Peter Staib

Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial

BACKGROUNDnOn the basis of promising results that were reported in several phase 2 trials, we investigated whether the addition of the monoclonal antibody rituximab to first-line chemotherapy with fludarabine and cyclophosphamide would improve the outcome of patients with chronic lymphocytic leukaemia.nnnMETHODSnTreatment-naive, physically fit patients (aged 30-81 years) with CD20-positive chronic lymphocytic leukaemia were randomly assigned in a one-to-one ratio to receive six courses of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days of each 28-day treatment course with or without rituximab (375 mg/m(2) on day 0 of first course, and 500 mg/m(2) on day 1 of second to sixth courses) in 190 centres in 11 countries. Investigators and patients were not masked to the computer-generated treatment assignment. The primary endpoint was progression-free survival (PFS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00281918.nnnFINDINGSn408 patients were assigned to fludarabine, cyclophosphamide, and rituximab (chemoimmunotherapy group) and 409 to fludarabine and cyclophosphamide (chemotherapy group); all patients were analysed. At 3 years after randomisation, 65% of patients in the chemoimmunotherapy group were free of progression compared with 45% in the chemotherapy group (hazard ratio 0·56 [95% CI 0·46-0·69], p<0·0001); 87% were alive versus 83%, respectively (0·67 [0·48-0·92]; p=0·01). Chemoimmunotherapy was more frequently associated with grade 3 and 4 neutropenia (136 [34%] of 404 vs 83 [21%] of 396; p<0·0001) and leucocytopenia (97 [24%] vs 48 [12%]; p<0·0001). Other side-effects, including severe infections, were not increased. There were eight (2%) treatment-related deaths in the chemoimmunotherapy group compared with ten (3%) in the chemotherapy group.nnnINTERPRETATIONnChemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab improves progression-free survival and overall survival in patients with chronic lymphocytic leukaemia. Moreover, the results suggest that the choice of a specific first-line treatment changes the natural course of chronic lymphocytic leukaemia.nnnFUNDINGnF Hoffmann-La Roche.

Basic Fibroblast Growth Factor Controls Migration in Human Mesenchymal Stem Cells

Little is known about the migration of mesenchymal stem cells (MSCs). Some therapeutic approaches had demonstrated that MSCs were able to regenerate injured tissues when applied from different sites of application. This implies that MSCs are not only able to migrate but also that the direction of migration is controlled. Factors that are involved in the control of the migration of MSCs are widely unknown. The migratory ability of isolated MSCs was tested in different conditions. The migratory capability was examined using Boyden chamber assay in the presence or absence of basic fibroblast growth factor (bFGF), erythropoietin, interleukin‐6, stromal cell‐derived factor‐β, and vascular endothelial growth factor. bFGF in particular was able to increase the migratory activity of MSCs through activation of the Akt/protein kinase B (PKB) pathway. The results were supported by analyzing the orientation of the cytoskeleton. In the presence of a bFGF gradient, the actin filaments developed a parallelized pattern that was strongly related to the gradient. Surprisingly, the influence of bFGF was not only an attraction but also routing of MSCs. The bFGF gradient experiment showed that low concentrations of bFGF lead to an attraction of the cells, whereas higher concentrations resulted in repulsion. This ambivalent effect of bFGF provides the possibility to a purposeful routing of MSCs.

Patients with de novo acute myeloid leukaemia and complex karyotype aberrations show a poor prognosis despite intensive treatment: a study of 90 patients

The clinical significance of complex chromosome aberrations for adults with acute myeloid leukaemia (AML) was assessed in 920 patients with de novo AML who were karyotyped and treated within the German AML Cooperative Group (AMLCG) trials. Complex chromosome aberrations were defined as three or more numerical and/or structural chromosome aberrations excluding translocations t(8;21)(q22;q22), t(15;17)(q22;q11–q12) and inv(16)(p13q22). Complex chromosome anomalies were detected in 10% of all cases with a significantly higher incidence in patients u200a60u2003years of age (17·8% vs. 7·8%, Pu2003<u20030·0001). Clinical follow‐up data were available for 90 patients. Forty‐five patients were <u200a60u2003years of age and were randomly assigned to double induction therapy with either TAD‐TAD [thioguanine, daunorubicin, cytosine arabinoside (AraC)] or TAD‐HAM (high‐dose AraC, mitoxantrone). Twenty‐one patients achieved complete remission (CR) (47%), 20 patients (44%) were non‐responders and 9% of patients died during aplasia (early death). The median overall survival (OS) was 7u2003months and the OS rate at 3u2003years was 12%. Patients receiving TAD‐HAM showed a significantly higher CR rate than patients receiving TAD‐TAD (56% vs. 23%, Pu2003=u20030·04). Median event‐free survival was less than 1u2003month in the TAD‐TAD group and 2u2003months in the TAD‐HAM group, respectively (Pu2003=u20030·04), with a median OS of 4·5u2003months vs. 7·6u2003months (Pu2003=u20030·13) and an OS after 3u2003years of 7·6% vs. 19·6%. Forty‐five patients were u200a60u2003years of age: 28 of these patient were treated for induction using one or two TAD courses and 17 cases received TAD‐HAM with an age‐adjusted reduction of the AraC dose. The CR rate was 44%, 38% were non‐responders and 18% experienced early death. The median OS was 8u2003months and the OS rate at 3u2003years was 6%. In conclusion, complex chromosome aberrations in de novo AML predicted a dismal outcome, even when patients were treated with intensive chemotherapy. Patients under the age of 60u2003years with complex aberrant karyotypes may benefit from HAM treatment during induction. However, long‐term survival rates are low and alternative treatment strategies for remission induction and consolidation are urgently needed.

Phase 3 randomized, placebo-controlled, double-blind study of high-dose continuous infusion cytarabine alone or with laromustine (VNP40101M) in patients with acute myeloid leukemia in first relapse

Laromustine is a sulfonylhdrazine alkylator with significant antileukemia activity. An international, randomized (2:1), double-blind, placebo-controlled study was conducted to compare complete remission (CR) rates and overall survival (OS) in patients with first relapse acute myeloid leukemia (AML) treated with laromustine and high-dose cytarabine (HDAC) versus HDAC/placebo. Patients received 1.5 g/m(2) per day cytarabine continuous infusion for 3 days and laromustine 600 mg/m(2) (n = 177) or placebo (n = 86) on day 2. Patients in CR received consolidation with laromustine/HDAC or HDAC/placebo as per initial randomization. After interim analysis at 50% enrollment, the Data Safety Monitoring Board (DSMB) expressed concern that any advantage in CR would be compromised by the observed on-study mortality, and enrollment was held. The CR rate was significantly higher for the laromustine/HDAC group (35% vs 19%, P = .005). However, the 30-day mortality rate and median progression-free survival were significantly worse in this group compared with HDAC/placebo (11% vs 2%; P = .016; 54 days vs 34; P = .002). OS and median response durations were similar in both groups. Laromustine/HDAC induced significantly more CR than HDAC/placebo, but OS was not improved due to mortality associated with myelosuppression and its sequelae. The DSMB subsequently approved a revised protocol with laromustine dose reduction and recombinant growth factor support. The study was registered as NCT00112554 at http://www.clinicaltrials.gov.

Prediction of individual response to chemotherapy in patients with acute myeloid leukaemia using the chemosensitivity index Ci

As the response to chemotherapy in patients with acute myeloid leukaemia (AML) may still not be accurately determined by known prognostic factors, such as karyotype, the ex vivo chemosensitivity profile may help to predict the individual response. The predictive accuracy of an ex vivo assay should be assessed by correlation of assay results with both response rate and survival. We prospectively investigated the prognostic relevance of pre‐therapeutic ex vivo chemosensitivity testing in primary cell cultures from adult AML patients by applying a new evaluation methodology, designated the chemosensitivity index, Ci. This Ci was designed as a prognostic index by taking the area under the curve as an exact measure of the total dose–response relationship. We found an overall predictive accuracy of 98·2% concerning treatment response, which compares favourably with previously published data ranging from 75% to 92%. Moreover, the Ci proved to be the strongest prognostic factor for overall survival in a multivariate Cox regression analysis including karyotype grouping and age (Pu2003<u20030·001), and enabled the evaluation of response to combination therapies and selection of possible treatment alternatives. Our data suggest that ex vivo chemosensitivity testing evaluated by the Ci could serve as a powerful tool for assay‐directed therapy strategies in AML.

Prognosis in adult AML is precisely predicted by the DISC-assay using the chemosensitivity-index Ci.

We prospectively investigated the correlation between DISC-assay results and clinical response and also survival in patients with AML using a new method of evaluation.

Lyme Disease in a Patient with Chronic Lymphocytic Leukemia Mimics Leukemic Meningeosis

Background: Involvement of the central nervous system (CNS) is a rare complication of chronic lymphocytic leukemia (CLL) and seems to be more frequent in patients with Richter’s syndrome or prolymphocytic transformation. Cases with leptomeningeal involvement reported in the literature mostly do not discuss the definition of CLL-associated meningeosis and the exclusion of neuroborreliosis. Patient and Methods: We present the case of a 75-year-old male patient who was admitted to a rural hospital with ataxia, disorientation, and signs of progressive CLL disease. He was diagnosed of suspicious meningeosis leukemica, and treatment was started with dexamethasone for leukemic CNS involvement. Results: When referred to our center, careful immunophenotyping of the CNS lymphocytes as well as assessment for infectious causes of lymphocytic meningitis led to the diagnosis of Lyme disease/neuroborreliosis. An antibiotic regimen with ceftriaxone for 3 weeks resulted in complete remission of all symptoms. There was no need for CLL treatment. Conclusion: In conclusion, this case report should alert clinicians that lymphocytic meningeal involvement in CLL patients accounts for the rare leukemic meningeosis only if cerebrospinal fluid cells show a predominating immunophenotype of typical BCLL cells, i.e. by flow cytometry, and if any infectious cause including Lyme disease has been ruled out.

Clinical safety and pharmacological profile of the HLA-DR antibody 1D09C3 in patients with B cell chronic lymphocytic leukemia and lymphoma: results from a phase I study.

Abstract1D09C3 is a human monoclonal IgG4-type antibody against human leukocyte antigen-DR (HLA-DR) which has demonstrated pro-apoptotic activity against lymphoid tumors in vitro and in vivo. We report results from a phase I dose-escalation study which aimed to identify tolerated dosing, and the pharmacokinetic and pharmacodynamic profile of 1D09C3. Fourteen patients with relapsed/refractory B cell type leukemia/lymphoma were treated and followed after up to 4 weekly infusions of 1D09C3, administered in 6 dose levels at 0.25–8xa0mg/kg/day. Treatment was tolerated well with mostly mild side effects. The most common grade III–IV toxicities were hematological events observed in 4 patients. In one patient, treated at 8.0xa0mg/kg/day, a dose limiting toxicity occurred, identified as an invasive catheter-related infection. Adverse events resolved completely without long-term sequelae. 1D09C3 reduced peripheral blood B cells and monocytes by a median of 73–81xa0% in all patients, with a nadir reached 30–60xa0min after infusion and sustained for <96xa0h. Granulocytes and natural killer cells predominantly increased with variable time courses. Pharmacokinetic assessments showed detectable drug concentrations at doses 4–8xa0mg/kg/day and a terminal half-life of 0.7–7.9xa0h. Effective saturation of HLA-DR on peripheral blood B cells/monocytes was achieved, varying consistently with available serum concentrations and the cell-reducing activity of 1D09C3. In summary, 1D09C3 could be administered safely in patients with advanced B cell malignancies. Pharmacodynamic studies demonstrated a strong dose dependent but transient reduction of peripheral blood B cells and monocytes, consistent with a short drug serum availability.

Predictive Value of Pretherapeutic In-Vitro Chemosensitivity Testing in Adult AML

Individual prognosis in adult AML may still not be determined by known prognostic factors, e.g. age, cytogenetics. Short term in-vitro drug sensitivity tests such as the differential staining cytotoxicity (DISC) assay were developed to determine individual treatment outcome. We prospectively correlated DISC assay results and treatment outcome in patients (pts.) with AML using a new method of analysis. Pts. were treated according to the TAD-HAM regimen (thioguanine, Ara-C, daunorubicin-high dose Ara-C, mitoxantrone) in de-novo AML or the Ida-FLAG regimen (idarubicin, fludarabine, Ara-C, G-CSF) in relapsed or MDS-AML. The DISC assay was performed as described by Weisenthal et al. [1]. All drugs used for therapy were pretherapeutically tested at 5 different concentrations in primary cell cultures in triplicate samples of each patient. Assay results measured in % tumor cell survival (TCS) were transformed into a mathematical equation, which described the dose response relation. The area under the curve (AUC) and the calculated TCS at the middle test-concentration were then transformed into an index called chemosensitivity index Ci. If Ci was > 0.5 probability of clinical response to that drug was defined to be high, and if Ci was 0.5 of at least one drug used for therapy (TP=true positive correlation). 6/7 pts. were nonresponders and identified with Ci 0.5 was 672 days, median is not yet reached. Mean survival of the group with Ci 0.5) was 449 days, median 275 days. In conclusion, in-vitro chemosensitivity tests may provide a valuable tool for prediction of individual treatment outcome in pts. with AML. Prospective clinical trials using the DISC assay for treatment stratification and assay directed therapy strategies would be justified.

Determination of caspase-3 activation fails to predict chemosensitivity in primary acute myeloid leukemia blasts

BackgroundEx-vivo chemosensitivity tests that measure cell death induction may predict treatment outcome and, therefore, represent a powerful instrument for clinical decision making in cancer therapy. Such tests are, however, work intensive and, in the case of the DiSC-assay, require at least four days. Induction of apoptosis is the mode of action of anticancer drugs and should, therefore, result in the induction of caspase activation in cells targeted by anticancer therapy.MethodsTo determine, whether caspase activation can predict the chemosensitivity, we investigated enzyme activation of caspase-3, a key executioner caspase and correlated these data with chemosensitivity profiles of acute myeloid leukemia (AML) blasts.ResultsThere was, however, no correlation between the ex-vivo chemosensitivity assessed by measuring the overall rates of cell death by use of the DiSC-assay and caspase-3 activation.ConclusionThus, despite a significant reduction of duration of the assay from four to one day, induction of apoptosis evaluated by capase-3 activity does not seem to be a valid surrogate marker for chemosensitivity.