Continuous lenalidomide treatment for newly diagnosed multiple myeloma

BACKGROUND

Lenalidomide has tumoricidal and immunomodulatory activity against multiple myeloma. This double-blind, multicenter, randomized study compared melphalan-prednisone-lenalidomide induction followed by lenalidomide maintenance (MPR-R) with melphalan-prednisone-lenalidomide (MPR) or melphalan-prednisone (MP) followed by placebo in patients 65 years of age or older with newly diagnosed multiple myeloma.

METHODS

We randomly assigned patients who were ineligible for transplantation to receive MPR-R (nine 4-week cycles of MPR followed by lenalidomide maintenance therapy until a relapse or disease progression occurred [152 patients]) or to receive MPR (153 patients) or MP (154 patients) without maintenance therapy. The primary end point was progression-free survival.

RESULTS

The median follow-up period was 30 months. The median progression-free survival was significantly longer with MPR-R (31 months) than with MPR (14 months; hazard ratio, 0.49; P<0.001) or MP (13 months; hazard ratio, 0.40; P<0.001). Response rates were superior with MPR-R and MPR (77% and 68%, respectively, vs. 50% with MP; P<0.001 and P=0.002, respectively, for the comparison with MP). The progression-free survival benefit associated with MPR-R was noted in patients 65 to 75 years of age but not in those older than 75 years of age (P=0.001 for treatment-by-age interaction). After induction therapy, a landmark analysis showed a 66% reduction in the rate of progression with MPR-R (hazard ratio for the comparison with MPR, 0.34; P<0.001) that was age-independent. During induction therapy, the most frequent adverse events were hematologic; grade 4 neutropenia was reported in 35%, 32%, and 8% of the patients in the MPR-R, MPR, and MP groups, respectively. The 3-year rate of second primary tumors was 7% with MPR-R, 7% with MPR, and 3% with MP.

CONCLUSIONS

MPR-R significantly prolonged progression-free survival in patients with newly diagnosed multiple myeloma who were ineligible for transplantation, with the greatest benefit observed in patients 65 to 75 years of age. (Funded by Celgene; MM-015 ClinicalTrials.gov number, NCT00405756.).

[Induction chemotherapy followed by chemoradiotherapy for the patients with far-advanced nasopharyngeal carcinoma - our treatment strategy]

Nasopharyngeal carcinoma(NPC)is a rare malignant neoplasm arising from the head and neck region that affects less than 1 per 100, 000 in the Japanese population. NPC is a highly radiosensitive and chemosensitive cancer when compared to other head and neck cancers. Its treatment has mainly been developed by using radiotherapy and chemotherapy, rather than surgery. The standard of care now calls for radiotherapy alone for early-stage patients, and chemoradiotherapy for the advanced stages. Despite its sensitivity to treatments, survival rates of patients with Stage IV A, IV B, N 2/3 have been inadequate. The effectiveness of triplet-regimen induction chemotherapy for patients with locally advanced head and neck cancer has recently been reported. Since 2009, we have tried to improve survival by treating patients with triplet-regimen induction chemotherapy consisting of docetaxel, cisplatin and S-1, followed by cisplatin-based chemoradiotherapy. This treatment strategy has dramatically improved both overall survival and the complete response rate. Although it is a very promising treatment, it is highly toxic at the same time. We have experienced more than a few hematological and non-hematological grade 3/4 toxicities. Therefore, when conducting a treatment, considering its indication and building a sufficient back-up system are very important.

[Fulminant hepatitis possibly caused by L-asparaginase during induction chemotherapy in a patient with acute lymphoblastic leukemia]

We report a 44-year-old man with acute lymphoblastic leukemia (ALL) presenting with fever and lymphadenopathy. Induction chemotherapy was initialed according to the JALSG ALL202 protocol, and L-asparaginase (L-asp) was given on days 20, 22, and 24 of therapy. Abrupt elevations of liver transaminase and bilirubin levels were observed on day 26. On day 30, coagulopathy and hepatic encephalopathy appeared. He was diagnosed with fulminant hepatitis and plasma exchange was performed, but he died on day 32, possibly due to L-asp-induced hepatitis. The common side effects of L-asp are hypersensitivity, ammonemia, coagulopathy, pancreatitis, convulsions, anaphylaxis, hepatotoxicity, and thrombosis. Although rare, reports of deaths due to hepatic failure during treatment with L-asp exist. L-asp is currently used for treatment of a wide range of hematological malignancies such as ALL and NK/T-cell lymphoma. A retrospective analysis of patients treated with L-asp should be carried out to elucidate the incidence and risk factors of liver dysfunction and fulminant hepatitis during L-asp treatment.

Tumor heparanase expression in predicting response to induction chemotherapy in patients with locally advanced laryngeal cancer

PURPOSE

Induction chemotherapy is a feasible alternative to surgery for the treatment of locally advanced laryngeal cancer. Determining predictive factors associated with a better response to chemotherapy would help choose the patients most likely to benefit from larynx preservation.

METHODS

Eighty-four patients diagnosed with locally advanced laryngeal cancer (stage III-IV) between April 1999 and May 2006 were retrospectively reviewed. Eightytwo of them received 2 cycles and 2 received only 1 cycle of cisplatin and 5-fluorouracil (5-FU) chemotherapy. Patients were then grouped, based on response to treatment, as either having complete response (CR), partial response (PR), stable (SD) or progressive disease (PD). Factors predicting response to treatment were evaluated. Paraffin blocks were immunohistochemically examined for heparanase activity to see for any link between heparanase expression and response to treatment.

RESULTS

There were 73 males and 11 females with a mean age of 59 years. After induction chemotherapy (cisplatin and 5-FU), 33 patients achieved PR and 20 CR. SD and PD occurred in 9 and 21 patients, respectively. Patients with stage III disease had better overall (CR and PR) response rates when compared with those with stage IV disease. Moreover, development of bone marrow suppression and heparanase positivity were both associated with better overall response rates.

CONCLUSION

This study supports the hypothesis that heparanase positivity is associated with better responses to induction chemotherapy, regardless of TNM stage. Furthermore, a higher overall response rate was observed in patients who developed myelosuppression secondary to chemotherapy.

[Clinical analysis on adult acute T-lymphoblastic leukemia]

This study was aimed to summarize and analyze the clinical features and biological characteristics of adult acute T-lymphoblastic leukemia (T-ALL), and compare the efficacy of chemotherapy and transplantation in order to explore the factors influencing the long term survival and prognosis. Twenty-two T-ALL patients, all of whom were initially diagnosed according to MICM classification criteria from May 2000 to May 2010, were enrolled in this study. All patients received VDCLP regimen as the induction chemotherapy. In consolidation stage, some of the patients received allogeneic hematopoietic stem cell transplantation (allo-HSCT) and the others underwent intensive chemotherapy. The clinical and laboratory parameters were summarized and the contribution to survival and efficacy was analyzed by using χ(2) test, Kaplan-Meier method, Cox regression analysis and log-rank test with the aid of SPSS13.0 software. The results showed that: (1) The median age of all 22 patients was 23.5 years (16 - 63 years). 15 patients with splenomegaly had much shorter event-free survival (EFS) period (P = 0.014) and overall survival (OS) period (P = 0.013). The median white blood cell (WBC) count was 148.82 (5.51-546.0) × 10(9)/L. 15 cases out of them had leucocytosis (WBC ≥ 80 × 10(9)/L), whose EFS period (P = 0.021) and OS time (P = 0.050) were reduced significantly. The similar condition was observed in 6 patients whose blood platelet (Plt) count was no more than 30 × 10(9)/L (P = 0.033 for EFS and P = 0.035 for OS, respectively); (2) Immunophenotypic analysis showed that from 22 cases 2 cases were of pro-T, 14 cases of pre-T, 3 cases of cortical-T and 3 cases of medullary-T. Supposing pro-T and pre-T as earlier period immunophenotype, cortical-T and medullary-T as advanced stage immunophenotype, there were significant differences between earlier period and advanced stage patients in terms of EFS and OS (P = 0.035 for EFS and P = 0.028 for OS, respectively); (3) Chromosome karyotype was analyzed in 19 cases at diagnosis, and among them 12 cases had normal karyotypes while abnormal karyotypes were observed in 7 cases. Correlation analysis showed that there were no significant differences between these two groups in time of EFS and OS; (4) The overall complete remission (CR) rate was 72.7 after the induction chemotherapy. The median CR period was 18.0 months. The EFS and OS rate were 57.9 and 67.1 for 1-year, and 23.0 EFS rate and 22.0 OS rate for 3-years, respectively. Six patients received allo-HSCT and the average EFS time and OS time were both 57.8 months, which were significantly longer than those of the intensive chemotherapy group (P = 0.001 and P = 0.002 for EFS and OS, respectively); (5) Cox regression analysis proved that allo-HSCT treatment was the independent favorable prognostic factor. It is concluded that higher CR rate can be achieved by using intensive induction chemotherapy in adult T-ALL, but the long term survival seems poor by chemotherapy only in consolidation treatment stage. Allo-HSCT is the optimal choice to improve the prognosis and the outcome.

Similar survival with single-agent capecitabine or taxane in first-line therapy for metastatic breast cancer

Capecitabine is often offered as a first-line chemotherapy option for metastatic breast cancer (MBC). In this study, we compare characteristics of and survival among women prescribed first-line capecitabine or taxane monotherapy for MBC. Women receiving first-line chemotherapy for MBC from 1998 to 2005 were identified from the North Carolina tumor registry linked with Medicaid and Medicare claims records, and were followed through the end of 2005 with survival data from the National Death Index. T Tests and Chi-square tests were used to compare baseline characteristics. Overall survival and cancer-specific survival were examined using Cox proportional hazard modeling. There were 257 patients with MBC starting first-line chemotherapy with capecitabine (n=71) or a taxane (n=186). No differences in age, race, or Charlson comorbidity status were observed between groups. Hormone receptor negative tumors (31.0 vs. 17.7%, p=0.02) and patients insured by Medicaid (28 vs. 12%, p=0.002) were more prevalent in the capecitabine group. Time from metastasis to first-line chemotherapy was longer in the capecitabine group (52 vs. 26% began after 3 months, p<0.001). In multivariate analysis, treatment received was not associated with overall or cancer-specific survival. Among standard demographics, age was the only factor significantly associated with overall survival (HR 1.02, p=04). In this population-based study, women who received capecitabine as first-line treatment for MBC were more often hormone receptor negative and insured by Medicaid. In multivariate analysis, first-line capecitabine and taxane for MBC yielded similar overall and cancer-specific survival outcomes.

Pharmacokinetic modeling of an induction regimen for in vivo combined testing of novel drugs against pediatric acute lymphoblastic leukemia xenografts

Current regimens for induction therapy of pediatric acute lymphoblastic leukemia (ALL), or for re-induction post relapse, use a combination of vincristine (VCR), a glucocorticoid, and L-asparaginase (ASP) with or without an anthracycline. With cure rates now approximately 80%, robust pre-clinical models are necessary to prioritize active new drugs for clinical trials in relapsed/refractory patients, and the ability of these models to predict synergy/antagonism with established therapy is an essential attribute. In this study, we report optimization of an induction-type regimen by combining VCR, dexamethasone (DEX) and ASP (VXL) against ALL xenograft models established from patient biopsies in immune-deficient mice. We demonstrate that the VXL combination was synergistic in vitro against leukemia cell lines as well as in vivo against ALL xenografts. In vivo, VXL treatment caused delays in progression of individual xenografts ranging from 22 to >146 days. The median progression delay of xenografts derived from long-term surviving patients was 2-fold greater than that of xenografts derived from patients who died of their disease. Pharmacokinetic analysis revealed that systemic DEX exposure in mice increased 2-fold when administered in combination with VCR and ASP, consistent with clinical findings, which may contribute to the observed synergy between the 3 drugs. Finally, as proof-of-principle we tested the in vivo efficacy of combining VXL with either the Bcl-2/Bcl-xL/Bcl-w inhibitor, ABT-737, or arsenic trioxide to provide evidence of a robust in vivo platform to prioritize new drugs for clinical trials in children with relapsed/refractory ALL.

Mycophenolate mofetil versus intravenous cyclophosphamide for induction treatment of proliferative lupus nephritis in a Japanese population: a retrospective study

OBJECTIVES

Recent studies have shown that mycophenolate mofetil (MMF) is similar to intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis (LN), but that treatment response may vary according to location and race/ethnicity. Moreover, no studies have been conducted to compare the efficacy of MMF with that of IVC for a Japanese population. We therefore conducted a retrospective study to clarify the efficacy and safety of MMF compared with that of IVC for induction therapy for active LN, classes III and IV, in a Japanese population of 21 patients, 11 of whom received MMF and 10 IVC.

METHODS

The primary endpoint was expressed as the percentage of responders, who in turn were defined as the patients who met complete or partial response criteria according to the European consensus statement. The secondary endpoints comprised the renal activity component and serological activity.

RESULTS

The primary endpoint was achieved in nine (81.8 %) patients receiving MMF and in four (40.0 %) receiving IVC, with no significant difference between the two groups (p = 0.081), while there was also no significant difference between them in terms of secondary endpoints. However, the MMF group suffered significantly fewer hematologic toxic effects than the IVC group.

CONCLUSIONS

MMF may be used as an alternative to IVC for inducing renal remission of LN in Japanese patients.

Prognostic relevance of integrated genetic profiling in acute myeloid leukemia

BACKGROUND

Acute myeloid leukemia (AML) is a heterogeneous disease with respect to presentation and clinical outcome. The prognostic value of recently identified somatic mutations has not been systematically evaluated in a phase 3 trial of treatment for AML.

METHODS

We performed a mutational analysis of 18 genes in 398 patients younger than 60 years of age who had AML and who were randomly assigned to receive induction therapy with high-dose or standard-dose daunorubicin. We validated our prognostic findings in an independent set of 104 patients.

RESULTS

We identified at least one somatic alteration in 97.3% of the patients. We found that internal tandem duplication in FLT3 (FLT3-ITD), partial tandem duplication in MLL (MLL-PTD), and mutations in ASXL1 and PHF6 were associated with reduced overall survival (P=0.001 for FLT3-ITD, P=0.009 for MLL-PTD, P=0.05 for ASXL1, and P=0.006 for PHF6); CEBPA and IDH2 mutations were associated with improved overall survival (P=0.05 for CEBPA and P=0.01 for IDH2). The favorable effect of NPM1 mutations was restricted to patients with co-occurring NPM1 and IDH1 or IDH2 mutations. We identified genetic predictors of outcome that improved risk stratification among patients with AML, independently of age, white-cell count, induction dose, and post-remission therapy, and validated the significance of these predictors in an independent cohort. High-dose daunorubicin, as compared with standard-dose daunorubicin, improved the rate of survival among patients with DNMT3A or NPM1 mutations or MLL translocations (P=0.001) but not among patients with wild-type DNMT3A, NPM1, and MLL (P=0.67).

CONCLUSIONS

We found that DNMT3A and NPM1 mutations and MLL translocations predicted an improved outcome with high-dose induction chemotherapy in patients with AML. These findings suggest that mutational profiling could potentially be used for risk stratification and to inform prognostic and therapeutic decisions regarding patients with AML. (Funded by the National Cancer Institute and others.).

Early treatment in Crohn's disease: do we have enough evidence to reverse the therapeutic pyramid?

Current guidelines on the medical therapy of Crohn's disease recommend a step-up strategy consisting of a progressive intensification of treatment as the disease severity increases. In the last fifteen years, the introduction of biologic therapies, particularly anti-TNFα antibodies, has offered new therapeutic opportunities. The efficacy of anti-TNF-alpha therapy for inducing and maintaining clinical response or remission in moderate to severe Crohn's disease has been extensively evaluated in randomised controlled trials and meta-analyses. Moreover, anti-TNF-alpha therapy can induce mucosal healing and this property may be potentially disease-modifying. Consequently, an early introduction of biologics and/or immunomodulators (top-down strategy) in newly diagnosed Crohn's disease has been advocated. This paper will review the evidence in favour and against this approach to Crohn's disease therapy, discuss which patients are potential candidates to early aggressive treatment, and how a conventional step-up approach can be optimized. The conclusion is that an indiscriminate top-down approach does not seem to be appropriate for all patients with moderate to severe Crohn's disease.

Cyclophosphamide, thalidomide, and dexamethasone as induction therapy for newly diagnosed multiple myeloma patients destined for autologous stem-cell transplantation: MRC Myeloma IX randomized trial results

BACKGROUND

Thalidomide is active in multiple myeloma and is associated with minimal myelosuppression, making it a good candidate for induction therapy prior to high-dose therapy with autologous stem-cell transplantation.

DESIGN AND METHODS

Oral cyclophosphamide, thalidomide, and dexamethasone was compared with infusional cyclophosphamide, vincristine, doxorubicin, and dexamethasone in patients with newly diagnosed multiple myeloma.

RESULTS

The post-induction overall response rate (≥ partial response) for the intent-to-treat population was significantly higher with cyclophosphamide-thalidomide-dexamethasone (n=555) versus cyclophosphamide-vincristine-doxorubicin-dexamethasone (n=556); 82.5% versus 71.2%; odds ratio 1.91; 95% confidence interval 1.44-2.55; P<0.0001. The complete response rates were 13.0% with cyclophosphamide-thalidomide-dexamethasone and 8.1% with cyclophos-phamide-vincristine-doxorubicin-dexamethasone (P=0.0083), with this differential response being maintained in patients who received autologous stem-cell transplantation (post-transplant complete response 50.0% versus 37.2%, respectively; P=0.00052). Cyclophosphamide-thalidomide-dexamethasone was non-inferior to cyclophosphamide-vincristine-doxorubicin-dexamethasone for progression-free and overall survival, and there was a trend toward a late survival benefit with cyclophosphamide-thalidomide-dexamethasone in responders. A trend toward an overall survival advantage for cyclophosphamide-thalidomide-dexamethasone over cyclophosphamide-vincristine-doxorubicin-dexamethasone was also observed in a subgroup of patients with favorable interphase fluorescence in situ hybridization. Compared with cyclophosphamide-vincristine-doxorubicin-dexamethasone, cyclophosphamide-thalidomide-dexamethasone was associated with more constipation and somnolence, but a lower incidence of cytopenias.

CONCLUSIONS

The cyclophosphamide-thalidomide-dexamethasone regimen showed improved response rates and was not inferior in terms of survival outcomes to the standard infusional regimen of cyclophosphamide-vincristine-doxorubicin-dexamethasone. Based on its oral administration and the reduced incidence of infection and cytopenia, cyclophosphamide-thalidomide-dexa-methasone may be considered an effective induction therapy option for patients with newly diagnosed multiple myeloma. (ISRCTN: 68454111).

Adalimumab for the induction and maintenance of clinical remission in Japanese patients with Crohn's disease

BACKGROUND AND AIMS

Adalimumab has been shown to be efficacious and well-tolerated in Western patients with Crohn's disease. These 2 randomized, double-blind clinical trials evaluated adalimumab efficacy and safety in Japanese patients with moderate to severe Crohn's disease.

METHODS

90 patients enrolled in the induction trial and were randomized to receive adalimumab 160/80 mg, adalimumab 80/40 mg or placebo at Weeks 0/2. At Week 4, patients who achieved a decrease in CDAI ≥ 70 points versus Baseline entered the maintenance trial and were randomized to adalimumab 40 mg every other week or placebo for 52 weeks. All other patients received 4 more weeks of blinded adalimumab before entering the open-label portion of the maintenance trial. At/after Week 4 of the maintenance trial, blinded patients who flared/failed to respond entered the open-label portion. Open-label maintenance patients received adalimumab 40 mg every other week with the option of 80 mg every other week for flare/non-response.

RESULTS

Clinical remission rates at Week 4 in the induction trial were 33.3%, 17.6% and 13.0% in the adalimumab 160/80 mg, adalimumab 80/40 mg and placebo groups, respectively. Maintenance remission rates were 38.1% for adalimumab and 9.1% for placebo at Week 52. Anti-TNF naïve patients achieved greater efficacy than anti-TNF exposed patients. Patients randomized to adalimumab achieved greater quality of life improvement versus placebo. There were no clinically relevant differences in safety between adalimumab and placebo.

CONCLUSIONS

Adalimumab is effective and well-tolerated for inducing and maintaining clinical remission in Japanese patients with moderate to severe Crohn's disease.

Clinical features and outcomes of ANCA-associated renal vasculitis

To determine the patterns and outcomes of the pauci-immune vasculitis in the nephrology department at hospital La Conception in Marseille, we conducted a retrospective study including all patients with diagnosis of pauci-immune renal vasculitis between January 1, 2000 and December 31, 2007. Among 33 cases, 25 were diagnosed as Wegener granulomatosis (WG), seven as microscopic polyangitis (MPA) and one as Churg-Strauss syndrome (SCS). The median age of the patients was 57.7 years and the sex-ratio (M/F) was 1.6. The visceral manifestations included kidneys (100% of patients), lungs (75%), ENT (52% of WG), and nervous system (57% of MPA). The mean serum creatinine at admission was 3.3 mg/dL. Renal biopsies revealed a pauci-immune crescentic gromerulonephritis in 96% of the cases. Two patients with WG received plasmapheresis and seven patients required emergency hemodialysis. Induction therapy comprised cyclophosphamide IV and corticosteroids, while maintenance therapy included azathioprine for the majority of patients. Eighty four percent of the patients experienced complete remission after induction therapy. During maintenance therapy relapses were more frequent among patients with MPA (28%) compared to WG cases (12%). After 35 months of follow-up, eight patients ended on chronic hemodialysis, and five patients died. ANCA associated vasculitis are frequent in our patients. Long-term outcomes are relatively good despite a mortality rate of 15% and 25% of the patients entering dialysis after three years of follow-up.

Acute myeloid leukemia following solid organ transplantation: case report and comprehensive review

Organ transplant recipients are at an increased risk for subsequent malignancies including hematologic malignancies. The development of acute myeloid leukemia (AML) after solid organ transplantation is a rare but well-documented event. It is thought to be a consequence of immune dysregulation secondary to the use of immunosuppressive agents. Herein, we present the management of a liver transplantation recipient who presented with AML and comprehensively review the relevant literature. A 59-year-old male patient presented with fever and cough eight years after an orthotopic liver transplantation for cirrhosis and hepatocellular carcinoma. He received methylprednisolone and mycofenolate mofetil (MMF) followed by tacrolimus and rapamycin as immunosuppression. Upon admission to our hospital, his peripheral blood demonstrated 34% blasts and pancytopenia. A bone marrow biopsy confirmed the diagnosis of myelodysplastic syndrome (MDS) in transformation to AML. He was treated with induction chemotherapy and his sirolimus was continued but he expired four weeks after from refractory disease. No specific guidelines exist for the treatment of AML in solid organ transplant recipients. Treatment should be individualized and concurrent use of chemotherapeutic and immunosuppressive agents should be carefully balanced.

Comparison of concurrent chemoradiotherapy versus induction chemotherapy followed by radiation in patients with nasopharyngeal carcinoma

PURPOSE

The study aimed to evaluate the efficacy of concurrent chemoradiotherapy (CCRT) with platinum-based chemotherapy as a primary treatment for nasopharyngeal carcinoma (NPC) and to further compare the results of CCRT with these of neoadjuvant chemotherapy (NAC) followed by radiotherapy (RT).

PATIENTS AND METHODS

Before 1998, 21 patients with NPC received NAC followed by RT (NAC-RT). Between 1999 and 2008, a total of 25 NPC patients received CCRT. The CCRT group received a regimen including docetaxel (50 mg/m(2), day1), cisplatin (CDDP, 60 mg/m(2), day4) and continuous 5-fluorouracil (5-FU) infusion (600 mg/m(2), day 1-5), the TPF regimen, or a regimen including CDDP (60 mg/m(2), day4), continuous 5-FU infusion (600 mg/m(2), day 1-5), methotrexate (MTX, 30 mg/m(2), day 1) and leucovorin (LV, 20 mg/m(2), day 1-5), PFML regimen. The CCRT group received 2 cycles of chemotherapy during definitive RT. The NAC group of patients received a PFML regimen.

RESULTS

The overall response rate after CCRT was 96%. The 3-year and 5-year disease-specific survival rates were 75.6% and 60.1%, respectively. In patients receiving NAC-RT, the 3-year and 5-year disease-specific survival rates were 84.1% and 67.3%, respectively. There was no difference observed in terms of survival rates between the group receiving CCRT and that receiving NAC-RT.

CONCLUSION

CCRT with the TPF or PFML regimen was tolerable, and the NPC patients receiving this treatment showed excellent survival rates. In comparison to the group receiving NAC-RT, CCRT had no advantage in terms of the survival rate. In the future, the control of distant metastasis might play an important role in improving the survival rate of patients with advanced NPC receiving CCRT.

Tandem high-dose chemotherapy and autologous stem cell transplantation in young children with atypical teratoid/rhabdoid tumor of the central nervous system

The feasibility and effectiveness of tandem high-dose chemotherapy and autologous stem cell transplantation (HDCT/autoSCT) were evaluated in children younger than 3 yr of age with atypical teratoid/rhabdoid tumors (ATRT). Tandem HDCT/autoSCT was administered following six cycles of induction chemotherapy. Radiotherapy (RT) was administered if the tumor relapsed or progressed, otherwise, it was administered after 3 yr of age. Tumors relapsed or progressed during induction chemotherapy in 5 of 9 patients enrolled; 3 of these 5 received tandem HDCT/autoSCT as a salvage treatment. One patient died from sepsis during induction chemotherapy. The remaining 3 patients proceeded to tandem HDCT/autoSCT; however, 2 of these patients showed tumor relapse/progression after tandem HDCT/autoSCT. All 7 relapses/progressions occurred at primary sites even in patients with leptomeningeal seeding. Toxicities during tandem HDCT/autoSCT were manageable. A total of 5 patients were alive with a median follow-up of 20 (range 16-70) months from diagnosis. Four of 5 patients who received RT after relapse/progression are alive. The probability of overall survival at 3 yr from diagnosis was 53.3% ± 17.3%. Our tandem HDCT/autoSCT is feasible; however, early administration of RT prior to tandem HDCT/autoSCT should be considered to improve the outcome after tandem HDCT/autoSCT.

Neoadjuvant chemoradiation therapy is beneficial for clinical stage T2 N0 esophageal cancer patients due to inaccurate preoperative staging

BACKGROUND

It remains unclear if patients with clinical stage T2 N0 (cT2 N0) esophageal cancer should be offered induction therapy vs surgical intervention alone.

METHODS

This was a retrospective cohort study of cT2 N0 patients undergoing induction therapy, followed by surgical resection, or resection alone, at the Johns Hopkins Hospital from 1989 to 2009. Kaplan-Meier analysis was used to compare all-cause mortality in cT2 N0 patients who had resection alone vs those who had induction chemoradiation therapy, followed by resection.

RESULTS

A study cohort of 69 patients was identified and divided into two groups: 55 patients (79.7%) received induction therapy and 14 (20.3%) did not. No statistically significant difference in 5-year survival rate was observed for the two groups: 49.5% for the resection-only group and 53.8% for the induction group. More than 50% of cT2 N0 patients were understaged.

CONCLUSIONS

For cT2 N0 esophageal cancer patients, the benefit of neoadjuvant therapy is still unclear. Induction therapy for cT2 N0 did not translate into a statistically significant improvement in survival. However, due to the significant understaging of T2 N0 patients, we recommend neoadjuvant therapy to all cT2N0 patients before operation.

[Efficacy of remission induction chemotherapy and prognostic analysis in elderly patients with acute myeloid leukemia]

OBJECTIVE

To explore the outcome of remission induction chemotherapy (IC) and prognostic in elderly patients with acute myeloid leukemia (AML).

METHODS

The clinical data of 156 AML patients older than 60 years in the Institute of Hematology, Union Hospital of Fujian Medical University from January 2003 to July 2010 were analyzed retrospectively. 104 patients received cytarabine-based regimens, including protocol DA,IA or CAG,while 52 patients received palliative treatment. The median survival time was compared between patients with and without IC. The prognostic factors were evaluated by using univariate and multivariate analyses.

RESULTS

145 (93%) cases were followed-up. The median survival time was 316 days in 96 IC patients, compared with 37 days in 49 PT patients (P < 0.01). Not receiving induction chemotherapy,high-risk karyotype,hyperleukocytosis (> or = 100 x 10(9)/L), Charlson Comorbidity Index (CCI) > or = 2 were adverse prognostic factors of the survival time with univariate analysis, and all were independent poor factors affecting the survival time with multivariate analysis.

CONCLUSIONS

IC can improve outcomes in elderly AML patients. The patients with hyperleukocytosis (> or = 100 x 10(9)/L) , high-risk karyotype, CCI > or = 2 and without receiving IC have poorer prognosis.

Therapy of lupus nephritis: lessons learned from clinical research and daily care of patients

Despite numerous randomized clinical trials over the last three decades for identifying the optimal treatment option for lupus nephritis, renal involvement still significantly impacts the survival and quality of life of patients with lupus and the search for the ideal immunosuppressive regimen is far from complete. The purpose of this review is to summarize the major recent achievements in the field. More specifically, the following topics will be discussed: intravenous cyclophosphamide versus mycophenolate mofetil (MMF) for induction; azathioprine versus MMF for maintenance; targeted therapies. The review will address clues for optimal global care, such as the need for complete initial evaluation, the importance of patient education, the unmasking of non-compliance to therapy, the reason for an early treatment switch in non-responding patients, the need for prolonged immunosuppression, optimal renal protection, and prevention of cardiovascular disease and other comorbidities.

Pretransplantation therapy with azacitidine vs induction chemotherapy and posttransplantation outcome in patients with MDS

Although allogeneic hematopoietic cell transplantation (HCT) has proven curative potential for myelodysplastic syndrome, relapse after HCT remains a problem. Pretransplantation cytoreduction with induction chemotherapy (IC) has been used to reduce relapse rates but is associated with significant toxicity and mortality. Hypomethylating agents may achieve cytoreduction with limited toxicity; however, data on the effect of pre-HCT hypomethylation on post-HCT outcomes are limited. We retrospectively reviewed results in 68 patients who underwent allogeneic HCT for myelodysplastic syndrome or acute myeloid leukemia transformed from MDS. Thirty-five patients had received cytoreduction with azacitidine before HCT with either a high-dose (40%) or a reduced-intensity (60%) conditioning regimen, and 33 had undergone IC before HCT with high-dose conditioning. The estimated 1-year overall survival (OS) was 57% in the azacitidine group and 36% in the IC group. The risk of post-HCT mortality (hazard ratio, 0.68; 95% confidence interval, 0.35-1.30), nonrelapse mortality (hazard ratio, 0.99; 95% confidence interval, 0.41-2.34), and relapse (hazard ratio, 0.34; 95% confidence interval, 0.41-2.34) were lower in the azacitidine group compared to the IC group, but only the hazard for relapse was significantly lower. After adjustment for cytogenetic risk, International Prognostic Scoring System, and donor, the rates of post-HCT relapse for the 2 cohorts were similar. Although the current study was retrospective and nonrandomized and needs to be interpreted in this context, the results add to the growing evidence that pre-HCT therapy with azacitidine is associated with less toxicity than IC and may allow for similar post-HCT outcomes.

First-line XELOX plus bevacizumab followed by XELOX plus bevacizumab or single-agent bevacizumab as maintenance therapy in patients with metastatic colorectal cancer: the phase III MACRO TTD study

PURPOSE

The aim of this phase III trial was to compare the efficacy and safety of bevacizumab alone with those of bevacizumab and capecitabine plus oxaliplatin (XELOX) as maintenance treatment following induction chemotherapy with XELOX plus bevacizumab in the first-line treatment of patients with metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

Patients were randomly assigned to receive six cycles of bevacizumab, capecitabine, and oxaliplatin every 3 weeks followed by XELOX plus bevacizumab or bevacizumab alone until progression. The primary endpoint was the progression-free survival (PFS) interval; secondary endpoints were the overall survival (OS) time, objective response rate (RR), time to response, duration of response, and safety.

RESULTS

The intent-to-treat population comprised 480 patients (XELOX plus bevacizumab, n = 239; bevacizumab, n = 241); there were no significant differences in baseline characteristics. The median follow-up was 29.0 months (range, 0-53.2 months). There were no statistically significant differences in the median PFS or OS times or in the RR between the two arms. The most common grade 3 or 4 toxicities in the XELOX plus bevacizumab versus bevacizumab arms were diarrhea, hand-foot syndrome, and neuropathy.

CONCLUSION

Although the noninferiority of bevacizumab versus XELOX plus bevacizumab cannot be confirmed, we can reliably exclude a median PFS detriment >3 weeks. This study suggests that maintenance therapy with single-agent bevacizumab may be an appropriate option following induction XELOX plus bevacizumab in mCRC patients.

Single institution experience

PURPOSE

To evaluate clinical and pathological characteristics of patients with inflammatory breast carcinoma (IBC). Also, to evaluate the importance of achieved clinical and pathological responses to induction chemotherapy (iCT) and their role in the prognosis of IBC.

METHODS

The medical records of 81 female patients with stage IIIB IBC, diagnosed between January 2008 and December 2010 at the Institute for Oncology and Radiology of Serbia (IORS) were evaluated. Almost all of the patients received anthracycline-based iCT. After 3-4 cycles of iCT, the clinical response (defined as complete response/CR, partial response/PR, stable disease/SD and disease progression/ PD) was assessed. Also, pathological response to iCT (defined as pathological complete response/pCR, near complete response/pNCR, partial response/pPR and no change/ pNC) was estimated in patients who had undergone surgery. All first metastatic sites were recorded.

RESULTS

Clinical CR/PR was observed in 61.8% of the patients, while the pathological response (pCR, pNCR/near complete response, and pPR) rate in patients who had undergone surgery was 70%. During follow-up 22 (27.2%) patients developed PD (8 responders and 14 non-responders). Most common metastatic sites were the skeleton in non-responders and the liver in responders. Central nervous system (CNS) metastases developed in 24% of non-responders while no responder developed such metastases. Non-responders had shorter OS compared to responders, but without statistical significance.

CONCLUSION

Although the number of the patients analysed in this study is relatively small, we believe that response to iCT could be used as a prognostic marker, since patients who initially failed to respond to iCT showed a higher risk for PD with development of distant metastases, primarily in bones and CNS, and shorter survival.

Efficacy and feasibility of induction chemotherapy and radiotherapy plus cetuximab in head and neck cancer

BACKGROUND

To determine the potential activity and tolerability of sequential treatment in head and neck cancer, we conducted a phase II trial based on induction chemotherapy of two cycles of taxotere, cisplatin and 5-fluorouracil followed by radiotherapy plus weekly cetuximab.

PATIENTS AND METHODS

Thirty-six patients with stage III or IV squamous cell carcinoma of the oral cavity, larynx, oropharynx and hypopharynx were treated and evaluated for response and acute toxicity.

RESULTS

Eighty-one percent of patients had stage IV disease and 42% had hypopharyngeal and oral cavity primaries. The overall response rate was 81.8%, with 60.6% complete response and 33.3% partial response. Severe toxicities were febrile neutropenia (6%) during induction chemotherapy and dermatitis (48%), mucositis (33%) and dysphagia (12%) during the concurrent phase.

CONCLUSION

Our protocol proved to be feasible, effective and well tolerated. This sequential strategy should be further investigated.

[Mycophenolate mofetil in induction and maintenance therapy for juvenile onset severe lupus nephritis]

OBJECTIVE

The aim of the present study was to evaluate the efficacy of mycophenolate mofetil (MMF) in the induction and maintenance therapy for juvenile onset severe lupus nephritis.

METHODS

Children with severe focal, and diffuse proliferative lupus nephritis were treated with prednisolone (initial dose; 1 mg/kg/day, maximum dose; 60 mg/day) and MMF (initial dose; 300 mg/m2/day, increased to 1 g/m2/day) for 24 months after high-dose intravenous methylprednisolone (30 mg/kg/day). Urinalysis was performed, and renal function, and albumin were evaluated. Serum anti-double-stranded DNA antibody, and also serum C3 and C4 were measured. The duration of induction therapy was defined as the initial 6 months after treatment. The duration of maintenance therapy was defined as 18 months after induction therapy.

RESULTS

Twelve children (mean age 12.6 +/- 1.7 years)were treated with induction therapy. With 6 months of induction therapy, urine protein, and serum anti-double-stranded DNA antibody, decreased significantly (p < 0.05), renal function improved, and albumin, serum C3 and C4 increased significantly (p < 0.05). Ten children received maintenance therapy. No patients had renal flares during maintenance therapy. The mean prednisolone dose was tapered to 9.2 +/- 2.3 mg/day. Among 5 patients who had a second biopsy after MMF therapy, 4 showed a significant reduction and one had no change in histology. Major infection episodes occurred in 5 patients: Herpes zoster in 3 patients, bacteremia in 2, and hair loss in 3, respectively. No patients discontinued MMF therapy.

CONCLUSIONS

MMF is an effective induction and maintenance therapy for juvenile onset severe lupus nephritis.

Clinical trial of weekly paclitaxel chemotherapy for papillary thyroid carcinoma with squamous cell carcinoma component

Papillary thyroid carcinoma (PC) can occasionally include a squamous cell carcinoma (SCC) component. In this study, we evaluated the effect of weekly paclitaxel chemotherapy in 3 patients with PC including an SCC component. None of these patients had lesions of anaplastic carcinoma on pathological examination. Weekly paclitaxel chemotherapy was performed as an induction chemotherapy for 2 patients. All 3 patients underwent locally curative surgery and weekly paclitaxel chemotherapy after surgery as an adjuvant therapy. The response to the chemotherapy was evaluated based on the RECIST guideline (version 1.1). Two patients had partial responses (PRs) and the remaining 1 had stable disease (SD). The response rate was 67% and the clinical benefit rate (PR+SD) was 100%. One patient died of the growth of lung metastases that had been detected before surgery 22 months after the diagnosis. The remaining 2 are still alive, 14 and 22 months after the diagnosis, respectively. Taken together, weekly paclitaxel may be one of the effective adjuvant therapies for PC with an SCC component.

Successful treatment of acute promyelocytic leukemia accompanied by serious subdural hematoma

We present a 56-year-old woman with acute promyelocytic leukemia (APL) complicated with serious chronic subdural hematoma at presentation. She was treated with urgent hematoma evacuation and subsequent prompt chemotherapy, with administration of platelets and fresh frozen plasma. After six weeks, she achieved hematological complete remission. Thereafter she received three courses of conventional consolidation chemotherapy and achieved molecular remission. Even under conditions of severe coagulatory disturbance, aggressive therapeutic intervention including surgical procedures can save the life of a patient suffering from simultaneous APL and fatal subdural hematoma at presentation.

[Maintainance treatment of anti-neutrophil cytoplasm associated antibodies (ANCA)]

ANCA-associated vasculitides are rare and complex systemic diseases. Collaborative studies in both Europe and the United States of America have been particularly important in the development of randomized clinical trials that have studied the safety of maintenance therapy for these diseases. Although cyclophosphamide continues to be the main drug utilized during induction therapy, its long-term side effects have given rise to the study of other immunosuppressive drugs for the maintenance phase. We herein review these studies with particular attention to combination therapy and the duration of treatment.

[Cardiogenic shock due to takotsubo cardiomyopathy during induction therapy for acute myeloid leukemia]

A 61-year-old man admitted for pancytopenia was diagnosed with acute myeloid leukemia. On day 26 of induction therapy, the patient suddenly developed cardiogenic shock. The ultrasound cardiogram showed imaging features typical of takotsubo cardiomyopathy. Cardiogenic shock caused by takotsubo cardiomyopathy is rare in patients with hematological malignancies but is a severe complication during chemotherapy.

Curing all patients with acute promyelocytic leukemia: are we there yet?

The introduction of all-trans retinoic acid to anthracycline-based chemotherapy has revolutionized the prognosis of patients with acute promyelocytic leukemia (APL). The introduction of arsenic trioxide enabled the therapeutic approach of rationally targeted frontline protocols with minimal or no traditional cytotoxic chemotherapy and without compromise of previously established outstanding outcomes with anthracycline-based regimens. Although most of the current investigative efforts in APL are focused on developing potentially curative therapy without the exposure to toxicities and risks of DNA-disrupting agents, the cure rate can further be increased by implementing meticulous supportive care strategies that counter early coagulopathy-related deaths.

[A case of esophageal cancer with intramural metastasis demonstrates a good clinical course after induction chemotherapy followed by chemoradiation]

A 63-year-old man with dysphagia visited our hospital in February 2007. Esophagogastroduodenoscopy and computed tomography revealed that he suffered from advanced esophageal cancer with intramural metastasis at clinical stage III (T3N1). The patient underwent induction chemotherapy because he had great difficulty deciding which treatment would be more beneficial for him use dash surgery or chemoradiation. The reason for his in decision was that esophageal cancer with intramural metastasis is known to have a poor prognosis after surgery, and although chemoradiation is the more attractive therapy that avoids invasive surgery, it is very difficult to predict a response. Currently, he has survived for more than 3 years with no recurrence, after chemoradiation that followed a good response to induction chemotherapy. This result suggested that induction chemotherapy followed by chemoradiation can be one of the useful strategies for patients who have esophageal cancer with a negative prognosis factor for surgery, such as intramural metastasis.

Phase III trial of induction gemcitabine or paclitaxel plus carboplatin followed by paclitaxel consolidation in ovarian cancer

OBJECTIVE

The safety and efficacy of gemcitabine plus carboplatin (GC) or paclitaxel plus carboplatin (TC) induction regimens with or without paclitaxel consolidation therapy were assessed in ovarian cancer (OC).

METHODS

Patients with stage IC-IV OC were randomized to either GC (gemcitabine 1,000 mg/m(2), days 1 and 8, plus carboplatin area under the curve [AUC] 5, day 1) or TC (paclitaxel 175 mg/m(2) plus carboplatin AUC 6, day 1) every 21 days for up to six cycles. Patients with complete response (CR) were allowed optional consolidation with paclitaxel 135 mg/m(2) every 28 days for ≤ 12 months. Patients without CR received single-agent crossover therapy at induction doses/schedules until CR, disease progression (PD), or unacceptable toxicity. PD or death in 636 patients was required to compare induction arms with 80% statistical power for progression-free survival (PFS), the primary endpoint.

RESULTS

Randomized induction therapy was received by 820 of 919 patients enrolled; 352 patients with CR received paclitaxel consolidation whereas 155 patients without CR received single-agent crossover therapy. PFS was similar for GC and TC (median, 20.0 and 22.2 months, respectively; P=.199). Despite high censoring rates (>52%), overall survival was longer for TC (median, 57.3 versus 43.8 months for GC; P=.013). Controlling for patient characteristics including performance status, residual tumor size, and tumor stage, there was no statistical difference in a multivariate analysis (HR=1.22; 95% CI=0.99-1.52; P=.067).

CONCLUSIONS

GC does not improve PFS over TC as first-line induction chemotherapy in OC. Although favoring TC, overall survival analyses were limited by the study design and high censoring rates.

[Clinical study on combination of homoharringtonine, Ara-C and idarubicin induction for treatment of newly diagnosed acute myeloid leukemia patients]

The purpose of this study was to assess the efficacy and toxicity of HAI regimen [(homoharringtonine 2.5 mg/(m(2)×d), days 1 - 7; cytarabine 150 mg/(m(2)×d), days 1 - 7; idarubicin 9 mg/(m(2)×d), days 1 - 7)] for induction treatment of newly diagnosed acute myeloid leukemia (AML) (except acute promyelocytic leukemia). 31 patients with newly diagnosed AML, aged 39 (14 - 58) years, were enrolled in this clinical study. The complete remission (CR) rate, especially after one course, the overall survival (OS) rate and relapse free survival (RFS) rate were estimated. The outcomes were compared between different prognostic groups according to World Health Organization (WHO) classification, genetics and initial WBC count. Safety was evaluated using standard WHO criteria. The results showed that 26 patients (84%) achieved CR after 1 course of induction. The CR rate for the patients with favorable, intermediate and unfavorable cytogenetics was 90%, 88% and 60% respectively. All 7 patients with a high initial WBC count (≥ 100×10(9)/L) obtained CR, while 19 out of 24 without a high initial WBC count obtained CR. With a median follow-up of 15(range 2-56) months, the estimated 3-year OS rate for all patients and the patients with CR was 44% and 52% respectively. The 3-year RFS rate was 51%. The patients receiving induction chemotherapy died of the chemotherapy. Profound myelosuppression was seen in all patients after the HAI induction with the median duration of neutropenia (ANC < 0.2×10(9)/L) of 16 (6 - 24) days. As the most common toxicity, severe infections (grade III-IV) involved in all the patients and the duration of febris was 6 (1 - 36) days. The incidence of septemia and invasive fungus infection were 19.4% and 45.2% respectively. The incidence of non-infection fever, increased glutamic-pyruvic transaminase (GPT), diarrhea, increased bilirubin and oral cavity mucositis were 6.5%, 6.5%, 3.2%, 3.2%, 3.2% respectively, as the more frequent severe non-hematological toxicities. It is concluded that HAI regimen is a high efficient induction schedule for the newly diagnosed AML, and archive the higher CR rate after one course than DNR/Ara-C standard induction regimen. Side effects are acceptable, except severe infection.

Omitting elective nodal irradiation and irradiating postinduction versus preinduction chemotherapy tumor extent for limited-stage small cell lung cancer: interim analysis of a prospective randomized noninferiority trial

BACKGROUND

Controversies exist with regard to thoracic radiotherapy volumes for limited-stage small cell lung cancer (SCLC). This study compared locoregional progression and overall survival between limited-stage SCLC patients who received thoracic radiotherapy to different target volumes after induction chemotherapy.

METHODS

Chemotherapy consisted of 6 cycles of etoposide and cisplatin. After 2 cycles of etoposide and cisplatin, patients were randomly assigned to receive thoracic radiotherapy to either the postchemotherapy or prechemotherapy tumor extent as study arm or control. Elective nodal irradiation was omitted for both arms. Forty-five Gy/30Fx/19 days thoracic radiotherapy was administered concurrently with cycle 3 chemotherapy. Prophylactic cranial irradiation was administered to patients who achieved complete remission. An interim analysis was planned when the first 80 patients had been followed for at least 6 months, for consideration of potential inferiority in the study arm.

RESULTS

Forty-two and 43 patients were randomly assigned to a study arm and a control, respectively. The local recurrence rates were 31.6% (12 of 38) and 28.6% (12 of 42), respectively (P = .81). The isolated nodal failure rates were 2.6% (1 of 38) and 2.4% (1 of 42), respectively (P = 1.00). All isolated nodal failure sites were in the ipsilateral supraclavicular fossa. Mediastinal N3 was the only factor to predict isolated nodal failure (P = .004; odds ratio [OR], 29.33; 95% CI, 2.94-292.38). One-year and 3-year overall survival rates were 80.6%, 36.2%, and 78.9%, 36.4%, respectively (P = .54).

CONCLUSIONS

Preliminary results indicated that irradiated postchemotherapy tumor extent and omitted elective nodal irradiation did not decrease locoregional control in the study arm, and the overall survival difference was not statistically significant between the 2 arms. Further investigation is warranted.

[Analysis of effectiveness and prognostic factors for (m)HAD regimen as induction therapy in acute monocytic leukaemia]

OBJECTIVE

To analyze the treatment outcome and impact of cytogenetic abnormalities on the response and survival of acute monocytic leukaemia (AMOL) patients received (m)HAD regimen as induction chemotherapy.

METHODS

Seventy-nine AMOL patients were treated with (m)HAD regimen as induction therapy (HHT 2 mg/m(2), d 1-7; Ara-C 100 mg/m(2), d 1-7 and increasing to 1.5 g×m(-2)×(12 h)(-1), d 5-7 in some patients; DNR 40 mg/m(2), d 1-3). The treatment outcome and prognostic factors were analyzed.

RESULTS

(1) The complete remission (CR) rate was 79.7% (63/79), partial remission (PR) rate was 6.3% (5/79), overall rate was 86.0%. (2) The chromosome karyotypes were analyzed in 75 patients, of whom 43 with normal karyotypes (NCR) and 30 abnormal karyotypes (ACR). For the cytogenetic prognostic groups, 49 patients were intermediate, 18 poor and 6 unknown. The CR, 1-year and 3-year overal survival (OS) rates in NCR group were significantly higher than those in ACR group (P < 0.05); but there was no significantly statistical difference in disease free survival (DFS) between the two groups (P > 0.05). The CR, 1-year OS, 3-year OS and 1-year DFS and 3-year DFS rates in intermediate prognostic group were significantly higher than those in poor prognostic group (85.7% vs 61.1%, 75.9% vs 51.3%, 65.4% vs 25.6%, 82.2% vs 66.7%, and 77.9% vs 26.7%, respectively) (P < 0.05). (3) Chromosome karyotype and the number of consolidation therapy courses had more important influence on survival in COX analysis.

CONCLUSION

(m)HAD regimen as induction chemotherapy for AMOL patients achieves a high CR rate. It has an important influence on survival for the patients to received adequate consolidation therapy. The frequency of cytogenetic abnormalities in AMOL is similar to that in other AMLs. The prognosis of AMOL patients with chromosome karyotype in intermediate prognostic group is significantly better than that in poor prognostic group.

Reduced tumor lysis syndrome with low dose chemotherapy for hyperleukocytic acute leukemia prior to induction therapy

Patients with hyperleukocytic acute leukemia (HAL) can succumb to leukostasis. In an attempt to reduce its incidence, 45 patients with newly diagnosed HAL and hyperleukocytosis were administered half the conventional dose of etoposide and cytosine arabinoside (EA: 50 mg/m2 daily each) until WBC counts were significantly reduced and standard induction therapy was initiated. We retrospectively reviewed their outcomes and analyzed potential factors with a logistic regression model. The incidence of early mortality (<30 days) was 4.4% (2/45). Patients who achieved complete remission with induction chemotherapy had significantly lower median WBC counts (26x10(9) L-1) after low dose EA treatment than the no response patients (median WBC: 65x10(9) L-1 (P<0.05). Low dose EA treatment of HAL patients reduced WBC for both lymphoid and myeloid leukemic cells and can be considered for preemptive administration to HAL patients prior to the differential diagnosis of the acute leukemia. This approach warrants further studies as a cytoreduction therapy for HAL.

Stem cell transplantation for multiple myeloma: current and future status

High-dose melphalan with autologous stem cell support has been an integral part of myeloma therapy for more than 25 years, either as salvage therapy or as consolidation of an initial remission. Although multiple phase 3 trials have demonstrated that this therapy results in higher response rates and longer remission times than conventional chemotherapy, the use of thalidomide, lenalidomide, and bortezomib as induction therapy has limited the clinical relevance of these trials. Moreover, ongoing trials have shown that initial induction therapy may affect transplantation outcome, and that long-term disease control can be achieved in a substantial number of patients with a variety of posttransplantation maintenance therapies. This article summarizes the results of ongoing and recently published clinical trials and describes how they have affected current transplantation recommendations.

Posttransplantation maintenance therapy and optimal frontline therapy in myeloma

One of the major efforts to improve the results of intensive therapy and autologous stem cell transplantation (ASCT) in multiple myeloma involves the integration of novel agents into the transplantation sequence. This can include their administration before, during, and after the transplantation procedure. Several phase 2 and 3 studies have evaluated the use of novel agents as part of induction therapy before transplantation to produce higher response rates and progression-free survival (PFS). Similarly, posttransplantation maintenance-or consolidation-with these agents consistently improves PFS. Survival benefits have been more difficult to demonstrate, although one trial using bortezomib before and after transplantation and a second using lenalidomide as maintenance have shown significantly longer survival times. This article reviews the different regimens used with ASCT, with an emphasis on randomized trials.