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Seizures following intrathecal cytosine arabinoside in young children with acute lymphoblastic leukemia.

Two young children (3 1/2 years and 19 months) developed seizures within 24 hours of receiving intrathecal cytosine arabinoside. Both had previously received intrathecal cytosine and methotrexate as well as cranial irradiation without untoward effect. Possible mechanisms of causation are discussed and caution is stressed for use of intrathecal cytosine arabinoside in young children.

Brain Neoplasms↗

Treatment of erythroleukemia with anthracycline antibiotics and cytosine arabinoside.

The introduction of the anthracycline antibiotics and cytosine arabinoside have significantly improved the remission induction rate for patients with acute nonlymphocytic leukemia. Erythroleukemia (M6 by French-American-British classification) has long been considered to be resistant to chemotherapy. Since 1973 we have treated 14 patients with erythroleukemia with daunorubicin 45 mg/m2 or doxorubicin 30 mg/m2 for three days and cytosine arabinoside 100 mg/m2 by continuous infusion for 7 to 10 days. Six complete remissions (43%) were obtained with remission durations of 3+, 4+, 9, 13, 29+, and 35 months. While this remission rate is somewhat lower than that obtained with other types of acute nonlymphocytic leukemia, the combination of anthracycline antibiotics and cytosine arabinoside is clearly effective against erythroleukemia. Five patients treated before mid 1976 died soon after remission induction therapy was started. Four of these five patients were treated for 6 to 9 months with prednisone, halotestin, and/or splenectomy before remission induction chemotherapy was started and three of these patients died of systemic fungal infection, suggesting that these modalities of treatment may interfere with patient tolerance to remission induction therapy. It is suggested that erythroleukemia should be treated with intensive chemotherapy soon after the diagnosis is made.

Adolescent↗

Mitoxantrone and high-dose cytosine arabinoside in refractory acute myelogenous leukemia.

Forty-four patients with a diagnosis of refractory or relapsed acute myelogenous leukemia received salvage chemotherapy with high-dose cytosine arabinosine 3 g/m2 intravenously over 2 hours every 12 hours for six doses and mitoxantrone 5 mg/m2 intravenously daily for 5 days. Overall 16 patients (36%) had a complete remission; 16 patients (36%) had resistant disease; and 12 (27%) died during induction therapy. The most significant predictive factor for remission was the duration of first remission: the response rate was 17% for patients whose first remission duration was shorter than 12 months (including those who did not achieve a first remission), 45% for those with a first remission lasting between 12 to 18 months, and 69% for those with longer remission durations (P = 0.008). Other predictive factors for higher response rates were a younger age group, a good performance status, and a favorable or diploid karyotype. The median survival from start of therapy was 4 months for the total population and 10 months for patients with remission. Serious side effects including pulmonary toxicity and neurotoxicity occurred in less than 10% of patients. This incidence was significantly lower than previous high-dose cytosine arabinoside schedules of 3 g/m2 for nine to 12 doses (total dose, 27 to 36 g per course). Significant granulocytopenia and thrombocytopenia were universal resulting in fever or documented infections in 98% of patients. We conclude that the combination of high-dose cytosine arabinoside and mitoxantrone is an effective antileukemic regimen with acceptable toxicity. Future studies should incorporate it as part of the frontline induction or maintenance strategies in newly diagnosed patients with acute myelogenous leukemia.

Adolescent↗

Epirubicin and cytosine arabinoside for the induction therapy of childhood acute nonlymphocytic leukemia.

Epirubicin, a new anthracycline, was used in combination with cytosine arabinoside for the induction therapy of de novo acute nonlymphocytic leukemia in childhood. The treatment consisted of epirubicin 20 mg/m2/day for 3 days and cytosine arabinoside 100 mg/m2/day for 7 days. The treatment could be repeated every 3 weeks. Remission induction rate was 80% (20/25). Moreover, in 13 patients, the remissions were obtained after a single course. In general, the side effects of epirubicin and cytosine arabinoside were tolerable. However, the main causes of all the three deaths were infections. Our study suggests that epirubicin is acceptable and effective for the induction therapy for de novo acute nonlymphocytic leukemia in childhood.

Adolescent↗

Reorganization of organotypic cultures of mouse cerebellum exposed to cytosine arabinoside: a timed ultrastructural study.

This study was designed to examine the sequential changes in the developing granuloprival cerebellar culture. In this model of anomalous cerebellar development, organotypic cultures derived from newborn Swiss-Webster mice were exposed to the DNA synthesis inhibitor, cytosine arabinoside, at explantation and were fixed for electron microscopic examination on successive days in vitro. Similar developmental stages were compared in control explants. Granule cell destruction began early, and was widespread by 2 days in vitro, when oligodendrocyte destruction also began in treated cultures. A few granule cells survived, but no recognizable oligodendrocytes remained by 7 days in vitro, at a time when myelin was initially evident in control explants. Purkinje cell recurrent axon collateral sprouting began at 3 days in vitro in cultures exposed to cytosine arabinoside, and the sprouted terminals initially synapsed with Purkinje cell somata, somatic spines and dendritic shafts. Synapses with Purkinje cell dendritic spines developed later, at approximately the same time as parallel fiber-Purkinje cell dendritic spine synapses formed in control cultures. Astrocytic ensheathment of control Purkinje cells was well underway by 6 days in vitro and Purkinje cell somata were relatively rounded and almost completely ensheathed by 9 days in vitro. Glial ensheathment did not occur in cytosine arabinoside treated cultures, and Purkinje cell somata were scalloped at 7 days in vitro by excess impinging recurrent axon collateral terminals, and never developed the smooth contours characteristic of control Purkinje cells. Purkinje cell somatic spines persisted in treated explants, and reduction of excess extracellular space was delayed until 12 days in vitro, when most of the developmental changes had been completed. The earlier development of synapses by excess recurrent axon collateral terminals with Purkinje cell somata, somatic spines and dendritic shafts, followed by the later development of heterotypical synapses with dendritic spines, in parallel with synapse formation by normal presynaptic elements, suggests that the sequence of development of synapses is a function of the maturational state of the postsynaptic components.

Animals↗

Retinoic acid alone and in combination with cytosine arabinoside induces differentiation of human myelomonocytic and monoblastic leukaemic cells.

The effect of retinoic acid (RA) alone and in combination with cytosine arabinoside (Ara-C) on differentiation of fresh human myeloid leukaemic cells from patients with AML was studied. Cells from six patients: three with acute myelomonocytic leukaemia AMMoL and three with acute monoblastic leukaemia AMoL with a percentage of blasts greater than 70, were treated in an in vitro primary suspension culture with retinoic acid (10(-7) M), cytosine arabinoside (100 ng/ml) or both in combination. Non-adherent mononuclear cells were seeded at a concentration of 5 x 10(5) cells/ml in RPMI 1640 culture medium supplemented with 20 per cent fetal bovine serum and 10 per cent (PHA-LCM) phytohaemagglutinin leucocyte conditioned medium and incubated for 6 days at 37 degrees C in a humidified incubator containing 5 per cent CO2 in air. Morphological and functional differentiation into terminal mature elements was induced in all leukaemia cells of the six patients following exposure to the combination of both agents. These results suggest the potential usefulness of the combination of a differentiating agent (retinoic acid) and an antileukaemic drug (cytosine arabinoside) in the treatment of acute myeloid leukaemias: AMMoL and AMoL. This combination warrants a clinical trial.

Adult↗

Treatment of murine L1210 lymphoid leukemia and melanoma B16 with lipophilic cytosine arabinoside prodrugs incorporated into unilamellar liposomes.

Lipophilic prodrugs of I-beta-D-arabinofuranosyl cytosine (Ara-C), namely N4- and 5'-oleyl-I-beta-D-arabinofuranosyl cytosine (N4-oleyl-ara-C, 5'-oleyl-ara-C) and N4-palmitoyl-I-beta-D-arabinofuranosyl cytosine (N4-palm-ara-C) were incorporated into liposomes of various lipid compositions. The phospholipid vesicles were prepared by controlled dialysis of lipid/prodrug/detergent micelles yielding homogeneous and stable unilamellar liposomes. The liposome size ranged from 70 to 120 nm depending on the lipid composition and the amounts of prodrug incorporated. Depending on the total amount of micellized Ara-C prodrugs, a maximal incorporation rate of 250 micrograms prodrug per mg egg phosphatidylcholine was achieved. The incorporation efficiency was in the range of 85 to 97%. The in vivo antitumor activity of the liposome preparations against L1210 lymphoid leukemia was clearly superior by factors of 2-8 depending on the therapy schedule and route of drug application. The treatment of melanoma B16 with free Ara-C as well as with the prodrug-liposomes exhibit rather weak antitumor activity. Drug application by means of prodrug-liposomes yields equal or higher tumor-inhibitory effects at drug concentrations which were 2-4 times lower than those of free Ara-C. Although drug tolerance and myelosuppression studies with Swiss albino mice revealed that the prodrug-liposomes were 5-10 times more toxic than free Ara-C, a substantial improvement of efficiency could be observed. The incorporation of the ara-C prodrugs into liposomes provides protection against fast degradation and systemic elimination which might be an explanation for the improved antitumor effect of these preparations.

Animals↗

Neoadjuvant chemotherapy with cytosine arabinoside by continuous infusion and cisplatin for resectable squamous cell carcinoma of the esophagus.

The combination of cisplatin and cytosine arabinoside has been shown in experimental models to be synergistic. We conducted a pilot study of cytosine arabinoside and cisplatin in unresectable or metastatic cancer of the esophagus in five patients and found significant activity, also on visceral metastasis. Therefore, we decided to examine this combination in the neoadjuvant setting. Since January 1989, eight patients with squamous cell carcinoma esophageal cancer were treated with two cycles of cytosine arabinoside (50 mg/m2) by continuous infusion for 4 days and by cisplatin (100 mg/m2) on the 5th day. Their ages ranged from 54-79 years. One patient had Stage I, three had Stage II, and four had Stage III disease. Responses assessed by endoscopy and computed tomographic (CT) scan prior to surgery were three with partial response, three with minor response, and two with no response. Only six patients were surgically resectable after chemotherapy. Toxicity consisted of grade 3 (one patient) and grade 4 (two patients) neutropenia, grade 3 (three patients) anemia, and grade 3 (two patients) and grade 4 (three patients) thrombocytopenia. All patients had subjective improvement of dysphagia 4 weeks after chemotherapy. Median survival of the whole group was 7.5 months. We concluded that there was no evidence of synergy of these drugs given in this manner in esophageal carcinoma since the response rate was no different from that achieved with cisplatin alone.

Aged↗

Central nervous system toxicity of high-dose cytosine arabinoside.

Ten patients with refractory acute leukemia were treated with high-dose cytosine arabinoside (Ara-C) infusions. Nine patients had previously achieved at least one complete remission using standard chemotherapy protocols that include cytosine arabinoside. Eight of the ten had been on maintenance therapy. Twelve courses of treatment were given, with the cytosine arabinoside infused over 1-2 hours in a dose of 3 gm/m2. Each course consisted of 12 to 16 doses given at 12-hour intervals. The drug was generally well tolerated but five patients developed central nervous system symptoms characterized by ataxia, dysphasia, nystagmus, dysdiadochokinesis, and a decreased level of consciousness. These changes began 3 to 34 days after the initiation of therapy and were severe at the time of death in two of the patients. One complete and one partial remission, lasting 2.5 months and 1 month, respectively, were documented. This experience suggests that high-dose Ara-C is of limited usefulness in refractory acute leukemia and may be frequently associated with significant neurotoxicity.

Acute Disease↗

Cytosine arabinoside differentially alters survival and neurite outgrowth of neuronal PC12 cells.

Cytosine arabinoside, a potent antimitotic agent, is used clinically as an anticancer drug with the side effect of severe neurotoxicity. Earlier reports suggested that this agent blocks the signaling pathway of nerve growth factor in sympathetic neurons, which results in neuronal death. The present study demonstrated that neuronal PC12 cells deprived of nerve growth factor showed a decrease of neurite outgrowth, which was not seen in cytosine arabinoside-treated neuronal PC12 cells, suggesting that this agent may not interfere with the part of the NGF signaling pathway that leads to neurite outgrowth. On the other hand, treatment of neuronal PC12 cells with cytosine arabinoside led to a dose- and time-dependent decrease of viability. These results suggest that there is a distinction between the neurite outgrowth and the survival promoting activities of nerve growth factor.

Animals↗

Perpetuation of cytosine methylation in Ascobolus immersus implies a novel type of maintenance methylase.

In the ascomycete Ascobolus immersus, duplicated DNA segments are subject to the methylation induced premeiotically (MIP) process. Affected sequences are heavily methylated at their cytosine residues. We used the bisulphite genomic sequencing method to determine the methylation status of every cytosine residue in a gene which had undergone MIP. Several individual DNA molecules, all issued from the replication of a single molecule initially subject to MIP, were sequenced. In each molecule, methylation extended over almost the whole length of the previously duplicated segment. The methylation extent was precisely delimited and constant in each of the molecules, leaving unmethylated a nearly 100-nucleotide region next to each end. In none of the molecules did methylation resulting from MIP extend beyond the ends. Although the DNA molecules were not all methylated with the same intensity, all cytosine residues in the methylated portion could be methylated, most of them belonging to non-symmetrical sequences. This finding contrasts with the situation in higher eukaryotes in which most, if not all, methylation is at short symmetrical sequences such as CpG or CpNpG, ensuring perpetuation of methylation. Methylation at non-symmetrical sequences implies that in A. immersus maintenance involves a novel sequence-non-specific methyltransferase.

Ascomycota↗

Cisplatin plus cytosine arabinoside in adults with malignant gliomas.

A combination of cisplatin and cytosine arabinoside was used to treat 21 patients with glioblastomas and 5 patients with recurrent grade II gliomas. Cisplatin 60-100 mg/m2 was given I.V. in 250 ml 0.45% saline and preceded by 500 ml dextrose 5% in 0.45% saline. Mannitol 50 g was given I.V. concurrently with the cisplatin. Cytosine arabinoside 500-1000 mg/m2 was given by rapid I.V. infusion immediately after the cisplatin. Of 25 evaluable patients, 10 (40%) experienced objective tumor shrinkage on CT scan, and 6 (24%) stabilized. There were 2 complete remissions. Patients who had had no prior treatment had a higher response rate (58%) than those previously treated (23%). Myelosuppression occurred in some patients 2-3 weeks after treatment. Gastrointestinal toxicity (vomiting and diarrhea) was dose-limiting. Two patients had possible neurological toxicity. Recommended doses for further studies are cisplatin 90 mg/m2 and cytosine arabinoside 900 mg/m2.

Adult↗

Pharmacodynamic and DNA methylation studies of high-dose 1-beta-D-arabinofuranosyl cytosine before and after in vivo 5-azacytidine treatment in pediatric patients with refractory acute lymphocytic leukemia.

The primary development of clinical resistance to 1-beta-D-arabinofuranosyl cytosine (ara-C) in leukemic blast cells is expressed as decreased cellular concentrations of its active anabolite. Correlations exist between the cellular concentrations of 1-beta-D-arabinofuranosyl cytosine 5'-triphosphate (ara-CTP) in leukemic blast cells and inhibition of DNA synthetic capacity with the clinical response to high-dose cytosine arabinoside (HDara-C). 5-Azacytidine (5-Aza-C) and its congeners are potent DNA hypomethylating agents, an action closely associated with the reexpression of certain genes such as that for deoxycytidine kinase (dCk) in ara-C-resistant mouse and human leukemic cells. Reexpression of dCk could increase the cellular ara-CTP concentrations and the sensitivity to ara-C. A total of 17 pediatric patients with refractory acute lymphocytic leukemia (ALL) received a continuous infusion of 5-Aza-C at 150 mg/m2 daily for 5 days after not responding to (13/17) or relapsing from (4/17) an HDara-C regimen (3 g/m2 over 3 h, every 12 h, x 8 doses). Approximately 3 days after the end of the 5-Aza-C infusion, the HDara-C regimen was given again with the idea that the induced DNA hypomethylation in the leukemic cells may have increased the dCk activity and that a reversal of the tumor drug resistance to ara-C could have occurred. Deoxycytidine kinase (expressed as cellular ara-CTP concentrations) in untreated blasts, DNA synthetic capacity (DSC), and the percentage of DNA methylcytidine levels were determined before and after 5-Aza-C administration. Cellular ara-CTP was enhanced to varying degrees in 15 of 16 patients after 5-Aza-C treatment. The average cellular concentration of ara-CTP determined in vitro by the sensitivity test was 314 +/- 390 microM, 2.3-fold higher than the average value before 5-Aza-C treatment. In 12 patients in whom the DNA methylation studies were completed before and after 5-Aza-C treatment, the average DNA hypomethylation level was 55.6% + 15.8% of pretreatment values (n = 13; mean +/- SD). DSC showed a profound decline in 2/9 evaluable patients who achieved a complete response (CR) after this regimen. The data suggest that treatment with a cytostatic but DNA-modulatory regimen of 5-Aza-C causes DNA hypomethylation in vivo, which is associated with dCk reexpression in the patients' leukemic blasts. The partial reversal of drug resistance to ara-C by 5-Aza-C yielded two CRs in this poor-prognosis, multiply relapsed patient population with refractory ALL.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

Prednimustine and vincristine compared with cytosine arabinoside and thioguanine for treatment of elderly patients with acute nonlymphoblastic leukemia.

Sixty-seven patients with acute nonlymphoblastic leukemia (ANLL) and above the age of 60 years were randomly allocated to treatment with either prednimustine + vincristine or cycles with cytosine arabinoside and thioguanine. Of the 67 patients, 13 (19%) entered a complete remission and four a partial remission. Of 33 patients randomized to prednimustine and vincristine (15 adequately treated), three entered a complete remission and one a partial remission. Four further patients went into complete remission after a switch to other treatment modalities. Of 34 patients randomized to cycles of ARA-C and thioguanine (22 adequately treated), four entered a complete remission and three a partial remission with the correct program. One patient entered a remission with intermittent cytosine arabinoside + thioguanine (wrong program) and one further patient entered a complete remission after a switch to prednimustine and vincristine. Prednimustine + vincristine did not appear to be superior to treatment with cytosine arabinoside thioguanine cycles for elderly patients with ANLL.

Acute Disease↗

Limited efficacy of a four-day course of high-dose cytosine arabinoside in the treatment of poor-risk patients with acute nonlymphocytic leukemia.

High-dose cytosine arabinoside therapy was administered to 29 patients with poor-prognosis acute nonlymphocytic leukemia. In an attempt to reduce toxicity, therapy was divided into an initial 4-day course of therapy, followed by a 3-day course of the marrow aspirate examined 1 week after the end of treatment contained substantial numbers of leukemic cells. Of the 29 patients, 5 entered complete remission, 2 of them after the initial 4-day course of therapy. The toxicity of split-course therapy was the same as that of conventional 6-day high-dose cytosine arabinoside therapy. This study demonstrates that the modification of high-dose cytosine arabinoside therapy used in this study failed to reduce toxicity and produced a lower remission rate than that obtained with the 6-day course of therapy.

Acute Disease↗

Modulation of cytosine arabinoside-induced proliferation inhibition by exogenous adenosylmethionine.

The effect of cytosine arabinoside on adenosylmethionine synthesis in relation to its proliferation-inhibiting ability was investigated in HT/29 and SW 620 human colon-tumor cell lines. A significant decrease in adenosylmethionine synthetase (E. C.2.4.2.13) activity was found after 2.5 h incubation with the drug, suggesting that depletion of adenosylmethionine pools might occur. Both this possible loss of adenosylmethionine and the cytostatic effect of cytosine arabinoside could partly be reversed by the exogenous administration of the former drug. Our data show that the cytostatic effect of cytosine arabinoside may be due in part to a shortage of adenosylmethionine; this finding is important for the design of combination chemotherapy regimens.

Cell Division↗

The pathogenesis of abnormal cytoarchitecture in the cerebral cortex and hippocampus of the mouse treated transplacentally with cytosine arabinoside.

Pregnant mice were treated with cytosine arabinoside on days 13.5 and 14.5 of pregnancy. Brains of the offspring were studied histologically. The matrix layer of the embryonic brains was extensively destroyed 12 h after the injection of cytosine arabinoside, but regenerated partially on day 17 of gestation. In the cerebral cortex of 1-, 3-, and 5-day-old treated mice, abnormal clusters of young neurons were found on the surface of the developing cerebral cortex. Some clusters still had a supply of immature neurons from the remnants of the regenerated matrix layer. After 20 days, the clusters became gradually indistinct, although some vestigial groups of neurons were observed even after 120 days. In the hippocampus of young mice, the pyramidal cells decreased in number and were disarranged. Heterotopic pyramidal cell masses were found in the stratum radiatum and in the molecular layer of the dentate gyrus. Apical dendrites of pyramidal cells exhibited abnormal arborization. It was demonstrated by 3H-thymidine autoradiography that young neurons in the abnormal clusters in the cerebral cortex were those produced in the matrix layer regenerated after the destructive change by cytosine arabinoside.

Abnormalities, Drug-Induced↗

The mechanism of cytosine arabinoside toxicity on quiescent astrocytes in vitro appears to be analogous to in vivo brain injury.

Neuronal cultures derived from the septal diagonal band region of the embryonic rat brain and grown in a chemically defined medium contained a very small number of contaminating astroglial cells. During the first week in culture, these cells were well dispersed in the form of a single isolated cell with fine fibrous branched processes. Treatment with 4 microM cytosine arabinoside for 24 h failed to kill these astrocytes (most probably present in quiescent form), as judged by glutamine synthetase activity and glial fibrillary acidic protein-positive cell count. On the other hand, the exposure of cultures to cytosine arabinoside resulted in a marked increase in choline acetyltransferase enzyme activity. The overall results, together with our previous findings, are consistent with the proposal that a brief exposure to a relatively low concentration of cytosine arabinoside induces quiescent astrocytes to produce a large quantity of a neurotrophic factor that is involved in the regulation of cholinergic cells.

Animals↗