Hajime Kawasaki

Risk-directed treatment of infant acute lymphoblastic leukaemia based on early assessment of MLL gene status: results of the Japan Infant Leukaemia Study (MLL96).

Summary.  We studied the effectiveness of risk‐directed therapy for infants younger than 13 months of age with acute lymphoblastic leukaemia (ALL). Fifty‐five infants were assigned to different treatment programs (from December 1995 to December 1998) on the basis of their MLL gene status at diagnosis. Forty‐two cases (76·3%) had a rearranged MLL gene (MLL+) and were treated with remission induction therapy followed by sequential intensive chemotherapy, including multiple genotoxic agents (MLL9601 protocol). Haematopoietic stem cell transplantation (HSCT) was attempted if suitable donors were available. Thirteen infants (23·7%) were classified as MLL– and treated for 2·5 years with intensive chemotherapy for high‐risk B‐ALL (MLL9602 protocol). Complete remission was induced in 38 of the 42 infants (90·5%) with MLL+ ALL and in all 13 patients (100%) with MLL– disease. In the MLL+ subgroup, the estimated event‐free survival (EFS) rate at 3 years post diagnosis was 34·0% ± 7·5%, compared with 92·3% ± 7·4% in the MLL– subgroup (overall comparison, P = 0·001 by log‐rank analysis). Both age less than 6 months (hazard ratio = 6·87, 95% CI = 0·91–52·3; P = 0·013) and central nervous system (CNS) involvement at diagnosis (hazard ratio = 2·92 95% CI = 1·29–6·63; P = 0·015) were significant independent predictors of an inferior outcome. These findings indicate a strategic advantage in classifying infant ALL as either MLL+ or MLL– early in the clinical course and selecting therapy accordingly. Standard chemotherapy for high‐risk B‐lineage ALL appeared adequate for MLL– cases. Novel therapeutic initiatives are warranted for infants with MLL+ disease, particularly those with initial CNS leukaemic involvement or age less than 6 months, or both.

2-Chlorodeoxyadenosine dose escalation in nonhematologic malignancies.

PURPOSE We performed a dose-escalation study of 2-chlorodeoxyadenosine (2-CdA) in solid tumors to determine the maximum-tolerated dose (MTD) and define its toxicity profile at higher doses. PATIENTS AND METHODS Twenty-one patients, seven with malignant astrocytoma, twelve with metastatic melanoma, and two with metastatic hypernephroma, were enrolled onto the study. Patients were entered onto cohorts that received 0.10, 0.15, or 0.20 mg/kg/d of 2-CdA by continuous intravenous infusion for 7 days every 28 days. 2-CdA levels were determined by radioimmunoassay. In tumor tissue samples, deoxycytidine kinase (dCK) levels were measured by both enzyme activity and immunoreactive protein analysis. RESULTS Of seven patients treated with 2-CdA at 0.1 mg/kg/d, one experienced grade 3 or 4 myelotoxicity. Of 11 patients treated at 0.15 mg/kg/d, four experienced myelotoxicity, two after a single course of 2-CdA. All three patients who received 2-CdA at 0.2 mg/kg/d experienced myelosuppression. Neurologic events occurred in two patients, both with malignant melanoma. Two of seven patients (28.6%) with astrocytomas obtained partial responses with a median duration of 8 months. 2-CdA penetrated the blood-brain barrier. An association was found between dCK levels as measured by enzymatic activity and immunoreactive proteins, but this did not correlate with 2-CdA tumor responsiveness. CONCLUSION The MTD for 2-CdA delivered as a 7-day intravenous infusion in patients with nonhematologic malignancies was determined to be 0.1 mg/kg/d, the same as the MTD for patients with hematologic malignancies. There was no clinical correlation with dCK expression and response to 2-CdA. The responses noted in patients with malignant astrocytoma warrant further phase II study.

Minimal residual disease with TEL-AML1 fusion transcript in childhood acute lymphoblastic leukaemia with t(12;21).

We analysed the TEL‐AML1 transcript using reverse transcription‐polymerase chain reaction (RT‐PCR) in order to detect minimal residual disease (MRD) in seven children with t(12;21)‐associated B‐lineage ALL. Leukaemic cells with the TEL‐AML1 transcript appear to be very sensitive to chemotherapy, and may be eradicated in most patients if adequate chemotherapy is given. However, a small number of patients with t(12;21) ALL may relapse under the currently used chemotherapy, and we believe that RT‐PCR for detecting MRD with the transcript is a suitable tool for monitoring the efficacy of chemotherapy or impending relapse in these patients. We analysed the TEL‐AML1 transcript using reverse transcription‐polymerase chain reaction (RT‐PCR) in order to detect minimal residual disease (MRD) in seven children with t(12;21)‐associated B‐lineage ALL. Two sets of primers, TEL exon 5 and AML1 exon 3 or 4, detected two types of transcript in four patients and two other types in two other patients. The two different translocation breakpoints in the AML1 gene with or without splicing out of AML1 exon 3 seemed to result in these four types of transcript in leukaemia samples.

Recent advances in the treatment of infant acute myeloid leukemia

Infant acute myeloid leukemia (AML) of less than 12 months old is generally characterized by a high incidence of acute monoblastic or myelomonoblastic leukemia with hyperleukocytosis and extramedullary involvement. Most of the leukemic cells have 11q23 translocations, which lead to the MLL gene rearrangements. The MLL gene rearrangements occur at a high frequency in monoblastic subtype, hyperleukocytosis or young age in infant AML. Compared with acute lymphoblastic leukemia, however, it remains unknown whether prenatal origin exists in the pathogenesis of infant AML. Recently, the treatment outcome of infant AML has been clarified by two study groups, which confirmed the effect of intensive chemotherapy including repeated cycles of cytarabine and anthracyclines for infant AML. Presence of the MLL gene rearrangements, gender, age and white blood cell count showed no influence on the outcome of infant AML. The allogeneic hematopoietic stem cell transplantation (HSCT) remains the treatment of choice for infant AML when a matched related donor is available. Monitoring of minimal residual disease by real-time PCR is a useful technique to predict the outcome or efficacy of the treatment in infant AML. Although intensive chemotherapy and/or allogeneic HSCT have cured most AML infants, some still relapse and ultimately die. A need remains for future development by exploiting the unusual biologic properties of leukemic progenitor cells expressing the abnormal MLL gene product.

Thrombopoietin level is inversely related to blast count, not platelet number, in Down syndrome neonates with transient myeloproliferative disorder

Transient myeloproliferative disorder (TMD) in neonates with Down syndrome is characterized by increased megakaryoblastic cells in the peripheral blood. Despite their spontaneous regression in weeks, prognosis is not always favorable because of fatal hepatic fibrosis. In this study, blood thrombopoietin (TPO) levels were measured by ELISA in six TMD patients and the expression of c‐Mpl, a ligand for TPO, was examined on the blast cells from four patients by flow cytometer. At the onset, TPO level was undetectable in one patient and significantly lower in five patients than six neonatal controls (mean 0.52 fmol/ml, range 0.30–0.93 vs. 3.70, 1.38–8.33, P < 0.001), although platelet counts were similar (mean 321 × 109/l, range 42–1,040 vs. 253 × 109/l, 124–381). Two patients died of hepatic failure. TPO levels were measured in five patients after regression of the blast cells. With regression of blast cells, TPO levels were remarkably increased in four survived patients. In one patient with hepatic failure, TPO level was poorly elevated and relatively lower compared to the others. TPO levels were inversely correlated with blast numbers (r = −0.85, P < 0.001), but not with platelet counts (r = 0.426). Blast cells from four patients were all positive for c‐Mpl. Our findings suggest that megakaryocyte mass is a major regulator of TPO levels and hepatic failure may affect the TPO level because liver is a major source of TPO production. Am. J. Hematol. 58:267–272, 1998.

Deoxycytidine kinase mRNA levels in leukemia cells with competitive polymerase chain reaction assay

Deoxycytidine kinase (dCyd kinase) is important for the phosphorylation of several different nucleoside antimetabolites. To understand the significance of dCyd kinase levels in chemotherapy, dCyd kinase mRNA levels were evaluated in several cells with a quantitative competitive polymerase chain reaction (PCR) assay. dCyd kinase catalytic activity and intracellular ara-CTP production were also compared with the levels of dCyd kinase mRNA. The assay was able to show: (i) that dCyd kinase catalytic activity and dCyd kinase mRNA levels were correlated in cells; (ii) that dCyd kinase mRNA levels were more sensitive in lower levels of 10 amol/micrograms of total RNA; and (iii) in cytosine arabinoside (ara-C)-resistant cells, both dCyd kinase mRNA levels and intracellular ara-CTP levels were lower compared with levels in sensitive cells. The PCR assay for dCyd kinase mRNA could be useful in the selection and monitoring of patients treated with nucleosides that are activated by this enzyme.

Sequence-dependent antitumor effect of VP-16 and 1-β-d-arabinofuranosylcytosine in L1210 ascites tumor

The sequence-dependence of the antitumor effect of etoposide (VP-16) and 1-beta-D-arabinofuranosylcytosine (ara-C) was investigated against the L1210 ascites tumor in BDF1 mice. Treatment with VP16 (7.5 or 15 mg/kg) and ara-C (25 or 500 mg/kg) was administered intraperitoneally on days 1, 4 and 7 after tumor inoculation. Six hour pretreatment with 15 mg/kg VP16 followed by 500 mg/kg ara-C yielded a 100% cure rate, but only a 20% cure rate was obtained with the reverse sequence. Simultaneous administration of 15 mg/kg of VP-16 and 500 mg/kg ara-C interacted synergistically, producing a 70% cure rate. In contrast with the results obtained with VP-16 and 500 mg/kg ara-C, simultaneous administration of 25 mg/kg ara-C neither antagonized nor potentiated the antitumor effect of VP-16. Twenty-five mg/kg ara-C was too low to produce any antitumor effect with VP-16 in simultaneous administration. At every dose investigated, pretreatment with VP-16 followed by ara-C was the most effective antitumor schedule in L1210 leukemia. This sequence of drug administration did not cause greater toxicity as measured by weight loss or toxic death.

Decreased DNA polymerase sensitivity to 1-β-d-arabinofuranosylcytosine 5′-Triphosphate in P388 murine leukemic cells resistant to vincristine☆

P388 murine leukemic cells 28.6-fold resistant to vincristine were cross-resistant to doxorubicin and etoposide. Although the intracellular ara-CTP in P388 murine leukemic cells resistant to vincristine (P388/VCR) was significantly higher than that in the parent cells, the cytotoxic effect of ara-C was not significantly different between the parent and resistant cells. Therefore, we investigated the DNA synthesis in P388/VCR and its parent cell line using the permeable cell system. The DNA synthesis in P388/VCR cells was less sensitive to ara-CTP and dTTP than that in P388 parent cells. These results suggested that the characteristics of DNA polymerase in P388/VCR cells might change when the cells developed multiple drug resistance.

A case of metastatic ovarian non-gestational choriocarcinoma: successful treatment with conservative type surgery and myeloablative chemotherapy.

origin. In contrast, non-gestational choriocarcinoma of the ovary (NGCO) is an exceedingly rare germ cell neoplasm.1–3 Non-gestational choriocarcinoma has a worse prognosis than gestational neoplasms and only occasional survivals have been reported in advanced cases.1,2,4 We report a case of metastatic NGCO successfully treated with combined highdose chemotherapy and autologous bone marrow stem cell transplantation with preservation of the reproductive system.

ENHANCED INCORPORATION OF 1-BETA -D-ARABINOFURANOSYLCYTOSINE BY PRETREATMENT WITH ETOPOSIDE

We examined the effects of timing of administration of etoposide on cytosine arabinoside (ara-C) incorporation into DNA in L1210 ascites tumor. At 1 hr after injection of ara-C, 3-hr and 6-hr pretreatments with 15 mg/kg of etoposide increased ara-C incorporation to more than 200% as compared to that of ara-C given alone. Simultaneous administration of etoposide, however, decreased ara-C incorporation to 33% of that of ara-C alone. These results might explain the previously reported sequence dependency of the antitumor effect of etoposide and ara-C.