Trial Information

Phase I Study of Low Dose 5-Aza-2'-Deoxycytidine Administered Daily for 5 Days Every Other Week for Patients With Relapsed or Refractory Acute Lymphocytic Leukemia

Decitabine is a potent hypomethylating agent with clinical activity in myelodysplastic
syndromes (MDS), and acute and chronic myelogenous leukemia (CML). In vitro, decitabine
induces loss of cell viability and apoptosis in ALL derived cell lines with known DNA
methylation alterations. Exposure of these cell lines to decitabine results in
hypomethylation and reactivation of putative tumor suppressor genes, an effect that is
thought to have a role in the antineoplastic activity of decitabine.

Aberrant DNA methylation of multiple promoter CpG islands is frequently observed in patients
with ALL both at initial presentation and at the time of relapse. Indeed these methylation
marks are stable in over 70% of patients with ALL at the time of relapse. Importantly,
methylation of specific molecular pathways has been associated with an extremely poor
prognosis in patients with ALL. For instance, data from our laboratory has identified
methylation, and silencing, of a cell cycle pathway composed of p73 and the cyclin dependent
kinase inhibitors p57KIP2 and p15, as a marker of poor prognosis in patients with
Philadelphia chromosome (Ph) negative disease. These results have been corroborated at the
protein level: expression of p57KIP2 and or p15/p73 has been associated with a better
prognosis. Finally, although the global methylation patterns observed in children with ALL,
that overall have an excellent prognosis, do not seem to differ with those of older patients
with the same genetic characteristics, methylation of prognostically significant pathways,
such as P73/P15/P57KIP2 are remarkably lower in the younger patients. Finally, introduction
of p57KIP2 in methylated/silenced ALL cell lines results in cell cycle arrest and induction
of apoptosis.

All these data indicates that aberrant methylation has a role in the clinical behavior of
patients with ALL and that its reversal may result in clinical benefit.