azacytidine a new active agent for the treatment of acute leukemia

8/2/2019 Azacytidine A New Active Agent for the Treatment of Acute Leukemia

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1973 42: 359-365

SwaneyMyron Karon, Lance Sieger, Suzanne Leimbrock, Jerry Z. Finklestein, Mark E. Nesbit and Jerry J.5-Azacytidine: A New Active Agent for the Treatment of Acute Leukemia

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Blood , Vol. 42. No. 3 (S ep tem be r). 1 97 3 35 9

5-A zacy tid in e : A N ew A ctive A gen t fo r th eTr eatm en t o f A cute L eukem ia

By M yro n Ka ron , La n ce S ie g e r, S u zanne Le im b roc k . J e rry Z . F in k leS te in ,Mark E . N esb it. an d Jerry J . Swane y

Th irty -se ven ch ild ren w ith acu te le u kem ia p le te rem is s ion w h ich las ted 3 m o Thew ere trea ted w ith 5 -aza cy tid in e in 5 -d ay m ax im um to le ra ted dose is b e tw een 150cou rse s g ive n every 14 days . S ix ou t o f 1 4 to00 m g /sq m on a da ily x 5 schedu lech ild ren w ith acu te m ye logenous leu kem ia g iv en eve ry 1 4 days . Th e im p ress iv e ac -w ho w e re adequate ly tre a ted ach ie v ed an tiv ity o f 5 -aza -C in pa tie n ts w ith a cu teM 1 m a rrow . F ive o f the se subsequent ly m ye logenous leu kem ia res is tan t to c y to -d eve lop ed com p le te rem iss ion s las tin g s in e arab ino s id e ind ic a te s th a t th is d rug8 m o, 6 m o , 3 m o,2 m o , an d 2 m o . O f w ill b e com e an im po rtan t add itio n to th e22 ch ild ren w ith acu te lym phocy tic leu ke - th e rap eu tic a rm am en ta ria ag a in s t th is typ em ia , o ne a ch ie ve d anM 1 ma r row and one o f leu kem ia .an M 2 m a rrow . The fo rm er a tta in ed a co rn -5 -A Z A C Y T ID IN E (5 -A Z A -C ) is an an alo g of cy tid in e firs t in tro duced fo r

the treatm en t o f acu te leu kem ia o f ch ildh ood in C zechos lovak ia . T hecritic al s tep in the m ech an ism o f d rug ac tio n is no t kn ow n , bu t th e ac tiv ity isp resum ab ly re la ted to inco rpo ra tion in to D N A and R N A p olyn uc leo tide sinp lace o fcy tid ine .2 T he co m po und is k now n to in te rfe re w ith D N A , R N A , andpro te in syn thesis .3 4 T he drug show s p re fe ren tia l ac tiv ity d urin g the S ph ase o fthe ce ll cy cle in v itro and h as sho w n schedu le dependen cy in an im a l sy stem s.5 6

T h is stu dy w as und e rtaken to estab lish a to lera ted do se o f 5 -aza-C on a d ailyx 5 sched u le eve ry 2 w k . D uring the cou rse o f th is phase I in vestiga tion 5-aza -Cw as fo und to have im p ressiv e ac tiv ity ag a in st acu te m ye log en ous leuk em ia, andso m e ac tiv ity ag ain st acu te lym p hocy tic leuk em ia.

F rom the D iv is io n o f H em ato lo gy . D epa rtm en t o f P ed ia tr ic s . C h ild re ns Ho sp ita l o f Lo s A nge les .an d th e USC S choo l o fM ed ic ine ; D ep a r tm en t o fP ed ia tric s . H a rbo r G enera l H o sp ita l, an d the U CLASc ho o l o f M ed ic in e , T o r ran ce , C a lif .; the D epar tm en t o f P ed ia tric s . U n iv e rs ity o f M inn es o ta Sc ho o lo f M ed ic in e , M inn ea po lis , M in n .; an d Ch ild ren s M em o ria l H o sp ita l a nd the D epartm en t o f Pe d i-a tr ic s , N o rthw e s te rn U n iv e rs ity . C h ic ag o . Ill .

S ubm it ted Jan ua ry 22 , 1 97 3 ; rev is e d M a rc h 1 2 , 1 97 3 ; a c c ep ted M arc h 22 , 1 97 3 .T he se s tud ie s w ere p e r fo rm ed un de r the a us p ic es o f C h ild ren s Canc e r S tud y G ro up A in th e

a uth ors in stitu tio ns .Su pp o rted b y G ran ts CA -026 49 , CA -073 06 a nd C A -07 43 / from th e Na tio na l C a nc e r Ins titu te an d

T ra in in g G ra n t H D -00 048 from the Na tion a l In s titu te fo r C h ild H ea lth an d H um an D ev e lo pm en t.N IH , DH EW .

M yro n K aron , M .D .: P ro fes s o r o f P ed ia tric s , H e ad , D iv is ion o f H em ato lo gy , C h ild ren s Ho sp ita lo f L os Ange les , L os A nge le s , C a lif. ; S c ho la r , Leu kem ia S oc ie ty o f Am er ic a .ance Siege r, M.D.:H em ato lo gy Fe llow . D iv is ion o f H em a to log y , C h ild re ns H os p ita l o f Lo s Ange les . Los A nge le s . C a lif90027 . Suzanne Le im b rock , P ha rm . D .:C lin ic a l Ph a rm ac is t . D iv is ion o f H em a to lo gy , C h ild re nsH os p ita l o f Lo s A nge le s . Lo s A nge le s , C a lif 900 27 .erry Z . F ink le s te in , M .D .: Ass is tan t P ro fes -s o r o f P ed ia tr ic s , H ea d . Pe d ia tric H em a to lo gy . H a rb o r G enera l H os p ita l. T o r ran ce , C a li fa rk E .Nesb i t , M.D.: P ro fes so r o f Pe d ia tric s , U n iv e rs ity o f M inn eso ta Sc ho o l o f M ed ic in e , M inn ea po lis .M i n n . Je rry J . Sw ane y , M .D .: A ss oc ia te in P ed ia tric s . C h ild re ns M em o ria l H os p ita l an d the De -p a rtm en t o f Pe d ia tric s , N o rthw es te rn U n iv e rs ity . C h ic a go , Il l.

1 97 3 by G run e & S tra tto n , Inc .

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36 0 KARON ET A L

INCREMENTS

MATER IALS AND M ETHODSIn fo rm ed co ns en t fo r the u se o f 5 -a za -C w as ob ta in ed from a t lea s t on e o f th e p a ren ts o f ea ch

ch ild p r io r to tre a tm en t. T h is re qu es t w as ba se d o n th e p o te n tia l e ffic ac y o f 5 -a za -C and th e fa c ttha t a ll o th e r ag en ts o f k n ow n ac tiv ity ha d be en us ed . T he re w ere no pa ren ts w ho re fu se d trea t-m en t fo r the ir c h ild .

Th irty -seven pa tien ts ran g ing in age from to 1 7 y r w ith acu te leukem ia re fra c tory to s tanda rdchem othe rapeu tic agen ts were trea ted w ith 5 -aza -C a t a sta rtin g dose o fm g/s q m at the au tho rs insti tutions. The d rug was adm in is te red as e ither an in travenous push o r a 15-mm fa s t d rip ,d a ily fo r 5 d ay s a nd rep ea ted e ve ry 14 d ay s , de pe nd ing u po n re sp on se and /o r tox ic ity . G en era llyin the absence o f s ign ificant to x ic ity , the dosage w as increased by 50 in crem ents (F ig , I). Insom e in s tanc es th e d ru g w as adm in is te re d in d iv id ed d os es e ith e r e ve ry 8 o r 1 2 h r to fo res ta lln au sea a nd v om itin g .

O b se rv a tio ns a t the be g in n in g o f trea tm en t in c lu de d phy s ic a l ex am ina tio n , a com p le te b lo odcoun t, a b on e m a rrow e xam ina t ion , p la te le t c oun t, u ric ac id , SG O T , a lk a line ph osp ha tas e , B UN ,a nd u rin a ly s is . D u ring the rap y , c om p le te b lood cou n ts w e re rep ea ted a t le as t w e ek ly a nd a bo nem arrow asp ira tio n pe rfo rm ed a t lea s t e ve ry 28 da y s . C rite ria fo r e va lua tio n w ere th os e in u seb y th e C h ild re ns C an ce r S tud y G roup A .7 A n Mm arrow c on ta in s 5#{176}/a or le s s o f b las ts o r o the rabno rm a l ce lls .

5-aza -C w as supp lied in 50 -m g v ia ls by the C lin ica l D rug Eva luation B ranch of the Na tiona lCanc e r Ins titu te . T he d rug wa s d is s o lv ed inm l o f d is tilled w a te r and a dm in is te red w ith in 15m m of reco ns titu tio n s in c e the d ru g be g in s to de com pos e in aq ue ou s so lu tion w ith in 1 h r .

RESULTSDetermination of M aximal l y Toler ated D ose

The pattern of dose escalation is illus trated in Fig . I. D o sage increments w erelogarithm ic be low 100 mg/sq m. The rate of initial e scalation w as based on thelack of response and tox ic ity at the low er doses. The broken curve represents amodified Fibonachi numerical progress ion recently propo sed by D r. O leg Se l-

F i g . 1 . Dos e e s c a l a t i on o f5-azac y t id ine .D o se e sca la tio n w a s lo g a rith m ic u n t il a d o se o f10 0 m g /s q m w h en th ere w a s a d ec re ase inth is ra te b ase d o n th e o cc u rren ce o f res p o n s ean d /o r to x ic ity . E a ch p o in t rep re se n ts a d o sein crem en t a c tu a lly u se d o n e o r m o re t im e s . T h e2 b ro ken cu rv e rep res en ts a m o d if ied F ib o n a ch ise arc h p ro ce d u re d es ig n e d to p e rm it rap ide sc a la tio n o f th e d o s ag e in itia lly w h ile d im in ish -in g th e ra te o f in c re ase n ea r th e m ax im u mto lera te d d o se in o rd e r to a vo id ex ce ss ive to x -ic ity . T h e m o d ified F ib o n a ch i s eries is as fo l-lo w s : 2 , 0 .7 . 0 .5 , 0 .3 . ... T h ese n u m b ers areu sed a s co effic ien ts to p re d ic t d o s e in c re m e n ts .If th e s ta rtin g d o se b as ed o n 0 .1 L D 1 0 in an i-m a ls w a s 2 m g /s q m , th e n d o sa g e in c rem e n tsw o u ld b e 2 , 4 , 6 .8 . 10 .2 , 1 3 .5 m g /s q mB lin d a d h eren ce to s u c h a sc h e m e w o u ld u n -n ece ss ar ily p ro lo n g a p h as e I tria l i f th e s ta rtin gd o se w as to o lo w .



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5A C ( flD INE 361

aw ry for predicting dose increm ents.7 The shape of this theoretical curve isquite sim ilar to that w hich w as obtained by increasing the dose until either re-sponse or toxicity occurred.

T he m axim um tolerated dose w as obtained by determ ining the num ber ofpatients given a particular dose of 5-aza-C per course. A s the dose of drug w asincreased, the num ber of patients at a given dose increased to a m axim um andthen declined abruptly betw een 150 and 200 m g/sq m . T he plateau value ofsuch a curve w as used to estim ate the low er lim it of drug toleration.Therapeuti c Effi cacy

The over-all results of treatm ent are tabulated in T able 1Six out of I 5 pa-tients w ith acute m yelogenous leukem ia achieved an bone m arrow status.

Five of these children obtained a com plete rem ission w hich lasted 8 m o,6 m o, 3 m o, 2 m o, 2 m o, and 2 m o. O ne patient w ith an M 1 m arrow diedw ithin 3 w k in partial rem ission. T he over-all rem ission rate for A M L, there-fore, is 6/ 15 (40% ). If one excludes one patient w ith acute m yelocytic leukem iaw ho received only one-fiftieth of the m axim um tolerated dose early in the study,then the rem ission rate becom es 6/14(42% ).

O f the 22 patients w ith acute lym phocytic leukem ia (A L L), one patientachieved an M l m arrow and another an M 2 m arrow . T he child w ith the M 1m arrow obtained a com plete rem ission w hich lasted for 3 m o. T he child w iththe M 2 m arrow (9% lym phoblasts) died of infection before achieving a com -plete rem ission. The difference in rem ission rates (M 1) betw een A M L and A L Lis significant, p


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36 2 KARON ET AL

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5-AZACYT ID INE 36 3

received 150 mg/sq m q.d. f or 2 consecuti ve days every week. Patient N S isreceiv ing 230 mg/sq m q.d. x every 3 w k. Patient JB has received 150mg/sq m q.d. x 5 every 5-6 w k . T his more prolonged interval w as necessarybecause JB s w hi te blood cel l count continued to decrease for approx imatel y4 w k f ol l ow ing therapy . Patients K K and PJ w ere maintained on-aza-C 100mg/sq m q.d. x 5 once per month.Toxicity

The most di sabl i ng tox i ci ty involves the gastrointesti nal tract. A t doses of150 mg/sq m or above, 5-aza-C causes prof ound nausea and vom i ti ng and diar-rhea in al l pati ents. T he severi ty of these tox i c mani festati ons, especial l y thef ormer, can be reduced by giv ing the drug in div ided doses or in some in-stances by the use of a 15 mm intravenous fast drip. A ntiemeti cs such aschlorpromazine can be of use w hen given in relati vel y large doses at least24-48 hr pr ior to beginning the course of 5-aza-C . A prur i ti c, fol l i cular sk inrash occurred in 50% of the patients, but w as usual l y transient and did not re-qui re drug dosage modi f i cati on.

The drug is myelosuppressive. A l though recovery usual l y occurs by day 14at a dose of 150 mg/ sq m dai l y x, myelosuppression may be more pro-longed, especial l y at 200 mg/sq m or above. M yelosuppression is not neces-sar i l y untow ard and accompanied response in every instance except one (T a-ble2).

D ISCUSS IONThese data indicate that 5-aza-C is an acti ve drug for the treatment of acute

leukem ia in chi l dren. T he compound has parti cularl y impressive acti v i tyagainst acute myelogenous leukem ia. A cti v i ty of 5-aza-C against adul t l eu-kem ia has recentl y been demonstrated by M cCredie and co-w orkers8 andagainst acute l ymphocy tic leukem ia in new ly diagnosed patients w ho w ere alsorecei vi ng predni sone.l

T he fact that the acti v i ty of 5-aza-C could be demonstrated in chi l dren w i thadvanced ref ractory leukem ia has important impl i cati ons for the evaluation ofother new drugs. A gents of uncertain potency do not need to be tested earl yin the course of a chi l d s di sease to demonstrate acti v i ty . Indeed, the acti v i tyof v incri sti ne, ara-C, and L -asparaginase, al l ef fecti ve anti l eukem ic agents, w asdemonstrated under sim i lar ci rcumstances. Since 5-aza-C is not cross-resi stantto ara-C, the use of these tw o agents in combination for the treatment of A M Lshould be prom ising.

A l though the original plan w as to adhere to a modi f i ed Fibonachi searchf or dose escalati on, thi s approach w as abandoned. The Fibonachi search in-volves a rapid ini ti al dose escalati on f ol l ow ed by decreasing dosage incrementswhich are predeterm ined and aimed at reducing the chance of grossl y over-shooting the max imum tolerated dose. T he original plan f or escalati on i s show non Fig. 1 as an interrupted l i ne, and is based on the ser ies 2, 0.7, 0.5, 0.3The ini ti al starti ng dose w as 2 mg/M 2,- he L D 10 determ ined in precl i ni calpharmacology . B ecause thi s dose proved to be 70-100-fold less than the max i -mum tolerated dose, stri ct adherence to Fibonachi s escalati on program w ould



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432

4 0 80 (20 60 20 0 2 40 2802 0DOSE PER COURSE (m g /M 2)

364 KARO N ET A L

F ig. 2. Frequ en cy d istrib u-tio n o f pa tie n ts rece iv in g apar t icular do se of 5-aza-C percou rse. T he plateau of this

U) cu rve determ in es th e m axi- m um to lerated d ose of 5-aza-C sin ce cou rses w h ich d o n ot p ro du ce to xicity or th erapeutick e ffe c t o r w hich p ro du ce exces-

sive to xicity are u su ally no t g iven to a larg e num ber o f p atien ts. w h ile to lerated cou rses that affect the d isease

favo rab ly are u sed in an in -creasin g n um b er of p atien t. A llpatients receivin g the dru g arein clu ded as lon g as th ey w erein the in du ction p hase. A p a-tien t ca n be rep resen ted on lyo nce for each do se level.

have been completely unworkable. T he shape of the actual dose escalationcurve, however, is similar to the Fibonachi modification, indicating that thereis a need to reduce the rate of dosage increment once there is either a thera-peutic effect or some toxic manifestations, but that this mathematical series perse has no particular magic.

The maximum tolerated dose was estimated by plotting the number of pa-tients receiving a given dose per course. Clearly such a curve would have a posi-tive slope at doses which were well tolerated and, therefore, used in more pa-tients and a negative slope when the tolerated dose was exceeded. This provedto be the case (Fig. 2) and was a useful way of predicting drug dosage. The maindanger of a more rapid escalation scheme is the development of cumulativetoxicity. This can be obviated by escalating the dosage every second course asthe maximum tolerated dose is approached.

The achievement of complete remission in two patients whose initial whitecounts were in excess of 100,000 indicates that such high white blood cellcounts may not necessarily predict for a poor prognosis, especially in advanceddisease. T his may be the result of a selection since patients w ith acute leukemiawho live long enough to receive phase I agents have usually responded to otheragents. T he practice in some phase I I studies designed to estimate the remis-sion rate in advanced disease to exclude certain patients because of the heightof their initial white blood cell count may not necessarily be justif ied.

REFERENCESI. H rod ek 0 , V ese ly J : 5 -aza cy tid ine in ch ild - LM : C y to tox ic ity an d m ode o f ac tion o f 5 -

h o o d l e uk e mi a . Neop lasm 1 8 : 4 9 3 , 1 97 1 a za cy t id in e o n L I2 IO leu kem ia . C a nce r R es2 . J uvov c ik M , R aska K J r. S ovm o va F , 3 0 :2 76 0 , 1 97 0

So rm F : An ab o lic tra ns fo rm a t ion o f a n ove l 4 . R aska KJ J r, Ju vov c ik M , Fu c ik V . T yk vaan tim e tab o lite , 5 -a zac y t id in e an d ev ide nce fo r R , S ovm ova Z , S orm F : M e ta bo lic e ffe c ts o f 5 -its inco rpo ra tion in to ribonuc le ic ac id . C o Il a z a c y t i di ne a n d 5 a z a , 2 l , de o x y c y t i d i ne i n mi c e .C zech C hem Comm un 30 :3 37 0 , 1 96 5 C o Il C zech Chem C omm un 3: 2 8 0 3 , 1 9 6 6

3 . L i LH , O lin J, Boskivk NH, Re i n e k e 5 . Li LH, O lin E J , F vosev T i, B h u yan BK :



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5 - AZACYT ID INE 36 5

Phase spec ific ity o f 5 -a zacytid ine aga in s t m am -m alian ce lls in tis sue cu ltu re . Cancer Res 30 :-2 77 0 , 1 97 0

6. Fucik V. Micha elis A , R eigev R : O n theind uc tio n o f s egm en t e x te ns ion a nd c h rom atids tru c tu ra l c h an ge s in v ic ia fab a ch rom os om esa fte r trea tm ent w ith 5-azacytid ine and 5 -azade -oxycytid ine . M u ta t R es : 599, 1970

7 . Le ik in S L , B rub ak e r C , H a rtm ann JR ,M u rph y M L, W o lff IA , P e rr in E : V a ry in gp red n is on e do sag e in rem is s ion ind uc tion o f

p re v io us ly u n trea ted ch ildh oo d le ukem ia . C an -c e r2 l:34 6 , 19 68

8 . S e law ry OS : C on s id e ra tio ns fo r in it ia lc lin ic a l tria l o f an ti-n eo p la s tic ag en ts . S ym po -s ium on S ta tis tic a l A spe c ts o f P ro toco l D e s ig n ,Decem be r 9-10, 1970

9 . M cC red ie K B , B od ey GP , Bu rge s s MA ,R od rigu ez V , Su lliv an M P , F re ire ic h EJ : T hetre a tm en t o f acu te le uk em ia w ith 5 -az ac y tid ine .Blood 40 :9 75 , 1972


azacytidine a new active agent for the treatment of acute leukemia

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