Ponatinib-review of historical development, current status, and future research.

Ponatinib is a third-generation BCR::ABL1 tyrosine kinase inhibitor (TKI) with high potency against Philadelphia chromosome (Ph)-positive leukemias, including T315I-mutated disease, which is resistant to first- and second-generation TKIs. Ponatinib was approved for T315I-mutated chronic myeloid leukemia (CML), CML resistant/intolerant to ≥2 prior TKIs, advanced phase CML and Ph-positive acute lymphoblastic leukemia (ALL) where no other TKIs are indicated, and T315I-mutated CML and Ph-positive ALL. The response-based dosing of ponatinib in chronic phase CML (CP-CML) improved treatment tolerance and reduced the risk of toxicities, including cardiovascular risks. Ponatinib-based therapy also resulted in significantly better outcomes in frontline Ph-positive ALL compared with prior TKIs and is becoming a new standard of care in this setting. As the clinical development of third-generation TKIs and their rational combinations progresses, we envision further transformative changes in the treatment of CML and Ph-positive ALL.

The role of therapy in the outcome of patients with myelofibrosis.

BACKGROUND: The treatment of patients with myelofibrosis (MF) has evolved in the past decade, as reflected in an increased use of various therapeutic agents that could potentially impact patient outcomes. METHODS: In this retrospective study, the authors evaluated the pattern of therapy and its possible impact on the survival of patients with MF at their institution. Patients (n = 802) with newly diagnosed, chronic, overt MF (MF fibrosis grade ≥2, <10% blasts) seen at their cancer center between 2000 and 2020 were included. RESULTS: Overall, 492 of the included patients (61%) initiated MF-directed therapy during follow-up. The most frequent initial therapy was the JAK inhibitor ruxolitinib (44% of treated patients), investigational agents excluding JAK inhibitors (21%), immunomodulatory agents (18%), other investigational JAK inhibitors (10%), and others (7%). Overall survival was superior for patients who received initial ruxolitinib therapy, with a median survival of 72 months versus approximately 50 months for the remaining approaches, excluding the last group. Thirty-two percent of patients required subsequent therapy (n = 159). The longest survival since the start of second-line therapy was observed in patients who initiated salvage ruxolitinib (median, 35 months; 95% CI, 25-45 months). CONCLUSIONS: This study demonstrated improved outcomes of patients with MF who received treatment with the JAK inhibitor ruxolitinib.

Improved survival of patients with myelofibrosis in the last decade: Single-center experience.

BACKGROUND: The management of myelofibrosis (MF) has changed over the last several years and could have an impact on patient outcome. This study evaluates the survival of patients with MF at the authors' institution to determine whether it changed in the last decade. METHODS: This retrospective study consists of 844 patients (64% male; median age, 66 years; range, 20-90 years) who were examined between 2000 and 2020 with a new diagnosis of MF. Only patients with available marrow biopsy who had reticulin fibrosis of grade 2 or higher were included. Patients were compared by year of presentation: 2000-2010 (n = 373) and 2011-2020 (n = 471). RESULTS: A statistically significant improvement in median survival in the last decade was noted: from 48 months (95% CI, 42-54 months) to 63 months (95% CI, 55-71 months) (P < .001; HR, 0.78 [95% CI, 0.64-0.95]). Improved survival was observed also in patients 65 years old or older and those having intermediate 2 or high-risk Dynamic International Prognostic Scoring System (DIPSS) or DIPSS-Plus risk scores. Among 532 patients treated with MF-directed therapy, patients exposed to JAK inhibitor ruxolitinib had superior outcomes with median overall survival of 84 months (95% CI, 70-94 months). CONCLUSIONS: The results demonstrate that survival of patients with MF has improved in the last decade. This improvement is likely due to increased disease awareness, advances in supportive care, and the development of effective treatments.

Accelerated Phase of Myeloproliferative Neoplasms.

BACKGROUND: Myeloproliferative neoplasms (MPNs) can transform into blast phase MPN (leukemic transformation; MPN-BP), typically via accelerated phase MPN (MPN-AP), in ∼20-25% of the cases. MPN-AP and MPN-BP are characterized by 10-19% and ≥20% blasts, respectively. MPN-AP/BP portend a dismal prognosis with no established conventional treatment. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the sole modality associated with long-term survival. SUMMARY: MPN-AP/BP has a markedly different mutational profile from de novo acute myeloid leukemia (AML). In MPN-AP/BP, TP53 and IDH1/2 are more frequent, whereas FLT3 and DNMT3A are rare. Higher incidence of leukemic transformation has been associated with the most aggressive MPN subtype, myelofibrosis (MF); other risk factors for leukemic transformation include rising blast counts above 3-5%, advanced age, severe anemia, thrombocytopenia, leukocytosis, increasing bone marrow fibrosis, type 1 CALR-unmutated status, lack of driver mutations (negative for JAK2, CALR, or MPL genes), adverse cytogenetics, and acquisition of ≥2 high-molecular risk mutations (ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1Q157). The aforementioned factors have been incorporated in several novel prognostic scoring systems for MF. Currently, elderly/unfit patients with MPN-AP/BP are treated with hypomethylating agents with/without ruxolitinib; these regimens appear to confer comparable benefit to intensive chemotherapy but with lower toxicity. Retrospective studies in patients who acquired actionable mutations during MPN-AP/BP showed positive outcomes with targeted AML treatments, such as IDH1/2 inhibitors, and require further evaluation in clinical trials. Key Messages: Therapy for MPN-AP patients represents an unmet medical need. MF patients, in particular, should be appropriately stratified regarding their prognosis and the risk for transformation. Higher-risk patients should be monitored regularly and treated prior to progression to MPN-BP. MPN-AP patients may be treated with hypomethylating agents alone or in combination with ruxolitinib; also, patients can be provided with the option to enroll in rationally designed clinical trials exploring combination regimens, including novel targeted drugs, with an ultimate goal to transition to transplant.

Anion-π interactions in supramolecular architectures.

The study of the noncovalent force between π-acidic aromatic systems and anions, referred to as the anion-π interaction, has recently emerged as a new branch of supramolecular chemistry. The anion-π contact is complementary to the cation-π interaction, a prominent noncovalent force involved in protein structure and enzyme function. Until recently, the scientific community had overlooked the anion-π interaction due to its ostensibly counterintuitive nature. Pioneering theoretical studies in 2002, however, established that anion-π interactions are energetically favorable (~20-70 kJ/mol) and prompted a flurry of reports in support of their existence. The interest in anion-π contacts was further fueled by the importance of anions in key chemical and biological processes and the involvement of π-rings in anion recognition and transport. Anion-π interactions hold great promise for the design of selective anion receptors, hosts or scaffolds, colorimetric sensors, and catalysts and may also affect biological functions. Currently, the area of anion-π research is highly topical in the scientific community and on a meteoric rise in the chemical literature. This Account highlights our leading findings in this burgeoning area. Our work has focused on comprehensive investigations of several unprecedented supramolecular systems, in which the anions and their close anion-π contacts are the driving elements of the final architectures. We surveyed several heterocyclic π-acidic aromatic systems amenable to anion-π contacts and explored the subtle interplay between ligand π-acidity, anion identity, and metal ions in mediating the ensuing self-assembled architectures. The reactions we performed between solvated first-row transition metal ions and the π-acidic ligands bptz (3,6-bis(2-pyridyl)-1,2,4,5-tetrazine) or bmtz (3,6-bis(2-pyrimidyl)-1,2,4,5-tetrazine) resulted in unprecedented metallacycles. Our investigations revealed that the identity of the encapsulated ion dictates the metallacycle nuclearity and close anion-π contacts are critical for the metallacycle stability. Our X-ray crystallographic, NMR spectroscopic, and mass spectrometric (MS) studies demonstrated that the tetrahedral ([BF4](-), [ClO4](-)) and octahedral ([SbF6](-), [AsF6](-), [PF6](-)) anions template discrete molecular squares and pentagons, respectively. The metal ions occupy the vertices, and bptz or bmtz moieties span the edges of the metallacycles. The encapsulated anions occupy the π-acidic cavities of the metallacycles and establish multiple close directional F/O···C(tetrazine) contacts with the edges. The observation of notable (19)F solid-state NMR chemical shifts reflects the short contacts of the encapsulated anions, findings that we corroborated by DFT calculations. The solution NMR data support the conclusion that bona fide metallacycle templation and interconversion between the metallacycles in solution occurs only in the presence of the appropriate anions. The NMR, MS, and CV data underscore the remarkable metallapentacycle stability despite the angle strain inherent in pentagons formed by octahedral metal ions. The low anion activation energies of encapsulation (ΔG(‡) ~ 50 kJ/mol) suggest that anion-π contacts assist the anion templation. We also studied reactions of Ag(I)X (X(-) = [PF6](-), [AsF6](-), [SbF6](-), [BF4](-)) with bptz or bppn (3,6-bis(2-pyridyl)-1,2-pyridazine) to assess the effect of the ligand π-acidity on the preferred structures. The X-ray data revealed that the higher π-acidity of the tetrazine ring in bptz leads to propeller-type products [Ag2(bptz)3](2+) exhibiting prominent short anion-π contacts. By contrast, the less π-acidic bppn preferentially favors grids [Ag4(bppn)4](4+) which exhibit maximized π-π interactions. Finally, we explored the reactions of the extended π-acidic heterocycle HAT(CN)6 (1,4,5,8,9,12-hexaazatriphenylene-hexacarbonitrile) with the Cl(-), Br(-), I(-) ions which lead to highly colored solutions/crystals. X-ray crystallographic studies of the HAT(CN)6/halide complexes revealed unprecedented multisite short peripheral charge-transfer and centroid anion-π contacts. In solution, the charge-transfer contacts were evidenced by electronic absorption, (13)C and halogen NMR, as well as MS data. The distinctly colored complex entities exhibit extraordinarily high association constants, which render them promising for anion-sensing receptor applications.

SOHO State of the Art Update and Next Questions: Novel Therapies for Polycythemia Vera.

In the recent years, landmark advancements in the treatment of polycythemia vera (PV) have been achieved. We witnessed the regulatory approval of ropeginterferon and the advanced clinical development of other novel agents that may affect the underlying pathophysiological mechanisms of the disease. Agents with the potential of disease modification may soon overtake preceding treatment options that were based on the patient's age and history of thrombosis. Recent studies using ropeginterferon in low-risk PV patients earlier in the disease course challenge the current treatment paradigm and shift the focus on modifying the course of the disease. Hepcidin mimetics offer an excellent alternative to phlebotomy, providing better quality of life, and may lead to improved outcomes in PV by tight hematocrit control. Novel agents, such as histone deacetylase inhibitors, hold promise to complement the therapeutic landscape of PV and might be particularly promising in rationale combinations. Ruxolitinib is well established as an approved second-line treatment for PV. In the frontline setting, the precise role of ruxolitinib, which also represents an appealing agent in combination regimens, will be determined in ongoing research studies. Longer follow-up is necessary to assess whether novel agents/regimens elicit fewer thromboembolic/ hemorrhagic events and halt disease progression to myelofibrosis and acute myeloid leukemia. We aspire that disease-modifying approaches in PV are on the horizon, and that we will be empowered to ultimately change the natural course of the disease and profoundly impact the lives of PV patients in the near future.

Hematopoietic stem cells with granulo-monocytic differentiation state overcome venetoclax sensitivity in patients with myelodysplastic syndromes.

The molecular mechanisms of venetoclax-based therapy failure in patients with acute myeloid leukemia were recently clarified, but the mechanisms by which patients with myelodysplastic syndromes (MDS) acquire secondary resistance to venetoclax after an initial response remain to be elucidated. Here, we show an expansion of MDS hematopoietic stem cells (HSCs) with a granulo-monocytic-biased transcriptional differentiation state in MDS patients who initially responded to venetoclax but eventually relapsed. While MDS HSCs in an undifferentiated cellular state are sensitive to venetoclax treatment, differentiation towards a granulo-monocytic-biased transcriptional state, through the acquisition or expansion of clones with STAG2 or RUNX1 mutations, affects HSCs' survival dependence from BCL2-mediated anti-apoptotic pathways to TNFα-induced pro-survival NF-κB signaling and drives resistance to venetoclax-mediated cytotoxicity. Our findings reveal how hematopoietic stem and progenitor cell (HSPC) can eventually overcome therapy-induced depletion and underscore the importance of using close molecular monitoring to prevent HSPC hierarchical change in MDS patients enrolled in clinical trials of venetoclax.

Supramolecular architectures with π-acidic 3,6-bis(2-pyridyl)-1,2,4,5-tetrazine cavities: role of anion-π interactions in the remarkable stability of Fe(II) metallacycles in solution.

The comprehensive investigation reported herein provides compelling evidence that anion-π interactions are the main driving force in the formation of self-assembled Fe(II)-templated metallacycles with bptz [3,6-bis(2-pyridyl)-1,2,4,5-tetrazine] in high yields. It was demonstrated by X-ray crystallography, (1)H NMR, solution and solid-state MAS (19)F NMR spectroscopies, CV and MS studies that the anions [X](-) = [BF(4)](-), [ClO(4)](-) and the anions [Y](-) = [SbF(6)](-), [AsF(6)](-), [PF(6)](-) template molecular squares [Fe(4)(bptz)(4)(CH(3)CN)(8)][X](8) and pentagons [Fe(5)(bptz)(5)(CH(3)CN)(10)][Y](10), respectively. The X-ray structures of [{Fe(4)(bptz)(4)(CH(3)CN)(8)}⊂BF(4)][BF(4)](7) and [{Fe(5)(bptz)(5)(CH(3)CN)(10)}⊂2SbF(6)][SbF(6)](8) revealed that the [BF(4)](-) and [SbF(6)](-) anions occupy the π-acidic cavities, establishing close directional F···C(tetrazine) contacts with the tetrazine rings that are by ~0.4 Å shorter than the sum of the F···C van der Waals radii (ΣR(vdW) F···C = 3.17 Å). The number and strength of F···C(tetrazine) contacts are maximized; the F···C(tetrazine) distances and anion positioning versus the polygon opposing tetrazine rings are in agreement with DFT calculations for C(2)N(4)R(2)···[X](-)···C(2)N(4)R(2) (R = F, CN; [X](-) = [BF(4)](-), [PF(6)](-)). In unprecedented solid-state (19)F MAS NMR studies, the templating anions, engaged in anion-π interactions in the solid state, exhibit downfield chemical shifts Δδ((19)F) ≈ 3.5-4.0 ppm versus peripheral anions. NMR, CV, and MS studies also establish that the Fe(II) metallacycles remain intact in solution. Additionally, interconversion studies between the Fe(II) metallacycles in solution, monitored by (1)H NMR spectroscopy, underscore the remarkable stability of the metallapentacycles [Fe(5)(bptz)(5)(CH(3)CN)(10)][PF(6)](10) ≪ [Fe(5)(bptz)(5)(CH(3)CN)(10)][SbF(6)](10) < [Fe(5)(bptz)(5)(CH(3)CN)(10)][AsF(6)](10) versus [Fe(4)(bptz)(4)(CH(3)CN)(8)][BF(4)](8), given the inherent angle strain in five-membered rings. Finally, the low anion activation energies of encapsulation (ΔG(‡) ≈ 50 kJ/mol), determined from variable-temperature (19)F NMR studies for [Fe(5)(bptz)(5)(CH(3)CN)(10)][PF(6)](10) and [Zn(4)(bptz)(4)(CH(3)CN)(8)][BF(4)](8), confirm anion encapsulation in the π-acidic cavities by anion-π contacts (~20-70 kJ/mol).

SOHO State of the Art Updates and Next Questions: Novel Therapeutic Strategies in Development for Myelofibrosis.

Development of myelofibrosis (MF) therapeutics has reached fruition as the transformative impact of JAK2 inhibitors in the MPN landscape is complemented/expanded by a profusion of novel monotherapies and rational combinations in the frontline and second line settings. Agents in advanced clinical development span various mechanisms of action (eg, epigenetic or apoptotic regulation), may address urgent unmet clinical needs (cytopenias), increase the depth/duration of spleen and symptom responses elicited by ruxolitinib, improve other aspects of the disease besides splenomegaly/constitutional symptoms (eg, resistance to ruxolitinib, bone marrow fibrosis or disease course), provide personalized strategies, and extend overall survival (OS). Ruxolitinib had a dramatic impact on the quality of life and OS of MF patients. Recently, pacritinib received regulatory approval for severely thrombocytopenic MF patients. Momelotinib is advantageously poised among JAK inhibitors given its differentiated mode of action (suppression of hepcidin expression). Momelotinib demonstrated significant improvements in anemia measures, spleen responses, and MF-associated symptoms in MF patients with anemia; and will likely receive regulatory approval in 2023. An array of other novel agents combined with ruxolitinib, such as pelabresib, navitoclax, parsaclisib, or as monotherapies (navtemadlin) are evaluated in pivotal phase 3 trials. Imetelstat (telomerase inhibitor) is currently evaluated in the second line setting; OS was set as the primary endpoint, marking an unprecedented goal in MF trials, wherein SVR35 and TSS50 at 24 weeks have been typical endpoints heretofore. Transfusion independence may be considered another clinically meaningful endpoint in MF trials given its correlation with OS. Overall, therapeutics are at the cusp of an exponential expansion and advancements that will likely lead to the golden era in treatment of MF.

Association of Myelofibrosis Phenotypes with Clinical Manifestations, Molecular Profiles, and Treatments.

Myelofibrosis (MF) presents an array of clinical manifestations and molecular profiles. The two distinct phenotypes- myeloproliferative and myelodepletive or cytopenic- are situated at the two poles of the disease spectrum and are largely defined by different degrees of cytopenias, splenomegaly, and distinct molecular profiles. The myeloproliferative phenotype is characterized by normal/higher peripheral blood counts or mildly decreased hemoglobin, progressive splenomegaly, and constitutional symptoms. The myeloproliferative phenotype is typically associated with secondary MF, higher JAK2 V617F burden, fewer mutations, and superior overall survival (OS). The myelodepletive phenotype is usually associated with primary MF, ≥2 cytopenias, modest splenomegaly, lower JAK2 V617F burden, higher fibrosis, greater genomic complexity, and inferior OS. Cytopenias are associated with mutations in epigenetic regulators/splicing factors, clonal evolution, disease progression, and shorter OS. Clinical variables, in conjunction with the molecular profiles, inform integrated prognostication and disease management. Ruxolitinib/fedratinib and pacritinib/momelotinib may be more suitable to treat patients with the myeloproliferative and myelodepletive phenotypes, respectively. Appreciation of MF heterogeneity and two distinct phenotypes, the different clinical manifestations and molecular profiles associated with each phenotype alongside the growing treatment expertise, the development of non-myelosuppressive JAK inhibitors, and integrated prognostication are leading to a new era in patient management. Physicians can increasingly tailor personalized treatments that will address the unique unmet needs of MF patients, including those presenting with the myelodepletive phenotype, to elicit optimal outcomes and extended OS across the disease spectrum.

ACVR1: A Novel Therapeutic Target to Treat Anemia in Myelofibrosis.

Activin receptor type I (ACVR1) is a transmembrane kinase receptor belonging to bone morphogenic protein receptors (BMPs). ACVR1 plays an important role in hematopoiesis and anemia via the BMP6/ACVR1/SMAD pathway, which regulates expression of hepcidin, the master regulator of iron homeostasis. Elevated hepcidin levels are inversely associated with plasma iron levels, and chronic hepcidin expression leads to iron-restricted anemia. Anemia is one of the hallmarks of myelofibrosis (MF), a bone marrow (BM) malignancy characterized by BM scarring resulting in impaired hematopoiesis, splenomegaly, and systemic symptoms. Anemia and red blood cell transfusions negatively impact MF prognosis. Among the approved JAK inhibitors (ruxolitinib, fedratinib, momelotinib, and pacritinib) for MF, momelotinib and pacritinib are preferably used in cytopenic patients; both agents are potent ACVR1 inhibitors that suppress hepcidin expression via the BMP6/ACVR1/SMAD pathway and restore iron homeostasis/erythropoiesis. In September 2023, momelotinib was approved as a treatment for patients with MF and anemia. Zilurgisertib (ACVR1 inhibitor) and DISC-0974 (anti-hemojuvelin monoclonal antibody) are evaluated in early phase clinical trials in patients with MF and anemia. Luspatercept (ACVR2B ligand trap) is assessed in transfusion-dependent MF patients in a registrational phase 3 trial. Approved ACVR1 inhibitors and novel agents in development are poised to improve the outcomes of anemic MF patients.

Biological drivers of clinical phenotype in myelofibrosis.

Myelofibrosis (MF) is a myeloproliferative disorder that exhibits considerable biological and clinical heterogeneity. At the two ends of the disease spectrum are the myelodepletive or cytopenic phenotype and the myeloproliferative phenotype. The cytopenic phenotype has a high prevalence in primary MF (PMF) and is characterized by low blood counts. The myeloproliferative phenotype is typically associated with secondary MF (SMF), mild anemia, minimal need for transfusion support, and normal to mild thrombocytopenia. Differences in somatic driver mutations and allelic burden, as well as the acquisition of non-driver mutations further influences these phenotypic differences, prognosis, and response to therapies such as JAK2 inhibitors. The outcome of patients with the cytopenic phenotype are comparatively worse and frequently pose a challenge to treat given the inherent exacerbation of cytopenias. Recent data indicate that an innate immune deregulated state that hinges on the myddosome-IRAK-NFκB axis favors the cytopenic myelofibrosis phenotype and offers opportunity for novel treatment approaches. We will review the biological and clinical features of the MF disease spectrum and associated treatment considerations.

Momelotinib: an emerging treatment for myelofibrosis patients with anemia.

The suite of marked anemia benefits that momelotinib has consistently conferred on myelofibrosis (MF) patients stem from its unique inhibitory activity on the BMP6/ACVR1/SMAD and IL-6/JAK/STAT3 pathways, resulting in decreased hepcidin (master iron regulator) expression, higher serum iron and hemoglobin levels, and restored erythropoiesis. Clinical data on momelotinib from the phase 2 and the two phase 3 SIMPLIFY trials consistently demonstrated high rates of sustained transfusion-independence. In a recent phase 2 translational study, 41% of the patients achieved transfusion independence for ≥ 12 weeks. In the phase 3 trials SIMPLIFY-1 and SIMPLIFY-2, 17% more JAK inhibitor-naïve patients and two-fold more JAK inhibitor-treated patients achieved or maintained transfusion independence with momelotinib versus ruxolitinib and best available therapy (89% ruxolitinib), respectively. Anemia is present in approximately a third of MF patients at diagnosis, eventually developing in nearly all patients. The need for red blood cell transfusions is an independent adverse risk factor for both overall survival and leukemic transformation. Presently, FDA-approved medications to address anemia are lacking. Momelotinib is one of the prime candidates to durably address the critical unmet needs of MF patients with moderate/severe anemia. Importantly, momelotinib may have overall survival benefits in frontline and second-line MF patients. MOMENTUM is an international registration-track phase 3 trial further assessing momelotinib's unique constellation of anemia and other benefits in second-line MF patients; the results of the MOMENTUM trial are keenly awaited and may lead to regulatory approval of momelotinib.

Mutational landscape of blast phase myeloproliferative neoplasms (MPN-BP) and antecedent MPN.

Myeloproliferative neoplasms (MPN) have an inherent tendency to evolve to the blast phase (BP), characterized by ≥20% myeloblasts in the blood or bone marrow. MPN-BP portends a dismal prognosis and currently, effective treatment modalities are scarce, except for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in selected patients, particularly those who achieve complete/partial remission. The mutational landscape of MPN-BP differs from de novo acute myeloid leukemia (AML) in several key aspects, such as significantly lower frequencies of FLT3 and DNMT3A mutations, and higher incidence of IDH1/2 and TP53 in MPN-BP. Herein, we comprehensively review the impact of the three signaling driver mutations (JAK2 V617F, CALR exon 9 indels, MPL W515K/L) that constitutively activate the JAK/STAT pathway, and of the other somatic non-driver mutations (epigenetic, mRNA splicing, transcriptional regulators, and mutations in signal transduction genes) that cooperatively or independently promote MPN progression and leukemic transformation. The MPN subtype, harboring two or more high-molecular risk (HMR) mutations (epigenetic regulators and mRNA splicing factors) and "triple-negative" PMF are among the critical factors that increase risk of leukemic transformation and shorten survival. Primary myelofibrosis (PMF) is the most aggressive MPN; and polycythemia vera (PV) and essential thrombocythemia (ET) are relatively indolent subtypes. In PV and ET, mutations in splicing factor genes are associated with progression to myelofibrosis (MF), and in ET, TP53 mutations predict risk for leukemic transformation. The advent of targeted next-generation sequencing and improved prognostic scoring systems for PMF inform decisions regarding allo-HSCT. The emergence of treatments targeting mutant enzymes (e.g., IDH1/2 inhibitors) or epigenetic pathways (BET and LSD1 inhibitors) along with new insights into the mechanisms of leukemogenesis will hopefully lead the way to superior management strategies and outcomes of MPN-BP patients.

SOHO State of the Art Updates and Next Questions: Novel Therapies in Development for Myelofibrosis.

Myeloproliferative neoplasms research has entered a dynamic and exciting era as we witness exponential growth of novel agents in advanced/early phase clinical trials for myelofibrosis (MF). Building on the success and pivotal role of ruxolitinib, many novel agents, spanning a wide range of mechanisms/targets (epigenetic regulation, apoptotic/intracellular signaling pathways, telomerase, bone marrow fibrosis) are in clinical development; several are studied in registrational trials and hold great potential to expand the therapeutic arsenal/shift the treatment paradigm if regulatory approval is granted. Insight into MF pathogenesis and its molecular underpinnings, preclinical studies demonstrating synergism of ruxolitinib with investigational agents, urgent unmet clinical needs (cytopenias, loss of response to JAK inhibitors); and progressive disease fueled the rapid rise of innovative therapeutics. New strategies include pairing ruxolitinib with erythroid maturation agents to manage anemia (luspatercept), designing rational combinations with ruxolitinib to boost responses in both the frontline and suboptimal response settings (pelabresib, navitoclax, parsaclisib), treatment with non-JAK inhibitor monotherapy in the second-line setting (navtemadlin, imetelstat), novel JAK inhibitors tailored to subgroups with challenging unmet needs (momelotinib and pacritinib for anemia and thrombocytopenia, respectively); and agents potentially enhancing longevity (imetelstat). Beyond typical endpoints evaluated in MF clinical trials (spleen volume reduction ≥ 35%, total symptom score reduction ≥ 50%) thus far, emerging endpoints include overall survival, progression-free survival, transfusion independence, anemia benefits, bone marrow fibrosis and driver mutation allele burden reduction. Novel biomarkers and additional clinical features are being sought to assess new agents and tailor emerging therapies to appropriate patients. New strategies are needed to optimize the design of clinical trials comparing novel combinations to standard agent monotherapy.

Systemic Mastocytosis and Other Entities Involving Mast Cells: A Practical Review and Update.

Evidence in the recent literature suggests that the presentation spectrum of mast cell neoplasms is broad. In this article, we elaborate on recent data pertaining to minor diagnostic criteria of systemic mastocytosis (SM), including sensitive testing methods for detection of activating mutations in the KIT gene or its variants, and adjusted serum tryptase levels in cases with hereditary α-tryptasemia. We also summarize entities that require differential diagnosis, such as the recently reclassified SM subtype named bone marrow mastocytosis, mast cell leukemia (an SM subtype that can be acute or chronic); the rare morphological variant of all SM subtypes known as well-differentiated systemic mastocytosis; the extremely rare myelomastocytic leukemia and its differentiating features from mast cell leukemia; and mast cell activation syndrome. In addition, we provide a concise clinical update of the latest adjusted risk stratification model incorporating genomic data to define prognosis in SM and new treatments that were approved for advanced SM (midostaurin, avapritinib).

Insight into the photoinduced ligand exchange reaction pathway of cis-[Rh2(µ-O2CCH3)2(CH3CN)6]2+ with a DNA model chelate.

We previously showed that [Rh(2)(O(2)CCH(3))(2)(CH(3)CN)(6)](2+) binds to dsDNA only upon irradiation with visible light and that photolysis results in a 34-fold enhancement of its cytotoxicity toward Hs-27 human skin fibroblasts, making it potentially useful for photodynamic therapy (PDT). With the goal of gaining further insight on the photoinduced binding of DNA to the complex, we investigated by NMR spectroscopy the mechanism by which 2,2'-bipyridine (bpy), a model for biologically relevant bidentate nitrogen donor ligands, binds to [Rh(2)(O(2)CCH(3))(2)(CH(3)CN)(6)](2+) upon irradiation in D(2)O. The photochemical results are compared to the reactivity in the dark in D(2)O and CD(3)CN. The photolysis of [Rh(2)(O(2)CCH(3))(2)(CH(3)CN)(6)](2+) with equimolar bpy solutions in D(2)O with visible light affords [Rh(2)(O(2)CCH(3))(2)(eq/eq-bpy)(CH(3)CN)(2)(D(2)O(ax))(2)](2+) (eq/eq) with the reaction reaching completion in ~8 h. Only vestiges of eq/eq are observed at the same time in the dark, however, and the reaction is ~20 times slower. Conversely, the dark reaction of [Rh(2)(O(2)CCH(3))(2)(CH(3)CN)(6)](2+) with an equimolar amount of bpy in CD(3)CN affords [Rh(2)(O(2)CCH(3))(2)(η(1)-bpy(ax))(CH(3)CN)(5)](2+) (η(1)-bpy(ax)), which remains present even after 5 days of reaction. The photolysis results in D(2)O are consistent with the exchange of one equiv CH(3)CNeq for solvent, and the resulting species quickly reacting with bpy to generate eq/eq; the initial eq ligand dissociation is assisted by absorption of a photon, thus greatly enhancing the reaction rate. The photolytic reaction of [Rh(2)(O(2)CCH(3))(2)(CH(3)CN)(6)](2+):bpy in a 1:2 ratio in D(2)O affords the eq/eq and (eq/eq)(2) adducts. The observed differences in the reactivity in D(2)O vs CD(3)CN are explained by the relative ease of substitution of eq D(2)O vs CD(3)CN by the incoming bpy molecule. These results clearly highlight the importance of dissociation of an eq CH(3)CN molecule from the dirhodium core to attain high reactivity and underscore the importance of light for the reactivity of these compounds, which is essential for PDT agents.

Single-center experience with venetoclax combinations in patients with newly diagnosed and relapsed AML evolving from MPNs.

In patients with acute myeloid leukemia evolving from myeloproliferative neoplasms (post-MPN-AML), the clinical activity of the B-cell lymphoma 2 inhibitor venetoclax remains to be determined. We review our experience with venetoclax-based regimens in 14 newly diagnosed (frontline [FL]) and 17 relapsed/refractory (R/R) post-MPN-AML patients. Venetoclax was used in combination with hypomethylating agents in 58% of cases and in 19% with intensive chemotherapy (treatment including cytarabine ≥1 g/m2 or CPX-351); the remaining patients received cladribine and low-dose cytarabine or isocitrate dehydrogenase 1/2 inhibitors. The median dose of venetoclax during the initial cycle was 100 mg in all patients (range, 50-800 mg) and 200 mg (range, 100-800 mg) for FL patients. The venetoclax dose was adjusted when used concomitantly with azole antifungal agents. In FL patients, complete remission with and without count recovery in 6 patients (median duration of 6.4 months) and partial remission in 1 patient was noted, with a median overall survival of 7 months. In R/R patients, no formal responses were seen, with a median overall survival of 3 months. Hematologic toxicities and adverse events were frequent; 83% of patients developed grade 3 or higher infection during the initial cycle. Severe hemorrhagic complications were observed in 14 patients, including 6 cases of intracranial and subdural hemorrhage. Overall 4-week and 8-week mortality were 10% and 32%, respectively. Given the substantial treatment-associated hematologic toxicity and mortality, and modest short-lived responses only in newly diagnosed patients with venetoclax-based regimens, additional treatment options are urgently needed for these patients.

Givinostat: an emerging treatment for polycythemia vera.

INTRODUCTION: Polycythemia vera (PV), a Philadelphia chromosome-negative myeloproliferative neoplasm, is characterized by panmyelosis, pancytosis, and a JAK2 mutation. Patients are at increased risk of thrombohemorrhagic events, and progression to myelofibrosis or acute leukemia. Current treatments include aspirin, phlebotomy, and cytoreductive drugs (most commonly hydroxyurea). Givinostat is a potent, class I/II histone deacetylase (HDAC) inhibitor that is in phase I/II clinical trials in PV. Givinostat was well tolerated and yielded promising clinico-hematological responses. A phase III study of givinostat versus hydroxyurea in high-risk PV patients is planned. AREAS COVERED: We present an overview of PV, current treatment guidelines, and the putative mechanism(s) of action of givinostat. We discuss the preclinical and clinical studies of givinostat in PV and briefly review approved and investigational competitor compounds. EXPERT OPINION: HDAC inhibitors have long been known to be active in PV, but chronic toxicities can be challenging. Givinostat, however, is active and well tolerated, and is entering a pivotal Phase III randomized trial. Givinostat offers the possibility of replacing hydroxyurea as the standard first-line cytoreductive choice for PV patients. This would completely change the current therapeutic paradigm and guidelines for PV management. Although surrogate clinical study endpoints may suffice for regulatory purposes, thrombosis reduction and prevention of disease progression remain most important to patients and clinicians.

Redox-regulated Inhibition of T7 RNA polymerase via establishment of disulfide linkages by substituted Dppz dirhodium(II,II) complexes.

The series of dirhodium(II) complexes cis-[Rh(2)(O(2)CCH(3))(2)(R(1)R(2)dppz)(2)](2+) 1-6 (R(1) = R(2) = H, MeO, Me, Cl, NO(2) for 1-4, 6, respectively, and R(1)= H, R(2) = CN for 5), coordinated to R(1)R(2)dppz ligands with electron-donating or -withdrawing substituents at positions 7,8 of dppz (dppz = dipyrido[3,2-a:2',3'-c]phenazine), were synthesized and their effect on the transcription process in vitro was monitored. Complexes 1-6 are easily reduced, readily oxidize cysteine, and engage in redox-based reactions with T7-RNA Polymerase (T7-RNAP), which contains accessible thiol groups. Transcription is inhibited in vitro by 1-6 via formation of intra- and inter-T7-RNAP disulfide bonds that affect the enzyme critical sulfhydryl cysteine groups. The progressively increasing electron-withdrawing character of the dppz substituents (MeO < Me < H < Cl < CN < NO(2)) gives rise to the order 2 < 3 < 1 < 4 < 5 < 6 for the measured IC(50) values of 1-6. The ease of reduction for 1-6 is consistent with the energies of the dppz-centered lowest unoccupied molecular orbitals (LUMOs), which decrease with the electron-withdrawing character of the dppz substituents. The ligand-centered reductions for 1-6 are supported by electron paramagnetic resonance (EPR) studies which support the conclusion that reduction of 1-6 leads to the formation of dppz centered radicals [Rh(2)(O(2)CCH(3))(2)(R(1)R(2)dppz)(2)](*+) with isotropic g values approximately 2.003 which are essentially identical to the reported value for the free radical dppz anions. The EPR results are corroborated by density functional theory (DFT) calculations, which indicate that the complexes contain dppz-based LUMOs primarily phenazine (phz) in character; the unpaired electron is completely delocalized in the phenazine orbitals in 4-6. The low IC(50) values for 1-6 lend further support to the fact that they exhibit redox-based activity with the enzyme and lead to the conclusion that the complexes constitute a sensitive redox-regulated series of T7-RNAP inhibitors with the potential to control or inhibit other important biochemical processes.