Management of myelodysplastic syndromes

New uses for old vitamins. The treatment of myelodysplastic disorders

The treatment of myelodysplastic disorders with vitamins A and D or derivatives and nutrients has been less than satisfactory. Combinations of vitamin D3 and 13-CRA with or without cytosine arabinoside appear to offer no advantage over any of the single agents alone. Until other vitamin D derivatives are developed that are effective but do not cause hypercalcemia, vitamin D3 cannot be recommended for the treatment of MDS. 13-CRA has been shown to be effective in some patients with MDS; however, it cannot be recommended as standard therapy because of the conflicting data cited above. Further clinical trials with 13-CRA perhaps in combination with vitamin E or colony-stimulating factors are clearly indicated for this disease for which we have no effective therapy.

Myelodysplastic syndromes (refractory anemia). A perspective of the biologic, clinical, and therapeutic issues

The myelodysplastic syndromes (MDS) are a diverse group of hematologic disorders that have an abnormality in differentiation of the hematopoietic stem cell resulting in varying degrees of peripheral blood cytopenias. The author reviews the hematologic and clinical aspects of MDS, summarizes the recent pertinent aspects of the advances in our understanding of the disease, and explores the current approaches in the new treatment programs.

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.

Successful treatment for perinephric abscess with recombinant human granulocyte colony-stimulating factor following nephrectomy in a patient of myelodysplastic syndrome: a case report

The 35-year-old man with myelodysplastic syndrome (MDS) and granulocytopenia with dry cough and high fever was eventually found to have a left perinephric abscess of Staphylococcus aureus. He underwent left nephrectomy and drainage of perinephric space in conjunction with appropriate antibiotics. However, because of persistent granulocytopenia, Staph. aureus never cleared up with formation of only poor granulation. Recombinant human granulocyte colony-stimulating factor (G-CSF) was added to the above treatment leading to prompt improvement in granulocytopenia and emergence of the good granulation tissue. G-CSF will probably become one of the important agents in treating MDS with granulocytopenia.

Successful treatment of refractory anemia with high-dose methylprednisolone

Five patients with refractory anemia were treated with high-dose methylprednisolone. An immediate and long-lasting hematological improvement without serious side effects was achieved in two of the patients, although chromosomal abnormalities persisted in both. The clinical course and laboratory data of these two patients are described. Restoration of normal hematopoiesis was achieved regardless of the enhancement of colony formation of granulocyte progenitor cells by the simultaneous addition of hydrocortisone in vitro. The same treatment was given to six patients who had refractory anemia with an excess of myeloblasts (RAEB), but no improvement was observed in any of these patients. It appears that high-dose methylprednisolone can be valuable in the treatment of refractory anemia, but is not useful for RAEB.

Reduction of leukemia cell growth in a patient with acute promyelocytic leukemia treated by retinol palmitate

A 67-year-old woman with acute promyelocytic leukemia (APL) showed a marked decrease in leukemic promyelocytes with concomitant maturation of leukemic cells during treatment with retinol palmitate. A culture study in vitro revealed that retinol, which is the main metabolite of retinol palmitate detected in plasma, induced morphological and functional maturation of leukemic promyelocytes. These findings may indicate that retinol palmitate induces cell differentiation and slows proliferation of leukemic cells in vivo, and that the reduction in cell growth is the key phenomenon in the clearing of leukemic cells, rather than the maturation phenomenon itself.

Treatment of myelodysplastic syndromes with recombinant human granulocyte colony-stimulating factor: a preliminary report

PURPOSE

The expansion of an abnormal hemopoietic stem cell line is responsible for the myelodysplastic syndromes, which are characterized by pancytopenias, often resulting in lethal infections. Cloned granulocyte colony-stimulating factor (G-CSF) was recently shown to enhance the growth and differentiation of normal granulocyte progenitor cells in vitro. The aim of our study was to examine the effects of recombinant human G-CSF in patients with myelodysplastic syndromes.

PATIENTS AND METHODS

Four patients with myelodysplastic syndromes and one patient with smoldering acute myelogenous leukemia following the occurrence of a myelodysplastic syndrome received recombinant human G-CSF by intravenous infusion for six days. Patients received different dosage levels (50 to 1,600 micrograms/m2).

RESULTS

A response was seen in all patients, with an increase in both immature myeloid cells in the bone marrow and mature granulocytes in the peripheral blood. The dose levels that could stimulate granulocytopoiesis differed among patients.

CONCLUSION

These results suggest that, at least in some cases of myelodysplastic syndromes, granulocytopenia can be improved by G-CSF, although it still remains to be determined whether the increase in the number of granulocytes is due to the differentiation and maturation of the myelodysplastic clone or restoration of a residual normal clone.

Phase II trial of fenretinide [N-(4-hydroxyphenyl) retinamide] in myelodysplasia: possible retinoid-induced disease acceleration

To determine the activity of fenretinide in patients with myelodysplastic syndromes, 15 patients were treated (300 mg/d starting dose, escalated to 400 mg/d) for a 12-week course. No responses were observed in 14 evaluable patients. Exacerbation of thrombocytopenia occurred in one patient with chronic myelomonocytic leukemia, who succumbed to an intracerebral hemorrhage after 3 weeks of treatment. Two patients with long-standing stable sideroblastic anemia experienced interval leukemic progression. In one patient, clinical features of chronic myelomonocytic leukemia appeared, characterized by a striking rise in peripheral monocyte count (0.49 x 10(9)/l to 10.8 x 10(9)/l) and hepatosplenomegaly, which resolved promptly after cessation of treatment. The second patient experienced evolution into acute myelomonocytic leukemia with cytogenetic progression. The drug was well tolerated with no patient having to discontinue treatment because of toxicity. We conclude that fenretinide lacks clinical efficacy in the treatment of myelodysplasia and in some patients may enhance leukemic progression.

The preleukemic syndrome (hematopoietic dysplasia)

It has been recognized for many decades that epithelial dysplasia can represent an early histological sign of epithelial neoplasia. So it is with hematopoietic tissue wherein dysplasia of bone marrow cells can be an early sign of impending acute myeloid leukemia. Although this 'preleukemic syndrome' of hematopoietic dysplasia can often be identified well in advance of the classic histological signs of acute leukemia, a wide variety of basic studies on bone marrow cells, from patients and from experimental animals with induced preleukemia, clearly indicate that the preleukemic marrow cells are members of a fully established neoplastic clone. Consequently, it is likely that the preleukemic syndrome is merely acute leukemia diagnosed earlier than usual and which, in some patients, can be very slowly progressive, and in others may not progress at all. This article reviews the evidence in support of the notion that the preleukemic syndrome is an 'early leukemia', places the preleukemic syndrome in the context of a larger group of myelodysplastic disorders, reviews the laboratory studies of value for both diagnosis and for use in the assessment of prognosis, and summarizes the therapeutic options available for the management of patients with this disorder.

Therapeutic efficacy of danazol in myelodysplastic syndromes

Sixteen unselected untreated patients with primary myelodysplastic syndromes (MDS) and various combinations of blood cytopenia were treated with danazol, an attenuated androgen reported to be of some value in these conditions. After a 12 week trial (danazol 600 mg/day/p.o.), anaemia improved in 4/14 patients, with transfusional requirements being reduced by 50% or more in four other cases (response 57%). An enhanced reticulocyte production was documented in 6/13 cases (46%), and thrombocytopenia resolved in 5/8 (62%). Results of the granulocyte count were less satisfactory, with only one partial response obtained among five cases. A normalization of the monocyte count was seen in 3/5 patients with chronic myelomonocytic leukaemia, with one of them achieving a complete haematological and clinical remission lasting 6 months. Circulating blast cells decreased significantly (50% or more) in 4/6 cases. Although clinical symptoms from anaemia and bleeding disappeared in responsive cases, four patients developed acute non-lymphocytic leukaemia. Danazol was well tolerated and produced no acute or chronic toxicity. The drug appears useful in the management of anaemic and thrombocytopenic MDS patients.

Effects of recombinant human granulocyte-macrophage colony-stimulating factor in patients with myelodysplastic syndromes

The myelodysplastic syndromes are characterized by ineffective hematopoiesis and refractory cytopenias. In an attempt to improve hematopoiesis, we administered recombinant human granulocyte--macrophage colony-stimulating factor (GM-CSF) to eight patients with myelodysplastic syndrome, as part of a Phase I trial. The GM-CSF was given by continuous intravenous infusion daily for two weeks and then again after a two-week rest period. Over the entire dose range tested (30 to 500 micrograms per square meter of body-surface area), treatment was associated with marked increases in peripheral-blood leukocytes (5- to 70-fold), including granulocytes (5- to 373-fold), in all eight patients. The absolute number of monocytes, eosinophils, and lymphocytes increased in all patients. Three of eight patients also had 2- to 10-fold increases in platelet counts and improvement in erythropoiesis, with the result that two of three patients who had required red-cell and platelet transfusions no longer needed them (at 20 to 27 weeks of follow-up). Treatment was also associated with increased marrow cellularity and a decreased percentage of blasts in the bone marrow of patients with excess blasts, resulting in an increase in the ratio of differentiated myeloid cells to immature myeloid cells. We observed relatively few side effects, but bone pain was dose-limiting when it was associated with high white-cell counts. Our results showed that GM-CSF is a potent stimulator of hematopoiesis in vivo and may produce hematologic improvement in the short term (8 to 32 weeks of observation) in patients with myelodysplastic syndrome. More experience, with longer follow-up periods, will be necessary to assess the long-term safety and efficacy of this new treatment.

Danazol in the treatment of myelodysplastic syndromes

20 patients with myelodysplastic syndromes (MDS) were treated with danazol, 800 mg daily in 4 divided doses. 18 patients were evaluable for response. 3 patients (17%), whose principal problem was anemia, responded to treatment, but only with an increase in platelet count. Responses were short-lived and lacked clinical significance. No patients with anemia or leukopenia responded to treatment and none of the 7 patients with a platelet count less than 30 x 10(9)/l responded. Danazol appears to have limited clinical utility in the treatment of MDS. However, occasional patients with thrombocytopenia may benefit.

Acute cerebellar syndrome, conjunctivitis, and hearing loss associated with low-dose cytarabine administration

An unusual reaction associated with chronic low-dose cytarabine is described. A 77-year-old man complained of three to four weeks of hearing loss and progressive inability to walk without assistance. He had received two courses of cytarabine 100 mg sc/wk for the management of myelofibrosis myeloid metaplasia over 21 months. He received a total of 3 g over seven months during his first course followed ten months later with a 1.2 g over four months. Conjunctivitis was also identified on physical examination at the time of his admission. He was admitted to the neurology service where a complete neurological work-up with consultations from the ophthalmology, audiology, hematology, and ear, nose, and throat services failed to identify a cause of his symptoms. Cytarabine was discontinued on the suspicion that his symptoms were drug induced. The conjunctivitis resolved completely with ophthalmic antibiotics and corticosteroids. His hearing slowly improved over three to four weeks, and he was able to ambulate with a walker. He continued to improve at home although some hearing loss remained three months after his initial presentation. Although conjunctivitis and neurotoxicity are well-known complications of high-dose cytarabine, there are no prior reports of these reactions after low-dose therapy. Hearing loss, which has not been previously reported with cytarabine alone, appears to be a new complication of cytarabine administration.

The management of leukaemia in the elderly

Leukaemia is relatively common in the elderly compared to the general population, with over half of all cases of leukaemia occurring in patients aged 65 and over. Special problems are associated with treating patients in this age group. The leukaemias may be intrinsically different, in part because of the high incidence of preceding myelodysplasia. There is increased likelihood of coincident disease. There is lower tolerance to toxic complications, such as infection and bleeding, associated with a decreased resilience of normal haematopoiesis. There is more difficulty in obtaining intravenous access in elderly patients. These problems render patients ineligible for marrow transplants. Myelodysplastic syndromes occur predominantly in the elderly. There are a number of myelodysplastic syndromes now identified, each with its characteristic natural history. Management decisions are based on accurate diagnosis of the specific syndrome, consideration of prognostic features, a period of observation, and conservative treatment principles. More than half the cases of acute myeloblastic leukaemia also occur in the elderly. Prognostic factors must be examined and the literature carefully scrutinized for results pertinent to the elderly patient. In some patients treatment may be justifiably withheld, others may benefit from low dose cytosine arabinoside and some patients should receive aggressive combination chemotherapy. Management of the chronic leukaemias in the elderly is a less controversial area. Chronic lymphocytic leukaemia is the most common of the leukaemias in this age group. Prognostic factors can be determined using staging criteria. observation alone is indicated in many patients. Chlorambucil and prednisone are the most widely used drugs for symptomatic disease. Aggressive combination chemotherapy may benefit a few patients with advanced or refractory CLL. Hairy cell leukaemia is a rare disorder but many of the patients are over age 65. The elderly male patient may have a particularly benign course and require no therapy. Splenectomy is the standard first line of therapy, but recombinant alpha-interferon is sufficiently effective and non-toxic that it should be the treatment of choice in some patients. Deoxycoformycin is also effective in preliminary trials and may soon be routinely indicated. It is not often appreciated that half of all patients with chronic myelogenous leukaemia are aged 65 and over.(ABSTRACT TRUNCATED AT 400 WORDS)