Hypercalcaemia and increased serum interleukin-6 levels induced by all-trans retinoic acid in patients with multiple myeloma

Hypercalcemia associated with interaction between all trans retinoic acid and fluconazole in an acute promyelocytic leukemia and acquired hypoparathyroidism case

INTRODUCTION

Acute promyelocytic leukemia (APL) is the most malignant form of acute myeloid leukemia (AML) with short survival without treatment. All trans retinoic acid (ATRA) is a vitamin A metabolite and plays an important role in the treatment of APL. Hypercalcemia is a rare side effect of ATRA.

CASE REPORT

A 67-year-old female patient was investigated due to widespread bruising and pancytopenia. The patient was diagnosed with APL and remission was achieved by administering idarubicin together with ATRA in the induction treatment. The patient has hypocalcemia due to acquired hypoparathyroidism, and it was observed that the calcium level increased with the initiation of fluconazole 200 mg/day for antifungal prophylaxis together with ATRA in the consolidation treatment. It was observed that the calcium value reached 13 mg/dL by increasing the fluconazole to 400 mg/day treatment dose due to oral mucositis.

MANAGEMENT AND OUTCOME

The development of hypercalcemia has been reported in previous case reports when ATRA is used together with voriconazole, fosfluconazole, itraconazole, and posaconazole, which inhibit cytochrome P450 enzymes. In this case, it is the first in the literature that a patient with hypocalcemia due to acquired hypoparathyroidism developed hypercalcemia after fluconazole and ATRA were used together.

DISCUSSION

Since hypercalcemia may develop while azole drugs are administered during ATRA treatment, it is important to monitor calcium levels to prevent complications of hypercalcemia.

All-Trans-Retinoic-Acid Unmasking Hypercalcemia of Hyperparathyroidism

We present a patient of acute promyelocytic leukaemia managed with all-trans-retinoic-acid and arsenic trioxide who developed hypercalcemia with target organ damage. The patient also was simultaneously discovered to be symptomatic from hyperparathyroidism, which was unmasked after ATRA administration. Patient was successfully managed without any interruption of ATRA therapy and parathyroidectomy. We discuss the mechanisms of ATRA in causing hypercalcemia and its possible role in index case in unmasking hyperparathyroidism. Present case refutes Occam's razor and emphasise that known adverse effects shouldn't withhold clinicians from working up for other common causes for a given condition.

Hypercalcemia in the Intensive Care Unit: A Review of Pathophysiology, Diagnosis, and Modern Therapy

Hypercalcemia may be seen in a variety of clinical settings and often requires intensive management when serum calcium levels are dramatically elevated. All of the many etiologies of mild hypercalcemia can lead to severe hypercalcemia. Knowledge of the physiologic mechanisms involved in maintaining normocalcemia and basic pathophysiology is essential for making a timely diagnosis and hence prompt institution of etiology-specific therapy. The development of new medications and critical reviews of traditional therapies have changed the treatment paradigm for severe hypercalcemia, calling for a more limited role for aggressive isotonic fluid administration and furosemide and an expanded role for calcitonin and the bisphosphonates. Experimental therapies such as denosumab show promise.

Evidence of a role for CD44 and cell adhesion in mediating resistance to lenalidomide in multiple myeloma: therapeutic implications

Resistance of myeloma to lenalidomide is an emerging clinical problem, and though it has been associated in part with activation of Wnt/β-catenin signaling, the mediators of this phenotype remained undefined. Lenalidomide-resistant models were found to overexpress the hyaluronan (HA)-binding protein CD44, a downstream Wnt/β-catenin transcriptional target. Consistent with a role of CD44 in cell adhesion-mediated drug resistance (CAM-DR), lenalidomide-resistant myeloma cells were more adhesive to bone marrow stroma and HA-coated plates. Blockade of CD44 with monoclonal antibodies, free HA or CD44 knockdown reduced adhesion and sensitized to lenalidomide. Wnt/β-catenin suppression by FH535 enhanced the activity of lenalidomide, as did interleukin-6 neutralization with siltuximab. Notably, all-trans retinoic acid (ATRA) downregulated total β-catenin, cell-surface and total CD44, reduced adhesion of lenalidomide-resistant myeloma cells and enhanced the activity of lenalidomide in a lenalidomide-resistant in vivo murine xenograft model. Finally, ATRA sensitized primary myeloma samples from patients that had relapsed and/or refractory disease after lenalidomide therapy to this immunomodulatory agent ex vivo. Taken together, our findings support the hypotheses that CD44 and CAM-DR contribute to lenalidomide resistance in multiple myeloma, that CD44 should be evaluated as a putative biomarker of sensitivity to lenalidomide, and that ATRA or other approaches that target CD44 may overcome clinical lenalidomide resistance.

Acute kidney injury, sodium disorders, and hypercalcemia in the aging kidney: diagnostic and therapeutic management strategies in emergency medicine

This article summarizes the current literature regarding the structural and functional changes of the aging kidney and describes how these changes make the older patient more susceptible to acute kidney injury and fluid and electrolyte disorders. It discusses the clinical manifestations, evaluation, and management of hyponatremia and shows how the management of hypernatremia in geriatric patients involves addressing the underlying cause and safely correcting the hypernatremia. The current literature regarding evaluation and management of hypercalcemia in older patients is summarized. The management of severe hypercalcemia is discussed in detail. The evaluation and management of acute kidney injury is described.

Hypercalcemia due to all trans retinoic acid in the treatment of acute promyelocytic leukemia potentiated by voriconazole

All-trans-retinoic acid (ATRA) is a new and effective treatment of acute promyelocytic leukemia. It has many side-effects, including the retinoic acid syndrome and Sweet's syndrome. There have been only nine cases of hypercalcemia associated with ATRA described in the literature. We discuss a case of hypercalcemia, which we believe was due to inhibition of cytochrome P450 function by voriconizole when used concomitantly with ATRA.

RARalpha2 expression is associated with disease progression and plays a crucial role in efficacy of ATRA treatment in myeloma

Specific genetic alterations in multiple myeloma (MM) may cause more aggressive diseases. Paired gene array analysis on 51 samples showed that retinoic acid (RA) receptor alpha (RARalpha) expression significantly increased at relapse compared with diagnosis. RARalpha encodes 2 major isoforms: RARalpha1 and RARalpha2. In this study, we examined the function of RARalpha2 in MM. Reverse transcription-polymerase chain reaction (RT-PCR) revealed ubiquitous RARalpha1 expression in MM cells, but RARalpha2 was expressed in 26 (32%) of 80 newly diagnosed patients and 10 (28%) of 36 MM cell lines. Patients with RARalpha2 expression had a significantly shorter overall survival on identical treatments. The presence of RARalpha2 remained significant on multivariate analysis. Knockdown of RARalpha2 but not RARalpha1 induced significant MM cell death and growth inhibition, and overexpressing RARalpha2 activated STAT3 and mitogen-activated protein kinase kinase (MEK)/extracellular signal-regulated kinase (ERK) signaling pathways. Interestingly, all-trans retinoic acid (ATRA) treatment induced potent cell death and growth inhibition in RARalpha2(+) but not RARalpha2(-) MM cells; overexpressing RARalpha2 in RARalpha2-deficient MM cells restored sensitivity to ATRA. Furthermore, ATRA treatment significantly inhibited the growth of RARalpha2-overexpressing MM tumors in severe combined immunodeficiency (SCID) mouse model. These findings provide a rationale for RA-based therapy in aggressive RARalpha2(+) MM.

Hypercalcemia and 13-cis-retinoic acid in post-consolidation therapy of neuroblastoma

We report 19 episodes of hypercalcemia in three children treated with 13-cis-retinoic acid (13-cis-RA) as a post-consolidation therapy for high-risk neuroblastoma. There was no concomitant overload in 13-cis-RA blood levels. Blood calcium fell after arrest of 13-cis-RA intake. Half dosage retinoid treatment resumption did not prevent the recurrence of hypercalcemia. Concomitant biological values showed massive bone resorption. Hence, hypercalcemia seemed not secondary to 13-cis-RA overload but rather to inter-individual variability in its interaction with bone metabolism. Current guidelines in case of hypercalcemia are to reduce 13-cis-RA dosage. Instead we propose to maintain the therapeutic dosage, but to shorten the duration of courses.

Effects of all-trans retinoic acid (ATRA) on human myeloma cells

All-trans retinoic acid (ATRA) is a natural oxidative metabolite of Vitamin A (retinol) and is known to be a regulator of cell proliferation differentiation, especially in various malignant cells. The cyto-differentiating action of ATRA has led to its usage in the treatment of several malignancies, particularly acute promyelocytic leukemia (APL). There have been many reports regarding the cell biological effects of ATRA on human myeloma cells and a few clinical trials. Most of these reports have revealed growth inhibition by ATRA mediated by down-regulation of the IL-6/IL-6R auto/paracrine loop, and upregulation of p21/Cip1. Here, we review previous reports and introduce experimental results obtained using various myeloma cell lines established in our laboratory.

Interleukin 10 abolishes the growth inhibitory effects of all-trans retinoic acid on human myeloma cells

Recently, it was disclosed that all-trans retinoic acid (ATRA) inhibits myeloma cell growth by downregulating the interleukin 6 (IL-6)/IL-6 receptor (IL-6R) auto/paracrine loop, and upregulating p21/Cip1 cyclin-dependent kinase inhibitor (CDK-I), thereby inducing apoptosis with a decrease in Bcl-2 protein expression. To elucidate and generalize the effects of ATRA on the proliferation and cellular biology of myeloma cells, 12 human myeloma cell lines established in our laboratory were utilized. Two out of the 12 lines showed enhanced growth on supplementation of ATRA and were characterized by IL-10 production, downregulation of membrane Fas and reduced upregulation of p21/Cip1 CDK-I message. These characteristics may prove important for the clinical use of ATRA and should be considered before starting ATRA therapy for myeloma.

Antitumor activity of oral 9-cis-retinoic acid in HIV-associated Kaposi's sarcoma

OBJECTIVE

To assess the efficacy, safety and tolerance of oral 9-cis-retinoic acid in HIV-infected patients with Kaposi's sarcoma.

METHODS

Sixty-six patients with AIDS-related Kaposi's sarcoma were enrolled at 14 centers; 60 received the study medication and were analyzed and, of these, 45 (75%) had received prior therapy for Kaposi's sarcoma. Once daily oral 9-cis-retinoic acid (alitretinoin, Panretin) was administered at doses up to 140 mg/m2. Most patients (72%) received a maximum dose of 100 mg/m2. Response was assessed using AIDS Clinical Trials Group (ACTG) criteria.

RESULTS

The median age was 38 years and the median absolute CD4 cell count was 194 x 10(6) cells/l (range 6-784 x 10(6)). Despite the use of three- and four-drug antiviral regimens (83%), the median HIV RNA at baseline was 8701 copies/ml [range < 500 (lower limit of detection) to 4.24 x 10(6)]. The tumor response rate was 37% (95% confidence interval 25-49). Tumor response was associated with improved quality-of-life measures. There was a significant increase in interleukin 6 (IL-6) levels from baseline to week 4. Responders had significantly lower baseline soluble IL-6 receptor levels (P = 0.029) than non-responders. The median time to response was 9 weeks (mean, 13 weeks; range, 4-36). HIV RNA levels did not change significantly during therapy nor did they correlate with tumor responses. Study drug was discontinued by 28 patients for adverse events, which included headache (13) and skin toxicity (10).

CONCLUSION

Oral 9-cis-retinoic acid is an active antitumor drug for AIDS-related Kaposi's sarcoma. Treatment is associated with skin and constitutional toxicity and further studies are needed to improve its long-term tolerance.

Hypercalcemia after High-Dose Chemoradiotherapy for Refractory Multiple Myeloma; Subject Heading

A 43-year-old man with refractory myeloma underwent allogeneic bone marrow transplantation from his HLA-matched sibling. He was conditioned with TBI (12 Gy) followed by melphalan (140 mg/m(2) ). Immediately after conditioning was initiated, he began complaining of severe lumbago, and the level of serum calcium rose from 2.25 to 3.34 mmol / l. However, the biochemical markers for tumor-lysis syndrome such as potassium, uric acid, and lactic dehydrogenase remained unchanged. Hydration with saline and pamidronate were started, but he developed acute renal failure requiring hemodialysis for 3 weeks. His plasma parathyroid hormonerelated protein (PTHrP)-NH2-terminal (3.9 pmol/l) and serum PTHrP-C-terminal (125.0 pmol / l) levels markedly increased immediately after conditioning. These results suggested that the increased release of PTHrP from myeloma cells, which resulted from destruction of myeloma cells by conditioning, was the primary contributes to the occurrence of hypercalcemia. We should be aware of the occurrence of hypercalcemia when high-dose therapy is to be given to patients with refractory myeloma.

Purging of myeloma cells using all-trans retinoic acid in a mouse model

OBJECTIVE

The 5T33 murine model of multiple myeloma was used to investigate the potential of all-trans retinoic acid (ATRA) to purge clonogenic myeloma cells from autologous hemopoietic stem-cell harvests by differentiating immature 5T33 cells into terminal-stage plasma cells with limited repopulation capacity.

MATERIALS AND METHODS

5T33 cells were treated with 10 microM ATRA and the effect on cell clonogenicity was determined by measuring the time to paraprotein detection in C57Bl/KaLwRij mice compared to control animals. Cell differentiation and apoptosis following ATRA treatment were investigated using flow cytometry and caspase-3 assay. Treatment with ATRA resulted in a 33% reduction in the in vitro cloning efficiency of 5T33 cells. Reduced in vitro clonogenicity of 5T33 cells following ATRA treatment was supported by a 16-49% increase in the time taken for C57Bl/KaLwRij mice to develop paraprotein following injection of 5T33 cells pretreated with ATRA for 8 days. Although ATRA was shown not to alter the in vitro growth characteristics of 5T33 cells, significant inhibition of apoptosis was observed.

RESULTS

Treatment with ATRA also resulted in an increase in the proportion of 5T33 cells expressing the CD54 adhesion molecule, which is known to be highly expressed on mature myeloma cells.

CONCLUSION

The ability of ATRA to decrease the clonogenicity of 5T33 cells in vitro and increase the time to disease development in vivo suggests that this drug may be useful for purging autologous stem cell harvests in the clinical setting.

Assessment of all-trans retinoic acid (ATRA) efficacy as a single agent in primary lymphoid neoplasia

All-trans retinoic acid (ATRA) is currently widely used in the therapy of acute promyelocytic leukemia and is being tested in vitro and in vivo on several other malignancies. Previously ATRA has been shown to inhibit the growth in vitro, of established human myeloma cell lines as well as cultured primary myeloma cells from patients. ATRA acts by down-regulating IL-6-receptor-alpha or gp130 on the surface of the myeloma cells. However, despite its in vitro effects on myeloma cells, ATRA therapy on advanced stage multiple myeloma (MM) patients has so far largely been ineffective. In current studies, we have assessed the efficacy of ATRA therapy against primary murine plasma cell tumors, which are an animal model for human MM. These tumors are induced at about 50% incidence in pristane-primed BALB/c mice by injection of v-raf/v-myc- containing retroviruses and are IL-6 dependent. Using this animal model, we assessed the effect of ATRA as a therapeutic agent against primary tumors at two early time points in disease development. ATRA was administered in liposomal vesicles (ATRAGEN), since liposomal-ATRA has been shown to circumvent clearance mechanisms by hepatic microsomes, which normally occur with free ATRA. In addition, ATRAGEN was previously shown to be less toxic in mice than free ATRA. ATRAGEN was administered beginning on day 25 or day 45 after virus injection and continued twice weekly for 8-11 weeks. ATRAGEN administration begun at either time point did not alter the incidence or the latency of plasma cell tumors compared with control animals. These results suggest that ATRA may not be an effective sole therapy against early MM.

Parathyroid hormone-related protein (107-139) stimulates interleukin-6 expression in human osteoblastic cells

The N-terminal region of both parathyroid hormone (PTH) and PTH-related protein (PTHrP) binds to the same PTH/PTHrP receptor in osteoblasts. However, C-terminal PTHrP (107-139) inhibits growth and various functions of osteoblasts and osteoclasts apparently through PTHrP-specific receptors. PTH (1-34) and PTHrP (1-34) rapidly induce interleukin-6 (IL-6) expression by osteoblasts. The aim of the present study was to assess the effects of PTHrP (107-139) on IL-6 gene expression and secretion by osteoblastic cells from human trabecular bone (hOB). Using reverse transcription followed by PCR, it was found that IL-6 mRNA was twofold maximally increased by either PTHrP (1-34) or PTHrP (107-139), at 10 nM, over basal within 1 to 2 h in hOB cells. This effect of PTHrP (107-139), and that of PTHrP (1-34), were abolished by the transcription inhibitor actinomycin D. Meanwhile, puromycin, a protein synthesis inhibitor, superinduced IL-6 expression in the presence or absence of each PTHrP peptide. Both PTHrP (1-34) and PTHrP (107-139), but not PTHrP (38-64), stimulated IL-6 secretion to the hOB cell-conditioned medium at 24 h, dose dependently. In addition, this maximal stimulatory effect (twofold over basal) was similar with each PTHrP peptide alone, and not additive when added together. PTHrP (107-139) stimulation of mRNA and protein in hOB cells was abolished by bisindolylmaleimide I, a protein kinase C inhibitor, but not by either adenosine 3',5'-cyclic monophosphorothioate, Rp-isomer (Rp-cAMPS), or N-[2-((p-bromocinnamyl)amino)ethyl]-5-isoquinolinesulfonamide dihydrochloride (H89), two protein kinase A inhibitors. These results indicate that C-terminal PTHrP, like its N-terminal domain, induces IL-6 production by human osteoblastic cells. This effect of both PTHrP regions could provide a mechanism to modulate bone turnover.

In vitro treatment with retinoids decreases bcl-2 protein expression and enhances dexamethasone-induced cytotoxicity and apoptosis in multiple myeloma cells

All-trans retinoic acid (ATRA) has been shown to inhibit in vitro growth of multiple myeloma (MM) cells, and this effect can be further potentiated by the addition of Dexamethasone (DEX). We here extended this study by testing the activity of 9-cis retinoic acid (9-cis RA) and 13-cis retinoic acid (13-cis RA), both alone and in combination with DEX, in two MM cell lines, U266 and RPMI 8226. Furthermore, we aimed at investigating the mechanisms involved in the interactions of retinoids and DEX in this setting. 9-cis RA appeared to be the most active agent in U266 cell line (IC50 = 1.2 mumol/l vs 10.5 and 9.8 mumol/l obtained with ATRA and 13-cis RA, respectively) while, in RPMI 8226 cell line, 9-cis RA and 13-cis RA were almost equally cytotoxic (IC50 = 1 and 0.8 mumol/l) and ATRA was less effective. Co-incubation with DEX resulted in a synergistic cytotoxic activity in both the cell lines except for the combinations DEX + 9-cis RA in U266 cell line and DEX + 13-cis RA in RPMI 8226 cell line, where the effect was merely additive. A synergistic cytotoxic effect of retinoids and DEX was also observed on fresh MM cells obtained from 7 patients. Both retinoids and DEX are known to be inducers of apoptosis; we verified that the combined inhibitory activity of retinoids and DEX could be attributed to an increased induction of apoptosis. This effect may be mediated by a reduced intracellular expression of BCL-2 protein, which indeed observed after prolonged in vitro treatment with retinoids. It has been described recently that an enhanced expression of BCL-2 protein can contribute to the occurrence of early chemoresistance; the downregulation of BCL-2 protein induced by retinoids could thus be exploited, by means of novel chemotherapy plus retinoids combinations, in order to improve the efficacy of conventional chemotherapy in MM.

Retinoid-induced hypercalcemia in a patient with kaposi sarcoma associated with acquired immunodeficiency syndrome

Retinoids are commonly used for the treatment of nonmalignant skin disorders and occasionally for the treatment of various neoplasms including epidemic Kaposi sarcoma (KS). Dry skin and mucus membranes, muscle and joint aches, alopecia, headaches, and liver and lipid abnormalities are the most frequent medication-related side effects. Very rarely, this class of drugs is associated with the development of hypercalcemia. The authors report the case of a man with acquired immunodeficiency syndrome (AIDS)-associated KS who, while participating in a phase II clinical trial of LGD 1057 (9-cis-retinoic acid) for treatment of epidemic KS, developed hypercalcemia, mental status changes, and renal insufficiency. The etiologic factors of retinoid-induced hypercalcemia are imperfectly understood, but with drug withdrawal his serum calcium, mental acuity, and renal function quickly normalized. Hypercalcemia occurs infrequently in the setting of AIDS and when present, is usually mediated by opportunistic infections. Clinicians should be alert to this potentially life-threatening iatrogenic complication that responds favorably to drug withdrawal.

Dexamethasone plus retinoids decrease IL-6/IL-6 receptor and induce apoptosis in myeloma cells

Interleukin 6 (IL-6) is the most important known growth factor for multiple myeloma, and IL-6 signalling pathways are potential targets for therapy. We hypothesized that interfering with the IL-6 signalling pathway at more than one level would be more effective than a single block in inhibiting proliferation of myeloma cells. Accumulating data support the concept that glucocorticoids down-regulate IL-6, whereas retinoic acid derivatives (RA) down-regulate IL-6R in myeloma. We found that all-trans RA (ATRA), 13-cis-RA and 9-cis-RA each similarly inhibited growth of RPMI 8226 myeloma cells and that addition of dexamethasone (DEX) added to RA growth inhibition. The major effects of retinoids were to reduce the proliferative fraction and induce apoptosis whereas DEX increased the apoptotic fraction. When combined, apoptosis was enhanced. Effects of RA + DEX were also least able to be overcome by exogenous IL-6. RA decreased IL-6R levels and addition of DEX to RA delayed recovery of IL-6R levels compared with RA alone. Since RPMI 8226 cells have undetectable IL-6, we investigated U266B1 cells and found that RA and DEX decreased both IL-6 secretion and IL-6 RNA levels. Mechanistically, IL-6R down-regulation by RA was enhanced by DEX, whereas IL-6 protein and RNA levels were reduced by DEX and by RA. In summary, combinations of RA + DEX were not only more effective in inhibiting myeloma cells growth by the dual mechanisms of decreasing proliferative fraction and increasing apoptotic fraction, but were also less able to be overcome by IL-6.

Differential in vitro and in vivo effects of all-trans retinoic acid on the growth of human myeloma cells

The effects of all trans retinoic acid (ATRA) on human myeloma cells growth were studied in vitro and in vivo using immunodeficient mice engrafted with malignant plasma cells. ATRA inhibited the in vitro proliferation of plasma cells originating from two patients with multiple myeloma whereas it had no effect on the in vivo growth of plasma cell grafts as assessed by the serial study of human Ig levels in mouse serum. Thus, the efficacy of ATRA for the treatment of human multiple myeloma remains to be ascertained.

Modulation of interleukin-6/interleukin-6 receptor cytokine loop in the treatment of multiple myeloma

Interluekin-6 (IL-6)/IL-6 receptor (IL-6R) play a major role in autocrine/paracrine growth regulation of myeloma cells and are the central mediators for bone destruction and other systemic manifestations of multiple myeloma. Modulation of the IL-6/IL-6R cytokine loop thus represents a rational therapeutic approach. We updated and reviewed the studies on the agents that targeted IL-6/IL-6R modulation and the results of selected clinical trials. Extensive in vitro studies with human myeloma cell lines or primary myeloma explants have shown that components of this cytokine loop could be modulated by various agents, and such modulation is associated with inhibition of myeloma cell growth. The purported mechanisms of action of these agents, down-regulation or neutralization of IL-6 and/or IL-6R and the interruption of IL-6 binding to IL-6R or gp 130 signal transducer, with possible exception for glucocorticoids and specific antibodies, remain to be formally proven. Clinical trials showed largely limited benefits of these agents. Given tumor cell heterogeneity and the complexity of inter-connected cytokine network in vivo, the future emphasis should be on the strategy of combination treatment that would modulate this cytokine loop at multiple sites. Further advances in delineating IL-6 and related cytokine signal transduction pathways should also suggest other targets for therapeutic intervention.

Myeloma biology and therapy. Present status and future developments

Recent progress in cytokine studies has made it possible to understand the pathophysiological roles of cytokines in multiple myeloma. Specifically, interleukin (IL)-6 is a potent growth factor for myeloma cells and is also responsible for the progressive bone resorption characteristic of this disease. On the basis of this evidence, clinical trials to interfere with IL-6 signals have been initiated for the treatment of patients with advanced myeloma. Such a new therapeutic approach as well as myeloblative therapy should be able to provide us with the breakthrough needed to prevail over this so far incurable disease.