Efficacy of escalated imatinib combined with cytarabine in newly diagnosed patients with chronic myeloid leukemia

Background

In order to improve the molecular response rate and prevent resistance to treatment, combination therapy with different dosages of imatinib and cytarabine was studied in newly diagnosed patients with chronic myeloid leukemia in the HOVON-51 study.

Design and Methods

Having reported feasibility previously, we hereby report the efficacy of escalated imatinib (200 mg, 400 mg, 600 mg or 800 mg) in combination with two cycles of intravenous cytarabine (200 mg/m² or 1000 mg/m² days 1 to 7) in 162 patients with chronic myeloid leukemia.

Results

With a median follow-up of 55 months, the 5-year cumulative incidences of complete cytogenetic response, major molecular response, and complete molecular response were 89%, 71%, and 53%, respectively. A higher Sokal risk score was inversely associated with complete cytogenetic response (hazard ratio of 0.63; 95% confidence interval, 0.50–0.79, P<0.001). A higher dose of imatinib and a higher dose of cytarabine were associated with increased complete molecular response with hazard ratios of 1.60 (95% confidence interval, 0.96–2.68, P=0.07) and 1.66 (95% confidence interval, 1.02–2.72, P=0.04), respectively. Progression-free survival and overall survival rates at 5 years were 92% and 96%, respectively. Achieving a major molecular response at 1 year was associated with complete absence of progression and a probability of achieving a complete molecular response of 89%.

Conclusions

The addition of intravenous cytarabine to imatinib as upfront therapy for patients with chronic myeloid leukemia is associated with a high rate of complete molecular responses (Clinicaltrials.Gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT00028847","term_id":"NCT00028847"}}NCT00028847).     

Reversible posterior leukoencephalopathy syndrome after repeat intermediate-dose cytarabine chemotherapy in a patient with acute myeloid leukemia

A 56-year-old man was admitted to our hospital with leukocytosis, anemia, and thrombocytopenia. Acute monoblastic leukemia was diagnosed. Two subsequent courses of consolidation chemotherapy consisted of conventional doses of cytarabine and intermediate-dose cytarabine. Intermediate-dose cytarabine was infused intravenously every 12 hr for 6 days. On day 15 after the final infusion of cytarabine, the patient suffered headache, and on day 21, he experienced a decrease in sensation on the sole of his left foot. Magnetic resonance imaging (MRI) of the brain revealed widespread areas of white matter edema. Cerebrospinal fluid (CSF) examination revealed an increase in the number of cells to 31 mm(-3); the majority were lymphocytes. No infiltration of leukemia cells was seen. After 2 months, brain MRI findings were normal. The clinicoradiologic features of the case were consistent with reversible posterior leukoencephalopathy syndrome (RPLS). RPLS in the present case was unlikely to have been caused by direct neurotoxicity because (1) the doses of cytarabine (500 mg/m(2); total dose 9.2 g) were much smaller than those in reported cases and were repeatedly infused until RPLS developed; (2) the RPLS developed 21 days after the final infusion of cytarabine, a much longer period than previously reported; (3) the slight leukocytosis in the CSF observed on day 33 might also have been related to the cellular immune responses evoked by the infused cytarabine. These details suggest not only that direct cerebral neurotoxicity of cytarabine but also that some type of allergic response may have been involved in the development of RPLS.     

Acute rhabdomyolysis as a complication of cytarabine chemotherapy for acute myeloid leukemia: case report and review of literature

Rhabdomyolysis is an unusual complication of chemotherapy that can lead to substantial morbidity through such complications as renal failure, infections, and disseminated intravascular coagulation. The syndrome has been described after treatment with cyclophosphamide, 5-azacytidine, interleukin-2, and interferon and after bone marrow transplantation. We report a patient with acute myeloid leukemia who developed fulminant rhabdomyolysis after treatment with a cytarabine-containing regimen. The syndrome was complicated by acute renal failure requiring hemodyalisis, respiratory insufficiency, and pancreatitis. We suggest that the muscle damage might be related to the known ability of cytarabine to trigger the release of cytochrome c from the mitochondria, which could lead to uncoupling of the oxidative phosphorylation with subsequent depletion of ATP reserves at the skeletal muscle and rhabdomyolysis.     

Intermediate dose cytarabine improves survival and relapse-free rate compared with standard-dose cytarabine as post-remission treatment for acute myeloid leukemia: A retrospection study

The exact dose of cytarabine still remain controversial for the management of patients with acute myeloid leukemia (AML) after complete remission (CR), but recent studies favor lower doses. This study aimed to investigate the toxic effects of single-intermediate dose (ID) cytarabine in patients with AML after achieving CR, compared with standard-dose cytarabine.In this retrospective study, AML patients who achieved CR after consolidation therapy before enrollment between 07/2008 and 05/2019 were included. All patients were divided into single-ID cytarabine and standard-dose cytarabine. The Kaplan-Meier method was used to compare overall survival (OS) and relapse-free time (RFS). Cox regression models were used to assess factors independently associated with OS and RFS. The toxic side effects of hematology and non-hematology were observed.52 patients were enrolled. There were 33 in ID group, 19 in Standard dose group. The 3-year RFS rate (40.4% vs 22.2%, P = .031) was better in the ID group than in the standard-dose group, while the 3-year OS rate was not different between the 2 groups (50.2% vs 27.8%, P = .074). Treatment stratage of ID cytarabine chemotherapy significantly improve the prognosis of AML regardless of patient age, risk grade, WBC count. There were no significant differences between the 2 groups in grade 3 to 4 bone marrow suppression, gastrointestinal symptoms, blood transfusion, infections.Patients with AML receiving ID cytarabine showed better survival and similar toxicity profiles compared with patients who received standard-dose cytarabine.     

减低剂量IA方案治疗老年急性髓细胞白血病患者的疗效观察

目的:探讨减低剂量去甲氧柔红霉素联合阿糖胞苷(IA)方案治疗老年急性髓细胞白血病(AML)患者的疗效和不良反应.方法:42例老年AML患者分别以减低剂量IA方案、标准剂量IA方案和标准剂量米托蒽醌联合阿糖胞苷方案(MA)治疗,比较3组病例在临床疗效、不良反应、病死率等指标上的差异.结果:减低剂量IA组完全缓解(CR)6...     

Azacitidine and low‐dose cytarabine in palliative patients with acute myeloid leukemia and high bone marrow blast counts – a retrospective single‐center experience

We retrospectively analyzed and compared the efficacy and toxicity of azacitidine (AZA) and low‐dose cytarabine (LD‐Ara‐C) in 65 palliative patients with acute myeloid leukemia (AML) showing high bone marrow blast counts (≥30%) before start of treatment. Twenty‐seven and 38 patients received AZA and LD‐Ara‐C, respectively. The median patient age was 71 yr. Patient and disease characteristics did not differ between the treatment groups, except for BM blast counts, and peripheral leukocyte and blast counts which were significantly higher in the LD‐Ara‐C group. AZA and LD‐Ara‐C were first‐line treatment in 12 (44%) and 17 patients (45%), respectively. Response and hematologic improvement rates were low and similar in both treatment groups. In both treatment groups, most common non‐hematologic toxicities included febrile neutropenia, pneumonia, and bleedings without significant differences regarding frequencies. Estimated 1‐yr survival rates were 15% (95% CI 8–22) and 13% (95% CI 7–19) in the AZA and LD‐Ara‐C groups, respectively, without statistically significant difference. In multivariate analysis (n = 65), previous treatment (HR 2.27, 95% CI 1.00–5.22, P = 0.05) and adverse cytogenetics (HR 2.50, 95% CI 1.20–5.22, P = 0.02) were independent predictors of poor survival. In our center and within the limitations of a retrospective study, both treatment regimens showed similar but limited efficacy in palliative patients with AML and high BM blast counts.     

Mitoxantrone, a topoisomerase II inhibitor, induces apoptosis of B-chronic lymphocytic leukaemia cells

B-chronic lymphocytic leukaemia (B-CLL) is characterized by the accumulation of long-lived CD5⁺ B lymphocytes. The effect of mitoxantrone, a topoisomerase II inhibitor, on B-CLL cells was studied. Treatment of B-CLL cells for 48 h with mitoxantrone (0.5 μg/ml) induced a decrease in cell viability as determined by MTT assay. The IC₅₀ calculated for the cells of three patients was 0.7 μg/ml for two of them and 1.4 μg/ml for the third. In all three patients the maximum effect was observed with 2 μg/ml. An additive cytotoxic effect was observed when mitoxantrone (0.5 μg/ml) was combined with fludarabine (5 μg/ml). Mitoxantrone induced DNA fragmentation and the proteolytic cleavage of poly(ADP-ribose) polymerase (PARP), a marker of the activation of caspases, in all the patients studied, demonstrating that the cytotoxic effect of mitoxantrone was due to induction of apoptosis. These results suggest that mitoxantrone, and possibly other topoisomerase II inhibitors, may be used in the chemotherapy of B-CLL, and that combination of mitoxantrone with fludarabine or other drugs could improve the effectiveness of the treatment.     

D-index dose not predict the development of pulmonary infection in acute myeloid leukemia patients undergoing consolidation chemotherapy with high-dose cytarabine

The D-index is calculated as the area over the neutrophil curve during neutropenia. We investigated the impact of the D-index on pulmonary infection in 33 acute myeloid leukemia patients undergoing consolidation chemotherapy with high-dose cytarabine. There was no difference in the D-index between chemotherapies with and without pulmonary infection. The cumulative D-index (c-D-index) until the development of infection exceeded 4000 in four of five patients with pulmonary infection. Although there was no difference in the total D-index throughout the overall consolidation chemotherapy, the total D-index from induction to consolidation and the D-index at induction chemotherapy were higher in patients with pulmonary infection during consolidation than in those without it (P = 0.014 and 0.019, respectively). Our results showed that the cumulative effect of neutropenia might determine the risk of pulmonary infection in consolidation chemotherapy. We are planning a clinical trial of c-D-index-guided preemptive antifungal therapy.     

Induction of remission of relapsed acute myeloid leukemia after unrelated donor cord blood transplantation by concomitant low-dose cytarabine and calcitriol in adults

Low-dose cytarabine and calcitriol (LDCA + VD3) combination therapy was performed in two adult patients with acute myeloid leukemia (AML) that relapsed within 1 yr after unrelated donor cord blood transplantation (URD CBT) performed in a relapse or non-remission stage. Concomitant aclarubicin was also administered in one patient. Remission because of recovery of donor cord blood hematopoiesis was obtained in both patients. The treatment was low intensive, and neither adverse effects in terms of digestive symptoms nor hypercalcemia was observed. Activity of daily life was maintained. The patients were followed as outpatients after remission, and the remission duration was approximately 6 months in both patients. Although LDCA + VD3 therapy is minimally intensive chemotherapy, it may prolong the survival time of patients with relapsed AML after URD CBT.     

Maintenance with low-dose cytarabine for acute myeloid leukemia in complete remission

Summary Thirty-four patients with acute myeloid leukemia (AML) in complete remission (CR), 30 of them aged over 60, received maintenance therapy scheduling four courses of low-dose cytarabine (LDA) 20 mg/m²/day in two subcutaneous injections for 3 weeks every 6 weeks. Each course was stopped when hematologic toxicity occurred, and doses of LDA were subsequently reduced by 50% for the following courses. During the first course of LDA, 15 patients needed blood and four patients platelet transfusions. Overall, 28 patients received four courses of LDA: 11 did not require any dose reduction, while 14 required one dose reduction and three neeeded two successive dose reductions. Two patients were hospitalized during maintenance. Median disease-free survival (DFS) is 308 days, with 16% of patients surviving at 5 years. Seven patients relapsed during the 168 days of maintenance, while ten of the 27 patients remaining at risk on day 169 relapsed during the 168 days following maintenance. We conclude that in AML in CR, the maximal dose of LDA tolerated by ambulatory patients is 10 mg/m²/day for 3 weeks. LDA seemed to delay relapse; however, precise assessment of the efficacy of this approach would require a randomized trial.     

大剂量阿糖胞苷巩固治疗急性髓细胞白血病后无病生存分析

目的：探讨大剂量阿糖胞苷（HDAra—C）对急性髓细胞白血病（AML）缓解后巩固治疗的无病生存（DFS）影响。方法：以阿糖胞苷3g，静滴2～3h，q12h，连续应用6个剂量为1疗程，共用5疗程。结果：中位完全缓解期为13．5（3～167）个月，中位DFS为17．5（3～167）个月，中位总生存为22．5（7～169）个月。3年和5年的DFS率分别为54％和42％。3年和5年OS率分别为68％和49％。结论：HDAra—C用于AML的缓解后巩固治疗，可望缩短化疗时间，提高无病生存率，改善牛活质量，且患者能耐受治疗中所出现的不良反应。     

APR-246 exhibits anti-leukemic activity and synergism with conventional chemotherapeutic drugs in acute myeloid leukemia cells

Background: APR‐246 belongs to a new generation of the compounds that restore normal p53 function in cells with mutated or wild type p53. The purpose of this study was to examine the effects of APR‐246 alone and in combination with other drugs in acute myeloid leukemia (AML) cells. Methods: Primary leukemic cells from patients with AML and AML cell lines were studied with respect to cytotoxic and apoptotic effects and mechanism of action of APR‐246, alone and in combination with Ara‐C, daunorubicin and fludarabine. Results: APR‐246 showed dose‐dependent cytotoxic and apoptotic effects in AML cell lines as well as in primary AML patient cells. Cells from patients with TP53 mutation and complex karyotype were more resistant to conventional drugs while these factors did not significantly affect the sensitivity to APR‐246. APR‐246 increased active caspase‐3, upregulated p53 protein levels, and increased the bax/bcl‐2 ratio independently of TP53 mutational status in patient cells sensitive to APR‐246. AML cells with high p14^ARF expression were significantly more sensitive to APR‐246. APR‐246 induced significant synergistic effects in combination with conventional chemotherapeutic agents. Pre‐incubation with APR‐246 induced more synergistic effects compared to other schedules. In patient cells, pronounced synergism was found when combining APR‐246 with danuorubicin. Conclusion: We conclude that APR‐246 is effective in AML cells irrespectively of TP53 mutational status and that it has promising properties for combination studies in AML.     

Immunoprofiling of patients with chronic myeloid leukemia at diagnosis and during tyrosine kinase inhibitor therapy

Tyrosine kinase inhibitors (TKIs) are the current standard treatment in chronic myeloid leukemia (CML). In addition to the BCR‐ABL target oncoprotein, they also inhibit off‐target kinases (e.g. c‐KIT, TEC, SRC), some of which have physiological functions in immune responses. In vitro studies have implied immunosuppressive effects of TKI treatment. As comprehensive in vivo data are missing, we aimed at analyzing the detailed immunoprofile of patients with CML at diagnosis and during therapy. We collected 88 peripheral blood (PB) and 73 bone marrow (BM) samples from 54 patients with CML at diagnosis, during imatinib and dasatinib therapies. Leukocytes and lymphocyte subclasses were analyzed with an extensive flow cytometry panel including markers for activation, differentiation and memory status. At diagnosis, a lower proportion of B cells and dendritic cells and an increased amount of NKT‐like cells were detected in the BM. During imatinib therapy, all these changes normalized and the immunoprofile resembled healthy controls. However, dasatinib patients were clearly divided into two distinct groups: one similar to healthy controls and the other showing immunoactivation characterized by significant elevations of CD8+, NK‐ and NKT‐like cells in PB. T cells of the latter group strongly expressed CD57+, HLA‐DR and CD45RO and had low CD62L antigen levels characteristic of late memory cytotoxic lymphocytes. Our results indicate that while both TKIs show immunosuppressive effects in vitro, they have a significant and differential effect on the numbers and proportions of immune effector cells in vivo. In particular, in a distinct subgroup of dasatinib‐treated patients, immune reactivity is markedly enhanced warranting careful follow‐up.     

Circulating endothelial cells in patients with acute myeloid leukemia

OBJECTIVES: The circulating endothelial cells (CEC) are proposed to be a non-invasive marker of angiogenesis. The level of CEC in peripheral blood (PB) of acute myeloid leukemia (AML) patients has not been investigated prior to this study. We evaluated the count of resting (rCEC), activated (aCEC) and endothelial progenitor cells (CEPC) in the PB of AML and healthy subjects. In addition we correlated the levels of CEC with disease status, known prognostic factors and response to treatment. METHODS: CEC were quantified by utilizing four-color flow cytometry procedures in 48 AML patients at the time of diagnosis and 29 healthy controls. Additionally, measurements were again taken after the first course of induction treatment in 12 of the patients. RESULTS: The numbers of aCEC, rCEC and CEPC were significantly higher in the AML patients than in the controls (P < 0.0001, P < 0.0001 and P < 0.001, respectively). The CEC count was significantly higher in the AML patients with white blood cell count (WBC) >15 G/L, elevated lactic dehydrogenase (LDH) levels and a higher (over median) absolute blasts count (ABC) in PB than in the group with WBC <15 G/L (P < 0.03), a normal LDH level (P < 0.03) and a lower (相似文献   

Hepatitis B reactivation in chronic myeloid leukemia patients receiving tyrosine kinase inhibitor

Hepatitis B virus(HBV) reactivation is a well-recognized complication in patients with chronic HBV infection receiving cytotoxic or immunosuppressive chemotherapy.Imatinib mesylate and nilotinib are selective Bcr/Abl tyrosine kinase inhibitors,which are now widely used in the treatment of patients with chronic myeloid leukemia.Although HBV reactivation induced by imatinib mesylate has been reported,nilotinib-related HBV reactivation has not been reported in the English literature.We report here 2 cases of HBV reactivation in chronic myeloid leukemia patients receiving imatinib mesylate and a novel case of nilotinib related HBV reactivation.     

普萘洛尔对急性髓系细胞白血病U937细胞增殖和凋亡的影响

目的:探究普萘洛尔对急性髓系细胞白血病U937细胞的增殖和凋亡的影响及可能的机制。方法:采用CCK8法检测不同药物对U937细胞增殖率的影响,分别为普萘洛尔(0、200、400、800、1000、2 000μmol/L)作用24、48、72 h,阿糖胞苷单用(0、10、50、100、200、400、800 nmol/L)24 h,普萘洛尔(400μmol/L)联合阿糖胞苷(10、50、100、200、400、800 nmol/L)作用24 h。普萘洛尔(0、200、400、800μmol/L)作用U937细胞24 h后,用流式细胞术检测细胞的凋亡和周期、线粒体膜电位的变化,用碱性彗星实验检测DNA的损伤,Caspase-Glo试剂盒检测Caspase-3、8、9相对活性的变化,Western blot法检测Bcl-2、Bax蛋白表达量的变化。结果:普萘洛尔可以有效抑制U937细胞的增殖,其效应具有一定的时间(200、400μmol/L,P0.05)和剂量相关性(0、200、400、800μmol/L,P0.01),普萘洛尔还可协同阿糖胞苷的抗肿瘤效应。流式、彗星、Caspase、Western blot结果分别表明普萘洛尔可增加细胞凋亡率,增加G_0/G_1期和减少G_2/M期细胞比例,降低线粒体膜电位水平,诱导DNA损伤,增强Caspase3、8、9活性,上调Bax的表达、下调Bcl-2的表达,且在实验浓度范围内与剂量呈相关性(P0.05)。结论:普萘洛尔可抑制急性髓系细胞白血病U937的增殖并诱导其凋亡,这一机制可能与其诱导G_0/G_1期细胞阻滞、损伤DNA,激活内、外源性凋亡途径有关。     

Deoxycytidine kinase expression and activity in patients with resistant versus sensitive acute myeloid leukemia

Resistance to cytarabine (AraC) is a major problem in treatment of patients with acute myeloid leukemia (AML). In contrast to in vitro AraC resistance, deoxycytidine kinase (dCK) mutations are rarely found in patients with refractory or relapsed AML. Previously we have demonstrated alternatively spliced dCK mRNA predominantly expressed in leukemic blasts from patients with resistant AML. In this study we investigated wild-type (wt) dCK expression and activity to elucidate the possible role of decreased dCK expression or activity in unresponsiveness to AraC in patients with AML. No alterations in dCK mRNA and protein expression or in dCK activity were detected between patients with clinically resistant vs. sensitive AML. In addition, wt dCK expression and activity were not reduced in leukemic blasts expressing alternatively spliced dCK forms as compared to blasts with only wt dCK. Also, no major differences in wt dCK expression and activity were observed between samples obtained from patients with AML and bone marrow or peripheral blood samples from healthy donors. These data implicate that in our patient group of refractory or relapsed AML cases, alterations in dCK expression and/or activity cannot explain unresponsiveness to chemotherapy including AraC.