High-dose Ara-C for remission induction and consolidation of previously untreated adults with ALL or lymphoblastic lymphoma

Thirty-two patients with untreated ALL (n = 26) or lymphoblastic lymphoma (n = 6) between 17 and 65 years of age were treated with a short remission induction course with VP16-213, amsacrine, intermediate dose Ara-C for 6 days, prednisone and intrathecal methotrexate, followed by a consolidation course with vincristine, amsacrine, high dose Ara-C for 4 days, prednisone and intrathecal methotrexate. After subsequent cranial irradiation, no further maintenance was planned. However, some patients underwent an allogenic (n = 5) or autologous (n = 5) bone marrow transplantation after the consolidation treatment. Twenty-three of 32 patients (72%) achieved a complete remission. Ten of 13 patients with T-ALL or lymphoma, six of eight patients with pre-B or common ALL, and seven of 11 patients with B-ALL or Burkitt's lymphoma achieved a complete remission. The median duration of remission was 24 months. Overall survival for the whole group was 35% at 5 years. The disease-free survival was 45% at 5 years. Long-term survival for patients with B or T-ALL was approximately 60%, compared with 15% for those with common or pre B-ALL. Short term intensive courses including intermediate or high dose Ara-C during remission and consolidation treatment lead to results comparable to those obtained with long-term maintenance regimens. Our regimen may be sufficient for patients with T or B-ALL. Larger randomized studies are needed to investigate the relative importance of our observations.

Short-term treatment for adult hypergranular and microgranular acute promyelocytic leukemia

A high hemorrhagic risk and a complete response to the differentiative agent all-trans-retinoic acid (ATRA) are the main clinical features of acute promyelocytic leukemia (APL), two distinct subtypes of which have been recognized, the common hypergranular leukopenic form (M3) and a microgranular hyperleukocytic variant (M3v). We analyzed, with emphasis on both disease- and therapy-related prognostic factors, the results from a 9-year trial in 65 adults with M3 and M3v APL, treated homogenously with a short-term therapy (STT) program excluding maintenance. STT comprised a maximum of six courses with doxorubicin, cytosine arabinoside (ara-C), and 6-thioguanine. Sixty-five APL patients formed the study group, M3v accounting for 25% of cases. In M3v, the absolute blast cell count was significantly higher (p < 0.0001) and early hemorrhagic deaths were more frequent (p = 0.05). The blast count correlated inversely with the probability of remission (p = 0.005), poor-risk patients being those with > 10 x 10(9)/l blast cells. During the study, the median survival improved from 0.1 to 2.7 years (p = < 0.005). In first place, response to chemotherapy increased from 42 to 84% (p = 0.006), by giving daily prophylactic platelet transfusions (to > 30 x 10(9)/l) and no heparin (course I), and by avoiding too toxic high-dose ara-C and deferring treatment in infected/neutropenic patients showing the atypical differentiative bone marrow pattern (course II). Secondly, the probability of first unmaintained remission differed significantly between patients given intentionally more than four total chemotherapy courses or intermediate/high-dose ara-C consolidation (0.59 at 5 years) and those treated less intensively (0.21) (p < 0.005). Intensive STT was very effective for the management of adult APL patients at standard hemorrhagic risk and receiving optimal supportive care. In high-risk patients with hyperleukocytosis and M3v, induction results could be improved by the concomitant use of ATRA. M3v in adults must be recognized promptly because of the very high early hemorrhagic risk.

Small noncleaved cell lymphoma and leukemia in adults. A retrospective study of 65 adults treated with the LMB pediatric protocols

In France, more than 80% of children with Burkitt's lymphoma or Burkitt's leukemia (ALL3) are now cured with the LMB (B-cell non-Hodgkin's lymphoma and B-ALL) protocols of the Société Française d'Oncologie Pédiatrique, but so far, poor results have been obtained in the few adult studies available. We have analyzed the experience with LMB protocols in adult patients. This retrospective study involved 65 adult patients with small noncleaved cell lymphoma or ALL3 treated with the LMB protocols. They were 17 to 65 years old and not previously treated. Human immunodeficiency virus-infected patients were excluded. The diagnoses were made between September 1984 and August 1991. According to the Murphy classification, 12 patients (18%) had stage I or II disease, 25 (38%), stage III disease; 4 (6%), stage IV disease; and 24 (37%), ALL3 (> or = 25% blasts). According to the Ann Arbor classification, 9 patients had stage I disease; 8 patients, stage II; 5 patients, stage III; 21 patients, stage IV disease; and 22 patients, ALL (> or = 30% blasts). Twelve patients had central nervous system (CNS) involvement before treatment. Thirty-nine patients were treated according to the LMB 84 protocol scheme; 14 according to the LMB 86 protocol, and 12 patients received the LMB 84 induction courses followed by the LMB 86 consolidation courses. Three patients underwent bone marrow transplantation (BMT) while in second complete remission (CR) and 3 others had refractory disease. There were some protocol violations caused by empirical medical decisions: local irradiation was performed in 4 patients, 2 patients received prophylactic radiation to the brain that was not specified in the protocol, 13 patients underwent BMT in first CR, and methotrexate doses were modified in 10 patients. Fifty-eight patients (89%) achieved a CR. There were four (6%) primary induction treatment failures, and three (4%) early treatment-related deaths. Eight patients relapsed between 2 and 30 months after CR (median, 4.7 months). Forty-seven patients are alive in CR (45 first CR, 2 second CR) with a median follow-up of 57 months (24 to 93 months). There were five toxicity-related deaths among patients in CR including four BMT-related deaths and five deaths caused by refractory relapses. One patient died in CR at 62 months of rectal cancer. The 3-year overall survival rate is 74% (SE = 5). According to the stages in the Murphy classification, the 3-year survival rates are stages I and II, 100%; stage III, 80% (SE = 7); and stage IV and ALL, 57% (SE = 8). Seven of 12 patients with initial CNS disease are alive with a median survival of 56 months.(ABSTRACT TRUNCATED AT 400 WORDS)

CD34 expression is associated with major adverse prognostic factors in adult acute lymphoblastic leukemia

Seventy-five adult patients with newly diagnosed acute lymphoblastic leukemia (ALL) were analyzed for CD34 expression on leukemic cells. CD34 was significantly associated with B-cell lineage ALL (p = 0.0002). In B-lineage ALL, CD34 positivity was significantly associated with expressions of CD9 (p = 0.001), CD19 (p = 0.00001) and CD22 (p = 0.002). CD34 was more expressed in B-ALLs with higher WBC cell count (p = 0.04), and higher percentage of peripheral blood leukemic cells (p = 0.005), total or partial monosomy of chromosome 7 (p = 0.0001) or Ph+ chromosome (p = 0.01); and less expressed in cases with hyperdiploidy (> or = 50 chromosomes) (p = 0.03). CD34 was more expressed in poor risk B-ALLs patients, defined according to Hoelzer criteria (p = 0.01). In T-lineage ALL, CD34 positivity was inversely correlated with the expression of CD10 (p = 0.05). After intensive induction therapy, 58 of 73 evaluable patients (79%) achieved a complete remission (CR). CD34 positivity was correlated with the persistence of blast cells in day 15 bone marrow aspirates (p = 0.001) and after one course of induction chemotherapy (p = 0.01). With a median follow-up of 11 months, no statistical differences were seen in leukemia-free survival and overall survival between CD34 positive and negative cases, even when stratifying by immunophenotype. We conclude that CD34 expression is associated with features of poor prognosis in adult ALL. Its study might therefore become useful in the design of future prognostic models.

Treatment of newly diagnosed acute promyelocytic leukemia (APL) by all transretinoic acid (ATRA) combined with chemotherapy: The European experience. European APL Group

All transretinoic acid (ATRA) gives complete remission (CR) rates of 80 to 90% in newly diagnosed acute promyelocytic leukemia (APL). However, it has two major drawbacks (1) a rapid rise in WBC in some patients, with potentially fatal ATRA syndrome (2) rapid relapse with maintenance therapy using ATRA alone or low dose chemotherapy. The French APL group therefore designed a treatment approach with ATRA followed by intensive chemotherapy. The latter was administered after CR achievement with ATRA, or was rapidly added to ATRA in case of rapid rise in leukocyte counts. This combined approach, in a pilot study and in a randomized trial, proved superior to intensive chemotherapy alone, by slightly increasing the CR rate but more importantly by reducing the relapse rate. These results were confirmed by the Chinese, Japanese and New York groups. Our group (and other European groups) are now testing in a new randomized trial the better timing of ATRA and chemotherapy administration (ATRA followed by chemotherapy or ATRA plus chemotherapy) and the role (after an intensive consolidation) of maintenance treatment with intermittent ATRA, continuous low dose chemotherapy or both.

[Treatment for elderly patients with acute non-lymphocytic leukemia]

A retrospective analysis was performed on forty nine elderly (34 males and 15 females) patients aged 65 years or more (median age 73, range 65-82) with acute non-lymphocytic leukemia (ANLL). Patients were studied to examine factors according to age group (65-69 years, 70-74, 75-79 and 80 or over), respectively. Patients were treated with either low dose Ara-C therapy or BHAC-DMP therapy according of the choice of their attending physicians. Complete remission (CR) was obtained in 20 of 49 patients (43%), and in 6 of 14 patients (43%) aged 65-69, in 8 of 18 (44%) aged 70-74, in 5 of 12 (42%) aged 75-79 years and in 1 of 3 (33%) aged 80 or over, respectively. The median survivals of these groups were 263, 298, 260, 168.5 and 38.5 days, respectively. Multivariate analysis revealed that the achievement of CR was associated with normal karyotype, and serum GOT level < or = 30 mu/ml and GPT < or = 40 mu/ml. Prolonged survival was related to the achievement of CR. The results indicated that liver function before chemotherapy was an important prognostic factor.

Modulation of the cellular metabolism of cytarabine and fludarabine by granulocyte-colony-stimulating factor during therapy of acute myelogenous leukemia

Previous in vitro investigations demonstrated that human leukemia cells, when incubated with hematopoietic growth factors such as granulocyte-colony-stimulating factor (G-CSF), augment the accumulation of the triphosphate 1-beta-D-arabinofuranosylcytosine (ara-C cytarabine). To test whether G-CSF infusion prior to ara-C infusion would biologically modulate the accumulation of ara-9-beta-D-arabinofuranosylcytosine 5'-triphosphate (ara-CTP) and other ara nucleotides in the leukemia blasts during therapy, protocols were designed to infuse G-CSF prior to fludarabine (9-beta-D-arabinofuranosyl-2-fluoroadenine monophosphate) and ara-C to increase the accumulation of the active triphosphates [9-beta-D-arabinofuranosyl-2-fluoroadenine 5'-triphosphate (F-ara-ATP) and ara-CTP] in acute myelogenous leukemia (AML) blasts during therapy. To complement these in vivo studies, ex vivo accumulation of ara-CTP was also investigated before and after G-CSF infusion. Patients (n = 5) treated on the fludarabine/ara-C/G-CSF regimen received a 30 mg/m2 dose of fludarabine followed by a 2 g/m2 dose of ara-C infused i.v. for 4 h. Beginning at 24 h, and every day, patients received a 6-h infusion of 400 microgram/m2 G-CSF. At 48 h, the fludarabine and ara-C couplet was repeated. Comparison of F-ara-ATP pharmacokinetics in circulating AML cells of patients on the fludarabine/ara- C/G-CSF regimen demonstrated that the area under concentration time curve (AUC) of F-ara-ATP increased significantly (median, 1.4-fold; range, 0.9-1.5; P = 0.045) after G-CSF infusion. This was due to an increased rate of F-ara-ATP accumulation by AML cells. The AUC of ara-CTP, on the other hand, was not affected (median, 1.0-fold; range, 1.0-1.2; P = 0.571) after G-CSF infusion. Because fludarabine potentiates the accumulation of ara-CTP, the effect of G-CSF on ara-CTP metabolism may not be evident in the AML blasts of patients on the fludarabine/ara-C/G-CSF regimen. To determine the effect of G-CSF when ara-C was infused alone, four additional patients were treated on a pilot protocol in which ara-C (2 g/m2) was infused on days 1 and 3 and G-CSF on day 2. The AUC of ara-CTP accumulation in these patients decreased by a median of 48% after G-CSF infusion. Consistent with these in vivo investigations, ex vivo ara-CTP accumulation was decreased in the AML blasts after G-CSF infusion. Based on these data it could be concluded that (a) infusion of G-CSF before fludarabine augmented the rate of F-ara-ATP synthesis in circulating AML blasts during therapy, suggesting that G-CSF may benefit fludarabine therapy by biological modulation; (b) G-CSF did not increase ara-CTP accumulation, rather it may have caused it to decrease; and (c) these data imply that when G-CSF and ara-C are used in combination, administration of fludarabine prior to ara-C may maintain the ara-CTP AUC.

[Complete remission achieved by low-dose Ara-C, aclarubicin and rhG-CSF (CAG) therapy in acute non-lymphocytic leukemia with monosomy 7 occurring after severe aplastic anemia]

We report a case of acute myelogenous leukemia (AML), which developed from severe aplastic anemia (SAA) and was successfully treated by low-dose Ara-C and aclarubicin with concomitant use of G-CSF (CAG therapy). A 37-year-old male was admitted for scrutiny of pancytopenia and diagnosed as SAA because of hypocellular bone marrow without abnormal or dysplastic cells. Although hematopoiesis recovered with steroid pulse therapy followed by administration of anabolic steroids, 29 months after initial onset of SAA, he presented as AML (FAB-M6), as his bone marrow Contained 21.6% leukemic myeloblasts and 56% of erythroblasts. Chromosome study revealed 45, XY, -7 in 14 of 20 cells analyzed. Complete remission was achieved by administration of low-dose Ara-C (20 mg/m2 for 7 days) and aclarubicin (14 mg/m2 for 4 days) along with G-CSF (200 micrograms/m2 for 7 days), without any severe complications. In the previous reports in Japan since 1982, 7 out of 8 cases with AML developing from SAA died within a year. Our results indicate that CAG therapy is useful for treatment for this subset of AML with poor prognosis.

Improved treatment results of non-Hodgkin's lymphoma in children: a report from the Children's Cancer and Leukemia Study Group of Japan

From 1985 to 1989, 69 patients with non-Hodgkin's lymphoma (NHL) were treated by members of the Children's Cancer and Leukemia Study Group of Japan with a protocol consisting of vincristine, prednisolone, cyclophosphamide, doxorubicin, high-dose methotrexate (HD-MTX), mercaptopurine and cytarabine; central nervous system (CNS) prophylaxis with intrathecal MTX and hydrocortisone (NHL855). The 4-year event-free survival (EFS) was 78% (S.E., 10%) for patients with localized disease (n = 18) and 38% (S.E., 7%) for those with advanced disease (n = 51). Among the patients with advanced disease, those with non-lymphoblastic lymphoma tended to have a better 4-year EFS than those with lymphoblastic lymphoma (52% vs. 25%). Based on these findings, we initiated a new protocol NHL890 in which patients were assigned to two different chemotherapies according to the histology. Non-lymphoblastic subtype was treated almost identically to NHL855 while asparaginase and VP-16 were newly added in the consolidation-maintenance phase in advanced-stage lymphoblastic lymphoma. Sixty-seven patients with advanced disease were assessable. The overall 4-year EFS for advanced disease improved to 69% (S.E., 6%). A significant improvement was gained in the lymphoblastic lymphoma with a 4-year EFS of 56% (S.E., 11%) as compared with 25% (S.E., 9%) in the preceding study (P < 0.05). These findings suggest the importance of histology in the treatment of advanced-stage non-Hodgkin's lymphoma in childhood.

[Extramedullary relapse in childhood acute lymphoblastic leukemia: experience at the Kyushu Yamaguchi Children's Cancer Study Group]

Since October 1984, children with acute lymphoblastic leukemia (ALL) were treated with six protocols of the Kyushu-Yamaguchi Children's Cancer Study Group (KYCCSG). We reviewed cases in whom the first relapse sites of ALL were CNS, testis and ovary. Between October 1984 and July 1993, 302 children with ALL were registered. Ten children (3.3%) developed CNS-L. After treatment for CNS-L, four cases were alive, however one of them has had several episodes of CNS-L. Testicular relapse occurred in 8 boys and three of them are alive. One girl developed ovarian and uterine involvement 7 months after completion of treatment and she survived after intensive chemotherapy for an additional 3 years. Before September 1990, children with ALL received 18Gy cranial irradiation in standard risk group and 24Gy in high risk group. Since October 1990, children with ALL received no cranial irradiation in low risk group, 15Gy in intermediate risk group and 18Gy in high risk group. Incidence of CNS-L has not increased in children treated with protocols, in which cranial irradiation was reduced.

Delayed neutrophil recovery after BEAM chemotherapy and autologous bone marrow transplantation for lymphoma is not associated with increased mortality from infection

Administration of high-dose cytotoxic therapy with autologous bone marrow transplantation (BMT) results in prolonged cytopenia and significant morbidity and mortality. Several groups have reported that the administration of recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) to patients with delayed haematological recovery following autologous BMT may accelerate neutrophil recovery and decrease mortality. We have determined the prevalence and natural history of delayed neutrophil recovery following BEAM chemotherapy and autologous BMT for malignant lymphoma in 261 patients treated at a single institution without the use of haemopoietic growth factors. Forty of 261 (15%) patients took > 28 days to reach an absolute neutrophil count (ANC) > 0.5 x 10(9)/L; 29 of these 40 (73%) with delayed engraftment reached an ANC > 0.5 x 10(9)/L by day +42. Five patients with delayed engraftment died before day +100, two of progressive lymphoma, one from unirradiated blood product-related GVHD and two of interstitial pneumonitis (IP). The patients with IP had negative culture and bronchoscopic examinations and onset of assisted ventilation was day +15 and +18, respectively. These results show a high rate of relatively rapid spontaneous recovery in individuals with delayed neutrophil recovery after BEAM plus autologous BMT with a low incidence of death from infection.

Factor VIII inhibitor prior to and during secondary acute nonlymphocytic leukemia in a patient with cured Hodgkin's disease

We report a 54-year-old patient with Hodgkin's disease who achieved a complete remission after combined modality treatment. Three years later the patient developed a severe hemorrhagic syndrome, concomitant with the onset of a factor VIII inhibitor in plasma. The control of very proteiform bleedings was extremely difficult, even with plasmaphereses, as well as with immunosuppressive and substitutive therapies. Two years later, a secondary acute nonlymphocytic leukemia (ANLL) was diagnosed. Two courses of chemotherapy with fludarabine, cytosine arabinoside and G-CSF (FLAG) were able to obtain a complete remission. Hemorrhagic complications were mainly linked to thrombocytopenia and continued until recovery of thrombopoiesis. Factor VIII inhibitor levels and related clinical symptoms decreased progressively. In conclusion, we suggest that FLAG succeeded in inhibiting an abnormal lymphoid clone responsible for factor VIII inhibitor production, suggesting a possible role for intensive chemotherapy in similar situations, which are often refractory to conventional immunosuppressive and depletive therapy.

Acute leukemia coexpressing myeloid, B- and T-lineage associated markers: multiparameter analysis of criteria defining lineage commitment and maturational stage in a case of undifferentiated leukemia

Coexpression of myeloid, B-, and T-lineage associated markers was found in a patient with morphologically and cytochemically undifferentiated acute leukemia. Surface marker analysis using two-color immunofluorescence staining characterized blast cells to express CD34, CD38, CD117, and class II antigens, coexpressing TdT, CD4, CD7, CD13, CD19, and CD33. Cytoplasmic expression of myeloperoxidase, CD3, and CD22 could not be demonstrated. Monosomy for chromosome 7 was found by cytogenetic analysis. The absence of clonal rearrangements of immunoglobulin or T-cell receptor genes was shown by Southern blot analysis. Using a 3H-thymidine incorporation assay, DNA synthesis of leukemic blasts could be stimulated by IL-3, IL-6 and G-CSF in vitro. The present case did not offer specific criteria of lineage commitment. Corresponding to an equivalent counterpart in normal hematopoiesis, the involved cell population may reflect an early, most immature developmental stage within a multipotent progenitor cell compartment.

[Leukemia and pregnancy. Review apropos of a clinical case]

A clinical case is presented of a 37 year old patient with acute myelocytic leukemia who conceived while in therapy. The pregnancy was controlled in our department in association with the Hematology Department. A cesarean section was performed in the 37th week of gestation, resulting in a healthy newborn. A review of literature is presented, analyzing the association between these two conditions, as well as repercussion on the mother and infant and the recommended obstetric management.

Heterogeneity of acute myeloblastic leukemia without maturation: an ultrastructural study

We demonstrated by ultrastructural examination that the leukemic blasts of 13 patients with acute myeloblastic leukemia (AML) without maturation (M1 in the French-American-British classification) showed heterogeneous features. In 7 patients, the leukemic blasts had a high level of light microscopic myeloperoxidase positivity (> 50%). Ultrastructurally, the cells were myeloblast-promyelocytes with 100% myeloperoxidase positivity, and these 7 patients appeared to have typical AML. In contrast, the remaining 6 patients had leukemic blasts with a low myeloperoxidase positivity (< 50%) and heterogeneous features. Three had ultrastructural features of myelomonocytic or monocytic lineage, 1 had myelomonocytic cells associated with megakaryoblasts, and 1 had undifferentiated blasts. The former group had a better prognosis than the latter, indicating that ultrastructural analysis of M1 leukemia may help predict the response to therapy.

Concurrent use of granulocyte colony-stimulating factor with low-dose cytosine arabinoside and aclarubicin for previously treated acute myelogenous leukemia: a pilot study

We used a new chemotherapy regimen for the treatment of 18 consecutive patients with relapsed AML (median age 44 years, range 18-74). The regimen consisted of low-dose cytosine arabinoside (10 mg/m2/12 h, usually day 1 to 14), low-dose aclarubicin (10-14 mg/m2/day, day 1 to 4), and concurrent use of G-CSF (200 micrograms/m2/day) (CAG regimen). Overall, 15/18 patients (83%) achieved complete remission (CR) after one or two courses, including eight out of ten refractory patients with early relapse, second or subsequent relapses, and/or resistant relapse. Two of three patients who relapsed, achieved CR again after reinduction with a modified CAG regimen. Fourteen of the 15 complete remitters received consolidation therapy with the CAG regimen modified, followed by oral busulfan in eight cases, and by allogeneic bone marrow transplantation in two cases. At a median follow-up of 12 months, median CR duration and survival were 6 months and 17 months, respectively. Myelosuppression in the first course of induction therapy was moderate to severe. However, severe non-hematologic toxicity (WHO grade > or = 3) was characteristically rare. Although this is a preliminary study, the CAG combination seems promising for the treatment of relapsed AML, with its low toxicity contributing to a higher quality of life for the patient.

Secondary tumours following etoposide containing therapy for germ cell cancer

BACKGROUND

Reports have implied etoposide as the cause of secondary leukaemia in patients treated for germ cell cancer.

PATIENTS AND METHODS

Between 1979 and 1992, 679 male patients with germ cell cancer received etoposide containing chemotherapy.

RESULTS

Six of 679 patients developed acute myeloid leukaemia (relative risk 150; CI: 55-326). None of these patients had a primary mediastinal germ cell tumour and only 1 patient received previous radiotherapy. The median interval between the onset of cytotoxic treatment and the development of leukaemia was 27 months. The FAB M4 morphology was seen in 4 of 6 cases.

CONCLUSION

The benefit of etoposide containing protocols outweigh the risk of leukaemia in patients with intermediate or high risk disease, however in patients with good risk disease non-etoposide containing protocols should be explored.

[Continuation of complete remission by oral administration of cytarabine ocfosfate in a patient with M0, who achieved remission by small doses of cytosine arabinoside with G-CSF]

A 70-year-old male was admitted to our hospital because of leukocytosis. The laboratory examination revealed leukocytosis (44,500/microliters) with blasts (99%) in the peripheral blood. Myeloperoxidase staining of the leukemia cells was negative, but the surface phenotype was CD13- and CD33-positive, and negative for all lymphoid antigens. Peroxidase staining using the electron microscope was positive. Thus, the patient was diagnosed as acute myeloblastic leukemia (M0), according to the FAB classification. Although the therapy regimens commonly used for ANLL were effective for some cases with M0, the regimens mainly for ALL were more effective for the others. Thus we cannot determine what is the most effective regimen for M0. Since the patient had many complications, he was treated with low-dose AraC instead of combination chemotherapy. After the beginning of treatment, he became febrile and we added G-CSF to Ara-C. One month later, the patient achieved complete remission without severe infection. After four courses of consolidation therapy, the patient was discharged. He has been maintained in remission for more than 3 years and 8 months with only 5-day oral administration of cytarabine ocfosfate every four weeks.

Recombinant interferon alpha 2a, thymopentin and low doses of cytosine arabinoside for the treatment of myelodysplastic syndromes: a pilot study

Eighteen patients (pts) with myelodysplastic syndrome (MDS) were treated with thymopentin (TP) (50 mg subcutaneously for 5 days) and recombinant interferon alpha 2a (rIFN alpha 2a) (3 MU/m2 subcutaneously on the sixth day); the courses were delivered every week. Moreover those pts with > or = 10% blasts in the bone marrow were additionally treated with low dose cytosine arabinoside (LDARAc) (20 mg standard dose, subcutaneously, twice a day for seven days every four weeks). Sixteen pts were finally assessable for response. Seven pts (44%) were classified as good responders, 5 (31%) had a PR; the overall response rate (GR+PR) was 75%. Two pts (12.5%) showed stable disease and the 2 remaining (12.5%) had progressive disease. Six pts with an initial moderate anemia never required supportive care before and during the therapy; in contrast to 10 pts who were transfusion-dependent. After six months of therapy 2 pts decreased their transfusional needs by 50% (1 of them did not receive any transfusion over the following six months of therapy); 2 pts needed no packed red cell infusions and 1 pt decreased his transfusional support by 75%. Five pts kept an unchanged supportive care load. The overall median survival was 12.5 months. Therapy was generally well tolerated with acceptable compliance; the most frequently recorded side effects were neutropenia and thrombocytopenia grade 2-3 among the group receiving LDARAc. However no life-threatening infectious episodes or bleeding were observed. TP, rIFN alpha 2a and LDARAc can be safely administered on an outpatient basis to MDS pts and appears to have significant activity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of induction therapy in newly diagnosed acute myeloid leukemias in study 911 at the Institute of Hematology and Blood Transfusion]

Thirty-seven patients with de novo acute myeloid leukemias were admitted to the Institute of Hematology and Blood Transfusion in Prague in February 1991-December 1993. Their age was 18-85 years with a median of 46 years. Two patients died on the day of admission, chemotherapy was initiated in 35 patients. Altogether 27 patients (77%) achieved complete remission (CR), i.e. 18 (81%) of 22 patients younger than 55 years and 9 (70%) of 13 patients older than 55 years. Only 7 (35%) of 20 patients achieved CR after a single therapy course 3/7 consisting of 3 doses of daunorubicin 45 mg/m2 on days 1, 3, 5 and cytosine arabinoside 150-200 mg/m2 every 12 hours for 7 days. However, 8 (61%) of 13 patients achieved CR after a single treatment course 4/7 with 4 doses of daunorubicin 45 mg/m2 on days 1, 3, 5, 7 and identical doses of cytosine arabinoside as in the 3/7 treatment. We used the course with 10 high-doses of cytosine arabinoside 2000 mg/m2 every 12 hours and daunorubicin 45 mg/m2 on days 4 and 5 (treatment HDAC/DNR) as the 1st, 2nd or 3rd induction therapy in 12 patients and 9 (75%) of them achieved CR. The treatment was associated with a high toxicity. An intensified therapy 3/7h similar to the 3/7 one but with the doubled dose of cytosine arabinoside 300-400 mg/m2 on days 5-7 was given to 5 patients as the 2nd induction but it did not improve the CR rate and it was associated with a high toxicity similar to the HDAC/DNR therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Polymer-coated liposomes: improved liposome stability and release of cytosine arabinoside (Ara-C)

Liposomes of dimyristoylphosphatidylcholine (DMPC) or dipalmitoylphosphatidylcholine (DPPC), cholesterol (CHOL) and dicetylphosphate (DCP) containing Ara-C were prepared at pH 4.5 and subsequently coated with a derivatized polysaccharide, O-palmitoylpullulan (OPP). Encapsulation efficiencies (EEF) of DMPC:CHOL:DCP (3:1:2 mol ratio) and DPPC:CHOL:DCP (3:1:0.5 mol ratio) liposomes were respectively 28 and 40% before and 15 and 27% after coating with polymer. Stabilities of liposomes in sodium cholate (SC) concentrations up to 16 mM at pH 5.6 or in SC solutions at pH 7.4 were increased by coating with OPP. At pH 2.0 and 37 degrees C, Ara-C was released at a slow rate, kuo (uncoated) or kco (coated), for 24 h after an initial rapid release phase that lasted for about 6 h and the ratio kuo/kco, was 1.9 and 5.7 for the DMPC:CHOL:DCP and the DPPC:CHOL:DCP compositions respectively. At pH 7.4 and 37 degrees C in the presence of 10 mM SC, the ratio kuo/kco was 5.1 and 1.4 respectively. It is concluded that coating liposomes with OPP increases the potential of using liposomes as a drug delivery system in harsh environments such as encountered after oral administration, although the magnitude of the effect is dependent on the liposome composition.

Mesna/ifosfamide, mitoxantrone, etoposide, bleomycin, vincristine, prednisone (MINE-BOP) combination chemotherapy in the treatment of refractory and relapsed non-Hodgkin's lymphoma

Twenty-one consecutive patients with refractory or relapsed non-Hodgkin's lymphomas were treated with a novel combination chemotherapy (MINE-BOP), comprising myelosuppressive (ifosfamide, mitoxantrone, etoposide) and non-myelosuppressive (bleomycin, vincristine and prednisone) drugs. Median age of the patients was 42 years and all had intermediate or high-grade lymphoma. Fifteen patients had refractory disease. All patients had previously been treated with one or two regimens, containing anthracyclines. In all cases the duration between the last chemotherapy and the MINE-BOP regimen was shorter than 12 months. Response rate was 57% with 33% complete remission (CR). Median disease-free and overall survivals were 7 and 10 months respectively. The serum LDH level was the only significant prognostic factor in this study. The toxicity of this regimen was moderate with 24% of febrile neutropenia and 9% of microscopic hematuria. Toxic death due to febrile neutropenia was observed in one patient who had bone marrow involvement. To conclude, the addition of non-myelosuppressive drugs to the chemotherapy regimen and shortening the interval between the application of cytotoxic drugs as used in the present study did not show any improvement of response and survival in this group of patients.