The progressive decline in immune functions render elderly individuals more susceptible to infections than younger patients. To evaluate potential age-related differences in nosocomial infections between younger (<60 yr) and elderly (> or =60 yr) patients with acute leukemia, we retrospectively reviewed 161 consecutive febrile episodes. All neutropenic patients with an absolute neutrophil count (ANC) less than 500/microl were examined during the different phases of intensive chemotherapy and hospitalized until fever and neutropenia resolved. Fever was recorded in 66% of younger and in 64% of elderly patients and occurred respectively in 45% and in 51% during induction, in 32% and in 36% during consolidation, in 23% and in 13% during relapse/refractory treatment (P=0.01). A central venous catheter (CVC) was present in 68% and in 42% of patients (P=0.001). Febrile episodes during severe neutropenia with ANC <100/microl were recorded in 47% and in 22% respectively, during neutropenia with ANC >100/microl in 53% and in 78% respectively (P=0.002). No significant difference was documented in the overall incidence of infections, type of febrile episodes, nosocomial pattern, defervescence-time, median duration of antimicrobic therapy and in overall outcome. Elderly patients do not seem to be more susceptible to infections than younger ones, although the lower frequency of some risk factors must be taken into account.

Relapsed/refractory myeloma has a poor outcome because of multi-drug resistance, patient low-performance status and toxicity of conventional chemotherapy. To improve results, standard chemotherapeutics and drugs targeting the microenvironment are applied at the same time. Bortezomib, by inhibiting proteasome function, may enhance chemosensitivity to other drugs and overcome drug-resistance. Notably, doxorubicin and bortezomib may reciprocally increase their efficacy. Thus, to improve outcome whilst minimizing therapy-related toxicity, liposomal doxorubicin was added to a bortezomib-based combination. From January 2004, relapsed/refractory myeloma patients referred to our Institution received bortezomib 1.0 mg/m(2) i.v. twice weekly for 2 weeks in a 28-d cycle for up to six cycles, oral dexamethasone 24 mg with the standard scheduling and thalidomide 100 mg continuously (VTD). From January 2005, liposomal doxorubicin, 50 mg/m(2) (30 mg/m(2) for patients older than 75 years), was added on day 4 of each cycle [VTD plus Myocet (MyVTD)]. In total, 70 patients were treated: 28 received VTD and 42 MyVTD. Baseline demographic and clinical characteristics were similar between the two groups. Toxicity was manageable although more pronounced with MyVTD. The overall response rate (81% vs. 50%, P = 0.009), time to progression (19 vs. 11 months, P = 0.01) and progression-free survival (15 vs. 8 months, P = 0.001) were significantly higher with MyVTD regimen, suggesting an improved quality of response.

To the editor: Elliott and colleagues have reported in a group of 73 patients with acute myeloid leukemia (AML) that the time to clearance of peripheral blood blasts (PBB) during standard induction therapy is a strong predictor of both overall (OS) and relapse-free survival (RFS).[1][1] We have

Background. Recently, gene expression profiling (GEP) indicated histone-deacetylases (HDAC) as potential therapeutic targets in peripheral T-cell lymphomas (PTCL) not otherwise specified (NOS), the commonest PTCL type. Consistently, phase II trials demonstrated the efficacy of some HDAC inhibitors (HDACi), including SAHA, which was approved for cutaneous T-cell lymphomas (CTCL) treatment.

Alessandro Pulsoni, Simona Iacobelli, Massimo Bernardi, Marco Borgia, Andrea Camera, Nicola Cantore, Francesco Di Raimondo, Paola Fazi, Felicetto Ferrara, Franco Leoni, Vincenzo Liso, Marco Mancini, Filippo Marmont, Angela Matturro, Luca Maurillo, Lorella Melillo, Giovanna Meloni, Salvo Mirto, Giorgina Specchia, Caterina Giovanna Valentini, Adriano Venditti, Giuseppe Leone, Robin Foà, Franco Mandelli, and Livio Pagano

Objective: Inhibition of histone deacetylases, well known for its antiproliferative efficacy in vivo, was recently shown to ameliorate inflammation in experimental colitis. Since inflammatory bowel disease is associated with an increased risk of developing colon cancer, here the combined anti-inflammatory and proapoptotic efficacy of histone deacetylase inhibitors was studied in mouse models.Methods: The novel histone deacetylase inhibitor ITF2357 was compared with suberoylanilide hydroxamic acid in models of experimental colitis. Effects on tumour growth were studied after treatment of mice with azoxymethane and dextran sulphate sodium, and in interleukin 10 (IL10) knockout mice, respectively. Possible underlying mechanisms involving apoptosis and nuclear factor (NF)-kappa B activation were addressed by flow cytometry and western blot.Results: In dextran sulphate sodium-and trinitrobenzene sulphonic acid-induced colitis, treatment with ITF2357 was superior to suberoylanilide hydroxamic acid as shown by macroscopic and histological amelioration of inflammation, by reduced production of interferon gamma (IFN gamma) and by increased production of IL10. In both models of inflammation-mediated tumourigenesis, inhibition of histone deacetylases resulted in a significant suppression of tumour growth in terms of size and number, along with reduced signs of inflammation. As for potential mechanisms of ITF2357 action, increased acetylation of histone 3, reduced production of IFN gamma and enhanced apoptosis in lamina propria mononuclear cells were found to accompany a histone deacetylase-dependent activation of NF-kappa B.Conclusions: These results indicate that inhibition of histone deactylases can attenuate inflammation-mediated tumour growth, which is paralled by an inhibition of NF-kappa B. Thus histone deacetylase inhibitors provide a promising strategy that combines anti-inflammatory and proapoptotic modes of action.

The clinical outcome of acute myeloid leukemia (AML) is extremely variable, ranging from survival of a few days to cure. Different clinical and biological features at diagnosis have been reported as useful for the prediction of clinical outcome; however, in most AML cases induction therapy must be initiated as soon as possible, therefore, the possibility of stratifying patients at diagnosis is generally not taken into account, with the exception of acute promyelocytic leukemia in which morphology, immunophenotype, and molecular biology allow a rapid diagnosis and the adoption of specific therapy. As a consequence, prognostic factors in AML are more useful for the prediction of relapse, rather than for the stratification of induction therapy. Most relevant studies, based on large multicenter trials have definitively demonstrated that age and cytogenetics at diagnosis are the most important prognostic determinants for patients with AML. Early blast clearance after induction chemotherapy represents a further important factor of potential utility into clinical practice. Finally, biologic parameters, such as mutations of FLT3 and nucleophosmin, have been reported as useful for the prognostic categorization mainly in patients with intermediate cytogenetics and can also represent potential targets for new therapeutic agents.

BACKGROUND:Gemtuzumab ozogamicin (GO) is effective as single agent in the treatment of acute myeloid leukemia (AML). We evaluated efficacy and safety of a chemotherapy including growth factors, cytarabine, and GO (G-AraMy) in the treatment of poor-prognosis AML in elderly patients.PATIENTS AND METHODS:In three Italian hematology departments from September 2003 to September 2006, 53 elderly patients [median age 69 years (range 65-77)] with untreated or primary refractory/relapsed AML were enrolled on the combination G-AraMy administered according to two consecutive schedules (G-AraMy1 and G-AraMy2), with intensified consolidation in the second. Twenty-three of 53 patients had a secondary acute myeloid leukemia (sAML).RESULTS:The overall response rate was 57%. The most common adverse event was myelosuppression. Seven patients died in induction (13%). No differences for response rate and toxicity profile were observed between untreated and primary resistant/relapsed patients, de novo AML and sAML, and in the two treatment trials. Median disease-free survival and overall survival were 8 months (range 2-23+) and 9 months (range 2-24+).CONCLUSIONS:G-AraMy therapy may be considered an useful treatment approach for poor-risk elderly AML patients, with a complete remission rate comparable to literature data with reduced side-effects, also in a poor-prognosis population.

In this study, we analysed the prognostic relevance of foetal liver tyrosine kinase 3 (FLT3) mutations in 73 patients with acute myeloid leukaemia (AML) with normal karyotype, who survived induction and consolidation and received autologous stem cell transplantation (ASCT) after successful mobilization of peripheral blood stem cell (PBSC). There were 44 males and 29 females with a median age of 54 years (range 20-77). Overall, 16 out of 73 autografted patients (22%) had FLT3 mutations. More in detail, FLT3/ITDs were detected in 10 out of 73 patients (14%), while FLT3 D835 mutations were detected in five cases (7%). One patient (1%) was found as having both abnormalities. White blood cell count (p=0.009), serum concentration of lactate dehydrogenase (p=0.01), and percentages of peripheral blood (p=0.002) and bone marrow blasts (p=0.03) were significantly higher in patients showing the FLT3 mutations. On the contrary, overall survival and disease-free survival were similar between patients with or without FLT3 mutations (p=0.73 and 0.78, respectively). In conclusion, our data suggest that myeloablative chemotherapy supported by auto-PBSCT may overcome the adverse prognostic implications of FLT3 mutations in AML. However, it is to consider that autografted patients are highly selected for best response to induction, consolidation and mobilization, as well as for minor non-haematologic toxicity.

Clinical risk classifications fail to predict relapse (REL) in about 25% and 50% of high- and standard-risk (HR, SR) ALL patients (pts.), respectively, with potential under-/over-exposure to chemotherapy or allogeneic stem cell transplant (SCT, with intrinsic mortality ≥20%). Between 2000–5, we studied MRD as major predictive factor for REL and key decisional tool for SCT or less aggressive therapy in individual pts. with SR/HR ALL. Induction/consolidation consisted of Ida/V/P/Asp/CY (blocks 1–3,5,6,8), HD-MTX/Ara-C (4,7), CNS phase and imatinib (Ph+). Risk classes were SR (pre-B, WBC<30; cortical T, WBC<100), HR (pro-B, early/mature T; late CR; adverse cytogenetics; WBC>30 [B]/100 [T]), and very HR (VHR) i.e. Ph/t(4;11)+. All cases were screened for fusion genes or IgH/TCRβγδ/Kde rearrangements (23/22 PCR amplifications for B/T subsets, respectively). Marrow cells obtained before blocks 4,6,8 (week 10,16,22 i.e. timepoints [TP]1-3) were analyzed by RQ-PCR using 1 or more pt.-specific probes. MRD negativity (Mneg) was defined by negative/low-positive (<10−4 ) TP2 and negative TP3. MRD-based therapy consisted of maintenance in Mneg, SCT (family-related/unrelated) in Mpos (positive), and 2–4 autologous stem cell-supported Hypercycles (H/C: L-PAM/VP/6MP; HD-MTX/Ara-C) plus maintenance in Mpos without donor. VHR pts. were always eligible to SCT. Pts. with undefined MRD were treated by risk class. Of 280 total pts. (median age 38 years [range 16–66], SR 96, HR 90, VHR 89, unknown 5), 236 achieved CR (84%). 279 total probe(s) were obtained in 199 CR pts. (84%), with sensitivity ≥10−4 in 89%. 142 pts. completed consolidation and 94 did not (relapse 19%, early SCT 12%, violations/toxicity 7%); 18 (13%) lacked a probe and 12 (8%) were not correctly sampled at TP1-3. 112 pts. were exactly classified as Mneg (n 58, 52%) or Mpos (n 54, 48%), with some influence from VHR class (P=.044). With minimum FUP 1 year, 117 (50%) pts. relapsed and 28 (12%) died in CR (13 after SCT, 22%). For CR pts., 5-year overall survival (OS), REL-free survival (RFS) and cumulative REL incidence (CIR) were 54/42/56% in SR, 31/28/65% in HR and 28/24/65% in VHR. In Mneg pts., OS/RFS/CIR were 75/72/28% vs 33/14/79% in Mpos (P<.001), with no difference by clinical risk class, vs 39/37/55% in pts. with unknown MRD. The dominant predictive role of MRD for REL was confirmed by Cox regression (Haz. Ratio 5.72, P<.001). Also, when TP3 MRD results were compared to TP1, 36/39 (92%) and 41/47 (87%) pts. were confirmed Mpos and Mneg, respectively, while only 9 changed MRD risk class (P<.001); MRD remained the most significant prognostic factor, along with WBC count (B subsets: OS 79% in Mneg vs 33% in Mpos/WBC<30 vs 0% in Mpos/WBC>30; P<.001). Finally, Mpos pts. could be rescued by SCT (3-year RFS 40%) and H/C (53%), particularly those with WBC<30 (58%) who became Mneg (79%). Early MRD analysis with ≥1 probe(s) supports optimal therapeutic choices in ALL. Mpos ≥10−4 confers the highest risk, mandating for early SCT/experimental therapy. Confirmed Mneg status allows standard therapy with minimal mortality and expected RFS ≥70%.

We have investigated the activity of ITF2357, a novel hydroxamate histone deacetylase inhibitor, on multiple myeloma (MM) and acute myelogenous leukemia (AML) cells in vitro and in vivo. ITF2357 induced apoptosis in 8/9 MM and 6/7 AML cell lines, as well as 4/4 MM and 18/20 AML freshly isolated cases, with a mean IC50 of 0.2 μ M. ITF2357 activated the intrinsic apoptotic pathway, upregulated p21 and downmodulated Bcl-2 and Mcl-1. The drug induced hyperacetylation of histone H3, H4 and tubulin. When studied in more physiological conditions, ITF2357 was still strongly cytotoxic for the interleukin-6 (IL-6)-dependent MM cell line CMA-03, or for AML samples maximally stimulated by co-culture on mesenchymal stromal cells (MSCs), but not for the MSCs themselves. Interestingly, ITF2357 inhibited the production of IL-6, vascular endothelial growth factor (VEGF) and interferon-γ by MSCs by 80–95%. Finally, the drug significantly prolonged survival of severe combined immunodeficient mice inoculated with the AML-PS in vivo passaged cell line already at the 10 mg/kg oral dose. These data demonstrate that ITF2357 has potent anti-neoplastic activity in vitro and in vivo through direct induction of leukemic cell apoptosis. Furthermore, the drug inhibits production of growth and angiogenic factors by bone marrow stromal cells, in particular IL-6 and VEGF.

Bortezomib (Velcade®) is effective in MM as single agent. A strong rationale supports the association of bortezomib with anthracyclines. Bortezomib may increase the activity of anthracyclines by inhibiting maturation of P-gp, suppressing DNA repair and inducing phosphorylation and cleavage of Bcl-2. Anthracyclines down-regulate the bortezomib anti-apoptotic effect. In vitro studies demonstrated that liposome encapsulated doxorubicin can overcome MDR-1 overexpression. It has a longer half-life, lower cardiac toxicity and comparable efficacy. Thus, we added non-pegylate liposomal doxorubicin (Myocet®) to the low dose VTD regimen (Ciolli et al. Leukemia & Lymphoma 2006; 47(1): 171–173). Aims of the study were to evaluate the feasibility of treatment and stem cells harvest and transplantation, to compare ORR and TTP in respect to LD-VTD. The study was performed in accordance with the Declaration of Helsinki. Eligibility criteria: pts primary refractory (PR) or relapsed and refractory (R/R), with a LVEF more than 45% and a measurable disease. Therapy: bortezomib 1.0 mg/m2 i.v. bolus days 1, 4, 8 and 11 of a 28-d cycle, Myocet 50 mg/m2 i.v over 60 minutes on day 4 (1 hour after bortezomib), oral dexamethasone 24 mg on the day of and the day following each bortezomib dose. Thalidomide 100 mg/d if non controindicated. All toxicities were defined according to NCI criteria. Response was evaluated after each cycle. Pts with progressive disease (PD) were removed from the study, the others continued until best response for a maximum of 4 cycles. Time to response was from the date of the first administration of bortezomib to the first evidence of response. From June 2005, 28 pts, median age 68 years, entered the study: 5 stage IIA, 20 IIIA and 3 IIIB. 16 (57%) were the PR pts and 12(43%) those R/R. 8(29%) had a β2microglobulin >4 mg/L, 7 a PS >2 and 8 a pre-existing peripheral neuropathy (PN) grade 2. Median time from diagnosis was 4 years and a median of 4 (range 2–6) were the prior therapy lines. All pts had previously received thalidomide plus dexamethasone; 8 had previously received bortezomib. 13 (46%) did not receive thalidomide due to a pre-existing neurological toxicity. Haematological toxicity was registered 14–17 days from the start of therapy and lasted for a maximum of 4 days: grade 2 neutropenia in 3 pts, grade 4 thrombocytopenia in 5. A patient had a grade 4 gastric haemorrhage. 3 pts had pneumonia, 2 HZ infection and 1 a DVT. Other adverse advents of grade >1 were fatigue (50%), nausea (60%), diarrhoea (15%), alopecia (10%). None progression of PN was observed. No patient experienced clinical evidence of cardiac toxicity. At July 31th 2006,. all pts were valuable for response: 3 PD, 4 SD, 21 responders: 8 CR, 2 nCR, 7 PR,4 MR (ORR 75%). Median time to best response was 1 month (range 1– 2). 3 pts successfully harvested the PBSC and 1 was transplanted. After a median follow-up of 9 months, median TTP and OS had not been reached, 23 pts were alive and 5 (2 PD and 3 responders) had died. Myocet did not add toxicity to LD-VTD. PBSC has been successfully performed in eligible pts. More pts and an adequate follow-up are needed to draw any definitive conclusion about TTP and OS, however, this regimen appears feasible and effective with an increased ORR compared to our previous LD-VTD experience (75% vs 53%).

Although several parameters are useful for risk stratification of patients with acute myeloid leukaemia (AML), there are no firm criteria for predicting response to induction treatment of individual patients. Daily flow cytometry (FC) analysis, carried out during induction treatment in 30 AML patients, showed that the clearance of blasts from peripheral blood (PBC) correlated closely with response, as assessed by bone marrow FC on day 14, and by morphologic analysis at haematopoietic recovery. Therefore, a major treatment outcome can be predicted very early in AML patients, thus providing an opportunity for tailoring treatment modalities from the outset.