Acute Nonlymphoid Leukemia Patients Research Articles

Single Large Dose (15 Mg/Kg) Amphotericin B Lipid Complex (L-AmB) as Prophylaxis of Fungal Infections during Induction Chemotherapy in Acute Non Lymphoid Leukemia (ANLL).

In ANLL, during intensive induction,invasive fungal infections (IFI) related to prolonged neutropenia,mucosal damage,steroids, geographical and center variations is the main factor wich can influence disease outcome The optimal prophylactic regimen has not yet to be identified. The AmB lipid formulations let to treat IFI in refractory or intolerant patients. The efficacy of these drugs appears to be related both to improved tissue penetration along with sustained bioactivity of drug levels in lung, brain, kidneys, liver and spleen.(Anaissie et al.2004).On this basis, in a cohort of adult (>18y) ANLL patients,during induction,we applied a pilot study for IFI prophylaxis in the aim to test the efficacy and safety of a single large dose of L-AmB.The primary endpoint was to evaluate the incidence of documented or suspected fungal infection during and up to four weeks after prophylaxis discontinuation.PATIENTS: From September 2004 to May 2005 18 consecutive adult ANLL (4 APL) patients −12 M,6 F, median age 56 y (range 39–75)- entered in this study. Intensive induction chemotherapy included standard /high dose cytosine-arabinoside + antracyclines +etoposide or fludarabine and retinoic acid + antracyclines in the 4 APL.METHODS: The criteria of inclusion were:1)neutropenia (PMN <0.5 109/L) longer than 10 days 2) initial surveillance coltures, mannano and galattomammano antigens negative 3) no fever and/or clinical infection features. At the day after induction end, patients received L-AmB(AMBISOME, GILEAD®) at the dosage of 15 mg/kg i.v as single dose. A second single dose was repeated after 15 days in those cases which were persistently neutropenic,but did not meet the criteria of suspected fungal infections.RESULTS:13 (72%) patients achieved complete hematological remission,1 was resistant and 4 died during induction aplasia. (2 for Aspergillosis). Overall median neutropenia duration was 22 d (range 17 – 45). The median dosage of L- AmB administered was 900 mg x dose( range 750 – 900);a second single dose at the same dosage was given in four cases. During L-AmB infusion, 2 patients had CTC grade II allergy, treated by i.v. steroids, thus drug infusion could be completed; no patient had renal or hepatic toxicity.Of the 18 enrolled patients,14 (80%) met the primary endpoint of the studys since none of them developed fungal infection, while the remaining 4 cases had IFI: 2 Candida spp.sepsis and 2 invasive Aspergillosis.On the basis of these encouraging clinical results, in further consecutive 5 patients we tested L-AmB PK profile at the following times: 0,12,24 hour,7th and 14 th day from drug administration.The median L-AmB PK results (lower standard rate 0,15mg/l + − standard deviation) are:0 h < 0,151 h 8,92 +/− 4,254 h 51,26 +/− 26,724 h 3,92 +/− 11,777° d 1,39 +/− 1,9714° d 0,27 +/− 0,092CONCLUSION:despite the low number of patients involved,in our experience a single large L-AmB dose (15mg/kg) did show an effective and safe approach for the IFI prophylaxis, since 80% of treated patients did not experience fungal infection;furthemore preliminary kinetic results show high plasma levels that are slowly eliminated. These data have to be confirmed in larger series of ANLL adult patients to define which may be the best dosage to achieve a good and prolonged tissue concentrations.

Study of heat shock protein HSP90 alpha, HSP70, HSP27 mRNA expression in human acute leukemia cells.

The expression of three heat shock proteins (HSPs)-HSP90 alpha, HSP70, HSP27 in cells obtained from 22 patients with leukemia, K562 erythroleukemia cell line, and normal blood cells was observed by means of RNA dot blot analysis. The results showed that the expression of the HSP27 gene was enhanced in 4 cases of acute lymphoid leukemia (ALL), 7 cases of acute nonlymphoid leukemia (ANLL) and 2 cases of myelodysplastic syndrome (MDS) as compared with that of the normal blood cells, yet there was no significant difference in the HSP27 expression between the ALL and ANLL cells. The expression of HSP70 in all the 5 ALL and ANLL patients was much lower than that of the normal subjects, except 1 case of ALL and 1 case of MDS, in which the expression was obviously enhanced. All the cases including 11 ANLL, 5 ALL and 1 MDS had higher HSP90 alpha expression than the normal subjects. The enhanced expression of HSP90 alpha in leukemia cells may be associated with the active and indefinite proliferation of leukemia cells. Our results also suggest that the high expression of the HSP27 gene may not be confined to a specific type of acute leukemia.

In Vitro Chemosensitivity of Newly Diagnosed and Relapsing Acute Non-Lymphoid Leukemia Patients

We evaluated the in vitro sensitivity of circulating blasts from 25 newly diagnosed and 7 relapsing ANLL patients to drugs employed in vivo for inducing remission. Ten of the 14 newly diagnosed complete responders were in vitro sensitive to cytosine arabinoside and daunorubicin, whereas 10/11 non-responders were resistant to both agents. Although cells from all 7 relapsing patients were in vitro sensitive to the remission inducing agents, only 4 entered complete remission. Even if only indicative, these findings suggest that the poor prognosis of relapsing patients may be due, at least in part, to factors other than drug resistance. Moreover, the chemosensitivity test adopted is a better predictor in newly diagnosed than relapsing patients, as indicated by the concordance between in vitro and in vivo results.

One-Stage Method for Assay of Tissue Factor Activity of Leukemic Cell with Special Reference to Disseminated Intravascular Coagulation

Tissue factor activity (TFA) of leukemic cells (1 x 10(8) cells/mL) was measured in 44 patients with acute nonlymphoid leukemia (ANLL) by the one-stage assay using factor-IX deficient plasma (OSA-dIX) and two-stage assay (TSA). According to the preventative heparin dose schedule based on the TFA measured by the TSA, all disseminated intravascular coagulation (DIC) was controlled successfully. The procedure of the TSA was too complicated for clinical use, and its minimal measurable value was 125 units (U)/L of TFA. The OSA-dIX was simpler in its procedure and sensitive enough to measure accurately a TFA quantity as small as 30 U/L with high reproducibility. In 20 ANLL patients with 125 U/L or more of TFA measured by both assays, there was a significant relationship between their logarithms of TFA (r = 0.93, P less than 0.01). These results suggested that DIC complication in ANLL patients would be controlled successfully by the administration of heparin dosage based on the TFA measured by the OSA-dIX.

Cancer Procoagulant in Acute Non Lymphoid Leukemia: Relationship of Enzyme Detection to Disease Activity

Blast cell extracts from patients with acute non lymphoid leukemia (ANLL) express cancer procoagulant (CP). This factor X (FX) activator is distinct from tissue factor (TF) in that it does not require factor VII (FVII) to trigger blood coagulation, it acts as a cysteine proteinase and is not present in normal mononuclear cells. To assess whether there is any relationship between the presence of CP and the status of the disease, ANLL patients have been studied at diagnosis, during remission, at relapse. The procoagulant activity in either the presence or absence of F VII and sensitivity to cysteine proteinase inhibitors were tested on cell extracts. Immunoreactivity was explored with an anti-CP polyclonal antibody. Data obtained in 91 newly-diagnosed ANLL patients (subtypes M1 to M5, FAB classification) confirmed the presence of CP in M1 to M4 groups (mean +/- SE FVII-independent activity: M1 = 2.1 +/- 0.7 unit/mg; M2 = 5.7 +/- 1.7 unit/mg; M3 = 31.5 +/- 8 unit/mg; M4 = 1.6 +/- 1.2 unit/mg); CP was absent in the M5 type. In eight patients analyzed in a subsequent phase of partial remission, specific activity had dropped from 26.9 +/- 7.8 to 10.5 +/- 4.0 unit/mg. Activity was virtually absent (0-0.05 unit/mg) in the bone marrow of 37 patients studied at complete remission. Bone marrow samples from six subjects tested at different intervals after complete remission were repeatedly negative for CP but became positive 2 to 5 months before relapse. Upon relapse, the FVII independent activity rose to 24.2 +/- 8.2 unit/mg.(ABSTRACT TRUNCATED AT 250 WORDS)

Effective reinduction therapy for childhood acute nonlymphoid leukemia using simultaneous continuous infusions of teniposide and amsacrine

The combination of teniposide (VM-26) and amsacrine (AMSA) was evaluated in a dose-finding and efficacy study in 58 patients with relapsed or refractory acute leukemia. Both agents were given as simultaneous continuous infusions for 72 h through separate i.v. lines. All patients were evaluable for toxicity and 57 were evaluable for response; only 2 of 20 with acute lymphoblastic leukemia (ALL), acute mixed-lineage leukemia, or chronic myelogenous leukemia in blast crisis achieved a complete remission (CR). More encouraging was a second-remission rate of 43% (13 complete and 3 partial) in the 37 patients with acute nonlymphoid leukemia (ANLL). Responses occurred only in patients who received VM-26 doses of greater than or equal to 200 mg/m2 per day and AMSA doses of greater than or equal to 100 mg/m2 per day. Thus, the CR rate for relapsed ANLL patients who received the higher doses of both agents was 40% (13 of 33). All responders had previously received epipodophyllotoxin therapy and 40% had also received AMSA. All but one patient had severe leukopenia (less than 2.0 x 10(9) leukocytes/l) and thrombocytopenia (less than 50.0 x 10(9) platelets/l) as a results of therapy. Severe mucositis (grade 3 or 4) was the dose-limiting toxicity. Our results indicate that VM-26 plus AMSA, given by continuous infusion, is effective in the treatment of ANLL. Further phase II studies should consider using VM-26 at 200 mg/m2 per day and AMSA at 100 mg/m2 per day, but the best administration schedule remains unclear.

Provocative pattern of rearrangements of the genes for the gamma and beta chains of the T-cell receptor in human leukemias.

To examine the distribution of rearrangements of the gamma- and beta-chain T-cell receptor (TCR) genes in T- and non-T acute lymphoblastic leukemias (ALLs), and potentially to determine which genes rearrange first in ontogeny, we analyzed high molecular weight DNA from 102 patients with acute leukemia. Rearranged gamma- and beta-chain genes were found in all T-cell ALLs (22/22) examined. Overall, 27% (18/66) of B-lineage ALLs had beta-chain gene rearrangements, and 41% (24/58) had gamma-chain gene rearrangements, but the distribution of rearranged genes varied according to the stage of B-cell differentiation. The gamma-chain genes were rearranged in 11% (1/9) of the B-lineage patients negative for the common acute lymphoblastic leukemia antigen (cALLA) and 50% (23/46) of cALLA+ ALL patients, while the beta-chain genes were not rearranged in any of the 7 cALLA- ALL patients examined but were rearranged in 32% (18/56) of the cALLA+ patients. Neither TCR gene was found to be rearranged in acute nonlymphoid leukemia patients (0/12) or in patients with B-cell (surface immunoglobulin-positive) leukemia (0/3). Of the 44 cALLA+ patients in which a direct comparison of gamma- and beta-chain gene rearrangements could be made, 34% had both genes rearranged, 16% had only gamma-chain gene rearrangements, and the remaining 50% had both genes in the germ-line configuration. beta-Chain rearrangements have not been found in the absence of gamma-chain rearrangements, thus supporting a proposed hierarchy of TCR gene rearrangements. A provocative finding was that only a small percentage (11%) of the patients with cALLA- B precursor cell ALLs had rearranged TCR genes, while 50% of the cALLA+ leukemia patients had at least gamma-chain rearrangement, raising a question as to whether indeed cALLA- cells are precursors to cALLA+ cells. Interestingly, 18% (2/11) of the cytoplasmic immunoglobulin (cIg)-positive cALLA+ (pre-B) ALLs involved TCR gene rearrangements, compared to 60% (21/35) of the cIg-negative cases, suggesting the possibility that the majority of functional B cells are derived from the cALLA+ pool that contains immunoglobulin but not TCR gene rearrangements.

Motility and oxidative metabolism of normal polymorphonuclear leukocytes in acute non-lymphoid leukemia in complete remission

Polymorphonuclear leukocytes (PMN) from 11 patients with acute non-lymphoid leukemia (ANLL) in complete remission and off therapy for at least 22 months were studied for their oxidative metabolism and motility. In all patients, PMN motility tests revealed no consistent abnormality, whereas cells from 2 patients showed a selective impairment of oxidative metabolism, as assessed by the low capacity to reduce nitroblue tetrazolium and/or to generate chemiluminescence when stimulated with phorbol myristate acetate. No morphological change was detectable in PMN from these patients. However, the functional alterations appeared related to an early tendency to relapse, as both patients developed an acute phase after 5 and 9 months from testing, respectively. This suggests that abnormal PMN may circulate in ANLL patients in complete remission in spite of a normal differential count and that functional studies may be useful for detecting such a population.

Bone marrow transplantation (BMT) for acute nonlymphoid leukemia (ANLL) in first remission.

20 patients with acute nonlymphoid leukemia (ANLL) in first remission were given cyclophosphamide, 120 mg/kg, followed by total body irradiation (TBI) and an HLA-identical allogeneic marrow transplant (BMT). TBI was delivered in a single dose (10 Gy on day -1) in 2 patients, or in fractionated doses (3.3 rad/day on days -3, -2, -1) in 18 patients. The median age of patients was 22 years (range 2-44). Median time from remission to BMT was 5 months (range 1-12). 5 patients died of transplant-related toxicity (graft-versus-host disease with or without interstitial pneumonia) and 15 are alive 7-77 months post-BMT (median 20). The actuarial 72 months survival is 73%. There has been one relapse in a 2-year-old child, 4 months post-BMT, in the marrow and in the testis. The 72-month actuarial disease-free survival is 68%. The actuarial probability of relapse is 7%. This study indicates that a high proportion of ANLL patients treated in first remission with fractionated TBI and allogeneic marrow transplantation can become long-term disease-free survivors.

Glucocorticoid receptors and hormonal responsiveness of human blood and bone-marrow cells in non-lymphocytic leukemia

In man, acute non lymphoid leukemia (ANLL) bas been shown to respond in an extremely variable manner to glucocorticoid therapy. In addition to glucocorticoids. other agents such as β-adrenergic agents and prostaglandins are known to modulate the proliferation and differentiation of granulocyte monocyte colonies (CFU-C). We have measured in vitro on the blood and bone-marrow cells from three patients with ANLL several parameters including glucocorticoid receptors, the percentage of cells in the S phase of the cell cycle (using pulse cytophotometry) and the effect of drugs on nucleoside incorporation, cell number and viability. Our results led to the following conclusions: (i) The examination of blood and bone-marrow samples of a given patient does not necessarily give similar results in terms of response to drugs and the level of glucocorticoid receptors, (ii) in the same patient, the effect of any agent varies greatly throughout the incubation period and is also variable from one subpopulation to another, (iii) Prostaglandin E 2 markedly enhanced the level of [ 3H]-thymidine incorporation in the patients tested. As steroid-induced prostaglandin production has been recently implicated in the differentiation of myeloid cells, this may explain the stimulatory action of glucocorticoids which has been observed both in vivo and in vitro in ANLL patients.

In vitro hormonal responsiveness of human blood and bone marrow cells in non-lymphocytic leukemia

Glucocorticoid, β-adrenergic agents and prostaglandin E 2 are all known to modulate the proliferation and differentiation of granulocyte-monocyte colonies (CFU-C). However, in man, acute non lymphoid leukemia (ANLL) has been shown to respond in a highly variable manner to glucocorticoid therapy. Therefore, we have measured in vitro on blood and bone-marrow cells of two patients with ANLL several parameters including glucocorticoid receptors, percentage of cells in the S phase of the cell-cycle, effects of drugs on nucleoside incorporation, cell number and viability. Our results led to the following conclusions: (i) the examination of blood and bone marrow samples in a given patient does not necessarily give similar results in terms of response to drugs and levels of glucocorticoid receptors, (ii) in the same patient, the effect of any agent varies greatly throughout the incubation period and is also variable from one cell subpopulation to another, (iii) prostaglandin E 2 markedly enhances the level of [ 3H]-thymidine incorporation in the two patients tested. As steroid-induced prostaglandin production has been recently implicated in the differentiation of myeloid cells, this may explain the stimulatory action of glucocorticoids demonstrated both in vivo and in vitro in ANLL patients.