Azacitidine fails to eradicate leukemic stem/progenitor cell populations in patients with acute myeloid leukemia and myelodysplasia

Epigenetic therapies demonstrate significant clinical activity in acute myeloid leukemia (AML) and myelodysplasia (MDS) and constitute an important new class of therapeutic agents. However hematological responses are not durable and disease relapse appears inevitable. Experimentally, leukemic stem/progenitor cells (LSC) propagate disease in animal models of AML and it has been postulated that their relative chemo-resistance contributes to disease relapse. We serially measured LSC numbers in patients with high-risk AML and MDS treated with 5'-azacitidine and sodium valproate (VAL-AZA). Fifteen out of seventy-nine patients achieved a complete remission (CR) or complete remission with incomplete blood count recovery (CRi) with VAL-AZA therapy. There was no significant reduction in the size of the LSC-containing population in non-responders. While the LSC-containing population was substantially reduced in all patients achieving a CR/CRi it was never eradicated and expansion of this population antedated morphological relapse. Similar studies were performed in seven patients with newly diagnosed AML treated with induction chemotherapy. Eradication of the LSC-containing population was observed in three patients all of whom achieved a durable CR in contrast to patients with resistant disease where LSC persistence was observed. LSC quantitation provides a novel biomarker of disease response and relapse in patients with AML treated with epigenetic therapies. New drugs that target this cellular population in vivo are required.

Analysis of the interaction of induction regimens with p-glycoprotein expression in patients with acute myeloid leukaemia: results from the MRC AML15 trial

Retrospective analyses in non-randomised cohorts suggest that regimens containing fludarabine/Ara C and/or idarubicin/ara C may be more effective than daunorubicin/AraC (DA)-containing regimens in cases of acute myeloid leukaemia (AML) overexpressing p-glycoprotein (Pgp). We prospectively measured Pgp protein and function by flow cytometry in CD45-gated blasts from 434 AML15 trial patients randomised to remission induction therapy with two courses of FLAG-Ida or DA±etoposide (DA/ADE). In all, 34% were positive for Pgp protein and 38% for function. Pgp protein-positive cases had a higher incidence of resistant disease (14% vs 5%), adjusted odds ratio 2.67 (1.14–6.24). There was a trend towards a higher cumulative incidence of relapse at 5 years for Pgp-positive cases (46% vs 55%), adjusted hazard ratio 1.42 (0.98–2.07) (P=0.06). For patients treated with FLAG-Ida, the complete remission (CR) rate was 86% for both Pgp-positive and Pgp-negative patients. In patients treated with DA/ADE, 78% of Pgp-positive and 90% of Pgp-negative cases achieved CR (P=0.06). In analyses of overall survival, there was no interaction between treatment received and Pgp expression. Data for Pgp function followed similar trends. Our data suggest that FLAG-Ida may improve the remission rate for Pgp-positive AML, but the malignant clone is reduced rather than eradicated such that the relapse rate remains high in Pgp-positive patients.

First Report of the Peach Brown Rot Fungus Monilinia fructicola Resistant to Demethylation Inhibitor Fungicides in New Jersey

Reduced sensitivity and resistance of Monilinia fructicola to demethylation inhibitors (DMIs; fungicide group 3) have been previously found in stone fruit orchards in Georgia, South Carolina, Ohio, and New York (2). Resistance development is a major concern because of the importance of DMIs for brown rot management. Eleven single-spore isolates, originally collected during 2006 from separate commercial peach (Prunus persica) orchards in southern New Jersey, were removed from cold storage (5°C) in early 2008 and examined in vitro for resistance to the DMI propiconazole (Orbit 3.6EC; Syngenta Crop Protection, Inc., Greensboro, NC). After 19 months at 5°C, isolate 7 was inhibited 53.4% in growth on potato dextrose agar (PDA) amended at the discretionary dose of 0.3 μg/ml propiconazole; inhibition of the remaining isolates ranged from 81.4 to 100%. Inhibition values were based on two replications of eight colonies per isolate performed after incubation at 25°C for 4 days. Because of the previously reported relationship between duration of cold storage and propiconazole sensitivity, isolate 7 was tentatively deemed resistant (1). To confirm the in vitro results, isolates were grown at 25°C for 7 days on cellophane over PDA. Genomic DNA was isolated from mycelium with the DNeasy Plant Mini Kit (Qiagen, Inc., Valencia, CA). PCR with primers INS65-F and INS65-R was conducted on a GeneAmp thermal cycler (Applied Biosystems, Inc., Foster City, CA) as described previously to amplify a 65-bp region named 'Mona' associated with DMI resistance (2). PCR products were separated via electrophoresis on 0.8% agarose gel. The primers amplified a 376-bp fragment from isolate 7 and a 311-bp fragment from all other isolates, thus indicating the presence of Mona in isolate 7. Restriction fragment length polymorphism analysis using the BsrBI enzyme, specific to a single restriction site within Mona, was conducted on the amplified fragments from all isolates. Electrophoresis results showed digestion of the 376-bp fragment from isolate 7 into 140-bp and 236-bp fragments, thereby confirming the presence of Mona; none of the 311-bp fragments from the remaining isolates were cut by BsrBI. Although economic loss from brown rot has not been reported in New Jersey, these results show that propiconazole-resistant strains have been detected since 2006 and it is most likely that resistant strains of the pathogen are still present in commercial peach orchards. To combat this risk, current brown rot control recommendations are incorporating quinone outside inhibitors (QoIs; fungicide group 11) and carboxamides (fungicide group 7) into control programs as a resistance management strategy. More extensive sampling is planned to ascertain the prevalence and location of resistant strains. References: (1) K. D. Cox et al. Phytopathology 97:448, 2007. (2) C.-X. Luo et al. Plant Dis. 92:1099, 2008.

Effect of visual display height on modelled upper and lower cervical gravitational moment, muscle capacity and relative strain

Head and neck posture is an important factor in neck pain related to computer use; however, the evidence for an optimal posture is unconvincing. This study measured the 3-D postures of 36 young adults during use of three different display heights. Cervical extensor muscle strain was estimated using modelled gravitational load moments and muscle capacities. The influence of more or less upper vs. lower cervical movement was also explored across a broad range of potential postures. Overall cervical extensor muscle capacity diminished away from a neutral posture whilst gravity moment increased with flexion. Overall cervical extensor muscle strain increased with head flexion but remained stable into head extension. Individual differences in the amount of upper and lower cervical movement had an important effect on strain, particularly for some muscles. Computer display height guidelines are an important component of ergonomics practice, yet the relative strain on neck extensor muscles as a function of display height has not been examined. The current findings provide more detailed biomechanical evidence that ergonomists can incorporate with usability and other evidence to determine appropriate display height recommendations.

Far-infrared spectroscopic characterization of explosives for security applications using broadband terahertz time-domain spectroscopy

Broadband terahertz time-domain spectroscopy (THz-TDS) has been used to measure the far-infrared (FIR) vibrational spectra of several commonly used pure explosives, including 2,4,6-trinitrotoluene (TNT), 1,3,5-trinitroperhydro-1,3,5-triazine (RDX), 1,3-dinitrato-2,2-bis(nitratomethyl)propane (PETN), and two types of plastic explosive, SEMTEX and SX2. A number of distinct absorption peaks, originating from FIR-active vibrational modes of these polycrystalline energetic materials, were observed in the frequency range 0.3-7.5 THz (10-250 cm(-1)). In addition, the temperature-dependent FIR vibrational spectra of PETN were measured between 4 K and 296 K with several well-resolved absorption peaks observed across this temperature range. We find that as the temperature is reduced, the observed absorption peaks resolve into narrower features and shift towards higher frequencies. The temperature dependence of the spectra is explained in terms of the anharmonicity of the vibrational potentials of crystalline compounds, and an empirical fit is given to describe the peak shift with temperature.

Fludarabine phosphate and melphalan: a reduced intensity conditioning regimen suitable for allogeneic transplantation that maintains the graft versus malignancy effect

Reduced intensity conditioning (RIC) for allogeneic stem cell transplantation allows stable donor cell engraftment with the maintenance of a graft versus malignancy effect. Many different regimens exist employing various combinations of chemotherapy, radiotherapy and T-cell depletion. We examined the role of non-T-cell depleted RIC regimens in 56 patients with haematological malignancies. Patients received fludarabine phosphate for 5 days (30 mg/m2 in 35 patients, 25 mg/m2 in 21 patients) and melphalan for 1 day (140 mg/m2 in 36 patients, 100 mg/m2 in 20 patients). Immunosuppression was with CyA alone in 33 patients and CyA/MTX in 23 patients. Twenty-four of the 26 patients with chimerism data showed >95% donor chimerism at 3 months post transplant. aGVHD occurred in 18% of patients receiving CyA/MTX compared to 53% of patients receiving CyA. The 100-day mortality rate was 0.16 (95%CI 0.08-0.28) and 1-year nonrelapse mortality was 0.24 (95%CI 0.13-0.38). Thirty-three patients remained alive and in CR at a median of 19 months post transplant (range 3-38 months). We have shown that patients transplanted with fludarabine phosphate, melphalan 100 mg/m2 and with CyA/MTX as post transplant immunosuppression can achieve good disease control with an acceptable level of toxicity. Further studies are required to confirm these findings.

Gene expression fingerprint of uterine serous papillary carcinoma: identification of novel molecular markers for uterine serous cancer diagnosis and therapy

Uterine serous papillary cancer (USPC) represents a rare but highly aggressive variant of endometrial cancer, the most common gynecologic tumour in women. We used oligonucleotide microarrays that interrogate the expression of some 10 000 known genes to profile 10 highly purified primary USPC cultures and five normal endometrial cells (NEC). We report that unsupervised analysis of mRNA fingerprints readily distinguished USPC from normal endometrial epithelial cells and identified 139 and 390 genes that exhibited >5-fold upregulation and downregulation, respectively, in primary USPC when compared to NEC. Many of the genes upregulated in USPC were found to represent adhesion molecules, secreted proteins and oncogenes, such as L1 cell adhesion molecule, claudin-3 and claudin-4, kallikrein 6 (protease M) and kallikrein 10 (NES1), interleukin-6 and c-erbB2. Downregulated genes in USPC included SEMACAP3, ras homolog gene family, member I (ARHI), and differentially downregulated in ovarian carcinoma gene 1. Quantitative RT-PCR was used to validate differences in gene expression between USPC and NEC for several of these genes. Owing to its potential as a novel therapeutic marker, expression of the high-affinity epithelial receptor for Clostridium perfringens enterotoxin (CPE) claudin-4 was further validated through immunohistochemical analysis of formalin-fixed paraffin-embedded specimens from which the primary USPC cultures were obtained, as well as an independent set of archival USPC specimens. Finally, the sensitivity of primary USPC to the administration of scalar doses of CPE in vitro was also demonstrated. Our results highlight the novel molecular features of USPC and provide a foundation for the development of new type-specific therapies against this highly aggressive variant of endometrial cancer.

Dose-finding study of valspodar (PSC 833) with daunorubicin and cytarabine to reverse multidrug resistance in elderly patients with previously untreated acute myeloid leukemia

INTRODUCTION

This trial was designed to determine the maximum tolerated dose of intravenous daunorubicin (DNR) in combination with valspodar and to test the feasibility of P-glycoprotein modulation using valspodar in elderly patients with previously untreated acute myelogenous leukemia receiving standard induction chemotherapy.

METHODS

Patients > or =60 years of age with previously untreated AML received valspodar (10 mg/kg/24 h by continuous intravenous infusion [CIV] on days 1-4 with a 2-mg/kg loading dose on day 1) in conjunction with two cycles of induction chemotherapy consisting of cytarabine (200 mg/m(2) CIV on days 1-7), and DNR (35 mg/m(2) [cohort 1] or 45 mg/m(2) [cohort 2] on days 1-3, intravenous bolus). Patients were assessed for dose-limiting toxicities (DLT), response rate, event-free and overall survival, and pharmacokinetics of valspodar and DNR.

RESULTS

Valspodar was well tolerated at the lower DNR dose level (ie, 35 mg/m(2)) resulting in a 21% rate of DLT and only three toxic deaths. Treatment-related mortality was unacceptably high at the 45 mg/m(2) DNR dose level. The complete response rate was 49% overall and similar in both cohorts. The median overall survival of patients was 333 days in cohort 1 compared to 98 days in cohort 2. At baseline, 70% of assessable patients were P-glycoprotein positive.

CONCLUSION

Substantial inhibition of P-glycoprotein activity can be achieved in this patient population at clinically tolerable doses of valspodar and DNR. The maximum tolerated dose of DNR was established as 35 mg/m(2). This regimen is being further evaluated in phase III trials.