Characterization of JAK2 V617F Allele Burden in Advanced Myelofibrosis (MF) Patients: No Change in V617F:WT JAK2 Ratio in Patients with High Allele Burdens despite Profound Clinical Improvement Following Treatment with the JAK Inhibitor, INCB018424
Authors: Verstovsek Srdan , Kantarjian Hagop M. , Pardanani Animesh D. , Burn Timothy , Vaddi Kris , Redman John , Bradley Edward C , Levy Richard , Friedman Steven , Hollis Gregory , Tefferi Ayalew 
Published: April 2020

Abstract
Background: Activating mutations in the pseudokinase domain of JAK2 occur at a high frequency in Philadelphia chromosome-negative myeloproliferative disorders (MPDs). Increasing JAK2 V617F allele burden has been shown to correlate with disease severity (bone marrow dysfunction, organomegaly and constitutional symptoms), which is consistent with exaggerated JAK2 signaling playing a central role in MPDs. INCB018424 is a potent and selective JAK1/2 inhibitor currently being evaluated in the clinic for the treatment of MPDs including primary myelofibrosis (PMF), post-polycythemia vera and essential thrombocythemia myelofibrosis (Post-PV/ET MF).
Methods: The percentage of mutant JAK2 V617F relative to wild-type JAK2 was determined in peripheral blood using a quantitative single-nucleotide extension assay. The assay is based on the single nucleotide extension of a DNA primer that anneals adjacent to the V617F mutation. The percentage of JAK2 V617F in bone marrow was determined using pyrosequencing as previously described. The relationship between JAK2 V617F allele burden and clinical phenotype was assessed with samples obtained at study entry. JAK2 V617F allele burden was assessed in nineteen PMF and Post-PV/ET MF patients treated with 25 mg BID INCB018424 for a minimum of three months using peripheral blood and bone marrow.
Results: There is an excellent correlation in the JAK2 V617F allele burden between samples obtained from bone marrow and peripheral blood, suggesting that the fraction of cells bearing the mutant clone remains stable during hematopoiesis in this patient group. The mean %V617F values were 59%, 80% and 86% for Post-ET MF (n=2), Post-PV MF (n=8) and PMF (n=9) patients. V617F allele burden correlated with spleen size, absolute neutrophil count (ANC) and Body Mass Index (BMI) in this patient population (R2 values if 0.61, 0.17 and 0.44, respectively), with a higher allele burden predicting larger spleen size, a higher ANC and a lower BMI. Eighteen of the nineteen evaluable JAK2 V617F-positive patients had baseline JAK2 V617F values above 50%, with the mean %V617F value for all evaluable patients being 81%, implying that the majority of hematopoietic stem cells contain the mutant allele in this patient population. During INCB018424 therapy (at least 3 months of treatment) in these patients, profound improvements in clinical endpoints including reduction or resolution of splenomegaly and constitutional symptoms are observed, yet only a modest decrease in JAK2 V617F allele burden is seen in both bone marrow and peripheral blood (13% and 9 % decrease from baseline, respectively, at 3 months).
Conclusions: While the patient group is small and heterogeneous in nature, clinical correlates of V617F allele burden observed in myelofibrosis patients in this study are similar to those reported in PV. In addition, despite profound clinical improvements in these patients, V617F allele burdens do not change dramatically suggesting that the clinical activity of INCB018424 might involve inhibition of downstream signaling in cells harboring activating JAK2 mutations rather than changing the allele burden.