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UTILITY OF NEXT GENERATION SEQUENCING TECHNIQUES TO EVALUATE POSSIBLE CAUSES OF REFRACTORINESS TO TREATMENT WITH ELTROMBOPAG IN ADULT PATIENTS WITH PRIMARY IMMUNE THROMBOCYTOPENIA (ITP) IN SPAIN.
Author(s): ,
Tomas Jose Gonzalez-Lopez
Affiliations:
Hematology,Hospital Universitario de Burgos,Burgos,Espagne;Hematology,Hospital Universitario de Burgos,Burgos,Spanien;Hematology,Hospital Universitario de Burgos,Burgos,Spagna;Hematology,Hospital Universitario de Burgos,Burgos,Spain;Hematology,Hospital Universitario de Burgos,Burgos,España;Hematology,Hospital Universitario de Burgos,Burgos,Spanje;Hematology,Hospital Universitario de Burgos,Burgos,
,
Ricardo Sanchez
Affiliations:
Hematology,Hospital Universitario 12 de Octubre,Madrid,Espagne;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanien;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spagna;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spain;Hematology,Hospital Universitario 12 de Octubre,Madrid,España;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanje;Hematology,Hospital Univers
,
Carmen Pastoriza
Affiliations:
Hematology,Complejo Hospitalario Universitario de Orense.,Orense,Espagne;Hematology,Complejo Hospitalario Universitario de Orense.,Orense,Spanien;Hematology,Complejo Hospitalario Universitario de Orense.,Orense,Spagna;Hematology,Complejo Hospitalario Universitario de Orense.,Orense,Spain;Hematology,Complejo Hospitalario Universitario de Orense.,Orense,España;Hematology,Complejo Hospitalario Univer
,
Blanca Sanchez Gonzalez
Affiliations:
Hematology,Hospital del Mar,Barcelona,Espagne;Hematology,Hospital del Mar,Barcelona,Spanien;Hematology,Hospital del Mar,Barcelona,Spagna;Hematology,Hospital del Mar,Barcelona,Spain;Hematology,Hospital del Mar,Barcelona,España;Hematology,Hospital del Mar,Barcelona,Spanje;Hematology,Hospital del Mar,Barcelona,Espanha;Hematology,Hospital del Mar,Barcelona,Испания;Hematology,Hospital del Mar,Barcelona
,
Pavel Olivera
Affiliations:
Hematology,Hospital Universitario Sagrado Corazón - Grupo Quirónsalud,Barcelona,Espagne;Hematology,Hospital Universitario Sagrado Corazón - Grupo Quirónsalud,Barcelona,Spanien;Hematology,Hospital Universitario Sagrado Corazón - Grupo Quirónsalud,Barcelona,Spagna;Hematology,Hospital Universitario Sagrado Corazón - Grupo Quirónsalud,Barcelona,Spain;Hematology,Hospital Universitario Sagrado Corazón -
,
Silvia Bernat
Affiliations:
Hematology,Hospital Universitario de la Plana,Castellón,Espagne;Hematology,Hospital Universitario de la Plana,Castellón,Spanien;Hematology,Hospital Universitario de la Plana,Castellón,Spagna;Hematology,Hospital Universitario de la Plana,Castellón,Spain;Hematology,Hospital Universitario de la Plana,Castellón,España;Hematology,Hospital Universitario de la Plana,Castellón,Spanje;Hematology,Hospital U
,
Fernando Fernandez-Fuertes
Affiliations:
Hematology,Hospital Universitario Insular de Gran Canaria,Las Palmas,Espagne;Hematology,Hospital Universitario Insular de Gran Canaria,Las Palmas,Spanien;Hematology,Hospital Universitario Insular de Gran Canaria,Las Palmas,Spagna;Hematology,Hospital Universitario Insular de Gran Canaria,Las Palmas,Spain;Hematology,Hospital Universitario Insular de Gran Canaria,Las Palmas,España;Hematology,Hospital
,
Isabel Caparrós Miranda
Affiliations:
Hematology,Hospital Universitario Virgen de la Victoria de Málaga.,Malaga,Espagne;Hematology,Hospital Universitario Virgen de la Victoria de Málaga.,Malaga,Spanien;Hematology,Hospital Universitario Virgen de la Victoria de Málaga.,Malaga,Spagna;Hematology,Hospital Universitario Virgen de la Victoria de Málaga.,Malaga,Spain;Hematology,Hospital Universitario Virgen de la Victoria de Málaga.,Malaga,E
,
Eva Mingot
Affiliations:
Hematology,Complejo Hospital Regional de Málaga,Malaga,Espagne;Hematology,Complejo Hospital Regional de Málaga,Malaga,Spanien;Hematology,Complejo Hospital Regional de Málaga,Malaga,Spagna;Hematology,Complejo Hospital Regional de Málaga,Malaga,Spain;Hematology,Complejo Hospital Regional de Málaga,Malaga,España;Hematology,Complejo Hospital Regional de Málaga,Malaga,Spanje;Hematology,Complejo Hospita
,
Gloria Pérez-Rus
Affiliations:
Hematology,Hospital Universitario Gregorio Marañón de Madrid.,Madrid,Espagne;Hematology,Hospital Universitario Gregorio Marañón de Madrid.,Madrid,Spanien;Hematology,Hospital Universitario Gregorio Marañón de Madrid.,Madrid,Spagna;Hematology,Hospital Universitario Gregorio Marañón de Madrid.,Madrid,Spain;Hematology,Hospital Universitario Gregorio Marañón de Madrid.,Madrid,España;Hematology,Hospital
,
Isidro Jarque
Affiliations:
Hematology,Hospital Universitario y Politécnico La Fe de Valencia,Valencia,Espagne;Hematology,Hospital Universitario y Politécnico La Fe de Valencia,Valencia,Spanien;Hematology,Hospital Universitario y Politécnico La Fe de Valencia,Valencia,Spagna;Hematology,Hospital Universitario y Politécnico La Fe de Valencia,Valencia,Spain;Hematology,Hospital Universitario y Politécnico La Fe de Valencia,Valen
,
Maria Esperanza Moreno Beltrán
Affiliations:
Hematology,Hospital Costa del Sol,Marbella (Malaga),Espagne;Hematology,Hospital Costa del Sol,Marbella (Malaga),Spanien;Hematology,Hospital Costa del Sol,Marbella (Malaga),Spagna;Hematology,Hospital Costa del Sol,Marbella (Malaga),Spain;Hematology,Hospital Costa del Sol,Marbella (Malaga),España;Hematology,Hospital Costa del Sol,Marbella (Malaga),Spanje;Hematology,Hospital Costa del Sol,Marbella (M
,
Emma López Abadía
Affiliations:
Hematology,Hospital General de Elche,Elche,Espagne;Hematology,Hospital General de Elche,Elche,Spanien;Hematology,Hospital General de Elche,Elche,Spagna;Hematology,Hospital General de Elche,Elche,Spain;Hematology,Hospital General de Elche,Elche,España;Hematology,Hospital General de Elche,Elche,Spanje;Hematology,Hospital General de Elche,Elche,Espanha;Hematology,Hospital General de Elche,Elche,Испан
,
Erik De Cabo
Affiliations:
Hematology,Hospital del Bierzo,Ponferrada (León),Espagne;Hematology,Hospital del Bierzo,Ponferrada (León),Spanien;Hematology,Hospital del Bierzo,Ponferrada (León),Spagna;Hematology,Hospital del Bierzo,Ponferrada (León),Spain;Hematology,Hospital del Bierzo,Ponferrada (León),España;Hematology,Hospital del Bierzo,Ponferrada (León),Spanje;Hematology,Hospital del Bierzo,Ponferrada (León),Espanha;Hemato
,
Shally Marcellini
Affiliations:
Hematology,Hospital General de Segovia,Segovia,Espagne;Hematology,Hospital General de Segovia,Segovia,Spanien;Hematology,Hospital General de Segovia,Segovia,Spagna;Hematology,Hospital General de Segovia,Segovia,Spain;Hematology,Hospital General de Segovia,Segovia,España;Hematology,Hospital General de Segovia,Segovia,Spanje;Hematology,Hospital General de Segovia,Segovia,Espanha;Hematology,Hospital
,
Gloria Pérez Segura
Affiliations:
Hematology,Hospital Universitario 12 de Octubre,Madrid,Espagne;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanien;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spagna;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spain;Hematology,Hospital Universitario 12 de Octubre,Madrid,España;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanje;Hematology,Hospital Univers
,
Carmen Fernández-Miñano
Affiliations:
Hematology,Hospital Vega Baja,Orihuela (Alicante),Espagne;Hematology,Hospital Vega Baja,Orihuela (Alicante),Spanien;Hematology,Hospital Vega Baja,Orihuela (Alicante),Spagna;Hematology,Hospital Vega Baja,Orihuela (Alicante),Spain;Hematology,Hospital Vega Baja,Orihuela (Alicante),España;Hematology,Hospital Vega Baja,Orihuela (Alicante),Spanje;Hematology,Hospital Vega Baja,Orihuela (Alicante),Espanha
,
María Jesús Peñarrubia
Affiliations:
Hematology,Hospital Clinico de Valladolid,Valladolid,Espagne;Hematology,Hospital Clinico de Valladolid,Valladolid,Spanien;Hematology,Hospital Clinico de Valladolid,Valladolid,Spagna;Hematology,Hospital Clinico de Valladolid,Valladolid,Spain;Hematology,Hospital Clinico de Valladolid,Valladolid,España;Hematology,Hospital Clinico de Valladolid,Valladolid,Spanje;Hematology,Hospital Clinico de Valladol
,
Maria Alvarez
Affiliations:
Hematology,Hospital Universitario La Paz,Madrid,Espagne;Hematology,Hospital Universitario La Paz,Madrid,Spanien;Hematology,Hospital Universitario La Paz,Madrid,Spagna;Hematology,Hospital Universitario La Paz,Madrid,Spain;Hematology,Hospital Universitario La Paz,Madrid,España;Hematology,Hospital Universitario La Paz,Madrid,Spanje;Hematology,Hospital Universitario La Paz,Madrid,Espanha;Hematology,Ho
,
Miguel Angel Fuertes Palacio
Affiliations:
Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Espagne;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Spanien;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Spagna;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Spain;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,España;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Spanje;Hematology,Hospital Clínico Lozano Blesa,Zaragoza,Espanha
Joaquín Martinez Lopez
Affiliations:
Hematology,Hospital Universitario 12 de Octubre,Madrid,Espagne;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanien;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spagna;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spain;Hematology,Hospital Universitario 12 de Octubre,Madrid,España;Hematology,Hospital Universitario 12 de Octubre,Madrid,Spanje;Hematology,Hospital Univers
(Abstract release date: 05/12/22) EHA Library. Jose Gonzalez-Lopez T. 06/10/22; 358496; P1639
Tomas Jose Gonzalez-Lopez
Tomas Jose Gonzalez-Lopez
Contributions
Abstract
Presentation during EHA2022: All (e)Poster presentations will be made available as of Friday, June 10, 2022 (09:00 CEST) and will be accessible for on-demand viewing until Monday, August 15, 2022 on the Congress platform.

Abstract: P1639

Type: Poster presentation

Session title: Platelet disorders

Background

Primary immune thrombocytopenia (ITP) is an autoimmune acquired disease characterized by low production and increased platelet destruction. Thrombopoietin receptor agonists (TPO-RAs) i.e. eltrombopag, romiplostim and avatrombopag are currently used as second line treatment for ITP. Eltrombopag has demonstrated high response rates (≥80%) both in clinical trials and in routine practice studies. Nevertheless, some patients are refractory to this drug and do not attain a response when using the maximum eltrombopag approved dose of 75 mg per day after at least four weeks of treatment. Next generation sequencing (NGS) may help us discover underlying molecular biology variants that may be involved in eltrombopag refractoriness.

Aims

To evaluate potential molecular markers of refractoriness to eltrombopag in ITP in routine clinical practice through the use of most recent molecular biology techniques (NGS).

Methods

Nationwide multicenter, retrospective NGS study to investigate most important cell-signaling pathways that are involved in eltrombopag mechanism of action. So, 108 genes directly related to the downstream signaling of eltrombopag, cytokine signaling pathways, cytotoxic pathways, growth factors, adhesion molecules, apoptotic mechanisms and physiological mechanisms of platelet production are analyzed in peripheral blood from 35 refractory and 35 controls who responded to the drug.

Results

Our refractory population involved 18/35 (51.4%) of male with a median age at diagnosis of 48 [range, 38-70] years and a median platelet count of 8 [range,  4-16] x 109/µL. At eltrombopag initiation, median time from diagnosis was 14 [range, 6-103] months with a median age of 60 [range, 41-75] years while median platelet count was 8 [range,  5-30] x 109/µL. 78.3% and 13.0% of cases were chronic and persistent ITP respectively. They have received a median of only two previous treatment lines [range, 2-4] (100% steroids, 42.8% IVIG, 40% splenectomy, 31.4% rituximab, 37.1% romiplostim). Eltrombopag treatment was maintained during 3 [range, 1-9] months as a median before discontinuation. No major grade 3-4 side effects were reported. On the other hand, characteristics of respondent controls were similar to refractory population. Statistical differences were observed regarding prior treatment lines, response and complete response rates (p=<0.001).

Of the total sum of the NGS variants found and after artefacts eliminated a list of 53 variants were found. 13 variants with statistical significance (p≤0.05) between case and controls were relevant being some of them potentially associated with cancer and others considered benign instead. Variant two and seven are described in gastric and lung cancer respectively. Variants one, four, five, six, nine, eleven and thirteen belong to the second group. Variants three, eight, ten and twelve are not previously described and its significance is unknown (Table 1).

Conclusion

To the best of our knowledge, none of the 13 statistically significant variants reported here have ever been correlated with eltrombopag refractoriness although some of them have been previously associated with different cancers. Here we describe four non-previously published DNA variants and other nine non-previously described in ITP which role in megakaryopoesis and ITP drug refractoriness must be elucidated. It is needed more studies (including functional) to establish a more robust correlation between these variants and eltrombopag refractoriness.

Keyword(s): Immune thrombocytopenia (ITP), Molecular markers, Refractory, Treatment

Presentation during EHA2022: All (e)Poster presentations will be made available as of Friday, June 10, 2022 (09:00 CEST) and will be accessible for on-demand viewing until Monday, August 15, 2022 on the Congress platform.

Abstract: P1639

Type: Poster presentation

Session title: Platelet disorders

Background

Primary immune thrombocytopenia (ITP) is an autoimmune acquired disease characterized by low production and increased platelet destruction. Thrombopoietin receptor agonists (TPO-RAs) i.e. eltrombopag, romiplostim and avatrombopag are currently used as second line treatment for ITP. Eltrombopag has demonstrated high response rates (≥80%) both in clinical trials and in routine practice studies. Nevertheless, some patients are refractory to this drug and do not attain a response when using the maximum eltrombopag approved dose of 75 mg per day after at least four weeks of treatment. Next generation sequencing (NGS) may help us discover underlying molecular biology variants that may be involved in eltrombopag refractoriness.

Aims

To evaluate potential molecular markers of refractoriness to eltrombopag in ITP in routine clinical practice through the use of most recent molecular biology techniques (NGS).

Methods

Nationwide multicenter, retrospective NGS study to investigate most important cell-signaling pathways that are involved in eltrombopag mechanism of action. So, 108 genes directly related to the downstream signaling of eltrombopag, cytokine signaling pathways, cytotoxic pathways, growth factors, adhesion molecules, apoptotic mechanisms and physiological mechanisms of platelet production are analyzed in peripheral blood from 35 refractory and 35 controls who responded to the drug.

Results

Our refractory population involved 18/35 (51.4%) of male with a median age at diagnosis of 48 [range, 38-70] years and a median platelet count of 8 [range,  4-16] x 109/µL. At eltrombopag initiation, median time from diagnosis was 14 [range, 6-103] months with a median age of 60 [range, 41-75] years while median platelet count was 8 [range,  5-30] x 109/µL. 78.3% and 13.0% of cases were chronic and persistent ITP respectively. They have received a median of only two previous treatment lines [range, 2-4] (100% steroids, 42.8% IVIG, 40% splenectomy, 31.4% rituximab, 37.1% romiplostim). Eltrombopag treatment was maintained during 3 [range, 1-9] months as a median before discontinuation. No major grade 3-4 side effects were reported. On the other hand, characteristics of respondent controls were similar to refractory population. Statistical differences were observed regarding prior treatment lines, response and complete response rates (p=<0.001).

Of the total sum of the NGS variants found and after artefacts eliminated a list of 53 variants were found. 13 variants with statistical significance (p≤0.05) between case and controls were relevant being some of them potentially associated with cancer and others considered benign instead. Variant two and seven are described in gastric and lung cancer respectively. Variants one, four, five, six, nine, eleven and thirteen belong to the second group. Variants three, eight, ten and twelve are not previously described and its significance is unknown (Table 1).

Conclusion

To the best of our knowledge, none of the 13 statistically significant variants reported here have ever been correlated with eltrombopag refractoriness although some of them have been previously associated with different cancers. Here we describe four non-previously published DNA variants and other nine non-previously described in ITP which role in megakaryopoesis and ITP drug refractoriness must be elucidated. It is needed more studies (including functional) to establish a more robust correlation between these variants and eltrombopag refractoriness.

Keyword(s): Immune thrombocytopenia (ITP), Molecular markers, Refractory, Treatment

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