From www.bloodjournal.org by guest on November 20, 2014. For personal use only. 1999 94: 3694-3701 A Randomized, Double-Blind, Placebo-Controlled Study With Pegylated Recombinant Human Megakaryocyte Growth and Development Factor (PEG-rHuMGDF) as an Adjunct to Chemotherapy for Adults With De Novo Acute Myeloid Leukemia Eric Archimbaud, Oliver G. Ottmann, John A. Liu Yin, Klaus Lechner, Herve Dombret, Miguel A. Sanz, Gerhard Heil, Pierre Fenaux, Wolfram Brugger, Alan Barge, Caroline O'Brien-Ewen, James Matcham and Dieter Hoelzer Updated information and services can be found at: http://www.bloodjournal.org/content/94/11/3694.full.html Articles on similar topics can be found in the following Blood collections Clinical Trials and Observations (3965 articles) Information about reproducing this article in parts or in its entirety may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests Information about ordering reprints may be found online at: http://www.bloodjournal.org/site/misc/rights.xhtml#reprints Information about subscriptions and ASH membership may be found online at: http://www.bloodjournal.org/site/subscriptions/index.xhtml Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American 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 20, 2014. For personal use only. CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS A Randomized, Double-Blind, Placebo-Controlled Study With Pegylated Recombinant Human Megakaryocyte Growth and Development Factor (PEG-rHuMGDF) as an Adjunct to Chemotherapy for Adults With De Novo Acute Myeloid Leukemia By Eric Archimbaud†, Oliver G. Ottmann, John A. Liu Yin, Klaus Lechner, Herve Dombret, Miguel A. Sanz, Gerhard Heil, Pierre Fenaux, Wolfram Brugger, Alan Barge, Caroline O’Brien-Ewen, James Matcham, and Dieter Hoelzer To determine the safety, biologic, and clinical benefits of pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF; Amgen, Thousand Oaks, CA) after myelosuppressive chemotherapy in acute myeloid leukemia (AML), 108 adult patients with de novo AML were randomized to receive either PEG-rHuMGDF (2.5 mg/kg/d or 5 mg/kg/d) for up to 21 doses (group A), a single dose of 2.5 mg/kg PEG-rHuMGDF, 7 daily doses of 2.5 mg/kg PEGrHuMGDF (group B), or placebo. The greatest biologic activity was seen in group A with a median peak platelet count of 1,084 3 109/L, occurring at a median 9 days after the last dose of study drug, compared with 517 3 109/L and 390 3 109/L in group B and placebo group, respectively. Thrombo- cytosis (platelets G1,000 3 109/L) was seen at rates of 52%, 8%, and 9% in groups A, B, and placebo, respectively, but were not associated with any adverse event. There was no effect on median time to transfusion independent platelet recovery (H20 3 109/L). The median time to neutrophil recovery (H500/µL) and red blood cell transfusion requirements were similar in all groups, and there was no apparent stimulation of leukemia. PEG-rHuMGDF was biologically active and well tolerated. Further investigation of dose and scheduling is required, specifically earlier dosing before and during chemotherapy. r 1999 by The American Society of Hematology. A counts fall below 20 3 109/L or 10 3 109/L.6,7 Recent randomized studies have shown that increasing intensity of induction and consolidation therapy in young patients with AML leads to increased disease-free and overall survival.2,5 Such increases in treatment intensity are likely to result in more severe, prolonged thrombocytopenia, with higher associated morbidity rates. Reducing the duration of severe thrombocytopenia could potentially reduce morbidity and mortality rates and the cost of AML therapy.8 Prophylactic platelet transfusions are routinely administered during periods of thrombocytopenia and to treat bleeding events. However, platelet transfusions are expensive and subject to the risks of acute transfusion reactions, alloimmunization, and transmissible disease.9 The recent identification and cloning of thrombopoietin by a number of groups has lead to considerable interest in the application of this agent in the setting of AML.10-16 Polyethylene glycol-conjugated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF; Amgen, Thousand Oaks, CA) is a polypeptide related to thrombopoietin, which includes the receptor-binding N-terminal domain. The polypeptide has 163 amino acids and is conjugated with polyethylene glycol on the N-terminal by reductive alkylation. In vitro, PEG-rHuMGDF is a growth and development factor for megakaryocytes.17,18 Administration of PEGrHuMGDF to normal animals increases megakaryocyte mass and platelet counts.19,20 After myelosuppressive treatment, animals treated with PEG-rHuMGDF recover their platelet counts more quickly than controls.21-23 Early human studies indicate that PEG-rHuMGDF will produce rises in the platelet counts of patients before receiving chemotherapy and will accelerate platelet recovery after myelosuppressive chemotherapy.24,25 The platelets produced in response to PEG-rHuMGDF appear to be morphologically and functionally normal.26 PEG-rHuMGDF appeared to be well CUTE MYELOID LEUKEMIA (AML) is characterized by an uncontrolled proliferation of a clone of immature myeloid cells in the bone marrow, leading to profound myelosuppression. Anemia, neutropenia, and thrombocytopenia are present in most patients at presentation. Intensive induction chemotherapy is the first step of any curative therapy and usually consists of a combination of daunorubicin and cytarabine (Ara-C).1,2 Therapy-related deaths are mainly related to infection.3 Nevertheless, hemorrhagic events are the source of significant mortality and morbidity both before treatment due to diseaserelated coagulation disorders and thrombocytopenia4 and as a result of chemotherapy-induced thrombocytopenia. Thrombocytopenia after chemotherapy may last for 3 weeks or more2-5 and prophylactic platelet transfusions are usually used when platelet From the Hoˆpital Edouard Herriot, Lyon, France; University of Frankfurt, Frankfurt, Germany; Manchester Royal Infirmary, Manchester, UK; University of Vienna, Vienna, Austria; Hoˆpital Saint-Louis, Paris, France; Hospital Universitario Le Fe, Valencia, Spain; Hannover Medical School, Hannover, Germany; CHU Lille, France; University of Tu¨bingen, Tu¨bingen, Germany; and Amgen Ltd, Cambridge, UK. †This paper is dedicated to Prof Eric Archimbaud, Hoˆpital Edouard Herriot, Lyon, France, who died in March 1998. Submitted April 6, 1999; accepted July 26, 1999. Supported by Amgen Ltd, Cambridge. Address reprint requests to Dieter Hoelzer, MD, PhD, Klinikum der JWG-University of Frankfurt, Med. Klinik III/Haematologie/Onkologie, Theodor-Stern-Kai 7, D-60596 Frankfurt, Germany. 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. r 1999 by The American Society of Hematology. 0006-4971/99/9411-0036$3.00/0 3694 Blood, Vol 94, No 11 (December 1), 1999: pp 3694-3701 From www.bloodjournal.org by guest on November 20, 2014. For personal use only. PEG-rHuMGDF AND CHEMOTHERAPY IN AML tolerated at the doses used in these studies. We conducted a study to determine the safety and biologic activity of PEGrHuMGDF in patients undergoing remission induction and consolidation treatment for de novo AML. MATERIALS AND METHODS Patients The study protocol was approved by the institutional review board of the participating centers, and all patients gave written informed consent before the study. Patients aged 16 and over with de novo AML as defined by the French-American-British (FAB) classification system and an Eastern Cooperative Oncology Group (ECOG) performance score of 0, 1, 2, or 3 were eligible. Patients with FAB subtypes M3 and M7, in blast transformation of chronic myeloid leukemia, or with a history of clinically relevant coagulation disorders within the previous 6 months were excluded. Study Design Patients were registered for the trial at the start of the 7-day chemotherapy regimen (day 1) and were randomized on days 5, 6, or 7 to receive PEG-rHuMGDF or placebo. In the first series, patients were randomized to receive either 2.5 µg/kg/d PEG-rHuMGDF subcutaneously (sc), 5 µg/kg/d PEG-rHuMGDF sc, or placebo (1:1:1) from 24 hours after the last dose of chemotherapy until a transfusionindependent platelet count greater than or equal to 50 3 109/L. In the second series, patients were randomized to receive 2.5 µg/kg PEGrHuMGDF sc either as a single dose administered on day 7, or for a duration of 7 days (day 8 to day 14), or placebo (1:1:1). Patients were stratified by age (,60 years and $60 years). The nomenclature for patient groups adopted for analysis was as follows: patients receiving PEG-rHuMGDF in the first series were referred to as group A, patients receiving PEG-rHuMGDF in the second series were referred to as group B, and all patients from both series receiving placebo were combined into a single placebo group. Investigators, study site staff, and monitors were blind to treatment assignment. The first induction chemotherapy was administered from day 1 to day 7. A further 2 courses of chemotherapy could be adminstered within the protocol, with study drug administered after each course as originally randomized. Tests, including diagnostic bone marrow, cytogenetics, full blood count, and blood chemistry were obtained at baseline. Full blood counts were measured daily from the start of study drug, and blood chemistry was obtained at weekly intervals. Remission status was assessed from a bone marrow examination after hematologic recovery. Serum was taken for measurement of antibodies to PEG-rHuMGDF at baseline and at the end of the study. Chemotherapy The first induction chemotherapy consisted of daunorubicin (45 mg/m2) for 3 days, Ara-C (100 mg/m2) twice a day for 7 days, and etoposide (100 mg/m2) for 5 days (DAV 31715). The second course of chemotherapy was determined by age and by remission status. Patients younger than 60 years old received a second course of DAV 31715, if in remission, and Ara-C (1 g/m2) for 4 days and mitoxantrone (12 mg/m2) for 3 days (MiDAC) if not in remission. All patients greater than or equal to 60 years old, regardless of remission status, received a second course consisting of daunorubicin (45 mg/m2) for 2 days, Ara-C (100 mg/m2) twice a day for 5 days, and etoposide (100 mg/m2) for 5 days (DAV 21515). Patients not in complete remission (CR) after a second induction were considered to have completed the study. After CR, patients aged less than 60 years old received Ara-C (3 g/m2) for 6 days and daunorubicin (30 mg/m2) for 2 days; patients older than or equal to 60 years old received DAV 21515 followed by the study drug. 3695 All chemotherapy courses were followed by the study drug as randomized. Transfusion Policy Prophylactic platelet transfusions were given in the absence of other clinical indications when the morning platelet count was less than 20 3 109/L. Therapeutic transfusions were administered when clinically indicated according to institutional policy. Packed red blood cell (RBC) transfusions were given when the hemoglobin level was less than 8 g/dL or when clinically indicated. Statistical Analysis All patients who received at least 1 dose of the study drug were included in the analyses. The time to transfusion-independent platelet recovery, neutrophil recovery, and peak platelet count were compared between the treatment groups by using the log-rank test. The days of platelet transfusion and of RBC transfusion were compared between groups by using the Kolmogorov-Smirnov test. The number and types of transfusion and reasons for transfusion were tabulated by treatment group. All statistical tests have been performed with a two-sided alternative hypothesis and the a 5 0.05 (5%) level of significance. Estimates of treatment difference have also been calculated along with associated 95% confidence intervals. RESULTS Patients One hundred eleven patients were registered in the trial, however, only 108 were randomized because 3 patients withdrew before randomization through ineligibility, death, and withdrawal of consent. In the first series, 24 patients were randomized to each of the PEG-rHuMGDF dose-to-target cohorts and 22 were randomized to placebo. In the second series, 12 patients were randomized to the single dose group, 14 to the 7-day dose group, and 12 to the placebo group. Patients treated with PEG-rHuMGDF in the first and second series are referred to as groups A and B, respectively, and the 2 placebo groups have been combined. There were no significant differences between the groups with respect to age or other baseline characteristics (Table 1). The number of patients starting each course of chemotherapy is shown in Table 2. There were 8 deaths during the study (3 patients in groups A/B, 5 patients in placebo); of the 8 deaths, 7 occurred during induction treatment and 1 after the second consolidation treatment. Eight patient withdrawals were due to adverse events (5 patients in groups A/B, 3 patients in placebo) and 1 was due to withdrawal of consent (group B). Five patients proceeded to alternative chemotherapy after completion of the first induction course (4 patients from groups A/B, 1 patient from the placebo group). Disease Outcome The remission rates for the individual patient cohorts are given in Table 3. The overall remission rate in the study population was 60% after 1 course of chemotherapy and 76% after 2 courses. There was no evidence of an effect of PEG-rHuMGDF on remission rate. Effect of PEG-rHuMGDF on Platelet Recovery Induction. The median daily platelet count for each individual treatment schedule, at the first induction, is shown in Fig From www.bloodjournal.org by guest on November 20, 2014. For personal use only. 3696 ARCHIMBAUD ET AL Table 1. Demographics and Disease Characteristics Group B Group A PEG-rHuMGDF 2.5 µg/kg/d to Target (%) No. of patients Age ,60 yr $60 yr Median (yr) Range Sex Male Female ECOG status 0 1 2 3 FAB subtype M0 M1 M2 M4 M5 M6 Not assessed Cytogenetic status Normal Abnormal* Good Intermediate Poor Not assessed PEG-rHuMGDF 5 µg/kg/d to Target (%) PEG-rHuMGDF 2.5 µg/kg/d Single Dose [Day 8 only] (%) PEG-rHuMGDF 2.5 µg/kg/d [Days 8 to 14] (%) Placebo (%) 24 24 12 14 34 17 (71) 7 (29) 49 19-71 16 (67) 8 (33) 48 20-77 8 (67) 4 (33) 55 21-78 7 (50) 7 (50) 60 17-71 23 (68) 11 (32) 52 20-75 11 (46) 13 (54) 14 (58) 10 (42) 5 (42) 7 (58) 11 (79) 3 (21) 16 (47) 18 (53) 2 (8) 17 (71) 4 (17) 1 (4) 10 (42) 10 (42) 4 (17) 0 (0) 3 (25) 7 (58) 2 (17) 0 (0) 6 (43) 7 (50) 1 (7) 0 (0) 6 (18) 20 (59) 6 (18) 2 (6) 1 (4) 6 (25) 6 (25) 6 (25) 3 (13) 1 (4) 1 (4) 0 (0) 4 (17) 12 (50) 5 (21) 3 (13) 0 (0) 0 (0) 1 (8) 4 (33) 2 (17) 2 (17) 1 (8) 1 (8) 1 (8) 1 (7) 2 (14) 3 (21) 1 (7) 4 (29) 1 (7) 2 (14) 0 (0) 9 (26) 9 (26) 8 (24) 6 (18) 2 (6) 0 (0) 11 (46) 12 (50) 2 (8) 1 (4) 9 (38) 1 (4) 9 (38) 12 (50) 3 (13) 6 (25) 3 (13) 3 (13) 6 (50) 6 (50) 2 (17) 3 (25) 1 (8) 0 (0) 5 (36) 7 (50) 1 (7) 4 (29) 2 (14) 2 (14) 12 (35) 20 (59) 7 (35) 5 (25) 8 (40) 2 (6) *Good: t(15,17), t(8,21), inv(16); Intermediate: abnormal; Poor: monosomy 5, 7, 7q-, 5q-, trisomy 8, 11q 23 abnormalities, complex abnormalities. 1. On subsequent grouping of patients from the 4 MGDF treatment schedules into groups A and B, group A patients showed a dose-dependent stimulation of platelet count peaking a median of 9 days after stopping the study drug and a median of 20 days and 13 days in group B and placebo patients, respectively. Taken from the start of chemotherapy, the median time to peak platelet count was 29, 27, and 28 days in the 3 groups, respectively. Table 4 shows the platelet parameters; the median peak platelet count in group A was 1,084 3 109/L, compared with 517 3 109/L and 390 3 109/L in group B and placebo patients, respectively. In addition, platelet counts rose to greater than or equal to 1,000 3 109/L in 52%, 8%, and 9% of patients in the 3 groups. The stimulation of platelet production in group A did not translate into a significant shortening of the time to transfusion-independent platelet recovery to greater than or equal to 20 3 109/L. Figure 2 shows that there was no difference in the median time to transfusion-independent platelet recovery between all patient groups. There was no signifiTable 2. Number of Patients Undergoing Chemotherapy Courses Induction 1 Induction 2 Consolidation 1 Consolidation 2 Group A Group B Placebo 48 16 28 3 26 6 12 3 34 9 19 4 cant difference in the number of days on which a platelet transfusion was required (4, 5, and 5.5 days in groups A, B, and placebo, respectively; group A v placebo, P 5 .41; group B v placebo, P 5 .44). Remission status was not an influencing factor as time to platelet recovery for patients with persistent disease was similar to those achieving CR. There was no effect of PEG-rHuMGDF administration on time to neutrophil recovery to greater than or equal to 500 3 109/L (24.5, 28, and 26 days in groups A, B, and placebo, respectively). Granulocyte colony-stimulating factor (G-CSF) usage was balanced between the groups. Consolidation. The median daily platelet count for each individual treatment schedule at the first consolidation is shown in Fig 3; the platelet parameters are summarized in Table 5, and time to platelet recovery is shown in Fig 4. There was no significant difference between any of the curves presented in Figs 3 and 4. Thus, none of the patient groups undergoing consolidation and treated with PEG-rHuMGDF behaved differently from other groups nor from placebo treated subjects in terms of platelet response, which reflects the response found at induction. Adverse Events The nature and incidence of reported adverse events were similar in all treatment groups for all phases of the study. In From www.bloodjournal.org by guest on November 20, 2014. For personal use only. PEG-rHuMGDF AND CHEMOTHERAPY IN AML 3697 Table 3. Outcome of Induction Chemotherapy Group A Group B PEG-rHuMGDF 2.5 µg/kg/d to Target PEG-rHuMGDF 5 µg/kg/d to Target PEG-rHuMGDF 2.5 µg/kg/d Day 8 PEG-rHuMGDF 2.5 µg/kg/d Days 8 to 14 All PEG-rHuMGDF Patients Placebo 24 16 8 0 67% 24 13 10 1 54% 12 8 3 1 67% 14 7 6 0 50% 74 44 27 2 59% 34 21 9 4 62% 7 3 4 0 43% 9 4 4 1 44% 2 1 0 1 50% 4 2 2 0 50% 22 10 10 2 45% 9 7 2 0 78% 79% 71% 75% 64% 73% 82% Induction 1 No. of patients Complete remission Persistant disease Induction 1 deaths Remission rate after induction 1 Induction 2 No. of patients Complete remission Persistant disease Not assessed Remission rate after induction 2 Overall remission rate Remission rate odds ratio (all PEG-rHuMGDF patients v placebo patients). Induction 1: 0.91 (0.40, 2.09); Induction 2: 0.23 (0.04, 1.35). induction 1, the most frequently reported events considered related to the study drug were fever (PEG-rHuMGDF 4%, placebo 0%) and thrombocytosis (.1,000 3 109/L) (PEGrHuMGDF 13%, placebo 0%). All other events reported as treatment related were single patient reports. In consolidation, the overall incidence of treatment-related adverse events was 8% in PEG-rHuMGDF treated patients and 4% in the placebo group, for which all were single patient reports (1 case each of colitis, rash, and thrombophlebitis in the active groups and 1 case of venous thrombosis in the placebo group). There were 4 reports of thrombotic events during the study period, 2 in PEG-rHuMGDF and 2 in placebo patients (Table 6); the platelet counts at the time of each event do not show an association with the administration of the study drug. There were no differences between the treatment groups in the nature, frequency, or severity of events. Overall, PEG-rHuMGDF was well tolerated. No neutralizing antibodies to MGDF were detected in serum samples obtained from 103 patients before and after the study drug was administered with a solid phase screening radioimmunoassay. DISCUSSION This is the first reported experience of the use of PEGrHuMGDF after chemotherapy for AML and suggests that daily sc doses of 2.5 µg/kg/d and 5 µg/kg/d administered to recovery of a target platelet count stimulate platelet production and are well tolerated. These results are consistent with observations made in other recently published studies of PEG-rHuMGDF in patients with solid tumors.24,25,27 The doses and schedule of PEG-rHuMGDF administered to the first series of patients led to marked thrombocytosis after recovery, peaking 9 days after discontinuing the cytokine. Despite marked postrecovery thrombocytosis, PEGrHuMGDF had no effect on the time to transfusion independent recovery of platelets to greater than or equal to 20 3 109/L. The explanation for this is not clear, but may lie in the kinetics of megakaryocyte differentiation and platelet production in response to PEG-rHuMGDF as indicated by in vitro studies.17 These suggest that there is a relatively fixed time period of 6 to 8 days from exposure of primitive progenitor cells to PEGrHuMGDF and the appearance of megakaryocytes and a further 4-day delay in platelet release. In this study, in the placebo group, spontaneous platelet recovery occurred 14 days after the initiation of the study drug, most likely stimulated by the higher than normal levels of endogenous thrombopoietin in patients with chemotherapy-induced thrombocytopenia.28 In retrospect, it may have been unrealistic to expect PEG-rHuMGDF to Table 4. Platelet Parameters—First Induction Group A Fig 1. Median platelet counts —first induction. No. of patients Median peak platelet count (3109/L) Range Median time to peak platelet count after last dose (days) Range Median time to peak platelet count after start of chemotherapy (days) Range Percentage of patients with platelet count .1,000 3 109/L Median days to transfusion-independent platelet recovery .20 3 109/L Range Group B Placebo 48 26 34 1,084 517 390 33-3,745 25-1,390 18-1,514 9 0-15 20 0-25 13 0-28 29 12-37 27 8-38 28 10-52 52% 21 13-43 8% 20.5 14-32 9% 21 12-36 From www.bloodjournal.org by guest on November 20, 2014. For personal use only. 3698 ARCHIMBAUD ET AL Table 5. Platelet Parameters—Consolidation Group A Group B Placebo No. of patients 31 15 23 416 498 409 Median peak platelet count (3109/L) Range 73-2,425 49-1,041 66-1,101 Median time to peak platelet count after last dose (days) 11 21 14 Range 7-28 12-42 7-32 Median time to peak platelet count after start of chemotherapy (days) 29 28 29 Range 9-43 23-40 22-43 Percentage of patients with platelet 19% 6% 4% count .1,000 3 109/L Median days to transfusion-indepen17 19 19 dent platelet recovery .20 3 109/L Range 14-48 15-34 15-42 Fig 2. Time to platelet recovery (H 20 3 109/L)— first induction. substantially shorten this period of severe thrombocytopenia. As a consequence, there was little impact on the use of platelet transfusions. Although maximum platelet counts exceeding 1,000 3 109/L were observed in approximately 50% of the patients, no excess of thrombotic events was noted in the PEG-rHuMGDF–treated patients. This may indicate that the platelets produced in response to PEG-rHuMGDF function normally and do not exhibit enhanced aggregation in vivo. This is consistent with the observation of relatively modest effects on platelet aggregation activation by PEG-rHuMGDF in vitro29-32 and the absence of activation in vivo.20,26 Interestingly, we also observed platelet counts of greater than 1,000 3 109/L in patients in the placebo group, most likely because of the effects of endogenous hematopoietic growth factors, including endogenous thrombopoietin, after intensive chemotherapy. The most likely explanation for the observed thrombocytosis is the time-dependent generation of megakaryocytes in response to PEG-rHuMGDF, which in vitro takes a minimum of approximately 8 days. Since the maximum platelet counts occurred approximately 8 days after cessation of PEG-rHuMGDF administration, it is likely that progenitor cells, present in the bone marrow at the time of the last few doses, were stimulated to Fig 3. Median platelet counts from start of chemotherapy— consolidation. begin differentiation into megakaryocytes and completed their maturation approximately 8 days later. Another potential contributing factor may be the prolonged circulation of PEGrHuMGDF after discontinuation of therapy. The in vivo halflife of PEG-rHuMGDF in this population has not been evaluated. However, it is estimated to be 30 to 36 hours in cancer patients after conventional chemotherapy.33 The administration of 2.5 µg/kg PEG-rHuMGDF as a single dose and 2.5 µg/kg for 7 days showed no difference from placebo with respect to platelet recovery or transfusion requirement. Accordingly, there was no evidence of significant thrombocytosis after recovery, unlike that observed in the earlier groups of patients who received the same daily doses of PEG-rHuMGDF until platelet recovery. Effects of PEG-rHuMGDF after consolidation chemotherapy were similar to those observed after induction. Daily administration of PEG-rHuMGDF did not significantly affect the duration of severe thrombocytopenia. Alternative schedules of 7-day or single doses of PEG-rHuMGDF did not significantly change the profile of platelet recovery, although postrecovery thrombocytosis was avoided. There was no effect of PEG-rHuMGDF on the rate of neutrophil recovery or the requirement for RBC transfusions, indicating the lack of clinically important effects on other cell lineages in this setting. The lack of effect on neutrophil recovery observed in our patients is consistent with the majority of animal studies,19,21,23,34 although some studies showed an accel- Fig 4. Time to platelet recovery (H 20 3 109/L)—consolidation. From www.bloodjournal.org by guest on November 20, 2014. For personal use only. PEG-rHuMGDF AND CHEMOTHERAPY IN AML 3699 Table 6. Thrombotic Events Event Cerebral infarction Subclavian vein thrombosis (catheter associated) Thrombosis in mesenteric vein (operative specimen) Brachiocephalic/subclavian vein thrombosis (catheter associated) Platelet Count (3109/L) at Time of Event 8 3 109/L 3,174 3 109/L 73 109/L 546 3 109/L Treatment Arm Placebo PEG-rHuMGDF to target (Gp A) PEG-rHuMGDF to target (Gp A) Placebo eration of neutrophil recovery by thrombopoietin.35,36 Phase 1 clinical studies also showed no evidence of significant stimulation of neutrophil recovery by PEG-rHuMGDF.24,25 Stimulation of erythropoiesis may be anticipated in some settings, given the known in vitro synergy between the 2 molecules37 as was observed in some animal models35,38,39 but not in phase 1 studies.24,25 The overall CR rate observed in our PEG-rHuMGDF–treated patients was 73%, not significantly different from the rate observed in the placebo arm, indicating a lack of any marked stimulation of leukemic cells by the administration of PEGrHuMGDF. Such a stimulation is theoretically possible, despite exclusion of the rare subgroup of M7 AML from our study, because it is known that leukemic cells from 20% to 60% of patients with nonmegakaryoblastic AML express Mpl,40-43 and, in some cases, show proliferative responses in vitro to PEGrHuMGDF.41,44 The safety of myeloid growth factors after chemotherapy for AML (G-CSF45-48 and GM [granulocytemacrophage]-CSF49-51) has been well established. This study has shown that PEG-rHuMGDF is biologically active and well tolerated in patients undergoing induction and consolidation therapy for AML. So far, no antibodies against PEG-rHuMGDF have been detected in AML patients, including the patients in this study. Despite clear evidence of lineagedominant activity, treatment with PEG-rHuMGDF at these doses and schedules, after chemotherapy, produced no clinical benefit. The explanation for this is not clear, but may reflect the difficulty in influencing the apparently obligatory 8 to 12 days required for progenitor cells to proliferate and mature into megakaryocytes. After the end of induction chemotherapy, platelet production in control patients recovered to 20 3 109/L platelets in approximately 14 days. Because platelets appearing in the circulation at that point are produced by megakaryocytes whose maturation began at least 8 days earlier, this suggests that there may be a very limited ‘‘window,’’ of perhaps only 6 days, after chemotherapy, in which PEG-rHuMGDF may realistically influence the number or differentiation of megakaryocyte progenitors. To exert such an influence, the presence of progenitors capable of responding to PEG-rHuMGDF in the bone marrow would be essential during this early period after the end of chemotherapy. In view of these considerations, alternative, earlier dosing schedules of PEG-rHuMGDF may need to be investigated. The scope for this in the context of induction therapy may be limited by the disease and by the need to initiate chemotherapy as quickly as possible. Such limitations may not apply in consolidation, in which prospective expansion of the megakaryocyte mass in the bone marrow, before chemotherapy, may offer the best opportunity of exploiting the biologic effects of PEG-rHuMGDF. REFERENCES 1. Mastriani DM, Tung NM, Tenen DG: Acute myelogenous leukemia: Current treatment and future directions. Am J Med 92:286, 1992 2. Zittoun RA, Mandelli F, Willemze R, de Witte T, Labar B, Resegotti L, Leoni F, Damasio, Visani G, Papa G, Caronia F, Hayat M, Stryckmans P, Rotoli B, Leoni P, Peetermans ME, Dardenne M, Vegna ML, Petti MC, Solbu G, Suciu S, for the European Organization for Research and Treatment of Cancer (EORTC) and the Gruppo Italiano Malattie Ematologiche Maligne dell’Adulto (GIMEMA) Leukemia Cooperative Groups: Autologous or allogeneic bone marrow transplantation compared with intensive chemotherapy in acute myelogenous leukemia. N Engl J Med 332:217, 1995 3. Anderlini P, Luna M, Kantarjian HM, O’Brien S, Pierce S, Keating MJ, Estey EH: Causes of initial induction failure in patients with acute myeloid leukemia and myelodysplastic syndromes. Leukemia 10:600, 1996 4. Tornebohm E, Lockner D, Paul C: A retrospective analysis of bleeding complications in 438 patients with acute leukaemia during the years 1972-1991. Eur J Haematol 50:160, 1993 5. Bishop JF, Matthews JP, Young GA, Szer J, Gillett A, Joshua D, Bradstock K, Enno A, Wolf MM, Fox R, Cobcroft R, Herrmann R, Van der Weyden M, Lowenthal RM, Page F, Garson OM, Juneja S: A randomized study of high-dose cytarabine in induction in acute myeloid leukemia. Blood 87:1710, 1996 6. Gmu¨r J, Burger J, Schanz U, Fehr J, Schaffner A: Safety of stringent platelet transfusion policy for patients with acute leukaemia. Lancet 338:1223, 1991 7. Rebulla P, Finazzi G, Marangoni F, Avvisati G, Gugliotta L, Tognoni G, Barbui T, Mandelli F, Sirchia G: The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. N Engl J Med 337:1870, 1997 8. Stalfelt AM, Brodin H, Wadman B: Cost analysis of different phases of acute myeloid leukemia. Leuk Res 18:783, 1994 9. Slichter-SJ: Platelet transfusions a constantly evolving therapy. Thromb Haemost 66:178, 1991 10. Lok S, Kaushansky K, Holly RD, Kuijper JL, Lofton-Day CE, Oort PJ, Grant FJ, Heipel MD, Burkhead SK, Kramer JM, Bell LA, Sprecher CA, Blumberg H, Johnson R, Prumkard D, Ching AFT, Mathewes SL, Bailey MC, Forstrom JW, Buddle MM, Osborn SG, Evans SJ, Sheppard FO, Presnell ST, O’Hara PJ, Hagen FS, Roth GJ, Foster DC: Cloning and expression of murine thrombopoietin cDNA and stimulation of platelet production in vivo. Nature 369:565, 1994 11. de Sauvage FJ, Hass PE, Spencer SD, Malloy BE, Gurney AL, Spencer SA, Darbonne WC, Henzel WJ, Wong SC, Kuang WJ, Oles KJ, Hultgren B, Solberg LA, Goeddel DV, Eaton DL: Stimulation of megakaryocytopoiesis and thrombopoiesis by the c-Mpl ligand. Nature 369:533, 1994 12. Bartley TD, Bogenberger J, Hunt P, Li YS, Lu HS, Martin S, Chang MS, Samal B, Nichol JL, Swift S, Johnson MJ, Hsu RY, Parker VP, Suggs S, Skrine JD, Merewether LA, Clogston C, Hsu E, Hokom MM, Hornkohl A, Choi E, Pangelinan M, Sun Y, Mar V, McNinch J, Simonet L, Jacobsen F, Xie C, Shutter J, Chute H, Basu R, Selander L, Trollinger D, Sieu L, Padilla D, Trail G, Elliott G, Zumi R, Covey T, Crouse J, Garcia A, Xu W, Del Castillo J, Biron J, Cole S, Hu MCT, Pacifici R, Ponting I, Saris C, Wen D, Yung YP, Lin H, Bosselman RA: Identification and cloning of a megakaryocyte growth and development factor that is a ligand for the cytokine receptor Mpl. Cell 77:1117, 1994 13. Wendling F, Maraskovsky E, Debili N, Florindo C, Teepe M, From www.bloodjournal.org by guest on November 20, 2014. For personal use only. 3700 Titeux M, Methia N, Breton-Gorius J, Cosman D, Vainchenker W: c-Mpl ligand is a humoral regulator of megakaryocytopoiesis. Nature 369:571, 1994 14. Kaushansky K, Lok S, Holly RD, Broudy VC, Lin N, Bailey MC, Forstrom JW, Buddle MM, Oort PJ, Hagen FS, Roth GJ, Papayannopoulou T, Foster DC: Promotion of megakaryocyte progenitor expansion and differentiation by the c-Mpl ligand thrombopoietin. Nature 369:568, 1994 15. Kuter DJ, Rosenberg RD: The reciprocal relationship of thrombopoietin (c-mpl ligand) to changes in the platelet mass during busulfaninduced thrombocytopenia in the rabbit. Blood 85:2720, 1995 16. Hunt P, Li YS, Nichol JL, Hokom MM, Bogenberger JM, Swift SE, Skrine JD, Hornkohl AC, Lu H, Clogston C, Merewether LA, Johnson MJ, Parker V, Knudten A, Farese A, Hsu RY, Garcia A, Stead R, Bosselman RA, Bartley TD: Purification and biologic characterization of plasma-derived megakaryocyte growth and development factor. Blood 86:540, 1995 17. Nichol JL, Hokom MM, Hornkohl A, Sheridan WP, Ohashi H, Kato T, Li YS, Bartley TD, Choi E, Bogenberger, Skrine JD, Knudten A, Chen J, Trail G, Sleeman L, Cole S, Grampp G, Hunt P: Megakaryocyte growth and development factor. Analyses of in vitro effects on human megakaryopoiesis and endogenous serum levels during chemotherapyinduced thrombocytopenia: J Clin Invest 95:2973, 1995 18. Choi ES, Hokom M, Bartley T, Li YS, Ohashi H, Kato T, Nochol JL, Skrine J, Knudten A, Chen J, Hornkohl A, Grampp G, Sleeman L, Cole S, Trail G, Hunt P: Recombinant human megakaryocyte growth and development factor (rHuMGDF), a ligand for c-Mpl, produces functional human platelets in vitro. Stem Cells 13:317, 1995 19. Ulich TR, del Castillo J, Senaldi G, Kinstler O, Yin S, Kaufman S, Tarpley J, Choi E, Kirley T, Hunt P, Sheridan WP: Systemic hematologic effects of PEG-rHuMGDF-induced megakaryocyte hyperplasia in mice. Blood 87:5006, 1996 20. Harker LA, Hunt P, Marzec UM, Kelly AB, Tomer A, Hanson SR, Stead RB: Regulation of platelet production and function by megakaryocyte growth and development factor in nonhuman primates. Blood 87:1833, 1996 21. Hokom MM, Lacey D, Kinstler OB, Choi E, Kaufman S, Faust J, Rowan C, Dwyer E, Nichol JL, Grasel T, Wilson J, Steinbrick R, Hecht R, Winters D, Boone T, Hunt P: Pegylated megakaryocyte growth and development factor abrogates the lethal thrombocytopenia associated with carboplatin and irradiation in mice. Blood 86:4486, 1995 22. Farese AM, Hunt P, Boone T, MacVittie TJ: Recombinant human megakaryocyte growth and development factor stimulates thrombocytopenia in normal nonhuman primates. Blood 86:54, 1995 23. Molineux G, Hartley CA, McElroy P, McCrea C, McNiece IK: Megakaryocyte growth and development factor stimulates enhanced platelet recovery in mice after bone marrow transplantation. Blood 88:1509, 1996 24. Fanucchi M, Glaspy J, Crawford J, Figlin R, Garst J, Sheridan W, Menchaca D, Tomita D, Ozer H, Harker L: Effects of polyethylene glycol-conjugated recombinant human megakaryocyte growth and development factor on platelet counts after chemotherapy for lung cancer. N Engl J Med 336:404, 1997 25. Basser RL, Rasko JEJ, Clarke K, Cebon J, Green MD, Hussein S, Alt C, Menchaca D, Tomita D, Marty J, Fox RM, Begley G: Thrombopoietic effects of pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) in patients with advanced cancer. Lancet 348:1279, 1996 26. O’Malley CJ, Rasko JEJ, Basser RL, McGrath KM, Cebon J, Grigg AP, Hopkins W, Cohen B, O’Byrne J, Green MD, Fox RM, Berndt MC, Begley CG: Administration of pegylated recombinant human megakaryocyte growth and development factor to humans stimulates the production of functional platelets that show no evidence of in vivo activation. Blood 88:3288, 1996 27. Basser RL, Rasko JEJ, Clarke K, Cebon J, Green MD, Grigg AP, ARCHIMBAUD ET AL Zalcberg J, Cohen B, O’Byrne J, Menchaca DM, Fox RM, Begley CG: Randomised blinded placebo controlled phase I trial of pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) with filgrastim after dose-intensive chemotherapy in patients with advanced cancer. Blood 89:3118, 1997 28. Meng YG, Martin TG, Peterson ML, Shuman MA, Cohen RL, Wong WL: Circulating thrombopoietin concentrations in thrombocytopenic patients, including cancer patients following chemotherapy, with or without peripheral blood progenitor cell transplantation. Br Haematol 95:535, 1996 29. Toombs CF, Young CH, Glaspy JA, Varnum BC: Megakaryocyte growth and development factor (MGDF) moderately enhances in-vitro platelet aggregation. Thromb Res 80:23, 1995 30. Chen J, Herceg-Harjacek L, Groopman JE, Grabarek J: Regulation of platelet activation by the c-mpl ligand, thrombopoietin. Blood 86:4054, 1995 31. Oda A, Miyakawa Y, Druker BJ, Ozaki K, Yabusaki K, Shirasawa Y, Handa M, Kato T, Miyazaki H, Shimosaka A, Ikeda Y: Thrombopoietin primes human platelet aggregation induced by shear stress and by multiple agonists. Blood 87:4664, 1996 32. Montrucchio G, Brizzi MF, Calosso G, Marengo S, Pegoraro L, Carmussi G: Effects of recombinant human megakaryocyte growth and development factor on platelet activation. Blood 87:2762, 1996 33. De Boer R, Fox S, Hopkins W, Casper L, Cheung E, Roskos L, Basser R, Cebon J: Pharmacodynamics of pegylated magakaryocyte growth & development factor from a Phase I study: Effects of platelet count on serum levels and clearance. Exp Hematol 24:1159, 1996 34. Kabaya K, Shibuya K, Torii Y, Nitta Y, Ida M, Akahori H, Kato T, Kusaka M, Miyasaki H: Improvement of thrombocytopenia following bone marrow transplantation by pegylated recombinant human megakaryocyte growth and development factor in mice. Bone Marrow Transplant 18:1035, 1996 35. Grossmann A, Lenox J, Deisher TA, Ren HP, Humes JM, Kaushansky K, Sprugel KH: Synergystic effect of thrombopoietin and granulocyte colony-stimulating factor on neutrophil recovery in myelosuppressed mice. Blood 88:3363, 1996 36. Akahori H, Shibuya K, Obuchi M, Nishizawa Y, Tsuji A, Kabaya K, Kusaka M, Ohashi H, Tsumura H, Kato K, Miyazaki H: Effect of recombinant human thrombopoietin in nonhuman primates with chemotherapy-induced thrombocytopenia. Br J Haematol 94:722, 1996 37. Papayannopoulou T, Brice M, Farrer D, Kaushansky K: Insights into the cellular mechanisms of erythropoietin-thrombopoietin synergy. Exp Hematol 24:660, 1996 38. Kaushansky K, Broudy VC, Grossmann A, Humes J, Lin N, Ren HP, Bailey MC, Papayannopoulou T, Forstrom JW, Sprugel KH: Thrombopoietin expands erythroid progenitors, increases red cell production, and enhances red cell recovery after myelosuppressive therapy. J Clin Invest 96:1683, 1995 39. Fibbe WE, Heemskerk DP, Laterveer L, Pruijt JF, Foster D, Kaushansky K, Willemze R: Accelerated reconstitution of platelets and erythrocytes after syngeneic transplantation of bone marrow cells derived from thrombopoietin pretreated mice. Blood 86:3308, 1335 40. Vigon I, Dreyfus F, Melle J, Viguie´ F, Ribrag V, Cocault L, Souyri M, Gisselbrecht S: Expression of the c-mpl protooncogene in human hematologic malignancies. Blood 82:877, 1993 41. Matsumara I, Kanakura Y, Kato T, Ikeda H, Ishikawa J, Horikawa Y, Hashimoto K, Moriyama Y, Tsujimura T, Nishiura T, Miyasaki H, Matsuzawa Y: Growth response of acute myeloblastic leukemia cells to recombinant human thrombopoietin. Blood 86:703, 1995 42. Quentmeier H, Zaborski M, Graf G, Ludwig WD, Drexler HG: Expression of the receptor MPL and proliferative effects of its ligand thrombopoietin on human leukemia cells. Leukemia 10:297, 1996 43. Drexler HG, Quentmeier H: Thrombopoietin expression of its From www.bloodjournal.org by guest on November 20, 2014. For personal use only. PEG-rHuMGDF AND CHEMOTHERAPY IN AML receptor MPL and proliferative effects on leukemic cells. Leukemia 10:1405, 1996 44. Piacibello W, Sanavio F, Brizzi MF, Garetto L, Severino A, Aronica MG, Dragonetti G, Aglietta M, Pegoraro L: Megakaryocyte growth and development factor (MGDF)-induced acute leukemia cell proliferation and clonal growth is associated with functional c-mpl. Leukemia 11:531, 1997 45. Dombret H, Chastang C, Fenaux P, Reiffers J, Bordessoule D, Bouabdallah R, Mandelli F, Ferrant A, Auzanneau G, Tilly H, Yver A, Degos L: A controlled study of recombinant human granulocyte colony-stimulating factor in elderly patients after treatment of acute myelogenous leukemia. N Engl J Med 332:1678, 1995 46. Heil G, Hoelzer D, Sanz MA, Lechner K, Yin JAL, Papa G, Noens L, Szer J, Ganser A, O’Brien C, Matcham J, Barge A: A randomized, double-blind, placebo-controlled, phase III study of filgrastim in remission induction and consolidation therapy for adults with de novo acute myeloid leukemia. Blood 90:4710, 1997 47. Ohno R, Hiraoka A, Tanimoto M, Asou N, Kuriyama K, Kobayashi T, Yoshida M, Teshima H, Saito H, Fujimoto K: No increase of leukemia relapse in newly diagnosed patients with acute myeloid leukemia who received granulocyte colony stimulating factor for life threatening infection during remission induction and consolidation therapy. Blood 81:561, 1993 (letter) 3701 48. Gowin JE, Kopecky KJ, Head DR, Hynes HE, Balcerzak SP, Applelbaum FR: A double blind placebo controlled trial of G-CSF in elderly patients with previously untreated acute myeloid leukaemia. A Southwest Oncology Group study. Blood 86:1723, 1995 (abstr) 49. Stone RM, Berg DT, George SL, Dodge RK, Paciucci PA, Schulman P, Lee EJ, Moore JO, Powell BL, Schiffer CA: Granulocyte macrophage colony stimulating factor after initial chemotherapy for elderly patients with primary acute myelogenous leukemia. N Engl J Med 332:1671, 1995 50. Rowe JM, Andersen JW, Mazza JJ, Bennett JM, Paietta E, Hayes A, Oette D, Cassileth PA, Stadtmauer EA, Wiernik PH: A randomized placebo controlled phase III study of granulocyte macrophage colony stimulating factor in adult patients (.55 to 70 years of age) with acute myelogenous leukemia: A study of the Eastern Cooperative Oncology Group (E1490). Blood 86:457, 1995 51. Lowenberg B, Suciu S, Archimbaud E, Ossenkoppele G, Verhoef GEG, Vellenga E, Wijermans P, Berneman Z, Dekker AW, Stryckmans P, Schouten H, Jehn U, Muus P, Sonneveld P, Dardenne M, Zittoun R: Use of recombinant granulocyte macrophage colony stimulating factor during and after remission induction chemotherapy in patients aged 61 years and older with acute myeloid leukemia (AML). Blood 90:2952, 1997
© Copyright 2024