Identification of AML and MDS Patients Who Could Potentially Benefit From Temozolomide Therapy: Proportion of Patients with Low Methyl Guanine Methyltransferase (MGMT) Expression Level

Temozolomide is an imidazotetrazine derivative of dacarbazine that functions as an alkylating agent. Temozolomide anti-tumor activity is attributed to methylation of DNA, leading to the formation of O⁶-methylguanine that eventually leads to apoptosis. Resistance to temozolomide may largely be conferred by O⁶-methylguanine DNA methyltransferase (MGMT) over-expression. The level of MGMT expression will determine the ability of a cell to withstand damage from an alkylating chemotherapeutic agent. Brandwein et al. (Leukemia 2007;21:821-4) previously showed that the complete response rate to temozolomide therapy in patients with acute myeloid leukemia (AML) was higher when MGMT expression was low.

In this prospective multicenter study we evaluated MGMT expression by Western blot in bone marrow or peripheral blood from older patients with previously untreated AML and high risk myelodysplastic syndrome (MDS). Expression was characterized by comparison with b-actin and results were expressed as an MGMT:b-actin ratio: Negative: < 0.2; Weak: 0.2 – 0.25; and Strong:> 0.25 MGMT promoter methylation was also evaluated using methylation-specific PCR. Both protein expression and promoter methylation were tested in a central lab.

Data were obtained for 152 patients; median age was 76 years old (range 46–94 years). A majority (63%) were male. Primary diagnosis was AML (84%) and MDS (16%). MGMT expression level could be determined in 128 of the 152 patients tested (84%). Expression ratios were: Negative (41%), Weak (11%), and Strong (48%). MGMT promoter methylation could be detected in 16% of cases in patients with either Negative or Weak expression ratio and in 2% of patients with Strong expression ratio. A majority of patients with promoter methylation (82%) had low MGMT expression.

One-half of patients with AML/MDS had either a Negative or Weak MGMT expression level, and would therefore be potential candidates for temozolomide therapy. These low levels could be explained by promoter methylation in a minority of cases. Thus, low level of MGMT expression in AML/MDS may be due to direct alteration of the MGMT gene or modulation of expression at the post-transcriptional level.

Brandwein:Merck: Honoraria, Research Funding. Off Label Use: temozolomide for acute myeloid leukemia. Kassis:Merck: Research Funding. Leber:Merck: Research Funding. Howson-Jan:Merck: Research Funding. Minden:Merck: Research Funding. Greaves:Schering-Plough/Merck: Employment. Pouliot:Schering-Plough/Merck: Employment.