NK subpopulations, CD107+ cells were lower numbered in Jak2VF mice as compared to Jak2WT cells (94.3% vs 88.9% p=.005). We also observed a differential profile of functional NK subsets between Jak2WT and Jak2VF NK cells. There was an increase of CD27-CD11b- and CD27+CD11b- NK cells in Jak2-mutated mice (5.6% vs 18.3% p=.007 and 2.1% vs 14.6% p=.01, respectively). On the other hand, the percentage of CD27-CD11b+ NK cells in Jak2VF mice was lower than in Jak2WT mice (78.1% vs 49.9% p=.01). In summary, when compared to controls, Jak2-mutated mice presented a reduction in the frequency of NK cells able to release their lytic granules, suggesting a lower cytotoxic function. The reduction of cytotoxicity in Jak2VF NK cells may be explained by two factors: (1) the augment of immature tolerant NK cells, and (2) the reduction of cytotoxicity of the mature subset (CD27-CD11b+). To date, although the functional and maturation subsets of NK cells have been studied in solid tumors, they have not been previously associated with MPNs. Conclusion: Considering that mature and functional NK cells play a critical role in tumor surveillance, it is plausible that an impair of their distribution and function can favor stem cell-derived diseases like Ph-neg MPNs DisclosuresNo relevant conflicts of interest to declare.

ATP binding to the pseudokinase domain of JAK2 is critical for pathogenic activation

Pseudokinases lack conserved motifs typically required for kinase activity. Nearly half of pseudokinases bind ATP, but only few retain phosphotransfer activity, leaving the functional role of nucleotide binding in most cases unknown. Janus kinases (JAKs) are nonreceptor tyrosine kinases with a tandem pseudokinase-kinase domain configuration, where the pseudokinase domain (JAK homology 2, JH2) has important regulatory functions and harbors mutations underlying hematological and immunological diseases. JH2 of JAK1, JAK2, and TYK2 all bind ATP, but the significance of this is unclear. We characterize the role of nucleotide binding in normal and pathogenic JAK signaling using comprehensive structure-based mutagenesis. Disruption of JH2 ATP binding in wild-type JAK2 has only minor effects, and in the presence of type I cytokine receptors, the mutations do not affect JAK2 activation. However, JH2 mutants devoid of ATP binding ameliorate the hyperactivation of JAK2 V617F. Disrupting ATP binding in JH2 also inhibits the hyperactivity of other pathogenic JAK2 mutants, as well as of JAK1 V658F, and prevents induction of erythrocytosis in a JAK2 V617F myeloproliferative neoplasm mouse model. Molecular dynamic simulations and thermal-shift analysis indicate that ATP binding stabilizes JH2, with a pronounced effect on the C helix region, which plays a critical role in pathogenic activation of JAK2. Taken together, our results suggest that ATP binding to JH2 serves a structural role in JAKs, which is required for aberrant activity of pathogenic JAK mutants. The inhibitory effect of abrogating JH2 ATP binding in pathogenic JAK mutants may warrant novel therapeutic approaches.

Limited Efficacy of BMS-911543 in a Murine Model of JAK2V617F Myeloproliferative Neoplasm

Activation of JAK2, frequently as a result of the JAK2V617F mutation, is a characteristic feature of the classical myeloproliferative neoplasms (MPN) polycythemia vera, essential thrombocythemia and myelofibrosis and thought to be responsible for the constitutional symptoms associated with these diseases. BMS-911543 is a JAK2 selective inhibitor that induces apoptosis in JAK2-dependent cell lines and inhibits the growth of CD34+ progenitor cells from patients with V617F+ MPN. To explore the clinical potential of this inhibitor, we tested BMS-911543 in a murine retroviral transduction – transplantation model of JAK2V617F MPN. Treatment was initiated at two dose levels (3 mg/kg and 10 mg/kg) when the hematocrit exceeded 70%. Following the first week, white blood cell counts were reduced to normal in the high dose group and were maintained well below the vehicle-treated mice throughout the study. However, BMS-911543 had no effect on red cell parameters. After 42 days of treatment, the proportion of JAK2V617F - positive cells in hematopoietic tissues was identical to controls or slightly increased compared to controls. Plasma concentrations of IL-6, IL-15, and TNFα were elevated in MPN mice and reduced in the high dose treatment group, while other cytokines were unchanged. Collectively, these results show that BMS-911543 has limited activity in this murine model of JAK2V617F – driven MPN and suggest that targeting JAK2 alone may be insufficient to achieve effective disease control. DisclosuresDeininger:BMS, Novartis, Celgene, Genzyme, Gilead: Research Funding; BMA, ARIAD, Novartis, Incyte, Pfizer: Advisory Board, Advisory Board Other; BMS, ARIAD, Novartis, Incyte, Pfizer: Consultancy.

A role for reactive oxygen species in JAK2V617F myeloproliferative neoplasm progression

Although other mutations may predate the acquisition of the JAK2(V617F) mutation, the latter is sufficient to drive the disease phenotype observed in BCR-ABL-negative myeloproliferative neoplasms (MPNs). One of the consequences of JAK2(V617F) is genetic instability that could explain JAK2(V617F)-mediated MPN progression and heterogeneity. Here, we show that JAK2(V617F) induces the accumulation of reactive oxygen species (ROS) in the hematopoietic stem cell compartment of a knock-in (KI) mouse model and in patients with JAK2(V617F) MPNs. JAK2(V617F)-dependent ROS elevation was partly mediated by an AKT-induced decrease in catalase expression and was accompanied by an increased number of 8-oxo-guanines and DNA double-strand breaks (DSBs). Moreover, there was evidence for a mitotic recombination event in mice resulting in loss of heterozygosity of Jak2(V617F). Mice engrafted with 30% of Jak2(V617F) KI bone marrow (BM) cells developed a polycythemia vera-like disorder. Treatment with the anti-oxidant N-acetylcysteine (NAC) substantially restored blood parameters and reduced damages to DNA. Furthermore, NAC induced a marked decrease in splenomegaly with reduction in the frequency of the Jak2(V617F)-positive hematopoietic progenitors in BM and spleen. Altogether, overproduction of ROS is a mediator of JAK2(V617F)-induced DNA damages that promote disease progression. Targeting ROS accumulation might prevent the development of JAK2(V617F) MPNs.

Givinostat and hydroxyurea synergize in vitro to induce apoptosis of cells from JAK2V617F myeloproliferative neoplasm patients

We investigated whether clinically achievable concentrations of the histone deacetylase (HDAC) inhibitors givinostat and hydroxyurea induce synergistic cytotoxicity in Jak2(V617F) cells invitro and through which possible mechanism. Givinostat and hydroxyurea at low doses potentiated the pro-apoptotic effects of each other in the Jak2(V617F) HEL and UKE1 cell lines. Givinostat induced 6.8%-20.8% and hydroxyurea (HU) 20.4%-42.4% cell death alone and 35.8%-75.3% in combination. The effect was statistically significant using the median effect Chou-Talalay method, resulting in a combination index less than 1, indicating synergy. Givinostat alone induced cell cycle arrest of the cell lines in G0/G1 and hydroxyurea in S phase, whereas both drugs together led to a G1 block. At the molecular level, hydroxyurea counteracted the induction of p21CDKN1A by Givinostat and potentiated caspase 3 activation, explaining at least in part the increased apoptosis observed in presence of both compounds. We also verified the effect of the same drugs in colony assays of freshly isolated Jak2(V617F) polycythemia vera cells. In this case, low doses of the compounds were additive to each other. These results suggest that combined treatment with givinostat and hydroxyurea is a potential strategy for the management of Jak2(V617F) myeloproliferative neoplasms.

The HDAC inhibitor Givinostat modulates the hematopoietic transcription factors NFE2 and C-MYB in JAK2V617F myeloproliferative neoplasm cells

We investigated the mechanism of action of the histone deacetylase inhibitor Givinostat (GVS) in Janus kinase 2 (JAK2)(V617F) myeloproliferative neoplasm (MPN) cells. GVS inhibited colony formation and proliferation and induced apoptosis at doses two- to threefold lower in a panel of JAK2(V617F) MPN compared to JAK2 wild-type myeloid leukemia cell lines. By global gene expression analysis, we observed that at 6 hours, GVS modulated 293 common genes in the JAK2(V617F) cell lines HEL and UKE1, of which 19 are implicated in cell cycle regulation and 33 in hematopoiesis. In particular, the hematopoietic transcription factors NFE2 and C-MYB were downmodulated by the drug specifically in JAK2(V617F) cells at both the RNA and protein level. GVS also inhibited JAK2-signal transducer and activator of transcription 5-extracellular signal-regulated kinase 1/2 phosphorylation, but modulation of NFE2 and C-MYB was JAK2-independent, as shown using the JAK2 inhibitor TG101209. GVS had a direct effect on the NFE2 promoters, as demonstrated by specific enrichment of associated histone H3 acetylated at lysine 9. Modulation by GVS of NFE2 was also observed in freshly isolated CD34(+) cells from MPN patients, and was accompanied by inhibition of their proliferation and differentiation toward the erythroid lineage. We conclude that GVS acts on MPN cells through dual JAK2-signal transducer and activator of transcription 5-extracellular signal-regulated kinase 1/2 inhibition and downmodulation of NFE2 and C-MYB transcription.

Treatment in Vitro with a Combination of Bcl-Xl Inhibitor-ABT-737 and a JAK2 Inhibitor Selectively Eliminates JAK2V617F MPN Progenitor Cells.

Abstract 752The Ph- myeloproliferative neoplasm (MPN) are associated with excessive production of red cells, platelets and granulocytes which largely determines their clinical manifestations. A mutation in the JAK2 tyrosine kinase (JAK2V617F) was identified in the majority of patients with MPNs. The JAK2V617F mutation has been shown to play a pivotal role in the pathogenesis of MPNs. We have reported that erlotinib (Tarceva), a kinase inhibitor which inhibits the epidermal growth factor induced kinase activity, is also a potent inhibitor of JAK2V617F activity. It has been shown that erythroblasts from patients with polycythemia vera (PV) express elevated levels of anti-apoptotic proteins, Bcl-2 and Bcl-xL. In addition, we have recently documented that megakaryocytes derived from patients with primary myelofibrosis (PMF) undergo a delayed pattern of apoptosis in vitro which might be attributed to the over-expression of Bcl-xL. We hypothesize that a combination of a JAK2V617F inhibitor and a Bcl-xL inhibitor might be capable of selectively eliminating MPN cells while sparing normal cells, and therefore, providing an optimal treatment strategy for Ph− MPNs.We then evaluated the combinations of a JAK2V617 inhibitor (erlotinib or INCB018424) and a Bcl-xL inhibitor (ABT-737) for their ability to selectively eliminate MPN (JAK2V617F positive) cells while sparing normal cells in vitro using a variety of screening systems. We first tested the ability of each of the JAK2 inhibitors alone or in combination with ABT-737 to induce death of HEL cells, which harbors JAK2V617F. Among these treatments, ABT-737 (0.25 uM) plus either erlotinib (1.0 uM), or INCB018424 (1 nM) were shown to have similar capability of inducing HEL cell apoptosis (50-70%) which was significantly greater than that by each of the single agents (<5%). However, the combination of ABT-737 (0.25 uM) plus erlotinib (1.0 uM) was the least potent of inducing normal CD34+ cells to undergo apoptosis (∼5%) as compared to ABT-737 plus INCB018424 (∼20%). We next examined the effects of each of the JAK2 inhibitors alone or in combination with ABT-737 on CD34+ cells isolated from patients with PV or PMF. PV or PMF CD34+ cells were incubated in the absence or presence of agent(s) for 4 days; the percentage of apoptotic cells was then determined using Annexin V/PI staining by flow cytometry. A fraction of both untreated and treated CD34+ cells were assayed for hematopoietic colonies in the presence of SCF, IL-6, IL-3, G-CSF and EPO; individual colonies were then randomly plucked for JAK2V617F genotyping using nested allele-specific PCR. Similar to HEL cells, the percentage of MPD CD34+ cells undergoing apoptosis were similar when cells were treated with ABT-737 (0.25 uM) plus either erlotinib (1.0 uM), or INCB018424 (1.0 nM) (∼40%), but were significantly higher than that of MPN CD34+ cells treated with each of the agents alone (∼5%). Interestingly, when the percentages of JAK2V617F positive colonies within each of the treated and untreated cell populations were analyzed, MPN CD34+ cells treated with ABT-737 plus each of the JAK2 inhibitors contained a significantly lower percentage of JAK2V617F positive colonies than those untreated or treated with each of the single agents. These data indicate that the combination of ABT-737 plus a JAK2 inhibitor specifically targets on the JAK2V617F positive progenitor cells. Collectively, we identified an agent combination of ABT-737 (0.25 uM) plus a JAK2 inhibitor that is capable of selectively eliminating JAK2V617F positive MPN progenitor cells while sparing normal progenitor cells in vitro. Disclosures:No relevant conflicts of interest to declare.