Sequential administration of recombinant interferon alpha and deoxycoformycin in the treatment of hairy cell leukaemia

Both recombinant interferon alpha and deoxycoformycin (dCF) are effective in the treatment of hairy cell leukaemia. In an attempt to reduce the complications from dCF therapy, a pilot study of the Eastern Cooperative Oncology Group (ECOG) first treated patients with interferon to improve peripheral blood cell counts before dCF treatment began. Thirty-four patients were treated for 3 months with recombinant interferon alpha-2a (rIFN alpha-2a), 3 x 10(6) IU subcutaneously three times a week for 3 months, and then by dCF, 4 mg/m2 intravenously every 2 weeks for a maximum of 12 months. The overall response rate was 94% (32/34); 76% of patients (26/34) had complete response (CR) (90% confidence interval, 62-88%) and 18% (6/34) partial response. One patient was found to have a Mycobacterium avium infection while receiving rIFN alpha-2a. Without specific antimycobacterial therapy and with continued administration of rIFN alpha-2a and dCF, the infection resolved and he achieved CR. Three patients had culture-negative febrile episodes during the dCF phase of treatment. Non-disseminated herpes zoster developed in four patients, but three of the episodes occurred only after treatment was discontinued. Sequential administration of rIFN alpha-2a and dCF resulted in fewer infections (P = 0.027) than in ECOG's previous study of dCF used alone. Two patients died, one of combined hairy cell leukaemia and non-Hodgkin's lymphoma of intermediate histologic type 17 months after entry into the study and the other of cardiac arrest 20 months after entry. Thirty-two patients were alive with a median follow-up of 21 months (range 13-31 months). This combination produces durable CRs with a low incidence of infection.

Marrow fibrosis associated with a Philadelphia chromosome

Three patients had marked marrow fibrosis and an apparent Philadelphia (Ph) chromosome. Hematologic, cytogenetic, and molecular studies demonstrated the heterogeneity of such cases, including the first example of clinically typical myelofibrosis (MF) associated with a bcr gene rearrangement characteristic of chronic myelogenous leukemia (CML).

Activity of fludarabine in previously treated non-Hodgkin's low-grade lymphoma: results of an Eastern Cooperative Oncology Group study

PURPOSE

Fludarabine (2-fluoro-arabanoside-monophosphate) is a new antimetabolite chemotherapeutic agent. We performed a multicenter, phase II study of this drug in previously treated patients with refractory or relapsed non-Hodgkin's lymphoma (NHL) to determine its response rate by histologic classification.

PATIENTS AND METHODS

Sixty-two assessable patients were given 18 mg/m2 by intravenous (IV) bolus injection daily for 5 days, every 28 days. Forty-eight percent had previously had one chemotherapy regimen, and the remainder had had two regimens; 42% had had radiation.

RESULTS

Patients received 273 cycles of fludarabine chemotherapy, with a median of two cycles and ranging up to 25 cycles. Sixty patients were assessable for response, including nine complete responses (CRs; 15%) and nine partial responses (PRs; 15%). The response rate for patients with lower-grade histology was 52% (13 of 25); the greatest response rate was seen in those with follicular small cleaved-cell lymphoma, including seven of 11 treated. Five responders remain in unmaintained remission; the median survival of responders is greater than 30 months. Toxicity included mild neutropenia and a 10% incidence of grade 3 neurologic toxicity with occasional reversible visual and auditory changes.

CONCLUSION

Fludarabine is active in patients with previously treated NHL (particularly low-grade histologies). Future studies will examine its activity in combination with other chemotherapeutic agents in previously untreated patients.

Danazol treatment of myelodysplastic syndromes

Peripheral cytopenias are common in patients with myelodysplastic syndromes. We previously successfully treated three such patients with improvement of some cytopenias with the impeded androgen danazol. To confirm this finding and elucidate the mechanism of response, we treated an additional 22 patients with myelodysplasia with oral danazol (600-800 mg daily) for 3-12 months. Eleven of 22 evaluable patients taking danazol met our criteria for improvement of peripheral counts, mainly thrombocytopenia. Chromosome analysis, marrow culture studies and serial bone marrow biopsies revealed no alteration of the abnormal clone or normal haematopoiesis in patients on danazol therapy. This suggested that improvement in blood counts was not related to modulation of ineffective haematopoiesis. Investigation of the thrombocytopenia in these patients revealed that most patients presented with markedly elevated platelet associated IgG (PAIgG), elevated plasma platelet-bindable IgG (PBIgG), and an elevated number of monocyte Fc gamma receptors. Treatment with danazol was associated with a decline in monocyte Fc gamma receptor number without significantly altering the elevated PAIgG or PBIgG levels. These results are similar to our observations in patients treated with danazol for chronic idiopathic thrombocytopenia purpura (ITP). Our data suggest that a component of the thrombocytopenia occurring in patients with myelodysplasia may be due to enhanced peripheral blood cell destruction by abnormal macrophages. Danazol may modulate cytopenia by decreasing the number of monocyte Fc gamma receptors. Danazol treatment was associated with minimal toxicity, but clinically meaningful responses were rare.

Pentostatin induces durable remissions in hairy cell leukemia

Fifty patients with hairy cell leukemia were treated with pentostatin (2'-deoxycoformycin; dCF) for a median of 3 months; 32 (64%) patients achieved complete remission (CR), and 10 (20%) patients achieved partial remission (PR), for an overall response rate of 84%. After reaching maximal response, no maintenance therapy was administered. The median duration of follow-up is now 39 months, and only four of 32 patients in CR and two of 10 patients in PR have relapsed. dCF therapy produces durable long-term, disease-free survival in patients with hairy cell leukemia.

Unexpected immunoglobulin light chain gene rearrangements in myeloid antigen positive acute lymphoid leukemia

Blast cells from 10 immunologically diagnosed adult acute lymphoid leukemias expressing myeloid antigens (M+ALL) were studied for immunoglobulin heavy (IgH) and light chain as well as T-cell receptor (TCR)-beta chain gene rearrangements. All but one leukemic isolate met the FAB-criteria for ALL. DNA from 2 patients with pre-pre-B-ALL (CD10-) and 1 patient with common ALL contained rearranged Ig light chain (kappa in two, lambda in one case) in addition to rearranged IgH genes. The TCR-beta chain gene was germline in all pre-pre-B leukemias and rearranged in common ALLs (bigenotypic features). One patient with mature B-ALL showed IgH and light chain gene rearrangements. DNA from 2 pre-T-ALLs contained rearranged TCR-beta chain genes plus rearranged IgH genes in one case. Ig light chain gene rearrangements in immature M+ALL were not associated with gross chromosomal abnormalities except for one Philadelphia chromosome positive case. The occurrence of Ig light chain gene rearrangements in M+ALL with immature lymphoid immunophenotype might represent an hitherto unrecognized aberrant differentiation potential of transformed multipotential stem cells with commitment towards the lymphoid lineage.

Long term survival in acute myeloid leukemia: the Eastern Cooperative Oncology Group (ECOG) experience

A retrospective analysis of two ECOG adult AML trials conducted from 1976 to 1983 was carried out focusing on long term disease-free survival. This report summarizes the data on 545 patients with a minimum follow up of 7 1/2 years. The complete remission rate was 57% with an estimated cure rate of 12%. Of several prognostic variables examined only FAB type M3 (promyelocytic leukemia) was statistically significant (estimated cure rate of 33% vs 9% for other FAB subtypes).

Report of the National Cancer Institute-sponsored workshop on definitions of diagnosis and response in acute myeloid leukemia

The National Cancer Institute (NCI) sponsored a workshop to develop a set of standardized diagnostic and response criteria for acute myeloid leukemia (AML) clinical trials. The French-American-British (FAB) classification was retained for diagnosing AML, with the addition of patients with bone marrow morphologic features of a myelodysplastic syndrome and less than 30% bone marrow blasts, but with greater than or equal to 30% blasts in the peripheral blood. In this report, there are four important subgroups of AML not defined in the FAB classification that are discussed: undifferentiated acute leukemia, MO (AML lacking definitive myeloid differentiation by morphology or conventional cytochemistry but with ultrastructural or immunophenotypic evidence for AML), mixed lineage leukemia, and hypocellular AML. Definitions of response for clinical trials are presented to facilitate comparisons among different studies. Complete remission is considered the only response worth reporting in phase III trials, since lesser responses do not improve survival. Partial remissions may be of interest to identify active new agents in phase I and II studies. Monoclonal antibodies and cytogenetic studies are not part of the routine assessment of remission or reassessment at relapse, and their role in the evaluation of patients with AML is currently being evaluated in clinical trials. Although we recognize that some of the definitions in this report are arbitrary, generalized use of these guidelines will make results of clinical trials more comparable and interpretable.

Etoposide in leukemia, lymphoma and bone marrow transplantation

Etoposide, an epipodophyllotoxin structurally related to vincristine, is active in solid tumors. Trials of etoposide in hematologic malignancies, particularly leukemia and lymphoma, were initiated in 1973. Subsequent studies indicate that etoposide, either as a single agent or in combination with other drugs, is active in acute myelogenous leukemia, non-Hodgkin and Hodgkin lymphoma. Etoposide may be effective in acute lymphoblastic leukemia, but it is inactive in chronic myelogenous leukemia. The major toxicity of etoposide is myelosuppression. Non-hematologic toxicity is relatively mild at doses up to 2000 mg/m2. This feature favors its use in high dose regimens such as those employed before bone marrow transplantation. Preliminary studies of etoposide in autologous bone marrow transplantation in lymphoma and Hodgkin disease are promising. Studies of high dose etoposide in combination with other chemotherapeutic agents or in the context of bone marrow transplantation are in progress.

Continuous infusion homoharringtonine (NSC 141633) in refractory acute nonlymphocytic leukemia. An ECOG pilot study

Single-agent homoharringtonine (HH) was evaluated as induction therapy in 20 patients with advanced acute nonlymphocytic leukemia (ANLL) in a pilot study of the Eastern Cooperative Oncology Group (ECOG). HH was given by continuous intravenous (i.v.) infusion at 3.5 mg/m2 on the first day and at 6.0 mg/m2/day on days 2-8. Fourteen men and six women with a median age of 43 years were treated. Sixteen patients had clearing of peripheral blasts, 10 patients achieved marrow hypoplasia, and 2 patients had progressive disease. No complete remission occurred. Drug-induced hypotension was the most significant toxicity, causing a delay in treatment in 8 patients. The median survival was 15 weeks (range 1-65 weeks) from the start of HH treatment. Despite a definite antileukemic effect, HH as a single agent cannot be recommended as a useful salvage regimen in patients with far advanced ANLL.

High dose cytarabine: a review

High dose cytarabine (HDARAC) therapy is used increasingly to treat hematologic malignancies. Recent data indicate that HDARAC at doses of 2-3 g/M2 every 12 hr x 10-12 doses is of comparable or greater efficacy in remission induction as standard doses of cytarabine in acute myelogenous leukemia. HDARAC can also produce remissions in individuals resistant to conventional doses. HDARAC-containing regimens are reported to result in substantially higher long-term, disease-free survival than previous approaches to post-remission therapy, but this has not yet been confirmed in controlled trials. HDARAC is also active in acute lymphocytic leukemia. Because intravenous HDARAC achieves high levels in the spinal fluid, it is useful to treat central nervous system leukemia and may provide adequate CNS prophylaxis in acute lymphocytic leukemia. HDARAC is reported to be active in advanced non-Hodgkin lymphomas and chronic myelogenous leukemia in acute phase; optimal use in these settings is under study. HDARAC has also been combined with other drugs. Randomized trials are needed to determine whether these combinations are more effective than HDARAC alone. Apart from potent myelosuppression, the dose-limiting toxicity of HDARAC is cerebellar damage. This occurs with increased frequency in patients greater than 50 years old. HDARAC is active in hematologic malignancies and may further improve therapeutic results if combined with other drugs.

Maintenance chemotherapy prolongs remission duration in adult acute nonlymphocytic leukemia

The value of maintenance therapy after the achievement of complete remission in adult acute nonlymphocytic leukemia (ANLL) has never been clearly established. A randomized Eastern Cooperative Oncology Group (ECOG) study of postremission therapy compared outcomes in patients who received no further therapy to those administered long-term maintenance chemotherapy. Adverse results in the group administered no further therapy led to early termination of this trial after only 51 patients were randomized. Patients receiving no postremission therapy experienced significantly inferior remission durations (P = .002) compared with patients receiving maintenance therapy. All 26 patients in the group administered no postremission therapy have relapsed, with a median duration of remission of 4.1 months. In contrast, four of 25 patients (16%) who received maintenance therapy remain disease free, with a median duration of remission of 8.1 months.

High peripheral blast count in adult acute myelogenous leukemia is a primary risk factor for CNS leukemia

The lengthening remission duration achievable in acute myelogenous leukemia (AML) places patients at risks for CNS leukemic relapse. We reviewed the data on two Eastern Cooperative Oncology Group (ECOG) trials in acute nonlymphocytic leukemia to determine the incidence of CNS leukemia (CNSL). The incidence of CNSL was 5% (30 of 569 patients) overall, and 3% (ten of 331) in patients in complete remission (CR). A number of factors were evaluated for association with increased risk of CNSL. Men more frequently developed CNSL than women at a three to one ratio, and median presenting WBC counts were higher in affected than unaffected patients (44,200/microL v 17,000/microL, P = .01). The low incidence of CNSL in AML supports the view that CNS prophylaxis is unnecessary. However, because 68% of patients (13 of 19) who developed CNSL early in the course of disease had presenting WBC counts greater than 40,000/microL, screening lumbar punctures should be routinely obtained during induction therapy in patients presenting with high circulating blast cell counts.

Persistent fever after recovery from granulocytopenia in acute leukemia

We reviewed the hospital admissions of 168 patients with acute leukemia to determine the incidence of persistent fever following recovery from chemotherapy-induced granulocytopenia. This phenomenon was observed during 26 (15.5%) hospital admissions. The microbiologically and/or clinically documented causes identified in 23 instances included viral infection (two patients), perirectal abscess (two patients), Hickman catheter-related bacteremia (two patients), intraabdominal infection (four patients), and nine fungal infections (five resolving pneumonia, one disseminated candidiasis, three focal hepatic and/or splenic mycosis). One patient had both cholecystitis and a pneumonia of uncertain origin and three patients had drug reactions. Although overall the source of fever was usually readily apparent, focal hepatic and/or splenic mycosis produced protracted fevers that were difficult to diagnose. Visceral fungal infection should be a leading diagnostic consideration in patients with leukemia who remain persistently febrile following recovery from chemotherapy-induced granulocytopenia.

The prognostic significance of myelonecrosis after induction therapy in acute leukemia

Myelonecrosis is a rare antemortem finding in acute leukemia and its clinical significance is uncertain. The clinical events in nine patients with acute leukemia whose bone marrow biopsies after induction therapy revealed myelonecrosis were reviewed. No patient gained a complete remission and four patients achieved a partial remission. The median duration of survival was 2 months (range, less than 1 month to 8.5 months) from the start of therapy. Myelonerosis after induction therapy in acute leukemia indicates a very poor prognosis.

Low dose cytosine arabinoside in myelodysplasia and acute myelogenous leukemia: a review

We analyzed clinical trials of low dose cytosine arabinoside (LDARA-C) in 324 patients with acute myelogenous leukemia (AML) and 129 patients with myelodysplasia (MDS). Complete and partial remission rates were 31% and 18%, respectively, in patients with AML, and 24% and 27% in patients with MDS. Toxicity was primarily hematologic. Although in vitro data suggested that LDARA-C acts as a differentiating agent, clinical data generally indicate a cytotoxic mechanism. Given the lack of effective therapeutic options in MDS and high risk AML (patients greater than 65 years old, secondary AML), these data are encouraging. LDARA-C warrants further study, comparing continuous infusion with intermittent subcutaneous administration and comparing LDARA-C to conventional dose therapy.

Cerebellar toxicity with high-dose cytosine arabinoside

CNS dysfunction, especially impaired cerebellar function, is the dose-limiting toxicity associated with high-dose cytosine arabinoside, which precludes doses of greater than 48 g/m2. Four hundred eighteen patients between the ages of 2 and 74 years with leukemia or lymphoma received 36 to 48 g/m2 cytosine arabinoside either alone or with anthracycline antibiotics, 4'-(9-acridinylamino) methane sulfon-m-anisidine (m-AMSA), or total body irradiation. In only 35 of 418 patients (8%) did severe cerebellar toxicity develop; it was irreversible or fatal in four (1%) patients. The age of the patient was a critical factor in the incidence of severe cerebellar toxicity. Patients greater than 50 years old had a statistically significant greater incidence of cerebellar toxicity compared with younger patients (26/137, 19%, v 9/281, 3%; P less than .0005, chi 2). Neither the diagnosis, disease status, sex, nor the regimen altered the incidence of severe cerebellar toxicity (when corrected for age). A second course of high-dose cytosine arabinoside, administered to 62 patients, did not increase the incidence of severe cerebellar toxicity, which occurred in five (8%) of these patients. Two of the five patients had severe toxicity with the initial course. Of the 60 patients with no antecedent cerebellar dysfunction, three (5%) had severe toxicity with the second course: one of 41 patients were less than 50 years old; two of 19 patients were greater than or equal to 50 years. Since the occurrence of severe cerebellar dysfunction is greatly affected by age, reduced doses of high-dose cytosine arabinoside should be given to patients greater than 50 years old, and methods for reducing the cerebellar toxicity should be investigated in these patients.

Remissions in hairy-cell leukemia with pentostatin (2'-deoxycoformycin)

The Eastern Cooperative Oncology Group conducted a study of pentostatin (2'-deoxycoformycin) in 37 patients with hairy-cell leukemia. Among the 27 patients who met all the study's entry criteria, the response rate was 96 percent, with 16 patients (59 percent) entering complete remission and 10 patients (37 percent) partial remission. In one patient no response was observed. These results were not significantly changed by the inclusion of nine additional patients who were found retrospectively not to have fulfilled the entry criteria. When complete remission was attained, maintenance therapy was not given. Despite this, no patient has had a relapse, and the duration of complete remission ranges from 1 to 375 days. Pentostatin appears to be equally effective in untreated patients and in those who have progressive disease after splenectomy or after both splenectomy and treatment with interferon. Whether pentostatin is superior to splenectomy or interferon as therapy for hairy-cell leukemia will have to be assessed by direct comparison in randomized studies. Lengthy follow-up will be required to determine a median duration for the responses of hairy-cell leukemia to pentostatin.

Prolonged unmaintained remission after intensive consolidation therapy in adult acute nonlymphocytic leukemia

Thirty-five adults with acute nonlymphocytic leukemia who were in complete remission after initial induction therapy received a single course of high-dose cytarabine and amsacrine as consolidation therapy. No further therapy was administered. Despite substantial toxicity, the median duration of disease-free survival was 12 months, and 30% of patients are projected to be alive in continuous complete remission at 3 years. A single course of intensive postremission chemotherapy provides long-term disease-free survival in the absence of any further treatment.

Differential effects of phorbol esters on normal myeloid precursors and leukemic cells: basis for autologous bone marrow reconstitution in acute nonlymphocytic leukemia using phorbol ester-treated bone marrow from patients in remission

The phorbol ester 12-O-tetradecanoylphorbol-13-acetate (TPA) induces macrophage-like differentiation of HL60 cells and cells from patients with acute nonlymphocytic leukemia (ANLL). We assessed the use of TPA as a means of eradicating residual leukemia from remission bone marrow prior to autologous bone marrow reconstitution. A 30-min incubation with TPA led to marked growth arrest in HL60 cells and in cells from most patients with acute myelogenous leukemia and acute myelomonocytic leukemia, whereas cells from most patients with acute promyelocytic leukemia and acute undifferentiated leukemia demonstrated a lesser degree of growth arrest. Freezing and thawing, a necessary step in autologous reconstitution, had no effect on the cessation of proliferation induced in HL60 or ANLL cells preincubated with TPA for 30 min. Virtually normal myeloid precursor growth occurred in normal or remission bone marrow cells preincubated with TPA and then frozen and thawed. Based on these observations, two patients with advanced ANLL in remission underwent marrow ablative therapy followed by autologous reconstitution using TPA-treated bone marrow. Limited normal hematopoiesis was reestablished in both patients, although they subsequently experienced leukemic relapse. These studies demonstrate that in ANLL cells, TPA stimulates growth arrest; in contrast, hematopoiesis is able to proceed both in vitro and in vivo.

Comparison of allogeneic bone marrow transplantation and chemotherapy in adult acute nonlymphocytic leukemia. An Eastern Cooperative Oncology Group Study

To compare the value of ABMT (allogeneic bone marrow transplantation) in first or second remission vs. conventional chemotherapy in adults with acute nonlymphocytic leukemia, we examined retrospectively the outcome of a recently completed chemotherapy trial. We evaluated the survival of patients, with and without histocompatible siblings, who were less than or equal to 45 years old and who had achieved initial complete remission. Of 20 patients who were referred by their physicians for ABMT in first remission, seven relapsed (median duration of remission, 4 months) prior to ABMT, three refused, and 10 underwent ABMT. Nine patients received ABMT in second remission. In comparison to the results of chemotherapy in patients who lacked histocompatible siblings (median duration of survival, 18.5 months), the survival of patients transplanted in first remission was worse (median, 8 months), whereas the survival of patients transplanted in second remission was substantially better (median greater than 22 months). Although ABMT in second remission clearly offers the potential for long-term survival not available by means of conventional chemotherapy, the value of ABMT in first remission remains uncertain.

Amsacrine: a review

Amsacrine is an acridine derivative that has been extensively evaluated for its antitumor activity in recent years. Amsacrine is active in the treatment of acute leukemias and lymphomas but largely ineffective in solid tumors. In acute myelogenous leukemia, amsacrine is as effective as the two most active drugs, cytarabine and daunorubicin and can produce complete remissions in patients refractory to these drugs. The addition of amsacrine to the limited therapeutic armamentarium for this disease offers the potential for improved remission rates and remission duration.

Effectiveness of acute nonlymphocytic leukemia induction chemotherapy in acute lymphocytic leukemia

Twelve adults with newly diagnosed acute lymphocytic leukemia (ALL) received a combination of daunorubicin, cytarabine, and 6-thioguanine (DAT) as induction chemotherapy. Eleven patients (91%) gained complete remission (ten patients after a single course of treatment). Because DAT alone seems effective in ALL, the combination of vincristine, prednisone, and DAT could improve the complete remission rate. Moreover, the resulting early leukemic cytoreduction could enhance remission duration in adults with ALL.

Invasive pulmonary aspergillosis and acute leukemia. Limitations in the diagnostic utility of the air crescent sign

The air crescent sign is regarded as an important diagnostic finding in invasive pulmonary aspergillosis (IPA). This study examined the incidence, clinical importance, and natural history of air crescents in 25 patients with acute leukemia and IPA. Twelve (50%) of the patients had cavities (ten with an air crescent) that appeared an average of 15 days after the initial infiltrate. The diagnostic utility of the air crescent sign was relatively minor; cavities developed after the diagnosis was established in 50% of cases and after therapy was started in 75% of cases. In each case, the pneumonia improved at the time of cavitation. In six patients (50%), the cavities resolved over 2-8 months. Three patients (25%), however, experienced massive hemoptysis. Air crescent formation, previously shown to be dependent on granulocyte recovery, was associated with improved survival (67%) compared with the group without cavitation (8%). In the latter group, the pneumonia in ten (77%) of 13 patients progressed to diffuse disease. In patients with leukemia, the diagnostic value of the air crescent sign is limited by cavities that develop relatively late, as the infection improves after white blood cell recovery; cavities that do not occur in patients who remain neutropenic; and associated hemorrhage, at times life-threatening, that obscures the air crescent. The diagnosis of IPA should not await observation of air crescents in these patients.

Invasive pulmonary aspergillosis in adult acute leukemia: clinical clues to its diagnosis

Invasive pulmonary aspergillosis, a leading cause of morbidity and mortality in patients with acute leukemia, is difficult to diagnose antemortem because its signs and symptoms are ill-defined. To refine the clinical description of this infection, we reviewed our experience with 15 pathologically documented cases of invasive pulmonary aspergillosis in a population of 60 patients treated for acute leukemia. Findings occurring significantly more often (P less than or equal to .001) among cases than controls included pleuritic chest pain; acute sinus tenderness, and nasal discharge, epistaxis and eschar; rales; development of multilobar infiltrates after the 14th hospital day; and presence of nodular or cavitary infiltrates. In addition, patients with invasive pulmonary aspergillosis had a significantly prolonged duration of granulocytopenia, more febrile days and febrile episodes without a fever diagnosis and more febrile days on antibiotics (P less than or equal to .001 in all). This complex of findings should improve the clinician's ability to diagnose invasive pulmonary aspergillosis in patients with acute leukemia.

Discriminant scorecard for diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia

Invasive pulmonary aspergillosis, a serious opportunistic infection in adult patients with acute leukemia, is difficult to diagnose antemortem. To identify patients with invasive pulmonary aspergillosis without reliance on invasive diagnostic procedures, a discriminant scorecard for invasive pulmonary aspergillosis based on clinical parameters was evaluated in a three-phase study. In phase I, the records of 62 patients, including 15 with invasive pulmonary aspergillosis, were reviewed. Eleven clinical parameters distinguished patients with invasive pulmonary aspergillosis from control subjects. These parameters were combined into a discriminant scorecard. In phase II, the discriminant scorecard was validated by a blinded, retrospective review of 94 consecutive admissions. The discriminant scorecard score was highly associated with the clinical outcome (p less than 0.0005). The sensitivity of the discriminant scorecard was calculated as a range from 62.9 to 92.8 percent and the specificity as a range from 87.5 to 98.3 percent. In phase III, the clinical utility of the discriminant scorecard was determined by its prospective application to 49 consecutive patient admissions. The discriminant scorecard identified patients with invasive pulmonary aspergillosis at an average of 4.1 days prior to clinical recognition of the disease and initiation of amphotericin B therapy. The discriminant scorecard outperformed a complex function based on multiple linear regressions, was easy to use, and did not require difficult calculations. Thus, for this patient population, the discriminant scorecard was an accurate, useful noninvasive screening test for invasive pulmonary aspergillosis. The scorecard allows more rapid clinical identification of patients with this infection and could lead to improved patient survival through earlier diagnostic and therapeutic intervention.

Danazol therapy in myelodysplasia

Platelet-associated IgG was markedly elevated in three patients with myelodysplasia and severe thrombocytopenia that had become refractory to platelet transfusions. The patients were treated with danazol because of its efficacy in treating immune thrombocytopenic purpura where platelet destruction is primarily mediated by IgG autoantibodies. After danazol therapy, the platelet counts of each patient rose and clinical bleeding stopped, and a decline in hemolysis was seen in two patients. Danazol probably impeded the peripheral clearance of cells by macrophages; however, a beneficial effect of danazol on hematopoiesis cannot be excluded.

Pulmonary cavitation and massive hemoptysis in invasive pulmonary aspergillosis. Influence of bone marrow recovery in patients with acute leukemia

The influence of bone marrow recovery on the clinical and radiographic course of invasive pulmonary aspergillosis in patients with acute leukemia has not been well characterized. We studied 26 patients with acute leukemia and invasive pulmonary aspergillosis, comparing those who recovered from chemotherapy-induced granulocytopenia (Group 1, 15 patients) with those who did not (Group 2, 11 patients). Radiographic evidence of pulmonary cavitation was not seen in any Group 2 patient, but developed in 11 of 15 (73%) Group 1 patients (p less than 0.005). In these patients, cavitation always occurred after marrow recovery, an average of 2.0 days (range: 0 to 6 days) after the granulocyte count exceeded 500/mm3. Eight patients in Group 1 and 2 in Group 2 experienced a total of 38 episodes of hemoptysis. Four of the 26 patients, all in Group 1, developed massive hemoptysis (greater than 150 ml of blood per episode), leading to 1 death. In 3 of these 4 patients, cavitation preceded the episode of massive hemoptysis. At the time of massive bleeding, the granulocyte count was greater than 500/mm3, the platelet count greater than 38,000/mm3, and the other coagulation parameters were normal in all 4 patients. Our findings demonstrate that in patients with acute leukemia undergoing chemotherapy, bone marrow recovery markedly influences the clinical and radiographic course of invasive pulmonary aspergillosis. Development of a granulocyte count greater than 500/mm3 is associated with pulmonary cavitation, and on occasion with massive hemoptysis.

A phase II trial of VP 16-213 in adults with refractory acute myeloid leukemia. An Eastern Cooperative Oncology Group study

VP-16-213 was studied in 38 adult patients with relapsed or refractory acute myeloid leukemia as part of a randomized trial in an ECOG master protocol. In this group of heavily pretreated patients, an overall response rate of 18% was achieved (5% CR, 13% PR). Toxicity was mild, and aplasia was rarely observed. Responses were seen in all of the FAB myeloid subtypes. Patients who had never achieved remission status responded as well as patients who had relapsed.

High-dose amsacrine (AMSA) therapy of relapsed and refractory adult acute nonlymphocytic leukemia A phase II study

Amsacrine (AMSA) has been shown to be an effective therapeutic agent in the treatment of adult acute nonlymphocytic leukemia (ANLL). The Eastern Cooperative Oncology Group studied the efficacy and toxicity of high-dose amsacrine (200 mg/m2/day for 5 days) in 38 adult patients with refractory and relapsed ANLL. The complete remission rate was low (8%). This dose level of amsacrine caused severe mucositis in 24% of patients and marked liver function abnormalities in 11%. Seizures did not occur, and two reversible cardiac events were not clearly attributable to amsacrine administration. Escalation of amsacrine beyond currently recommended total doses of 600-750 mg/m2 is unlikely to be of benefit.

Role of fiberoptic bronchoscopy in the diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia

The utility and safety of fiberoptic bronchoscopy in the diagnosis of invasive pulmonary aspergillosis in patients with acute leukemia have not been examined. The results of 21 bronchoscopic procedures in 19 patients with invasive pulmonary aspergillosis and acute leukemia were reviewed. Analysis was confined to the 16 patients who had histopathologically documented infection on biopsy or at autopsy. Fiberoptic bronchoscopy established or suggested the diagnosis of invasive pulmonary aspergillosis in eight of 16 (50 percent) patients. Transbronchial or bronchial biopsy added only one diagnosis to those obtained by bronchial washing and brushing. Although fiberoptic bronchoscopy was a safe and well-tolerated procedure in our patients with invasive pulmonary aspergillosis and acute leukemia, its success rate was only 50 percent overall, and it appeared to be even less successful when performed early in the course of the disease. Fiberoptic bronchoscopy is a useful first procedure for the evaluation of patients with acute leukemia and possible invasive pulmonary aspergillosis, but a negative result does not exclude aspergillosis. Further diagnostic procedures, including repeated bronchoscopy, or institution of empiric antifungal therapy may be warranted if the clinical suspicion of invasive pulmonary aspergillosis is high.

Adult acute nonlymphocytic leukemia

Chemotherapy of adults with acute nonlymphocytic leukemia has improved in recent years, yielding complete remissions in 65 per cent and cure in 10 to 15 per cent of all treated patients. Allogeneic bone marrow transplantation cures approximately one half of eligible young patients who gain an initial remission with chemotherapy. Autologous bone marrow transplantation may ultimately prove to be of value for the large numbers of patients who are over 40 years of age or who lack histocompatible siblings. Current investigative approaches in all these areas, based on insights into the pathophysiology of disease discussed in this article, should enhance the outcome for affected patients in the next decade.

A critical comparison of allogeneic bone marrow transplantation and conventional chemotherapy as treatment for acute nonlymphocytic leukemia

Published data from two centers conducting bone marrow transplantation on patients with acute nonlymphocytic leukemia in first remission were pooled and compared with results from an Eastern Cooperative Oncology Group (ECOG) study in which patients were treated with conventional chemotherapy. A series of adjustments were made to the ECOG sample to account for selection factors that restrict access of patients to transplantation. The transplant sample exhibits considerably higher disease-free survival when compared to the adjusted ECOG series (53% versus 21% at three years). The transplant series is somewhat younger than the ECOG series (median, 24 years versus 28 years). The impact of age on the disease-free survival results is difficult to assess because of the relatively small samples in the different age groups. However, by defining a suitable control group, methodology for making a critical comparison between the two modalities is presented which, if applied to larger samples of patients, should help to resolve the issue. In the absence of data from a large, prospective randomized study, a critical retrospective comparison of available data is essential in the assessment of treatment options.

A randomized study of the efficacy of consolidation therapy in adult acute nonlymphocytic leukemia

The Eastern Cooperative Oncology Group conducted a randomized study to determine the efficacy of consolidation therapy in prolonging the duration of complete remission (CR) in adults with acute nonlymphocytic leukemia (ANLL). Induction chemotherapy with daunorubicin, cytosine arabinoside, and 6-thioguanine (DAT) yielded CR in 65% of 283 patients with ANLL, aged 16-69. For patients aged 60-69, the CR rate was 58%. Of 184 patients in CR, 146 patients were then randomized to receive either maintenance therapy with weekly cytosine arabinoside and 6-thioguanine alone (69 patients) or two courses of reduced doses of DAT 1 mo apart, before commencing the same maintenance program (77 patients). Consolidation therapy resulted in hematologic toxicity, but was not lethal in any of the eligible patients. Patients receiving consolidation plus maintenance therapy experienced a longer CR duration (40 wk) and disease-free survival at 2 yr (28%) than did those patients receiving maintenance therapy alone (34 wk and 14%, respectively). These differences are not statistically significant. These results suggest that approaches to consolidation therapy employing reduced doses of the induction therapy regimen can have, at best, only a small benefit. For consolidation therapy to provide substantial improvement in CR duration, intensive regimens with non-cross-resistant drugs will be required.

Prolonged granulocytopenia: the major risk factor for invasive pulmonary aspergillosis in patients with acute leukemia

A case-control study of patients with acute leukemia was done to identify significant risk factors for invasive pulmonary aspergillosis by reviewing the medical histories of 15 cases of pathologically proven invasive pulmonary aspergillosis and 45 controls. A history of lung or sinus disease, smoking, and multiple recurrences of leukemia did not increase the risk of invasive pulmonary aspergillosis. Cases and controls received similar chemotherapeutic regimens, and exposure to aminoglycosides, carbenicillin, trimethoprim-sulfamethoxazole, or corticosteroids was not significantly associated with development of invasive pulmonary aspergillosis. Among the factors tested, only granulocytopenia was associated with development of invasive pulmonary aspergillosis. Early in the course of granulocytopenia, patients developed signs of invasive pulmonary aspergillosis at a rate of approximately 1% per day. As the duration of granulocytopenia increased, the rate increased, approximating 4.3% per day between the 24th and 36th days. Of the 13 patients remaining granulocytopenic at 28 days, 7 had developed signs of invasive pulmonary aspergillosis. For patients with acute leukemia, granulocytopenia persisting longer than three weeks is the major risk factor for developing invasive pulmonary aspergillosis.

Identification of early relapsing patients with adult acute nonlymphocytic leukemia by bone marrow biopsy after initial induction chemotherapy

Bone marrow biopsies obtained from 69 adult patients with acute nonlymphocytic leukemia (ANLL) six to 10 days after initial induction chemotherapy were reviewed blindly to detect the presence of residual leukemia. Discrimination between the presence or absence of leukemic cells was provided by assessment of the numbers, clustering, and nuclear morphology of blasts and promyelocytes. Twenty-six patients had frank leukemia, 25 had no apparent leukemic cells, and 18 had focal residual leukemia. Of 25 patients whose bone marrow contained no detectable residual leukemic cells, 21 gained complete remission without further chemotherapy. These patients had a median duration of remission of 278 days, with five patients still remaining in remission for 578-882 days. Similarly, all of the 18 patients who had focal residual leukemia achieved complete remission without additional chemotherapy; however, all have relapsed with a median duration of remission of 163 days. This study indicates that patients with foci of residual leukemia in their one-week posttreatment bone marrow samples readily achieve remission, but carry a substantial leukemic burden that increases the likelihood of early relapse.

Antigen detection in the diagnosis of invasive aspergillosis. Utility in controlled, blinded trials

Two blinded, controlled trials were done to evaluate the usefulness of fungal antigen detection for the diagnosis of invasive aspergillosis. Detection of Aspergillus fumigatus carbohydrate by radioimmunoassay was compared with antibody detection by an enzyme-linked immunosorbent assay and with diagnostic microbiologic and histopathologic procedures. In the first trial, antigenemia was detected in 4 of 6 leukemic patients with invasive pulmonary aspergillosis, but not in 8 acute leukemic controls or in 24 normal controls. Fungal antigenemia persisted for 8 to 75 days in 4 patients and seroconversion occurred at the onset of pulmonary infiltrates in 3. Antibody to A. fumigatus was detected in 2 of the 6 patients with aspergillosis, but also in 2 leukemic controls and 6 normal controls. Aspergillus species were identified in four of seven bronchoscopies done in 5 patients with invasive pulmonary aspergillosis. Prospective nasal cultures grew Aspergillus species in 4 of the 6 patients with invasive aspergillosis, but in only 1 patient was this information available before a histologic diagnosis was made. In a second trial, antigenemia was detected in 2 patients with invasive aspergillosis, and in 1 with possible invasive aspergillosis, but not in 9 controls. This study indicates that the radioimmunoassay for A. fumigatus antigen is a highly specific and moderately sensitive serodiagnostic test for invasive pulmonary aspergillosis. Prospective nasal cultures grew Aspergillus species in 4 of the 6 patients with invasive aspergillosis, but in only 1 patient was this information available before a histologic diagnosis was made. In a second trial, antigenemia was detected in 2 patients with invasive aspergillosis, and in 1 with possible invasive aspergillosis, but not in 9 controls. This study indicates that the radioimmunoassay for A. fumigatus antigen is a highly specific and moderately sensitive serodiagnostic test for invasive pulmonary aspergillosis.

Antiemetic efficacy of dexamethasone therapy in patients receiving cancer chemotherapy

To assess the value of high-dose dexamethasone therapy in preventing the gastrointestinal (GI) side effects of chemotherapy, a randomized double-blind study was conducted in women receiving outpatient therapy for breast cancer. Single-dose dexamethasone sodium phosphate (10 mg) or placebo was administered intravenously in 57 trials in 22 women immediately before chemotherapy. Questionnaires (administered before therapy and 24 hours later) were compared for evidence of nausea, vomiting, and anorexia produced by chemotherapy. No GI intolerance to chemotherapy was noted in 24 (83%) of the 29 dexamethasone trials v 16 (57%) of the 28 placebo trials. Dexamethasone trials produced the following results: no side effects in 50% (14/29), insomnia the night after chemotherapy in 21% (6/29), an increase in energy levels in 24% (7/29), and an improvement in mood in 14% (4/29). High-dose dexamethasone therapy has useful application in alleviating the emetic effects of cancer chemotherapy.

The oral flor as a source of septicemia in patients with acute leukemia

This study was performed to determine the role of the oral cavity in causing septicemia in patients with acute leukemia. Thirty-three patients with acute nonlymphocytic leukemia were investigated prospectively via clinical, hematologic, and microbiologic techniques. The mouth was the most likely source of septicemia in seven of twelve cases. Necessary dental treatment prior to chemotherapy was accompanied by a significant reduction in the rate of septicemia. The authors conclude that oral sources of bacteremia should be eliminated prior to chemotherapy in patients with acute leukemia.

Early changes in phosphatidylcholine metabolism in human acute promyelocytic leukemia cells stimulated to differentiate by phorbol ester

The HL-60 leukemia cell line derived from a human acute promyelocytic leukemia is stimulated to differentiate into macrophages within 24-28 hr after exposure to the phorbol ester, 12-O-tetradecanoylphorbol-13-acetate (TPA). We studied early alterations (within 90 min of exposure to TPA) in phosphatidylcholine metabolism in HL-60 cells and found that phosphatidylcholine synthesis by methylation is phosphatidylethanolamine was inhibited in a dose-dependent fashion. In contrast, synthesis of phosphatidylcholine from endogenous choline was enhanced and correlated inversely with the degree of inhibition of the methylation pathway. Phorbol ester congeners of TPA caused similar alterations in phosphatidylcholine metabolism in direct relationship to their capacity to induce differentiation in HL-60 cells. Perturbation of phosphatidylcholine metabolism is an early membrane even in TPA-induced HL-60 cell differentiation.

Inhibition of sterol and phospholipid synthesis in HL-60 promyelocytic leukemia cells by inducers of myeloid differentiation

Myeloid differentiation is induced in HL-60 promyelocytic leukemia cells by dimethyl sulfoxide, retinoic acid, hypoxanthine, and a number of other chemical agents. We questioned whether the induction process was associated with changes in lipid synthesis. With [14C]acetate, a precursor for all cell lipids, a decrease in sterol and phospholipid synthesis (but not triglyceride synthesis) was observed within the first 5 hr after exposure to inducer, a time prior to inhibition of DNA synthesis or cessation of cell growth. Similarly, the membrane fraction of HL-60 cells exhibited decreased incorporation of newly synthesized lipid. Synthesis of phosphatidylcholine from choline as well as from the transmethylation of membrane phosphatidylethanolamine was also inhibited by myeloid inducers. In contrast, neither sterol nor phospholipid degradation was stimulated under these conditions. Both cholesterol and lanosterol were synthesized by growing HL-60 cells, but cholesterol esters were not. Synthesis of sterols was subject to feedback inhibition by cholesterol in the medium, but such feedback inhibition did not affect differentiation in the presence of myeloid inducers and did not alter the effect of myeloid inducers on phospholipid synthesis. Removal of dimethyl sulfoxide at 16 hr permitted a return to normal lipid synthesis and prevented differentiation, whereas removal of dimethyl sulfoxide at 40 hr was followed by continued inhibition of lipid synthesis and progressive differentiation. These studies demonstrate that the induction of myeloid differentiation is associated with an early inhibition of the synthesis of those lipids which are normally a part of cell membranes.

Induction therapy and intensive consolidation with daunorubicin, cytosine arabinoside, and 6-thioguanine in adult acute nonlymphoblastic leukemia

Twenty-one patients with acute nonlymphocytic leukemia were treated with a regimen including daunorubicin, cytosine arabinoside, and 6-thioguanine and 15 patients (71%) achieved a complete remission. Thirteen of the 15 remissions occurred after a single course of therapy and two after two courses of treatment resulting in a rapid time to complete remission. The time from treatment initiation to complete remission was 21-82 days with a median of 29 days. Nine of the 15 patients who gained a complete remission were then treated with two cycles of consolidation therapy utilizing the three induction drugs in modified dosages to determine the toxicity of a consolidation program. With the doses used in consolidation, pancytopenia regularly occurred but only 5/15 courses were associated with complications of bleeding or infection that required hospitalization. No patient died as a result of consolidation therapy. This study confirms the rapid effectiveness of the induction program which provided equivalent complete remission rates for adults at any age (up to 66 years). The consolidation regimen is now being used in a randomized study to determine whether it contributes to the duration of complete remission.

Pathologic flail chest complicating multiple myeloma

Pathologic flail chest complicated the initial presentation of multiple myeloma in two patients. Both had severe hypercalcemia and diffuse bone disease. Atelectasis and pulmonary edema preceded the appearance of flail chest in one patient; atelectasis complicated the flail chest in the second patient and increased the severity of the flail. Both were treated with radiotherapy and chemotherapy. However, delay in stabilizing the first patient's chest wall with positive airway pressure was followed by extension of the flail chest and irreversible respiratory failure. On the other hand, prolonged stabilization of the chest wall in the second patient until a chemotherapy-induced remission occurred was associated with resolution of the flail chest.

Chemotherapy for adult acute nonlymphocytic leukemia with daunorubicin and cytosine arabinoside

Fourteen of 21 adult patients (67%) with acute nonlymphocytic leukemia achieved a complete remission (CR) after receiving combination chemotherapy with daunorubicin and cytosine arabinoside (ara-C). Eight of the 14 CRs developed after a single course and four of 14 after two courses of induction therapy making initial hospitalization relatively brief (median, 38 days). Four of five patients greater than 60 years old achieved CR. The induction therapy was repeated monthly up to the dosage limits imposed by daunorubicin cardiotoxicity in an attempt to lengthen subsequent remission duration. The media duration of CR was 12 months which compares favorably with previously reported series. In this series, treatment with 3 days of daunorubicin and 7 days of ara-C proved to be a highly effective induction regimen for patients with acute nonlymphocytic leukemia regardless of age. The improved duration of CR may be a manifestation of the extent of initial leukemic cell-kill in successful induction and consolidation therapy rather than an effect of maintenance therapy cycles.