Volume 308, number 1.4-6

FEBS 11381

August 1992

1992 Federation of European Oiuct~¢raical Societies 601a:t?O3~9~dSS.00

Bleomycin-reactive iron in patients with acute non-lymphocytic leukemia Victor R. G o r d e u k and G a r y M, Brittrnham Depttrlmcnt of Medk'hw, MelroHeMth Mcdic4d C¢,ter ~m,l Can+¢ Westert~ Reserve UtJiversity School oj" Medici~w. Ctevelw~¢L Obl 44109, USt! Received 23 June t992 Btcom¥cin-r©activeiron swasdetected in Ih¢ scra ofs/x out of nine adults undergoing- intensivechrmothcru W for acute non.lymphocytic leukemia. In these individuals the corresponding transfcrrin saturation ranged from 96"~ to I 13~ and the serum fcrritin from 775 to 99"/S,uWI. Nontransfcrrinbound iron has bern postulated to b¢a factor in origin tc,xicky in iron overload conditiolLssuch as beta tb.~hLSse~ and hereditary hemochromatosis by racilitatinll the production or tissuc.damailing f:¢e radicals. Wc propose that bleomycin.rcactiv¢ iron should L'c r,ons~'dcrrd as a possible factor in origen dysfunctiolt seen with intensive cancer chemotherapy,

Non.transferrin bound iron: Acute non.lymphocytic leukemia. Cancer chemotherapy: l.':r¢¢ radials: Serum iron; Scram fcrrhln

I. INTRODUCTION In iron overload conditions such as,8 thalassemia and hereditary hemochromatosis, an abnormal fraction of serum iron that is not bound to transferrin has been postulated to be a factor in organ toxicity [I.2], Such nontransfcrrin-bound iron might facilitate the production of free radicals that promote damage to lipids, proteins and DNA [3-6]. Patients treated with intensive cancer chemotherapy for acute non.lymphocytic leukemia regularly experience marked elevations in serum iron concentrations and transferrin sltturations [7] that are similar to values observed with iron overload. These patieat~ o~,¢a experience hepatic [8], pulmonary [9,10], and other organ dysfunction that may not be clearly related to chemotherapeutic agents, infections, or other identifiable causes. The capability of bleomycin to degrade DNA in the presence of ferrous iron [11] has been used as the basis for an assay to m=asur¢ iron not bound to transferrin or ferritin in plasma of patiP.nts with iron overload [12.13]. Halliwell and colleagues found bleomycin-reactiv¢ iron in plasma samples from six sab,i:cts who were treated for acute non-lymphocytic leukemia [t4]. Such an abnormal iron fraction might be a potential cause of some organ toxicity, We examined tl~e sere of nine patients with acute non-lymphocytic leukemia for the presence of bleomycin-reactive iron before, during and after intensive chemotherapy,

Correxpondenc¢ address; V,R, Gordeuk, MetroHealth Medical Center. 2500 MetroHealth Drive, gesoareh 369, Cleveland. OH 44109. 199~, USA,

4

2. M A T E R I A L S

AND METHODS

Serial scru ,r. samples w~re prosi~ctively obtained with inform¢d consent from patients undrrl|oing chemotherapy for acute +ton.lyrephocyti¢ leukemia :Lt Mctrol'lealth Medical Center or University Hop pi|als of Clcv~h~nd, Nontransfcrrin-bound iron ',,,'asmeasured using the blcomycin assay [13] as drs~rih¢d, except tl~at rcra was u ~ instead of plasnla, S~rum iron and total iron binding capacity (TIBC) were measured using methods of (he [ntrrnatim~al Committee for Standardization in Hematology. modified to be um:d for small quantities of~rum [i S.16l.-',+dt~nsrerrin saturationwasreticulated.Sert~m ferritin was n~casurrd USilIB FER-IRON immunoradiomctric a~,ay kits (Ram¢o Labontmri~. Inc., Houston. TX).

3, RESULTS Nine patients were studied (Table 1), including seven males and two females with ages ranging from 24 to 64 years, Seven patients received induction chemotherapy regimens (two for initial treatment, five for relapsed leukemia) and two patients were given consolidation therapy, Chemotherapeutic drugs included cytosine arabinoside (8 patients), daunorubicin (5 patients), 6thioguanine (3 patients), amsacrine (1 patient), mitoxantrone (l patient) and etoposide (1 patient), Duration of chemotherapy ranged from 5 to 9 days, median 7. Bleomycin-detectable iron was identified in th,~ sere of six of the nine patient~ from I to 6 days after chemotherapy was started, Before onset of chemotherapy only two patients had bleomycin-reactiv¢ iron. In two patient~ with bleomycin-detectable iron. repeat analysis demonstrated that it persisted on day 11. In all of six patients tested 12 to 29 days after onset of chemotherapy no bleomycin.reactive iron was lbund. At the tim~ bleomycin-detcctable iron was fo,nd, the corresponding transferrin saturation was greater than 95% in all but one serum sample. Puhlished hy Elsevier SelecteePublishers B. V.

Volume 308, number i

FEBS LE.'g'I'ERS

4. D I £ C U S S I O N Over one-half of patients with acute non-lymphocytic leukemia who are treated with intensive chemotherapy develop elevations of hepatic enzymes [9.17], Although these patients receive multiple blood products and are at a high risk for transfusion associated viral hepatitis, not all hepatic dysfunction is clearly related to this etiology, Some patients develop hepatic venu-uucl-~iv¢ disease, a condition that is not typical of viral hepatitis and has high mortality, A m o n g patients undergoing bone marrow transplantation for malignancy, up to 21% develop hepatic veno-occlusiv¢ disease it 8,19], Unexplained pulmonary dysfunction is also common in patients treated with intensive cancer chemotherapy. In an autopsy series of patients with leukemia at Johns Hopkins Hospital, 42 of 51 patients who had received chemotherapy within 30 days of death had evidence of pulmonary edema it0], In one-third of these, a cause (i.c. infection, cardiac failure, renal failure, aspiration) for the pulmonary edema could he found, but twothirds of the cases were idiopathic. The investigators attributed those pulmonary abnormalities to cytosine arabinoside toxicity, but the evidence for this was only circumstantial. In another series from the National Cancer Institute studying antibiotic therapy in cancer patients with fever and neutropenia. 6 of 33 deaths were due to pneumonit[s and respiratory hilure of undetermined cause [l l]. In three recent studies documenting the o~urrcnce o f adult respiratory distress syndrome in neutropenic pati¢nts [20-22]. most o f the patients re-

August 1992

ported were cancer patients who had recently received chemotherapy, Our data suggest that. in patients treated with intensive cancer chemotherapy, the circulation may be presented with iron in exc=ss of what can be bound to the highly saturated transferrin molecules, and that in some patients iron that is detectable by the bl¢omycin a=ay is present. In most of the== patients there are markedly elevated s=rua~ f¢¢tltin concentrations (Table I) that most likely are related, at least in part, to lysis of leukemic cells and release of tissue ferritin. Although PootrakuI and colleagues [23] have propped that iron conrained in plasma fcrritin is an explanation for non. transferrin iron, the bleomycin assay report~ly does not detect iron contained in concentrated solutions of t'erritin that is fully saturated with iron [13]. Under normal circumstances circulating iron is tightly bound to transferrln so that there is virtually no free iron in the plasma [13]. The presence of iron not bound to transt'~rrin in the serum is distinctly abnormal and might ~Luse formation of the highly reactive and damaging hydroxyl radical leading to ptroxidation of membrane iipids and tissue damage [3,24]. We propose that circulating bleomycin-reactive iron should be considered as a possible factor in some cases o f hepatic. palmon:Lry. ~nd other dysfunction seen during intensive

chemotherapy. Iron chelation conceivably might lag protective for some toxicity seen in patients with acute non-lymphocytic leukemia [251,

Ack,,,'h'dg~n:¢nls: Tiffs inwstil~ation ~'as supported ia part by a 8rant from the Dep;inment of Medicine. C'tcvcland Metropolitan

T;ible t Oleomycin.r¢:tctivc iron in scra of p:Lfients treated for acute non.lymphocytic leukemia

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Volume 308. number !

FEBS LETTERS

Gcn©ral Hospital, and by Public H~lth Service Grant P30CA4:Z?0~ awarded by the National Cancer Institute. Department o1"He'~lth and Human ~rviccs.

REFERENCES [I] Hcr~hko. C. Graham, G. Ba|~, G,W, and Radnilewi|~. E,A, (197~) Br. J. H-~ematoL 40, 25.¢-263, [2] Ba|cy, R.G,, Chuns Fonll, P,L,, $hamir, S, ~nd Sherlock, $. (19~) Dill, Dis. Sci. 2S, 340..346, [;)] Guttcrids¢. J,M.C,, Rewley, D,A., Gri~ths, E. and HailiwelI, 13. (19Z1$)Clin. Sci. 68. 463-467, [4| Halliv,~ll, B. and Gutterid~, J,M,C, (1985) MoL Aspects Med. 8, 89.-103. IS] Aruoma. O.1, and Halllwcll. 13,(1987) Biochcln. J. 241,27~-2"/1i. [6] Halliv~li, B. and Gutteridge, J,M,C, (19U6) Arch, Biochcm. Llio. phys, 246, 501-50IL ['7] Gordeuk. V.R., Brittenham. G,M,, McL-acn, G,U, and Spagnoulo, P.J, (1986) J, L~b, Clin, Med, [08. 466-412. [8] Barton. J.C, and Conrad. M.E. (1979) Ann. Intern, Med. 90, 188-190. [9] H~lupt. H.M.. Hutchins. G.M. and Moore. G.W. (198[) Am. J. Meal, ?0, 2S6-'s61. {10J Piz~.o.P.A,.Hathorn. J.W,. Hicrnenz,J,,Browne. M,. Commcrs. J.. Cotton. D.. Grc,,s, J.. LonlJo. D,. Marshall, D., McKnilht, J., Rub[n, M.. Skchon. J,. Thaler. M, .nd Wesley. R, (19~6) N. Engl. J. Med, 315, S~2-S58. [I l} Sau/ville. P".A., Pci~ch. J, and Horwitz, S.B. (1978) Biochemistry I 7, 2740,-2746. [12] Gutteridgc, J,M,C.. Rowlcy. D.A, and Halliw¢ll. B, (1981) 13iochem. J, 199. 263-26S,

August 1992

[13} Ar.omz~, O,i., Oomturd, A,. Pol~n, R,J, and Hu0iw¢ll, U, (19118) Blood 72, 1416-1419. [14] Haliiw¢ll, B,, Aruoma, O,L and Bomforcl, A. (Illli) FEBS Lair. 24 i, 202-204, [15} [n|crnational Committee for Standardi,x~t[on in Hematoloiw (iron Panel) (1978) The measurement or total .nd unsaturated iron.blndin~ cupacit)' in forum, Br, J, HaematoL :ZS, 28[-2R7, [16] International Committee {'or Standardi~tion in Hcmatololw (iron Pane|) (1978) Recommendat ions I'or measurement or~rum iron in human blood. Br. J, Hacmzz¢ol. 39, 291-294. [17] Julia, A. and Font, L, (1980) Ann, [at. Med. 93. 780, [IBj Grin(r. P,F.. EIb~dawi. A. and Puckman. C,H, (1976) Ann. intern, M ~ , gS, STtl-S~2. [19] McDonald. G.U., Shanna, P., Matthcws, D.E., Sl~ulman, H,M. and Thomas, D.E. (19i14) HcpatoloBy 4, 116-122, {20] l.~urc. M.D.. Simon. ILH.. Flint. A. and Keller. J.B. (i986) Am. J, Med, 80. 1022-1026. [21} Olin[bone. F.P.. Man[n. S.E.. Parker. M.M.. 5¢hlcsinller. T.. Roach. P.. Bulch. C.. Shelhamcr. J.H. ,nd Parr|llo. J.E. ([986) N. Engl, ]. Mcd. 315. 547-~151. [22] Maunder, R,J,. Hackman. R,C,. Rift, E,. Albert. R.K. and Sprin~mcycr. S.C, (19i16) Am, Rcv. Rcspir, Dis;, 133. 313-316, {23J Pootr~kui. P,, Josephr,on, 13., Huebers, H,A. and Finch. C,A, (J9I~B) Blood ?l, 1120-1123, [24] Peters, $.W,. Jones. U.M., Jucobs, A, and WaiistalT, M.. in: Problems o1" irun $toralc and Trnnsport (G, Spik, J, Montrcail. R,R. Crichton ~nd J. M~zurier. F..ds.) Elsevier, 198.5, pp, 321-324, [2SJ Gut|cridse. J,M.C., Richmond. R, and Hnlli~ll, B, (1979) Bio. them, J, 184. 469-4?2,