Selinexor is the first oral selective inhibitor of nuclear export compound tested for cancer treatment. Selinexor has demonstrated a safety therapy profile with broad antitumor activity against solid and hematological malignancies in phases 2 and 3 clinical trials (#NCT03071276, #NCT02343042, #NCT02227251, #NCT03110562, and #NCT02606461). Although selinexor shows promising efficacy, its primary adverse effect is high-grade thrombocytopenia. Therefore, we aimed to identify the mechanism of selinexor-induced thrombocytopenia to relieve it and improve its clinical management. We determined that selinexor causes thrombocytopenia by blocking thrombopoietin (TPO) signaling and therefore differentiation of stem cells into megakaryocytes. We then used both in vitro and in vivo models and patient samples to show that selinexor-induced thrombocytopenia is indeed reversible when TPO agonists are administered in the absence of selinexor (drug holiday). In sum, these data reveal (1) the mechanism of selinexor-induced thrombocytopenia, (2) an effective way to reverse the dose-limiting thrombocytopenia, and (3) a novel role for XPO1 in megakaryopoiesis. The improved selinexor dosing regimen described herein is crucial to help reduce thrombocytopenia in selinexor patients, allowing them to continue their course of chemotherapy and have the best chance of survival. This trial was registered at www.clinicaltrials.gov as #NCT01607905.

Key Points Mouse megakaryocytes can differentially sort and package endocytosed fibrinogen and endostatin into distinct α-granules. Platelet progenitors contain subpopulations of α-granules.

Antisense oligonucleotides (ASOs) are DNA-based, disease-modifying drugs. Clinical trials with 2'-O-methoxyethyl (2’MOE) ASOs have reported dose- and sequencespecific lowering of platelet counts according to two phenotypes. Phenotype 1 is a moderate (but not clinically severe) drop in platelet count. Phenotype 2 is rare, severe thrombocytopenia. This paper will focus on the underlying cause of the more common Phenotype 1, investigating the effects of ASOs on platelet production and platelet function. Five phosphorothioate ASOs were included: three 2’MOE sequences; 487660 (no effects on platelet count), 104838 (associated with Phenotype 1), 501861 (effects unknown) and two CpG sequences; 120704 and ODN 2395 (known to activate platelets). Human cord blood-derived megakaryocytes were treated with these ASOs to study effects on proplatelet production. Platelet activation (surface P-selectin) and platelet-leukocyte aggregates (PLAs) were analyzed in ASO-treated blood from healthy human volunteers. None of the ASOs inhibited proplatelet production from human megakaryocytes. All the ASOs were shown to bind to the platelet receptor glycoprotein VI (GPVI, KD ~0.2-1.5μM). CpG ASOs had the highest affinity to GPVI and the most potent platelet activating effects and PLA formation. 2’MOE ASO 487660 had no detectable platelet effects, while 2’MOE ASOs 104838 and 501861 triggered moderate platelet activation and SYK-dependent formation of PLAs. Donors with higher platelet GPVI levels had larger ASO-induced platelet activation. Sequence-dependent ASO-induced platelet activation and PLAs may explain Phenotype 1- moderate drops in platelet count. Platelet GPVI levels could be useful as a screening tool to identify patients at higher risk of ASO-induced platelet side effects.

Background: The mechanisms that regulate platelet biogenesis remain unclear; factors that trigger megakaryocytes (MKs) to initiate platelet production are poorly understood. Platelet formation begins with proplatelets, which are cellular extensions originating from the MK cell body. Objectives: Proplatelet formation is an asynchronous and dynamic process that poses unique challenges for researchers to accurately capture and analyze. We have designed an open-source, high-content, high-throughput, label-free analysis platform. Methods: Phase-contrast images of live, primary MKs are captured over a 24-hour period. Pixel-based machine-learning classification done by ilastik generates probability maps of key cellular features (circular MKs and branching proplatelets), which are processed by a customized CellProfiler pipeline to identify and filter structures of interest based on morphology. A subsequent reinforcement classification, by CellProfiler Analyst, improves the detection of cellular structures. Results: This workflow yields the percent of proplatelet production, area, count of proplatelets and MKs, and other statistics including skeletonization information for measuring proplatelet branching and length. We propose using a combination of these analyzed metrics, in particular the area measurements of MKs and proplatelets, when assessing in vitro proplatelet production. Accuracy was validated against manually counted images and an existing algorithm. We then used the new platform to test compounds known to cause thrombocytopenia, including bromodomain inhibitors, and uncovered previously unrecognized effects of drugs on proplatelet formation, thus demonstrating the utility of our analysis platform. Conclusion: This advance in creating unbiased data analysis will increase the scale and scope of proplatelet production studies and potentially serve as a valuable resource for investigating molecular mechanisms of thrombocytopenia.

Megakaryocytes (MKs) are specialized precursor cells committed to producing and proliferating platelets. In a cytoskeletal-driven process, mature MKs generate platelets by releasing thin cytoplasmic extensions, named proplatelets, into the sinusoids. Due to knowledge gaps in this process and mounting clinical demand for non-donor-based platelet sources, investigators are successfully developing artificial culture systems to recreate the environment of platelet biogenesis. Nevertheless, drawbacks in current methods entail elaborate procedures for stem cell enrichment, extensive growth periods, low MK yield, and poor proplatelet production. We propose a simple, robust method of primary MK culture that utilizes fetal livers from pregnant mice. Our technique reduces expansion time to 4 days, and generates ~15,000-20,000 MKs per liver. Approximately, 20-50% of these MKs produce structurally dense, high-quality proplatelets. In this review, we outline our method of MK culture and isolation.

Introduction Antisense oligonucleotides (ASOs) are a new class of single-stranded DNA based drugs that hold great therapeutic promise for their disease modifying potential in a wide range of genetic diseases. Preclinical toxicology studies in monkeys, as well as late stage clinical trials in humans, have upon repeated dosing, reported events of ASO sequence-specific lowering of platelet counts (mild to severe thrombocytopenia) (Henry et al. Nucleic acid therapeutics 2017). The underlying cause of this platelet decrease is still unclear in humans. We have investigated if the thrombocytopenia associated with ASOs is due to either impaired platelet production and/or destruction of platelets (clearance) due to increased platelet reactivity (activation/aggregation status). Preliminary data from mouse derived fetal liver megakaryocytes suggest that pro-platelet production does not seem to be reduced by ASOs and hence in the current study we hypothesized that the ASO-induced thrombocytopenia is due to increased clearance of platelets from the circulation. Methods In the current study we explored how ASOs affect platelet aggregation in platelet rich plasma (PRP) and platelet-leukocyte aggregates in whole blood (WB) obtained from healthy volunteers after informed consent. PRP or WB was treated with a clinically relevant concentration of ASO (5µM) corresponding to expected maximum plasma concentration levels, or a 20x-supra-therapeutic concentration (100µM). Four ASOs were tested: two CpG-rich phosphorothioate deoxyoligonucleotide (PS ODN) sequences: 818290 and 120704, and two non-CpG 2'-MOE containing sequences: 104838 and 501861. 818290 was included as a positive control since it has been shown to cause direct platelet activation (Flierl et al. JEM 2015). 104838 have been reported to cause moderate, dose dependent drops in platelet counts in monkeys and humans, with platelet sequestration in the liver and spleen (Narayanan PK, et al. Toxicol Sci. 2018). 501861 has triggered sporadic severe thrombocytopenia in select monkeys. ASO treated PRP was analyzed for platelet aggregation using 96-well optimul aggregometry (Lordkipanidzé et al. Blood 2014) in the presence of vehicle (PBS) or 6 concentrations of thrombin receptor activating peptide-6 (0.08-80µM,TRAP6). In a separate experiment, PRP was incubated with ASOs plus the spleen tyrosine kinase (Syk) inhibitor PRT-060318 (10µM). ASO treated WB was incubated with fluorescently labelled CD41/61 antibody to label platelets and a leukocyte-specific antibody CD14, and platelet-leukocyte aggregates were analyzed by FACS according to (Gerrits et al. Curr. Protoc. 2016). Results The two non-CpG rich 2'-MOE ASO sequences 104838 and 501861 did not affect platelet aggregation at either concentration (5µM + 100µM) (Figure 1 A+B). Whilst the two CpG-rich PS ODN ASOs (818290 and 120704) triggered spontaneous platelet aggregation in PRP at 100µM (Figure 1 C+D), that was normalized by co-incubating these ASOs with a Syk inhibitor (Figure 2). 5µM of ASO treatment triggered a significant increase in platelet-leukocyte aggregates in WB for all the ASOs tested (Figure 3). Conclusion We have shown that the two CpG-rich PS ODN ASOs (818290 and 120704) triggered spontaneous platelet aggregation in PRP at 100µM. This effect was inhibited by a Syk inhibitor. 818290 has previously been identified to activate platelets through a Syk-dependent, GPVI receptor mediated mechanism (Flierl et al. JEM 2015). Here, we report for the first time that the aggregatory effects of 120704 have been identified to be Syk dependent as well, possibly through a similar interaction with platelet GPVI receptors. We have also presented novel data that therapeutically relevant concentrations of all the ASOs tested cause an increase in platelet-leukocyte aggregates in WB. Based on these data we highlight the importance of screening ASOs in multi-cellular assays, not just PRP, since there was no effect of the ASOs 104838 or 501861 on platelet aggregation. Enhanced formation of platelet-leukocyte aggregates could be one contributing factor for increased platelet clearance, explaining ASO-induced thrombocytopenia. Further investigation into the ASO-induced interactions between platelets and immune cells are warranted. Defining the mechanisms by which ASO-based drugs cause low platelet count may yield strategies to manage this drug-induced thrombocytopenia in patients. Disclosures Thon: Platelet Biogenesis: Employment, Equity Ownership, Other: Co-founder, Patents & Royalties. Henry:Ionis Pharmaceuticals: Employment. Narayanan:Ionis Pharmaceuticals: Employment. Italiano:Platelet Biogenesis: Equity Ownership, Other: Co-founder, Patents & Royalties.

Background: Proteasome inhibitors such as bortezomib, a chemotherapeutic used to treat multiple myeloma, induce thrombocytopenia within days of initiation. The mechanism for this thrombocytopenia has been tied to data revealing that proteasome activity is essential for platelet formation. The major pathway of selective protein degradation uses ubiquitin as a marker that targets proteins for proteolysis by the proteasome. This pathway is previously unexplored in megakaryocytes (MKs). Objectives: We aim to define the mechanism by which the ubiquitin-proteasome pathway affects MK maturation and platelet production. Results: Pharmacologic inhibition of proteasome activity blocks proplatelet formation in megakaryocytes. To further characterize how this degradation was occurring, we probed distinct ubiquitin pathways. Inhibition of the ubiquitin-activating enzyme E1 significantly inhibited proplatelet formation up to 73%. In addition, inhibition of the deubiquitinase proteins UCHL5 and USP14 significantly inhibited proplatelet formation up to 83%. These data suggest that an intact ubiquitin pathway is necessary for proplatelet formation. Proteomic and polysome analyses of MKs undergoing proplatelet formation revealed a subset of proteins decreased in proplatelet-producing megakaryocytes, consistent with data showing that protein degradation is necessary for proplatelet formation. Specifically, the centrosome stabilizing proteins Aurora kinase (Aurk) A/B, Tpx2, Cdk1, and Plk1 were decreased in proplatelet-producing MKs. Furthermore, inhibition of AurkA and Plk1, but not Cdk1, significantly inhibited proplatelet formation in vitro over 83%. Conclusions: We hypothesize that proplatelet formation is triggered by centrosome destabilization and disassembly, and that the ubiquitin-proteasome pathway plays a crucial role in this transformation. Specifically, regulation of the AurkA/Plk1/Tpx2 pathway may be key in centrosome integrity and initiation of proplatelet formation. Determination of the mechanism by which the ubiquitin-proteasome pathway regulates the centrosome and facilitates proplatelet formation will allow us to design better strategies to target and reverse thrombocytopenia.