1. No category

From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
1996 88: 1198-1205
Combination of quinine as a potential reversing agent with
mitoxantrone and cytarabine for the treatment of acute leukemias: a
randomized multicenter study
E Solary, B Witz, D Caillot, P Moreau, B Desablens, JY Cahn, A Sadoun, B Pignon, C Berthou, F
Maloisel, D Guyotat, P Casassus, N Ifrah, Y Lamy, B Audhuy, P Colombat and JL Harousseau
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Society of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036.
Copyright 2011 by The American Society of Hematology; all rights reserved.
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
Combination of Quinine as a Potential Reversing Agent With Mitoxantrone
and Cytarabine for the Treatment of Acute Leukemias: A Randomized
Multicenter Study
By Eric Solary, Brigitte Witz, Denis Caillot, Philippe Moreau, Bernard Desablens, Jean-Yves Cahn, Alain Sadoun,
Bernard Pignon, Christian Berthou, FranGois Maloisel, Denis Guyotat, Philippe Casassus, Norbert Ifrah, Yves Lamy,
Bruno Audhuy, Philippe Colombat. and Jean-Luc Harousseau
A phase 111 prospective randomized multicenter study was
performed t o determine whether quinine could improve the
response rate of poor-riskacute leukemias (ALs) t o standard
chemotherapyincluding a multidrug resistance (MDR)-related cytotoxicagent. The rationale of the study was based
on thenegative prognostic value of MDR phenotype in ALs
and the ability of quinine t o reverse this phenotype both in
vitro and ex vivo. Three hundred fifteen patients (median
age, 49 years; range, 16 t o 65) with relapsed (n = 108) or
refractory (n = 32) acute myeloblastic leukemia (AML), relapsed (n = 27) or refractory (n = 9) acute lymphoblastic
leukemia (ALL), secondary AL (n = 22) or blastic transformation of myelodysplastic syndrome ([MDS] n = 74) or myeloproliferative syndrome ([MPS] n = 4 3 ) were randomly assigned t o receive mitoxantrone ([MXNI 12 mg/m2/d, days 2
t o 5) and cytarabine ([Ara-Cl 1 g/m2/12 h, days 1 t o 5) alone
or in combination with quinine (30 mg/kg/d, days 1 t o 5;
continuous intravenous infusion beginning 24 hours before
MXN infusion). Side effects of quinine were observed in 56
of 161 quinine-treated patients and disappeared in all but
four cases after one or t w o 20% dose decreases. Sera from
quinine-treated patients showed increased MXN uptake in
an MDR-positive cell line compared with matched sera obtained before quinineinfusion. Quinine induced a significant
increase in the incidence of nausea, vomiting, mucositis, and
cardiac toxicity. A complete response (CR) was observed in
85 of 161 patients (52.896) from the quinine-treated group
versus 70 of 154 patients (45.5%) in the control group(P=
.19). The most important differences between quinine and
control group CR rates were observed in patients with refractory AMLs and blastic transformation of MDS andMPS.
The CR rate was higher in P-glycoprotein-positive cases,
although the difference was not significant. Failure of the
regimen due t o blastic persistence or blast number increase
was higher in the control group (61 of 154 patients) than in
the quinine group (45 of 161, P = ,041. Early death was observed in eight cases (four in each arm) and death in aplasia
in 27 cases (20 in quinine group Y seven in control group, P
= .01). The significant increase of toxicity in thequinine arm
could have masked the clinical benefit of MDR reversion in
poor-risk ALs.
0 1996 by The American Society of Hematology.
T
ciently in vitro by a number of noncytotoxic agents.’”’ The
in vivo use of most of these agents is precluded by serum
protein binding or clinical toxicity,”,“ and circumvention of
the MDR phenotype has not yet proven clinically useful.
We previously showed that intravenous infusion of conventional doses of quinine allowed attainment of a sufficient
concentrationin serumto reverse the anthracyclineresistance of rat colon cancer cells and MDR human leukemic
cells.’J~15Then,we defined theconditionsfor
the use of
1/11
quinineas a MDR modifier”andperformedaphase
clinical trial to demonstrate that quinine could beused safely
in combinationwithmitoxantrone
(MXN) and cytarabine
(Ara-C) for thetreatment of clinically resistant ALS.’‘ Here,
we report the results of a phase I11 multicenter clinical study
designed to answer the question
of whether the response rate
of poor-risk ALstoconventionalchemotherapy
could be
improved by quinine. In thistrial,patients with either relapsed, secondary, or refractory AL were treated with acombination of MXN and high-dose Ara-C.
After randomization,
half the patients also received quinine as a potential MDRreversing agent.
HEMAINREASONforthefailure
of conventional
regimens combining an anthracycline or an aminoanthraquinone with cytarabine or etoposide for the treatment
of acute leukemias (ALs) is the primary or secondary resistance of leukemic cells to cytotoxic drugs.According to the
Goldie and Coldman’hypothesis, these regimens select drugresistant clones that develop by spontaneous mutation or
tumor celladaptation. In vitro cell culture systems
have identified several mechanisms of cellular resistance to cytotoxic
drugs. One of these mechanisms is characterized by the multidrug resistance (MDR) phenotype that is associated with
increased expression of the mdrl gene product,called Pglycoprotein, in the leukemic cell plasma membrane.’ This
increased expression has been identified in clinical samples,
mainly from relapsed and refractory ALs, and related
to a
lower response rate to conventional treatment and a shorter
event-free survival and overall ~urvival.~” Thedecreased
intracellular accumulation of a variety of cytotoxic agents,
characteristic of the MDR phenotype, can be reversed effi-
From the Clinical Hematology Unit, Centre Hospitalirr Univer,sitaire (CHU) Le Bocage, Dijon, France.
Submitted February 26, 1996; accepted April 12, 1996.
Supported by grants from the Direction de la Recherche Clinique
and the Ligue Bourguignonne Contre le Cancer.
Address reprint requests to Eric Solary,MD, Clinical Hematology
Unit, CHU Le Bocage, BP1542, 21034 Dijon Cedex, France.
The publication costs of this article were defrayedin part by page
chargepayment. This article must thereforebeherebymarked
“advertisement” in accordance with 18 U.S.C. section 1734 solely to
indicate this fact.
0 1996 by The American Society of Hematology.
0006-4971/96/8804-0020$3.00/0
1198
PATIENTS AND METHODS
Patients. The study was an open phase 111 prospective randomized trial with15 participating medical centers, performed from
March 1992 to February 1995. The protocol received approval from
the ethics board of the Dijon hospital. Before therapy, all patients
provided informed consent after having been advised about the purpose and investigational nature of the study, as wellas potential
risks. Patients eligible for the study were older than 14 and younger
than 66 years, with a bone marrow diagnosis of acute nonlymphoblastic or acute lymphoblastic leukemia (ALL) as defined by the
French-American-British classification system.” These patients eiBlood, Vol 88, NO 4 (August 15). 1996: pp 1198-1205
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
1199
MDR REVERSION IN ACUTELEUKEMIAS
ther had relapsed from or were refractory to standard first-line chemotherapy. Refractory patients were defined as those with de novo
AL failing to achieve complete remission (CR) after one or two
cycles of chemotherapy. Relapsed patients included those with acute
nonlymphoblastic leukemia or ALL who achieved a previous CR
with a standard therapeutic regimen, which sometimes included autologous or allogeneic bone marrow transplantation. Patients with
secondary leukemia or blastic transformation of myelodysplastic
(MDS) or myeloproliferative (MPS) syndromes were also eligible.
Other eligibility criteria included adequate kidney and hepatic function (creatinine <250 pmol/L, serum bilirubin < 14 m&, and transaminases <4N), adequate cardiac ejection fraction as measured by
echocardiography (>30%) or radionuclide ejection (>50%), and
cumulative dose of anthracycline less than 400 mg/m2 adriamycinequivalent. Patients with recent myocardial infarction or vascular
cerebral infarction and those with known hypersensitivity to quinine
were ineligible. Random permuted blocks of 10 were used to generate the randomization list. No stratification was used.All randomizations were performed by the Clinical Hematology Unit of the Dijon
hospital. The data were collected centrally by this office and were
subsequently reviewed by three clinicians.
Regimen. The therapy regimen consisted ofAra-C 1 g/m' administered by 2-hour intravenous infusion twice daily on days 1
through 5 and MXN 12 mg/m' as a 30-minute infusion on days 2
through 5. After randomization, half the patients received quinine
formiate (Quinimax; Labaz Laboratories, Paris, France) at a dosage
of 30 mg/kg/d started 24 hours before the first dose of MXN and
administered as a continuous intravenous infusion until 24 hours
after the end of the last MXN infusion. Toxicity was assessed according to the World Health Organization (WHO) grading system.
CR was defined by the presence of less than 5% leukemic blast cells
in the bone marrow, their disappearance from the blood and possible
extramedullary sites, including the cerebral fluid, and an increase of
the peripheral granulocyte count to greater than 1,00O/pL. Partial
response was defined by a percentage of bone marrow blast cells
less than 25%, a percentage of peripheral blood blast cells less than
5%, and peripheral blood granulocyte count higher than l,OOO/pL.
In patients in CR, the duration of critical cytopenia was evaluated
by the time required for leukocyte (>500/pL), granulocyte (>500/
pL), and thrombocyte (> 100,OOO/pL) recoveries and the red blood
cell transfusion requirement (hemoglobin <80 g/L) from the onset
of treatment.
Quantzjication of quinine concentrations in semm. Total quinine
concentrations were determined as previously described.18 Patient
serum was mixed with 0.5 mol/L borate buffer, pH 9.8, and hydroquinidine as internal standard. Extraction was performed with a mixture of dichloromethane and isoamylic alcohol (98:2 vol/vol). After
centrifugation, the organic phasewas evaporated to dryness, dissolved in the mobile phase (potassium dihydrogen phosphate 0.045
moUL, acetonitrile 4:1 vol/vol, pH 3.8), and injected into the highperformance liquid chromatography (HPLC) apparatus equipped
with a U6K injector and a M45 pump (Waters Associates, SaintQuentin-en-Yvelines, France). The column was a Nova-pak C18
(150 X 3.9 mm, 5 pm). Detection was made with a FP 210 spectrofluorometer (Prolabo, Vaux-en-Velin, France) with excitation and
emission wavelengths of 350 and 440 nm, respectively. Retention
times were 2.4 and 3 minutes for quinine and hydroquinidine, respectively.
Ex vivo assay. To determine the ability of serum from quininetreated patients to increase the MXN intracellular concentration by
reversing the MDR phenotype, we designed an ex vivo flow-cytometry assay using the CEMNLB human leukemic cell line (Genne et
al, manuscript submitted). This cell line overexpressed both mdrl
mRNA and P-glycoprotein (not shown). CEMNLB cells (2 x IOs)
were seeded in microtiter plates (24 wells/plate) and cultured for 24
hours, and then incubated for 2 hours at 37°C with 20 pmoUL MXN
diluted in serum samples obtained from patients either before or 2
days after the beginning of quinine infusion. After a 2-hour incubation, cells were rinsed three times with ice-cold phosphate-buffered
saline and resuspended in phosphate-buffered saline (PBS) for measurement of MXNintracellular accumulation, using a Becton Dickinson (Pont de Claix, France) FACScan flow cytometer at an excitation
of 488 nm and an emission of 675 nm.
Detection of P-glycoprotein. P-glycoprotein expression was determined using MRK16, a monoclonal antibody that recognizes the
extracellular determinant of P-glycoprotein (Immunotech, Luminy,
France), and a previously described indirect immunofluorescent
assay." Briefly, cells werefixed in 1% paraformaldehyde for 30
minutes at 4°C and incubated inhuman AB serum before a 30minute incubation with MRK16 antibody (2 pg/mL), and then with
fluorescein-conjugated F(ab'), fragments of goat anti-mouse IgG
(37.5 pg/mL; Silenius Laboratories, Paris, France). The percentage
of positive cells was determined by cytofluorimetry on gated blast
cells using a Becton Dickinson FACScan flow cytometer. A nonrelesame goat
vant IgG2a (Coulter, Raritan, NJ) wasusedwiththe
antimouse second-step reagent to calibrate the assay on the FACScan
and determine the positivity for individual cells. P-glycoproteinpositive K562/ADM cells were used as a positive control. Various
cutoff values for positivity were tested.
Statistical analysis. According to previous studies, the CR rate
induced by the MXN-Ara-C regimen was approximately 50%.19-2'
The study was designed to detect a 20% improvement intheCR
rate (two-sided test) with a significance level of .05. A total of 137
patients per treatment group was calculated to be necessary to reach
this goal, whichwas expected to require 3 years. At the time of
statistical analysis, categorical data obtained from the patients before
treatment and their response rates were compared by the x' test or
Fisher's exact test in cases of small expected values. The MantelHaenszel test was used for adjustment ofthe results for thesex
imbalance. The t test for nonpaired samples was used to compare
quantitative parameters. A two-way ANOVA was performed to compare hepatic enzymes and bilirubinemia changes during treatment
in both arms of the trial. A stepwise logistic regression model was
used to assess the joint effect of prestudy variables on response.
Validity of the model was evaluated by the Homer-Lameshow test.
Statistical analyses were made with either Statview (Alsyd, Meylan,
France) or BMDP software systems.
RESULTS
Characteristics of patients. From March 1992 to February 1995, 328 patients entered the study. Data were obtained
from 318 patients. One patient was not eligible (diagnosis
error), and two were not assessable (one did not receive the
treatment, and the other died after randomization and before
treatment onset). Three hundred fifteen patients were assessable: 161 received quinine, and 154 were treated without
quinine. Despite the lack of stratification at initial randomization, the two arms of the study were well balanced in the
15 centers. Initial diagnoses of these assessable patients and
their pretreatment characteristics are summarized in Table
1. MPSs included chronic myelogenous leukemias (n = 32),
polycythemia vera (n = 6), essential thrombocytemia (n =
3), and myelofibrosis (n = 2). The only significant imbalance
in the pretreatment variables was the higher number of
women in the control arm ( P = .03). Analysis of response
rates was adjusted for this imbalance.
Serum quinine levels and MDR-reversing activity of sera.
Serum samples from 40 patients (n = 20 per treatment arm)
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SOLARY ET AL
1200
Table 1. Pretreatment Characteristics of Patients at Study Entry
Characteristic
Median age (yr)
46.0
Sex (n)
Male
Female
Previous MDR-related drugs (n)"
No
Yes
Diagnosis (n)
Refractory AML
Relapsed AML
Refractory ALL
Relapsed ALL
Secondary AL
M DS
M PS
Previous bone marrow transplantation (n)
None
Autologous
Allogeneic
Duration of first CR (mo)
Median
Range
(n)
Time between chronic and acute-phase MDS and MPS (mo)
Median
Range
(n)
Performance status, WHO grade (n)
0
1I2
314
Extramedullary site (n)
No
Yes
White blood cell count at diagnosis (per bL)
Median
Mean
Range
Mean hemoglobin (g/dL)
Mean platelet count (x1.0001~L)
Mean peripheral blood blast cell count (%)
Mean marrow blast cell infiltration (%)
Without Quinine
(n = 154)
With Quinine
(n = 161)
49.5
Total
( n = 315)
P
49.0
NS
84
70
107
54
191
124
.02
53
101
58
102
111
203
NS
15
55
5
13
12
36
18
17
53
4
14
10
38
25
32
NS
108
9
27
22
74
43
146
4
4
150
9
2
296
13
6
NS
11.0
0-288
91
8.0
0-70
88
9.0
0-288
179
NS
17.5
0-157
54
15.0
0- 180
63
16.0
0-180
117
NS
23
117
14
28
115
18
51
232
32
NS
119
35
127
33
246
68
NS
3.7
23.4
0.2-425
98.6
93.2
29.7
57.2
5.5
23.5
0.7-256
99.6
86.7
20.7
53.0
4.7
23.5
0.2-425
99.1
89.9
20.7
55.1
NS
NS
NS
NS
NS
Abbreviation: NS, not significant.
MDR-related drugs included anthracyclines, vinca alkaloids, and epipodophyllotoxins.
were tested before and at day 2 of treatment. In quininetreated patients, sera obtained on day 2 showed increased
MXN uptake in CEMNLB cells compared with matched
sera obtained before treatment (mean k SD, 43% 2 30%;
range, 13% to 117%).The mean concentration of quinine in
these samples was 6.5 pg/mL (range, 1.5 to 13.0). When
tested under the same conditions, sera from control patients
did not demonstrate any significant effect on MXN accumulation (data not shown). When various concentrations of quinine were added to a control serum, a linear relationship was
observed between quinine concentration and MXN uptake
in CEMNLB cells incubated for 2 hours in this serum (R2
= .97, P = .0003; Fig 1A). The same experiment was per-
formed with sera obtained before and 2 days after the beginning of treatment in 20 quinine-treated and 20 control patients. Although less significant (R2 = .67, P = .03; Fig lB),
a linear correlation was again found between quinine serum
level measured by HPLC and MXN uptake in CEMNLB
cells.
Toxicity of quinine. Adverse effects due to quinine infusion were observed in 56 of 161 quinine-treated patients
(34.8%) and included tinnitus (45 of 161,28%),vertigo (24
of 161, 14.9%),and tachycardia or bradycardia (six of 161,
3.7%). Mild hearing loss was also reported in 10 patients
(6.2%). In 48 patients, quinine-induced side effects decreased or disappeared after a unique 20% quinine dose
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
1201
MDRREVERSIONINACUTELEUKEMIAS
T
e
V
0
4
8
12
l
0
e
4
8
1 2 1 6
Quinine serum level (pglml)
Fig 1. Effects of serum M X N uptake in MDR-positive CEMlVLB
cells. (A) Effects of various concentrations of quinine added to a control serum (RZ= .97). (B) Relationships between serum quinine level
determined by HPLC in serum samples from patients and M X N uptake in CEM/VLB cells (R2= ,671.
decrease. In four patients, an additional 20% dose decrease
was necessary. In the last four patients. quinine infusion was
stopped after day 2 (one patient) or day 3 (three patients),
due to an excessive QT interval increase or bradycardia. The
mean age of patients who demonstrated hearing loss was
significantly higher than the mean age of patients who did
not report a hearing change (53.5 5 13 1’44.2 ? 14.2 years,
P < .OS). No relationship was found between side effects
and other pretreatment characteristics of patients. In quininetreated patients, the occurrence of quinine-related side effects
was associated with a significant increase in the timeto
discharge from hospital (37.8 ? 11.7 11 31.4 ? I I .0 days, P
< .0008) and leukopenia duration (27.7 ? 1 1.4 1’ 22.3 ? 8.7,
P = .02). By contrast, no difference was observed between
quinine-treated patients who did not receive quinine and the
control group.
Nonhematopoietictoxicity.
The nonhematopoietic toxicity associated with the regimen is reported in Fig 2. Quinine
infusion significantly increased the incidence of nausea,
vomiting, and .mucositis. The duration of these side effects
was slightly increased in quinine-treated patients, but the
differences did not reach significance. By contrast, quinine
had no influence on renal and hepatic toxicity and did not
induce a significant increase of bilirubinemia. Although cardiotoxicity was reported in only six patients during quinine
perfusion, late toxicity (mainly cardiac failure) was observed
in 10 additional patients from the quinine arm. compared
with two patients from the control arm ( P = .03). Twelve
of 16 patients who demonstrated cardiotoxicity were older
than 50 years. In six patients, cardiotoxicity was reported in
the absence of previous anthracycline treatment.
Hrntatologictoxicity.
Among responding patients, quinine slightly increased the median timeto leukocyte recovery
over SOO/pL, granulocyte recovery over 500/pL, platelet recovery over 50.000/pL. and hemoglobin recovery over 8 g/
dL (Table 2). However, only the time to platelet count recovery in the relapsed AML group was significantly increased
by quinine (mean, 35.6 2 12.5 v 29.4 ? 9.9 days. P = .037).
In this group of patients, quinine also significantly increased
the meantime to discharge fromhospital (38.1 ? 10.0 v
32.1 ? 10.0 days, P = .007). Seven responding patients
from the control group and ninefrom the quinine-treated
group never recovered a platelet count over 100 X I O 9 L
Similarly. 13 responding patients from the control group and
I I patients from the quinine-treated group required red blood
cell transfusions for longer than 60 days. Quinine did not
significantly increase the incidence of febrile episodes or
aspergilloses (Table 2).
Response to treatment. CR rates are listed in Table 3.
Univariate analysis indicated that the overall CR rate was
associated with younger age. lower white blood cell count,
and lower percentages of peripheral blood and marrow blast
cells at diagnosis (not shown). When these parameters were
entered in the logistic regression in association with quinine
and sex, a higher CR rate was related only to age less than
40, lower white blood cell count, and lower percentage of
marrow blast cells. The CR rate was higher in the quinine120
100
Heart
p = 0.03
51
1
0
1
2
3
4
0
1
WHO grade
2
3
4
Quinine
w/o Quinine
0
1
2
3
4
WHO grade
Fig 2. Effects of quinine infusion on the incidence and severom
(according to the WHO grading system) of side effects induced by
chemotherapy. NS, not statistically significant.
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
1202
SOLARY ET AL
Table 2. Hematologic Toxicity of the Two Arms of the Trial
and Its Consequences on the Duration of Hospitalization
and Febrile Episodes
Without
Quinine
ToxicityIEffect
Leukopenia (d)
Mean ? SD
Median
Neutropenia (d)
Mean i SD
Median
Thrombopenia (d)
Mean ? SD
Median
Anemia (d)
Mean f SD
Median
Time to discharge from hospital (d)
Mean 2 SD
Median
No. of febrile episodes
No. of CR/No. of Cases (%)
Without
Quinine
P
With Quinine
22.3 -t 7.9
22.0
23.9 f 9.1 .26
23.0
25.9 ? 7.8
25.0
28.2 i 9.2 .l0
26.0
P-GlycoproteinPositive Cells (%)
2 1
25
210
28.6 t 10.0 31.6 ? 11.5 .l1
32.0
27.0
29.0 t 8.8
28.0
32.1 t 12.0 .l0
30.0
35.5 f 17.9 35.8? 8.8
33.0
32.5
1
2
3
4
5
6
No. of aspergillosis episodes
Table 4. Relationships Between P-Glycoprotein
Expression and CR Rate
22
8
67
56
18
5
0
27
6
51
61
27
14
1
NS
NS
NS
Abbreviation: NS, not significant.
treated group (85 of 161 patients, 52.8%) than in the control
group (70 of 154 patients, 45.5%), but the difference was
not significant ( P = .19). The estimated relative odds ratio of
CR (quininekontrol) adjusted for sex was 1.32 (confidence
interval, 0.81 to 2.00). Quinine significantly improved the
CR rate in previously treated patients who relapsed after a
first CR shorter than 18 months (42 of 76 patients in the
quinine arm v 26 of 67 in the control arm, P < .05). In MDS
and MPS, the CR rate was significantly improved by quinine
when the delay from chronic phase to blastic phase was less
than 48 months (eight of 14 patients in the quinine arm v
26 of 67 in the control arm, P < .05).
Failure of the regimen due to blastic persistence or blast
number increase was higher in the control group (61 of 154
patients) than in the quinine group (45 of 161 patients, P =
No.
With Quinine
%
40
14/35
7120 15/2554
44
4/13
%
No.
28145 .05 62
60
9/17.28 53
P
.09
.04). Eight patients died during treatment (four in each arm).
Twenty-seven patients died in aplasia after day7:seven
were inthe control group (refractory AML, one; relapsed
AML, three; and blastic phase of MDS, three) and 20 in the
quinine group (refractory AML, two; relapsed AML, six;
relapsed ALL, four; secondary AL, two; blastic phase of
MDS, three; and blastic phase of MPS, 3; P = .01). Postremission therapy was heterogeneous. The median duration of
CR was 6.0 months and median survival was 11.5 months,
without significant differences between control and quininetreated groups.
Relationships between response rate and P-glycoprotein
expression. P-glycoprotein expression was determined on
blast cells from 102 patients (control arm, 47; quinine arm,
5 5 ) using MRK16 monoclonal antibody. Its expression
ranged from 0% to 86% of positive cells. This expression
was greater than 5% in 45 patients and greater than 10% in
30 patients, without a significant difference between treatment groups. The CR rate was higher in P-glycoproteinpositive cases at all tested cutoff values for P-glycoprotein
positivity (Table 4). However, these differences never
reached statistical significance. Similarly, no relationship
was found between either CD34 expression on blast cells or
other biologic or clinical pretreatment parameters and the
influence of quinine on the response rate (not shown).
DISCUSSION
Although there is evidence that MDR phenotype is a prognostic factor in ALs, the issue of whether P-glycoprotein is
a useful therapeutic target is still unresolved. Combined therapy with MDR-related drugs and P-glycoprotein modulators
prolonged the life span in some animal
and en-
Table 3. Number of Patients Who Achieved CR Related to the Total Number of Patients in Each Group
Without Quinine
Group
All patients
Refractory AML
Relapsed AML
Refractory ALL
Relapsed ALL
Secondary AL
Blastic phase of MDS
Blastic phase of MPS
%
No.
851161
7011
54
4115
33/55
315
4113
511 2
16/36
10125
511 8
Abbreviation: NS, not significant.
With Quinine
411
511
45.5
26.7
60.0
60.0
30.8
41.7
50.0
44.4
27.8
No.
1551315
12/32
8117
671108
34/53
619314
8/27 4
10/22
0
237/74
1/38
15/43
Overall
%
52.8
47.1
64.2
75.0
28.6
50.0
55.3
40.0
No.
%
P
49.2
37.5
62.0
66.7
29.6
45.4
NS
NS
NS
NS
NS
NS
NS
NS
34.9
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
MDR REVERSION IN ACUTELEUKEMIAS
1203
couraging results have been obtained in individual cases23 the brain stem. Nausea and vomiting could also be the consequence of an increased drug exposure as an effect of quinine
and phase VI1 pilot studies.'6324Here, we report the first
infusion on MXN pharmacokinetics in humans.29 Bothveralarge randomized trial that evaluates the clinical relevance
pamil and cyclosporin were reported to increase the plasma
of MDR reversion in ALs. Although this study failed to
area under the curve of several MDR-related drugs in anidemonstrate a significant increase in the response rate for the
mals
Cinchonine, a diastereoisomer of
quinine arm, several arguments suggest that MDR reversion and
quinine and a potent MDR-reversing agent in vitro and in
could improve the efficacy of conventional treatments invivo, did not modify doxorubicin pharmacokinetics in rat
cluding an MDR-related agent. The most important effects
but modified the distribution of the cytotoxic drug in several
of quinine on the response rate were observed in refractory
tissues.33 Such a pharmacokinetic effect could explain the
AML and blastic transformation of MDS and MPS, which
increased incidence of mucositis and could be involved in
are also the most resistant ALs to conventional therapy.
the increased cardiotoxicity of the regimen observed mainly
Moreover, quinine induced a significant decrease in the failin older patients.34Whatever its mechanism, this significant
ure rate due to blastic persistence or blastic growth during
increase in toxicity of the regimen could have masked the
treatment. Lastly, there was a trend for quinine to improve
clinical benefit of MDR reversion, and better management
the response rate in P-glycoprotein-positive ALs. Therefore,
of this toxicity could reveal the clinical advantage of the
quinine could be useful in a selected group of poor-risk
combination.
leukemias that overexpress P-glycoprotein.
P-glycoprotein is expressed only in a subset of patients,
The lack of significant improvement in the overall reand leukemic cells without P-glycoprotein should not response rate could be related to insufficient potency of quinine
spond toattempted modulation. Previous studies have shown
as MDR-reversing agent. Quinine andmany other agents
that the number of P-glycoprotein-expressing cases was
tested so far are first-generation chemosensitizers that have
higher in poor-risk ALs than in de novo ALs.3-7.35
However,
been developed for pharmacologic effects other than MDR
results are discordant from one study to another, depending
circumvention. All these agents increase accumulation of
on the disease and the technique chosen to identify MDR
MDR-related drugs in MDR-positive cells in
Quinine
p h e n ~ t y p e Using
. ~ ~ MRK16 monoclonal antibody to detect
also allows subcellular redistribution of doxorubicin in a
P-glycoprotein in 102 assessable patients, MDR phenotype
MDR-positive leukemic cell line.26Many of the potent rewas identified in a limited number of cases, suggesting that
versing agents in vitro are too toxic in vivo at doses that
only a minority of the quinine-treated patients could have
mimic the conditions in vitro.13 Consequently, a number of
been sensitive to MDR-reversing activity in our series of
studies actually used suboptimal concentrations. Even when
patients. Moreover, some P-glycoprotein-positive leukemic
the chemosensitizer plasma level is within the range of concentrations active in vitro, protein binding could limit its
cells could not respond to quinine because of a lack of functional P-glycoprotein. The extent to which mutations and
ability to reverse MDR in V ~ V O . ' * * ' ~ The
* ~ ~ MDR-reversing
polymorphism of P-glycoprotein may confer altered binding
activity of quinine is retained in serum despite serum protein
specificity in leukemic cells is notknown.37Functional MDR
binding. The ability of serum to increase MXN accumulation
phenotype was reported to be predominant in CD34+ leukein a MDR-positive leukemic cell line was linearly related
mic cells, whereas P-glycoprotein could not be functional in
to quinine level in the serum of quinine-treated patients.
CD34- cells.38Nevertheless, no significant relationship was
Conversely, the ability of serum samples from control pafound between CD34 expression and the response to treattients to reverse MDR phenotype did not increase during
ment in 136 patients in whom its expression was studied
cytotoxic treatment (data not shown). However, quinine se(data not shown).
rum levels remained sometimes as low as 1.5 kg/mL at day
2 of continuous intravenous infusion. Tinnitus and vertigo
Two other reasons could account for the lack of clinical
are well-known complications of quinine administration
benefit from quinine in the present study. EvenwhenPwhose appearance was previously related to the highest quiglycoprotein is present and functional, its inhibition could
nine serum levels.27A significant relationship was observed
not be sufficient to render the leukemic cells sensitive
between the occurrence of these side effects and the inenough to a MDR-related cytotoxic drug, due to thepresence
creased duration of neutropenia in responding patients. This
of other mechanisms of resistance in poor-risk A L s . ~Ac~
later effect could be explained by either the reversion of Pcordingly, quinine and other reversing agents could be more
glycoprotein function inbonemarrow precursors28or the
potent in MDR-positive de novo ALs inwhich other mechaalteration of MXN and Arg-C metabolism or excretion by
nisms of resistance might be less present. Lastly, high doses
normal tissues that express the MDR phen~type.'~
Only one
of Ara-C were demonstrated to induce high response rates
third of the patients reported quinine-related side effects,
in poor-risk ALs.@Ara-C is not involved in MDR, and idensuggesting that the quinine serum level could have been too
tification of both MDR phenotype and resistance to Ara-C
low to efficiently inhibit P-glycoprotein in a majorityof
was shown recently to better identify the more resistant
patients.
ALs.~'Therefore, the clinical benefit of quinine could have
P-glycoprotein is expressed in endothelial cells of the cenbeen masked by the efficacy of Ara-C.
tral nervous system and is thought to contribute to the bloodSeveral recent randomized studies also failed to show any
brain barrier.30 Therefore, the increase of nausea and
benefit of MDR-reversing agents, including quinidine and
vomiting in quinine-treated patients could be related to the
verapamil, in terms of response to chemotherapy or length
increased distribution of MXN to the vomiting centers of
of survival in patients with multiple myeloma, small-cell
From www.bloodjournal.org by guest on November 19, 2014. For personal use only.
1204
SOLARY ET AL
lung cancer, and breast ~ a n c e r . ~These
~ - ~ ’ negative results
should not prevent further trials that testthe potential interest
of these and more potent MDR-reversing agents in ALs.
Better management of the regimen toxicityor the use of
second-generation chemosensitizers that have been designed
in this respectzs could improve either the response rate or
the survival. While waiting for the possibility of testing new
compounds in randomized controlled trials, the Groupe Est
Ouest LeucCmies Aigues MyCloblastiques has initiated a
phase 111 study in de novo AML testing the effect of quininemediated MDR reversion on survival.
ACKNOWLEDGMENT
The authors gratefully acknowledge Bruno Chauffert and Philippe
Genne for a critical reading of the manuscript, and Serge Aho for
advice about statistical analysis. This study was performed on behalf
of the GOELAMS group.
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