Eltrombopag Added to Immunosuppression in Severe Aplastic Anemia

BACKGROUND

A single-group, phase 1-2 study indicated that eltrombopag improved the efficacy of standard immunosuppressive therapy that entailed horse antithymocyte globulin (ATG) plus cyclosporine in patients with severe aplastic anemia.

METHODS

In this prospective, investigator-led, open-label, multicenter, randomized, phase 3 trial, we compared the efficacy and safety of horse ATG plus cyclosporine with or without eltrombopag as front-line therapy in previously untreated patients with severe aplastic anemia. The primary end point was a hematologic complete response at 3 months.

RESULTS

Patients were assigned to receive immunosuppressive therapy (Group A, 101 patients) or immunosuppressive therapy plus eltrombopag (Group B, 96 patients). The percentage of patients who had a complete response at 3 months was 10% in Group A and 22% in Group B (odds ratio, 3.2; 95% confidence interval [CI], 1.3 to 7.8; P = 0.01). At 6 months, the overall response rate (the percentage of patients who had a complete or partial response) was 41% in Group A and 68% in Group B. The median times to the first response were 8.8 months (Group A) and 3.0 months (Group B). The incidence of severe adverse events was similar in the two groups. With a median follow-up of 24 months, a karyotypic abnormality that was classified as myelodysplastic syndrome developed in 1 patient (Group A) and 2 patients (Group B); event-free survival was 34% and 46%, respectively. Somatic mutations were detected in 29% (Group A) and 31% (Group Β) of the patients at baseline; these percentages increased to 66% and 55%, respectively, at 6 months, without affecting the hematologic response and 2-year outcome.

CONCLUSIONS

The addition of eltrombopag to standard immunosuppressive therapy improved the rate, rapidity, and strength of hematologic response among previously untreated patients with severe aplastic anemia, without additional toxic effects. (Funded by Novartis and others; RACE ClinicalTrials.gov number, NCT02099747; EudraCT number, 2014-000363-40.).

The TKI Era in Chronic Leukemias

Tyrosine kinases are proteins involved in physiological cell functions including proliferation, differentiation, and survival. However, the dysregulation of tyrosine kinase pathways occurs in malignancy, including hematological leukemias such as chronic myeloid leukemia (CML) and chronic lymphocytic leukemia (CLL). Particularly, the fusion oncoprotein BCR-ABL1 in CML and the B-cell receptor (BCR) signaling pathway in CLL are critical for leukemogenesis. Therapeutic management of these two hematological conditions was fundamentally changed in recent years, making the role of conventional chemotherapy nearly obsolete. The first, second, and third generation inhibitors (imatinib, dasatinib, nilotinib, bosutinib, and ponatinib) of BCR-ABL1 and the allosteric inhibitor asciminib showed deep genetic and molecular remission rates in CML, leading to the evaluation of treatment discontinuation in prospective trials. The irreversible BTK inhibitors (ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and spebrutinib) covalently bind to the C481 amino acid of BTK. The reversible BTK inhibitor pirtobrutinib has a different binding site, overcoming resistance associated with mutations at C481. The PI3K inhibitors (idelalisib and duvelisib) are also effective in CLL but are currently less used because of their toxicity profiles. These tyrosine kinase inhibitors are well-tolerated, do have some associated in-class side effects that are manageable, and have remarkably improved outcomes for patients with hematologic malignancies.

Anti-complement Treatment for Paroxysmal Nocturnal Hemoglobinuria: Time for Proximal Complement Inhibition? A Position Paper From the SAAWP of the EBMT

The treatment of paroxysmal nocturnal hemoglobinuria has been revolutionized by the introduction of the anti-C5 agent eculizumab; however, eculizumab is not the cure for Paroxysmal nocturnal hemoglobinuria (PNH), and room for improvement remains. Indeed, the hematological benefit during eculizumab treatment for PNH is very heterogeneous among patients, and different response categories can be identified. Complete normalization of hemoglobin (complete and major hematological response), is seen in no more than one third of patients, while the remaining continue to experience some degree of anemia (good and partial hematological responses), in some cases requiring regular red blood cell transfusions (minor hematological response). Different factors contribute to residual anemia during eculizumab treatment: underlying bone marrow dysfunction, residual intravascular hemolysis and the emergence of C3-mediated extravascular hemolysis. These two latter pathogenic mechanisms are the target of novel strategies of anti-complement treatments, which can be split into terminal and proximal complement inhibitors. Many novel terminal complement inhibitors are now in clinical development: they all target C5 (as eculizumab), potentially paralleling the efficacy and safety profile of eculizumab. Possible advantages over eculizumab are long-lasting activity and subcutaneous self-administration. However, novel anti-C5 agents do not improve hematological response to eculizumab, even if some seem associated with a lower risk of breakthrough hemolysis caused by pharmacokinetic reasons (it remains unclear whether more effective inhibition of C5 is possible and clinically beneficial). Indeed, proximal inhibitors are designed to interfere with early phases of complement activation, eventually preventing C3-mediated extravascular hemolysis in addition to intravascular hemolysis. At the moment there are three strategies of proximal complement inhibition: anti-C3 agents, anti-factor D agents and anti-factor B agents. These agents are available either subcutaneously or orally, and have been investigated in monotherapy or in association with eculizumab in PNH patients. Preliminary data clearly demonstrate that proximal complement inhibition is pharmacologically feasible and apparently safe, and may drastically improve the hematological response to complement inhibition in PNH. Indeed, we envision a new scenario of therapeutic complement inhibition, where proximal inhibitors (either anti-C3, anti-FD or anti-FB) may prove effective for the treatment of PNH, either in monotherapy or in combination with anti-C5 agents, eventually leading to drastic improvement of hematological response.

Protonated Ozone: Experimental Detection of O3H+ and Evaluation of the Proton Affinity of Ozone

The elusive protonated ozone ion (O(3)H(+)) has been long postulated as a reactive intermediate but never experimentally observed. This ion has been detected here in mass spectrometric experiments with the use of Fourier transform ion cyclotron resonance. In these experiments, ozone (O(3)) was protonated by strong acids-for example, H(3)(+), KrH(+), XeH(+), and CH(5)(+). The hitherto experimentally unknown proton affinity of O(3) was evaluated by a "bracketing" technique and determined to be 148 -/+ 3 kilocalories mole(-1) at 298 kelvin, in excellent agreement with a value determined in a recent theoretical study of the O(3)/O(3)H(+) system, which was 148 kilocalories mole(-1) at zero temperature ( approximately 149.5 kilocalories mole(-1) at 298 kelvin).

Experimental detection of tetranitrogen

Tetranitrogen (N4), which has been the subject of great theoretical interest, has been prepared from the N4+ cation and positively detected as a gaseous metastable molecule with a lifetime exceeding 1 microsecond in experiments based on neutralization-reionization mass spectrometry. An examination of the geometry of N4+ and the fragmentation pattern of the (14)N2(15)N2 neutral molecule has revealed that the latter is characterized by an open-chain geometry with two distinct, closely bound N2 units joined by a longer weaker bond.

S3O, a new sulfur oxide identified in the gas phase

S3O, a novel, linear sulfur oxide has been detected in the gas phase by means of neutralization reionization mass spectrometry; the upper limit of stability of acyclic forms of SnO oxides has been set by theoretical calculations.

Ionization of ozone/chlorofluorocarbon mixtures in atmospheric gases: formation and remarkable dissociation of

The reactions occurring upon ionization of mixtures containing ozone and CHX2Y (X = H, Cl, F; Y = Cl, F) halocarbons diluted in atmospheric gases (O2, N2) have been investigated in detail by mass spectrometric and theoretical methods. In all systems investigated the reactivity pattern is characterized by the preliminary formation of [CHXY x O3+] adducts which undergo unimolecular dissociation into HXYO2+ and CO. This remarkable dissociation which requires extensive molecular reorganization is exceptional for hydrogenated halocarbons. The work represents the first systematic study of the ionic chemistry in systems containing both ozone and halocarbons diluted in atmospheric gases.

Fast interconversion of C4H7+ cations in the gas phase and in a gaseous microsolvated environment

The equilibration of cyclobutyl 1 and 1' and the cyclopropylmethyl cation (2) has been studied in the gas phase by utilizing FT-ICR mass spectrometry and high-pressure radiolytic techniques. A suitable gaseous nucleophile, C6X6 (X=H,D), was used to sample the equilibration of C4H7+ ions, produced from both cyclobutanol and cyclopropylmethanol. These are either dispersed in the bulk gas or confined within a C4H7+/C6X6 complex that contains a molecule of solvent (H2O). The analysis of the products shows that, irrespective of their source and of the intermolecular or intracomplex nature of the process, the C4H7+ ions undergo equilibration before they are trapped. The equilibrium (1+1')/2 ratio is very close to unity at 300 K, and the results from the intracomplex trapping experiment show that equilibration occurs within a time interval < or =10(-10) s.

Im Memoriam Alfred P. Wolf

Dr. Alfred P. Wolf, Al, died on 17 December 1998. A great scientist has left us, whose 47 years´ service in the field of radioisotope applications in organic chemistry, hot atom chemistry, and radiopharmaceutical chemistry had a tremendous impact on applied radiochemsitry and nuclear medicine.

Gas-phase reactions of nitronium ions with acetylene and ethylene: an experimental and theoretical study

A comparative study of the gas-phase reactions of NO2+ with acetylene and ethylene was performed by using FT-ICR, MIKE, CAD, and NfR/ CA mass spectrometric techniques, in conjunction with ab initio calculations at the MP2/6-31+G* level of theory. Both reactions proceed according to the same mechanism, that is, 1,3-dipolar cycloaddition, but yield products of different stability. The C2H2NO2+ adduct from acetylene has an aromatic character and hence is highly stabilized with respect to the C2H4NO2+ adduct from ethylene. Both cycloadducts tend to isomerize into O-nitroso derivatives, that is, nitrosated ketene and nitrosated acetaldehyde, which represent the thermodynamically most stable products from the addition of NO2+ to acetylene and ethylene, respectively. As prototypal examples of the reactivity of free nitronium ions with most simple pi systems, the reactions investigated are useful starting points to model the mechanism of aromatic nitration.

Isomeric Cl(2)O(2)(+) and Cl(2)O(2)(-) ions

Charged species structurally related to several isomers of Cl(2)O(2), of considerable importance in atmospheric chemistry, were obtained by chemical ionization (CI) and characterized by collisionally activated dissociation (CAD) mass spectrometry. The ClOClO(+) and [Cl(2)-O(2)](+) species were prepared by positive ion Cl(2)/CI of ClO(2) and O(2), respectively, whereas the ClClO(2)(+) isomer proved an elusive species of considerably lower stability. The ClClO(2)(-) anion was obtained from the negative ion Cl(2)/CI of ClO(2). The formation process, structure and stability of the ions are discussed in connection with available theoretical results and related to the recent preparation of (Cl(2)O(2))(+)SbF(6)(-) and (Cl(2)O(2))(+)Sb(2)F(11)(-) salts in the solid phase. Copyright 1999 John Wiley & Sons, Ltd.

Experimental detection of hydrogen trioxide

Hydrogen trioxide (HO3) has long been postulated as a key intermediate in important atmospheric processes but has proved difficult to detect. The molecule was unequivocally detected in experiments based on neutralization-reionization and neutralization-reionization/collisionally activated dissociation mass spectrometry, using protonated ozone (HO3+) as the charged precursor. Hydrogen trioxide is a relatively stable species and has a H-O-O-O connectivity and a lifetime exceeding 10(-6) seconds at ambient temperature.

Gas-phase NO+ affinities

A scale of relative gas-phase NO+ binding energies (BEs) has been constructed by evaluation of NO+-transfer equilibria LINO+ + L2 <==> L2NO+ + L1 by Fourier-transform ion cyclotron resonance mass spectrometry and by application of the kinetic method, based on the metastable fragmentation of L1(NO+)L2 nitryl-ion bound dimers. The relative scale, anchored to the NO+ affinity of water, for 52 ligands, including alkyl halides, alkyl nitrates, alcohols, nitroalkanes, nitriles, aldehydes, ketones, and aromatic and heterocyclic compounds, led to an absolute NO+ affinity scale. The results are compared with those of an earlier study, and the apparent discrepancies are traced to a different choice of the absolute BE value used as the reference standard. The NO+ BEs fit a satisfactorily linear correlation when plotted versus the corresponding proton affinities (PAs). The NO+ BEs, while much lower than the PAs, are nevertheless higher than the corresponding BEs of the strictly related NO2+ cation, a result consistent with the experimental and theoretical results currently available on the structure and the stability of NO+ and NO2+ complexes. The NO+ BE vs. PA correlation allows one to estimate within 1-2 kcal x mol(-1) the NO+ BE of the molecules included in the comprehensive PA compilations currently available. For example, the correlation gives the following NO+ affinities of the DNA bases, in kcal x mol(-1) (1 kcal = 4.18 kJ): adenine, 40.3; cytosine, 40.4; guanine, 40.1; and thymine, 34.9. The experimental NO+ BE of thymine, the only one accessible to direct measurement, amounts to 35.6 +/- 2 kcal x mol(-1), which underlines the predictive value of the correlation. This study reports the second successful extension of the kinetic method to the evaluation of the absolute BEs of polyatomic cations, following our recent application to the strictly related NO2+ ion.

Gas-phase nitronium ion affinities

Evaluation of nitronium ion-transfer equilibria, L1NO2+ + L2 = L2NO2+ + L1 (where L1 and L2 are ligands 1 and 2, respectively) by Fourier-transform ion cyclotron resonance mass spectrometry and application of the kinetic method, based on the metastable fragmentation of L1(NO2+)L2 nitronium ion-bound dimers led to a scale of relative gas-phase nitronium ion affinities. This scale, calibrated to a recent literature value for the NO2+ affinity of water, led for 18 ligands, including methanol, ammonia, representative ketones, nitriles, and nitroalkanes, to absolute NO2+ affinities, that fit a reasonably linear general correlation when plotted vs. the corresponding proton affinities (PAs). The slope of the plot depends to a certain extent on the specific nature of the ligands and, hence, the correlations between the NO2+ affinities, and the PAs of a given class of compounds display a better linearity than the general correlation and may afford a useful tool for predicting the NO2+ affinity of a molecule based on its PA. The NO2+ binding energies are considerably lower than the corresponding PAs and well below the binding energies of related polyatomic cations, such as NO+, a trend consistent with the available theoretical results on the structure and the stability of simple NO2+ complexes. The present study reports an example of extension of the kinetic method to dimers, such as L1(NO2+)L2, bound by polyatomic ions, which may considerably widen its scope. Finally, measurement of the NO2+ affinity of ammonia allowed evaluation of the otherwise inaccessible PA of the amino group of nitramide and, hence, direct experimental verification of previous theoretical estimates.

Nuclear Decay Techniques in Ion Chemistry

The spontaneous decay of chemically bound radioactive atoms affords a route to ions of well-defined structure and charge location, free of counterions. The nuclear nature of the ionization process makes it insensitive to environmental effects, so that exactly the same charged species can be generated, and its reactivity investigated, in widely varying media, from low-pressure gases to liquids and solids. Techniques based on nuclear decay are used in studies of the production of otherwise inaccessible species, the structural characterization of free ions, and the comparative evaluation of their reactivity in different environments, in particular, gas phase and solution.

Intraarterial chemotherapy through carotid transposition in advanced head and neck cancer

We report results of intraarterial chemotherapy (IAC) in patients with advanced unresectable (T4, N0-3, MO) squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) of the oral cavity, oropharynx, or facial skin, given through a subcutaneously transposed external carotid artery by a fine gauge needle. Forty patients entered the study and 39 were evaluable for clinical response and toxicity. The infusion technique was done in two consecutive series of patients with the same characteristics: 17 had treatment with vincristine, bleomycin, and methotrexate (VBM), and 22 received cisplatin and bleomycin (PB) with a median number of six and five cycles, respectively. The total objective response (OR) rate was 76.9%, which included 12.8% of complete response (CR). A better percentage of OR was attained in BCC than SCC (83.3% versus 75.8%), in tumors of the skin of the face than other sites (87.5% versus 74.2%), and in the group that received PB than the group that received VBM (77.3% versus 76.5%). Our series had an overall technique-related toxicity of 18%; 10.3% with neurologic disturbances and 7.7% with skin inflammation (almost all were reversible). The most common systemic toxic side effects were generally mild and well tolerated (30.8%), whereas major toxicities (severe modifications of the cardiopulmonary function) occurred in four patients (10.3%) in the group that received VBM. After chemotherapy, 28 patients (71.8%) were deemed resectable; 23 of these patients (82.1%) agreed to surgery. Pathologic CR were obtained in 13 patients (56.5%). Our technique has significant advantages over the conventional methods of infusion, because tumor perfusion is feasible and selective, technique-related and catheter-related complications are almost completely eliminated, and fatal drug-related side effects are avoided.

5-Fluorouracil and high-dose folinic acid as second-line chemotherapy in head and neck cancer

Experimental and clinical data support the concomitant use of 5-fluorouracil (5-FU) and high-dose folinic acid (HDFA). To verify the role of such a combination in far advanced head and neck cancer, we performed a phase II study employing weekly HDFA, 500 mg/m2 in 2-h infusions, and 5-FU, 600 mg/m2 bolus injection. Twenty-seven evaluable patients with recurrent disease entered the study. One complete response, seven partial responses, 10 stable disease, and nine progressions were observed: the overall response rate was 29.6%. Oral mucositis and diarrhea were major side effects; five patients discontinued the treatment due to toxicity; no deaths correlated to the treatment were detected. Considering the characteristics of our patients, the 5-FU/HDFA combination has shown a satisfactory antitumoral activity, but toxicity was similar to other chemotherapy regimens.

A possible role of chromatin and tightly-bound chromatin proteins on enzyme-catalyzed methylation of DNA

Upon extensive digestion with DNAaseI of placenta chromatin matrix, previously "stripped" from its loosely-bound components by high-salt extraction, a fraction is obtained that contains almost no endogenous DNA methylase activity but whose DNA, if still included in this whole fraction--not if it has been purified to a protein-free condition--is a good substrate for externally added enzyme. This chromatin matrix can even cause a significant stimulation of methylation of single-stranded Micrococcus luteus DNA by placental methylase. In vivo, this phenomenon may have possible counterparts in the existence of highly-methylated regions of chromatin loops that appear to be protected by tightly-bound protein components from digestion of the "stripped loops" with DNAaseI.

Localization, in human placenta, of the tightly bound form of DNA methylase in the higher order of chromatin organization

In human placenta, the DNA of all subfractions of the third level of chromatin organization exhibits similar values of the methylcytosine-to-cytosine ratio. The tightly bound form of DNA methyltransferase is mostly recovered in the 'stripped loop' fraction, although, on the basis of the DNA content, the 'stripped loops' and the 'stripped matrix' appear to possess a similar amount of the enzyme. DNA methyltransferase activity is instead totally absent from the 'digested matrix', i.e., from the fraction remaining after digestion of the 'stripped matrix' with DNAase I. Upon addition of exogenous DNA methyltransferase, however, the DNA of this fraction, which is only 1% (in weight) of the total chromatin DNA and which has a length of approx. 9 kbp, can readily undergo methylation.

5-Methylcytosine levels in nucleosome subpopulations differently involved in gene expression

Sucrose density gradient centrifugation in the presence or absence of Na-EDTA and at different ionic strengths allows one to obtain well-defined nucleosome subpopulations the DNA of which, examined by gas chromatography-mass spectrometry, is in all cases hypermethylated as compared to spacer regions, but to a different extent for the different subpopulations. The various nucleosomes differ also in their content of histones and of high-mobility-group proteins, as well as in the levels of RNA polymerase activity associated with them. Such data suggest that these nucleosome subpopulations originate from chromatin fractions differently involved in gene expression.

Decay-induced incorporation of tritium into nucleosides in aqueous solutions

In view of environmental and biological implications, the decay-induced incorporation of tritium from T2 into nucleosides in aqueous solutions has been studied by chromatographic methods. It could be shown that at T2 concentrations of about 1 to 2 mCi/ml, labeling of thymidine or deoxyuridine mainly occurs via the 3HeT+ decay ion rather than via beta--radiolysis. In a saturated solution of thymidine, the number of thymidine molecules labeled per tritium decay (L-value) is only 8 X 10(-4), concomitantly 0.6 HTO molecules are also formed, together with CH3T (L = 0.2) and an unidentified organic product (L = 10(-3). Compared to identical concentrations of HT and HTO in aqueous deoxyuridine solutions, the labeling efficiency of T2 is an order of magnitude higher.

Continuous Elemental Analysis of Organic Compounds in Gas-Chromatographic Effluents

The compounds emerging from the gas-chromatographic column are quantitatively converted to a mixture of CO(2) and H(2). These gases are separated by means of an auxiliary column. The ratio of C and H atoms of each substance is deduced from the areas of carbon dioxide and hydrogen peaks.