Long-term outcome of intensive chemotherapy for adults with de novo acute myeloid leukaemia (AML): the nationwide AML-92 study by the Finnish Leukaemia Group

Efficacy of conventional-dose cytarabine, idarubicin and thioguanine versus intermediate-dose cytarabine and idarubicin in the induction treatment of acute myeloid leukemia: Long-term results of the prospective randomized nationwide AML-2003 study by the Finnish Leukemia Group

OBJECTIVES

AML-2003 study sought to compare the long-term efficacy and safety of IAT and IdAraC-Ida in induction chemotherapy of acute myeloid leukemia (AML) and introduce the results of an integrated genetic and clinical risk classification guided treatment strategy.

METHODS

Patients were randomized to receive either IAT or IdAraC-Ida as the first induction treatment. Intensified postremission strategies were employed based on measurable residual disease (MRD) and risk classification. Structured questionnaire forms were used to gather data prospectively.

RESULTS

A total of 356 AML patients with a median age of 53 years participated in the study. Long-term overall survival (OS) and relapse-free survival (RFS) were both 49% at 10 years. The median follow-up was 114 months. No significant difference in remission rate, OS or RFS was observed between the two induction treatments. Risk classification according to the protocol, MRD after the first and the last consolidation treatment affected the OS and RFS significantly (p < .001).

CONCLUSIONS

Intensified cytarabine dose in the first induction treatment was not better than IAT in patients with AML. Intensification of postremission treatment in patients with clinical risk factors or MRD seems reasonable, but randomized controlled studies are warranted in the future.

Bloodstream infections in acute myeloid leukemia patients treated according to the Finnish Leukemia Group AML-2003 protocol - a prospective nationwide study

BACKGROUND

Infections greatly influence the outcome of acute myeloid leukemia (AML) patients receiving intensive treatment. The aim of this study was to establish the incidence, microbial etiology, risk factors and prognosis of bloodstream infections (BSIs) in patients with AML and compare the results with the previous treatment protocol (AML-92).

METHODS

Registery data were gathered prospectively from 357 patients aged 16-65 years recruited on the AML-2003 treatment protocol between November 2003 and November 2011 during different treatment cycles.

RESULTS

Blood culture data were available on 977 treatment episodes, in which there were 503 BSIs (51%). The overall incidence rate (IR) for BSIs (per 1000 hospital days) was 16.7. Twenty patients (5.6%) died due to an infection and 16 of them (80%) had a BSI. The most commonly detected microbes (polymicrobial episodes included) in blood cultures were coagulase-negative staphylococci (CoNS, 24.7%), viridans group streptococci (VGS, 19.1%), enterococci (13.9%) and Enterobacteriacae group (25.9%). The etiology of BSIs varied greatly from treatment cycle to cycle.

CONCLUSIONS

Enterococcal BSIs have increased compared to our previous treatment protocol, and they represent significant pathogens in blood cultures. Infection-related mortality has decreased despite the increase in the IR of BSIs. Enterococci seem to be an increasingly prominent pathogen underlying BSIs in the AML patients, especially during induction therapy (20%).

A comparative study of idarubicin 12 mg/m(2) and 8 mg/m(2) combined with cytarabine as the first induction regimen for adult acute myeloid leukemia patients

OBJECTIVE

This study aimed to explore a suitable dose of idarubicin (IDA) combined with cytarabine for the initial induction regimen for acute myeloid leukemia (AML) patients.

PATIENTS AND METHODS

A total of 100 adult patients with de novo AML aged between 14 years and 80 years were enrolled in the current study and randomized into two arms for the initial induction: an IDA 12 mg/m(2) arm and an IDA 8 mg/m(2) arm. All patients received the same consolidation chemotherapy. The follow-up period was January 1, 2009, to December 31, 2014. Overall survival (OS), disease-free survival (DFS), and morphology leukemia relapse (hematological and/or extramedullary) were recorded.

RESULTS

The complete remission rates were 80% and 75% in the IDA 12 mg/m(2) and IDA 8 mg/m(2) arms, respectively, after initial induction. High-dose IDA (12 mg/m(2)) resulted in a higher complete remission rate after two courses of induction therapy (96.4% vs 76.5%) in the cytogenetic intermediate-risk group (P=0.026). There were no differences in the number of units of infused red blood cells, agranulocytosis time, or infection rates between the two arms. Patients in the IDA 12 mg/m(2) arm received more platelet transfusions (P=0.047). In the intention-to-treat analysis, after a median follow-up of 13 months, high-dose IDA (12 mg/m(2)) resulted in improved OS (median OS, 54.0 months vs 26.7 months, P=0.021) and DFS (median DFS, 54.0 months vs 18.3 months, P=0.031), particularly in the cytogenetic intermediate-risk group (median OS, 54.0 months vs 29.5 months, P=0.009; median DFS, 54.0 months vs 15.3 months, P=0.014). IDA 12 mg/m(2) significantly improved OS and DFS in the cytogenetic intermediate-risk group (P=0.009 and P=0.018).

CONCLUSION

Our results suggest that a high dose of IDA (12 mg/m(2)) combined with cytarabine is a suitable and safe initial remission induction regimen that results in superior long-term survival of adult AML patients, particularly patients in the cytogenetic intermediate-risk group.

Acquired multidrug resistance in human K562/ADM cells is associated with enhanced autophagy

Autophagy, as a necessary process for survival in mammalian cells deprived of nutrients or growth factors, will be activated in many tumor cells while treated with chemotherapeutic drugs, but the role of autophagy in acquired multidrug resistance of human acute myelogenous leukemia to adriamycin-based chemotherapy remains to be clarified. Our aim was to address that question by surveying the autophagic activity in parental acute myelogenous leukemia cell line K562 and resistant sub cell line, K562/ADM, which were obtained by treating adriamycin with increasing concentrations. K562/ADM and K562 cells were exposed to PBS culture medium for 3 hours, then the stress-induced autophagy was measured. Real-time quantitative RT-PCR revealed the expression of LC3 mRNA was higher in K562/ADM than in K562 cells. LC3-II, as an autophagosomal marker, was more abundant in K562/ADM than in K562 cells measured by Western blotting. To determine the effect of 3-MA, a known specific inhibitor of autophagy, on overcoming acquired multidrug resistance induced by adriamycin, the MTT assay and flow cytometry were performed. We also found that 3-MA can enhance the growth inhibition and apoptotic effect of adriamycin in acquired resistant cells (K562/ADM). Collectively, our results provide evidence that the upregulation of autophagy plays a major role in multidrug resistance of K562/ADM cells induced by adriamycin.

Inpatient rehabilitation improved functional status in asthenic patients with solid and hematologic malignancies

OBJECTIVE

The aim of this study was to compare functional outcomes in asthenic patients with hematologic malignancies with those of asthenic patients with solid tumors after inpatient rehabilitation. We hypothesized that asthenic patients with hematologic malignancies are less likely than patients with solid tumors to make functional improvement after rehabilitation.

DESIGN

The records of 60 asthenic cancer patients (30 consecutive patients with solid tumors and 30 consecutive patients with hematologic malignancies) who underwent inpatient rehabilitation at a comprehensive cancer center between October 2005 and October 2007 were retrospectively reviewed. Patients with focal neurologic deficits were excluded. All patients admitted to the inpatient rehabilitation unit received 3 hrs of more of therapy per weekday. The main outcomes included total, motor, and cognitive Functional Independence Measure (FIM) scores, hospital and rehabilitation length of stay, and FIM efficiency.

RESULTS

The mean total FIM score significantly improved in patients with solid tumors (mean, 15; range, -6 to 38) and in patients with hematologic malignancies (mean, 17; range, -3 to 27); however, between-group differences in FIM scores were not significant (P = 0.31). The solid tumor patients were significantly older than the hematologic malignancy patients (71 ± 11 vs. 64 ± 12 yrs; P = 0.02), but the mean rehabilitation lengths of stay were the same for each group (9.5 days; P = 0.82). The mean FIM efficiency in the hematologic malignancy group was higher than that of the solid tumor group (1.9 vs.1.4; P = 0.049).

CONCLUSIONS

Asthenic patients with solid tumors or hematologic malignancies could benefit from inpatient rehabilitation and make significant functional gain.

SKP2 siRNA inhibits the degradation of P27kip1 and down-regulates the expression of MRP in HL-60/A cells

S-phase kinase-associated protein 2 (SKP2) gene is a tumor suppressor gene, and is involved in the ubiquitin-mediated degradation of P27kip1. SKP2 and P27kip1 affect the proceeding and prognosis of leukemia through regulating the proliferation, apoptosis and differentiation of leukemia cells. In this study, we explored the mechanism of reversing of HL-60/A drug resistance through SKP2 down-regulation. HL-60/A cells were nucleofected by Amaxa Nucleofector System with SKP2 siRNA. The gene and protein expression levels of Skp2, P27kip1, and multi-drug resistance associated protein (MRP) were determined by reverse transcription-polymerase chain reaction and western blot analysis, respectively. The cell cycle was analyzed by flow cytometry. The 50% inhibitory concentration value was calculated using cytotoxic analysis according to the death rate of these two kinds of cells under different concentrations of chemotherapeutics to compare the sensitivity of the cells. HL-60/A cells showed multi-drug resistance phenotype characteristic by cross-resistance to adriamycin, daunorubicin, and arabinosylcytosine, due to the expression of MRP. We found that the expression of SKP2 was higher in HL-60/A cells than in HL-60 cells, but the expression of P27kip1 was lower. The expression of SKP2 in HL-60/A cells nucleofected by SKP2 siRNA was down-regulated whereas the protein level of P27kip1 was up-regulated. Compared with the MRP expression level in the control group (nucleofected by control siRNA), the mRNA and protein expression levels of MRP in HL-60/A cells nucleofected by SKP2 siRNA were lower, and the latter cells were more sensitive to adriamycin, daunorubicin, and arabinosylcytosine. Down-regulating the SKP2 expression and arresting cells in the G0/G1 phase improve drug sensitivity of leukemia cells with down-regulated MRP expression.

Intensive induction chemotherapy with regimen containing intermediate dose cytarabine in the treatment of de novo acute myeloid leukemia

To improve long-term outcome of de novo acute myeloid leukemia (AML) patients by intermediate dose of cytarabine integrated in induction therapy and to explore the impact of cytogenetic abnormalities on the prognosis. Eighty-seven AML patients were treated with HAD regimen containing intermediate dose cytarabine (IDAra-C) as induction therapy, 83 from which with karyotype results were divided into three cytogenetic groups according to SWOG criteria. Complete remission (CR) rate, disease-free survival (DFS), and overall survival (OS) among different groups were evaluated. The CR rate of the 87 cases was 80/87 (92%). Median DFS and OS have not reached (NR). DFS rates at 1 and 3 years were 76.3% and 63.4%, respectively. OS rates at 1 and 3 years were 86.0% and 58.7%, respectively. According to SWOG criteria, CR rate, median DFS, and OS were 100%, NR and NR for the favorable group; 88.9%, NR, and 16 months for the intermediate group; 83.3%, 4.5 months, and 7.5 months for the adverse group. The differences among the three groups were statistically significant excepting for CR rate between adverse and intermediate groups. HAD regimen containing IDAra-C as induction chemotherapy regimen is effective in de novo AML of adult patients and can achieve higher CR rate and longer survival than standard dose of cytarabine (SDAra-C) regimen. Most of the patients were able to endure the therapy. Cytogenetics is still an important prognostic factor despite of the incorporation of IDAra-C in induction chemotherapy. The differences among the three groups were statistically significant. Am. J. Hematol., 2009. (c) 2009 Wiley-Liss, Inc.

Reliability of ambulatory walking activity in patients with hematologic malignancies

OBJECTIVES

To determine the relative and absolute reliability of the assessment of ambulatory walking activity during 2 consecutive weeks in patients with hematologic malignancies recovering at home from their medical treatment and to compare the physical activity level of hematologic cancer patients after high-dose chemotherapy with healthy subjects.

DESIGN

Test-retest study of 2 consecutive 7-day recordings using the microprocessor-based step accelerometer 3 (SAM3).

SETTING

Home and community.

PARTICIPANTS

Patients (n=23) with hematologic malignancies recovering from high-dose chemotherapy and healthy controls (n=30).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The intraclass correlation coefficient (ICC(3,1)) and its 95% confidence interval (CI), SE of measurement procedure and its 95% CI, the smallest detectable difference (SDD), the coefficient of variation (CV), and t tests for the variables total steps and peak activity.

RESULTS

The day-to-day and week-to-week CVs for walking activity and peak activity were 35.17% and 13.17% and 18.61% and 6.90%, respectively. For relative reliability, the ICCs for 2 consecutive 7-day recordings including the 95% CI for total steps and peak activity were 0.90 (95% CI, 0.75-0.98) and 0.85 (95% CI, 0.66-0.94), respectively. The absolute reliability for total steps and peak activity including the SE of measurement procedure and the 95% CI were 564 (95% CI, +/-1106) and 2.42 steps (95% CI, +/-4.74), respectively, for 2 consecutive 7-day recordings. The week-to-week SDD was 1564 for total steps and 6.70 for peak activity. The 7-day mean for total step activity was 5355 for the patients with hematologic malignancies and 6364 for healthy subjects (P<0.05).

CONCLUSIONS

The results of this study indicate that there is good relative reliability for the assessment of 2 consecutive 7-day recordings of ambulatory walking activity, and it showed that the SDD derived from this sample may be useful in detecting changes in daily walking activity in hematologic cancer patients who are recovering from intensive medical treatment. The study also documented compromised levels of ambulatory walking activity among hematologic cancer patients recovering from high-dose chemotherapy as compared with healthy controls.

Quality of life beyond 6 months after diagnosis in older adults with acute myeloid leukemia

Although intensive chemotherapy may improve survival in older people with acute myeloid leukemia (AML) without adverse cytogenetics, its impact on quality of life (QOL) is mixed and most patients complain of fatigue up to 6 months after diagnosis. Little information is available on longer-term QOL outcomes. We prospectively followed 20 patients age 60 or older with AML who provided QOL data more than 6 months after diagnosis. Over the first 6 months, there were clinically important improvements in global health, role function, social function, and emotional function. Physical function and cognitive function were stable over time. Over the next 6 months, social function and fatigue improved, and other domains remained stable. Achievement of complete remission appeared to be associated with improvements in global health, physical function, and role function without negatively affecting other health domains. This information may aid discussions with patients about treatment.

Neutropenic fever and severe sepsis in adult acute myeloid leukemia (AML) patients receiving intensive chemotherapy: Causes and consequences

The objective of this study was to evaluate etiology and consequences of neutropenic fever in AML patients. Two hundred and ninety neutropenic periods following chemotherapy in 84 AML patients were retrospectively evaluated. Neutropenic fever was found in 280 periods (97%). Severe sepsis developed in 35 occasions (13%) and 9 patients (11%) died due to severe sepsis. In 165 episodes with neutropenic fever (59%), the potential causative organism was found in blood cultures. Gram-negative bacteria were more commonly found in patients who developed severe sepsis (40% vs. 23%, p = 0.03). CRP after 2 - 3 days from start with fever was higher in patients with severe sepsis (190 mg/L vs. 96 mg/L, p < 0.001) but the rise in CRP rather coincided than preceded with the development of severe sepsis. Severe sepsis is associated with significant mortality in AML patients. Earlier methods than CRP are needed to predict development of severe sepsis.

Wilms tumour gene 1 overexpression in bone marrow as a marker for minimal residual disease in acute myeloid leukaemia

OBJECTIVES

Wilms tumour gene 1 (WT1) is overexpressed in leucocytes of most acute myeloid leukaemia (AML) patients. However, the clinical relevance of WT1 gene expression as minimal residual disease (MRD) marker in AML has been questioned.

METHODS

We determined the expression of WT1 gene in bone marrow (BM) mononuclear cells of 100 AML patients at diagnosis and compared it with other MRD markers during follow up in 16 patients using quantitative reverse transcription-polymerase chain reaction.

RESULTS

The median WT1 gene expression was 9.7% of K562 cell line WT1 expression (lower quartile 1.5%, upper quartile 29.9%, n = 100) at diagnosis and, 0.053% (lower quartile 0.022%, upper quartile 0.125%, n = 87) in molecular or immunophenotypic remission. Median WT1 expression in control BM was 0.029% (lower quartile 0.013%, upper quartile 0.061%, n = 22). The upper 99% percentile of remission samples was 0.3%, which was regarded as the cut-off of increased WT1 gene expression in AML and was exceeded in 87% of all AML patients at diagnosis. WT1 and the other MRD markers showed only minor differences in profiles during follow-up. WT1 expression at diagnosis with median value 9.7% as the cut-off level or as a continuous variable had no prognostic significance for 2-yr survival.

CONCLUSIONS

The sensitivity of WT1 as a MRD marker was low due to the relatively high background WT1 gene expression in BM cells at remission and in subjects without haematological malignancies. Therefore, WT1 gene expression analysis would be beneficial only in those patients who do not have a more specific and sensitive MRD marker.