Cyclosporine A in chronic lymphocytic leukemia: dual anti-leukemic and immunosuppressive role?

Cyclosporine A therapy of chronic lymphoblastic leukemia-related pancytopenia: A case report

To explore the clinical characteristics, diagnosis, and treatment of chronic lymphocytic leukemia with secondary pancytopenia. Here, a case of pancytopenia secondary to chronic lymphocytic leukemia is reported. Additionally, a review of relevant chronic lymphocytic leukemia literature was conducted to summarize its diagnosis, clinical characteristics, treatment history, and experience. After treatment with cyclosporine A, the patient's chronic lymphocytic leukemia continued to resolve, and hematopoiesis returned to normal. Cyclosporine A therapy resulted in improved patient outcomes. However, the mechanism by which cyclosporine A rebuilds the immune microenvironment and its antileukemia effect in the body remains to be studied.

Role of NFAT in Chronic Lymphocytic Leukemia and Other B-Cell Malignancies

In recent years significant progress has been made in the clinical management of chronic lymphocytic leukemia (CLL) as well as other B-cell malignancies; targeting proximal B-cell receptor signaling molecules such as Bruton Tyrosine Kinase (BTK) and Phosphoinositide 3-kinase (PI3Kδ) has emerged as a successful treatment strategy. Unfortunately, a proportion of patients are still not cured with available therapeutic options, thus efforts devoted to studying and identifying new potential druggable targets are warranted. B-cell receptor stimulation triggers a complex cascade of signaling events that eventually drives the activation of downstream transcription factors including Nuclear Factor of Activated T cells (NFAT). In this review, we summarize the literature on the expression and function of NFAT family members in CLL where NFAT is not only overexpressed but also constitutively activated; NFAT controls B-cell anergy and targeting this molecule using specific inhibitors impacts on CLL cell viability. Next, we extend our analysis on other mature B-cell lymphomas where a distinct pattern of expression and activation of NFAT is reported. We discuss the therapeutic potential of strategies aimed at targeting NFAT in B-cell malignancies not overlooking the fact that NFAT may play additional roles regulating the inflammatory microenvironment.

Computational Drug Repositioning Identifies Potentially Active Therapies for Chordoma

BACKGROUND

Chordomas are aggressive bone tumors that often recur despite maximal resection and adjuvant radiation. To date there are no Food and Drug Administration (FDA)-approved chemotherapies. Computational drug repositioning is an expanding approach to identify pharmacotherapies for clinical trials.

OBJECTIVE

To identify FDA-approved compounds for repurposing in chordoma.

METHODS

Previously identified highly differentially expressed genes from chordoma tissue samples at our institution were compared with pharmacogenomic interactions in the Comparative Toxicogenomics Database (CTD) using ksRepo, a drug-repositioning platform. Compounds selected by ksRepo were then validated in CH22 and UM-Chor1 human chordoma cells in Vitro.

RESULTS

A total of 13 chemical compounds were identified in silico from the CTD, and 6 were selected for preclinical validation in human chordoma cell lines based on their clinical relevance. Of these, 3 identified drugs are FDA-approved chemotherapies for other malignancies (cisplatin, cytarabine, and lucanthone). Cytarabine, a deoxyribonucleic acid polymerase inhibitor approved for the treatment of various leukemias, exhibited a significant concentration-dependent effect against CH22 and UM-Chor1 cells when compared to positive (THZ1) and negative (venetoclax) controls. Tretinoin exhibited a significant concentration-dependent cytotoxic effect in CH22, sacral chordoma-derived cell lines but to a much lesser extent in UM-Chor1, a cell line derived from skull base chordoma.

CONCLUSION

Cytarabine administration reduces the viability of human chordoma cells. The equally effective reduction in viability seen with tretinoin seems to be cell line dependent. Based on our findings, we recommend the evaluation of cytarabine and tretinoin in an expanded set of human chordoma cell lines and animal models.

Calcineurin inhibitors and rapamycin: cancer protection or promotion?

Since the introduction of cyclosporin A (CsA) in the early 1980s, the use of immunosuppressants has markedly increased. Already established drugs have proved effective in the treatment of a wide range of diseases outside transplantation medicine and new immunosuppressants have been developed for more specific indications such as psoriasis and atopic dermatitis. Patients in transplantation medicine as well as in dermatology have benefited significantly from systemic and topical application of both new and established drugs. But are these drugs without risks? Cancer-protecting effects have been reported for some of the available immunosuppressants. Conversely, other publications and the issue of a black box warning by the US Food and Drug Administration have increased concerns about cancer-promoting effects. Knowledge of the specific effects as well as adverse effects is paramount to ensure an application that is safe and beneficial for the patient. Here we review the mechanisms of action and therapeutic potential, and critically review recent literature with respect to possible carcinogenic side effects of systemic and topical CsA, tacrolimus, pimecrolimus and rapamycin.

Cyclosporin A for the treatment of cytopenia associated with chronic lymphocytic leukemia

BACKGROUND

Autoimmune cytopenias are a frequent complication in patients with chronic lymphocytic leukemia (CLL). Anecdotal reports suggest that cyclosporin A (CsA) may be beneficial for patients with CLL-associated pure red cell aplasia. In the current study, the authors investigated the use of CsA in the management of anemia or thrombocytopenia of presumed autoimmune etiology associated with CLL.

METHODS

Thirty-one patients with CLL and anemia or thrombocytopenia of presumed autoimmune etiology were treated with CsA at a dose of 300 mg/day. Sixteen patients (52%) had anemia (hemoglobin <or= 11 g/dL) and 29 patients (94%) had thrombocytopenia (platelet count <or= 100 x 10(9)/L). Seventeen patients (55%) had cytopenia that developed during the course of treatment with fludarabine-based regimens. Nineteen patients (61%) had received prior therapy for this complication using steroids, intravenous immunoglobulin, and/or splenectomy.

RESULTS

Eighteen patients (62%) with thrombocytopenia and 10 patients (63%) with anemia had a major response defined as an increase in the platelet count >or= 50 x 10(9)/L or an increase in hemoglobin >or= 3 g/dL. The median time to initial response was 3 weeks (range, 1-13 weeks) and the median time to best response was 10.5 weeks (range, 1-48 weeks). The median duration of response was 10 months (range, 1+-39+ months). Three patients with fludarabine-associated cytopenias were able to receive further therapy with fludarabine with a lesser decrease in the platelet count. A modest decrease in the tumor burden was observed in six patients. The most common toxicity was <or= Grade 2 (according to the National Cancer Institute's Common Toxicity Criteria) elevation of creatinine, which was observed in 6 patients (19%). Three patients developed opportunistic infections.

CONCLUSIONS

CsA is an effective alternative for the treatment of anemia or thrombocytopenia of suspected autoimmune etiology, including those cases occurring in the course of treatment with fludarabine. A modest antileukemic effect was observed in some patients.

Minimal residual disease is common after allogeneic stem cell transplantation in patients with B cell chronic lymphocytic leukemia and may be controlled by graft-versus-host disease

Following allogeneic stem cell transplantation (SCT), we studied the presence of donor and recipient derived cells within the CD19+ B cell fraction, in patients with B cell chronic lymphocytic leukemia (CLL). The chimeric status of the six patients studied was further investigated with minimal residual disease (MRD) detection, by sequencing and using patient-specific primers derived from junctional regions of clonally rearranged immunoglobulin heavy-chain (IgH) receptor genes. To date, five of six patients are alive with a median follow-up time of 24 months (range 15-60) post-SCT. All patients experienced acute and chronic graft-versus-host disease and responded clinically to SCT. All patients were MRD positive after SCT, which correlated to mixed chimerism within the CD19+ cell fraction in all samples except one (25/26). High levels of tumor necrosis factor-alpha (TNF-alpha) and soluble interleukin-2 receptor (sIL-2R) indicated advanced disease, and patients with increased levels pre- and post-SCT were also those with the most long-lasting PCR-detectable MRD post-SCT. Hence, a high tumor burden pre-SCT may reflect the long duration of detectable MRD in patients with B-CLL after SCT. A durable anti-leukemic effect was probably important in these patients.

Novel biologic approaches to hematologic malignancies

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.