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Jayani R, Rosko A, Olin R, Artz A. Use of geriatric assessment in hematopoietic cell transplant. J Geriatr Oncol 2019; 11:225-236. [PMID: 31761694 DOI: 10.1016/j.jgo.2019.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022]
Abstract
Hematopoietic cell transplant (HCT) is an important aspect of treatment for many hematologic malignancies. As cancer is a disease associated with aging, and hematologic malignancies are no exception, rates of autologous and allogeneic HCT utilization in older adults are on the rise. The most common indications for autologous HCT are multiple myeloma and lymphoma, and for allogenic HCT are acute myeloid leukemia and myelodysplastic syndrome. Older adults into their eighth decade of life can have favorable outcomes after autologous and allogeneic HCT, at least among select patients. Evaluation of older adults prior to HCT can be aided by utilizing a geriatric assessment (GA). GA can identify areas of vulnerability in older adults prior to HCT not captured by more traditional measures. In the future, GA may be utilized to guide interventions prior to HCT to improve outcomes of older adults. Further studies are needed to expand the paucity of data in utilizing GA to identify three groups of patients: those who clearly benefit from HCT, those who would clearly be harmed, and those who might benefit but would require additional support during and after HCT.
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Affiliation(s)
- Reena Jayani
- Moffitt Cancer Center, Blood and Marrow Transplant and Cellular Immunotherapy Program, 12902 USF Magnolia Dr, Tampa, FL 33612, United States of America; Vanderbilt University Medical Center, Division of Hematology and Oncology, 2220 Pierce Ave, 777 Preston Research Building, Nashville, TN 37232-6307, United States of America.
| | - Ashley Rosko
- The Ohio State University, Department of Internal Medicine, Division of Hematology, 460 W 10th Ave, Columbus, OH 43210, United States of America.
| | - Rebecca Olin
- University of California San Francisco, Department of Medicine, Division of Hematology/Oncology, 400 Parnassus Ave., Fourth Floor, San Francisco, CA 94143, United States of America.
| | - Andrew Artz
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, 1500 E. Duarte Road, Duarte, CA 91010, United States of America.
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Mian H, Mian OS, Rochwerg B, Foley R, Wildes TM. Autologous stem cell transplant in older patients (age ≥ 65) with newly diagnosed multiple myeloma: A systematic review and meta-analysis. J Geriatr Oncol 2019; 11:93-99. [PMID: 31153809 DOI: 10.1016/j.jgo.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/08/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE While autologous stem cell transplant (ASCT) is a standard of care for newly-diagnosed younger patients with multiple myeloma, its role in older patients remains controversial. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) assessing the efficacy and toxicity of ASCT in older patients (age ≥ 65 years) with newly-diagnosed myeloma. METHODS We searched Medline, Embase, and the Cochrane database through February 2, 2018. The primary outcome was overall survival; secondary outcomes included progression-free survival, response rates and toxicity. The Grading of Recommendations Assessment, Development and Evaluation criteria (GRADE) method was used to assess certainty in evidence. RESULTS Of 8614 abstracts screened, six observational studies and two RCTs were included in the systematic review. For overall survival, pooled observational data favored ASCT (Hazard Ratio [HR] 0.44, 95% Confidence Interval [CI] 0.34-0.58, p < .0001), while the impact of the RCT data was uncertain (HR 0.94, 95% CI 0.25-3.54, p = .93). Observational data showed higher complete response rates with ASCT (odds ratio 5.06, 95% CI 2.60-9.88, p < .0001). Progression free survival benefit from the RCTs was uncertain (HR 1.05, 95% CI 0.36-3.12, p = .93). Data were insufficient to pool for toxicity. CONCLUSION For older patients with newly diagnosed multiple myeloma, ASCT may improve the overall survival and complete response rates based upon observational data although the quality of this evidence is very low. The role of ASCT in improving overall survival based upon RCT data remains uncertain with low quality of evidence. Our study highlights the urgent need for well-conducted studies to understand the role of ASCT in older patients.
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Affiliation(s)
- Hira Mian
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, Canada.
| | - Owais S Mian
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ronan Foley
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
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Manapuram S, Hashmi H. Treatment of Multiple Myeloma in Elderly Patients: A Review of Literature and Practice Guidelines. Cureus 2018; 10:e3669. [PMID: 30761222 PMCID: PMC6364954 DOI: 10.7759/cureus.3669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/30/2018] [Indexed: 11/25/2022] Open
Abstract
Multiple myeloma (MM) is a clonal disorder of malignant plasma cells that comprises approximately 10% of hematologic malignancies. With median age of 66 at the time of presentation, multiple myeloma is predominantly a disease of the elderly. The availability of new combination regimens and the enhanced safety of autologous hematopoietic stem cell transplant has increased the treatment options for elderly patients with multiple myeloma. We provide a summary of data supporting the current management of elderly patients with newly diagnosed multiple myeloma.
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Affiliation(s)
- Suresh Manapuram
- Internal Medicine, Saint Francis Hospital and Medical Center, Grand Island, USA
| | - Hamza Hashmi
- Oncology, University of Louisville School of Medicine, Louisville, USA
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4
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Reprint of: Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:S10-S17. [PMID: 28236837 DOI: 10.1016/j.bbmt.2017.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/23/2022]
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Rosko A, Artz A. Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:193-200. [PMID: 27864162 PMCID: PMC5967228 DOI: 10.1016/j.bbmt.2016.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Ashley Rosko
- Department of Internal Medicine, Ohio State University, Columbus, Ohio
| | - Andrew Artz
- Department of Medicine, University of Chicago, Chicago, Illinois.
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6
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Garderet L, Beohou E, Caillot D, Stoppa AM, Touzeau C, Chretien ML, Karlin L, Moreau P, Fontan J, Blaise D, Polge E, Gueye MS, Ikhlef S, Marjanovic Z, Labopin M, Mohty M. Upfront autologous stem cell transplantation for newly diagnosed elderly multiple myeloma patients: a prospective multicenter study. Haematologica 2016; 101:1390-1397. [PMID: 27612987 DOI: 10.3324/haematol.2016.150334] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/06/2016] [Indexed: 11/09/2022] Open
Abstract
The feasibility and efficacy of high-dose melphalan followed by autologous hematopoietic stem cell transplantation in newly diagnosed elderly patients with multiple myeloma was analyzed prospectively. Fifty-six multiple myeloma patients, aged 65 years or over, from 6 French centers were studied. The induction therapy was bortezomib-based in combination with dexamethasone and either thalidomide, cyclophosphamide or lenalidomide, for 4-6 cycles. Peripheral blood stem cells were collected after high-dose cyclophosphamide plus G-CSF or G-CSF alone, with plerixafor if needed. The conditioning regimen consisted of melphalan at 140 mg/m2 in 18 patients (36%) and 200 mg/m2 in 32 (64%). Three months post autologous hematopoietic stem cell transplantation, a 2-month consolidation phase with either lenalidomide plus dexamethasone or bortezomib-based combination therapy was allowed, but maintenance treatment was not given. All but 6 patients underwent autologous hematopoietic stem cell transplantation and 3 had tandem transplantations. The treatment-related mortality was 0% at 100 days post transplantation. Sixty-eight percent received consolidation therapy following transplantation. The best response achieved was 40% complete response, 36% very good partial response, and 18% partial response. After a median follow up of 21 months (range 6-31), the estimated progression-free and overall survival rates at two years were 76% [95%CI: (61.6-94.1)] and 88% [95%CI: (76.7-100)], respectively. The higher dose of melphalan (200 mg/m2) afforded superior progression-free and overall survival rates. This prospective study provides evidence for the safety and efficacy of autologous hematopoietic stem cell transplantation as a first-line treatment approach in elderly multiple myeloma patients. (clinicaltrials.gov identifier: 01671826).
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Affiliation(s)
- Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
| | | | | | - Anne Marie Stoppa
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | - Cyrille Touzeau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | | | - Lionel Karlin
- Department of Hematology, CHU Lyon Sud, Pierre Bénite, Paris, France
| | - Philippe Moreau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | - Jean Fontan
- Department of Hematology, CHU Besançon, Paris, France
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | | | - Mor Seny Gueye
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Souhila Ikhlef
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Zora Marjanovic
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | | | - Mohamad Mohty
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
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7
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Wildes TM, Finney JD, Fiala M, Gao F, Vij R, Stockerl-Goldstein K, Carson KR, Mikhael J, Colditz G. High-dose therapy and autologous stem cell transplant in older adults with multiple myeloma. Bone Marrow Transplant 2015; 50:1075-82. [PMID: 25961765 PMCID: PMC4526374 DOI: 10.1038/bmt.2015.106] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/04/2015] [Accepted: 02/23/2015] [Indexed: 12/22/2022]
Abstract
Randomized trials showing that high-dose therapy with autologous stem cell transplant (ASCT) improved the overall survival (OS) in multiple myeloma (MM) excluded patients over age 65. To compare the outcomes of older adults with MM who underwent ASCT with non-transplant strategies, we identified 146 patients aged 65-77 with newly diagnosed MM seen in the Washington University School of Medicine from 2000 to 2010. Survival among patients who did (N=62) versus did not (N=84) undergo ASCT was compared using Cox proportional hazards modeling, controlling for comorbidities, Eastern Cooperative Oncology Group performance status (PS) and the propensity to undergo ASCT. Median age was 68 years (range 65-77). PS and comorbidities did not differ significantly between those who did versus those who did not undergo ASCT. Median OS was significantly longer in patients who underwent ASCT than in those who did not (median 56.0 months (95% confidence intervals (CIs) 49.1-65.4) versus 33.1 months (24.3-43.1), P=0.004). Adjusting for PS, comorbidities, Durie-Salmon stage and the propensity to undergo ASCT, ASCT was associated with superior OS (HR for mortality 0.52 (95% CI 0.30-0.91), P=0.02). In a cohort of older adults with MM, undergoing ASCT was associated with a nearly 50% lower mortality, after controlling for PS, comorbidities, stage and the propensity to undergo ASCT.
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Affiliation(s)
- T M Wildes
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - J D Finney
- Rush University Medical College, Chicago, IL, USA
| | - M Fiala
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - F Gao
- Division of Biostatistics, Washington University School of Medicine, St Louis, MO, USA
| | - R Vij
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - K Stockerl-Goldstein
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - K R Carson
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St Louis, MO, USA
| | | | - G Colditz
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
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8
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Wildes TM, Rosko A, Tuchman SA. Multiple myeloma in the older adult: better prospects, more challenges. J Clin Oncol 2014; 32:2531-40. [PMID: 25071143 DOI: 10.1200/jco.2014.55.1028] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Multiple myeloma (MM) is disproportionately diagnosed in older adults; with the aging of the population, the number of older adults diagnosed with MM will increase by nearly 80% in the next two decades. Duration of survival has improved dramatically over the last 20 years, but the improvements in older adults have not been as great as those in younger adults with MM. METHODS In this article, we address treatment approaches in older adults who are eligible for and those ineligible for high-dose therapy with autologous stem-cell transplantation as well as supportive care considerations and the potential role for geriatric assessment in facilitating decision making for older adults with MM. RESULTS The evidence from recent studies demonstrates that combinations of novel and conventional antimyeloma agents result in improved response rates and, in some cases, improved progression-free and overall survival. However, some older adults are particularly vulnerable to toxicities of therapy and discontinuation of therapy and, consequently, they have poorer survival. In addition, older adults may prioritize other outcomes of therapy, such as quality of life, over more conventional end points such as disease response and duration of survival. Geriatric assessment can facilitate risk-stratification of older adults at greater risk for adverse events from therapy and aid in personalizing therapy for vulnerable or frail older adults. CONCLUSION Survival in older adults with MM is improving with novel therapeutics, but efficacy must be balanced with risk of toxicity of therapy and maintenance of quality of life. Novel instruments such as geriatric assessment tools may facilitate these aims.
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Wildes TM, Stirewalt DL, Medeiros B, Hurria A. Hematopoietic stem cell transplantation for hematologic malignancies in older adults: geriatric principles in the transplant clinic. J Natl Compr Canc Netw 2014; 12:128-36. [PMID: 24453296 DOI: 10.6004/jnccn.2014.0010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hematopoietic cell transplantation (HCT) provides a life-prolonging or potentially curative treatment option for patients with hematologic malignancies. Given the high transplant-related morbidity, these treatment strategies were initially restricted to younger patients, but are increasingly being used in older adults. The incidence of most hematologic malignancies increases with age; with the aging of the population, the number of potential older candidates for HCT increases. Autologous HCT (auto-HCT) in older patients may confer a slightly increased risk of specific toxicities (such as cardiac toxicities and mucositis) and have modestly lower effectiveness (in the case of lymphoma). However, auto-HCT remains a feasible, safe, and effective therapy for selected older adults with multiple myeloma and lymphoma. Similarly, allogeneic transplant (allo-HCT) is a potential therapeutic option for selected older adults, although fewer data exist on allo-HCT in older patients. Based on currently available data, age alone is not the best predictor of toxicity and outcomes; rather, the comorbidities and functional status of the older patient are likely better predictors of toxicity than chronologic age in both the autologous and allogeneic setting. A comprehensive geriatric assessment (CGA) in older adults being considered for either an auto-HCT or allo-HCT may identify additional problems or geriatric syndromes, which may not be detected during the standard pretransplant evaluation. Further research is needed to establish the utility of CGA in predicting toxicity and to evaluate the quality of survival in older adults undergoing HCT.
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Affiliation(s)
- Tanya M Wildes
- From aWashington University School of Medicine, St. Louis, Missouri; bFred Hutchinson Cancer Research Center, Seattle, Washington; cStanford University School of Medicine, Stanford, California; and dCity of Hope Comprehensive Cancer Center, Duarte, California
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Mactier CE, Islam MS. Haematopoietic stem cell transplantation as first-line treatment in myeloma: a global perspective of current concepts and future possibilities. Oncol Rev 2012; 6:e14. [PMID: 25992212 PMCID: PMC4419629 DOI: 10.4081/oncol.2012.e14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 06/15/2012] [Accepted: 06/15/2012] [Indexed: 12/22/2022] Open
Abstract
Stem cell transplantation forms an integral part of the treatment for multiple myeloma. This paper reviews the current role of transplantation and the progress that has been made in order to optimize the success of this therapy. Effective induction chemotherapy is important and a combination regimen incorporating the novel agent bortezomib is now favorable. Adequate induction is a crucial adjunct to stem cell transplantation and in some cases may potentially postpone the need for transplant. Different conditioning agents prior to transplantation have been explored: high-dose melphalan is most commonly used and bortezomib is a promising additional agent. There is no well-defined superior transplantation protocol but single or tandem autologous stem cell transplantations are those most commonly used, with allogeneic transplantation only used in clinical trials. The appropriate timing of transplantation in the treatment plan is a matter of debate. Consolidation and maintenance chemotherapies, particularly thalidomide and bortezomib, aim to improve and prolong disease response to transplantation and delay recurrence. Prognostic factors for the outcome of stem cell transplant in myeloma have been highlighted. Despite good responses to chemotherapy and transplantation, the problem of disease recurrence persists. Thus, there is still much room for improvement. Treatments which harness the graft-versus-myeloma effect may offer a potential cure for this disease. Trials of novel agents are underway, including targeted therapies for specific antigens such as vaccines and monoclonal antibodies.
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Affiliation(s)
| | - Md Serajul Islam
- Department of Haematology, Lewisham University Hospital, London; ; Department of Haematology & Stem cell Transplant, Guy's and St Thomas' Hospital, London, UK
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Klastersky J, Gombos A, Georgala A, Awada A. Prevention of neutropenia-related events in elderly patients with hematological cancer. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ahe.11.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The aging of the population makes it necessary to define more precisely the needs of elderly patients in terms of anticancer therapy as the number of older cancer patients is expected to increase. There is evidence that many elderly cancer patients can benefit from relatively aggressive treatments, provided major side effects can be prevented or treated. In patients with hematological malignancies, infection is the most common and threatening complication resulting from chemotherapy administration. Discussion of the prevention of infection in the setting described above is the aim of this paper.
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Affiliation(s)
| | - Andrea Gombos
- Institut Jules Bordet, Université Libre de Bruxelles, Rue Héger-Bordet 1, 1000 Brussels, Belgium
| | - Aspasia Georgala
- Institut Jules Bordet, Université Libre de Bruxelles, Rue Héger-Bordet 1, 1000 Brussels, Belgium
| | - Ahmad Awada
- Institut Jules Bordet, Université Libre de Bruxelles, Rue Héger-Bordet 1, 1000 Brussels, Belgium
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Kostková H, Etrych T, Říhová B, Ulbrich K. Synergistic effect of HPMA copolymer-bound doxorubicin and dexamethasone in vivo on mouse lymphomas. J BIOACT COMPAT POL 2011. [DOI: 10.1177/0883911511406326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
N-(2-Hydroxypropyl)methacrylamide (HPMA) copolymer—drug conjugates bearing the antiinflammatory and anti-proliferative drug dexamethasone (DEX) and the anti-cancer drug doxorubicin (DOX) bound to either the polymer carrier separately or in combination, were synthesized. Both the in vitro and in vivo anti-cancer activity on mouse B-cell (38C13) and T-cell (EL4) lymphoma was studied. The conjugates were fairly stable in model buffers at pH 7.4, simulating blood pH, and the drug was released by chemical hydrolysis at pH values based on the endosomal and lysosomal environments in the target cells (pH 5—6). As a control, polymer conjugates containing only a single-drug (DOX or DEX) attached to the HPMA copolymer carrier were synthesized and tested. Contrary to the treatment with either single drug conjugate, where no significant long-term survival was observed, a synergistic effect of the two drugs was manifested in vivo. Treatment of mice bearing B-cell lymphoma 38C13 formulated as a mixture of both single drug-containing conjugates or a as a conjugate with both drugs in combination gave long-term survivors.
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Affiliation(s)
- Hana Kostková
- Institute of Macromolecular Chemistry, Academy of Sciences of the Czech Republic v.v.i, Heyrovský Sq. 2, 162 06 Prague 6, Czech Republic,
| | - Tomáš Etrych
- Institute of Macromolecular Chemistry, Academy of Sciences of the Czech Republic v.v.i, Heyrovský Sq. 2, 162 06 Prague 6, Czech Republic
| | - Blanka Říhová
- Institute of Microbiology, Academy of Sciences of the Czech Republic v.v.i, Vídeňská 1083, 142 20 Prague 4, Czech Republic
| | - Karel Ulbrich
- Institute of Macromolecular Chemistry, Academy of Sciences of the Czech Republic v.v.i, Heyrovský Sq. 2, 162 06 Prague 6, Czech Republic
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