Vorinostat Combined with High-Dose Gemcitabine, Busulfan, and Melphalan with Autologous Stem Cell Transplantation in Patients with Refractory Lymphomas

Experimental Hematology

et al. 2016

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Hematopoietic stem cell transplantation (HSCT) is an effective treatment for patients with refractory lymphomas. Nucleoside analogues (NA) and DNA alkylating agents are efficacious in treating hematologic malignancies. To design an efficacious and more economical pre-transplant regimen for lymphoma patients, we analyzed the cytotoxicity of cladribine (Clad), gemcitabine (Gem), busulfan (Bu) and suberoylanilide hydroxamic acid (SAHA) in lymphoma cell lines. J45.01 and U937 lymphoma cell lines were exposed to drugs, alone or in combination, for 48 hrs and analyzed by the MTT and Annexin V assays, Western blotting and flow cytometry. Using the IC5–10 values of the drugs, [Clad+Gem+Bu] combination inhibited the proliferation of both cell lines to ~55%–60%. Addition of SAHA to this combination further decreased proliferation to ~30%. Exposure to [Clad+Gem+Bu+SAHA] combination activated the DNA damage response and ATM-CHK2 pathway, modified histones, decreased the mitochondrial membrane potential which caused leakage of apoptosis-inducing factors, and activated apoptosis. Pre-treatment of cells with a pan-caspase inhibitor Z-VAD-FMK blocked the phosphorylation of histone 2AX and cleavage of PARP-1 and caspases. The [Clad+Gem+Bu+SAHA] combination provides synergistic cytotoxicity in lymphoma cell lines. Our results may be used as a basis for using this combination as a pre-transplant conditioning regimen in a clinical trial for lymphoma patients undergoing hematopoietic stem cell transplantation, replacing the more expensive nucleoside analog clofarabine.

Section: Discussionmentioning

confidence: 99%

“…Hematopoietic stem cell transplantation (HSCT) is a potential curative approach for most hematologic diseases including lymphoma [Salit et al, 2010; Nieto et al, 2015]. However, relapse is still a major concern.…”

Section: Introductionmentioning

confidence: 99%

Cladribine, gemcitabine, busulfan, and SAHA combination as a potential pretransplant conditioning regimen for lymphomas: A preclinical study

Experimental Hematology

et al. 2016

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“…Increased DNA damage and apoptosis were observed when the HDAC inhibitor vorinostat (suberoylanilide hydroxamic acid) was added to the Gem/Bu/Mel combination . Those preclinical observations led us to test vorinostat/Gem/Bu/Mel clinically, and we observed that vorinostat could be safely combined with full‐dose Gem/Bu/Mel and produced marked activity in refractory lymphomas …”

Section: Introductionmentioning

confidence: 95%

Double epigenetic modulation of high‐dose chemotherapy with azacitidine and vorinostat for patients with refractory or poor‐risk relapsed lymphoma

Nieto

Thall

et al. 2016

Cancer

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BACKGROUND More active high-dose chemotherapy (HDC) regimens are needed for refractory lymphomas. The authors previously combined infusional gemcitabine with busulfan and melphalan (Gem/Bu/Mel) pursuing DNA damage repair inhibition. Subsequently, they combined Gem/Bu/Mel with vorinostat, which facilitates chemotherapy access to DNA. The resulting regimen was safe and synergistic. However, vorinostat induced DNA methyltransferase up-regulation, which could be preclinically abrogated by azacitidine, increasing tumor-cell kill. Those observations led to a clinical combination of azacitidine with vorinostat/Gem/Bu/Mel. METHODS Patients ages 12 to 65 years with refractory or poor-risk relapsed lymphomas were eligible. They received intravenous azacitidine on days −11 through −3 at doses from 15 to 35 mg/m2 daily (dose levels 1–3), followed by oral vorinostat (1000 mg once daily on days −11 through −3), gemcitabine (2775 mg/m2 over 4.5 × 2), busulfan (at an area under the receiver operating characteristic curve of 4000 daily × 4), and melphalan (60 mg/m2 × 2). Patients who had tumors that were positive for CD20 (cluster of differentiation 20; B-lymphocyte antigen) received rituximab on day −9. RESULTS In total, 60 patients were enrolled, including 26 with diffuse large B-cell lymphoma (DLBCL) (10 double hit/double expressors), 21 with Hodgkin lymphoma, 8 with T-cell lymphoma, and 5 with other B-cell lymphomas. The median patient age was 41 years (range, 16–65 years), patients had received a median of 3 prior lines of chemotherapy (range, 2–7 lines of chemotherapy); and 32% of tumors were positive on positron emission tomography studies at the time of HDC. Two patients died from treatment complications (respiratory syncytial virus pneumonia and sepsis, respectively). The maximum tolerated dose of azacitidine was encountered at dose level 1 (15 mg/m2 daily). The toxicity profile (mainly mucositis and dermatitis) was manageable and was identical to that of vorinostat/Gem/Bu/Mel. Neutrophils and platelets engrafted promptly. At a median follow-up of 15 months (range, 8–27 months), the event-free and overall survival rates were 65% and 77%, respectively, among patients with DLBCL; 76% and 95%, respectively, among patients with Hodgkin lymphoma; and 88% for both among patients with T-cell lymphoma. CONCLUSIONS Double epigenetic modulation of Gem/Bu/Mel with azacitidine/vorinostat is feasible and highly active in patients with refractory/poor-risk relapsed lymphomas, warranting further evaluation.

“…A cohort analysis showed that combined gemcitabine (Gem), busulfan (Bu) and melphalan (Mel) provided better outcomes when compared with BEAM (BCNU, etoposide, ara-C, melphalan) for refractory relapsed Hodgkin’s lymphoma patients who had autologous HSCT. [5,6] The efficacy of this drug combination may be attributed to the ability of Gem to inhibit DNA replication and repair of DNA adducts mediated by Bu and Mel[7] and/or its ability to induce chromatin relaxation and increase access of the DNA alkylators to DNA. [8,9] Addition of epigenetic modifiers to this pre-transplant regimen further improved the survival of patients with refractory relapsed lymphoma,[10] suggesting the relevance of chromatin remodeling to their mechanisms of action.…”

Section: Introductionmentioning

confidence: 99%

The PARP inhibitor olaparib enhances the cytotoxicity of combined gemcitabine, busulfan and melphalan in lymphoma cells

Murray³

et al. 2017

Leukemia & Lymphoma

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The combination of gemcitabine (Gem), busulfan (Bu) and melphalan (Mel) is a promising regimen for autologous stem-cell transplantation (SCT) for lymphomas. To further improve the efficacy of [Gem+Bu+Mel], we added PARP inhibitor olaparib (Ola). We hypothesized that Ola would inhibit the repair of damaged DNA caused by [Gem+Bu+Mel]. Exposure of J45.01 and Toledo cell lines to IC10–20 of individual drug inhibited proliferation by 6%–16%; [Gem+Bu+Mel] by 20%–27%; and [Gem+Bu+Mel+Ola] by 61%–67%. The synergistic cytotoxicity of the 4-drug combination may be attributed to activation of the DNA-damage response, inhibition of PARP activity and DNA repair, decreased mitochondrial membrane potential, increased production of reactive oxygen species, and activation of the SAPK/JNK stress signaling pathway, all of which may enhance apoptosis. Similar observations were obtained using mononuclear cells isolated from patients with T-cell lymphocytic leukemia. Our results provide a rationale for undertaking clinical trials of this drug combination for lymphoma patients undergoing SCT.