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 Previous Article | Table of Contents | Next Article 
Blood, Vol. 94 No. 1 (July 1), 1999:
pp. 39-45
Complete Remission of t(11;17) Positive Acute Promyelocytic Leukemia
Induced by All-trans Retinoic Acid and Granulocyte
Colony-Stimulating Factor
By
J.H. Jansen,
M.C. de Ridder,
W.M.C. Geertsma,
C.A.J. Erpelinck,
K. van Lom,
E.M.E. Smit,
R. Slater,
B.A. vd Reijden,
G.E. de Greef,
P. Sonneveld, and
B. Löwenberg
From the Institute of Hematology, the Department of Clinical Genetics
and the Department of Cell Biology and Genetics, Erasmus University
Rotterdam, Rotterdam, The Netherlands.
 |
ABSTRACT |
The combined use of retinoic acid and chemotherapy has led to an
important improvement of cure rates in acute promyelocytic leukemia.
Retinoic acid forces terminal maturation of the malignant cells and
this application represents the first generally accepted differentiation-based therapy in leukemia. Unfortunately, similar approaches have failed in other types of hematological malignancies suggesting that the applicability is limited to this specific subgroup
of patients. This has been endorsed by the notorious lack of response
in acute promyelocytic leukemia bearing the variant t(11;17)
translocation. Based on the reported synergistic effects of retinoic
acid and the hematopoietic growth factor granulocyte colony-stimulating
factor (G-CSF), we studied maturation of t(11;17) positive leukemia
cells using several combinations of retinoic acid and growth factors.
In cultures with retinoic acid or G-CSF the leukemic cells did not
differentiate into mature granulocytes, but striking granulocytic
differentiation occurred with the combination of both agents. At
relapse, the patient was treated with retinoic acid and G-CSF before
reinduction chemotherapy. With retinoic acid and G-CSF treatment alone,
complete granulocytic maturation of the leukemic cells occurred in
vivo, followed by a complete cytogenetical and hematological remission.
Bone marrow and blood became negative in fluorescense in situ
hybridization analysis and semi-quantitative polymerase chain reaction
showed a profound reduction of promyelocytic leukemia zinc
finger-retinoic acid receptor- fusion transcripts. This shows that
t(11;17) positive leukemia cells are not intrinsically resistant to
retinoic acid, provided that the proper costimulus is administered.
These observations may encourage the investigation of combinations of
all-trans retinoic acid and hematopoietic growth factors in
other types of leukemia.
© 1999 by The American Society of Hematology.
| |
INTRODUCTION |
IN MORE THAN 95% of the cases of acute
promyelocytic leukemia (APL) a balanced t(15;17)(q22;q21) chromosome
translocation is present that fuses the promyelocytic leukemia (PML)
and retinoic acid receptor- (RAR) genes.1-7 The
resulting PML-RAR fusion protein is implicated in the leukemic
transformation of the cells in a dominant fashion.5-14 APL
cells respond to treatment with the vitamin A derivative
all-trans retinoic acid (ATRA) with terminal granulocytic
differentiation followed by cell death, and treatment with ATRA alone
may induce complete remissions in more than 80% of the
cases.15-18 Remissions induced with ATRA alone are
short-lived, but combination of ATRA with chemotherapy has improved
durable disease-free survival up to 75%.19,20 The additive
value of ATRA and chemotherapy probably reflects the disparate modes of action of maturation induction and cytotoxic treatment. Unfortunately, as yet, similar approaches have failed in other types of leukemia. Even
in cases of APL bearing the variant t(11;17)(q23;q21) translocation, which represents a fusion of the RAR gene to another gene named promyelocytic leukemia zinc finger (PLZF),21 treatment with ATRA does not induce terminal differentiation, and complete remissions cannot be achieved with ATRA alone.22,23 Although one
patient has been reported with a good response on ATRA and one course of chemotherapy,24 t(11;17) positive leukemia is generally
considered to have a poor prognosis. Interestingly, the patient that
responded well to therapy24 was randomized to receive G-CSF
at completion of chemotherapy, and a role for G-CSF can therefore not
be excluded in this case.
In vitro studies have shown that induction of differentiation of
PML-RAR-positive cells by ATRA can be enhanced when G-CSF is
applied as a costimulus.25,26 The basis of this synergistic effect is not known and because treatment with ATRA alone is sufficient to induce granulocytic maturation in t(15;17) positive leukemia, the
combination of ATRA and G-CSF has not been extensively examined clinically. Here, we present a patient with a t(11;17)-positive APL
whom we evaluated to determine if the combined use of ATRA and G-CSF
could overcome the maturation block of the leukemic cells.
| |
MATERIALS AND METHODS |
Case report.
A 31-year-old man was referred with a white blood cell (WBC) count of
69 × 109/L, 128 × 109/L platelets and a
hemoglobin (Hb) of 5.4 mmol/L. The bone marrow and blood contained more
than 90% leukemic cells that varied morphologically from promyelocytes
to metamyelocytes. Several leukemic cells contained multiple small,
bright red granules, sometimes together with more basophilic larger
granules; other cells were hypogranulated. Auer rods were frequently
observed, either as single rods or as bundles, and cells with
pseudo-Pelger nuclei were present. The immunophenotype of the cells was
CD13+, CD33+, myeloperoxidase+,
CD14 , CD15, CD34,
CD117, TdT, and
HLADR. A diagnosis of acute myeloid
leukemia (AML)-M3 was made according to the
French-American-British-classification.27 Treatment with ATRA (45 mg/m2/d) was initiated, but was discontinued at
day 7 when cytogenetic analysis showed a t(11;17)(q23;q21) chromosomal
translocation that was confirmed by fluorescence in situ hybridization
(FISH). Three cycles of chemotherapy were applied according to the
AML-29 protocol of the Dutch-Belgian Hematology-Oncology Group (HOVON) and the Swiss Cancer Leukemia Group (SAKK). The first cycle consisted of cytosine-arabinoside (Ara-C) (200 mg/m2/d per continuous
infusion for 7 days) and idarubicin (12 mg/m2 bolus
infusion on days 5 through 7). The second cycle consisted of Ara-C
(1,000 mg/m2, twice daily for 6 days) and amsacrine (120 mg/m2/d on day 3 through 5). The third cycle consisted of
etoposide (100 mg/m2/d for 5 days) and mitoxantrone (10 mg/m2/d for 5 days). The leukemia did not respond to the
first cycle, but following the second cycle, the patient entered a
complete hematological and cytogenetic remission. In addition, the bone marrow and blood became polymerase chain reaction (PCR)-negative for
the PLZF-RAR fusion transcript. After the third cycle of chemotherapy, the patient remained in an unmaintained complete remission for 11 months when he presented with a medullary relapse. The
bone marrow contained 20% leukemic cells, the WBC count was 3.7 × 109/L with no apparent leukemic cells in the differential
count, platelets were 95 × 109/L and the Hb value was 8.8 mmol/L. At this time, cytogenetic analysis of a bone marrow
sample showed 1 among 50 metaphases to be t(11;17)(q23;q21)-positive.
Interphase FISH showed 15% t(11;17) positive cells in the bone marrow,
whereas the number in the peripheral blood was not above background
(4%). Reinduction treatment was started with a combination of ATRA and
G-CSF following informed consent, before chemotherapy.
In vitro proliferation and differentiation.
At first presentation, fresh leukemic cells were obtained from the
blood (containing more than 90% leukemia cells) by
Ficoll-Isopaque (Amersham Pharmacia Biotech AB, Uppsala, Sweden)
density centrifugation (density = 1.077). Cells were washed and kept
at 37°C in a completely humidified 5% CO2 atmosphere in
RPMI-1640 medium (GIBCO, Paisley, UK) supplemented with 2 mmol/L
glutamine (GIBCO) and 10% fetal calf serum (FCS; GIBCO). For
differentiation studies, cells were cultured in this medium
supplemented with either 106 mol/L ATRA (Sigma, St
Louis, MO), 0.1 µg/mL G-CSF (Amgen, Thousand Oaks, CA), or a
combination of ATRA and G-CSF. At several time points, cell
numbers were counted and cytospin preparations were made for
cytological examination.
PCR analysis.
The breakpoint in the PLZF and RAR genes in the leukemic cells was
determined by sequencing of a PCR fragment generated with PLZF and
RAR specific primers. The breakpoint was located in the fourth
intron of the PLZF and the second intron of the RAR gene. For
follow-up monitoring, a more sensitive nested reverse transcription
(RT)-PCR was developed both for PLZF-RAR and RAR-PLZF amplification. Reverse cDNA transcription was performed on CsCl-cushion purified RNA, and nested PCR was performed with two times 30 cycles of
1 minute at 94°C, 1 minute at 46°C, and 1 minute at 72°C in 2.0 mmol/L MgCl2 buffer. PLZF-RAR transcripts were amplified with oligonucleotides 5'GGA GCC AAC TCT GGC TGG G3' and 5'CAT GTT CTT
CTG GAT GCT GC3' for the first PCR and 5'TCG GAG AGC AGT GCA GCG TG3'
and 5'GGC GCT GAC CCC ATA GTG GT3' for the nested PCR. For RAR-PLZF,
oligonucleotides 5'GGC CAG CAA CAG CAG CTC CT3' and 5'TTT GAG AGC CGT
GTG GCT G3' were used for the first PCR and 5'GGT GCC TCC CTA CGC CTT
CT3' and 5'TGC GCT CTG CGC CTG GAAG C3' for the nested PCR. The
sensitivity of the PLZF-RAR PCR was 1 positive cell in
104 negative cells, and the sensitivity of the RAR-PLZF
RT-PCR was 1 positive cell in 105 negative cells as
assessed with serial dilutions of t(11;17) leukemic cells with
t(11;17)-negative NB4 cells. To verify proper RNA isolation and reverse
transcription, a parallel PCR was performed on each sample using
primers specific for the nonrearranged RAR transcripts (5'CAG CAC
CAG CTT CCA GTT AG3' and 5'GGC GCT GAC CCC ATA GTG GT3'). PCR products
were separated on 1.5% agarose gels and their identity was confirmed
in Southern blots using radiolabeled oligonucleotide probes spanning
the PLZF-RAR and RAR-PLZF breakpoints.
FISH analysis.
The numbers of leukemic cells in sequential bone marrow and blood
samples were also monitored by FISH analysis of interphase nuclei.
After incubation with biotin and digoxigenin-labeled cosmid probes of
the RAR and NCAM genes (kindly provided by Dr F. Birg, Institut
Paoli-Calmettes, Marseilles, France), slides were incubated with
fluorescein-isothiocyanate (FITC) and Texas red-conjugated secondary
antibodies (Boehringer, Mannheim, Germany). Nuclei were visualized with
4,6 diamidino-2-phenylindole (DAPI; Sigma). The presence of the
t(11;17) was visible as a fusion spot formed by the colocalization of
red and green signals. The background, which represents the percentage
of signal colocalization in cells without the t(11;17) translocation,
was maximally 5% as determined on bone marrow and blood samples
from 10 non-t(11;17) positive acute leukemia patients
(mean = 2.7% ± 1.8, range = 0% to 5%), 16 patients with
myelodysplastic syndrome (mean = 1.6% ± 1.2, range = 0% to 4%), and 5 healthy donors (mean = 0.72% ± 0.9 range = 0% to
2%).
| |
RESULTS |
In vitro proliferation and differentiation.
To test the in vitro response of the t(11;17)-positive leukemia cells
to ATRA and G-CSF, nucleated cells were isolated from the blood at
first diagnosis, containing more than 90% leukemic cells. The cells
were cultured in medium supplemented with G-CSF (0.1 µg/mL), ATRA
(106 mol/L), or G-CSF and ATRA. In medium alone and in
cultures with G-CSF, cell numbers doubled over a 7-day period, whereas
in cultures with ATRA or ATRA and G-CSF, no significant increase of
cell numbers was observed (Fig 1). Cytospin
preparations from the same cultures showed that the cells incubated in
medium remained promyelocytic throughout the culture period (14 days),
while cells cultured with G-CSF or ATRA showed some differentiation
toward metamyelocytes (Fig
2, Table
1). The limited differentiation in response
to ATRA is in concordance with previous reports22,23 and
confirms the insensitivity of the t(11;17) positive leukemia cells to
ATRA. Strikingly, after 1 week of culture with the combination of ATRA and G-CSF, the majority of the cells showed complete differentiation with nuclear segmentation, frequently in association with prominent Auer rods (Fig 2E and Table 1). The complete differentiation of the
t(11;17)-positive cells raised the question of whether the combination
of ATRA and G-CSF could be of clinical use in case of a relapse.
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| Fig 1.
Proliferation of t(11;17)-positive leukemia cells in
response to G-CSF and ATRA. Mononuclear cells, consisting of more than
90% of leukemic cells, were isolated from the peripheral blood at
first diagnosis. Cells were cultured at 2 × 105 cells/mL
with medium alone, G-CSF (0.1 µg/mL), ATRA (106
mol/L), or with a combination of ATRA and G-CSF. At the indicated times
cell numbers were counted. Values represent the mean of triplicate
measurements.
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| Fig 2.
Morphology of t(11;17) positive leukemia cells cultured
with G-CSF and ATRA. Mononuclear cells, consisting of more than 90% of
leukemic cells, were isolated from the blood at first diagnosis and
cultured under various conditions for up to 14 days. Cytospins were
made after various time intervals and stained with
May-Grünwald-Giemsa. Depicted are uncultured cells (A) and cells
that were grown for 1 week in medium (B), 106 mol/L ATRA
(C), 0.1 µg/mL G-CSF (D), and ATRA and G-CSF (E).
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Treatment of relapse with G-CSF and ATRA.
Because of the in vitro differentiation of the leukemic cells in
response to ATRA and G-CSF, treatment with the combination of both
agents was applied before reinduction chemotherapy at the time of a
relapse at 14 months after presentation.
To evaluate a potential stimulatory effect of ATRA and G-CSF on
clonogenic leukemia growth, bone marrow mononuclear cells obtained at
relapse (containing 15% FISH-positive leukemia cells) were cultured in
methylcellulose with titrated amounts of G-CSF (0 to 100 ng/mL), in the
presence and absence of ATRA (106 mol/L). In cultures
with G-CSF, colony formation by the bone marrow cells was similar to
the number of colonies in cultures of bone marrow cells from healthy
donors. In cultures with ATRA and G-CSF, colony numbers were
considerably lower than in cultures with G-CSF alone (data not shown).
Thus the addition of G-CSF and ATRA did not stimulate detectable
clonogenic leukemia growth in vitro.
Treatment with a combination of ATRA (45 mg/m2/d) and G-CSF
(5 µg/kg/d) was started (Fig 3). After 2 days the WBC count began to rise, reaching 55 × 109/L at
day 5 (Fig 3A). At this time, the G-CSF treatment was interrupted, but
ATRA treatment was maintained. The WBC count continued to rise for 2 additional days, and then rapidly declined. At day 9, G-CSF treatment
was restarted at a 10-fold lower dose (0.5 µg/kg/d). Cell numbers
continued to decrease to below 10 × 109/L at day 16, and
the dose of G-CSF was adjusted to 1 µg/kg/d. Subsequently, the WBC
counts stabilized at 10 to 15 × 109/L. Cytological
examination showed a transient appearance of promyelocytes in the blood
from day 4, which peaked at day 6 and had disappeared by day 11 (Fig
3B). More mature (meta)myelocytes appeared after day 5, peaked at day 7 and normalized after day 14. The number of mature granulocytes was
elevated from day 4 to day 15 with peak levels around day 11 of
treatment. A normal differential was seen on day 14 and beyond.
Platelet counts dropped from 124 to 80 × 109/L between
days 1 and 18, but subsequently rose to stabilize at around 200 × 109/L, concurrently with the disappearance of t(11;17)
FISH-positive cells from bone marrow and blood (Fig 3A, Table
2). The Hb gradually dropped from 8.8 mmol/L before treatment to 6.5 to 7.0 at day 22, and subsequently
stabilized at 7.5 to 8.0 mmol/L from day 25 (not shown).
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| Fig 3.
Peripheral blood counts during ATRA plus G-CSF treatment.
During ATRA and G-CSF treatment, platelet and WBC counts were
determined (A). Cytological differentiation of peripheral blood smears
was assessed daily. The percentage of promyelocytes, (meta)myelocytes,
band cells, and segmented granulocytes was scored. From the total WBC
counts, the absolute numbers of cells with the various stages of
differentiation was calculated (B). The treatment regimen is indicated
at the bottom.
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Table 2.
Percentage of t(11;17) FISH-Positive Cells in Sequential
Bone Marrow Samples During ATRA and G-CSF Treatment
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Monitoring of leukemic cells in marrow and blood during ATRA and
G-CSF treatment.
At day 7, when the WBC count peaked, t(11;17) interphase FISH became
positive in 20% of the peripheral blood cells. Because the bone marrow
showed 15% FISH-positive cells before treatment (Table 2), and the
peripheral blood values at that time were below background (4%), this
suggested that the treatment with ATRA and G-CSF had mobilized both
normal and malignant cells from the bone marrow to the blood.
Sequential bone marrow samples analyzed by FISH showed 12% t(11;17)
positive cells at day 5 and 10% positive cells at day 12. Subsequent
values at days 15 to 39 were below background. Interestingly, at day
12, FISH-positivity was seen predominantly in cells with segmented
nuclei (visualized by DAPI-staining), indicative of granulocytic
differentiation of t(11;17) positive leukemia cells. To document this,
concurrent FISH and morphological staining28 of the same
cytospin slides was performed and FISH-positive cells were shown to be
morphologically mature granulocytes (Fig 4). This provides further
evidence for the in vivo maturation of leukemia cells. Because of the
limited sensitivity of FISH, residual leukemia was also monitored with
semi-quantitative RT-PCR using the leukemia-specific PLZF-RAR fusion
transcript as a target (Fig 5). PLZF-RAR
expression before ATRA and G-CSF treatment was high in bone marrow (Fig
5A), and barely detectable in peripheral blood cells (Fig 5B). The
levels of PLZF-RAR expression in bone marrow gradually dropped and
became undetectable after 8 weeks of treatment (Fig 5A). In peripheral
blood, PLZF-RAR expression initially rose concomitantly with the
leukocytosis, probably because of the mobilization of leukemic cells to
the blood, but subsequently became negative along with the maturation
and disappearance of t(11;17) FISH-positive cells (Fig 5B). To see
whether the expression of the reverse fusion transcript followed the
same pattern, we also performed RT-PCR for the RAR-PLZF transcript
(Fig 5C and D). Similar to PLZF-RAR, the expression of RAR-PLZF
in the bone marrow continued to drop throughout the treatment (Fig
5C), whereas the expression in the peripheral blood cells was
downregulated after an initial increment during leukocytosis (Fig 5D).
Interestingly, both in the bone marrow and in the peripheral blood, the
disappearance of RAR-PLZF transcripts went slower than PLZF-RAR
suggesting that the expression level of both fusion transcripts was
influenced differentially by the treatment. The cytological, FISH, and
RT-PCR data are all consistent with a transient phase of mobilization of normal and leukemic cells from the bone marrow to the peripheral blood, followed by maturation and disappearance of the malignant cells, compatible with a complete hematological and partial molecular remission following treatment with G-CSF and ATRA.
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| Fig 4.
In vivo maturation of t(11;17) FISH-positive leukemia
cells. Twelve days after initiation of ATRA and G-CSF treatment,
FISH-positive cells in bone marrow and blood predominantly showed
segmented nuclei (as visualized by DAPI staining) indicative of
granulocytic differentiation of the leukemic cells. To establish the
morphology of the FISH-positive cells, slides were stained with
May-Grünwald-Giemsa (A). The same fields were photographed after
hybridization of the slides with labeled FISH probes (B) to obtain dual
morphological and FISH staining. The t(11;17) translocation is
indicated by the colocalization of red and green signals.
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| Fig 5.
PLZF-RAR and RAR-PLZF expression in bone marrow and
blood cells during ATRA and G-CSF treatment. RNA from sequential bone
marrow (A and C) and peripheral blood samples (B and D) was obtained
and RT-PCR for PLZF-RAR (A and B) or RAR-PLZF (C and D) fusion
transcripts was performed. Transcripts were quantified by serial,
10-fold dilutions of the patient cells in t(11;17)-negative cells, and
subsequent RNA isolation and RT-PCR. The dilution at which
amplification of the transcript is lost indicates the abundance of the
fusion transcript. For each sample, an undiluted and five 10-fold
dilutions were processed (left to right). Numbers indicate days before
(negative numbers) or after the start of treatment. In addition to
sequential samples taken at the time of relapse, a sample from the
initial first diagnosis was analyzed. To verify proper RNA isolation
and reverse transcription, a control amplification was performed on
each sample using primers that are specific for unrearranged RAR
transcripts (not shown). For uniformity, RNA isolation, reverse
transcription, and PCR was performed on all samples at the same time.
The specificity of the amplification was confirmed by Southern blotting
and hybridization with oligonucleotide probes spanning the respective
fusion points (not shown). Data are representative of 3 independent
experiments.
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Subsequent clinical course.
After 46 days of treatment, reappearance of FISH-positivity (4% above
background) was seen in the bone marrow indicating that the response
had been transient (Table 2). Notably, at that time, very low to
undetectable PLZF-RAR and RAR-PLZF expression levels were
measured (Fig 5). Apparently, therapy-resistant leukemia cells emerged
with a very low expression of both fusion transcripts. At day 54 chemotherapy was started and after allogeneic bone marrow transplantation the patient now remains in complete remission for more
than 12 months, with no detectable FISH or PCR signals in bone marrow
or blood.
| |
DISCUSSION |
The application of retinoic acid to the treatment of t(15;17) positive
acute promyelocytic leukemia has established that induction of
differentiation can be a valuable means of tumor cell eradication. The
additive effect of retinoic acid and cytotoxic treatment on durable
disease-free survival is probably the result of the targeting of
different biological processes by both forms of treatment. So far,
therapeutic approaches based on maturation-induction have failed in
other types of leukemia, suggesting that the applicability of this type
of treatment might be limited to patients with acute promyelocytic
leukemia with PML-RAR gene fusions.
This report shows that induction of terminal differentiation and a
subsequent complete clinical and partial molecular remission may be
obtained with retinoic acid in t(11;17) positive leukemia, provided
that G-CSF is applied as a costimulus. In t(15;17) positive leukemia,
addition of G-CSF is not required for ATRA-induced differentiation and
complete remission induction. However, a role for G-CSF cannot be ruled
out, as ATRA induces the expression of both G-CSF and the G-CSF
receptor in these cells,25,26 which might result in
autocrine stimulation.
Retinoid receptors are ligand-dependent transcription factors that
directly regulate the expression of target genes by binding to their
regulatory DNA-sequences. Which target genes initiate the granulocytic
differentiation program in the malignant cells is not well known.
Recent studies have provided a mechanism by which the PML-RAR and
PLZF-RAR fusion proteins may deregulate the expression of target
genes.29-32 Unliganded retinoic acid receptors inhibit gene
expression by recruiting corepressor proteins like N-CoR or SMRT and
histone deacetylase to the DNA. This results in histone deacetylation
and silencing of the expression of target genes. Upon ligand binding,
the corepressor complex is released and replaced by a coactivator
protein complex with histone acetylation activity, on which
transcription is activated. The release of corepressor proteins from
the PML-RAR fusion protein was shown to require higher doses of
ligand when compared with the unrearranged RAR receptor, explaining
why pharmacological doses are needed to induce differentiation of
t(15;17)-positive leukemia cells. Interestingly, retinoic acid was
unable to completely release the corepressor proteins from the
PLZF-RAR fusion protein because of a second binding site for
corepressor proteins in the PLZF part of the fusion protein, which is
not sensitive to retinoic acid. This explains the insensitivity of
t(11;17)-positive leukemia to retinoic acid. The synergistic action of
ATRA and G-CSF reported here could be explained if activation of G-CSF
receptor signaling would lead to the release of corepressor proteins
from the PLZF part of the PLZF-RAR fusion protein. This hypothesis
is currently being tested.
The effect of ATRA and G-CSF described in this report was significant
because it was characterized by a complete hematological and
cytogenetical response, a partial molecular response with normalization
of bone-marrow morphology and recovery from thrombocytopenia toward
normal platelet values. The response was transient, as FISH-positive
cells reappeared in the bone marrow after 7 weeks of treatment. In
analogy, treatment of t(15;17)-positive leukemia with ATRA alone does
generally not render the patients PCR-negative for PML-RAR and does
not induce durable remissions. The observed downregulation of both the
PLZF-RAR and the RAR-PLZF fusion transcripts in the reappearing
leukemia suggests a selective pressure during treatment for low
expression of both fusion transcripts. This might suggest that both
fusion transcripts play a role in conferring the differentiation signal
by ATRA and G-CSF. In addition, these results indicate that both
PLZF-RAR and RAR-PLZF were dispensable for the transformed
phenotype of the reappearing leukemia cells, possibly because of extra
genetic alterations in the resistant cells. The relapse within 7 weeks
suggests that a shorter period of ATRA and G-CSF treatment should be
administered before chemotherapy is started, or that ATRA and G-CSF
should be applied concomitantly with the chemotherapy. Although this
approach should be confirmed in other t(11;17) positive leukemia
patients, this report might warrant the investigation of combinations
of ATRA with hematopoietic growth factors in other types of leukemia.
| |
ACKNOWLEDGMENT |
We thank Jacqueline Wijsman for help with the FISH experiments and
Karola van Rooyen for help with the figures.
| |
FOOTNOTES |
Submitted December 29, 1998; accepted March 1, 1999.
Supported by grants from the Dutch Cancer Society (M.R. and C.E.) and
the Royal Netherlands Academy of Arts and Sciences KNAW (J.J.).
The publication costs of this
article were defrayed in part by
page charge payment. This article
must therefore be hereby marked
"advertisement"
in accordance with 18 U.S.C. section
1734 solely to indicate this fact.
Address reprint requests to J.H. Jansen, PhD, Institute of
Hematology Erasmus University Rotterdam, PO Box 1738, 3000 DR
Rotterdam, The Netherlands; e-mail: jansen{at}hema.fgg.eur.nl.
| |
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ABSTRACT
INTRODUCTION