Low-dose Cytosine Arabinoside Research Articles

High Dose Cytosine Arabinoside- Induced Asymptomatic Bradycardia

Cytosine Arabinoside (Cytarabine) is commonly used agents in acute myeloid leukemia (AML). Cardiovascular side effects are not common during treatment. We aimed to present asymptomatic bradycardia developed during the first consolidation treatment in a patient with acute myeloid leukemia. A 34-year-old male patient was diagnosed with AML in February. After induction chemotherapy, high dose cytarabine treatment was started at 2x1.5 grams/m² for consolidation treatment. On the 11th day of the treatment, his pulse decreased to 39 beats/min. On the 12th day after the initiation of high dose cytosine arabinoside treatment (6 days after chemotherapy treatment ends), the patient's pulse rate was above 50/min, and there was no bradycardia in the following days. Other causes of other causes of bradycardia were excluded. It was reported that the patient had sinus bradycardia with an ejection fraction of 65% and his heart rate was rhythmic. There are seven patients with acute myeloid leukemia, one patient with acute lymphoblastic leukemia, one patient with non-Hodgkin's lymphoma, and one patient with Hodgkin's lymphoma who reported high dose cytosine arabinoside associated bradycardia. In addition, one patient with acute myeloid leukemia developed bradycardia with low dose cytosine arabinoside. Our case is the 11th case in the literature that develops bradycardia due to cytarabine.

Comparison of low dose cytosine arabinoside, azacitidine and azacitidine venetoclax combination treatment as remission induction in elderly acute myeloid leukemia patients

Aims: Low-intensity therapies are widely preferred in the treatment of advanced age, fragile acute myeloid leukemia (AML) patients. In this study, we aimed to compare hematological recovery rates after first cycle chemotherapy and overall survival for advanced aged AML patients treated with azacitidine (AZA) or low dose cytosine arabinoside (LDCA) or venetoclax (Ven) with AZA combination.
 Methods: Ninety-one patients were retrospectively analyzed. 
 Results: Forty-one patients treated with LDCA, 30 patients treated with AZA and 20 patients treated with AZA+Ven were included in the study. Patients who received these three treatments and who achieved response and did not receive any other treatment during the follow-up period were included in the study. Median age at diagnosis was 70. The percentage of patients who achieved neutrophil recovery after the first cycle was 27%, 73% and 50% of the patients treated with LDCA, AZA and AZA+Ven respectively. The rate of patients who achieved platelet recovery was 60%, 80%, 70% respectively. Erythrocyte transfusion independency was 54% for LDCA patients, 73% for AZA patients and 60% for combination therapy. Overall survival was longer in patients receiving AZA+Ven than other treatment groups while grade 3-4 infections were more common in the first cycle of the treatment.
 Conclusion: According to our study, patients treated with AZA had better platelet and neutrophil recovery rates with also longer overall survival than patients treated with LDCA, but total overall survival was superior in AZA+Ven combination. Hypomethylating agents with venetoclax is a preferable treatment option in elderly AML patients.

A randomised evaluation of low-dose cytosine arabinoside plus lenalidomide versus single-agent low-dose cytosine arabinoside in older patients with acute myeloid leukaemia: Results from the LI-1 trial.

Improving outcomes for older patients with acute myeloid leukaemia remains an unmet need. As part of the LI-1 trial, we evaluated lenalidomide (LEN) in combination with low-dose cytosine arabinoside (LDAC) in patients aged >60 years unfit for intensive therapy and compared this to LDAC alone. Two hundred and two patients, randomised 1:1, were evaluable. Overall response rate (CR + CRi) was higher for LDAC + LEN versus LDAC (26% and 13.7% respectively p = 0.031). However, there was no difference in overall survival between the arms (14% and 11.5% at 2 years for LDAC + LEN and LDAC respectively). The addition of LEN was associated with increased toxicity and supportive care requirements.

Evaluation of leukapheresis and leukapheresis with additional cytoreduction in acute leukemia with hyperleukocytosis

Background Hyperleukocytosis is a high-mortality emergency that must be diagnosed and treated promptly. The treatment options are low-dose cytosine arabinoside, hydroxyurea, steroids and leukapheresis. The risks and benefits of leukapheresis and leukapheresis with cytoreductive drugs in hyperleukocytosis are unclear. Therefore, we aimed to evaluate the efficacy of leukapheresis and the effect of adding cytoreductive drugs to leukapheresis in reducing leukocyte count and mortality in our patients.
 Material and Methods Thirty-four adult patients with acute leukaemia who underwent leukapheresis were included in this retrospective study.
 Results The median age was 66.5 years old, and 88.2% of the patients were acute myeloid leukaemia. The total number of leukapheresis was 69 cycles, and the median number of the procedure was 2. The most common symptoms were associated with the pulmonary system (67.6%). The median follow-up was 17.5 days. The mean reduction of leukocyte count was 69,112/mm3, and the efficacy of leukapheresis was 40.9%. The decrease in leukocyte and platelet counts was statistically significant when compared before and after leukapheresis. The mortality rate was 76.5% during hospitalization. While 24 patients received concomitant cytoreductive drugs with leukapheresis, ten did not. There was no statistically significant difference between these groups regarding reducing leukocyte count, efficiency of leukapheresis and mortality (p values 0.857, 0.562 and 0.553).
 Conclusions In our study, we showed the efficacy of leukapheresis in hyperleukocytosis but failed to show any difference in leukocyte reduction or mortality with additional cytoreductive drugs. Leukapheresis with concomitant cytoreduction does not abolish or increase mortality.

Abstract 981: BCL-2 inhibitor APG-2575 and homoharringtonine (HHT) synergistically induces apoptosis and inhibits tumor growth in preclinical models of acute myeloid leukemia and myelodysplastic syndromes (AML/MDS)

Abstract The AML treatment landscape has improved dramatically in the past decade, with improved objective response rates and overall survival after treatment with newly approved targeted therapies. BCL-2 inhibition combined with a hypomethylating agent or low-dose cytosine arabinoside (Ara-C) is also effective in previously untreated elderly patients who are not candidates for standard induction therapy. However, the effect of BCL-2 inhibition is commonly weakened when tumor cells upregulate antiapoptotic protein MCL-1 to escape apoptosis. Thus, combination therapy is introduced to suppress MCL-1 levels. HHT (omacetaxine mepesuccinate) has been widely used in Chinese patients with AML for 30 years. As an inhibitor of protein synthesis, HHT decreases MCL-1. This study investigated the effect of combining clinical stage BCL-2 selective inhibitor APG-2575 with HHT in AML and MDS cells, as well as murine xenograft tumor models. In AML (MV-4-11, OCI-AML-3) and MDS (SKM-1) cell lines, single-agent HHT exerted stronger antiproliferative and apoptogenic activities compared to APG-2575 (as assessed by Cell Titer Glo assay or flow cytometry). When combined, these treatments synergistically inhibited cellular proliferation and induced apoptosis. In a mouse xenograft tumor model derived from MV-4-11 cells, APG-2575 demonstrated limited antitumor activity, with a T/C (Treated/Control tumor volume %) value of 63% whereas HHT showed stronger activity, with T/C equal to 30%. Most importantly, these antitumor effects were potentiated when APG-2575 and HHT were combined, yielding a T/C value of 3% and partial regression in all treated tumors. Mechanistically, BCL-2 inhibition with APG-2575 decreased BCL-2:BIM complexes and but increased MCL-1:BIM complexes, as liberated BIM was re-sequestered by MCL-1. On the other hand, concomitant treatment with HHT abolished induction of MCL-1:BIM complexes. Besides BIM complexes, MCL-1:PUMA and MCL-1:BAK pairings also decreased after exposure to HHT. The decrease in MCL-1 complex coincided with its downregulation at protein levels. Thus, under such an MCL-1-supressed condition facilitated by HHT treatment, the freed proapoptotic proteins (BIM, PUMA, BAK) more potently manifested apoptotic signals triggered by APG-2575. In summary, APG-2575 synergizes with HHT to potentiate antitumor activity in preclinical models of AML/MDS. HHT suppresses MCL-1 protein, preventing or abolishing formation of MCL-1:BIM, MCL-1:PUMA, and MCL-1:BAK complexes, and hence allowing prodeath proteins to fully engage in tumor cell apoptosis induction. Our results provide scientific rationale for clinical development of APG-2575 plus HHT in patients with AML/MDS. Citation Format: Douglas D. Fang, Qiuqiong Tang, Yanhui Kong, Tao Rong, Qixin Wang, Jing Deng, Dajun Yang, Yifan Zhai. BCL-2 inhibitor APG-2575 and homoharringtonine (HHT) synergistically induces apoptosis and inhibits tumor growth in preclinical models of acute myeloid leukemia and myelodysplastic syndromes (AML/MDS) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 981.

A randomised evaluation of low-dose cytosine arabinoside (ara-C) plus tosedostat versus low-dose ara-C in older patients with acute myeloid leukaemia: results of the LI-1 trial.

Older patients with acute myeloid leukaemia (AML) account for nearly half of those with the disease. Because they are perceived to be unfit for, unwilling to receive, or unlikely to benefit from conventional chemotherapy they represent an important unmet need. Tosedostat is a selective oral aminopeptidase inhibitor, which in phase I/II trials showed acceptable toxicity and encouraging efficacy. We report the only randomised study of low-dose cytosine arabinoside (LDAC) combined with tosedostat (LDAC-T) versus LDAC in untreated older patients not suitable for intensive treatment. A total of 243 patients were randomised 1:1 as part of the 'Pick-a-Winner' LI-1 trial. There was a statistically non-significant increase in the complete remission (CR) rate with the addition of tosedostat, LDAC-T 19% versus LDAC 12% [odds ratio (OR) 0·61, 95% confidence interval (CI) 0·30-1·23; P=0·17]. For overall response (CR+CR with incomplete recovery of counts), there was little evidence of a benefit to the addition of tosedostat (25% vs. 18%; OR 0·68, 95% CI 0·37-1·27; P=0·22). However, overall survival (OS) showed no difference (2-year OS 16% vs. 12%, hazard ratio 0·97, 95% CI 0·73-1·28; P=0·8). Exploratory analyses failed to identify any subgroup benefitting from tosedostat. Despite promising pre-clinical, early non-randomised clinical data with acceptable toxicity and an improvement in response, we did not find evidence that the addition of tosedostat to LDAC produced a survival benefit in this group of patients with AML. International Standard Randomised Controlled Trial Number: ISRCTN40571019.

Pevonedistat, a Nedd-8 Activating Enzyme Inhibitor, Upregulates NOXA to Increase Effectiveness of Azacitidine and Venetoclax in Preclinical Models of Acute Myelogenous Leukemia

Introduction: Venetoclax (VEN), a selective BCL-2 inhibitor, has yielded exceptional response rates in patients with acute myeloid leukemia (AML). VEN binds BCL-2 to directly inhibit sequestration of pro-apoptotic proteins such as the activator BIM. Free BIM can bind to BAX, enabling its oligomerization with BAK, mitochondrial outer membrane permeabilization (MOMP) and subsequent apoptosis (PMID 24074954, 9687260, 19641500, 20164920). VEN has limited efficacy in relapsed-refractory AML as a single agent, but when used in combination with DNA methyltransferase inhibitors (DNMTi; 5'azacitidine-AZA-or decitabine) or low-dose cytosine arabinoside (LDAC), 50-70% of untreated patients in recent clinical trials achieved complete remission (PMID 27520294, 30361262, 30892988). Despite this progress in AML therapy, the majority of AML patients treated with VEN ultimately relapse, and a large subset of patients never respond (PMID 30361262, 30892988). One postulated route of resistance to VEN is cellular upregulation of myeloid cell leukemia-1 protein (MCL-1), which, similarly to BCL-2, functions as an anti-apoptotic protein. VEN in combination with selective MCL-1 inhibitors has demonstrated added benefit over either agent alone in AML cells in vitro and in xenograft models but efficacy of this combination in the clinic has yet to be reported (PMID 30185627). Both MCL-1-dependent and MCL-1-independent mechanisms of VEN resistance are emerging (PMID 31048321, 30148320, 31262744) and new approaches aimed at addressing these are moving toward the clinic. Pevonedistat (PEV) was developed as a targeted inhibitor of NEDD-8 activating enzyme (NAE), which disrupts protein turnover mediated by Cullin-RING ligases (PMID 19360080) and has been shown to have activity in combination with AZA (PMID 29348128). PEV and AZA both upregulate NOXA, a BCL-2 family member that is known to suppress MCL-1 (PMID 26045051, Jin, Cojocari, Purkal et al.,unpublished data), so we postulated that PEV/AZA in combination synergizes with VEN in a triple combination with efficacy superior to VEN/AZA alone. Methods/Results: AML cell lines were treated with PEV, AZA and VEN alone, and compared with various VEN/PEV/AZA combinations revealing improved combinatorial activity with the triplet in the majority of cell lines and associated NOXA induction. Similar results were seen in primary AML patient samples ex vivo (Figure 1). These combinations were compared in vivo in an OCI-AML2 cell line xenograft model, also illustrating significantly improved response with the PEV/AZA/VEN combination (Figure 2). CRISPR/Cas 9 deletion of PMAIP1 in AML cell lines demonstrated that NOXA deletion abrogates this synergy. Discussion: Together, these results demonstrate that, in several pre-clinical models of AML, the PEV/AZA/VEN triple combination provides stronger anti-tumorigenic activity than either agent alone or the VEN/PEV and VEN/AZA combinations. Importantly, the three-drug combination may be effective in AML cells which do not respond to VEN/AZA alone. Further studies to delineate this mechanism of action, and a clinical trial (NCT03862157) testing the combination in newly diagnosed AML are underway. Figure 1 Disclosures Cojocari: AbbVie Inc: Employment, Other: DC, JP, ERB, JDL, and DCP are employees of AbbVie. JP, ERB, JDL & DCP are stockholders of AbbVie Inc. The design study conduct, and financial support for this research were provided by AbbVie. AbbVie Inc. participated in the interpretation of data, review. Purkal:AbbVie Inc: Employment, Other: DC, JP, ERB, JDL, and DCP are employees of AbbVie. JP, ERB, JDL & DCP are stockholders of AbbVie Inc. The design study conduct, and financial support for this research were provided by AbbVie. AbbVie Inc. participated in the interpretation of data, review. Leverson:AbbVie Inc: Employment, Other: Stock or options. Boghaert:AbbVie Inc: Employment, Other: DC, JP, ERB, JDL, and DCP are employees of AbbVie. JP, ERB, JDL & DCP are stockholders of AbbVie Inc. The design study conduct, and financial support for this research were provided by AbbVie. AbbVie Inc. participated in the interpretation of data, review. Phillips:AbbVie Inc: Employment, Other: DC, JP, ERB, JDL, and DCP are employees of AbbVie. JP, ERB, JDL & DCP are stockholders of AbbVie Inc. The design study conduct, and financial support for this research were provided by AbbVie. AbbVie Inc. participated in the interpretation of data, review. Savona:AbbVie: Membership on an entity's Board of Directors or advisory committees; Sunesis: Research Funding; Boehringer Ingelheim: Patents & Royalties; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; TG Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Incyte Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm Therapeutics: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Selvita: Membership on an entity's Board of Directors or advisory committees.

Clinical Characteristics and Treatment Outcome of Hypocellular Acute Myeloid Leukemia Based on WHO Classification

The hypocellular acute leukemia is very rare atypical leukemia with frequency of 5-7% among patients with acute leukemias. It mainly occurs in older patients and usually has a myeloid phenotype. It is still unclear whether the outcome of hypocellular acute myeloid leukemia is less favorable than adult acute myeloid leukemia with normal cellularity. We retrospectively analyzed all hypocellular acute myeloid leukemias which were treated in 16years period, between January 1998 and December 2014. There were 33 patients, 21 male and 12 female. The median age of the patients was 58.9years (ranging from 19 to 88years) and median cellularity of bone marrow was 16%. All patients presented with cytopenias with median white blood cell count 1.9 × 109/l, platelets 47.2 × 109/l and hemoglobin 85.9g/l. Nineteen patients were treated with standard 3 + 7 protocol (daunoblastin 45mg/m2 1, 3, 5days, cytosin-arabinozide 100mg/m2/12h for 7days), 5 patients with HDAC protocol and, 3 (9%) with low dose cytosin-arabinoside and in 6 (18.1%) patients only supportive therapy was applied. One patient died on 34day after treatment with HiDAC, 3 patients after treatment with 3 + 7 regimen in full doses on days 23, 35, and 58days. Complete remission was achieved in 20/33 (60.60%) patients, with median duration of 14months. Median overall survival (OS) of the entire cohort was 16months, and for the treated group 21months (range 5-67months). Median OS of patients treated with low dose cytosine-arabinoside was 6months. The advanced age (p = 0.009, KK = - 0.46, Log rank, p = 0.031) as well as therapy options (Log rank p < 0.0001) shows a significant correlation with OS. We report a cohort of patients with hypocellular acute myeloid leukemia who responded to standard induction chemotherapy as are in standard acute myeloid leukemia.

Congenital Undifferentiated Pure Erythroid Leukemia

INTRODUCTIONCongenital pure erythroid leukemia (M6b) is exceedingly rare with only a few reported cases to date. Because of the extreme rarity, almost nothing is known about the pathogenesis, appropriate therapy and prognosis. Diagnosis of erythroid leukemia is usually based on the positivity for Glycophorin A, Glycophorin C or PAS staining. We report a first case of congenital pure erythroid leukemia expressing E-cadherin in the absence of Glycophorin A, Glycophorin C and PAS staining. We analyzed the cytogenetic abnormalities of this extremely rare disease. RESULTSThe patient was the first daughter of healthy and non-consanguineous Japanese parents, born at 40 weeks of gestation by emergency cesarean section in non-reassuring fetal state after uncomplicated pregnancy. Apgar score was 8/9. Characteristic facial appearance was not recognized. At birth, she presented with marked hepatomegaly, purpura and disseminated intravascular coagulation. White blood cell (WBC) count was 63.5x109/L with blastic cells with vacuoles. Although congenital leukemia was suspected, flow cytometric analyses using CD45 blast gating failed to demonstrate leukemic cells. Karyotype was 46, XX. Fluorescence in situ hybridization (FISH) for trisomy 21 and MLL split signal were negative. GATA1 mutation was not detected. WBC count has gradually decreased within 3-4 weeks with supportive care.However, liver failure, hemophagocytic lymphohistiocytosis and schistocytosis developed. Although treatment with dexamethasone and etoposide has started, multiple nodules appeared in the liver 11 weeks after birth. Liver biopsy demonstrated small round cell tumor with high N/C ratio and vacuoles infiltrating the liver. The tumor cells were immunohistochemically positive for CD43, CD71, E-cadherin, beta-catenin, Ki-67 and c-Myc and negative for CD45, CD20, CD10, PAX5, CD3, CD4, CD8, TdT, CD1a, CD34, CD56, cyMPO, c-kit, CD42b, CD61, Glycophorin A, Glycophorin C, tyrosine hydroxylase, PGP9.5, myogenin, glypican3, NKX2.2, CAM5.2 and Periodic Acid Schiff (PAS) staining etc. Flow cytometric analysis revealed CD43+ CD71+ CD36+ CD58+ cells within large CD45 negative cell population. These cells expressed almost no other hematopoietic cell markers used to screen for leukemia. These cells were indistinguishable from normal erythroblast based on surface markers only. However, flow cytometric cell sorting revealed these cells are blasts with vacuoles. Karyotype of tumor cells has changed to 50, XX, +7, +8, add(15)(q22), +19, add(19)(q13.1-13.3)×2, +21. Based on these results, she was diagnosed with pure erythroid leukemia. Low dose Cytosine Arabinoside improved her clinical symptoms. She is alive at 5 months of age. DISCUSSIONE-cadherin is a selective marker of immature erythroblast. In our case, E-cadherin was key in erythroid lineage assignment. To our knowledge, this is the first reported case of infantile pure erythroid leukemia expressing E-cadherin in the absence of Glycophorin A, Glycophorin C and PAS staining. These results suggest that the tumor cells originated from undifferentiated erythroblast. This disease entity should be recognized. Immunohistochemical staining of c-Myc showed strong positivity. The c-Myc gene is located on chromosome 8. FISH for c-Myc split signal was negative. G-banding and FISH revealed trisomy 8. Overexpression of c-Myc may be involved in the pathogenesis of this undifferentiated pure erythroid leukemia. At birth, karyotype was 46, XX and blasts in peripheral blood decreased with supportive care only. However, we observed changes in karyotype of blasts. We assume that second hit was added during clinical course. Whole exome sequencing analysis is in progress to reveal somatic and germline mutations underlying this unrecognized disease. DisclosuresNo relevant conflicts of interest to declare.

A Retrospective Analysis of Ultra Low-Dose Decitabine Combined with Gha Regimen in Patients with Middle and High Risk Myelodysplastic Syndrome

Background:Myelodysplastic syndrome (MDS) represents a heterogenous group of meyloid clonal disorders typically characterized by aberrant myeloid differentiation, dysplasticchanges, ineffective hematopoiesis and high potential to progress into acute meyloid leukemia. In the general population, the incidence of MDS is approximately 5/100000 and the mean age of onset of MDS is 68 years. Most of the patients in middle-2 and high risk were uneligible for intensive therapy.It have been confirmed that epigenetic play important roles in processes of tumorigenesis both in soild tumer and hematopoic malignacies. The aberrant changes of this key epigenetic process contribute significantly to the development of hematologic malignancies.Irregular DNA hypermethylation which lead to the silencing of tumor suppressor genes is a very commonamong MDS. The epigenetic therapy with hypomethylating agents has become a new strategy for the treatment ofpatients with MDS.The decitabine (DAC) is an inhibiter of DNA hypermethylationand act as an anti-tumor by reactivating the tumor suppressor genes. While the treatment dose and schedule of DAC haven't reach a consensus.The CAG chemotherapy regimen is widely used for the treatment of patients with relapsed AML since 1995. The regimen is composed of low-dose cytosine arabinoside (10 mg/m2/12 h, usually day 1~14), low-dose aclarubicin (10-14 mg/m2/day, day 1~4), and concurrent use of G-CSF (200 micrograms/m2/day).But the cardiotoxicity limit its application among elder patients. So we tried to modify the regimen by replacing the aclarubicin with homoharringtonine (HHT) which was reported have the function of arresting leukemic cell cycle, inducing apoptosis and it has been used in the treatment of AML in China for decades.The aim of this study was to provide a retrospective analysis of the safety and performance of ultra low-dose decitabine combined a modified protocol GHA to find an option for middle-2 and high risk MDS patients.Methods:Retrospective analysis of 40 MDS patients who were enrolled in the low-dose decitabine combined with GHA regimen. All the patients were classified in to RAEB1/2(Refractory anemia with excess blasts) or RCMD (Refractory cytopenia with multilineage dysplasia) by 2008 WHO classification of MDS. In IPSS (international prognostic scoring system), all the patients were categoried in intermediate-2 or high risk. The decitabine were used at the dose of 10 mg/d given intravenously over 1 h daily for 5 days (d1~5). The GHA regimen consisted of homoharringtonine 1mg/m2 daily by intravenous continuous infusion d 1~14), cytarabine 10mg/m212hr by subcutaneous injection (day 1~14), and G-CSF200 mg/m2/day by subcutaneousinjection one day prior to chemotherapy and continued until the end of chemotherapy or when the peripheral white blood cell (WBC) >20*109/L. The clinical efficiency and side effects were observed.Results:27 patients achieved CR and 5 patients achieved PR. The CR and PR rate were 67.5% and 12.5%, respectively. Total effective rate was 80%. In the induction therapy, a total of 10/40(25.0 %) patients experienced absolute neutrophol count (ANC) less than 0.5*109/L with a mean 8 days of agranulocytic period, and 28/40 (70%) patients experienced platelets less than 20*109/L with a mean 7 days of recovery over 20*109/L. The nonhematologic toxicities were mild and early death was zero. The median follow up time was 28 months; the median overall survival (OS) and disease free survival (DFS) were 25 and 12 months, respectively.Conclusion:The ultra low-dose decitabine combined with regimen is effective and well tolerated in induction therapy for intermediate-2 and high-risk MDS who were uneligible for intensive therapy and the results are better than the single regimen of decitabine or GHA. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Liver fibrosis with hypereosinophilia causing transient abnormal myelopoiesis

Transient abnormal myelopoesis is mostly self-resolving and has a good prognosis, but some patients subsequently die of liver fibrosis. We report the case of an infant with Down syndrome who developed life-threatening liver fibrosis at the same time as the blasts were about to disappear. This patient also had a marked increase in eosinophils, which were possibly harboring a GATA1 mutation and were expressing a high level of platelet-derived growth factor-B mRNA; these may have been involved in the development of liver fibrosis. Low-dose cytosine arabinoside therapy effectively treated both hypereosinophilia and liver fibrosis.

Abstract 4507: New JAK2 heterozygous loss: A role in overall survival in acute myeloid leukemia patients

Abstract Acute Myeloid Leukemia (AML) is a clonal hematopoietic disorder characterized by an abnormal proliferation and differentiation of immature blast cells in the bone marrow. SNP microarray approach has resulted in genome-wide screening for genomic alterations with information not previously achievable and also it allows to map all the genes involved in these alterations which may plays a role in oncogenesis. Our objective is to evaluate the prognostic impact of these genetic alterations on clinical outcome. We analyzed 285 AML samples at diagnosis of which 221 by SNP Array 6.0 (Affymetrix) (Affymetrix), while 64 by by CytoScan HD Array (Affymetrix). The results obtained were analyzed by Chromosome Analysis Suite (ChAS) v1.2 (Affymetrix Inc.) and Nexus Copy Number™ v7.5 softwares (BioDiscovery). The 285 AML patients (pts) analyzed are equally distributed between both sexes, they have a median age of 60 years, include miscellaneous cytogenetic abnormalities and normal karyotype. The 44% of pts are treated with chemotherapy (CHT), the 16% of pts with low-dose cytosine arabinoside, the 20% of pts with 5-azacytidine and the 19% of pts are not treated or had only supportive therapy. The ratio between responders and non responders pts was 57/43. Each pt presented an average of 1448 events so distributed: 31% of homozygous deletions, 32% of homozygous amplifications, while irrelevant events are related to heterozygous deletions and amplifications. We also found 36% of uniparental disomy (UPD)events. Among all these macroscopic and submicroscopic alterations, we focused on JAK2 gene, which is located on human chromosome 9 at p24.1 locus. It is composed of 25 exons and encodes a 1132 amino-acid protein of 130.7 kDa. This gene was amplified in 12/285 pts (4%) and deleted in 13/285 (5%). All these pts are treated with CHT but only those characterized by JAK2 deletion are responsive in first line. We showed that the group of pts which present this deletion had a better overall survival rate than the group with the amplification of this gene (p-value &amp;lt; 0,01). The deletion event of JAK2 gene involved two different regions: the first region had a length of 7.429 bp involving the intron 4 and was found in the database genome variant (DGV); the second deletion presented a variable length between different pts: the smallest deleted region had a length of 3342 bp and included the exons 17, 18, 19, while the largest one had a length of 76903 bp which included the portion from exon 9 to exon 19. This second deletion has not been described in DGV and it involved the pseudokinase and kinase domain of JAK2 protein. We have identified Copy Number Variation involving important cancer genes in AML. We have identified a new JAK2 deletion involving its Pseudokinase and Kinase domain and we observed that this deletion of JAK2 correleted with overall survival. ELN, AIL, AIRC, PRIN, progetto Regione-Università 2010-12 (L. Bolondi), FP7 NGS-PTL project Citation Format: Viviana Guadagnuolo, Maria Chiara Fontana, Cristina Papayannidis, Marco Manfrini, Antonella Padella, Giorgia Simonetti, Anna Ferrari, Giovanni Marconi, Andrea Ghelli Luserna di Rorà, Stefania Paolini, MariaChiara Abbenante, Sarah Parisi, Chiara Sartor, Emanuela Ottaviani, Giovanni Martinelli. New JAK2 heterozygous loss: A role in overall survival in acute myeloid leukemia patients. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4507.

Changing Times for the IJHBT.

I welcome you to 2016 with the latest 120-page issue of our journal, up from the 70 pages previously. In this issue too, we maintain our focus on original articles and reviews for the printed journal, and increasingly hope to move towards special online editions for case reports and letters to the Editor. The invited reviews in his issue focus on the old and the new. On one hand, they deliberate on how the advent of genomics and personalized medicine is revolutionizing the way we diagnose and manage hematological malignancies [1, 2]. On the other, they remind us that good medicine is based on astute evaluation of all evidence, be it from fashionable new techniques or from conventional ones that have stood the test of time. In that regard, the diverse monoclonal protein electrophoretic patterns reviewed by Misra et al. [3] reveal myeloma to be as intriguingly heterogeneous a disease at the paraprotein level as it is at the genomic, morphological and clinical levels. As chemotherapeutic management and acute care of hematological malignancies improve across the country, quality-of-life issues are assuming greater importance. In this issue, Kumar et al. [4] investigate growth impairment and short stature among children treated for acute lymphoblastic leukemia, while Rohilla et al. [5] report on obstetric outcomes in women with chronic myelogeneous leukemia. Another tricky management issue is the judicious management of elderly AML or high-risk MDS, and this is addressed by a Turkey study which looks at epigenetic modifiers alone as well as in combination with low-dose cytosine arabinoside in such patients. New technologies often bring with them new and unexpected complications. Among the benign disorders, Dubey et al. [6] investigate how life-saving intra-uterine blood transfusions to Rh-negative fetuses of Rh-positive mothers may carry the risk of inducing additional maternal antibodies against fetal antigens, thereby aggravating Rhisoimmunization. Sen et al. [7] similarly caution that highpressure carbon dioxide insufflation, commonly used in laparoscopic surgeries, may depress natural anticoagulant systems as well as fibrinolysis thus contributing to surgeryassociated thrombophilia. In the midst of these rapidly changing times for hematology in general and the journal in particular, the coming of the New Year offers us an opportunity to pause, reflect and take stock. The entire Editorial Board welcomes your inputs on what you think the IJHBT’s goals for the future should be, and how best can they be realized. Comments, suggestions and letters from readers on published articles and ongoing events are, as always, welcome. Wishing everyone a very happy new year ahead.

Prospective Study of 168 Infants with Transient Abnormal Myelopoiesis with Down Syndrome: Japan Pediatric Leukemia/Lymphoma Study Group, TAM-10 Study

Introduction: Transient abnormal myelopoiesis (TAM) occurs in approximately 10% of infants with Down syndrome (DS). Although most patients achieve spontaneous remission, some develop severe organ failure and die in their infancy. Previous studies have identified several risk factors associated with early death in such cases, including a high white blood cell (WBC) count, early gestational age, and ascites (Massey GV, 2006; Muramatsu H, 2008; Klusmann JH, 2008). Although chemotherapy with low-dose cytosine arabinoside (LDCA) has been applied for severe cases, its side effect profile has not been fully demonstrated in an adequate number of patients. Here we prospectively analyzed 168 infants with DS who were diagnosed with TAM, including 52 patients treated with LDCA. We assessed the efficacy and safety of LDCA therapy in these cases.Patient and Methods: Between May 2011 and February 2014, 168 infants (90 boys and 78 girls) were diagnosed with TAM and prospectively registered in the Japan Pediatric Leukemia/Lymphoma Study Group (JPLSG) TAM-10 study. GATA1 gene mutations were identified in all except 7 patients who had a very low blast percentage. The median (range) of WBC count was 38.6 (2.4-478.7) × 109 cells/L, and the median (range) of gestational age was 37 (29-40) weeks. Thirty one (18%) patients developed anasarca at diagnosis, and 23 (14%) patients developed acute megakaryocytic leukemia.Results: The overall survival (OS) rate and the event-free survival (EFS) rate at 1 year from diagnosis [95% confidential interval (CI)] were 86.3% (80.1-90.7), and 80.2% (73.2-85.5), respectively. Univariate analysis identified the following covariates as risk factors associated with early death (<9 months): early gestational age [<37 weeks; hazard ratio (HR; 95% CI) = 4.482 (1.826-10.997), p = 0.001], parenchymal bleeding [HR (95% CI) = 5.746 (2.241-14.734), p < 0.001], anasarca [HR (95% CI) = 13.344 (5.419-32.860), p < 0.001], and high WBC count [ ≥100 × 109 cells/L; HR (95% CI) = 8.013 (3.354-19.144), p < 0.001]. The multivariate Cox hazard model identified anasarca and a high WBC count (≥100 × 109 cells/L) as independent risk factors for early death. With regard to the 52 patients who received LDCA therapy, only anasarca remained an independent risk factor for early death. Subgroup analysis in patients with a high WBC count (≥100 × 109 cells/L; n = 36) showed that LDCA therapy significantly improved survival [1-year OS (95% CI) = 78.3% (55.4-90.3; n = 23) vs. 38.5% (14.1-62.8; n = 13); p = 0.009]. In contrast, the survival rate of patients with anasarca (n = 31) did not improve on receiving LDCA therapy [1-year OS (95% CI) = 58.3% (27.0-80.1; n = 12) vs. 47.4% (24.4-67.3; n = 19); p = 0.525]. The most common side effect of LDCA was neutropenia (grade 3-4 = 59%), and one patient died due to tumor lysis syndrome.Conclusion: This prospective study confirmed that a high WBC count and anasarca are risk factors for early death in patients with DS who were diagnosed with TAM. Although LDCA therapy could significantly improve the survival rate in patients with a high WBC count, it failed to change the prognosis of patients with anasarca. A new treatment modality is required for most severe TAM patients with anasarca at diagnosis. DisclosuresNo relevant conflicts of interest to declare.

SPARC ectopic overexpression inhibits growth and promotes programmed cell death in acute myeloid leukemia transformed from myelodysplastic syndrome cells, alone and in combination with Ara-C treatment.

Secreted protein acidic and rich in cysteine (SPARC) has a complex and pleiotropic biological role in cell life during disease. The role of SPARC in myelodysplastic syndrome (MDS) is not yet fully understood. In the present study, we investigated the role of SPARC protein overproduction in the proliferation and apoptosis of SKM-1 cells, an acute myeloid leukemia cell line transformed from MDS. SKM-1 cells were infected with the pGC-GV-SPARC vector. The cells were then assessed for proliferation and cell death following treatment with low-dose cytosine arabinoside (Ara‑C). The microarray analysis results revealed that samples from SPARC‑overexpressed cells compared to SPARC protein, in SKM-1 cells led to proliferation inhibition and promoted programmed cell death and these effects were greater when treated with Ara-C. The mRNA and protein expression levels of SPARC were detected by SPARC overexpression in cells treated with Ara-C resulting in a significant upregulation of the mixed lineage kinase domain-like (MLKL) gene expression and five other genes. The results showed that the necrotic signaling pathway may play a role when the two conditions were combined via the upregulation of the MLKL protein. MLKL upregulation in SPARC overexpressed cells treated with Ara-C, indicates necrosis as a possible cell death process for the SKM-1 cells under these stringent conditions.

Low Dose Cytosine Arabinoside and Azacitidine Combination in Elderly Patients with Acute Myeloid Leukemia and Refractory Anemia with Excess Blasts (MDS-RAEB2).

Only one-third of elderly (>60years) AML and MDS-RAEB2 patients may receive intensive chemotherapy treatment alternatives that are limited in this patient group due to the potential of severe toxicity. Previous studies have shown that azacitidine and low dose cytarabine treatments may be a beneficial treatment option for these patients. In this study, we aimed to good results with low toxicity in elderly patients. We retrospectively analyzed the AML and MDS-RAEB2 patients who received azacitidine monotherapy and azacitidine and LDL-ara-c combination therapy for a comparison of their response to therapy, survival rates, and toxicity rates and for determining the factors that could affect their overall survival. A total of 27 patients who were diagnosed with de novo AML and MDS-RAEB2 and who received at least four cycles of chemotherapy were included in the study, and the data were evaluated retrospectively. When monotherapy and combination therapy groups were compared, the pretreatment bone marrow blast count was observed to be greater in the combination therapy group. A statistically significant difference was not detected between the groups regarding the response to therapy ratios (p=0.161) (42.9 and 57.1%, respectively). No difference was detected between the groups regarding therapy-related toxicity. Infections were the most common complication. Progression-free survival was 30.3% for the azacitidine monotherapy group and 66.7% for the combination (azacitidine+LD-ara-c) group. The factors influencing the overall survival rate were determined based on the response to the first-line therapies, more than a grade 2 infection, fever, and relapse in a multi-variance analysis. The combination therapy may be a well-tolerated treatment option for the elderly, vulnerable AML patients whose blast count is high in response to therapy rates, overall survival rates, and toxicities are not different, although the pre-treatment bone marrow blast count was greater in the combination therapy groups compared with the monotherapy group.

The Efficacy of Low-Dose Cytosine Arabinoside Therapy for Patients of Down Syndrome with Transient Abnormal Myelopoiesis

<Introduction>Transient abnormal myelopoiesis (TAM) occurs in about 10% of neonates with Down syndrome. While TAM is generally considered as self-limiting disease, substantial number of patients suffer from serious complications including liver fibrosis or pericardial effusion and eventually leads to fatal clinical outcomes. Low-dose cytosine arabinoside (CA) therapy has been reported to be effective for clinical symptoms of TAM patients, but it is still controversial as to which patient should be treated. We have retrospectively reviewed the clinical outcomes of TAM patients in our institution to confirm the efficacy as well as the safety of low-dose CA therapy by comparing the clinical outcomes before and after introduction of CA.<Patients>Before introduction of CA, we have experienced 20 TAM patients of 13 male and 7 female between September 1992 and November 2008. The median gestational age of those was 37w4d (range, 31w5d - 39w2d) , median peak value of white blood cell (WBC) count was 48×109/L (range, 19.8 - 399×109/L), and median peak direct bilirubin(DB) level was 0.9 mg/dL (range, 0.1 - 18.4 mg/dL), respectively. Sixteen of twenty patients (80%) had various complications including dyspnea, hepatosplenomegaly, pericardial effusion, and ascites.Since 2009, we have introduced low dose CA (0.4 - 1.0mg/kg/day) for those with high WBC count (>100×109/L) until WBC count decrease to 10×109/L . Three patients received chemotherapy, but one patient with high WBC count did not, because consent was not obtained. The median gestational age of those was 36w4d (range, 33w6d - 39w2d) , median peak value of WBC count was 106×109/L (range, 101 - 267×109/L), and median peak DB level was 1.95mg/dL (range, 1.0 - 11.0 mg/dL), respectively. All of them had various complications including dyspnea, hepatosplenomegaly, pericardial effusion, liver fibrosis and ascites.<Results>Before introduction of low dose CA therapy, five of six patients (83%) with high WBC count (>100×109/L) died of liver failure(4 of 5 patients) or AML, and one of 14 patients (7%) with low WBC count (<100×109/L) died of pneumonia at the age of eight without any relation to TAM. After introduction of CA, all three patients who received chemotherapy are alive without serious complications related to TAM or chemotherapy. Their blast cells in the peripheral blood disappeared promptly and liver dysfunction as well as biomarker of liver fibrosis is getting normalized. One patient who did not receive chemotherapy died of liver failure in spite of supportive care.<Conclusion>It is suggested that low dose CA therapy is safely conducted and is effective to improve the clinical outcomes of TAM patients with high WBC count. Prospective analysis is mandatory to confirm our findings by multi-institutional basis. DisclosuresNo relevant conflicts of interest to declare.

The differentiation effect of low-dose cytosine arabinoside is disturbed in PU.1-knockdown K562 cells.

We recently demonstrated by using PU.1-knockdown K562 (K562 PU.1KD) cells stably expressing PU.1 short inhibitory RNAs and PU.1-overexpressing K562 (K562 PU.1OE) cells, that therapeutic concentrations of 5-aza-2'-deoxycytidine (5-azadC) induce erythroid differentiation of these cells and that the PU.1 expression level is closely associated with the differentiating and apoptotic effects of 5-azadC on K562 cells. In this study, we investigated whether the effects of low-dose cytosine arabinoside (Ara-C), which is another erythroid differentiation inducer in K562 cells, is associated with the expression level of PU.1 in these cells. As a result, we demonstrated that the effect of Ara-C on cell viability and differentiation, as determined by the WST-8 assay and β-globin mRNA expression analysis, respectively, was suppressed in K562 PU.1KD cells compared to their controls. Collectively, these findings suggest that sufficient expression of PU.1 is indispensable for the erythroid differentiation of K562 cells.

Control of thrombotic thrombocytopenic purpura by sirolimus in a child with juvenile myelomonocytic leukemia and somaticN-RASmutation

We describe an infant who developed juvenile myelomonocytic leukemia (JMML) at the age of 6 months. Myeloproliferation was effectively controlled by low-dose cytosine arabinoside and 13-cis retinoic acid therapy. Two years after therapy for JMML was stopped, at the age of 5 years, the patient developed autoimmune thrombotic thrombocytopenic purpura (TTP). TTP was transiently controlled by plasma exchange, prednisolone, rituximab, and cyclophosphamide, but relapsed within a short time. Long-term control of TTP was established by sirolimus. Somatic N-RAS G38A→Gly13Asp substitution was restricted to hematopoietic cells. The somatic N-RAS mutation may link myeloproliferation and autoimmunity.

How old is old: the beginning of a new era for therapeutic challenges for elderly patients with AML.

How old is old: the beginning of a new era for therapeutic challenges for elderly patients with AML.