bluuebunny/crossref_metadata_2025 huggingface dataset:
Dose-Intensified Combined Modality Treatment with 2 Cycles of BEACOPP Escalated Followed by 2 Cycles of ABVD and Involved Field Radiotherapy (IF-RT) Is Superior to 4 Cycles of ABVD and IFRT in Patients with Early Unfavourable Hodgkin Lymphoma (HL): An Analysis of the German Hodgkin Study Group (GHSG) HD14 Trial
Authors: Borchmann Peter , Engert Andreas , Pluetschow Annette , Fuchs Michael , Markova Jana , Lohri Andreas , Kral Zdenek , Greil Richard , Topp Max , Villalobos Matthias , Zijlstra Jose , Soekler Martin , Stein Harald , Eich Hans Theodor , Mueller Rolf Peter , Diehl Volker
Published: April 2020

Purpose: Combined modality treatment consisting of 4 cycles of chemotherapy and IF-RT is the standard treatment for early unfavourable HL. Overall survival (OS) and freedom from treatment failure (FFTF) in this group of patients was 91% and 83%, respectively, at 5 years in our prior HD8 study. Thus, the rationale for HD14 was to improve on these results by increasing dose intensity using BEACOPP escalated.

Methods: Between January 2003 and January 2007, 1.216 patients aged 16–60 with untreated early unfavourable stage HL (CS I, IIA with one of the following risk factors: large mediastinal mass (a), extranodal disease (b), elevated ESR (c), or ≥ 3 nodal areas (d); IIB with risk factors c and d) were randomized to either 4 cycles of ABVD (arm A) or 2x BEACOPP escalated followed by 2x ABVD (arm B). All patients received 30Gy IF-RT after chemotherapy. Primary objective was the improvement of the FFTF. Here we present the results of the predefined 3rd interim analysis within the prespecified group sequential test design.

Results: Of the 1.216 patients included, 1.010 were evaluable for this analysis. Patient characteristics were well balanced between both arms. At 3 years, the FFTF for arm A is 90% (95% CI: 87%–93%), and for arm B 96% (95% CI: 94%–98%). Since the observed inverse normal test statistic exceeds the critical level, the null hypothesis of equal FFTF in each arm can already be rejected. The improved FFTF is mainly due to differences in progression and early relapses (arm A 5.9% versus arm B 1.8%). Protocol adherence for chemotherapy was high and not different in both arms (arm A 98.8%, am B 97.3%). Though the chemotherapy-intensity was higher in the experimental arm, safety was comparable to the standard treatment. Secondary neoplasias occurred in 8 patients in each arm so far.

Conclusion: Based on the significantly superior FFTF of the intensified therapy (2x BEACOPP escalated + 2x ABVD + IF-RT) compared to the prior standard (4x ABVD + IF-RT), this more aggressive treatment strategy will become the new standard for early unfavourable HL patients within the GHSG. Whether the improved FFTF translates into an improved overall survival must be awaited. Future strategies should aim at identification of those patient subgroups that profit most from this approach.
Pharmacological Inhibition of NF-KB Underpins the Strong Synergy Between LC-1 and Fludarabine in Chronic Lymphocytic Leukaemia Cells
Authors: Hewamana Saman , Lin Thet Thet , Fegan Chris , Knapper Steven , Burnett Alan , Brennan Paul , Rowntree Clare , Pepper Chris
Published: April 2020

Chronic lymphocytic leukaemia (CLL) is incurable with conventional chemotherapy and all currently available agents eventually fail because of drug resistance or unacceptable toxicities. We have recently shown that the novel NF-κB inhibitor LC-1 is effective in primary CLL cells and is capable of overcoming drug resistance. In this study, we elucidated the mechanism of action of LC-1, evaluated its relative cytotoxicity in prognostic subsets (n=96) and investigated its potential synergistic interaction with fludarabine (n=26). LC-1 induced cell death was associated with caspase-3 activation that was mediated via the upstream activation of both caspase-8 and caspsase-9. Apoptosis was preceded by a reduction in nuclear Rel A DNA binding and down regulation of the anti-apoptotic NF-κB target genes CFLAR, BIRC5 and BCL2. Importantly, LC-1 was able to overcome the cytoprotective effects by IL-4 and CD40 ligand indicating that it would retain its potency in vivo even in the solid tissue micro-environment. LC-1 was equally effective in CLL cells derived from good and bad prognostic subsets and exhibited strong synergy with fludarabine (mean combination index 0.26). The combination produced a highly significant mean dose reduction index of >1000 that would facilitate a theoretical 3 log reduction in the standard clinical dose of fludarabine. Taken together our data confirm the therapeutic potential of LC-1 both as a single agent and in combination with fludarabine and provide a compelling rationale for early clinical trials of this agent in CLL patients.
Inhibited Maturation of Ter119+CD71+ Erythroid Precursors in Mice with Chronic Sterile Abscess.
Authors: Prince Olivier D. , Prince Ian C. , Walston Jeremy , Andrews Nancy C. , Civin Curt I. , Roy Cindy N.
Published: April 2020

Anemia associated with inflammation or chronic disease (AICD) is a mild, normocytic, normochromic anemia that is additionally characterized by a blunted response of erythroid precursors to erythropoietin, decreased erythrocyte survival, adequate or increased iron in macrophages, and low serum iron. AICD is classically associated with chronic disease states that generate systemic inflammatory mediators, including rheumatoid arthritis, infections, severe trauma, congestive heart failure, chronic renal failure, and cancer. Many laboratory animal models of AICD have been developed based on relatively short periods of inflammation (less than 24 hours) and resulting hypoferremia. To investigate the anemia associated with chronic inflammation, we induced experimental chronic sterile abscess in C57BL/6 mice. Three weeks of abscess resulted in a mild anemia similar to that of mice with chronic over-expression of the hepcidin (hepc) transgene, but additionally characterized by moderately elevated interleukin-6 production. We previously found hepc transgenic mice have significantly reduced serum iron and non-heme liver iron concentrations, but we found no significant reduction in serum iron concentration or liver non-heme iron stores in mice with abscess at this time point. To better understand changes in erythroid precursor development in the sterile abscess model, we analyzed markers of erythroid maturation in mouse bone marrow. Flow cytometric analysis of bone marrow erythroid progenitor-precursors revealed elevated mean CD71 expression in Ter119+CD71+ precursors from mice with sterile abscess as compared to controls. This result suggests a greater proportion of Ter119+CD71+ precursors are less mature in mice with abscess. These data support the hypothesis that chronic inflammation may continue to inhibit maturation of erythroid precursors even after iron sequestration is relieved. Mice with sterile abscess are a valuable in vivo model for assessment of the various regulatory systems contributing to AICD.
Phosphatidic Acid Enhances Procoagulant Activity and Thrombosis through Phosphatidylserine Exposure in Human Erythrocytes.
Authors: Noh Ji-Yoon , Lim Kyung-Min , Chung Jin-Ho
Published: April 2020

The increased phospholipase D (PLD) activity and phosphatidic acid (PA) level are frequently observed in various disease states including cancers, diabetes, inflammation, sepsis, and thrombosis. While PA has been previously regarded as a precursor for lysophosphatidic acid (LPA) and diacylglycerol (DAG), increasing evidence suggests the biological activities of PA, itself. Here we demonstrated that the PA can enhance procoagulant activities in human erythrocytes and thrombus formation mediated through phosphatidylserine (PS) exposure. Conspicuously, the PS exposure by PA was substantially greater than that of LPA and we examined its mechanism of action in an effort to elucidate the biological significance of PA. In human erythrocytes, PA treatment resulted in PS exposure without microvesicle generation or hemolysis as determined by flow cytometry. These effects were not attenuated by inhibitors of phospholipase A2 and phosphatidate phosphatase, that convert PA to LPA and DAG, respectively, suggesting that PA directly induced PS exposure. PA exposed erythrocytes showed significantly high intracellular calcium level and resultant protein kinase C (PKC) a activation. Consistent with these findings, the activity of scramblase was enhanced by PA treatment, while that of flippase was inhibited. Furthermore, PA-exposed erythrocytes were aggregated, accelerated thrombin generation, and increased adherence to endothelial cells, implying PA treatment enhanced the thrombogenic activities of erythrocytes indeed. Of note, these procoagulant activations by PA were confirmed in rat in vivo venous thrombosis model. These results suggest that PA can contribute to enhanced thrombosis, mediated through PS exposure on erythrocytes. With this study, we believe a novel insight was given into the role of PA in cardiovascular diseases.
Varialibility of Neurological Complications in the Treatment of Acute Lymphoblastic Leukemia:Experience of a Single Pediatric Institution
Authors: Parasole Rosanna , Petruzziello Fara , Marra Nicoletta , Marchese Luciano , Mangione Argia , Cianciulli Ernesto , Menna Giuseppe , Misuraca Aldo , Poggi Vincenzo
Published: April 2020

Intensive chemotherapy significantly improves the outcome of pediatric acute lymphoblastic leukemia (ALL) but unfortunately increases the incidence and severity of acute adverse events. The current study analyses the incidence of central nervous system (CNS) complications during ALL treatment in a single pediatric institution. CNS leukemic infiltration at diagnosis, therapy-related peripheral neuropathy and leukoencephalopathy and neurocognitive defects after treatment were excluded by the study. From September 2000 to July 2008, two hundred and forty ALL patients (pts) were treated in our Institution according to BFM-AIEOP ALL 2000 protocol. Twenty-four out of 240 patients (10 %) (15 females and 9 males, median age at the event 7.7 years, range 2–16 years) developed CNS complications during treatment. Thirteen presented tonic-clonic seizures, four showed dyskinesia and dyslalia, one presented visual impairment and enuresis, and six had loss of consciousness. In 18 pts a rapid resolution of the event was obtained by administration of benzodiazepines or barbiturates; 6 pts required admission in intensive care unit, instead. Only two out of twenty-four patients presented neurological sequelae (one pts with recurrent seizures and one pts with right limb disability). Co-morbidity at the time of neurological accident included: blood pressure increase (6 pts), electrolytes imbalance (4 pts), LDH increase (4 pts), coagulation disorders (6 pts), hepatic enzyme increase (2 pts), severe anemia (1 pts), severe thrombocytopenia (4 pts), renal failure (1 pts), and Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (1 pts). Radiological scanning (either CT or MRI) and electroencephalography (EEG) performed within 48 hr from the onset of the clinical symptoms revealed different etiologies: 8 posterior reversible leukoencephalopathies (PRES), 3 cerebral bleedings, 2 ischemic cerebral diseases, 2 methotrexate toxicity, 1 SIADH, 2 temporal lobe epilepsy and 6 unidentified problems. In conclusion this retrospective study on CNS complications during ALL treatment shows that the most frequent neurological accident (33%) is the PRES.
Analysis of T Cell Cloanlity of Ph+ Acute Lymphoblastic Leukemia with Chronic Gvhd in Continuous Remission after Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Wu Xiuli , Liu Qifa , Li Yangqiu , Chen Shaohua , Du Xuan , Zha Xianfeng , Zhou Shuyun
Published: April 2020

Chronic graft-versus-host disease (cGVHD) is one of the major complications following allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, recent study suggested that the presence of cGVHD might reduce the risk of relapse in Ph+ acute lymphoblastic leukemia (ALL) after allo-HSCT. GVHD is mediated by proliferation of special T-cell clones, we analyzed the T cell receptor (TCR) Vβ repertoire and cloanlity in Ph+ ALL patients undergone cGVHD after allo-HSCT in order to find the special T-cell clones associated with continuous remission.

Allogeneic transplantations were performed in the first complete remission (CR) (6 ALLP190+ patients). The numbers of BCR-ABL copies in peripheral blood samples were assessed with the real-time quantitative RT-PCR (RQ-PCR) test at diagnosis, and every month after HSCT. The quantity of BCR-ABL transcript was normalized for normal ABL expression and the result was expressed as the ratio of BCR-ABL copies to ABL copies. With monitoring BCR-ABL copies of 6 BCR-ABLP190+ ALL patients after HSCT (the mean ratio of BCR-ABLP190/ABL at diagnose was 0.41 ± 0.39%), we found that 4 patients with extensive cutancous cGVHD had no evidence of leukemia recurrence, and the BCRABL transcripts of patients with cGVHD were remaining 0 copy, while 2 patients without cGVHD relapsed (the mean ratio of BCR-ABLP190/ABL was 7.56 ± 2.49%) and even dead within six months of HSCT.

The expression and cloanlity analysis of TCR Vβ repertoire was detected in peripheral blood samples from patients with cGVHD by RT-PCR and genescan technique. TCR Vβ repertoires with polyclonal pattern were identified in normal controls and donor groups. However, the skew expression pattern of TCR Vβ repertoire could be detected in patients with cGVHD even more than 1 year after allo-HSCT. Among the 24 Vβ subfamilies, there were only 11~17 Vβ subfamilies expressed in cGVHD patients. Oligoclonal or monoclonal expanded T cells were identified in TCR Vβ 1, 2, 3, 7, 8, 12, 14, 16~20, 22 and 23 subfamilies in 4 ALL patients (BCR-ABLP190 remission) with cGVHD. As a contrast, oligoclonal or monoclonal expanded T cells were identified in TCR Vβ 2, 7, 8, 14, 17, 20, and 22 subfamilies in 2 chronic myeloid leukemia patients (BCR-ABLP210 remission) with cGVHD.

In conclusion, the predominant usage and clonal expansion of TCR Vβ subfamily T cells could be found in Ph+ ALL patients with cGVHD and these groups of specific T-cell clones (Vβ 1, 3, 12, 16, 18, 19 and 23) were potentially associated with cGVHD in ALL and might be responsible for maintaining CR in Ph+ ALL patients after allo-HSCT. Research Funding.
Results of the Hyper-CVAD Regimen in Elderly Acute Lymphocytic Leukemia (ALL)
Authors: O’Brien Susan , Thomas Deborah , Ravandi-Kashani Farhad , Faderl Stefan , Pierce Sherry , Kantarjian Hagop
Published: April 2020

Background. Understanding the causes of failure in older patients with ALL may help improve treatment strategies for this age group.

Study Aims. To define the causes of death in older (age ≥60 years) patients with ALL during induction and consolidation-maintenance with the dose intensive Hyper-CVAD regimen, and compare their outcome to those of older patients treated previously with less intensive regimens, and to those of younger patients treated with Hyper-CVAD.

Study Groups. 122 older patients treated with Hyper-CVAD were compared with 34 older patients treated with less intensive regimens, and 409 younger patients treated with Hyper-CVAD.

Results. The outcome in older patients on Hyper-CVAD, older patients on other regimens, and younger patients on Hyper-CVAD are shown in the Table.

Conclusion. Intensifying the chemotherapy in older patients with ALL reduced the incidence of leukemia resistance but increased the incidence of death in CR from myelosuppression-associated infections. The overall benefit: risk was favorable. Identifying novel low-intensity agents/regimens for older patients with ALL may improve the results.

Parameter Older; Hyper CVAD Older; Other Younger; Hyper CVAD P value Most deaths during induction and in CR were related to infections Number 122 34 409 % CR 84 59 92 <0.001 % Induction mortality 10 12 2 NS for older % Resistance 5 27 2 <0.001 % Death in CR 34 15 7 <0.001 % Relapse 40 80 48 0.004 % 5-year survival 20 9 48 <0.001
Single-Institution Experience with HyperC-VAD Protocol for Adult Acute Lymphoblastic Leukemia
Authors: Costa Maria Joao , Santos-Sousa Pedro Miguel A , Guerra Maria Lurdes , Gomez Maria Belén , Lopes Conceição , Esteves Graça , Fajardo José , Raposo João , d’Oliveira José João Gomes
Published: April 2020

Acute lymphoblastic leukemia (ALL) is much rarer in adult age than in childhood, accounting for less than a quarter of acute leukemias, and with an overall survival rate at 5 years below 38%. The authors report the group experience in the treatment of adult ALL with HyperC-VAD protocol. From 2004 to 2007, 21 patients with adult ALL (15 male/6 female), with a median age at diagnosis of 29 years [18;58], were treated: four with ALL-L3/Burkitt lymphoma, six with T cell ALL/lymphoblastic lymphoma, eight with B cell ALL/lymphoblastic lymphoma, and three with ALL with t(9;22). The protocol consists of 4 courses of HyperC-VAD (cyclophosphamide 300mg/m2 IV q12h, on days 1–3; vincristine 2mg IV qd, on days 4 and 11; doxorubicin 50mg/m2 IV, on day 4; dexamethasone 40mg IV/PO qd, on days 1–4 and 11–14) that alternate with 4 courses of HD MTX-ARAC (methotrexate 1g/m2 IV, on day 1; cytarabine 3g/m2 IV q12h, on days 2–3). Those patients with ALL with t(9;22) received imatinib 400mg IV qd, on days 1–14 of each course; and CD20-positive cases received rituximab 375mg/m2 IV qd, on days 1 and 11 (odd courses) or on days 1 and 8 (even courses) of the first 4 courses. All patients received central nervous system prophylaxis in each course with methotrexate 12mg intrathecal on day 2 and cytarabine 100mg intrathecal on day 8. All patients (21/21) achieved complete remission after the first course of chemotherapy. Two patients abandoned the protocol due to neurologic and hematologic toxicity. The relapse rate was 47.6% (10/21), and the overall survival was 61.9% (13/21) – all deaths were due to disease progression. Overall, 131 courses were completed (69 odd courses/62 even courses). The most frequent complication was febrile neutropenia (32.8% - 18 in odd courses; 25 in even courses). The most severe complications were gram-negative septic shock (2 in even courses) and severe axonal polyneuropathy (1 in an odd course; 1 in an even course). Although these results are consistent with the literature, a longer follow up is needed to draw definitive conclusions.
Potential Role of Heme Oxygenase-1 in Arsenic Trioxide and Hemin-Mediated Differentiation of Human Promyelocytic Leukemia Cells
Authors: Yang Casey , Beckman Joan D , Schmidt Thomas E , Nguyen Julia , Belcher John D , Vercellotti Gregory M.
Published: April 2020

Acute promyelocytic leukemia (APL) is a myeloid-derived leukemia characterized by a block of differentiation at the promyelocytic stage of development. APL is associated with a reciprocal translocation of chromosomes 15 and 17 involving the retinoic acid receptor-alpha (RARα) locus and the promyelocytic leukemia locus (PML) forming a new fusion gene, PML/RARα. The fusion protein prevents the cells from differentiating by repressing transcription of target genes necessary for differentiation. Therapy with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) have improved the clinical outcomes in APL. ATRA differentiates APL cells by promoting degradation of PML/RARα and relieving transcriptional repression. ATO induces apoptosis and differentiation of APL cells through separate pathways involving activation of apoptotic pathways and degradation of the PML/RARα protein. The heme-catabolizing protein heme oxygenase-1 (HO-1) which produces carbon monoxide, biliverdin/bilirubin and releases Fe/ferritin can be cytoprotective and anti-apoptotic. HO-1 message and protein are markedly upregulated in response to hemin. ATO also can induce HO-1 expression and has been shown to induce differentiation of leukemic cells. We hypothesize that induction of HO-1 mediates APL differentiation in response to ATO and hemin. We utilized a human APL cell line, NB4, to test our hypothesis in vitro using NBT reduction to assess cell differentiation. ATRA (p < 0.005 at both 72 and 96 hours), ATO (p < 0.005 at 72 hours, and p < 0.05 at 96 hours), and hemin (p < 0.05 at both 72 and 96 hours, n=3) were shown to differentiate NB4 cells compared to untreated groups. RT-PCR indicated HO-1 expression increased in response to ATRA, ATO, and hemin, while biliverdin reductase (BVR), a signaling protein that degrades biliverdin to bilirubin, was only induced by hemin. Inhibition of HO-1 activity with tin-protoporphyrin significantly (p<0.05, n=2) blocked differentiation induced by ATO but had no effect on ATRA–treated cells. We speculate that HO-1 and its downstream metabolic products play critical roles in ATO-induced differentiation of APL cells.
Acute Myeloid Leukemia in Adolescents and Young Adults (AYA): The MD Anderson Cancer Center (MDACC) Experience
Authors: Pemmaraju Naveen , Kantarjian Hagop M. , Ravandi Farhad , O’Brien Susan , Wierda William G. , Thomas Deborah A. , Garcia-Manero Guillermo , Borthakur Gautam , Pierce Sherry , Cortes Jorge
Published: April 2020

Background: Acute myeloid leukemia (AML) is a heterogeneous group of hematopoietic neoplasms demonstrating clonal proliferation of myeloid precursors and is typically a disease of older adults. In acute lymphoblastic leukemia (ALL) adolescent and young adult (AYA) patients (pts) have a distinct outcome, possibly influenced by type of therapy (i.e., usually better with more intensive regimens). There is little information about outcome of AML in AYA.

Aims: To define the characteristics and outcome of AYA pts with AML treated at MDACC.

Methods: We retrospectively analyzed the data of all pts with AML treated at MDACC from 1965 to 2008. Those aged 16 to 21 years were defined as AYA.

Results: Among 3934 adult pts seen during this period, 163 (4%) were AYA. The median age was 19 yrs. These included 27 (17%) pts with Core Binding Factor (CBF)-AML [inv(16), t (8:21)]and 19 pts (12%) with acute promyelocytic leukemia (APL). Among other evaluable pts, 50% had diploid cytogenetics, 39% miscellaneous changes, and 11% 5-and/or 7- abnormalities. Antecedent hematologic disorders were present in 33 (20%) and AML was a secondary malignancy in 6%. Among 20 evaluable pts, FLT3 ITD was documented in 4 and mutation in 2. CR rates were 89% for CBF AML, 79% for APL, and 75% for all others. The median survival for the total group was 88 weeks (wks) with 36% alive at 3 yrs, and median CR duration of 67 wks (30% CR at 3 yrs). Outcome is better for pts with CBF leukemias (3-yr survival 56%, CR duration 49%) and APL (3-yr survival 51%, CR duration 36%) compared to other AML (3-yr survival 28%, CR duration 24%). CR rates have improved from 71% in 1965–84, to 85% in 1985–94 and 83% after 1994. Similarly, overall survival (OS) has increased during the same time periods (3-yr survival 18%, 44%, and 53%, respectively) together with CR duration (3-yr CR duration 21%, 32% and 39%, respectively) as early mortality has decreased (11%, 8%, and 4%, respectively). To compare outcome with older adults, we focused on those with diploid cytogenetics (Table 1):

Percentage by age group Outcome 16–21 22–45 46–60 >60 CR 81 75 68 54 Induction mortality 2 11 13 24 3-year survival 46 36 28 16 3-year remission duration 39 32 30 22

Conclusion: The outcome of AYA pts with AML is significantly better than that of older adults with AML. Despite these improvements over time, there is still significant room for improvement in this area, particularly among those with AML other than CBF and APL. Exploration of new treatment options is needed in this patient population.
Systemic Delivery of Nanoliposomal Ceramide Displays Anti-Leukemic Activity in a Rat Model of Large Granular Lymphocytic Leukemia
Authors: Liu Xin , Ryland Lindsay , Yang Jun , Aliaga Cesar , Kaiser James , Zhang Ranran , Thomas Kendall , Jarbadan Ruth Nancy , Hughes Joseph , Kester Mark , Loughran Thomas P.
Published: April 2020

We have previously demonstrated that enhanced survival rather than increased proliferation accounts for the accumulation of natural killer (NK) cells in large granular lymphocyte (LGL) leukemia patients. To further elucidate the mechanism by which NK survival is enhanced, we analyzed leukemic NK cells isolated either from patient peripheral blood or rat splenic cells for altered expression of members of the inhibitor of apoptosis protein (IAP) family, which act as suppressors of apoptosis in a variety of human solid tumors and hematological malignancies. We now report that the IAP, survivin, was highly expressed in NK cells. In contrast, survivin was barely detectable in NK cells from the blood of normal human donors or the splenic cells from normal rats. We next asked if the lipid-derived second messenger, ceramide, which selectively induces apoptosis in cancer cells would diminish survivin protein expression. Treatment of NKL, a human NK-LGL leukemia cell line, or RNK-16, a rat NK-LGL leukemia cell line, with the cell-permeable, short-chain C6-ceramide (C6) in a pegylated liposomal formulation, led to cell apoptosis and diminished survivin protein expression, in a time and dose dependent manner. We next extended these in vitro studies to an in vivo rat model of NK-LGL leukemia. Systemic i.v. delivery of liposomal ceramide displayed significant anti-leukemia activity in a syngeneic Fischer F344 rat NK-LGL leukemia model that exhibits clonal expansion of CD3-CD8a+ lymphocytes. Over a 6-week treatment period, a well-tolerated dose of 40 mg/kg liposomal-C6, three times a week, elicited a 3 to 10- fold reduction in the weight of various lymphoid and non-lymphoid organs, compared with liposomal formulations that did not contain ceramide (ghost). Untreated or ghost-treated leukemic rats presented with lymphocytosis (LGL counts between 2 × 1011 and 3.5 × 1011/L), anemia and thrombocytopenia. Furthermore, the percentage of NK LGL cells, defined as CD3-CD8a+ by flow cytometry, was drastically elevated in the spleen, lymph node, thymus, bone marrow, blood, liver and lung in these leukemic rats, compared with their normal counterparts. In contrast, leukemic rats treated with liposomal ceramide had undetectable LGL cells in the blood and normal counts of red blood cells and platelets. Additionally, the CD3-CD8a+ NK cells in spleen, thymus and liver were found to be remarkably decreased, whereas the NK cells in bone marrow, blood and lung were within normal range. Collectively, these results indicate that bioactive ceramide analogues can be incorporated into pegylated liposomal vehicles for anti-leukemic efficacy in a rat model of NK LGL leukemia, possibly via decreased survivin expression or signaling.
Therapeutic Potential of Small Molecule Inhibitor of Wnt Signaling in Acute Myelogenous Leukemia
Authors: Briaud Isabelle , Tenzin Fnu , Chun Jae Kwang , Oh Se-Woong , Chung Jae Uk , Jung Kyung Yun , Jeong Min Wook , Cha Joo Young , Pyon Younghee , Lee Donghee , Jung Ji Eun , Emami Katayoon H.
Published: April 2020

Wnt signaling pathway controls various cellular and developmental processes. Deregulation of this pathway, in a wide range of human solid tumors, has been well established. However, less is known about its role in etiology of hematological cancers. Some characteristics of acute myelogenous leukemia (AML) cells such as inappropriate proliferation in the absence of normal growth signals and indefinite self-renewal similar to a stem cell are thought to be due to mutations in β-catenin, the hallmark of canonical Wnt pathway, and/or activation of Wnt pathway by fusion transcription factors. For therapeutic purposes, we have screened a peptidomimetic, β-turn library of small molecules for an inhibitor of Wnt pathway. Through massive chemical modifications the lead compound CWP231904 was selected. CWP231904 showed good inhibitory activity in the Reporter Gene Assay (RGA) on Topflash promoter in SW480 and HEK293 cells. Wnt target genes, survivin and c-myc were both down regulated upon CWP231904 treatments at the level of RNA and protein in MV4-11 and HL-60 AML cells. CWP231904 treatments of both cell lines induce cleavage of caspase-3, -8, and -9 by apoptotic signals. Propidium Iodide staining of these cells show dramatic increase in Apoptotic Index. CWP231904 treatment of MV4- 11 and HL-60 cells led to degradation of β-catenin in both cell lines. Proteasome inhibitor, MG132, prevented the CWP231904 induced degradation of β-catenin in MV4-11 cells. In order to unravel the mode of action of CWP231904, we utilized Wnt3a conditioned media (CM) or an overexpressed, Estradiol (ER) inducible Dishevelled plasmid (ER-DVL-2) to activate Wnt signaling in HEK293 cell line. Immunoblotting of HEK293 cells induced with ER and treated with CWP231904 showed a nuclear migration of the phosphorylated form of DVL-2 in treated cells. Thus, our data suggest that CWP231904 targets β-catenin degradation by relocating DVL-2 from cytoplasm where it makes puncta and inactivates GSK-3β containing destruction box complex into the nucleus. Moreover, CWP231904 treatment of HEK293 cells growing in Wnt3a CM lowered the inhibitory phosphorylation of GSK3-β on Serine9 which is induced upon Wnt activation, thereby keeping GSK3-β in its active form to phosphorylate β-catenin and signal it for degradation. CWP231904 significantly reduced tumor growth in MV4-11, HL-60 and MOLM-13 xenograft models, significantly increased the life span of the SCID mice, and decreased the number of CD45+ AML cells in the bone marrow after engraftment of MV4-11 cells via intravenous injection withoutdetectable toxicity. Together, these results suggest that CWP231904 has therapeutic potential for the treatment of AML disease by inhibiting Wnt signaling pathway through destabilization of β-catenin.
Acute Myelogenous Leukemia in the Elderly. Intensive Induction Chemotherapy Improves Survival
Authors: Sharma Anant , Shi Runhua , Turturro Francesco
Published: April 2020

Acute Myeloid Leukemia (AML) in the elderly has poor prognoses and carries inferior results with therapy. The purpose of this study was to determine the incidence of elderly AML, examine clinical outcomes with treatment and investigate the impact of intensive induction chemotherapy and other variables such as such as age, leucocytoses, cytogenetics and presence of antecedent hematologic disorder (AHD) on survival, in a cohort of elderly patients with AML treated at our institution.

Patients and Methods: The retrospective review included all patients (age>59) treated between January 1999 and February 2008. Patients diagnosed with acute promyelocytic leukemia were excluded. Records were reviewed from time of diagnoses till death or last follow-up.

Statistical analyses: Median survival was calculated using Kaplan Meier method and differences in survival between patients treated with intensive chemotherapy and those receiving supportive care were compared using the logrank test which was also used to determine the association between survival and variables such as older age (<69 vs. ≥ 69), leucocytoses (WBC >10k), cytogenetics and history of AHD.

Results: Study cohort included 51 patients with age>59. This represented 29% of all AML cases (n=176) treated at our institution. 31(60.78%) were males. Mean age was 68.42 years, range (60–82) with 23 (45.10%) being >69 years of age. History of AHD was observed in 15 (29.41%). Results of cytogenetic studies were available for 29(56.86%) patients of which 11(37.93%) had poor risk cytogenetics with the remainder falling in the intermediate risk group. Elevated WBC count was seen in 25(49.02%). Intensive induction chemotherapy was administered with an anthracycline and cytarabine regimen to 42(82.35%) patients with an induction mortality of 26%. Total of 23 (54.76%) patients achieved first complete remission (CR1). Of those who achieved CR1, 19(82.60%) underwent consolidation. Median survival was 120 days, range (1–2035). By univariate analyses, survival was not affected by older age (p=0.98), poor cytogenetics (p=0.23) or history of AHD (p=0.59), but was affected by induction chemotherapy (p=0.0001), ability to achieve CR1 (p=0.0001) and elevated WBC (p=0.05). In multivariate analyses after adjusting for other variables risk of death was influenced by ability to achieve CR1 (HR 0.146), AHD (HR=2.66) and elevated WBC count (HR=2.48).

Conclusion: Elderly AML has poor clinical outcomes. Risk of death is reduced by intensive induction chemotherapy and achievement of CR1. It is increased by history of AHD and elevated WBC at presentation.
Mitoxantrone, Etoposide, and Intermediate-Dose Cytarabine in the Treatment of Refractory/Relapsed Acute Myeloid Leukemia : Single-Center Experience
Authors: Sung Hwa Jung , Kim Eui Bae , Lee Se Ryeon , Seo Hee Yun , Park Kyong Hwa , Choi In keun , Oh Sang Chul , Choi Chul Won , Kim Byung Soo , Kim Yeul Hong , Kim Jun Suk
Published: April 2020

Background: The results of salvage chemotherapy for patient with refractory or relapsed acute myeloid leukemia(AML) have been generally disappointing with low response rates and occasional long-term survivors in most studies. Since therapeutic failure seems to be inevitable in the great majority of these patients, development of more effective salvage therapy is warranted. Recent approaches to the treatment of previously treated AML generally involved the use of cytarabine in intermediate or high-dose alone or in association with new intercalating agents, such as amsacrine, mitoxantrone or idarubicin, etoposide, or asparaginase.

Methods: A single course of mitoxantrone 6 mg/m2 intravenous (IV) bolus, etoposide 80 mg/m2 IV for 1 hour, and cytarabine (Ara-C) 1g/m2 IV for 6 hours daily for 6 days (MEC), has been proposed as a salvage regimen. Between October 1998 and May 2005, thirty refractory/relapsed AML patients have been treated by MEC salvage chemotherapy. Twenty two patients were in relapse and eight patients were refractory after conventional induction chemotherapy including cytarabine and idarubicin or mitoxantrone. Two patient were in relapse after allogenous hematopoietic stem cell transplantation(SCT).

Results: Complete remission(CR) was obtained in 12 of 30 patients(40%) and 3 of 30(10%) died during salvage treatment: 2 due to intracranial hemorrhage and 1 due to fungemia sepsis. After CR achievement, 5 patients received consolidation chemotherapy. Two patients with an HLA-identical sibling donor underwent allogeneic SCT, and one patient received autologous SCT. Severe myelosuppression was observed in all patients resulting in fever or documented infections in 90% of patients. Nonhematologic toxicity was minimal. At the time of analysis, 9 of 11 patients who achieved CR have relapsed. Median disease-free survival was 12 months. Median overall survival was 13.5 months. There were only two longterm remitters. Several clinicolaboratory and treatment-related variables were analyzed to determine their prognostic significance for CR achievement, duration of CR, overall survival.

Conclusions: Our results suggest that MEC combination chemotherapy might induce CR in a patient with refractory or relapsed AML, although new agents or new therapeutic strategies should be required for long term remission.
Specific Immune Response Induced by PML-Rarα-hIL-2 Vaccine in BALB/C Mice
Authors: Li Yangqiu , Cen Dongzhi , Zhou Yubing , Yang Lijian , Hu Gang , Chen Shaohua , Lin Chen
Published: April 2020

Specific active immunotherapy with DNA vaccines offers the hope for a natural nontoxic alternative to eradicate minimal residual disease in cancer patients. However, little data are regarding the DNA vaccines in leukemia. Our previous study has successfully developed a vector containing PML-RARα segment fused to human Interleukin- 2 (hIL-2) gene. In the present study, we analyzed the specific immune response by immunization with the recombinant plasmid in BALB/c mice. The recombinant plasmids were injected into BALB/C mice with a total of 200 μg DNA in normal saline at 14-day intervals for three cycles. The plasmid containing the same sequence of PML-RARα segment or hIL-2 gene alone and blank plasmid served as controls. Two weeks after the final DNA boost, the transcription and expression of PML-RARα and hIL-2 in injection site were detected by RT-PCR and immunohistological methods; the specific cytotoxicity of spleen cells from the vaccinated BALB/C mice was detected by LDH release assay; interferon-γ secretion was measured by ELISA; antibodies against human PML-RARα were detected by indirect immunofluorescene analysis (flow cytometry); and T-cell receptor rearrangement excision circles (TRECs) in DNA from mice thymic cells were detected by real-time quantitative RT-PCR (TaqMan), thereby to evaluate the content of naïve T cells. After immunization, the PML-RARα/hIL-2 mRNA and protein could be identified in the injection site of PML-RARα- hIL-2 vaccinated mice. Time dependent antibody production and an increase in INF–γ could be detected in vaccinated mice serum (p<0.05). Specific cytotoxicity on NB4 cells was significantly higher than that from control groups (p=0.012). TRECs level form PML-RARα-hIL-2 vaccine group was significantly higher than that from PML-RARα, hIL-2 vaccine or control groups (p<0.05). In conclusions, the reconstructed PML-RARα plasmids might display the common feature of DNA vaccine, which can induce specific humoral and cellular immune responses in BALB/c mice in vivo and can induce the increase of naïve T cells in mice thymus, it might relate to stronger cellular immune response, it is to our knowledge, the first description on the change of naïve T cells in response to vaccine.
The DNA Crosslinking Agent SJG-136 (SG2000, BN2629) Is Highly Potent in Acute Myeloid Leukaemia and Is Synergistic with Cytarabine
Authors: Walsby Elisabeth J , Burnett Alan , Knapper Steven , Fegan Chris , Pepper Chris
Published: April 2020

Standard treatment of acute myeloid leukemia (AML) results in a median survival of approximately 1 year. However, increased understanding of the complex biology of AML has led to the introduction of more targeted therapies, including gemtuzumab ozogamycin and a number of FLT3 inhibitors, in the expectation that they will improve outcomes in this condition. The future is likely to see combinations of new targeted drugs together with more standard therapies. The challenge will be to identify the optimal combinations for individual patients based on their specific disease markers. SJG-136 (SG2000, BN2629) is a pyrrolo[2,1-c][1,4]benzodiazepine dimer which binds into the minor grove of DNA with a preference for 5′Œ-GATC-3′Œ sequences. The crosslinks that SJG-136 forms are more persistent than those formed by nitrogen mustard agents like melphalan due to their slow rate of repair. We have previously shown that SJG-136 is very potent against primary chronic lymphocytic leukaemia (CLL) cells so we set out to investigate its effect on AML cell lines and primary AML. The AML cell lines, NB4 and HL60, had LD50 values of 5.75nM and 12.10nM respectively following exposure to SJG-136 for 48 hours. Apoptosis induction was dose-dependent, as evidenced by Annexin V/propidium iodide assay and caspase-3 activation assay. Subsequently, primary AML cells from 37 diagnostic samples were isolated and treated with SJG-136 and cytarabine yielding an average LD50 of 19.4nM (±22.8) and 5.7mM (±5.6) respectively. SJG-136 was >100 times more potent than cytarabine in samples derived from the same patients (P< 0.0001). We next investigated the potential for synergy between cytarabine and SJG-136 in the AML cell lines (cytarabine:SJG-136, 100:1). NB4 cells demonstrated a combination index (CI) for the two agents of 0.37 and HL60 cells showed a CI of 0.69 indicating that these two agents were synergistic in the two cells lines under these conditions. The primary AML samples were also tested in vitro for synergy between SJG-136 and cytarabine at the same ratio. In these samples the mean CI was 0.56 (± 0.49) with synergy being demonstrated in 29/37 patient samples. Closer examination of these results showed that the 8 patient samples with a CI greater than 1 were all particularly sensitive to cytarabine as a single agent. Therefore, the increased sensitivity of these patient samples to cytarabine may account for their apparent lack of synergy as calculated by the median effect method. These results indicate that SJG-136 has significant potential as a therapy for AML both as a single agent and in combination with cytarabine.
Unique Pharmacokinetic Self-Potentiation of Idarubicin through Induction of Carbonyl Reducing Enzymes in Contrast to Other Anthracyclines, Pharmacologic and Clinical Study
Authors: Kishi Shinji , Yamashita Taro , Fukushima Toshihiro , Urasaki Yoshimasa , Seo Tamami , Nakamura Toru , Haba Toshihiro , Kamiya Ken-ichi , Murakami Jun , Ueda Mikio , Nakao Shinji , Ueda Takanori
Published: April 2020

Idarubicin (IDA) is one of the key drugs for treating hematological malignancies. Severe myelosuppression is one of the major adverse events of IDA. Interestingly, when IDA is administered in 2 consecutive courses of therapy, IDA tends to exert a stronger bone marrow suppressive effect in the second course compared with the first course while other anthracyclines such as daunorubicin tend to milder suppressive effect in the second course compared with the first course (Wiernik PH et al, Blood, 1992). In order to clarify this unique characteristics, in vivo and in vitro studies regarding the pharmacokinetic behavior were performed. When RLN-B2 (a rat liver cell line) was precultured in the presence of IDA, higher carbonyl reducing enzymes (CREs) activity was observed compared with non-precultured cells, suggesting the anthracycline-reducing enzymes was induced in the cells incubated in the presence of IDA. We examined the in vivo effects of IDA administration on the induction of CREs and subsequent enhanced formation of the 13-OH metabolite, idarubicinol (IDAol) which is more active compared with IDA and has a remarkably long half-life in the blood. The rats (F344) preadministered IDA showed higher enzymatic activity than that from non-preadministered rats (p < 0.05). At 4 hours after IDA administration, the production of IDAol was facilitated in the preadministered group compared with the non preadministered group (p < 0.05). Clinically, the duration of leucopenia was compared between IDA and mitoxantrone, an CREs independent anthraquinone, in combination with enocytabine, 6-mercaptopurine and etoposide. In 2 consecutive therapy, namely remission-induction and first consolidation therapy, in 30 cases of acute myelogenous leukemias, the duration of leucopenia was substantially equal in IDA group while it was substantially shorter in consolidation therapy compared with induction therapy in mitoxantrone group. These results suggest that CREs was induced by IDA pretreatment in vitro and in vivo, resulting in increased IDAol, which could potentiate the myelosuppressive and probably antitumor effects of IDA in contrast to other anthracyclines. This unique PK/PD characteristics of pharmacokinetic self-potentiation could be important in the safe and effective use of IDA in the therapy for hematological malignancies.
Acute Pulmonary Hemorrhage in Patients with Acute Myeloid Leukemia (AML) during Remission Induction Chemotherapy
Authors: Alameri Ali M , Koller Charles Asa , Pierce Sherry , Mattiuzzi Gloria
Published: April 2020

Background: Acute pulmonary hemorrhage is an established complication during remission induction in patients with AML. Its pathogenesis is not well known. Injury to the alveolar capillary endothelium and release of inflammatory cytokines may play a role. The standard management is usually not effective.

Aim: To analyze the course of patients with newly diagnosed AML who develop pulmonary hemorrhage during induction chemotherapy.

Study Group: 1765 patient with AML received frontline therapy from 1998–2005. We analyzed 53 patients (3%) who were admitted to medical intensive care unit due to acute pulmonary hemorrhage.

Results: The incidence of pulmonary hemorrhage was 3%. Outcome by patients characteristic was:

parameters category Total No. Pulmonary Hemorrhage (%) P value Age (years) >60  ≤60 998  767 32  21 3%  3% 0.569 Diagnosis M3  M4-M5  others 109  319  1337 812  33 7%  4%  2% 0.011 Platelet (×109/L) ≥20  <20 1475  290 43  10 3%  3% 0.624 WBC (×109/L) >10  ≤10 653  1112 32  21 5%  2% 0.000 Performance status 0–2  3–4 1662  103 44  9 3%  9% 0.000 Serum CR (mg/dl) <1.5  >1.5 1622  140 46  7 3%  5% 0.150 HGB (g/dl) <8.0  >8.0 872  893 32  21 4%  2% 0.105 Infection No  Yes 1218  494 32  21 3%  3% 0.089

The predictive factors for pulmonary hemorrhage were: leukemia morphology (M3, M4–5), performance status and WBC count. The 8week survival of patients who develop pulmonary hemorrhage was 32%, (median survival days from pulmonary hemorrhage to death is 16 days).

Conclusion: pulmonary hemorrhage is a serious complication of induction therapy in AML. Modalities that reduce its incidence are needed.
Experience with the Combination of a Hypomethylating Agent and Valproic Acid in Pediatric Acute Myelogenous Leukemia
Authors: Rytting Michael , Zweidler-McKay Patrick , Hui Yang , Kantarjian Hagop , Garcia-Manero Guillermo
Published: April 2020

Combination epigenetic therapy consists of the combination of a hypomethylating agent (5-aza-2′-deoxycitidine [decitabine] or 5-azacitidine) with a histone deacetylase (HDAC) inhibitor. We have performed two studies combining either decitabine (n=55) or 5-azacitidine (n=54) with valproic acid (VPA). VPA is a neurotropic agent with weak HDAC inhibitory capacity in the mM range. Both studies were open to children with relapsed or refractory AML age 2 or older. Of the 109 patients, 10 (9%) were considered pediatric patients (pts). Seven patients were treated with a fixed dose of intravenous decitabine (DAC) and escalating doses of VPA, and three patients were treated with 5-azacytidine, VPA and all-trans retinoic acid (ATRA). All of the pediatric pts were refractory to a minimum of two chemotherapy regimens for AML or had multiple relapses of AML. The median age was 17 (range 5–21), 5 (50%) were diploid, and the median WBC at presentation was 3.4 (range 0.9 to 16.3). Five of the 10 pts derived benefit from the combination. In the DAC plus VPA trial, three pts achieved a complete marrow response, defined as a hypocellular marrow with less than 5% blasts without recovery of peripheral counts. An additional pt had a partial response with 6% marrow blasts after therapy and improvement in transfusion requirements. In the 5AZA/VPA/ATRA trial, 1 complete marrow response was observed. No complete remission (CR) was observed. No differences were observed in terms of LINE methylation (measured using a bisulfite pyrosequencing assay) pretreatment in pediatric versus adult patients (44.7% [40–65] pediatric versus 46.3 [37–65] adult, p=0.3) or after therapy with the combination treatment. There was a trend towards higher bound VPA levels in the adult group on days 5 or 7 (median 72 [0–202] in adult versus 32 [2–114], p=0.49). Pediatric pts treated with DAC/VPA had less acetylation compared to adult pts (14% vs 35%) and showed no evidence of mRNA activation of p21. Overall, administration of DAC/VPA or 5AZA/VPA/ATRA was safe with no grade 3 or 4 toxicity and no induction mortality in the pediatric group. Combination epigenetic therapy has potential clinical activity in pediatric pts with highly pre-treated relapsed or refractory AML and should be studied in pediatric specific clinical trials.