High-dose combination chemotherapy for acute nonlymphoblastic leukemia in adults

Types and outcomes of cytopenia in critically ill patients

Cytopenia is common complication in critically ill patients. Aim: Incidence and pattern of different types of cytopenia as well as its impact on mortality and length of stay in critically ill patients were evaluated. Methods: Critically ill patients with any kind of cytopenia for more than 2 days were evaluated. Results: Anemia was the most common type of cytopenia in the patients (99.14%), followed by lymphocytopenia (32.17%), thrombocytopenia (27.82%), and leukopenia (19.13%). Mortality rate was significantly higher in patients with anemia (p < 0.0001), thrombocytopenia (p < 0.0001), leukopenia (p < 0.0001), neutropenia (p = 0.004), lymphopenia (p = 0.002) and pancytopenia (p < 0.0001). Higher duration of anemia, lymphopenia and thrombocytopenia were associated with longer intensive care unit stay (p < 0.0001, p < 0.0001 and p < 0.001, respectively). Conclusion: Among all assessed variables, incidence of thrombocytopenia could independently predict the mortality.

A phase 1 dose-escalation study of ARRY-520, a kinesin spindle protein inhibitor, in patients with advanced myeloid leukemias

BACKGROUND

ARRY-520 selectively inhibits the mitotic kinesin spindle protein (KSP), which leads to abnormal monopolar spindle formation and apoptosis.

METHODS

A phase 1 trial was conducted to establish the safety and the maximum tolerated dose (MTD) of ARRY-520 given as a 1-hour infusion in either a single dose or on a day 1, 3, and 5 divided-dose schedule per cycle in patients with advanced or refractory myeloid leukemias. Additional objectives were to characterize pharmacokinetics, assess preliminary clinical activity, and explore biomarkers of KSP inhibition with ARRY-520. A total of 36 patients with acute myelogenous leukemia (n = 34) or myelodysplastic syndromes (n = 2) with a median age of 66 years (range, 21-88 years) were enrolled: 15 in the single-dose schedule (dose levels: 2.5, 3.75, 4.5, and 5.6 mg/m(2)) and 21 in the divided-dose schedule (dose levels: 0.8, 1.2, 1.5, and 1.8 mg/m(2)/day).

RESULTS

The MTD was 4.5 mg/m(2) total dose per cycle for both dose schedules. Dose-limiting toxicities included mucositis, exfoliative rash, hand-foot syndrome, and hyperbilirubinemia. Grades 3 or 4 reversible drug-related myelosuppression were observed in 33 of 36 patients. Plasma pharmacokinetic analyses revealed low clearance of ARRY-520 (~3 L/hour), a volume of distribution of ~450 L, and a median terminal half-life of >90 hours. Monopolar spindles were observed in blood mononuclear cells, through use of 4',6-diamidino-2-phenylindole nucleic acid stain and antitubulin antibodies.

CONCLUSIONS

On the basis of the relative lack of clinical activity, further development of ARRY-520 as an antileukemic agent was halted. (Clinicaltrials.gov identifier NCT00637052).

Cancer chemotherapy in the elderly

As the geriatric population is growing, it is increasingly important to be familiar with chemotherapy for the elderly. Age-related changes in pharmacokinetics are documented for doxorubicin, etoposide, ifosfamide, daunorubicin, mitomycin, cisplatin and methotrexate. The hematological toxicity of most standard-dose chemotherapy is not affected by age in patients with normal organic functions and good performance status, although increased toxicity with aging is suggested in the use of actinomycin-D, etoposide, vinblastin, methotrexate, methyl-CCNU, doxorubicin and mitomycin, and in dose-intensive chemotherapy. Among non-hematological toxicities, only doxorubicin-induced cardiomyopathy and bleomycin-induced pulmonary toxicity are demonstrated to be accelerated in the elderly. There is no evidence that advanced age decreases the efficacy of chemotherapy for tumors, except for Hodgkin's disease and acute leukemia. These results suggest that advanced chronological age alone is not always associated with severe toxicity and poor prognosis, and that many elderly patients with cancer will benefit from chemotherapy. To answer questions regarding the optimal chemotherapy regimen, dose and intensity in this population, the influence of age should be analyzed in a multivariate approach in future studies.

AMSA combination chemotherapy in patients with acute myelogenous leukemia unsuitable for standard antileukemic treatment

Forty-eight patients with acute myelogenous leukemia (AML) not eligible for anthracycline or mitoxantrone treatment, mostly due to cardiac contraindications, were given aggressive therapy using m-amsacrine (AMSA) in combination with conventional or high-dose cytarabine for remission induction. Twenty-nine patients (60.4%) responded to treatment, and complete remission was attained in 19 (39.6%), partial remission in 4 (8.3%) and death in bone marrow aplasia without detectable blasts in 6 patients (12.5%). Median time to granulocyte recovery was 32 days, median duration of relapse-free survival 199 days. One patient experienced a serious cardiac adverse event; nausea and vomiting were observed in 73%, diarrhea in 44%, and hepatoxicity in 29% of patients. All potentially AMSA-related side effects were fully reversible, and a lethal complication did not occur. It is concluded that combination chemotherapy with AMSA and Ara-C is also effective and tolerable in leukemic patients in whom cardiotoxic drugs are contraindicated.

A randomized study of intermediate versus conventional-dose cytarabine as intensive induction for acute myelogenous leukaemia

The optimal dose of cytarabine for induction chemotherapy is unknown. Most studies have utilized doses of 100-200 mg/m2/d, although higher doses have been proposed to increase the concentration of the active metabolite ara-CTP within leukaemia cells. To address this question 101 adults with newly diagnosed acute myeloid leukaemia were randomized to receive treatment with daunorubicin and either conventional-dose cytarabine (200 mg/m2/d by continuous infusion) or an intermediate-dose of cytarabine (500 mg/m2 every 12 h). 36/51 (71%) patients assigned to conventional-dose cytarabine achieved complete remission compared to 37/50 (74%) who achieved remission with intermediate-dose cytarabine (P = 0.9). Patient age significantly affected remission rate. 8/17 patients age greater than 60 assigned to conventional-dose cytarabine and 10/17 assigned to intermediate-dose cytarabine achieved complete remission compared to 27/33 patients under age 60 assigned to the conventional dose and 28/34 patients assigned to the intermediate dose arm (P = 0.004). Actuarial 4-year disease-free survival for patients assigned to conventional-dose cytarabine was 20 +/- 16% versus 28 +/- 17% for patients assigned to intermediate-dose cytarabine (P = 0.9). We conclude that intermediate dose cytarabine did not substantially improve results of induction chemotherapy for acute myeloid leukaemia.

Higher cure rates in acute leukemia: now more probable with increasingly effective induction therapy

Traditional therapy of acute myelogenous leukemia has not cured more than 10% of patients and, of acute lymphoblastic leukemia not more than 30% of adults. In part, this is due to the lack of agents effective enough to induce remissions of such quality that cure is possible. The introduction of mitoxantrone and its use in high dose with high-dose cytarabine for induction therapy, raises the possibility of an increased cure rate of acute myelogenous leukemia and acute lymphoblastic leukemia.

Therapy of acute myelogenous leukemia

Treatment of acute myelogenous leukemia (AML) is divided into remission induction and post-remission therapy. Remission induction is usually with cytarabine and an anthracycline. Daunorubicin is commonly used but recent data suggest idarubicin or mitoxantrone are equally effective, possibly better. High-dose cytarabine has also been used for remission induction but is not proven superior. Post-remission treatment is typically with two or more courses of drugs similar to those used for remission induction. Other studies use non-cross resistant drugs and/or high-dose cytarabine. Although some data favor use of high-dose cytarabine, no approach is clearly superior. There is considerable controversy whether persons in first remission and with an HLA-identical sibling should receive a bone marrow transplant immediately or after relapse. Although transplant results appear superior, especially in persons less than 20 years of age, the most effective strategy may be reserving transplants for persons failing chemotherapy. This strategy also applies to persons receiving autologous transplants or transplants from alternative donors, like HLA-matched related or unrelated persons.

Prevention of indigenous infection of mice with Escherichia coli by nonspecific immunostimulation

We have previously reported that the lethal toxicity of 5-fluorouracil (5-FU) in specific-pathogen-free mice is due to an intestinal infection with indigenous Escherichia coli induced by the drug (K. Nomoto, T. Yokokura, Y. Yoshikai, M. Mitsuyama, and K. Nomoto, Can J. Microbiol. 37:244-247, 1991). In the present study we demonstrate that nonspecific immunostimulation is effective in the protection of mice from the lethal indigenous infection induced by 5-FU. Intravenous or subcutaneous injection of a preparation of heat-killed Lactobacillus casei YIT 9018, a potent nonspecific immunostimulant, into BALB/c mice reduced the lethal toxicity of 5-FU at doses ranging from 338 to 800 mg/kg of body weight if YIT 9018 was injected 7 to 40 days before administration of 5-FU. Systemic infection with E. coli developed in all of the 5-FU-treated control mice 7 days or more after administration of 5-FU in large doses and was accompanied by overgrowth of the bacteria in the intestinal tract. Pretreatment of mice with YIT 9018 resulted in a decreased occurrence of systemic infection with E. coli to levels of 0 to 20% and no significant changes in the population levels of E. coli in the intestinal tract during the 14 days after administration of 5-FU. The levels of leukopenia in the spleen and peripheral blood were lower, and recovery of granulocyte-macrophage precursor cells in the spleen and femur began earlier in the treated animals than in the 5-FU-treated controls. Intravenous transfusion of syngeneic normal bone marrow cells or spleen cells into the mice at an early period after administration of 5-FU diminished markedly the occurrence of the lethal indigenous infection, suggestion that an earlier recovery from chemotherapy-induced myelosuppression is important in the mechanisms of protection of the host from the infection.

The clinical pharmacology and use of antimicrotubule agents in cancer chemotherapeutics

Although there has been a rapid expansion of the number of classes of compounds with antineoplastic activity, few have played a more vital role in the curative and palliative treatment of cancers than the antimicrotubule agents. Although the vinca alkaloids have been the only subclass of antimicrotubule agents that have had broad experimental and clinical applications in oncologic therapeutics over the last several decades, the taxanes, led by the prototypic agent taxol, are emerging as another very active class of antimicrotubule agents. After briefly reviewing the mechanisms of antineoplastic action and resistance, this article comprehensively reviews the clinical pharmacology, therapeutic applications, and clinical toxicities of selected antimicrotubule agents.

Acute myeloid leukemia in the elderly: biological features and search for adequate treatment

AML in elderly patients is a heterogeneous disease which is characterized by a number of unfavorable features such as development, cytogenetics, blast cell differentiation, and poor treatment response. Specifically, the association between a higher incidence of unfavorable cytogenetic abnormalities in elderly patients and poor prognosis has been well documented. Low treatment response may be due to the specific biology of AML in this patient group, but also to host-specific factors such as higher treatment-related morbidity and mortality. Treatment tolerance cannot be judged on grounds of chronological age alone; risk factor analysis with regard to performance status, organ function, and underlying systemic disease need to be considered as well. For effective induction treatment in elderly patients, instant and intensive chemotherapy appears to be necessary, while delayed treatment or administration of supportive care alone provide unsatisfactory results. Standard-dose ara-C/anthracycline-containing regimens are the treatment of choice in patients with good performance status. However, patients with a WHO grading of greater than 3 might rather benefit from reduced regimens such as low-dose ara-C. At present, greatest improvement of AML treatment in elderly patients can be expected from an improvement of supportive care.

The toxicity of cytarabine

The principal toxicity of standard induction regimens for acute non-lymphocytic leukemia (ANLL) [including cytarabine (ARA-C) 100 mg/m2 for 7 days plus an anthracycline] is myelotoxicity, leading to death in at least 25% of cases during induction in non-selected patients. The complete remission rate is less than 35% in patients over 65 years of age, due in part to an age-related increase of myelotoxicity. The other important adverse effect of standard-dose cytarabine is gastrointestinal toxicity, especially oral mucositis, diarrhoea, intestinal ulceration, ileus and subsequent Gram-negative septicaemia. Idiosyncratic reactions like exanthema, fever and elevation of hepatic enzymes are relatively frequent, but do not represent therapeutic problems. Intermittent high-dose cytarabine (3 g/m2 in 8 to 12 doses) is extremely myelosuppressive. Similarly, the gastrointestinal toxicity is formidable and dose-limiting. Severe, and sometimes irreversible, cerebellar/cerebral toxicity in 5 to 15% of courses of treatment limits the peak dose of cytarabine. The pathogenesis, prophylactic and therapeutic measures are unknown. These major toxicities are age-related and prohibitive to the use of high-dose cytarabine therapy in patients older than 55 to 60 years. Subacute noncardiogenic pulmonary oedema occurs in some patients, with an incidence of about 20%, and seems to have an intriguing coincidence with precedent streptococcal septicaemia; high-dose systemic steroids may be beneficial. Corneal toxicity is very frequent in high-dose cytarabine therapy but is always reversible. It is largely preventable with prophylactic steroid or 2-deoxycytidine eyedrops. Fever, exanthema and hepatic toxicity have an incidence similar to that in standard dosage. The maximum tolerable cumulated dose of cytarabine is significantly lower when the agent is administered as a continuous infusion, due to myelosuppression and gastrointestinal toxicity. Conversely, continuous infusion may be less neurotoxic. The antileukaemic effect of continuous infusion high-dose cytarabine is less well established. The only significant toxicity of low-dose cytarabine is myelosuppression. Given the generally poor condition of leukaemia patients, low-dose cytarabine therapy is well tolerated, although occasional cases of diarrhoea, reversible cerebellar symptoms, peritoneal and pericardial reactions, and ocular toxicity have been reported. Continuous infusion may be more toxic than the usual intermittent dosage. It is concluded that the toxicity of the standard induction regimen for ANLL is acceptable in patients younger than 60 to 65 years with no concurrent disease. Low dose cytarabine is tolerable for virtually all ANLL patients, but the overall therapeutic efficacy still needs to be defined and compared to standard therapy in the relevant age groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Infectious disease management of adult leukemic patients undergoing chemotherapy: 1982 to 1986 experience at Stanford University Hospital

PURPOSE

The purpose of this study was to determine the recent incidence of infection and to evaluate antimicrobial usage among adult leukemic patients undergoing chemotherapy for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL) at Stanford University Hospital.

PATIENTS AND METHODS

The records of 142 adult patients from a consecutive series of 226 induction or consolidation/maintenance chemotherapy courses for AML or ALL between 1982 to 1986 were reviewed retrospectively. Data were analyzed to compare the infectious disease complications and antimicrobial usage for patients receiving identical chemotherapy for a specific phase of leukemia treatment. Evaluation for each chemotherapy course included assessments for the following: compliance with criteria for initiating antibiotics, incidence of infection that was documented by culture or clinical criteria, predictive value of surveillance cultures, incidence of superinfection, survival outcomes, antimicrobial usage, antibiotic-related adverse effects, and cost for antibiotics and diagnostic studies.

RESULTS

Antimicrobials were employed in 190 (84%) of 226 chemotherapy courses. Broad-spectrum antibiotics were regularly begun within the first five days of admission and they were continued for an average of 3.5 weeks until the granulocyte count was greater than 1,000/microL after discontinuation of chemotherapy. There were no differences in the types of infection or outcomes among the patient groups. There was only a 37% rate of documented infections by culture or clinical signs among these patients during their entire hospital stay. Bacterial infections, especially those caused by coagulase-negative staphylococci in patients with Hickman catheters, accounted for 93% of the episodes. Viral and fungal infections accounted for 4% and 3% of documented cases, respectively, and occurred more than 10 days after the institution of broad-spectrum antibiotic therapy. A total of 922 different antimicrobials were employed in 190 courses (average 4.9 per course). The rationale for excessive usage and multiple changes was a persistent or intermittent fever, rather than documented infection(s). This practice led to usage of more broad-spectrum and expensive antibiotics. Further analyses indicate that the greater number of antibiotics employed correlated with apparent increased toxicity, especially renal and hepatic adverse reactions. These toxicities were associated with higher rates of fatal outcomes, i.e., 12 (39%) of 31 patients died with antibiotic-associated hepatic and/or renal insufficiency, compared with 12 (7.5%) of 159 patients who died without antibiotic-associated organ damage.

CONCLUSION

Excessive antibiotic usage and multiple antibiotic changes among adult leukemic patients undergoing chemotherapy appear to increase the risks of adverse hepatic and renal effects and death. Furthermore, this practice leads to use of more broad-spectrum and expensive antibiotics...

Role of maintenance chemotherapy in acute promyelocytic leukemia

The effect of maintenance chemotherapy on remission duration was analyzed in 39 of 70 patients (56%) with acute promyelocytic leukemia (APL) who achieved complete remission on induction chemotherapy. Overall, the median remission duration was 26 months, with a 3-year remission rate of 42%. The 3-year remission rate was significantly higher in patients who received 6-mercaptopurine and methotrexate (POMP) during maintenance, compared with those who did not (56% versus 30%; P less than 0.01), and in patients who received long-term maintenance therapy (P less than 0.01). A multivariate regression analysis selected maintenance therapy with POMP to be the only statistically significant factor associated with long-term remission duration. The type of maintenance chemotherapy is important in overall prognosis of patients with APL, and should be investigated further.

A randomized comparison of maintenance treatment with androgens, immunotherapy, and chemotherapy in adult acute myelogenous leukemia. A Leukemia-Lymphoma Group Trial of the EORTC

Twenty-three European centers participated in a randomized clinical trial (AML-5) to study the effect of androgens and immunotherapy during maintenance in adult acute myelogenous leukemia. Induction treatment consisted of Adriamycin (doxorubicin) 50 mg/m2 day 1, vincristine VCR 1 mg/m2 day 2, and cytosine arabinoside 80 mg/m2 every 12 hours by push injection days 3-9. Patients in complete remission were randomized into four groups: (1) 6-mercaptopurine 70 mg/m2 days 1-14, methotrexate 15 mg/m2 twice weekly days 15-28, and reinduction with daunorubicin 35 mg/m2 and vincristine 1 mg/m2 day 29; (2) chemotherapy as in group 1 plus stanozolol 0.15 mg/kg/day; (3) 6-thioguanine 70 mg/m2 orally on 4 consecutive days and cytosine arabinoside 80 mg/m2 subcutaneously day 5 every week; and (4) chemotherapy as in Group 3 plus irradiated blast cells treated with neuraminidase. Three hundred forty-eight patients were eligible and 295 were evaluable. The median age was 45 yrs. A complete remission was achieved in 64% of the patients, with 158 complete remissions randomized. Patients not randomized and patients receiving bone marrow transplantation (BMT) were analyzed separately. There was no difference in disease-free survival (DFS) or survival in the four maintenance arms. For patients reaching complete remission, the median DFS was 40 weeks, and median survival was 22 months with 30% surviving at 4 years. The overall survival was 18% at 4 years. There was no beneficial effect for DFS or survival by adding either immunotherapy or androgens to chemotherapy during maintenance. However, patients receiving immunotherapy seemed to have a higher rate of responses to reinduction after relapse than those in the other treatment arms.

Treatment of acute nonlymphocytic leukemia in young and elderly patients

Among 95 consecutive patients with acute nonlymphocytic leukemia (ANLL), 61 were treated with a high-dose chemotherapeutic induction regimen consisting of daunorubicin, vincristine, and cytosine arabinoside (DOA). The complete remission (CR) rate was 66%. Although young patients responded better than older patients, only sex was found to be of prognostic significance for achieving CR (84% CR in men versus 47% in women, P less than 0.005, independent of age). Patients in CR received consolidation, monthly maintenance therapy, and late intensification for a period of 2 years. Median remission duration was 57 weeks and median survival, 93 weeks. Projected CR rate at 5 years was 30%. CR and survival duration were significantly longer in patients 40 to 60 years old when compared with younger and older patients (P = 0.023). They were also longer in male than in female patients (P = 0.018), but this may be due to an effect of age. In the 34 patients who did not receive DOA treatment because of age or poor clinical conditions, there was no survival beyond 57 weeks, except in a 73-year-old woman who reached a spontaneous remission during acute infection. ANLL characteristics at presentation revealed a tendency toward a smaller tumor mass (P less than 0.05) and rarer Auer rods present (P = 0.03) with increasing age. Features and treatment of ANLL in elderly patients are discussed in view of the poor results obtained with conservative management.

Meningeal involvement in patients with acute nonlymphocytic leukemia. Incidence, management, and predictive factors

Between 1977 and 1983, symptomatic meningeal leukemia was diagnosed in 9 of 93 adult patients with acute nonlymphocytic leukemia (10%). All cases occurred after complete remission had been achieved (46 patients), either as the only site of relapse (3 patients), or together with a first bone marrow relapse (3 patients), or after a bone marrow relapse (3 patients). Extramedullary involvement at initial diagnosis was the only independent predictive factor (P = 0.005), the number of patients with initial hyperleukocytosis being too small (three) for evaluation. Remission of the meningeal leukemia was obtained after treatment in four of eight patients. The presence of meningeal leukemia and the response to therapy had no influence on survival. However, the morbidity and therapy related toxicity of meningeal leukemia were impressive. Some recommendations for prophylactic treatment are suggested.

Allogeneic bone marrow transplantation for acute leukemia refractory to induction chemotherapy

This article compares the outcome of 14 patients with primary refractory acute leukemia who underwent bone marrow transplantation from human leukocyte antigen (HLA)-identical donors with that of 18 age-matched control patients who received chemotherapy. Complete clearing of leukemia was seen in all 14 transplanted patients. Five of the transplanted patients are alive 98 to 1790 days posttransplant, and four are free of leukemia. Nine patients have died, eight with severe graft-versus-host disease associated with interstitial pneumonia or systemic infections and one with relapse from chemotherapy-associated infections. Engraftment was seen in all patients. Severe graft-versus-host disease (grades III and IV) was seen in ten patients and resolved in three patients following high-dose corticosteroid treatment. Three of the 18 control patients are alive, none of them in complete remission. It appears that the combination of piperazinedione and total-body irradiation followed by allogeneic transplant is effective induction treatment for primary refractory acute leukemia and will be considered in the future as first salvage treatment for patients failing induction treatment.

Therapy for acute myeloid leukemia in 119 adults: a comparison of two treatment protocols

Of 119 patients with acute myeloid leukemia, 69 were treated with Adriamycin, Vincristine and Cytosine Arabinoside (Therapy 1) and 50 with Daunorubicin, Cytosine Arabinoside and 6-Thioguanine (Therapy 2) as well as a consolidation therapy. The maintenance therapy with Cytosine Arabinoside and 6-Thioguanine was the same for both groups. The complete remission rate was 44% for Therapy 1 and 68% for Therapy 2 (p less than 0.05). - The median values for remission duration were 7 and 13 months respectively (p = 0.10); for survival time the median values were 18 and 19 months. These figures show in retrospect that high remission rates can be attained through intensive induction therapy and that longer remission duration is correlated with more aggressive induction therapy. A mild form of maintenance therapy seems to have little effect on the duration of complete remission.

Low dose cytosine arabinoside in the treatment of acute non-lymphocytic leukaemia

Complete remissions were obtained with low dose cytosine arabinoside (ARA-C) in 8 of 21 previously untreated patients with ANLL above 60 years of age and in 2 of 4 previously treated patients below 60 years of age. 7 of the patients remain in remission after 1-26 months. The results demonstrate that low dose ARA-C with rather low toxicity may induce remissions in elderly patients with ANLL.

Multivariate analysis of factors associated with outcome of treatment for adults with acute myelogenous leukemia

Utilizing multivariate logistic regression statistical analysis, the authors evaluated prognostic features associated with achievement of complete remission (CR) and remission and survival duration in acute myelogenous leukemia (AML). These clinical variables were analyzed in 77 consecutive adult patients who underwent 108 courses of remission induction therapy with daunomycin, cytosine arabinoside, and 6-thioguanine (DAT) chemotherapy for newly diagnosed and first relapse of AML. Eight patients had developed leukemia in the setting of other malignant or immunologic diseases (therapy-linked AML) and 69 patients had not (primary AML). Sixty-three percent of patients with primary AML achieved CR with median remission and survival durations of 11 and 24 months, respectively. Significant unfavorable predictive features for achievement of CR were splenomegaly, and elevated leukocyte count or serum alkaline phosphatase levels. Patients who had leukocyte counts of less than or equal to 10,000/mm3 at diagnosis or less than or equal to 40,000/mm3 at the start of therapy, and those who received greater than 120 mg/m2 of daunomycin had significantly longer remissions and survival than those who did not. Fifty-seven percent of patients in first relapse also achieved CR; however, relative to first remissions, second remission durations were significantly shorter (median, 4.6 months). Sixty-two percent of patients with therapy-linked AML achieved CR, but remission durations (median, 2.8 months) were significantly shorter than first remissions of primary AML patients. These data identify clinical features associated with increased risk of failure to achieve CR and potential for short remission duration and survival. Alternative forms of therapy should be considered for such high-risk patients.

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.

Prolonged survival in acute myelogenous leukaemia without maintenance chemotherapy

46 adults with previously untreated acute myelogenous leukaemia who achieved complete remission with 6-thioguanine, cytarabine, and daunorubicin (TAD) received two courses of intensive consolidation chemotherapy. The first cycle consisted of 5-azacytidine and doxorubicin followed by a second consolidation cycle with TAD. Maintenance chemotherapy was not administered. Median remission duration was 14 months and 26% (95% confidence interval, 11%-41%) remained in continuous remission at 5 years. Actuarial 5 year survival was 31% (+/- 15%). Results were most favourable in patients who achieved complete remission within 60 days of chemotherapy being initiated. These data indicate that prolonged disease-free survival can be achieved in patients treated with intensive induction and consolidation treatment alone without maintenance chemotherapy.

Treatment of advanced bone marrow neoplasms with ifosfamide combinations

Ifosfamide, in combination with other cytostatics, was given to 15 patients with advanced neoplasia derived from bone marrow cells. A response to therapy was obtained in 8 patients. It is suggested that ifosfamide, in combination with other drugs, deserves larger trials in the treatment of advanced bone marrow neoplasia.

Intensification therapy for acute nonlymphoblastic leukemia in adults

Thirty-nine adults with acute nonlymphoblastic leukemia (ANL) in complete remission (CR) for six months were considered for intensification therapy. All patients had received a high dose chemotherapeutic remission-induction regimen consisting of daunorubicin, cytosine arabinoside, 6-thioguanine, prednisone, and vincristine, followed by one consolidation course of the same drugs at reduced doses and then monthly maintenance course of low-dose chemotherapy. The intensification therapy consisted of the same intensive chemotherapy regimen utilized for remission induction in place of the sixth and 12th monthly courses of postremission induction chemotherapy. Twenty-three of the 39 patients received intensification therapy, whereas 16 patients refused or were not offered such therapy for medical reasons and, therefore, received only monthly therapy. The median remission duration of the 23 patients who received intensification therapy was 157 weeks, and 9 remain in continuous first remission at 176-285 weeks. The remission duration of the 16 patients who did not receive intensification therapy was 73 weeks (P = 0.03). Kaplan-Meier estimates of remission duration and survival from time of remission computed by including the patients who either relapsed or received bone marrow transplantation before the time of intensification (6 months) revealed a median remission duration and survival of 100 and 172 weeks for patients receiving intensification compared to 37 and 72 weeks, respectively, for patients not receiving intensification therapy. Since results in patients not receiving intensification therapy are consistent with our previous results in patients receiving the same induction and consolidation regimens without intensification, this nonrandomized study suggests that intensification therapy prolongs remission duration and survival in adults with ANL.

Colistin and trimethoprim-sulfamethoxazole for the prevention of infection in patients with acute non-lymphocytic leukaemia. Decrease in the emergence of resistant bacteria

In a previous study we demonstrated that trimethoprim-sulfamethoxazole decreases the prevalence of infection in patients with severe granulocytopenia. However, treatment was accompanied by a relatively high incidence of multiresistant microorganisms. We therefore conducted this study to determine whether the addition of colistin to the trimethoprim-sulfamethoxazole regimen prevents the emergence of these resistant bacteria. Thirty consecutive adult patients with acute non-lymphocytic leukaemia received trimethoprim-sulfamethoxazole plus colistin p.o. prophylactically. The results of this study were compared with the results of our previously published controlled study. Trimethoprim-sulfamethoxazole plus colistin was as effective as trimethoprim-sulfamethoxazole in preventing infection. However, the addition of colistin significantly reduced the acquisition of and infection by gram-negative bacilli which were resistant to trimethoprim-sulfamethoxazole. Only two patients were colonized with resistant strains, and no infections with these strains were observed. We have concluded that patients with acute non-lymphocytic leukaemia should receive a combination of trimethoprim-sulfamethoxazole plus colistin prophylactically during remission induction treatment.

Allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation now has an established place in the treatment of severe aplastic anemia and acute leukemia. Major problems to be overcome in transplantation in patients with aplastic anemia are marrow graft rejection and graft vs. host disease. Results are better in younger patients and in patients who have not been previously transfused. Newer approaches to the control of graft vs. host disease, for example total lymphoid irradiation and the immunosuppressive agent, cyclosporin A, hold promise for future progress. In patients with acute leukemia, the major clinical problems are early infections, recurrent leukemia, graft vs. host disease, and interstitial pneumonia. Both ultra-isolation and prophylactic granulocyte transfusions are able to decrease the incidence of early infections. Attempts to intensify the conditioning regimen have failed to decrease the incidence of recurrent leukemia, but transplantation earlier in the course of disease, particularly in patients with acute, nonlymphoblastic leukemia in first remission, have decreased the incidence of recurrent leukemia. Both acute and chronic forms of graft vs. host disease have been recognized. Acute graft vs. host disease continues to be a significant clinical problem, in spite of the use of Cyclosporin A. Chronic graft vs. host disease is being recognized earlier and treated successfully with immunosuppressive agents. Interstitial pneumonia, primarily secondary to cytomegalovirus, remains the major cause of death post-transplantation. In spite of these problems, however, patients with acute non-lymphoblastic leukemia in first remission have a 60% likelihood of remaining alive, free of disease following allogeneic marrow transplantation from an HLA identical sibling. Patients with acute leukemia who have relapsed who undergo allogeneic marrow transplantation have a longer survival than patients treated with conventional chemotherapy and even patients in relapse have a significant likelihood of cure following high-dose chemoradiotherapy and allogeneic marrow transplantation.

Short-term treatment for acute myelogenous leukaemia

Short-term treatment with doxorubicin, cytarabine, and 6-thioguanine was given to 91 consecutive adults with acute myelogenous leukaemia. Fifty patients received high doses (regimen I) and 41 very high doses (regimen II). Where possible, six treatment cycles were given (total dose of doxorubicin 450 mg/m2) regardless of the number of cycles required to achieve complete remission. No additional treatment was given. The remission rate was significantly higher with regimen I than with regimen II (34/50 compared with 15/41, p less than 0.01), the latter, more intensive regimen being associated with a greater incidence of fatal infection (13/41 compared with 5/50, p less than 0.01). Duration of remission was, however, significantly longer with regimen II (p less than 0.05); the median has not yet been reached after a minimum follow-up of two years. Intensive short-term treatment is a feasible strategy for the treatment of acute myelogenous leukaemia.

Treatment of chronic granulocytic leukemia with chemoradiotherapy and transplantation of marrow from identical twins

Twelve patients in the chronic phase of Ph1 (Philadelphia)-positive chronic granulocytic leukemia (CGL) received chemoradiotherapy and marrow from their normal, identical twins. All had a complete remission, with disappearance of all Ph1-positive cells. One patient died of pneumonitis while in remission. Three had a cytogenetic relapse 22 to 30 months after grafting; only one of these three entered blast crisis and died. Eight remain in complete remission 21 to 65 months (median, 30) after transplantation. Thus, the Ph1-positive clone can be ablated and blast crisis delayed or prevented. Of 10 patients with CGL who received transplants during the terminal phase, eight died soon after, one is in complete remission 11 months after receiving a second graft, and one remains in complete remission 71 months after transplantation. This experience suggests to us that every patient with CGL and an identical twin should receive a marrow graft, preferably in the chronic phase. On the basis of our results, trials of allogeneic-marrow transplantation for CGL seem justified.

A comparison of two schedules of cytosine arabinoside used in combination with adriamycin and 6-thioguanine in the treatment of acute myelogenous leukemia

The most effective schedule of cytosine arabinoside (Ara-C) administration remains controversial and is further confused by the use of combination chemotherapy. Two remission induction regimens comprising adriamycin, Ara-C, and 6-thioguanine have been compared in patients with acute myelogenous leukemia. Administration of Ara-C by continuous intravenous infusion resulted in faster clearing of leukemic blasts from the peripheral blood and bone marrow than after administration of the same dose by twice daily intravenous injection. Myelosuppression and gastrointestinal toxicity were, however, more pronounced when Ara-C was given by infusion. The complete remission rate was higher in the patients treated with intravenous infusions. It is too early to assess the duration of remission in the infusion study; however, despite the relatively low remission rate, 80% of patients under the age of 60 in the intravenous bolus study remain in remission with a minimum follow-up of two years.