[Adult B-cell acute lymphoblastic leukemias: Conclusions of the Russian prospective multicenter study ALL-2009]. / Ostrye V-limfoblastnye leikozy vzroslykh: vyvody iz Rossiiskogo prospektivnogo mnogotsentrovogo issledovaniia OLL-2009.

AIM: To analyze the efficiency and reproducibility of the ALL-2009 protocol within the Russian prospective multicenter study based on different principles of cytostatic effects (non-intensive, but continuous cytotoxic treatment and a small number of allogeneic hematopoietic stem cells). SUBJECTS AND METHODS: The ALL-2009 (NCT01193933) study conducted in April 2009 to December 2016 included 194 patients (95 males and 99 females) aged 15 to 55 years (median age 28 years) with Ph-negative B-cell acute lymphoblastic leukemia (ALL). There was early pre-B-cell ALL in 54 patients, common ALL in 101, pre-B ALL in 39, initial leukocytosis in 9.4·109/l (0.4-899.0), lactate dehydrogenase in 901 IU (31-13 059), an initial central nervous system lesion in 17 (8.7%), mediastinal injury in 3 (1.5%), and splenomegaly in 111 (57.2%). The results of standard cytogenetic analysis are known in 113 (60.4%) patients. Normal karyotypes were detected in 49 (54.5%) out of the patients; t(4;11) in 9 (5.4%), t(1;19) in 2 (1.2%), and other karyotypic abnormalities in 53 (46.9%). Thirteen (7.8%) patients underwent allogeneic hematopoietic stem cell transplantation in first complete remission (CR); their proportion did not differ in the federal and regional centers. RESULTS: The frequency of CR achievement was the same in the federal and regional centers and generally amounted to 87.5%. Early (8.8%) and CR (9.6%) mortality rates remained high despite the low aggressiveness of cytotoxic action, necessitating the improvement of auxiliary treatment. The five-year overall survival (OS) rates vary considerably in the federal and regional centers (72.6 and 43.8%), the relapse-free survival (RFS) (70.2 and 53.4%) and recurrence risk (23.1 and 36.5%) are comparable. This suggests that the non-intensive, but continuous exposure principle built in the ALL-2009 protocol makes it possible to reproduce the envisaged treatment program and to achieve satisfactory results. CONCLUSION: The ALL-2009 protocol allows both the federal and regional centers to obtain the long-term results comparable with those of current foreign studies: OS (54.2%), RFS (56.5%); and relapse risk (35.4%). Multivariate analysis has identified age (over 30 years), initial leukocytosis (30·109/l and more) and t(4;11) among the main clinical prognostic factors. Gene mutation detection evaluated in a small number of patients (8/36) is not a poor prognostic sign. There is a need for further investigations with centralized evaluation of the mutation status of leukemic cells and the clearance of minimal residual disease.

[Acute Ph-negative lymphoblastic leukemias in adults: Risk factors in the use of the ALL-2009 protocol]. / Ostrye Ph-negativnye limfoblastnye leikozy vzroslykh: faktory riska pri ispol'zovanii protokola OLL-2009.

AIM: to analyze well-known risk factors (RFs), such as age, immunophenotype, baseline leukocytosis, enhanced lactate dehydrogenase (LDH) activity, time to achieve complete remission, a risk group, and cytogenetic abnormalities) in patients with acute lymphoblastic leukemia (ALL) in the use of the ALL-2009 protocol. SUBJECTS AND METHODS: The protocol covered 298 patients (137 women (including 13 pregnant women) and 161 men) aged 15 to 55 years (median age 28 years) with Ph-negative ALL. The phenotype was unknown in 6 patients. Three (1%) were ascertained to have a biphenotypic variant. 182 (62.4%) patients were found to have B-cell ALL (early pre-B ALL (n=51); common ALL (n=92), and pre-B ALL (n=39); 107 (36.6%) patients had T-cell ALL (early T-ALL (n=56); thymic T-ALL (n=41), and mature T-ALL (n=10). According to the baseline clinical and laboratory parameters (leukocytosis of 30·109/l and more for B-ALL; and that of 100·109/l and more for T-ALL; phenotype В-I for B-ALL, phenotype Т-I-II-IV for T-ALL; LDH activity was more than twice the normal values; the presence of translocation t(4;11)), the high-risk group included most patients with B-ALL (n=110 (72.8%)) and T-ALL (n=76 (76%)). Thirty-five patients with T-ALL underwent autologous bone marrow transplantation (BMT). Allogeneic BMT was performed in 18 (7%) of the 258 patients who had undergone an induction phase. RESULTS: Five-year overall survival for all the patients included in the investigation was 59%; relapse-free survival was 65%, which was significantly different in the patients with B-ALL and in those with T-ALL: the overall survival rates were 53.3 and 67.5% (p=0.1); the relapse-free survival was 56 and 79% (p=0.005), respectively. Multivariate analysis including the well-known RFs demonstrated that the latter for T-ALL were of no independent prognostic value and only the patient's age was identified for B-ALL (p=0.013). CONCLUSION: A lower chemotherapeutic load and a small number of allogeneic BMTs did not affect total positive treatment results in adult patients with ALL, by complying with the principle achieving the continuity of cytostatic effects and by preserving the total cytostatic loading dose. The results of the Russian investigation casts some doubt on the necessity of using very intensive consolidation cycles and performing a large number of allogeneic BMTs in adult patients with ALL.

[Autologous hematopoietic stem cell transplantation as late high-dose consolidation in adult patients with T-cell lymphoblastic leukemias: Results of a Russian multicenter study].

AIM: To analyze the efficiency of the ALL-2009 protocol (ClinicalTrials.gov NCT01 193933) in patients with T-cell leukemias, particularly the role of autologous hematopoietic stem cell transplantation (auto-HSCT) after non-myeloablative BEAM conditioning, followed by maintenance therapy. SUBJECTS AND METHODS: Since 2009, the ALL-2009 study has enrolled 90 patients with T-cell acute lymphoblastic leukemia (T-ALL), the treatment results were assessed in 86 patients: 6 and 28 patients underwent allogeneic HSCT and auto-HSCT, respectively. A landmark analysis was used to compare survival rates in patients who had undergone auto-HSCT and in those who had not. For this, the median time from complete remission to the date of auto-HSCT was determined (the median was 6 months). Then to compare with the auto-HSCT group, only 27 patients who had been in complete remission for 6 months or more were included in a chemotherapy group. RESULTS: The achievement of complete remission in patients with thymic T-ALL (100%) was significantly higher than in those with early (85.7%) or mature (70%) variants. The patients with early and mature T-ALL as compared to those with thymic T-ALL showed high death rates in the remission induction (7.4 and 10% versus 0) and the patients with mature T-ALL had a.higher proportion of refractory forms (20% versus 0). The 5-year overall and relapse-free survival rates in all the T-ALL patients were 66 and 76%, respectively. After auto-HSCT, the risk of recurrence was 0% versus 21% after chemotherapy (p=0.03). The relapse-free survival rates significantly differed in the auto-HSCT and non-auto-HSCT groups: 100 and 66%, respectively (p=0.047). CONCLUSION: The long-term survival rates obtained during this multicenter study in the T-ALL patients treated according to the ALL-2009 protocol, the basis for which is the principle of continuity of cytostatic effects, are exclusively optimistic. Late consolidation with auto-HSCT following non-myeloablative BEAM conditioning, followed by maintenance therapy, considerably reduces the risk of recurrence.

[Russian experts' clinical guidelines for acute myeloid leukemia treatment in patients less than 60 years of age].

The purpose of the paper is to present Russian experts' consolidated opinion about acute myeloid leukemia (AML) treatment in adult patients aged less than 60 years. The guidelines have been elaborated having regard to foreign publications and Russian experience, on the basis of global and Russian clinical trials to treat AML and to define indications for allogeneic bone marrow transplantation in patients during first complete remission.

[The first results of treatment for adult acute myeloid leukemia according to the AML-01.10 protocol of the Research Group of the Hematology Centers of Russia].

AIM: To give the preliminary results of the AML-01.10 Russian multicenter randomized trial to treat adult acute myeloid leukemia (AML), the basic principle of which is to use high-dose anthracycline antibiotics in induction/consolidation. SUBJECTS AND METHODS: By December 2011, 145 patients with AML had been randomized from 18 hematology centers of 15 cities and towns of the Russian Federation; the median age of all the patients was 44 years. Seventy-one patients were analyzed in August 2011 (a 1.5-year follow-up). RESULTS: The efficiency of 2 courses 7+3 using high-dose daunorubicin (60 mg/m2 per administration) and continuous infusion of cytarabine during the second course was high and comparable with that in the use of a high-dose HAM protocol as a second induction course and can achieve a complete remission in 74.6%. The protocol toxicity evaluated from its early mortality (11.3%) and its death in complete remission (16.6%) was permissible, particularly by taking into consideration the multicenter pattern of the trial. At the completion of analysis, 53 (68.8%) out of the 77 patients on whom the data on their vital status were available were alive. In this follow-up period, the frequency of recurrences was 19.2% (10/52). Only 3 (4.2%) patients out of the 71 patients in whom the efficiency of the protocol had been completely evaluated underwent allogeneic bone marrow transplantation. CONCLUSION: The total high dose (720 mg/m2) of anthracycline antibiotics, which is used in the period of induction and consolidation, determines the long periods of myelosuppression and intercourse intervals. Protocol deviations (no course of consolidation therapy, lower-dose idarubicin during consolidation therapy, a course of low-dose cytarabine, between the courses of induction and consolidation chemotherapy, and very long intercourse intervals) were recorded in a total of 20 (28%) patients.

[First results of Ph-negative acute lymphoblastic leukemia therapy of adults according to the protocol of Research Group of Russian Hematological Centers ALL-2009].

AIM: To review results of 2-year experience in execution of the protocol on the treatment of adult acute Ph-negative lymphoblastic leukemia ALL-2009. MATERIAL AND METHODS: Of 111 patients registered in the study from November 2008 to December 2010 the analysis covered 96 patients from 23 hematological centers in 18 towns of the RF. RESULTS: Treatment according to the Protocol ALL-2009 resulted in achievement of a complete remission in 91.2% patients with low early lethality of 5.5%. Postremission lethality fell to 3.7% versus previous studies (22%). Overall 2-year survival and recurrence-free survival reached 77.6 and 78.4%, respectively. Detection of any chromosomic aberrations significantly affected recurrence-free survival: 74 vs 100% in patients with normal karyotype. CONCLUSION: Protocol All-2009 demonstrates high efficacy in moderate toxicity and good reproducibility in any hematologic center.

[Construction of norovirus (Caliciviridae: Norovirus) virus-like particles containing VP1 of the Echovirus 30 (Picornaviridae: Enterovirus: Enterovirus B)].

INTRODUCTION: Enterovirus (nonpolio) infection is widespread all over the world, registered as sporadic cases and large-scale outbreaks and can cause severe lesions such as serous meningitis. Epidemiological studies have shown that enterovirus (Picornaviridae; Enterovirus) variant Echovirus 30 (E30) is the most frequently detected variant in patients with enterovirus meningitis in the Russian Federation. However, no vaccines to prevent the disease caused by this pathogen have been developed so far. One of the promising modern trends in terms of creating vaccine preparations is the use of virus-like particles (VLPs), including chimeric ones containing the biological structures of viruses belonging to different species.The aim of this work was to obtain norovirus (Caliciviridae; Norovirus) VLPs displaying enterovirus Echovirus E30 full-length VP1 on the surface. MATERIAL AND METHODS: The nucleotide sequences of VP1 protein of norovirus genotype GII.4 and VP1 E30 of genotype h circulating in Russia were used. The SN-VP1E30 protein was constructed, in which the shell (S) and the hinge regions of the norovirus VP1 are fused into one molecule with the full-length VP1 of the E30 virus. The protein was expressed in E. coli, purified using affinity chromatography, and characterized by polyacrylamide gel electrophoresis (PAGE) and immunoblotting. VLPs were visualized by electron microscopy. RESULTS: The S N-VP1E30 protein expressed in E. coli as insoluble form, so the conditions for SN-VP1E30 solublisation were defined. Sucrose has been shown to significantly increase the efficiency of renaturation. Electrophoretic mobility comparison of denatured and non-denatured SN-VP1E30 demonstrated that most monomers form high molecular weight compounds. Electron microscopy showed that renatured SN-VP1E30 spontaneously forms empty virus-like particles about 50 nm in diameter. CONCLUSION: Chimeric protein SN-VP1E30 self-assemble into VLPs displaying the VP1 protein of E30 variant that is highly prevalent in Russia. Further immunological research is necessary to characterize VLPs potential for development of the vaccine for enteroviral meningitis prevention.

[Toxicity of different treatment protocols for acute myeloid leukemias in adults: the results of four Russian multicenter studies].

AIM: To comparatively analyze the toxicity of 4 treatment protocols in patients with acute myeloid leukemia (AML), which were used in the Russian multicenter center in 1992 to 2009. MATERIALS AND METHODS: The information obtained in 4 Russian multicenter studies conducted in 33 hematology departments of 26 cities and towns of the Russian Federation in 1992 to 2009 was analyzed. Randomization was made in 243 patients with AML (median age 38 years) in 1992-1995, 396 patients (median age 39 years) in 1995-1999, 392 patients (median age 39 years) in 2001-2006, and 137 patients (median age 40 years) in 2006-2009. The analysis excluded patients with acute promyelocytic leukemias who were recruited in the AML-92 and AML-95 studies. These patients' statutory forms adequately filled in were 60-70% therefore toxicity was analyzed on the basis of the data of 631 patients. RESULTS: The baseline clinical and laboratory parameters in the patients enrolled in the studies in different years slightly differ in the count of leukocytes at the onset of the disease and in the level of lactate dehydrogenase (LDH): the recent studies revealed a larger number of high-risk group patients (leukocytes more than 30 10(9)(/l; LDH more than 500 units) possibly due to the later diagnosis of AML. During the studies, the number of complete remissions remained as before (55%) after the first course and increased from 65 to 78% after the second course using cytosine arabinoside in high doses. Despite treatment intensification, mortality in the induction period remained as before (19-21%). Remission mortality decreased from 18 to 10-13%. The long-term results of using the aggressive therapy did not differ from those obtained during the standard treatment protocols. The duration of leucopenia after standard induction courses during the all studies remained equal (17-19 days); the exclusion was a HAM course as the second induction course after which the duration of neutropenia was much more than that of the standard course (17 and 10 days, respectively). During the study years, there was an increase in platelet transfusion volumes (from 20 to 53 doses during the first course and from 7 to 28 doses during the second course) and a reduction in the percentage of severe hemorrhagic complications. The incidence of pneumonias remained at the same level (40-50%) during the induction courses and that of septic complications and necrotic enteropathy considerably decreased from 40-46 to 17-19%. The incidence of invasive aspergillosis during the current programs from AML treatment was 10% (two induction courses), that of invasive candidiasis was 4.7% (two induction courses). CONCLUSION; The long-term results of treatment for AML were virtually unchanged regardless significant therapy intensification. Mortality remained high during induction treatment and in the postremission period. Its cause is severe infectious complications developing during myelotoxic agranulocytosis. The results of the analysis provide the basis for developing a new AML treatment protocol that should take into account all the merits and demerits of the previous protocols and provide a toxicity-treatment efficiency balance.

[The results of a multicenter randomized trial on the treatment of acute myeloid leukemia of adults].

AIM: Systematization of the results of 20-year multicenter randomized trial of the efficacy of treatment of acute myeloid leukemia (AML) of adults; presentation of the design of the study of the strategy of consolidation and maintenance therapy after high-dose consolidation initiated in 2007. MATERIAL AND METHODS: Treatment outcomes on the protocol AML-01.01 are presented for 354 AML patients from 29 hematological centers located in 22 towns of Russia and 2 towns of Ukraine. The patients were randomized into 3 groups by variant of therapy: 124 patients (62 males and 62 females; age median 42 years) received 4 courses of 7+3+VP-16 and 5 courses of maintenance therapy (7+3 with thioguanin); 130 patients (65 males and 65 females, age median 41 year) received 2 courses of 7+3+VP-16, 2 courses 7+3, maintenance--5 courses 7+3 with thioguanin; 126 patients (57 males and 68 females, age median 40 years) were given 2 courses of 7+3+VP-16, 2 HAD courses, treatment discontinuation. RESULTS: A complete remission after the first course of 7+3+VP-16 was achieved in 55% patients, after the second course--in 30% after the course 7+3+VP-16 or 7+3 with mitoxantron, in 70%--after NAM. Overall and recurrence-free survival were 18 and 35%; 30 and 20%; 36 and 30%, respectively. There was no significant difference in efficacy of the treatment scheme. CONCLUSION: The multivariate analysis has shown that a leading factor having impact on treatment results was the number of randomized patients: the less patients were randomized, the worse were the results.

[The evaluation of hemostatic disorders in patients with systemic lupus erythematosus]. / Otsenka narushenii gemostaza u bol'nykh sistemnoi krasnoi volchankoi.

AIM: Assessment of hemostasis in SLE patients. MATERIALS AND METHODS: We studied different coagulation parameters such as activated partial thromboplastin time (APTT), thrombin time (TT), prothrombin time (PT), activated clotting time (ACT); platelet aggregation (spontaneous and induced), fibrinolytic activity, concentration of fibrinogen, fibrinogen degradation products (FDP) and serotonin. RESULTS: Coagulation abnormalities were found with prevalence of hypercoagulation in APTT and TT tests. Fibrinolysis was inhibited. Levels of serotonin, FDP and spontaneous aggregation activity significantly increased. CONCLUSION: The above changes were typical for lingering DIC syndrome.

[Superhigh doses of dexamethasone in treatment of refractory forms of acute lymphoblast leukemia of adults]. / Sverkhvysokie dozy deksametazona v lechenii refrakternykh form ostrogo limfoblastnogo leikoza vzroslykh.

AIM: Assessment of high-dose dexamethasone efficacy in combination with standard drugs (adriablastin, vincristin, alpha-asparaginase) in patients with refractory acute lymphoblastic leukemia (ALL). MATERIAL AND METHODS: A pilot multicenter trial with participation of hematological departments of Hematological Research Center (Moscow), municipal hospital N 1 (Krasnoyarsk), municipal hospital N 8 (Yaroslavl), Research Institute of Hematology and Blood Transfusion (Kirov) included 34 patients (10 patients with late recurrences, 24--with primary resistant forms, early and secondary recurrences). RESULTS: In patients with late ALL recurrences a complete remission (CR) was achieved in 70% cases, the median being 10 months. In patients with primary resistant ALL, early and secondary recurrences CR reached 37.5%, the median was 14 months. CONCLUSION: The program HiDexa is highly effective: overall complete remission rate reached 47%, median of complete remission duration was 10 months. Dexamethasone in high doses must be used only intravenously.

[Combination of interferon-alpha and all-trans-retinoic acid as a treatment for maintaining remission in high-risk group patients with acute myeloid leukemia]. / Sochetanie interferona-alpha i polnost'iu trans-retinoevoi kisloty v kachestve programmy terapii podderzhaniia remissii u bol'nykh ostrymi mieloidnymi leikozami iz gruppy vysokogo riska.

AIM: To evaluate the efficiency of combination of interferon-alpha (INF) and all trans-retinoic acid (ATRA) as a treatment for maintaining remission in high risk group patients with acute myeloid leukemia (AML). MATERIALS AND METHODS: Three-day INF + ATRA course was administered every 3 months to 22 patients with AML from high risk group (impossibility of drug therapy during the first complete remission, resistant forms of AML, relapses, secondary AML, acute promyelocytic leukemia after attaining molecular remission). RESULTS: INF + ATRA during remission maintained a long first complete remission (median 18 months) in patients with primary AML after small-volume drug therapy, led to long first and second complete remissions (median 12 months) in patients with resistant AML, and induced and maintained molecular remissions in patients with acute promyelocytic leukemia.

[The empirical antibiotic therapy of patients with acute leukemias: the results of a multicenter study]. / Empiricheskaia antibioticheskaia terapiia u bol'nykh ostrymy leikozami: itogi mnogotsentrovogo issledovaniia.

AIM: To evaluate efficacy of ampicilline/sulbactame and fluconasole in the regimen of empirical antibiotic therapy in patients with acute leukemia. MATERIALS AND METHODS: The trial covered 14 hematological departments of Russia and 1 of Ukraine. Acute myeloid leukemia patients were included. 92 cases of fever in 56 patients with analysis of efficacy in 66 cases were considered. At the first stage of empirical antibiotic therapy, cefoperason (4 g/day) and gentamycin (240 mg/day) were administered. If no response was reached, ampicilline/sulbactam (7.5 g/day) was added. This was the second stage. If no response occurred for 5 days the three drugs were joined by fluconasol (400 mg followed by 200 mg). RESULTS: Fever of unclear genesis was cured in 82% (28 of 34), clinical infection--in 80% (20 of 25), microbiologically confirmed infection--in 4 of 7 cases. A complete response to the empirical antibiotic therapy was registered in 52 of 66 cases (79%). 7(10.5%) patients died of infectious complications. 7(10.5%) received other antibiotics.

[Preliminary results of a multicenter randomized study on the treatment of acute promyelocytic leukemias]. / Predvaritel'nye rezul'taty mnogotsentrovogo randomizirovannogo issledovaniia po lecheniiu ostrykh promielotsitarnykh leikozov.

AIM: To study efficacy of maintenance therapy of patients with acute promyelocytic leukemia (APL) in the APL treatment Russian multicenter trial. MATERIAL AND METHODS: The trial was made with participation of 18 hematological departments of clinics in Russia. A total of 68 APL patients entered the trial. The maintenance therapy consisted of 5-day courses of cytostatic drugs which alternated or did not alternate with 5-day courses of ATRA. Cytogenetic tests were made in 31 patients, t(15;17) was detected in 26 of them. Molecular examination conducted in 28 patients discovered chimeric transcript PML/RARa in 26 of them. Of 20 patients examined in Hematological Research Center, 7 (35%) had a bcr 1/2 variant of the transcript PML/RARa, 13 (65%)--bcr 3 variant. RESULTS: 65 patients were eligible for assessment. A complete remission was achieved in 90% cases. No resistance was observed. In follow-up within 30 months the recurrence rate was similar on both treatments. The results of the induction therapy and survival in patients with different variants of the transcripts were also similar. Overall 2.5 year survival for all the patients was 77%, recurrence-free--80%. The survival analysis in patients with leukocytosis higher and lower 10 x 10(9)/l found no statistical differences by the survival. Patients with hyperleukocytosis had higher early lethality than patients with leukocytes under 10 x 10(9)/l (25% vs 5.3%, p = 0.03). CONCLUSION: The APL 06.01 protocol showed high efficacy of the relevant maintenance which provides a complete molecular remission in the majority of patients with probable recurrence-free 2.5 year survival 80%.

[The use of radioisotope labelling for studying the feeding of sandflies (Phlebotominae) and their move into colonies of the greater gerbil (Rhombomys opimus Licht.)]. / Ispol'zovanie radioizotopnogo mecheniia dlia izucheniia prokormleniia moskitov (Phlebotominae) i ikh peremeshchenii v poseleniiakh bol'shoi peschanki (Rhombomys opimus Licht.).

The fly off and distribution of sandflies, vectors of zoonotic cutaneous leishmaniasis after meal on great gerbils were studied by means of radioisotope techniques. The experiments were carried out near the town of Mubarek (Uzbekistan). Three Rhombomys opimus were marked by intraperitoneal injection of 14C-glycine solution. Then they were allowed to come back to their burrows. The sandflies were radioactively labelled during bloodsucking on the rodents. Fifty-seven labeled female sandflies were caught on the surface of burrows with the marked R. opimus and on 5 colony burrows at a distance of 70-280 m from it for 6 nights. Seventeen females were Phlebotomus papatasi (0.9% of all the caught females of this species) and 40 females belonged to the Paraphlebotomus subgenus (7.0%). The fly off occurred both before and against the wind. The labeled females were found on all burrows where sticky papers were placed, but their density was 16 times lower at a distance of 280 m than in the burrow colony of their release.