bluuebunny/crossref_metadata_2025 huggingface dataset:
Imatinib 400 mg in Early Chronic Phase CML: Results of a Multicentric, Prospective Non Academical Observational Study (by the GIMEMA CML Working Party).
Authors: Rosti Gianantonio , Castagnetti Fausto , Iacobucci Ilaria , Amabile Marilina , Palandri Francesca , Giannoulia Panagiota , Alimena Giuliana , Testoni Nicoletta , Luatti Simona , Martino Bruno , Specchia Giorgina , Rupoli Serena , Capucci Adele , Cavazzini F. , Radaelli Franca , Orlandi Ester , Cambrin Giovanna Rege , Usala Emilio , Testoni Nicoletta , Pane Fabrizio , Saglio Giuseppe , Martinelli Giovanni , Baccarani Michele
Published: April 2020

Imatinib 400 mg (SD) is the established first line treatment of chronic myeloid leukemia (CML) in chronic phase. The efficacy of imatinib in early chronic phase has been demonstrated by phase 2 and 3 controlled trials like the IRIS study (O’ Brien et al NEJM 348:11, 2004). Large multicentric studies aimed to evaluate the impact of imatinib 400 mg outside strictly monitored frameworks are not yet available. The GIMEMA (Gruppo Italiano Malattie Ematologiche dell’Adulto) CML Working Party opened in January, 2004, an observational study (serial n. CML/023) to investigate the efficacy of imatinib SD in newly diagnosed CML pts. Clinical and anagraphical data were collected through a web-based system. Peripheral blood samples for quantitative molecular analysis (RT-Q-PCR, Bcr-Abl/Abl × 100 - Taqman) were centralized in Bologna. Overall, 55 italian centers enrolled 367 (359 evaluable) newly diagnosed CML pts in chronic phase between Jan 2004 and Jan 2006. Median age was 50 yrs (range 18–84), 220 male and 139 females. Sokal risk at diagnosis was low, intermediate and high in 221 (62%), 123 (34%), 15 (4%) pts, respectively. 359 pts are evaluable for response at 3 months, 310 at 6 months and 187 at 12 months. The median observation time is 12 months. At 3 months, 94% of the pts reached a stable CHR. At 6 months, 80% of evaluable cases obtained a complete cytogenetic response (100% Ph-neg, CCgR). A major molecular response (MMolR) defined as a Bcr-Abl/Abl × 100 ratio < 0.1%, was shown in 52% of CCgR pts. At 12 months, the CCgR rate was 87% and the MMolR rate in CCgR pts was 63%. At 12 months, 3% of CCgR cases showed an undetectable level of transcript (ratio Bcr-Abl/Abl × 100 < 0,0001). With this short observation period, only 4 pts (1,1%) progressed to accelerated/blastic phase. Limiting the observation to low Sokal risk, at 12 months 221 such pts got a CCgR and MMol rates of 88% and 62%, respectively; 201 low Sokal risk pts were enrolled in the IRIS trial: at 12 months CCgR and MMolR (reduction of Bcr-Abl/Bcr ratio level > 3 logs) rates were 76% and 66%, respectively ( (T Hughes et al, NEJM 349:15, 2003). This study confirns that imatinib is efficacious and manageable, confirming and improving the results of the IRIS trial.
Additional Cytogenetic Abnormalities and/or Philadelphia Chromosome Metaphase Mosaicism Might Adversely Influence Survival and Imatinib Response in Chronic Myeloid Leukemia.
Authors: Landstrom Andrew P. , Ketterling Rhett P. , Knudson Ryan A. , Dewald Gordon W. , Tefferi Ayalew
Published: April 2020

Background: Chronic myeloid leukemia (CML) is invariably associated with the reciprocal translocation of BCR and ABL to form the Philadelphia chromosome (Ph), t(9;22)(q34;q11). At diagnosis, a small proportion of patients display additional cytogenetic abnormalities and/or a variable proportion of cytogenetically normal metaphases that coexist with Ph-positive metaphases. The objective of the current study was to examine the prognostic relevance of these two scenarios.

Methods: The study population consisted of 65 (47.7% female) consecutive, newly diagnosed CML patients seen at the Mayo Clinic with a median age of 59 years. 44.5 percent were initially treated with interferon alpha (IFN) resulting in complete cytogenetic remission in 10.7 percent for a median length of 5.83 years, partial cytogenetic remission in 3.57 percent for a median length of 2 years. 55.5 percent were treated with imatinib (Gleevec) resulting in complete cytogenetic remission in 54.1 percent for a median length of 3.08 years, partial cytogenetic remission in 13.5% for a median length of 1.08 years.

Results: Survival at five years through Kaplan-Meier analysis was approximately 92 percent in patients demonstrating only the Ph chromosome (n = 53), versus 60 percent in patients with additional chromosomal abnormalities (n = 12; p < 0.0001 by both Logrank and Breslow-Gehan-Wilcox analysis). Furthermore, patients with additional chromosomal abnormalities demonstrated lower rates of either complete or partial cytogenetic remission with imatinib therapy. Similarly, five year survival of patients with less than 90% Ph-positive metaphases at diagnosis (n = 4) was approximately 60% compared to 92% in patients with greater than 90% Ph-positive metaphases (n = 61; p = 0.01 by Logrank and p = 0.001 by Breslow-Gehan-Wilcox analysis). Additionally, the former group of patients was significantly less responsive to imatinib. Finally, there was significant correlation between Ph-positive metaphase mosaicism and the presence of additional chromosomal abnormalities (p = 0.05).

Conclusion: Although it is tempting to speculate the possibility that Ph-chromosome mosaicism and/or additional cytogenetic abnormalities at presentation of CML is a surrogate for the presence of Ph-negative imatinib-resistant clones, the preliminary results from the current study require validation from a larger study.

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Detection of BCR-ABL Transcript by Quantitative Real-Time PCR and Amp-CML (Transcript Mediated Amplification) during Imatinib Therapy for Chronic Myeloid Leukemia.
Authors: Miyamura Koichi , Yagasaki Fumiharu , Kyo Taiichi , Ohnishi Kazunori , Naoe Tomoki , Takeuchi Hitoshi , Nishimura Miki , Fujiwara Shin , Tauchi Tetsuzo , Ohno Ryuzo
Published: April 2020

Imatinib induces a complete cytogenetic response in the majority of patients and a reduction of BCR-ABL to 0.1% of the level at diagnosis is associated with longer progression free survival. However, the methods of BCR-ABL detection differ from study to study. Mostly, quantitative real-time PCR assay (RQ-PCR) has been used however, the control gene and expression of results have not been standardized to date. In Japan, only Amp-CML, a commercial kit composed of TMA (transcription mediated amplification) and HPA (hybridization protection assay) has been approved by the government. BCR-ABL was expressed by copy number per microgram RNA. The range of detection is between 50 to 2500 copies per assay. If 0.05 ug of RNA is used for the assay, the detection ranges between 1000 to 50000 copies per microgram RNA. However, the accuracy and sensitivity of Amp-CML in comparison with RQ-PCR are not well known. Thus we compared Amp-CML with RQ-PCR using a large number of patients enrolled in the Japan Adult Leukemia Study Group (JALSG).

In the JALSG clinical trial, imatinib was used as initial therapy for 171 patients with chronic myelogenous leukemia. We measured levels of BCR-ABL transcripts in the blood of all patients in this trial before and 1, 2, 3, 6 and 12 months after the treatment using RQ-PCR and Amp-CML. In both assays the results expressed the copy numbers of BCR-ABL per microgram of RNA. The median number of BCR-ABL transcripts detected by RQ-PCR was 98,964 at diagnosis and 63,442, 33182, 3342, 331 and 98 at 0, 1, 2, 3, 6, 12 months, respectively, after treatment. The median number of BCR-ABL transcripts detected by Amp-CML was >50000 at diagnosis and >50000, 20284, 2180, <1000 and <1000 at 0, 1, 2, 3, 6, 12 months, respectively, of treatment. These results suggested that results of Amp-CML and RQ-PCR were well correlated (R=0.67), although the range of Amp-CML was restricted. In the next step, we attempted to improve the sensitivity by increasing the amount of RNA used for Amp-CML. Using 0.5 ug of RNA, the range of detection by Amp-CML is between 100 and 5000 copies, and 50 additional samples were analyzed. In this range, BCR-ABL copy number was also well correlated. (R=0.968) Using 2ug of RNA, we are investigating more sensitive methods expecting range of detection by Amp-CML is between 25 and 1250 copies. Tentatively 13 samples which showed 10–100 copy/ug by RQ-PCR was reevaluated by both methods. Ratio of Amp-AML to RQ-PCR is 1.4 in median and range is 0.3-2.1. Thus Amp-CML may have accuracy even the very small range. Thus, Amp-CML can be used for the monitoring BCR-ABL transcripts during treatment with imatinib.
Renal Function Impairment and Outcomes of Reduced-Intensity Allogeneic Hematopoietic Stem Cell Transplantation.
Authors: de Souza Jonas A. , Saliba Rima , Patah Poliana A. , Rondon Gabriela , Qazilbash Muzaffar H. , Hosing Chitra , Popat Uday , Champlin Richard E. , de Lima Marcos
Published: April 2020

Non-relapse mortality (NRM) after reduced-intensity allogeneic transplants is likely to be influenced by abnormalities in renal function. We hypothesized that moderate to mild renal function impairment increases NRM in this setting.

Methods: We studied 141 patients diagnosed with AML (n=131) or high-risk MDS (n=10) who underwent allogeneic transplantation with Fludarabine (Flu)/Melphalan (Mel)-based regimens between August 1996, and May 2006 in our institution. Flu dose was 30–40mg/m2 for 4 days and Mel doses were100–180mg/m2. ATG was added for recipients of unrelated donor (UD) HSCT. GVHD prophylaxis was tacrolimus and mini-methotrexate for all but 2 patients. Donors were HLA-compatible siblings (n=69) and matched UD (n=72). Disease status at transplant was complete remission (n=56, 40%) or active disease (n=85, 60%). The influence of the estimated glomerular filtration rate (GFR) measured before transplant on outcomes was analyzed. GFR was calculated by both the Cockcroft Gault (CG) and the Modified Diet in Renal Disease (MDRD) equations, using the creatinine value obtained prior to starting chemotherapy. We considered GFR ≥ 90 as normal and GFR < 90 as decreased. Evaluated outcomes were overall survival, NRM, and regimen-related mortality (RRM) at day 100 and 1-year post transplant.

Results: Median age was 55 years (range, 21–74); 59% of the patients were male. Estimated GFR by CG was normal for 45 patients (32%), and decreased for 96 patients (68%). When estimated by MDRD, 65 patients (46%) had normal and 76 (54%) had reduced GFR. The majority of patients by both estimations had a GFR between 60 and 89 (n= 78 by CG and n= 66 by MDRD) with no difference in the evaluated outcomes between this group and the subgroup of patients with a GFR <60 (p>0.05). There was no difference in overall and NRM at day 100 and 1 year post transplant in both groups by any GFR estimation method. There was a small trend towards lower RRM at day-100 for patients with GFR ≥ 90 when using CG, but this was not statistically significant.

Conclusion: A mild to moderate decrease in GFR is not associated with an increase in non-relapse mortality.

Transplant outcomes as a function of GFR at start of conditioning regimen Outcome N 100-Day Mortality HR p 1-year Mortality HR p Abbreviations: NRM: non-relapse mortality; RRM: regimen-related mortality (excludes deaths due to GVHD); GFR: glomerular filtration rate (estimated by CG) Survival- GFR ≥ 90 45 11 (25%) 0.9 0.9 24 (53%) 1.2 0.5 Survival- GFR < 90 96 24 (25%) 44 (46%) NRM* - GFR ≥ 90 45 9 (21%) 0.9 0.9 14 (31%) 0.98 0.9 NRM* - GFR < 90 96 19 (20%) 31 (32%) RRM* - GFR ≥ 90 45 3 (7%) 0.5 0.3 6 (13%) 0.9 0.9 RRM* - GFR < 90 96 12 (13%) 14 (15%)
Hematopoietic Progenitor Cells Harbouring BCR-ABL Exhibit Increased Adhesiveness but an Impaired Migration and Homing Potential.
Authors: Fierro Fernando A. , Taubenberger Anja , Ehninger Gerhard , Mueller Daniel , Bornhaeuser Martin , Illmer Thomas
Published: April 2020

Recent studies suggest that one of the most important treatment resistance mechanisms of cells with the BCR-ABL translocation could be the interaction with the hematopoietic niche. During the contact with the respective microenvironment, leukemic stem and progenitor cells acquire both a state of cell adhesion mediated drug resistance (CAM-DR) and may change their proliferation and differentiation potential.

Studies on the effect of the BCR-ABL oncogene on cell adhesion and migration have yielded conflicting results due to different cell type models (primary cells vs. transduced cell lines), non-standardized quantification methods and diverse substrates (fibronectin vs. bone marrow stromal cells) studied. In the present work, we investigated the adhesion properties of 32D cells which were stably transformed with the BCR-ABL fusion transcript in comparison to an empty vector transformed control. The commonly used panning-style adhesion assay determining the percentage of hematopoietic cells adhering to a stroma cell line (M2-10B4) clearly demonstrated higher adhesion capacity of BCR-ABL transformed cells. Accordingly, an atomic force microscopy (AFM)-based method to measure adhesion forces of a single leukemic cell over stroma cells, showed an increased ‘stickyness’ of BCR-ABL transformed cells. AFM experiments demonstrated highly different forces that were needed to retract attached 32D-vector cells as compared to 32D/BCR-ABL cells (1000 pN vs. 3500 pN; p<0.01). This higher superficial adhesion of BCR-ABL transformed cells was associated with a decreased migration and homing potential of adhering cells into the stromal layer (quantified by cell tracking movies analysis) and cobblestones formation which was analysed by confocal laser scanning microscopy. The differences found between control and BCR-ABL-expressing cells were reversible by pre-incubation with 0.5 μM Imatinib Mesylate (IM), suggesting that altered adhesion is a tyrosine kinase-activity dependent process.

To further gain insight in the mechanisms of adhesion we used a cDNA microarray (Affymetrix-Gene chip 430A 2.0) for the identification of BCR-ABL related gene expression with special focus on adhesion associated genes. P-Selectin upregulation (40 folds) in cells harbouring BCR-ABL was seen as the most dramatic change in adhesion related molecules. Consequently, a monoclonal antibody against P-selectin inhibited adhesion capacity of BCR-ABL cells on M2-10B4.

In conclusion, we describe an increased adhesion capacity of 32/BCR-ABL transformed cells which is associated with an up-regulation of P-selectin expression. Moreover, whilst 32D/BCR-ABL cells show a high potential to primarily attach to the stroma layer, physiological functions like cobblestone formation is impaired by a reduced migration and consecutively impaired homing potential of the cells into the supporting niches formed by the feeder cells.
MabThera (Rituximab) Plus Cyclophosphamide, Vincristine and Prednisone (CVP) Chemotherapy Improves Survival in Previously Untreated Patients with Advanced Follicular Non-Hodgkin’s Lymphoma (NHL).
Authors: Marcus Robert E. , Solal-Celigny Philippe , Imrie Kevin , Catalano John V. , Dmoszynska Anna , Raposo João C. , Offner Fritz C. , Gomez-Codina José
Published: April 2020

Design/methods: Rituximab added to 8 cycles of CVP (R-CVP) chemotherapy improves time to progression and duration of response in previously untreated patients with stage III/IV CD20 positive follicular NHL compared with CVP alone (Marcus et al Blood2005;105:1417–23). A protocol pre-planned analysis of this study with a median follow-up of 53 months has now been performed.

Results: A total of 321 patients (median age 53 years) were recruited. Eighty-three percent of patients in both arms had intermediate to high-risk disease according to the Follicular Lymphoma International Prognostic Index (FLIPI, score 2–5). Median time to progression or death (TTP) in the R-CVP arm was 34 months compared with 15 months in the CVP arm, p<0.0001 (log rank). This increase in TTP was observed in all FLIPI groups with a risk ratio of 0.40 (95% confidence interval 0.27 to 0.60) for good intermediate risk patients and 0.51 (95% confidence interval 0.34 to 0.76) for poor risk patients; overall the risk ratio was 0.44 (95% confidence interval 0.32 to 0.57). In patients achieving a complete response (CR) or CR unconfirmed (CRu), disease-free survival (DFS) was significantly prolonged (p=0.0001, log rank); the estimated 4-years’ DFS rate was 54% for patients receiving R-CVP compared with 17% for CVP. Nineteen percent (31/162) of patients in the R-CVP group have now died compared with 29% (46/159 patients) in the CVP group. Patients receiving R-CVP had a significant improvement in overall survival compared with CVP (p=0.03, log rank; hazard ratio 0.60 [95% confidence interval 0.38 to 0.96]).

Conclusion: When added to first-line chemotherapy in patients with follicular NHL, rituximab not only improves TTP and DFS, but also has a favorable effect on overall survival.
Activity of ABL Kinase Inhibitors in Two Distinct Models of Imatinib Resistance.
Authors: Donato Nicholas J. , Wu Ji , Bornmann William , Talpaz Moshe
Published: April 2020

The tyrosine kinase inhibitor imatinib mesylate (Gleevec) is effective in controlling BCR-ABL expressing leukemias but resistance occurs in a small subset of early stage patients and is very common in advanced stage patients. Resistance is associated with overexpression and/or mutations in the BCR-ABL gene but patients are also increasingly reported to fail imatinib therapy while retaining wild-type BCR-ABL expression. To circumvent or overcome resistance novel kinase inhibitors have been synthesized and tested clinically. However, while investigators have designed models to measure and predict activity of novel compounds in mutation-mediated imatinib resistance, other mechanisms of resistance have not been modeled or shown clinical relevance. In this report, the activity of four novel kinase inhibitors (norlotinib, dasatinib, SKI-606, ON012380) was compared in two distinct models of imatinib resistance. These models include cell lines established from natural resistant variant clones selected from imatinib sensitive cell lines and associated with a T315I BCR-ABL mutation (BV-173R) or overexpressed Lyn kinase (K562R). Kinase inhibitory activity in these models was compared to transfectant-based resistance models including BaF3 cells expressing the T315I mutant form of BCR-ABL and overexpression of Lyn kinase in K562 cells. K562R cells were completely resistant to imatinib and norlotinib but highly sensitive to Src/Abl inhibitors (dasatinib, SKI-606) but only partially sensitive to ON012380. Overexpression of Lyn in K562 cells reduced imatinib and norlotinib sensitivity (3-fold) but did not affect sensitivity to the other kinase inhibitors. BV-173R cells expressing the T315I mutant form of BCR-ABL were completely resistant to Abl-selective kinase inhibitors (imatinib, norlotinib) and ~100-fold less sensitive (IC50 ~ 2 microM) to Src/Abl-directed inhibitors (dasatinib, SKI-606) while the non-ATP competitive kinase inhibitor, ON012380, was equally effective against both BV-173 and BV-173R cells. Expression of the T315I mutant form of BCR-ABL in BaF3 cells completely blocked kinase inhibitory activity of all inhibitors except ON012380. IL-3 dependent BaF3 cells were not inhibited by imatinib, norlotinib or SKI-606 but were equally sensitive to ON012380 when compared to IL-3 independent BCR-ABL transfectants. Cellular sensitivity was associated with reduced phosphorylation of BCR-ABL, CrkL and Lyn kinase with all inhibitors except ON012380, which mediated apoptosis in the absence of alterations in tyrosine phosphorylation. Together, our results suggest that imatinib resistant cell models are useful in evaluating the activity of novel kinase inhibitors but need to be carefully interpreted and mechanistically tested. Additional mediators of imatinib resistance need to be defined and modeled so that an appropriate individualized therapy can be applied to most effectively overcome resistant disease.
Therapeutic Drug Monitoring of Imatinib and Impact on Clinical Decision Making.
Authors: Blasdel Carolyn , Wang Yanfeng , Lagattuta Theodore , Druker Brian , Letvak Laurie , Egorin Merrill
Published: April 2020

OBJECTIVES: Imatinib (IM) has demonstrated durable clinical efficacy in the majority of chronic myeloid leukemia (CML) patients. Optimal response may be influenced by multiple innate and external factors, some of which may be controlled by monitoring plasma concentrations of the drug. This abstract reports 6 cases where analyzing plasma IM trough concentrations (Cmin) in patients treated with three commonly used IM doses (400, 600, and 800 mg daily) influenced clinical decision making.

METHODS: IM trough blood samples were collected at a time before that day’s IM dosing. Plasma concentrations of IM were determined by a validated LC/MS/MS method.

RESULTS: In large population studies of CML patients enrolled in Phase I, II, and III clinical trials, the mean Cmin levels of IM at 400 mg qd, 600 mg qd, and 400 mg bid doses were: 981 (±543, 55%, n=394), 1572 (±1032, 66%, n=14), and 3479 (±1264, 36%, n=14) ng/mL, respectively. Large inter-patient variability was shown at all three doses. Of the 6 cases detailed in the table below, 4 (ID 1, 3, 4, and 5) had dose reduction due to tolerability concerns with subsequent improvement of symptoms following dose adjustment. One patient (ID 2) had a dose increase because of a poor qRT-PCR response. Another (ID 6) had a dose increase due to low plasma IM exposure resulting from drug-drug interaction with phenytoin, a known inducer of CYP3A4 (the major metabolizing isozyme for IM). After dose adjustment, all six patients showed good clinical response to IM treatment. The new mean Cmin value in these patients was 2000 (±471) ng/mL, representing a 24% coefficient of variability.

CONCLUSIONS: Although the data is limited, IM drug monitoring proved useful in managing tolerability, lack of efficacy, adherence or potential drug interactions that modulate imatinib drug concentrations. More prospective studies are needed to demonstrate the value of IM drug monitoring in routine clinical practice.

Patient ID Age, Sex CML Stage IM Daily Dose 1st Cmin (ng/mL) Reason for Dose Change New Dosing Regimen New Cmin (ng/mL) CP, chronic phase1 1 54, f CP 200 mg bid, Jan 03 3048, Sep 05 transfusion-dependent, anemia, Sep 05 300 mg, Oct 05 2130, Jan 06 2 9, f CP 300 mg, Jan 05 not done qRT-PCR 0.016, Jan 06 400 mg, Jan 06 2341, Jul 06 3 13, f CP 300 mg bid, May 05; 700 mg, Aug 05; 600 mg, Sep 05 1966, Feb 06 nausea, fatigue, arthralgias, myalgia, ongoing 400 mg, Mar 06 1222, May 06 4 67, f CP 400 mg, Feb 05 not done myelosuppression, Mar 05 200 mg, Mar 05 1928, May 06 5 53, f CP 400 mg, Apr 03; 600 mg, May 03; 800 mg, Jul 04 not done inflammatory pulmonary reaction with shortness of breath; dose held, Mar 05 400 mg, Oct 05 2378, May 06 6 73, m CP 350 mg, on phenytoin, Apr 99 35, Jun 99 stopped phenytoin, Jul 99 500 mg, Jul 99 not done; qRT-PCR negative, Jul 06
Prognostic Significance of Serial Determinations of LDH Levels in Primary (De Novo) Myelodysplastic Syndromes.
Authors: Wimazal Friedrich , Sperr Wolfgang R. , Vales Anja , Kundi Michael , Boehm Alexandra , Thalhammer Renate , Schwarzinger Ilse , Valent Peter
Published: April 2020

An increased lactate dehydrogenase (LDH) level at diagnosis is associated with a reduced probability of survival and an enhanced risk of AML development in primary (de novo) myelodysplastic syndromes (MDS). However, so far, little is known about the prognostic value of an increase in LDH levels during the follow up in these patients. We have serially determined LDH levels in 221 patients (102 males, 119 females) with de novo MDS (median age 70 years; FAB-types: RA, n=62; RARS, n=46; RAEB, n=48; RAEBT, n=36; CMML, n=29), and examined the prognostic value of LDH as a follow-up parameter. Confirming previous data, an elevated LDH level at diagnosis was found to be associated with a significantly increased probability of AML evolution and a significantly decreased probability of survival (p<0.05). In the follow up, an increase in LDH (from normal to elevated) was found to be associated with progression of MDS and AML evolution in most cases. Moreover, in those patients who progressed to AML, LDH levels were found to be significantly higher in the two three-months-periods preceding progression compared to the two initial three-months-periods examined (p<0.005). In most patients, the increase in LDH was accompanied or followed by other signs of disease progression, such as the occurrence of thrombocytopenia or an increase in blasts. Together, our data show that LDH can be employed as a prognostic follow-up variable in patients with MDS. In those patients in whom an increase in LDH is noted, a thorough re-evaluation of the progression-status of the disease including a bone marrow examination should be considered.
Secondary Myelodysplastic Syndrome after Hydroxychloroquine Therapy.
Authors: Muslimani Alaa , Spiro Timothy , Chaudhry Asif , Hamed Daw
Published: April 2020

Introduction: The myelodysplastic syndromes (MDSs) include a group of marrow disorders united by the common feature of ineffective hematopoiesis. Primary MDS is defined as occurring in the absence of exposure to ionizing radiation, chemotherapeutic agents or myelotoxic drugs. Secondary MDS occurs in the presence of such exposure. The reported hematological side effects of hydroxychloroquine include aplastic anemia, agranulocytosis, thrombocytopenia, and hemolytic anemia in individuals with G-6-PD deficiency. However the frequency of secondary MDS after treatment with hydroxychloroquine is unknown. We report four patients who developed MDS after hydroxychloroquine therapy, a previously unrecognized association.

Methods: We did a retrospective chart analysis of 217 patients on hydroxychloroquine for rhematological conditions in 2005. None of these patients had exposure to myelosuppressive drugs including methotrexate, radiation, chemotherapeutic agents, or benzene. Amongst these patients, 4 had been diagnosed with MDS in 2005. The demographics, type of MDS, karyotypic abnormalities, dose and duration of treatment with hydroxychloroquine were reviewed.

Results: Two patients were male (M) and two female (F); the median age was 69.75 years, (range 65–76). There was no personal or family history of hematopoietic cancer. The dose of hydroxychloroquine for all patients was 400 mg daily, with median treatment duration of 10.5 years and a range of 6–16. All patients had bone marrow biopsy confirmation of the diagnosis of MDS, and two had karyotype abnormalities.

Conclusion: The incidence of MDS in a group older than 70 years ranges from 15 to 50/100,000 persons/year. The diagnosis of four cases of MDS among 217 patients in one year is approximately 123–37 fold higher than the risk of MDS in the general population aged more than 70 years (P < 0.001) and suggest that long-term treatment with hydroxychloroquine is associated with an increased risk of developing secondary MDS.

Age (years)/sex Dose (daily) / duration of hydroxychloroquine treatment MDS subtype Cytogenetic studies. Two (or more) cytogenetically different populations of cells are indicated by a slanted line (/) between their karyotype notations.The number in brackets [ ] indicates the number of cells seen with the preceding karyotype.del (deletion): loss of part of a chromosome. q: the long arm of the chromosome. +: extra copy of the chromosome. −: random loss of chromosomes. Case 1 65/M 400 mg/6 years Refractory anemia without ringed sideroblasts. 45 XY case 2 73/F 400 mg/7 years Refractory anemia without ringed sideroblasts. 46 XX case 3 76/M 400 mg/16 years Refractory anemia with excess blasts 49,XY,+4,+8,+12[5]/46,idem,−5, −6,−13[1]/46,XY[15] case 4 65/F 400mg/13 years Refractory anemia with ringed sideroblasts 46 XX, del (20) (q11.2q13.3)[2]/46 XX[18]
Phase II Study of Thymglobulin, Cyclosporin, and G-CSF for the Initial Treatment of Aplastic Anemia and Low Risk Myelodysplastic Syndrome.
Authors: Ravandi-Kashani Farhad , Estrov Zeev , Ferrajoli Alessandra , Borthakur Gautam , Beran Miloslav , Pierce Sherry , Koller Charles A. , Cortes Jorge , Faderl Stefan , Kantarjian Hagop M.
Published: April 2020

Standard therapy of aplastic anemia (AA) involves the use of equine anti-thymocyte globulin (ATG) in combination with cyclosporine. Hematological responses occur in 40% to 50% of patients treated with ATG alone. The addition of cyclosporine to ATG has improved response and survival; response rates have been up to 65%, and the 5-year survival rate in the responding patients has been over 80%. Several lines of observation have also implicated an autoimmune mechanism in at least a subset of patients with myelodysplastic syndrome (MDS) whose disease process may overlap AA. The rationale for treating refractory or relapsing patients with ATG from a different animal has been the lower risk of potentially life-threatening allergic reactions. In a recent study, most patients who received rabbit ATG (Thymoglobulin) after unsuccessful treatment with ATG became transfusion independent (Di bonna E, Br J Haematol, 1999). Another study has reported high responses to Thymoglobulin in patients with relapsed AA (Scheinberg P, Br J Haematol, 2006). We are conducting a clinical trial of Thymoglobulin in combination with cyclosporin and GCSF in the first line therapy of patients with AA or low-risk MDS. Patients receive Thymoglobulin 3.5 or 2.5 (if they were 55 years or older) mg/kg/day IV for 4 days, methyl prednisone 1 mg/kg/day IV for 4 days followed by a tapering dose of oral prednisone, cyclosporine 5 mg/kg orally, and G-CSF 5 μg/kg daily for up to 3 months at the discretion of the treating physician. All patients receive prophylactic broad-spectrum antibiotics. We have enrolled 13 patients in the study including 7 patients with AA and 6 patients with MDS. The median age for AA patients was 61 years (range 45 – 73 years), and for MDS patients 60 years (range, 41 – 71 years). The median absolute neutrophil count (ANC) for AA patients was 0.74 × 109/L (range, 0.1 – 1.0 × 109/L) and for MDS patients 2.0 × 109/L (range, 1.1 – 8.1 × 109/L). The median Hgb for AA patients was 6.9 g/dL (range, 3.9 – 7.9 g/dL) and for MDS patients 8.1 g/dL (range 6.4 – 10.7 g/dL). The median platelet count for AA patients was 8 × 109/L (range, 0 – 153 × 109/L) and for MDS patients 10 × 109/L (range, 6 – 16 × 109/L). Flow cytometry for a PNH clone was negative in all patients. Seven patients (4 AA, 3 MDS) were positive for HLA-DR15. So far, 6 patients with AA have responded including 3 CRs, 2 PRs and 1 HI. One patient with MDS had a PR. Toxicity has been acceptable with no grade 3 or 4 side effects. Other side effects (grade 1 and 2) included infusion-related reactions, hypomagnesemia, elevation of serum creatinine, and hyperbilirubinemia. We conclude that Thymoglobulin can be administered safely in combination with cyclosporin and GCSF to treat patients with untreated AA and MDS.
Analysis of the Incidence of Treatment-Related Myelodysplastic Syndrome and Acute Myelogenous Leukemia in Registration and Compassionate-Use Trials of Ibritumomab Tiuxetan Radioimmunotherapy (RIT).
Authors: Czuczman Myron S. , Emmanouilides Christos , Darif Mohamed , Witzig Thomas E. , Gordon Leo I. , Revell Steven , Vo Katie , Molina Arturo
Published: April 2020

Radioimmunotherapy (RIT) is a therapeutic modality indicated for the treatment of patients with relapsed or refractory low-grade, follicular, or transformed non-Hodgkin’s lymphoma (NHL), where the mechanism of action involves the intrinsic activity of the monoclonal antibody and the cytotoxic effects of radiation. The primary toxicity is a late-occurring, transient, and reversible myelosuppression. Because of concerns regarding the long-term effects of radiation on the bone marrow, we investigated the incidence of treatment-related myelodysplastic syndrome (t-MDS) and treatment-related acute myelogenous leukemia (t-AML) after ibritumomab tiuxetan RIT. A total of 746 patients with NHL were treated with the ibritumomab tiuxetan regimen in registration and compassionate-use trials between 1996 and 2002. Patients had a median age of 61 years (range, 24–87) and had received a median of 3 prior therapies (range, 0–9+). The crude incidence of t-MDS or t-AML was 2.3% (17/746), with an incidence of 4.7% (10/211) in patients enrolled in registration trials and of only 1.3% (7/535) in patients included in the compassionate-use trial, with a median follow-up of 5.7 and 3.5 years, respectively. These malignancies were documented at a median of 5.6 years (range, 1.2–13.9) after the diagnosis of NHL and 1.5 years (range, 0.1–5.8) after RIT. The annualized rates were 0.3% (95% CI, 0.2%–0.4%) a year after the diagnosis of NHL and 0.7% (95% CI, 0.4%–1.0%) a year after RIT. Cox multivariate regression analysis found that previous treatment with a purine nucleoside analog was a significant risk factor for t-MDS or t-AML (hazard ratio, 3.9 [95% CI, 1.5–10.4]; P = .006). All patients in whom t-MDS or t-AML developed and in whom cytogenetic data were available (n = 15) had multiple cytogenetic aberrations, commonly of chromosomes 5 and 7, suggesting an association with previous exposure to chemotherapy. There were documented bone marrow cytogenetic abnormalities before treatment in 2 patients who developed t-MDS or t-AML. These data suggest that the annualized incidence of t-MDS or t-AML following ibritumomab tiuxetan RIT is consistent with that expected on the basis of the patients’ history of treatment for NHL. Cytogenetic testing before administration of RIT may identify existing chromosomal abnormalities in previously treated patients, particularly in those who have been treated with alkylating agents and/or purine nucleoside analogs and who are thereby at a higher risk for t-MDS or t-AML.
The Impact of GM-CSF on Arsenic Trioxide (As2O3, Trisenox) Therapy in Patients with Myelodysplastic Syndrome (MDS): Preliminary Results of a Phase II Study.
Authors: Mavromatis Blanche H. , Kessler Craig M. , Cheson Bruce D. , Sein Aung , Sharp Stewart A.
Published: April 2020

Background: Arsenic trioxide(As2O3) has proven clinical efficacy in relapsed acute promyelocytic leukemia, and is currently being studied in the upfront setting. At micromolar doses, As2O3 induces apoptosis and cellular differentiation, promotes histone acetylation, and inhibits tumor angiogenesis. In preclinical MDS studies, As2O3 inhibits proliferation of malignant hematopoietic cells, and increases rates of apoptosis in short term cultures. Notably, pre-treatment with GM-CSF increases sensitivity of cells to the effect of As2O3. Single agent clinical activity has also been demonstrated in MDS and multiple myeloma.

Methods: As2O3 was combined with GM-CSF in pts with MDS in a phase II trial. Eligible patients included those with Low/Int-1 and Int-2/High risk disease. Pts received treatment with As2O3 0.25 mg/Kg d1–d5 the first week, then twice a week for 9 weeks, then 2 weeks off. The cycle was repeated if a response was observed. GM-CSF was administered twice a week for the entire cycle. Pt characteristics are summarized in the table below.

Toxicity: Grade 3 and 4 study related AEs included peripheral neuropathic pain (1/7), febrile neutropenia (2/7), infection (4/7), abdominal pain (2/7), thrombocytopenia (2/7), hypoxia (1/7), chills associated with infusion (1/7), VT despite normal electrolytes (1/7), AV block (1/7). Results. 7 pts were enrolled (5M/2F), RA (1), RARS (3) and RAEB (3). A minor hematologic response was seen in one patient with RARS. One patient with RAEB2 showed a reduction of marrow blast count from 15% to < 5% after one cycle. 3 pts completed less than one cycle and response could not be assessed.

Conclusion: The data suggest that As2O3 with GM-CSF is active in MDS, however with significant side effects. The study of As2O3 with the newer approved agents such as 5-azacitidine or lenalidomide should be undertaken, but done sequentially in order to minimize any overlapping toxicities.

Patient Characteristics and Results Patient Age MDS Subtype Cytogenetics IPSS Number of Cycles Response Overall Survival months) Nl: normal, RA: refractory anemia; RARS: refractory anemia with ringed sideroblasts; RAEB1: refractory anemia with excess blasts 1; Int risk: intermediate risk; IPSS: international prognostic scoring system 1 76 RARS Nl Int risk-1 3 Minor HI-E 28+ 2 75 RAEB1 Nl Int risk-2 2 PR 10 3 78 RA Nl Int risk-1 1 SD 7 4 69 RAEB1 Nl Int risk-1 <1 NA NA 5 58 RARS Nl Int risk-1 1 SD 25+ 6 65 RARS 7 del, 20 del Int risk-2 1 SD NA 7 62 RAEB1 Complex: 3q-, abn ch 12, 5q-, -7, 2 ring ch8, trisomy 22 Int risk-2 <1 NA NA
Single Treatment with Rituximab Monotherapy for Low-Tumor Burden Follicular Lymphoma (FL): Survival Analyses with Extended Follow-Up (F/Up) of 7 Years.
Authors: Colombat Philippe , Brousse Nicole , Morschhauser Franck , Franchi-Rezgui Patricia , Soubeyran Pierre , Delwail Vincent , Deconinck Eric , Haioun Corinne , Foussard Charles , Sebban Catherine , Tilly Herve , Milpied Noel-Jean , Boue Francois , Karsenti Jean-Michel , Lederlin Pierre , Najman Albert , Thieblemont Catherine , Moreau Delphine , Bergougnoux Loic , Salles Gilles Andre , Solal-Celigny Philippe
Published: April 2020

As previously reported (Colombat, Blood2001;97:101), rituximab (4 weekly doses of 375mg/m²) can lead to high response rates (RR) and prolonged remissions with minimal toxicity as 1st line therapy for low tumor burden FL. We report the final analysis of a trial evaluating long term efficacy and safety of rituximab in untreated low tumor burden FL (GELF criteria). 49 patients (pts) were included in the initial trial (median age 52 yrs), 2 refused consent for the extended F/Up period, and 1 pt died at M12. Molecular bcl2-JH rearrangement was assessed throughout the study.

The median F/up was 83.8 mths. Overall best RR, complete/unconfirmed RR and partial RR at D78 were 74%, 50% and 24% respectively. Median PFS was 23.5 mths for the study population. Median duration of response (34 responders at D78, i.e 6 weeks after the last rituximab dose) was 28.6 mths, but response was still maintained without any further treatment in 11 pts after 5 years (24%) and in 7 pts after 7 years (15%).

31/46 pts were bcl2 positive in blood and/or marrow samples before rituximab: 11 (35%) became negative at D50, and 20 remained positive (65%). Median PFS was 37 mths for bcl2-negative pts at D50, and 12 mths for patients remaining positive (p=0.018 Log-rank). Of the 7 pts with sustained response after 7 years, 5 were bcl2 positive at D0, 2/5 became negative at D50, and 5/5 were still negative at M84.

At year 7, 4/46 pts have died (1 from myelodysplasia, 3 from NHL), 35/42 have progressed, and 7 have never progressed without any other treatment than the initial rituximab therapy.

Time to progression was significantly longer in the bcl2-negative population at D50 (p= 0.018, Log-rank). Duration of response was not correlated with bcl2 status at D50, but was associated with ‘Best response CR/Cru’ (p=0.007 Log-rank).

Long-term tolerance was good, with only 13 SAE observed in 13 pts during the additional 4 years of F/Up (4 surgeries for non NHL-related pathologies, 1 node biopsy, 1 sleep apnea syndrome, 1 ischemic cardiopathy, 2 deaths from NHL, 1 depression, 1 pneumonia, 1 erysipela, 1 bronchitis).

This long-term update confirms that a single 4-dose rituximab treatment yields durable benefits without the toxicity of chemotherapy for pts with low burden FL :

Median PFS of 23.5 mths for the cohort, 28.6 mths for responders and 37 mths for pts turning bcl2-negative at D50, 15% of pts have maintained their response after 7 years, (2bis) the quality (CR/Cru) of the initial response was associated with a longer response duration high overall survival is observed with 4 deaths/46 pts (8.6%).
A Retrospective Analysis of 70 Cases of Transient Leukemia (TL) in Neonates with Down Syndrome (DS).
Authors: Muramatsu Hideki , Watanabe Nobuhiro , Matsumoto Kimikazu , Nakamura Tomohiko , Mimaya Junichi , Suzuki Chizuko , Kojima Seiji , Kato Koji
Published: April 2020

Transient Leukemia (TL) occurs in approximately 10% of infants with Down syndrome(DS). Most of cases achieve spontaneous remission, but there are severe, potentially lethal cases which manifest hepatic fibrosis or cardiopulmonary failure. COG reported the incidence of 17% early death in 48 TL cases in DS, but no other large case series reported till now. We retrospectively analyzed Japanese 70 cases of TL in DS to identify the prognostic factors associated with early death. From 1992 to 2006, 46 boys and 24 girls were treated in 14 Japanese institutes. 16 cases (22.9%) were dead in their early life, and 12cases (17.1%) developed AMKL. One patient died with relapsed AMKL, so the overall survival rate was 75.7%. Univariate analysis showed that mechanical ventilation (p=0.001), pulmonary hypertension (p=0.0105), low birth weight (p=0.0063), early gestational age (p=0.0016), low Apgar score at 1min (p=0.0003), low Apgar score at 5min (p=0.0057), high WBC count (p=0.0006), elevated aspartate aminotransferase(AST) (p=0.0004) and elevated direct bilirubin (p<0.0001) are associated with early death of TL in DS. Multivariate proportional hazard model identified gestational age (p=0.0266; RR 0.708) and elevated direct bilirubin (p=0.0487; RR 1.076) as independent prognostic factors. Prospective clinical study is needed to find the optimal therapeutic approach to save neonates with TL who have these poor prognostic factors.
Leukocyte Alkaline Phosphatase Score in Myelodysplastic Syndrome: A Comparison of Patients with Normal and Abnormal Proportions of Bone Marrow Blasts.
Authors: Lipshitz Jay , Tafel Natalie , Patel Dilip
Published: April 2020

The expression of leukocyte alkaline phosphatase (LAP) in neutrophils has been shown to be reduced in some patients with myelodysplastic syndrome (MDS), but increased in the refractory anemia (RA) subtype. We performed a retrospective study looking at the LAP scores of 14 patients with MDS. Patients were grouped according to bone marrow blast percentage. Those with less than 5% blasts in the marrow (refractory anemia and refractory anemia with ringed sideroblasts) comprised one group (n=7) and those with 5% to 19% blasts (refractory anemia with excess blasts) comprised a second group (n=7). LAP scores in the group with fewer than 5% blasts were significantly higher (range 71 to 116, mean 93.6) than LAP scores in the 5%–19% group (range 2 to 46, mean 26.6) (p<0.0001). Our results suggest that LAP score may correlate with disease severity in MDS. If this finding is confirmed in larger prospective studies then LAP score may be a useful, relatively non-invasive aide in assessing the course and progression of myelodysplastic syndrome.

LAP Scores for Patients 1 through 7 in the Groups “Marrow Blasts <5%” and “Marrow Blasts 5%–19%” 1 2 3 4 5 6 7 The LAP scores of the two groups differed significantly (p<0.0001). The mean for the “Blasts<5%” group was 93.6 (SD=16.9), and the mean of the “Blasts 5%–19%” group was 26.6 (SD=7.1). There was no crossover between groups, in that the lowest LAP score in the <5% group was 25 points higher than the highest LAP score in the 5%–19% group. Blasts < 5% 91 76 88 103 116 71 90 Blasts 5%–19% 16 45 30 42 5 2 46
Automated Neutrophil Morphology and Its Utility in the Assessment of Neutrophil Dysplasia and in the Diagnosis of Myelodysplastic Syndromes.
Authors: Miguel Amparo , Orero Maite , Collado Rosa , Perez Pedro L. , Pacios Alejandro , Carbonell Felix
Published: April 2020

The assessment of neutrophil dysplasia is very useful for the diagnosis of the Myelodysplastic Syndromes (MDS), and the common accepted method for that purpose is the microscopic examination of blood and/or bone marrow smears. But one of the problems in the daily practice, is the lack of reproducibility between the different observers, and technical problems, like the time of the stain, quality of the stain, including quality of the reagents and time of the smear after blood draw. The last advanced hematology instruments, like the Coulter LH750®, provide, together with the report of the WBC differential, automated morphological data about some of the different types of leukocytes: Neutrophils, Lymphocytes, Monocytes and Eosinophils. This Research Data (RPD), gives information about the Mean and Standard deviation of the Cell Volume, Conductivity, and Scatter using a technology called VCS technology. We have collected 53 patients affected of MDS, and 18 affected with Chronic Myelomonocytic Leukemia (CMML) and we compared the leukocyte automated leukocyte morphological data (WRPD) of the patients with the WRPD of 59 normal persons. One of the modifications in the actual WHO classifications is the differentiation between CMML with or without dysplasia and Mylodysplastic Syndromes with or without trilineage dysplasia, that also affect the prognosis. We have checked also these new parameters for this purpose. The results have shown: The Mean Neutrophil Scatter (MNES) and Mean Neutrophil Conductivity (MNEC) was significant lower in the MDS compared with the normal (both p<0.0001) the ROC curve analysis show a Sensitivity of 71.8% with a Specificity of 86.4% and a cut off of < 139.3 for the MNESand a Sensitivity of 70.4% with a Specificity of 76.3% and a cut off of < 150.9 for the MNECdetecting MDS. For the differentiation of MDS and CMML with or without dysplasia the results have shown a significant difference p = 0.02 in the MNESbetween CMML-1 and CMML-2 and MDS with or without trilineage dysplasia. The changes in the Neutrophil Scatter and in the Neutrophil Conductivity (lower values) correlates with the dysplastic feature neutrophil degranulation observed in the microscope.

Conclussion: MNEC and MNES seem to be useful in the detection of neutrophil dysplasia and helpful in the diagnosis of MDS.

Figure Figure
Coexistence of a Heterozygous JAK2(V617F) Mutation and a Secondary BCR-ABL Translocation within the Compartment of Committed Myeloid Progenitors in Chronic Idiopathic Myelofibrosis.
Authors: Bornhaeuser Martin , Mohr Brigitte , Oelschlaegel Uta , Bornhauser Peter , Jacki Swen , Ehninger Gerhard , Thiede Christian
Published: April 2020

Myeloproliferative disorders such as polycythemia vera (PV), essential thrombocytosis (ET) and chronic idiopathic myelofibrosis (CIMF) are clonal hematopoietic diseases with clinical similarities including the risk of transformation into acute myelogeneous leukemia. By definition, these diseases have been separated from Philadelphia chromosome positive (Ph+) CML requiring negativity for the BCR-ABL transcript in PCR studies of bone marrow or peripheral blood. Several groups independently discovered a gain of function mutation of the Janus kinase 2 (JAK2) gene in Ph-negative myeloproliferative diseases. This mutation has been associated with the proliferation of clonogenic progenitors independently of exogenous cytokine stimulation. A sixty-six year old male patient presented with moderate splenomegaly (3 cm under the costal marigin), mild anemia (11.3 g/dl), elevated lactate deyhdrogenase, an increased count of circulating CD34+ cells and a dry bone marrow aspirate. Marrow histology confirmed a prefibrotic stage of chronic idiopathic myelofibrosis (CIMF). Metaphase cytogenetics as well as BCR-ABL FISH were performed on samples from bone marrow, blood and sorted CD34+, CD3+, CD19+ and CD14+ cells from a steady-state back-up leukapheresis. The JAK2(V617F) mutation was confirmed by an allele-specific PCR assay. A screen for BCR-ABL was performed by FISH and PCR in sorted cells as well as in individual colonies (CFU-GM and CFU-E).

Four Philadelphia-chromosome positive metaphases could be detected out of 86 derived from the autologous leukapheresis product harvested and cryopreserved as back-up shortly after diagnosis. The BCR-ABL translocation could be detected by fluorescence in-situ hybridisation (FISH) in 2/16 (12.5%) isolated granulocyte/macrophage colonies only whereas all erythroid colonies were negative. The JAK2 mutation was detectable in all clones and was enriched in CD34+ selected cells. The patient experienced progressive splenomegaly despite the achievement of a molecular response measured by quantitative BCR-ABL PCR after treatment with imatinib mesylate.

Our in-vitro investigations suggest that the secondary BCR-ABL translocation within the myeloid compartment was of minor pathophysiological relevance in this patient with CIMF harbouring a heterozygous JAK2 mutation.