A prospective randomized trial of KRN8602 and cytosine arabinoside vs. daunorubicin and cytosine arabinoside in adult patients with newly diagnosed acute myelogenous leukemia. The KRN8602 Leukemia Study Group.

A prospective randomized study was conducted to compare the efficacy and toxicity of two anthracyclines for the treatment of patients with acute myelogenous leukemia (AML). Fifty-eight patients were randomized and received induction therapy consisting of cytosine arabinoside (AraC) 100 mg/m2/day for 7 days combined with either KRN8602 (3'-deamino-3'-morpholino-13-deoxo-10-hydroxycarminomycin hydrochloride [KRN]) 15 mg/m2/day for 5 days (KRN/AraC group) or daunorubicin (DNR) 40 mg/m2/day for 3 days (DNR/AraC group). Complete remission rate was 78.6% (22/28) in the KRN/AraC group and 73.1% (19/26) in the DNR/AraC group. There was a higher incidence of nausea/vomiting and anorexia observed in the KRN/AraC group compared to the DNR/AraC group, while the incidence of other adverse effects (stomatitis, diarrhea, and infectious complications) were similar between both groups. No electrocardiogram (ECG) abnormalities were observed after treatment in the KRN/AraC group, while in the DNR/AraC group, one patient showed ECG abnormality and three patients exhibited either arrhythmia, heart failure, or tachycardia. Mental disorder was reported in two cases in the KRN/AraC group. These findings suggest that KRN/AraC is similar in effectiveness to DNA/AraC but more toxic in central nervous system and gastrointestinal symptoms and less toxic regarding cardiac function in patients with previously untreated AML.

A phase II study employing combination regimens containing KRN8602 in drug-resistant acute myeloid leukemia and acute lymphoblastic leukemia. KRN8602 Leukemia Study Group.

We conducted a phase II multicenter study in order to evaluate the efficacy and toxicity of two combination regimens containing KRN8602 (MX2) for drug-resistant acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). AML was treated with KRN8602, 15 mg/m2 i.v. push for 5 days, and cytarabine (AraC), 100 mg/m2 by 24 h coutinuous infusion for 7 days. ALL was treated with KRN8602, 15 mg/m2 i.v. push for 5 days, vincristine (VCR), 1.4 mg/m2 i.v. push, once weekly, and prednisolone (PSL), 40 mg/m2, 3 h infusion for 5 days. In AML and ALL, the complete remission (CR) rate was 36.4% (16 of 44) and 24.1% (seven of 29), and the overall response rate (CR+PR) was 52.3% (23 of 44) and 51.7% (15 of 29), respectively. Among the 29 relapsed cases of AML, a higher CR rate, 51.7% (15 of 29), was obtained. A high incidence of nausea/vomiting and anorexia was observed, and some patients experienced central nervous system disorders and peripheral neuropathy. There was a low incidence of severe neurotoxicities; all other toxicities were manageable. KRN8602 was found to overcome drug resistance clinically, confirming results based on the preclinical studies. We conclude that KRN8602 is an effective novel anthracycline for drug-resistant acute leukemias.

[Pilot late phase II study of KRN8602 (MX2), a novel anthracycline derivative, for acute leukemia--a dose finding study in combination].

In order to determine the clinically optimal dose of KRN8602, a new anthracycline derivative, in combination therapy for acute leukemia, we performed a pilot late phase II study in combination with cytarabine (Ara-C) for acute myelogenous leukemia (AML), and with vincristine (VCR) and prednisolone (PSL) for acute lymphocytic leukemia (ALL). KRN8602 was given at a dose of 12 or 15 mg/m2 for 5 consecutive days, Ara-C at a dose of 100 mg/m2 for 7 consecutive days, VCR 1.4 mg/m2 (max. 2.0 mg/body) weekly for 4 weeks, and PSL 40 mg/m2 for principally 28 consecutive days. Of 14 patients with relapsed or refractory leukemia entered in the study, thirteen patients were evaluable for safety and 12 were evaluable for response. In AML, there was 1 partial response (PR) in 4 patients at a dose of 12 mg/m2. Against 1 complete response (CR) and 3 PRs in 4 patients at a dose of 15 mg/m2. In ALL, there was 1 PR in 1 case at a dose of 12 mg/m2, and 1 CR and 2 PR in 3 at a dose of 15 mg/m2. Major toxicities were nausea/vomiting and anorexia, but incidences and grades of toxicities were not dose-dependent, and all toxicities were tolerable and manageable. From these results it is concluded that the optimal dose of KRN8602 is 15 mg/m2 for 5 consecutive days in combination with Ara-C for AML, and with VCR and PSL for ALL.

[Immunoblastic lymphadenopathy-like T cell lymphoma with high levels of serum interleukin-6, cold agglutinin disease, and immune thrombocytopenia].

An 88-year-old woman was admitted with generalized lymphadenopathy, anemia, and thrombocytopenia. On admission, a peripheral blood examination showed a red blood cell count of 146 x 10(6)/microliter, a hemoglobin concentration of 6.9 g/dl, and a platelet count of 5.0 x 10(4)/microliter. Blood examination detected polyclonal hypergammaglobulinemia; the results of the direct/indirect Coombs' test were positive; and an elevated cold agglutinin titer and high platelet associated IgG (PA-IgG) level indicated the existence of autoantibodies. Serum cytokine measurements disclosed an elevated level of interleukin-6 (IL-6). Immunoblastic lymphadenopathy-like T cell lymphoma was diagnosed on the basis of lymph node biopsy specimens. VP-16 and steroid therapy alleviated the patient's lymphadenopathy, anemia, thrombocytopenia, and hypergammaglobulinemia. These findings suggest that tumor cells with a T cell phenotype produced IL-6 in large quantities, thus provoking B-cell and plasmacytic histologic changes and humoral disease manifestations, including hypergammaglobulinemia.

[Phase II study of KRN8602 (MX2) for malignant lymphoma].

We performed a clinical phase II study of KRN8602, a new anthracycline derivative, for relapsed or recurrent malignant lymphoma. KRN8602 was given at doses of 12-15 mg/m2 for 3 consecutive days, repeating every 3-4 weeks. Among 44 patients entered into the study, 36 were evaluable for safety, and 35 were evaluable for efficacy. The response rate was 18.2% (6PR/33) for non-Hodgkin's lymphoma and 0% (0/2) for Hodgkin's disease. Major toxicities were bone marrow suppression and gastrointestinal toxicity. Leukopenia was observed in 77.8%, thrombocytopenia in 44.4%, hemoglobin decrease in 44.4%, nausea and vomiting in 94.4% and anorexia in 80.6%. However, all toxicities were clinically manageable.

[Early phase II study of KRN8602 (MX2), a novel anthracycline derivative for acute leukemia].

We performed an early phase II study of KRN8602, a new anthracycline derivative for refractory or relapsed acute leukemias. KRN8602 was given at a dose of 15 mg/m2 for 3 to 5 consecutive days, repeating every 3-4 weeks. Among 53 patients entered in the study, 51 were evaluable for safety, and 46 were evaluable for efficacy. The response rate at schedules of 3 and 4 consecutive days was 9.1% (1 PR/11), while that at a schedule of 5 consecutive days was 22.9% (3 CR + 5 PR/35). With the 5 consecutive day schedule, the response rates were 21.4% (1 CR + 2 PR/14) for acute myelogenous leukemia and 29.4% (2 CR + 3 PR/17) for acute lymphocytic leukemia, but no response was observed in 4 patients with blastic crisis of chronic myelogenous leukemia. Major toxicities were nausea/vomiting and anorexia, however, all these toxicities were clinically manageable. From these results it is concluded that KRN8602 is effective against acute leukemias, and the optimal dose is 15 mg/m2 for 5 consecutive days.

Feasibility of salvage chemotherapy for refractory or relapsed non-Hodgkin's lymphoma with two topoisomerase II inhibitors, MST-16 and VP-16. MST-16 Study Group.

A feasibility study was carried out on the treatment for refractory and relapsed non-Hodgkin's lymphomas with a combination of two oral topoisomerase II inhibitors, MST-16 and VP-16. On the basis of the synergistic activity in preclinical studies and the schedule dependency in these drugs, low-dose and long-term administration was planned. For the anticipated myelosuppression, two different regimens were designed as an open label trial in this study. In Regimen I, 400 mg of MST-16 combined with 25 mg of VP-16 was administered daily. With this regimen, the response rate (RR)/median time to tumor progression (TTP) in all evaluable patients was 50% (2/4)8.5 months in low grade (indolent) lymphoma and 60% (6/10)/5.2 months in intermediate/high grade (aggressive) lymphomas. In Regimen II, 400 mg of MST-16 combined with 25 mg of VP-16 was administered intermittently (3 days a week or every other day). With this regimen, there was an RR/median TTP of 60% (3/5)/7.0 months in indolent lymphoma and 33.3% (4/12)/1.1 months in aggressive lymphoma. A major side effect in both of these regimens was myelosuppression, with the incidence of grades 3 and 4 toxicity being higher in Regimen I than in Regimen II. The other side effects were uncommon and not severe. These findings indicated that two regimens were tolerated well and were promising for refractory and relapsed aggressive non-Hodgkin's lymphomas. To define the anti-tumor activity and safety of these regimens precisely, large-scale prospective randomized trials are necessary.

[Empiric therapy with fluconazole in granulocytopenic patients with carcinoma or leukemia].

We performed a randomized clinical trial in granulocytopenic patients with carcinoma or leukemia. Patients with persistent fever for more than 2 days despite antibiotic therapy were randomized to antibiotic plus fluconazole therapy group (FLCZ group) or antibiotic therapy only group (antibiotic group) by the envelope method. It was possible to evaluate clinical efficacies in 62 patients (37 patients in FLCZ group and 25 patients in antibiotics group). In patients whose neutrophil counts were less than 100/microliters on the initial day of therapy, clinical efficacy rates were 72.0% (18/25) in FLCZ group and 57.1% (8/14) in antibiotics group. In patients whose neutrophil counts continued to be less than 100/microliters during therapy, clinical efficacy rates were 64.3% (9/14) and 50.0% (3/6), respectively. Further, in patients whose neutrophil counts continued to be less than 500/microliters during therapy, they were 76.9% (20/26) and 53.3% (8/15), respectively. No severe side effects nor severe case of abnormal change in laboratory test values due to fluconazole were observed in this trial. These data suggest that empiric antifungal therapy with fluconazole is effective for fungal infections in granulocytopenic patients with carcinoma and leukemia.

[Initial anthracycline-based chemotherapy without radiotherapy in patients older than 70 years with localized lymphoma arising from Waldeyer's ring].

Between July 1982 and November 1992 twenty-six patients older than 70 years with localized stage of non-Hodgkin's lymphoma (NHL) arising from Waldeyer's ring were treated with initial chemotherapy consisting of anthracycline-based combination chemotherapies without regional radiotherapy in Saitama Cancer Center and Chiba Cancer Center. Patients with stage I-II were eligible for this study. There were 9 men and 17 women, ranging in age from 70 to 86 years with a median age of 77. Eight patients were aged over 80. The initial chemotherapy consisted of 400 mg/m2 of cyclophosphamide iv on day 1, either 40 mg/m2 of adriamycin or 40 mg/m2 of epirubicin iv on day 1, 2.0 mg/m2 of vindesine iv on day 1 and 40 mg/m2 of prednisolone po for 5 days. This combination chemotherapy was repeated every 4 weeks and given 6-10 cycles. There were 4 cass of stage I disease and 22 cases of stage II disease. Histologic subtypes were follicular large (1 case), diffuse large (16 cases), diffuse mixed (4 cases), and diffuse medium (4 cases). A complete response was obtained in 23 (88%) of the 26 patients. The median courses of chemotherapies in complete responders were 6 (range, 2-10). There were 7 recurrences among the 23 responders. The complete response was well sustained with an actuarial relapse-free survival of 59% at 5 years. To date 9 patients expired, four after a recurrence, four under complete remission and the remaining one without attaining CR. The survival curve of all patients became flat at 56 months and was well sustained with an actuarial survival of 34%.

[Intensive 1-(4-amino-2-methyl-5-pyrimidinyl) methyl-3-(2-chloroethyl)-3- nitrosourea hydrochloride (ACNU) and cryopreserved autologous bone marrow transplantation].

High-dose ACNU followed by autologous bone marrow transplantation was administered alone or together with other agents such as cyclophosphamide, dacarbazine, carboquone or/and VP-16. The starting dose of ACNU was 200 mg/m2, with gradual escalation up to 400 mg/m2. Median duration of granulocytes of less than 100/mm3 and platelets of less than 30,000/mm3 was 4.5 days (range; 0-9) and 10.5 days (range; 0-43), respectively. Bacteremia occurred in 4 cases, but no case of pneumonia was encountered. Heart failure possibly due to the cyclophosphamide was noted in one case with arrhythmia. Out of 13 cases with measurable diseases, three patients with Hodgkin's disease, two patients with diffuse lymphoma, and one patient with follicular lymphoma attained a complete response. Partial response was obtained in two patients with non-Hodgkin's lymphoma. Two patients with melanoma and one with acute nonlymphocytic leukemia without measurable disease still remain disease-free.

Differentiation of human myeloblastic leukemia ML-1 cells into macrophages by staurosporine, an inhibitor of protein kinase activities.

Protein kinase activities are involved in cellular proliferation and differentiation, and inhibitors of these activities are useful for studying the mechanisms of induction of differentiation. We found that staurosporine, an inhibitor of protein kinase activities, induced morphological differentiation of human myeloblastic leukemia ML-1 cells along myelomonocytic lineage and also induced functional differentiation (increase in nitroblue tetrazolium-reducing and lysozyme activities) in the cells. Several other protein kinase inhibitors such as 1-(5-isoquinolinesulfonyl)-2-methylpiperazine dihydrochloride (H-7), sphingosine, N-(6-aminoethyl)-5-chloro-1-naphthalenesulfonamide and 1-(5-chloronaphthalene-1-sulfonyl)-1H-hexahydro-1,4-diazepine hydrochloride (ML-9) did not induce the differentiation of ML-1 cells. Treatment with staurosporine induced formation of granules in ML-1 cells, and the granules showed metachromasia by toluidine blue staining; however, histamine content did not increase. The "metachromatic" ML-1 cells were positive for CD14, indicating that staurosporine induced the differentiation of ML-1 cells into metachromatic monocytes/macrophages, 1 alpha,25-dihydroxyvitamin D3 (VD3) enhanced appearance of metachromatic granules in staurosporine-treated cells. These results suggest that modulation of protein phosphorylation by a staurosporine-sensitive protein kinase(s) may be associated with differentiation of ML-1 leukemia cells.

A comparative study of CHOP versus MEVP (mitoxantrone, etoposide, vindesine, prednisolone) therapy for intermediate-grade and high-grade non-Hodgkin's lymphoma: a prospective randomized study.

To evaluate a new combination chemotherapy with mitoxantrone (MXT), etoposide (VP-16), vindesine (VDS), and prednisolone (MEVP therapy) as a front-line chemotherapy for non-Hodgkin's lymphoma (NHL), a prospective randomized study comparing this therapy (28 patients) with CHOP therapy (29 patients) was conducted in 57 patients with intermediate-grade or high-grade NHL with stages II-IV. The MEVP therapy consisted of 10 mg/m2 of MXT intravenously on day 1, 2 mg/m2 of VDS intravenously on day 1, 200 mg/m2 of VP-16 orally on days 1-3, and 40 mg/m2 of prednisolone orally on days 1-5. This regimen was repeated every 3 weeks for up to 10 courses. Complete responses (CR) were achieved in 17 (63.0%) of the 27 evaluable patients treated with MEVP therapy, and in 20 (71.4%) of the 28 evaluable patients treated with CHOP therapy. Relapse-free survival rates and overall survival rates at 3 years were 58.8% and 46.4%, respectively, for the MEVP group and 70.0% and 54.0%, respectively, for the CHOP group. Granulocytopenia was more severer and associated infection episodes were more frequent in the MEVP group. MEVP therapy was effective as a front-line chemotherapy for intermediate- and high-grade NHL, although it was not superior to CHOP therapy in treatment effect and was not less toxic than CHOP.

[Comparative study of cefpiramide + amikacin versus piperacillin + amikacin in granulocytopenic patients: a randomized, prospective study].

Cefpiramide + amikacin (CPM + AMK) was compared in a prospective randomized trial with our standard regimen of piperacillin plus amikacin (PIPC + AMK) as an empiric therapy for fever in 252 episodes of 141 patients with granulocytopenia. Initial profound granulocytopenia (fewer than 100/mm3 mature granulocytes) was present in approximately 69% of the patient trials in both treatment groups. Both groups were equally distributed in regard to age, disease, pretreatment WBC count and duration of antibiotic treatment, although septic shock was more frequently seen in CPM + AMK. Responses to PIPC + AMK and CPM + AMK were similar for microbiologically and clinically documented infection, while the response rate for clinically documented infections treated with PIPC + AMK was superior to CPM + AMK (63% vs. 52%). Patients with persistent granulocytopenia of less than 100/mm3 of mature granulocytes without a rise during therapy responded significantly less in both groups (22% vs. 9%) than those in whom the granulocyte count rose (79% vs. 79%). Toxicities of jaundice or disordered hepatic function test were infrequent in both groups. Disordered renal function test occurred in one case in PIPC + AMK groups.

Effects of novel uracil analogs on proliferation and differentiation of human myeloid leukemia cells.

Twenty-seven novel nucleobases and nucleosides were synthesized by structural modification of uracil, and their effects on growth and differentiation of human myeloid leukemia HL-60 cells were examined. Some of the compounds inhibited the growth of HL-60 effectively. The nitroblue tetrazolium (NBT)-reducing activities of cells treated with the concentrations of these compounds for 50% inhibition of growth were compared. TI-66 (2,4-dibenzyl-6-fluoro-7,7,8,8-tetramethyl-cis-2,4-diazabicyclo-[4.2.0] octane-3,5-dione) was the most effective inducer of NBT-reducing activity and morphological differentiation of HL-60 cells into cells of the myelomonocytic lineage. TI-66 was also effective for induction of differentiation of another human myelogenous leukemia cell line, ML-1 cells, but not for differentiation of human erythroid leukemia K562 or HEL cells, or monocytic U937 cells. The effect of TI-66 in inducing differentiation of HL-60 cells was additive or more than additive in combination with retinoic acid or vitamin D3. Adenine or hypoxanthine alone induced NBT-reducing activity of the cells, and at suboptimal concentrations these compounds enhanced the effect of TI-66, but the enhanced NBT-reducing activities did not exceed the maximal activity induced by TI-66 alone. Simultaneous treatment of HL-60 cells with hypoxanthine reduced the growth inhibition by TI-66 alone. TI-66 was about 150 times more potent on a molar basis than adenine in inducing differentiation of HL-60 cells. These results suggest that nucleobase analogs such as TI-66 should be useful for differentiation therapy of some types of myelogenous leukemia.

[Malignant lymphoma occurring subsequent to autoimmune disease].

The authors report six cases of non-Hodgkin's lymphoma (NHL) (3B-cell type, one T-cell type, one non-T non-B cell type, one unclassified type) occurring subsequently to autoimmune diseases. The patients were females aged 43 to 70 (median 61). Rheumatoid arthritis was most frequent as the preceding autoimmune disease, and the intervals from the onset of an autoimmune disease to that of NHL were 10 to 36 years (median 20). Polyclonal hypergammaglobulinemia was seen in 4 cases, lymphocytopenia in 3 cases, and conversion to negative PPD reaction in 2 cases. Only one patient had been given corticosteroids, and immunosuppressive agents may not contribute much to the development of lymphoma in patients with autoimmune diseases.

[A comparison of nystatin with norfloxacin for prevention of infection after consolidation therapy in patients with acute leukemia or autologous bone marrow transplantation: a randomized study].

Seventy-three patients mainly receiving consolidation therapy for acute leukemia or autologous bone marrow transplantation were studied in a randomized trial comparing nystatin with norfloxacin (800 mg) given orally QID, for prevention of infection. Both groups were equally distributed in regard to age, disease, and duration of granulocytopenia, although far more patients entered the laminar air flow room in the norfloxacin group. Duration of more than a 39 degrees C fever was much longer in the nystatin group than in the norfloxacin group: Bacteremia, microbiologically documented infections, and fever of unknown origin were more frequently seen in the nystatin group, but there was no significant difference between the two groups. On the other hand, patients without fever during granulocytopenia were more numerous in the norfloxacin group than in the nystatin group (p less than 0.05). Furthermore, three deaths during granulocytopenia occurred in the nystatin group. In conclusion, prophylactic administration of norfloxacin during granulocytopenia showed a significant afebrile period.

Stage I malignant lymphoma of Waldeyer's ring: frequent relapse after radiation therapy.

The natural history and therapeutic results of 26 patients with stage I malignant lymphoma of Waldeyer's ring (ML-WR) were analyzed retrospectively. Complete response was achieved in all 26. Relapse occurred in 9 of 21 (43%) patients treated with radiation therapy (RT) alone, while no relapse was seen in those treated with a combination chemotherapy consisting of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP therapy). Relapse occurred within 1 year in 8 of the 9 patients. Relapse-free survival in the patients treated with RT alone was considered suboptimal.

Induction of differentiation of human myeloid leukemia HL-60 cells by novel pyrimidine nucleoside analogs.

New pyrimidine nucleoside analogs (18 compounds) were synthesized and their growth-inhibiting and differentiation-inducing activities on human myeloid leukemia HL-60 cells were examined. Some of the analogs were found to induce nitroblue tetrazolium (NBT) reducing activity in the HL-60 cells. The inducing activities of these compounds were compared at their concentrations for 50% inhibition of cell growth. TI-79 (3-benzyl-5-methyl-3-(beta-D-ribofuranosyl)pyrido[2,3-d]pyrimidine- 2,4(1H,3H)-dione) was a very effective inducer of NBT-reduction and of differentiation of the cells into mature granulocytes. The induction of NBT-reducing activity by TI-79 was inhibited by high concentrations of the natural nucleoside, adenosine. Other differentiation inducers, such as retinoic acid, 1 alpha,25-dihydroxyvitamin D-3 and staurosporin markedly enhanced the induction of differentiation of HL-60 cells by TI-79. Nucleoside analogs such as TI-79 should be useful for differentiation therapy of some types of myelogenous leukemia.

Induction of differentiation of human leukemia cells by inhibitors of myosin light chain kinase.

Inhibitors of myosin light chain kinase, 1-(5-chloronaphthalene-1-sulfonyl)-1H-hexahydro-1,4-diazepine hydrochloride (ML-9) and 1-(5-iodonaphthalene-1-sulfonyl)-1H-hexahydro-1,4-diazepine hydrochloride (ML-7), induced Nitroblue tetrazolium reducing activity, lysozyme activity and morphological maturation of human monoblastic U937, THP-1 and promyelocytic HL-60 cells, but not of erythroblastic K562 cells. However, three analogs of ML-9, which are an inhibitor and an activator of protein kinase C, and a calmodulin antagonist, respectively, did not induce differentiation of the cells.