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Arsenic trioxide and ascorbic acid interfere with the BCL2 family genes in patients with myelodysplastic syndromes: an ex-vivo study

Sara Galimberti16*, Francesca Guerrini1, Flavia Salvi2, Iacopo Petrini3, Daniela Gioia2, Emanuela Messa2, Giuseppe A Palumbo4, Daniela Cilloni5, Mario Petrini1 and Alessandro Levis2

Author Affiliations

1 Department of Oncology, Transplant, New Advances in Medicine, Section of Hematology, University of Pisa, Pisa, Italy

2 S.O.C. di Ematologia, Azienda Ospedaliera SS Antonio e Biagio, Alessandria, Italy

3 Department of Oncology, Transplant and New Advances in Medicine, BIOS, University of Pisa, Pisa, Italy

4 Department of Clinical and Molecular Bio-Medicine, Section of Hematology, Oncology and General Pathology, Catania, Italy

5 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy

6 Division of Haematology, Department of Oncology, Transplant and Advances in Medicine, University of Pisa, Via Roma 67, Pisa, 56126, Italy

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Journal of Hematology & Oncology 2012, 5:53  doi:10.1186/1756-8722-5-53

Published: 10 September 2012



Arsenic Trioxide (ATO) is effective in about 20% of patients with myelodysplasia (MDS); its mechanisms of action have already been evaluated in vitro, but the in vivo activity is still not fully understood. Since ATO induces apoptosis in in vitro models, we compared the expression of 93 apoptotic genes in patients’ bone marrow before and after ATO treatment. For this analysis, we selected 12 patients affected by MDS who received ATO in combination with Ascorbic Acid in the context of the Italian clinical trial NCT00803530, EudracT Number 2005-001321-28.


Real-time PCR quantitative assays for genes involved in apoptosis were performed using TaqMan® Assays in 384-Well Microfluidic Cards “TaqMan® Human Apoptosis Array”.

Quantitative RT-PCR for expression of EVI1 and WT1 genes was also performed. Gene expression values (Ct) were normalized to the median expression of 3 housekeeping genes present in the card (18S, ACTB and GAPDH).


ATO treatment induced up-regulation of some pro-apoptotic genes, such as HRK, BAK1, CASPASE-5, BAD, TNFRSF1A, and BCL2L14 and down-regulation of ICEBERG. In the majority of cases with stable disease, apoptotic gene expression profile did not change, whereas in cases with advanced MDS more frequently pro-apoptotic genes were up-regulated. Two patients achieved a major response: in the patient with refractory anemia the treatment down-regulated 69% of the pro-apoptotic genes, whereas 91% of the pro-apoptotic genes were up-regulated in the patient affected by refractory anemia with excess of blasts-1. Responsive patients showed a higher induction of BAD than those with stable disease. Finally, WT1 gene expression was down-regulated by the treatment in responsive cases.


These results represent the basis for a possible association of ATO with other biological compounds able to modify the apoptotic pathways, such as inhibitors of the BCL2 family.

ATO; Ascorbic acid; Myelodysplastic syndromes; MDS; Apoptosis