Notch- and vitamin D signaling in 1,25(OH)2D3-resistant glioblastoma multiforme (GBM) cell lines.

Recently, an important role of Notch activation for Ras-induced transformation of glial cells and for glioma growth and survival has been demonstrated. It was concluded that activation of Notch-signaling may represent a new target for glioblastoma multiforme (GBM) therapy. We now analyzed five GBM cell lines (Tx3095, Tx3868, U87, U118, U373) for key components of Notch-signaling pathways (Notch-1, Notch-2, Notch-3, Notch-4, Delta-like 1, Delta-like 3, Delta-like 4, Jagged-1, Jagged-2) using conventional RT-PCR. We found that some components (Notch-1, Notch-2, Notch-4, Jagged-1) were consistently expressed in all cell lines analyzed while, in contrast, other key components of Notch-signaling were differentially expressed. Notch-3 was expressed in three out of five cell lines (in U87, U118 and U373), but was missing in Tx3095 and Tx3868 cells. Jagged-2 was expressed in U87, U373 and Tx3868, but not in U118 or Tx3095 cells. Delta-like 1 and Delta-like 3 were not detected in Tx3905 cells, but in all other cell lines. RNA for Delta-like 4 was only found in U373 and Tx3868 GBM cell lines. Treating GBM cell lines with 1,25(OH)2D3 (10(-6), 10(-8), and 10(-10) M), the biologically active form of vitamin D, did not result in significant dose- or time-dependent antiproliferative effects, indicating that GBM cell lines are resistant against the antiproliferative activity of 1,25(OH)2D3. In vitro treatment of GBM cells with 1,25(OH)2D3 did not result in a modulation of the expression of key components of the Notch-signaling pathway. Treatment with HDAC-inhibitor TSA or DNA-methyltransferase inhibitor 5-aza exerted dose- and time-dependent antiproliferative effects on GBM cell lines. We asked the question whether the resistance against 1,25(OH)2D3 could be restored by co-treatment with TSA or 5-aza. However, combination therapy with 1,25(OH)2D3 and TSA or 5-aza did not result in enhanced antiproliferative effects as compared to treatment with TSA or 5-aza alone. In contrast, antiproliferative effects of TSA and 5-aza were partially antagonized by concomitant treatment with 1,25(OH)2D3, indicating a protective effect of 1,25(OH)2D3 against the antiproliferative effects of TSA and 5-aza in GBM cell lines. In conclusion, our findings point at a differential expression of key components of Notch-signaling in GBM cell lines that may be of importance for the growth characteristics of GBM. Our findings indicate that GBM cell lines are resistant against the antiproliferative effects of 1,25(OH)2D3, and that this resistance may not be overcome by modulation of epigenetic silencing. Our findings do not support the hypothesis that modulation of Notch-signaling pathways by 1,25(OH)2D3 may regulate growth of GBM cell lines.

Gemtuzumab ozogamicin (mylotarg) for the treatment of acute myeloid leukemia--ongoing trials.

The value of the combination of gemtuzumab ozogamicin (GO) and chemotherapy for the treatment of acute myeloid leukemia (AML) is currently analyzed within clinical trials. GO (6 mg/m2) and standard-dose cytarabine (100 mg/m2) is evaluated for the treatment of newly diagnosed AML in elderly patients in the SAL phase II trial. Preliminary results of the MRC AML15 trial support the application of GO 3 mg/m2 with standard- and high-dose cytarabine and anthracyclines for the treatment of de novo AML. Within this trial the addition of GO seems especially of value for favorable and intermediate cytogenetic risk groups. The combination of GO (3 mg/m2) and high-dose cytarabine (3 g/m2) is safe and more effective for the treatment of refractory AML than previous combinations from the AMLSG study group. First results prove the possibility of allogeneic stem cell transplantation after GO therapy. Initial data of a phase II trial document the safety and efficacy profile of GO within a reduced-intensity conditioning protocol applying fludarabine and total body irradiation.

Aspects of chemotherapy schedules in young and elderly patients with aggressive lymphoma.

The CHOP (cyclophosphamide/doxorucibin/vincristine/prednisone) regimen has been established as the standard treatment for diffuse large B-cell lymphoma (DLBCL). With the availability of granulocyte colony-stimulating factor and the tool of autologous stem cell support, different strategies of dose intensification have been pursued to further improve treatment results. Although dose-escalation strategies, including high-dose approaches, have not convincingly been shown to be superior to CHOP-21, dose densification by reducing treatment intervals from 21 days to 14 days (CHOP-14) has led to improved outcome for elderly patients. Furthermore, the implementation of rituximab has been proven to be superior to chemotherapy alone with regard to complete remission, event-free survival, and overall survival rates in elderly patients in a number of randomized trials. Although it has not been formally determined in young patients with poor prognosis, the combined immunochemotherapy with CHOP and rituximab has become an accepted standard for the treatment of DLBCL worldwide. For patients aged > 60 years, 6 courses of CHOP-14 with rituximab (R-CHOP-14) followed by 2 additional courses of rituximab, yielded the best treatment results, without a relevant increase in toxicity compared with CHOP-21. For younger, patients at low risk, 6 courses of R-CHOP-21 is the standard treatment. Young patients at high risk (International Prognostic Index > or = 2) should be treated with dose-dense regimens and/or autologous stem cell support within clinical trials. The optimal dose and schedule of rituximab has yet to be determined. Aspects of supportive measures meant to ensure optimal adherence to dose-dense regimens are discussed herein.

Neoplastic meningitis.

Neoplastic meningitis is a complication of the CNS that occurs in 3-5% of patients with cancer and is characterised by multifocal neurological signs and symptoms. Diagnosis is problematic because the disease is commonly the result of pleomorphic manifestations of neoplastic meningitis and co-occurrence of disease at other sites. Useful tests to establish diagnosis and guide treatment include MRI of the brain and spine, cerebrospinal fluid (CSF) cytology, and radioisotope CSF flow studies. Assessment of the extent of disease of the CNS is of value because large-volume subarachnoid disease or CSF flow obstruction is prognostically significant. Radiotherapy is an established and beneficial treatment for patients with neoplastic meningitis with large tumour volume including parenchymal brain metastasis, sites of symptomatic disease, or CSF flow block. Because neoplastic meningitis affects the entire neuraxis, chemotherapy treatment can include intra-CSF fluid (either intraventricular or intralumbar) or systemic therapy. Most patients (>70%) with neoplastic meningitis have progressive systemic disease and consequently treatment is palliative and tumour response is of restricted durability. Furthermore, as there is no compelling evidence of a survival advantage with aggressive multimodal treatment, future trials need be done to determine the effect of treatment on quality of life and control of neurological symptoms.

CD10- pre-B acute lymphoblastic leukemia (ALL) is a distinct high-risk subgroup of adult ALL associated with a high frequency of MLL aberrations: results of the German Multicenter Trials for Adult ALL (GMALL).

Immunophenotyping disclosed CD10 negativity in 70 of 2408 cases of B-lineage acute lymphoblastic leukemia (ALL), although other criteria followed classification of pre-B ALL (eg, cytoplasmic immunoglobulin positivity). These blasts showed high myeloid antigen expression (60% CD65 positivity) and reacted with antibody 7.1 in 95% of the cases. MLL-AF4 fusion transcripts or an 11q23/MLL rearrangement or both were evident in 46 of 56 samples (82%). Although 83% of the patients achieved complete remission, the remission duration remained remarkably low: 141 days for MLL rearrangement-positive and 245 days for MLL rearrangement-negative CD10(-) pre-B ALL. Thus, the overall survival probability 3 years after diagnosis was 0.34 +/- 0.20 SE in MLL-rearrangement-negative versus 0.12 +/- 0.06 SE in MLL rearrangement-positive CD10- pre-B ALL. Our data identify CD10- cytoplasmic immunoglobulin-positive pre-B ALL as a rare (2.2%) but distinct immuno-subtype of adult ALL that is characterized by a high MLL rearrangement rate and a worse outcome.

Molecular genetic events in adult acute lymphoblastic leukemia.

Treatment of acute lymphoblastic leukemia in adults focuses on the initial assessment of prognostic relevant genetic features as well as response-guided therapy based on molecular data. In at least half of adult acute lymphoblastic leukemia patients, clonal chromosomal abnormalities can be identified that deregulate candidate oncogenes or transcription factors by introducing a heterologous promoter or enhancer. Altered cell cycle progression or upregulated tyrosine kinase activity are other important mechanisms. Most of the translocations can lead to the generation of fusion genes that are translated into chimeric oncogeneic proteins, such as BCR-ABL, providing targets for novel therapeutic agents.

Leading prognostic relevance of the BCR-ABL translocation in adult acute B-lineage lymphoblastic leukemia: a prospective study of the German Multicenter Trial Group and confirmed polymerase chain reaction analysis.

The BCR-ABL fusion, the molecular equivalent of the Philadelphia translocation, gains importance for treatment stratification in adult acute lymphoblastic leukemia (ALL). In this prospective study, samples from 478 patients with CD10(+) B-cell precursor ALL (c-ALL and pre-B ALL) underwent BCR-ABL reverse transcription-polymerase chain reaction (RT-PCR) analysis with double testing of positive samples. Patients were stratified according to the PCR result and treated in 2 German Multicenter Trials of Adult ALL. The outcome was followed and the prognostic impact of BCR-ABL was compared to clinical risk features. Of the 478 samples, 432 had an evaluable BCR-ABL result. Thirty-seven percent of the c-ALL and pre-B ALL patients were BCR-ABL(+) (p190, 77%; p210, 20%; simultaneous p190/p210, 3%). BCR-ABL positivity was associated with the high-risk features of older age (45 years versus 30 years median age; P =.0001) and higher white blood cell counts (23 500/microL versus 11 550/microL; P =.0001). Univariate and multivariate analyses revealed BCR-ABL as the leading factor for a poor prognosis (P =.0001) in comparison to clinical risk criteria. Irrespective of the breakpoint, presence of any BCR-ABL transcript predicted a lower chance of initial treatment response (68.4% versus 84.6%; P =.001) and a lower probability of disease-free survival at 3 years (0.13 versus 0.47; P =.0001). This bad outcome was not influenced by postinduction high-dose treatment stratifications. The results show a high prevalence of BCR-ABL fusion transcripts with predominance of p190. BCR-ABL RT-PCR is confirmed as a sensitive, rapid method to diagnose t(9;22), and p190 and p210 are unequivocally demonstrated as the most important predictors of poor long-term survival despite intensified chemotherapy.