Result of interferon-alpha therapy in patients with chronic myelogenous leukemia 60 years of age and older

Measuring prognosis in chronic myeloid leukemia: what's new?

Introduction: The outcome of chronic myeloid leukemia (CML) patients in chronic phase has changed after the introduction of tyrosine kinase inhibitors (TKIs). The life expectancy is actually similar to that of the general population. Prognostic stratification at baseline is part of a patient-centered approach to decide the best therapeutic approach.Areas covered: In this review, the current prognostic factors examined at baseline are detailed and the meaning is explained. A broad research on Medline, Embase and archives from EHA and ASH congresses, was performed. Prognostic factors have been divided into patient-related (age, gender, comorbidities, etc.) and disease-related (additional cytogenetic abnormalities, type of transcript, etc). New information about genomic data and the potential role of patient-reported outcomes is also discussed.Expert Opinion: Prognostic factors at baseline should be considered to evaluate the long-term probability of disease-related death, the possible toxicity, and the projected long-term overall survival. The genomic assessment would provide the basis for a genomic-based risk and help in oriented decision-making process.

Management of Elderly Patients with Newly Diagnosed Chronic Myeloid Leukemia in the Accelerated or Blastic Phase

In the elderly population, the accelerated and blastic phases of chronic myeloid leukemia (CML) are difficult to treat, not just because of the higher chance of acquired mutations than in younger individuals, but because of additional associated co-morbidities. Tyrosine kinase inhibitors are well-established in the treatment of the chronic phase of CML, and their use in advanced phases is ever-increasing. Elderly patients who are still eligible candidates for transplant can undergo reduced-intensity transplants from related or unrelated donors after reverting to chronic phase. Post-transplantation, these patients require adequate monitoring and therapy to prevent relapses. Newer modalities of treatment or interventions are urgently required in this complex group of patients.

First-line treatment of newly diagnosed elderly patients with chronic myeloid leukemia: current and emerging strategies

Chronic myeloid leukemia (CML) is a disease of the hematopoietic stem cell characterized by a median age at diagnosis of 60-65 years according to most epidemiologic registries. Prior to the tyrosine kinase inhibitor (TKI) era, older age was considered an adverse prognostic factor and was included in two of the most used scoring systems for CML, the Sokal score and the Euro score. Moreover, older age was generally considered a limitation for the use of allogeneic stem-cell transplantation, given the higher toxicity observed. After the introduction of TKIs, age lost much of its prognostic impact in patients in chronic phase (CP), and the EUTOS score, developed in patients treated with imatinib, did not identify age as a risk variable. However, most CML patients require life-long treatment; therefore, as patients age while taking a TKI, the complexity of the management of elderly patients may increase over time. To date, imatinib, the first TKI introduced, and two second-generation TKIs, nilotinib and dasatinib, have been approved in most Western countries for the first-line treatment of CML. These drugs differ in terms of efficacy, safety, and costs; therefore, knowledge of their characteristics is extremely relevant for optimal management of elderly CML patients. We reviewed the impact of age on the first-line treatment of CP CML patients in the TKI era, considering the epidemiology of the disease, the role of comorbidities, and analyzing data from population-based studies and clinical trials.

Overcoming therapy failure in elderly patients with chronic myeloid leukemia

SUMMARY 

Chronic myeloid leukemia (CML) affects mainly older adults, as median age at diagnosis is 60–65 years. For a long time, survival of elderly CML patients has been shorter compared with younger patients. With the advent of the first tyrosine kinase inhibitor (TKI), imatinib, long-term outcome has significantly improved, including in the elderly, with rates of cytogenetic and molecular responses roughly equal to those attained in the young, as well as manageable toxicity. More recently, second-generation (dasatinib, nilotinib and bosutinib) and third-generation (ponatinib) TKIs were employed in CML patients failing imatinib or other front-line treatments. Despite a shorter follow-up, these TKIs showed remarkable activity in elderly patients. This review focuses on the therapeutic strategies to prevent and overcome treatment failure in elderly CML patients.

Age influences initial dose and compliance to imatinib in chronic myeloid leukemia elderly patients but concomitant comorbidities appear to influence overall and event-free survival

We applied Charlson comorbidity index (CCI) stratification on a large cohort of chronic myeloid leukemia (CML) very elderly patients (>75 years) treated with imatinib, in order to observe the impact of concomitant diseases on both compliance and outcome. One hundred and eighty-one patients were recruited by 21 Italian centers. There were 95 males and 86 females, median age 78.6 years (range 75-93.6). According to Sokal score, 106 patients were classified as intermediate risk and 55 as high risk (not available in 20 patients). According to CCI stratification, 71 patients had score 0 and 110 a score ≥ 1. Imatinib standard dose was reduced at start of therapy (200-300 mg/day) in 68 patients independently from the evaluation of baseline comorbidities, but based only on physician judgement: 43.6% of these patients had score 0 compared to 34% of patients who had score ≥ 1. Significant differences were found in terms of subsequent dose reduction (39% of patients with score 0 compared to 53% of patients with score ≥ 1) and in terms of drug discontinuation due to toxicity (35% of patients with score 0 vs 65% of patients with score ≥ 1). We did not find significant differences as regards occurrence of hematologic side effects, probably as a consequence of the initial dose reduction: 39% of patients with score 0 experienced grade 3/4 hematologic toxicity (most commonly anemia) compared to 42% of patients with score ≥ 1. Independently from the initial dose, comorbidities again did not have an impact on development of grade 3/4 non-hematologic side effects (most commonly skin rash, muscle cramps and fluid retention): 62% of patients with score 0 compared to 52.5% of patients with score ≥ 1. Notwithstanding the reduced dose and the weight of comorbidities we did not find significant differences but only a trend in terms of efficacy: 66% of patients with score 0 achieved a CCyR compared to 54% of patients with score ≥ 1. Comorbidities appeared to have an impact on median OS (40.8 months for patients with score 0 vs 20.16 months for patients with score ≥ 1) on EFS and on non-CML death rate. Our results suggest that treatment of very elderly CML patients might be influenced by personal physician perception: evaluation at baseline of comorbidities according to CCI should improve initial decision-making in this subset of patients.

Long-term safety and efficacy of imatinib mesylate (Gleevec®) in elderly patients with chronic phase chronic myelogenous leukemia: results of the AFR04 study

Data from registries suggest that the median age of chronic myelogenous leukemia (CML) patients is 10-15 years older than that of clinical trials. We conducted a prospective phase II study to evaluate imatinib mesylate (IM, 400 mg daily) in newly diagnosed chronic phase CML (CP-CML) patients. Patients aged 70 years and over diagnosed with CP-CML within 12 months were eligible. Thirty patients were enrolled from April 2002 to October 2004. Median age was 74.8 years (range, 70-90). Male/female ratio was 1.72. At inclusion, comorbidities were reported in all but one patient, Cumulative Illness Rating Scale for Geriatrics comorbidity mean index was 1.47, and 66% of patients had cardiovascular disease. The median daily IM dose was 392 mg (range, 256-445). IM was interrupted in patients with severe comorbidities. Treatment discontinuation was observed in 36.6% of patients. Cumulative incidence of complete cytogenetic response was 71.4 and 78.5% at 12 and 24 months, respectively. A high level of sustained responses was observed in patients with mild or moderate comorbidities. Seven-year estimated overall survival was 80.8% (95% CI: 59.0-91.7). Two-thirds of the patients were still on long-term therapy at cut-off, and no patients had died from progression. This trial was registered at http://www.clinicaltrials.gov as # NCT00219765.

Analysis of outcomes in adolescents and young adults with chronic myelogenous leukemia treated with upfront tyrosine kinase inhibitor therapy

BACKGROUND

Outcomes in chronic myeloid leukemia have improved with tyrosine kinase inhibitor treatment. However, little is known about outcomes of chronic myeloid leukemia in adolescent and young adult patients.

DESIGN AND METHODS

We reviewed all 468 chronic myeloid leukemia patients treated at our institution with tyrosine kinase inhibitors as initial therapy: imatinib (n=281), nilotinib (n=98) or dasatinib (n=89).

RESULTS

Median age was 47 years, median follow up 71 months and median treatment time with initial tyrosine kinase inhibitors 48 months. Adolescent and young adult was defined as aged 15-29 years. Sixty-one adolescent and young adult patients were identified. The only significant differences between adolescent and young adult and older patients were incidence of splenomegaly and distribution in Sokal risk groups. Only 3 adolescent and young adult patients have died. Rates of complete cytogenetic, major molecular and complete molecular response were significantly higher in older patients compared to adolescent and young adult patients, with a favorable trend in event-free survival for older patients. Transformation-free and overall survival were similar for the two groups.

CONCLUSIONS

The unfavorable trend in outcome for adolescent and young adult patients with chronic myeloid leukemia is unexpected. Additional research in this population is required to better define outcomes, understand the cause of this difference, and to help make better treatment recommendations.

Frontline imatinib treatment of chronic myeloid leukemia: no impact of age on outcome, a survey by the GIMEMA CML Working Party

The median age of chronic myeloid leukemia (CML) patients is ∼ 60 years, and age is still considered an important prognostic factor, included in Sokal and EURO risk scores. However, few data are available about the long-term outcome of older patients treated with imatinib (IM) frontline. We analyzed the relationship between age and outcome in 559 early chronic-phase CML patients enrolled in 3 prospective clinical trials of Gruppo Italiano Malattie Ematologiche dell'Adulto CML Working Party, treated frontline with IM, with a median follow-up of 60 months. There were 115 older patients (≥ 65 years; 21%). The complete cytogenetic and major molecular response rates were similar in the 2 age groups. In older patients, event-free survival (55% vs 67%), failure-free survival (78% vs 92%), progression-free survival (62% vs 78%), and overall survival (75% vs 89%) were significantly inferior (all P < .01) because of a higher proportion of deaths that occurred in complete hematologic response, therefore unrelated to CML progression (15% vs 3%, P < .0001). The outcome was similar once those deaths were censored. These data show that response to IM was not affected by age and that the mortality rate linked to CML is similar in both age groups. This trial was registered at www.clinicaltrials.gov as #NCT00514488 and #NCT00510926.

Chronic myeloid leukaemia and hairy cell leukaemia coexisting in a single patient: Difficulties at diagnosis and rational of the therapeutic strategy

Chronic myeloid leukemia (CML) and hairy cell leukemia (HCL) are two distinct haematological disorders. Only one single case of coexistence of the two pathologies at diagnoses has been previously reported. We present a second case of coexistence at diagnosis, indicating the diagnostic procedures involving morphological, immunophenotyping, and molecular testing. We decided to use Interferon as common first-line therapy and Imatinib and Rituximab (anti-CD20 monoclonal antibody), to improve the first-line therapy result, obtaining a complete molecular remission for CML and clinical remission with molecular minimal residual disease for HCL. After a critical analysis of the results, we speculate on the different clonal origin of the two pathologies.

Natural history and staging of chronic myelogenous leukemia

The natural history of chronic myelogenous leukemia (CML) has changed in recent years, partly due to earlier diagnosis but mostly as a consequence of the availability of effective therapies that have the potential to eradicate the Philadelphia chromosome-positive clone. Highly effective therapy with imatinib has changed the prognostic significance of clinical features traditionally associated with poor outcome. Achieving a complete cytogenetic response and a major molecular response early during the course of therapy with imatinib may be the most important factor in determining longterm outcome. Therefore, treatment modalities that increase the probability of achieving this goal should be pursued. This article describes the natural history of CML and its prognostic factors,with emphasis on changes due to the emergence of imatinib.

Treatment Patterns, Outcomes and Costs Among Elderly Patients with Chronic Myeloid Leukaemia

BACKGROUND AND OBJECTIVE

Chronic myeloid leukaemia (CML) affects approximately 3000-5000 Americans each year, with the American Cancer Society expecting 4600 new cases in 2004. The incidence of CML increases with age; median age at diagnosis is 67 years. Long-term data on the economic burden associated with CML among the elderly are sparse. To fill this void, our study uses population-based data to evaluate longer-term treatment patterns, outcomes and costs among elderly Medicare beneficiaries following their diagnosis of CML.

PATIENTS AND METHODS

This retrospective cohort analysis used linked data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute and Medicare claims. Study cohorts included 567 patients aged > or = 65 years newly diagnosed with CML between 1991 and 1993 in a SEER registry and followed for 5 years or until death, whichever occurred first. In addition, 567 control patients without CML matched 1 : 1 by age and sex (average age 78 years, 52% male) were included. The costs of care were based on total Medicare payments (in constant 1998 dollars). Groups were generally similar in terms of nonmatched variables.

RESULTS

Five years following diagnosis, 13% of CML patients were still alive versus 68% of the control patients (median survival: 14 months vs > 60 months, respectively). The average total Medicare payments were USD35,785 for CML patients versus USD21,161 for control subjects (monthly payments: USD1688 vs USD428, respectively; p < 0.001). Approximately 25% of CML patients underwent Medicare-covered cancer treatment (11% outpatient chemotherapy, 6% inpatient chemotherapy and 8% outpatient interferon-alpha therapy). Younger patients and those diagnosed in the later years were most likely to be treated. Costs for treated patients were higher, and they lived longer.

CONCLUSION

Our findings suggest low treatment rates, and substantial excess mortality and costs associated with CML among the elderly. The recent introduction of imatinib has dramatically changed the treatment of CML, which is likely to cause important changes to the economic burden of CML. Our results can be used as a baseline for evaluating the impact of such new therapies as data from clinical trials become available. Further work is needed to characterise this disease and the complex factors that influence treatment decisions and associated health outcomes in elderly patients.

Chronic myelogenous leukemia: elements of conventional chemotherapy and an overview of autografting in the treatment of the chronic phase

Chronic myelogenous leukemia (CML) consists of a clonal malignancy that arises from a pluripotent hematopoietic stem call. In most cases, neoplastic cells are characterized by the formation of a shortened chromosome 22 called the Philadelphia chromosome. It results from a reciprocal translocation between long arms of chromosomes 9 and 22. A rearranged gene (bcr-abl) is the consequence of this translocation, and it may be considered as the first step toward leukemic transformation. Conventional chemotherapy of CML in the chronic phase is unable to suppress the Ph+ leukemic clone. The treatment with the IFNalpha may induce an overall cytogenetic response rate of 40-50% of patients. Autografting for patients with CML in chronic phase may induce a 53% overall cytogenetic response rate with a duration of disease-free time and survival from the autograft ranging, respectively, from 4 to 24 mo and from 8 to 40 mo.

[Cytogenetic remission 10 years after the start of monotherapy with interferon alpha-2b in elderly chronic myelogenous leukemia]

A 69-year-old man was found to have leukocytosis and a bleeding tendency, when he underwent surgery for hemorrhoids in November 1992, at the age of 69. The patient was referred to our department for further examination, and was admitted on December 4. On admission, he had hepatomegaly (5 cm) and splenomegaly (12 cm). Laboratory data on admission showed that the leukocyte count was 173,400/microliter, erythrocyte count, 314 x 10(4)/microliter, hemoglobin level, 10.5 g/dl, hematocrit value, 29.7%, and platelet count, 14.4 x 10(4)/microliter, respectively. Peripheral hemogram revealed neutrophilia with a shift to the left to promyelocytes, and the positivity of neutrophil alkaline phosphatase (NAP) was very low. The bone marrow was hyperplastic with a high M/E ratio (5.8). As the chromosome analysis revealed that he had 9:22 translocation in all 20 karyotypes, chronic myelogenous leukemia in the chronic phase, was diagnosed. After the daily intramuscular administration of 9 megaunits interferon alpha-2b was started on December 9, 1992, his leukocyte count stabilized between 5,000 and 8,000/microliter. Thereafter, intramuscular administration of IFN alpha has been continued regularly almost twice a week at the outpatient clinic until now. The leukocyte count ranges from 3,000 to 6,000/ml and he is asymptomatic. In April 1995, complete cytogenetic response was achieved 28 months after the start of interferon alpha therapy. The recent bone marrow chromosomes examination showed Philadelphia-negative metaphases until now, December, 2002, although major bcr-abl still remains positive. This case suggests that treatment with interferon alpha may still be useful in some elderly patients with chronic myelogenous leukemia.

Effects of age on prognosis with imatinib mesylate therapy for patients with Philadelphia chromosome-positive chronic myelogenous leukemia

BACKGROUND

Older age is a consistent poor prognostic factor in patients with Philadelphia chromosome (Ph)-positive chronic myelogenous leukemia (CML). Whether this is related to an intrinsic worse disease biology or to inadequate drug delivery or excessive treatment-associated toxicity is unknown. The availability of imatinib mesylate, a selective, Bcr-Abl-targeted therapy that is administered orally with minimal side effects, may clarify whether older age would remain an adverse factor (thus, implying a different age-related CML biology).

METHODS

Seven hundred forty-seven patients in different phases of Ph-positive CML who were treated with imatinib from 1999 until the time of last follow-up were evaluated. Among them, 187 patients had newly diagnosed, early chronic phase CML; 351 patients had chronic phase CML after interferon alpha (IFN) failure; 133 patients had accelerated phase CML; and 76 patients had blastic phase CML. The imatinib daily dose varied from 400 mg to 800 mg orally, according to the protocol design. Patients were categorized into a group of older patients (age 60 years or older) or younger patients (age younger than 60 years). Their characteristics, responses to therapy, and survival were compared by univariate and multivariate analyses.

RESULTS

One hundred eighty-seven patients had newly diagnosed CML, and 49 patients (26%) were in the older age group. Older patients had similar cytogenetic response rates and survival compared with younger patients. Among 351 patients with late chronic phase CML after IFN failure, 120 patients (34%) were in the older age group. Although the older patients had a lower incidence of achievement of complete cytogenetic response (Ph, 0%) by univariate analysis (56% vs. 44%; P = 0.05), age was not found to be an independent poor prognostic factor in the multivariate analysis. Similarly, older age was not an adverse poor prognostic factor for survival. Forty-two of 133 patients (32%) with accelerated phase CML were older. The incidence of any cytogenetic response was lower in older patients (53% vs. 33%; P = 0.04), but age was not significant in the multivariate analysis. Older patients also had a trend toward worse survival (P = 0.09) that was not significant in the multivariate analysis. Twenty-eight of 76 patients (37%) evaluated in blastic phase were older. Older age was not a significant prognostic factor either for achieving response or for survival.

CONCLUSIONS

With imatinib therapy, older age appears to have lost much of its prognostic relevance. This suggests that the previous poor prognosis observed with older age was related to treatment-associated factors (e.g., toxicity with allogeneic transplantation or with IFN therapy) rather than to an intrinsic, different disease biology of CML in older patients.

Chronic myeloid leukemia in the elderly: long-term results from randomized trials with interferon alpha

Chronic myeloid leukemia (CML) in older patients has not been studied well. To assess the long-term outcome of older patients with Philadelphia- and/or BCR-ABL-positive CML, 199 patients aged >/=60 years representing 23% of 856 patients enrolled in the German randomized CML-studies I (interferon alpha (IFN) vs hydroxyurea (HU) vs busulfan (BU) and II (IFN+HU vs HU alone) were analyzed after a median observation time of 7 years. In all, 45 patients were treated with Bu, 63 with HU, and 91 with IFN. The 5-year survival was 38% in patients >/=60 years and 47% in patients <60 years (P<0.001). Whereas 5-year survival in chemotherapy-treated older patients was inferior to that in younger patients (33 vs 46%, P=0.006 for HU and 29 vs 38%, P=0.042 for Bu), no significant survival difference could be verified in IFN-treated patients (46 vs 53%, P=0.077). Calculation of age-adjusted, relative survival confirmed these results. Adverse effects of IFN were similar in both age groups, but IFN dosage to achieve treatment goals was lower in older patients. We conclude that the course of CML is not different in the elderly. They require lower IFN doses, achieve the same hematologic and cytogenetic response rates and the same survival advantage at comparable toxicity.

Clinical factors associated with cancer-related fatigue in patients being treated for leukemia and non-Hodgkin's lymphoma

PURPOSE

To describe fatigue severity, fatigue interference, and associated factors in hematologic malignancies.

PATIENTS AND METHODS

Patients being treated for leukemia and non-Hodgkin's lymphoma (n = 228) completed the Brief Fatigue Inventory to rate fatigue severity and functional interference caused by fatigue. Data on patient demographics, Eastern Cooperative Oncology Group performance status, other physical symptoms, current treatments, and laboratory values were also collected. Descriptive statistics, bivariate correlation, and logistic regression were used for data analysis.

RESULTS

Fifty percent of the sample reported severe fatigue, which was defined as a "fatigue worst" rating of 7 or greater. More patients with acute leukemia (61%) reported severe fatigue compared with those with chronic leukemia (47%) and non-Hodgkin's lymphoma (46%). Increased fatigue severity significantly compromised patients' general activity, work, enjoyment of life, mood, walking, and relationships with others. Fatigue severity was strongly associated with performance status, use of opioids, blood transfusions, gastrointestinal symptoms, and sleep disturbance items, as well as with low serum hemoglobin and albumin levels. Regression analysis indicated that nausea was the significant clinical predictor of severe fatigue (odds ratio, 13), and low serum albumin was the significant laboratory value predictor (odds ratio, 3.8).

CONCLUSION

Disabling fatigue occurs with high frequency in hematologic malignancy, supporting a need to develop better methods of fatigue management. Better control of gastrointestinal and other symptoms may be of benefit. The mechanism and relationship between low albumin and severe fatigue needs to be investigated further, and longitudinal studies of the effects of treatment, host factors, and other symptoms are needed.

The benefit of long-term interferon alfa therapy for symptomatic mixed cryoglobulinemia (cutaneous vasculitis/membranoproliferative glomerulonephritis) associated with chronic hepatitis C infection

The efficacy of long-term interferon therapy for chronic hepatitis C infection with symptomatic mixed cryoglobulinemia has not clearly been defined. We describe a patient with chronic hepatitis C, symptomatic mixed cryoglobulinemia (cutaneous vasculitis), and membranoproliferative glomerulonephritis (MPGN) who responded clinically, biochemically, and virologically to a 1-year course of interferon therapy. Interferon side effects were minimal. Relapse occurred when interferon was discontinued, and suppressive maintenance interferon therapy was required for clinical, biochemical, and virologic remission. During the 5th year of maintenance therapy, she developed potential side effects that necessitated discontinuation of interferon treatment. After treatment stoppage, a clinical, biochemical, and virologic remission was maintained for more than 1 year. However, the potential side effects, which included eye irritation, arthralgias, myalgias, fatigue, insomnia, memory loss, and depression, persisted. Ophthalmologic, rheumatologic, and neurologic evaluations were nondiagnostic. Psychometric testing revealed dementia and mood disorder. Because the disabling symptoms persisted after 9 months, a health-related quality of life assessment was carried out with the SF-36 survey. Compared with healthy individuals and patients with chronic hepatitis C, our case had a lower health-related quality of life assessment on six out of seven scales and on four out of seven scales of the SF-36 survey, respectively. This case report indicates that long-term maintenance interferon therapy was effective in the treatment of symptomatic mixed cryoglobulinemia and its renal complications and resulted in a clinical, biochemical, and virologic sustained response. It is postulated that the side effects of long-term interferon therapy in this setting may be problematic.

Chronic myelogenous leukaemia

In the last decade, improvements in both non-transplant and transplant therapy have extended the lives of patients with CML, particularly those in chronic phase. The future will probably bring a greater understanding of molecular leukaemogenesis and options for treating CML. Non-transplant therapies in development include novel agents and combination therapy. Transplant strategies seek to decrease regimen-related toxicity and directly manipulate the immune system to eradicate disease. Clinical and laboratory science seems poised to add novel therapies to the armamentarium against CML. It is exciting to contemplate what reviews of CML written 10 years from now will discuss.

A prospective randomized study of alpha-2b interferon plus hydroxyurea or cytarabine for patients with early chronic phase chronic myelogenous leukemia: the International Oncology Study Group CML1 study

A prospective randomized international study of 143 patients showed no apparent early survival advantage conferred by combining cytarabine, rather than hydroxyurea, with INF as first-line CML therapy. Combinations of alpha-interferon (INF) and chemotherapeutic agents are currently first-line therapy for the majority of patients with chronic myeloid leukemia (CML). The International Oncology Study Group conducted a prospective randomized study comparing INF combined with hydroxyurea or cytarabine. The primary study aim was to compare the survival durations in these patient cohorts. Patients with early chronic phase CML were randomized to receive INF 5 million units (Mu) given five times per week subcutaneously plus hydroxyurea or cytarabine as required to achieve a complete hematologic response and to maintain a WBC count between 2x10(9)/L and 10x10(9)/L and a platelet count between 75x10(9)/L and 100x10(9)/L. Therapy continued as tolerated unless progressive or blast phase disease occurred. At 36 months, the actuarial survival rate was equivalent in both groups: HI group (79 patients) survival was 85% (95% CI, 68-100%), as compared to 95% (95% CI, 79-100%) in the CI group (64 patients). In conclusion if seems that there is no apparent early survival advantage conferred by combining cytarabine, rather than hydroxyurea, with INF as first-line CML therapy.

Interferon-alpha for the treatment of elderly patients with chronic myeloid leukaemia

The present retrospective analysis is based on data of 213 patients with chronic myeloid leukaemia (CML). They were treated with interferon (IFN)alpha-2C (Berofor) at daily doses of 3.5 MU subcutaneously (s.c.), alone or in combination with low-dose ara-C or hydroxyurea, according to four consecutive studies of the Austrian CML Study Group. Comparisons were made between 41 patients aged > or = 60 years and 172 younger patients. The elderly patients (median: 64 years; range: 60-73) showed similar pretreatment characteristics compared with the younger group, but included a higher percentage of Sokal Stage three (51 vs 20%). Median observation periods were similar (38 vs 39 months), whereas the duration of IFNalpha treatment was shorter in the elderly group (median 57 vs 42 weeks). The rate of overall haematological responses (73 vs 78%) and complete haematological response (44 vs 54%), was similar in both cohorts. Differences seen in partial (5 vs 12%) and complete cytogenetic response (10 vs 13%), were not statistically significant, but a tendency in favour of the younger cohort had to be noted. Summing up, in elderly patients acceptable rates of haematological and cytogentic response can be expected after treatment with IFNalpha alone or in combination with LD ara-C or HU.

Clinical course and therapy of chronic myelogenous leukemia with interferon-alpha and chemotherapy

This article begins with a review of the natural history of chronic myelogenous leukemia (CML), with an emphasis on prognostic features. Current standard therapy of CML with interferon-alpha based regimens, and interferon-alpha, in the context of allogenic stem cell transplantation is then discussed. Finally, some potentially effective novel agents including homoharringtonine, decitabine, ATRA, and topotecan are described.

Natural history and staging of chronic myelogenous leukaemia

The natural history of chronic myelogenous leukaemia has changed in recent years, partly as a result of earlier diagnosis but mostly as a consequence of the availability of effective therapies that have the potential to eradicate the Philadelphia-positive clone. The prognostic models designed in the pre-interferon-alpha (IFN-alpha) era based on clinical characteristics of the disease are still useful in identifying different risk groups after treatment with IFN-alpha, but achieving a cytogenetic response with IFN-alpha is now the most important prognostic factor for survival. The significance of other molecular and biological variables remains to be determined.

[Raynaud syndrome complicated by digital gangrene during treatment with interferon-alpha]

In a 43-year old male suffering from idiopathic hypereosinophilic syndrome (HES) since 1984, successfully treated with alpha interferon (alpha IFN) for 32 months, a severe Raynaud's phenomenon of the four extremities occurred and eventually evolved into digital necrosis within a few weeks. The arterial echography/doppler and plethysmography patterns were suggestive of isolated small-to medium-size digital artery occlusions. An extensive search for an aetiology of digital necrosis, including complete tests of autoimmunity, remained negative. Two months later, despite alpha IFN withdrawal and intravenous infusions of ilomedin, the digital ischemia evolved to extensive necrosis that necessitated several amputations and a definitive spinal chord stimulation. Pathologic examination of arteries showed no vasculitis but diffuse arterial occlusions by thrombi.