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Darwish C, Farina K, Tremblay D. The core concepts of core binding factor acute myeloid leukemia: Current considerations for prognosis and treatment. Blood Rev 2023; 62:101117. [PMID: 37524647 DOI: 10.1016/j.blre.2023.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/04/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
Core binding factor acute myeloid leukemia (CBF AML), defined by t(8;21) or inv(16), is a subset of favorable risk AML. Despite its association with a high complete remission rate after induction and relatively good prognosis overall compared with other subtypes of AML, relapse risk after induction chemotherapy remains high. Optimizing treatment planning to promote recurrence free survival and increase the likelihood of survival after relapse is imperative to improving outcomes. Recent areas of research have included evaluation of the role of gemtuzumab in induction and consolidation, the relative benefit of increased cycles of high dose cytarabine in consolidation, the utility of hypomethylating agents and kinase inhibitors, and the most appropriate timing of stem cell transplant. Surveillance with measurable residual disease testing is increasingly being utilized for monitoring disease in remission, and ongoing investigation seeks to determine how to use this tool for early identification of patients who would benefit from proceeding to transplant. In this review, we outline the current therapeutic approach from diagnosis to relapse while highlighting the active areas of investigation in each stage of treatment.
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Affiliation(s)
- Christina Darwish
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA
| | - Kyle Farina
- Department of Pharmacy Practice, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
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2
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Minetto P, Candoni A, Guolo F, Clavio M, Zannier ME, Miglino M, Dubbini MV, Carminati E, Sicuranza A, Ciofini S, Colombo N, Pugliese G, Marcolin R, Santoni A, Ballerini F, Lanino L, Cea M, Gobbi M, Bocchia M, Fanin R, Lemoli RM. Fludarabine, High-Dose Cytarabine and Idarubicin-Based Induction May Overcome the Negative Prognostic Impact of FLT3-ITD in NPM1 Mutated AML, Irrespectively of FLT3-ITD Allelic Burden. Cancers (Basel) 2020; 13:cancers13010034. [PMID: 33374216 PMCID: PMC7796342 DOI: 10.3390/cancers13010034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Simple Summary The prognostic relevance of molecular aberrations in acute myeloid leukemia (AML) has been prevalently tested in patients receiving conventional 3+7 induction. Recently, there has been a renewed interest in intensified inductions, but very few data are available on the impact of the most frequent genetic alterations with these alternative treatments. We analyzed a large multicentric cohort of younger AML patients harboring NPM1 and FLT3-ITD mutations receiving an intensified fludarabine-containing regimen (FLAI). Our data suggest that in NPM1 mut patients, FLAI may overcome the prognostic influence of co-mutated FLT3-ITD. The increased efficacy of this treatment seems to reduce the need for early consolidation with allogeneic transplant in double-mutated patients. Our data strongly support FLAI as an ideal backbone for combination with innovative targeted drugs, in order to further improve patients’ outcome. Abstract The mutations of NPM1 and FLT3-ITD represent the most frequent genetic aberration in acute myeloid leukemia. Indeed, the presence of an NPM1 mutation reduces the negative prognostic impact of FLT3-ITD in patients treated with conventional “3+7” induction. However, little information is available on their prognostic role with intensified regimens. Here, we investigated the efficacy of a fludarabine, high-dose cytarabine and idarubicin induction (FLAI) in 149 consecutive fit AML patients (median age 52) carrying the NPM1 and/or FLT3-ITD mutation, treated from 2008 to 2018. One-hundred-and-twenty-nine patients achieved CR (86.6%). After a median follow up of 68 months, 3-year overall survival was 58.6%. Multivariate analysis disclosed that both NPM1mut (p < 0.05) and ELN 2017 risk score (p < 0.05) were significant predictors of survival. NPM1-mutated patients had a favorable outcome, with no significant differences between patients with or without concomitant FLT3-ITD (p = 0.372), irrespective of FLT3-ITD allelic burden. Moreover, in landmark analysis, performing allogeneic transplantation (HSCT) in first CR proved to be beneficial only in ELN 2017 high-risk patients. Our data indicate that FLAI exerts a strong anti-leukemic effect in younger AML patients with NPM1mut and question the role of HSCT in 1st CR in NPM1mut patients with concomitant FLT3-ITD.
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Affiliation(s)
- Paola Minetto
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Correspondence: (P.M.); (F.G.); Tel.: +39-10-555-4329 (P.M.); +39-10-555-4491 (F.G.)
| | - Anna Candoni
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Fabio Guolo
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Correspondence: (P.M.); (F.G.); Tel.: +39-10-555-4329 (P.M.); +39-10-555-4491 (F.G.)
| | - Marino Clavio
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Maria Elena Zannier
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Maurizio Miglino
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Maria Vittoria Dubbini
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Enrico Carminati
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Anna Sicuranza
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Sara Ciofini
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | | | - Girolamo Pugliese
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Riccardo Marcolin
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Adele Santoni
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Filippo Ballerini
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Luca Lanino
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Michele Cea
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Marco Gobbi
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
| | - Monica Bocchia
- Hematology Unit, University of Siena, Azienda Ospedaliera Universitaria, 53100 Siena, Italy; (A.S.); (S.C.); (A.S.); (M.B.)
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy; (A.C.); (M.E.Z.); (M.V.D.); (R.F.)
| | - Roberto Massimo Lemoli
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, 16132 Genova, Italy; (M.C.); (M.M.); (E.C.); (G.P.); (R.M.); (F.B.); (L.L.); (M.C.); (M.G.); (R.M.L.)
- IRCCS-Ospedale Policlinico San Martino, 16132 Genova, Italy;
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Identification of Two DNMT3A Mutations Compromising Protein Stability and Methylation Capacity in Acute Myeloid Leukemia. JOURNAL OF ONCOLOGY 2019; 2019:5985923. [PMID: 31827512 PMCID: PMC6881567 DOI: 10.1155/2019/5985923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/11/2019] [Indexed: 12/30/2022]
Abstract
Somatic mutations of DNMT3A occur in about 20% of acute myeloid leukemia (AML) patients. They mostly consist in heterozygous missense mutations targeting a hotspot site at R882 codon, which exhibit a dominant negative effect and are associated with high myeloblast count, advanced age, and poor prognosis. Other types of mutations such as truncations, insertions, or single-nucleotide deletion also affect the DNMT3A gene, though with lower frequency. The present study aimed to characterize two DNMT3A gene mutations identified by next-generation sequencing (NGS), through analysis of protein stability and DNA methylation status at CpG islands. The first mutation was a single-nucleotide variant of DNMT3A at exon 20 causing a premature STOP codon (c.2385G > A; p.Trp795 ∗ ; NM_022552.4). The DNMT3A mutation load increased from 4.5% to 38.2% during guadecitabine treatment, with a dominant negative effect on CpG methylation and on protein expression. The second mutation was a novel insertion of 35 nucleotides in exon 22 of DNMT3A (NM_022552.4) that introduced a STOP codon too, after the amino acid Glu863 caused by a frameshift insertion (c.2586_2587insTCATGAATGAGAAAGAGGACATCTTATGGTGCACT; p. Thr862_Glu863fsins). The mutation, which was associated with reduced DNMT3A expression and CpG methylation, persisted at relapse with minor changes in the methylation profile and at protein level. Our data highlight the need to better understand the consequences of DNMT3A mutations other than R882 substitutions in the leukemogenic process in order to tailor patient treatments, thus avoiding therapeutic resistance and disease relapse.
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Cerrano M, Candoni A, Crisà E, Dubbini MV, D'Ardia S, Zannier ME, Boccadoro M, Audisio E, Bruno B, Ferrero D. FLAI induction regimen in elderly patients with acute myeloid leukemia. Leuk Lymphoma 2019; 60:3339-3340. [PMID: 31159609 DOI: 10.1080/10428194.2019.1620943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Marco Cerrano
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Anna Candoni
- Division of Hematology and SCT, University of Udine, Udine, Italy
| | - Elena Crisà
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Stefano D'Ardia
- Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Mario Boccadoro
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ernesta Audisio
- Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Dario Ferrero
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Department of Oncology, Division of Hematology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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5
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Tiribelli M, Michelutti A, Fanin R, Damiani D. ABCG2 overexpression and deoxyadenosine analogue activity in acute myeloid leukemia. Cancer 2017; 123:4934-4935. [PMID: 29053186 DOI: 10.1002/cncr.31037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation Department of Medicine, University Hospital, Udine, Italy
| | - Angela Michelutti
- Division of Hematology and Bone Marrow Transplantation Department of Medicine, University Hospital, Udine, Italy
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation Department of Medicine, University Hospital, Udine, Italy
| | - Daniela Damiani
- Division of Hematology and Bone Marrow Transplantation Department of Medicine, University Hospital, Udine, Italy
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6
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Mannargudi MB, Deb S. Clinical pharmacology and clinical trials of ribonucleotide reductase inhibitors: is it a viable cancer therapy? J Cancer Res Clin Oncol 2017. [PMID: 28624910 DOI: 10.1007/s00432-017-2457-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Ribonucleotide reductase (RR) enzymes (RR1 and RR2) play an important role in the reduction of ribonucleotides to deoxyribonucleotides which is involved in DNA replication and repair. Augmented RR activity has been ascribed to uncontrolled cell growth and tumorigenic transformation. METHODS This review mainly focuses on several biological and chemical RR inhibitors (e.g., siRNA, GTI-2040, GTI-2501, triapine, gemcitabine, and clofarabine) that have been evaluated in clinical trials with promising anticancer activity from 1960's till 2016. A summary on whether their monotherapy or combination is still effective for further use is discussed. RESULTS Among the RR2 inhibitors evaluated, GTI-2040, siRNA, gallium nitrate and didox were more efficacious as a monotherapy, whereas triapine was found to be more efficacious as combination agent. Hydroxyurea is currently used more in combination therapy, even though it is efficacious as a monotherapy. Gallium nitrate showed mixed results in combination therapy, while the combination activity of didox is yet to be evaluated. RR1 inhibitors that have long been used in chemotherapy such as gemcitabine, cladribine, fludarabine and clofarabine are currently used mostly as a combination therapy, but are equally efficacious as a monotherapy, except tezacitabine which did not progress beyond phase I trials. CONCLUSIONS Based on the results of clinical trials, we conclude that RR inhibitors are viable treatment options, either as a monotherapy or as a combination in cancer chemotherapy. With the recent advances made in cancer biology, further development of RR inhibitors with improved efficacy and reduced toxicity is possible for treatment of variety of cancers.
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Affiliation(s)
- Mukundan Baskar Mannargudi
- Clinical Pharmacology Program, Medical Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, USA
| | - Subrata Deb
- Department of Biopharmaceutical Sciences, Roosevelt University College of Pharmacy, 1400 N. Roosevelt Blvd., Schaumburg, IL, 60173, USA.
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De-Mello RAB, Pinho-Vaz C, Branca R, Campilho F, Rosales M, Roncon S, Campos-Júnior A. Outcomes of allogeneic stem cell transplantation among patients with acute myeloid leukemia presenting active disease: Experience of a single European Comprehensive Cancer Center. Rev Assoc Med Bras (1992) 2016; 62:641-646. [PMID: 27925043 DOI: 10.1590/1806-9282.62.07.641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/19/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction: Allogeneic hematopoietic stem cell transplantation (ASCT) representes a potentially curative approach for patients with relapsed or refractory acute myeloid leukemia (AML). We report the outcome of relapsed/refractory AML patients treated with ASCT. Method: A retrospective cohort from 1994 to 2013 that included 61 patients with diagnosis of relapsed/refractory AML. Outcomes of interest were transplant-related mortality (TRM), incidence of acute and chronic graft-versus-host disease (GVHD), relapse incidence, progression-free survival (PFS) and overall survival (OS). Statistical significance was set at p<0.05. Results: The median age was 61 years (range 1 to 65). The cumulative incidence of 90 days, 1 year, and 3 years TRM were 60%, 26.7%, and 13.3%, respectively (p<0.001). The incidence of relapse was 21.7% at 1 year, 13% at 3 years, and 8.7% at 5 years. Median OS was estimated to be 8 months (95CI 3.266-12.734) and median PFS, 3 months (95CI 1.835-4.165). Conclusion: In our cohort, TRM in first years after ASCT remains considerable, but ASCT in this setting seems to be a good choice for AML patients with active disease. However, novel approaches are needed to reduce TRM and relapse in this set of patients.
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Affiliation(s)
- Ramon Andrade Bezerra De-Mello
- Professor of Medicine and Clinical Oncology, Instituto Português de Oncologia Francisco Gentil (IPO-Porto) and Universidade do Algarve, Faro, Portugal
| | | | | | | | - Maria Rosales
- Immune Hematology Therapist, IPO-Porto, Porto, Portugal
| | - Susana Roncon
- Immune Hematology Therapist, IPO-Porto, Porto, Portugal
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8
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Guolo F, Minetto P, Clavio M, Miglino M, Di Grazia C, Ballerini F, Pastori G, Guardo D, Colombo N, Kunkl A, Fugazza G, Rebesco B, Sessarego M, Lemoli RM, Bacigalupo A, Gobbi M. High feasibility and antileukemic efficacy of fludarabine, cytarabine, and idarubicin (FLAI) induction followed by risk-oriented consolidation: A critical review of a 10-year, single-center experience in younger, non M3 AML patients. Am J Hematol 2016; 91:755-62. [PMID: 27084986 DOI: 10.1002/ajh.24391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/16/2016] [Accepted: 04/13/2016] [Indexed: 11/09/2022]
Abstract
About 105 consecutive acute myeloid leukemia (AML) patients treated with the same induction-consolidation program between 2004 and 2013 were retrospectively analyzed. Median age was 47 years. The first induction course included fludarabine (Flu) and high-dose cytarabine (Ara-C) plus idarubicin (Ida), with or without gemtuzumab-ozogamicin (GO) 3 mg/m(2) (FLAI-5). Patients achieving complete remission (CR) received a second course without fludarabine but with higher dose of idarubicin. Patients not achieving CR received an intensified second course. Patients not scheduled for early allogeneic bone marrow transplantation (HSCT) where planned to receive at least two courses of consolidation therapy with Ara-C. Our double induction strategy significantly differs from described fludarabine-containing regimens, as patients achieving CR receive a second course without fludarabine, to avoid excess toxicity, and Ara-C consolidation is administrated at the reduced cumulative dose of 8 g/m(2) per cycle. Toxicity is a major concern in fludarabine containing induction, including the recent Medical Research Council AML15 fludarabine, cytarabine, idaraubicin and G-CSF (FLAG-Ida) arm, and, despite higher anti-leukemic efficacy, only a minority of patients is able to complete the full planned program. In this article, we show that our therapeutic program is generally well tolerated, as most patients were able to receive subsequent therapy at full dose and in a timely manner, with a 30-day mortality of 4.8%. The omission of fludarabine in the second course did not reduce efficacy, as a CR rate of 83% was achieved and 3-year disease-free survival and overall survival (OS) were 49.6% and 50.9%, respectively. Our experience shows that FLAI-5/Ara-C + Ida double induction followed by risk-oriented consolidation therapy can result in good overall outcome with acceptable toxicity. Am. J. Hematol. 91:755-762, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabio Guolo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Paola Minetto
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marino Clavio
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Maurizio Miglino
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Carmen Di Grazia
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Filippo Ballerini
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giordana Pastori
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Daniela Guardo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Nicoletta Colombo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Annalisa Kunkl
- Service of Flow-Cytometry, Department of Pathology; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giuseppina Fugazza
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Barbara Rebesco
- Pharmacology Division; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Mario Sessarego
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Roberto Massimo Lemoli
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Andrea Bacigalupo
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marco Gobbi
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
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Damiani D, Tiribelli M, Geromin A, Cerno M, Zanini F, Michelutti A, Fanin R. ABCG2, Cytogenetics, and Age Predict Relapse after Allogeneic Stem Cell Transplantation for Acute Myeloid Leukemia in Complete Remission. Biol Blood Marrow Transplant 2016; 22:1621-1626. [PMID: 27178373 DOI: 10.1016/j.bbmt.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/02/2016] [Indexed: 11/12/2022]
Abstract
Recent studies have shown that ABGG2 protein overexpression in acute myeloid leukemia (AML) may be associated with poor response to therapy and increased relapse risk. Few data are available in patients with AML undergoing allogeneic stem cell transplantation (SCT), particularly when in complete remission (CR). We analyzed 105 patients with AML who underwent allogeneic SCT in CR evaluating the role of ABCG2 and other pretransplantation features on subsequent transplantation outcomes. Factors negatively associated with leukemia-free survival (LFS) were unfavorable cytogenetics (3-year LFS 48% versus 80%, P = .0035) and ABCG2 positivity (65% versus 80%, P = .045). Three-year cumulative incidence of relapse (CIR) in the whole population was 20%; a higher incidence of relapse was associated with adverse cytogenetics (41% versus 16%, P = .018), ABCG2 overexpression (29% versus 15%, P = .04), and, marginally, age > 50 years (30% versus 14%, P = .06). We grouped patients according to the combination of these 3 risk factors: no patient relapsed within 3 years from SCT in the group without risk factors, whereas the 3-year CIR was 12% (95% confidence interval [CI], 2% to 25%) in the group with 1 risk factor and 47% (95% CI, 31% to 70%) in patients with 2 or 3 risk factors (P = .00005). In conclusion, allogeneic SCT does not seem to abrogate the negative prognosis associated with ABCG2 overexpression at diagnosis, specifically in terms of a higher relapse risk. ABCG2, age, and cytogenetics can predict AML relapse after SCT in patients who undergo transplantation while in CR.
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Affiliation(s)
- Daniela Damiani
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy.
| | - Mario Tiribelli
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Antonella Geromin
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Michela Cerno
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Francesca Zanini
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Angela Michelutti
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Renato Fanin
- Division of Hematology and Stem Cell Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
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10
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Maschio M, Marchesi F, Dispenza S, Dinapoli L, Sperati F, Petreri G, Gumenyuk S, Dessanti ML, Zarabla A, Cantelmi T, Mengarelli A. Effect of high dose cytosine arabinoside on quantitative EEG in patients with acute myeloid leukemia. Cogn Neurodyn 2016; 10:185-8. [PMID: 27066155 DOI: 10.1007/s11571-015-9370-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022] Open
Abstract
Background EEG activity is considered an index of functional state of brain. Chemotherapy (CT), used for non-central nervous system (CNS) cancer, can cross the blood brain barrier and contribute to changes in the functional state of brain that can alter background EEG activity. Quantitative EEG (qEEG) is superior to conventional EEG in the detection of subtle alterations of EEG background activity and for this reason, the use of qEEG might assist the clinician in evaluating the possible effect of CT on the CNS. The nucleoside analog cytosine arabinoside (Ara-C) is one of the milestone chemotherapeutic agents used for treatment of acute myeloid leukemia (AML). Our observational study evaluates the possible effect of Ara-C on the qEEG of patients with AML, without CNS involvement. We conducted an observational study on newly diagnosed AML patients without CNS involvement, undergoing treatment with Ara-C to analyze the possible effect of Ara-C high doses on EEG background activity using qEEG analyses. A total of nine AML patients, 5 with Ara-C i.v. high dose (≥3 g/m(2) die), 4 with standard dose (100 mg/m(2) die) underwent qEEG (at rest, during hyperpnoea, mental arithmetic task and blocking reaction). We compared the EEG background activity of the two groups at baseline and after 6 months. Statistical analysis showed no significant differences between the two groups in mean relative power for all frequency bands, at rest and during hyperpnoea, mental arithmetic task and blocking reaction. Our data indicate that high dose Ara-C i.v. did not induce significant changes on EEG background activity in our patients. Future research in this area could include prospective studies that would combine qEEG and neuropsychological testing to assess the impact of CT on brain functions.
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Affiliation(s)
- Marta Maschio
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Sabrina Dispenza
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Loredana Dinapoli
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Francesca Sperati
- Biostatistics/Scientific Direction, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Gianluca Petreri
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Svitlana Gumenyuk
- Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Maria Laura Dessanti
- Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Alessia Zarabla
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Tonino Cantelmi
- Center for Tumor-Related Epilepsy, Area of Supporting Care, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
| | - Andrea Mengarelli
- Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144 Rome, Italy
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11
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DiPersio JF, Erba HP, Larson RA, Luger SM, Tallman MS, Brill JM, Vuagniaux G, Rouits E, Sorensen JM, Zanna C. Oral Debio1143 (AT406), an antagonist of inhibitor of apoptosis proteins, combined with daunorubicin and cytarabine in patients with poor-risk acute myeloid leukemia--results of a phase I dose-escalation study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:443-9. [PMID: 25842225 DOI: 10.1016/j.clml.2015.02.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of acute myeloid leukemia (AML) remains difficult owing to the development of treatment resistance, which might be overcome through antagonists of inhibitors of apoptosis proteins (IAPs). PATIENTS AND METHODS The present multicenter, open-label, dose-escalation study aimed to evaluate the tolerability, pharmacokinetics (PK), pharmacodynamics (PD), and efficacy of Debio1143 (formerly AT-406), a new IAP antagonist, when given along with a standard "7 plus 3 regimen" of daunorubicin and cytarabine to poor-risk patients with AML during the induction cycle. Consecutive patient cohorts received once-daily 100, 200, 300, or 400 mg of oral Debio1143 on treatment days 1 to 5. Blood samples were collected regularly until hematologic recovery or response was documented. Bone marrow samples were collected on days 0, 14, and 29 and PK and PD samples on days 1, 3, 5, 8, and 10 and 1, 2, and 8, respectively. RESULTS Of the 29 enrolled patients, 23 completed the study. The most common adverse events of any grade deemed related to treatment were nausea (31% of patients), diarrhea (14%), and febrile neutropenia (14%). Exposure exceeded dose proportionality, without accumulation over 5 days. Inhibition of cellular IAP1 was detectable in the CD34/CD117(+) cells and blasts. A total of 11 patients (38%) achieved complete remission, most in the 100-mg dose cohort. Of these, 6 (56%) developed a relapse within the study period. The patients with a response more frequently showed plasma increases of tumor necrosis factor-α and interleukin-8 after the first dose of Debio1143. CONCLUSION Debio1143 ≤ 400 mg/d showed good tolerability in combination with daunorubicin and cytarabine. Additional studies in subsets of patients with AML are warranted.
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Affiliation(s)
- John F DiPersio
- Division of Oncology, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO.
| | | | | | - Selina M Luger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Claudio Zanna
- Debiopharm International S.A., Lausanne, Switzerland
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12
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Nazha A, Kantarjian H, Ravandi F, Huang X, Choi S, Garcia-Manero G, Jabbour E, Borthakur G, Kadia T, Konopleva M, Cortes J, Ferrajoli A, Kornblau S, Daver N, Pemmaraju N, Andreeff M, Estrov Z, Du M, Brandt M, Faderl S. Clofarabine, idarubicin, and cytarabine (CIA) as frontline therapy for patients ≤60 years with newly diagnosed acute myeloid leukemia. Am J Hematol 2013; 88:961-6. [PMID: 23877926 DOI: 10.1002/ajh.23544] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/25/2013] [Accepted: 07/09/2013] [Indexed: 11/06/2022]
Abstract
Clofarabine is a second generation nucleoside analogue with activity in adults with acute myeloid leukemia (AML). A phase I trial of clofarabine, idarubicin, and cytarabine (CIA) in relapsed and refractory AML had shown an overall response rate (ORR) of 48%. To explore this combination further, we conducted a phase II study of (CIA) in patients with newly diagnosed AML ≤60 years. Patients ≥18-60 years with AML and adequate organ function were enrolled. Induction therapy consisted of clofarabine (C) 20 mg m⁻² IV daily (days 1-5), idarubicin (I) 10 mg m⁻² IV daily (days 1-3), and cytarabine (A) 1 g m⁻² IV daily (days 1-5). Patients in remission received up to six consolidation cycles (C 15 mg m⁻² × 3, I 8 mg m⁻² × 2, and A 0.75 g m⁻² × 3). Fifty-seven patients were evaluable. ORR was 79%. With a median follow up of 10.9 months, the median overall survival (OS) was not reached, the median event-free survival (EFS) was 13.5 months. Most toxicities were ≤grade 2. Four week mortality was 2%. In subgroup analysis, patients ≤40 years had better OS (P = 0.04) and EFS (P = 0.04) compared to patients >40 years. Compared to historical patients treated with idarubicin and cyarabine (IA), the OS and EFS were significantly longer for CIA treated patients. In multivariate analysis, CIA retained its favorable impact on OS compared to IA. Thus, CIA is an effective and safe therapy for patients ≤60 years with newly diagnosed AML.
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Affiliation(s)
- Aziz Nazha
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Farhad Ravandi
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Xuelin Huang
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Sangbum Choi
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | | | - Elias Jabbour
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Gautam Borthakur
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Tapan Kadia
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Marina Konopleva
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Jorge Cortes
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Alessandra Ferrajoli
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Steve Kornblau
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Naval Daver
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Naveen Pemmaraju
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Michael Andreeff
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Zeev Estrov
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Min Du
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Mark Brandt
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
| | - Stefan Faderl
- Department of Leukemia; The University of Texas-M.D. Anderson Cancer Center; Houston Texas
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13
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Chemomodulation of sequential high-dose cytarabine by fludarabine in relapsed or refractory acute myeloid leukemia: a randomized trial of the AMLCG. Leukemia 2013; 28:1001-7. [DOI: 10.1038/leu.2013.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/27/2013] [Accepted: 10/03/2013] [Indexed: 11/08/2022]
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Abstract
Anthracyclines have received significant attention due to their effectiveness and extensive use as anticancer agents. At present, the clinical use of these drugs is offset by drug resistance in tumours and cardiotoxicity. Therefore, a relentless search for the 'better anthracycline' has been ongoing since the inception of these drugs > 30 years ago. This review focuses on the most recent pharmacology and medicinal chemistry developments on the design and use of anthracyclines. Based on their crystal structures as well as molecular modelling, a more detailed mechanism of topoisomerase poisoning by these new anthracyclines has emerged. Chemical modifications of anthracyclines have been found to possibly change the target selectivity among various topoisomerases and, thus, vary their anticancer activity. Additionally, recent sugar modifications of anthracyclines have also been found to overcome P-glycoprotein-mediated drug resistance in cancer therapy. The continued improvement of anthracycline clinical applications so far and the clinical trials of the 'third generation' of anthracyclines (such as sabarubicin) are also discussed. To finally find the 'better' anthracycline, further areas of research still need to be explored such as: the elucidation of the topoisomerase and P-glycoprotein crystal structures, molecular modelling based on crystal structure in order to design the next generation of better anthracycline drugs, the continued modifications of the anthracycline sugar moieties, and the further improvement of anthracycline drug delivery methods.
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Affiliation(s)
- Janos Nadas
- Department of Chemistry, College of Pharmacy, The Ohio Sate University, Columbus, OH 43210, USA
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15
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Kim I, Koh Y, Yoon SS, Park S, Kim BK, Kim DY, Lee JH, Lee KH, Cheong JW, Lee HK, Kim SH, Kim H, Joo YD, Lee SM, Won JH, Park SK, Hong DS, Kim SH, Sohn SK, Kim CS, Park E, Kim MK, Park MR, Lee JH, Min YH. Fludarabine, cytarabine, and attenuated-dose idarubicin (m-FLAI) combination therapy for elderly acute myeloid leukemia patients. Am J Hematol 2013; 88:10-5. [PMID: 23077109 DOI: 10.1002/ajh.23337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 08/29/2012] [Accepted: 08/30/2012] [Indexed: 12/11/2022]
Abstract
We performed a phase II trial to evaluate the efficacy and safety of the modified fludarabine, cytarabine, and attenuated-dose idarubicin (m-FLAI) regimen in elderly acute myeloid leukemia (AML) patients. Elderly (≥60 years) AML patients who had not previously received chemotherapy were enrolled in the study. Patients received two consecutive cycles of m-FLAI chemotherapy as an induction. The m-FLAI regimen comprised fludarabine (25 mg/m(2) , days 1-4), cytarabine (1,000 mg/m(2) , days 1-4), and attenuated-dose idarubicin (5 mg/m(2) , days 1-3). The primary end point was complete remission (CR) rate. Secondary end points were overall survival (OS), event-free survival (EFS), and treatment-related mortality (TRM). There were 108 patients (median age 68.4 years, M:F = 64:44) enrolled in the study. CR was achieved in 56.5% of patients, and the TRM rate was 21.3%. Median OS and median EFS were 10.2 and 6.6 months, respectively. The mortality at 30 and 60 days was 15 and 21%, respectively. Performance status and comorbidity did not have prognostic value in this patient cohort. Bone marrow expression of CD117 was associated with increased EFS and OS. m-FLAI is an effective induction regimen for previously untreated AML in elderly patients. In addition, bone-marrow CD117 expression is an independent favorable prognostic factor in elderly AML patients. (ClinicalTrials.gov number, NCT01247493).
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Affiliation(s)
- Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Korea
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16
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Tefferi A, Letendre L. Going beyond 7 + 3 regimens in the treatment of adult acute myeloid leukemia. J Clin Oncol 2012; 30:2425-8. [PMID: 22529263 DOI: 10.1200/jco.2011.38.9601] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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17
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Malagola M, Skert C, Vignetti M, Piciocchi A, Martinelli G, Alimena G, Mecucci C, Testoni N, Iacobucci I, Clavio M, Gobbi M, Candoni A, Damiani D, Bocchia M, Lauria F, Zaccaria A, Mazza P, Visani G, Peli A, Colombi C, Cancelli V, Mancini M, Foà R, Martelli M, Cantore N, Di Raimondo F, Petrini M, De Fabritiis P, Fioritoni G, Nobile F, Fabbiano F, Specchia G, Baccarani M, Lo Coco F, Amadori S, Mandelli F, Russo D. A simple prognostic scoring system for newly diagnosed cytogenetically normal acute myeloid leukemia: retrospective analysis of 530 patients. Leuk Lymphoma 2011; 52:2329-35. [PMID: 21745171 DOI: 10.3109/10428194.2011.596965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We retrospectively analyzed the data of 337 patients with cytogenetically normal (CN) acute myeloid leukemia (AML), aged ≤ 65 years (training set). A prognostic index score (PIS) was calculated by totaling the score derived from the regression coefficients of each clinical variable, significantly associated with prognosis by multivariate analysis. The variables that were independent prognostic factors for event-free survival (EFS) and overall survival (OS) in the training set were: age ≥ 50 years, secondary AML and white blood cell count (WBC) ≥ 20 × 10(9)/L. The patients of the training set were stratified into three groups: low-, intermediate- and high-risk. The median EFS was 25, 12 and 7 months in the low-, intermediate- and high-risk groups (p < 0.0001), respectively. The median OS was not reached in the low-risk group and was 19 and 10 months in the intermediate- and high-risk groups (p < 0.0001). This PIS was validated in a series of 193 patients with CN-AML. The median EFS was 66, 16, and 3 months (p < 0.0001) and the median OS was 66, 16, and 5 months in the three risk groups, respectively (p < 0.0001). This PIS may be useful for clinical decision-making in CN-AML and may be prospectively integrated with the newest biological markers which at present are not routinely assessed and need prognostic validation.
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Affiliation(s)
- Michele Malagola
- Chair of Hematology, Unit of Blood Disease and Cell Therapy, Spedali Civili Hospital, Brescia, Italy.
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18
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Robak T, Wierzbowska A. Current and emerging therapies for acute myeloid leukemia. Clin Ther 2010; 31 Pt 2:2349-70. [PMID: 20110045 DOI: 10.1016/j.clinthera.2009.11.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a clonal disease characterized by the proliferation and accumulation of myeloid progenitor cells in the bone marrow, which ultimately leads to hematopoietic failure. The incidence of AML increases with age, and older patients typically have worse treatment outcomes than do younger patients. OBJECTIVE This review is focused on current and emerging treatment strategies for nonpromyelocytic AML in patients aged <60 years. METHODS A literature review was conducted of the PubMed database for articles published in English. Publications from 1990 through March 2009 were scrutinized, and the search was updated on August 26, 2009. The search terms used were: acute myeloid leukemia in conjunction with treatment, chemotherapy, stem cell transplantation, and immunotherapy. Clinical trials including adults with AML aged > or =19 years were selected for analysis. Conference proceedings from the previous 5 years of The American Society of Hematology, The European Hematology Association, and The American Society for Blood and Marrow Transplantation were searched manually. Additional relevant publications were obtained by reviewing the references from the chosen articles. RESULTS Cytarabine (AraC) is the cornerstone of induction therapy and consolidation therapy for AML. A standard form of induction therapy consists of AraC (100-200 mg/m(2)), administered by a continuous infusion for 7 days, combined with an anthracycline, administered intravenously for 3 days. Consolidation therapy comprises treatment with additional courses of intensive chemotherapy after the patient has achieved a complete remission (CR), usually with higher doses of the same drugs as were used during the induction period. High-dose AraC (2-3 g/m(2)) is now a standard consolidation therapy for patients aged <60 years. Despite substantial progress in the treatment of newly diagnosed AML, 20% to 40% of patients do not achieve remission with the standard induction chemotherapy, and 50% to 70% of first CR patients are expected to relapse within 3 years. The optimum strategy at the time of relapse, or for patients with the resistant disease, remains uncertain. Allogeneic stem cell transplantation has been established as the most effective form of antileukemic therapy in patients with AML in first or subsequent remission. New drugs are being evaluated in clinical studies, including immunotoxins, monoclonal antibodies, nucleoside analogues, hypomethylating agents, farnesyltransferase inhibitors, alkylating agents, FMS-like tyrosine kinase 3 inhibitors, and multidrug-resistant modulators. However, determining the success of these treatment strategies ultimately requires well-designed clinical trials, based on stratification of the patient risk, knowledge of the individual disease, and the drug's performance status. CONCLUSIONS Combinations of AraC and anthracyclines are still the mainstay of induction therapy, and use of high-dose AraC is now a standard consolidation therapy in AML patients aged <60 years. Although several new agents have shown promise in treating AML, it is unlikely that these agents will be curative when administered as monotherapy; it is more likely that they will be used in combination with other new agents or with conventional therapy.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland.
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19
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Damiani D, Tiribelli M, Michelutti A, Geromin A, Cavallin M, Fabbro D, Pianta A, Malagola M, Damante G, Russo D, Fanin R. Fludarabine-based induction therapy does not overcome the negative effect of ABCG2 (BCRP) over-expression in adult acute myeloid leukemia patients. Leuk Res 2010; 34:942-5. [PMID: 20122734 DOI: 10.1016/j.leukres.2010.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/04/2010] [Accepted: 01/08/2010] [Indexed: 01/13/2023]
Abstract
Over-expression of multidrug resistance (MDR) proteins PGP and BCRP has a negative prognostic impact in acute myeloid leukemia (AML) patients. Inclusion of fludarabine in induction chemotherapy increases remission rate in PGP over-expressing cases. We investigated the role of BCRP in 138 adult AML patients receiving induction therapy with fludarabine. None of the MDR-related proteins influenced complete remission attainment. Conversely, high levels of BCRP significantly affected disease-free survival, as higher relapse rates (48.5% vs 28.5%) and earlier relapse occurred in BCRP+ patients. Also overall survival was affected by BCRP positivity, and survival significantly worsened in case of concomitant PGP and BCRP over-expression.
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Affiliation(s)
- Daniela Damiani
- Clinica Ematologica e Centro Trapianti e Terapie Cellulari C. Melzi, Azienda Ospedaliero-Universitaria di Udine, Dipartimento di Ricerche Mediche e Morfologiche, Università di Udine, Udine, Italy.
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20
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Candoni A, Simeone E, Tiribelli M, Malagola M, Russo D, Fanin R. FLAIE (fludarabine, cytarabine, idarubicin, and etoposide), a four drug induction chemotherapy for adult acute myeloid leukemia: A single center experience. Am J Hematol 2009; 84:690-2. [PMID: 19731308 DOI: 10.1002/ajh.21516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Shipley JL, Butera JN. Acute myelogenous leukemia. Exp Hematol 2009; 37:649-58. [PMID: 19463767 DOI: 10.1016/j.exphem.2009.04.002] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 04/09/2009] [Accepted: 04/13/2009] [Indexed: 12/18/2022]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease with outcomes dependent upon several factors, including patient age, karyotype, mutational status, and comorbid conditions. For younger patients, approximately 60% to 80% achieve complete remission with standard therapy involving cytarabine and an anthracycline. However, only 20% to 30% have long-term disease-free survival. For adults older than 60 years of age, only 40% to 55% achieve a complete remission, with dismal long-term survival rates. Unfortunately, the median age at diagnosis for AML is 70 years. Significant advances in our understanding of the molecular biology of AML have led to newer therapies that specifically target molecular abnormalities. Examples of such therapies include the immunoconjugate gemtuzumab ozogamicin, FMS-like tyrosine kinase 3 inhibitors, farnesyl transferase inhibitors, histone deacetylase inhibitors, DNA hypomethylating agents, multidrug-resistance inhibitors, BCL-2 inhibitors, antiangiogenesis agents, and various nucleoside analogs. This review summarizes the standard treatments for AML and discusses the role of novel therapies.
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Affiliation(s)
- Joshua L Shipley
- Department of Hematology/Oncology, Brown University, Providence, RI 02903, USA
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22
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Miglino M, Grasso R, Varaldo R, Fugazza G, Colombo N, Clavio M, Canepa L, Garuti A, Ibatici A, Pierri I, Ballerini F, Sessarego M, Gobbi M. Molecular analysis of the Imatinib-induced complete cytogenetic response in chronic myelogenous leukemia. Leuk Lymphoma 2009; 47:1348-51. [PMID: 16923567 DOI: 10.1080/10428190500525607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this study was to elucidate the relationship between clonal and normal haematopoiesis in chronic myelogenous leukemia (CML). Thirteen female patients who reached complete cytogenetic response (CCR) after Imatinib treatment were studied. Although all the study patients exhibited a polyclonal pattern of X inactivation, p210 BCR/ABL transcript remained detectable in all cases by nested RT-PCR. This study also demonstrated the presence of p190 transcript in nine out of 13 study patients. A longer follow-up analysis is needed to clarify the prognostic value of these results. The recent observation that clonal cytogenetic abnormalities may occur in CML patients in polyclonal remission after imatinib suggests that a neoplastic stem cell lacking BCR/ABL rearrangement may acquire further cytogenetic alterations other than Philadelphia chromosome.
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Affiliation(s)
- Maurizio Miglino
- Department of Haematology and Oncology, Azienda Ospedale S.Martino e Cliniche Universitarie Convenzionate, Genova, Italy
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23
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Malagola M, Baccarani M, Russo D. Leukemia and multi-drug resistance: too many mechanisms of drug resistance or too many doctors resistant? Leuk Lymphoma 2009; 50:1058-60. [PMID: 19504396 DOI: 10.1080/10428190902898255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Therapy of acute myelogenous leukemia in adults. Cancer Treat Res 2009; 145:257-71. [PMID: 20306256 DOI: 10.1007/978-0-387-69259-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Malagola M, Peli A, Damiani D, Candoni A, Tiribelli M, Martinelli G, Piccaluga PP, Paolini S, De Rosa F, Lauria F, Bocchia M, Gobbi M, Pierri I, Zaccaria A, Zuffa E, Mazza P, Priccolo G, Gugliotta L, Bonini A, Visani G, Skert C, Bergonzi C, Roccaro AM, Filì C, Fanin R, Baccarani M, Russo D. Incidence of bacterial and fungal infections in newly diagnosed acute myeloid leukaemia patients younger than 65 yr treated with induction regimens including fludarabine: retrospective analysis of 224 cases. Eur J Haematol 2008; 81:354-63. [PMID: 18637030 DOI: 10.1111/j.1600-0609.2008.01122.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Infections are the major cause of morbidity and mortality in patients with acute myeloid leukaemia (AML). They primarily occur during the first course of induction chemotherapy and may increase the risk of leukaemia relapse, due to a significant delay in consolidation therapy. The intensification of induction chemotherapy and the use of non-conventional drugs such as fludarabine are considered responsible for the increased risk of infections. METHODS In this study, we retrospectively analysed the infections occurred in 224 newly diagnosed AML patients </=65 yr, consecutively treated between 1997 and 2002 with an induction regimen including fludarabine, arabinosyl cytosine and idarubicin, with or without etoposide (FLAI/FLAIE), in the context of three multicentric prospective trials (AML97, AML99, AML02). RESULTS During the induction phase, 146 (65%) patients experienced fever of undetermined origin (FUO), 30 (13%) and 47 (21%) patients had Gram-negative and positive bacteremias, respectively, and 10 (4%) patients developed a probable/proven invasive fungal infection (IFI). The fatality rate for Gram-negative, Gram-positive bacteremias and probable/proven IFI was 10%, 8% and 60% respectively. During consolidation, 75 (35%) patients had FUO, 43 (20%) and 40 (19%) patients had Gram-negative and positive bacteremias, respectively, and 5 (2%) patients developed a probable/proven IFI. The fatality rate for Gram-negative, Gram-positive bacteremias and probable/proven IFI was 14%, 5% and 80% respectively. Interestingly, the overall incidence of microbiologically documented infections during induction was 38% and the incidence of probable/proven IFIs during the induction/consolidation programme was 7%. No infections caused by viruses or opportunistic pathogens were observed neither during induction, nor during consolidation. CONCLUSIONS These data, although retrospectively collected, suggest that fludarabine-based chemotherapy is not associated with an increased incidence of infections, in particular IFIs, compared to conventional regimens commonly used for AML induction.
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Affiliation(s)
- Michele Malagola
- Unit of Blood Diseases and Cell Therapies, University of Brescia, Brescia, Italy.
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Candoni A, Martinelli G, Toffoletti E, Chiarvesio A, Tiribelli M, Malagola M, Piccaluga PP, Michelutti A, Simeone E, Damiani D, Russo D, Fanin R. Gemtuzumab-ozogamicin in combination with fludarabine, cytarabine, idarubicin (FLAI-GO) as induction therapy in CD33-positive AML patients younger than 65 years. Leuk Res 2008; 32:1800-8. [PMID: 18621416 DOI: 10.1016/j.leukres.2008.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 04/24/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The addition of gemtuzumab-ozogamicin (GO) to an induction regimen including synergistic drugs, such as intermediate dose of cytarabine (Ara-C), idarubicin and fludarabine (FLAI), could reduce treatment failure in acute myeloid leukemia (AML) patients. Nevertheless, the role and safety of this antibody target-therapy in first-line chemotherapy in patients younger than 65 years has not yet been defined. PATIENTS AND METHODS The primary goal of this prospective phase II pilot study was to evaluate the efficacy and the safety profile of FLAI plus GO as induction regimen. Thirty consecutive AML patients were included. All patients were younger than 65 with a median age of 53 years and CD33 expression exceeded 20% in all cases. The M/F ratio was 16/14 and 21/30 (70%) of patients were poor-risk at diagnosis. The induction regimen (FLAI-GO) included fludarabine (30mg/m(2)) and Ara-C (2g/m(2)) on days 1-5, idarubicin (10mg/m(2)) on days 1, 3, and 5 and GO (3mg/m(2)) on day 6. Hematopoietic stem cell transplant (HSCT) was planned for all high risk AML patients in first complete remission (CR) after consolidation with intermediate doses of Ara-C and idarubicin (IDAC-IDA). Cytogenetic, multidrug-resistance phenotype, FLT3 mutation status, and WT1 quantitative expression analyses were performed at diagnosis in all patients. WT1 expression and cytogenetic (in positive cases) analyses were performed after induction to detect and follow minimal residual disease. RESULTS Patients were evaluated for response rate, treatment-related adverse events, overall survival and relapse free survival. After induction with FLAI-GO, CR rate was 90% (26 of 29 evaluable pts); one patient achieved partial remission and two were resistant. There was only one case of death during induction (DDI). After FLAI-GO, the mean value of WT1 dropped from 4200+/-2777 copies/10(4)ABL to 192+/-399 copies/10(4)ABL. The toxicity of FLAI-GO was acceptable; 57% of patients experienced transient and reversible GO infusion-related adverse events (especially fever and chills), but no cases of veno-occlusive disease occurred during CHT or after HSCT. After a median follow-up of 16 months (range 2-25), 24/30 (80%) patients are alive (24/24 in CR). The probability of 1-year OS and RFS was 90 and 85%, respectively. Allogeneic and autologus HSCT was performed in 19 (63%) and 4 (13%) patients, respectively. CONCLUSIONS These preliminary results suggest that FLAI-GO is an effective and well tolerated induction regimen for CD33 positive AML patients younger than 65 years, with a high complete response rate, favourable safety profile, low DDI. These results encourage the testing of this regimen in a multicenter prospective trial.
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Affiliation(s)
- Anna Candoni
- Division of Hematology, Bone Marrow Transplantation Unit, Department of Clinical and Morphological Research, University Hospital, Udine, Italy.
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Zhao X, Wu J, Muthusamy N, Byrd JC, Lee RJ. Liposomal Coencapsulated Fludarabine and Mitoxantrone for Lymphoproliferative Disorder Treatment**Xiaobin Zhao and Jianmei Wu contributed equally to this study. J Pharm Sci 2008; 97:1508-18. [PMID: 17722102 DOI: 10.1002/jps.21046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Fludarabine (FLU)-based combination therapies are commonly used to treat low-grade lymphoma and chronic lymphocytic leukemia (CLL) patients. In vitro and clinical studies have indicated advantages when FLU and mitoxantrone (MTO) are applied in combination. To further enhance this effect, these two agents were coencapsulated in liposomes. FLU was passively encapsulated during liposome formation, and MTO was loaded with a transmembrane pH gradient. Entrapment efficiency, particle size, stability, and drug release kinetics were characterized. In vitro cytotoxicity study was carried out in two representative B-cell lines: Wac3CD5 and Raji. Synergism as measured by combination index (CI) was observed in cells treated with liposomes coencapsulating FLU and MTO. Annexin V/propidium iodide (PI) analysis further confirmed that coencapsulated FLU and MTO improved the percentage of apoptosis among primary CLL cells. These data suggest that adopting liposomes containing coencapsulated drug combinations constitutes a potential strategy to promote drug synergism and may have utility in the treatment of leukemia and lymphoma.
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Affiliation(s)
- Xiaobin Zhao
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, USA
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Laurent S, Palmisano GL, Martelli AM, Kato T, Tazzari PL, Pierri I, Clavio M, Dozin B, Balbi G, Megna M, Morabito A, Lamparelli T, Bacigalupo A, Gobbi M, Pistillo MP. CTLA-4 expressed by chemoresistant, as well as untreated, myeloid leukaemia cells can be targeted with ligands to induce apoptosis. Br J Haematol 2007; 136:597-608. [PMID: 17367412 DOI: 10.1111/j.1365-2141.2006.06472.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We have previously reported that about 80% of acute myeloid leukaemia (AML) samples tested at diagnosis constitutively expressed cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4). The present study compared CTLA-4 expression and function of leukaemic cells from AML patients at diagnosis with those from AML patients resistant to conventional chemotherapy. We also explored the possibility of targeting CTLA-4 for apoptosis induction in chemoresistant AML cells. AML cells either from untreated patients (n = 15) or in chemoresistant phase (n = 10) were analysed for CTLA-4 protein and transcript expression by flow cytometry and reverse transcription-polymerase chain reaction respectively. CTLA-4 expression was similar in untreated and in chemoresistant samples and was not associated with patients' clinical features. In chemoresistant AML cells, CTLA-4 transduced an apoptotic signal on engagement with its recombinant ligands r-CD80 and r-CD86, which induced an average of 71% and 62% apoptotic cells, respectively, at highest concentration. Apoptosis was equally induced in untreated leukaemic cells accompanied by cleavage of procaspase-8 and -3. Thus, this study provides the first evidence that killing of leukaemic cells from AML patients may be obtained by the engagement of CTLA-4 with its ligands, opening the way to a novel potential therapeutic approach based on triggering the CTLA-4 molecule to circumvent chemoresistance in AML.
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MESH Headings
- Adult
- Aged
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation/genetics
- Antigens, Differentiation/metabolism
- Antigens, Neoplasm/metabolism
- Apoptosis
- B7-1 Antigen/metabolism
- B7-2 Antigen/metabolism
- CTLA-4 Antigen
- Caspases/metabolism
- Drug Resistance, Neoplasm
- Female
- Humans
- Leukemia, Myeloid/drug therapy
- Leukemia, Myeloid/immunology
- Leukemia, Myeloid/pathology
- Ligands
- Male
- Middle Aged
- Reverse Transcriptase Polymerase Chain Reaction/methods
- Transcription, Genetic
- Tumor Cells, Cultured
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Affiliation(s)
- Stefania Laurent
- Unit of Translational Research A, National Cancer Research Institute, Genova, Italy
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Damiani D, Tiribelli M, Raspadori D, Michelutti A, Gozzetti A, Calistri E, Candoni A, Chiarvesio A, Lenoci M, Russo D, Fanin R. The role of MDR-related proteins in the prognosis of adult acute myeloid leukaemia (AML) with normal karyotype. Hematol Oncol 2007; 25:38-43. [PMID: 17200981 DOI: 10.1002/hon.806] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cytogenetic abnormalities are among the most important factors affecting the outcome of patients with acute myeloid leukaemia (AML), but approximately 40-50% of AML cases display a normal karyotype at diagnosis. Multidrug resistance (MDR) proteins overexpression is associated with worse prognosis in acute leukaemias, but its role in normal karyotype AML is less defined. We analysed the expression of P-glycoprotein (PGP), MDR-related protein (MRP) and lung resistance protein (LRP) in 135 adult patients with normal karyotype AML and its correlation with other biological features of the disease, to evaluate the impact of MDR proteins on response to therapy and on survival. Increased PGP expression was associated with lower rate of complete remission (CR; p = 0.006), similarly to advanced age. Cases overexpressing PGP displayed also a shorter event-free survival (EFS; 4 vs. 10 months, p = 0.035) and the increased expression of at least one MDR protein was associated with a reduced overall survival (OS; p = 0.038). Also age was predictive of worse prognosis. Our data confirm the prognostic role of MDR proteins, in particular of PGP, also in AML patients with normal karyotype at diagnosis. This finding could be used to stratify patients with different prognosis and to design risk-adapted therapeutic strategies.
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Affiliation(s)
- Daniela Damiani
- Chair of Hematology and Division of Hematology and Bone Marrow Transplantation, Udine University, Udine, Italy.
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Malagola M, Damiani D, Martinelli G, Michelutti A, Cesana B, Vivo AD, Piccaluga PP, Ottaviani E, Candoni A, Geromin A, Tiribelli M, Fanin R, Testoni N, Lauria F, Bocchia M, Gobbi M, Pierri I, Zaccaria A, Zuffa E, Mazza P, Priccolo G, Gugliotta L, Bonini A, Visani G, Skert C, Bergonzi C, Roccaro AM, Filí C, Baccarani M, Russo D. Case?control study of multidrug resistance phenotype and response to induction treatment including or not fludarabine in newly diagnosed acute myeloid leukaemia patients. Br J Haematol 2007; 136:87-95. [PMID: 17222198 DOI: 10.1111/j.1365-2141.2006.06390.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
One hundred and six patients aged </=60 years with newly diagnosed acute myeloid leukaemia (AML) treated with fludarabine-based regimens (cases) were matched with 106 AML patients treated with conventional non-fludarabine-based regimens (controls). The cases and controls were matched by expression of the multidrug resistance P-glycoprotein (MDR-Pgp), measured by flow cytometry as mean fluorescence index (MFI), cytogenetics, and age. The complete remission (CR) rate of the cases was 61% among the MDR-Pgp-positive (pos(ve)) patients (MFI >/= 6) vs. 75% among the MDR-Pgp-negative (neg(ve)) ones (MFI < 6) (P = 0.16). Conversely, in the controls, the CR rate was 44% among the MDR-Pgp-pos(ve) patients vs. 67% among the MDR-Pgp-neg(ve) ones (P = 0.02). The 4-year disease-free survival (DFS) and overall survival (OS) of MDR-Pgp-pos(ve) cases were significantly longer than those of MDR-Pgp-pos(ve) controls (DFS, 28.1% vs. 6.5%, P = 0.004; OS, 33.5% vs. 9.6%, P = 0.01). This difference was not found among the MDR-Pgp-neg(ve) patients. By univariate (P = 0.007) and multivariate (P = 0.007) analysis, the MDR-Pgp-pos(ve) phenotype was negatively correlated with CR and it emerged as the most important independent negative prognostic factor, after cytogenetics. Our study confirms the prognostic impact of the MDR phenotype in AML and strongly suggests fludarabine-based induction treatments as a promising strategy for MDR-Pgp-pos(ve) AML patients. In this setting of patients, large prospective randomised studies should be planned.
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Affiliation(s)
- Michele Malagola
- Chair of Haematology, Unit of Blood Diseases and Cell Therapies, University of Brescia, Brescia, Italy
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Abstract
Fludarabine is a prodrug that is converted to the free nucleoside 9-beta-D-arabinosyl-2-fluoroadenine (F-ara-A), which enters cells and accumulates mainly as the 5'-triphosphate, F-ara-ATP. F-ara-ATP has multiple mechanisms of action, which are mostly directed toward DNA. Collectively, these actions affect DNA synthesis, which is the major mechanism of F-ara-A-induced cytotoxicity. Secondarily, incorporation into RNA and inhibition of transcription has been shown in cell lines. As a single agent, fludarabine has been effective for indolent leukemia. Biochemical modulation strategies resulted in enhanced accumulation of cytarabine triphosphate and led to the use of fludarabine for the treatment of acute leukemia. The combination of fludarabine with DNA-damaging agents to inhibit DNA repair processes has been highly effective for indolent leukemia and lymphomas. Other strategies have incorporated fludarabine into preparative regimens for nonmyeloablative stem-cell transplantation.
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Affiliation(s)
- Marco Montillo
- Department of Oncology/Haematology, Division of Haematology, Niguarda Ca'[Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
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Leger DY, Liagre B, Beneytout JL. Low dose leflunomide activates PI3K/Akt signalling in erythroleukemia cells and reduces apoptosis induced by anticancer agents. Apoptosis 2006; 11:1747-60. [PMID: 16927021 DOI: 10.1007/s10495-006-9439-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Rheumatoid arthritis (RA) is characterized by persistent joint synovial tissue inflammation. Leflunomide is an immunomodulatory agent that has been approved for treatment of active RA. In the past few years, uses other than RA treatment have appeared. Leflunomide has been reported to show antitumor potential through inhibition of cancer cell proliferation. We thus tested the antiproliferative potential of leflunomide on HEL and K562 erythroleukemia cells. The findings summarized in this report demonstrate for the first time that low dose leflunomide prolonged survival and reduced apoptosis induced by several anticancer agents in erythroleukemia cells. We showed that in treated cells, leflunomide reduced the signalling pathways involved in promoting apoptosis by reducing p38 MAPK and JNK basal activity. On the other hand, leflunomide transiently activated the ERK signalling pathway and induced a sustained activation of Akt. We also showed that leflunomide reduced caspase-3 activity and DNA fragmentation induced by anticancer agents. By using an inhibitory strategy, we showed that inhibition of Akt activation but not ERK abolished the protective effect of leflunomide. Thus our findings suggested that leflunomide reduced apoptosis induced by anticancer agents through PI3K/Akt signalling activation.
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Affiliation(s)
- D Y Leger
- Laboratoire de Biochimie, UPRES EA 4021, Faculté de Pharmacie, 2 rue du Docteur Marcland, 87025 Limoges Cedex, France
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Gianfaldoni G, Mannelli F, Baccini M, Antonioli E, Leoni F, Bosi A. Clearance of leukaemic blasts from peripheral blood during standard induction treatment predicts the bone marrow response in acute myeloid leukaemia: a pilot study. Br J Haematol 2006; 134:54-7. [PMID: 16803567 DOI: 10.1111/j.1365-2141.2006.06100.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although several parameters are useful for risk stratification of patients with acute myeloid leukaemia (AML), there are no firm criteria for predicting response to induction treatment of individual patients. Daily flow cytometry (FC) analysis, carried out during induction treatment in 30 AML patients, showed that the clearance of blasts from peripheral blood (PBC) correlated closely with response, as assessed by bone marrow FC on day 14, and by morphologic analysis at haematopoietic recovery. Therefore, a major treatment outcome can be predicted very early in AML patients, thus providing an opportunity for tailoring treatment modalities from the outset.
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Affiliation(s)
- Giacomo Gianfaldoni
- Department of Haematology, Azienda Ospedaliera-Universitaria Careggi, University of Florence, Florence, Italy.
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Russo D, Malagola M. The importance of consistent use of denominators across patient groups in assessing responses in clinical trials - response to Davies & Cavenagh. Br J Haematol 2006. [DOI: 10.1111/j.1365-2141.2006.05963.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Russo D, Malagola M. Corrigendum. Br J Haematol 2006. [DOI: 10.1111/j.1365-2141.2006.05961.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Current Awareness in Hematological Oncology. Hematol Oncol 2006. [DOI: 10.1002/hon.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Davies JK, Cavenagh JD. The importance of consistent use of denominators across patient groups in assessing responses in clinical trials. Br J Haematol 2006; 132:794-5; author reply 795. [PMID: 16487183 DOI: 10.1111/j.1365-2141.2006.05962.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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