Amsacrine combined with etoposide and methylprednisolone is a feasible and safe component in first-line intensified treatment of pediatric patients with high-risk acute lymphoblastic leukemia in CoALL08-09 trial

BACKGROUND

The prognosis of children with acute lymphoblastic leukemia (ALL) has improved considerably over the past five decades. However, to achieve cure in patients with refractory or relapsed disease, novel treatment options are necessary.

METHODS

In the multicenter trial Cooperative Study Group for Childhood Acute Lymphoblastic Leukemia (CoALL)08-09, one additional treatment element consisting of the rarely used chemotherapeutic agent amsacrine combined with etoposide and methylprednisolone (AEP) (amsacrine 2 × 100 mg/m² , etoposide 2 × 500 mg/m² , and methylprednisolone 4 × 1000 mg/m² ) was incorporated into the first-line treatment of pediatric patients with poor treatment responses at the end of induction (EOI), measured by minimal residual disease (MRD). These patients were stratified into a high-risk intensified arm (HR-I), including an AEP element at the end of consolidation. Patients with induction failure (IF), that is, with lack of cytomorphological remission EOI, were eligible for hematopoietic stem cell transplantation (HSCT) after remission had been reached. These patients received AEP as a part of their MRD-guided bridging-to-transplant treatments.

RESULTS

A significant improvement in probability of overall survival (pOS) was noted for the CoALL08-09 HR-I patients compared to MRD-matched patients from the preceding CoALL07-03 trial in the absence of severe or persistent treatment-related toxicities. Relapse rate and probability of event-free survival (pEFS) did not differ significantly between trials. In patients with IF, stable or improved MRD responses after AEP were observed without severe or persistent treatment-related toxicities.

CONCLUSION

In conclusion, AEP is well tolerated as a component of the HR treatment and is useful in bridging-to-transplant settings.

Enhanced etoposide sensitivity following adenovirus-mediated human topoisomerase IIalpha gene transfer is independent of topoisomerase IIbeta

The roles that the alpha and beta isoforms of topoisomerase II (topo II) play in anticancer drug action were determined using MDA-VP etoposide-resistant human breast cancer cells and a newly constructed adenoviral vector containing the topo IIalpha gene (Ad-topo IIalpha). MDA-VP cells were more resistant to etoposide than to amsacrine and had more resistance to etoposide than did MDA-parental cells. MDA-VP cells also expressed lower topo IIalpha RNA and protein levels than parental cells but had comparable topo IIbeta levels. After infection with Ad-topo IIalpha, topo IIalpha, RNA and protein levels increased significantly, as did the cells' sensitivity to etoposide. In contrast, topo IIbeta levels remained constant with little alteration in the cells' sensitivity to amsacrine. Band-depletion immunoblotting assays indicated that topo IIalpha was depleted in etoposide-treated, Ad-topo IIalpha-transduced MDA-VP cells but not in amsacrine-treated cells. Topo IIbeta was depleted in amsacrine-treated, Ad-topo IIalpha-MDA-VP cells, with little change in the topo IIalpha levels. These results suggest that topo IIalpha gene transfer does not alter topo IIbeta expression and that enhanced sensitivity to etoposide is therefore secondary to change in topo IIalpha levels. These studies support the theory that etoposide preferentially targets topo IIalpha, while amsacrine targets topo IIbeta.