A Randomized Trial of Liposomal Daunorubicin andCytarabine versus Liposomal Daunorubicin andTopotecan with or without Thalidomide as InitialTherapy for Patients with Poor Prognosis AcuteMyelogenous Leukemia or Myelodysplastic Syndrome

Jorge Cortes, M.D.

Hagop Kantarjian, M.D.

Maher Albitar, M.D.

Deborah Thomas, M.D.

Stefan Faderl, M.D.

Charles Koller, M.D.

Guillermo Garcia-Manero, M.D.

Francis Giles, M.D.

Michael Andreeff, M.D.

Susan O’Brien, M.D.

Michael Keating, M.D.

Elihu Estey, M.D.

Department of Leukemia, The University of TexasM. D. Anderson Cancer Center, Houston, Texas.

Jorge Cortes, M.D., is a Clinical Research Scholarfor The Leukemia and Lymphoma Society.

Address for reprints: Jorge Cortes, M.D., AssociateProfessor of Medicine, Department of Leukemia,The University of Texas, M. D. Anderson CancerCenter, 15151 Holcombe Blvd., Box 428, Houston,TX 77030; Fax: (713) 794-4297; E-mail:jcortes@mdanderson.org

Received July 11, 2002; revision received October8, 2002; accepted October 9, 2002.

BACKGROUND. Because angiogenesis may play a role in the pathogenesis of acute

myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS), and

thalidomide (Th) has shown significant anti-angiogenic activity, this study was

designed to investigate the potential role of Th in the treatment of patients with

AML and MDS and the possible role of a non–ara-C-containing regimen.

METHODS. Adults with AML or high-risk MDS and cytogenetic abnormalities other

than inv (16), t(8;21), -Y or -X were randomized to receive liposomal daunorubicin

(DNX) and ara-C (DA) or DNX and topotecan (DT). Within each arm, patients were

randomized to receive chemotherapy alone (DA or DT) or with thalidomide (DATh

or DTTh). Vascular endothelial growth factor (VEGF) plasma levels and microvas-

cular density was measured before and after therapy. Eighty-four patients (median

age, 65 years; range, 27– 84 years) were treated.

RESULTS. None of 11 patients treated with DT or DTTh responded and these arms

were closed. Seventeen of 37 patients treated with DA and 15 of 36 treated with

DATh achieved an early complete remission. Median complete response duration

was 38 and 34 weeks (P � 0.57) and median survival 35 and 28 weeks (P � 0.15),

respectively. Patients with high pretreatment VEGF levels had an inferior survival.

There was no significant difference in the changes in VEGF levels or microvascular

density after treatment in patients who did versus those who did not receive

thalidomide.

CONCLUSIONS. The authors concluded that thalidomide in combination with che-

motherapy does not result in clinical benefit in patients with AML or high-risk

MDS. Cancer 2003;97:1234 – 41. © 2003 American Cancer Society.

DOI 10.1002/cncr.11180

KEYWORDS: angiogenesis, vascular endothelial growth factor, thalidomide, acutemyeloid leukemia, myelodysplastic syndrome.

Recent evidence suggested that angiogenesis may play a role in thepathogenesis of leukemias and myelodysplastic syndromes

(MDS).1 Perez-Atayde et al.2 reported increased microvascular density(MVD) in the bone marrow of children with acute lymphoblasticleukemia. Fiedler et al. initially reported the presence of vascularendothelial growth factor (VEGF) transcripts and its receptors inleukemia cells from patients with acute myeloid leukemia (AML).3

Increased MVD was later reported in patients with AML4,5 and MDS.5

Plasma levels of VEGF are elevated in AML and MDS compared with

1234

© 2003 American Cancer Society

controls,5 and elevated cellular levels of VEGF are in-dependently associated with shorter survival and dis-ease-free survival in patients with AML.6 Correlationof angiogenesis with poor prognosis was also reportedin solid tumors,7–9 suggesting that therapeutic inter-ventions aimed at inhibiting angiogenesis might bebeneficial.

Thalidomide was first used as an oral sedative andantiemetic agent. D’Amato et al. reported that thalid-omide inhibited the angiogenesis induced by basicfibroblast growth factor in an animal model.10 Subse-quent studies demonstrated inhibition of VEGF-de-pendent corneal neovascularization.11 Based on theseobservations, Singhal et al. treated 84 patients withrefractory multiple myeloma with thalidomide with anoverall response rate of 32%.12

The backbone of AML therapy has been cytara-bine in combination with an anthracycline. However,the long-term results have been disappointing for pa-tients with high-risk AML (i.e., poor prognosis cytoge-netic abnormalities). Some studies have suggestedthat higher doses of anthracyclines may be associatedwith improved outcome,13 although dose-intensitymay be limited by cardiotoxicity. Liposomal formula-tions of anthracyclines have been proposed to in-crease delivery to tumor areas, while sparing normaltissues.14 A Phase I study of liposomal daunorubicin(DNX) found a maximally tolerated dose of 450 mg/m2

per cycle.15 In combination with cytarabine, an overallresponse rate of 40% was reported in relapsed AML.16

Because variations of cytarabine-based combinationshave not improved the outcome of high-risk AMLpatients, noncytarabine regimens have been ex-plored.17 One possible such regimen was DNX andtopotecan, which produced a complete response (CR)rate of 19% among patients with refractory or relapsedAML (Beran et al., unpublished data, 1999).

We therefore explored the role of thalidomide andof a noncytarabine-based regimen in the treatment ofpatients with AML or high-risk MDS and unfavorablecytogenetic abnormalities. Patients were randomizedto receive DNX and ara-C (DA) or DNX and topotecan(DT). Within each arm, they were randomized to re-ceive or not to receive thalidomide (Th). Thus, pa-tients could be randomized to one of four arms: DA,DATh, DT, or DTTh.

MATERIALS AND METHODSPatients with AML (excluding acute promyelocyticleukemia) or MDS (including refractory anemia withexcess of blasts [RAEB] or RAEB in transformation[RAEB-t]) were eligible. Inclusion criteria were: 1) age� 16 years; 2) cytogenetic abnormalities other than inv(16), t(8;21), -Y, or -X; 3) signed informed consent as

per institutional guidelines; 4) no prior therapy ortherapy with at most one previous cycle of chemother-apy containing cytarabine, an anthracycline, and/ortopotecan, with no response. This criterion reflectsprevious observations that outcome is unaffected bywhether patients were previously untreated or havereceived and failed to respond to one course of ther-apy given prior to referral to M. D. Anderson CancerCenter (MDACC). Patients � 65 years could be startedon therapy prior to documentation of the cytogeneticstudies if start of therapy was considered to be urgentbecause of blast count � 50 � 109/L or organ dysfunc-tion attributed to disease; this age criterion reflectedthe likelihood that such patients would have a cyto-genetic abnormality. The study was conducted be-tween July 30, 1999 and June 27, 2000. Ninety-onepatients were registered, of which 7 were later foundto have normal metaphases (n � 5), insufficient met-aphases (n � 1), or an inv (16) (n � 1). These patientswere excluded from this report. The 84 patients withabnormal cytogenetic studies treated in this study rep-resent 85% of all newly diagnosed patients with ab-normal cytogenetics seen during this period. Thestudy was approved by the Institutional Review Boardat MDACC, and all patients signed an informed con-sent.

The treatment schedules were as follows:1) DA: DNX 100 mg/m2/day intravenously (IV)

over 2 hours on Days 1–3 and ara-C 1 g/m2/day over24 hours continuous infusion (CI) on Days 1– 4.

2) DT: DNX 75 mg/m2/day IV over 2 hours onDays 1–3 and topotecan 1.25 mg/m2/day IV CI onDays 1–3. The dose of DNX was adjusted for bilirubin:Patients with a total bilirubin of 2.0 – 4.9 mg/dL re-ceived 75% of the dose, and those with � 5.0 mg/dLreceived 50%. The dose of topotecan was decreased to1.0 mg/m2/d if the creatinine was 1.6 –2.9 mg/dL andto 0.6 mg/m2 daily if it was 3.0 –5.0 mg/dL. Patientsage � 65 years assigned to ara-C arms received 1g/m2/d for 3 days only.

3) Patients assigned to receive thalidomide re-ceived a starting dose of 400 mg orally daily. If notoxicity was seen after 1 week, the dose was increasedto 600 mg/day. The dose could be reduced by 200 mgat any time if Grade � 3 toxicity developed. Adminis-tration of thalidomide continued until remission.

Based on previous experience of benefit of theprotective environment (PE) in older patients at ourinstitution, patients age � 50 years were offered in-duction therapy in laminar airflow rooms. Patientsreceived prophylaxis with a quinolone or tri-methoprim/sulfamethoxasole and with fluconazoleand itraconazole.

Patients were followed with complete blood

Chemotherapy � Thalidomide in AML/Cortes et al. 1235

counts (CBC) at least three times weekly and bloodchemistry at least twice weekly. A bone marrow aspi-ration was performed on Day 21 of induction andrepeated as indicated until response could be deter-mined. Patients not achieving an early CR (ECR), de-fined as achieving CR by Day 50 of Course 1 of induc-tion, were considered failures and removed fromstudy. A CR was defined by standard criteria.18 Thereason for distinguishing ECR is our data indicatingthat the prognosis of patients achieving a later CRmore resembles that of patients who are resistant totherapy than to patients who achieve an early CR.19

Once in remission, patients received two morecourses of the same regimen given for remission in-duction. The first such course was to start once CR wasdocumented. The second was to be started once theneutrophil count was � 1 � 109/L and platelets � 75� 109/L. The doses of postremission therapy were: 1)DA: DNX 50 mg/m2/day IV on Days 1–2 and ara-C 0.75g/m2/day IV CI on Days 1–2; 2) DT: DNX 50 mg/m2/day IV on Days 1–2 and topotecan 0.6 mg/m2/day IVCI on Days 1–3. Patients assigned to receive thalido-mide received 400 mg daily.

Angiogenesis StudiesMeasures of plasma VEGF and MVD were performedas follows:5

Immunohistochemical preparationAll blood vessels were highlighted by staining endo-thelial cells with antifactor VIII (FVIII)-related antigenantibody using a standard immunoperoxidase tech-nique described previously. FVIII-related antigen an-tibodies were purchased from Dako Corporation (San-ta Barbara, CA) and used at a dilution of 1:400.

Measurement of bone marrow MVDMVD was assessed blindly. All bone marrow biopsieswere evaluated for cellularity by light microscopy witha 10� power ocular lens. Five cellular representativeareas were chosen randomly and examined by 20�power objective lens. Pictures of the five fields weredigitized. Individual microvessesls (stained in brown)were counted in each field, and the vascular areaswere measured using National Institutes of Healthshared image analysis software. The relationship be-tween the total area of blood vessels selected (ex-pressed in squared pixels) and the total picture takenby 20� power objective lens was calculated and ex-pressed as a percentage. The average number of bloodvessels and average area of the blood vessels wereobtained for the five fields. Neither vessel lumens norred blood cells in vessel lumens were used to define ablood vessel in the absence of FVIII staining.

Megakaryocytes were stained with FVIII but were eas-ily distinguishable and not counted.

Measurement of Angiogenic FactorsEnzyme-linked immunosorbent assay (ELISA)ELISA for VEGF was performed using commerciallyavailable kits from R&D Systems (Minneapolis, MN)according to the protocols recommended by the man-ufacturer. Briefly, plasma was collected using EDTA asanticoagulant and stored at �82 °C. Patient sampleswere added to separate microplates each containing aspecific monoclonal antibody. The mixtures were in-cubated at room temperature for 2 hours. The plateswere washed three times to remove any unboundsubstances. Enzyme-linked polyclonal antibodies spe-cific for each protein were added to the wells, andmixtures were incubated at room temperature for 2hours followed by another washing to remove anyunbound antibody or enzyme reagent. A substratesolution was added to the wells, and a blue colordeveloped. The intensity of the blue was proportion-ate to the amount of cytokine bound in the initial step.The color development was stopped, and the intensityof the color was measured and compared with a stan-dard curve. Reading was done at 450-nm wavelengthas per the manufacturer’s recommendations.

Statistical MethodsWe used the Bayesian selection design described byThall and Sung20 to assess whether any of the fourregimens (DA, DATh, DT, DTTh) were sufficientlypromising to warrant future study. Patients were ran-domly assigned to one of the four arms using thedynamic allocation method of Pocock and Simon21 soas to achieve balance between the arms with regard tothe type of cytogenetic abnormality (abnormalities inchromosomes 5 and/or 7 vs. others), age/performancestatus (age � 65 years and performance status [PS] �3 vs. age � 65 years or PS � 3), and presence orabsence of an antecedent hematologic disorder (adocumented abnormality in blood count for � 1month prior to M. D. Anderson presentation). Accrualinto any arm was to stop if, given the ECR rate whenthe next patient was to be accrued, the posterior prob-ability was � 0.05 that the ECR rate with that arm wasat least 0.66. This would represent an improvement of0.20 over the ECR rate of 0.46 (296/645, i.e., the priorprobability) observed with ara-C-containing combina-tions at MDACC in similar patients. The above rule ledto termination of accrual into an arm if the number ofECRs/number of patients treated was � 1/5, 4/10,7/15, or 10/20. If early stopping did not occur, a max-imum of 20 patients were to be treated on an arm, fora maximum sample size of 20 � 4 � 80 patients; if an

1236 CANCER March 1, 2003 / Volume 97 / Number 5

arm terminated early, the remaining patients wouldbe randomized among the arms that remained open.After 20 patients had been entered, that arm associ-ated with the highest ECR rate would be selected forsubsequent study in a larger number of patients. Be-cause the sample sizes described above, and in par-ticular the number of failures that would lead to ter-mination of accrual, are less than those associatedwith more typical Phase II trials, it is important todescribe the performance of the design under variousscenarios. Assuming that the true ECR rate with threeof the arms was the historical 0.46, but was 0.66 (thedesired improvement) with the fourth arm, the prob-ability that the fourth arm would be selected was 0.75,whereas the probabilities that each of the other threearms would be selected was 0.05,and the probabilitythat no arms would be selected (equivalently that allfour arms would terminate before 20 patients hadbeen entered in each) was 0.10. Thus, under this sce-nario, the false-negative rate was 1.0 � 0.75 � 0.25 andthe power 0.75. In contrast, if each of the arms pro-duced a true ECR rate of 0.46, the probability that noarm would be selected was 0.48 (i.e., the false-positiverate was 0.52). The rationale for accepting such false-positive rates is described in Thall et al.;22 at any ratethis issue is not relevant to the DA, DATh, DT, DTThtrial as will be made clear in the following section.

RESULTSThe population consisted of 84 patients with abnor-mal cytogenetics; their characteristics by treatmentarm are shown in Table 1. One patient assigned to DAwho refused therapy after registration is considered inthe analysis on an intention to treat. The median ageof the population was 65 years (range, 27– 84 years),with 35 patients (38%) age � 70 years. Eight patients

(10%) had performance status � 3. Five patients (6%)had a serum creatinine �2 mg/dL and 5 (6%) had abilirubin �1.5 mg/dL. The most frequent cytogeneticabnormality was a monosomy or loss of the long armof chromosomes 5 and/or 7 (-5/-7) (n � 48; 57%); 9patients (11%) had trisomy 8 (�8), 4 (5%) had abnor-malities of the long arm of chromosome 11 (11q), and23 (27%) had miscellaneous abnormalities. Sixty pa-tients (71%) were treated in the physical examination(PE). Groups were well balanced by pretreatmentcharacteristics except for a higher white blood cell(WBC) count in patients treated with DT. None of the6 patients given DT or the 5 given DTTh responded.Thus, the posterior probability that DT produced anECR rate � 20% higher than the historical was 0.000;the posterior probability that it produced an ECR rate� 10% higher was 0.003 (Table 2). Corresponding val-ues for DTTh were 0.001 and 0.006. Therefore, accrualwas terminated on these arms and patients random-ized only between DA and DATh thereafter: 37 pa-tients were treated with DA and 36 with DATh.

Seventeen of the 37 patients (46%) treated withDA and 15 of 36 (42%) with DATh achieved ECR (P� 0.71). The CR rates were 17/37 (46%) and 16/36(44%) (P � 0.71). Given these ECR rates, the posteriorprobability that DA produced an ECR rate � 20%higher than the historical was 0.007; the posteriorprobability that it produced an ECR rate � 10% higherwas 0.11 (Table 2). Corresponding values for DAThwere 0.002 and 0.055. The early mortality rate (i.e.,death during the first 6 weeks) was similar for thesetwo arms (9/37 and 8/36, respectively). The medianCR duration was 38 versus 34 weeks with DA andDATh, respectively (P � 0.57; Fig. 1). There was nodifference in survival between the two arms; the me-dian survival was 35 and 28 weeks, respectively, for DAand DATh (P � 0.15; Fig. 2). The median follow-up forpatients who are currently alive is 47 weeks.

As mentioned, thalidomide was to be adminis-

TABLE 1Patient Characteristics by Treatment Arm

DA DATh DT DTTh P value

No. of patients 37 36 6 5Median age (yrs) 63 65 66 70 0.81Median platelet count

(� 109/L)65 43 33 38 0.27

Median WBC (� 109/L) 2.6 6.5 19.8 1.9 0.03Treated in PE 24 (65) 26 (72) 5 (83) 5 (100) 0.36PS � 3 4 (11) 4 (11) 0 0 0.72�5, �7 19 (51) 21 (58) 5 (83) 3 (60) 0.52RAEB or RAEB-t 11 (30) 11 (31) 2 (33) 0 0.53

DA: liposomal daunorubicin and ara-C; DATh: liposomal daunorubicin and ara-C with thalidomide;

DT: liposomal daunorubicin and topotecan; DTTh: liposomal daunorubicin and topotecan with tha-

lidomide; WBC: white blood cells; PE: physical examination; PS: performance status; RAEB: refractory

anemia with excess of blasts; RAEB-t: RAEB in transformation.

TABLE 2ECR Rates and Posterior Probabilities

Treatmentarm ECR rate

Posterior probability thatECR is > 0.66 (> 0.20higher than control)

Posterior probability thatECR is > 0.56 (> 0.10higher than control)

DT 0/6 0.000 0.003DTTh 0/5 0.001 0.006DA 17/37 0.007 0.11DATh 15/36 0.002 0.055

ECR: early complete response; DT: liposomal daunorubicin and topotecan; DTTh: liposomal dauno-

rubicin and topotecan with thalidomide; DA: liposomal daunorubicin and ara-C; DATh: liposomal

daunorubicin and ara-C with thalidomide.

Chemotherapy � Thalidomide in AML/Cortes et al. 1237

tered at 400 mg daily p.o. and increased to 600 mg/dayafter 1 week. Because of toxicity (mostly sedation andconstipation), 12 patients were never able to receive600 mg. The actual median dose received by all 41patients randomized to thalidomide was 61% of theplanned dose during induction. There was no corre-lation between actual daily dose of thalidomide re-ceived and response (median, 344 and 317 mg/day inresponders and nonresponders, respectively; P� 0.39).

Angiogenesis StudiesThe median plasma VEGF levels pretreatment was45.2 pg/mL (range, 24.4 –59.3 pg/mL). There was nosignificant difference in plasma VEGF levels betweenthe four arms. There was a trend for higher pretreat-

ment plasma VEGF levels in patients who did notachieve a CR (median, 59.3 pg/mL; range, 26.1–593.6pg/mL) compared with patients who achieved a CR(median, 38.9 pg/mL; range 18.9 –237.9 pg/mL; P� 0.05). A high plasma VEGF level (� 45.2 pg/mL) wasassociated with an inferior probability of survival (Fig.3). Patients who received thalidomide had a mediandecrease in plasma VEGF levels at Day 14 (comparedwith baseline) of 51.4 pg/mL (range, �515 to �.1pg/mL; n � 11 evaluable), not significantly differentfrom the changes observed by patients who did notreceive thalidomide (n � 10; �24.1 pg/mL; range, �91to �25.2 pg/mL). Similarly, patients who achieved aCR had a change in VEGF levels (�2.9 pg/mL; range,�194 to �25.2 pg/mL; n � 9) similar to that of patientswho did not achieve a CR (�37.8 pg/mL; range, �515to �.1 pg/mL; n � 12). Change in FGF plasma levelson Day 14 was similar with (�9.3 pg/mL; range,�13.45 to �6.6 pg/mL; n � 4) or without thalidomide(�2.5 pg/mL; range, �29.5 to �0.91 pg/mL; n � 4) (P� 0.86). There was a trend for a greater decrease after50 days for patients who received thalidomide (�4.5pg/mL; range, �12.8 to �9.6 pg/mL; n � 7) comparedwith those who did not receive thalidomide (�8.8pg/mL; range, �11.6 to 30.4 pg/mL; n � 7) (P � 0.08).The median number of marrow blood vessels (MVD)among 26 patients was 19.6 (range, 10 – 42.2; n � 29).There was no difference in the MVD among patientswho did and did not achieve CR; this is true whetherpatients treated in the DT and DTTh arms were in-cluded or not in the analysis. There was no significantchange in MVD 14 days after the start of chemother-apy (median, 23.1; range, 5–33.6; n � 14) or 50 daysafter the start of chemotherapy (median, 21.5; range,

FIGURE 1. Complete response (CR) duration of patients receiving liposomal

daunorubicin and ara-C (DA) and DA with thalidomide (DATh). Median CR

duration was 38 weeks for patients treated with DA and 34 weeks for those

treated with DATh (P � 0.57).

FIGURE 2. Overall survival for patients treated with DA and DATh. The

median survival was 35 weeks for patients treated with DA and 28 weeks for

patients treated with DATh (P � 0.15).

FIGURE 3. Overall survival according to pretreatment plasma VEGF levels.

Patients with a plasma VEGF level � 49.2 pg/mL (i.e., median value) prior to

therapy had a median survival of 45 weeks compared with 12 weeks for

patients with higher levels (P � 0.01).

1238 CANCER March 1, 2003 / Volume 97 / Number 5

10.2– 41.8; n � 20). The median relative area of vascu-larity was 4.6% (range, 1.2–18%) among these 26 pa-tients. As for MVD, there was no difference betweenpatients who did and did not achieve a CR and nochanges during the course of therapy. There was nocorrelation between changes in MVD or relative areaof vascularity and response or use of thalidomide.

DISCUSSIONThis study was designed to investigate the effect of twointerventions on the early CR rate in AML, RAEB, orRAEB-t with poor-risk cytogenetics: 1) the use of anon–ara-C-containing regimen in patients with previ-ously untreated AML; 2) the effect of thalidomide as ananti-angiogenic intervention. Our data suggested thatneither intervention was effective.

Most patients with AML are currently treated withan ara-C-containing regimen for induction of initialremission. Non–ara-C-containing regimens havedemonstrated marginal activity at best in this setting.One frequently used non–ara-C-containing regimencombines mitoxantrone and VP-16. Response rates of20 – 60% were reported in patients with refractory orrelapsed AML.23–25 Among 67 patients age 60 – 80 yearswith previously untreated AML treated with this regi-men, 37 (55%) achieved a CR.17 The median survivalwas 9.2 months. We have recently investigated a dif-ferent non–ara-C-containing approach for patientswith high-risk cytogenetic abnormalities. We con-ducted a pilot study using the combination of DNXand topotecan in patients with refractory or relapsedAML or high-risk MDS (Beran et al., unpublished data,1999). Two different schedules were investigated: se-quential administration with topotecan followed byDNX, and simultaneous administration of the twodrugs such as was done on this trial. The sequentialadministration resulted in significant toxicity, mostlygastrointestinal, and none of 9 patients responded.Sixteen patients were treated with the simultaneousschedule and 3 (19%) achieved a CR. In view of thepoor prognosis features of these patients (7 previouslyrefractory to high-dose ara-C-containing chemother-apy; median first CR duration 34 weeks for the others;poor-risk cytogenetics in 11), this regimen was con-sidered to have meaningful antileukemic activity. Wethus investigated this regimen in high-risk, previouslyuntreated patients. However, none of the 11 patientstreated in this study responded to this combination.According to the design, the likelihood that any of thetwo arms using this combination (DT and DTTh)would yield a response rate at least 0.20 better thanthe historical rate was � 5%. In contrast, 47% of thosetreated with DA or DATh (i.e., ara-C-containing regi-mens) achieved a CR. These results were somehow

unexpected and may have been due in part to the useof a lower dose of liposomal daunorubicin in the DTarms compared with the DA arms. A possible antago-nism between the two drugs should also be consid-ered. Still, despite the poor results obtained with ara-C-based regimens in patients with high-risk,previously untreated AML, these regimens are still thebest alternative.

The second question was the possible effect ofthalidomide on the outcome. We did not find anybeneficial effect of thalidomide in this study. Severalreasons might explain this failure. First, although an-giogenesis appears increased in AML and MDS, it maynot be a therapeutic target. Consistent with this theoryis the lack of correlation between the changes inplasma VEGF levels and response in this study, despitethe correlation between pretreatment plasma VEGFlevels and survival. We also did not see an associationbetween change in MVD and response. This contrastswith the findings of Steins et al.,26 who treated 20patients with refractory or high-risk AML with thalid-omide. Four patients had a partial response and one ahematologic improvement. A response to thalidomidewas associated with a significant decrease in MVD inthe bone marrow and in plasma levels of bFGF and atrend for plasma VEGF levels.26 Similar results wereobserved by Padro et al.27 using chemotherapy only.Patients with AML receiving chemotherapy with TADwere found to have a significant reduction in MVD byDay 16 after the start of chemotherapy. Patients with� 5% blasts by this time had a higher MVD thanpatients without blast infiltration.27 Although theMVD was lower in CR than at diagnosis, it was notdifferent than on Day 16. Interestingly, in multiplemyeloma, responses to thalidomide did not correlatewith a change in MVD. Second, thalidomide may notbe the optimal anti-angiogenesis agent. Consistentwith this possibility was our finding that there was nodifference in the change of plasma VEGF levels ac-cording to whether patients received thalidomide ornot. New anti-angiogenesis agents such as VEGF re-ceptor tyrosine kinase inhibitors (e.g., SU6668) or anti-VEGF monoclonal antibodies (e.g., bevacizumab)might be more effective. Third, thalidomide is a pleo-morphic agent with multiple effects on angiogenesis,cytokine synthesis, adhesion molecules, and immuno-logic function. It is possible that some of these addi-tional effects may in some other way adversely influ-ence the outcome, therefore negating any possiblefavorable anti-angiogenic effect. Fourth, thalidomidemay require a longer time to have any positive effect.In the study of Raza et al., the time to initial responsein MDS was usually � 12 weeks.28 In multiple my-eloma, the responses may occur earlier, with a median

Chemotherapy � Thalidomide in AML/Cortes et al. 1239

time to a decrease in paraprotein levels of at least 25%of 29 days, although more marked reductions oc-curred after a median of 2–3 months.12 In our studydespite continuation of thalidomide throughout con-solidation, we found no benefit on the CR duration.Fifth, angiogenesis could be an epiphenomenonrather than an initiating pathophysiologic event. If so,suppression of angiogenesis may not change thecourse of the disease and could occur with nonspecificinterventions. Several chemotherapeutic agents havebeen reported to suppress angiogenesis.29 –33 Finally,we may have studied the “wrong patients.” Raza et al.treated 83 patients with MDS with thalidomide, start-ing at 100 mg/day and increased as tolerated to 400mg/day. Sixteen patients (19%) showed a hematologicimprovement, 10 of them becoming transfusion-inde-pendent. No complete responses were observed. Pa-tients with a higher blast count were less likely torespond.28 Thirty-two patients (39%) could not com-plete the planned 12 weeks of therapy, and only 8patients (10%) were able to tolerate 400 mg for at least8 weeks. Patients with higher-risk disease (i.e., Inter-national Prognostic Scoring System [IPSS] intermedi-ate-2 or high) were significantly more likely to stoptherapy early. In the study of Steins et al.,26 7 of 20patients also discontinued therapy prematurely. In astudy including only patients with refractory or re-lapsed high-risk MDS or AML, none of 12 patients withAML achieved a CR, although one had a significantreduction in the bone marrow blast percentage.34 Thetarget dose in this study was 800 mg/day, and nearly50% of patients reached � 600 mg/day, although themedian time on therapy was 3 weeks (range, 3 days to4.5 months).34 Considering the results obtained withthalidomide as a single agent, the lack of efficacy maybe because we treated mostly patients with AML orhigh-risk MDS. Thalidomide might be effective in bet-ter prognosis patients or in patients in CR for treat-ment of minimal residual disease.

We conclude that a non–ara-C-containing regi-men, such as liposomal daunorubicin and topotecan,has no activity in AML or MDS with poor cytogenetics.Also, thalidomide in combination with chemotherapyas given in this study did not result in clinical benefit,and no evidence of an antiangiogenic effect could bedocumented.

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