Cytarabine plus idarubicin or daunorubicin as induction and consolidation therapy for previously untreated adult patients with acute myeloid leukemia

The purpose of this study was to determine the relative merits of idarubicin and daunorubicin in acute myeloid leukemia (AML) therapy. Thirty-two sites provided 214 previously untreated adults with AML aged 15 years or more who were randomized to receive for induction therapy cytarabine 100 mg/m2/d as a continuous 7-day infusion plus either daunorubicin 45 mg/m2/d (A + D) or idarubicin 13 mg/m2/d (A + I), daily on the first three days of treatment. Postremission therapy consisted of two courses of the induction regimen at the same daily doses, with the anthracycline administered for 2 days and cytarabine for 5. The complete response (CR) rates for evaluable patients were 70% (A + I) and 59% (A + D) (P = .08). The difference in CR rates was significant in patients aged 18 to 50 years (88% for A + I, 70% for A + D, P = .035). Resistant disease was a significantly more frequent cause of induction therapy failure with A + D than with A + I. Hyperleukocytosis (white blood cell count greater than 50,000/microL) unfavorably affected the attainment of CR with A + D but not with A + I. CR duration was significantly greater after A + I. CR duration was significantly greater after A + I treatment, and the survival of all randomized patients treated with A + I was significantly better than that observed after A + D treatment (median 12.9 months v 8.7 months, respectively, P = .038). Toxicity of the two treatments was similar, although A + I patients experienced more prolonged myelosuppression during consolidation therapy, and a greater incidence of mild chemical hepatitis was observed in the A + I group. It is concluded that, at the doses and schedule used in this study, A + I is superior to A + D for induction therapy of AML in adults.

[Sudden death in leukemic patients treated with doxorubicin]

Cardiotoxicity of the anthracycline antineoplastic drugs is well known, especially the chronic effects, manifested mainly as congestive heart failure. Fewer reports have been published about the acute cardiotoxicity of these medications, and risk factors associated with their use. Two cases of malignant arrhythmias leading to sudden death associated with severe hypokalemia are reported. These cases suggest a synergistic effect between anthracyclines and electrolyte disorders resulting in the acute cardiotoxicity of these drugs. The administration of these antineoplastic drugs should include regular and systematic control of serum electrolytes and correction of hypokalemia during treatment.

Inadvertent intrathecal injection of daunorubicin with fatal outcome

We report the first known case of daunorubicin administered directly into the human central nervous system. A 3 1/2-year-old female with pneumonia and otitis media was diagnosed with acute lymphoblastic leukemia and was admitted for antibiotics and chemotherapy. On the first day she inadvertently received a 17 mg intrathecal (IT) injection of daunorubicin. When the error was recognized about 1 hour later, her cerebrospinal fluid (CSF) was exchanged with sterile saline by barbotage, IT hydrocortisone was given, a subarachnoid catheter was inserted, and the CSF was allowed to drain for 36 hours. Only 5.6 mg (33%) of the dose was recovered from CSF, 2.7 mg as daunorubicin and 2.9 mg as the metabolite, daunorubicinol. Initially she was asymptomatic and induction therapy continued with vincristine, 1-asparaginase, prednisone, and IT methotrexate. One week after the daunorubicin injection she developed headache and irritability; CSF protein was 3.2 gm/dl. On the 12th day, she developed fungal sepsis and worsening pneumonia. On the 15th day, she became comatose with a flacid paraparesis, areflexia, and an ascending progressive bulbar palsy. A series of computerized tomography scans over 6 weeks showed increasing diffuse cerebral atrophy. Nerve conduction velocity studies were consistent with an axonal neuropathy. Despite her multiple concurrent medical problems, the timing and characteristics of neurologic damage suggest that IT daunorubicin caused progressive destruction of the nervous system.

A discrepancy between the instantaneous and the overall collection efficiency of the fenwal CS3000 for peripheral blood stem cell apheresis

The collection efficiency (CE) of the Fenwall CS3000 continuous flow blood cell separator in the apheresis of peripheral blood stem cells during haemopoietic recovery following myelosuppressive chemotherapy was analysed. Ninety-three apheresis were performed in 19 patients using procedure 3 on the Fenwal CS3000. The overall CE was calculated from the pre-apheresis cell counts and the stated blood volume processed. Instantaneous CE was calculated from cell counts in the inlet and return lines. The overall mononuclear cell and granulocyte-macrophage colony forming unit CE were 64.0% and 55.8%, respectively, significantly lower than the instantaneous CEs of 94.5% and 95.4%, respectively (P = 0.0001, t test, for both comparisons). Three factors unrelated to machine performance contributed to the lower overall CE despite a high instantaneous CE: (1) A fall in the patient's mononuclear cell counts during apheresis leading to an overestimation of the cells available for collection, (2) dilution of blood by anti-coagulant, and (3) the operational dead space of the Fenwal CS3000. The overall CE corrected for these 3 factors approximated the instantaneous CE closely. Thus there is little room for further enhancement of machine performance because the Fenwal CS3000 is already operating with a very high instantaneous CE. To achieve major improvement in the yield of peripheral blood stem cell harvests, more effective mobilization protocols and better timing of apheresis are required.

Anthracyclines and their C-13 alcohol metabolites: growth inhibition and DNA damage following incubation with human tumor cells in culture

Anthracyclines are important antitumor agents used in the treatment of solid tumors, lymphomas, and acute lymphoblastic as well as myelocytic leukemias. The clinical utility of agents such as doxorubicin and daunorubicin and their well-characterized cardiotoxicity have prompted many efforts to develop analogs that retain the desired spectrum of activity but are less cardiotoxic. One such analog is idarubicin (4-demethoxydaunorubicin), which is currently under study in the treatment of adult and pediatric leukemias. The major circulating metabolite of idarubicin is the alcohol product of ketoreductase biotransformation, idarubicinol. Following the administration of idarubicin to adult or pediatric patients, systemic exposure to idarubicinol is greater than that to idarubicin. Moreover, we have also documented the presence of idarubicinol in the cerebrospinal fluid of pediatric patients who have received idarubicin. Idarubicinol has been reported to have greater cytotoxic activity than other anthracycline alcohol metabolites, which are regarded as much less active products of metabolism. We therefore evaluated the growth-inhibitory and DNA-damaging activities of idarubicin, daunorubicin, doxorubicin, epirubicin, and their alcohol metabolites against three relevant (CCRF-CEM lymphoblastic leukemia, K562 myelogenous leukemia, and U87-MG glioblastoma) human tumor cell lines. We found that whereas idarubicin was 2-5 times more potent than the other three anthracycline analogs against these tumor cell lines, idarubicinol was 16-122 times more active than the other alcohol metabolites against the same three cell lines. In addition, idarubicinol and the parent drug idarubicin were equipotent, unlike the other anthracycline alcohol metabolites, which were much less cytotoxic than the corresponding parent drugs. We also assessed the ability of the four parent drugs and their alcohol metabolites to induce DNA single-strand breaks. Idarubicin was more potent than the other three anthracycline analogs and idarubicinol was much more effective than the other alcohol metabolites in inducing DNA damage. These studies in human leukemia and human glioblastoma cell lines support the hypothesis that idarubicinol plays an important role in the antitumor activity of idarubicin and that the activities of idarubicin and idarubicinol are related to their ability to damage DNA.

Determination of the maximum tolerated dose of idarubicin when used in a combination chemotherapy program of reinduction of childhood ALL at first marrow relapse and a preliminary assessment of toxicity compared to that of daunorubicin: a report from the Childrens Cancer Study Group

An escalating-dose trial of idarubicin, used weekly for 3 doses in combination with vincristine, prednisone, and L-asparaginase (VPLI), to reinduce remission of childhood ALL at first bone marrow relapse was conducted by the Childrens Cancer Study Group (CCSG). The maximum tolerated dose (MTD) of idarubicin, used in the manner, was determined to be 12.5 mg/m2/dose. Twelve of 16 (75%) evaluable patients in first marrow relapse of ALL treated at a dose of 10 or 12.5 mg/m2 entered a second complete remission, compared to 41 of 69 evaluable patients (59%) treated in a comparable way with daunorubicin (30 mg/m2) (VPLD). Prolonged myelosuppression was observed in both groups, but the frequency of documented bacterial sepsis and the duration of required hospitalization were greater among patients treated with idarubicin. No additional toxicity, specifically attributable to idarubicin, was observed at these doses.

[Clinical usefulness of quantitative two-dimensional echocardiographic analysis of segmental kinesis of the left ventricle in monitoring of patients with neoplasms treated with anthracyclines]

To determine whether serial quantitative two-dimensional echocardiographic analysis of left ventricular wall motion could be effective in selecting patients in whom anthracycline treatment must be stopped, 26 patients (18 M and 8 F, mean age 10 +/- 3, range 6 to 16 years) with malignancy, receiving doxorubicin or daunomycin were followed up. Left ventricular regional wall motion abnormalities were detected in 11 patients (42%), while left ventricular ejection fraction at rest (although progressively decreased from baseline value [63 +/- 2 vs 55 +/- 2%; p = 0.0001]) was still in normal range. The following distribution of left ventricular contraction abnormalities was noted: septal, anteroseptal and posteroseptal akinesis with posterior wall hypokinesis in one patient; septal, anteroseptal and posteroseptal akinesis with anterolateral free-wall hypokinesis in another; septal, anteroseptal and posteroseptal hypokinesis in four; lateral and posterolateral free-wall hypokinesis in one; septal, anteroseptal, posteroseptal and posterior hypokinesis in four. The drug was discontinued in only two patients with akinesis, since we regarded this contraction abnormality as a predictive index of more serious and extensive myocardial damage. We began to detect hypokinesis when cumulative doses of doxorubicin or daunorubicin were 155-420 mg/m2 and 270-285 mg/m2 respectively, while akinesis was seen at doses of 395 mg/m2 of body-surface area for doxorubicin and 575 mg/m2 for daunorubicin. Follow-up examination was conducted six months after the last dose of anthracycline, and improvement or recovery of left ventricular regional wall motion abnormalities was noted in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of patients with newly diagnosed poor prognosis acute myelogenous leukaemia: response to treatment and treatment failure

The failure of poor prognosis patients with newly diagnosed AML to enter remission is usually due to two phenomena: a high mortality rate and resistance of the leukaemia to chemotherapy. We conducted a pilot study of a regimen designed to overcome these two types of treatment failure. Patients were carefully selected for therapy on the basis of their likelihood of surviving. Chemotherapy consisted of high dose cytosine arabinoside (HDaraC) with the doses modified on the basis of patient age so as to reduce the risk of toxicity. Finally, daunorubicin was administered only to those patients for whom HDaraC was not likely to produce sufficient antileukaemia effects to produce a remission. The median patient age was 67 years and 69/88 (78%) patients had a history of preleukaemia and/or toxic exposure. Only 11/84 (13%) patients died during remission induction therapy and 40/84 (48%) entered CR. Patients with only one risk factor had a higher CR rate than those with more than one risk factor (56% v. 30%, P = 0.02) and also had longer durations (222 d v. 113.5 d, P = 0.035). Two types of resistance to chemotherapy were observed: 'classical resistance' (the failure of chemotherapy to produce substantial killing of leukaemia cells) and the rapid regrowth of leukaemia cells subsequent to a level of cytoreduction which otherwise would have been sufficient to produce a CR.

[Torsade de pointes ventricular tachycardia in a patient with acute myelocytic leukemia]

The anti-leukemic antibiotics, anthracyclines, are most effective agents in the treatment of acute leukemia. However, they have severe cardiac toxicities, which ordinarily shows dose-dependency, but sometimes produce acute cardiomyopathy. We experienced Torsade-de-pointes arrhythmia during the treatment of acute myelocytic leukemia (AML); The patient was a 28 year old woman and had an AML-M1. After the short course administration of daunorubicin (total 90 mg/m2) and aclarubicin (total 219 mg/m2), she suffered from an attack of Torsade-de-pointes ventricular tachycardia and passed away, since any treatment against ventricular arrhythmia was not effective. Autopsy studies revealed degeneration and atrophy of cardiac muscle in the area around His's bundle, which suggested an anthracycline-induced cardiac toxicity.

[Focal hepato-splenic mycosis caused by Trichosporon beigelii in a patient with acute leukemia]

We report a case of infection produced by Trichosporon beigelii in a patient with acute leukaemia. In spite of treatment with amphotericin B the patient died and the necropsy studies showed only involvement of liver and spleen without disseminated infection. Focal hepatosplenic fungal infection has been recognized with increasing frequency in recent years as a serious complication in immunosuppressed patients. Usually it is produced by Candida spp and this is the first case described in the literature due to the newly recognized fungus T. beigelii.

[Long-term study of anthracycline-induced cardiomyopathy in children and adolescents]

In order to detect changes in cardiac function, electrocardiographic, echocardiographic and radiologic studies were performed in 71 patients (age 1-26 yrs) who had been treated at the University Children's Hospital Berlin because of malignant diseases according to protocols of the DAL/GPO and had received anthracyclines (doxorubicin or daunorubicin) at cumulative doses up to 480 mg/m2 (median 280 mg/m2). Clinically overt cardiomyopathy was observed in one girl and required transient administration of digoxin. In 2 patients echocardiographic changes led to a reduction of the scheduled anthracycline doses. No patient died from congestive heart failure. During treatment, an increase in the cardiothoracic index was observed in 14 children, and in 16 the ECG showed pathological findings. A decrease in contractility to 25% or less as detected by ultrasound was seen in 15 patients. More than 50% of patients developed echocardiographical signs indicating an impairment of myocardial function. However, persistent changes were only found in 1 patient after discontinuation of treatment. Long-term echocardiographic follow-up studies for 4-48 months (median 14 months) after completion of anthracycline therapy were performed in 18 patients and the findings compared to matched-pair controls. The observed M-mode parameters were completely normal, and the ejection fractions calculated from the two-dimensional ultrasound investigations were in the normal range but slightly diminished compared to controls. Cardiac ultrasound is a non-invasive, reproducible and tolerable procedure for early detection of an anthracycline cardiomyopathy. In our patients, time of occurrence and the extent of pathological changes were not associated with the cumulative applied anthracycline doses.(ABSTRACT TRUNCATED AT 250 WORDS)

Cell kinetics with in vivo bromodeoxyuridine and flow cytometry: clinical significance in acute non-lymphoblastic leukaemia

From 1986 to 1988, 54 consecutive previously untreated patients with acute non-lymphoblastic leukaemia (ANLL), median age 54 years, were treated for remission (CR) induction with vincristine and intravenous medium-dose cytarabine sequentially followed by daunomycin and infusion cytarabine. CR patients received intensive consolidation. Bone marrow blast kinetics was studied before therapy with in vivo bromodeoxyuridine and bivariate flow cytometry. CR rate was 70.2%, median CR was 13.2 months, responsive patient survival was 16.9 months and overall survival was 9.2 months. Besides lower median age, the 33 responsive patients also had shorter potential doubling time (Tpot) and greater cell production rate (PR) than the 14 unresponsive patients (mean values = 10.9 vs. 25.4 days, P less than 0.05, and 14.7 vs. 8.9 cells/100 cells/day, P less than 0.02, respectively), due to a higher mean labelling index (7.0 vs. 5.1%, P less than 0.05) and/or to a shorter mean DNA synthesis time (13.6 vs. 18.6 hours, P less than 0.05). Besides lower white blood cell count and bone marrow blast percentage, patients who experienced CR longer than 13.2 months had shorter Tpot (P less than 0.05) and a greater PR (P less than 0.02) than those who relapsed before this time. These data indicate that kinetic parameters have prognostic relevance in ANLL patients treated with sequential vincristine, cytarabine and daunomycin for inducing CR and with intensive consolidation after CR, a high proliferative activity being a favourable factor for both CR achievement and its duration.

[Systolic time intervals and echocardiography in monitoring adriamycin-treated tumor patients]

By means of systolic time intervals (PEP/LVET) and echocardiography (Vfr) 218 tumour patients were controlled concerning a cardiomyopathy induced by cytostatic agents. 13% of the patients (28/218) transgressed an absolute cumulative dose of 1,000 mg of doxorubicin or daunorubicin, of which, however, 12% (26/218) showed normal values for PEP/LVET. 11% of the patients (24/218) showed pathologic PEP/LVET values in 6% (49/787) of the investigations, in which case in 15 patients the clinical diagnosis of a cardiomyopathy could be assumed with simultaneously decreased shortening fraction. The sex and age distribution of this group corresponded to that one of the total cohort. The investigation presented confirm the value of systolic time intervals and of echocardiography as screening methods for a cardiomyopathy and speak against a general establishment of a borderline diagnosis.

[Gastroenterologic findings in graft versus host disease after allogenic bone marrow transplantation]

We are reporting on a 25 years old patient with acute myelogenous leukemia, who developed an acute graft-versus-host disease (GVHD) 43 days after allogeneic bone marrow transplantation (BMT). The clinical symptoms included exanthema, diarrhea and abdominal cramps. The patient was treated with cyclosporine A and prednisone and the clinical symptoms disappeared subsequently. At day 225 post BMT the patient became icteric as the clinical manifestation of chronic GVHD. We describe in this case report endoscopical and histological findings during the episodes of acute and chronic graft-versus-host disease. The results obtained by sigmoidoscopy and liver biopsy confirmed the clinical diagnosis. The clinical work up of patients with acute or/and chronic GVHD should also include sigmoidoscopy in order to verify this transplantation related complication.

Phase III trial of brief intensive treatment of adult acute lymphocytic leukemia comparing daunorubicin and mitoxantrone: a CALGB Study

This paper reports a study of the Cancer and Leukemia Group B (CALGB) comparing daunorubicin (DNR) or mitoxantrone (DHAD) in induction followed by multidrug intensification over 8 months in adult patients with acute lymphocytic leukemia (ALL). A total of 164 newly diagnosed patients were randomly assigned to either DNR or DHAD plus vincristine, prednisone and methotrexate given intravenously (i.v.) and interthecally (i.t.). Patients received four more intensification courses of chemotherapy and then all therapy was stopped. Central nervous system (CNS) prophylaxis consisted of nine infusions of intermediate dose methotrexate (MTX) and intrathecal MTX. DHAD and DNR were equally effective in producing complete remissions (63 and 65%, respectively). The estimated median remission duration is 10.2 and 12.3 months for the DHAD and DNR arms, respectively (p = 0.56). This study was stopped earlier than planned when it became apparent that remission duration for both arms was shorter than seen in our prior study in which all patients received more than 1 year of maintenance therapy. The estimated median survival is 18.3 and 20.6 months for the DHAD and DNR arms, respectively (p = 0.90). Younger patients and patients with a pre-treatment white blood count of less than 30,000/microliters had a significantly longer remission duration and survival. Eleven per cent of patients who achieved a complete remission have had a CNS relapse to date, which is not different from the rate in our prior study using cranial irradiation and i.t. MTX, implying that intermediate dose MTX with i.t. MTX may be as effective as cranial irradiation and i.t. MTX. This study suggests that some form of maintenance chemotherapy is required for the eradication of residual leukemia cells.

Functional myocardial impairment in children treated with anthracyclines for cancer

A non-invasive exercise method was used to look for myocardial damage in apparently normal children who had received moderate doses of anthracyclines for treatment of cancer. 19 children (mean [SD] age 10.6 [4.3] years) who had received anthracyclines (mean total dose 230 [119] mg/m2) and 10 who had received other cytotoxic drugs (mean age 13.3 [4.9] years) were selected from 263 children attending routine follow-up examinations. They underwent measurement of heart rate, blood pressure, and left ventricular dimensions by echocardiography before and after exercise on a bicycle for a maximum of 10 min. All 29 were in remission. All the subjects showed normal fractional shortening (FS = left ventricular end-diastolic minus end-systolic diameter as a percentage of the end-diastolic diameter) at rest, but the increase in FS on exercise was significantly lower in the children who had received anthracyclines than in those who had not (3 [16]% vs 23 [17]%; p less than 0.05). This difference remained significant after adjustment for age and drug exposure. However, there were no significant differences between the groups in the adjusted mean percentage changes on exercise in heart rate or systolic or diastolic blood pressure. Disease type had no effect on the cardiological indices. Thus, many children who have received anthracyclines may have suffered subclinical myocardial damage. Post-exercise echocardiography seems a useful non-invasive method for detecting such damage. Long-term cardiological follow-up of these patients is needed.

[Cardiotoxicity of anthracycline cytostatic agents--a proposal for routine monitoring and supportive therapy]

The authors investigated a group of 57 patients with acute leukaemia and 30 patients with malignant lymphomas, who were treated by combinations of cytostatics containing the anthracycline antibiotics daunorubicin and adriamycin. Using examination methods which are widely available they tried to find indicators which detect early manifestations of cardiac damage during this treatment. The most valuable indicators of incipient anthracycline cardiomyopathy were the heart rate at rest and the QTc interval on the ECG tracing. The validity of polygraphy and echocardiography could not be assessed in the present work. The authors suggest a procedure of routine monitoring of patients treated with anthracycline cytostatics and methods of supportive therapy to ensure safe treatment.

Mitoxantrone and cytarabine versus daunorubicin and cytarabine in previously untreated patients with acute myeloid leukemia

A total of 44 adults aged 18-78 years were allocated to an open randomized study whose aim was to compare the efficacy and toxicity of mitoxantrone with those of daunorubicin in previously untreated patients presenting with acute myeloid leukemia. In one arm, induction treatment consisted of mitoxantrone plus cytarabine given on a 3- plus 7-day schedule. Post-induction treatment consisted of two courses of mitoxantrone plus cytarabine given on a 2- plus 5-day schedule. In the control arm, mitoxantrone was replaced by daunorubicin. In all, 14 of 21 eligible and evaluable patients in the mitoxantrone arm achieved a complete remission (CR). In the control arm, 14 of 20 subjects attained a CR. The median survival was 365 days for patients randomized to mitoxantrone-cytarabine and 401 days for those given daunorubicin-cytarabine. The efficacy and toxicity of mitoxantrone were similar to those of daunorubicin.

[Lipid metabolism in daunomycin-induced nephrotic rats (5)]

Lipid metabolism of intestine, liver and kidney was examined in daunomycin-induced nephrotic rats. 1) Phospholipids, triglycerides and cholesterol contents in chylomicrons were increased in daunomycin-induced nephrotic rats. 2) Cholesterol absorption in intestine (in vivo and situ) was similar in daunomycin-induced nephrotic rats and control rats. 3) Total bile acids levels in bile and portal vein were similar in two groups. 4) There was no difference in incorporation of 14C-mevalonate into cholesterol by liver and kidney slices in two groups. The oxidation of 14CO2 from 14C-mevalonate in kidney slices was decreased in daunomycin-induced nephrotic rats. These results show that the hypercholesterolemia in daunomycin-induced nephrotic rats are not caused by increased absorption of cholesterol in intestine. The increased cholesterol esters in liver are not derived from decreased bile acids catabolism. The increased cholesterogenesis in the liver of daunomycin-induced nephrotic rats may be due to an increased rate at the step prior to mevalonate. The oxidation of 14CO2 from mevalonate by shunt pathway may be decreased in the kidney of daunomycin-induced nephrotic rats.

Osseous changes and abnormalities of mineral metabolism in daunomycin rats

We examined whether daunomycin rats could be used as an experimental model of human chronic renal failure in terms of their osseous changes and mineral metabolism. The daunomycin rats revealed hyperphosphatemia and osteodystrophic bone changes. In this respect, they were similar to human chronic renal failure. A high calcium level was found in the daunomycin rats at first due to the effect of the daunomycin injection, but later there was a lower calcium level than in the control rats due to chronic renal failure. We conclude that daunomycin rats can be successfully used as an experimental model of chronic renal failure from the standpoint of their osseous changes and mineral metabolism.