Query: Busulfan

title: Lentiviral Gene Therapy Combined with Low Dose Busulfan in Infants with SCID X1
abstract: Allogeneic hematopoietic stem cell transplantation for X linked severe combined immunodeficiency (SCID X1) often fails to reconstitute immunity associated with T cells, B cells, and natural killer (NK) cells when matched sibling donors are unavailable unless high dose chemotherapy is given. In previous studies, autologous gene therapy with g retroviral vectors failed to reconstitute B cell and NK cell immunity and was complicated by vector related leukemia.  We performed a dual center, phase 1 2 safety and efficacy study of a lentiviral vector to transfer IL2RG complementary DNA to bone marrow stem cells after low exposure, targeted busulfan conditioning in eight infants with newly diagnosed SCID X1.  Eight infants with SCID X1 were followed for a median of 16.4 months. Bone marrow harvest, busulfan conditioning, and cell infusion had no unexpected side effects. In seven infants, the numbers of CD3+ CD4+ and naive CD4+ T cells and NK cells normalized by 3 to 4 months after infusion and were accompanied by vector marking in T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors. The eighth infant had an insufficient T cell count initially, but T cells developed in this infant after a boost of gene corrected cells without busulfan conditioning. Previous infections cleared in all infants, and all continued to grow normally. IgM levels normalized in seven of the eight infants, of whom four discontinued intravenous immune globulin supplementation; three of these four infants had a response to vaccines. Vector insertion site analysis was performed in seven infants and showed polyclonal patterns without clonal dominance in all seven.  Lentiviral vector gene therapy combined with low exposure, targeted busulfan conditioning in infants with newly diagnosed SCID X1 had low grade acute toxic effects and resulted in multilineage engraftment of transduced cells, reconstitution of functional T cells and B cells, and normalization of NK cell counts during a median follow up of 16 months.

title: Conditioning with busulfan plus melphalan versus melphalan alone before autologous haemopoietic cell transplantation for multiple myeloma: an open label, randomised, phase 3 trial.
abstract: Retrospective studies suggest that conditioning therapy with busulfan plus melphalan could result in longer progression free survival compared with melphalan alone in patients with multiple myeloma undergoing autologous haemopoietic cell transplantation (auto HCT) We aimed to test this hypothesis in a randomised trial.  The primary objective of the study was to compare progression free survival with conditioning of busulfan plus melphalan with melphalan alone in patients with multiple myeloma. Patients with newly diagnosed multiple myeloma who were eligible for cell transplantation, aged 70 years or younger, with at least stable disease, were randomly assigned (1:1) to treatment. Patients received either busulfan plus melphalan, with a test dose of busulfan 32 mg/m2 followed by pharmacokinetically adjusted doses on days 7, 6, 5, and 4 to achieve a target daily area under the curve (AUC) of 5000 mmol minute and melphalan 70 mg/m2 per day on days 2 and 1 (total melphalan dose 140 mg/m2) or a melphalan dose of 200 mg/m2 on day 2. Randomisation was performed via a Clinical Trial Conduct Website at the University of Texas MD Anderson Cancer Center. The accrual is complete and final results are presented here. The study is registered with ClinicalTrials.gov, number NCT01413178.  Between Oct 12, 2011, and March 22, 2017, 205 patients were assessed for eligibility and randomly assigned to treatment. The primary analysis of progression free survival was measured in 202 patients who received treatment: 104 patients in the busulfan plus melphalan group and 98 patients in the melphalan alone group. 90 days after auto HCT, 102 (98% of 104 patients given busulfan plus melphalan and 95 (97% of 98 patients given melphalan alone achieved partial response or better. The median follow up in the busulfan plus melphalan group was 22*6 months (IQR 15*2 47*1) and 20*2 months (IQR 8*8 46*6) in the melphalan alone group. Median progression free survival was 64*7 months (32*9 64*7) with busulfan plus melphalan versus 43*5 months (19*9 not estimated) with melphalan alone (hazard ratio 0*53 [95% CI 0*30 0*91] p=0*022) There were no treatment related deaths by day 100 in either group. Grade 2 3 mucositis was observed in 77 (74% of 104 patients in the busulfan plus melphalan group versus 14 (14% of 98 patients in the melphalan alone group.  These findings, if confirmed in other ongoing studies, suggest that busulfan plus melphalan could replace melphalan alone as the conditioning regimen for auto HCT in patients with newly diagnosed myeloma.  This study was funded in part by the National Institutes of Health (NIH) through MD Anderson's Cancer Center Support Grant (CA016672)

title: Treosulfan or busulfan plus fludarabine as conditioning treatment before allogeneic haemopoietic stem cell transplantation for older patients with acute myeloid leukaemia or myelodysplastic syndrome (MC FludT.14/L) a randomised, non inferiority, phase 3 trial.
abstract: Further improvement of preparative regimens before allogeneic haemopoietic stem cell transplantation (HSCT) is an unmet medical need for the growing number of older or comorbid patients with acute myeloid leukaemia or myelodysplastic syndrome. We aimed to evaluate the efficacy and safety of conditioning with treosulfan plus fludarabine compared with reduced intensity busulfan plus fludarabine in this population.  We did an open label, randomised, non inferiority, phase 3 trial in 31 transplantation centres in France, Germany, Hungary, Italy, and Poland. Eligible patients were 18 70 years, had acute myeloid leukaemia in first or consecutive complete haematological remission (blast counts <5% in bone marrow) or myelodysplastic syndrome (blast counts <20% in bone marrow) Karnofsky index of 60% or higher, and were indicated for allogeneic HSCT but considered at an increased risk for standard myeloablative preparative regimens based on age =50 years) an HSCT specific comorbidity index of more than 2, or both. Patients were randomly assigned (1:1) to receive either intravenous 10 g/m2 treosulfan daily applied as a 2 h infusion for 3 days (days 4 to 2) or 0*8 mg/kg busulfan applied as a 2 h infusion at 6 h intervals on days 4 and 3. Both groups received 30 mg/m2 intravenous fludarabine daily for 5 days (days 6 to 2) The primary outcome was event free survival 2 years after HSCT. The non inferiority margin was a hazard ratio (HR) of 1*3. Efficacy was assessed in all patients who received treatment and completed transplantation, and safety in all patients who received treatment. The study is registered with EudraCT (2008 002356 18) and ClinicalTrials.gov (NCT00822393) FINDINGS Between June 13, 2013, and May 3, 2016, 476 patients were enrolled (240 in the busulfan group received treatment and transplantation, and in the treosulfan group 221 received treatment and 220 transplanation) At the second preplanned interim analysis (Nov 9, 2016) the primary endpoint was met and trial was stopped. Here we present the final confirmatory analysis (data cutoff May 31, 2017) Median follow up was 15*4 months (IQR 8*8 23*6) for patients treated with treosulfan and 17*4 months (6*3 23*4) for those treated with busulfan. 2 year event free survival was 64*0% (95% CI 56*0 70*9) in the treosulfan group and 50*4% (42*8 57*5) in the busulfan group (HR 0*65 [95% CI 0*47 0*90] p<0*0001 for non inferiority, p=0*0051 for superiority) The most frequently reported grade 3 or higher adverse events were abnormal blood chemistry results (33 [15% of 221 patients in the treosulfan group vs 35 [15% of 240 patients in the busulfan group) and gastrointestinal disorders (24 [11% patients vs 39 [16% patients) Serious adverse events were reported for 18 (8% patients in the treosulfan group and 17 (7% patients in the busulfan group. Causes of deaths were generally transplantation related.  Treosulfan was non inferior to busulfan when used in combination with fludarabine as a conditioning regimen for allogeneic HSCT for older or comorbid patients with acute myeloid leukaemia or myelodysplastic syndrome. The improved outcomes in patients treated with the treosulfan fludarabine regimen suggest its potential to become a standard preparative regimen in this population.

title: Melatonin Ameliorates Busulfan Induced Spermatogonial Stem Cell Oxidative Apoptosis in Mouse Testes
abstract: Many men endure immunosuppressive or anticancer treatments that contain alkylating agents before the age of sexual maturity, especially the increasing number of preadolescent males who undergo busulfan treatment for myeloablative conditioning before hematopoietic stem cell transplantation. Before sperm production, there are no sperm available for cryopreservation. Thus, it is necessary to identify a solution to ameliorate the busulfan induced damage of spermatogonial stem cells (SSCs)  In this study, we demonstrated that melatonin relieved the previously described SSC loss and apoptosis in mouse testes. Melatonin increased the expression of manganese superoxide dismutase (MnSOD) which regulated the production of busulfan induced reactive oxygen species (ROS) Moreover, melatonin promoted sirtuin type 1 (SIRT1) expression. SIRT1 participated in the deacetylation of p53, which promotes p53 ubiquitin degradation. Decreased concentrations of deacetylated p53 resulted in spermatogonial.

title: Protective effect of L carnitine and L arginine against busulfan induced oligospermia in adult rat
abstract: Busulfan is an anticancer drug caused variety of adverse effects for patients with cancer. But it could cause damage to the male reproductive system as one of its adverse effects. This study aimed to investigate the protective effect of L carnitine and L arginine on semen quality, oxidative stress parameters and testes cell energy after busulfan treatment. Adult male rats were divided into four groups: control (Con) busulfan (Bus) busulfan plus L arginine (Bus L arg) and busulfan plus L carnitine (Bus L car) After 28 days, the semen was collected from the epididymis and the testes were assessed. Sperm count, motility and velocity were measured by CASA, and smears were prepared for assessment of sperm morphology. Serum and testes supernatants were separated for DNA metabolites, oxidative stress and cell energy parameters. Testes tissues also subjected for caspase 3. The results showed significant improvement in sperm morphology, motility, velocity and count in the groups treated with L arginine and L carnitine and accompanied with an increase in MDA, GSSG and ATP, reduction in GSH, AMP, ADP, NO and 8 OHDG also recorded. These results are supported by caspase 3.  Administration of L arg and L car attenuated the cytotoxic effects of busulfan by improving semen parameters, reducing oxidative stress and maintaining cell energy.

title: Busulfan and melphalan versus carboplatin, etoposide, and melphalan as high dose chemotherapy for high risk neuroblastoma (HR NBL1/SIOPEN) an international, randomised, multi arm, open label, phase 3 trial.
abstract: High dose chemotherapy with haemopoietic stem cell rescue improves event free survival in patients with high risk neuroblastoma; however, which regimen has the greatest patient benefit has not been established. We aimed to assess event free survival after high dose chemotherapy with busulfan and melphalan compared with carboplatin, etoposide, and melphalan.  We did an international, randomised, multi arm, open label, phase 3 cooperative group clinical trial of patients with high risk neuroblastoma at 128 institutions in 18 countries that included an open label randomised arm in which high dose chemotherapy regimens were compared. Patients (age 1 20 years) with neuroblastoma were eligible to be randomly assigned if they had completed a multidrug induction regimen (cisplatin, carboplatin, cyclophosphamide, vincristine, and etoposide with or without topotecan, vincristine, and doxorubicin) and achieved an adequate disease response. Patients were randomly assigned (1:1) to busulfan and melphalan or to carboplatin, etoposide, and melphalan by minimisation, balancing age at diagnosis, stage, MYCN amplification, and national cooperative clinical group between groups. The busulfan and melphalan regimen comprised oral busulfan (150 mg/m2 given on 4 days consecutively in four equal doses) after Nov 8, 2007, intravenous busulfan was given (0*8 1*2 mg/kg per dose for 16 doses according to patient weight) After 24 h, an intravenous melphalan dose (140 mg/m2) was given. Doses of busulfan and melphalan were modified according to bodyweight. The carboplatin, etoposide, and melphalan regimen consisted of carboplatin continuous infusion of area under the plasma concentration time curve 4*1 mg/mL per min per day for 4 days, etoposide continuous infusion of 338 mg/m2 per day for 4 days, and melphalan 70 mg/m2 per day for 3 days, with doses for all three drugs modified according to bodyweight and glomerular filtration rate. Stem cell rescue was given after the last dose of high dose chemotherapy, at least 24 h after melphalan in patients who received busulfan and melphalan and at least 72 h after carboplatin etoposide, and melphalan. All patients received subsequent local radiotherapy to the primary tumour site followed by maintenance therapy. The primary endpoint was 3 year event free survival, analysed by intention to treat.  Between June 24, 2002, and Oct 8, 2010, 1347 patients were enrolled and 676 were eligible for random allocation, 598 (88% of whom were randomly assigned: 296 to busulfan and melphalan and 302 to carboplatin, etoposide, and melphalan. Median follow up was 7*2 years (IQR 5*3 9*2) At 3 years, 146 of 296 patients in the busulfan and melphalan group and 188 of 302 in the carboplatin, etoposide, and melphalan group had an event; 3 year event free survival was 50% (95% CI 45 56) versus 38% (32 43; p=0*0005) Nine patients in the busulfan and melphalan group and 11 in the carboplatin, etoposide, and melphalan group had died without relapse by 5 years. Severe life threatening toxicities occurred in 13 (4% patients who received busulfan and melphalan and 29 (10% who received carboplatin, etoposide, and melphalan. The most frequent grade 3 4 adverse events were general condition (74 [26% of 281 in the busulfan and melphalan group vs 103 [38% of 270 in the carboplatin, etoposide, and melphalan group) infection (55 [19% of 283 vs 74 [27% of 271) and stomatitis (138 [49% of 284 vs 162 [59% of 273) 60 (22% of 267 patients in the busulfan and melphalan group had Bearman grades 1 3 veno occlusive disease versus 21 (9% of 239 in the carboplatin, etoposide, and melphalan group.  Busulfan and melphalan improved event free survival in children with high risk neuroblastoma with an adequate response to induction treatment and caused fewer severe adverse events than did carboplatin, etoposide, and melphalan. Busulfan and melphalan should thus be considered standard high dose chemotherapy and ongoing randomised studies will continue to aim to optimise treatment for high risk neuroblastoma.

title: Allogeneic Hematopoietic Stem Cell Transplantation for GATA2 Deficiency Using a Busulfan Based Regimen.
abstract: Allogeneic hematopoietic stem cell transplantation (HSCT) reverses the bone marrow failure syndrome due to GATA2 deficiency. The intensity of conditioning required to achieve reliable engraftment and prevent relapse remains unclear. Here, we describe the results of a prospective study of HSCT in 22 patients with GATA2 deficiency using a busulfan based conditioning regimen. The study included 2 matched related donor (MRD) recipients, 13 matched unrelated donor (URD) recipients, and 7 haploidentical related donor (HRD) recipients. MRD and URD recipients received 4 days of busulfan and 4 days of fludarabine. HRD recipients received low dose cyclophosphamide for 2 days, fludarabine for 5 days, 2 to 3 days of busulfan depending on cytogenetics, and 200 cGy total body irradiation. MRD and URD recipients received tacrolimus and short course methotrexate for graft versus host disease (GVHD) prophylaxis. HRD recipients received high dose post transplant cyclophosphamide (PTCy) followed by tacrolimus and mycophenolate mofetil. At a median follow up of 24 months (range, 9 to 50) 19 of 22 patients were alive with reversal of the disease phenotype and correction of the myelodysplastic syndrome, including eradication of cytogenetic abnormalities. Three patients died: 1 from refractory acute myelogenous leukemia, 1 from GVHD, and 1 from sepsis. There was a 26% incidence of grades III to IV acute GVHD in the MRD and URD groups and no grades III to IV acute GVHD in the HRD cohort. Similarly, there was a 46% incidence of chronic GVHD in the MRD and URD cohorts, whereas only 28% of HRD recipients developed chronic GVHD. Despite excellent overall disease free survival (86% GVHD remains a limitation using standard prophylaxis for GVHD. We are currently extending the use of PTCy to the MRD and URD cohorts to reduce GVHD.

title: Thiotepa busulfan fludarabine compared to busulfan fludarabine for sibling and unrelated donor transplant in acute myeloid leukemia in first remission
abstract: A preparatory regimen consisting of thiotepa busulfan fludarabine (TBF) has been associated with reduced relapse in patients with haematological malignancies after haploidentical and cord blood transplants; however, few data exist regarding TBF conditioning in sibling (MSD) and unrelated donor (URD) transplants for AML.  Among patients receiving a myeloablative (MAC) regimen, TBF MAC was associated with significantly lower relapse (HR 0.47, p 0.005) however higher non relapse mortality (NRM, HR 2.69, p 10 4) as compared to BF. This led to similar leukemia free (LFS) and overall survival (OS) between the two regimens (LFS: p 0.6; OS: p 0.27) When we selected TBF MAC patients receiving busulfan 9.6 mg/kg, NRM resulted still higher but no more significantly different as compared to BF MAC with busulfan 12.8 mg/kg (HR 1.53, p 0.12) despite the lower busulfan dose, relapse remained inferior with TBF MAC (HR 0.45, p 0.01) however no difference in survival could be demonstrated (LFS: p 0.31; OS: 0.82) Among patients receiving a reduced intensity (RIC) regimen, similar outcome was observed with TBF RIC and BF RIC (LFS: p 0.77; OS: p 0.88) Conclusions TBF MAC as conditioning regimen for transplant from MSD and URD in AML patients in first remission provided stronger anti leukemic activity but higher NRM as compared to BF MAC, thus leading to similar survival. TBF MAC with busulfan 9.6 mg/kg was associated with low relapse and acceptable NRM, however again with no survival benefit. TBF RIC and BF RIC resulted in comparable outcome.  We conducted a registry based study comparing outcomes of patients with AML in first remission undergoing transplant from MSD or URD prepared with either TBF (n 212) or BF (n 2698) conditioning.

title: Melatonin Ameliorates Busulfan Induced Spermatogonial Stem Cell Oxidative Apoptosis in Mouse Testes.
abstract: Many men endure immunosuppressive or anticancer treatments that contain alkylating agents before the age of sexual maturity, especially the increasing number of preadolescent males who undergo busulfan treatment for myeloablative conditioning before hematopoietic stem cell transplantation. Before sperm production, there are no sperm available for cryopreservation. Thus, it is necessary to identify a solution to ameliorate the busulfan induced damage of spermatogonial stem cells (SSCs)  In this study, we demonstrated that melatonin relieved the previously described SSC loss and apoptosis in mouse testes. Melatonin increased the expression of manganese superoxide dismutase (MnSOD) which regulated the production of busulfan induced reactive oxygen species (ROS) Moreover, melatonin promoted sirtuin type 1 (SIRT1) expression. SIRT1 participated in the deacetylation of p53, which promotes p53 ubiquitin degradation. Decreased concentrations of deacetylated p53 resulted in spermatogonial cell resistance to apoptosis.  T cell leukemia cell assay demonstrated that melatonin does not affect busulfan induced cancer cell apoptosis and ROS.  The current evidence suggests that melatonin may alleviate the side effects of alkylating drugs, such as busulfan.  Melatonin promoted MnSOD and SIRT1 expression, which successfully ameliorated busulfan induced SSC apoptosis caused by high concentrations of ROS and p53.

title: Effects of Carob (Ceratonia siliqua) on Sperm Quality, Testicular Structure, Testosterone Level and Oxidative Stress in Busulfan Induced Infertile Mice
abstract: Ceratonia silique has antioxidant activities that may inactivate toxic factors and influence sperm quality. To the best of the authors' knowledge, there is no available data on the effects of carob on male fertility. Hence, the purpose of this study was to investigate the effects of carob on sperm quality, testicular structure, and level of testosterone hormone in busulfan induced infertile mice.  Sixty four adult male mice were randomly divided into 8 groups (control, sham, busulfan and carobs 1 to 5) The busulfan group was injected a single dose of 10 mg/kg busulfan intraperitoneally. Carobs 1 to 5 groups received intraperitoneal doses of 800, 400, 200, 100 and 50 mg/kg of carob extract plus a single dose of 10 mg/kg busulfan for 35 days. The sperm analysis, morphometric study, testosterone levels and oxidative stress determination were done on the 35th day of the experiment.  The lowest percentage of sperm parameters was related to the busulfan group and the highest was related to the carobs 1 and 2 groups. The seminal vesicles index of the carob 1 group showed a significant increase as compared to the busulfan group (p 0.001) A significant increase was observed in the mean value of germinal epithelium thickness, as well as thiol and catalase levels in carobs 1 and 2 groups as compared to the busulfan group (p 0.001) There was a significant increase in the mean level of testosterone in the carob groups as compared to the busulfan group (p 0.001) Also, there was a significant decrease in the mean value of malondialdehyde level in the carobs 1 and 2 groups p 0.001) and a significant increase in the mean value of superoxide dismutase enzyme in the carob groups as compared to the busulfan group (p 0.001)  Administration of 800 mg/kg of carob extract for 35 days improved sperm quality, biochemical parameters, thickness of germinal epithelium and testosterone levels in infertile mice induced by busulfan.