Fludarabine Plus Cyclophosphamide Research Articles

The occurrence of cytokine release syndrome and its impact on the prognosis of patients with relapsed and refractory multiple myeloma following chimeric antigen receptor T-cell therapy

Objective: To analyze the incidence of cytokine release syndrome (CRS) and its impact on the prognosis of patients with relapsed and refractory multiple myeloma (RRMM) following treatment with chimeric antigen receptor T-cell (CAR-T) therapy. Methods: A retrospective collection was conducted of the clinical data of 91 patients with RRMM who underwent CAR-T therapy at the Affiliated Hospital of Xuzhou Medical University from January 2020 to October 2022. Before CAR-T cell infusion, the patient underwent pretreatment with the fludarabine plus cyclophosphamide (FC) regimen. On day 0 (d0), the patient received a dose of 1×106 cells/kg of CAR-T. The occurrence of CRS was recorded post-treatment and graded accordingly, with grades 1 to 2 indicating mild CRS and grade≥3 indicating severe CRS. The follow-up cut-off date was February 14, 2023, with a median follow-up time [M (Q1, Q3)] of 14.1 (3.1, 37.7) months. Kaplan-Meier survival curve analysis assessed the progression-free survival (PFS) and overall survival (OS) of Grade 1 and Grade 2 CRS patients. Furthermore, univariate logistic regression analysis was conducted to identify factors associated with the development of severe CRS. Results: In a cohort of 91 patients diagnosed with RRMM, there were 51 male and 40 female individuals, with a median age [M (Q1,Q3)] of 57 (31, 73) years. All 91 cases (100%) experienced CRS, with 82 cases (90%) classified as mild (grades 1-2) CRS and 9 cases (10%) classified as severe (grades 3-5) CRS. In a study involving 9 patients with severe CRS, 8 cases resulted in mortality. The Kaplan-Meier survival curve analysis revealed that among grade 1 CRS patients, neither the median PFS nor the median OS was achieved. For grade 2 CRS patients, the median PFS was 12 months (95%CI: 4-not achieved), and the median OS was 21 months (95%CI: 4-not achieved). The progression-free survival and overall survival rates of grade 2 CRS patients were both lower than those of grade 1 CRS patients (both P<0.05). Single-factor logistic regression analysis revealed that a high tumor burden (OR=1.025, 95%CI: 1.002-1.049, P=0.031), a prolonged duration of CRS onset (OR=0.809, 95%CI: 0.646-0.971, P=0.037) and persistence (OR=1.758, 95%CI: 1.349-2.481, P=0.001) were identified as significant factors associated with severe CRS in patients with RRMM. Conclusions: Patients with RRMM who undergoes CAR-T therapy have a high incidence of CRS, with a higher mortality rate among those experiencing severe CRS. Furthermore, patients with grade 2 CRS exhibit lower rates of progression-free survival and overall survival compared to those with grade 1 CRS. Factors associated with the development of severe CRS in RRMM patients include high tumor burden and prolonged duration and onset of CRS.

Excellent Safety Profile of a Low-Cost Novel Humanized CD19 CAR T-Cell Therapy, Actalycabtagene Autoleucel : Potential Impact on Access and Feasibility

Background: A high incidence of severe toxicities especially grade 3/4 immune effector cell-associated neurotoxicity syndrome (ICANS) and cytokine release syndrome (CRS), need for hospitalization, and the cost of supportive care is an hindrance to the implementation of CAR-T cell therapy for low and middle income countries (LMICs). To address these limitations, we designed a novel humanized CD19 CAR and demonstrated a favorable balance of efficacy to toxicity in the preclinical model and in the first-in-human Phase I study (Dwivedi et al. Mol Cancer Ther. 2021, Karulkar et al. ASH 2022). Here, we quantified the healthcare resource utilization (HCRU) and associated cost of clinical management of Actalycabtagene autoleucel (Actaly-cel) in India from an ongoing Phase I/II study in B-cell malignancies. Methods: This is a retrospective analysis of the HCRU costs of patients with r/r B-cell malignancies treated on Phase I/II study with Actaly-cel at 3 centers in India between June 2021 through July 2023. The key components of HCRUs are defined in Table 1 and were quantified from the electronic records from the time of enrolment till their last follow-up. Once enrolled, bridging therapy was allowed at investigator's discretion. After lymphodepletion (LD) with a fludarabine plus cyclophosphamide (FC) regimen for 3 days, patients received Actaly-cel at a target dose ≥ 5 million CAR-T cells/kg (upper limit; total 2 x10 9). The patients were monitored for toxicities particularly CRS, ICANS and cytopenias, as inpatient (non-HEPA filtered rooms) for at least a week. CRS and ICANS were graded as per ASTCT grading system and cytopenias as per CTCAE v5. Results: Total 59 patients were enrolled in this study and 47 patients received the infusion. Thirty seven patients (r/r lymphoma; n=28, r/r B-ALL; n=9) who completed 28 days post-infusion were evaluable for HCRU analysis. The median age was 37 years (16-71). The median follow-up of the cohort was 60 days (21-644); 19% (7/36) and 11% (4/36) patients completed 6 months and 12 months follow-up respectively. Among all patients (n=37) who received LD therapy, 46% of lymphoma patients received LD in the outpatient setting while 78% of B-ALL patients required hospitalization for LD. The median hospitalization period post Actaly-cel infusion was only 8 days (range: 7-17 days) in the lymphoma cohort, and 13 days (range: 7-19 days) for B-ALL patients. Importantly, none of the lymphoma patients required ICU admission, and only one B-ALL patient required ICU admission for management of adverse events. In the lymphoma cohort, 54% (15/28) of patients developed Grade 1/2 CRS and none had grade &amp;gt;/=3. A single dose of tocilizumab was given to 36% (10/28) of patients and only 4% (1/28) received tocilizumab plus corticosteroids. None of the patients required vasopressor support. Majority of B-ALL patients developed CRS. The incidence and severity of CRS was as follows: G1; 44% , G2; 11% and G3; 22%. There were no grade 4/5 CRS events. While 11% (1/9) of patients received a single dose of tocilizumab, 44% (4/9) received tocilizumab in combination with corticosteroids. Vasopressors were required in 22% of patients. None of the patients developed ICANS of any grade . Most patients (lymphoma and B-ALL) developed hematological toxicities(Table 1). The severity of Grade 3-4 was more prevalent in the B-ALL cohort. IVIG was administered to 25% of lymphoma and 22% of B-ALL patients. The induction and severity of the above toxicities were not dependent on the Actaly-cel dosage (median: 9 x 10 6 ;range: 2 x 10 6-21 x 10 6 CAR-T cells/kg). The projected production cost of Actaly-cel in the regional decentralized manufacturing model at the scale of 300 patients/year is ~15,000 USD per patient. The mean cost of HCRU for clinical management (until last follow-up) per patient was ~ 4,400 USD in an academic centre (lymphoma; ~4,000 USD, B-ALL; ~5,565 USD) and interestingly, only about 14% of these costs were incurred due to inpatient management (Figure 1). Conclusions: Actaly-cel was efficacious, with no incidence of ICANS and manageable CRS across a wide dose range. More importantly, this study reported low HCRUs due to negligible ICU admission and shorter duration of hospitalization, ensuring potential usage of Actaly-cel in outpatient settings, and ultimately improving the access and feasibility of CD19 CAR-T cell therapy in resource constrained settings such as LMICs.

Fludarabine plus cyclophosphamide versus fludarabine alone in first-line therapy of younger patients with chronic lymphocytic leukemia

AbstractCombination chemotherapy with fludarabine plus cyclophosphamide (FC) was compared with the standard regimen of fludarabine monotherapy in first-line treatment of younger patients with chronic lymphocytic leukemia (CLL). Between 1999 and 2003, a total of 375 patients younger than 66 years who predominantly had advanced CLL were randomly assigned to receive either fludarabine (25 mg/m2 for 5 days intravenously, repeated every 28 days) or FC combination therapy (fludarabine 30 mg/m2 plus cyclophosphamide 250 mg/m2 for 3 days intravenously, repeated every 28 days). Both regimens were administered to a maximum of 6 courses. FC combination chemotherapy resulted in significantly higher complete remission rate (24%) and overall response rate (94%) compared with fludarabine alone (7% and 83%; P < .001 and P = .001). FC treatment also resulted in longer median progression-free survival (48 vs 20 months; P = .001) and longer treatment-free survival (37 vs 25 months; P < .001). Thus far, no difference in median overall survival has been observed. FC caused significantly more thrombocytopenia and leukocytopenia but did not increase the number of severe infections. In summary, first-line treatment with FC increases the response rates and the treatment-free interval in younger patients with advanced CLL.

Association of SLC28A3 Gene Expression and CYP2B6*6 Allele with the Response to Fludarabine Plus Cyclophosphamide in Chronic Lymphocytic Leukemia Patients.

Fludarabine plus cyclophosphamide (FC) chemotherapy is the basis of treatment protocols used in management of chronic lymphocytic leukemia (CLL). In some patients, response to therapy may be affected by aberrant function of genes involved in pharmacokinetics and pharmacodynamics of the drugs. The aim of this research was to assess the impact of pharmacogenetic variability, namely expression of SLC28A3 gene and the presence of CYP2B6*6 variant allele, on the FC treatment efficacy. Forty-four CLL patients with functional TP53 gene at the time of FC initiation were enrolled in this study. CYP2B6 genotyping was performed by polymerase chain reaction and direct sequencing. SLC28A3 expression was measured by quantitative reverse-transcriptase polymerase chain reaction. Significantly higher pretreatment levels of SLC28A3 mRNA were detected in patients who failed to respond to FC in comparison to patients who achieved complete and partial response (p = 0.01). SLC28A3 high-expressing cases were almost ten times more likely not to respond to FC than low-expressing cases (OR = 9.8; p = 0.046). However, association of SLC28A3 expression with progression-free survival (PFS) and overall survival (OS) was not observed. CYP2B6*6 allele, detected in 24 patients (54.6%), exerted no association with the attainment of response to FC, as well aswith PFS and OS. The results of this study demonstrate that SLC28A3 expression is a significant predictor of FC efficacy in CLL patients with intact TP53. Elevated SLC28A3 mRNA levels are associated with inferior short-term response to FC, suggesting that, if validated on larger cohorts, SLC28A3 expression may become a biomarker useful for pretreatment stratification of patients.

The Aberrantly Expressed Long Noncoding RNA, TRERNA1, Predicts for Aggressive Disease in Chronic Lymphocytic Leukemia

Long noncoding RNAs (lncRNAs) have emerged as important regulators of gene expression, and dysregulated expression of lncRNAs has been reported in many cancers. One of the most documented ways by which lncRNAs can contribute to cancer aggressiveness is by altering gene expression through associations with chromatin modifying proteins. However, the vast majority of lncRNAs dysregulated in cancer remain to be functionally characterized. Specifically, there have been few studies investigating the role of lncRNAs in chronic lymphocytic leukemia (CLL). Numerous studies have been published documenting the role of micro RNAs (miRs) in CLL, indicating that non-coding RNAs can play a significant role in this disease. Therefore we hypothesize that dysregulated lncRNA expression in CLL contributes to aggressive disease. We performed microarray analysis using Arraystar Human LncRNA Array v2.0, a platform that analyzes over 30,000 lncRNA transcripts in addition to 30,000 coding transcripts. We found that many lncRNAs are aberrantly expressed in CLL compared to healthy donor B cells. We identified the lncRNA treRNA (TRERNA1) as overexpressed in CLL cells (p = .0014). treRNA has been previously described to have enhancer-like function (Ørom et al., 2010) as well as translational regulatory functions (Gummireddy et al., 2013). It has been reported as overexpressed in breast cancer lymph-node metastases and colon cancer (Gummireddy et al., 2013). In addition to expressing spliced treRNA, CLL cells contain a transcript that retains the intron between the two coding exons due to insufficient splicing. Therefore we investigated the prognostic significance of both spliced and retained intron treRNA (ri-treRNA) in subsequent studies. We obtained 144 well-characterized CLL patient samples from the CLL Research Consortium (CRC) and measured transcript expression by quantitative reverse transcription PCR (qRT-PCR). We separated patients into high or low expressers of treRNA relative to the overall median expression and found that patients with higher expression of treRNA have significantly shorter time to treatment (p = .04). High expression of treRNA also correlates with the poor prognostic indicators unmutated IGHV (p < .0001) and low ZAP70 methylation (p <.001). We validated the correlation with unmutated IGHV in a second cohort of 147 previously untreated CLL samples collected prior to starting therapy in a clinical trial (E2997; Grever et al., 2007) comparing fludarabine to the combination of fludarabine plus cyclophosphamide (FC). We found that high expression (relative to the median) of spliced, but not ri-treRNA, independently predicts for shorter progression free survival in patients receiving FC (HR 3.14, 95% CI 1.61-6.14, p < .001). Since the data from this clinical study suggests a role for treRNA in mediating DNA damage response, we established a stable retroviral system to further study this observation in vitro. We used the CLL cell line established in our lab (OSUCLL; Hertlein et al., 2013) to express empty vector or treRNA. Expression of treRNA does not alter viability, proliferation, or migration. However, OSUCLL expressing treRNA display modest resistance to FC treatment. This correlates with less induction of the DNA damage indicator, γH2AX, as well as the DNA damage response protein, TP53, although these changes were not statistically significant. Consistent with the clinical data, ri-treRNA did not show a differential response to in vitro FC treatment. In summary, we have identified a lncRNA in CLL which may play a role in DNA damage response, and serve as a biomarker predictive of aggressive disease. DisclosuresFlinn:Celgene Corporation: Research Funding.

The long-term outcome of patients in the LRF CLL4 trial: the effect of salvage treatment and biological markers in those surviving 10years.

SummaryWith 10+ years follow‐up in the Leukaemia Research Fund (LRF) CLL4 trial, we report the effect of salvage therapy, and the clinical/biological features of the 10‐year survivors treated for chronic lymphocytic leukaemia (CLL). Overall survival (OS) was similar in the three randomized arms. With fludarabine‐plus‐cyclophosphamide (FC), progression‐free survival (PFS) was significantly longer (P < 0·0001), but OS after progression significantly shorter, than in the chlorambucil or fludarabine arms (P < 0·0001). 614/777 patients progressed; 524 received second‐line and 260 third‐line therapy, with significantly better complete remission (CR) rates compared to first‐line in the chlorambucil arm (7% vs. 13% after second‐, 18% after third‐line), but worse in the FC arm (38% vs. 15% after both second and third‐line). OS 10 years after progression was better after a second‐line CR versus a partial response (36% vs. 16%) and better with FC‐based second‐line therapy (including rituximab in 20%) or a stem cell transplant (28%) versus all other treatments (10%, P < 0·0001). The 176 (24%) 10‐year survivors tended to be aged <70 years, with a “good risk” prognostic profile, stage A‐progressive, achieving at least one CR, with a first‐line PFS >3 years and receiving ≤2 lines of treatment. In conclusion, clinical/biological features and salvage treatments both influence the long‐term outcome. Second‐line therapies that induce a CR can improve OS in CLL patients.

Bortezomib plus Dexamethasone versus Fludarabine plus Cyclophosphamide in initial treatment of patients with Waldenström macroglobulinemia

PurposeWe examined the efficacy of bortezomib plus dexamethasone(BD) versus fludarabine plus cyclophosphamide(FC) in patients with symptomatic, untreated Waldenström macroglobulinemia(WM). Furthermore, to evaluate the toxicity of BD regimen in WM. Patients and methods: 17 untreated WM patients received either bortezomib and dexamethasone(n=7) or fludarabine and cyclophosphamide(n=10). BD group: A cycle of therapy consisted of bortezomib 1.3 mg/m2 intravenously; dexamethasone 40 mg on days 1, 4, 8, and 11. Patients received 4 cycles at least. FC group: A cycle of therapy consisted of fludarabine 25 mg/m2 on days 1-3; cyclophosphamide 250mg/m2 on days 1-3. Patients received 4-6 consecutive cycles for induction therapy. Responses were based on paraprotein levels. Herpes zoster prophylaxis was instituted with using oral valacyclovir. Results: In BD and FC groups, the overall response rates(PR+MR) were 86% versus 70% respectively. There was not complete response in two groups. In BD and FC groups, minor and partial responses occurred at a median of 25 vs. 54 days and 55 vs. 94 days respectively(P<0.05, respectively). The median progression-free survival(PFS) was 27 months, and a median follow-up of 62 months the actuarial 5-year overall survival(OS) rate was 80% in FC group. Because of a short following time, there were not PFS and OS that can be observed in BD group. Hemoglobin and platelet levels increased normally in 83% vs. 50% and 100% vs. 66% patients in BD and FC groups respectively(P<0.05, respectively). In BD group, peripheral neuropathy was the most common toxicity(57% grade 1- 2, no grade 3- 4). Hematologic toxicities included grade 3 to 4 thrombocytopenia in 2/7(28%) and neutropenia in 1/7(14%). 42% patients developed herpes zoster. Conclusions: The results demonstrate that BD produces rapid responses, along with high rates of response in WM, and it was generally well-tolerated in our study. Herpes zoster prophylaxis is necessary with BD, and peripheral neuropathy was the most common toxicity, but not leading to discontinuance of BD. This retrospective analysis confirms that BD therapy is an effective initial treatment in WM. Disclosures:No relevant conflicts of interest to declare.

Positron emission tomography detection of synchronous colon cancer in a patient with chronic lymphocytic leukemia

Positron emission tomography detection of synchronous colon cancer in a patient with chronic lymphocytic leukemia

Telomere Length Is An Independent Predictor of Outcome After Therapy in CLL: Results From the UKCLL4 Trial,

Abstract 3884▪▪This icon denotes a clinically relevant abstractTelomere length measurement has been reported to predict time to first treatment (TTFT) and overall survival from diagnosis in chronic lymphocytic leukaemia (CLL). Of note, the study by Rossi et al (Leukemia, 2009), of presentation samples from over 400 CLL patients, showed short telomere length predicted reduced TTFT, independent of established prognostic biomarkers such as disease stage, immunoglobulin heavy chain variable region (IGHV) mutation status and unfavourable genomic aberrations. However, to date no studies have been reported on the value of telomere length as a biomarker in CLL at time of first therapy.We have used the monochrome multiplex quantitative PCR (MMQPCR) method of Cawthon (Nucleic Acids Research, 2009), to determine relative average telomere length in peripheral blood mononuclear cell DNA from treatment naive CLL patients at time of enrolment into the phase III UKCLL4 trial. MMQPCR reports a telomere length value (T/S) which has been shown to correlate linearly with mean telomere terminal restriction fragment length as determined by southern blotting. Telomere length was measured for 375/777 patients selected from the trial, of the 375 cases 157, 85 and 133 were randomised to the Chlorambucil, Fludarabine or Fludarabine plus Cyclophosphamide (FC) arms respectively. Other than an increased proportion of cases from FC arm, the selected cohort did not differ from the whole trial cohort.The median T/S for all cases was 2.60 (range, 0.61–19.05). In a multiple linear regression model, only age at trial entry and IGHV homology to germline had significant predictive effect for T/S (p=0.023 and <0.0001 respectively). Whereas, Beta-2 microglobulin levels (B2M), WBC, time from diagnosis to study entry, percentage ZAP70 positive tumour cells and percentage CD38 positive tumour cells did not. T/S was significantly lower in cases with unmutated compared with mutated IGHV genes, with del 17p compared with no del 17p and with del 11q compared with no del 11q (all p<0.001) but did not significantly differ with disease stage, gender, or between those cases with or without trisomy 12.Splitting cases into two groups based on those with T/S above or below the median, short telomeres were associated with TP53 loss or mutation, del 11q and unmutated IGHV (all p<0.001) but not with gender or disease stage. Cases with short telomeres also showed significantly higher expression of ZAP70 and CD38 (both p<0.001) and of B2M (p=0.03).In univariate survival analysis, cases with short telomeres showed significantly reduced progression free survival after therapy (PFS) (median; 21.1 months v 33.3 months, p<0.001) and overall survival after therapy (OS) (median; 57.5 months v 108.7 months, p<0.001). Stratifying by IGHV mutational status; short telomeres remained associated with significantly reduced PFS and OS in both IGHV mutated cases (PFS, median; 22.1 months v 42.3 months, p=0.002 and OS, median; 75.9 months v not reached, p<0.001) and IGHV unmutated cases (PFS, median; 21.7 months v 25.7 months, p=0.049 and OS, median; 54.8 months v 81.9 months, p=0.005).Multivariate survival analysis, selected short telomere length as an independent predictor of reduced PFS (Hazard ratio (HR) 1.5; 95% CI 1.1–2.0; p=0.011) and OS (HR 1.9; 95% CI 1.3–2.8; p=0.002) in a model containing treatment arm, IGHV mutational status, age, gender, disease stage, del17p, del11q, ZAP70 expression and CD38 expression (Table 1).Table 1 –Multivariate Analysis for PFS and OS in a 236 Patient Cohort from UKCLL4 Trial.OutcomeCovariateHazard Ratio (HR)95% CI for HRSignificance (p)PFSShort telomeres1.501.10–2.050.011Treatment with FC0.360.26–0.49<0.001IGHV unmutated1.731.28–2.35<0.001Deletion 17p6.513.56–11.92<0.001Deletion 11q1.521.08–2.150.017OSShort telomeres1.881.27–2.780.002IGHV unmutated2.441.58–3.77<0.001Age1.051.03–1.07<0.001Deletion 17p6.843.63–12.89<0.001Only covariates selected as significant are listed above.These results demonstrate that telomere length is a powerful independent predictor of outcome after alkylating agent/purine analogue therapy in CLL. The simplicity and low cost of the MMQPCR assay for telomere length measurement warrants validation of these findings and comparison with other assays for telomere length in other large clinical trials. If confirmed, this prognostic biomarker has the potential for more widespread use in CLL. Disclosures:Gonzalez de Castro:The Institute of Cancer Research: Employment.

Incidence of therapy-related myeloid neoplasia after initial therapy for chronic lymphocytic leukemia with fludarabine-cyclophosphamide versus fludarabine: long-term follow-up of US Intergroup Study E2997

AbstractChemotherapy-related myeloid neoplasia (t-MN) is a significant late toxicity concern after cancer therapy. In the randomized intergroup phase 3 E2997 trial, initial therapy of chronic lymphocytic leukemia with fludarabine plus cyclophosphamide (FC) compared with fludarabine alone yielded higher complete and overall response rates and longer progression-free, but not overall, survival. Here, we report t-MN incidence in 278 patients enrolled in E2997 with a median 6.4-year follow-up. Thirteen cases (4.7%) of t-MN occurred at a median of 5 years from initial therapy for chronic lymphocytic leukemia, 9 after FC and 4 after fludarabine alone. By cumulative incidence methodology, rates of t-MN at 7 years were 8.2% after FC and 4.6% after fludarabine alone (P = .09). Seven of the 9 cases of t-MN after FC occurred without additional therapy. Abnormalities involving chromosomes 5 or 7 were found in 10 cases, which suggests alkylator involvement. These data suggest that FC may induce more t-MN than fludarabine alone.

Evaluación económica de rituximab en combinación con fludarabina y ciclofosfamida en comparación con fludarabina y ciclofosfamida en el tratamiento de la leucemia linfática crónica

Objectives We evaluated the cost-effectiveness of rituximab added to the chemotherapy regimen of fludarabine plus cyclophosphamide (R-FC) versus fludarabine plus cyclophosphamide (FC) for the treatment of patients with previously untreated or relapsed/refractory chronic lymphocytic leukemia (CLL). Methods Two Markov models were built, using published results on progression-free survival (PFS) in patients receiving first- or second-line therapy with R-FC vs FC, rates of disease progression and mortality rates in Spain. Patient-elicited utilities were applied to PFS and progressed health states. The cost of drugs, supportive care, and quality-adjusted life years (QALY) were estimated over a 10-year period. Univariate and probabilistic (Monte Carlo) sensitivity analyses were performed. Results The addition of rituximab to chemotherapy in first- and second-line therapy increased life-years gained (LYG) and QALYs compared with chemotherapy. The incremental cost per LYG and QALY gained was €20,703 and €19,343 for first-line treatment and was €23,183 and €24,781 for second-line treatment. Conclusion In patients with previously untreated or relapsed/refractory CLL, the addition of rituximab to the FC regimen increased life expectancy and quality-adjusted life expectancy. In both types of patient, the treatment was cost-effective.

Autologous stem cell transplantation as a first-line treatment strategy for chronic lymphocytic leukemia: a multicenter, randomized, controlled trial from the SFGM-TC and GFLLC

AbstractLong-term responses have been reported after autologous stem cell transplantation (ASCT) for chronic lymphocytic leukemia (CLL). We conducted a prospective, randomized trial of ASCT in previously untreated CLL patients. We enrolled 241 patients < 66 years of age with Binet stage B or C CLL. They received 3 courses of mini-CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone/prednisolone) and then 3 courses of fludarabine. Patients in complete response (CR) were then randomized to ASCT or observation, whereas the other patients were randomized to dexamethasone, high-dose aracytin, cisplatin (DHAP) salvage followed by either ASCT or 3 courses of fludarabine plus cyclophosphamide (FC). The primary end point was event-free survival (EFS). After up-front treatment, 105 patients entered CR and were randomized between ASCT (n = 52) and observation (n = 53); their respective 3-year EFS rates were 79.8% and 35.5%; the adjusted hazard ratio was 0.3 (95% CI: 0.1-0.7; P = .003). Ninety-four patients who did not enter CR were randomized between ASCT (n = 46) and FC (n = 48); their respective 3-year EFS rates were 48.9% and 44.4%, respectively; the adjusted hazard ratio was 1.7 (95% CI: 0.9-3.2; P = .13). No difference in overall survival was found between the 2 response subgroups. In young CLL patients in CR, ASCT consolidation markedly delayed disease progression. No difference was observed between ASCT and FC in patients requiring DHAP salvage.

Comparison between oral and intravenous fludarabine plus cyclophosphamide regime as front-line therapy in patients affected by chronic lymphocytic leukaemia: influence of biological parameters on the clinical outcome

The fludarabine plus cyclophosphamide (FC) regimen was reported to be superior to chlorambucil or fludarabine alone in terms of complete response (CR), overall response (OR) and progression-free survival (PFS) in previously untreated patients with chronic lymphocytic leukaemia (CLL). In the present study, we compared the efficacy and toxicity of FC administered through oral and intravenous route in 65 untreated patients affected by advanced CLL. No statistical differences were noticed between the two routes of administration in terms of OR, PFS, time to re-treatment (TTR) and overall survival (OS) of analysed patients. We also assessed the influence on the clinical outcome of the mutation status of the immunoglobulin variable region heavy chain (IgVH) gene, of the cytogenetic abnormalities and of the expression of ZAP70 and CD38 in patients' primary samples. Among the 58 evaluable patients, 31 (53%) achieved a CR and 18 (31%) a partial response. The median PFS was 35 months, median TTR was 42 months and median OS was not reached after 45 months (range, 1-161). A significantly lower OR rate was noticed in patients with high-risk cytogenetic abnormalities (del 17p, del 11q). In this study, high-risk cytogenetic abnormalities and unmutated IgVH genes were independent predictors of TTR. These results underline the importance of biological stratifications in front-line treatment of CLL patients. We confirm that FC is an effective regimen with mild toxicities; it could be recommended for patients with low-risk biological parameters who represent, in our experience, about 30% of the total.

Bendamustine in B-Cell Malignancies: The New 46-Year-Old Kid on the Block

On March 20, 2008, bendamustine HCl (Treanda, Cephalon, Inc.) was approved by the U.S. Food and Drug Administration (FDA) for treatment of chronic lymphocytic leukemia (CLL). This approval was based on a randomized, multicenter trial comparing the test drug ( n = 162) to chlorambucil ( n = 157) as a

Pentostatin Is Advantageous Relative to Fludarabine for in Vivo Murine T Cell Depletion, Suppression of T Cell Cytokine Secretion, and Inhibition of HVGR

Although fludarabine and pentostatin are variably utilized for conditioning prior to clinical allogeneic transplantation, limited data exists with respect to their relative efficacy in terms of host immune T cell depletion and T cell suppression. To directly compare these agents in vivo in a murine model, we compared a regimen of fludarabine plus cyclophosphamide (FC) similar to one that we previously developed (Petrus et al, BBMT, 2000) to a new regimen of pentostatin plus cyclophosphamide (PC). Cohorts of mice (n=5–10) received a three-day regimen consisting of P alone (1 mg/kg/d), F alone (100 mg/kg/d), C alone (50 mg/kg/d), or combination PC or FC. Similar to our previous data, administration of P, F, or C alone yielded minimal host T cell depletion (as measured by enumeration of splenic CD4+ and CD8+ T cells) and minimal T cell suppression (as determined by CD3, CD28 co-stimulation of a constant number of remaining splenic T cells and measuring resultant cytokine secretion by multi-analyte assay). The PC and FC regimens were similar in terms of myeloid suppression (p=.2). However, the PC regimen was more potent in terms of depleting host CD4+ T cells (remaining host CD4 number [× 10^6/spleen], 2.1±0.3 [PC] vs. 4.4±0.6 [FC], p<0.01) and CD8+ T cells (remaining host CD8 number, 1.7±0.2 [PC] vs. 2.4±0.5 [FC], p<0.01). Moreover, the PC regimen yielded greater T cell immune suppression than the FC regimen (cytokine values are pg/ml/0.5×10^6 cells/ml; all comparisons p<0.05) with respect to capacity to secrete IFN-γ (13±5 [PC] vs. 48±12 [FC]), IL-2 (59±44 [PC] vs. 258±32 [FC]), IL-4 (34±10 [PC] vs. 104±12 [FC]), and IL-10 (15±3 [PC] vs. 34±5 [FC]). In light of this differential in both immune T cell depletion and suppression of T cell effector function, we hypothesized that T cells from PC-treated recipients would have reduced capacity to mediate a host-versus-graft rejection response (HVGR) relative to FC-treated recipients. To directly test this hypothesis, we utilized a host T cell add-back model of rejection whereby BALB/c hosts were lethally irradiated (1050 cGy; day -2), reconstituted with host-type T cells from PC- or FC-treated recipients (day -1; 0.1 × 10^6 T cells transferred), and finally challenged with fully MHC-disparate transplantation (B6 donor bone marrow cells, 10 × 10^6 cells; day 0). In vivo HVGR was quantified by the following method at day 7 post-BMT: harvest of splenic T cells, stimulation with host- or donor-type dendritic cells, and use of six-color flow cytometry to detect host T cells, CD4 and CD8 subsets, and cytokine secretion by capture method. Consistent with our hypothesis, PC-treated cells acquired greatly reduced alloreactivity in vivo relative to FC-treated cells: the percentage of host CD4+ T cells secreting IFN-γ in an allospecific manner was 2.3±0.8% in recipients of PC-treated T cells and 62.7±13.4% in recipients of FC-treated cells (p<0.001). Similarly, the percentage of host CD8+ T cells secreting IFN-γ in an allospecific manner was 8.6±2.8% in recipients of PC-treated T cells and 92.7±4.1% in recipients of FC-treated T cells (p<0.001). We therefore conclude that at similar levels of myeloid suppression, the PC regimen is superior to the FC regimen in terms of murine T cell depletion, suppression of global T cell cytokine secretion, and inhibition of in vivo capacity to acquire allospecificity in response to fully genetically disparate marrow allografts. These data provide a rationale to develop PC regimens as an alternative to currently utilized FC regimens.

Low‐dose oral fludarabine plus cyclophosphamide in elderly patients with untreated and relapsed or refractory chronic lymphocytic Leukaemia

Fludarabine plus cyclophosphamide (FC) at conventional doses is an effective treatment for chronic lymphocytic leukaemia (CLL). However, FC at standard doses may give hematological and non-hematological toxicity, predominantly in the elderly. Intravenous or oral low-dose FC regimens remain highly effective in elderly patients with Low-Grade Lymphomas other than CLL and are well tolerated. We tested efficacy and toxicity of oral FC at reduced doses in 26 elderly patients (median 71 years) with previously untreated (UT-CLL, n = 14) or relapsed/refractory CLL (R-CLL, n = 12), unfit for conventional treatments. Twentyfour-of-26 (92%) patients (14/14, 100% UT-CLL; 10/12, 83.5% R-CLL) obtained a response, with 12/26 (46%) complete responses (9/14, 64.2% in UT-CLL; 3/12, 25% in R-CLL). Non-hematological toxicity was mild and myelosuppression was documented in 8/26 (31%) patients (4/14, 28% UT-CLL; 4/12, 33% R-CLL). With a median follow-up of 24 months, median event-free survival was 48 months with no differences between UT-CLL and R-CLL and all responders were alive. Low-dose oral FC treatment showed good efficacy in both untreated and refractory/relapsed CLL. The treatment is useful in elderly patients who cannot benefit of more aggressive schedules and is easy to administer on an outpatient basis.

Influence of Chromosomal Aberrations on Response to First Line Therapy in B-Cell Chronic Lymphocytic Leukemia: Interim Analysis of PALG-CLL3 Randomized Study Comparing Cladribine Plus Cyclophosphamide vs Fludarabine Plus Cyclophosphamide.

Impact of cytogenetic abnormalities on treatment with different purine nucleoside analogs in patients (pts) with B-cell chronic lymphocytic leukemia (B-CLL) is largely unknown. One of objectives of PALG-CLL3 trial, comparing cladribine plus cyclophosphamide (CC) with fludarabine plus cyclophosphamide (FC) in previously untreated progressive B-CLL, was to verify the response to treatment in subsets of pts characterized by common cytogenetic abberrations. Chromosomal abnormalities were assessed using fluorescence in situ hybridization (FISH) on interphase nuclei of lymphocytes on whole blood smears prior to the start of the study treatment. Pts were screened for trisomy 12, deletions (del) 11q, del 13q and del 17p using DNA probes: CEP12, LSI: ATM, D13S319 and p53 (Vysis), respectively. For the purpose of the present interim analysis complete cytogenetic results were available in 133 pts out of 423 pts included to the study. In this group the chromosomal aberrations were detected in 102 pts (77%) including single abnormalities observed in 69 pts (52%) and two or more aberrations in 33 pts (25%). Thirty-one pts (23%) exhibited a normal interphase FISH pattern. The most frequent single abnormality was del 13q found in 38 pts (29%), while del 17p, trisomy 12 and del 11q were identified in 14 pts (11%), 11 pts (8%), and 6 pts, (5%), respectively. The most frequently observed associations of chromosomal aberrations were: del 13q with del 11q (11 pts, 8%) and del 13q with del 17p (10 pts, 8%). Four pts (3%) revealed three chromosomal abnormalities including association of trisomy 12/del 11q/del 13q in two pts, trisomy 12/del 11q/del 17p in one pt and del 11q/del 13q/del 17p in one pt. Overall, treatment was completed and response assessed in 113 out of 133 pts with known FISH pattern. In this group of pts del 17p was the only chromosomal abnormality that correlated significantly with treatment outcome. Pts with del 17p (21, 19%) had lower probability to achieve a complete response (CR) (0.044). Interestingly, in independent analyses of both treatment arms, the negative impact of 17p was seen in pts treated with FC (p=0.002), but not in pts treated with CC (p=0.6). Moreover, comparing response rates between treatment arms we found that CC was superior to FC in terms of complete response in pts with del 17p (57% CR in CC v 14% CR in FC arm, p=0.04). In conclusion, chromosomal abnormalities can be detected in majority B-CLL pts requiring treatment. Our preliminary results suggest that CC combination may have some advantage in terms of CR achievement in B-CLL pts harboring del 17p.

Low Dose Oral Fludarabine Plus Cyclophosphamide in Elderly Patients with Untreated and Refractory Chronic Lymphocytic Leukemia.

The intravenous regimen of fludarabine plus cyclophosphamide (FC) at conventional doses is highly effective in Chronic lymphocytic leukemia (CLL), where it is currently indicated in first line therapy, and low-grade non Hodgkin lymphomas (LG-NHL). We have shown that intravenous or oral FC regimens at reduced doses remain highly effective in elderly patients with LG-NHL other than CLL. We tested tolerability and efficacy of oral FC at reduced doses in elderly patients with previously untreated (UT-CLL) or relapsed/refractory CLL (R-CLL). Twenty-five patients (>60 years) with UT-CLL (n=13) or R-CLL (n=12) were given oral F (25mg/m2/day, 40 mg total dose) and C (150mg/m2/day, 200 mg total dose) in an outpatient regimen for 4 consecutive days every 4 weeks for a maximum of 4 cycles. Patients were evaluated after every cycle for toxicity and hematological response. Toxicity was defined according to NCI criteria. Responses were defined as Complete (CR) when a normalization of blood count and misurable masses (lymph nodes and spleen) was documented, partial (PR) when at least a 50% reduction of lymphocytosis or nodes/splenomegaly occured, no response (NR) when disease was stable (less than PR) or progressed (>25% increment of tumor manifestations). Progression, new treatment or death was defined as “event”. Median age of the whole population was 70 years (range 61–80), 70 (61–80) in the UT-CLL, 71 (62–79) in the R-CLL. M:F distribution was 14:11 (7:6 in UT-CLL, 7:5 in R-CLL). Performance status was ≥1 in 80% patients. Of 25 patients, 16 (64%) were diagnosed CLL in stage A, 8 (32%) in stage B, 1 (4%) in stage C. Tumor IGHV gene was unmutated in 90% cases (in 85% UT-CLL, in 100% R-CLL). CD38 was positive in 68% (77% UT-CLL, 55% R-CLL) and ZAP-70 in 68% (82%, 67%). Chromosomal deletions of 11q or 17p regions were documented in 25.5% patients (27% UT-CLL, 25% R-CLL). The R-CLL had received 1–4 (median 2) treatment lines prior to FC. Median time from diagnosis or from prior treatment to FC was 24 months (range 1–77), 37 (1–77) in the UT-CLL, 12 (3–48) in the R-CLL. Overall, biological risk and clinical characteristics were indicative of an aggressive behavior of the investigated cohort. Patients received median 3 cycles (4 in UT-CLL, 3 in R-CLL). Nine-of-25 (36%) reduced the number of cycles because of fatigue (1 patient), heart failure (1), idiopathic thrombocytopenic purpura (1) in the UT-CLL (3/13) or infection (2), femur fracture (1), prolonged isolated thrombocytopenia or pancitopenia (2) and idiopathic thrombocytopenic purpura (1) in the R-CLL (6/12). Overall, 23/25 patients (92%) obtained a response (11/25 CR, 44%; 12/25 PR, 48%). Among UT-CLL, all responded to treatment (8/13 CR, 61.5%; 5/13 PR, 38.5%). Among R-CLL, 10/12 (83.5%) responded (3/12 CR, 25%; 7/12 PR, 58.5%; 2/12 NR, 16.5%). With a median follow-up of 23 months, 14/25 patients (56%) were event-free and 23/25 (92%) were alive. Among UT-CLL (median follow-up 12 months), 9/13 (69%) were event-free and all were alive. Among R-CLL (median follow-up 25 months), 5/12 (42%) were event-free and 10/12 (83%) were alive. Deaths occurred in the 2 R-CLL that had not responded to treatment, after 2 and 4 years, respectively. Despite the poor risk of the investigated population, this low-dose oral FC treatment showed good efficacy both in untreated and refractory/relapsed CLL. The treatment may be useful in elderly patients who cannot benefit of more aggressive or eradicating strategies and is easy to administer on an outpatient basis.

Dose Escalation Study To Evaluate Dose Limiting Toxicity (DLT), Maximum Tolerated Dose (MTD) and Safety of Alemtuzumab for Consolidation Therapy in Patients with Chronic Lymphoycytic Leukemia: Phase I/II Trial of the German CLL Study Group (GCLLSG).

Introduction: Alemtuzumab has shown considerable activity in both relapsed/refractory chronic lymphocytic leukemia (CLL) and frontline treatment setting. In a prior randomised phase III trial we have demonstrated that consolidation with alemtuzumab significantly improves progression-free survival and the rate of molecular remissions in CLL patients after fludarabine based chemotherapy. However, significant toxicity including severe infections were observed. This ongoing phase I/II trial investigates the maximum tolerated dose (MTD) of alemtuzumab consolidation in patients with CLL after 2nd line chemotherapy.Methods: 12 patients (pts) in complete or partial remission after induction chemotherapy with either fludarabine plus cyclophosphamide (FC) or fludarabine plus cyclphosphamide plus rituximab (FCR) were eligible to receive alemtuzumab consolidation 90 to 150 days after last chemo infusion. Alemtuzumab was administered in 2 different cohorts either intravenously (iv, cohort A) or subcutaneously (sc, cohort B), once weekly for 8 weeks. Dose escalation was started with 10 mg iv/sc and increased in 10 mg intervals per dose level, each dose level including a minimum of 3 pts. All pts received standard premedication and infection prophylaxis. Blood samples were taken to determine pharmacokinetics in week 4 and 8. MRD was evaluated in peripheral blood and bone marrow by 4-colour flow cytometry at week 8 and 3-monthly thereafter.Results: 10 pts (median age 68 years) in complete or partial remission (1 CR, 1 nPR, 8 PR) after FC/FCR were treated with alemtuzumab in cohort A. Due to 2 dose limiting toxicities (DLT) at dose level 2 (20 mg iv, 1 FUO requiring iv antibiotics, 1 exacerbated erythema exsudativum multiforme) the MTD of alemtuzumab was determined at 10 mg iv. In cohort B, so far 2 patients (1 CR, 1 PR) have been treated with 10 mg alemtuzumab sc and no DLT has been observed. Besides the 2 DLT overall toxicity was tolerable in both cohorts with 8 CTC grade III cytopenias reversible in less then 2 weeks, 1 FUO and 2 subclinical CMV reactivations. All infections were successfully treated. After the last dose of alemtuzumab (week 8) the clinical response status of 4 pts converted from PR to CR. Up to a median follow up of 22 months 3 pts presented with PD, 2 of them died due to disease progression. MRD negativity (< 1 × 10E-4) was achieved in 3/10 pts in cohort A and 1/2 pts in cohort B. The median PFS of all pts was 19.9 months. For the majority of patients examined alemtuzumab plasma concentrations in week 4 and 8 showed rapid accumulation with stable levels after administration in the range of 100 to 300 ng/ml.Conclusion: Consolidation with alemtuzumab in CLL pts after 2nd line therapy is safe and able to achieve response improvement including MRD negativity. Dose escalation of alemtuzumab has determined a MTD of 10 mg, if administered intravenously. Ongoing trial activity is attempting to determine the MTD, pharmacokinetic and clinical efficacy of subcutaneous alemtuzumab consolidation.

Health-Related Quality of Life in Younger Patients With Chronic Lymphocytic Leukemia Treated With Fludarabine Plus Cyclophosphamide or Fludarabine Alone for First-Line Therapy: A Study by the German CLL Study Group

To date, only a few studies have evaluated the health-related quality of life (HRQOL) of patients with chronic lymphocytic leukemia (CLL) receiving chemotherapy. Therefore, the German CLL Study Group assessed HRQOL in younger patients with advanced CLL receiving first-line chemotherapy with fludarabine or fludarabine plus cyclophosphamide (FC). Three hundred seventy-five patients younger than 66 years with advanced CLL were randomly assigned to receive either fludarabine alone (fludarabine 25 mg/m2/d for 5 days intravenously [IV], repeated every 28 days) or FC (fludarabine 30 mg/m2/d for 3 days IV plus cyclophosphamide 250 mg/m2/d for 3 days, repeated every 28 days). Six courses of treatment were planned to be administered. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 was sent to all patients at baseline and after 6, 12, and 24 months. Eighty-nine percent of 362 included patients completed at least one questionnaire (163 fludarabine- and 158 FC-treated patients). Comparing the baseline levels of 249 CLL patients with the general German population, significant differences in nearly all HRQOL scales were assessed between the two groups. A multivariate analysis showed no significant differences in all HRQOL scales between both arms. In both treatment arms, symptoms such as fatigue, insomnia, and appetite loss improved to lower levels after the end chemotherapy. Except for lower physical status, no significant difference in HRQOL between male and female patients was evaluated. Fludarabine-based treatment seems to improve HRQOL little to moderately in younger patients with advanced CLL. No significant difference between fludarabine- and FC-treated patients was observed.