Metronomic cyclophosphamide for bone marrow carcinomatosis in metastatic castration-resistant prostate cancer

PURPOSE

In some patients with prostate cancer, bone marrow carcinomatosis develops later in the course of the disease, which has a poor prognosis. These are often heavily pretreated patients in the castration-resistant situation for whom there are no other therapeutic options, because either all available systemic therapies have already been used or the use of one is not possible due to the cytopenias associated with bone marrow carcinomatosis. In our literature search, there are no data on this treatment in the setting available, especially no clinical trial or even randomized data. This case series is to determine the clinical efficacy of metronomic cyclophosphamide in patients with metastatic castration-resistant prostate cancer and bone marrow carcinomatosis, particularly with regard to stabilization of the blood count (thrombocytopenias) and thus the possibility of further (more toxic) lines of therapy.

METHODS

Retrospective unicenter analysis was performed on eleven patients between 54 and 84 years of age on metronomic cyclophosphamide for bone marrow carcinomatosis in metastatic castration-resistant prostate cancer treated at a Swiss cancer center between 2014 and 2023.

RESULTS

Eleven patients received metronomic cyclophosphamide for varying periods of time; the majority had severe cytopenias (especially thrombocytopenias). Partially hematologic stabilization was achieved with administration of further systemic therapies.

CONCLUSION

Our case series demonstrates that the use of metronomic cyclophosphamide allows hematologic stabilization for months, benefiting patients who had already received all available therapies for metastatic castration-resistant prostate cancer. Alternatively, it may act as bridging therapy to allow consecutive administration of more toxic therapies with proven survival benefit.

Analysis of the incidence, characteristics, and risk factors of complications during induction chemotherapy in children with high-risk neuroblastoma

Patients with high-risk neuroblastoma (HR-NB) exhibit suboptimal 5-year survival rates, leading to a widespread international preference for high-intensity chemotherapeutic regimens in these children. We analyzed the incidence and risk factors for complications during induction chemotherapy in children with HR-NB and tried to assist clinicians in predicting such complications and optimizing therapeutic strategy. The clinical data of children with HR-NB admitted to our hospital from January 2007 to December 2019 were retrospectively analyzed. The incidence, characteristics, and risk factors of complications (infection, hemorrhage, and chemotherapy-related adverse reactions (CRAR)) requiring hospitalization during induction chemotherapy in these children were explored. (1) A total of 108 patients with HR-NB were included in the final analysis. The overall infection rate was 92.6% (100/108), with the highest incidence of 71.3% observed during the first cycle. FN, bacterial infection, as well as fungal infection were common infectious complications in children with HR-NB during induction chemotherapy. (2) The overall hemorrhage rate was 24.1% (26/108), with the highest incidence of 14.8% also observed in the first cycle. Among the children with hemorrhage, there were 72% with bone marrow involved, while 65.0% of them had a high vanillylmandelic acid (VMA) value. And children with hemorrhage also exhibited neuron-specific enolase (NSE) ≥ 200 µg/L in 88.5% of cases and lactic dehydrogenase (LDH) ≥ 1000U/L in 73.1% of cases. (3) The incidence of CRAR rate was 100%, and 99.1% (107/108) patients experienced myelosuppression. The incidence of myelosuppression peaked in the third cycle, reaching up to 85.2%. Most children suffered severe myelosuppression existed with bone marrow metastases (76.3%), abnormal VMA (67.5%), and LDH ≥ 1000 U/L (60%). (4) Non-myelosuppressive adverse effects were observed in 75.9% children (82/108), with the highest incidence occurring in the third cycle at 42.6%. (5) Patients who experienced three types of complications had a lower median survival time (MST) of 54.4 months, a 3-year event-free survival (EFS) rate of (44.2 ± 10.7)%, and a 3-year overall survival (OS) rate of (75.8 ± 8.6)%, in comparison to those with only one or two complications, who had a higher MST of 59.5 months, a 3-year EFS rate of (73.5 ± 5.2)% (X2 = 10.457, P = 0.001), and a 3-year OS rate of (84.8 ± 4.1)% (X2 = 10.511, P = 0.001).

CONCLUSION

The presence of bone marrow involved and increased VMA were high-risk factors for infection, while NSE ≥ 200 µg/L and LDH ≥ 1000 U/L were high-risk factors for hemorrhage. For those children who had experienced severe myelosuppression, the presence of bone marrow metastases, increased VMA, and LDH ≥ 1000 U/L were their risk factors. The presence of bone involvement was a high-risk factor for children to have non-myelosuppressive adverse effects. Complications that arise during induction chemotherapy could negatively impact the children's prognosis and overall quality of life.

WHAT IS KNOWN

• The high-risk neuroblastoma (HR-NB) had a worse prognosis; there was a general international preference for high-intensity chemotherapeutic regimens in the induction phase to these children.

WHAT IS NEW

• We analyzed the incidence and risk factors of complications during induction chemotherapy in children with HR-NB and tried to help clinicians predict such complications and adopt optimized therapeutic strategy.

[Effectiveness of autologous hematopoietic stem cell transplantation in the treatment of high-risk neuroblastoma in children: a single-center clinical study]

OBJECTIVES

To investigate the effectiveness of high-dose chemotherapy combined with autologous hematopoietic stem cell transplantation (ASCT) in the treatment of children with high-risk neuroblastoma (NB).

METHODS

A retrospective analysis was performed on 29 children with high-risk NB who were admitted to Shanghai Children's Hospital and were treated with high-dose chemotherapy combined with ASCT from January 2013 to December 2021, and their clinical features and prognosis were analyzed.

RESULTS

Among the 29 children treated by high-dose chemotherapy combined with ASCT, there were 18 boys (62%) and 11 girls (38%), with a median age of onset of 36 (27, 59) months. According to the International Neuroblastoma Staging System, 6 children (21%) had stage III NB and 23 children (79%) had stage IV NB, and the common metastatic sites at initial diagnosis were bone in 22 children (76%), bone marrow in 21 children (72%), and intracalvarium in 4 children (14%). All 29 children achieved reconstruction of hematopoietic function after ASCT. After being followed up for a median time of 25 (17, 45) months, 21 children (72%) had continuous complete remission and 8 (28%) experienced recurrence. The 3-year overall survival rate and event-free survival rate were 68.9%±16.1% and 61.4%±14.4%, respectively. Presence of bone marrow metastasis, neuron-specific enolase ≥370 ng/mL and positive bone marrow immunophenotyping might reduce the 3-year event-free survival rate (P<0.05).

CONCLUSIONS

Children with high-risk NB who have bone marrow metastasis at initial diagnosis tend to have a poor prognosis. ASCT combined with high-dose chemotherapy can effectively improve the prognosis of children with NB with a favorable safety profile.

Clinicopathological features and prognosis of breast cancer combined with symptomatic bone marrow metastases: A 10-year, single-center, real-world study of 67 cases

PURPOSE

Bone marrow metastasis (BMM) is uncommon in breast cancer (BC), and early diagnosis is challenging. BMM lacks definitive treatment options and poses a great threat to the survival of patients. Herein, we investigated the clinical features, prognosis, and factors affecting the prognosis of BC patients with symptomatic BMM to help improve the understanding of this disease and provide effective diagnostic and treatment strategies.

METHODS

Clinical data of 67 patients with BC and BMM were retrospectively analyzed for clinical characteristics, treatment, and prognosis of BMM. Univariate and multivariate analyses were performed to determine factors affecting overall survival following BMM (BMMOS).

RESULTS

Among patients with BMM, 86.6% were diagnosed after bone metastasis (BM), while 13.4% were diagnosed simultaneously with BM. A total of 73.1%, 13.4%, and 13.4% of the patients had hormone receptor-positive/human epidermal growth factor 2-negative (HR+/HER2-) tumors, HER2+ tumors, and triple-negative tumors, respectively. The most common symptoms of BMM were the coexistence of anemia and thrombocytopenia (26.9%), anemia (19.4%), and pancytopenia (17.9%). The median BMMOS was 7.6 months (95% CI, 3.9-11.3). Univariate and multivariate analyses showed that BMMOS was associated with platelet count <75 × 109 /L at the time of BMM diagnosis. The BMMOS of patients who underwent endocrine therapy, combined chemotherapy, and mono-chemotherapy after BMM was 15.7, 9.7, and 8.6 months, respectively, whereas that of untreated patients was 2.9 months, and the difference among the results was statistically significant (χ2  = 20.102, p < 0.0001). Changes in patient hemogram and/or body temperature during treatment were consistent with the overall effect of the disease (p < 0.0001).

CONCLUSION

BMM should be considered in BC patients with BM, an unexplained reduction in hemogram parameters, especially anemia and thrombocytopenia, and/or fever without chills. Active, effective, individualized treatment strategies can prolong BMMOS.

Docetaxel and fluorouracil as first-line therapy for gastric cancer with bone marrow metastasis and disseminated intravascular coagulation

Gastric cancer with bone marrow metastasis and disseminated intravascular coagulation constitutes a highly aggressive gastric cancer subtype which presents a peculiar biological behavior and very poor prognosis. Retrospective studies have shown chemotherapy could prolong survival, but a prospective trial is still unavailable. This study is the first prospective clinical trial to evaluate the safety and efficacy of chemotherapy for advanced gastric cancer patients with bone marrow metastasis.

[A Case of Rectal Cancer with Disseminated Intravascular Coagulation Successfully Treated with Emergent Chemotherapy]

A 70's woman complaining blood stool and lower abdominal pain visited a local doctor and was given the diagnosis of rectal cancer by colonoscopy. CT, MRI, and bone scintigraphy revealed multiple lymph node and bone metastasis and peritoneal dissemination. She had developed disseminated intravascular coagulation(DIC)during hospitalization, and the cause was considered to be disseminated carcinomatosis of the bone marrow. Thus, we emergently started chemotherapy with mFOLFOX6, in conjunction with anticoagulation therapy, and the DIC was resolved 11 days after the introduction. Partial response was achieved and the chemotherapy has been continued after 5 months from the onset of the DIC. Since the prognosis of solid tumor patients who developed DIC has been reported to be extremely poor, prompt introduction of chemotherapy should be considered.

A nomogram of clinical and biologic factors to predict survival in children newly diagnosed with high-risk neuroblastoma: An International Neuroblastoma Risk Group project

BACKGROUND

Long-term outcome remains poor for children with high-risk neuroblastoma (five-year overall survival [OS] ∼50%). Our objectives were to (a) identify prognostic biomarkers and apply them in a nomogram to identify the subgroup of ultra-high-risk patients at highest risk of disease progression/death, for whom novel frontline therapy is urgently needed; and (b) validate the nomogram in an independent cohort.

METHODS

A total of 1820 high-risk patients (≥18 months old with metastatic neuroblastoma), diagnosed 1998-2015, from the International Neuroblastoma Risk Groups (INRG) Data Commons were analyzed in a retrospective cohort study. Using multivariable Cox regression of OS from diagnosis, a nomogram was created from prognostic biomarkers to predict three-year OS. External validation was performed using the SIOPEN HR-NBL1 trial cohort (n = 521), evidenced by receiver operating characteristic curves.

RESULTS

The nomogram, including MYCN status (P < 0.0001), lactate dehydrogenase (LDH) (P = 0.0007), and presence of bone marrow metastases (P = 0.004), had robust performance and was validated. Applying the nomogram at diagnosis (a) gives prognosis of an individual patient and (b) identifies patients predicted to have poor outcome (three-year OS was 30% ± 5% for patients with a nomogram score of > 82 points; 58% ± 1% for those ≤82 points). Median follow-up time was 5.5 years (range, 0-14.1).

CONCLUSIONS

In high-risk neuroblastoma, a novel, publicly available nomogram using prognostic biomarkers (MYCN status, LDH, presence of bone marrow metastases; https://neuroblastoma.shinyapps.io/High-Risk-Neuroblastoma-Nomogram/) has the flexibility to apply a clinically suitable and context-specific cutoff to identify patients at highest risk of death. This will facilitate testing urgently needed new frontline treatment options to improve outcome for these children.

[A Case Report of Cancer Chemotherapy for Disseminated Carcinomatosis of the Bone Marrow Associated with Gastric Cancer Accompanied by Disseminated Intravascular Coagulation]

A 72-year-old woman was admitted to our hospital because of symptoms of bleeding diathesis such as hematuria and purpura. A blood test revealed disseminated intravascular coagulation(DIC). Upper gastrointestinal endoscopy showed advanced gastric cancer. Bone marrow aspiration cytology demonstrated diffuse hyperplasia of large atypical cells, and metastasis of the epithelial tumor was suspected on immunohistochemical examination. She was diagnosed with disseminated carcinomatosis of the bone marrow associated with gastric cancer accompanied by DIC. She was treated with weekly infusion of methotrexate 100 mg/m2 plus 5-fluorouracil 600 mg/m2 for 4 courses; and she completely recovered from DIC. She received oral tegafur/gimeracil/oteracil as an outpatient. However, DIC recurred 126 days after the initial chemotherapy, and 5-fluorouracil plus cisplatin was administered subsequently. After 1 course, she died 166 days after the initial chemotherapy. Although the prognosis of patients with disseminated carcinomatosis of the bone marrow associated with gastric cancer accompanied by DIC is extremely poor, this case shows that secession of DIC and prognostic improvement by chemotherapy could occur. Chemotherapy could be considered a potentially effective treatment in this case.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Carcinoma of the Rectum Diagnosed by Disseminated Intravascular Coagulation]

A 77-year-old man with rectal cancer was admitted to our hospital. After neoadjuvant chemotherapy, laparoscopic abdominoperineal resection of rectum with D3 dissection was performed. The pathological diagnosis was poorly differentiated carcinoma, pT3, N1a, M0, pStage Ⅲa. Adjuvant chemotherapy was not performed. Fifteen months after operation, his chief complaint was fatigue. Thrombocytopenia and elevation of tumor maker was detected by blood test and disseminated intravascular coagulation(DIC)was suspected. He was admitted to our hospital and we started anti DIC therapy immediately. Bone scintigraphy revealed multiple bone metastases, then we diagnosed disseminated carcinomatosis of the bone marrow. He died 10 days after hospitalization. Disseminated carcinomatosis of the bone marrow with colon cancer is rare and prognosis is very poor. It is important to diagnose and start treatment as early as possible.

[A Case of Advanced Gastric Cancer with Bone Marrow Metastasis Treated with Low-Dose Combination Chemotherapy Containing S-1 and Docetaxel]

A 77-year-old woman was admitted to our hospital with complaints of lumbago. Based on MRI, bone marrow biopsy, and upper endoscopy, she was diagnosed as having advanced gastric cancer accompanied by bone marrow metastasis and multiple bone metastases. She underwent combination chemotherapycontaining S-1 and docetaxel(TXT). However, during the first course of chemotherapy, she developed Grade 4 neutropenia and sepsis, and her ADL worsened. The anticancer agent doses were reduced drasticallyto 40% of the initial dose from the next course of chemotherapy. She was able to continue treatment without developing severe adverse events, and the disease did not progress for 11 months. However, during the 6 course of chemotherapy, she developed Grade 4 neutropenia and sepsis again, and it became difficult to continue treatment. Subsequent S-1 monotherapywas not efficacious, and she died 17 months after diagnosis. From the view of persistence and efficacy, we believe that low-dose combination chemotherapycontaining S-1 and TXT maybe a suitable regimen for advanced gastric cancer with bone marrow metastasis.

[A Case of Bone Marrow Carcinomatosis of Occult Breast Cancer Treated Effectively with Fulvestrant]

A 63-year-old woman experienced left cervical lymph node swelling since May 2012. Based on PET-CT findings, metastases of a malignant tumor to the mediastinal, axillary, and left cervical lymph nodes were suspected. Her left cervical lymph node biopsy revealed metastatic carcinoma of occult cancer, because no primary tumor could be identified despite the specific examinations. She rejected further therapeutic intervention. In July 2013, she was admitted because of anemia, cardiac failure, and fever. She was diagnosed with bone marrow carcinomatosis from occult cancer based on her bone marrow biopsy. Metastatic breast cancer was mostly considered because she tested positive for estrogen and progesterone receptors, CA15-3 levels were increased, and her axillary lymph nodes were swollen. Fulvestrant and zoledronic acid were administered and continued for 20 months, with improvement in anemia and tumor marker levels, and also maintenance of partial response.

[A Case of Microangiopathic Hemolytic Anemia with Bone Marrow Carcinomatosis from Breast Cancer]

We report a case of microangiopathic hemolytic anemia(MHA)caused by metastatic breast cancer treated with weekly paclitaxel. A 58-year-old woman was diagnosed with metastatic breast cancer 2 years earlier. She was treated with various chemotherapy regimens and hormonal therapy, before being switched to fulvestrant 3 months earlier. She presented with severe anemia, and was diagnosed with MHA with bone marrow carcinomatosis following bone marrow biopsy. She was treated with weekly paclitaxel and recovered successfully. A subsequent biopsy showed that the bone marrow carcinomatosis had decreased. MHA due to breast cancer is rare and is associated with poor prognosis; however, rapid initiation of chemotherapy may be effective.

A Spindle Cell Tumor of Unknown Origin and Diffuse Bone Marrow Involvement in a Patient with Hypercalcemia

Background

Metastasis of unknown origin in bone marrow is infrequent, although, when it occurs, adenocarcinoma is the most common histologic type. Involvement of bone marrow by a spindle cell tumor and presentation with hypercalcemia are very rare.

Method

This report describes a 21-year-old man with diffuse bone marrow involvement from a spindle cell tumor.

Results

The patient presented with low back pain, anemia, thrombocytopenia, azotemia, and hypercalcemia. Bone marrow biopsy revealed a spindle cell tumor that was positive for vimentin staining but whose primary site could not be identified. A bone marrow scan revealed absence of uptake, which suggested systemic disease. We treated this case as a type of sarcoma by giving combined chemotherapy consisting of vincristine, actinomycin-D and cyclophosphamide. The patient showed a clinical response for seven months, but the disease progressed despite chemotherapy and he died one year after diagnosis.

Conclusions

We have documented a rare case of spindle cell tumor involving bone marrow without evidence of the tumor's primary site.

Use of hormone therapies in disseminated carcinomatosis of the bone marrow associated with hormone receptor-positive breast cancer

Disseminated carcinomatosis of the bone marrow (DCBM) is diffusely invasive bone metastasis resulting from solid tumors. DCBM is often associated with disseminated intravascular coagulation (DIC) or hemolytic anemia. Generally, DCBM treatment includes cytotoxic chemotherapy for underlying solid tumors and management of hematological conditions if present. We report a case of DCBM accompanied with DIC in hormone receptor-positive breast cancer. Due to her life-threatening condition, we used hormone therapies, not cytotoxic chemotherapies, to treat her DCBM. With zoledronic acid, her DIC and general condition gradually improved and eventually she could return to her daily life. If DCBM occurs in hormone receptor-positive breast cancer, hormone therapy can be one of the treatment choices.

[Prolonged Survival Following Chemotherapy in Bone Marrow Carcinomatosis Due to Esophagogastric Junctional Carcinoma - A Case Report]

A 60s-year-old Japanese male underwent curative resection for an advanced adenocarcinoma of the esophagogastric junction(Stage III C), followed by adjuvant chemotherapy.Twenty -one months later, he was admitted to our hospital with a complaint of marked decline in activities of daily living(ADL).The patient was diagnosed with pancytopenia, disseminated intravascular coagulation(DIC), multiple lymph node and bone metastases, and bone marrow carcinomatosis.After completing a sufficient informed consent process, he received chemotherapy along with blood transfusion, and then DIC, pancytopenia, and ADL of the patient improved.However, the lack of response of pancytopenia and DIC to transfusion relapsed and his ADL worsened after the second course of chemotherapy.It was difficult to administer additional chemotherapy in the patient and he died 24 months after surgery.There is no established treatment for disseminated carcinomatosis of the bone marrow, and the prognosis of these patients without treatment is reported to be only one month.Our case with prolonged survival following chemotherapy and blood transfusion may support the clinical usefulness of chemotherapy for bone marrow carcinomatosis from esophagogastric junctional carcinoma.

[Clinical Efficacy of Paclitaxel plus Bevacizumab Combination Therapy for Bone Marrow Carcinomatosis Arising from Breast Cancer - A Case Report]

We report a case of a 42-year-old woman with bone marrow carcinomatosis in the course of metastatic breast cancer who responded well to paclitaxel plus bevacizumab(PTX plus Bev)combination therapy. Four years after initial breast conserving surgery, she was admitted to our hospital with back pain and general malaise and was diagnosed as multiple bone metastases with bone marrow carcinomatosis originating from previous breast cancer(ER+/HER2-). While administering denosumab, we initiated systemic chemotherapy with PTX plus Bev. There has been no sign of progression at 1 year after beginning the treatment. Therefore, we conclude that PTX plus Bev combination therapy could be effective and sustainable treatment for bone marrow carcinomatosis arising from metastatic breast cancer.

Rituximab and dose-dense chemotherapy for adults with Burkitt's lymphoma: a randomised, controlled, open-label, phase 3 trial

BACKGROUND

Short intensive chemotherapy is the standard of care for adult patients with Burkitt's leukaemia or lymphoma. Findings from single-arm studies suggest that addition of rituximab to these regimens could improve patient outcomes. Our objective was to test this possibility in a randomised trial.

METHODS

In this randomised, controlled, open-label, phase 3 trial, we recruited patients older than 18 years with untreated HIV-negative Burkitt's lymphoma (including Burkitt's leukaemia) from 45 haematological centres in France. Exclusion criteria were contraindications to any drug included in the chemotherapy regimens, any serious comorbidity, poor renal (creatinine concentration >150 μmol/L) or hepatic (cirrhosis or previous hepatitis B or C) function, pregnancy, and any history of cancer except for non-melanoma skin tumours or stage 0 (in situ) cervical carcinoma. Patients were stratified into two groups based on disease extension (absence [group B] or presence [group C] of bone marrow or central nervous system involvement). Patients were further stratified in group C according to age (<40 years, 40-60 years, and >60 years) and central nervous system involvement. Participants were randomly assigned in each group to either intravenous rituximab injections and chemotherapy (lymphome malin B [LMB]) or chemotherapy alone by the Groupe d'Etude des Lymphomes de l'Adulte datacentre. Randomisation was stratified by treatment group and centre using computer-assisted permuted-block randomisation (block size of four; allocation ratio 1:1). We gave rituximab (375 mg/m(2)) on day 1 and day 6 during the first two courses of chemotherapy (total of four infusions). The primary endpoint is 3 year event-free survival (EFS). We analysed all patients who had data available according to their originally assigned group. This trial is registered with ClinicalTrials.gov, number NCT00180882.

RESULTS

Between Oct 14, 2004, and Sept 7, 2010, we randomly allocated 260 patients to rituximab or no rituximab (group B 124 patients [64 no rituximab; 60 rituximab]; group C 136 patients [66 no rituximab; 70 rituximab]). With a median follow-up of 38 months (IQR 24-59), patients in the rituximab group achieved better 3 year EFS (75% [95% CI 66-82]) than did those in the no rituximab group (62% [53-70]; log-rank p stratified by treatment group=0·024). The hazard ratio estimated with a Cox model stratified by treatment group, assuming proportionality, was 0·59 for EFS (95% CI 0·38-0·94; p=0·025). Adverse events did not differ between the two treatment groups. The most common adverse events were infectious (grade 3-4 in 137 [17%] treatment cycles in the rituximab group vs 115 [15%] in the no rituximab group) and haematological (mean duration of grade 4 neutropenia of 3·31 days per cycle [95% CI 3·01-3·61] vs 3·38 days per cycle [3·05-3·70]) events.

INTERPRETATION

Addition of rituximab to a short intensive chemotherapy programme improves EFS in adults with Burkitt's leukaemia or lymphoma.

FUNDING

Gustave Roussy Cancer Campus, Roche, Chugai, Sanofi.

[A Case of Disseminated Bone Marrow Carcinomatosis Arising from Breast Cancer for Which Paclitaxel and Bevacizumab Treatment Was Effective]

A 42-year-old woman visited our hospital with high fever and general malaise. A CT examination revealed that she had carcinoma of the left breast with axillary lymph node metastases and multiple bone metastases. A blood test showed anemia, thrombopenia and the existence of blast-like cells. Adenocarcinoma cells were detected in a bone marrow aspiration specimen, and the patient was diagnosed with disseminated carcinomatosis of the bone marrow. Systemic chemotherapy with paclitaxel plus bevacizumab was initiated while a blood transfusion was performed. Her symptoms improved, and the blood test results normalized. Disseminated carcinomatosis of the bone marrow is reported to have a poor prognosis, but paclitaxel plus bevacizumab is a possible effective chemotherapy.

[HER2-Positive Advanced Gastric Cancer with Disseminated Intravascular Coagulation and Diffuse Bone Marrow Carcinomatosis Successfully Treated with S-1/Trastuzumab Chemotherapy--A Case Report]

Trastuzumab, a humanized monoclonal antibody against human epidermal growth factor receptor 2 (HER2), has been proven to result in a survival benefit for the treatment of patients with HER2-positive advanced gastric cancer (AGC). However, data are lacking for the treatment of those with disseminated intravascular coagulation (DIC) and diffuse bone marrow carcinomatosis. A 77-year-old woman presented with back pain and fatigue since 2 months. Esophagogastroduodenoscopy showed a scirrhous lesion in the gastric corpus, which was biopsied and identified as signet-ring cell carcinoma with HER2 overexpression on immunohistochemistry. Laboratory testing, bone scintigraphy, and bone marrow biopsy were conducted, and she was diagnosed with HER2-positive AGC with DIC and diffuse bone marrow carcinomatosis. She underwent chemotherapy with the following regimen: oral administration of 80 mg/m2 S-1 for 2 weeks and 6 mg/kg trastuzumab infusion on day 6 every 3 weeks, which significantly improved the DIC. She was discharged from the hospital 73 days after admission and survived for 438 days after diagnosis. To the best of our knowledge, this is the first case report in which HER2-positive AGC complicated by DIC with diffuse bone marrow carcinomatosis was successfully treated with combined chemotherapy consisting of S-1 plus trastuzumab.

[A Case of Signet-Ring Cell Carcinoma of the Sigmoid Colon with Disseminated Carcinomatosis Successfully Treated with CPT-11/Panitumumab]

A 70-year-old man, who had undergone S-1/oxaliplatin/bevacizumab combination chemotherapy for LNs metastasis of signet-ring cell carcinoma of the sigmoid colon, complained of back pain and lumbago.He was diagnosed with disseminated carcinomatosis of the bone marrow and disseminated intravascular coagulation (DIC). He was treated with systemic chemotherapy consisting of CPT-11/panitumumab. After 2 courses of the treatment, the DIC resolved and the back pain and lumbago improved.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Disseminated Intravascular Coagulation Caused by Cecal Cancer Successfully Treated with mFOLFOX6]

Disseminated carcinomatosis of the bone marrow is often accompanied by disseminated intravascular coagulation syndrome (DIC). This condition is rarely caused by colorectal cancer, and there are no established therapies.

OUR CASE

A 66-year-old woman was admitted to our hospital because of DIC. She had been diagnosed with cecal cancer and multiple metastases of the lymph nodes, liver, and bone. She was diagnosed with disseminated carcinomatosis of the bone marrow and treated with systemic chemotherapy by modified FOLFOX6 (mFOLFOX6). Subsequently, the DIC rapidly resolved, and she was discharged from the hospital.

JAK Inhibition Impairs NK Cell Function in Myeloproliferative Neoplasms

Ruxolitinib is a small-molecule inhibitor of the JAK kinases, which has been approved for the treatment of myelofibrosis, a rare myeloproliferative neoplasm (MPN), but clinical trials are also being conducted in inflammatory-driven solid tumors. Increased infection rates have been reported in ruxolitinib-treated patients, and natural killer (NK) cells are immune effector cells known to eliminate both virus-infected and malignant cells. On this basis, we sought to compare the effects of JAK inhibition on human NK cells in a cohort of 28 MPN patients with or without ruxolitinib treatment and 24 healthy individuals. NK cell analyses included cell frequency, receptor expression, proliferation, immune synapse formation, and cytokine signaling. We found a reduction in NK cell numbers in ruxolitinib-treated patients that was linked to the appearance of clinically relevant infections. This reduction was likely due to impaired maturation of NK cells, as reflected by an increased ratio in immature to mature NK cells. Notably, the endogenous functional defect of NK cells in MPN was further aggravated by ruxolitinib treatment. In vitro data paralleled these in vivo results, showing a reduction in cytokine-induced NK cell activation. Further, reduced killing activity was associated with an impaired capacity to form lytic synapses with NK target cells. Taken together, our findings offer compelling evidence that ruxolitinib impairs NK cell function in MPN patients, offering an explanation for increased infection rates and possible long-term side effects associated with ruxolitinib treatment.

Nasopharyngeal carcinoma with bone marrow metastasis: positive response to weekly paclitaxel chemotherapy

A 51-year-old man with nasopharyngeal carcinoma underwent chemoradiotherapy with cisplatin and 5-fluorouracil, followed by a left cervical lymphadenectomy. Distant metastatic disease was excluded using fluoro-deoxyglucose positron emission tomography. Seven months later, bone marrow metastasis and disseminated intravascular coagulation were diagnosed. The patient received weekly paclitaxel therapy and maintained a good performance status for seven months. During the treatment period, the patient developed no severe organ toxicity except for neutropenia. Weekly paclitaxel may therefore be considered as the treatment of choice in patients with advanced or recurrent nasopharyngeal carcinoma with bone marrow metastasis.

[Cerebral aspergillosis in an immunocompromised patient with follicular lymphoma]

We present a case of central nervous system aspergillosis in an immunocompromised 69-year-old male with a history of chemotherapeutic treatment for follicular lymphoma. The patient presented with aphasia, apraxia and confusion. An MRI of the central nervous system and Aspergillus antigen in the spinal fluid was suggestive for this invasive fungal infection. Despite treatment with voriconazole the patient succumbed to the infection. A rise in rare, severe infectious complications as presented is expected due to increasing dose-intensity of chemotherapy.

[A case of bone marrow carcinomatosis with disseminated intravascular coagulation arising from breast cancer successfully treated with paclitaxel plus bevacizumab]

We report a case of bone marrow carcinomatosis with disseminated intravascular coagulation (DIC) originating from metastatic breast cancer that was treated with paclitaxel plus bevacizumab. A woman in her 30s was diagnosed with bone marrow carcinomatosis arising from metastatic breast cancer 2 years previously. Pathologically, estrogen receptor (ER) and progesterone receptor(PgR) / -positive and human epidermal growth factor receptor 2(HER2/neu)-negative scirrhous carcinoma was diagnosed. She improved after treatment with paclitaxel plus bevacizumab and zoledronic acid. Subsequently, she was treated with hormonal therapy(tamoxifen plus luteinizing-hormone-releasing hormone [LH-RH]agonist) for 7 months. Because progressive bone metastasis was identified and tumor markers increased, the patient was administered paclitaxel plus bevacizumab again. Fifteen days after chemotherapy was initiated, DIC developed. Chemotherapy was continued without decreasing the dose, and recombinant human soluble thrombomodulin (rTM) was added. The DIC resolved in 5 days. After 6 courses of paclitaxel plus bevacizumab, improvement of tumor markers and bone metastasis was observed. Paclitaxel plus bevacizumab can be effective for treatment of bone marrow carcinomatosis with DIC originating from metastatic breast cancer.

[A case of disseminated carcinomatosis of the bone marrow with disseminated intravascular coagulation caused by advanced colon cancer successfully treated with SOX/bevacizumab]

Our patient was a 58-year-old man who was diagnosed with a large bowel obstruction caused by ascending colon cancer, together with multiple liver metastases for which a right hemicolectomy was performed. After the operation, he developed disseminated intravascular coagulation(DIC)and severe anemia. Bone marrow biopsy findings led to a diagnosis of disseminated carcinomatosis of the bone marrow caused by colon cancer. We administered S-1+oxaliplatin(SOX) and bevacizumab( BV)chemotherapy, which improved the DIC. The patient was discharged from the hospital. After a total of six courses of chemotherapy, the carcinoma became resistant. We changed the drug regimen and his clinical condition improved. He survived for 292 days from the onset of disease.

Molecular characterization of enzalutamide-treated bone metastatic castration-resistant prostate cancer

BACKGROUND

Enzalutamide is a novel antiandrogen with proven efficacy in metastatic castration-resistant prostate cancer (mCRPC).

OBJECTIVE

To evaluate enzalutamide's effects on cancer and on androgens in blood and bone marrow, and associate these with clinical observations.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective phase 2 study, 60 patients with bone mCRPC received enzalutamide 160mg orally daily and had transilial bone marrow biopsies before treatment and at 8 wk of treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Androgen signaling components (androgen receptor [AR], AR splice variant 7 (ARV7), v-ets avian erythroblastosis virus E26 oncogene homolog [ERG], cytochrome P450, family 17, subfamily A, polypeptide 1 [CYP17]) and molecules implicated in mCRPC progression (phospho-Met, phospho-Src, glucocorticoid receptor, Ki67) were assessed by immunohistochemistry; testosterone, cortisol, and androstenedione concentrations were assessed by liquid chromatography-tandem mass spectrometry; AR copy number was assessed by real-time polymerase chain reaction. Descriptive statistics were applied.

RESULTS AND LIMITATIONS

Median time to treatment discontinuation was 22 wk (95% confidence interval, 19.9-29.6). Twenty-two (37%) patients exhibited primary resistance to enzalutamide, discontinuing treatment within 4 mo. Maximal prostate-specific antigen (PSA) decline ≥ 50% and ≥ 90% occurred in 27 (45%) and 13 (22%) patients, respectively. Following 8 wk of treatment, bone marrow and circulating testosterone levels increased. Pretreatment tumor nuclear AR overexpression (> 75%) and CYP17 (> 10%) expression were associated with benefit (p = 0.018). AR subcellular localization shift from the nucleus was confirmed in eight paired samples (with PSA decline) of 23 evaluable paired samples. Presence of an ARV7 variant was associated with primary resistance to enzalutamide (p = 0.018). Limited patient numbers warrant further validation.

CONCLUSIONS

The observed subcellular shift of AR from the nucleus and increased testosterone concentration provide the first evidence in humans that enzalutamide suppresses AR signaling while inducing an adaptive feedback. Persistent androgen signaling in mCRPC was predictive of benefit and ARV7 was associated with primary resistance.

PATIENT SUMMARY

We report a first bone biopsy study in metastatic prostate cancer in humans that searched for predictors of outcome of enzalutamide therapy. Benefit is linked to a pretreatment androgen-signaling signature.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01091103.

[A case of rapidly fatal gastric cancer with disseminated carcinomatosis of the bone marrow]

A 50-year-old man underwent thorough examination for a chief complaint of melena. Gastric cancer and right kidney cancer were diagnosed. The gastric cancer was in the antrum, and poorly differentiated adenocarcinoma was diagnosed by biopsy. The right kidney cancer was diagnosed as clear cell carcinoma by computed tomography-guided biopsy. We performed right nephrectomy and distal gastrectomy. The final diagnosis of the gastric cancer was por2, pT3( ss), pN3b( 46/ 61), M0, pStage IIIB, R0, and that of the kidney cancer was clear cell carcinoma, pT3a, pN0, pM0. The patient reported lower back pain approximately 2 months after surgery. Several examinations revealed that the patient had multiple bone metastases, disseminated carcinomatosis of the bone marrow, and disseminated intravascular coagulation (DIC).We treated the bone metastasis with denosumab and palliative radiation therapy and the gastric cancer with weekly paclitaxel (PTX). The DIC subsided during the first course but recurred during the discontinuation period. We attempted additional trastuzumab treatment but did not achieve a curative effect, and the patient died. It is necessary to provide appropriate medical care while taking into consideration the possibility of disseminated carcinomatosis of the bone marrow in cases with a high likelihood of lymph node metastasis.

[A case of gastric cancer accompanied by disseminated carcinomatosis of the bone marrow successfully controlled by S-1 and cisplatin combination therapy]

We report a case of gastric cancer accompanied by disseminated carcinomatosis of the bone marrow treated with S-1 and cisplatin( CDDP) combination chemotherapy. The patient was a 68-year-old woman who was detected as having disseminated intravascular coagulation( DIC) during an examination for gastric cancer and she was diagnosed as having disseminated carcinomatosis of the bone marrow by lumbar puncture. She was immediately treated with S-1 and CDDP combination chemotherapy( S-1, 80 mg/body orally administered[ po] on days 1-21 and CDDP, 60 mg/body intravenously [iv] administered on day 8) and her DIC improved on the fourth day. Subsequently, the patient was treated with 3 courses of combination chemotherapy and she survived for 184 days from the initiation of the treatment. Although disseminated carcinomatosis of the bone marrow is associated with a poor prognosis, we believe that the duration of survival of our patient was extended due to initiation of chemotherapy at an early stage.

[A case of mucinous adenocarcinoma of the sigmoid colon with disseminated carcinomatosis of the bone marrow successfully treated with FOLFOX4/bevacizumab]

A 68-year-old man complaining of back pain was given the diagnosis of mucinous adenocarcinoma of the sigmoid colon with disseminated carcinomatosis of bone marrow and disseminated intravascular coagulation(DIC). We started chemotherapy using FOLFOX4. After we confirmed that DIC had improved following 2 courses of FOLFOX4, bevacizumab was added to FOLFOX4. Laboratory studies revealed a serum CEA level of 11, 432 ng/mL, which improved to 245 ng/mL after a total of 9 courses of chemotherapy. Chemotherapy is continuing as scheduled at 6 months from the onset of this disease.

[A case of progressive gastric carcinoma accompanied by disseminated carcinomatosis of bone marrow (DCBM)due to bone metastasis, with DIC recovery by administration of S-1 and docetaxel]

A 63-year-old- female was admitted to our hospital complaining of cough. Based on CT, bone centigram and peripheral blood findings, a diagnosis of gastric carcinoma accompanied by bone marrow metastasis was made. As DIC developed following hospital admission, S-1 and docetaxel(DOC)therapy was initiated(daily oral administration of 80 mg/m(2) S-1 for 14 days and DOC at 40 mg/m(2) on day 1, q3w). Recovery from DIC was achieved. S-1 and DOC therapy is considered to be effective for DIC due to bone marrow metastasis of gastric carcinoma. S-1/DOC is thought to be an effective chemotherapy against progressive gastric carcinoma accompanied by disseminated carcinomatosis bone marrow with DIC.

[A case of cancer of the pancreatic tail with disseminated carcinomatosis of the bone marrow]

Disseminated carcinomatosis of the bone marrow derived from solid cancer has a very poor prognosis, with disseminated intravascular coagulation(DIC). A 72-year-old man was admitted to our hospital after detection of a tumor in the pancreatic tail by CT imaging. Several images revealed that he suffered from cancer of the tail of the pancreas with multiple liver and bone metastases. Endoscopic ultra-sonography-guided fine needle aspiration detected adenocarcinoma cells from the tumor of the pancreatic tail. We also performed bone marrow aspiration, which confirmed adenocarcinoma cells in the bone marrow. We started to administer 1,000 mg/m2 of gemcitabine weekly. Laboratory data revealed that thrombocytopenia had occurred, and it developed into DIC after the first the administration of gemcitabine. In spite of the DIC state with thrombocytopenia, we were able to provide anticancer treatment using combination gemcitabine and S-1. He recovered from his DIC state, and the primary tumor was shrunk with a decrease of tumor markers after 2 courses of combination chemotherapy. Chemotherapy might be required for disseminated carcinomatosis of the bone marrow in order to promote tumor shrinkage and to prolonged expected survival, even if DIC was developed.

The prostate cancer bone marrow niche: more than just 'fertile soil'

The hematopoietic stem cell (HSC) niche in the bone marrow has been studied extensively over the past few decades, yet the bone marrow microenvironment that supports the growth of metastatic prostate cancer (PCa) has only been recently considered to be a specialized 'niche' as well. New evidence supports the fact that disseminated tumor cells (DTCs) of PCa actually target the HSC niche, displace the occupant HSCs and take up residence in the pre-existing niche space. This review describes some of the evidence and mechanisms by which DTCs act as molecular parasites of the HSC niche. Furthermore, the interactions between DTCs, HSCs and the niche may provide new targets for niche-directed therapy, as well as insight into the perplexing clinical manifestations of metastatic PCa disease.

[A case of disseminated carcinomatosis of bone marrow treated by S-1 and cisplatin after distal gastrectomy for early gastric cancer]

Patients with bone metastasis originating from gastric cancer experience complications from DIC. They are treated with anticoagulation therapy or platelet transfusion, but their prognosis is poor. Our case was a 50-year-old male who had undergone distal gastrectomy for early gastric cancer[pT1a(M)N0M0, pStage I a]ten years previously. He was admitted to our hospital complaining of backache. As a result of his examination, he was diagnosed with disseminated carcinosis of bone marrow with DIC as a postoperative recurrence of gastric cancer. The patient was treated with combination chemotherapy of S-1 and cisplatin(S-1 80 mg/body, po, day 1-21 and cisplatin 50mg/body, iv, day 8). After one course of treatment, DIC was resolved and his pain was relieved. He survived for about nine months. S-1 and cisplatin are considered to be effective for disseminated carcinosis of bone marrow.

[A case of bone marrow carcinomatosis from breast cancer treated with weekly Paclitaxel]

We report a case of bone marrow carcinomatosis originating from breast cancer that was treated with weekly paclitaxel (PTX). A 42-year-old female patient underwent mastectomy with axillary lymph node dissection for breast cancer in 2001. Multiple bone metastases were diagnosed in 2008, but she remained stable with chemotherapy and hormonal therapy for about two years. In 2010, thrombocytopenia occurred, and she was diagnosed with bone marrow carcinomatosis after bone marrow biopsy. She was treated with weekly PTX(80 mg/m2), and recovered successfully after treatment. About one year has elapsed since initiation of therapy, and there has been no recurrence. Bone marrow carcinomatosis originating from breast cancer is very rare, and is regarded as a disease with a poor prognosis. However, weekly PTX could be a valid treatment for prolonging survival of bone marrow carcinomatosis originating from breast cancer.

Impact of histone deacetylase inhibitor valproic acid on the anticancer effect of etoposide on neuroblastoma cells

OBJECTIVES

Etoposide (Vepesid, VP-16), an inhibitor of topoisomerase II, is a chemotherapeutic drug commonly used for treatment of different types of malignant diseases. By inhibiting the topoisomerase II enzyme activity in cancer cells, this drug leads to DNA damage and subsequently to cell death. In this study, we investigated the effect of this anticancer drug alone and in combination with a histone deacetylase (HDAC) inhibitor, valproic acid (VPA), on a human UKF-NB-4 neuroblastoma cell line.

METHODS

The effects of etoposide and VPA on UKF-NB-4 cells were tested under the normoxic and also the hypoxic (1% O2) cultivation conditions. The cytotoxicity of etoposide and VPA to a UKF-NB-4 neuroblastoma cell line was evaluated with MTT assay. Apoptosis of the cells was analyzed by flow cytometry using an Annexin V and propidium iodide binding method. The effect of etoposide and VPA on the cell cycle distribution was determined by flow cytometric analysis using propidium iodide staining.

RESULTS

The results of the study demonstrate that UKF-NB-4 neuroblastoma cells are sensitive both to etoposide and to VPA. They also indicate that the impact of VPA on cytotoxicity of etoposide in these tumor cells varies depending on the sequence of cultivation of the cells with the drugs. As a suitable sequence of cultivation, with a high rate of suppression of neuroblastoma cell growth was found the preincubation of the cells with etoposide, which was followed by their cultivation with VPA. In contrast, the reversed combination (preincubation of the cells with VPA before their treating with etoposide) did not give any increase in etoposide cytotoxicity. The effect of such combined treatment can be explained by measuring the cell cycle distribution, which shows that both etoposide and VPA change the cell cycle phase distribution.

CONCLUSION

Etoposide and VPA were found as cycle phase specific drugs that are cytotoxic to human UKF-NB-4 neuroblastoma cells used either as single drugs or both together. However, whereas VPA might sensitize the cells to etoposide, inappropriate sequence of cultivation of the cells with VPA can decrease the etoposide cytotoxic efficacy. The results found here warrant further studies of combined treatment of neuroblastoma cells with etoposide with HDAC inhibitors and may help in the design of new protocols geared to the treatment of high risk neuroblastomas.

Symptomatic bone marrow involvement in breast cancer--clinical presentation, treatment, and prognosis: a single institution review of 22 cases

AIM

In contrast to marrow micrometastasis, development of symptomatic bone marrow involvement (bone marrow carcinomatosis, BMC) is a rare event in the course of metastatic breast cancer; published evidence on the outcome with systemic treatment is even more scarce. The objective of this study was to provide our institution's experience with the clinical presentation, prognosis, treatment, and associated complications of marrow involvement in breast cancer.

PATIENTS AND METHODS

Twenty-two breast cancer patients with BMC diagnosed between 1995 and 2009 were analyzed.

RESULTS

All patients presented with osseous metastases at the time of diagnosis of BMC. Anemia was the most prominent hematologic sign present in 17/22, followed by thrombocytopenia. Cytotoxic treatment was offered to 21/22 of patients. The majority showed an improvement of cytopenia following treatment (10 out of 14 anemic patients, 6 out of 9 thrombocytopenic patients, all 4 leukopenic patients). The complication rate was acceptable, with only 5 grade 3 or 4 events related to cytopenia (febrile neutropenia, bleeding). The estimated median overall survival from the date of BMC diagnosis was 19 months. After 4 years, 4 of the patients were still alive. Interestingly, prognosis from the time of first diagnosis of BMC was independent of the duration of metastatic disease before BMC had been diagnosed.

CONCLUSION

Bone marrow involvement has to be considered in breast cancer patients, in particular in those with bone metastases and otherwise unexplained cytopenia. The peripheral blood smear can serve as a simple diagnostic tool, but the extent of erythroblastosis is not correlated with survival. Even with severe BMC-associated cytopenia, aggressive combination treatment regimens are indicated, since most patients show improved marrow function after chemotherapy and long-lasting survival is possible.

[Successful chemotherapy of carcinomatosis of the bone marrow with disseminated intravascular coagulation from a rectal carcinoma found by eosinophilia]

A 71-year-old man with eosinophilia was given a diagnosis of poorly differentiated adenocarcinoma of the rectum. Further examination showed that it had invaded the bone marrow. He had disseminated intravascular coagulation (DIC) from disseminated carcinomatosis of the bone marrow after colostomy. Chemotherapy (mFOLFOX6) was successful and his eosinophil count, DIC score and tumor markers normalized. We were able to continue chemotherapy after 5 months from the outbreak of disseminated carcinomatosis of the bone marrow. It is said that disseminated carcinomatosis of the bone marrow has a poor prognosis, but we were able to obtain a good response in this case by chemotherapy.

[A case of gastric cancer accompanied by disseminated carcinomatosis of bone marrow with DIC, and subdural hematoma successfully treated with sequential methotrexate and 5-fluorouracil therapy]

A 44-year-old man visited a nearby hospital because of severe headache. Brain MRI revealed a subdural hematoma, and he was transferred to the Department of Neurosurgery of our hospital. Burr hole surgery was performed on the second day of hospitalization because of an enlargement of the hematoma. Laboratory data on admission showed the presence of a disseminated intravascular coagulation(DIC). Bone marrow aspiration revealed metastases of signet ring cell carcinoma, and abdominalCT showed gastric cancer. He was diagnosed as having DIC with bone marrow metastases of advanced gastric cancer. Despite anti-DIC therapy and blood transfusion, his systemic bleeding tendency was not improved. The neurosurgeon therefore consulted with a palliative care team. Since the patient was still young, we considered that he should be treated with anti-cancer drugs. At first, his family did not accept chemotherapy because they were pessimistic about his prognosis. However, after he regained his consciousness, we were able to perform sequential MTX and 5-FU therapy with the consent of the patient and his family. The therapy was successful, and he recovered from DIC and was discharged on the 57th hospital day.

[A case of prostate cancer with disseminated carcinomatosis of bone marrow which responded to Zoledronic acid]

A 76-year-old man underwent radical prostatectomy under the diagnosis of stage C prostate cancer (cT3bN0M0, Gleason score 3＋4) in 1999. Endocrine treatment for postoperative biochemical failure started in 2001. He was admitted to our hospital because of general fatigue and multiple bone pain with a prostate specific antigen (PSA) level of 1,141 ng/ml in August 2009. On admission, no metastasis was detected on bone scintigraphy or computed tomography. Bone marrow biopsy was finally performed for the assessment of bone metastasis after PSA further increased to 8,679 ng/ml with the manifestation of severe anemia and thrombocytopenia. The biopsy findings disclosed disseminated carcinomatosis of bone marrow (DCBM). Treatment with Zoledronic acid (ZA) not only mitigated bone pain, but also rapidly improved of PSA and hematological findings. Although the prognosis of a patient with DCBM is generally considered to be very poor, ZA contributed to the improvement for the survival of the patient in the present case.

New ways to use DNA methyltransferase inhibitors for the treatment of myelodysplastic syndrome

Ongoing analysis of the seminal AZA-001 study has taught many important lessons in the use of DNA methyltransferase (DNMT) inhibitors. The data emphasize the importance of patience in the use of these drugs, with several cycles required for the manifestations of hematologic responses. Improved survival in patients with high-risk myelodysplastic syndrome (MDS) treated with azacitidine extends to patients with any International Working Group-defined hematologic response; however, the benefit to patients with stable disease is less clear. A great deal remains to be learned about the optimal dosing and scheduling of the DNMT inhibitors, alone and in combination. New information on the impact of DNMT inhibitors on the immune system and on stem cells will likely lead to novel uses of these drugs in MDS and other hematologic and nonhematologic malignancies.