Enhancement of melphalan-induced gastrointestinal toxicity in mice treated with regional hyperthermia and BSO-mediated glutathione depletion

Busulfan 12 mg/kg plus melphalan 140 mg/m2 versus melphalan 200 mg/m2 as conditioning regimens for autologous transplantation in newly diagnosed multiple myeloma patients included in the PETHEMA/GEM2000 study

BACKGROUND

The aim of this study was to compare the long-term safety and efficacy of oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) and melphalan 200 mg/m(2) as conditioning regimens for autologous stem cell transplantation in newly diagnosed patients with multiple myeloma in the GEM2000 study.

DESIGN AND METHODS

The first 225 patients received oral busulfan 12 mg/kg plus melphalan 140 mg/m(2); because of a high frequency of veno-occlusive disease, the protocol was amended and a further 542 patients received melphalan 200 mg/m(2).

RESULTS

Engraftment and hospitalization times were similar in both groups. Oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) resulted in higher transplant-related mortality (8.4% versus 3.5%; P=0.002) due to the increased frequency of veno-occlusive disease in this group. Response rates were similar in both arms. With respective median follow-ups of 72 and 47 months, the median progression-free survival was significantly longer with busulfan plus melphalan (41 versus 31 months; P=0.009), although survival was similar to that in the melphalan 200 mg/m(2) group. However, access to novel agents as salvage therapy after relapse/progression was significantly lower for patients receiving busulfan plus melphalan (43%) than for those receiving melphalan 200 mg/m(2) (58%; P=0.01).

CONCLUSIONS

Conditioning with oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) was associated with longer progression-free survival but equivalent survival to that achieved with melphalan 200 mg/m(2) but this should be counterbalanced against the higher frequency of veno-occlusive disease-related deaths. This latter fact together with the limited access to novel salvage therapies in patients conditioned with oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) may explain the absence of a survival difference. Oral busulfan was used in the present study; use of the intravenous formulation may reduce toxicity and result in greater efficacy, and warrants further investigation in myeloma patients. (Clinicaltrials.gov identifier: NCT00560053).

Veno-occlusive disease of the liver after high-dose cytoreductive therapy with busulfan and melphalan for autologous blood stem cell transplantation in multiple myeloma patients

Veno-occlusive disease of the liver (VOD) is a potentially severe complication of high-dose cytoreductive therapy (HDT) used for stem cell transplantation (SCT). This complication is uncommon after HDT for autologous SCT (ASCT) in patients with multiple myeloma (MM). The Spanish Myeloma Group/PETHEMA conducted a study (MM2000) for patients with newly diagnosed MM consisting of induction with alternating VBMCP/VBAD chemotherapy followed by intensification with busulfan/melphalan (Bu/MEL) with a second high-dose therapy procedure in patients not achieving at least near-complete remission with the first procedure. After 2 years of the trial, a number of episodes resembling classical VOD but with a late onset were recognized. Consequently, the protocol was modified, and Bu/MEL was replaced by melphalan 200 mg/m(2) (MEL-200). Three years later, after a total of 734 patients had undergone first autologous SCT, the incidence and characteristics of VOD episodes were analyzed in the whole series. Nineteen cases of VOD (8%) were observed among the first 240 patients receiving Bu/MEL, whereas only 2 (0.4%) were observed among the 494 patients treated with MEL-200 (P < .0001). VOD manifestations in the Bu/MEL group appeared at a median of 29 days (range, 3-57 days) after ASCT. Mortality directly attributable to VOD was 2% in the Bu/MEL group and 0.2% in the MEL-200 group (P = .026). This high incidence of severe VOD probably had a multifactorial origin (busulfan followed by melphalan and previous use of BCNU). This observation should be kept in mind when designing future trials for the treatment of MM.

Enhancement of lipid peroxidation and of the antitumor effect of hyperthermia upon combination with oral eicosapentaenoic acid

The present study was designed to determine the effect of eicosapentaenoic acid (EPA) on the susceptibility of tumor cells to treatments that kill the cells by lipid peroxidation. Using AH109A carcinoma, a rat liver cancer, we measured EPA content, levels of antioxidants, and degree of lipid peroxidation in tumor tissue and normal liver tissue after oral administration of EPA. In the control group treated with distilled water, EPA in tumor tissue was lower than in normal liver tissue, suggesting that its content of polyunsaturated fatty acids (the substrates for lipid peroxidation) was inherently low. Levels of antioxidants also tended to be lower in tumor tissue. EPA level increased in both tumor and normal tissues after oral administration of EPA. At the same time, glutathione peroxidase (GSH-Px) increased in normal tissue, whereas tumor tissue displayed no increase in antioxidants; instead GSH decreased. The EPA-induced change in balance between substrates for lipid peroxidation and antioxidants suggested that tumor tissue might become more susceptible to lipid peroxidation than normal liver tissue. In fact, hyperthermia treatment did enhance lipid peroxidation and antitumor action. Our results indicate that oral EPA specifically increases the susceptibility of liver tumor tissue to lipid peroxidation, and hence enhance the antitumor effect of hyperthermia and prolongs survival.

Hyperthermic modulation of radiolabelled antibody uptake in a human glioma xenograft and normal tissues

These experiments investigate the biodistribution of radiolabelled MAb in a human glioma xenograft model after 4 h of local hyperthermia (HT) with a twofold purpose: to maximize the ratio of cumulative isotope activity in tumour relative to normal tissues, and to examine the temperature dependence of the effect. Restrained, unanaesthetized athymic nude mice bearing 150-200 mm3 s.c. human glioma xenografts (D-54 MG) were given 5 micrograms 125I-labelled specific and 131I-labelled non-specific MAb immediately prior to HT (water bath) for 4 h. Cohorts of five animals were killed at 0, 4, 8, 12 and 24 h after HT, and normal and tumour tissues were analysed for activity of each isotope. MAb uptake in tumour was greater with HT than with controls, and greater for specific MAb than for non-specific MAb. Uptake in thyroid was not significantly affected by tumour HT, suggesting that HT does not increase the rate of dehalogenation. Uptake in several other normal tissues away from the heated site was significantly increased (as were reported previously in mice anaesthetized with pentobarbital sodium during treatment; Cope et al. 1990), but the temporal pattern was different from that observed in tumour, suggesting that short-lived isotopes might lead to preferential dose deposition in heated tumour. Doses to various tissues were calculated for isotopes having a range of half-lives; the results clearly indicated that maximum differential in uptake between tumour and normal tissues would occur for isotopes with half-lives < 3 days. A separate series of experiments compared tumour uptake for 40, 42 and 44 degrees C HT. These results demonstrated that 42 and 44 degrees C HT created maximum enhancement in specific antibody uptake over controls. Specific MAb was retained over time in 42 degrees C-heated tumours, whereas significant washout occurred for non-specific MAb, which indicates that MAb retention was due to increased specific binding at this temperature and not vascular damage with antibody trapping. Retention of both specific and non-specific MAb was seen at 44 degrees C, suggesting that vascular damage becomes an important non-specific mechanism for antibody retention at higher temperatures.