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Smith FO, Dvorak CC, Braun BS. Myelodysplastic Syndromes and Myeloproliferative Neoplasms in Children. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Danazol as First-Line Therapy for Myelodysplastic Syndrome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 18:e109-e113. [PMID: 29268959 DOI: 10.1016/j.clml.2017.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 11/07/2017] [Accepted: 11/22/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Allogeneic stem cell transplantation (ASCT) represents the only option with a potential cure rate of 30% to 50% in myelodysplastic syndrome (MDS); however, < 5% of patients are optimal candidates for this management. Therapeutic options are limited in patients unsuitable for ASCT. Evidence that androgens might be beneficial in MDS is controversial. We aimed to document the clinical outcomes of patients diagnosed with MDS treated with danazol as first-line therapy. PATIENTS AND METHODS We retrospectively reviewed patients diagnosed in our center with MDS according to the World Health Organization 2008 criteria and treated with danazol between 2005 and 2015. Response was defined according to international working group criteria. RESULTS We included 42 patients treated exclusively with danazol. Median dose was 400 mg/d (range, 100-600 mg/d). Median follow-up was 12 (range, 3-76) months. Twenty-four of these patients (60%) achieved clinical response. Median overall survival was 24 months (95% confidence interval, 5.1-42). Responders were older than nonresponders (P = .025) and had higher baseline hemoglobin concentration (P = .009). No patients discontinued danazol because of toxicity. Fifteen patients died (35.7%) and 5 progressed to acute myeloid leukemia. CONCLUSION Danazol as first-line therapy is an acceptable treatment option with low side effects for patients with MDS who cannot receive ASCT.
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Diagnosis and treatment of primary myelodysplastic syndromes in adults: recommendations from the European LeukemiaNet. Blood 2013; 122:2943-64. [PMID: 23980065 DOI: 10.1182/blood-2013-03-492884] [Citation(s) in RCA: 478] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Within the myelodysplastic syndrome (MDS) work package of the European LeukemiaNet, an Expert Panel was selected according to the framework elements of the National Institutes of Health Consensus Development Program. A systematic review of the literature was performed that included indexed original papers, indexed reviews and educational papers, and abstracts of conference proceedings. Guidelines were developed on the basis of a list of patient- and therapy-oriented questions, and recommendations were formulated and ranked according to the supporting level of evidence. MDSs should be classified according to the 2008 World Health Organization criteria. An accurate risk assessment requires the evaluation of not only disease-related factors but also of those related to extrahematologic comorbidity. The assessment of individual risk enables the identification of fit patients with a poor prognosis who are candidates for up-front intensive treatments, primarily allogeneic stem cell transplantation. A high proportion of MDS patients are not eligible for potentially curative treatment because of advanced age and/or clinically relevant comorbidities and poor performance status. In these patients, the therapeutic intervention is aimed at preventing cytopenia-related morbidity and preserving quality of life. A number of new agents are being developed for which the available evidence is not sufficient to recommend routine use. The inclusion of patients into prospective clinical trials is strongly recommended.
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Allogeneic transplantation for therapy-related myelodysplastic syndrome and acute myeloid leukemia. Blood 2009; 115:1850-7. [PMID: 20032503 PMCID: PMC2832815 DOI: 10.1182/blood-2009-10-249128] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapy-related myelodysplastic syndromes (t-MDSs) and acute myeloid leukemia (t-AML) have a poor prognosis with conventional therapy. Encouraging results are reported after allogeneic transplantation. We analyzed outcomes in 868 persons with t-AML (n = 545) or t-MDS (n = 323) receiving allogeneic transplants from 1990 to 2004. A myeloablative regimen was used for conditioning in 77%. Treatment-related mortality (TRM) and relapse were 41% (95% confidence interval [CI], 38-44) and 27% (24-30) at 1 year and 48% (44-51) and 31% (28-34) at 5 years, respectively. Disease-free (DFS) and overall survival (OS) were 32% (95% CI, 29-36) and 37% (34-41) at 1 year and 21% (18-24) and 22% (19-26) at 5 years, respectively. In multivariate analysis, 4 risk factors had adverse impacts on DFS and OS: (1) age older than 35 years; (2) poor-risk cytogenetics; (3) t-AML not in remission or advanced t-MDS; and (4) donor other than an HLA-identical sibling or a partially or well-matched unrelated donor. Five-year survival for subjects with none, 1, 2, 3, or 4 of these risk factors was 50% (95% CI, 38-61), 26% (20-31), 21% (16-26), 10% (5-15), and 4% (0-16), respectively (P < .001). These data permit a more precise prediction of outcome and identify subjects most likely to benefit from allogeneic transplantation.
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Ria R, Moschetta M, Reale A, Mangialardi G, Castrovilli A, Vacca A, Dammacco F. Managing myelodysplastic symptoms in elderly patients. Clin Interv Aging 2009; 4:413-23. [PMID: 19966910 PMCID: PMC2785865 DOI: 10.2147/cia.s5203] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Indexed: 11/23/2022] Open
Abstract
Most patients with myelodysplastic syndromes (MDS) are elderly (median age range 65 to 70 years); as a consequence, the incidence and prevalence of these diseases are rising as the population ages. Physicians are often uncertain about how to identify patients who may benefit from specific treatment strategies. The International Prognostic Scoring System is a widely used tool to assess the risk of transformation to leukemia and to guide treatment decisions, but it fails to take into account many aspects of treating elderly patients, including comorbid illnesses, secondary causes of MDS, prior therapy for MDS, and other age-related health, functional, cognitive, and social problems that affect the outcome and managing of myelodysplastic symptoms. Patients with low-risk disease traditionally have been given only best supportive care, but evidence is increasing that treatment with novel non-conventional drugs such as lenalidomide or methyltransferase inhibitors may influence the natural history of the disease and should be used in conjunction with supportive-care measures. Supportive care of these patients could also be improved in order to enhance their quality of life and functional performance. Elderly patients commonly have multiple medical problems and use medications to deal with these. In addition, they are more likely to have more than one health care provider. These factors all increase the risk of drug interactions and the consequent treatment of toxicities. Manifestations of common toxicities or illnesses may be more subtle in the elderly, owing to age-associated functional deficits in multiple organ systems. Particularly important to the elderly MDS patient is the age-related decline in normal bone marrow function, including the diminished capacity of response to stressors such as infection or myelosuppressive treatments. Through the integration of geriatric and oncological strategies, a personalized approach toward this unique population may be applied. As with many diseases in the elderly, reliance on family members or friends to maintain the prescribed treatments, including travel to and from appointments, may place additional stressors on the patient and his/her support network. Careful evaluation and knowledge of functional status, ability to tolerate treatments, effect of disease progression, and general overall health conditions can provide the best opportunity to support these patients. Immediate assessment of daily living activities may detect deficiencies or deficits that often require early interventions.
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Affiliation(s)
- R Ria
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Medical School, Bari, Italy.
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van der KERKHOF P, STEIJLEN P, RAYMAKERS R. Acrodermatitis continua of Hallopeau in a patient with myelodysplastic syndrome. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.90802.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Visani G, Malagola M, Piccaluga PP, Isidori A. Low dose Ara-C for myelodysplastic syndromes: is it still a current therapy? Leuk Lymphoma 2004; 45:1531-8. [PMID: 15370203 DOI: 10.1080/10428190310001653727] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The myelodysplastic syndromes (MDS) are characterized by hemopoietic insufficiency associated with severe cytopenias, leading to serious morbidity, and acute leukemia development. MDS typically occur in elderly people, with a median age at diagnosis ranging between 60 and 75 years. The patients' prognosis, estimated according to the International Prognostic Scoring System, age and performance status should be considered before choosing among the various treatment options. A therapeutic dilemma exists in MDS, due to the multifactorial pathogenetic features of the disease, the heterogeneous stage and the elderly age of patients at diagnosis. This is underlined by the absence of a Food and Drug Administration-approved agent with an indication for this disease. The therapeutic end-points vary from symptom management (using low-intensity treatment with biological targeted agents, or only supportive therapy), to attempts to change the natural history of the disease (generally using high intensity treatment, including intensive chemotherapy and hemopoietic stem cell transplantation). The main goal of low-intensity therapies is generally to induce hematological improvements and is mainly used for low-risk disease. On the other hand, high-intensity therapies generally aims to alter the disease's natural history (improving survival, and decrease progression to acute myeloid leukemia), and are mainly used for high-risk disease. This review will focus on the current role of low-dose Ara-C therapy in the management of MDS. In fact, there is evidence that low-dose chemotherapy with Ara-C can induce responses in patients with MDS. In particular, the use in combinations with growth factors, such as G-CSF or M-CSF, looks promising, suggesting further investigations about this old new therapeutic tool.
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Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous hematopoietic stem cell disorder characterized by bone marrow dysplasia and peripheral cytopenias. Eighty percent of patients found to have MDS are older than 60 years and therefore not eligible for the only potentially curative therapy, bone marrow transplantation. Currently, there is no standard for treating MDS; therapies range from supportive care with transfusions or hematopoietic growth factors and low-intensity cytarabine therapy, to intensive anti-acute myeloid leukemia-type chemotherapy. Some of these treatments induce a limited hematologic response, but none consistently extends survival. Many are highly toxic. More than half of patients with MDS die within 3 to 4 years of infections, bleeding complications, or progression to acute leukemia. Agents in development for MDS include all-trans retinoic acid (ATRA), decitabine, and thalidomide. Farnesyltransferase inhibitors modulate many of the cancer-signaling pathways implicated in MDS initiation or progression and may therefore be well suited for treatment of these biologically diverse hematologic malignancies. Phase I and II clinical studies in our center show that the oral FTI ZARNESTRA (formerly R115777, Ortho Biotech Oncology, Raritan, NJ) has promising anti-MDS activity, suggesting that further investigation of this agent and of this class in MDS is warranted.
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Affiliation(s)
- Razelle Kurzrock
- Department of Bioimmunotherapy, M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Silverman LR, Demakos EP, Peterson BL, Kornblith AB, Holland JC, Odchimar-Reissig R, Stone RM, Nelson D, Powell BL, DeCastro CM, Ellerton J, Larson RA, Schiffer CA, Holland JF. Randomized controlled trial of azacitidine in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B. J Clin Oncol 2002; 20:2429-40. [PMID: 12011120 DOI: 10.1200/jco.2002.04.117] [Citation(s) in RCA: 1334] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Patients with high-risk myelodysplastic syndrome (MDS) have high mortality from bone marrow failure or transformation to acute leukemia. Supportive care is standard therapy. We previously reported that azacitidine (Aza C) was active in patients with high-risk MDS. PATIENTS AND METHODS A randomized controlled trial was undertaken in 191 patients with MDS to compare Aza C (75 mg/m(2)/d subcutaneously for 7 days every 28 days) with supportive care. MDS was defined by French-American-British criteria. New rigorous response criteria were applied. Both arms received transfusions and antibiotics as required. Patients in the supportive care arm whose disease worsened were permitted to cross over to Aza C. RESULTS Responses occurred in 60% of patients on the Aza C arm (7% complete response, 16% partial response, 37% improved) compared with 5% (improved) receiving supportive care (P <.001). Median time to leukemic transformation or death was 21 months for Aza C versus 13 months for supportive care (P =.007). Transformation to acute myelogenous leukemia occurred as the first event in 15% of patients on the Aza C arm and in 38% receiving supportive care (P =.001). Eliminating the confounding effect of early cross-over to Aza C, a landmark analysis after 6 months showed median survival of an additional 18 months for Aza C and 11 months for supportive care (P =.03). Quality-of-life assessment found significant major advantages in physical function, symptoms, and psychological state for patients initially randomized to Aza C. CONCLUSION Aza C treatment results in significantly higher response rates, improved quality of life, reduced risk of leukemic transformation, and improved survival compared with supportive care. Aza C provides a new treatment option that is superior to supportive care for patients with the MDS subtypes and specific entry criteria treated in this study.
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Affiliation(s)
- Lewis R Silverman
- Division of Medical Oncology, Mount Sinai School of Medicine and Memorial Sloan-Kettering Cancer Center, Box 1129, One Gustave L. Levy Place, New York, NY 10029, USA.
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Hofmann WOLFKARSTEN, Hoelzer DIETER. Malignancy: Current Clinical Practice: Current Therapeutic Options in Myelodysplastic Syndromes. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2001; 4:91-112. [PMID: 11399556 DOI: 10.1080/10245332.1999.11746435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Myelodysplastic syndromes (MDS) are characterized initially by ineffective hematopoiesis and subsequently the frequent development of acute myelogenous leukemias (AML). During the last 15 years, important progress has been made in the understanding of the biology and prognosis of myelodysplastic syndromes. Risk-adapted treatment strategies were established due to the high median age (60-75 years) of MDS-patients and the individual history of the disease (number of cytopenias, cytogenetical changes, transfusion requirements). The use of allogeneic bone marrow transplantation for MDS patients currently offers the only potentially curative treatment, but this treatment modality is not available for the most of the "typical" MDS-patients aged >60 years. Based on in-vitro findings analyzing the potential of several agents to differentiate or to stimulate hematopoietic progenitor cells a number of therapeutic options were evaluated in clinical trials: hematopoietic growth factors (e.g. erythropoietin, G-CSF), differentiation inducers (e.g. retinoids), or cytoprotective substances (amifostine). The role of immunsuppressive agents (antithymocyte globulin, cyclosporine A) either alone or in combination is being actively investigated. Using intensive cytotoxic treatment in patients with advanced MDS or AML after MDS complete remission rates comparable with those known from the treatment of de novo AML were reported. The therapy related toxicity (early death rate <10%) was reduced by using G-CSF given prior ("Priming") and/or after the cytotoxic treatment.
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Affiliation(s)
- WOLF-KARSTEN Hofmann
- Department of Hematology, Johann Wolfgang Goethe University Hospital, 60590 Frankfurt/Main, Germany
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Affiliation(s)
- H I Saba
- MDS Center of Excellence and the Malignant Hematology Program at the H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida, and the Hematology/Oncology Program at the James A. Haley Veterans Hospital, Tampa, USA
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Sadek I, Zayed E, Hayne O, Fernandez L. Prolonged complete remission of myelodysplastic syndrome treated with danazol, retinoic acid and low-dose prednisone. Am J Hematol 2000; 64:306-10. [PMID: 10911385 DOI: 10.1002/1096-8652(200008)64:4<306::aid-ajh12>3.0.co;2-v] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Myelodysplastic syndrome (MDS) is a diverse group of clonal hematologic neoplasms. Different medications have been tried in MDS; however, no effective treatment has been yet established. We report a patient with MDS who achieved a complete remission in response to combination therapy of danazol, retinoic acid, and prednisone. A 53-year-old female presented with pancytopenia, macrocytosis, and hypercellular bone marrow with erythroid hyperplasia and dysplasia and 10% ringed sideroblasts. Cytogenetic studies revealed the presence of two abnormal clones. She was diagnosed as having MDS-refractory anemia and was given blood transfusions to maintain blood cell counts at acceptable levels. At the same time, she was started on a combination of danazol (600 mg/day), retinoic acid (100 mg/day), and prednisone (10 mg every other day). Fourteen months later, the patient was in complete hematologic remission; she had normal peripheral blood count, and the blood smear showed normal morphology. Bone marrow studies revealed normal trilineage hematopoiesis. She was continued on the same combination treatment for 86 months, and she remained in complete clinical remission. Eighty-eight months from diagnosis, she relapsed with acute myeloid leukemia. This is the first reported case of MDS-RA that sustained a complete hematologic remission for a prolonged period in response to this combination treatment. This report indicates that restoration of normal hematopoiesis, prolongation of disease-free survival, and delay in the transformation to acute leukemia may be achieved by this combination of treatment in a subset of patients with MDS, especially refractory anemia with severe thrombocytopenia.
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Affiliation(s)
- I Sadek
- Department of Pathology, Dalhousie University, Queen Elizabeth II Health Science Centre, Halifax, Nova Scotia, Canada.
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Abstract
Biologic agents have made a major impact on the treatment of hematologic malignancies and will continue to play a major role as we better understand their function in normal and malignant cell regulation. The examples provided in this chapter are a brief introduction to the potential of these agents. Many have yet to be used in conjunction with current cytotoxic therapy in these diseases, and perhaps combinations will prove even more successful. This possibility provides substantial ground for further investigation and therapy.
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Affiliation(s)
- J P Dutcher
- Albert Einstein Cancer Center, Montefiore Medical Cancer, Bronx, New York 10467, USA
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Beran M, Estey E, O'Brien SM, Giles FJ, Koller CA, Kornblau S, Keating M, Kantarjian HM. Results of topotecan single-agent therapy in patients with myelodysplastic syndromes and chronic myelomonocytic leukemia. Leuk Lymphoma 1998; 31:521-31. [PMID: 9922042 DOI: 10.3109/10428199809057611] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The activity of topotecan was evaluated in patients with myelodysplastic syndrome (MDS) and chronic myelomonocytic leukemia (CMML). Sixty patients with a diagnosis of MDS (n = 30) or CMML (n = 30) were treated. Their median age was 66 years, with 50 patients (83%) being over 60 years of age at time of study entry. Chromosomal abnormalities were present in 50% of patients and thrombocytopenia of less than 50 x 10(9)/L in 50%. Topotecan was administered as 2 mg/m2 by continuous infusion over 24 hours daily for five days (10 mg/m2 per course) every 4 to 6 weeks for two courses, then at maximum tolerated dose level (1-2 mg/m2 by continuous infusion over 24 hours daily for five days) once every 4-8 weeks for a maximum of 12 courses. Evaluation of outcome and of differences among subgroups was performed according to standard methods; the criteria for response were those used for acute leukemia. Nineteen patients (31%) achieved a complete response (CR). A CR was achieved in 11 of 30 patients with MDS (37%) and in eight of 30 with CMML (27%). A CR was achieved in 10 of 23 patients with previously untreated MDS (43%). Eight of 11 patients who presented with cytogenetic abnormalities (five of which involved chromosome 5 and/or 7 abnormalities) and achieved CR, were evaluated cytogenetically in CR: all were cytogenetically normal in CR. Characteristics associated with a higher CR rate were lack of previous chemotherapy, absence of ras oncogene mutations, and presence of less than 10% monocytes in either peripheral blood or bone marrow. In contrast, CR rates were similar by different agent groups, by different karyotype abnormalities, and by other pre-therapy peripheral blood counts. Non-myelosuppressive side effects were mucositis in 67% of patients (severe [grade 3-4] 23%), diarrhea in 38% (severe 17%), and nausea and vomiting in 28% (severe 5%). Febrile episodes during neutropenia occurred in 85% of patients and documented infections in 47 %. Mortality in the first four weeks was 20%. With a median follow-up duration of 31 months, the 12 month survival rate was 38%, median survival time 10.5 months, and median remission duration 7.5 months. In summary, topotecan has significant single-agent activity in MDS and CMML. Complete responses associated with topotecan therapy often involve the disappearance of abnormal, poor-prognosis karyotypes, which is particularly encouraging. Future strategies to optimize topotecan's role include combination regimens with topoisomerase II reactive agents, cytarabine, or hypomethylating agents (azacytidine and decitabine).
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MESH Headings
- Adult
- Aged
- Anemia, Refractory, with Excess of Blasts/drug therapy
- Anemia, Refractory, with Excess of Blasts/genetics
- Anemia, Refractory, with Excess of Blasts/pathology
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Chromosome Aberrations
- Genes, ras
- Humans
- Infusions, Intravenous
- Karyotyping
- Leukemia, Myelomonocytic, Chronic/drug therapy
- Leukemia, Myelomonocytic, Chronic/genetics
- Leukemia, Myelomonocytic, Chronic/mortality
- Leukemia, Myelomonocytic, Chronic/pathology
- Middle Aged
- Remission Induction
- Survival Analysis
- Topotecan/adverse effects
- Topotecan/therapeutic use
- Treatment Outcome
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Affiliation(s)
- M Beran
- Department of Leukemia, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, USA
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Affiliation(s)
- V Santini
- Department of Haematology, University of Florence, Firenze, Italy
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List AF. Hematopoietic stimulation by amifostine and sodium phenylbutyrate: what is the potential in MDS? Leuk Res 1998; 22 Suppl 1:S7-11. [PMID: 9734693 DOI: 10.1016/s0145-2126(98)00034-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A F List
- The Arizona Cancer Center and University of Arizona College of Medicine, Tucson 85718-0524, USA
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Nair R, Nair CN, Advani SH. All trans retinoic acid with low dose cytosine arabinoside in the treatment of myelodysplastic syndrome. Leuk Lymphoma 1998; 29:187-92. [PMID: 9638988 DOI: 10.3109/10428199809058394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The demonstration of synergistic interaction between differentiation inducing agents and DNA synthesis inhibitors suggests that these two groups act by two different mechanisms. We prospectively studied the response rate, response duration, survival, and toxicity in 10 patients with myelodysplastic syndrome (MDS) treated with all trans retinoic acid (ATRA) and low dose cytosine arabinoside (ara-C). These patients diagnosed between October 1993 and May 1995 were treated with ATRA (45 mg/M2/day) for 90 days followed by 90 mg/M2 on alternate day till Day 275; together with Ara-C (10 mg/m2) subcutaneously twice daily for 21 days for a total of 6 cycles. These patients were analyzed for response after 3 cycles of LD Ara-C and at the time of completion of therapy. Toxicity was recorded at the end of each cycle of Ara-C. There were 6 male and 4 female patients in the age range of 24 to 76 years. The morphological diagnosis was chronic myelomonocytic leukemia in 2, refractory anemia with excess blasts in 4 and refractory anemia with excess blasts in transformation in 4. Only 1 patient achieved a complete remission and 1 patient achieved a partial response. Four patients had progressive disease on treatment. One patient died of neutropenic sepsis and 1 of resistant thrombocytopenia and intracranial hemorrhage while on treatment. One patient refused further treatment after a minor clinical response and in 1 patient treatment was stopped due to toxicity. This data in a pilot study with a limited number of patient suggests that ATRA in combination with Ara-C has little effect in MDS.
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Affiliation(s)
- R Nair
- Department of Medical Oncology, Tata Memorial Hospital, Parel Mumbai, India
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Modulation of Idarubicin-Induced Apoptosis in Human Acute Myeloid Leukemia Blasts by All-Trans Retinoic Acid, 1,25(OH)2 Vitamin D3, and Granulocyte-Macrophage Colony-Stimulating Factor. Blood 1997. [DOI: 10.1182/blood.v90.11.4578] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The relationship between differentiation of human myeloid cells and apoptosis remains unclear. Recent studies have shown that terminal differentiation need not necessarily lead to the apoptotic demise of myeloid cells, while other studies have shown that induction of differentiation is associated with increased resistance to apoptosis-inducing agents, such as chemotherapy and γ-irradiation. Such results are pertinent to the treatment of acute myeloid leukemia (AML) and myelodysplastic syndrome, where differentiating agents and hemopoietic growth factors are being combined with chemotherapy to enhance response and limit toxicity. To elucidate the factors governing apoptosis in human AML blasts, we have studied the cytotoxic effect of idarubicin on HL60, U937 and KG1 cells, after incubation with all-trans retinoic acid (ATRA), 1,25(OH)2 D3, and granulocyte-macrophage colony-stimulating factor (GM-CSF ). We show that prior incubation of human myeloid leukemic cells with ATRA or 1,25(OH)2 D3 induced resistance to idarubicin-induced apoptosis, which was modulated by coincubation with GM-CSF. The altered chemosensitivity of cells depended on the degree of G0/G1 cell-cycle arrest induced by incubation with ATRA, 1,25(OH)2 D3, and GM-CSF and was independent of differentiation status or Bcl-2 oncoprotein expression. These findings suggest that cell-cycle arrest in human leukemic cells can be induced by exogenous agents and may promote drug resistance. Determining the mechanisms by which cell-cycle arrest is induced may permit understanding of the processes by which the cells escape cytotoxic drug-mediated apoptosis.
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Modulation of Idarubicin-Induced Apoptosis in Human Acute Myeloid Leukemia Blasts by All-Trans Retinoic Acid, 1,25(OH)2 Vitamin D3, and Granulocyte-Macrophage Colony-Stimulating Factor. Blood 1997. [DOI: 10.1182/blood.v90.11.4578.4578_4578_4587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The relationship between differentiation of human myeloid cells and apoptosis remains unclear. Recent studies have shown that terminal differentiation need not necessarily lead to the apoptotic demise of myeloid cells, while other studies have shown that induction of differentiation is associated with increased resistance to apoptosis-inducing agents, such as chemotherapy and γ-irradiation. Such results are pertinent to the treatment of acute myeloid leukemia (AML) and myelodysplastic syndrome, where differentiating agents and hemopoietic growth factors are being combined with chemotherapy to enhance response and limit toxicity. To elucidate the factors governing apoptosis in human AML blasts, we have studied the cytotoxic effect of idarubicin on HL60, U937 and KG1 cells, after incubation with all-trans retinoic acid (ATRA), 1,25(OH)2 D3, and granulocyte-macrophage colony-stimulating factor (GM-CSF ). We show that prior incubation of human myeloid leukemic cells with ATRA or 1,25(OH)2 D3 induced resistance to idarubicin-induced apoptosis, which was modulated by coincubation with GM-CSF. The altered chemosensitivity of cells depended on the degree of G0/G1 cell-cycle arrest induced by incubation with ATRA, 1,25(OH)2 D3, and GM-CSF and was independent of differentiation status or Bcl-2 oncoprotein expression. These findings suggest that cell-cycle arrest in human leukemic cells can be induced by exogenous agents and may promote drug resistance. Determining the mechanisms by which cell-cycle arrest is induced may permit understanding of the processes by which the cells escape cytotoxic drug-mediated apoptosis.
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Schmetzer HM, Rapp L, Wilmanns W, Gerhartz HH. Effect of GM-CSF, 1, 25-Dihydroxycholecalciferol (Vit.D) and All-Trans-Retinoic Acid (ATRA) on the Proliferation and Differentiation of MDS-Bone Marrow (BM)-Cells In Vitro. Hematology 1997; 2:11-9. [PMID: 27406722 DOI: 10.1080/10245332.1997.11746315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogenous group of stem cell disorders characterized by an impaired differentiation of the pluripotent stem cell resulting in dysplastic changes of all three hemopoietic lineages. We studied the effect of vitamin D (Vit.D) or all-trans retinoic acid (ATRA; 10(-6) and 10(-8)M) in combination with GM-CSF on the proliferation and differentiation of mononuclear bone marrow-cells (MNC) of 48 MDS-patients as compared to 9 normal bone marrow (BM)-controls in a special colony assay: 30,000 MNC were cultured in agar plugs for 7 days (d) and the resulting colonies immunophenotyped in situ by a panel of monoclonal antibodies. In 14 of 48 cultured MDS-BM-samples hemopoietic clones could be grown which expressed myelomonocytic antigens (CD14 (21%*), CD15 (35%*)) as well as blast antigens (CD20 (9%*), CD34 (10%*), Glycophorin A (Glyco A, 18%*)) whereas all normal BM-colonies were negative for blast markers. Vit.D or ATRA in combination with GM-CSF could not induce an (immunologically measurable) increased differentiation (5 higher percentage of differentiated clones) as compared to GM-CSF alone. We conclude that Vit.D and ATRA have no sufficient differentiation effect on MDS-cells. Our colony assay in combination with immunophenotyping enables an in vitro measurement of differentiation and proliferation in MDS. We suggest the use of this technique to measure effects of therapy in the course of the disease.
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Affiliation(s)
- H M Schmetzer
- a Med. Dept. III, Klinikum Groβhadern , Marchioninistr. 15, 81366 Munich , Germany
| | - L Rapp
- a Med. Dept. III, Klinikum Groβhadern , Marchioninistr. 15, 81366 Munich , Germany
| | - W Wilmanns
- a Med. Dept. III, Klinikum Groβhadern , Marchioninistr. 15, 81366 Munich , Germany
| | - H H Gerhartz
- b Med. Dept., Klinikum Kalkweg , Zu den Rehwiesen 9, 47055 Duisburg , Germany
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22
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Abstract
"Differentiation, Differentiation/Gene Therapy and Cancer" is intended to suggest that an understanding of the cell and molecular biology of cell differentiation should advance the development of new cancer therapies. This article, therefore, reviews four general topics and their relationship to each other: (1) the multistep process of cell differentiation in nontransformed and transformed cells, (2) the use of drugs that induce differentiation in vitro as potential clinical differentiation therapy agents for cancer, (3) the evolving emphasis on gene therapy as a new cancer therapy modality, and (4) the concept of differentiation/gene therapy.
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Affiliation(s)
- R E Scott
- Department of Pathology, University of Tennessee Medical Center, Memphis 38163, USA
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23
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Ferrero D, Bruno B, Pregno P, Stefani S, Larizza E, Ciravegna G, Luraschi A, Vietti-Ramus G, Schinco P, Bazzan M, Gallo E, Pileri A. Combined differentiating therapy for myelodysplastic syndromes: a phase II study. Leuk Res 1996; 20:867-76. [PMID: 8960111 DOI: 10.1016/0145-2126(95)00156-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
An in vitro synergism between different inducers of AML cell differentiation has been previously observed. Therefore, we treated 53 myelodysplastic (MDS) patients with a low dose combination of cis-retinoic acid (cRA, 20-40 mg/day) and 1,25 alpha (OH)2 cholecalciferol [(OH)2D3, 1-1.5 micrograms/day] +/- intermittent 6-thioguanine (30 mg/m2/day). The latter was reserved for patients with bone marrow (BM) blast excess (> or = 5%). The treatment was well tolerated, without major toxicity. Among 25 patients with BM blasts less than 5%, we observed one complete, eight partial and four minor responses (response rate 52%) with a median response duration of 8 months (2 +/- 24). Median survival, which did not correlate with response, is projected at 76 months. Thirty-one patients with BM blast excess (> or = 5%), including three of the previous group who progressed to refractory anemia with excess of blasts (RAEB), were treated with the three-drug protocol. One complete, 12 partial and six minor responses were obtained (response rate 61%) with a median response duration of 6 months (2-29+). A significant difference in survival (P < 0.005) was observed between the 19 responders (median 25 months) and the 12 non-responders (median 9 months). A reduction in the transfusion need was observed in 41% of the transfusion-dependent patients with blast excess and in 53% of those without blast excess. Therefore, combined differentiating therapy seems more effective than previously reported single agent treatments and should be considered for a larger randomized study to assess its actual impact on survival of MDS patients.
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Affiliation(s)
- D Ferrero
- Dipartimento di Medicina ed Oncologia Sperimentale, Ospedale Molinette, Italy
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24
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San Miguel JF, Sanz GF, Vallespí T, del Cañizo MC, Sanz MA. Myelodysplastic syndromes. Crit Rev Oncol Hematol 1996; 23:57-93. [PMID: 8817082 DOI: 10.1016/1040-8428(96)00197-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- J F San Miguel
- Hematology Service, Hospital Clínico Universitario of Salamanca, Spain
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25
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Economopoulos T, Papageorgiou E, Stathakis N, Constantinidou M, Parharidou A, Kostourou A, Dervenoulas J, Raptis S. Treatment of high risk myelodysplastic syndromes with idarubicin and cytosine arabinoside supported by granulocyte-macrophage colony-stimulating factor. (GM-CSF). Leuk Res 1996; 20:385-90. [PMID: 8683977 DOI: 10.1016/0145-2126(95)00169-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In this prospective study, patients with "high risk' primary MDS, namely RAEB or RAEBt, were treated with combination chemotherapy (CT) supported by GM-CSF. The induction CT consisted of idarubicin 6 mg/m2 days 1-3 and cytosine-arabinoside 200 mg/m2 in 12 h infusion, days 1-5. The GM-CSF 3 micrograms/kg s.c. was given on day 6 until the neutrophil count was 1 x 10(9)/l. Postremission CT consisted of two similar courses. Patients not in remission after two courses of CT were considered as treatment failures. Twenty-two patients with a median age of 64 years, range 50-79 years (11 RAEB and 11 RAEBt) were evaluable. Twelve out of 22 patients (54.5%) achieved complete remission (CR) and four, partial remission. Six patients were resistant to treatment; there were two toxic deaths; seven patients achieved CR after the first course and five after two courses. The median time of neutrophil recovery to 1 x 10(9)/l was day 15 (range 3-22) after the first course of treatment and day 14 (range 4-21) after the second. Thirteen out of 22 patients developed febrile episodes after the first course of treatment and nine after the second. The median duration of CR was 12 months. The median survival for CR patients was 24 months, for non-CR patients, 12 months; while survival for the whole population was 18 months. In conclusion, the results of this study indicate that the administration of moderately intensive CT supported by GM-CSF in "poor risk' MDS gives promising results; the response rate is high for this disease, while the incidence of toxic death is low. GM-CSF appears to accelerate neutrophil recovery and probably reduces the incidence of infection.
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Affiliation(s)
- T Economopoulos
- Second Department of Internal Medicine, Propaedeutic, Athens University, Evangelismos Hospital, Greece
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26
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KERKHOF P, STEIJLEN P, RAYMAKERS R. Acrodermatitis continua of Hallopeau in a patient with myelodysplastic syndrome. Br J Dermatol 1996. [DOI: 10.1111/j.1365-2133.1996.tb06985.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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27
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Abstract
Myelodysplastic syndrome (MDS) comprises a group of heterogeneous clonal bone marrow disorders leading to peripheral cytopenia(s) and hypercellular marrow in the majority of the patients. The morphology of the cell lines is characterized by dysplastic features in some or all cell lines. The FAB classification has divided MDS in five subgroups, namely (1) RA (refractory anemia); (2) RARS (refractory anemia with ring sideroblasts); (3) CMML (chronic myelomonocytic leukemia); (4) RAEB (refractory anemia with excess blasts); and (5) RAEB-T (refractory anemia with excess blasts in transformation). Myelodysplastic syndrome remains primarily a disease of the elderly. With a reported median age of 74.4 years, patients have a chronic relentless course with complication of cytopenias, and a significant number of MDS patients, especially from the RAEB and RAEB-T categories, end up in acute myeloid leukemic transformation. Cytogenetic abnormalities are present in 40-58% of the cases and can provide not only help in diagnosis, but also understanding regarding the clinical course and prognostic aspect. Management of MDS is quite pragmatic and at this stage far from satisfactory. Various modalities have included use of differentiating agents, aggressive chemotherapy, bone marrow transplant and, more recently, significant interest has been generated in the use of hematopoietic growth factors. Differentiating agent trials have been unrewarding so far; chemotherapy trials have resulted in less benefit and more early toxic deaths, especially in the elderly MDS patients where the disease predominates. Bone marrow transplant appears suitable for some patients who are at a younger age. Salvation from this disease is being searched in the proper usage of hematopoietic growth factors and cytokines. There has been concern, however, that usage of growth factors has led to early and enhanced transformation of these patients to frank acute leukemic states. This concept appears to be somewhat refuted by newer controlled trials with GM-CSF and G-CSF, emphasizing that the acute leukemic transformation is the natural course of the disease and is not hastened by growth factor use. Preliminary studies are also suggesting that a combination of growth factors, especially G-CSF and erythropoietin as compared to chemotherapies, could be more beneficial in prolonging the survival of MDS patients who have progressed to the acute leukemic phase. More studies are needed for the understanding of the pathogenetic mechanism(s) in order to facilitate a more suitable and appropriate management strategy for MDS.
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Affiliation(s)
- H I Saba
- Leukemia and Lymphoma Center, Division of Medical Oncology and Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612-9497, USA
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28
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Schultz AB, Geller RB, Hillyer CD. The role of bone marrow transplantation in the treatment of myelodysplastic syndromes. JOURNAL OF HEMATOTHERAPY 1995; 4:323-34. [PMID: 7489147 DOI: 10.1089/scd.1.1995.4.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- A B Schultz
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
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29
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Porter SR, Scully C. Gingival and oral mucosal ulceration associated with the myelodysplastic syndrome. EUROPEAN JOURNAL OF CANCER. PART B, ORAL ONCOLOGY 1994; 30B:346-50. [PMID: 7703805 DOI: 10.1016/0964-1955(94)90037-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- S R Porter
- Eastman Dental Institute for Oral and Dental Healthcare Sciences, London, U.K
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30
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Abstract
Clinical trials of differentiation therapy on MDS with retinoic acid are reviewed, and it is discussed whether the differentiation therapy with this drug has scientific relevance for MDS. 13-Cis retinoic acid (13-CRA) may have moderate effect on 20-30% of patients with MDS. In general, the responses are short and toxicity is significant. Since the responses may take at least three weeks and sometimes several months to occur, only patients with a relatively indolent clinical course of MDS would be suitable candidates for this therapy. However, a placebo-controlled prospective randomized study could not confirm the effectiveness of this retinoic acid on MDS. There are only a few clinical trials of all-trans retinoic acid (ATRA) for treatment of MDS. ATRA may have a moderate effect on MDS, but no such a remarkable effect shown on acute promyelocytic leukemia. A placebo-controlled randomized study as having been conducted in 13-CRA is definitely needed to confirm the effectiveness of ATRA on MDS.
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Affiliation(s)
- R Ohno
- Department of Medicine III, Hamamatsu University School of Medicine, Japan
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31
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Abstract
Allogeneic BMT is the treatment of choice for patients with MDS or sAML, offering a good chance of long-term disease-free survival if the transplant is performed in an early stage of disease or if the patient receives the transplant in complete remission after polychemotherapy. The transplant is limited to a minority of relatively young patients (aged below 55 years) with an HLA-identical sibling. Allogeneic BMT may also be considered when a closely- or fully-matched unrelated donor has been identified for a young and fit patient. All patients, including those without an excess of blasts, should be conditioned with bone marrow ablative therapy rather than an immune suppressive regime, such as cyclophosphamide alone. For the majority of patients there is no standard therapy other than appropriate supportive care. Relatively young patients below the age of 60 years with poor risk features can be considered for treatment with combination chemotherapy. Maintaining remission after remission-induction chemotherapy is a difficult issue. Patients not eligible for allogeneic BMT could be treated with post-remission chemotherapy or autologous BMT in the framework of prospective studies. Older patients can be considered for treatment with haematopoietic growth factors alone or in combination with differentiating agents such as low-dose Ara-C. This treatment should be delivered within the context of carefully designed and conducted trials.
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Affiliation(s)
- T De Witte
- Department of Internal Medicine, University Hospital St. Radboud, Nijmegen, The Netherlands
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32
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Abstract
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.
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Affiliation(s)
- D L McCarley
- Department of Medicine, University of Florida, Gainesville
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33
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Treatment of Therapy-Related Acute Myelogenous Leukemia and Myelodysplastic Syndromes. Hematol Oncol Clin North Am 1993. [DOI: 10.1016/s0889-8588(18)30253-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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34
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Kantarjian HM, Estey EH, Keating MJ. Treatment of Therapy-Related Leukemia and Myelodysplastic Syndrome. Hematol Oncol Clin North Am 1993. [DOI: 10.1016/s0889-8588(18)30259-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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35
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Abstract
Since initial studies identifying the important role of vitamin A and its derivatives (retinoids) in maintaining the integrity of epithelial tissues, these compounds have served as paradigms for experimental studies exploring the pharmacologic modification of carcinogenesis. Retinoids have clearly been shown to inhibit chemically induced mammary and urothelial carcinogenesis in experimental animals. Prohibitive toxicity of the parent compound, vitamin A, led to a systematic search for synthetic derivatives with an improved therapeutic index. More than 1500 such compounds have been synthesized, many retaining chemopreventive potential, but with less toxicity. Although several anecdotal reports confirming therapeutic benefits of cis-retinoic acid in patients with acute promyelocytic leukemia and myelodysplastic syndromes appeared in the late 1970s and early 1980s, the remarkable studies of Huang and his colleagues in China in 1988 reporting complete remissions in patients with this uncommon variety of acute myelogenous leukemia with the transisomer of retinoic acid (all-trans-retinoic acid) led to a resurgence of interest in the retinoids as differentiating agents for the prevention and therapy of cancer. Furthermore, molecular studies showing DNA rearrangements of the alpha nuclear receptor for retinoic acid located on chromosome 17 in patients with acute promyelocytic leukemia, a disease invariably associated with a translocation between chromosomes 15 and 17, provided a direct connection between an altered nuclear receptor and the development of a human malignancy. The retinoids also may have important beneficial effects in prevention of recurrent malignancies once the primary tumor has been treated, such as in squamous cell carcinoma of the head and neck. Because retinoids appear to be less effective in inducing differentiation in nonpromyelocytic leukemia cells, investigators have conducted a number of studies to exploit potential synergism between retinoids and other differentiating agents or biologic effectors. Differentiation therapy and chemoprevention are attractive alternative approaches to intensive cytotoxic chemotherapy. It is now clear that retinoids represent one class of compounds with which it may be possible to reverse the progression of malignant disease and prevent carcinogenesis.
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Affiliation(s)
- M S Tallman
- Division of Hematology-Oncology, Northwestern University Medical School, Chicago, IL 60611
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36
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Economopoulos T, Papageorgiou E, Stathakis N, Asprou N, Karmas P, Dervenoulas J, Bouronikou H, Chalevelakis G, Raptis S. Treatment of myelodysplastic syndromes with human granulocytic-macrophage colony stimulating factor (GM-CSF) or GM-CSF combined with low-dose cytosine arabinoside. Eur J Haematol 1992; 49:138-42. [PMID: 1446728 DOI: 10.1111/j.1600-0609.1992.tb00918.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In a phase II study, 21 patients with MDS (RAEB, RAEBt, CMML and RA and RAS with severe cytopenia) were randomized to be treated with 3 courses of GM-CSF (3 micrograms/kg/day s.c.) alone (11 patients) or in combination with AraC (20 mg/m2/d s.c.) (10 patients) for 14-d periods, interrupted by 14-d rest periods. Eight patients discontinued the treatment. In the GM-CSF group a marked increase in WBC and neutrophil counts during each course of treatment administration were seen in most patients. Platelet counts decreased in 14 of 24 courses of treatment in the GM-CSF plus AraC group but in none of the GM-CSF group. Although the changes in the circulating blood cells were transient and the counts tended to return to the pretreatment levels during the rest periods, some more durable effects were seen. In 3/6 patients of the GM-CSF group who completed the designed treatment, both WBC and neutrophils remained elevated above the pretreatment levels throughout the 3-month period of treatment, while in one of them thrombocytopenia improved considerably. In the GM-CSF plus AraC group, 4 out of the 7 patients who completed the treatment showed an improvement of neutropenia as well as anaemia. In these 4 patients the BM percentage of blasts was also decreased. In conclusion, the results of this study indicate that GM-CSF given intermittently improves leukopenia in some patients with MDS. In addition, the administration of GM-CSF seems to prevent granulocytopenia of concurrent AraC treatment and may be of benefit in the treatment of these diseases.
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Affiliation(s)
- T Economopoulos
- Second Department of Internal Medicine, Athens University, Greece
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37
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Hayani A, Mahoney DH, Taylor LD. Therapy-related myelodysplastic syndrome in children with medulloblastoma following MOPP chemotherapy. J Neurooncol 1992; 14:57-62. [PMID: 1469465 DOI: 10.1007/bf00170945] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Between 1978 and 1988, 20 children with medulloblastoma (MB) of the brain were treated postoperatively with MOPP (nitrogen mustard, vincristine, prednisone, and procarbazine). All but one received post-operative radiation prior to MOPP. Eight of 20 patients remained in continuous complete remission from MB, two of whom eventually developed myelodysplastic syndrome (MDS). Following resection of MB at age 12 months, one patient was treated with 24 courses of MOPP over 2 years without radiation therapy. She developed pancytopenia, and MDS was diagnosed 19 months after the completion of MOPP. Analysis of unstimulated bone marrow (BM) chromosomes showed structural abnormalities involving chromosomes 7, 10, 17, and 21. Eight months later, MDS evolved into acute myeloid leukemia. The second patient was diagnosed with MB at age 7 years and received postoperative craniospinal radiation followed by 12 courses of MOPP over one year. Five months after completion of MOPP, she developed MDS with monosomy 7 on chromosome analysis of bone marrow cells. Therapy-related MDS may be a complication of MOPP chemotherapy for MB in young children.
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Affiliation(s)
- A Hayani
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
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38
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39
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Noël P, Solberg LA. Myelodysplastic syndromes. Pathogenesis, diagnosis and treatment. Crit Rev Oncol Hematol 1992; 12:193-215. [PMID: 1379818 DOI: 10.1016/1040-8428(92)90054-t] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Our understanding of the biology of leukemia and myelodysplasia is still only partial. The diagnosis of myelodysplasia is often based on quantitative and qualitative findings in the peripheral blood and bone marrow. These findings are often shared by other disorders. There is a need for sensitive and inexpensive laboratory tests to determine clonality and karyotypic abnormalities in this disorder. Future classifications of these syndromes will need to be based on morphologic and biologic markers that are closely linked to disease progression, response to treatment, and survival. Our limited understanding of the pathogenesis of MDS decreases the specificity and effectiveness of our therapeutic interventions. Agents that are minimally toxic such as CRA, danazol, 1,25-dihydroxyvitamin D3, androgens, and pyridoxine are seldom useful. Antileukemic therapy and allogeneic bone marrow transplantation have a major role to play in patients younger than 45 years of age; in older patients these treatment modalities remain controversial because of their toxicity. Hematopoietic growth factors, used alone or in combination, may improve the quality of life and improve survival of patients with MDS. Growth factors may also decrease treatment-related mortality associated with chemotherapy and bone marrow transplantation and render these treatment modalities available for a higher percentage of patients. The development of more specific differentiating agents may permit hematopoietic differentiation while minimizing side effects.
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Affiliation(s)
- P Noël
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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40
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Besa EC. Myelodysplastic syndromes (refractory anemia). A perspective of the biologic, clinical, and therapeutic issues. Med Clin North Am 1992; 76:599-617. [PMID: 1578959 DOI: 10.1016/s0025-7125(16)30342-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- E C Besa
- Department of Medicine, Medical College of Pennsylvania, Philadelphia
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41
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Abstract
Aggressive chemotherapy of myelodysplastic syndromes is rarely feasible because these disorders predominantly occur in elderly patients who often have concurrent illnesses. Alternative treatment modalities must therefore be evaluated. This review summarizes the results that have been obtained with low-dose chemotherapy, especially with low-dose cytosine arabinoside (Ara-C). Overall response rates to treatment with low-dose Ara-C are about 40%, with some 20% of patients achieving a complete remission. Transition of MDS to AML does not reduce the probability of response. The therapeutic outcome cannot be reliably predicted by clinical or experimental parameters. Hematological toxicity is substantial, with approximately 10-25% treatment-related deaths. Duration of response is short and rarely exceeds one year. In terms of overall survival, low dose Ara-C does not appear to be superior to supportive care only. Other cytotoxic agents have not been studied in detail, but data available do not suggest an appreciable advantage over Ara-C. Before denying low-dose chemotherapy a helpful role in MDS, randomized studies should concentrate on those patients who can be expected to derive the greatest benefit. Because of their short survival, patients with RAEBt or those transformed to overt leukemia are such candidates.
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Affiliation(s)
- C Aul
- Department of Internal Medicine, Heinrich Heine University, Düsseldorf, Germany
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42
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Gerhartz HH, Marcus R, Delmer A, Zwierzina H, de Witte T, Jacobs A, Visiani G, Fiere D, Sonneveld P, Labar B. Treatment of myelodysplastic syndromes (MDS) and high leukaemic risk with low-dose cytosine arabinoside (LD-AraC) plus granulocyte-macrophage colony-stimulating factor (rh GM-CSF). The EORTC Leukaemia Group. Infection 1992; 20 Suppl 2:S116-23. [PMID: 1493935 DOI: 10.1007/bf01705030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Symptomatic patients with myelodysplastic syndromes (MDS) and 10-30% blasts in the bone marrow were treated with low-dose AraC (2 x 10 mg/m2 subcutaneously (sc) days 1-14) and GM-CSF (fully glycosylated, Sandoz/Schering-Plough, 2 x 150 micrograms protein/day sc) given either subsequently (days 15-21) or simultaneously (days 8-14 and one week rest). Evaluations were carried out after three courses (nine weeks); responding patients could be continued for two further cycles. Eighty-two patients with refractory anaemia and excess of blasts (RAEB), with (RAEBt) or without transformation, were evaluable: 45 RAEB and 37 RAEBt, mean age 64 years (range 17-80 years). A complete remission was achieved in 14 cases (17%), 11 had a good response (13%), and 12 a partial response (15%). Stable disease was found in 21 cases (26%). There were 12 cases of toxic death (15%), progression was noted in eight patients (10%), and death due to disease in three (4%). No difference existed between the two treatment arms with respect to response. Major adverse events during treatment were haemorrhage (25%), infections (23%), and fever with GM-CSF (21%). GM-CSF did not induce leukaemia nor contribute to haemorrhage induced by AraC, but gave rise to an overall response rate of 46% which is high and relatively durable as compared to other treatments in this disease.
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Affiliation(s)
- H H Gerhartz
- Medizinische Klinik III, Klinikum Grosshadern, München, Germany
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43
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De Rosa L, Montuoro A, De Laurenzi A. Therapy of 'high risk' myelodysplastic syndromes with an association of low-dose Ara-C, retinoic acid and 1,25-dihydroxyvitamin D3. Biomed Pharmacother 1992; 46:211-7. [PMID: 1467449 DOI: 10.1016/0753-3322(92)90084-k] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Forty-four patients with high risk primary myelodysplastic syndromes and an excess of marrow blasts were treated with a combination of low-dose Ara-C, retinoic acid and vitamin D3. Morphological subtypes were refractory anemia with excess of blasts (RAEB) in 16, RAEB in transformation (RAEB-T) in 20 and chronic myelomonocytic leukemia (CMML) in eight patients. The therapy was continued in responders until relapse or death. The results were compared to those of a matched control of 44 patients given a supportive therapy only. In the treated group the overall response rate was 50% (75% in RAEB, 50% in RAEB-T and 0% in CMML) and the survival was significantly better than in the control group (P < 0.025). Comparing separately each FAB subgroup gave statistical evidence that the treatment prolonged the survival in the RAEB-T subgroup only (P < 0.002). The median duration of response was 15 months and the survival in responders was statistically better than in non-responders (P < 0.0001). Myelosuppression has been the most important side effect, however, no death related to the treatment was observed. Our study suggests that patients with RAEB-T, who are not suitable candidates for aggressive chemotherapy, could benefit from our treatment schedule. The long duration of therapy seems to be of value for patients achieving a response in order to prolong the survival. The toxicity is acceptable and the therapy can be given on an outpatient basis.
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Affiliation(s)
- L De Rosa
- Department of Haematology, St Camillo Hospital, Rome, Italy
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44
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Abstract
Myelodysplastic syndromes (MDS) include hemopoietic cytopenias of different origin, which are usually refractory to treatment. Therefore MDS patients should generally be treated conservatively. Transfusions of packed red cells (given in a strict regimen to minimize the risk for secondary hemochromatosis) may be sufficient to maintain a good quality of life. Indications for cytotoxic treatment include signs of progression of the disease. In patients with symptomatic cytopenias low-dose cytarabine (ara-C) should be tried. It is essential then to monitor each patient individually and to avoid fixed treatment schedules. Standard (high-dose) chemotherapy in MDS, is associated with a high mortality and a low response rate, and should be considered only in younger patients with advanced MDS. Allogeneic bone marrow transplantation (BMT) may be offered to younger MDS patients, when a suitable donor is available. Treatment with differentiation inducers has not met with expectations and should not be used outside clinical trials at the present. The use of recombinant hemopoietic growth factors (GF) seems promising. GF, like GM-CSF, G-CSF, IL-3, and erythropoietin, can be used either alone or in combinations, to support failing peripheral blood values, and decrease the risk for lethal complications. GF can also be given together with chemotherapy, in an effort to make the leukemic clonogenic cells more susceptible to cytotoxic drugs. Other treatments for MDS include: IFN-alpha and etoposide, with responses primarily in chronic myelomonocytic leukemia; hem arginate, whose role is still not clear; and corticosteroids, but only in carefully selected cases.
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Affiliation(s)
- R Hast
- Department of Medicine, Danderyd Hospital, Sweden
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45
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Abstract
The myelodysplastic syndromes are composed of a group of clonal hematologic neoplasms, the course of which is complicated by ineffective hematopoiesis or leukemic transformation (or both). Therapeutic results may have been misleading in the past. Most patients have been managed with supportive measures, such as transfusions of erythrocytes, administration of antibiotics, and transfusions of platelets during active bleeding episodes. These supportive measures have prolonged and improved the quality of life of patients with myelodysplastic syndromes. Vitamin supplementation (folate, vitamin B12, and pyridoxine) has seldom been rewarding. Differentiation agents such as cis-retinoic acid and 1,25-dihydroxyvitamin D3 have been of benefit in only a limited number of patients. Androgens have not been useful, although danazol, which is an attenuated androgen, has been effective in a subset of patients with the presence of cell-bound platelet antibodies. Low-dose cytarabine, which has been studied extensively because of its differentiating activity in vitro, is associated with a generally low rate of complete remission and substantial toxicity. Antileukemic therapy is generally useful in young patients with rapidly progressive disease. Several hematopoietic growth factors are currently being evaluated in clinical trials; their use in combination or in conjunction with chemotherapy may be opening new horizons for these patients. With improvements in the prevention and treatment of graft-versus-host disease, allogeneic transplantation is a viable option for patients younger than 55 years of age who have severe cytopenias.
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Affiliation(s)
- P Noël
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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46
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Bruetman DG, Harris JE, Anderson KM. Differentiating agents in malignant disease. MEDICAL AND PEDIATRIC ONCOLOGY 1991; 19:71-83. [PMID: 2011099 DOI: 10.1002/mpo.2950190202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- D G Bruetman
- Department of Internal Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
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47
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Chomienne C. Low-dose chemotherapy and differentiating agents. BAILLIERE'S CLINICAL HAEMATOLOGY 1991; 4:47-68. [PMID: 2039861 DOI: 10.1016/s0950-3536(05)80284-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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48
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Besa EC, Abrahm JL, Bartholomew MJ, Hyzinski M, Nowell PC. Treatment with 13-cis-retinoic acid in transfusion-dependent patients with myelodysplastic syndrome and decreased toxicity with addition of alpha-tocopherol. Am J Med 1990; 89:739-47. [PMID: 2252043 DOI: 10.1016/0002-9343(90)90215-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of this study was to determine the response and tolerance to long-term treatment using 13-cis-retinoic acid (13-CRA) in transfusion-dependent patients with the myelodysplastic syndrome (MDS) and to determine the effects of therapy on the natural history of the disease. PATIENTS AND METHODS Sixty-six consecutive patients with transfusion-dependent MDS seen in a medical school hospital and outpatient clinic from 1981 to 1988 were studied. The first 21 patients were treated with 13-CRA alone and the next 45 patients with 13-CRA plus alpha-tocopherol (AT). We compared responses to and toxicities of therapy, rates of transformation, and survival from onset of therapy in 20 evaluable patients treated with 13-CRA alone and 43 patients treated with 13-CRA plus AT. RESULTS Four patients responded (20%) at 4 to 8 months to 13-CRA alone, but this response was associated with considerable toxicity and resulted in cessation of therapy. Among the responders, only one continued therapy and is currently in remission, whereas three discontinued therapy because of toxicity and have had a relapse and died. In the 13-CRA plus AT group, we observed one prolonged complete remission and 10 partial remissions (26%), with a decrease in skin and constitutional toxicities by the addition of AT, which enabled the continuation of 13-CRA indefinitely. Although the response rates were similar in both groups, fewer patients (28% versus 60%) experienced progression to acute leukemia in the 13-CRA plus AT group than in the group receiving 13-CRA alone, who terminated treatment (p = 0.018). A twofold increase in median survival of the RA/RARS and RAEB/CMML patient groups was observed with 13-CRA plus AT but was not significant (p greater than 0.5). CONCLUSION This study shows a 20% to 26% response rate to 13-CRA and suggests that 13-CRA, if given continuously, decreases the rate of progression or transformation to acute leukemia in patients with MDS. The addition of AT ameliorates the toxicity of 13-CRA and allows for long-term treatment with 13-CRA. Since the standard treatment for MDS is currently unsatisfactory, these findings indicate that longer treatment with a non-marrow-suppressive agent such as 13-CRA is important, and further trials to determine the role of 13-CRA plus AT in combination with new recombinant growth factors in the therapy for transfusion-dependent MDS should offer a new approach to a disease common in the elderly population.
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Affiliation(s)
- E C Besa
- Department of Medicine, Medical College of Pennsylvania, Philadelphia 19129
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Hellström E, Robèrt KH, Samuelsson J, Lindemalm C, Grimfors G, Kimby E, Oberg G, Winqvist I, Billström R, Carneskog J. Treatment of myelodysplastic syndromes with retinoic acid and 1 alpha-hydroxy-vitamin D3 in combination with low-dose ara-C is not superior to ara-C alone. Results from a randomized study. The Scandinavian Myelodysplasia Group (SMG). Eur J Haematol 1990; 45:255-61. [PMID: 2261951 DOI: 10.1111/j.1600-0609.1990.tb00470.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
63 evaluable patients with myelodysplastic syndromes (MDS) and 15 with acute myelogenous leukemia (AML) were randomized between low-dose ara-C (arm A) and low dose ara-C in combination with 13-cis-retinoic acid (13-CRA) and 1 alpha-hydroxy-vitamin D3 (1 alpha D3) (arm B). 69 patients were evaluable and 18 (26.1%) responded to therapy. The addition of 13-CRA and 1 alpha D3 had no positive influence on survival of the patients, remission rates or duration of remissions. 12/27 patients in arm A and 6/29 patients in arm B progressed from MDS to AML during the course of the study (p = 0.0527). Arm B gave significantly more side-effects than arm A (p = 0.005). Therapeutic effects of 13-CRA and 1 alpha D3 on MDS is not supported by this study. However, an inhibiting effect on AML development in some MDS subgroups cannot be excluded.
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Affiliation(s)
- E Hellström
- Department of Medicine, Huddinge Hospital, Stockholm, Sweden
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De Witte T, Muus P, De Pauw B, Haanen C. Intensive antileukemic treatment of patients younger than 65 years with myelodysplastic syndromes and secondary acute myelogenous leukemia. Cancer 1990; 66:831-7. [PMID: 2386911 DOI: 10.1002/1097-0142(19900901)66:5<831::aid-cncr2820660503>3.0.co;2-e] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Intensive antileukemic treatment was evaluated in 22 patients with secondary acute myelogenous leukemia (sAML) and 14 patients with myelodysplastic syndrome (MDS). Results of combination remission-induction chemotherapy were compared with 126 patients contemporarily treated for primary AML. The duration of hypoplasia, induced by remission induction chemotherapy, tended to be longer in the sAML and MDS patients when compared to de novo AML, but reached significance only for the duration of thrombocytopenia: 26 days versus 18 days (P less than 0.01). The number of hypoplastic deaths during remission-induction chemotherapy of patients with sAML and MDS was low. Four of the 36 patients treated for sAML or MDS died during hypoplastic phases induced by remission-induction chemotherapy. The complete remission (CR) rates were similar in primary AML (67%), sAML (62%), and MDS (64%). The CR rates of patients younger than 45 years were 75% for de novo AML, 75% for sAML, and 71% for MDS. Remission rates in patients older than 45 years were identical in the three subgroups but significantly (P less than 0.005) inferior to those obtained in younger patients: 56%, 50%, and 57%, in de novo AML, sAML, and MDS, respectively. The remission duration without bone marrow transplant (BMT) was significantly shorter (P less than 0.01) in MDS and sAML when compared with primary AML. Long-lasting CR in MDS and sAML was only obtained in three of the six patients treated with allogeneic BMT. Intensive antileukemic therapy could be considered in young patients with MDS and life-threatening cytopenias or patients with sAML.
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Affiliation(s)
- T De Witte
- Department of Internal Medicine, University Hospital Nijmegen, The Netherlands
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