Nodular Partial Remission Research Articles

Early and Risk-Adapted Therapy with Fludarabine in High-Risk Binet Stage A CLL Patients Prolongs Progression Free Survival but Not Overall Survival: Results of the CLL1 Protocol of the German CLL Study Group (GCLLSG).

Background: Most patients (pts) with CLL present at early stages of their disease. This group is not homogenous with regard to its prognosis, and some pts show progression within 12 months after diagnosis. So far it is not clear if these pts benefit from early risk-adapted therapy. The CLL1 protocol, a randomized phase III trial of the GCLLSG, was conducted to assess if the early use of fludarabine prolongs progression free survival (PFS) in high risk (HR) CLL pts. High risk was defined by an elevated thymidine kinase (>7 U/L) or beta-2-microglobulin (>3,5 mg/L) and short lymphocyte doubling time (<12 months) or diffuse bone marrow infiltration. Combining the biological and clinical factors, at least one parameter of each group needed to be positive to qualify for the high risk cohort.Patients: From 09/1997 to 12/2004 877 previously untreated Binet A pts were enrolled. 788 pts could be stratified, 471 pts (68,3%) to the low risk (LR), 218 pts (31,6%) to the HR cohort for disease progression. 99 pts were not eligible due to violation of inclusion/exclusion criteria. 104 pts (HRF) were randomized to treatment with fludarabine (fludarabine IV 25 mg/m2/d, day 1–5, every 28 days), 114 pts (HRWW) to “watch and wait”. 30 pts were not eligible for PFS and OS. Analyses on PFS and OS on 188 pts are presented here. Response was defined by NCI-WG criteria (Cheson et al., 1996), progression was defined by slightly modified NCI-WG criteria with regard to the early stage.Results: The median observation time was 45.3 months (95% CI, 3.2–96 mo) for HRF and 40.4 months (95% CI, 6.9–92 mo) for HRWW. The median age in the HRF arm was 61 vs. 62 yrs in the HRWW arm. The HRWW arm contained significantly more male pts (p=0.03). All other parameters used for risk stratification and other characteristics like age, performance state, comorbidity, B symptoms, absolute lymphocyte count, hemoglobine, platelets, lymphadenopathy, splenomegaly or hepatomegaly were not significantly different at time of randomization. Response to fludarabine could be evaluated in 70 pts. The overall response rate was 91%, 11 pts had complete remission (16%), 5 pts had nodular partial remission (PR) (7%), 48 pts (69%) had PR, 3 pts (4%) had stable disease and 3 pts (4%) had progressive disease. Main toxicities (grade 3 or grade 4 CTC) were leukocytopenia and infections. Infections were not significantly higher in the treatment arm (p=0.12). Dose reduction was necessary in 20% of pts due to toxicity. 20 deaths were reported in the HRF arm, 12 deaths were reported in the HRWW arm (p=0.47).Discussion: On an intent-to-treat analysis PFS was significantly longer in the HRF arm in comparison to the HRWW arm (24.2 vs. 15.9 mo, p=0.03). Though the median OS was not yet reached, no significant difference between both groups in OS was assessed (p= 0.47).Conclusion: CLL pts of Binet stage A but with risk features have a median time to progression of 15.9 months. Fludarabine prolongs the PFS, but not the OS in this group of patients.

High Dose Methylprednisolone and Rituximab Is an Effective Therapy in Advanced Refractory Chronic Lymphocytic Leukaemia Resistant to Fludarabine Therapy.

The management of refractory advanced chronic lymphocytic leukaemia (CLL) continues to pose a considerable challenge to the clinician. CLL patients who are refractory or become resistant to fludarabine containing regimens currently have a poor prognosis. High dose methylprednisolone (HDMP) has been shown to be an effective therapeutic option in patients who are resistant to fludarabine particularly those with bulky lymphadenopathy or refractory cytopenias who are unsuitable for alemtuzumab therapy. We have used HDMP in combination with the anti-CD20 monoclonal antibody, Rituximab, to treat 14 patients with advanced refractory CLL. Eight of fourteen patients were male. The median age was 62.5 years (range 30–71). Twelve patients had bulky lymphadenopathy with nodal masses greater than 5 centimetres in diameter. Nine patients had Binet stage C and the remainder were stage B. Autoimmune manifestations were present in five of the patients, and in one of them fludarabine therapy was contraindicated due to active autoimmune haemolysis. FISH analysis was performed to detect 17p, 11q and 13q deletions and showed 11q23 deletions in five patients. The overall response rate was 93% with a median progression free survival (PFS) of seven months. Two patients achieved a CR, another a nodular PR and 10 patients had a PR. Responses were seen in all 4 patients who had not responded to alemtuzumab as a single agent. Only one patient failed to respond. The median survival was 20 months. All five patients with 11q23 deletions responded, and the mean progression free survival in this subgroup was 10.5 months. These results compare extremely favourably with our own previous study (Thornton et al, 1998) that used HDMP alone in the management of advanced/refractory CLL where only 43% of patients responded and no patients achieved a CR. We have demonstrated that the combination of HDMP with rituximab is more effective than HDMP alone (p<0.01) in advanced refractory CLL. Although HDMP in combination with rituximab causes little or no myelosuppression, 6/14 patients (43%) developed opportunistic fungal or viral infections and this included fungal mould infections, fungal yeast infections and opportunistic viral infections. Three patients died of pulmonary fungal infections, although 2 of these patients had been retreated with alternative regimens. While the immunosuppressive effects of high dose steroids are well recognised, it appears that the addition of rituximab has made these patients more prone to opportunistic infections. In summary, HDMP in combination with rituximab is an effective rescue regime in purine analogue refractory CLL particularly in patients with bulky lymphadenopathy who are unsuitable for alemtuzumab, and in patients with 11q23 deletions.

Seventy percent of complete responders remain in continuous remission: Five-year follow-up of 300 patients treated with fludarabine, cyclophosphamide, and rituximab (FCR) as initial therapy of CLL

7008 Background: The early results of 224 CLL patients receiving the FCR regimen were previously reported (JCO 23:4079). Mature follow-up data (median 62 months for survivors) is now available for the complete cohort of 300 patients. Methods: Eligible patients were =16 years old with previously untreated CLL requiring therapy. Median age was 57 years (31%=60 years, 14% =70 years), and 61% &amp; 36% were in modified Rai intermediate &amp; high risk categories respectively. Prognostic factors: B2m &gt;2x normal 42% (n=295), CD38 positive 28% (n=253), abnormal metaphase cytogenetics 29% (n=221), IgVH unmutated 66% (n=94), ZAP-70 positive 49% (n=88). The planned six cycles of therapy were completed in 74% patients. Results: Responses were: 72% CR, 11% nodular PR (PRn) &amp; 12% PR. On multivariate analysis, CR rates were inferior in patients with B2m &gt;2N (p=0.001) and white cell count &gt;150 × 109/L (p=0.01). Rai stage, CD38 positivity, IGVH mutational status and ZAP-70 positivity were not associated with inferior CR. Median Times to Progression (TTP) were 80 months for CR (n=216), 80 months for PRn (n=32) &amp; 27 months for PR (n=36), with 77%, 65% and 28% projected to be progression-free at five years; projected 5 yr survival were 90%, 81% and 37% respectively. Restricting the analysis to 190 patients with at least five years followup, actual 5 yr TTP and 5yr survival were 70% &amp; 88% respectively in complete responders. Five cases of Richter transformation and eight cases of MDS/AML occurred during remission, with projected 5 yr risk of 2% &amp; 3% respectively. When compared with a historical cohort of patients receiving fludarabine (n=190) or fludarabine and cyclophosphamide/mitoxantrone (n=140) in multivariate analysis, FCR was independently associated with superior TTP (p&lt;0.001) and survival (p&lt;0.001). Conclusion: FCR is the most effective CLL frontline regimen reported to date. 70% of complete responders remain progression-free at five years. No significant financial relationships to disclose.

Therapy with Fludarabine, Cyclophosphamide and Rituximab (FCR) for Relapsed or Untreated Progressive Chronic Lymphocytic Leukemia (CLL). A Single Center Experience.

Purpose: To evaluate the efficacy of FCR in improving complete remission (CR), disease-free survival (DFS) and overall survival (OS) rates in patients previously treated with chlorambucil-prednisolone and untreated CLL patients.Patients and methods: A total of 45 CLL patients started FCR. Forty-one patients completed treatment: 16 following previous relapse and 25 previously untreated with progressive disease. Four patients are still receiving treatment. Median patient age was 63 years (range 34–88 years). Binet's stage were: A: 8%, B: 34% and C: 58%. CD38 expression was positive (> 7% of cells) in 56% of patients and negative in 44%. FCR consisted of: fludarabine (25 mg/m2/day × 3); cyclophosphamide (250 mg/m2/day × 3) and rituximab (375 mg/m2/day × 1), all given intravenously, every 4 weeks for 4–6 cycles. CR was defined by CLL/NCI-WG criteria. Minimal residual disease (MRD) negativity was < 1% CD19, CD5 positive cells in peripheral blood and bone marrow. Results: The results of this study are detailed in Table 1. To summarise: CR: 69%; nodular partial remission (PR): 15%; PR: 7% and stable disease: 2%. Grade 3–4 neutropenia occurred in 33% of patients and 34% required hospitalization due to infections.Table 1:Patient details following FCR treatmentPatients% CR% MRD negative% DFS 36 moP% OS 36 moPUntreated2587969095Treated165387750.10890.90Total4174928393CD38 Positive237190710.02870.27CD38 Negative187694100100Conclusions: FCR induces a high CR (74%) and DFS (83%) rate and increases MRD negativity (92%). Significantly higher DFS rates at 36 months were observed in patients who were CD38 negative vs. CD38 positive (100 % vs. 71% P=0.02).

Self-Administered, Subcutaneous (SQ) Alemtuzumab To Eliminate Residual Disease in Patients (pts) with CLL.

Alemtuzumab is highly effective at eliminating chronic lymphocytic leukemia (CLL) from bone marrow, the usual site of residual disease following treatment with a fludarabine-based regimen. Eradication of residual disease has been associated with longer time to progression and overall survival. A clinical trial was conducted to evaluate the activity of alemtuzumab 30mg SQ thrice weekly for 4 weeks each course (up to 2) to eliminate residual disease. Eligible pts were recently treated and achieved NCI-WG partial remission (PR) with measurable disease or complete remission (CR) with residual disease present in the bone marrow by 2-color flow cytometry. Responders on this trial were pts with NCI-WG PR that converted to CR or nodular PR, pts with nPR converted to CR, or pts in CR that had no evidence of disease by 2-color flow cytometry following treatment. To date, 29 pts have been enrolled and treated, 3 CR, 7 nPR, and 19 PR. The median number of prior treatments was 1 (range, 1–6); 2 PR pts were fludarabine-refractory. The median age=65(49–82) yrs; WBC=4.9(2.5–18.3)K/μ L; HGB=13.7(10.8–16.6)g/dL; PLT=186(93–418)K/μ L; ANC 2.4(.2–7.1)K/μ L; β 2M=1.7(1.3–3.5)mg/L. There were 12 / 23 ZAP70+; 13 / 23 with unmutated IgVH; all had PS 0–1. Twenty-three pts completed 1 and 6 completed 2 courses. There was 1 death (PR) due to uncontrolled hemolytic anemia and 1 pt was not assessable (CR) for response. Of the 27 assessable pts, there were 21 (78%) responders: 2 / 2 CR, 8 / 9 nPR, and 11 / 16 PR. The median follow-up time is 10 mo; 11 / 22 continue with their response, the median time to loss of response is 10 mo. Grade (G)3 and G4 neutropenia was experienced by 4 and 3 pts during treatment, respectively. Anemia, G3 was seen in 2 pts; only 1 pt experienced G4 thrombocytopenia. Therapy was well-tolerated; 25 / 29 pts developed G1–2 injection-site reactions. Twenty-five pts self-administered alemtuzumab without difficulties. No patients developed anti-alemtuzumab antibodies. Two pts received treatment for documented CMV reactivation, and 1 received empiric treatment for fever but was CMV negative by PCR. There were 4 pts with serious adverse events: 1 neutropenic gram positive bacteremia; 1 neutropenic fever without infection; 1 neutropenic pneumonia; 1 pt with pneumonia and fatal AIHA. On a previous trial with alemtuzumab IV for residual disease (O'Brien et al. Cancer 98:2657, 2003), the updated response rate for 58 pts is 53%; the median time to loss of response is 34 mo, 9 mo for pts who had minimal residual disease (MRD) at end of treatment by PCR for IgVH. Therefore the median time to loss of response is shorter in this trial, despite a higher response rate. Evaluation for MRD in bone marrow is ongoing to determine if the shorter time to loss of response can be attributed to more MRD, possibly suggesting that longer treatment time may be needed for more durable responses with SQ alemtuzumab administration.

Alemtuzumab and Rituximab for Therapy of Patents with Early Stage High Risk CLL: Report of a Planned Interim Analysis.

The standard of care for CLL is to treat only patients with obvious clinical progression because earlier intervention is not of proven benefit. The discovery of more accurate prognostic markers for CLL could change that paradigm. The predictors of more aggressive disease include 17p13 deletion (17p13−), 11q22-3 deletion (11q22−), unmutated (UM) immunoglobulin heavy-chain variable region (IgVH), and expression of ZAP-70 and CD38. In addition, monoclonal antibody (MoAb) therapies provide effective treatment with less toxicity than chemotherapy and are likely to be most efficacious in early stage CLL. The combination of alemtuzumab (ALEM) and rituximab (RIT) is of interest because of non-overlapping mechanisms of action. ALEM is also effective therapy for patients with defects in the p53 apoptotic pathway that are more resistance to purine analogue therapy. We tested the hypothesis that MoAb therapy with ALEM and RIT will eliminate/greatly decrease the high risk clone characterized by 17p13−, 11q22−, or UM IgVH plus either ZAP70+ or CD38+, in early stage CLL.Methods This trial will enroll a maximum of 30 patients and be considered promising if ≥ 19 patients respond. All patients with previously untreated CLL (Rai stage 0 −II) not meeting NCI-WG 1996 treatment criteria and with a high risk CLL clone were evaluated for enrollment. Treatment duration was 30 days (subcutaneous ALEM dose escalation, 3 mg - 10 mg - 30 mg on days 1–3) then 30 mg Monday, Wednesday and Friday for 4 weeks. RIT (375 mg/m2/dose IV x 4) was administered weekly staring on day 8. All patients received PCP and herpes virus prophylaxis and had CMV viral DNA testing for 7 months. Response was evaluated using NCI-WG 1996 criteria and minimal residual disease (MRD) was measured in peripheral blood using sensitive flow cytometry (1:104) for CD19+/CD5+/CD79b− lymphocytes.Results Since January 2005, 17 patients have been enrolled and the interim analyses are for the first 11 patients accrued. Median age was 62 years (29 – 75) with 6 males and 5 females. The qualifying high risk features were 17p13− (n = 4), 11q22− (n = 3), and UM IgVH + CD38+ +/− ZAP-70+ (n = 4). Median time from diagnosis to treatment was 11 months (2–72). Clinical stage (Rai) was 0 in 3 patients, I in 5 patients and II in 3 patients. Median absolute lymphocyte count was 25.6 x 109/L (15.9 – 81.8), Hgb 14.4 g/dL (12 – 15.8), and platelet count 171 x 109/L (125 – 312). Two patients had serious adverse reactions requiring intervention (CMV reactivation responsive to treatment; febrile drug reaction to sulfamethoxazole/trimethoprim). Grade 3–4 adverse reactions not requiring interventions were leukopenia (n = 4), neutropenia (n = 2), anemia (n = 1), elevated ALT (n = 1), and skin reaction to ALEM (n =1). There were no “first dose” reactions. All patients responded to therapy with 5 CR (4 of these MRD negative), 3 nodular PR, and 3 PR. Median duration of response has not yet been reached at median follow up of 11.7 months (6.5 – 14.9). Patients with a MRD negative CR had recurrence of detectable MRD at 120 – 210 days after completing therapy but all remain in CR. One patient died off study of complications of a myeloablative allogeneic transplant for progressive CLL.Discussion ALEM and RIT is effective and tolerable therapy for early stage high risk CLL. All patients responded with 36% achieving a MRD negative CR but serial MRD assays showed that the CLL clone was not deleted. This promising, treatment requires further improvement.

Lenalidomide Induces Complete and Partial Responses in Patients with Relapsed and Treatment-Refractory Chronic Lymphocytic Leukemia (CLL).

Lenalidomide is an immunomodulatory drug indicated as treatment for 5q-MDS and previously treated MM. Several of its properties, i.e. inhibition of TNF-α and VEGF, modulation of T-cell activity and impact on the microenvironment suggest that lenalidomide may play a role in the treatment of CLL. A pilot study by Chanan-Khan et al. has shown clinical activity in this disease (Blood 106: 447a). To further investigate the activity of lenalidomide in CLL, we conducted a phase II study. Patients (pts) were eligible if they had received at least one purine analog-based regimen. All pts received lenalidomide at 10 mg daily for 28 days followed by titration upward by 5 mg increments every 28 days to a maximum dose of 25 mg daily. De-escalation to 5 mg daily was allowed. The planned 35 pts have been enrolled. Twenty-two pts have received treatment for at least 3 months and are therefore evaluable for response. The median daily dose of lenalidomide at three months was 10 mg. The median age was 64 yrs (range 49–82), the median number of prior treatments was 4 (1–15), and the median β2M was 4.1 mg/dL (1.6–10.1). Twelve pts (55%) had Rai stage III or IV disease. Eight pts (36%) were refractory to fludarabine and 7 pts (32%) to alkylating agents. Responses according to NCI-WG criteria assessed after 3 months of treatment showed that 7 pts (32%) achieved a response [1 CR (5%), 1 nodular PR (5%), 5 PR (23%)]. Nine pts (41%) attained stable disease or clinical improvement and are continuing on treatment, and 6 pts (27%) progressed, including one early death that occurred on day 22 secondary to mucormycosis. A tumor flare reaction was observed in 6 pts (27%), fatigue was reported in 59% (G3 in 5%), nausea in 45%, pruritus in 31% and diarrhea in 22% (G 3 in 5%). Myelosuppression occurred in 55% of the pts (32% ≥G3 neutropenia and/or thrombocytopenia). Infectious complications were observed in 6 pts: 2 cases of neutropenic fever and 4 episodes of pneumonia. To decipher lenalidomide's mechanism of action we measured plasma levels of tumor necrosis factor (TNF)-α, soluble TNF receptor 1 (TNF-R1), interferon (IFN)-γ, VEGF, bFGF, interleukin (IL)-1β, -2, -6, -8, -10, -12, IL-1 receptor antagonist (IL-1RA), and soluble IL-2 receptor (IL-2R) in 19 pts pre-treatment, on day 28, and after 3 months of therapy. We found a significant reduction in plasma VEGF level on day 28 in 4 pts that achieved a response [mean reduction of 55.6 (± 15.3) pg/mL, p = 0.036] and on day 90 in 4 pts with stable disease or clinical improvement [mean reduction of 50.9 (± 3.3) pg/mL, p = 0.003]. There were no changes in the levels of the other cytokines, including TNF-α. Further correlative studies include measurement of marrow vascularity, number of circulating T regulatory cells and CLL apoptotic rate. In conclusion, we found that lenalidomide is active in heavily pre-treated pts with relapsed CLL. Myelosuppression has been the most significant toxicity. Results of ongoing correlative studies will be presented.

The combination of rituximab and GM-CSF in elderly patients with chronic lymphocytic leukemia (CLL)

6602 Background: CLL is a disease found more frequently in the elderly (50% of the patients are age ≥70 at diagnosis). Nevertheless treatment startegies for elderly patients have not been optimized. Elderly patients are often excluded from chemotherapy programs because of fear of severe toxicities resulting from myelosuppression. Therefore, we explored the activity of rituximab in combination with GM-CSF in elderly patients with CLL. The rationale for this combination stems from in vitro data showing increased activity of rituximab when administered togheter with GM-CSF (Venugopal P. Leuk. Res.2000). Methods: Patients age ≥70 years, untreated or previously treated, were eligible if they had indications for treatment (NCI-WG criteria). Treatment consisted of rituximab 375 mg/m2 administered weekly for 4 weeks and GM-CSF 250 mcg s.q. three times weekly for 8 weeks. In the first week GM-CSF was given on day 1 and 3 and rituximab was given on day 4. Genomic aberrations, IgVH mutation status, ZAP-70 and CD38 expression were evaluated prospectively. Correlative studies measured changes in cell surface and soluble CD20, apoptosis and quality of life (FACT-An V4). Results: 39 patients have been enrolled, 28 are evaluable for response and 31 for toxicity. According to NCI criteria the OR rate was 61%. 7% of the patients achieved CR, 11% nodular PR and 43% PR. Thirty patients are alive and the median time to treatment failure has not been reached with a median follow up of 5 months. Toxicity attributable to GM-CSF was G1 injection site reaction observed in 16% of the patients. OR rates were higher in naive than in previously treated patients (74% vs 46%), in patients with favorable genomic features (73% vs 40%) and mutated IgVH (89%vs 44%). No difference in OR was found in patients expressing high or low CD38 (60% vs 55%). Upregulation of surface CD20, measured 24h after the 2nd dose of GM-CSF, was observed in 3 out of 4 patients studied. Fatigue level was reduced by a mean of 7 points according to the FACT-An scale (6 patients). Conclusions: Treatment with rituximab and GM-CSF induced a high response rate with minimal toxicity in elderly patients with CLL. Priming with GM-CSF resulted in increased expression of surface CD20. This combination of rituximab and GM-CSF improved systemic symptoms such as fatigue. [Table: see text]

Extended Follow-Up of a Chemo-Immunotherapy Regimen FCR (Fludarabine, F; Cyclophosphamide, C; and Rituximab, R) as Initial Therapy for Chronic Lymphocytic Leukemia (CLL).

Combination regimens are increasingly being used in CLL. The addition of R to F±C has increased the complete response (CR) rate in previously untreated patients (pts) with CLL. FCR was given to 300 previously untreated pts with CLL; 70.3% male, 33% Rai stage III-IV, with median value and ranges for age − 57 years (17–86), hemoglobin − 12.5G% (6.1–18.7), white cell count − 76 x 103/μl (2.1–620), platelets − 154 x 103/μl (8–406). 51% had splenomegaly. All pts fulfilled the NCIWG indications for therapy. 72% achieved CR, 10% nodular partial remission (NPR), and 12% PR. The pretreatment characteristic most strongly associated with CR was the beta-2-microglobulin level (P<.001) with significant differences between those with a value less than twice normal versus higher values. Advanced age (≥ 70 yrs), advanced stage, low hemoglobin (<11G%), low albumin (<3.6G%), and elevated BUN (>23mg%) were all significantly associated with a lower CR rate (P<.01). CD38 was not associated with CR. Mutation status, ZAP70, and FISH cytogenetics were not routinely measured. Median follow-up was 43 months (18–73). Several characteristics were associated with remission duration (R Dur). Multivariate analysis showed that (1) PCR for IgVH, (2) NCIWG response, and (3) flow responses were all independently associated with R Dur. PCR negativity for IgVH was most strongly correlated with R Dur. Seven of 79 PCR negative pts have relapsed at 31, 39, 43, 44, 62, 64, and 67 months.ResponsePatients4-Yr. R Dur Θ4-Year Surv.Flow CR†PCR Neg.$CR21783%*84%*165/208 (79%)69/160 (43%)NPR3164%84%10/27 (37%)7/19 (37%)PR3738%50%10/26 (38%)3/13 (23%)Overall30077% (CR+PR)83%185/261 (71%)NA*P<.01;θProjected;†Marrow CD5+CD19<1%;$PCR IgVHThere was no significant difference in survival between CR and NPR pts despite a significantly shorter R Dur (P<.01) for NPR pts. Survival was similar for progressive Rai 0-II and III-IV pts with projected four-year survival of >80%. The median survival for the 300 patients and various prognostic subgroups has not been reached. Second cancers occurred in 53 cases (20 with non-melanomatous skin cancers). Three cases of AML and 3 additional cases of myelodysplastic syndrome occurred. Autoimmune hemolytic anemia (AIHA) or red cell aplasia (RCA) occurred in 25 and 6 cases respectively. These complications remain a significant clinical problem in CLL. There was no significant difference in the IgA or IgM levels over time but a lower mean initial IgG (837±567mg%) versus 690±338mg% six months after FCR was completed (P<.005) was noted. 56/72 (78%) who failed or relapsed have been started on salvage therapy. The salvage response rate on retreatment with FCR+alemtuzumab was 9/17 (53%). More pts failing after initial CR or NPR claimed a second response (17/29, 59%) compared with the PR or refractory pts (3/20, 16%; P=.002).Multivariate analysis of characteristics associated with CR rate and survival for FCR and preceding non-R protocols demonstrated a significant advantage for FCR (P<.001).ConclusionWhen compared with other completed chemotherapy protocols without R, FCR significantly improved CR rate, time-to-progression and treatment failure, and overall survival establishing FCR as the most successful protocol which we have conducted to date.

Combined Chemotherapy with Fludarabine, Cyclophosphamide and Rituximab (FCR) for Relapsed or Untreated Progressive Chronic Lymphocytic Leukemia (CLL). A Single Center Experience.

Introduction: During the last decade, strong prognostic factors and new compounds emerged for the treatment of CLL. The initial experience with the combination of FCR at MDACC as salvage therapy and later in untreated patients (pts) promote us to use these regimen since March 2001.Purpose: To evaluate the efficacy of FCR in improving the complete remission (CR), disease free survival (DFS) and overall survival (OS) rates in pts previously treated with chlorambucil-prednisone as a single therapy and untreated CLL pts.Patients and methods: A total of 32 CLL pts, 16 after relapse and 16 untreated with progressive disease completed treatment and evaluation, 3 pts are still on treatment. FCR consisted of Fludarabine 25 mg/m2 iv on days 1 to 3, Cyclophosphamide 250 mg/m2 iv on day 1 to 3 and Rituximab 375 mg/m2 iv on day 1 given at 4 weeks interval up to 4–6 cycles. Response was assessed 4–8 weeks after treatment. CR was defined by CLL/NCI-WG. Minimal residual disease (MRD) negative was defined as <1% CD19, CD5 positive cells in peripheral blood and bone marrow as assessed by three colour flow cytometry. Median age was 63 years (range 34–80). Binet's clinical stage were A: 9%, B: 31% and C: 60%. The CD38 expression was positive (>7% of cells) in 53% and negative in 47% of the cases.Results: The CR was obtained in 66% of the pts, nodular partial remission (NPR) in 19%, PR in 9% and stable disease in 6%.CharacteristicsPts. #% CR% MRD negative% DFS 24 moP=# OS 24 moP=Untreated Pts1681100810.64900.81Treated Pts1650817687CD38 Positive176582650.01800.28CD38 Negative156787100100Total3266847889Neutropenia grade 3–4 was observed in 31% of the courses, 5% of the pts required hospitalisation due to infeccious episodes.Conclusion: In patients with CLL, FCR induce a high CR, MRD negative and DFS rate. Patients with CD38 negative expression correlated with a better DFS.

Pax-5 Demonstrates Residual B-Cells in Bone Marrow Trephines Post Anti-CD20 Immunotherapy.

Background: Immunohistochemical stains for CD20 are reliable in both formalin and mercuric-based fixed tissues. Anti-CD20 (rituximab (R)) immunotherapy for B- cell malignancies has negated the usefulness of CD20 immunohistochemistry post-therapy. Many other routine B-cell immunohistochemical stains are unreliable in mercuric-based fixatives. Thus, a reliable B-cell stain is needed post-R treatment.Pax-5 is a transcription factor specific for B-cells that is required for normal B-cell development. It is expressed from the Pro-B stage through to mature B-cells and is expressed on both normal and malignant B-cells. The Pax-5 immunohistochemical stain has proven to be reliable in formalin-fixed tissue. Its role in mercuric-fixed tissue has yet to be determined.Aim: To demonstrate residual CD20-negative B-cells, using the Pax-5 immunohistochemical stain, on mercuric-fixed bone marrow trephines following R treatment.Methods: We performed CD20 and Pax-5 immunostains on bone marrow trephines in patients who had received combined chemoimmunotherapy with R. Patients underwent restaging bone marrows midway through treatment (range 2–4 cycles) and at the end of treatment (range 6–8 cycles). We divided analysis into two groups; 1. Patients with overt residual disease on H&E stains. 2. Patients with morphologic complete remission on trephine.Results: Patient diagnoses included: CLL/SLL n=20; Follicular lymphoma n=2; Mantle cell lymphoma n=1; Waldenstrom macroglobulinaemia n=3. Patients' morphologic responses were: complete remission (CR) n=5; partial remission (PR) n=9; nodular partial remission (nPR) n=10; no response (NR) n=2. In the non-CR group (PR, nPR, NR) 4 patients were positive for CD20 and all 21 patients were positive for Pax-5. In the CR group 0 patients were positive for CD20 and 5 patients were positive for Pax-5.Conclusion: Pax-5 is a robust and reliable immunohistochemical stain that demonstrates B-cells post anti-CD20 immunotherapy. While it stains both normal and malignant B-cells, it may prove to be a useful tool in assessing minimal residual disease following immunotherapy.

The Treatment of Complicated and High Risk Chronic Lymphocytic Leukemia (CLL) with Fludarabine, Cyclophosphamide and Rituximab (FCR).

Between November 2000 and November 2004, we treated 11 patients with the FCR regimen for complicated CLL. The median age was 64 years (51–80 years) and the median number of prior regimens received was 1(0–4). Median number of FCR cycles delivered was 4 (2–6). Four patients were treated due to active autoimmune hemolytic anemia (AIHA), three patients due to massive lymphadenopathy, two patients for short lymphocyte doubling time, one patient for active AIHA and immune thrombocytopenia and one patient for progressive splenomegaly. Two patients received only 2 cycles of FCR due to prolonged pancytopenia secondary to hypoplastic bone marrow. Four of the patients with AIHA had prior splenectomies. Overall response rate, according to NCIWG criteria, was 100% including the patients who had received only 2 cycles. One patient achieved a complete remission, seven patients achieved nodular partial remissions and three achieved partial remissions. Among the 7 patients with nodular PR's, 4 had no evidence of residual CLL by flow cytometry and are continuing to be in remission at a median follow up of 53 months. The other 3 patients with nPR who had evidence of disease by flow cytometry relapsed at a median of 23 months (16–33 months). The patient who had a CR by NCIWG criteria, still had evidence of disease by flow cytometry and relapsed at 35 months. All patients with AIHA and immune thrombocytopenia achieved a remission of their autoimmune processes, including those who failed splenectomy. Grade 3–4 neutropenia, thrombocytopenia and anemia occurred in 8, 2 and 2 patients respectively. The median progression free interval was 33 months (9+ to 54 m) and the overall survival was 56 months (9+ to 56m). Four patients had expired at the time of this report due to progression of CLL(1), sepsis while still in remission(1), high grade transformation and subsequent sepsis(1) and complications of allogeneic transplant(1). Cytogenetic remissions were achieved in 7/9 patients. Three of them continue to be in remission at the time of this report with a median follow up of 53 months since initiation of therapy.Conclusion: FCR is an effective treatment regimen for CLL associated AIHA, even after failing splenectomy and can result in high response rates and prolonged remissions. Flow cytometry remission seems to correlate with prolonged disease free survival in patients achieving nodular partial remissions according to the NCIWG criteria. We suggest treatment with FCR until elimination of minimal residual disease by flow cytometry irrespective of histopathological remission.

Rituximab® and High Dose Methylprednisolone (HDMP) as a First Line Treatment for Patients with Chronic Lymphocytic Leukemia.

High-dose methylprednisolone (HDMP) and the anti-CD20 mAb Rituximab® each can effect partial responses in patients with chronic lymphocytic leukemia (CLL). Previously, we noted that these two agents used in combination were highly effective in treating CLL patients with relapse/refractory disease. We examined whether patients with CLL could respond to these agents when used in combination as a first line therapy. To mitigate the toxicity associated with HDMP, the dose of methylprednisolone was reduced to 60% of that used in salvage regimens. Sixteen patients with CLL were treated with three four-week cycles of methylprednisolone at 1 gm/m2 daily for 3 days and weekly Rituximab® at 375 mg/m2 for four weeks. All patients satisfied NCI-working group criteria for requiring treatment. The median age of the patients was 60 years, the male to female ratio was 4:1, the ECOG performance status was ? 2. Eighty-six percent of the patients had high-risk disease prior to therapy, as per the modified Rai classification. Fifty-six percent of the patients had CLL cells that expressed ZAP-70 and/or unmutated immunoglobulin variable region genes. Response assessment was performed at the end of each cycle, two months after completion of treatment, and each 3–6 months thereafter until the patient experienced disease progression and/or required further treatment. Objective responses were observed in 14 out of 16 patients (Overall response rate 93%), with 1 patient achieving a complete response (CR) without disease detectable in the marrow, 1 patient achieving a nodular PR, 12 patients obtaining an excellent PR only with minimal residual disease in the bone marrow, and 1 patient having stable disease, as per the NCI-working group criteria. We observed significant reductions in the white blood cell (WBC) counts, increases in hemoglobin, elevations in platelet counts, and dramatic reduction and resolution in lymphadenopathy and splenomegaly. The median time to progression (TTP) after 12 months of follow up has not been reached. Overall, the treatment was well tolerated and all but one patient completed 3 cycles of therapy. Most adverse events were Grade I-II (fluid retention, cough, transient hyperglycemia, fatigue). We also observed 2 transient episodes of grade III–IV toxicity secondary to infection, resulting in pneumonia or sinusitis that resolved completely after antibiotic treatment. Pharmacodynamic studies showed that leukemia cells from patients responding to this combination regimen were induced to express pro-apoptotic molecules, such as Bid, Apaf-1, Smac-Diablo, and to downregulate expression of anti-apoptotic molecules, such as XIAP and Mcl-1. These data indicate that modified-dose HDMP/Rituximab® may be an effective and well-tolerated first line treatment for patients with CLL.

Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab for relapsed and refractory chronic lymphocytic leukemia.

The efficacy, toxicity, and tolerability of chemoimmunotherapy with the combination of fludarabine, cyclophosphamide, and rituximab (FCR) were evaluated in previously treated patients with chronic lymphocytic leukemia (CLL). The purpose of this study was to improve the complete remission (CR) rate for previously treated patients and evaluate the quality of bone marrow response. One hundred seventy-seven previously treated patients with CLL were evaluated. Treatment consisted of rituximab 375 mg/m(2) day 1 of course 1 and 500 mg/m(2) day 1 of courses 2 to 6; fludarabine 25 mg/m(2)/d days 2 to 4 of course 1 and days 1 to 3 of courses 2 to 6; and cyclophosphamide 250 mg/m(2)/d days 2 to 4 of course 1 and days 1 to 3 of courses 2 to 6. Courses were repeated every 4 weeks. CR was achieved in 25% of 177 patients, and nodular partial remission and partial remission were achieved in 16% and 32% of patients, respectively; the overall response rate was 73%. Twelve (32%) of 37 complete responders tested achieved molecular remission in bone marrow. Univariate and multivariate analyses were used to identify pretreatment patient characteristics associated with CR and overall remission, longer time to progression, and overall survival. The FCR regimen was an active and well-tolerated treatment for previously treated patients with CLL. Myelosuppression was the most common toxicity. FCR induced the highest CR rate reported in a clinical trial of previously treated patients with CLL. Furthermore, molecular remissions were achieved in a third of patients achieving CR.

Early Results of a Chemoimmunotherapy Regimen of Fludarabine, Cyclophosphamide, and Rituximab As Initial Therapy for Chronic Lymphocytic Leukemia

Fludarabine and cyclophosphamide (FC), which are active in treatment of chronic lymphocytic leukemia (CLL), are synergistic with the monoclonal antibody rituximab in vitro in lymphoma cell lines. A chemoimmunotherapy program consisting of fludarabine, cyclophosphamide, and rituximab (FCR) was developed with the goal of increasing the complete remission (CR) rate in previously untreated CLL patients to >/= 50%. We conducted a single-arm study of FCR as initial therapy in 224 patients with progressive or advanced CLL. Flow cytometry was used to measure residual disease. Results and safety were compared with a previous regimen using FC. The median age was 58 years; 75 patients (33%) had Rai stage III to IV disease. The CR rate was 70% (95% CI, 63% to 76%), the nodular partial remission rate was 10%, and the partial remission rate was 15%, for an overall response rate of 95% (95% CI, 92% to 98%). Two thirds of patients evaluated with flow cytometry had less than 1% CD5- and CD19-coexpressing cells in bone marrow after therapy. Grade 3 to 4 neutropenia occurred during 52% of courses; major and minor infections were seen in 2.6% and 10% of courses, respectively. One third of the 224 patients had >/= one episode of infection, and 10% had a fever of unknown origin. FCR produced a high CR rate in previously untreated CLL. Most patients had no detectable disease on flow cytometry at the end of therapy. Time to treatment failure analysis showed that 69% of patients were projected to be failure free at 4 years (95% CI, 57% to 81%).

Conventional Dose Fludarabine-based Regimens are Effective but have Excessive Toxicity in Elderly Patients with Refractory Chronic Lymphocytic Leukemia

The best approach to elderly patients with relapsing chronic lymphocytic leukemia (CLL) or disease refractory to conventional therapy with alkylating agents has not yet been established. Fludarabine and its combination with mitoxantrone and/or cyclophosphamide, which is the most effective treatment in younger patients, has not been extensively utilized in the elderly CLL. Here we report our results with fludarabine-based chemotherapy in 32 previously treated patients over the age of 65 years. The overall response rate was 59% with no complete remission, 3 nodular partial remissions and 16 partial remissions. The median time to progression of disease was 7 months. Only 10 patients completed the entire treatment program, because of poor compliance due to toxicity. Eight patients developed neutropenic fever, 14 severe bacterial infections and 2 patients showed progressive encephalopathy. For comparison, in a younger group of patients with refractory CLL (<65 years), 38 of 50 patients completed the treatment plan, and the ORR was 80% (10 CR, 11 PR-nodular, 19 PR) with a median response of 12 months. Neutropenic fever was diagnosed in 10 and severe bacterial infection in 4 patients. In conclusion, fludarabine-based chemotherapy is effective for refractory CLL, however, excessive toxicity such as severe infections and neurological complications, do not allow completion of treatment in the majority of the elderly patients. Because maintenance of a good quality of life should be the main goal in the elderly CLL population, dose reduction of fludarabine and the appropriate use of myeloid growth factors and prophylactic antibiotics appear mandatory in this group of patients.

Phase II trial of subcutaneous anti-CD52 monoclonal antibody alemtuzumab (Campath-1H) as first-line treatment for patients with B-cell chronic lymphocytic leukemia (B-CLL)

AbstractThis phase II study determined the efficacy and safety of alemtuzumab, a humanized anti-CD52 monoclonal antibody, delivered subcutaneously as first-line therapy, over a prolonged treatment period of 18 weeks in 41 patients with symptomatic B-cell chronic lymphocytic leukemia (B-CLL). Injections were administered subcutaneously 3 times per week, from week 2 to 3 onward. An overall response rate (OR) of 87% (95% CI, 76%-98%; complete remission [CR], 19%; partial remission [PR], 68%) was achieved in 38 evaluable patients (81% of intent-to-treat population). CLL cells were cleared from blood in 95% patients in a median time of 21 days. CR or nodular PR in the bone marrow was achieved in 66% of the patients and most patients achieved this after 18 weeks of treatment. An 87% OR (29% CR) was achieved in the lymph nodes. The median time to treatment failure has not yet been reached (18+ months; range, 8-44+ months). Transient injection site skin reactions were seen in 90% of patients. Rigor, rash, nausea, dyspnea, and hypotension were rare or absent. Transient grade IV neutropenia developed in 21% of the patients. Infections were rare, but 10% patients developed cytomegalovirus (CMV) reactivation. These patients rapidly responded to intravenous ganciclovir. One patient, allergic to cotrimoxazole prophylaxis, developedPneumocystis carinii pneumonia. Alemtuzumab is highly effective as first-line treatment in patients with B-CLL. Prolonged treatment is important for maximal bone marrow response. Subcutaneous administration induced very few “first-dose” flulike symptoms and may reduce health care costs in comparison with the intravenous infusions.

Significance of the levels of bone marrow lymphoid infiltrate in chronic lymphocytic leukemia patients with nodular partial remission.

Patients with chronic lymphocytic leukemia (CLL) are considered in nodular partial remission (nPR) when they are in remission but bone marrow biopsies show rare nodules. The significance of the level of residual disease in nPR is not known. We studied 91 previously untreated CLL patients who were treated with fludarabine alone, fludarabine with prednisone, or fludarabine with cyclophosphamide and achieved nPR at the end of six courses. We compared bone marrow lymphoid infiltration before therapy and at the end of three and six courses of therapy as evaluated by a pathologist in retrospective fashion with that of the routine evaluation at the time of performing bone marrow biopsy. We then compared these results with those obtained by computer-aided histomorphometry in 28 patients in nPR. There was significant correlation (P < 0.05) between pathologists as well as between pathologists and histomorphometry. Upon correlation with clinical characteristics, there was significant correlation (P 0.01) between marrow involvement before therapy and white blood cell counts (wbc), hemoglobin (hgb), absolute lymphocyte counts, and beta2-microglobulin (beta2-m) but none of these parameters correlated with the lymphoid infiltrate at the end of three or six courses of therapy. more importantly, lymphoid infiltration after three and six courses did not correlate with time to progression (ttp) or overall survival (os). however, patients with >70% marrow involvement before therapy had a significantly shorter TTP (P = 0.02). All 91 patients showed similar results. However, we found reverse correlation between marrow lymphoid infiltrate at the end of three courses and OS (P = 0.01).

Clonotypic polymerase chain reaction confirms minimal residual disease in CLL nodular PR: results from a sequential treatment CLL protocol

AbstractPatient–tumor-specific oligonucleotides were generated for the detection of minimal residual disease (MRD) in a highly specific and sensitive clonotypic polymerase chain reaction (cPCR). The clone-specific region of highest diversity, CDR-III, was PCR amplified and sequenced. Nested CDR-III clonotypic primers were used in a semi-nested cPCR with a sensitivity of at least 1 in 105cells. Patients with protocol-eligible Rai intermediate or high-risk chronic lymphocytic leukemia (CLL) received induction with fludarabine 25 mg/m2 per day for 5 days every 4 weeks for 6 cycles, followed by consolidative high-dose cyclophosphamide (1.5, 2.25, or 3g/m2). cPCR was performed on peripheral blood and bone marrow mononuclear cells. All 5 patients achieving a clinical partial remission (PR) studied by cPCR were positive. Five patients achieved nodular PR (nPR) (residual nodules or suspicious lymphocytic infiltrates in a bone marrow biopsy as the sole suggestion of residual disease). Five of 5 patients with nPR were cPCR positive. In contrast, flow cytometry for CD5–CD19 dual staining and κ–λ clonal excess detected MRD in only 3 of the same 5 nPR patients, all of whom were cPCR positive, and immunohistochemistry detected MRD in only 1 of 4 assessable patients. Three of 7 CR patients evaluable by cPCR had MRD. Only 1 CR patient had MRD by flow cytometry; that patient was also cPCR positive. These data support the conclusions that nodular PR in CLL represents MRD and that clonotypic PCR detects MRD in CLL more frequently than flow cytometry or immunohistochemistry.

Analysis of residual disease in chronic lymphocytic leukemia by flow cytometry

We have investigated the value of both conventional and quantitative flow cytometry to detect minimal residual disease in 21 CLL patients in remission including bone marrow histology: eight in complete remission (CR), 11 in nodular partial remission (nPR) and two in PR. The techniques used were double immunostaining with CD5 and CD19 and quantitative estimation of the number of both antigens with standard microbeads. Reference values were established on normal peripheral blood and bone marrow controls. Patients were considered in 'immunological' remission when the percentage of CD5+ CD19+/total CD19+ cells was <25% in PB and <15% in BM. In six of the eight patients in CR, CLL cells were still detectable by flow cytometry. Only two patients, that underwent allogeneic bone marrow transplant, achieved immunological remission. CLL samples showed significantly higher CD5 and lower CD19 antigen density than normal controls (P < 0.001). Persistence of residual disease was a predictor of time to progression. None of the two patients in immunological remission relapsed within a period of 13 and 33 months, whilst two of the six patients in CR with positive flow cytometry relapsed 3 and 6 months after achieving CR. This study demonstrates that flow cytometry contributes to increase the sensitivity of the clinicohematological criteria to detect residual malignant cells in CLL patients and may be useful to monitor disease status following treatment.