A Phase I/II Multicenter, Safety and Efficacy Study of Combination Treatment with Melphalan, Arsenic Trioxide and Vitamin C (MAC) in Patients with Relapsed or Refractory Multiple Myeloma.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 2398-2398 ◽  
Author(s):  
James R. Berenson
Keyword(s):  
Multiple Myeloma ◽  
Ascorbic Acid ◽  
Arsenic Trioxide ◽  
Stable Disease ◽  
Low Dose ◽  
Objective Response ◽  
Multicenter Trial ◽  
In Vivo Studies

Abstract Background: An urgent need exists for new treatments to overcome chemoresistance in MM patients. Recent in vitro and In vivo studies in our laboratory show that arsenic trioxide (ATO) can sensitize chemoresistant MM cells to melphalan-induced cytotoxic effects. Pre-clinical studies also show the most profound anti-MM effects when ATO, ascorbic acid and melphalan are used in combination compared with the effects observed when the drugs are used alone or combinations of any two of these agents. Based on encouraging results from a pilot study1, a larger, multicenter trial was recently started. Methods: MM patients who showed relapse after responding to first-line chemotherapy and/or having proved to be refractory to chemotherapy are enrolled. Patients received a loading dose of ATO at 0.25 mg/kg IV followed by ascorbic acid 1 g IV days 1–4 of week 1 of each six-week cycle. ATO/ascorbic acid was given twice-weekly for the next 4 weeks of each cycle. Low-dose melphalan (0.10 mg/kg) was administered orally for the first 4 days of each cycle. Patients received a maximum of 6 cycles followed by weekly maintenance treatment with weekly ATO followed by ascorbic acid. The primary objectives of this study are to determine response rate and safety and tolerability of MAC therapy. Results: Twenty patients have received at least one treatment cycle. Preliminary data show that eight (4 PR, 4 MR) of the 14 evaluable patients (57%) had an objective response, an additional three patients achieved stable disease, resulting in a total of 11 patients (79%) with disease control. Since responses were seen after 2 to 5 treatment cycles, it is possible that some patients with stable disease may experience additional disease response. Seven of the eight responding patients had failed two or more treatments: five patients had received prior thalidomide therapy, two had received melphalan and bortezomib, and two patients had undergone autologous peripheral stem cell transplantation. Of the six patients who have now completed the maximal numbers of cycles, four achieved PR, one MR, and one SD. The regimen was well tolerated with few significant side effects reported; mild cytopenias were reported as reversible. Conclusions: These preliminary results in this treatment group of heavily pre-treated MM patients who had either relapsed or were refractory to standard and/or investigational multiple myeloma treatments suggests that the MAC treatment regimen (1) shows efficacy using a low dose of melphalan supporting the preclinical evidence that ATO can sensitize tumors to chemotherapy; (2) is well tolerated; (3) may require multiple cycles before response.

A Multicenter Phase II Study of Combination Treatment with Melphalan, Arsenic Trioxide and Vitamin C (MAC) for Patients with Relapsed or Refractory Multiple Myeloma.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2564-2564 ◽  
Author(s):  
James Berenson ◽  
Ralph Boccia ◽  
David Siegel ◽  
Marek Bozdech ◽  
Alberto Bessudo ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Ascorbic Acid ◽  
Vitamin C ◽  
Arsenic Trioxide ◽  
Phase Ii ◽  
Stable Disease ◽  
Objective Response ◽  
In Vivo Studies

Abstract Background: Despite the recent increase in treatment options for patients with multiple myeloma (MM), the disease remains largely incurable. Both arsenic trioxide (ATO) and melphalan have shown clinical activity in MM. Recent in vitro and in vivo studies in our laboratory have shown that arsenic trioxide sensitizes chemoresistant MM cells to melphalan-induced cytotoxicity; the addition of ascorbic acid (AA) further improves this effect. We conducted a multi-center clinical trial to evaluate the safety and efficacy of this steroid-free combination, melphalan, ATO and vitamin C (MAC), for patients with relapsed/refractory MM. Methods: MM pts who relapsed after responding to 1st-line therapy and/or were refractory to prior treatment were enrolled. During week 1 of each 6-week cycle, pts received ATO, 0.25 mg/kg IV, followed by ascorbic acid (AA), 1 g IV, days 1–4. ATO followed by AA was given twice-weekly for the next 4 weeks of each cycle. Low-dose melphalan (0.10 mg/kg) was administered orally for the first 4 days of each cycle. Pts received a maximum of 6 cycles followed by weekly maintenance treatment with ATO and AA. The primary objectives of this study were to determine response rate and safety and tolerability of MAC therapy. Results: 65 patients have been enrolled and 51 are currently evaluable for response. 26 (1 CR, 10 PR, 15 MR) of the 51 evaluable patients (51%) had an objective response and an additional 14 patients achieved stable disease, resulting in a total of 40 patients (78%) with disease control. Among patients with elevated serum creatinine levels at baseline, renal function improved for those with responsive or stable disease. 20 of the 26 responding patients had failed ≥ 2 prior therapies: 19 pts had received prior thalidomide or lenalidomide therapy and 8 pts had received prior bortezomib. The regimen was well-tolerated with few significant side effects reported. Mild cytopenias occurred infrequently and were reversible. Conclusions: The results from this large multi-center phase II trial show that the MAC regimen is active in a group of MM patients who had either relapsed or were refractory to standard and/or investigational MM treatments. The regimen was well-tolerated even in this heavily pre-treated patient population. These findings are consistent with preclinical studies that showed the efficacy of this combination from both in vitro and in vivo studies.

A Phase II Study of PXD101 in Advanced Multiple Myeloma.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3583-3583 ◽  
Author(s):  
Daniel Sullivan ◽  
Seema Singhal ◽  
Michael Schuster ◽  
James Berenson ◽  
Peter Gimsing ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Cell Lines ◽  
Stable Disease ◽  
Progressive Disease ◽  
Synergistic Effects ◽  
Objective Response ◽  
Study Drug ◽  
Primary Objective

Abstract Background: PXD101 is a small molecule HDAC inhibitor of the hydroxamate class, which demonstrates broad anti-neoplastic activity in vitro and in vivo. PXD101 has antiproliferative activity on multiple myeloma cell lines, and shows additive/synergistic effects with standard agents used in myeloma, against these cell lines. PXD101 is being tested as monotherapy and in combination with standard agents for treatment of multiple myeloma. Methods: The primary objective of this study was to assess the activity of PXD101 alone or with dexamethasone, in multiple myeloma patients (pts) who have failed at least 2 prior therapies. Response was measured using the Blade criteria. PXD101 was administered as a 30-min IV infusion on Days 1–5 of a 3-wk cycle, at a dose of 1000 mg/m2/d (900 mg/m2/d in earlier patients). Patients are initially treated with PXD101 alone for two cycles. At the end of cycle two and every cycle thereafter, pts are evaluated for tumor response and continue on the study as follows: pts with objective response or stable disease continue on PXD101 monotherapy, while pts who have progressive disease (PD) are treated with a combination of PXD101 + dexamethasone (Dex). Dex was given orally 40 mg daily on Days 2–5 and 10–13 of the treatment cycle. Results: To date, 24 pts have been enrolled, 19 for which data are currently available. These pts have received a median of 5 (range 2–10) prior therapies. Seventeen pts are evaluable, 12 of whom are evaluable for ≥ 2 cycles, and 5 evaluable for 1 cycle only; 2 pts are unevaluable due to inconsistent baseline that prevented response assessment. Of the 5 pts evaluable for 1 cycle only, 4 discontinued due to PD and one withdrew from study. The 12 pts evaluable for ≥ 2 cycles received a median of 4 treatment cycles (range 2–12); 6 of these patients went on to receive PXD101+Dex. In these 12 pts, duration of PXD101 monotherapy was for 2–4 cycles, with almost all pts (10) receiving only 2 cycles. PXD101+Dex treatment in 6 pts was for 1–10 cycles (10, 6, 4, 4, 3, and 1). In 12 pts on monotherapy for ≥ 2 cycles, there were 6 SD (duration 6–12 wks) and 6 PD. The short duration of SD in PXD101 monotherapy was attributed to patient withdrawal or moving to Dex addition in spite of disease stabilization. All 6 pts receiving PXD101+Dex had previously received at least 2 Dex-containing regimens. One pt had MR (duration 6 wks), and 5 pts had SD. One pt has had SD for 35 wks, with 90% decrease in serum M-component sustained in the last 12 wks; another pt has had SD for 15 wks. In 69 cycles of treatment there were 7 Grade 3/4 adverse events assessed by the investigator as potentially related to study drug. These include anemia (2), infection, respiratory distress, hyperglycemia, thrombocytopenia, and fatigue. Conclusions: PXD101 treatment has resulted in stabilization of advanced and progressive disease, providing clinical benefit to patients. PXD101 combination with dexamethasone led to an MR as well as long duration of stable disease in patients who have previously received multiple Dex regimens. These observations support the continued exploration of PXD101 in combination with other agents for treatment of multiple myeloma.

A Phase I/II Trial Evaluating the Combination of Arsenic Trioxide, Bortezomib and Ascorbic Acid for Patients with Relapsed or Refractory Multiple Myeloma.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2565-2565 ◽  
Author(s):  
James Berenson ◽  
Jeff Matous ◽  
Delina Ferretti ◽  
Regina Swift ◽  
Russell Mapes ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Ascorbic Acid ◽  
Phase I ◽  
Arsenic Trioxide ◽  
In Vivo Studies ◽  
Current Phase ◽  
Refractory Multiple Myeloma ◽  
Early Results ◽  
Dose Levels

Abstract Background: Both arsenic trioxide and bortezomib as single agents have shown efficacy for patients with relapsed/refractory multiple myeloma (MM). Recently, we have demonstrated synergistic anti-MM effects when these two agents are combined to treat human MM in SCID mice and evaluated in in vitro studies. In addition, we and others have also shown that the addition of ascorbic acid (AA) sensitizes MM cells to the cytotoxic effects of arsenic trioxide both through in vitro and in vivo studies. Thus, the objective of the current Phase I clinical trial was to assess the safety and tolerability of bortezomib + arsenic trioxide + AA treatment for patients with refractory/relapsed MM. Methods: A treatment cycle comprised of intravenous injections of arsenic trioxide, bortezomib and AA on days 1, 4, 8, and 11 followed by a 10-day rest period every three weeks. Bortezomib was given at one of three dose levels (0.7, 1.0, or 1.3 mg/m2), followed by arsenic trioxide at one of two doses (0.125 or 0.25 mg/kg) intravenously followed by AA (1000 mg). Patients were treated for a maximum of eight cycles and were eligible for maintenance therapy with the same treatments given once every other week. Results: Eighteen patients have been enrolled to date, with three patients enrolled in each of the six cohorts. Patients had received a median of three prior therapies (range, 1–6), and five patients had received prior bortezomib therapy. Fifteen patients are evaluable for efficacy to date, and response data are summarized in Table 1. Overall, among the 15 evaluable patients, seven patients responded (2 PR, 5 MR), three patients showed stable disease, and five patients progressed. Among the six patients (in cohorts 1 and 4) enrolled at the lowest (0.7 mg/m2) bortezomib dose level, only one achieved a MR whereas among the nine evaluable patients enrolled at the higher (1.0 and 1.3 mg/m2) bortezomib dose levels six patients responded (2 PR, 4 MR). In general, the regimen was well tolerated. One patient in cohort 3 was removed from study during the first cycle because of the development of an asymptomatic arrhythmia which resolved spontaneously. Other serious adverse events included pneumonia in two patients, chest pain, and abdominal pain (one patient each). Conclusion: These early results from this Phase I/II study indicate that the combination of bortezomib, arsenic trioxide and ascorbic acid has efficacy and is well tolerated in a heavily pretreated population of patients with relapsed or refractory MM. Because of these encouraging clinical results, we plan to further evaluate this combination in a larger group of patients with relapsed/refractory myeloma. Table 1. Dose escalation scheme Cohorts Arsenic trioxide Bortezomib No. of evaluable pts Response *one patient in cohort 3 went off study during cycle 1 (see above), and the other two patients (one each in cohorts 3 and 6) are too early for response evaluation Cohort 1 0.125 mg/kg 0.7 mg/m2 3 1 MR, 2 PD Cohort 2 0.125 mg/kg 1.0 mg/m2 3 1 PR, 1 SD, 1 PD Cohort 3 0.125 mg/kg 1.3 mg/m2 1* 1 PR Cohort 4 0.25 mg/kg 0.7 mg/m2 3 1 SD, 2 PD Cohort 5 0.25 mg/kg 1.0 mg/m2 3 3 MR Cohort 6 0.25 mg/kg 1.3 mg/m2 2* 1 SD, 1 MR

In-vitro and in-vivo studies of PLA / PCL / gelatin composite scaffold containing ascorbic acid for bone regeneration

2020 ◽  
pp. 102077 ◽  
Author(s):  
Seyedeh Fatemeh Hashemi ◽  
Mohsen Mehrabi ◽  
Arian Ehterami ◽  
Anneh Mohammad Gharravi ◽  
Fateme Sadat Bitaraf ◽  
...  
Keyword(s):  
Ascorbic Acid ◽  
Bone Regeneration ◽  
Composite Scaffold ◽  
In Vivo Studies

scholarly journals Erythrocyte Membrane-Coated Arsenic Trioxide-Loaded Sodium Alginate Nanoparticles for Tumor Therapy

Pharmaceutics ◽  
2019 ◽  
Vol 12 (1) ◽  
pp. 21 ◽  
Author(s):  
Yumei Lian ◽  
Xuerui Wang ◽  
Pengcheng Guo ◽  
Yichen Li ◽  
Faisal Raza ◽  
...  
Keyword(s):  
Arsenic Trioxide ◽  
Sodium Alginate ◽  
Primary Liver Cancer ◽  
Tumor Therapy ◽  
Average Particle Size ◽  
In Vivo Studies ◽  
Average Particle ◽  
Promising Alternative

Arsenic trioxide (ATO) has a significant effect on the treatment of acute promyelocytic leukemia (APL) and advanced primary liver cancer, but it still faces severe side effects. Considering these problems, red blood cell membrane-camouflaged ATO-loaded sodium alginate nanoparticles (RBCM-SA-ATO-NPs, RSANs) were developed to relieve the toxicity of ATO while maintaining its efficacy. ATO-loaded sodium alginate nanoparticles (SA-ATO-NPs, SANs) were prepared by the ion crosslinking method, and then RBCM was extruded onto the surface to obtain RSANs. The average particle size of RSANs was found to be 163.2 nm with a complete shell-core bilayer structure, and the average encapsulation efficiency was 14.31%. Compared with SANs, RAW 264.7 macrophages reduced the phagocytosis of RSANs by 51%, and the in vitro cumulative release rate of RSANs was 95% at 84 h, which revealed a prominent sustained release. Furthermore, it demonstrated that RSANs had lower cytotoxicity as compared to normal 293 cells and exhibited anti-tumor effects on both NB4 cells and 7721 cells. In vivo studies further showed that ATO could cause mild lesions of main organs while RSANs could reduce the toxicity and improve the anti-tumor effects. In brief, the developed RSANs system provides a promising alternative for ATO treatment safely and effectively.

Effects of Ethanol on Human Natural Killer Cell Activity: In Vitro and Acute, Low-Dose In Vivo Studies

1994 ◽  
Vol 18 (6) ◽  
pp. 1361-1367 ◽  
Author(s):  
Miriam Ochshorn-Adelson ◽  
Gershon Bodner ◽  
Per Toraker ◽  
Henrik Albeck ◽  
Ann Ho ◽  
...  
Keyword(s):  
Natural Killer Cell ◽  
Low Dose ◽  
Natural Killer Cell Activity ◽  
Killer Cell ◽  
Cell Activity ◽  
In Vivo Studies ◽  
Human Natural Killer Cell ◽  
Killer Cell Activity

Arsenic Trioxide Shows Synergistic Anti-Myeloma Effects When Combined with Bortezomib and Melphalan In Vitro and Helps Overcome Resistance of Multiple Myeloma Cells to These Treatments in Vivo.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 2467-2467
Author(s):  
Richard A. Campbell ◽  
Haiming Chen ◽  
Daocheng Zhu ◽  
Janice C. Santos ◽  
Benjamin Bonavida ◽  
...  
Keyword(s):  
Arsenic Trioxide ◽  
Cell Lines ◽  
Combined Therapy ◽  
In Vivo Studies ◽  
Low Doses ◽  
Drug Resistant ◽  
Early Results ◽  
Post Implantation

Abstract Arsenic trioxide (ATO) induces apoptosis of plasma cells through a number of mechanisms including inhibiting DNA binding by NF-κB. These results suggest that this agent may be synergistic when combined with other active anti-myeloma drugs. To evaluate this we examined the effect of ATO alone and in combination with anti-myeloma treatments evaluated in vitro with MTT assays and using our severe combined immunodeficient (SCID)-hu murine myeloma models. First, we determined the effects of combining ATO with bortezomib or melphalan on the myeloma cell lines RPMI8226 and U266. Cell proliferation assays demonstrated marked synergistic anti-proliferative effects of ATO at concentrations ranging from 5x10−5M – 5x10−9M and melphalan concentrations ranging from 3x10−5M – 3x10−9M. Similar effects were observed when these cell lines were treated with bortezomib and varying concentrations of ATO (5x10−5 M – 5x10−10 M). We also investigated the potential of ATO to increase the efficacy of anti-myeloma therapies in our SCID-hu murine model LAGλ–1 (Yang H et al. Blood 2002). Each SCID mouse was implanted with a 0.5 cm3 LAGλ–1 tumor fragment into the left hind limb muscle. Mice were treated with ATO alone at 6.0 mg/kg, 1.25 mg/kg, 0.25 mg/kg, and 0.05 mg/kg intraperitoneally (IP) daily x5/week starting 19 days post-implantation. Mice receiving the highest dose of ATO (6.0 mg/kg) showed marked inhibition of tumor growth and reduction of paraprotein levels while there was no effect observed in all other treatment groups. Next, 27 days following implantation of our LAGλ–1 intramuscular (IM) tumor, LAGλ–1 mice were treated with ATO (1.25 mg/kg) IP, bortezomib (0.25 mg/kg), or the combination of both drugs at these doses in the schedules outlined above. ATO or bortezomib treatment alone had no anti-myeloma effects at these low doses consistent with our previous results whereas there was a marked decrease in both tumor volume (57%) and paraprotein levels (53%) in mice receiving the combined therapy. The combination of melphalan and ATO was also evaluated in this model. LAGλ–1 bearing mice received therapy with melphalan IP x1/weekly at 12.0 mg/kg, 6.0 mg/kg, 0.6 mg/kg, and 0.06 mg/kg starting 22 days post-implantation and showed no anti-myeloma effects. Twenty-eight days following implantation of LAGλ–1 tumor, mice received ATO (1.25 mg/kg) or melphalan (0.6 mg/kg) alone at doses without anti-myeloma effects, or the combination of these agents at these doses. The animals treated with these drugs alone showed a similar growth and increase in paraprotein levels to control mice whereas the combination of ATO and melphalan at these low doses markedly suppressed the growth of the tumor by >50% and significantly reduced serum paraprotein levels. These in vitro and in vivo studies suggest that the addition of ATO to other anti-myeloma agents is likely to result in improved outcomes for patients with drug resistant myeloma. Based on these results, these combinations are now in clinical trials with promising early results for patients with drug resistant myeloma.

scholarly journals Bone marrow fibroblasts parallel multiple myeloma progression in patients and mice: in vitro and in vivo studies

Leukemia ◽  
2013 ◽  
Vol 28 (4) ◽  
pp. 904-916 ◽  
Author(s):  
M A Frassanito ◽  
L Rao ◽  
M Moschetta ◽  
R Ria ◽  
L Di Marzo ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
In Vivo Studies ◽  
Bone Marrow Fibroblasts

Low-dose arsenic trioxide sensitizes glucocorticoid-resistant acute lymphoblastic leukemia cells to dexamethasone via an Akt-dependent pathway

Blood ◽  
2007 ◽  
Vol 110 (6) ◽  
pp. 2084-2091 ◽  
Author(s):  
Beat C. Bornhauser ◽  
Laura Bonapace ◽  
Dan Lindholm ◽  
Rodrigo Martinez ◽  
Gunnar Cario ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Arsenic Trioxide ◽  
Low Dose ◽  
Lymphoblastic Leukemia ◽  
Phosphorylation Site ◽  
Inhibitory Effect ◽  
Resistant Cell ◽  
Apoptosis Protein

Abstract Incorporation of apoptosis-inducing agents into current therapeutic regimens is an attractive strategy to improve treatment for drug-resistant leukemia. We tested the potential of arsenic trioxide (ATO) to restore the response to dexamethasone in glucocorticoid (GC)–resistant acute lymphoblastic leukemia (ALL). Low-dose ATO markedly increased in vitro GC sensitivity of ALL cells from T-cell and precursor B-cell ALL patients with poor in vivo response to prednisone. In GC-resistant cell lines, this effect was mediated, at least in part, by inhibition of Akt and affecting downstream Akt targets such as Bad, a proapoptotic Bcl-2 family member, and the X-linked inhibitor of apoptosis protein (XIAP). Combination of ATO and dexamethasone resulted in increased Bad and rapid down-regulation of XIAP, while levels of the antiapoptotic regulator Mcl-1 remained unchanged. Expression of dominant-active Akt, reduction of Bad expression by RNA interference, or overexpression of XIAP abrogated the sensitizing effect of ATO. The inhibitory effect of XIAP overexpression was reduced when the Akt phosphorylation site was mutated (XIAP-S87A). These data suggest that the combination of ATO and glucocorticoids could be advantageous in GC-resistant ALL and reveal additional targets for the evaluation of new antileukemic agents.

Treatment of Acute Myelogenous Leukemia (non-APL) with Intravenous Trisenox® (Arsenic Trioxide) and Ascorbic Acid: Preliminary Results.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1815-1815 ◽  
Author(s):  
Dan Douer ◽  
Kristy Watkins ◽  
Robert Louie ◽  
Ilene Weitz ◽  
Ann Mohrbacher ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Ascorbic Acid ◽  
Arsenic Trioxide ◽  
Peripheral Blood ◽  
Sensory Neuropathy ◽  
Myelogenous Leukemia ◽  
Clinical Activity ◽  
Preliminary Results ◽  
Induced Apoptosis

Abstract Introduction: Arsenic trioxide (ATO) is an exceptionally active drug in acute promyelocytic leukemia (APL), inducing complete remissions in 85% of relapsed patients. ATO also has clinical activity in myelodysplastic syndrome (MDS). In non-APL AML cells lines, ATO induces apoptosis in vitro; however, in a small study of 11 non-APL AML patients, ATO showed no activity (Parmer et al Leuk Res28:090, 2004). In some types of cancer cells, ATO-induced apoptosis has been shown to correlate inversely with the level of intracellular reduced glutathione (GSH) via generation of reactive oxygen species; cells with high concentrations of GSH are more resistant to ATO. Ascorbic acid (AA) increases apoptosis and overcomes resistance to ATO in multiple myeloma, non-APL AML and other cell lines by reducing intracellular GSH levels. AA alone has no activity in these cells. We therefore conducted a clinical trial in patients with non-APL AML combining ATO and AA. Methods: ATO at a dose of 0.25 mg/kg is administrated intravenously over 1–3 hour with 1 gram of intravenous AA given within 30 minutes daily for five days a week (five days on/2 days off) for five weeks (25 doses - one cycle). These doses were based on a phase I/II trial of ATO+AA in patients with multiple myeloma (Behalis et al Clin Cancer Res8:3658, 2002)). Responding patients receive an additional consolidation cycle of 25 doses followed by maintenance of two weeks of every month of ATO+ AA for 4 cycles. Patients who fail to respond after two cycles are considered treatment failures. Results: Seven patients have so far enrolled: three (aged 36,52,59) had relapsed after chemotherapy, and four aged 66–84 (median 70), never received chemotherapy. For these untreated patients ATO+AA was given as front line treatment. In three of the four previously untreated patients the number of bone marrow blasts dropped from > 40% to < 5% (2 pts. after 1 cycle; 1 pt. after 2 cycles) At the time of this report only one of the responding patients received more than one cycle and had improvement in the peripheral blood counts. The three patients, who failed chemotherapy, did not respond to ATO+AA (one patient received only one cycle). Despite the high doses of ATO, higher than used in APL and MDS, the combination was very well tolerated with grade 3 toxicity in one patient only (sensory neuropathy). One responding patient developed shortness of breath with severe hypoxemia, reminiscent of the APL differentiation syndrome, which responded immediately to dexamethasone. Conclusion: These preliminary results in patients with non-APL AML suggest that: (1) AA +ATO has anti-leukemia activity in untreated non-APL AML patients with minimal toxicity; (2) more than one cycle is probably needed to achieve a response in the peripheral blood counts; (3) in non-APL AML, ATO can cause the so called “differentiation syndrome” which should be anticipated and treated early. If confirmed in additional patients, ATO+AA might be a less toxic alternative upfront approach to intensive chemotherapy in elderly patients with non-APL AML.

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