The ruxolitinib effect: understanding how molecular pathogenesis and epigenetic dysregulation impact therapeutic efficacy in myeloproliferative neoplasms

Abstract

The myeloproliferative neoplasms (MPN), polycythaemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) are linked by a propensity to thrombosis formation and a risk of leukaemic transformation. Activation of cytokine independent signalling through the JAK/STAT cascade is a feature of these disorders. A point mutation in exon 14 of the JAK2 gene resulting in the formation of the JAK2 V617F transcript occurs in 95% of PV patients and around 50% of ET and PMF patients driving constitutive activation of the JAK/STAT pathway. Mutations in CALR or MPL are present as driving mutations in the majority of remaining ET and PMF patients. Ruxolitinib is a tyrosine kinase inhibitor which inhibits JAK1 and JAK2. It is approved for use in intermediate and high risk PMF, and in PV patients who are resistant or intolerant to hydroxycarbamide. In randomised controlled trials it has demonstrated efficacy in spleen volume reduction and symptom burden reduction with a moderate improvement in overall survival in PMF. In PV, there is demonstrated benefit in haematocrit control and spleen volume. Despite these benefits, there is limited impact to induce complete haematological remission with normalisation of blood counts, reduce the mutant allele burden or reverse bone marrow fibrosis. Clonal evolution has been observed on ruxolitinib therapy and transformation to acute leukaemia can still occur. This review will concentrate on understanding the clinical and molecular effects of ruxolitinib in MPN. We will focus on understanding the limitations of JAK inhibition and the challenges to improving therapeutic efficacy in these disorders. We will explore the demonstrated benefits and disadvantages of ruxolitinib in the clinic, the role of genomic and clonal variability in pathogenesis and response to JAK inhibition, epigenetic changes which impact on response to therapy, the role of DNA damage and the role of inflammation in these disorders. Finally, we will summarise the future prospects for improving therapy in MPN in the JAK inhibition era.

Keywords: Epigenetics; Essential thrombocythemia; Myeloproliferative neoplasms; Polycythaemia vera; Primary myelofibrosis; Ruxolitinib.

Fig. 1

a This demonstrates the relative proportions of driver gene mutation observed in each MPN phenotype. b This demonstrates the proportion of patients with each MPN phenotype with a mutations in a panel of genes commonly mutated in myeloid malignancy. Frequency of mutations presented is based on data acquired in by Tefferi et al. [34, 35]

Fig. 2

This schematic demonstrates the potential mechanisms of escape from JAK2 inhibition by ruxolitinib. (1) Ineffective JAK inhibition (2) Acquired tyrosine kinase domain mutation (3) Heterodimerization of JAK2 with JAK1 or TYK2 (4) Alternative signaling cascade activation (5) External cytokine effects (6) Epigentic mechanisms of transcriptional regulation