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BACKGROUND Reticulin-stained bone marrow fibrosis is associated with a poor prognosis in patients with chronic myelogenous leukemia (CML). Resolution of fibrosis with therapy may improve patient outcome. METHODS The effect of imatinib therapy on bone marrow fibrosis was evaluated in 40 patients with chronic-phase CML who were treated after interferon-α failure. RESULTS Thirty-one patients (78%) had severe (Grade 3 or 4) reticulin fibrosis prior to therapy. After imatinib therapy was administered for 3 to > 24 months, fibrosis was reduced by at least 2 grades in 19 of the 31 patients (61%) and by at least 1 grade in 34 patients (85%). There was no correlation noted between reduction of fibrosis and cytogenetic response. However, a reduction in fibrosis was found to correlate with a reduction in bone marrow megakaryocytosis (P = 0.002). CONCLUSIONS Treatment with imatinib mesylate appears to reduce CML-associated bone marrow fibrosis in most patients who are treated during the chronic phase of disease. This effect may be independent of the degree of suppression of Philadelphia chromosome-positive cells, and may improve prognosis in patients with CML. Cancer 2004. © 2004 American Cancer Society.

BACKGROUND The effect on prognosis of adding imatinib mesylate to the treatment of patients with Philadelphia chromosome (Ph)-positive chronic myelogenous leukemia (CML) has not been explored fully. The objective of the current study was to evaluate the benefit of adding imatinib to the treatment sequence of patients with early chronic phase Ph-positive CML who received interferon α (IFN)-based regimens as frontline therapy. METHODS A total of 201 patients with early chronic phase Ph-positive CML who were treated on our 3 recent frontline IFN–based programs and were impacted early by the availability of sequential therapy with imatinib were analyzed. Their outcome was compared with that of a historical control group of 293 patients treated from 1982 until 1990 who were treated with IFN programs for early chronic phase CML and who did not have the opportunity of early access to imatinib (because it was not available during that period). Multivariate analysis was used to evaluate the independent effect of imatinib therapy on survival. RESULTS Of 201 patients who were treated, 159 patients (79%) had their regimen changed sequentially to imatinib after a median duration of 14 months of IFN therapy. Of 139 patients who continued evaluation at our institution, 101 patients (73%; 64% of the total group) achieved a complete cytogenetic response, and 20 of 80 patients analyzed (25%; 10% of the total group) had no disease according to molecular studies (quantitative polymerase chain reaction studies). The estimated 5-year survival rate for the total study group of 201 patients was 86%. Survival of this group was significantly superior to the historic control group of IFN-treated patients who did not have the benefit of imatinib (P = 0.03). The trend also was observed within defined CML risk groups. Imatinib therapy was confirmed as an independent, significant, favorable prognostic factor for survival by multivariate analysis, after accounting for the independent prognostic effect of pretreatment prognostic factors (P = 0.005). CONCLUSIONS The current analysis is the first to indicate the independent, favorable effect of imatinib on the survival of patients with Ph-positive CML. Cancer 2003;98:1430–7. © 2003 American Cancer Society. DOI 10.1002/cncr.11665

BACKGROUND Older age is a consistent poor prognostic factor in patients with Philadelphia chromosome (Ph)-positive chronic myelogenous leukemia (CML). Whether this is related to an intrinsic worse disease biology or to inadequate drug delivery or excessive treatment-associated toxicity is unknown. The availability of imatinib mesylate, a selective, Bcr-Abl-targeted therapy that is administered orally with minimal side effects, may clarify whether older age would remain an adverse factor (thus, implying a different age-related CML biology). METHODS Seven hundred forty-seven patients in different phases of Ph-positive CML who were treated with imatinib from 1999 until the time of last follow-up were evaluated. Among them, 187 patients had newly diagnosed, early chronic phase CML; 351 patients had chronic phase CML after interferon α (IFN) failure; 133 patients had accelerated phase CML; and 76 patients had blastic phase CML. The imatinib daily dose varied from 400 mg to 800 mg orally, according to the protocol design. Patients were categorized into a group of older patients (age 60 years or older) or younger patients (age younger than 60 years). Their characteristics, responses to therapy, and survival were compared by univariate and multivariate analyses. RESULTS One hundred eighty-seven patients had newly diagnosed CML, and 49 patients (26%) were in the older age group. Older patients had similar cytogenetic response rates and survival compared with younger patients. Among 351 patients with late chronic phase CML after IFN failure, 120 patients (34%) were in the older age group. Although the older patients had a lower incidence of achievement of complete cytogenetic response (Ph, 0%) by univariate analysis (56% vs. 44%; P = 0.05), age was not found to be an independent poor prognostic factor in the multivariate analysis. Similarly, older age was not an adverse poor prognostic factor for survival. Forty-two of 133 patients (32%) with accelerated phase CML were older. The incidence of any cytogenetic response was lower in older patients (53% vs. 33%; P = 0.04), but age was not significant in the multivariate analysis. Older patients also had a trend toward worse survival (P = 0.09) that was not significant in the multivariate analysis. Twenty-eight of 76 patients (37%) evaluated in blastic phase were older. Older age was not a significant prognostic factor either for achieving response or for survival. CONCLUSIONS With imatinib therapy, older age appears to have lost much of its prognostic relevance. This suggests that the previous poor prognosis observed with older age was related to treatment-associated factors (e.g., toxicity with allogeneic transplantation or with IFN therapy) rather than to an intrinsic, different disease biology of CML in older patients. Cancer 2003;98:1105–13. © 2003 American Cancer Society. DOI 10.1002/cncr.11629

BACKGROUND Little is known regarding long-term prognosis among patients with Philadelphia chromosome (Ph)-positive chronic myelogenous leukemia (CML) who achieve a complete cytogenetic response (0% Ph-positive cells) after treatment with interferon-α. METHODS The authors analyzed 512 patients with Ph-positive, early chronic-phase CML who were treated with interferon-based therapies between 1981–1995 for the incidence and durability of complete cytogenetic response, and in relation to long-term prognosis. RESULTS One hundred forty patients (27%) achieved a complete cytogenetic response. Their 10-year survival rate was 78%. At the time of last follow-up, 44 patients (31%, 9% of the total) were alive, 21 in first and 23 in second durable complete cytogenetic response (median, 127 months; range, 88–191 months); 39 patients had not received any therapy for a median of 50 months (range, 11–139 months). Analysis by reverse transcriptase-polymerase chain reaction in 78 patients during complete cytogenetic response showed 46 who had achieved at least 1 complete molecular response. Five of these 78 patients had died by the time of last follow-up, but only 2 had died of disease-specific causes. Recurrence rates were significantly lower and cytogenetic response durations were significantly longer among patients who achieved at least one complete molecular response. CONCLUSIONS Achieving a complete cytogenetic or molecular response after therapy with interferon-α appears to be associated with excellent long-term prognosis. Approximately 10% of patients reportedly can achieve durable complete cytogenetic response, with or without continuation of interferon. This finding emphasizes the potential of long-term event-free survival in CML patients outside the context of allogeneic stem cell transplantation, which may be improved with new therapies such as imatinib mesylate. Cancer 2003;97:1033–41. © 2003 American Cancer Society. DOI 10.1002/cncr.11223

BACKGROUND The authors conducted a series of four Phase I–II trials of high-dose and intermediate-dose docetaxel, cisplatin, and 5-fluorouracil (TPF)-based induction chemotherapy for patients with advanced squamous cell carcinoma of the head and neck (SCCHN). The chemotherapy regimens and response rates for each trial were published previously. In the current analysis, the authors report the data on long-term survival, patterns of failure, and morbidity among the patients who were treated at their institution. METHODS A total of 101 patients with previously untreated, locally advanced, curable SCCHN were entered onto the studies. Overall, 68 patients (67%) had N2–N3 disease, and 86 patients (85%) had Stage IV disease. Patients were treated with combinations of TPF with or without leucovorin. Cycles were repeated every 21–28 days for a total of 3 cycles followed by hyperfractionated radiotherapy. RESULTS After a median follow-up of 49 months, 65 patients (64%) remain alive with no evidence of disease (NED), and 3 patients remain alive with disease, for an overall survival rate of 67% (68 patients). Twenty-six patients had locoregional recurrences (LRR), and 5 patients had both LRR and distant metastasis (DM). Only five patients had DM as the sole site of failure. Four patients underwent salvage surgery at the primary site and remain alive with NED. Excluding 17 patients with nasopharyngeal carcinoma, of 84 patients, 55 patients remain alive with NED (65%). Notably, 43 of 84 patients (51%) had oropharyngeal primary tumors, and 30 of those patients remain alive with NED (70%). Significant morbidity was low, with two treatment-related deaths. All but two of the surviving patients are able to swallow and had their feeding tubes removed. CONCLUSIONS These data suggest that docetaxel adds incrementally to the efficacy of cisplatin and fluorouracil. Local-regional failures continue to be the major impediment to cure in these patients. Given the increase in local-regional dose intensity with chemoradiation, sequential treatment plans that integrate induction chemotherapy and chemoradiotherapy seem to be the logical next step. Cancer 2003;97:412–8. © 2003 American Cancer Society. DOI 10.1002/cncr.11063

BACKGROUND Imatinib mesylate induces high rates of hematologic and cytogenetic response in patients with chronic myelogenous leukemia (CML). During therapy with imatinib, up to 45% of patients with CML reportedly experience myelosuppression ≥ Grade 3, requiring interruption of therapy and/or dose reductions. The significance of myelosuppression for response to imatinib is unknown. METHODS The authors analyzed 143 patients with late chronic-phase CML who were treated with imatinib after failing interferon. Univariate and multivariate analyses were performed to determine patient characteristics that were correlated with myelosuppression response and the association between myelosuppression and cytogenetic response. RESULTS Neutropenia ≥ Grade 3 (according to National Cancer Institute Common Toxicity Criteria) occurred in 64 patients (45%), and thrombocytopenia ≥ Grade 3 occurred in 31 patients (22%). Any myelosuppression ≥ Grade 3 was associated with a lower rate of major (P = 0.04) or complete (P = 0.01) cytogenetic responses. This was more pronounced with myelosuppression that lasted > 2 weeks. The major cytogenetic response rate was 58% with Grade ≥ 3 myelosuppression compared with a rate of 75% without Grade ≥3 myelosuppression (P = 0.03); the complete cytogenetic response rates were 36% and 63%, respectively (P = 0.001). In a multivariate analysis, pretreatment platelet count, imatinib dose reductions, and duration of myelosuppression were associated significantly with response. CONCLUSIONS Myelosuppression is an independent adverse factor for achieving cytogenetic response with imatinib in patients with CML. Intervention with hematopoietic growth factors in patients with CML who are treated with imatinib should be investigated. Cancer 2004;100:116–21. © 2003 American Cancer Society.

Background Oxaliplatin is a third-generation platinum analog that is used to treat a variety of solid tumors, particularly colorectal carcinoma. Patients may develop hypersensitivity reactions, although this complication occurs infrequently. Methods Three patients developed hypersensitivity reactions to oxaliplatin while undergoing treatment on a Phase I trial of oxaliplatin and capecitabine. An Entrez PUBMED search was performed to identify other cases. Results Two patients experienced the abrupt onset of erythema alone or with pruritus during the 9th and 11th infusions of oxaliplatin, whereas the other patient developed fever and mild dyspnea a few hours after the 9th oxaliplatin infusion. All 3 patients were rechallenged successfully for at least 1 additional oxaliplatin infusion by using oral dexamethasone, 20 mg orally, 6 and 12 hours before the administration of oxaliplatin and by administering intravenously 125 mg of solumedrol, 50 mg of diphenhydramine, and 50 mg of cimetidine 30 minutes before oxaliplatin. The literature review suggests two distinct patterns of reactions: classic hypersensitivity (as experienced by the first two patients) and idiosyncratic reactions (as experienced by the third patient). Conclusions Patients who develop mild to moderate hypersensitivity to oxaliplatin may be pretreated with steroids and antagonists of Type 1 and 2 histamine receptors, whereas patients who develop severe reactions are unlikely to tolerate further therapy.

BACKGROUND Interleukin-2 (IL-2) has activity in metastatic melanoma when given in high doses by the intravenous (IV) route, but its side effects and effectiveness when given in intermediate to high doses by the subcutaneous (SC) route have not been studied adequately. This study sought to determine the maximum tolerated dose (MTD) of IL-2 administered once daily by the SC route. METHODS Outpatients with progressive metastatic melanoma after chemotherapy were enrolled in a Phase I trial of IL-2 administered SC daily for 5 days per week for 4 consecutive weeks, repeated at 6-week intervals. Patients were instructed to drink at least 2 L of fluid daily. IL-2 pharmacokinetic studies were performed at the two highest dose levels. Toxicity was recorded weekly using the National Cancer Institute Common Toxicity Criteria. Response was assessed at 6-week intervals. RESULTS Three patients, 6 patients, 6 patients, and 4 patients received a median of 2 courses of SC IL-2 at dose levels of 6 MIU/m2, 9 MIU/m2, 12 MIU/m2, and 15 MIU/m2, respectively. Failure to maintain adequate fluid intake was responsible for 2 episodes of syncope at the 9 MIU/m2 dose level and for 2 incidents of reversible prerenal azotemia at the 15 MIU/m2 dose level. IL-2 treatment was resumed in these patients without incident. At the 15 MIU/m2 dose level, 2 patients had severe headaches, depression, and visual hallucinations requiring discontinuation of treatment. Cough and fluid retention at the end of the third and fourth weeks at the 15 MIU/m2 dose level approximated the symptoms reported by inpatients treated by continuous IV infusion at 9 MIU/m2 on the same schedule. There was a partial response and a complete response in subcutaneous disease at the 12 MIU/m2 and 15 MIU/m2 dose levels, respectively, each lasting < 2 months. Plasma IL-2 levels after SC injection of 1000–5000 pg/mL reached maximum by 3 hours and were detectable for up to 48 hours after administration. The half-lives for SC IL-2 absorbance and clearance were 1.6 hours and 5.2 hours, respectively, and the calculated area under the curve was 30,584 pg/mL × hour. CONCLUSIONS SC IL-2 was well tolerated and had high sustained bioavailability at the higher doses studied. The MTD for a daily SC regimen was 12 MIU/m2 and is recommended for future studies. Cancer 2002;95:127–34. © 2002 American Cancer Society. DOI 10.1002/cncr.10631

BACKGROUND The mechanisms favoring the growth advantage of Philadelphia chromosome positive cells over normal cells in chronic myelogenous leukemia (CML) are not fully elucidated but could be due partly to altered apoptosis and longer survival of CML clones. Also, little is known about the biologic characteristics of disease progression in CML. Bcl-2 expression has been demonstrated to exert an antiapoptotic effect resulting in increased cell survival. Other proteins such as Bax and Bad are proapoptotic proteins. Fas, a cell surface protein, can be triggered by an appropriate death-promoting ligand (FasL) to activate downstream caspases pivotal in initiation of programmed cell death. Although the mechanisms underlying cellular proliferative and apoptotic pathways are complex, with involvement of multiple interlocking proteins, the relative expression of pro- and antiapoptotic proteins may have an influence on disease progression. This study aimed to determine whether the changes in the cellular expression of Bcl-2, Bax, and Fas correlate with caspase-3 activity and disease progression in CML, or with response to interferon (IFN)–α therapy and prognosis in early chronic phase CML. METHODS Bcl-2, Bax, and Fas expression were measured on whole cell lysates from bone marrow mononuclear cell fractions by Western blot analysis and quantitative radioimmunoassay. Caspase-3 activity was determined using the DEVD system. Specimens from 203 patients with CML were examined. These included 130 patients in early chronic phase disease (ECP; diagnosis to therapy, ≤12 months), 33 patients in late chronic phase (diagnosis to therapy, > 12 months), 27 patients in accelerated phase, and 13 patients in blastic phase. Correlations between apoptosis proteins and CML phases, risk groups in ECP, and response to IFN-α therapy and survival in ECP were investigated by standard statistical methods, and positive findings were assessed by multivariate analysis. RESULTS Levels of Bcl-2, Fas, Bax, and caspase-3 activity did not correlate with disease progression. Among patients in ECP, higher Fas levels correlated with poorer risk groups (P = 0.05) and higher caspase-3 activity correlated with better risk groups (P = 0.048). With IFN-α therapy, major cytogenetic responses were noted in 30% of patients with high Fas and 53% with low Fas (P = 0.016) and failure to achieve a complete hematologic response (CHR) in 25% versus 2% (P = 0.0001). Survival was shorter with high Fas levels (5-year rates, 71% vs. 52%; P = 0.002), and the independent poor prognostic significance of high Fas levels was confirmed by multivariate analysis (P = 0.014). Response to IFN-α therapy and survival were not significantly different by different levels of Bcl-2, Bax, or caspase-3 activity. CONCLUSIONS High Fas levels were associated with intrinsically worse disease at diagnosis, whereas high caspase-3 activity was associated with good risk disease. In ECP CML, high Fas levels were associated with significantly worse response to IFN-α therapy and with significantly worse survival. The influence of these cellular proteins and caspase-3 activity on apoptosis in CML is complex and merits further investigation. Cancer 2001;91:1964–72. © 2001 American Cancer Society.

BACKGROUND Onycholysis has been reported in association with the use of several noncytotoxic drugs and with chemotherapy in 135 patients. Onycholysis may be precipitated by exposure to ultraviolet radiation. METHODS The authors studied 91 patients who received paclitaxel and 187 patients who received doxorubicin. RESULTS Onycholysis occurred in 5 of 21 patients who received > 6 courses of weekly paclitaxel, developing in the summer months in all 5 patients. It did not occur in patients who received fewer weekly paclitaxel courses or those who were treated every 3 weeks. Onycholysis did not occur in 187 patients who received doxorubicin. Review of the literature revealed that onycholysis is nearly exclusively associated with anthracycline and taxane therapy. CONCLUSIONS Prolonged weekly paclitaxel, other taxanes, and anthracyclines cause onycholysis in some patients, which may be precipitated by exposure to sunlight. Patients receiving these drugs should protect their nails from sunlight. Cancer 2000;88:2367–71. © 2000 American Cancer Society.

BACKGROUND Many patients with advanced transitional cell carcinoma are unable to receive cisplatin-based therapy. The efficacy and toxicity of a carboplatin-based regimen in the treatment of patients with advanced transitional cell carcinoma was therefore evaluated. METHODS Twenty-three patients with advanced transitional cell carcinoma were treated. Metastatic disease was present in 19 of 23 patients (83%) whereas 4 patients with T4, and/or N1, disease were treated. Patients were treated every 28 days with methotrexate, 30 mg/m2 intravenously (i.v.) on Days 1 and 15, along with leucovorin, 15 mg/m2 orally every 6 hours, 3 times daily beginning 24 hours after each methotrexate dose; vinblastine, 3 mg/m2 i.v. on Days 1 and 15; mitoxantrone, 15 mg/m2 i.v. on Day 1; and carboplatin, 300 mg/m2 i.v. on Day 1, adjusted for creatinine clearance (MVNCa). Dosage in subsequent cycles was adjusted according to hematologic toxicity. RESULTS Median age was 70 years (range, 52–83 years) and median pretreatment creatinine clearance was 50 mL/min (range, 30–106 mL/min). Of 23 patients, 8 (34.8%) obtained a complete response, and 5 (21.7%) obtained a partial response. The overall response proportion was 56.5% (95% confidence interval, 34.5–76.8%). Median survival was 10 months (range, 1–44+ months). Toxicity was moderate. Grade 4 neutropenia occurred in 10 of 107 (9.3%) administered treatment cycles; Grade 4 thrombocytopenia occurred in 11 of 107 (10.3%). There were 4 episodes of febrile neutropenia (3.7% of cycles). Renal, neurologic, or otic toxicity were not observed. Age older than 70 did not appear to impact on response proportion, survival, and toxicity. CONCLUSIONS The carboplatin-based MVNCa regimen is active in the treatment of patients with advanced transitional cell carcinoma and is well tolerated. Therapy with this regimen may be a less toxic alternative for patients for whom treatment with cisplatin is not an option. Cancer 1996;78:1775-80.

BACKGROUND Interleukin-2 (IL-2) has been used widely in the treatment of advanced melanoma, most often using a high dose bolus schedule of administration. We have evaluated the antitumor activity and toxicity of IL-2 when administered by a continuous infusion schedule in patients with metastatic melanoma. METHODS Thirty-three patients with metastatic melanoma were treated with IL-2 using the maximum tolerated dose level of 12 × 106 IU/m2 as a continuous infusion over 24 hours × 4d/week for 4 weeks every 6 weeks. All patients but one had previously received and failed chemotherapy and had evidence of progressive disease. They were required to have normal organ functions and a performance status of 0 to 1. RESULTS We observed 1 complete response and 6 partial responses among 31 evaluable patients for a response rate of 22% (95%, confidence interval: 10% to 41%). The median response duration was 6 months, with a range of 4 to 18 months. The toxicity of IL-2 was severe but manageable on the general inpatient ward. One patient died of hepatic necrosis that was probably related to IL-2. Five patients required dose reduction of IL-2 due to toxicity in the form of hepatic or renal insufficiency, which was rapidly reversible. CONCLUSIONS IL-2, used as a continuous infusion at a dose level of 12 × 106 IU/m2/day, 4 times every week for 4 weeks, has activity against metastatic melanoma similar to that reported with high dose IL-2 given in a bolus schedule. Cancer 1996;77:89-96.

Background. The breakpoint site of the breakpoint cluster region (bcr) has been correlated with patient characteristics, with the disease phase, and with the prognosis of patients with chronic myelogenous leukemia (CML), but the findings remain controversial. Methods. Appropriate restriction enzymes and the 3′ and universal probes were used to map the breakpoint site by Southern blot analysis into 5′ and 3′ breakpoints and a breakpoint in zone 3 (or fragment 2) in 362 patients in different phases of CML (238 in early chronic phase, 69 in late chronic phase, 31 in accelerated phase, and 24 in blastic phase). Standard statistical methods were used to evaluate differences in characteristics and in prognosis by the breakpoint site. Results. No correlation was noted between CML phases and breakpoint site. Among patients in the early chronic phase, thrombocytosis was significantly associated with the 3′ breakpoint site (P = 0.02), whereas peripheral basophilia occurred more frequently with the 5′ breakpoint site (P = 0.05). Other patient and disease characteristics were similar in frequency among the breakpoint-site subgroups. There was no difference in response to alpha-interferon therapy (186 patients treated) by the breakpoint site. Survival, dated from either referral to the authors' institution or from diagnosis, was not significantly different among patients with early chronic phase CML by the breakpoint site. However, patients with a 3′ deletion tended to have a shorter survival. Conclusion. Determination of the breakpoint site by Southern blot analysis does not help to predict prognosis of patients with CML. Cancer 1995;76:992–7.

Background. Etoposide displays remarkable schedule dependency. To better define the optimal dose and schedule, the authors administered etoposide as a prolonged low daily dose infusion in patients with a variety of advanced malignancies. Methods. Between October 1989 and April 1992, 40 patients met inclusion criteria and were enrolled in this study; the initial dose of infusional etoposide was 25 mg/m2/day. Doses were not escalated further, because it became evident that 25 mg/m2/day was the maximum tolerated dose (MTD) in most patients using this prolonged schedule. Because the initial dose proved to be the MTD on this prolonged schedule, several patients received a starting dose of either 20 mg/m2/day or 18 mg/m2/day. This continuous infusion was administered for at least 21 days or until either the leukocyte count dropped to less than 2,000/mm3, platelets dropped to less than 75,000/ mm3, or tumor progression occurred. Plasma etoposide levels were obtained at random times during infusions at 25mg/m2/day. Results. Duration of therapy ranged from 15–561 days. Myelosuppression was the major toxic reaction, although it was mild in most patients and reduced compared with other schedules. Myelosuppression correlated with the extent of prior treatment: minimally pretreated patients tolerated prolonged infusions with only mild hematologic toxic effects, whereas heavily pretreated patients experienced moderate myelosuppression. Patients treated at an initial dose of 25mg/m2/day had more myelosuppression than did those treated at 20mg/m2/day. A leukocyte count of less than 1,000/mm3 developed in only 5 of 40 patients (12%) at any time during therapy. Twenty-one patients required packed erythrocyte transfusions, and one required platelet transfusion. The mean serum etoposide concentration in patients receiving 25 mg/m2/day was 0.7 plus or minus 0.42 μg/ml. Objective responses were obtained in 5 of 10 patients with previously treated non-Hodgkin's lymphoma and 2 of 3 patients with previously untreated extensive stage small cell lung cancer. Conclusions. Etoposide administered by continuous infusion can be given at 25mg/m2/day for prolonged periods to most patients and is the MTD in previously treated patients. Tumoricidal activity in selected tumor types is demonstrated with this dose. Further study in neoplasms that considered “etoposide-sensitive” seems warranted. Cancer 1994; 73:2824–31.

Oncogenic Myc is known to alter cellular metabolism resulting in glutamine addiction, and the MYCN-amplified subclass of neuroblastoma is associated with extremely poor prognosis. Successful identification of therapeutic agents that are effective in neuroblastoma, particularly in tumors with MYCN amplification, could significantly increase patient survival. To explore the effect of inhibiting glutamine metabolism in neuroblastoma, we used the glutamine antagonist DON (6-diazo-5-oxo-norleucine). DON is an irreversible competitive inhibitor which alkylates enzymes that utilize glutamine. Although first studied in the 1950s as a possible cancer chemotherapeutic, DON was associated with severe nausea which limited its use in patients. DON remains a potent inhibitor, and a useful tool to study the effect of modulating glutamine metabolism in vivo. We tested the DON sensitivity of six human neuroblastoma cell lines (Kelly, IMR-32, SK-N-BE2, SK-N-AS, SK-N-FI, and SH-SY5Y) compared to immortalized BJ fibroblast control cells. DON effectively inhibited all neuroblastoma cell lines tested with minimal effect on BJ cells. Furthermore, MycN overexpression in SK-N-AS cells, a cell line which is not MYCN-amplified and expresses low levels of cMyc, was sufficient to make cells significantly more sensitive to DON. Next, we tested the effect of DON treatment on subcutaneous xenografts. For these experiments we used the cell lines SK-N-AS (not MYCN-amplified), SK-N-BE2 (MYCN-amplified with moderate MycN levels), and IMR-32 (MYCN-amplified with high MycN levels). Mice were treated twice per week by intraperitoneal injection with DON (50 or 100mg/kg) or water control. Treatment with 50mg/kg DON significantly inhibited tumor growth of all three cell lines, suggesting neuroblastoma tumors may be broadly sensitive to glutamine inhibitors. IMR-32 tumors were the most sensitive to DON treatment, leading to a 6-fold reduction in tumor size after 2.5 weeks of treatment. Tumor BrdU incorporation decreased following DON treatment, and IMR-32 tumors showed increased levels of cleaved caspase 3, a marker of apoptosis. At the higher 100mg/kg dose, DON treatment led to a more substantial decrease in BrdU incorporation, and at this dose BE2 tumors also showed significantly increased levels of cleaved caspase 3, which were not detected in AS tumors. These results suggest that MYCN-amplified tumors may be particularly sensitive to glutamine inhibition. To examine the mechanism of DON-induced cell death, we treated cells with the pan-caspase inhibitor QVD. QVD treatment for 48 or 72hr significantly rescued both MYCN-amplified cell lines (Kelly, IMR-32) and cells that express high levels of cMyc (SY5Y), while having minimal effect in the remaining neuroblastoma cell lines with low Myc levels. These results confirm that DON induces cell death partially by activating apoptosis in high Myc expressing cell lines. Next, we used shRNA to show that in Kelly cells DON-induced apoptosis occurs by signaling through Bax, but not Bak. Lastly, we tested DON in combination with pro-apoptotic compounds in vitro. We found that DON treatment combined with the Bcl-2 family inhibitor ABT-263 had synergistic effects on cell death in the MYCN-amplified cell lines Kelly and BE2. Our results suggest that combined targeting of glutamine metabolism while reducing the threshold for tumor cell apoptosis may be beneficial for neuroblastoma treatment. Citation Format: Rachelle R. Olsen, Michelle N. Mary-Sinclair, Zhirong Yin, Kevin W. Freeman. Targeting Myc-reprogrammed glutamine metabolism for treatment of neuroblastoma. [abstract]. In: Proceedings of the AACR Special Conference on Myc: From Biology to Therapy; Jan 7-10, 2015; La Jolla, CA. Philadelphia (PA): AACR; Mol Cancer Res 2015;13(10 Suppl):Abstract nr B37.

BACKGROUND The effect of imatinib mesylate on survival in the accelerated phase of chronic myelogenous leukemia (CML) is unknown. The objectives of this study were to update the long-term experience with imatinib in patients who had accelerated-phase CML and to compare outcomes with historic experience. METHODS The outcomes of 176 patients who received treatment with imatinib were reviewed and compared with the outcomes of 213 historic control patients with accelerated-phase CML who received treatment with interferon-α or with other modalities. RESULTS With imatinib, the complete hematologic response rate was 82% versus a rate ≤ 50% for others, and the complete cytogenetic response rate was 43% versus rates of 0–6% for others. The estimated 4-year survival rates were 53% with imatinib, 42% with interferon-α, and 0–21% for others. A multivariate analysis of the total population of 389 patients indicated that imatinib therapy (vs. other therapies) was an independent, favorable prognostic factor for survival (P < 0.0001; hazard rate, 0.62). A subset analysis that included only patients who were treated with imatinib and interferon-α (276 patients) also identified imatinib as an independent favorable prognostic factor (P < 0.0001; hazard rate, 0.65). The 3-month cytogenetic response to imatinib was associated with significantly different survival outcomes (P < 0.0001). A multivariate analysis that included pretreatment characteristics and 3-month cytogenetic response among 150 patients who received imatinib and were alive at 3 months identified only 2 adverse independent prognostic factors: lack of a cytogenetic response at 3 months (P < 0.001) and anemia (hemoglobin < 10 g/dL; P = 0.003). Patients who had neither factor (41%) had an estimated 4-year survival rate of 88%; in the other patients, the 4-year survival rate was ≤ 60%. This may have implications in relation to subsequent therapy, because, according to the outcomes of patients who underwent allogeneic transplantation in accelerated phase at the authors' institution and from literature reports, the estimates of 5-year survival were 25–30%. CONCLUSIONS The current results suggest that imatinib improved survival compared with other therapies in patients with accelerated-phase CML. Cancer 2005. © 2005 American Cancer Society.

BACKGROUND Myelosuppression occurs in up to 50% of patients with chronic myeloid leukemia (CML) who are treated with imatinib and ≥ Grade 3 myelosuppression is reported in approximately 10% of patients. METHODS The authors investigated the prognostic significance of anemia occurring during therapy with imatinib in patients with CML in chronic phase. RESULTS Of 338 patients treated with imatinib (150 patients after interferon failure and 188 patients with newly diagnosed CML), 230 (68%) developed anemia. In a multivariate analysis, factors associated with an increased probability of developing anemia were a starting hemoglobin level < 12 g/dL, age ≥ 60 years, female gender, higher imatinib dose, and intermediate or high Sokal risk group. Of these 230 patients, 102 patients received treatment with 40,000 U of recombinant human erythropoietin administered subcutaneously once weekly. An increase in the hemoglobin level of ≥ 2 g/dL was achieved in 69 patients (68%) and 22 patients (22%) had an increase of 1–1.9 g/dL. Patients who developed anemia had a trend toward a lower probability of complete cytogenetic remission compared with patients without anemia (68% vs. 77%; P = 0.14), as well as a trend for inferior survival. Patients with anemia and other manifestations of myelosuppression were found to have a significantly worse outcome than those with isolated anemia. CONCLUSIONS The authors concluded that erythropoietin is safe and effective in patients in chronic-phase CML who develop anemia with imatinib therapy. Cancer 2004. © 2004 American Cancer Society.

BACKGROUND To evaluate the activity and toxicity of weekly Schering 54301, a polyethylene glycol formulation of interferon- α-2b (PEG-IFN-α-2b), with cytosine arabinoside (ara-C) in patients with chronic myelogenous leukemia (CML). METHODS Seventy-six patients with Philadelphia chromosome (Ph)-positive early chronic-phase CML were treated with the combination of PEG-IFN-α-2b and ara-C (10 mg daily subcutaneously [s.c.]). The starting dose of PEG-IFN-α-2b was 6 μg/kg s.c. weekly in the first 24 patients but was reduced to 4.5 μg/kg in the next 52 patients. RESULTS Overall, 73% of patients had a complete hematologic response, 35% of patients had a major cytogenetic response (Ph < 35%), and 21% of patients had a complete cytogenetic response (Ph = 0%). With a median follow-up of 19 months, the estimated 2-year survival rate was 89%. Therapy was discontinued in 24% of patients due to Grade III–IV toxicity. Frequent severe side effects that required dose reductions included neutropenia (49%), fatigue (43%), and neurologic toxicity (17%). The median PEG-IFN-α-2b and ara-C doses delivered were 3 μg/kg weekly and 7.5 mg daily, respectively, at 12 months of therapy. The activity and toxicity profiles of this combination was similar to those observed in historical patients treated with IFN-α and cytarabine. CONCLUSIONS The combination of PEG-IFN-α-2b and ara-C is active but has significant toxicity in patients with chronic-phase CML at the dose schedule used. The recommended dose of PEG-IFN-α-2b in future combination studies is 3 μg/kg or less. Cancer 2003;97:3010–6. © 2003 American Cancer Society. DOI 10.1002/cncr.11424

BACKGROUND Women with a history of breast carcinoma generally have been advised to avoid estrogen replacement therapy (ERT). The validity of this approach has been scrutinized and debated in recent years, and reassessment through appropriate clinical trials has been suggested. METHODS The authors conducted a prospective clinical trial to assess the safety and efficacy of prolonged ERT in a group of menopausal women with localized (Stage I or Stage II) breast carcinoma and a minimum disease free interval of 2 years if estrogen receptor (ER) was negative or 10 years if ER status was unknown. For 5 years, the authors followed 77 trial participants and 222 other women with clinical and prognostic characteristics comparable to those of the trial participants. Overall, 56 women were on ERT, and 243 women were not on ERT. The association of ERT with skeletal and lipid changes was assessed in the randomized trial participants. The effect of ERT on the development of recurrent or new breast carcinoma and other carcinomas was analyzed both in the trial participants and in the overall group. RESULTS Patient and disease characteristics, such as tumor size, number of lymph nodes involved, ER status, menopausal status, and disease free interval were comparable for women who were on ERT and women who were not on ERT. These same parameters also were comparable for women who joined the trial and women who did not. ERT use was associated with modest lipid and skeletal benefits. The introduction of ERT did not compromise disease free survival. Two of 56 women on ERT (3.6%) developed a contralateral, new breast carcinoma. In the group that was not on ERT, 33 of 243 women (13.5%) developed new or recurrent breast carcinoma. There were no differences in the development of other carcinomas with respect to ERT. CONCLUSIONS ERT did not compromise disease free survival in select patients who were treated previously for localized breast carcinoma. Larger scale randomized trials are needed to confirm these findings. Cancer 2002;95:1817–26. © 2002 American Cancer Society. DOI 10.1002/cncr.10913

BACKGROUND A T cell lymphoid blastic phase of chronic myelogenous leukemia (CML) is a rare occurrence, with only a few reported cases worldwide. Standard therapy for such patients is undetermined. Imatinib mesylate, a Bcr-Abl tyrosine kinase inhibitor, has shown activity in CML. METHODS The authors report on a patient with CML and marrow as well as extramedullary nodal T cell lymphoid blastic phase who was treated with imatinib mesylate. RESULTS The patient achieved complete morphologic and cytogenetic remission within two months of therapy. Competitive quantitative polymerase chain reaction analysis of marrow cells was negative after 15 months. Response had lasted for 26+ months at the time of writing. CONCLUSIONS The current data suggest that imatinib mesylate may produce long-term event free survival in patients with T-cell lymphoid blastic phase CML. Its potential role alone or in combinations should be further explored in this condition. Cancer 2002;94:2996–9. © 2002 American Cancer Society. DOI 10.1002/cncr.10576

Therapeutic targeting of aberrant cancer metabolism is currently an area of great interest in pediatric oncology. Previous reports have established that oncogenic Myc alters cellular metabolism resulting in cells dependent on exogenous glutamine. Therefore, we chose to target glutamine metabolism in the pediatric cancers Neuroblastoma and Ewing's Sarcoma. Neuroblastoma (NB) is a pediatric malignancy of the developing sympathetic nervous system, and approximately 20% of patients have amplified MYCN and very poor prognosis. Ewing's Sarcoma (EWS) is an aggressive tumor of the bone and soft tissue characterized by chromosome translocations resulting in EWSR1/ETS family fusion proteins. Approximately 85% of EWS cases contain an EWSR1/FLI fusion protein that targets c-Myc for overexpression and potentially cooperates with c-Myc in cell transformation. We chose to use the glutamine antagonist DON (6-diazo-5-oxo-norleucine) as a tool to examine the effect of inhibiting glutamine metabolism in NB and EWS cells. DON was first explored as a cancer chemotherapeutic in the 1950s and 1960s, but severe nausea in patients following treatment limited its use as a cancer therapeutic. DON is a competitive inhibitor which irreversibly alkylates glutamine-utilizing enzymes, including those involved in nucleotide biosynthesis and glutaminolysis, two important Myc-regulated metabolic pathways in cancer. DON effectively inhibited a panel of six NB and three EWS cell lines, while having minimal effect on BJ fibroblast control cells. In addition, we found a strong correlation between sensitivity to glutamine addiction and susceptibility to DON (R2 = 0.73). Next, we used human tumor xenografts in nude mice to examine the effect of inhibiting glutamine metabolism in the context of an established tumor. Following injection of neuroblastoma (SK-N-AS, SK-N-BE2) or Ewing's Sarcoma (SK-N-MC, SK-ES-1) cells, tumors were allowed to reach 200mm3 in size before being randomized into treatment groups. Mice were then treated with 100mg/kg DON or water control twice per week. DON treatment significantly inhibited both tumor growth and BrdU incorporation in all NB and EWS tumors tested, suggesting that targeting glutamine metabolism could be an effective therapeutic approach. Interestingly, although DON treatment was strongly cytostatic in all cell lines tested, only in the SK-N-BE2 cells did we detect increased cleavage of caspase-3 as a marker for apoptosis. These results suggest that perhaps combining glutamine inhibition with therapies to induce apoptosis may be more effective than targeting glutamine metabolism alone. To further examine the mechanism by which DON and glutamine withdrawal induce cell death, we treated NB and EWS cell lines with the pan-caspase inhibitor QVD. Treatment with 20uM QVD for either 48hr or 72hr significantly rescued cell number after DON treatment. This effect was most pronounced in NB cell lines with NMyc amplification, such as Kelly and IMR-32. Lastly, we performed an in vitro screen to identify pro-apoptotic compounds that increased the effects of DON on NB and EWS cell lines. We found three compounds which increased the effects of DON at clinically relevant concentrations: the synthetic retinoic acid derivative fenretinide, and the Bcl-2 family inhibitors obatoclax mesylate and navitoclax. Of these, navitoclax caused the greatest increase in DON activity across the entire panel of cell lines tested, suggesting that antagonizing Bcl-2 family members may be beneficial in combination with glutamine deprivation. Our results strongly suggest that combining therapeutic approaches to inhibit glutamine metabolism and induce tumor cell apoptosis may be a promising strategy for treatment of both NB and EWS tumors. Citation Format: Rachelle R. Olsen, Michelle N. Mary, Kevin W. Freeman. Targeting glutamine metabolism in neuroblastoma and Ewing's sarcoma. [abstract]. In: Proceedings of the AACR Special Conference on Pediatric Cancer at the Crossroads: Translating Discovery into Improved Outcomes; Nov 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;74(20 Suppl):Abstract nr B67.

The results of injections of Zyderm™ collagen implant in six patients for correction of depressed scars on the nose resulting from Mohs' surgery are presented. Two cases are illustrated. Three of the six patients achieved 85–100% correction after completion of their series of injections. The one patient who achieved 100% correction subsequently experienced 15–20% regression, although none of the other five patients showed regression of the correction achieved.