[Development of program therapy for patients with acute myeloid leukemia under the age of 60 years, based on the principles of differentiated effects].

AIM: To analyze the results of treatment in patients with acute myeloid leukemia (AML) within protocols AML-17 and modified AML-17 (mOML-17) as part of two consecutive pilot studies in order to develop the best treatment strategy for AML patients aged below 60 years. MATERIALS AND METHODS: The study included 89 AML patients who were aged below 60 years and received treatment within the AML-17 and mOML-17 protocols. Cytogenetic and molecular genetic studies were performed in all patients. The presence of mutations in the FLT3, NPM1, CEBPa genes was assessed by fragment analysis. 35 patients underwent a study for mutTP53, mutRUNX1 using next generation sequencing (NGS). The minimum residual population of tumor cells was evaluated by multicolor flow cytometry. Statistical analysis was performed using the procedures of the SAS 9.3 package. RESULTS: Complete remission (CR) was achieved in 89.7% of patients treated with intensive chemotherapy (CT) courses and in 52.4% of patients treated with low-dose CT courses. 8.8% of intensively treated patients were refractory to therapy, and 38% did not respond to low-dose exposure. The early mortality rate was 3%. The overall survival and disease-free 3-year survival for patients included in 2 consecutive studies was were 60% and 67%, respectively. The level of minimal residual disease (MRD) after the first course of induction CT was an important prognostic indicator. The three-year relapse-free survival for patients in whom CR was achieved after the first course of induction CT and in whom MRD was not detected (MRD-negative status was obtained) was 90% compared to 43% for patients who were MRD positive after the first course of induction CT (p=0.00001). CONCLUSION: The key factor that significantly affects the long-term results of therapy is the rate of MRD after the first course of induction CT.

Results of program acute myeloid leukemia therapy use in National Medical Research Center for Hematology of the Ministry of Health of Russian Federation.

AIM: To analyze treatment results of 172 patients with acute myeloid leukemia (AML) aged 18-60 years in National Medical Research Center for Hematology of MHRF. MATERIALS AND METHODS: Inductive and consolidation program for 139 (80%) patients was based on a standardized protocol: 4 courses "7+3" with different anthracycline use (2 courses of daunorubicin, idarubicin, mitoxantrone) and continuous use of cytarabine on the second inductive course. In 20% of patients cytarabine courses at the dose of 1 g/m2 2 times a day for 1-3 days combined with idarubicin and mitoxantrone were used as two consolidation courses. Allogenic bone marrow transplantation was performed in the first complete remission (CR) period in 40% of patients. RESULTS: The frequency of CR achievement in all patients was 78.6%, refractory forms were observed in 13.9% of patients, early mortality - in 7.5% of patients. Seven-year overall survival (OS) rate was 40.7%, relapse free survival (RFS) - 43.2%. When estimating effectiveness depending on cytogenetic risk group it was demonstrated that 5-year OS and RFS in patients with translocation (8; 21) cannot be considered as satisfying, it accounted for 50 and 34%, respectively. At the same time in patients with 16th chromosome inversion (inv16) these characteristics accounted for 68.6 and 63.5%. Acquired results forced reconsidering of the consolidation program in AML patients of this subgroup. The median time to allogenic blood stem cells transplantation (allo-BSCT) in patients with first CR was 6.5 months that was taken as a reference point in landmark analysis of patients in whom allo-BSCT was not performed. Landmark analysis showed that in AML patients of favorable prognosis group allo-BSCT does not significantly reduce the probability of relapse (0 and 36%) and does not influence RFS (33 and 64%). In patients of border-line and poor prognosis allo-BSCT significantly reduces relapse probability (26 and 66%; 20 and 100%) and significantly increases a 7-year RFS (68.7 and 30%; 45.6 and 0%). Allo-BSCT also results in significant RFS increase and reduces the probability of relapse (25 и 78%) in patients in whom CR was achieved only after the second induction course. At the same time allo-BSCT does not influence patients who achieved CR after the first treatment course: 55 and 50%. CONCLUSION: Multivariate analysis showed that cytogenetic risk group (HR=2.3), time of CR achievement (HR=2.9), and allo-BSCT transplantation (HR=0.16) are independent factors for disease relapse prognosis after achieving CR.

[Treatment in adult patients with acute myeloid leukemias and hyperleukocytosis at disease onset].

AIM: To evaluate the efficiency of the treatment policy for patients with acute myeloid leukemia (AML) and hyperleukocytosis (HL), which is aimed at preventing rapid hypercytolysis and massive tumor lysis (cytolysis) syndrome and/or at reducing the degree of the latter at the start of induction polychemotherapy. SUBJECTS AND METHODS: In 2010 to 2014, the Hematology Research Center, Ministry of Health of Russia, treated 92 patients with AML, out of them 18 patients were found to have white blood cell counts of 100 to 408-10(9)/1 (median, 130-10(9)/l) at the onset of the disease. All the examinees received cytoreductive therapy with hydroxyurea and, in presence of leukostasis and/or leukocytosis (≥150-10(9)/1), with leukocytapheresis. In case of reduced leukocytosis, plasmapheresis was carried out to prevent (treat) cytolysis. Daunorubicin was injected on days 3-5 of the 7+3 induction cycle. RESULTS: The signs of leukostases were detected in more than half of the 18 patients with higher white blood cell counts: 13 (72%) with lung injury, including 5 of them with signs of respiratory distress syndrome, 6 (27.8%) with neurological symptomatology, 7 (38.9%) with disseminated intravascular coagulation syndrome, including 1 with intracranial hemorrhage. Cytoreduction therapy with hydroxyurea (10 mg/kg/day) was performed 1-5 (median 2) days before initiating induction chemotherapy in 17 patients; 9 patients underwent 1-2 (median 2) leukocytapheresis sessions. Sixteen patients received 1-4 (median 2) plasmapheresis sessions prior to and within the first days of the 7+3 treatment regimen. Daunorubicin (60 mg/m2) was administered to 16 patients on days 5-7 of the 7+3 cycle and to 2 patients on days 3-5 of the cycle. There were no signs of severe cytolysis with the development of multiple organ dysfunction in any patient. 50% (9/18) achieved remission after the first 7+3 cycle and 7 more examinees did after the second cycle. Thus, the remission rate was 89%; early mortality was 5.5% (1/18), three-year overall and relapse-free survival rates were 50%. CONCLUSION: Adequate cytoreductive and accompanying therapies for AML with HL can virtually completely prevent massive tumor cytolysis syndrome and early mortality during the first days of induction chemotherapy.

[Secondary dysmyelopoiesis in patients with myelodysplastic syndromes].

To interpret hematopoietic cell myelodysplastic changes found during the primary diagnosis of myelodysplastic syndromes or other diseases and during therapy is an enormously complex clinical and laboratory problem. In what cases do these changes serve as a manifestation of clonal disease and in what cases are these changes a result of various effects? Alimentary, toxic factors, infectious agents, and iatrogenic effects may cause myelodysplastic signs in the hematopoietic cells. This review depicts diverse hematopoietic cell dysplastic changes that can be observed as a result of the effects of one drug or another, toxic factors, and infectious agents.

[Cytogenetic characteristics of hematopoietic and stromal progenitor cells in myelodysplastic syndrome].

AIM: To study and compare cytogenetic abnormalities in the bone marrow (BM) and peripheral blood (PB) CD34+ hematopoietic progenitor cells and in the BM mesenchymal stromal cells (MSCs) in patients with myelodysplastic syndrome (MDS). Subjects and methods. The results of a cytogenetic analysis of the total population of BM cells (BMC), CD34+ hematopoietic progenitor cells from BM and PB, and BM MSCs were analyzed in 35 patients (29 patients with MDS and 6 with MDS transformed into acute myeloid leukemia (AML)) and 7 healthy BM donors. Cytogenetic examinations were performed by G-banding of chromosomes and fluorescence in situ hybridization (FISH). RESULTS: The BMC karyotype was abnormal in 17 (49%) of the 35 patients (13 with MDS and 4 with AML); the others were found to have a normal BM karyotype. The FISH analysis confirmed the same cytogenetic abnormalities in the BM and PB CD34+ hematopoietic progenitor cells in all the examinees with an abnormal karyotype. The mean abnormal clone sizes in the total population of BMCs and BM and PB CD34+ progenitor cells did not differ and constituted 65.8, 73.1, and 74.8%, respectively. The patients with a normal BM karyotype had no chromosome abnormalities in the CD34+ cells either. The karyotype of MSCs was analyzed in 23 (19 with MDS and 4 with AML) of the 35 patients. No karyotype abnormalities were revealed in the patients with MDS transformed into AML. There were structural chromosome aberrations in 2 (11%) of the 19 patients with MDS (one with constitutional inv(9)(p1 3q21) was found to have non-clonal translocation t(2;22)(p10;q1 1) and the other had a clone with an additional segment of the long arm of chromosome 2 in 35% of the cells. No numerical MSC karyotype abnormalities were detected. A normal MSC karyotype was defined in 7 healthy BM donors. CONCLUSION: The cytogenetic analysis of hematopoietic and mesenchymal progenitor cells showed that the chromosome abnormalities revealed in these cell populations were different in the patients with MDS. The isolated CD34+ cells displayed the same cytogenetic abnormalities as in a total population of BMC. Examination of the latter could reveal no cytogenetic abnormalities in the majority of the patients. A normal BMC karyotype was detectable in the patients with AML. Two (11%) patients with MDS were found to have structural chromosome abnormalities that differed from those detected in the total population of BMC and in isolated CD34+ cells. The differences of chromosome abnormalities in the hematopoietic and mesenchymal progenitor cells point to the fact that the stromal microenvironment is not part of the abnormal clone in MDS, however, it may be of great importance in the pathogenesis of the disease.

[Morphological evaluation of dysmyelopoiesis in decitabine-treated patients with myelodysplastic syndromes].

AIM: To estimate a change in myelodysplasia in decitabine-treated patients with myelodysplastic syndromes (MDS). SUBJECTS AND METHODS: Thirteen MDS patients from a high-risk group were examined; 75 bone marrow puncture specimens and 67 bone marrow trepanobiopsy specimens from these patients were analyzed before and after decitabine treatment. Dysplastic changes in the hematopoietic cells were monitored during the treatment. RESULTS: The dysplastic changes in the hematopoietic cells are a morphological portrayal of the ineffective hematopoiesis in patients with MDS. The study has indicated that the use of the hypomethylating agent decitabine promotes the restoration of cell differentiation to mature forms, causing hematopoiesis to be more effective. The incidence of myelodysplasias (including mixed double- and triple-lineage ones) was statistically significantly reduced by decitabine treatment, which was associated with a positive response to treatment as a whole. The count of cells with dysplastic features remained unchanged in patients with therapy resistance or further disease progression. CONCLUSION: Analysis of myelodysplastic manifestations in different hematopoietic lineages in patients with MDS should be based on the comprehensive dynamic assessment of cytological and histological parameters at both the primary diagnosis of the disease and different stages of treatment. With a response to decitabine therapy (as shown by the results of aspiration and trepanobiopsy), all cell lines displayed reduced myelodysplastic changes, indirectly indicating a decrease of the abnormal clone itself in high-risk MDS patients.

[Treatment for acute promyelocytic leukemia during pregnancy].

AIM: To study the experience in managing patients with acute promyelocytic leukemia (APL) diagnosed in different periods of pregnancy. SUBJECTS AND METHODS: Nine women with APL were treated in 1998-2013. When APL was diagnosed in the first trimester of pregnancy, the latter was terminated (n = 1); when its diagnosis was made in the second trimester, chemotherapy (CT) followed by delivery (D) was performed (n = 3); when it was done in the third trimester, D followed by CT was done in relation to gestational age (n = 2) or these were performed at a later gestational age (n = 1). APL was treated in 5 and 1 patients according to the AIDA protocol and the 7+3 plus ATRA one, respectively. RESULTS: All the patients with APL achieved remission after the first cycle of induction CT; 5 of the 6 patients did at the moment of delivery; one patient underwent emergency delivery during cytopenia after the cycle. The gestational age at delivery after CT was 34 (34-40) weeks. Spontaneous term labor occurred in 2 patients at an obstetric hospital. Cesarean section was made in 4 of the 6 patients. All babies were born alive, healthy, and without developmental abnormalities. Their age at the time of analyzing the results was 2.5 months to 15 years. Four of the 9 patients are presently alive. Late recurrences occurred in 3 (33%) patients. The median overall survival is 26 (0.25-128) months; the median relapse-free survival is 17.5 (0-127) months. CONCLUSION: APL treatment in pregnant women, which is aimed at saving two lives, is effective and reasonable.

[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.

[Efficiency of cyclosporin A therapy in patients with myelodysplastic syndrome].

AIM: To evaluate the efficacy of cyclosporin A (CsA) in patients with myelodysplastic syndromes (MDS) and to identify determinants of a response to this therapy. SUBJECTS AND METHODS: The efficacy of CsA was evaluated in 52 patients (30 men and 22 women aged 16 to 74 years) with MDS. Thirty-two patients were given CsA as first-line therapy; 20 patients took the agent after prior therapy. CsA was used in a daily oral dose of 5 mg/kg. Its efficacy was evaluated following 3, 6, and 12 months. Actuarial survival was determined by the Kaplan-Meier method. RESULTS: The efficacy of CsA used as first- and second-line therapy was 56 and 55%, respectively; complete remissions were achieved in 19 and 20% of cases. Baseline refractory anemia (RA) transformed to RA with excess blasts (RAEB) in 31% of cases; baseline RAEB did to acute myeloid leukemia in 34%. Overall survival was significantly associated with bone marrow (BM) blast cell percentage (< 5% or > 5%; p = 0.0009), BM cellularity (hypoplasia and focal hypoplasia of hematopoiesis or BM hyperplasia; p = 0.03), focal polyclonal lymphoid infiltration in the BM (p = 0.01) and karyotype anomalies (low, moderate, and high risks; p = 0.001). CONCLUSION: CsA is the drug of choice in treating patients with MDS, including RA, RA with ringed sideroblasts, refractory cytopenia with multilineage dysplasia, with hypoplasia of hematopoiesis, with nodular polyclonal lymphoid infiltration in the BM, a normal karyotype or changes corresponding to a low or moderate IPSS risk.

[Splenectomy in programmed therapy of aplastic anemia].

AIM: To define efficacy of splenectomy (SE) in current programmed therapy of aplastic anemia (AA). MATERIALS AND METHODS: SE efficacy was analysed in 2 stages: a retrospective study of efficacy of surgery as monotherapy (1986-1996) (74 AA patients) and of SE in programs of immunosuppressive therapy (IST) (1991-2002). Program treatment of AA patients was conducted on the base of IST algorithm developed in Hematological Research Center after many year investigations. RESULTS: SE as monotherapy improved AA course in 73.3% patients with non-severe AA (NAA) and 18.2% patients with severe AA (SAA). Three and five year survival in NAA postsplenectomy patients was 80%. One-year survivors after surgery were likely to survive long. Overall survival of SAA after SE was significantly less (p < 0.0001): 3-year survival - 6%. SE efficacy in programs including antilymphocytic globulin (ALG) and cyclosporin A (CsA) was studied in 69 AA patients. A 85.5% response was registered to program treatment including ALG, CsA and SE, being 81% in SAA and 1% in NAA patients. Efficacy of SE in combination with CsA at the first stage NAA treatment (a 30% positive response) was much inferior to ALG+CsA (68% response). At stage two treatment SE improved treatment results in most of SAA patients. Long-term survival in SAA patients after program treatment with SE is 60%. CONCLUSION: SE in the program of combined therapy in adult AA patients including CsA is an alternative to ALG in NAA patients. In SAA, SE can be included in the program at the first stage in ALG intolerance or in the absence of the drug, at the second stage--to overcome resistance to conducted therapy.

[Clonal chromosomal aberrations in patients with aplastic anemia at the disease onset and transformation].

AIM: To estimate detectability and characteristic features of chromosomal aberrations in bone marrow cells of patients with aplastic anemia (AA). MATERIAL AND METHODS: The trial covered 155 AA patients admitted to the Hematological Research Center in 1987-2002. Cytogenetic study by G-differential staining was performed in 58 patients with AA and 5 patients with AA transforming into myelodysplastic syndrome (MDS) or acute leukemia (AL). Cytogenetic and morphological specimens of the latter's bone marrow were studied retrospectively using fluorescent in situ hybridization (FISH) with DNA probes for detection of monosomia 7 and deletion 7q. RESULTS: Clonal chromosomal aberrations were detected in 4 out of 28 patients. Further examinations revealed no aberrations. Clonal diseases developed in 7 (4.5%) of 155 patients. In 2 patients the disease transformed into paroxysmal nocturnal hemoglobinuria, 5 (3.2%) patients developed variants of MDS and AL. Monosomia 7 or deletion 7q were diagnosed in 3 cases of MDS/AL. In retrospective study of bone marrow specimens of patients with transformation in MDS/AL with monosomia 7, FISH recognized a small elevation over control values in 2 cases. CONCLUSION: Stable clonal chromosomal aberrations are not characteristic of AA. Some AA patients with subsequent MDS/AL may have minor neoplastic clone in the disease onset.

[Apoptosis and proliferative activity of bone marrow cells in patients with aplastic syndromes as evidenced by trephine biopsy]. / Apoptoz i proliferativnaia aktivnost' kletok kostnogo mozga u bol'nykh s aplasticheskimi sindromami po dannym trepanobiopsii.

AIM: To clarify the effect of cyclosporin A (CSA) on the apoptosis and proliferative activity of bone marrow cells in patients with aplastic syndromes by trepanobiopsy evidence. MATERIALS AND METHODS: The TUNEL immunohistochemical assay was used to study apoptosis of bone marrow cells in the histological specimens from 24 patients: 8 with refractory anemia (RA), 8 with acute small-proportion leukemias [RA with excessive blasts (RAEB) + RAEB in transformation (RAEBt)], 3 with acute non-lymphoblastic leukemia (ANLL), 5 with lymphogranulomatosis (LGM). Control apoptosis examination was made in 10 patients treated with CSA. The proliferative activity of bone marrow cell was evaluated by bone marrow histological specimens from 10 patients (8 patients with RA and 2 with RAEB + RAEBt) at the onset of disease and during CSA therapy in the immunohistochemical test with primary nuclear antigen Ki-67 antigen antibodies. Changes in the proliferative activity and degree of apoptosis of bone marrow cells were assessed in relation to the cellularity detectable by the histological specimens. RESULTS: Patients with RA showed an increase in bone marrow cell apoptosis to 25.375 +/- 6.874 (-10.8 +/- 5.122 and 8.333 +/- 5.84 in controls and ANLL patients, respectively). The cells of hemopoiesis and stromal microenvironment are in the process of cell death. Higher bone marrow cellularity is observed in CSA-treated patients at clinical and hematological remission, which is followed by rises in the index of proliferation and the degree of apoptosis. CONCLUSION: The clinical effect of CSA in patients with aplastic syndromes is induced by its direct or mediated stimulating effect on pluripotent stem cells of hemopoiesis, by increasing bone marrow cellularity at the expense of clonal and/or normal hemopoiesis.

[Effectiveness of cyclosporin A in the treatment of adult patients with aplastic anemia]. / Effektivnost' tsiklosporina A v lechenii vzroslykh bol'nykh aplasticheskoi anemiei.

AIM: To evaluate the efficacy of cyclosporin A (CyA) at different stages of immunosuppressive therapy (IST) in patients with aplastic anemia (AA). MATERIALS AND METHODS: The efficacy of CyA was studied in 56 patients with AA. The agent was orally given in an initial dose of 10 mg/kg as solution or capsules. Its daily dose during a treatment course varies with the serum CyA levels and clinical tolerance. CyA was used in 17 patients at the first stage of treatment, in 8 with recurrent AA, and in 31 after ineffective previous therapy (antilymphocytic globulin therapy--ALGT, splenectomy). Erythropoiesis was evaluated by the count of erythrokaryocytes and by relative erythroid hyperplasia of the bone marrow and by using erythrokaryocytic PAS reaction, by calculating the total count of sideroblasts and ringed sideroblasts. RESULTS: A positive response was obtained in 41% of the patients with AA. Its pattern depended on the severity of AA, on CyA use regimens, and treatment duration: when treatment with CyA lasted 6-12 months, its efficacy considerably increased (positive responses in severe AA and mild AA being in 64 and 94%, respectively). It has been found that high (over 6%) baseline bone marrow ringed sideroblasts in patients with AA may be regarded as a poor predictor in the context of the efficacy of this agent. CONCLUSION: CyA is recommended for combined IST in patients with AA at the second stage of treatment (after antilymphocytic globulin administration) in order to perform long-term (12-month) immunosuppression by choosing the optimum dose on an individual basis and by continuously monitoring the quality of a response.