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Sensitivity and Resistance to Therapy

Combined action of PSC 833 (Valspodar), a novel MDR reversing agent, with mitoxantrone, etoposide and cytarabine in poor-prognosis acute myeloid leukemia

Leukemia volume 15, pages 764–771 (2001)Cite this article

Abstract

PSC 833 (Valspodar) can reverse multidrug resistance (MDR) in patients with hematologic malignancies, but alters the pharmacokinetics of concomitant anticancer agents. A phase I, dose-finding study was initiated to define a safe and effective regimen of mitoxantrone, etoposide, and cytarabine (MEC) when administered with PSC 833 to patients with early relapsed or refractory acute myeloid leukemia (AML). Poor-prognosis AML patients refractory to first-line induction therapy or relapsing within 9 months of attaining complete remission (CR) were treated with cytarabine (1.0 g/m2/day), etoposide (30 mg/m2/day), and mitoxantrone at a dose of either 3.0 mg/m2/day (cohort 1) or 4.5 mg/m2/day (cohorts 2 and 3) for 6 days plus continuous-infusion PSC 833 (10 mg/kg/24 h with a 2.0 mg/kg loading dose) for 6 or 7 days each 21-day cycle. Patients achieving CR were given a 4-day MEC plus PSC 833 consolidation cycle. Twenty-three patients were enrolled (eight with primary refractory AML and 15 in relapse). Dose-limiting toxicity occurred in one of six patients in cohort 2 (grade 4 mucositis) and one of seven patients in cohort 3 (grade 4 hyperbilirubinemia). The maximum tolerated dose of mitoxantrone was defined as 4.5 mg/m2/day. Clinically significant grade 4 hyperbilirubinemia, possibly related to PSC 833, occurred in four patients. Hematologic toxicities were as expected in this patient population, but were not dose limiting. Mild to moderate cerebellar ataxia and paresthesia occurred in six (26%) and five (22%) patients, respectively, but were not dose limiting. Overall, six of 23 (26%) patients achieved CR, including five patients with demonstrated P-glycoprotein expression and/or function. The median overall survival was 4 months. All six patients with a CR were alive and four (17%) patients were disease free at 12 months. Blood levels of PSC 833 were well above the target level of 1000 ng/ml, a concentration that is known to reverse MDR in vitro. PSC 833 reduced the clearance of etoposide by approximately two-fold. No correlation was observed between the mitoxantrone or etoposide area under the curve and response. In conclusion, the MEC plus PSC 833 tested regimen was well tolerated and the 26% CR rate warrants further testing of this regimen in a randomized, phase III trial.

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Acknowledgements

This study was supported in part by MURST (40%) and FONDI (60%).

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Authors and Affiliations

  1. Istituto di Ematologia e Oncologia Medica ‘L & A Seragnoli’, Università degli Studi di Bologna, Azienda Ospedaliera Policlinico ‘Sant'Orsola-Malpighi’, Bologna, Italy

    G Visani & A Isidori

  2. Department of Haematology, Birmingham Heartlands Hospital, Birmingham, UK

    D Milligan

  3. Università degli Studi di Firenze, Unità Operativa di Ematologia, Azienda Ospedaliera ‘Careggi’, Firenze, Italy

    F Leoni

  4. Christie Hospital BHS Trust, Manchester, UK

    J Chang

  5. Department of Haematology, Royal London Hospital, London, UK

    S Kelsey

  6. Department of Haematology, Addenbrookes Hospital, Cambridge, UK

    R Marcus

  7. Leukaemia and Myeloma Unit, Royal Marsden Hospital, Sutton, UK

    R Powles

  8. Department of Haematology, Guys Hospital, London, UK

    S Schey

  9. Novartis Pharma AG, Basel, Switzerland

    A Covelli, H Mayer, M Malagola & C Pfister

  10. Novartis Pharmaceuticals Corporation Inc., East Hanover, NJ, USA

    M Litchman & PP Piccaluga

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Visani, G., Milligan, D., Leoni, F. et al. Combined action of PSC 833 (Valspodar), a novel MDR reversing agent, with mitoxantrone, etoposide and cytarabine in poor-prognosis acute myeloid leukemia. Leukemia 15, 764–771 (2001). https://doi.org/10.1038/sj.leu.2402117

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