Clinical study of daunomycin and prednisone for induction of remission in children with advanced leukemia

Daunorubicin during delayed intensification decreases the incidence of infectious complications - a randomized comparison in trial CoALL 08-09

Anthracyclines are integral components of antileukemic treatment. Apart from cardiotoxicity, myelosuppression and infectious complications have been described for doxorubicin (DOX) and daunorubicin (DNR) as predominant side effects, but little is known about their differential toxicities. To address the question whether DNR is associated with a lower rate of infectious complications compared with DOX, 307 children with newly diagnosed acute lymphoblastic leukemia, enrolled in trial CoALL 08-09, were randomized to receive either DOX 30 mg/m² (n = 153) or DNR 36 mg/m² (n = 154) in delayed intensification. Hematologic toxicities and stomatitis were less frequent in the DNR group resulting in a significantly lower rate of infections in the DNR arm (27% vs. 59%, p < .0001). Survival was equal in both arms (95% SE 2%) (p = .55), with an insignificant difference in the relapse rate (RR 0.12 (SE = 0.03) in the DOX arm vs. 0.16 (SE = 0.04) in the DNR arm; p = .37; Hazard ratio 1.3; 95% confidence interval 0.7-2.6). In conclusion, DNR given in delayed intensification is associated with a lower incidence of infectious complications without loss of efficacy.

Combination Chemotherapy with Methotrexate, Endoxan, and Vincristine (M.E.V.) in the Treatment of non-Hodgkin's Lymphoma

Twelve patients with lymphocytic lymphoma (L.L.), and 9 patients with histiocytic lymphoma (H.L.), stage III and IV, were treated as outpatients with combination chemotherapy including six courses of cyclophosphamide (Endoxan), Methotrexate, and vincristine (M.E.V. regimen). Marrow depression and side-effects were moderate. In the 12 patients with L.L., there were 6 complete remissions (C.R.), 3 incomplete remission (I.R.), and 3 partial failures (P.F.). In the 9 patients with H.L., there were 7 C.R., 1 I.R. and 1 P.F. Median survival from the end of the therapy is 7 + mos. for the L.L. patients, and 10 + mos. for H.L. patients, all patients being alive but one.

Mechanism of the susceptibility of remodeled pulmonary vessels to drug-induced cell killing

Background

Pulmonary arterial hypertension remains a devastating disease without a cure. The major complication of this disease is the abnormal growth of vascular cells, resulting in pulmonary vascular remodeling. Thus, agents, which affect the remodeled vessels by killing unwanted cells, should improve treatment strategies. The present study reports that antitumor drugs selectively kill vascular cells in remodeled pulmonary vessels in rat models of pulmonary hypertension.

Methods and Results

After developing pulmonary vascular remodeling in chronic hypoxia or chronic hypoxia/SU‐5416 models, rats were injected with antitumor drugs including proteasome inhibitors (bortezomib and MG‐132) and daunorubicin. Within 1 to 3 days, these agents reduced the media and intima thickness of remodeled pulmonary vascular walls, but not the thickness of normal pulmonary vessels. These drugs also promoted apoptotic and autophagic death of vascular cells in the remodeled vessels, but not in normal vessels. We provide evidence that the upregulation of annexin A1, leading to GATA4‐dependent downregulation of Bcl‐x_L, is a mechanism for specific apoptotic killing, and for the role of parkin in defining specificity of autophagic killing of remodeled vascular cells. The reversal of pulmonary vascular remodeling increased the capacity of vasodilators to reduce pulmonary arterial pressure.

Conclusions

These results suggest that antitumor drugs can specifically kill cells in remodeled pulmonary vascular walls and may be useful for improving the efficacy of current therapeutic strategies to treat pulmonary arterial hypertension.

Doxorubicin or daunorubicin given upfront in a therapeutic window are equally effective in children with newly diagnosed acute lymphoblastic leukemia. A randomized comparison in trial CoALL 07-03

BACKGROUND

The anthracyclines daunorubicin (DNR) and doxorubicin (DOX) are among the most important drugs in the treatment of childhood acute lymphoblastic leukemia, however there are conflicting in vitro data about the comparative efficacy and equivalent doses of both anthracyclines. To address the question of in vivo efficacy of both anthracyclines, patients enrolled in the CoALL 07-03 trial were randomized to receive one single dose of either doxorubicin 30 mg/m(2) , daunorubicin 30 mg/m(2) , or daunorubicin 40 mg/m(2) upfront induction therapy.

PROCEDURE

Children with newly diagnosed B-Precursor ALL or T-ALL were eligible for the randomized comparison. From the percentage of blasts and the white blood cell count (WBC) the absolute number of leukemic cells per µl peripheral blood (PB) was calculated and the initial value before DOX/DNR infusion equated as 100%. Main target criterion of this study was the leukemic cell decrease from Day 0 to Day 7.

RESULTS

Seven hundred forty three patients were randomized: 247 to the DOX; 252 to the DNR 30 mg/m(2) ; and DNR to the 40 mg/m(2) arm. The in vivo response was similar in all three treatment arms with a comparable blast decline in the peripheral blood. The percentages of patients with a clear non-response (M3 marrow) and moreover, the level of minimal residual disease (MRD) on Day 15 or at the end of induction were similar.

CONCLUSION

In vivo efficacy of a single dose daunorubicin 30 or 40 mg/m(2) is similar to that of doxorubicin given in a dose of 30 mg/m(2) .

Cardiotoxicity of chemotherapeutic agents: incidence, treatment and prevention

Cytostatic antibiotics of the anthracycline class are the best known of the chemotherapeutic agents that cause cardiotoxicity. Alkylating agents such as cyclophosphamide, ifosfamide, cisplatin, carmustine, busulfan, chlormethine and mitomycin have also been associated with cardiotoxicity. Other agents that may induce a cardiac event include paclitaxel, etoposide, teniposide, the vinca alkaloids, fluorouracil, cytarabine, amsacrine, cladribine, asparaginase, tretinoin and pentostatin. Cardiotoxicity is rare with some agents, but may occur in >20% of patients treated with doxorubicin, daunorubicin or fluorouracil. Cardiac events may include mild blood pressure changes, thrombosis, electrocardiographic changes, arrhythmias, myocarditis, pericarditis, myocardial infarction, cardiomyopathy, cardiac failure (left ventricular failure) and congestive heart failure. These may occur during or shortly after treatment, within days or weeks after treatment, or may not be apparent until months, and sometimes years, after completion of chemotherapy. A number of risk factors may predispose a patient to cardiotoxicity. These are: cumulative dose (anthracyclines, mitomycin); total dose administered during a day or a course (cyclophosphamide, ifosfamide, carmustine, fluorouracil, cytarabine); rate of administration (anthracyclines, fluorouracil); schedule of administration (anthracyclines); mediastinal radiation; age; female gender; concurrent administration of cardiotoxic agents; prior anthracycline chemotherapy; history of or pre-existing cardiovascular disorders; and electrolyte imbalances such as hypokalaemia and hypomagnesaemia. The potential for cardiotoxicity should be recognised before therapy is initiated. Patients should be screened for risk factors, and an attempt to modify them should be made. Monitoring for cardiac events and their treatment will usually depend on the signs and symptoms anticipated and exhibited. Patients may be asymptomatic, with the only manifestation being electrocardiographic changes. Continuous cardiac monitoring, baseline and regular electrocardiographic and echocardiographic studies, radionuclide angiography and measurement of serum electrolytes and cardiac enzymes may be considered in patients with risk factors or those with a history of cardiotoxicity. Treatment of most cardiac events induced by chemotherapy is symptomatic. Agents that can be used prophylactically are few, although dexrazoxane, a cardioprotective agent specific for anthracycline chemotherapy, has been approved by the US Food and Drug Administration. Cardiotoxicity can be prevented by screening and modifying risk factors, aggressively monitoring for signs and symptoms as chemotherapy is administered, and continuing follow-up after completion of a course or the entire treatment. Prompt measures such as discontinuation or modification of chemotherapy or use of appropriate drug therapy should be initiated on the basis of changes in monitoring parameters before the patient exhibits signs and symptoms of cardiotoxicity.

Treatment of refractory adult acute lymphocytic leukaemia and acute undifferentiated leukaemia with an anthracycline antibiotic and cytosine arabinoside

Ten patients with acute lymphocytic leukaemia (ALL) and four patients with acute undifferentiated leukaemia (AUL) in relapse or refractory to conventional therapy were treated with remission induction therapy consisting of an anthracycline antibiotic and cytosine arabinoside. Twelve patients had previously demonstrated resistance to vincristine-prednisone and nine patients had prior anthracycline therapy. Nine patients achieved complete remission after one course of therapy with a median time to remission of 30 d. Of five nonresponders, three died of sepsis with marrow hypocellularity and no evidence of residual leukaemia. Only two patients had unequivocal evidence for resistance to an anthracycline-cytosine arabinoside regimen. Myelosuppression and infection were the most significant complications of therapy. The data presented indicate that marrow ablative chemotherapy with an anthracycline antibiotic and cytosine arabinoside is an effective regimen for remission induction in adults with ALL and AUL refractory to vincristine-prednisone. The use of these agents in remission consolidation therapy may offer the possibility of providing a reduction in residual resistant cells that are present after successful remission induction therapy with conventional agents.

Adriamycin and other anthracycline antibiotics under study in the United States

Adriamycin is now firmly established as a drug with a very broad spectrum of antitumor activity. It has had a major impact on the therapy of sarcomas. The dose response effect in this tumor is steep and combinations which compromise the dose of adriamycin too greatly are showing inferior results. In lung and breast cancer combinations with adriamycin have been extensively tried. The FAC Regimen in breast cancer has given excellent results at the M.D. Anderson Hospital. The inclusion of adriamycin in combinations has had an impact in the poor prognosis histologies of non-Hodgkin's lymphomas. The CHOP regimen is one of the best developed to date for diffuse histiocytic lymphomas. In the leukemias adriamycin is probably equivalent to daunorubicin which has been more extensively used in this country. A new analog called Rubidazone has shown good activity in AML with a smooth induction and its incorporation into combination with Ara-C, vincristine and prednisone in a regimen called ROAP is being investigated. Adriamycin in complex with DNA has been clinically evaluated, but at this time, no advantage for this approach can be demonstrated.

Daunomycin-induced cardiotoxicity in children and adults. A review of 110 cases

Daunomycin, like its anthracycline analog adriamycin, is a cardiotoxic antitumor antibiotic. Reports on 5,613 patients receiving daunomycin were reviewed for cardiotoxicity. Two distinct patterns of cardiotoxicity were defined, congestive heart failure (cardiomyopathy) and electrocardiographic changes. Dose-response curves were constructed using the percent incidence of cardiomyopathy versus the total dose of daunomycin in mg/m2. There was a dose-response relationship between the total dose of daunomycin and the development of cardiomyopathy, both in children and adults. The children seem more susceptible to the drug-induced cardiomyopathy. The electrocardiographic changes in the children and adults did not show a dose-dependent relationship, were present consistently even at the lowest dosage levels, and did not predict for subsequent development of cardiomyopathy. The dose-response curves constructed enable the clinician to judge the relative risk of developing cardiomyopathy at a given total dosage level and allows comparison of the human experience with the experimental animal model data.

Preliminary Studies on the Distribution and Excretion of Tritiated Daunomycin in Men

3H-daunomycin was injected in 10 patients with widespread cancer (in 7 cases intravenously, in 1 case into the ascitic fluid and in 2 cases intraarterially) at the dose of 1 mg/kg. The radioactivity was determined in plasma, urine, stools, ascitic fluid and cerebrospinal fluid with the hyamine hydroxide method. The radioactivity was determined with a Tri-Carb apparatus, model 3003. From this study 3H-daunomycin seems to be rapidly fixed by body tissues regardless of the route of administration. Low plasma levels of radioactivity were detected even at early intervals after drug administration. 3H-daunomycin levels fall very rapidly when the drag is injected into the ascitic fluid; low urinary and fecal excretion were also observed during the first week. No radioactivity was detected in the cerebrospinal fluid, which indicates that daunomycin at the dose given does not cross the blood brain barrier. Since daunomycin appears to be taken up quickly by the cells, where it is retained for long periods of time, accumulation and toxic effects are more likely to occur with a daily dose rather than with intermittent dose schedule.