bluuebunny/crossref_metadata_2025 huggingface dataset:
Prostate-Apoptosis-Response-Gene-4 Increases Sensitivity to TRAIL-Induced Apoptosis.
Authors: Boehrer Simone , Nowak Daniel , Puccetti Elena , Ruthardt Martin , Sattler Nicole , Trepohl Bettina , Schneider Bernd , Hoelzer Dieter , Mitrou Paris S. , Chow Kai Uwe
Published: April 2020

The capacity of tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) to preferentially induce apoptosis in malignant cells while sparing normal tissues renders it an attractive therapeutic agent. Nevertheless, the molecular determinants governing sensitivity towards TRAIL remain to be defined. Acknowledging the previously demonstrated deregulation of prostate-apoptosis-response-gene-4 (par-4) in ex vivo cells of patients suffering from acute and chronic lymphatic leukemia, we here tested the hypothesis that expression of par-4 influences sensitivity to TRAIL. We here show, that expression of par-4 in T-lymphoblastic Jurkat cells i) considerably increases TRAIL-induced apoptosis; ii) enforces cleavage of c-FlipL and the subsequent activation of the initiator caspases-8 and -10; iii) does not alter expression of the Bcl-2 family members Bax and Bak; iv) does not enhance the disruption of mitochondrial membrane potential; v) promotes down-regulation the inhibitor-of-apoptosis proteins cIAP-1, cIAP-2, XIAP and survivin; vi) concomitantly augments activation of the executioner caspases-6 and -7. Moreover we prove the crucial role of caspase-8 in par-4-promoted apoptosis by demonstrating that inhibition of caspase-8 considerably reduces TRAIL-induced apoptosis in mock- as well as par-4-transfected Jurkat clones and reverses the described molecular changes. In conclusion, we here provide first evidence that expression of par-4 determines sensitivity to TRAIL-induced lymphocytic cell death and outline the responsible molecular determinants.
Surface Chemistry Proteomics and Biomarker Discovery in Multiple Myeloma.
Authors: Chen Bangzheng J. , Hong Huixiao , Ge Weigong , Tong Weida , Walker Ronald , Alpe Terri L. , Barlogie Bart , Epstein Joshua
Published: April 2020

Introduction:

To further evaluate the utility of surface-enhanced laser desorption and ionization-time of flight mass spectroscopy (SELDI-TOF MS) proteomics in the diagnosis, prognosis, monitoring response to therapy, and follow up of patient with myeloma, we examined the ability of protein chips with 4 different surface chemistries to detect biomarkers of lytic bone disease.

Method:

Sera from 47 untreated myeloma patients were collected and stored at −80°C for future analysis. 22 serum samples were from patients with 1–26 lytic bone lesions as identified on X-ray skeletal surveys and 25 serum samples were from patients without lytic lesions. The sera were analyzed by SELDI-TOF MS using Ciphergen’s ProteinChip Biology System II (PBS II), to identify protein patterns associated with lytic bone disease. Each sample was applied in 2 replicates to randomly assigned spots on protein chips with different surface chemistries: immobilized metal affinity capture (IMAC30) activated with Cu++, weak cathion exchange (CM10), reverse phase (H50), and strong anaion exchange (Q10), all under conditions of low stringency, using a Biomek2000 robot. The mass spectra of proteins, generated using an average of 66 laser shots, were calibrated using peptide standards and normalized to total ion current using CiphergenExpress 3.0 software. We randomly selected 80% of patients for developing classification models that separate patients with lytic bone lesions from those without lesions, using a stepwise logistic regression method; 76 calibrated and normalized spectra from randomly selected patients, 18 with lytic bone lesions and 20 without lytic lesions were used for model development. The other 18 spectra from 4 patients with lytic lesions and 5 without lesions were used as a test dataset. The same datasets were used for all 4 chip types. Protein peaks that were significantly different between the two groups were used for modeling.

Results:

All 4 chip types yielded models with fit accuracies of 71%–92%. The spectra produced by each chip were different, reflecting the differences in surface chemistries, and each model used different protein peaks from each of the chip types; the IMAC30-based model used 11 protein peaks ranging in size from 2903 to 8226 kilodaltons (KDa); H50 model used 7 peaks, 2802–18837 KDa in size; CM10 model used 5 peaks, 2805–23307 KDa; and Q10 used 3 peaks, 6975–37210 KDa. Prediction accuracy was 89% for CM10, 78% for IMAC30, 76% for Q10 and only 33% for H50. CM10 and IMAC30 based models correctly assigned all patients with no lytic bone lesions. Wrongly assigned patients were different for the two chip types.

Conclusions:

Since each model wrongly assigned different patients and used different protein peaks, it is likely that a model that combines information from several surface types (consensus approach) will prove to provide the most accurate predictions, as needed for making clinical decision.
Galectin-1 Can Support the Survival of Human Myeloma Cells in In Vitro Culture.
Authors: Abroun Saeid , Li Fu-Jun , Tsuyama Naohiro , Shamsasenjan Karim , Asaoku Hideki , Gondo Toshikazu , Kawano Michio M.
Published: April 2020

Myeloma cells as well as other hematopoietic cells exist in the bone marrow (BM), where adhesion molecules, cytokines and chemokines may play very important roles in regulating the survival, proliferation and lodgment of myeloma cells.

Galectin-1(Gal-1) is a 14 KDa protein with the binding affinity to the molecules which carry β galactosides in their structure such as CD3, CD4, CD7, CD43, CD45 and integrins. Although Gal-1 is considered to be ubiquitously present in the BM, it remains to be clarified what is the effect of Gal-1 on the survival of myeloma cells. First, we confirmed that Gal-1 as well as SDF-1 was ubiquitously present in the extracellular space of BM samples from MM patients by the immunohistochemical staining.

Furthermore, the expression of Gal-1 gene was found in a BM stromal cell line, KM-102, and also in primary myeloma cells as well as myeloma cell lines, while the expression of SDF-1 gene was detected in KM-102 cells but not in myeloma cells. In the serum-free culture in vitro, Gal-1 could support the survival of primary myeloma cells in the combination with IL-6 and SDF-1 at least for 2 weeks. In order to clarify the mechanism of the effect of Gal-1, we examined the effect of Gal-1 on the survival of myeloma cell lines and B cell l,ines; Ga-1 could support the survival of CD45- U266 and KMS-5 cells, but not support and suppress the survival of B cell lines (Raji and KUS cells) which express CD45, CD45RA and CD45RB but not CD45RO. By using the transfectants of CD45RA, CD45RB or CD45RO in U266 cells, we confirmed that Gal-1 could suppress the survival of CD45RA+ U266 cells as well as B cell lines but not of CD45RB or CD45RO transfectants of U266 cells. These data confirmed that Gal-1 could bind to the CD45RA molecule more effectively than CD45RB or CD45RO. We also revealed that Gal-1 stimulation inhibited the phosphorylation of ERK1/2 in CD45RA+ U266 cells as well as B cell lines, while in CD45- myeloma cells as well as CD45RO+ myeloma cells Gal-1 induced the activation of Akt. Therefore, these data suggest that Gal-1 plays an important role in the supporting the survival of myeloma cells but not B cells in the BM microenvironment.
Identification of Novel Receptors on Myeloma Cells and Monocytes That Contribute to Myeloma Tumor Proliferation and Angiogenesis.
Authors: Gordon Melinda S. , Lee Hee Jin , Campbell Richard A. , Chen Haiming , Bonavida Benjamin , Berenson James R.
Published: April 2020

Hyper-activation of multiple cell signaling pathways, including Akt, IRS-1, JAK/ STAT3, NF-kB, Wnt and MAPK, contribute to myeloma cell survival and/or proliferation, and myeloma tumor vascularization. We discovered the novel expression of two cell surface receptors that are able to activate these cell signals but were not previously known to be expressed by hematopoietic cells or to be involved in hematological malignancies. We analyzed bone marrow (BM) and peripheral blood (PB) mononuclear cells (MCs) from multiple myeloma (MM) patients and normal donors for the expression of new surface receptors by flow cytometry. We found that the malignant cells from myeloma patients (N = 10) and the MM cell lines RPMI 8226 and U266 express the receptor protein tyrosine phosphatase b/z (RPTPb/z). RPTPb/z contributes to the growth of solid tumors, including glioblastoma, neuroblastoma and melanoma by aberrant accumulation of b-catenin, leading to activation of Wnt, NF-kB and Akt-mediated cell signals. We interfered with RPTPb/z stimulation by its ligand, pleiotrophin (PTN), using specific anti-PTN antibody and showed significant inhibition of MM proliferation in vitro by MTT assay. Importantly, when this antibody was administered to MM tumor-bearing mice in vivo a significant decrease in tumor volume was detected. We have also discovered that peripheral blood monocytes from MM patients (N = 9) and normal donors (N = 7), and a monocytic cell line (THP-1), display untranslocated anaplastic lymphoma kinase (ALK) on the cell surface. Dysregulated ALK expression on a variety of solid tumors is associated with tumor growth, vascularization and metastasis. ALK+ monocytes and THP-1 cells, but not ALK− peripheral B or T lymphocytes or the ALK− monocytic cell line U937, respond to ALK stimulation by modulating hematopoietic genes and inducing the expression of endothelial genes as well as exhibiting changes in morphology typical of early vascular endothelial cells (Chen et al, 2004, Blood104: 1472). ALK cross-linking leads to activation of the signaling intermediates IRS-1, PI3′K/Akt, STAT3 and MAPK, that are known to play key roles in angiogenesis. Thus RPTPb/z and ALK, or their downstream signal mediators, could be important new molecular targets for anti-myeloma (RPTPb/z) or anti-angiogenic (ALK) therapy. We are defining the signaling pathway(s) leading from RPTPb/z stimulation to MM cellular proliferation and survival, and from ALK to tumor vascularization via monocytic transdifferentiation. These studies provide potential new targets that should lead to new therapeutic strategies for treating MM.
Serum Total-RANKL Is Elevated in Patients with Multiple Myeloma, Increases with ISS Stage and Decreases after Induction Therapy.
Authors: Jakob Christian , Sterz Jan , Kleeberg Lorenz , Zavrski Ivana , Kaiser Martin , Eucker Jan , Heider Ulrike , Possinger Kurt , Sezer Orhan
Published: April 2020

Enhanced osteolytic bone resorption is a hallmark of multiple myeloma. Several studies demonstrated an elevation of RANKL levels in the bone marrow microenvironment in multiple myeloma, but serum levels of soluble RANKL (sRANKL) revealed controversial results. One study reported elevated sRANKL in serum in myeloma patients, but using the same test, the levels in the majority of the patients were below the detection limit in the hand of other groups. Thus, a novel test was developed which measures both soluble and OPG-bound RANKL (total-RANKL, tRANKL). The objective of the present study was to investigate the clinical significance of circulating levels of tRANKL in monoclonal gammopathies of undetermined significance (MGUS) or multiple myeloma (MM). Serum levels of tRANKL were analyzed by ELISA in 128 individuals: 20 healthy donors, 20 with MGUS and 88 newly diagnosed patients with multiple myeloma. Multiple myeloma patients had significantly (P<0.001) higher serum tRANKL values (median 7.01 μmol/L, range < 2 – 57.6) than healthy controls (median < 2 μmol/L) and individuals with MGUS (median < 2 μmol/L). Serum tRANKL levels increased significantly (P<0.001) from Durie & Salmon stage I to stage III (median values: stage I = 2.98, stage II = 4.61, stage III = 10.45 μmol/L) und from ISS stage I to stage III (median values: stage I = 4.64, stage II = 7.98, stage III = 23.12 μmol/L). Furthermore the serum tRANKL concentrations were significantly elevated in MM Durie & Salmon stage I versus MGUS (P=0.01). Multiple myeloma patients with osteolytic bone lesions in conventional radiography had significantly higher tRANKL levels than those without bone lesions (median 8.34 vs. 4.02 μmol/L, P=0.01). In 32 patients with multiple myeloma in stages II and III, who received chemotherapy and a monthly bisphosphonate treatment with zoledronic acid or pamidronate additional serum samples after 3 months were available. There was a significant (P<0.001) decrease from pre- to post-treatment tRANKL concentrations after three months of treatment. Our study shows that serum tRANKL levels are detectable in the majority of myeloma patients using this novel ELISA test. Advanced disease stages and osteolytic bone lesions in multiple myeloma patients are associated with increased serum tRANKL levels. The decrease of tRANKL after 3 months of induction therapy and bisphosphonates suggest a positive effect of anti-myeloma treatment on RANK ligand expression in multiple myeloma patients.
Alternate Week Administration of the Farnesyltransferase Inhibitor Tipifarnib (ZARNESTRA®, R115777) in Patients with Myelodysplastic Syndrome: Results of a Phase 1 Study.
Authors: Kurzrock Razelle , Verstovsek Srdan , Wright John J. , Pilat Susan R. , Cortes Jorge E. , Estey Elihu H. , Giles Francis J. , Beran Miloslav , Kantarjian Hagop M.
Published: April 2020

Tipifarnib (ZARNESTRA®, R115777), an oral selective inhibitor of farnesyltransferase (FTase), demonstrates potent antiangiogenic, antiproliferative, and apoptotic effects. This phase 1 study assessed the tolerability and response rate in patients with myelodysplastic syndrome (MDS) receiving tipifarnib on an alternate week (1 week on/1 week off) schedule. Starting dose of tipifarnib was 100 mg BID, for a total initial treatment period of 8 weeks, with a standard 3+3 design. Dose escalation was 100 mg PO BID until grade 2 nonhematologic toxicity was observed, then 100 mg total dose per day escalation until the maximum tolerated dose (MTD) was reached. Sixty-three patients were treated (median age 68 years; range, 35–84 years) with RA (n = 15), RARS (n = 6), RAEB (n = 26), RAEB-t (n = 8), and CMMoL (n = 8). Five patients (8%) had IPSS score low, 27 (43%) INT-1, 23 (36%) INT-2, and 8 (13%) high. Three patients had an N-Ras mutation and one had a K-Ras mutation. A total of 63 patients were evaluable for toxicity and 61 were evaluable for response (1 noncompliant, 1 ineligible). This alternate week regimen of tipifarnib was well tolerated; the most common toxicity was myelosuppression (all grades, 60% of patients). No side effects were reported by 20% of patients. Nonhematologic toxicities (all grades) included fatigue (20%), skin rash (9%), diarrhea (16%), increase in SGPT (14%), increase in bilirubin (11%), and nausea (11%). Dose-limiting toxicities of ataxia (n = 1), insomnia (n = 1), fatigue (n = 1), nausea (n = 1), and neutropenic fever (n = 2) occurred at tipifarnib 1,300 mg/day to 1,500 mg/day. The MTD of tipifarnib in this patient population was 1,200 mg/day. Fifteen of 61 (25%) evaluable patients responded (3 CRs and 12 hematologic improvements). Major platelet responses were most common; they were observed in 11 of 15 responders. There was no obvious dose-response relationship and three of the fifteen patients (20%) at the lowest dose level (100 mg bid) responded including one CR. Only one patient among the responders (hematologic improvement) had a Ras (N-Ras) mutation. Median time to response was eight weeks (range, 4–32 weeks). In conclusion, an alternate week regimen of tipifarnib was well tolerated and a response rate of 25% was achieved in this phase 1 study in MDS patients. Responses were seen at all dose levels, and major platelet responses were most common. This schedule is therefore conducive to combination regimens as well as to maintenance therapy.
Analysis of Survival, AML Transformation, and Transfusion Independence in Patients with High-Risk Myelodysplastic Syndromes (MDS) Receiving Azacitidine Determined Using a Prognostic Model.
Authors: Silverman Lewis R. , McKenzie David R. , Peterson Bercedis L. , Demakos Erin P. , Holland James F. , Larson Richard R. ,   The Cancer Leukemia Group B (CALGB).
Published: April 2020

The International Prognostic Scoring System (IPSS) requires cytogenetic data to evaluate risk in MDS. Cytogenetic data were not available for all patients from the CALGB trial 9221 (Silverman et al, JCO2002; 20:2429). Therefore, we developed an alternative prognostic model that identified a homogeneous subgroup of high-risk MDS patients based on the following risk factors: percent marrow blasts, number of cytopenias, age, gender, FAB classification, and time since diagnosis (IPSS used data at time of diagnosis; CALGB 9221 used data at time of randomization). The model was validated using 2,318 patients from the MDS Registry, Düsseldorf. Using these baseline prognostic factors, we predicted survival for each of the 191 CALGB patients, identified a high-risk subgroup with a survival prognosis of ≤ 1.2 years (the IPSS INT-2 survival median), and compared azacitidine to supportive care. Patients were analyzed as randomized (azacitidine or supportive care) according to the intention-to-treat (ITT) principle. The two groups had similar demographic and disease characteristics. All 70 high-risk patients were followed until death. There was a statistically significant difference in overall survival curves between the azacitidine and supportive care groups (p=0.03). The one-year survival rate was 63% (95% CI: 47 to 78%) in the azacitidine group and 37% (95% CI: 19 to 54%) in the supportive care group (p=0.03; 26% difference with a 95% CI of 3 to 49%). The two-year survival rate was 35% (95% CI: 20 to 50%) in the azacitidine group and 13% (95% CI: 1 to 25%) in the supportive care group (p=0.03; 22% difference with a 95% CI of 3 to 41%). Similarly, statistically significant differences in time to AML transformation, and death or AML transformation, were observed. Transfusion independence was defined as free from transfusions for at least 2 months. Among patients who were RBC transfusion dependent at baseline, a significantly greater number of patients from the azacitidine group (11/25, 44%) compared with patients from the supportive care group (1/14, 7%) achieved transfusion independence (p=0.03; 37% difference with a 95% CI of 7 to 59%). Additionally, patients in the azacitidine group with baseline transfusion independence experienced significantly prolonged duration of RBC (p<0.0001) and platelet (p=0.0002) transfusion independence compared with those in the supportive care group. Use of this prognostic model has identified a subgroup of high-risk MDS patients who significantly benefited from treatment with azacitidine.

Time of Even Analysisa
Azacitidine Prolongs Survival and Time to AML Transformation in High-Risk Myelodysplastic Syndrome (MDS) Patients ≥ 65 Years of Age.
Authors: Silverman Lewis R. , McKenzie David R. , Peterson Bercedis L. , Demakos Erin P. , Malone Neil T. , Holland James F. , Larson Richard A. ,   The Cancer Leukemia Group B (CALGB).
Published: April 2020

The prognosis for patients with refractory anemia with excess blasts (RAEB) or RAEB in transformation (RAEB-T) ≥ 65 years of age has been poor. These high-risk patients are often not eligible for intensive induction/transplantation regimens or combination chemotherapies, leaving few treatment options besides supportive or palliative care. In the publication of the CALGB trial by Silverman et al (JCO2002;20:2429), no age- and/or risk- related subgroup analyses for azacitidine (Vidaza®) were presented. To assess the treatment effect of azacitidine versus supportive care on survival and time to AML transformation in a homogeneous sample of high-risk patients with MDS, we performed a subgroup analysis on the 191 patients included in the CALGB trial. All patients with a baseline diagnosis of RAEB or RAEB-T who were ≥ 65 years of age were included in the comparative analysis, using intent-to-treat (ITT) principles based on randomization to azacitidine or supportive care. Efficacy was analyzed using three survival endpoints: overall survival, time to death or AML transformation, and time to AML transformation. In all, 31 azacitidine patients and 37 supportive care patients met the criteria for this high-risk subgroup analysis. No significant differences in demographics or disease characteristics between the two groups were observed. For all three survival analyses, a statistically significant difference was observed for patients in the azacitidine group compared with those in the supportive care group. (Table) Median time to transformation to AML, in particular, was prolonged for 24 months in azacitidine patients compared with patients in the supportive care group. A sensitivity analysis of the overall survival results was conducted by performing 10 additional subgroup analyses based on ages ≥ 60 through ≥ 70 years in increments of one year with all overall survival results remaining significant (p < 0.05, except for 2 subgroup analyses based on ages ≥ 60 and ≥ 66 where both p-values were 0.051). The sensitivity results demonstrated robust patient benefit in the subgroup ≥ 65 years of age. The most common adverse event observed with azacitidine was myelosuppression, which decreased in frequency as therapy continued. Azacitidine provided clear treatment effect and patient benefit to this difficult-to-treat, high-risk group of RAEB and RAEB-T patients ≥ 65 years of age by significantly prolonging overall survival and time to AML transformation.

Time of Even Analysis
Rates of Infection and Bleeding Are Not Increased in Patients with Myelodysplastic Syndromes (MDS) Treated with Azacitidine Compared with Supportive Care.
Authors: Silverman Lewis R. , McKenzie David R. , Peterson Bercedis L. , Odchimar-Reissig Rosalie , Hinkle Randy , Backstrom Jay T. , Larson Richard A. ,   The Cancer Leukemia Group B (CALGB).
Published: April 2020

MDS are heterogeneous hematopoietic disorders characterized by dyspoiesis and cytopenias. Most patients with high-risk MDS die within 1 year from infection or hemorrhage usually attributable to bone marrow failure or progression to AML. In a phase 3, open-label, multicenter, randomized study comparing azacitidine (Vidaza®) plus supportive care (N=99) versus supportive care alone (N=91) in patients with MDS (JCO2002;20:2429), treatment with azacitidine was associated with worsening of pre-existing cytopenias in up to 78% (115/147) of patients with pre-existing cytopenias. The median time to first occurrence of any worsening cytopenia was 8 days (interquartile range: 6 to 15 days). All patients were treated with the same initial dose of azacitidine (75 mg/m2/day); no dose adjustments were made for pre-existing cytopenias despite the severity. We examined rates of infection and bleeding associated with azacitidine therapy in comparison with the rates seen with the underlying disease (supportive care). Our results are based on re-collected data from patients described in the published report; our analyses were conducted separately and independently. Total exposure for azacitidine was the cumulative time from the first dose to the end of study (30 days after last dose), and for supportive care was the cumulative time from randomization to withdrawal from study or day prior to crossover. The azacitidine group included all patients exposed to azacitidine (N=150), which included patients randomized to azacitidine (N=99) and patients after crossing over from supportive care (N=51). Similar to the rate of infections previously reported in patients with MDS (AJM1991; 90:338), infections occurred in patients in the supportive care group at nearly one per patient-year. However, infections occurred at an overall lower rate (patient-years) in the azacitidine group (0.64) compared with the supportive care group (0.95). (Table). Similarly, the overall rate (patient-years) of bleeding events was comparable between azacitidine (0.56) and supportive care (0.60). In particular, bleeding events in the gastrointestinal system occurred at a similar rate between the azacitidine group (0.26) and the supportive care group (0.25). This was also true for bleeding events in the central nervous system (azacitidine: 0.01, supportive care: 0.02). The rates of infection and bleeding were 3 to 4 times higher during cycles 1 and 2 in both treatment groups, reflecting the severity of the underlying disease at study entry. In summary, despite the potential to exacerbate pre-existing cytopenias early in therapy, treatment with azacitidine did not increase the rate of infection and bleeding above the rate due to the underlying disease.

Infection Rates (Patient-Years of Exposure) in Protocol 9221
Response Rates Using International Working Group (IWG) Criteria in Patients with Myelodysplastic Syndromes (MDS) Treated with Azacitidine.
Authors: Silverman Lewis R. , McKenzie David R. , Peterson Bercedis L. , De Castro Carlos M. , Ellerton John , Knapp Kathryn N. , Beach C.L. , Larson Richard A. ,   The Cancer Leukemia Group B (CALGB).
Published: April 2020

The CALGB conducted a series of clinical trials with azacitidine (Vidaza®) administered subcutaneously or intravenously in patients with MDS using the FAB classification (JCO2002;20:2429). Since the publication of these CALGB studies (8421, 8921, 9221), new response criteria for evaluating new treatments for MDS have been published by the IWG (Blood2000;96:3671). Two general differences between the CALGB and IWG response criteria are the required duration of improvement (CALGB: ≥4 weeks; IWG: ≥8 weeks) and peripheral blood values (CALGB: different criteria for hemoglobin targets for males and females; IWG: same criteria for males and females). The results reported here are based on re-collected data from patients described in the published report. After applying the IWG response criteria, the overall response rate (CR+PR+HI) in the azacitidine groups were similar across studies 8421, 8921, and 9221: 44% (21/48), 40% (28/70), and 48% (47/99), respectively.

Best Response using IWG Response Criteria for MDS in Studies 8421, 8921, and 9221

Median duration of any response (CR, PR or HI) in the 114 azacitidine-treated responders was 366 days (range: 56 to 4641+ days). The median duration of CR in the 32 azacitidine-treated responders was 379 days (range: 92 to 4412+ days). The median number of cycles from first treatment with azacitidine to any response (CR, PR or HI) was 3 cycles (range: 1 to 17 cycles). Although 75% of the responders achieved a response by cycle 4, the other 25% achieved a response as late as cycle 17. The majority (90%) of responders achieved a response by cycle 6. Best response was observed, on average, 2 cycles after the initial response. In summary, reanalysis of the response rates using IWG criteria demonstrate consistent results across three sequential studies and further validate the superiority of azacitidine over supportive care alone.
Vitamin K2 (VK2) Monotherapy and VK2 Plus D3 Combination Therapy in Low-Risk Myelodysplastic Syndrome: A Prospective Japanese Study.
Authors: Miyazawa Keisuke , Ohyashiki Kazuma , Akiyama Nobu , Kanda Yoshinobu , Tohyama Kaoru , Omine Mistuhiro , Mitani Kinuko
Published: April 2020

Vitamin K2 (VK2) analogs, including menaquinone-4 (MK4) but not vitamin K1, effectively induce apoptosis in acute myeloid leukemia cells (AML). Apoptosis induction by VK2 is specific toward leukemia cells, and almost no effect is observed in normal hematopoietic progenitor cells (Miyazawa K, Leukemia 1999, 2000, 2001). Combined treatment with VK2 plus 1α, 25-dihydroxy-vitamin D3 (D3) dramatically enhanced differentiation of leukemia cells as compared to the cells treated with D3 alone. Concomitant with the induction of differentiation and final maturation by VK2 plus D3, the cells became resistant to various apoptotic stimuli (Funato K, Leukemia, 2002). VK2 has been shown to improve the supportive hematopoietic functions of bone marrow stromal cells (Miyazawa K, Stem Cell Dev. 2004). Since VK2 (MK4, GlakayR) has been used to treat patients with osteoporosis in Japan, its non-toxicity and safety for long-term daily administration have already been well established. Case reports demonstrating the clinical benefits of using VK2 with or without D3 for treating patients with myelodysplastic syndrome (MDS) and AML have been accumulating, i.e. improving cytopenias in refractory anemia (RA) and reduction of blast cells in AML. We performed a multicenter prospective trial to determine the therapeutic benefit of VK2 with or without D3 in MDS. Patients with RA/RCMD with low/ int-1 by IPSS received VK2 (Glakay, 45 mg/day, po) for 16 weeks. The therapeutic response was assessed according to the International Working Group Criteria. Patients who did not respond to VK2 were sequentially re-registered and received a combination of VK2 plus D3 (alfacalcidol, AlfarolR, 0.75 microgram/day, po) for 16 weeks. Patients showing response to VK2 alone or VK2 plus D3 after 16 weeks continued to receive therapy for a total of 12 months. Forty-three patients have been enrolled and 29 patients were evaluable for their response to VK2. Five patients (17.2 %) showed improvement of cytopenia (major HI-E (1), minor HI-E (2), major HI-P (3), and minor HI-P (1)). Twenty out of 24 patients who showed no response to VK2 alone subsequently received VK2 plus D3. Eleven patients were eligible for evaluation and 4 patients (36.4%) showed improvement of cytopenia in response to VK2 plus D3 (major HI-E (3), minor HI-E (1) and major HI-P (1)). Four out of 7 patients (57 %) with anemia showed hematologic response. No adverse events were observed, except for one case of skin rash (Grade I) during VK2 plus D3 therapy. These data suggest that the therapeutic response rate is improved by combined treatment with VK2 plus D3 as compared with that by VK2 monothrapy. Safety and low price also support the therapeutic benefit of VK2 with D3 for improving cytopenia in RA.
Early and Sustained Response to Azacytidine in High-Risk MDS Patients with Monosomy 7 Correlates with Increased Apoptosis and Not CDKN2B Demethylation.
Authors: Raj Kavita K. , John Alison M. , Ho Aloysius , Thomas Nicholas Shaun B. , Mufti Ghulam J.
Published: April 2020

Disease progression in MDS is associated with CDKN2B (encodes p15INK4b) promoter methylation and an inhibition of apoptosis. We therefore studied predominantly high-risk MDS patients treated with azacitidine in order to determine whether clinical responses correlated with changes in CDKN2B promoter methylation and bone marrow apoptosis. In all, 24 patients (19 male) with a median age of 66.7 years were treated with azacitidine (75mg/m2/day x 7 days, every 28 days). Patients were FAB RA (n=2), RAEB (n=7), RAEB-T (n=13) and AML (n=2) with 18/24 having an IPSS risk of Int-2 or High. Cytogenetic abnormalities were present in 17 patients (4 patients with monosomy 7; 1 with der(7) as the sole cytogenetic abnormality and 1 as part of a complex karyotype; 4 with trisomy 8; 1 with 11q abnormalities; 1 with 5q-, 1 with 20q, 1 with iso 17p; and the remaining -y or misc). A median of 5 courses of azacitidine was administered (range: 1–13). Complete remission was achieved in 6 patients: 2 with trisomy 8, 3 with monosomy 7, and 1 with der(7). Haematological Improvement (HI) in Platelets occurred in 6 patients, HI-E in 2 patients, and HI-N in 3 patients. Five patients had a reduction in blast percentage. Importantly, even in complete cytogenetic remission bone marrow dysplasia persisted. All patients with monosomy 7/der(7) are in complete remission (median follow up of 10 months) whereas those with trisomy 8 relapsed their response at 2 and 5 months. CDKN2B promoter methylation in patients pre-treatment and at hematological remission was studied by bisulfite genomic sequencing (region: −263 to +243). There was no difference in CDKN2B methylation in CD34+ or CD33+ cells of responders and non-responders (both had low level, heterogeneous methylation patterns). However, CDKN2B was unmethylated in lymphocytes of responders and methylated in non-responders. Demethylation was not evident following treatment. Baseline bone marrow mononuclear cell apoptosis of 16 patients (12 RAEB, 2 RAEB T, 2 AML) analysed by PI/Annexin V staining (6% mean, 4.06% median); was not significantly different from normal controls (2%: mean, 0.77%; median, n=3) (2 sample T-test 0.103). From 12 treated patients, 8 patients responding to azacitidine (6 CR; 2 blast reduction with HI-E major and HI-N major, regardless of cytogenetic subtype), the mean apoptosis at the time of remission (11.61% mean; 9% median) was significantly higher than the mean apoptosis of 1.82% (median, 1.095%) in 4 non- responders (2 sample t-test p = 0.006). Azacitidine treatment induced sustained responses in all patients with monosomy 7, in whom the CDKN2B promoter is unmethylated. We propose that increased bone marrow apoptosis disrupts the leukaemic clone and leads to disease regression to an earlier stage.
Myelodysplastic Syndromes (MDS): An International Practice and Treatment Survey.
Authors: List Alan F. ,   for the MDS Foundation Inc.
Published: April 2020

Results from The MDS Foundation’s 2004–2005 Practices & Treatment Survey, distributed to 102 Centers of Excellence (48 US and 53 international academic medical centers), indicate that the perceived incidence of MDS patients is increasing. 70% of the 70 responding centers that reported higher case loads in the last five years attributed the increase to rising participation in and interest in clinical trials (37%), improved diagnostics and treatments (27%), and increased awareness and referrals (16%). Although 83% of the respondents indicated that their institution uses the World Health Organization (WHO) classification system, only 28% of referred patients were categorized by WHO subtype. Analyses of treatment strategies revealed that an average of 41% of patients in Low and Intermediate-1 International Prognostic Scoring System (IPSS) risk groups received supportive care only (median, 50%), 34% received active treatment (median, 30%), and 25% are being followed expectantly (median, 25%). For IPSS Intermediate-2 and High risk groups, an average of 30% of patients received supportive care (median, 30%), whereas 63% received active treatment (median, 70%), and 7% are being observed (median, 10%). Survey responses showed a wide array of interventions including transfusions (94%, with 28% indicating transfusion as the only type of supportive care used), erythropoietin alone or with myeloid growth factors, G- or GM-CSF alone, cyclosporine, antibiotics, vitamins (B12, B6, folic acid), or corticosteroids. Median ranking of the current investigative agents for the treatment of MDS indicate that lenalidomide, decitabine, and oral iron chelation therapy are viewed as the most clinically useful agents for all IPSS risk groups; amifostine and calcitriol were viewed as being least useful; arsenic trioxide and thalidomide were viewed as somewhat useful. These survey responses from investigators associated with academic medical centers with clinical research or diagnostic programs in MDS suggest that more disparate MDS treatment approaches may be expected in the office-based setting. The epidemiologic and treatment survey responses indicate that there is an urgent need for establishing guidelines that would assist clinicians in effectively matching patient and disease characteristics with treatment options, particularly as a number of therapies are moving forward in clinical testing phases.
Darbepoetin Alfa for the Treatment of Anemia in Patients with Myelodysplastic Syndrome.
Authors: Giraldo Pilar , Nomdedeu Benet , Loscertales Javier , Requena Carmen , de Paz Raquel , Tormo Mar , Navarro Pilar , Benedit Patricia , Gasquet Jose Antonio ,   On Behalf of the ARM Study Group
Published: April 2020

Background: Anemia is one of the main problems associated with myelodysplastic syndrome (MDS) leading to fatigue, increased red blood cell transfusions, and reduced quality of life. Erythropoiesis-stimulating proteins (ESPs) have been used to treat MDS-induced anemia. Darbepoetin alfa (Aranesp®) is a unique ESP that can be administered less frequently than recombinant human erythropoietin (rHuEPO) due to its longer serum half-life, increasing patient convenience and possibly enhancing treatment compliance.

Methods: We performed a retrospective analysis of medical records from anemic patients with confirmed MDS that had been treated with darbepoetin alfa in 2004 in 9 Spanish centers. Data were collected 16 weeks before and 16 weeks after the starting date of darbepoetin alfa treatment. Response to darbepoetin alfa was evaluated using the International Working Group criteria.

Results: This study included data from 81 patients. Median age was 70 years (range, 38.0 – 87.0) at diagnosis and 75 years (range, 39.0 – 91.0) at the beginning of treatment with darbepoetin alfa. The proportion of female patients was 56.8%. French-American-British (FAB) classification: 39.5% refractory anemia (RA), 46.9% RA with ringed sideroblasts (RARS), 9.9% RA with excess blasts (RAEB), 1.2% RAEB in transformation (RAEB-T), and 2.5% chronic myelomonocytic leukemia (CMML). International Prognostic Scoring System (IPSS) classification: 55.3% low; 36.2% intermediate-1 and 8.5% intermediate-2. ECOG status: 0–1 in 79% of patients. Median baseline hemoglobin level was 8.9 g/dL (range, 8.4 – 9.1). Previous treatment with recombinant human erythropoietin (rHuEPO) occurred in 44.4% of patients and time from last rHuEPO dose to initiation of darbepoetin alfa treatment was lower than 1 week in 53.1% of patients (average of 16.7 weeks; range, 0.0–159.0). Starting darbepoetin alfa dose was 150 mcg/week in 69.1% and 300 mcg/week in 29.6% of patients. Darbepoetin alfa dose was increased in 18.5% and reduced in 9.9% of patients. Median time until dose adjustment was 8 weeks. Granulocyte colony-stimulating factor (G-CSF, Filgrastim) support was required in 6.5% of patients and this percentage was maintained during the 16-week followup. A total of 69 patients (34 rHuEPO-naïve and 35 rHuEPO-treated) were evaluable for efficacy analysis (Hb and transfusion data available). Erythroid response was achieved in 55% of patients (29% major and 26% minor) with 65% of rHuEPO-naïve responders and 46% of rHuEPO-treated responders. A total of 66% responses were achieved before or at week 8.

Conclusion: These results indicate that darbepoetin alfa treatment appears to be effective in patients with MDS regardless of whether or not they had received previous treatment with rHuEPO.
Bortezomib in Combination with High-Dose Dexamethasone and Continuous Low-Dose Oral Cyclophosphamide for Relapsed Multiple Myeloma.
Authors: Kropff Martin , Bisping Guido , Liebisch Peter , Sezer Orhan , Einsele Hermann , Straka Christian , Kroeger Nicolaus , Metzner Bernd , Engelhardt Monika , Lang Nicola , Hentrich Marcus , Wolf Hans , von Schilling Christoph , Salwender Hans , Berdel Wolfgang E. , Kienast Joachim
Published: April 2020

Single agent bortezomib treatment yields ≥ partial responses (PR) in 24% of patients with relapsed, refractory multiple myeloma (MM) and 38% of patients who had received 1 – 3 previous therapies. Dexamethasone (DEX) adds to anti-myeloma activity of bortezomib. The present phase II trial was intitiated to study bortezomib combined with DEX and continuous low-dose oral cyclophosphamide (CY).

50 patients with advanced MM were scheduled to receive bortezomib 1.3 mg/m2 IV days 1, 4, 8, and 11 q 3 weeks for 8 cycles in combination with DEX 20 mg PO on the day of bortezomib injection and the day thereafter, and CY 50 mg PO daily; followed by 3 cycles bortezomib 1.3 mg/m2 IV days 1, 8, 15, and 22 q 5 weeks in combination with corresponding DEX and CY schedules. Patient characteristics included median age 63 years; B2M > 3,0 mg/L, 64%; CRP > 3,0 mg/L, 25%; deletion of chromosome 13, 46%; median number of prior regimens, 2 (range 1 – 9), and prior standard therapy > 12 mo, 94 %. 78% of patients had relapsed after high-dose melphalan. The EBMT criteria were used for definition of response. Five patients (10%) achieved a complete response, 33 (66%) a PR, and 6 (12%) a minor response (MR) resulting in an overall response rate (≥MR) of 88%. On an intention-to-treat basis, median event-free survival (EFS) with this combination was 10 months. After a median follow-up of 10 months, median overall survival has not been reached. Notably, chromosome 13 deletion was predictive of a favorable outcome (higher response rate, longer EFS) in this setting.

The median number or treatment cycles given was 6. 56% of the patients terminated study treatment prematurely, mainly for disease progression (10%) or adverse events (34%). Grade 4 neutropenia during at least one treatment cycle occurred in one patient (2%), grade 4 thrombocytopenia in 17%; one thrombocytopenic bleeding. Grade 3/4 non-hematologic toxicities requiring dose or schedule modifications included infections (26%), peripheral neuropathy (25%), fatigue (15%), herpes zoster (13%), and cardiovascular events (11%). One patient succumbed to infection without predisposing neutropenia.

Bortezomib in combination with DEX and CY appears to be a highly active regimen without increased toxicity compared to a single agent treatment with bortezomib. Maintenance treatment might be required for prolonged EFS.
Doxil, Vincritine, Reduced Frequency Dexamethasone in Combination with Thalidomide (DVd-T) Is Associated with Higher Overall and Progression Free Survival as Compared to DVd in Patients with Multiple Myeloma (MM).
Authors: Almhanna Khaldoun , Suppiah Revathi , Baz Rachid , Karam Mary Ann , Faiman Beth , Reed Janice , Hussein Mohamad
Published: April 2020

Background: Although initially responsive to chemotherapy, multiple myeloma ultimately relapses. Replacing Adriamycin with pegylated liposomal doxorubicin in the VAD regimen results in a regimen with better safety profile (less neutropenia, alopecia, fewer hospital and clinic visit). DVd resulted in normalizing the angiogenic process however this did not improve PFS or OS. Thalidomide because of its antiangiogenic, immunomodulatory effects and chemo-sensitizing activity through modulating integrins was added to the DVd regimen. Adding the thalidomide to the DVd regimen resulted in an overall response rate of 89% with a CR/NCR rate of 49 % as compared to 60% and 18 % respectively for the DVd. At this stage it is not clear if the quality of response affects outcome in multiple myeloma patients receiving conventional dose therapy. To better assess the prognostic implication of improved quality responses and to define the role of up front Thalidomide, we compared the DVd to the DVd-T regimen by retrospectively reviewing the two trial data, the follow up for both trials is mature. It is still not clear whether thalidomide is more appropriately used up front or in the management of relapse.

Methods: we recruited a total of 68 patients in our DVd trial versus 105 patient in the DVd-T trial. A total of 155 patients in both groups were evaluable for follow-up and response (58 received DVd and 97 received DVd-T). Patients were matched for age, disease prognosticators, disease stage, and bone marrow involvement. The newly diagnosed patients were comparable in both groups except for the b 2 microglobulin which was higher in the DVd-T group as compared to the DVd (3.2 vs. 5.0; respectively. p0.05). In the relapsed/refractory group of patients, all variables were comparable.

Results: The median follow up was 5 years for the DVd group and 2 years for the DVd-T group. Median age for the DVd was 62 years, which was similar to the DVd-T. For the DVd vs. the DVd-T group of patients achieving complete and near complete remission was 17% vs. 49.5% respectively with a p value of 0.001. Progression free survival was significantly longer for the DVd-T regimens vs. the DVd (28 vs. 13 months p= 0.0002) Figure 1., and for over all survival the median is not reached for the DVd-T vs. 28 months for he DVd (p=0.006).

Conclusion: we conclude that the addition of thalidomide significantly improved the quality of response and this appears to translate in to a PFS and OS benefit. While, recently published SWOG data suggests that the overall survival is determined by the duration of the PFS and not the quality of the response, this discrepancy could be related to the small number of patients in our study or the lack of use of biologic immune modulators among SWOG patients.

Figure Figure
Weekly Bortezomib with or without Glucocorticosteroids Is Effective in Patients with Relapsed or Refractory Multiple Myeloma.
Authors: Suvannasankha Attaya , Smith Gina G. , Abonour Rafat
Published: April 2020

Well-tolerated, effective and simple regimens are warranted in multiple myeloma (MM). Bortezomib is an active novel agent for MM therapy. A phase III randomized trial in patients with relapsed and refractory MM demonstrates bortezomib to be superior to dexamethasone in time to progression and overall survival. The FDA approved schedule of bortezomib (days 1, 4, 8 and 11 infusion of a 21-day cycle) is rather inconvenient. We investigated the synergy between weekly bortezomib and glucocorticosteroids in order to the frequency of patients’ clinic visits.

Methods: Patients with relapsed or refractory MM referred to Indiana University Cancer Center were offered bortezomib 1.3 mg/m2 by intravenous push and methylprednisone 500–2000 mg by intravenous infusion over 30 minutes. Treatments were given on days 1, 8 and 15 of 28-day cycles. Therapy was maintained as long as subjects’ diseases were responding and side effects were minimal. Both efficacy and tolerability of the regimen were evaluated.

Results: Thirty patients were treated on the protocol. Twenty six received bortezomib in combination with methylprednisone, while 4 received single agent bortezomib. Patient age ranged from 50–79 years (median 62); there were 15 females and 15 males. Twenty-one patients (70%) had prior high dose chemotherapy and stem cell transplantation, including 2 with prior allogeneic stem cell transplantation. Thirteen patients were in third relapse or higher. The response was evaluable in 28 patients. Eighteen patients achieved clinical response (60 %), including 1 (3%) complete response, 1 (3%) near complete response, and 16 (53%) partial response. Five (17%) had stable disease, and 5 (17%) had progression. The median number of treatment cycles was 5 (range 2 to 12). Among responders, the median number of cycles given to achieve the best response was 3 cycles (range 1–8 cycles). Major adverse effects included neuropathy (2 grade III), gastrointestinal side effects (1 grade III) and congestive heart failure (1 grade III). The updated time to progression and overall survival will be presented at the meeting.

Conclusion: Weekly bortezomib with or without steroid is a convenient and efficacious therapy for patients with heavily pretreated relapsed and refractory MM and should be further explored in a larger patient cohort.