Correspondence
Treatment of Acute Promyelocytic Leukemia with Arsenic Trioxide
N Engl J Med 1999; 340:1043-1045April 1, 1999
- Article
To the Editor:
Soignet et al. (Nov. 5 issue)1 report the induction of complete remissions in patients with acute promyelocytic leukemia after treatment with low doses of arsenic trioxide. They conclude, “The clinical response is associated with incomplete cytodifferentiation and the induction of apoptosis with caspase activation in leukemic cells.” Since the latter point is one of the major novelties discussed in the article, we would like to comment on this conclusion.
The authors apparently analyzed bone marrow from one patient to make the point that arsenic induces apoptosis in leukemic cells in vivo. The analysis of all mononuclear cells in the bone marrow by Western blotting is of very limited value for determining the induction of caspase activation specifically in tumor cells, since the ratio of tumor cells to nontumor cells in bone marrow decreases after treatment. Also, lanes with the pattern of caspase expression in normal bone marrow are clearly needed as controls in the Western blot included in the report, in order to illustrate differences in the expression of caspases in normal and leukemic cells. It has been shown that certain cell populations in normal bone marrow express high levels of caspase 3.2 Therefore, it is possible that the reported increase in caspase expression was actually related to an increase in normal cells after treatment rather than to a change in the pattern of caspase expression in the leukemic cells. Also, the observed cleavage of caspase 1 and 3 may have been the result of physiologic cell turnover in the bone marrow. An increase in the expression of caspase 3 with no consequent increase in apoptosis has been reported in certain non-Hodgkin's lymphomas and solid tumors.3,4 Therefore, instead of all mononuclear cells, only the purified tumor-cell population should have been analyzed.
As an additional technical comment, we would like to note that proper conditions for the preparation of the protein lysates for analysis of caspase include the use of a special buffer with an increased percentage of sodium dodecyl sulfate. Otherwise, the caspases may become artificially cleaved during the procedure, leading to the incorrect conclusion that caspase cleavage is actually happening in vivo.5
5 ReferencesIngo Tamm, M.D.
Giovanni Paternostro, M.D., Ph.D.
Juan M. Zapata, Ph.D.
Burnham Institute, La Jolla, CA 920371
Soignet SL ,Maslak P ,Wang Z-G , et al. Complete remission after treatment of acute promyelocytic leukemia with arsenic trioxide. N Engl J Med 1998;339:1341-1348
Full Text | Web of Science | Medline2
Krajewska M ,Wang H-G ,Krajewski S , et al. Immunohistochemical analysis of in vivo patterns of expression of CPP32 (Caspase-3), a cell death protease. Cancer Res 1997;57:1605-1613
Web of Science | Medline3
Krajewski S ,Gascoyne RD ,Zapata JM , et al. Immunolocalization of the ICE/Ced-3-family protease, CPP32 (Caspase 3), in non-Hodgkin's lymphomas, chronic lymphocytic leukemias, and reactive lymph nodes. Blood 1997;89:3817-3825
Web of Science | Medline4
Zapata JM ,Krajewska M ,Krajewski S , et al. Expression of multiple apoptosis-regulatory genes in human breast cancer cell lines and primary tumors. Breast Cancer Res Treat 1998;47:129-140
CrossRef | Web of Science | Medline5
Zapata JM ,Takahashi R ,Salvesen GS ,Reed JC . Granzyme release and caspase activation in activated human T-lymphocytes. J Biol Chem 1998;273:6916-6920
CrossRef | Web of Science | Medline
To the Editor:
Soignet et al. report that low doses of arsenic trioxide induced complete remissions in patients with relapsed acute promyelocytic leukemia (the M3 subtype). The authors note that successful studies in China led them to conduct their trial.1
The benefit of arsenic in the treatment of myelogenous leukemia is not a new observation in Western medicine. In 1865, Lissauer administered arsenous oxide (Fowler's solution) to a patient with chronic myelogenous leukemia and reported a clinical remission.2 Arsenicals subsequently became the treatment of choice for myelogenous leukemias, even though remissions were unpredictable and usually transient. In his 1892 textbook of medicine, Osler stated, “There are certain remedies which have an influence upon the disease. Of these, arsenic, given in large doses, is the best. I have repeatedly seen improvement under its use.”3 Responses of the white-cell count to arsenic therapy could be dramatic, as illustrated in Osler's textbook (Figure 1Figure 1
Figure from Osler's Textbook, The Principles and Practice of Medicine, 3 Showing the Response to the Treatment of Chronic Myelogenous Leukemia with Arsenic.). The benefit of arsenic in the treatment of leukemia prompted a search for safer methods of treating patients and resulted in the synthesis of organic arsenical compounds, which were used to treat infectious diseases. Roentgen rays were discovered in 1895, and this approach supplanted the use of arsenic as a treatment for leukemia during the early years of the 20th century.4 However, the observations made in the late 19th century suggest that arsenicals may be useful as salvage therapy in patients with myelogenous leukemias other than the M3 subtype.4 ReferencesMarcel E. Conrad, M.D.
University of South Alabama, Mobile, AL 366881
Zang P ,Wang SY ,Hux H . Arsenic trioxide treated 72 cases of acute promyelocytic leukemia. Chin J Haematol 1996;17:58-622
Lissauer H . Zwei Fälle von Leukämie. Berl Klin Wochenschr 1865;2:403-4033
Osler W. The principles and practice of medicine. New York: D. Appleton, 1892:701-3.
4
Pusey WA . Report of cases treated with Roentgen rays. JAMA 1902;38:911-919
Web of Science
Author/Editor Response
The authors reply:
To the Editor: A single Western blot was shown in our article, but serial analyses were performed with bone marrow specimens from 5 of the 11 patients who could be evaluated. One patient had high levels of activated caspase 3 at base line, and protein samples from one other patient were technically unsatisfactory. Analyses of samples from the three other patients had results similar to those shown in the article. As Tamm et al. note, static observations of the expression and activation of caspase 3 have been based on immunohistochemical studies of various cell types, including normal hematopoietic progenitors. In our article, we noted that arsenic trioxide induced partial differentiation of myeloid leukemic cells before their eventual disappearance. The results of our analyses, which showed increasing levels of activated caspase 1 and caspase 3 in bone marrow mononuclear cells during induction therapy, are in accord with the finding reported by Krajewska et al.,1 who noted high levels of activated caspase 3 in mature myeloid cells as compared with progenitor cells. During treatment with a drug that induces cytodifferentiation, the “purified tumor-cell population” is necessarily heterogeneous, owing to the dynamics of the malignant-cell population. Our in vivo data also confirm the observation of induction of apoptosis after exposure of promyelocytic leukemic cells to arsenic in vitro.2-4
Tamm et al. also note that the activation of caspase 3 can be artifactually induced in T lymphocytes by certain buffers. It remains to be seen whether this phenomenon is applicable to other types of cells. However, this explanation would not account for the changes in the expression and activation of caspase 1 that we and others have observed in myeloid leukemic cells. In other experiments, we have not observed basal activation of caspase 1 in myeloid progenitors, using methods described in our article (unpublished data).
The report in Osler's textbook, noted by Dr. Conrad, is one of many from the 19th and early 20th centuries involving the use of Fowler's solution for the treatment of chronic myelogenous leukemia. The medicinal use of arsenic in pastes, powders, and solutions extended over many centuries. External preparations were used as a caustic by Fuchs in 1594 and also in combination with “cow's feet, dog fennel, and sulphur” by Plunkett — with the latter use waning after the death of Lord Bolingbroke in 1751 from arsenic poisoning.4 We are indebted to our colleagues in Harbin, China, for contributing their original observations.5
5 ReferencesRaymond P. Warrell, Jr., M.D.
Pier Paolo Pandolfi, M.D., Ph.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 100211
Krajewska M ,Wang HG ,Krajewski S , et al. Immunohistochemical analysis of in vivo patterns of expression of CPP32 (Caspase-3), a cell death protease. Cancer Res 1997;57:1605-1613
Web of Science | Medline2
Gianni M ,Koken MH ,Chelbi-Alix MK , et al. Combined arsenic and retinoic acid treatment enhances differentiation and apoptosis in arsenic-resistant NB4 cells. Blood 1998;91:4300-4310
Web of Science | Medline3
Shao W ,Fanelli M ,Ferrara FF , et al. Arsenic trioxide as an inducer of apoptosis and loss of PML/RARα protein in acute promyelocytic leukemia cells. J Natl Cancer Inst 1998;90:124-133
CrossRef | Web of Science | Medline4
Bainbridge WS. The cancer problem. New York: Macmillan, 1914:3, 284
5
Sun HD ,Ma L ,Hu XC ,Zhang TD . Treatment of acute promyelocytic leukemia by Ailing-1 therapy with use of syndrome differentiation of traditional Chinese medicine. Chin J Comb Trad Chin Med West Med 1992;12:170-171
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Mitsushi Okada, Yoko Inoue, Hitomi Karube, Masato Niitsuya, Hideki Tohnori, Yoshiharu Aizawa, Isao Okayasu, Makoto Kotani. (2001) Cytotoxic evaluation of arsenic compounds in alveolar macrophages in hamsters. Applied Organometallic Chemistry 15:4, 252-260
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Mitsushi Okada, Hitomi Karube, Masato Niitsuya, Yoshiharu Aizawa, Isao Okayasu, Makoto Kotani. (1999) In Vitro Toxicity of Gallium Arsenide in Alveolar Macrophages Evaluated by Magnetometry, Cytochemistry and Morpholegy.. The Tohoku Journal of Experimental Medicine 189:4, 267-281
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