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Purpose To describe the health-related quality of life (HRQoL) of an unselected population of patients with chronic lymphocytic leukaemia (CLL) including untreated patients. Methods HRQoL was measured by the EORTC QLQ-C30 including the CLL16 module, EQ-5D, and VAS in an observational study over multiple years. All HRQoL measurements per patient were connected and analysed using area under the curve analysis over the entire study duration. The total patient group was compared with the general population, and three groups of CLL patients were described separately, i.e. patients without any active treatment (“watch and wait”), chlorambucil treatment only, and patients with other treatment(s). Results HRQoL in the total group of CLL patients was compromised when compared with age- and gender-matched norm scores of the general population. CLL patients scored statistically worse on the VAS and utility score of the EQ-5D, all functioning scales of the EORTC QLQ-C30, and the symptoms of fatigue, dyspnoea, sleeping disturbance, appetite loss, and financial difficulties. In untreated patients, the HRQoL was slightly reduced. In all treatment stages, HRQoL was compromised considerably. Patients treated with chlorambucil only scored worse on the EORTC QLQ-C30 than patients who were treated with other treatments with regard to emotional functioning, cognitive functioning, bruises, uncomfortable stomach, and apathy. Conclusions CLL patients differ most from the general population on role functioning, fatigue, concerns about future health, and having not enough energy. Once treatment is indicated, HRQoL becomes considerably compromised. This applies to all treatments, including chlorambucil, which is considered to be a mild treatment. Electronic supplementary material The online version of this article (doi:10.1007/s11136-015-1039-y) contains supplementary material, which is available to authorized users.

OBJECTIVES: Patients receiving therapy for haematological malignancies have a higher risk of invasive fungal infections (IFIs). Antifungal prophylaxis is an effective strategy against IFIs, but relative effectiveness estimates across agents are inconclusive. A mixed treatment comparison (MTC) was conducted to estimate the relative effectiveness of all agents for a number of outcomes of interest.METHODS: A systematic review was performed to collect evidence from randomized controlled trials (RCTs) on the risk of IFIs and on mortality after antifungal prophylaxis. The agents analysed were no prophylaxis/placebo, fluconazole, itraconazole, micafungin, caspofungin, liposomal amphotericin B and posaconazole. Meta-analyses and MTCs were used to synthesize the evidence. The primary outcome was the risk of proven or probable IFI. Secondary outcomes were risk of candidiasis/aspergillosis, risk of IFI mortality and risk of all-cause mortality.RESULTS: Antifungal prophylaxis was more effective than no prophylaxis/placebo in reducing IFI risk. The IFI risk after voriconazole or posaconazole was lower than after fluconazole [relative risk (RR) 0.38, 95% CI 0.14-0.83 and RR 0.34, 95% CI 0.14-0.83] or itraconazole tablets (RR 0.22 95% CI 0.06-0.72 and RR 0.20 95% CI 0.05-0.72). Posaconazole was also found to be more effective than no prophylaxis/placebo in reducing all-cause mortality (RR 0.56, 95% CI 0.30-0.98). Posaconazole had the highest probability of being the most effective agent in reducing IFI risk and all-cause mortality.CONCLUSIONS: IFI prophylaxis has a positive effect on IFI risk reduction. However, its effect on all-cause mortality is not as pronounced. The analysis has additionally pinpointed posaconazole as potentially the most effective IFI prophylaxis in neutropenic patients.

There has been a large increase in the incidence of invasive fungal infections (IFIs) over the past decades, largely because of the increasing size of the population at risk. One of the major risk groups for IFIs are patients with haematological malignancies treated with cytotoxic chemotherapy or undergoing haematopoietic stem cell transplantation. These IFIs are associated with high morbidity and mortality rates. Consequently, as the diagnosis of IFIs is difficult, antifungal prophylaxis is desirable in high-risk patients. Furthermore, as the economic impact of IFIs is also significant, it is important to assess the cost benefit and cost effectiveness of each prophylactic agent in order to aid decisions concerning which prophylactic agent provides the best value for limited healthcare resources. This article systematically reviews the available pharmacoeconomic evidence regarding antifungal prophylaxis in immunocompromised patients treated for haematological malignancies. Furthermore, specific points of interest concerning economic analyses of antifungal prophylaxis are briefly discussed. Considering the available evidence, antifungal prophylaxis in immunocompromised patients treated for haematological malignancies seems to be an intervention with favourable cost-benefit, cost-effectiveness and cost-saving potential. Furthermore, recently introduced antifungal agents seem to be attractive alternatives to fluconazole from a pharmacoeconomic point of view. However, due to wide heterogeneity in patient characteristics, underlying diseases, hospital settings and study methods in the included economic studies, as well as the lack of 'head-to-head' trials, it is difficult to find clear evidence of the economic advantages of a single prophylactic agent. Furthermore, we show that the results of cost-effectiveness analyses are highly dependent on several crucial factors that influence the baseline IFI incidence rates and, therefore, differ per patient population or region.

In human hematopoietic malignancies, RAS mutations are frequently observed. Yet, little is known about signal transduction pathways that mediate KRAS-induced phenotypes in human CD34(+) stem/progenitor cells. When cultured on bone marrow stroma, we observed that KRAS(G12V)-transduced cord blood (CB) CD34(+) cells displayed a strong proliferative advantage over control cells, which coincided with increased early cobblestone (CAFC) formation and induction of myelomonocytic differentiation. However, the KRAS(G12V)-induced proliferative advantage was transient. By week three no progenitors remained in KRAS(G12V)-transduced cultures and cells were all terminally differentiated into monocytes/macrophages. In line with these results, LTC-IC frequencies were strongly reduced. Both the ERK and p38 MAPK pathways, but not JNK, were activated by KRAS(G12V) and we observed that proliferation and CAFC formation were mediated via ERK, while differentiation was predominantly mediated via p38. Interestingly, we observed that KRAS(G12V)-induced proliferation and CAFC formation, but not differentiation, were largely mediated via secreted factors, since these phenotypes could be recapitulated by treating non-transduced cells with conditioned medium harvested from KRAS(G12V)-transduced cultures. Multiplex cytokine arrays and genome-wide gene expression profiling were performed to gain further insight into the mechanisms by which oncogenic KRAS(G12V) can contribute to the process of leukemic transformation. Thus, angiopoietin-like 6 (ANGPTL6) was identified as an important factor in the KRAS(G12V) secretome that enhanced proliferation of human CB CD34(+) cells.

Event-free survival (EFS) at 5 years in pediatric acute lymphoblastic leukemia (ALL) is 480%. Outcome in adult ALL is still unsatisfactory, which is due to less cumulative dosing of chemotherapy and less strict adherence to timing of successive cycles. In the present phase II trial, we evaluated a pediatric regimen in adult patients with ALL under the age of 40. Treatment was according to the pediatric FRALLE approach for high-risk ALL patients and characterized by increased dosages of asparaginase, steroids, methotrexate and vincristin. However, allogeneic stem cell transplantation was offered to standard risk patients with a sibling donor and to all high-risk patients in contrast to the pediatric protocol. Feasibility was defined by achieving complete remission (CR) and completion of treatment within a strict timeframe in at least 60% of patients. In all, 54 patients were included with a median age of 26. CR was achieved in 49 patients (91%), of whom 33 completed treatment as scheduled (61%). Side effects primarily consisted of infections and occurred in 40% of patients. With a median follow-up of 32 months, EFS estimated 66% at 24 months and overall survival 72%. These data show that a dose-intensive pediatric regimen is feasible in adult ALL patients up to the age of 40. Leukemia (2011) 25, 1697-1703; doi:10.1038/leu.2011.141; published online 7 June 2011

Objective. Mucin1 is a membrane glycoprotein that is overexpressed in a variety of human cancers. Here, we analyzed the role of Mucin1 in human hematopoietic stem/progenitor cells as well as in acute myeloid leukemia (AML) cells.Materials and Methods. Mucin1 expression was determined within the normal stem cell and progenitor compartment, as well as in the AML CD34(+) and CD34(-) subfractions of patient samples. Stem cells were enumerated in long-term culture-initiating cell (LTC-IC) assays in limiting dilution and progenitor frequencies in colony-forming cell (CFC) assays in methylcellulose, and consequences of elevated Mucin I expression were studied using retroviral overexpression systems in cord blood (CB) CD34(+) cells.Results. Ten percent of CB and 5% of peripheral blood CD34(+) cells expressed Mucin1. Retroviral overexpression of Mucin1 in CB CD34(+) cells resulted in elevated stem cell and progenitor frequencies as determined in LTC-IC and CFC assays without affecting differentiation, which coincided with increased proliferation. Overexpression of intercellular adhesion molecule-1, a ligand for Mucin1, in MS5 stromal cells further increased LTC-IC frequencies. Mucin1 overexpression was associated with increased nuclear factor-kappa B p50 nuclear translocation, suggesting that Mucin1-induced phenotypes involve increased cell survival mechanisms. Finally, we observed increased Mucin1 expression in 70% of the AML cases (n = 24), suggesting that elevated Mucin1 levels might be involved in regulating the proliferative potential of the immature leukemic compartment as well.Conclusions. Our data indicate that hematopoietic stem cells as well as CD34(+) AML subfractions are enriched for Mucin1 expression, and that overexpression of Mucin1 in CB cells is sufficient to increase both progenitor and LTC-IC frequencies. (C) 2008 ISEH - Society for Hematology and Stem Cells. Published by Elsevier Inc.

Purpose: Cancer patients treated with cytostatic drugs often develop oral mucositis, considered to be a mucosal injury in which various cytokines, such as interleukin 8 (IL-8), may play a role. Plasma IL-8 is a systemic inflammatory response parameter. This study investigated whether oral mucositis affects plasma IL-8 levels in febrile neutropenic cancer patients. Patients and Methods: Patients (n = 57) who were hospitalized with chemotherapy-induced neutropenic fever were scored for oral mucositis on the second day of hospitalization according to a validated oral mucositis assessment scale (OMAS) and WHO toxicity grading. Patients (n = 20) with a clinical sepsis or local bacterial infection were excluded from this evaluation. The remaining 37 patients were divided in groups with and without oral mucositis. Results: The difference in plasma IL-8 level between patients with and without mucositis was not significant (P = 0.7). Similarly no difference was observed in the degree and duration of granulocytopenia. Conclusion: These results indicate that low-grade oral mucositis is not related to the systemic plasma IL-8 level in febrile neutropenic cancer patients without a clinical sepsis or local bacterial infection.

Purpose To investigate the feasibility of withholding antibiotics and early discharge for patients with chemotherapy-induced neutropenia and fever at low risk of bacterial infection by a new risk assessment model. Patients and Methods Outpatients with febrile neutropenia were allocated to one of three groups by a risk assessment model combining objective clinical parameters and plasma interleukin 8 level. Patients with signs of a bacterial infection and/or abnormal vital signs indicating sepsis were considered high risk. Based on their interleukin-8 level, remaining patients were allocated to low or medium risk for bacterial infection. Medium-risk and high-risk patients received standard antibiotic therapy, whereas low-risk patients did not receive antibiotics and were discharged from hospital after 12 hours of a febrile observation. End points were the feasibility of the treatment protocol. Results Of 196 assessable episodes, 76 (39%) were classified as high risk, 84 (43%) as medium risk, and 36 (18%) as low risk. There were no treatment failures in the low-risk group (95% CI, 0% to 10%). Therefore, sensitivity of our risk assessment model was 100% (95% CI, 90% to 100%), the specificity, positive, and negative predictive values were 21%, 13%, and 100%, respectively. Median duration of hospitalization was 3 days in the low-risk group versus 7 days in the medium- and high-risk groups (P < .0001). The incremental costs of the experimental treatment protocol amounted to a saving of €471 (US $572) for every potentially low-risk patient. Conclusion This risk assessment model appears to identify febrile neutropenic patients at low risk for bacterial infection. Antibiotics can be withheld in well-defined neutropenic patients with fever.

Objective. Hematopoietic stem cells (HSC) are considered to display a quiescent state with low turnover rate. We investigated the cell-cycle kinetics of HSC after a single dose of cytarabine (Ara-C).Materials and Methods. We analyzed by flow cytometry the cell-cycle status of lin(low)sca-1(+) c-kit(+) (LSK) stem cells isolated from the bone marrow of C57131/6 mice sacrificed at 0, 2, 4, 6, 8, 12, 20, 48, 72, and 96 hours after intraperitoneal injection of Ara-C (100 mg/kg) using 7-aminoactinomycin-D (7-AAD) for DNA staining. In vivo bromodeoxyuridine (BrdU) incorporation and Ki-67 expression in HCS were also measured.Results. Two hours after administration of Ara-C, LSK cells ceased to incorporate BrdU. At 4 hours, a decrease of S-phase cells from 10% at baseline to 4% was found (p Conclusion. This data shows that a single injection of Ara-C first rapidly induced S-phase arrest in HSC for up to 4 hours. Subsequently, an unexpectedly rapid activation of HCS with recruitment of GO cells into cell cycle was observed. The mechanism of cell-cycle activation of LSK cells remains unknown, but reduction of the number of differentiated end cell did not appear to be the primary trigger. (C) 2005 International Society for Experimental Hematology. Published by Elsevier Inc.

Cyclosporin A (CsA) inhibits the P-gp pump that can be responsible for failure of cytostatic treatment in acute myeloid leukaemia (AML). Eighty patients with relapsing/refractory AML were randomly assigned to mitoxantrone (M) and etoposide (VP) (MVP) in unmitigated antileukaemic doses with or without CsA, to investigate if toxicity was manageable and if antileukaemic therapy could be improved. CsA did not delay haematological recovery, but fewer CsA patients received post-induction therapy because of haematological and non-haematological toxicity. CR rate was 43% for MVP and 53% for CsA; DFS was 9 and 8 months, and OS 8 and 9 months, respectively. Seventeen of 38 CR patients proceeded to stem cell transplantation (SCT). After a median follow-up of 66 months, six patients were still alive. Addition of CsA did not improve treatment outcome, possibly due to inadequate post-induction therapy as a result of increased toxicity.

There is a distinct difference in prognosis between childhood versus adult acute lymphoblastic leukaemia (ALL). To define whether multidrug resistance (MDR) genes might contribute to this distinction, the expression and functional activity of P-glycoprotein (P-gp) and MDR associated proteins (MRP) were determined with RT-PCR (MDR-1, MRP1, MRP2, MRP3) and flow cytometry (P-gp and MRP). Patient samples were obtained from 36 children and 35 adults with de novo ALL. Of these patients, 38 showed a T-lineage and 33 showed a B-lineage immunophenotype. In the samples, large variability in P-gp activity (0.8-4.9) and MRP activity (1.1-13.9) was observed. Most T-ALL patients with high P-gp activity were adults (89%). The mRNA expression of MDR-1 correlated weakly with P-gp activity. In contrast, MRP activity did not correlate with the mRNA expression of MRP1, MRP2 and MRP3. In T-ALL, a worse overall survival and event-free survival was observed with increasing P-gp activity. P-gp activity had no prognostic impact in B-lineage ALL. In addition, high MRP activity did not influence treatment outcome in either T- or B-lineage ALL. Multivariate Cox regression analysis, showed P-gp activity to be the only unfavourable prognostic factor for overall survival in T-ALL. In conclusion, this study demonstrates the prognostic relevance of P-gp activity in T-ALL. Since the majority of the patients with high P-gp activity were adults, P-gp might contribute to the poor prognosis of adult T-ALL.

We performed a comprehensive cost calculation identifying the main cost drivers of treatment of chronic lymphocytic leukaemia in daily practice. In our observational study 160 patient charts were reviewed repeatedly to assess the treatment strategies from diagnosis till the study end. Ninety-seven patients (61%) received >= 1 treatment lines during an average follow-up time of 6.4 years. The average total costs per patient were (sic)41,417 ((sic)539 per month). The costs varied considerably between treatment groups and between treatment lines. Although patients were treated with expensive chemo(immuno-)therapy, the main cost driver was inpatient days for other reasons than administration of chemo(immuno-)therapy. (C) 2013 Elsevier Ltd. All rights reserved.

Resistance to chemotherapy-induced apoptosis in CLL is associated with overexpression of antiapoptotic proteins induced by signals from the microenvironment. In vitro, dasatinib effectively inhibits expression of anti-apoptotic regulators and restores fludarabine sensitivity in activated CLL.The aim of this study was to evaluate efficacy of one cycle of dasatinib monotherapy (100 mg/day, days 1-28) followed by combination of dasatinib with fludarabine (40 mg/m(2)/day, days 1-3 every 28 day) for a total of it cycles in fludarabine-refractory. The primary endpoint was overall response rate according to the IWCLL'08 criteria.20 patients were enrolled: 18 completed at least one cycle of treatment of which 67% finishsed at Pact 2 cycles of combination treatment. 3 of these 18 patients reached a format PR (16,7%). Majority of patients obtained some reduction in lymph node (LN) size. Most frequent toxicity was related to myelosuppression.NF-kappa B RNA expression levels of circulating CLL cells decreased whereas the levels of pro-apoptotic NOXA increased during trot merit.In conclusion, dasatinib/fludarabine combination has modest clinical efficacy in fludarabine-refractory patients. (C) 2013 Elsevier Ltd, All rights reserved.

Glycopeptide antibiotics are used extensively in the empirical treatment of febrile patients with neutropenia. To come to a more rational and restricted application of these expensive drugs and to reduce the risk of emergence of resistance, we carried out a prospective, double-blinded, placebo-controlled single-centre study to investigate whether the addition of teicoplanin improved the outcome of neutropenic patients who remained febrile after 72-96 h of imipenem monotherapy. Patients with known infections caused by imipenem-resistant microorganisms were excluded. From the 114 evaluable episodes (out of a total of 125) in 105 patients who met the eligibility criteria, 56 episodes were randomized to receive teicoplanin and 58 to placebo. At 72 h after the start of the assigned intervention, 52 (45.6%) of the patients were afebrile; at the end of the aplastic phase, 10 (8.8%) had succumbed. There was no difference between the two study arms. When febrile episodes were subdivided between microbiologically documented infections, clinically documented infections and fevers of unknown origin, again no significant differences were observed. With the exception of methicillin-resistant bacteria, Gram-positive infections seemed to respond well to imipenem monotherapy. It is concluded that the addition of teicoplanin on empirical grounds, i.e. for persistent fever only, is not necessary and that the use of glycopeptides should be restricted to well-defined clinical situations where methicillin-resistant bacteria are involved. Furthermore, it seems that many neutropenic patients respond slowly over more than 72-96 h even when they are treated with antibacterial drugs such as imipenem that are effective against the causative microorganism.

It has been suggested that a better outcome of neutropenia-associated invasive fungal infections can be achieved when high doses of lipid formulations of amphotericin B are used. We now report a randomized multicentre study comparing liposomal amphotericin B (AmBisome, 5 mg/kg/d) to amphotericin B deoxycholate (AmB, 1 mg/kg/d) in the treatment of these infections. Of 106 possible patients, 66 were enrolled and analysed for efficacy: nine had documented fungaemia, 17 had other invasive mould infections and 40 had suspected pulmonary aspergillosis. After completion of the course medication, in the AmBisome group (n = 32) 14 patients had achieved complete response, seven a partial response and 11 were failures as compared to 6, 13 and 15 patients (n = 34) treated with AmB (P=0.09); P=0.03 for complete responders. A favourable trend for AmBisome was found at day 14, in patients with documented infections and in patients with pulmonary aspergillosis (P=0.05 and P=0.096 respectively). Mortality rates were lower in patients treated with AmBisome (adjusted for malignancy status, P=0.03). More patients on AmB had a >100% increase of their baseline serum creatinine (P

The tolerance of aerosolised amphotericin B as prophylaxis against invasive pulmonary aspergillosis was investigated in 61 granulocytopenic periods in 42 patients treated for a haematologic malignancy. Each patient was to receive amphotericin B in doses escalating to 10 mg three times daily (t.i.d.), but only 20 (48%) patients managed to complete the scheduled regimen. One patient tolerated the full dose initially, but had to discontinue treatment when dyspnea developed as a result of pneumonia and acute respiratory distress. Another 22 patients (52%) experienced side effects, including eight (19%) who reported mild coughing and dyspnea but who tolerated the full dose and three (7%) patients whose dose was reduced to 5 mg t.i.d. Another six (14%) patients could tolerate only 5 mg t.i.d., and five (12%) others stopped treatment because of intolerance. Elderly patients (p0.05) and those with a history of chronic pulmonary obstructive disease (p = 0.09) were more likely to develop side effects during inhalation. Twelve (28%) patients developed proven of possible invasive fungal infections, but no correlation was established between infection and the total amount of amphotericin B inhaled. Inhalation of aerosolised amphotericin B is poorly tolerated and does not appear useful in preventing invasive pulmonary aspergillosis in granulocytopenic patients.

Background: Tyrosine kinase inhibitors treatment in responding chronic myeloid leukaemia (CML) patients is generally continued indefinitely. In this randomised phase II trial, we investigated whether CML patients in molecular response(4.5) (MR4.5, quantitative reverse-transcription polymerase chain reaction (RQ-PCR)) after previous combination therapy with imatinib and cytarabine may discontinue imatinib treatment safely.Patients and methods: Thirty-three patients from the HOVON 51 study with an MR4.5 for at least 2 years who were still on imatinib treatment were randomised between continuation of imatinib (arm A, n = 18) or discontinuation of imatinib (arm B, n = 15).Results: After a median follow up of 36 months since randomisation, 3 patients (17%) in arm A and 10 patients (67%) in arm B had a molecular relapse. All 3 relapsing patients in arm A had also stopped imatinib after randomisation. All but one relapsing patient relapsed within 7 months after discontinuation of imatinib. The molecular relapse rate at 12 and 24 months after randomisation was 0% and 6% (arm A) and 53% and 67% (arm B) respectively. As-treated analysis revealed 56% and 61% relapses at 1 and 2 years since cessation in patients who discontinued imatinib, in contrast to 0% of patients who continued imatinib. All evaluable patients remained sensitive to imatinib after reinitiation and regained a molecular response.Conclusion: Our data suggest that discontinuation of imatinib is safe in patients with durable MR4.5. (C) 2013 Elsevier Ltd. All rights reserved.

Background Treatment options in older acute myeloid leukaemia (AML) patients include intensive chemotherapy, best supportive care (BSC), and hypomethylating agents. Currently, limited data is available on hypomethylating agents in older AML patients in unselected patient populations. Methods To compare the effectiveness of azacitidine with conventional therapy, we collected data of 227 consecutive AML patients (≥60 years) who were treated with azacitidine (N = 26), intensive chemotherapy (N = 90), or BSC (N = 97). Results Azacitidine-treated patients were older and had more comorbidities, but lower white blood cell- and bone marrow blast counts compared with intensive chemotherapy patients. Complete or partial response was achieved in 42% of azacitidine-treated patients and in 73% of intensive chemotherapy patients (P = 0.005). However, the overall survival (OS) was similar (1-year-OS 57% versus 56%, P = 0.93; 2-year-OS 35% versus 35%, P = 0.92), and remained similar after correction for risk factors in a multivariate analysis. Patients treated with BSC had an inferior OS (1-year- and 2-year-OS 16% and 2%, P < 0.001). Compared to intensive chemotherapy, azacitidine-treated patients spent less days in the hospital (median in first three months 0.5 versus 56, P P P Conclusions Azacitidine treatment is associated with a comparable OS but higher tolerability in a subgroup of older AML patients compared with intensive chemotherapy. Patients receiving BSC had a poor prognosis.

Intensive chemotherapy to improve outcome in patients with acute lymphoblastic leukemia over the age of 40: a phase II study for efficacy and feasibility by HOVON

143 aplastic episodes with fever in 91 haematological patients with granulocytopenia were treated empirically in a randomized prospective study using either imipenem (Imi) or a combination of tobramycin and cefuroxime (T/C). Response after 72 h was significantly better in patients receiving Imi (44/75 vs 27/68, p < 0.05). This was seen especially in patients with bacteriologically proven infections where the isolated staphylococci and streptococci were more susceptible to Imi. In both groups, patients who failed to respond to the initial antibiotic therapy were given vancomycin and aztreonam (V/A). The response rate after another 72 h, measured using the same criteria as after the first 72 h, did not differ statistically between the groups. One patient in each study group died from the bacterial infection, both from Gram-positive bacteraemia. Duration of fever was significantly shorter in the Imi group (4 days vs 7 days, p < 0.04). Serum peak and trough concentrations of the antibiotics were comparable. Both regimens were well tolerated. Our results show that monotherapy with imipenem is superior to the combination of tobramycin and cefuroxime during the first 72 h of therapy and can be safely administered to neutropenic patients with predominantly Gram-positive infections. A combination of vancomycin and aztreonam, given when initial imipenem treatment has failed, was effective in only a few patients. Adjuvant glycopeptide therapy from the outset in the treatment of febrile granulocytopenic patients did not seem worthwhile.

The transcription factor signal transducer and activator of transcription 5 (STAT5) fulfills essential roles in self-renewal in mouse and human hematopoietic stem cells (HSCs), and its persistent activation contributes to leukemic transformation, although little molecular insight into the underlying mechanisms has been obtained. In the present study, we show that STAT5 can impose long-term expansion exclusively on human HSCs, not on progenitors. This was associated with an enhanced cobblestone formation under bone marrow stromal cells of STAT5-transduced HSCs. Hypoxia-induced factor 2α (HIF2α) was identified as a STAT5 target gene in HSCs, and chromatin immunoprecipitation studies revealed STAT5 binding to a site 344 base pairs upstream of the start codon of HIF2α. Lentiviral RNA interference (RNAi)–mediated down-modulation of HIF2α impaired STAT5-induced long-term expansion and HSC frequencies, whereas differentiation was not affected. Glucose uptake was elevated in STAT5-activated HSCs, and several genes associated with glucose metabolism were up-regulated by STAT5 in an HIF2α-dependent manner. Our studies indicate that pathways normally activated under hypoxia might be used by STAT5 under higher oxygen conditions to maintain and/or impose HSC self-renewal properties.

A population of B cells with characteristics of chronic lymphocytic leukaemia was found in the peripheral blood of four patients who presented with cutaneous infiltration of atypical CD4+ T cells with cerebriform nuclei. The B cells had a low density of immunoglobulin on their surface membrane, expressed CD5-positivity, and showed monoclonality based on the restriction to either kappa or lambda light chains. In one patient with tumourous pleiomorphic CD4+CD30- T-cell lymphoma of the skin, it was the first manifestation of a concomitant B-cell non-Hodgkin's lymphoma of low-grade malignancy. In three other patients with reactive atypical T-cell erythroderma, there was no evidence for the coexistence of a B-cell malignancy. The number of CD5+ B cells decreased in two erythroderma patients with clinical remission of the cutaneous lesions. It is speculated that the presence of a monoclonal B cell population in patients with T-cell disorders of the skin is due either to a reactive process possibly conferring some protective effect, or a response to an unknown stimulus produced by the T cells.

Based on previous studies where it was shown that non-absorbable antibiotics can influence the normal hematopoiesis via changes in factors related to the intestinal microflora, the influence of vancomycin on the progression of acute myeloid leukemia was investigated in the BNML rat model. Oral vancomycin, which selectively reduces Gram-positive bacteria in the gut, leads to diminution of the leukemic load in liver and spleen by 30-60%. This 'antileukemic effect' is not dependent on Gram-negative bacteria as source for endotoxin. The presumed mechanism is a decrease of the leukemic growth fraction caused by alterations in the absorption of substances from intestinal Gram-positive bacteria.

Studies with synchronized or exponentially growing bacteria and mammalian cell lines are not able to demonstrate small changes in buoyant density during the cell cycle. Flowcytometric analysis of density separated acute myeloid leukemia cells, a system not dependent on time-related variables, shows that the cellular buoyant density increases slightly with up to 0.008 g/ml during the S-phase, at least in cryo-preserved cells used in this study. This contrasts with the generally accepted belief that S-phase cells have a lower or constant buoyant density. A practical implication is that separation of cell (sub)populations based on differences in buoyant density could be flawed to the extent that these populations contain S-phase cells.

Contains fulltext : 88715schattenberg.pdf (Publisher’s version ) (Open Access) BACKGROUND: In order to improve the molecular response rate and prevent resistance to treatment, combination therapy with different dosages of imatinib and cytarabine was studied in newly diagnosed patients with chronic myeloid leukemia in the HOVON-51 study. DESIGN AND METHODS: Having reported feasibility previously, we hereby report the efficacy of escalated imatinib (200 mg, 400 mg, 600 mg or 800 mg) in combination with two cycles of intravenous cytarabine (200 mg/m(2) or 1000 mg/m(2) days 1 to 7) in 162 patients with chronic myeloid leukemia. RESULTS: With a median follow-up of 55 months, the 5-year cumulative incidences of complete cytogenetic response, major molecular response, and complete molecular response were 89%, 71%, and 53%, respectively. A higher Sokal risk score was inversely associated with complete cytogenetic response (hazard ratio of 0.63; 95% confidence interval, 0.50-0.79, P

Contains fulltext : 89507.pdf (Publisher’s version ) (Open Access) We report the use of PCR techniques on a formalin-fixed and paraffin-embedded tissue specimen for direct detection of one dominant azole resistance mechanism in a case of disseminated invasive aspergillosis. Rapid detection of mutations associated with azole resistance directly in tissue significantly reduces diagnostic delay. 01 april 2010

The haematopoietic recovery after i.v. cytarabine was studied in C3H/Law mice as a measure for stem cell susceptibility in relation to the intestinal Gram-negative bacteria (GNB) and endotoxin. Reduction or elevation of GNB and endotoxin was induced by either polymyxin or bacitracin, both non-absorbable antibiotics. Bacitracin caused less suppression of the splenic cellularity after cytarabine, and an advancement of the recovery of femoral nucleated cells. The femoral recovery of CFU-GM exhibited a biphasic pattern. The speed and height of the rebound increase of CFU-GMs were significantly affected by the antibiotics. Thus, (modulation of) the murine intestinal microflora influences the haematopoietic recovery after cytostatic drugs. The mechanisms involved are complex; intestinal endotoxin seems to play a role.

230 leukaemic patients were entered into a randomised, prospective, multicentre trial of either ciprofloxacin (1 g/day) or co-trimoxazole (1920 mg/day) plus colistin (800 mg/day) for the prevention of infection during granulocytopenia. Bacteraemia due to resistant gram-negative rods occurred only in the co-trimoxazole-colistin group though both regimens were effective for selective gastrointestinal tract decontamination. However, there were fewer patients without any infective complications (31% vs. 18%: P = 0.02), fewer febrile days [mean (S.D.) 5.9 (1.1) vs. 8.2 (1.4): P = 0.0242], a lower proportion of infective events (0.9 (0.16) vs. 1.2 (0.18): P = 0.005) and fever occurred later (median 19 vs. 14 days: 0.025 less than P less than 0.05) in the co-trimoxazole-colistin group. The choice of prophylactic regimen therefore appears to depend upon whether or not protection against gram-negative infection is required or better systemic prophylaxis overall.

Cytostatic drugs are known to produce disturbances in intestinal absorption of carbohydrates. To further explore the gastrointestinal (GI) toxicity of cytostatic therapy, 37 patients with acute leukaemia were investigated during and/or after remission induction courses by the use of the differential sugar absorption test (DSAT) and the intestinal clearance of alpha-1-antitrypsin (Cl AAT ). The ratio of the lactulose to the mannitol excretion in the urine was found abnormal in 44% of the tests. The Cl AAT was increased in 74% of tests. The test results differed considerably from patient to patient and depended on the chemotherapy course; correlation between the tests was low, probably indicating that unrelated pathophysiological processes were measured. After haematological regeneration, abnormal test results normalised. It is concluded that aggressive chemotherapy not only causes a reduction in the absorption of sugars, but commonly also protein leakage. These GI side-effects are reversible, and the application of both tests in combination provides a practical and reproducible method for investigation of GI toxicity in patients treated with cytostatic drugs.

The influence of intestinal flora modulation by oral bacitracin on the recovery of myelopoiesis after Ara-C was studied in C3H/Law mice. Bacitracin resulted in a 3-5 log increase of Gram-negative bacteria and a 10-fold increase of the intestinal endotoxin concentration. Initiation of bacitracin before Ara-C stimulated the initial rebound increase of colony-forming units for granulocytes and macrophages (CFU-GM) from 23.2 +/- 1.3 to 28.4 +/- 1.4 x 10(3) per femur. Starting the bacitracin after Ara-C advanced the second phase of the rebound CFU-GM increase with 6 days. An important role in the recovery of myelopoiesis after cytostatic drugs in C3H/Law mice is suggested for the intestinal Gram-negative microflora, probably mediated by bacterial endotoxin.

Aim: To demonstrate whether serum Interleukin-8 (IL-8) is a relevant parameter to select hospitalised patients with chemotherapy-induced neutropenic fever with low or high probability of infection.Results: 90 assessable febrile episodes in 73 patients were evaluated; 46% of the febrile episodes were microbiologically documented infection (MDI), 8% clinical documented infection (CDI), and 47% fever of unknown origin (FUO). Median IL-8 level was lower in the FUO group compared to CDI and MDI (p = 60 ng/l while in 18 of 21 episodes (86%) with IL-8 level = 60 ng/l and responsive on antibiotic treatment showed a decline of IL-8 levels within days in contrast to non-responding patients.Conclusions: Serum IL-8 level can be a useful marker to identify hospitalised FUO patients with low probability of infection. (C) 2008 Elsevier Ltd. All rights reserved.

Background: B-cell expression of ZAP-70, normally expressed in T and NK cells, correlates with poor prognosis in B-CLL. Poor discrimination between ZAP-70 positive and negative cells hampers routine application of flow cytometry. We examined the usefulness of FACS Lysing Solution.Methods: ZAP-70 expression in 65 healthy volunteers was measured by four-color flow cytometry, comparing FACS Lysing Solution for fixation and permeabilization with the Fix & Perm kit. Separation between ZAP-70 positive T cells and negative B cells was based on a ratio of median ZAP-70 staining of T cells to B cells. In 25 B-CLL patients, ZAP-70 expression was estimated using the lower limit of the fluorescence range corresponding with 98% of ZAP-70 positive T cells as threshold marker as well as a ratio of B-CLL cell to internal T-cell median ZAP-70 staining.Results: Use of FACS Lysing Solution resulted in approximately fourfold increased separation between ZAP-70 positive T cells and negative B cells, when compared with the Fix & Perm kit. In B-CLL samples, ZAP-70 negative and positive B-cell expression could be clearly discerned.Conclusions: FACS Lysing Solution is a simple procedure that markedly improves discrimination between ZAP-70 positive and negative cells. (C) 2007 Clinical Cytometry Society.

Background: Invasive fungal infections in neutropenic patients treated for haematological malignancies are associated with a high mortality rate and, therefore, require early treatment. As the diagnosis of invasive fungal infections is difficult, effective antifungal prophylaxis is desirable. So far, fluconazole has been the most commonly used. Objective: To assess the cost effectiveness of itraconazole compared with both fluconazole and no prophylaxis for the prevention of invasive fungal infections in haematological patients, mean age 51 years, in Germany and The Netherlands. Study design: We designed a probabilistic decision model to fully incorporate the uncertainty associated with the risk estimates of acquiring an invasive fungal infection. These risk estimates were extracted from two meta-analyses, evaluating the effectiveness of fluconazole and itraconazole and no prophylaxis. The perspective of the analysis was that of the healthcare sector; only medical costs were taken into account. All costs were reported in (sic), year 2004 values. Cost effectiveness was expressed as net costs per invasive fungal infection averted. No discounting was performed, as the model followed patients during their neutropenic period, which was assumed to be less than 1 year. Results: According to our probabilistic decision model, the monetary benefits of averted healthcare exceed the costs of itraconazole prophylaxis under baseline assumptions (95% Cl: from cost-saving to (sic)5000 per invasive fungal infection averted). Compared with fluconazole, itraconazole is estimated to be both more effective and more economically favourable, with a probability of almost 98%. Conclusions: In specific groups of neutropenic patients treated for haematological malignancies, itraconazole prophylaxis could potentially reduce overall healthcare expenditure, without harming effectiveness, in settings where fluconazole is common practice in the prophylaxis of invasive fungal infections.

Rhodococcus equi, mainly known from veterinary medicine as a pathogen in domestic animals, can also cause infections in immunocompromised humans, especially in those with defects in cellular immunity. Alemtuzumab, an anti-CD52 monoclonal antibody, causes lymphocytopenia by eliminating CD52-positive cells. We report a patient in whom Rhodococcus equi infection developed after alemtuzumab therapy.

Contains fulltext : 34676schattenberg.pdf (Publisher’s version ) (Closed access) A prospective randomized phase III study was performed to evaluate whether intensified cytarabine would induce a higher response rate and longer event-free interval as compared to low-dose cytarabine in chronic myeloid leukemia (CML). One hundred and eighteen patients with CML in early chronic phase entered the study. Twenty-eight out of 32 patients assigned to group A received two cycles of a combination of intensified cytarabine and idarubicin followed by interferon alfa (IFN-alpha) maintenance, 28 patients in group B received standard treatment by a combination of low-dose cytarabine and IFN-alpha. Forty-nine patients with a human leukocyte antigen-identical sibling donor proceeded to allogeneic stem cell transplantation (allo-SCT) and nine patients were excluded from the analysis. Hematological response was observed in 97% of the patients in group A vs 86% of the patients in group B during the first year of treatment. In group A, 16 patients (50%) achieved a major cytogenetic response, which compared to seven patients (25%) with a major cytogenetic response in group B. With a median follow-up of 58 months (range 34-76), event-free survival was not significantly different between arms A and B. The estimated 5-year survival rate was 56% in the intensified arm and 77% in the low-dose arm (P = 0.05). Recipients of allo-SCT showed a 5-year estimated survival rate of 55%. Although intensified cytarabine induced a higher initial percentage of major and complete cytogenetic responses, responses were not sustained by IFN-alpha maintenance therapy.

The Dutch-Belgian Hemato-Oncology Cooperative Group and the Swiss Group for Clinical Cancer Research (HOVON-SAKK) collaborative study group evaluated outcome of patients (pts) with acute myeloid leukemia (AML) in first remission (CR1) entered in 3 consecutive studies according to a donor versus no-donor comparison. Between 1987 and 2004, 2287 pts were entered in these studies of whom 1032 pts (45%) without FAB M3 or t(15;17) were in CR1 after 2 cycles of chemotherapy, received consolidation treatment, and were younger than 55 years of age and therefore eligible for allogeneic hematopoietic stem cell transplantation (allo-SCT). An HLA-identical sibling donor was available for 326 pts (32%), whereas 599 pts (58%) lacked such a donor, and information was not available in 107 pts. Compliance with allo-SCT was 82% (268 of 326). Cumulative incidences of relapse were, respectively, 32% versus 59% for pts with versus those without a donor (P < .001). Despite more treatment-related mortality (TRM) in the donor group (21% versus 4%, P < .001), disease-free survival (DFS) appeared significantly better in the donor group (48% ± 3% versus 37% ± 2% in the no-donor group, P < .001). Following risk-group analysis, DFS was significantly better for pts with a donor and an intermediate- (P = .01) or poor-risk profile (P = .003) and also better in pts younger than 40 years of age (P < .001). We evaluated our results and those of the previous MRC, BGMT, and EORTC studies in a meta-analysis, which revealed a significant benefit of 12% in overall survival (OS) by donor availability for all patients with AML in CR1 without a favorable cytogenetic profile.

Purpose Cloretazine (VNP40101M) is a sulfonylhydrazine alkylating agent with significant antileukemia activity. A multicenter phase II study of cloretazine was conducted in patients 60 years of age or older with previously untreated acute myeloid leukemia (AML) or high-risk myelodysplastic syndrome (MDS). Patients and Methods Cloretazine 600 mg/m2 was administered as a single intravenous infusion. Patients were stratified by age, performance score, cytogenetic risk category, type of AML, and comorbidity. Results One hundred four patients, median age 72 years (range, 60 to 84 years), were treated on study. Performance status was 2 in 31 patients (30%) and no patient had a favorable karyotype. Forty-seven patients (45%) had cardiac disease, 25 patients (24%) had hepatic disease, and 19 patients (18%) had pulmonary disease, defined as per the Hematopoietic Cell Transplantation–Specific Comorbidity Index, at study entry. The overall response rate was 32%, with 29 patients (28%) achieving complete response (CR) and four patients (4%) achieving CR with incomplete platelet recovery. Response rates in 44 de novo AML patients, 45 secondary AML patients, and 15 high-risk MDS patients were 50%, 11%, and 40%, respectively. Response by cytogenetic risk category was 39% in 56 patients with intermediate cytogenetic risk and 24% in 46 patients with unfavorable cytogenetic risk. Nineteen (18%) patients died within 30 days of receiving cloretazine therapy. Median overall survival was 94 days, with a 1-year survival of 14%; the median duration of survival was 147 days, with a 1-year survival of 28% for those who achieved CR. Conclusion Cloretazine has significant activity and modest extramedullary toxicity in elderly patients with AML or high-risk MDS. Response rates remain consistent despite increasing age and comorbidity.

Cloretazine (VNP40101M) is a sulfonylhydrazine alkylating agent with significant anti-leukemia activity. A multicenter phase II study of cloretazine was conducted in patients with first relapse of acute myeloid leukemia (AML) following an initial complete remission (CR) of less than 12 months. Cloretazine was given as a single intravenous infusion at a dose of 600 mg/m(2). Fifty-three patients (median age 62 years (18-84), 41 of 44 (93%) evaluable with intermediate or high risk cytogenetics, 32 (60%) with initial CR durations < or =6 months) were treated on study. Two patients (4%) achieved a second CR. Five (9%) patients died within 30 days of receiving cloretazine therapy. Median overall survival (2.3 months) in the study cohort was directly comparable to that of 233 matched patients treated with other single agents. The study cloretazine regimen had minimal activity in a very high risk subset of patients with relapsed AML.

Thalidomide is an effective agent for patients with refractory multiple myeloma (MM) with a response rate of 30-40% at doses of 200-800 mg but with considerable side effects. We questioned whether lower doses of thalidomide in combination with a daily dose of cyclophosphamide might be an effective regimen with fewer side effects. We included 38 patients with relapsed or refractory MM. The median doses of thalidomide and cyclophosphamide were 100 and 95 mg/day, respectively. Side effects were observed in all patients, with neurotoxicity as the most troublesome. With a median follow-up of 14 months 84% of the patients responded, including 64% partial responses. The median time of progression-free survival was 30 months and the median overall survival time was 20 months. In conclusion, the results demonstrate that the combination of low-dose thalidomide with a daily dose of cyclophosphamide is an effective regimen with a high overall response rate and manageable side effects.

Fludarabine in addition to cytosine-arabinoside (ARA-C) increases the accumulation of ARA-C-5'-triphosphate (ARA-CTP), which is responsible for the cytotoxic effect in leukemic blasts. In a randomized phase 3 trial, patients with high-risk myelodysplastic syndrome (MDS) (n = 91) or elderly patient's with acute myeloid leukemia (AML) (n = 43) were randomized to receive 2 induction courses consisting of ARA-C (2 g/m(2) days 1 through 5) and granulocyte colony-stimulating factor (G-CSF) (filgrastim, 5 mug/kg) during and after chemotherapy with or without fludarabine (25 mg/m(2), days 1 through 5) (FLAG versus AG). Consolidation consisted of daunorubicin (45 mg/m(2), days 1 through 3) and ARA-C (200 mg/m(2), days 1 through 7). Complete remission (CR) rate following AG was 65% versus 71% with FLAG (P = .49). Overall survival (OS) at 24 months was 24% for AG treatment and 39% for FLAG (P = .32). Event-free survival (EFS) at 2 years was 10% and 19% (P = .31) for the AG and FLAG treatments, respectively. Platelet and granulocyte recovery times after the second cycle were prolonged in the FLAG treatment group. Grades 3 to 4 neurotoxicities were more often reported in the FLAG arm (14% versus 3%, P = .03), whereas no significant differences in other toxicities were observed. In a cohort of patients, the in vivo accumulation of ARA-CTP in leukemic cells was determined. Although ARA-CTP accumulation in leukemic cells after FLAG was enhanced, clinical outcome in terms of CR rate, OS, EFS, and disease-free survival (DFS) was not significantly improved by combining fludarabine with ARA-C. (C) 2004 by The American Society of Hematology.

Cyclosporin A (CsA) inhibits the P-gp pump that can be responsible for failure of cytostatic treatment in acute myeloid leukaemia (AML). Eighty patients with relapsing/refractory AML were randomly assigned to mitoxantrone (M) and etoposide (VP) (MVP) in unmitigated antileukaemic doses with or without CsA, to investigate if toxicity was manageable and if antileukaemic therapy could be improved. CsA did not delay haematological recovery, but fewer CsA patients received post-induction therapy because of haematological and non-haematological toxicity. CR rate was 43% for MVP and 53% for CsA; DFS was 9 and 8 months, and OS 8 and 9 months, respectively. Seventeen of 38 CR patients proceeded to stem cell transplantation (SCT). After a median follow-up of 66 months, six patients were still alive. Addition of CsA did not improve treatment outcome, possibly due to inadequate post-induction therapy as a result of increased toxicity.

Cancer patients treated with chemotherapy are susceptible to bacterial infections. When an adult patient presents with febrile neutropenia. standard diagnostic care includes physical examination, laboratory diagnostics, chest X-ray (CXR) and sinus radiography. However, the yield of routine radiography in the diagnostic evaluation of ambulatory adult febrile neutropenic patients with normal findings at their physical examination is questionable. Two CXRs and one sinus X-ray were obtained in 109 and 106 febrile neutropenic episodes after chemotherapy in ambulatory adult patients who had no clinical signs suggesting pulmonary infection or sinusitis. We found that in only two of 109 (1.8%; 95% Confidence Interval (Cl): 0.3-5.8%) febrile neutropenic episodes without clinical signs of new pulmonary disease, the CXR showed a consolidation suggesting pneumonia. In addition, in five of 88 (5.7% 95% Cl: 2.2-12.0%) febrile episodes in asymptomatic patients, sinus X-ray suggested sinusitis. In none of these seven episodes was a change of antibiotic therapy necessary. In the absence of clinical signs indicating pneumonia or sinusitis, the yield of CXR and sinus radiography in ambulatory adult cancer patients presenting with febrile neutropenia is minimal; CXR and sinus radiography should no longer be performed on a routine basis. (C) 2003 Elsevier Ltd. All rights reserved.

Objective. Cancer patients with febrile neutropenia after chemotherapy have a variable risk of bacterial infection. Especially Gram-negative bacteremia is associated with high mortality and/or morbidity. Early diagnosis of patients with Gram-negative bacteremia at the onset of febrile neutropenia is potentially useful in tailoring therapy. Design and setting. Prospective study at the Department of Pediatric Oncology and Internal Medicine of a university hospital. Patients. Were analyzed 66 febrile neutropenic episodes in 57 adults and children. Patients were divided into four groups: those with Gram-negative bacteremia, Gram-positive bacteremia, clinical sepsis, or fever of unknown origin. Measurements and results. Plasma lipopolysaccharide-binding protein (LBP) and C-reactive protein (CRP) concentrations were determined. LBP at the onset of febrile neutropenia was significantly higher in patients with Gram-negative bacteremia than those with fever of unknown origin and those with Gram-positive bacteremia. Using a cutoff value for LBP proved to have much greater sensitivity, specificity, and positive and negative predictive value for Gram-negative bacteremia than the best cutoff value for CRP. Conclusions. An initial high LBP level might predict Gram-negative bacteremia in cancer patients with febrile neutropenia. These results may have potential clinical impact by allowing therapy to be initiated for these patients at a very early stage.

Cancer patients treated with chemotherapy are susceptible to bacterial infections. Therefore, all neutropenic cancer patients with fever receive standard therapy consisting of broad-spectrum antibiotics and hospitalization. However, febrile neutropenia in cancer patients is often due to other causes than bacterial infections. Therefore, standard therapy should be re-evaluated and new treatment strategies for patients with variable risk for bacterial infection should be considered. This paper reviews the changing spectrum of microorganisms and resistance of microorganisms to antibiotics in infection during neutropenia and discusses new strategies for the selection of patients with low-risk for bacterial infection using clinical and biochemical parameters such as acute phase proteins and cytokines. These low-risk patients may be treated with alternative therapies such as oral antibiotics, early discharge from the hospital or outpatient treatment.

Phenytoin is a commonly used antiepileptic agent that also has a place in the prophylaxis of seizures in patients with haematological malignancies. It is co-administered in patients receiving busulfan and in patients with meningeal involvement of haematological malignancies. As patients with these disorders encounter prolonged chemotherapy-induced neutropenia, they are at risk of bacterial and fungal infections. For the treatment of invasive pulmonary aspergillosis (IPA), one of the predominant fungal infections in these patients, voriconazole has been recommended as the first line agent [1]. However, voriconazole is extensively metabolized by CYP2C9 and CYP2C19 and, to a lesser extent, by CYP3A4 and at the same time inhibits CYP2C9 and CYP3A4. Phenytoin is widely known for inducing CYP3A4 as well as CYP2C9 and CYP2C19 activity. Besides this, it is a substrate of CYP2C9 and CYP2C19. This drug–drug interaction was recognized earlier and therefore evaluated in a prospective study in healthy volunteers [2]. This study showed that phenytoin in a dose of 300 mg once daily reduced the area under the concentration–time curve (AUC) of voriconazole given in a dose of 200 mg twice daily by 69%. From the same study it appeared that a dose increase of voriconazole to 400 mg twice daily, while receiving phenytoin 300 mg once daily, resulted in an AUC increase by 39%. The authors concluded that increasing the dose of voriconazole from 200 mg twice daily to 400 mg twice daily compensated for the effect of phenytoin on voriconazole AUC and this statement was incorporated in the product information [3]. In our institute, we monitor voriconazole serum trough concentrations regularly in patients with an invasive fungal infection. Serum samples are measured by liquid chromatography tandem mass spectrometry with a validated method of analysis. When phenytoin is co-administrated, the dosage of voriconazole is increased to 400 mg twice daily according to the manufacturer's advice. From the hospital database (2007–2009) we retrieved three Caucasian patients (49–57 years; two female, one male) with a diagnosis of malignant lymphoma who received co-medication with both agents and in whom the voriconazole and phenytoin serum concentrations were evaluated. Despite the increased dose, very low voriconazole serum concentrations (0.1–0.2 mg l−1) were observed at steady state in all three patients. The patients had received voriconazole as empiric treatment for IPA in a dose of 400 mg twice daily and phenytoin in a dose of 300 mg daily for prophylaxis of busulfan-induced seizures in one patient, or brain metastases in two patients. The phenytoin steady state serum concentration was 21.7 mg l−1 and 21.4 mg l−1 in two patients and 5.5 mg l−1 in the third patient (therapeutic range 8–20 mg l−1). The patients were receiving no other co-medication that could have influenced voriconazole metabolism. Evaluation of the voriconazole concentration resulted in switching phenytoin to levetiracetam in one patient, discontinuation of phenytoin because prophylaxis for busulfan-induced seizures was no longer indicated in the second patient, and discontinuation of voriconazole because there was no suspicion any more of an invasive fungal infection in the third patient. CYP genotyping was performed in one patient and did not show any mutation in CYP2C9 or CYP2C19. These three cases show that, compared with healthy volunteers, the effect of the drug–drug interaction for voriconazole and phenytoin seems to be more profound in ill patients. This can possibly be explained by the large variability in the pharmacokinetics of voriconazole observed in patients [4, 5] which might be caused by several mechanisms including genotypic heterogeneity for CYP2C19 that distinguishes rapid from slow metabolizers. The exposure to voriconazole in patients with already low voriconazole serum concentrations could be further reduced to almost undetectable concentrations by phenytoin as observed in our three patients. A similar case, describing a patient with low voriconazole concentrations during phenytoin treatment, has been reported before and is consistent with our observations [6]. Recently it was shown that CYP2C19*17 polymorphism resulted in significantly lower exposure after a single dose of 200 mg or 400 mg voriconazole [7, 8]. Although voriconazole tends to accumulate considerably with time, the rapid metabolism of voriconazole is expected to result in significantly lower voriconazole exposure. However, the extent of the effect on voriconazole steady state serum concentrations is unknown and needs to be determined at steady state. The prevalence of CYP2C19 polymorphism varies considerably [7, 8] but the difference between our patients and the healthy volunteers cannot be explained solely based on CYP2C19 polymorphisms as in one patient no polymorphism was observed. Besides, in two patients high phenytoin concentrations were observed, which contradicts rapid metabolism. In our opinion, the combination of voriconazole and phenytoin should be avoided. Levetiracetam, a newer anti-epileptic agent, could be a good alternative for phenytoin in the prophylaxis of busulfan-induced seizures [9] and additionally it could prevent the drug–drug interaction between busulfan and phenytoin [10]. In the case where pre-existing epilepsy is treated with phenytoin, antifungal treatment should preferably be started with a lipid formulation of amphotericin B or anidulafungin as both are not metabolized by CYP450 enzymes. If the combination of phenytoin and voriconazole cannot be avoided, serum concentrations of voriconazole should be monitored at all times and when necessary the dose of voriconazole should be adjusted. From these cases it can be concluded that a drug–drug interaction between voriconazole and phenytoin in severely ill patients can be more profound and less predictable than in healthy volunteers. Monitoring of voriconazole and phenytoin is needed, but the drug–drug interaction should be avoided whenever possible by using other combinations of anti-epileptic and antifungal drugs.

Voriconazole has become the drug of first choice to treat invasive fungal infections (IFI) [1]. Standard intravenous dosing of voriconazole consists of an infusion of a dose of 6 mg kg–1 b.i.d. on day 1 followed by a maintenance dose of 4 mg kg–1. Voriconazole is metabolized by the liver, by CYP2C19, CYP2C9 and CYP3A4 enzymes, with renal excretion of the metabolites. The elimination half-life of voriconazole is approximately 6 h. As the capacity of the CYP isoenzymes is limited, the metabolism of voriconazole can be saturated [2]. The observed large inter- and intrapatient variation of its pharmacokinetics [3], the possible relationship between therapeutic failure and low serum levels [3–5], and the relation of high serum levels with adverse effects [6, 7] have resulted in the advice to monitor serum levels. How to adjust the dosage to improve therapy is unfortunately not described. We report our experience with therapeutic monitoring of voriconazole in 20 patients with haematological malignancies receiving voriconazole for the treatment of proven or suspected IFI. In most of these patients multiple samples (trough levels) were drawn for pharmacokinetic evaluation of voriconazole concentrations over time. It has been recommended that trough levels should be 1–2 mg l–1 and not exceed 5 mg l–1[8]. In 11 of the 20 patients (55%), a mean trough concentration of 2.7 mg l–1 (range 1.6–4.1 mg l–1) was observed, i.e. within the desired range. In three of the 20 patients (15%) a mean trough concentration below the therapeutic range was observed (mean 0.6 mg l–1, range 0.2–0.9 mg l–1). In six of the 20 patients (30%), however, standard intravenous dosing led to trough concentrations 5 mg l–1 (mean 7.2 mg l–1; range 5.4–8.8 mg l–1), which is the presumed toxic range. High voriconazole concentrations occurred within 2–3 days after the start of therapy. As voriconazole is mainly metabolized by the liver, we focused our evaluation on the possibility of voriconazole metabolism influencing factors such as CYP isoenzymes and concomitant medication. The hepatic function in relation to medication, chemotherapy and parenteral nutrition were evaluated from 1 week before the start of until 2 weeks after stopping voriconazole therapy. In five of the six patients with a trough level 5 mg l–1, mild pre-existing liver dysfunction was present at the start of voriconazole. Mild hepatic dysfunction was characterized by a bilirubin level of five times > upper level of normal (ULN) and at least two of the following: alkaline phosphatase (ALP), aspartate aminotransferase (ASAT), alanine transaminase (ALAT), gamma glutamyl transpeptidase, with a level of three times > ULN. In these cases, the high voriconazole level seemed to result from, rather than being the cause of, the liver dysfunction. Only in one patient was acute deterioration of hepatic liver tests observed, probably caused by voriconazole since the Naranjo score was 8 (where 5–8 is probable, and 9 is definite) [9]. The hepatic dysfunction displayed a characteristic pattern of a strong rise in ASAT/ALAT level combined with a smaller and enduring increase in ALP level, pointing to acute drug-induced liver toxicity [10]. In five of these six patients, CYP2C19 and CYP2C9 isoenzymes were determined, but in only one patient was an intermediate CYP2C19 isoenzyme for reduced metabolism detected. In none of the six patients could any drug–drug interaction be noted between co-medication and voriconazole. In patients presenting with a trough level of 5 mg l–1, voriconazole was stopped. Strikingly, an exponentially increased voriconazole elimination half-life of 77.6 h (range 46.8–99.4 h) was calculated [11] in patients presenting with a voriconazole trough level of 5 mg l–1, compared with the commonly observed half-life of 6–8 h [12]. Our results show that voriconazole could be stopped for at least two consecutive days. Meanwhile, serum monitoring continued, and voriconazole levels slowly decreased to levels within the therapeutic window (Figure 1). Voriconazole was then restarted successfully using a lower dosage and monitoring continued in those patients who needed continued therapy. Eventually the dosage had to be increased stepwise in two patients to maintain levels within the therapeutic window. The nonlinear pharmacokinetics of voriconazole combined with decreased hepatic function is probably the most logical explanation of these high serum voriconazole levels and increased elimination half-lives. It seems logical that voriconazole metabolism is reduced above a certain serum threshold level (limited capacity of hepatic clearance), compatible with a saturation mechanism for enzymatic degradation [13]. In our experience patients presenting with multiple liver enzyme values of three to five times ULN are ‘at risk’ of developing high voriconazole trough levels. The observations suggest that routine monitoring of voriconazole levels in patients with haematological malignancies after 3 days of therapy is necessary to prevent voriconazole adverse effects caused by toxic levels. Figure 1 Voriconazole concentration over time after stopping of voriconazole. Dosage of voriconazole at time of stopping is displayed. Case 1 was a 55-year-old man with diffuse large B-cell lymphoma who received empiric stepping-up after not responding to antibacterial ...

The clinical use of autologous marrow transplantation in acute myeloid leukemia (AML) has been hampered by the inability to collect adequate numbers of cells after remission induction chemotherapy and the notably delayed hematopoietic regeneration following autograft reinfusion. Here we present a study in which the feasibility of mobilizing stem cells was investigated in newly diagnosed AML. Among 96 AML patients, 76 patients (79%) entered complete remission. Mobilization was undertaken with low dose and high dose schedules of G-CSF in 63 patients, and 54 patients (87%) were leukapheresed. A median of 2.0 x 10(6) CD34+ cells/kg (range 0.1-72.0) was obtained in a median of three leukaphereses following a low dose G-CSF schedule (150 microg/m2) during an average of 20 days. Higher dose regimens of G-CSF (450 microg/m2 and 600 microg/m2) given during an average of 11 days resulted in 28 patients in a yield of 3.6 x 10(6) CD34+ cells/kg (range 0-60.3) also obtained following three leukaphereses. The low dose and high dose schedules of G-CSF permitted the collection of 2 x 10(6) CD34-positive cells in 46% and 79% of cases respectively (P = 0.01). Twenty-eight patients were transplanted with a peripheral blood stem cell (PBSC) graft and hemopoietic repopulation was compared with the results of a previous study with autologous bone marrow. Recovery of granulocytes (>0.5 x 10(9)/l, 17 vs 37 days) and platelets (>20 x 10(9)/l; 26 vs 96 days) was significantly faster after peripheral stem cell transplantation compared to autologous bone marrow transplantation. These results demonstrate the feasibility of PBSCT in the majority of cases with AML and the potential advantage of this approach with respect to hemopoietic recovery.

A 50-year-old male is described who presented with Fournier's gangrene as what is probably the first manifestation of a newly diagnosed acute myelogenous leukemia (AML), promyelocytic type or variant type M-3, according to the FAB classification. Despite aggressive fluid resuscitation, tuned infusion of vasoactive drugs, appropriate antibiotics and extensive surgical debridement, the patient died within 24 h as a result of irreversible septic shock. (C) 1998 Elsevier Science Ltd. All rights reserved.

Abstract 1798 Introduction Development of chemoresistance in chronic lymphocytic leukemia (CLL) is at least partly mediated by protective stimuli within the lymph node (LN) microenvironment. Dasatinib has activity against multiple kinases which have been reported to be activated by the microenvironment, including SRC, c-Abl and BTK. We have recently shown that Dasatinib can effectively inhibit the anti-apoptotic program and as a consequence, restore fludarabine sensitivity in vitro. Patients and methods We conducted an open-label phase 2 trial of Dasatinib combined with fludarabine in twenty refractory CLL patients. Patients were treated with Dasatinib 100 mg once daily for 28 days. In patients who did not reach at least a PR, fludarabine was added (40 mg/m2 for 3 consecutive days q28) for at least 2 and a maximum of 6 cycles. Response assessments included CT-scans at baseline, following 4 weeks of Dasatinib monotherapy, after 2 cycles of combination therapy and at the end of protocol. In a subset of patients with high numbers of circulating lymphocytes at baseline, RNA expression profiles of apoptosis regulator genes as well as inflammation genes were analyzed prior and during treatment by MLPA analysis. Results Toxicities were comparable to those observed in fludarabine containing regimens and as expected in heavily pre-treated refractory patients. Three patients (18%) reached a PR. Although most patients did not reach a formal nodal response, most patients showed reduction in lymph node (LN) size with a median of −20% as best response. Subsequent dasatinib fludarabine treatment following dasatinib monotherapy induced additional clinical effects but primarily in patients without del11q or del17p. Patients with a LN reduction of at least 20% had a significant improved PFS (256 days) and OS (510 days) as compared to non-responders (80 days and 158 days respectively). Also, in responding patients PFS was superior to PFS after last prior treatment. NF-κB expression levels decreased while expression levels of the pro-apoptotic gene NOXA increased both after Dasatinib treatment and combination treatment. Conclusion In conclusion, Dasatinib fludarabine combination treatment has clinical efficacy in heavily pretreated refractory patients which correlated with decreased NF-κB and increased NOXA expression. As recently showed with other targeted agents, improvement of PFS and OS is also observed in patients with tumor responses less than 50%. These data do encourage further studies on a broad-spectrum kinase inhibitor like Dasatinib in combination with other classes of drugs in relapsed and refractory CLL. Disclosures: No relevant conflicts of interest to declare.