Treatment of older patients with AML

PPARγ activation by pioglitazone enhances the anti-proliferative effects of doxorubicin on pro-monocytic THP-1 leukemia cells via inducing apoptosis and G2/M cell cycle arrest

PURPOSE

Doxorubicin (DOX) is a common chemotherapeutic agent, with toxic side effects, and chemoresistance. Combination chemotherapy is a successful approach to overcome these limitations. Here, we investigated the effects of pioglitazone (PGZ), a PPARγ agonist, and/or DOX on the viability, cell cycle, apoptosis on THP-1 cells and normal human monocytes (NHMs).

METHODS

MTT assay was used to evaluate the cytotoxicity of DOX and/or PGZ. Cell cycle progression and apoptosis induction were examined by PI or Annexin V-PI double staining, and analyzed by flow cytometry. Quantitative RT-PCR was used to evaluate the changes in the mRNA expression of cell cycle progression or apoptosis-associated genes including P27, P21, CDK2, P53, BCL2 and FasR.

RESULTS

DOX, PGZ and DOX + PGZ exerted their cytotoxic effects in a dose- and time-dependent manner with low toxicity on NHMs. The cell growth inhibitory effects of DOX were in association with G2/M arrest, while PGZ executed S phase arrest. PGZ treatment enhanced G2/M among DOX-treated combinations with moderate elevation in the S phase. DOX, PGZ and combined treatments induced apoptosis (mostly late phase) in a dose-dependent manner. All treatments resulted in the significant overexpression of p21, p27, p53 and FasR genes and downregulation of CDK2. DOX + PGZ combined treatments exhibited the most significant changes in mRNA expression.

CONCLUSION

We demonstrated that the antiproliferative, cell cycle regulation and apoptosis-inducing capacity of DOX was enhanced by PGZ in THP-1 leukemia cells in a dose-dependent manner. Therefore, the combination of DOX + PGZ could be used as a novel combination to target AML.

Multidrug-related protein 1 (MRP1) polymorphisms rs129081, rs212090, and rs212091 predict survival in normal karyotype acute myeloid leukemia

Resistant disease is still a main obstacle in acute myeloid leukemia (AML) treatment. Therefore, individual genetic variations affecting therapy response are gaining increasing importance. Both SNPs and ABC transporter genes could already be associated with drug resistance. Here, we report allelic variants of MRP1 (ABCC1) SNPs rs129081, rs212090, and rs212091 with significant influences on survival in AML patients. DNA was extracted from bone marrow samples (n = 160) at diagnosis. Genotyping 48 SNPs within seven different ABC transporter genes using real-time PCR revealed rs129081 GG variant with a significant higher OS (p = 0.035) and DFS (p = 0.01). Comparing TT and AA rs212090 variants showed significant influences on DFS (p = 0.021). SNP rs212091 GG expression was associated with worse OS (p = 0.006) and a significant difference in DFS between alleles GG and AA (p = 0.018). The multivariable models confirmed a significant influence on OS for rs212091 (AA HR = 0.296, 95% CI 0.113–0.774, p = 0.013 and GG p = 0.044). Rs129081 variant CG, TT of rs212090, AA, and AG of rs212091 demonstrated significant impact on DFS (p = 0.024, p = 0.029, p = 0.017, and p = 0.042, respectively). This analysis demonstrates a significant influence of MRP1 SNPs on survival in AML. As they were not associated to prognostic characteristics, we suggest these SNPs to be independent prognostic markers for AML.

Defining and Treating Older Adults with Acute Myeloid Leukemia Who Are Ineligible for Intensive Therapies

Although acute myeloid leukemia (AML) is primarily a disease of older adults (age ≥60 years), the optimal treatment for older adults remains largely undefined. Intensive chemotherapy is rarely beneficial for frail older adults or those with poor-risk disease, but criteria that define fitness and/or appropriateness for intensive chemotherapy remain to be standardized. Evaluation of disease-related and patient-specific factors in the context of clinical decision making has therefore been largely subjective. A uniform approach to identify those patients most likely to benefit from intensive therapies is needed. Here, we review currently available objective measures to define older adults with AML who are ineligible for intensive chemotherapy, and discuss promising investigational approaches.

ROS production and their influence on the cellular antioxidative system in human erythrocytes incubated with daunorubicin and glutaraldehyde

This study examined the effects of daunorubicin and glutaraldehyde on some parameters of erythrocytes. The aim of the article was to present the results of research aiming to identify the level of glutaraldehyde at which the hemoglobin oxidation, externalization of phosphatidylserine and the changes in the viability (hemolysis) of erythrocytes are not statistically significant and therefore this level of glutaraldehyde can be used for the drug carriers' preparation. Glutaraldehyde was used as a crosslinking agent to enhance the uptake of the drug within red blood cells and to prevent its leakage from the cells. Fluorescence microscopy, flow cytometry and fluorimetric measurements confirmed higher levels of the drug in glutaraldehyde-treated human erythrocytes. Unfortunately, substantial damage to the red blood cells was also noted. DNR increased oxidative processes in the cell, which in turn led to an increase in the reactive oxygen species (ROS) level. When the red blood cells were also treated with glutaraldehyde, ROS production was significantly higher. We also observed loss of both the reduced and the total glutathione. Moreover the decreased activity of glutathione reductase (GR) and glucose-6-phosphate dehydrogenase (G6PD) was also observed. As hemoglobin, the erythrocytes' main component plays an essential role in the erythrocytes, the level of its oxidized form (metHb) in the erythrocytes and the phosphatidylserine exposure on the erythrocyte surface were also investigated. When higher concentrations of glutaraldehyde (0.0025-0.005%) were used for the uptake of DNR the elevated level of metHb was observed. Only at 0.0005% the level of oxidized form of Hb was within the physiological level and at that level the increase in the exposure of phosphatidylserine at the cell surface was not observed to be statistically significant. Moreover the percent of released hemoglobin was less than 1%. Based on these results it was concluded that glutaraldehyde can be used as a cross-linker between the drug (DNR) and the erythrocytes only at low concentration of about 0.0005%.

Effect of NPM1 and FLT3 mutations on the outcomes of elderly patients with acute myeloid leukemia receiving standard chemotherapy

BACKGROUND

The effect of prognostically important gene mutations (MUTs), nucleophosmin (nucleolar phosphoprotein B23, numatrin) (NPM1) and fms-related tyrosine kinase 3 (FLT3), in elderly patients with acute myeloid leukemia (AML) is not well defined.

PATIENTS AND METHODS

We analyzed 557 patients, 65 years of age or older with newly diagnosed AML, treated at our institution between 2000 and 2010 with cytotoxic chemotherapy. NPM1 and FLT3 analysis were available in 146 patients (26%) and 388 patients (70%), respectively.

RESULTS

NPM1 and FLT3 MUTs occurred in 16% and 12% of patients, respectively. No difference in median overall survival was observed between FLT3-MUT and NPM1-MUT patients who received cytotoxic chemotherapy. Outcome was significantly better among patients with NPM1-MUT/FLT3-wild type (WT) genotype (n = 14) compared with patients carrying FLT3/NPM1 genotypes other than NPM1-MUT/FLT3-WT (n = 125). The complete remission rates were 71% and 49%, respectively (P = .11). The median survival was 21.5 months vs. 9.0 months and estimated 2-year survival rates were 51% vs. 38%, respectively (P = .003). NPM1 and FLT3 MUTs appear to occur less frequently in elderly AML patients. The prognostic effect of isolated NPM1- or isolated FLT3-MUT is minimal.

CONCLUSION

Elderly AML patients with NPM1-MUT/FLT3-WT genotype have significantly improved outcomes compared with patients with other NPM1/FLT3 genotypes when treated with cytotoxic chemotherapy.

Natural killer cells generated from cord blood hematopoietic progenitor cells efficiently target bone marrow-residing human leukemia cells in NOD/SCID/IL2Rg(null) mice

Natural killer (NK) cell-based adoptive immunotherapy is an attractive adjuvant treatment option for patients with acute myeloid leukemia. Recently, we reported a clinical-grade, cytokine-based culture method for the generation of NK cells from umbilical cord blood (UCB) CD34⁺ hematopoietic progenitor cells with high yield, purity and in vitro functionality. The present study was designed to evaluate the in vivo anti-leukemic potential of UCB-NK cells generated with our GMP-compliant culture system in terms of biodistribution, survival and cytolytic activity following adoptive transfer in immunodeficient NOD/SCID/IL2Rg^null mice. Using single photon emission computed tomography, we first demonstrated active migration of UCB-NK cells to bone marrow, spleen and liver within 24 h after infusion. Analysis of the chemokine receptor expression profile of UCB-NK cells matched in vivo findings. Particularly, a firm proportion of UCB-NK cells functionally expressed CXCR4, what could trigger BM homing in response to its ligand CXCL12. In addition, high expression of CXCR3 and CCR6 supported the capacity of UCB-NK cells to migrate to inflamed tissues via the CXCR3/CXCL10-11 and CCR6/CCL20 axis. Thereafter, we showed that low dose IL-15 mediates efficient survival, expansion and maturation of UCB-NK cells in vivo. Most importantly, we demonstrate that a single UCB-NK cell infusion combined with supportive IL-15 administration efficiently inhibited growth of human leukemia cells implanted in the femur of mice, resulting in significant prolongation of mice survival. These preclinical studies strongly support the therapeutic potential of ex vivo-generated UCB-NK cells in the treatment of myeloid leukemia after immunosuppressive chemotherapy.

Replication-dependent irreversible topoisomerase 1 poisoning is responsible for FdUMP[10] anti-leukemic activity

Previous studies have indicated that 5-Fluoro-2'-deoxyuridine-5'-O-monophosphate 10mer (FdUMP[10]) displays strong antileukemic activity through the dual targeting of thymidylate synthase (TS) and DNA topoisomerase 1 (Top1). The present studies were undertaken to clarify the relationship between the induction of a thymineless state and the formation of Top1 cleavage complexes (Top1CC) for inducing cell death and to clarify the role of DNA replication for induction of lethal DNA double-strand breaks (DSBs) in FdUMP[10]-treated acute myeloid leukemia (AML) cells. Human promyelocytic (HL60) and AML (KG1a, Molm13, THP-1) cells were synchronized by serum starvation and treated with FdUMP[10] with thymidine (Thy) rescue. Cells were assayed for TS inhibition, DNA DSBs, Top1CC, and apoptosis to clarify the interrelationship of TS inhibition and Top1CC for cell death. FdUMP[10] induced a thymineless state in AML cells and exogenous Thy administered within the first 18 hours of treatment rescued FdUMP[10]-induced Top1CC formation, γH2AX phosphorylation, and apoptosis induction. Exogenous Thy was not effective after cells had committed to mitosis and undergone cell division in the presence of FdUMP[10]. FdUMP[10] treatment resulted in Chk1 activation, and Chk1 inhibition enhanced FdUMP[10]-induced DNA damage and apoptosis. Jnk-signaling was required for FdUMP[10]-induced apoptosis in promyelocytic HL60 cells and in THP1 cells, but was antiapoptotic in Molm13 and to a lesser extent KG1a AML cells. The results are consistent with FdUMP[10] inducing a thymineless state, leading to misincorporation of FdU into genomic DNA of proliferating cells. Top1CC form in cells upon re-entry into S-phase, resulting in DNA double-strand breaks, and initiating apoptotic signaling that can be either muted or enhanced by Jnk-signaling depending on cell type.

Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure

Acute respiratory failure (ARF) is the leading reason for intensive care unit (ICU) admission in patients with cancer. The aim of this study was to identify early predictors of death in patients with cancer admitted to the ICU for ARF who were not intubated at admission. We conducted analysis of a prospective randomized controlled trial including 219 patients with cancer with ARF in which day-28 mortality was a secondary endpoint. Mortality at day 28 was 31.1%. By multivariate analysis, independent predictors of day-28 mortality were: age (odds ratio [OR] 1.30/10 years, 95% confidence interval [CI] [1.01-1.68], p = 0.04), more than one line of chemotherapy (OR 2.14, 95% CI [1.08-4.21], p = 0.03), time between respiratory symptoms onset and ICU admission > 2 days (OR 2.50, 95% CI [1.25-5.02], p = 0.01), oxygen flow at admission (OR 1.07/L, 95% CI [1.00-1.14], p = 0.04) and extra-respiratory symptoms (OR 2.84, 95%CI [1.30-6.21], p = 0.01). After adjustment for the logistic organ dysfunction (LOD) score at admission, only time between respiratory symptoms onset and ICU admission > 2 days and LOD score were independently associated with day-28 mortality. Determinants of death include both factors non-amenable to change, and delay in ARF management. These results suggest that early intensive care management of patients with cancer with ARF may translate to better survival.

Quality of life issues in elderly acute myeloid leukemia patients

The median age of acute myeloid leukemia (AML) is 70 years. Treatment approaches include standard chemotherapy, palliative chemotherapy and investigational agents, depending upon disease biology and patient factors. In this article, we highlight the issues involved in the treatment of AML in older patients, focusing on the quality of life changes associated with each treatment modality at different stages of their disease course. We further discuss recent insights into the biological basis of quality of life changes, and examine potential ways to improve these through pharmacological and nonpharmacological means. Finally, we explore avenues for future research into the quality of life of the older AML patient.

Exercise for older adult inpatients with acute myelogenous leukemia: A pilot study

OBJECTIVES

Acute myelogenous leukemia (AML) largely affects older adults. Few interventions have sought to improve functional status and health-related quality of life (HRQL) during treatment. The objective of this study is to examine the feasibility of an exercise intervention among older adults with AML undergoing induction chemotherapy.

MATERIALS AND METHODS

Pilot study of adults ≥50 years of age hospitalized for AML chemotherapy. The four week exercise intervention included stretching, walking, and strength exercises. Feasibility measures included recruitment, retention, number of exercise sessions completed, and barriers to participation. Physical function, HRQL, depression, and distress were assessed at baseline (week 1), upon completion of intervention (week 5), and during follow-up (weeks 9-13). Exploratory analyses used repeated measures ANCOVA to model changes over time.

RESULTS

Among 55 eligible inpatients, 24 enrolled (43.6%). Mean age was 65.1 years (SD 7.8). 87.5% of participants completed baseline measures; 70.8% attended ≥1 exercise sessions, and 50.0% completed post-intervention assessment. Among baseline characteristics, only higher physical performance was associated with greater number of exercise sessions attended (p=0.001). Post intervention, HRQL and depressive symptoms improved (p <0.05).

CONCLUSIONS

Recruitment to an exercise intervention was feasible. Exercise shows promise to maintain physical function and enhance HRQL. Strategies to enhance adherence to exercise are needed to maximize benefit.

Advances in the management of acute myeloid leukemia in older adult patients

PURPOSE/OBJECTIVES

To update oncology nurses on new developments in the care of older adult patients with acute myeloid leukemia (AML).

DATA SOURCES

Clinical trial data, published guidelines, review articles, and conference proceedings.

DATA SYNTHESIS

Therapies for older adult patients with AML include cytarabine-based intensive-induction chemotherapy, investigational therapy, and supportive care. Nonmyeloablative allogeneic hematopoietic stem cell transplantation may provide the best opportunity for cure following remission if a human leukocyte antigen-matched hematopoietic stem cell donor is available. Careful assessment of patient- and disease-related factors is critical in determining the appropriate treatment modality for individuals. Assessment tools and algorithms may identify patients likely to be intolerant of intensive therapies. Supportive care may improve treatment tolerance and quality of life.

CONCLUSIONS

Survival outcomes have not improved significantly for older adult patients with AML. Novel therapies, coupled with better understanding of prognostic factors, may allow more highly individualized care. Performance status or comorbidity score may provide insights regarding outcome, particularly when combined with age, cytogenetic risk, or molecular markers. Efforts to improve transplantation safety may increase use in the older adult patient population.

IMPLICATIONS FOR NURSING

Nurses provide disease and treatment information, manage adverse effects, and offer emotional support. Knowledge of the key management issues for older adult patients with AML is critical in fulfilling this role.

Reduced intensity conditioning prior to allogeneic stem cell transplantation in first complete remission is effective in patients with acute myeloid leukemia and an intermediate-risk karyotype

To evaluate the efficacy of reduced intensity conditioning (RIC) prior to allogeneic stem cell transplantation (alloSCT) in patients with acute myeloid leukemia (AML) in first complete remission (CR1), we retrospectively analyzed the outcome of 93 consecutive patients transplanted at our institution either following RIC (n = 37) or standard myeloablative conditioning (MAC) (n = 56) between 1999 and 2007. Projected overall survival (OS) or disease-free survival (DFS) for all patients at 1, 2, and 5 years was 78 or 70%, 65 or 57%, and 61 or 53% in the RIC group versus 73 or 70%, 68 or 62%, and 56 or 54% in the standard MAC group. In the subgroup of patients with an intermediate-risk karyotype projected OS at 1, 2, and 5 years was 86, 68, and 68% following RIC (n = 21) or 75, 69, and 66% following standard MAC (n = 36). Relapse or treatment-related mortality (TRM) was 15 or 17% (RIC group) and 26 or 14% (standard MAC group). Taken together, these data suggest that RIC-alloSCT may induce stable remissions in patients with AML transplanted in CR1. In particular, patients with an intermediate-risk karyotype ineligible to transplantation following standard MAC may benefit from RIC-alloSCT in CR1 at a low TRM.

Reduced intensity conditioning compared with myeloablative conditioning using unrelated donor transplants in patients with acute myeloid leukemia

PURPOSE

Reduced intensity conditioning regimen (RIC) is increasingly used in hematopoietic stem cell transplantation (HSCT). Unrelated donor (UD) transplants have more complications. We wanted to examine if RIC is a valid treatment option using UD in acute myeloblastic leukemia (AML).

PATIENTS AND METHODS

Between 1999 and 2005, 401 patients with AML were treated with RIC and 1,154 received myeloablative conditioning (MAC), using UD and reported to the European Group for Blood and Marrow Transplantation Registry. Patients < and > or = 50 years of age were analyzed separately.

RESULTS

Patients receiving RIC were older, received transplants more recently, received peripheral blood stem cells more frequently, and were treated with total-body irradiation less often. In multivariable analysis, in patients younger than 50 years of age, nonrelapse mortality (NRM) was similar using RIC (hazard ratio [HR], 0.85; P = .41), relapse was increased (HR, 1.46; P = .02) and leukemia-free survival (LFS) was the same (HR, 0.88; P = .28), as compared with MAC. In patients > or = 50 years of age, NRM was decreased in the RIC group (HR, 0.64; P = .04), relapse probability was not significantly different (HR, 1.34; P = .16) and LFS was similar (HR, 1.04; P = .79) compared with MAC. CONCLUSION RIC-UD transplants are associated with higher relapse in AML patients younger than 50 years of age and decreased NRM in those > or = 50 years compared with MAC-UD. LFS was similar after both conditioning regimens, regardless of age. Therefore, RIC-UD extend the use of allotransplants for elderly patients and strategies that decrease relapse should be considered mainly in younger patients with AML.

Acute myelogenous leukemia in older adults

The incidence of acute myelogenous leukemia (AML) increases with age. Older AML patients, generally defined by age > or = 60 years, have worse treatment outcomes than younger patients. While selected older patients can benefit from standard therapies, as a group they experience greater treatment-related toxicity, lower remission rates, shorter disease-free survival times, and shorter overall survival times. Outcome disparity is in part explained by age-related biologic features. Older patients are more likely to present with unfavorable cytogenetic abnormalities, multidrug resistance phenotypes, and secondary AML. However, even older adults with favorable tumor biology have a worse prognosis than younger patients. Patient-specific factors, including impaired physical function and comorbidity, independently predict greater treatment toxicity and shorter survival. Improving patient assessment strategies is critical to identify those patients who are most likely to benefit from induction and postremission therapies. In addition, continued efforts to identify more effective and tolerable induction and postremission strategies are needed for this population. Investigations of hypomethylating agents and signal transduction inhibitors hold promise for the treatment of AML patients. Steady advances in the field of hematopoietic transplantation, including use of reduced intensity transplants, may result in additional curative options available to selected older adults. Finally, improved supportive care strategies are needed to maximize treatment outcomes.

[The older patient with malignant diseases]

Most malignancies show a steep increase of incidence with growing age. Because of this age specific incidence and the general aging of the population in western industrial countries the number of elderly cancer patients continuously and rapidly increases. Despite this development elderly cancer patients are currently underrepresented in clinical trials. This is caused in part by the lack of a common definition of the elderly patient and by the fact that a part of the elderly patients suffers from co-morbidities, not allowing a more dose intense treatment in these patients. It is one of the key current challenges to compensate this deficit and to develop therapeutic concepts specifically for the elderly patients, taking the individual somatic, but also social situation and finally the quality and perspective of life of the elderly patient into account.

Gemtuzumab ozogamicin in combination with attenuated doses of standard induction chemotherapy can successfully induce complete remission without increasing toxicity in patients with acute myeloid leukemia aged 55 or older

BACKGROUND

In this study, the effectiveness and safety of combining gemtuzumab ozogamicin (GO) with an abbreviated schedule of standard induction chemotherapy were assessed in 37 patients (aged > or =55) yr with previously untreated acute myeloid leukemia (AML).

METHODS

GO was administered at a dose of 6 mg/m(2) as a single 2-h intravenous infusion on day 1. Following GO, an abbreviated schedule of induction chemotherapy consisting of idarubicin (12 mg/m(2)/d, days 2-4), and N4-behenoyl-1-beta-arabinofuranosyl cytosine (300 mg/m(2)/d, days 2-6) was given.

RESULTS

Thirty-seven patients were treated with GO in combination with chemotherapy. Complete remission (CR) and CR with incomplete platelet recovery were achieved in 28 patients (75.7%) and one patient (2.7%) respectively. Two patients (5.4%) died during induction and two patients (5.4%) with grade 4 treatment emergent adverse effects during chemotherapy did not complete induction chemotherapy. The majority of toxicities were mild and manageable. Severe myelosuppression was universal with significantly prolonged thrombocytopenic period. In total, 25 patients who received consolidation treatment, 19 patients remain alive at the time of analysis. Thirteen patients had undergone hematopoietic stem cell transplantation, three are preparing for transplantation and seven are receiving their consolidation chemotherapy course.

CONCLUSION

Although only a relatively small number of cases were included in this preliminary study and the follow-up duration was short, frontline GO in combination with attenuated conventional chemotherapy was found to be effective and feasible in elderly patients with AML.

Cardiac assessment of patients for haematopoietic stem cell transplantation

The expanding role of haematopoietic stem-cell transplantation (HSCT) renders the previous policy of avoiding transplantation in high-risk cardiac patients obsolete. Patients with amyloid, autoimmune conditions, sickle-cell disease, or thalassaemia, and patients over the age of 60 years are increasingly being offered HSCT. It is evident that the policy of avoiding transplantation in patients with impaired systolic function fails to identify all high-risk patients in such groups, and will deprive some patients of the benefits of HSCT unnecessarily. The development of an appropriate algorithm for cardiac pre-assessment and peri-transplant management is hampered by an inadequate understanding of the predictive value of various tests of cardiovascular function, the rapid evolution of advanced management strategies for cardiac dysfunction, and the development of non-cardiotoxic conditioning regimens. To meet this need we propose that an algorithm based on evidence from other clinical situations - already been found to be successful in the management of HSCT in patients with systemic sclerosis - should be used uniformly, and registry studies should be undertaken to distinguish those aspects of the algorithm that positively help to expand the remit of HSCT from those that add little of value.

Comorbidity is an independent predictor of complete remission in elderly patients receiving induction chemotherapy for acute myeloid leukemia

BACKGROUND

: Elderly patients with acute myeloid leukemia (AML) have a poor prognosis, which is explained by the disease itself and by host-related factors. The objective of this study was to determine the prognostic role of comorbidities in this population.

METHODS

: For this single-center, retrospective study, the authors analyzed the outcome of 133 patients aged >/=70 years who received induction chemotherapy for nonpromyelocytic AML between 1995 and 2004. Comorbidities were evaluated by using an adapted form of the Charlson comorbidity index (CCI).

RESULTS

: The median patient age was 73 years. The CCI score was 0 for 83 patients (68%), 1 for 16 patients (13%), and >1 for 23 patients (19%). The complete remission (CR) rate was 56%, and the median overall survival was 9 months. In multivariate analysis, 4 adverse prognostic factors for CR were identified: unfavorable karyotype, leukocytosis >/=30 g/L, CD34 expression on leukemic cells, and CCI >1. A score could be generated to allow the stratification of patients into low-, intermediate-, and high-risk groups with CR rates of 87%, 63%, and 37%, respectively. The risk of early mortality and the probability of survival also were different in the 3 risk groups (P = .02 and P = .01, respectively).

CONCLUSIONS

: The results from this study indicated that associated comorbidities are independent factors that may influence achievement of CR in elderly patients with AML. Such a scoring system may be useful in the prognostic staging systems that are used to identify patients with AML who can benefit from induction chemotherapy.

Phase 1 and pharmacologic study of MS-275, a histone deacetylase inhibitor, in adults with refractory and relapsed acute leukemias

MS-275 is a benzamide derivative with potent histone deacetylase (HDAC) inhibitory and antitumor activity in preclinical models. We conducted a phase 1 trial of orally administered MS-275 in 38 adults with advanced acute leukemias. Cohorts of patients were treated with MS-275 initially once weekly x 2, repeated every 4 weeks from 4 to 8 mg/m2, and after 13 patients were treated, once weekly x 4, repeated every 6 weeks from 8 to 10 mg/m2. The maximum-tolerated dose was 8 mg/m2 weekly for 4 weeks every 6 weeks. Dose-limiting toxicities (DLTs) included infections and neurologic toxicity manifesting as unsteady gait and somnolence. Other frequent non-DLTs were fatigue, anorexia, nausea, vomiting, hypoalbuminemia, and hypocalcemia. Treatment with MS-275 induced increase in protein and histone H3/H4 acetylation, p21 expression, and caspase-3 activation in bone marrow mononuclear cells. No responses by classical criteria were seen. Our results show that MS-275 effectively inhibits HDAC in vivo in patients with advanced myeloid leukemias and should be further tested, preferably in patients with less-advanced disease.

Poorer outcome of elderly patients treated with extended-field radiotherapy compared with involved-field radiotherapy after chemotherapy for Hodgkin's lymphoma: an analysis from the German Hodgkin Study Group

BACKGROUND

The optimal treatment of elderly patients with Hodgkin's lymphoma (HL) is still a matter of debate. Since many of these patients receive combined modality treatment, we evaluated the impact of different radiation field sizes, that is extended-field (EF) or involved-field (IF) technique when given after four cycles of chemotherapy.

PATIENTS AND METHODS

In the multicenter HD8 study of the German Hodgkin Study Group, 1204 patients with early-stage unfavorable HL were randomized to receive four cycles of chemotherapy followed by either radiotherapy (RT) of 30 Gy EF + 10 Gy to bulky disease (arm A) or 30 Gy IF + 10 Gy to bulky disease (arm B). A total of 1064 patients were assessable for the analysis. Of these, 89 patients (8.4%) were 60 years or older.

RESULTS

Elderly patients had a poorer risk profile. Acute toxicity from RT was more pronounced in elderly patients receiving EF-RT compared with IF-RT [World Health Organization (WHO) grade 3/4: 26.5% versus 8.6%)]. Freedom from treatment failure (FFTF, 64% versus 87%) and overall survival (OS, 70% versus 94%) after 5 years was lower in elderly patients compared with younger patients. Importantly, elderly patients had poorer outcome when treated with EF-RT compared with IF-RT in terms of FFTF (58% versus 70%; P = 0.034) and OS (59% versus 81%; P = 0.008).

CONCLUSION

Elderly patients with early-stage unfavorable HL generally have a poorer risk profile and outcome when compared with younger patients. Treatment with EF-RT instead of IF-RT after chemotherapy has a negative impact on survival of elderly patients and should be avoided.

Identification of 2-acylaminothiophene-3-carboxamides as potent inhibitors of FLT3

A series of 2-acylaminothiophene-3-carboxamides has been identified which exhibit potent inhibitory activity against the FLT3 tyrosine kinase. Compound 44 inhibits the isolated enzyme (IC50 = 0.027 microM) and blocks the proliferation of MV4-11 cells (IC50 = 0.41 microM). Structure-activity relationship studies within this series are described in the context of a proposed binding model within the ATP binding site of the enzyme.

Controversies in treatment of AML: case-based discussion

Treatment of acute myeloid leukemia (AML) in older adults remains a tremendous challenge. Standard approaches to treatment have resulted in progression-free survival in only a small minority of patients with AML over the age of 60. Elucidation of the molecular genetic events that contribute to the pathogenesis of AML in older patients are providing insights into mechanisms of resistance. This knowledge is also providing new opportunities to begin to refine and direct novel therapies for these heterogeneous diseases. In this case-based review, prognostic factors for treatment outcome in older adults will be covered along with discussion of a risk-based approach to potential therapeutic options, ranging from palliative care to novel therapies and reduced-intensity allogenic transplant.