Enhanced growth of clonogenic cells from acute myeloblastic leukaemia by erythropoietin

Brain and cancer: the protective role of erythropoietin

Erythropoietin (Epo) is a pleiotropic agent, that is to say, it can act on several cell types in different ways. An independent system Epo/Epo receptor (EpoR) was detected in brain, leading to the hypothesis that this hormone could be involved in cerebral functions. Epo/EpoR expression changes during ontogenesis, thus indicating the importance of this system in neurodevelopment. Moreover, the hypoxia-induced production of Epo in the adult brain suggests that it could exert a neurotrophic and neuroprotective effect in case of brain injury. Epo could also influence neurotransmission, inducing neurotransmitters (NT) release. Epo therapy in anemic cancer patients is still a controversial issue, because of its possible action as a growth and an angiogenic factor. In our speculative hypothesis Epo could be involved in a "two steps process" that, after a neovascularization phase, leads to its down regulation. Moreover, Epo-activated signaling pathways could be modulated as possible targets to interfere in neoplastic cells cycle. In conclusion, treatment with rHuEpo could change therapeutical perspectives in different pathological conditions, such as central nervous system (CNS) diseases, but further studies are needed to clarify its physiopathological activities in different clinical fields.

Erythropoietin is effective in improving the anemia induced by imatinib mesylate therapy in patients with chronic myeloid leukemia in chronic phase

BACKGROUND

Myelosuppression occurs in up to 50% of patients with chronic myeloid leukemia (CML) who are treated with imatinib and > or = Grade 3 myelosuppression is reported in approximately 10% of patients.

METHODS

The authors investigated the prognostic significance of anemia occurring during therapy with imatinib in patients with CML in chronic phase.

RESULTS

Of 338 patients treated with imatinib (150 patients after interferon failure and 188 patients with newly diagnosed CML), 230 (68%) developed anemia. In a multivariate analysis, factors associated with an increased probability of developing anemia were a starting hemoglobin level < 12 g/dL, age > or = 60 years, female gender, higher imatinib dose, and intermediate or high Sokal risk group. Of these 230 patients, 102 patients received treatment with 40,000 U of recombinant human erythropoietin administered subcutaneously once weekly. An increase in the hemoglobin level of > or = 2 g/dL was achieved in 69 patients (68%) and 22 patients (22%) had an increase of 1-1.9 g/dL. Patients who developed anemia had a trend toward a lower probability of complete cytogenetic remission compared with patients without anemia (68% vs. 77%; P = 0.14), as well as a trend for inferior survival. Patients with anemia and other manifestations of myelosuppression were found to have a significantly worse outcome than those with isolated anemia.

CONCLUSIONS

The authors concluded that erythropoietin is safe and effective in patients in chronic-phase CML who develop anemia with imatinib therapy.

Leukemic cells and the cytokine patchwork

BACKGROUND

In leukemia, the clonal population is characterized by a hierarchical organization. Although the majority of the leukemic population is generated after post-determinic divisions, a subset of cells retain undifferentiated "blast" morphology. In addition, leukemic cells often have numerical or structural chromosomal abnormalities, aberrant gene expression patterns, and abnormal cell surface marker profiles. Despite these differences when compared to normal bone marrow and blood cells, leukemic cell survival and proliferation, just like that of normal progenitor cells, is influenced by hematopoietic growth factors. A major issue is whether differential regulation of normal and leukemic hematopoietic cells by cytokines can be exploited in antileukemic treatment or, in contrast, whether in vivo cytokine therapy may even be harmful to the patients.

PROCEDURE

Here we review the results of recent experimental and clinical observations that investigated the influence of cytokines on leukemic cell growth and differentiation in vitro and in vivo.

RESULTS

The majority of studies indicate that hematopoietic growth factors are involved in the regulation of proliferation and terminal differentiation of leukemic blast cells. Genetic aberrations involving cytokines or their receptors may contribute to leukemogenesis. Abundant interactions, cross-lineage stimulation, and aberrant response patterns seem to transform the complex cytokine network regulation of normal hematopoiesis into an even more interlaced "patchwork" that controls leukemic hematopoiesis.

CONCLUSIONS

Since hematopoietic growth factors are present in high serum concentrations in patients with acute leukemia and myelodysplastic syndromes, consequences of possible interactions should be kept in mind even when well-defined human recombinant factors in single application are to be involved in antileukemic protocols.

Erythropoietin-dependent transformation of myelodysplastic syndrome to acute monoblastic leukemia

Acute monoblastic leukemia (acute myeloid leukemia [AML], French-American-British type M5a) with leukemia cutis developed in a patient 6 weeks after the initiation of erythropoietin (EPO) therapy for refractory anemia with ringed sideroblasts. AML disappeared from both marrow and skin after the discontinuation of EPO. Multiparameter flow cytometric analysis of bone marrow cells demonstrated coexpression of the EPO receptor with CD45 and CD13 on the surface of blasts. The incubation of marrow cells with EPO, compared to without, resulted in 1.3- and 1.6-fold increases, respectively, in tritiated thymidine incorporation and bromodeoxyuridine incorporation into CD13(+) cells. Clinical and laboratory findings were consistent with the EPO-dependent transformation of myelodysplastic syndrome (MDS) to AML. It is concluded that leukemic transformation in patients with MDS treated with EPO may be EPO-dependent and that management should consist of the discontinuation of EPO followed by observation, if clinically feasible.

Quantitative expression of erythropoietin receptor (EPO-R) on acute leukaemia cells: relationships between the amount of EPO-R and CD phenotypes, in vitro proliferative response, the amount of other cytokine receptors and clinical prognosis. Japan Adult Leukaemia Study Group

Expression of erythropoietin (EPO) receptor (EPO-R) was analysed in leukaemia cells from 150 patients with acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL). EPO-R was expressed in 81 (60%) out of 136 AML, and in vitro treatment with EPO led to proliferation of leukaemia cells in 13 (16%) out of 81 AML examined. EPO-R expression and in vitro response to EPO were observed in all subtypes of AML according to the French-American-British (FAB) classification. All eight patients with FAB-M6 expressed EPO-R, and one out of four showed an in vitro response to EPO. Although there was no significant correlation (r = 0.2522) between the amount of EPO-R and the in vitro response to EPO, all of the AML patients who showed in vitro response expressed EPO-R. Stem cell factor significantly enhanced both EPO-R expression and in vitro response to EPO. Interleukin-3 tended to increase in vitro response to EPO. CD phenotypes, the amount of granulocyte colony-stimulating factor (G-CSF) receptors and the amount of TPO receptors had no significant relationship with the amount of EPO-R. Patients with both EPO-R expression and in vitro response to EPO had shorter duration of complete remission than those without EPO-R (P = 0.0053). EPO-R was expressed in four (29%) out of 14 ALL, and none out of five ALL showed in vitro response to EPO.

Inhibition of P-Glycoprotein and Recovery of Drug Sensitivity of Human Acute Leukemic Blast Cells by Multidrug Resistance Gene (mdr1) Antisense Oligonucleotides

To overcome the problem of multidrug resistance, we investigated the effectiveness of phosphrothioate antisense oligonucleotides (MDR1-AS) in suppressing multidrug resistance gene (mdr1) expression in drug-resistant acute myelogenous leukemia (AML) blast cells and the K562 adriamycin-resistant cell line K562/ADM. The percentage of cells with the mdr1 gene product P-glycoprotein (P-gp) was decreased from 100% to 26% by 20 μmol/L MDR1-AS in the K562/ADM cells, and from 48.1% to 10.2% by 2.5 μmol/L MDR1-AS in the AML blast cells. Western blot analysis also showed a decrease in the amount of P-gp in the MDR1-AS–treated K562/ADM cells. This effect was specific to MDR1-AS, and not observed with sense or random control oligonucleotides. The expression of mdr1 mRNA in K562/ADM and AML blast cells treated with MDR1-AS was decreased compared with the random control. Intracellular rhodamine retention and [3H]daunorubicin also increased after antisense treatment. Chemosensitivity to daunorubicin increased in MDR1-AS–treated blast cells up to 5.9-fold in the K562/ADM cells and 3.0- to 6.4-fold in the AML blast cells. The expression of mdr1mRNA derived from colony cells decreased in the MDR1-AS–treated groups. No inhibitory effect of the oligonucleotides on normal bone marrow progenitors was observed. These findings suggest that MDR1-AS is useful to overcome multidrug resistance in the treatment of leukemia.

Inhibition of P-Glycoprotein and Recovery of Drug Sensitivity of Human Acute Leukemic Blast Cells by Multidrug Resistance Gene (mdr1) Antisense Oligonucleotides

To overcome the problem of multidrug resistance, we investigated the effectiveness of phosphrothioate antisense oligonucleotides (MDR1-AS) in suppressing multidrug resistance gene (mdr1) expression in drug-resistant acute myelogenous leukemia (AML) blast cells and the K562 adriamycin-resistant cell line K562/ADM. The percentage of cells with the mdr1 gene product P-glycoprotein (P-gp) was decreased from 100% to 26% by 20 μmol/L MDR1-AS in the K562/ADM cells, and from 48.1% to 10.2% by 2.5 μmol/L MDR1-AS in the AML blast cells. Western blot analysis also showed a decrease in the amount of P-gp in the MDR1-AS–treated K562/ADM cells. This effect was specific to MDR1-AS, and not observed with sense or random control oligonucleotides. The expression of mdr1 mRNA in K562/ADM and AML blast cells treated with MDR1-AS was decreased compared with the random control. Intracellular rhodamine retention and [3H]daunorubicin also increased after antisense treatment. Chemosensitivity to daunorubicin increased in MDR1-AS–treated blast cells up to 5.9-fold in the K562/ADM cells and 3.0- to 6.4-fold in the AML blast cells. The expression of mdr1mRNA derived from colony cells decreased in the MDR1-AS–treated groups. No inhibitory effect of the oligonucleotides on normal bone marrow progenitors was observed. These findings suggest that MDR1-AS is useful to overcome multidrug resistance in the treatment of leukemia.

Iron status of children with short stature during accelerated growth due to growth hormone treatment

We determined the influence of human growth hormone (hGH) treatment on blood soluble transferrin receptor (sTfR) in 35 children with short stature. Whereas the serum concentration of ferritin decreased from 29.6 micrograms/l to 19.7 micrograms/l, and that of transferrin increased from 2.9 g/l to 3.2 g/l during 6 months (p < 0.001), only a minimum rise in the sTfR concentration was observed (7.12 +/- 0.20 mg/l vs 7.51 +/- 0.19 mg/l, p = 0.025). The prevalence of anaemia or microcytosis did not increase. Most of the changes in serum ferritin and transferrin concentrations occurred during the first week. The study demonstrates that rapid body growth per se does not affect the sTfR concentration, but it may affect the serum transferrin and ferritin concentrations. Alternatively, GH may have a specific effect on serum ferritin and transferrin concentrations.

Hematopoietic Growth Factors and Blast Progenitors in Acute Leukemia

Leukemic cells are maintained by a minor subpopulation of cells called leukemic stem cells (LSC) with proliferative and self-renewal capacity, both of which are detected with leukemic colony assay, with the latter being an important prognositic factor. Drug sensitivity tests employing leukemic colony assay revealed the effects of cytotoxic drugs on LSC to be diverse and that cytosine arabinoside predominantly suppresses self-renewal, which probably accounts for its effectiveness in AML therapy. Hematopoietic growth factors (HGFs) regulate the growth of LSC and various in vitro effects of HGFs on acute leukemia cells have been reported. These effects appear to reflect physiological functions of each HGF and can be categorized into groups according to their distinct functions. Endogenously produced HGFs stimulate LSC in an autocrine or a paracrine fashion, resulting in autonomous growth of these cells, which also correlates with the patients' prognosis. HGFs can enhance the cytotoxicity of anti-leukemia drugs in vitro, possibly mainly through recruitment of LSC from the dormant state into active cell cycling. HGFs have been clinically tested in leukemia therapy. Although recovery of blood leukocyte counts can consistently be accelerated with HGF treatment, the effectiveness of HGFs in sensitizing leukemia cells to chemotherapeutic agents and/or improving patient prognosis has not been clearly demonstrated. Different strategies using HGFs and related molecules must be tested in future leukemia therapy.

5q- syndrome in a child

A boy aged 8 years, 10 months presented with refractory anemia. Bone marrow investigation revealed monolobular megakaryocytes. Cytogenetic analysis showed a clonal abnormality: 46, XY, del(5)(q14q32). This is the youngest individual ever reported with this disorder. A year after diagnosis, while on treatment with human recombinant erythropoietin, the bone marrow showed an excess of blasts. No bone marrow donor could be found. Transformation to acute myelomonocytic leukemia occurred 3 months later. In spite of intensive chemotherapy, the child died of progressive disease with massive splenomegaly and jaundice. The case illustrates that the 5q- syndrome can occur de novo in children. The outcome in this child was poor, which may reflect a difference from the adult 5q- syndrome or may possibly be related to the erythropoietin the child received.

Haemopoietic growth factors in acute myeloblastic and lymphoblastic leukaemia

Acute leukaemia blast cells fail to mature into terminally differentiated cells and accumulate in the haemopoietic tissues. In analogy with normal haemopoiesis, the leukaemic mass is largely non-dividing and descends from a small pool of leukaemic progenitor cells with high proliferative activity. In vitro culture methods have become powerful instruments to analyse human leukaemia progenitor cells. These techniques have in recent years been considerably improved as the result of the availability of the recombinant HGFs. Here we have summarized the current insights in the growth properties of acute leukaemia progenitor cells, derived from the application of fully defined in vitro assays. We have discussed the proliferation and maturation abilities in relation to cytogenetic abnormalities, status of growth factor receptors and the property of autocrine growth stimulation and evaluated the significance of these findings for the understanding of the pathogenesis of acute myeloblastic leukaemia and acute lymphoblastic leukaemia.

A hematological remission by clonal hematopoiesis after treatment with recombinant human granulocyte-macrophage colony-stimulating factor and erythropoietin in a patient with therapy-related myelodysplastic syndrome

We treated a patient with therapy-related myelodysplastic syndrome (MDS) with human recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) and erythropoietin (Epo). The patient achieved a hematological remission which continued for more than 16 months despite discontinuation of the treatment. Before the treatment with GM-CSF and Epo the patient had severe pancytopenia, required frequent red cell transfusions, and experienced episodes of severe infection, but after the therapy he no longer needed transfusion and no longer had the infection. While the patient remained in hematological remission, bone marrow examination revealed trilineage dysplasia, and cytogenetic analysis showed an abnormal karyotype [48, XY, +8, +der(1q5p)] in 100% of the metaphases examined. These findings suggest that the hematological remission of this patient may not result from the recovery of the non-clonal hematopoiesis of a normal clone, but result from the monoclonal hematopoiesis of a neoplastic clone.

Recombinant human erythropoietin for the treatment of anemia in the myelodysplastic syndromes: a clinical and erythrokinetic assessment

The clinical and ferrokinetic effects of escalating doses of subcutaneously administered recombinant human erythropoietin (rh-EPO) were studied in ten patients with myelodysplastic syndromes and severe transfusion-dependent anemia. Red blood cell transfusion requirements diminished in four patients, and one of the patients eventually became transfusion independent with an EPO-induced rise of Hb from 7.7 g/dl to 12.3 g/dl. Endogenous serum levels of EPO were significantly increased in all patients (100-5700 mU/ml), but three of four responders had a relatively low baseline level. The effective red cell iron turnover (RCIT) improved in two responding patients and even normalized in one patient. This increase in RCIT was accompanied with a decline in the ineffective red cell iron turnover (IIT). The other responding patients had a relatively preserved RCIT before EPO treatment. EPO therapy further increased the fraction of IIT in the latter patients. Red cell survival time did not increase during EPO therapy, even in the responding patients. One transient and one maintained increase in platelet count were observed. Disease progression with a sustained increase in blast cells in one patient and a transient elevation of blasts in another patient was seen. No other side effects of EPO therapy were observed. These results suggest that anemic MDS patients with low serum EPO levels and relatively spared effective erythropoiesis as measured by ferrokinetic studies may be the best candidates for treatment with recombinant human EPO.

The role of recombinant haematopoietic growth factors in human long-term bone marrow culture in serum-free medium

We have previously reported prolonged in vitro maintenance of human bone marrow progenitor cells using a serum-free (SF) liquid culture system. The present study was undertaken to determine recombinant growth factor (rGF) requirement of long-term marrow culture (LTMC) in absence of exogenous serum, to avoid interference of any undefined components. Our data clearly show that the presence of serum is a major obstacle to the correct evaluation of rGF activity. However, in SF conditions the sequential analysis of these rGFs, alone or in combination, clearly showed a stimulating activity of interleukin 3 (IL3), granulocyte-macrophage colony-stimulating factor (GM-CSF) and erythropoietin (EPO) on granulopoiesis and erythropoiesis. Indeed, the cumulative number of progenitors recovered during an 8-week period exceeded the initial input by a factor of 1.7 for granulocyte-macrophage (CFU-GM), of 3 for erythroid blast-forming units (BFU-E) and of 5.45 for CFU-E when EPO, GM-CSF and IL3 were combined. This study has confirmed that the system is able to sustain haematopoiesis for 8 weeks in a way similar to that in serum-dependent LTMC, despite diminished stromal adherent layer development which never covered more than 50% of the flask surface. We conclude that this defined SF-LTMC system provides a reproducible technique for studying human haematopoiesis.

Practical aspects and diagnostic significance of in vitro manipulation of progenitors in human acute myeloid and lymphoid leukaemia

Since their introduction in the early seventies, in vitro culture techniques for human acute leukaemia cells have been modified and improved considerably. Primarily, this is the result of the availability of the recombinant haematopoietic growth factors (HGFs). It is now possible to evaluate HGF responses of acute leukaemia cells in colony and DNA synthesis assays under fully defined conditions. In this chapter we summarize the current insights into the growth properties of human acute leukaemia progenitor cells and evaluate the potential significance of the application of in vitro clonogenic assays for refining the diagnosis of acute leukaemia, for detecting minimal residual disease and for monitoring therapy.