Tagraxofusp Shows Promising Anti-Tumoral Efficacy in Preclinical in Vitro Models of Myelofibrosis, Both As a Single Agent and in Combination with Janus Kinase Inhibitors

BACKGROUND: Myelofibrosis (MF) is an aggressive myeloproliferative neoplasm. Abnormal growth of hematopoietic stem and progenitor cells in MF is driven by somatic mutations affecting the Janus Kinase (JAK) signaling pathway with JAK2 V617F occurring in 50-60% of patients (Cardoso et al, Plos One 2015). The role of the JAK/Signal transducer and activator of transcriptions (STAT) pathway in MF has led to the recent approval of three different JAK2 inhibitors (ruxolitinib, pacritinib, and fedratinib) for MF treatment. However, despite limiting the symptoms of the disease, JAK2 inhibitors do not result in remission due to persistence of JAK2 activation and MF-driving cells (Pandey et al, Blood Cancer J 2022). Thus, there remains a high unmet need for treatment strategies for patients with MF. Tagraxofusp, a first-in-class CD123-directed therapy, is a recombinant fusion protein consisting of human interleukin-3 conjugated to a truncated diphtheria toxin payload approved (US/EU) for the treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm. In MF, CD123 is expressed on malignant cells and bone marrow (BM) accessory cells that support the proliferation of neoplastic cells (Bao et al, Hematol Oncol Stem Cell Ther 2019; Lasho et al, Blood 2014). Based on CD123 expression, tagraxofusp is a potential, novel approach for MF treatment either alone or in combination. Initial results from a two-stage multicenter, phase 2 study (STML-0401-0314; NCT02268253) of single-agent tagraxofusp in pts with relapsed or refractory (R/R) MF demonstrated encouraging clinical efficacy and a manageable safety profile (Yacoub et al. ASH 2021). We aim to further investigate the antitumoral efficacy of tagraxofusp in MF preclinical models and the potential improvement of antitumoral efficacy by combining tagraxofusp with the JAK inhibitors, ruxolitinib, and pacritinib. METHODS: MF cell lines (SET2, UKE1, HEL: JAK2 V617F; UT7: JAK2 wild type [wt]) and bone marrow mononuclear cell (BMMC) samples from healthy donors (HD) were characterized for the extracellular expression of CD123 by flow cytometry staining. In vitro cytotoxicity experiments in CD123-positive MF cell lines (SET2, UT7, UKE-1) tested tagraxofusp and ruxolitinib or pacritinib either as single agents or in combination (MTS assay; 72 h). The combination index (CI) was calculated according to the Compusyn-Chou method (Chou TC., Pharmacol Rev, 2006) and Combenefit platform. In vitro co-culture experiments were performed with MF c