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. Author manuscript; available in PMC: 2025 Aug 25.
Published in final edited form as: Am J Hematol. 2017 Nov 27;93(2):277–285. doi: 10.1002/ajh.24972

A phase II trial of ruxolitinib in combination with azacytidine in myelodysplastic syndrome/myeloproliferative neoplasms

Rita Assi 1, Hagop M Kantarjian 1, Guillermo Garcia-Manero 1, Jorge E Cortes 1, Naveen Pemmaraju 1, Xuemei Wang 2, Graciela Nogueras-Gonzalez 2, Elias Jabbour 1, Prithviraj Bose 1, Tapan Kadia 1, Courtney D Dinardo 1, Keyur Patel 3, Carlos Bueso-Ramos 3, Lingsha Zhou 1, Sherry Pierce 1, Romany Gergis 1, Carla Tuttle 1, Gautam Borthakur 1, Zeev Estrov 1, Rajyalakshmi Luthra 3, Juliana Hidalgo-Lopez 3, Srdan Verstovsek 1, Naval Daver 1
PMCID: PMC12376909  NIHMSID: NIHMS2102789  PMID: 29134664

Abstract

Ruxolitinib and azacytidine target distinct disease manifestations of myelodysplastic syndrome/myeloproliferative neoplasms (MDS/MPNs). Patients with MDS/MPNs initially received ruxolitinib BID (doses based on platelets count), continuously in 28-day cycles for the first 3 cycles. Azacytidine 25 mg/m2 (Day 1–5) intravenously or subcutaneously was recommended to be added to each cycle starting cycle 4 and could be increased to 75 mg/m2 (Days 1–5) for disease control. Azacytidine could be started earlier than cycle 4 and/or at higher dose in patients with rapidly proliferative disease or with elevated blasts. Thirty-five patients were treated (MDS/MPN-U, n =14; CMML, n =17; aCML, n =4), with a median follow-up of 15.2 months (range, 1.0–41.5). All patients were evaluable by the 2015 international consortium proposal of response criteria for MDS/MPNs (ICP MDS/MPN) and 20 (57%) responded. Nine patients (45%) responded after the addition of azacytidine. A greater than 50% reduction in palpable splenomegaly at 24 weeks was noted in 9/14 (64%) patients. Responders more frequently were JAK2-mutated (P = .02) and had splenomegaly (P = .03) compared to nonresponders. New onset grade 3/4 anemia and thrombocytopenia occurred in 18 (51%) and 19 (54%) patients, respectively, but required therapy discontinuation in only 1 (3%) patient. Patients with MDS/MPN-U had better median survival compared to CMML and aCML (26.5 vs 15.1 vs 8 months; P = .034). The combination of ruxolitinib and azacytidine was well-tolerated with an ICP MDS/MPN-response rate of 57% in patients with MDS/MPNs. The survival benefit was most prominent in patients with MDS/MPN-U.

1 |. INTRODUCTION

The myelodysplastic syndrome/myeloproliferative neoplasms (MDS/MPNs) are a group of Philadelphia (Ph) chromosome–negative myeloid malignancies with clinical, laboratory, and morphologic characteristics that overlap between myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPNs).1–4 The myelodysplastic/myeloproliferative diseases (MDS/MPDs) category was first introduced in the third edition of the World Health Organization (WHO) sponsored classification of hematopoietic tumors1 to define a group of myeloid neoplasms that included chronic myelomonocytic leukemia (CMML), juvenile myelomonocytic leukemia (JMML), atypical chronic myeloid leukemia (aCML), and myelodysplastic/myeloproliferative-unclassified (MDS/MPN-U). The category was subsequently renamed as myelodysplastic syndrome/myeloproliferative neoplasms (MDS/MPNs).2

The incidence of MDS/MPNs in the United States is around 3 per 100,000 individuals,5 accounting for approximately 5% of cases of MDS. The MDS/MPNs exhibit significant morphological, cytogenetic, and clinical heterogeneity and the diagnosis remain “clinicopathologically assigned,” requiring integration of bone marrow and peripheral blood morphology with clinical and laboratory findings.5 The molecular landscape within the different MDS/MPNs is diverse. In CMML, the most commonly mutated genes are SRSF2, TET2, and ASXL1 (seen in >80% of cases),6,7 with ASXL1 mutations associated with aggressive disease behavior.8 MDS/MPN-U frequently harbor mutations in genes encoding epigenetic regulators (e.g., TET2, ASXL1, EZH2), spliceosome components (e.g., SRSF2, SF3B1, ZRSR2, U2AF1), and/or signaling molecules (JAK2, NRAS), RUNX1.9 Approximately 40% of patients with aCML harbor SETBP1, CSF3R, and/or ETNK1 mutations.10,11

The absence of successful therapies in this setting may, in part, stem from our limited understanding of the underlying pathophysiology and molecular profile of the different MDS/MPNs. Based on their known activity in myelofibrosis (MF) and MDS, a number of agents have been used for the treatment of patients with MDS/MPNs, with limited successes and a median overall survival (OS) of <2 years in most cases.12–14 These included hydroxyurea,15 alpha-interferon,16,17 hematopoietic growth factors, hypomethylating agents (HMAs), immunomodulatory drugs, and combination approaches (thalidomide, arsenic, dexamethasone, ascorbic acid). In MF the JAK1/2 inhibitor ruxolitinib resulted in the reduction of spleen size, control of symptoms, improvement in the quality of life and overall survival (OS).18–20 HMAs improved cytopenias and OS and delayed the transformation to acute myeloid leukemia (AML) in patients with MDS21,22 and CMML.23–27 HMAs have also shown activity in small studies and case-series in patients with MDS/MPN-U,13 aCML,28,29 MF,30,31 and post-MPN AML.32

The recent acceptance of MDS/MPNs as an independent entity, their heterogeneous presentation, and the lack of clearly defined molecular profiles, have resulted in a dearth of prospective clinical trial literature in this patient population. The independent activity of ruxolitinib and azacytidine in patients with MPNs and MDS, respectively, and their nonoverlapping toxicity profiles suggest that the combination of these two agents administered sequentially and at lower doses may be tolerable and efficacious in patients with MDS/MPNs. This is the first report of a prospective phase II trial evaluating the efficacy and safety of azacytidine with ruxolitinib in patients with MDS/MPNs.

2 |. METHODS

2.1 |. Study design and participants

We conducted an open-label, nonrandomized phase II study of the combination of ruxolitinib and azacytidine in patients with MDS/MPNs, at the University of Texas MD Anderson Cancer Center (UT/MDACC). The trial was initiated in May 2013. Patients aged 18 years or older with newly diagnosed or previously treated MDS/MPNs with intermediate-1 or 22, or high-risk according to the Dynamic International Prognostic Scoring system (DIPSS) criteria for MF33 were enrolled. The diagnosis of MDS/MPN (including CMML, MDS/MPN-U, aCML) was made by a hemato-pathologist at UT/MDACC based on evaluation of the bone marrow aspirate and biopsy, peripheral blood, cytogenetic, and molecular studies done at our center and by using the criteria outlined in the 2008 revision of the WHO classification of myeloid neoplasms and acute leukemia.2 At the time the study was initiated (May 2013) uniform criteria for risk-stratification and response for MDS/MPN had not been published. As these patients have features of both MF and MDS we wanted to choose a prognostic criteria that would be applicable to one of these conditions leading to the decision to use the DIPSS criteria, widely used in MF prognostication.33 Our MDS/MPN population included patients with a confirmed WHO diagnosis of MDS/MPN-U, CMML, or aCML based on pathologist review.2 Patients with platelet count of ≥50 × 109/L and an absolute neutrophils count (ANC) of ≥1.0 × 109/L, Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≤ 2; serum creatinine ≤ 2.5 mg/dL; serum direct bilirubin ≤ 2.0 mg/dL; serum transaminase ≤ 2.5 times the upper limit of the normal range (ULN) or ≤ 5 times ULN if the transaminase elevation was deemed related to the MDS/MPN, were included. The main exclusion criteria were prior therapy with ruxolitinib or azacytidine, uncontrolled concurrent clinically significant illness, or standard or experimental therapy for MDS/MPN within 14 days of starting study therapy with the exception of hydroxyurea, which was allowed for up to a total of up to 14 days while on protocol. All patients signed an informed consent form approved by the UT/MDACC Institutional Review Board. The study was conducted in accordance with the Declaration of Helsinki (ClinicalTrials.gov identifier: NCT01787487).

2.2 |. Baseline and on-study assessments

Pretreatment evaluation included a complete history, physical examination (including documentation of spleen and liver measurements obtained by manual palpation by the treating physician), and ECOG performance status. Baseline assessments also included obtaining a transfusion history for 3 months prior to start of study therapy and documentation of the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and the MD Anderson Symptom Inventory (MDASI) questionnaire. All patients were tested for the BCR/ABL translocation by fluorescence in situ hybridization (FISH) and/or PCR, and JAK2-V617F was assessed by standard PCR technique, previously described.34 The entire coding sequences of 28 genes known to be frequently mutated in myeloid hematologic malignancies (ABL1, ASXL1, BRAF, DNMT3A, EGFR, EZH2, FLT3, GATA1, GATA2, HRAS, IDH1, IDH2, KIT, KRAS, MDM2, IKZF2, JAK2, MLL, MPL, MYD88, NOTCH1, NPM1, NRAS, PTPN11, RUNX1, TET2, TP53, and WT1) were sequenced using the Illumina MiSeq platform as previously described35 (Supporting Information Table S1). Testing for SRSF2 mutations was not performed. Testing for CALR mutations was performed separately and included, as previously described.14

Enrolled patients were followed with complete blood counts and chemistries weekly for cycles 1–3, every 2 weeks for cycles 4–6, and monthly from cycle 7 onwards. Bone marrow evaluations (including cytogenetic and molecular studies) were performed at baseline, after 6 and 12 cycles of therapy, and then every 12 cycles. MPN-SAF and MDASI were obtained prior to every cycle for the first 6 cycles, then every 3 cycles for the remainder of the study. Response assessment by the 2015 international consortium proposal of response criteria for MDS/MPNs (ICP MDS/MPN) in adults36 was documented at the end of each cycle for the first 6 cycles, then after every 3 cycles for the remainder of the study.

2.3 |. Treatment regimen

A sequential approach was adopted with single-agent ruxolitinib 5 mg orally twice daily administered continuously in 28-day cycles for the first 3 cycles if the baseline platelet count was 50–100 × 109/L, 15 mg orally twice daily if the baseline platelet count was 100–200 × 109/L, or 20 mg twice daily if the baseline platelet count was >200 × 109/L. The dose of ruxolitinib was modified during these 3 cycles based on the lack of efficacy or excess toxicity. After this initial run-in phase, azacytidine was to be added to ruxolitinib and was given at a dose of 25 mg/m2 intravenously or subcutaneously daily on Days 1–5 of each 28-day cycle, starting on Day 1 of cycle 4. If well-tolerated and deemed necessary for disease control, the azacytidine dose could be gradually increased to 50 mg/m2 and further to 75 mg/m2 in subsequent cycles. The azacytidine could be started earlier than cycle 4 and/or at a higher dose in patients with rapidly proliferative disease or with elevated blasts (>10%). The maximum dose of azacytidine allowed on this trial was 75mg/m2 given on Days 1–5 of each cycle.

Treatment cycles were repeated every 4 to 6 weeks. Therapy was continued until disease progression, the development of unacceptable toxicity, concurrent illness preventing further treatment, or patient’s request to withdraw from the study. Dose adjustments for adverse events (AEs) for grade 3 hematologic and nonhematologic drug-related toxicities were outlined in the protocol. Patients who received at least one dose of either study drug were eligible for efficacy and toxicity evaluation per an intent-to-treat approach.

2.4 |. Outcomes

The primary objective was to determine the objective response rate (ORR), defined as the best objective 2015 ICP MDS/MPN response achieved at any time on study. Secondary endpoints included the determination of safety and tolerability of the combination. Exploratory endpoints included the time to response (TTR) and the duration of response (DOR). DOR was defined as the time interval between the date of response and the date of first evidence of disease recurrence or treatment failure. Additional exploratory outcomes included evaluation of the effect of the combination on anemia and transfusion dependence in patients with MDS/MPNs, and the impact of baseline mutational profile and baseline anemia on the attainment of ICP MDS/MPN response and on OS with this combination.

Adverse events (AEs) were graded according to the latest common terminology criteria for adverse events (CTCAE) version 4.03. The adverse events were recorded from the time of enrollment on study until 30 days after the last dose of either study drug.

2.5 |. Statistical considerations

Summary statistics were used to describe the demographic and clinical characteristics of the study population. Pearson’s chi-squared test (or Fisher’s exact test) and t-test (or Wilcoxon’s rank sum test) were used to determine the differences between the cohort subgroups.

The primary endpoint was the 2015 ICP MDS/MPN ORR achieved with the regimen. The ORR was evaluated along with its 95% confidence interval. The method of Thall, Simon and Estey37 was used for futility monitoring for this study. OS was estimated using the Kaplan-Meier method. OS was calculated as the number of months from the start of treatment to death or last follow-up date; patients who were alive at their last follow-up were censored on that date.

Statistical analysis was performed using IBM SPSS Statistics 21 for Windows (SPSS Inc., Chicago, Illinois) and GraphPad Prism 7 (GraphPad Software, Inc., La Jolla, CA).

2.6 |. Role of funding source

This study was funded by Incyte pharmaceuticals, the MD Anderson Cancer Center Support Grant CA016672, the MD Anderson Cancer Center Leukemia SPORE CA100632 from the National Cancer Institute, the Charif Souki Cancer Research Fund and philanthropic contributions to the MD Anderson Moon Shots Program. The funders had no role in data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

3 |. RESULTS

3.1 |. Patient characteristics

Between May 2013 and December 2016, 35 patients were enrolled in the trial and included in the analysis of the primary endpoint; 14 had MDS/MPN-U, 17 had CMML, and 4 had aCML. The pretreatment characteristics are summarized in Table 1. The median age of patients was 70 years (range, 43–79); 60% were older than 65 years. Twenty-eight (80%) were intermediate-2 or high-risk per the DIPSS criteria for MF,33 12/32 (38%) had splenomegaly > 5 cm below costal margin (3 had prior splenectomy), and 12/30 (40%) had European Myelofibrosis Network (EUMNET) MF-2/MF-3 fibrosis on the baseline bone marrow. Twelve of the 35 patients (34%) had received prior therapy for MDS/MPN with the most prior therapies being hydroxyurea (n = 12; 34%), and/or anagrelide (n = 1; 3%), and/or pegylated interferon alfa-2a (n = 1; 3%). Targeted sequencing using the 28-gene panel35 was performed in 34 of the 35 (97%) patients. Ten (29%) patients had JAK2V617 mutation. Other common mutations included RAS (27%), ASXL1 (21%), TET2 (18%), and DNMT3A (12%). Fifteen (44%) patients had more than one mutation.

TABLE 1.

Baseline characteristics (N = 35)

Characteristics N (%)/Median [range]
Age, years 70 [43–79]
 >65 years 23 (66)
Male 21 (60)
Diagnosis
 MDS/MPNU/CMML/aCML 14 (40)/17 (49)/4 (11)
MF DIPSS
Int-1/Int-2/High 7 (20)/18 (51)/10 (29)
MDS IPSS
 Low/Int-1/Int-2/High 14 (40)/14 (40)/6 (17)/1 (3)
MDS R-IPSS
 Very Low/Low/Int/High/ 8 (23)/12 (34)/10
 Very High    (28)/3 (9)/2 (6)
MDA Global score
 Low/Int-1/Int-2/High 3 (9)/20 (57)/9 (25)/3 (9)
Splenomegaly 12/32 (38%)
Peripheral blood blasts ≥1% 24 (69)
WBC [×109/L] 26.3 [3–123.2]
Platelets [×109/L] 170 [53–1429]
Hemoglobin [g/dL] 10.1 [6.4–14.4]
LDH 860 [409–3230]
Cytogenetics
 Diploid/Abnormal 25 (71)/10 (29)
EUMNET Fibrosis Grade
 MF-1/MF-2/MF-3 17/29 (59)/8/29
   (28)/4/29 (14)
Patients with prior treatment 12 (34)
JAK2 mutation 10 (29)
JAK2 allele burden (%) 42.2 [3–90]
CALR mutation 0/8
MPL mutation 1/34 (3)
Molecular (28-gene profile, N = 34) a
 ASXL1 7(21)
 TET2 6(18)
 KRAS 5(15)
 NRAS 4(12)
 DNMT3A 4 (12)
 PTPN11 3(9)
 IDH2 2 (6)
 RUNX1 1 (3)
 GATA2 1 (3)
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a

Frequently identified mutations.

Abbreviations; Int: Intermediate; MDA: MD Anderson; WBC: white blood cell count; LDH: Lactate dehydrogenase; EUMNET: European myelofibrosis network.

3.2 |. Response to therapy

The median number of administered cycles of ruxolitinib with or without azacytidine was 10 (range, 1–47); treatment is ongoing in 8 (23%) patients. Azacytidine was administered in 32 of 35 (91%) patients. Three (9%) patients never started the azacytidine due to prohibitive cytopenias. Eighteen of the 32 (56%) patients initiated the azacytidine earlier than cycle 4 due to rapidly proliferative disease or increased blasts (>10%) as follows: in cycle 1 (n = 8), in cycle 2 (n = 6), and in cycle 3 (n = 4). Of the 32 patients who received azacytidine, the starting dose was 25mg/m2 in 23 (72%) patients, 50mg/m2 in 3 (9%) patients, and 75mg/m2 in 6 (19%) patients. The azacytidine dose was increased from a starting dose of 25mg/m2 to 50mg/m2 in 10 (31%) patients, from a starting dose of 25mg/m2 to 75mg/m2 in 1 (3%) patient, and from a starting dose of 50mg/m2 to 75mg/m2 in 4 (12.5%) patients (Supporting Information Table S2).

All 35 patients were evaluable for response per the 2015 ICP MDS/MPN criteria. Twenty patients (57%) achieved an objective response, and 11 (55%) of these achieved responses in more than one 2015 ICP MDS/MPN response category. The details of the responses achieved are shown in Table 2. Ten patients had >5% pretreatment bone marrow blasts and 7 (70%) of these achieved a reduction in bone marrow blasts to <5%. A >50% reduction in palpable spleen length at 24 weeks was seen in 9 of 12 (75%) patients with pretreatment palpable spleen >5 cm below left subcostal margin (Figure 1A). Overall, the median time to achieving any ICP MDS/MPN response (TTR) was 1.25 months (range, 0.7–3.7).

TABLE 2.

Distribution of international Working Group (IWG) responses for MDS/MPN patients

IWG MDS-MPN 2015 Response N (%)/Median [range]
Objective Responses a 20/35 (57)
CI Spleen (spleen > 5 cm) 9/14 (64)
 After AZA addition 5/9 (56)
Median time to CI spleen, (month) 1.8 (0.7–7.3)
 After AZA addition 0.8 (0.3–4.5)
CI Total symptom Score (TSS > 20) 14/18 (78)
 Median time to CI TSS, (month) 1 (0.9–1.8)
CI Transfusion Independence 1/11 (9)
 Time to transfusion independence 3.7 months
Marrow response
 Partial marrow response 9/22 (41)
 Optimal marrow response 1/22 (5)
 Median time to marrow response, (month) 5.5 (2–11.2)
BM blast reduction (>5% blast) 7/10 (70)
Complete cytogenetic remission 1/5 (20)
 Time to cytogenetic remission 32.1 months
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a

(11 patients have >1 response).

Data are expressed as n (%) or median [range].

Abbreviations; CI: clinical improvement; AZA: azacytidine; TSS: total symptom score; BM: Bone marrow.

FIGURE 1.

FIGURE 1

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(A) depicts the percentage of change in spleen volume during therapy. Of the 12 patients with baseline splenomegaly palpable >5 cm below costal margin, 9 (64%) showed clinical improvement with >50% reduction of spleen volume when treated with AZA 1 RUX, at a median time of 1.8 months (range, 0.7–7.3 months), including 4 patients with 100% decrease from baseline. One patient achieved 45% reduction of splenomegaly, while 2 patients did not have any clinical improvement of spleen volume. (B) Overall survival, per diagnosis cohort, of patients with MDS/MPN treated with ruxolitinib and azacytidine. Kaplan–Meier estimates. (C) Overall survival of patients with MDS/MPN who have achieved clinical response in general compared to those who had no response; Kaplan–Meier analysis. mOS: Median overall survival [Color figure can be viewed at wileyonlinelibrary.com]

Among the 20 responders, 2 patients never received azacytidine, 2 started azacytidine concomitantly with ruxolitinib in cycle 1, and 16 started the azacytidine after cycle 1 with median start time of azacytidine in cycle 4 (range, 2–4). Of the 20 responders, a total of 9 (45%) responded only after the addition of azacytidine with a median time to achieving response after the addition of azacytidine of 1.0 months (range, 0.3–4.5); of these, 6 patients who achieved a clinical improvement (CI) in one ICP MDS/MPN category on ruxolitinib alone went on to achieve a deeper response after the addition of the azacytidine [namely, optimal marrow response (OMR) in 1 patient and partial marrow response (PMR) in 5 including 1 with cytogenetic remission]. Five of the 9 spleen responses (56%) occurred after the addition of azacytidine with a median time to achieving response after the addition of azacytidine of 0.8 months (range, 0.3–4.5).

Baseline characteristics of responders and nonresponders are compared in Supporting Information Table S3. Patients with JAK2-mutation and baseline palpable spleen >5 cm had a higher ICP MDS/MPN response rate to the combination (P = .02 and P = .03, respectively). There was no correlation with pretherapy age, karyotype, number of molecular mutations, and MF-DIPSS,33 MDS-IPSS,38 MDS-revised IPSS39 (MDS-RIPSS) or MD Anderson (MDA) global40 scores and response to the combination of azacytidine and ruxolitinib by univariate analysis.

Five (14%) patients progressed to AML while on study with a median time to progression of 13.5 months (range, 6–34.5), 3 of them transformed following an initial period of clinical response per the ICP MDS/MPN criteria. The details of the patients who transformed are given in Supporting Information Table S4.

3.3 |. Survival endpoints

The median duration of treatment in the study population was 13.8 months (range, 0.9–47). The median follow-up for all patients was 15.2 months (range, 1.0–41.5). At the date of the last follow-up, 15 (43%) patients remain alive. The median duration of response (DOR) on this regimen was 8 months (range, 2.3–32.0; 95% CI: 5.7–19) and treatment is ongoing in 8 (23%) patients. The median OS for the study population was 16.6 months (range, 1.0–41.0), with 1-year and 2-year OS rates of 76% and 41%, respectively. Patients with MDS/MPN-U had a significantly better median OS (26.5 months) as compared to CMML (15.1 months) and aCML (8 months), respectively (P = .034) on this regimen, which translated to a 1-year OS rate of 100% vs 76% vs 50%, and a 2- year OS rate of 62% vs 39% vs 25%, respectively for MDS/MPN-U, CMML, and aCML (Figure 1B).

We conducted a univariate analysis to evaluate the impact of baseline and on-treatment characteristics that could impact OS (Supporting Information Table S5). None of the baseline characteristics including WBCs, blast percentage, mutational characteristics, and MDS/MF scoring systems (MF-DIPSS, MDS-IPSS, MDS-RIPSS, and MDA global scores) predicted for improved OS (Supporting Information Table S5). Patients who achieved a 2015 ICP MDS/MPN response (N = 20) had a trend to improved OS when compared to nonresponders (N = 15) (26.5 months vs 14.5 months; P = .08; HR 0.45; 95% CI: 0.16–1.12) with 1-year and 2-year OS rates of 89% vs 77% and 60% vs 28%, respectively (Figure 1C).

Twenty-seven (77%) patients have discontinued protocol therapy due to progressive leukocytosis (n = 7), lack of response (n = 6), progression to AML and transition to AML induction therapy (n = 5), elective allogeneic stem cell transplant (ASCT) (n = 4), progressive thrombocytopenia (n = 1), pneumothorax (n = 1), concurrent T-cell neoplasm and anal cancer requiring chemotherapy (n = 1, each), and loss of insurance (n = 1).

Five patients were successfully bridged to ASCT; of these, 3 died post-ASCT of ASCT-related complications including sepsis (n = 1) and graft-versus host disease (n = 2) with median time to death post-ASCT of 7.1 months (range, 0.9–8.2). Two patients remain alive post-ASCT (11 months and 8 months post-SCT, respectively) with no clinical or morphologic evidence of disease.

3.4 |. Safety

The median number of cycles of ruxolitinib received was 10 (range, 1–47) and the median number of cycles of azacytidine received was 8 (range, 0–42). The regimen was well tolerated with only one patient (3%) requiring therapy discontinuation due to thrombocytopenia. The most commonly reported nonhematologic AEs of any grade irrespective of attribution were nausea and vomiting (23%), constipation (23%), diarrhea (9%), and abdominal pain (9%) (Table 3). These were transient with no patients requiring therapy discontinuation. New onset grade 3–4 hematologic AEs irrespective of attribution at any time on study included thrombocytopenia (54%), anemia (51%) and neutropenia (29%). These were manageable with dose modifications and/or short interruptions, with one patient requiring discontinuation of study therapy due to refractory cytopenias.

TABLE 3.

Adverse events on study, regardless of causality

Toxicities Grade 1–2 N (%) Grade 3–4 N (%)
Constipation 8 (23)
Nausea/Vomiting 8 (23)
Diarrhea 3 (9)
Myalgias/Abdominal Pain 3 (9)
Chest pain 2 (6) 1 (3)
Anorexia 2 (6)
Dizziness 2 (6)
Fatigue 1 (3) 2 (6)
Bruising 2 (6)
Insomnia 1 (3)
Edema - limbs 1 (3) 1 (3)
Periorbital edema 1 (3) 1 (3)
Shingles 1 (3)
Actinic Keratosis 2 (6)
Urinary tract infections 2 (6) 3 (9)
Pneumonia 2 (6) 3 (9)
Skin/soft tissue infections 2 (6) 3 (9)
Constrictive pericarditis 1 (3)
Heart failure 1 (3) 3 (9)
Headache 1 (3)
Hyperuricemia 1 (3)
Transaminitis 7 (20)
Hyperbilirubinemia 2 (6)
Thrombocytopenia 7 (20) 19 (54)
Anemia 6 (17) 18 (51)
Neutropenia 1 (3) 10 (29)
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At a median follow-up of 15.2 months (range, 1–41.5), 20 (57%) patients have died from sepsis (n = 7), progression to AML (n = 7), pneumonia (n = 5), and cardiac arrest (n = 1).

4 |. DISCUSSION

Establishing standard diagnostic, prognostic and treatment algorithms for the MDS/MPNs has remained challenging given the relative infrequency of this condition, and the heterogeneous clinical and mutational profiles of various MDS/MPN subsets.3–5,13 Mutational profiling indicates that the JAK/STAT and epigenetic pathways play an important role in the pathogenesis of CMML and MDS/MPN-U suggesting that concomitant blockade with ruxolitinib and HMAs may be effective. Clinically, ruxolitinib has recently shown efficacy in patients with CMML-1 with particular benefit in proliferative patients.41 Ruxolitinib may specifically offer benefit in the aCML patients with JAK2 or CSF3R42,43 mutations and potentially in aCML patients not harboring these mutations (NCT02092324). HMA therapy produced a complete hematologic remission (CHR) in 7 of the 8 patients with aCML, described in 4 separate reports.29 We aimed to derive synergistic benefit from the combination, with hypomethylation improving cytopenias and delaying progression to acute leukemia,21,44 while JAK/STAT-inhibition mitigating cytokine-related symptoms, splenomegaly, and reversing or stabilizing marrow fibrosis.18,45–47

Objective responses as defined by the 2015 ICP MDS/MPN 2015 criteria36 were seen in 57% of the patients on this trial. As expected, the combination was particularly effective in improving proliferative features including ICP MDS/MPN reductions in palpable splenomegaly and improvements in the total symptom score by MPN-SAF, in 64% and 78% of patients, respectively. Another encouraging response was the attainment of bone marrow morphologic remissions in 7 of 10 patients who had >5% bone marrow blasts at baseline. Bone marrow blast reduction is not frequently seen with single agent ruxolitinib in patients with MF18,48 and bone marrow blasts >10% is known to be an adverse prognostic factor for response to single-agent azacytidine in CMML,49 indicating that achievement of bone marrow blast remissions in patients with MDS/MPNs may be one of the areas where the combination of azacytidine and ruxolitinib provided a specific advantage to either single agent alone.

Patients with a JAK2 mutation had a significantly higher ICP MDS/MPN response rate as compared to patients without a JAK2 mutation on univariate analysis although responses were seen among both JAK2 mutated (n = 10; response rate = 90%) and nonmutated patients (n = 24; response rate = 29%). This is similar to what has been well established with single agent ruxolitinib therapy in primary MF.18,19 Similarly, patients with baseline splenomegaly had higher response rates and this may be due to the fact that as opposed to patients without a baseline enlarged spleen these patients had the added possibility of being counted for spleen responses, an independent response category per the ICP MDS/MPN 2015 response criteria. An achievement of response was associated with improved OS indicating disease modification in the responders, and is similar to findings in primary MF wherein the degree of spleen reduction was the only factor associated with improved OS.50 Mutational profiles, either quantitatively (<3 or >/=3 mutations) or qualitatively (presence of ASXL1, EZH2, IDH1/2) did not predict for response or OS in our study, in contrast to what has been shown in primary MF.51,52

HMA and ruxolitinib have successfully been used as an “induction” therapy before ASCT for patients with MDS and MF, respectively, to potentially reduce the disease burden and to improve the performance status (especially in patients with accelerated or advanced MF), thereby potentially reducing post ASCT morbidity.53–58 In patients with MDS/MPNs the use of these drugs alone or in combination as a priming therapy prior to allogeneic SCT has not been formally assessed. In our study, 5 patients electively underwent SCT following the achievement of response to the combination, and 3 died of transplant-related complications at a median time of 7.1 months (range, 0.9–8.2) post-SCT. These are small numbers but suggest the need for careful selection of patients with MDS/MPN for ASCT.

The combination of azacytidine and ruxolitinib was overall well tolerated with only one patient discontinuing therapy due to prolonged thrombocytopenia, similar to discontinuation rates seen with single agent ruxolitinib in studies in primary MF.18,19 Myelosuppression was a frequent adverse event but was manageable with interruptions and dose-modifications in the majority of the patients. Despite the limited number of patients that underwent SCT and a high incidence of transformation to AML, the median OS of this population was 16.6 months (range, 1.0 – 41) with 1-year and 2-year OS of 76% and 41%, respectively. The survival benefit seems to be more profound in the MDS/MPN-U subgroup, frequently reported to have dismal survival.5,59 A significant improvement in median survival was seen when we compared MDS/MPN-U patients treated on this combination (N = 14) to a previously published contemporary historical cohort of MDS/MPN-U patients treated with AZA alone (N = 36) at our institution13 (median OS of 26.5 months vs 16.4 months; P = .045) (Supporting Information Figure S1). The benefit remained significant when the patients were stratified by MDS-IPSS (P = .006), MDS-RIPSS (P = .04), DIPSS-MF scores (P = .009) and MDA Global model (P = .1) and was most pronounced in patients with intermediate-, high- or very high-risk scores (Supporting Information Figure S2A–D). We believe that the MDS/MPN-U subgroup most specifically benefited from this combination approach and further investigation of the combination in prospective, multicenter studies is most compelling in this patient population.

Supplementary Material

Supinfo

Additional Supporting Information may be found online in the supporting information tab for this article.

Funding information

Incyte Pharmaceuticals and the MD Anderson Cancer Centre Leukaemia Support Grant (CCSG), Grant/Award Number: CA016672, the MD Anderson Cancer Center Leukemia, Grant/Award Number: SPORE CA100632, the Charif Souki Cancer Research Fund and generous philanthropic contributions to the MD Anderson Moon Shots Program

Footnotes

CONFLICT OF INTEREST

This study was supported by a grant from Incyte Inc. HK, GGM, JC, NP, SV, and ND have received research funding from Incyte. HK, GGM, JC, NP, EJ, PB, ZE, CBR, and ND have received honoraria from Incyte Inc.

Trial Registration ID: Clinicaltrials.gov identifier: NCT01787487.

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