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Leukemia (2001) 15, 1510–1516
© 2001 Nature Publishing Group All rights reserved 0887-6924/01 $15.00
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Cladribine combined with cyclophosphamide and mitoxantrone as front-line therapy
in chronic lymphocytic leukemia
T Robak 1 , JZ Błoński 1 , M Kasznicki 1 ,JGóra-Tybor 1 , J Dwilewicz-Trojaczek 2 , P Boguradzki 2 , L Konopka 3 , B Ceglarek 3 ,
J Sułek 4 , K Kuliczkowski 5 , D.Wołowiec 5 , B Stella-Hołowiecka 6 , AB Skotnicki 7 , W Nowak 7 , B Moskwa-Sroka 8 ,
A Dmoszyńska 9 and M Calbecka 10
1
Department of Hematology, Medical University , Łódź; 2 Department of Hematology, Medical Academy, Warsaw; 3 Institute of Hematology
and Blood Transfusion, Warsaw; 4 Department of Internal Medicine, Military Medical Academy, Warsaw; 5 Department of Hematology,
Medical University, Wrocław; 6 Department of Internal Medicine, Medical Academy, Katowice; 7 Department of Hematology, Jagiellonian
University, Kraków; 8 Department of Hematology, City Hospital, Gorzów Wielkopolski; 9 Department of Hematology, University Medical
School, Lublin; and 10 Department of Hematology, District Hospital, Toruń, Poland
The objective of the study was to determine the effectiveness
and the toxicity of a combined chemotherapy consisting of cladribine
(2-CdA), mitoxantrone and cyclophosphamide (CMC
regimen) in the treatment of previously untreated B cell chronic
lymphocytic leukemia (B-CLL). From August 1998 to December
2000 2-CdA was administered at a dosage of 0.12 mg/kg for 3
(CMC3) or 5 (CMC5) consecutive days, mitoxantrone at 10
mg/m 2 on day 1 and cyclophosphamide at 650 mg/m 2 on day 1
to 62 patients with advanced or progressive B-CLL. The cycles
were repeated at 4 week intervals or longer if severe myelosuppression
occurred. Twenty patients received CMC5 and 42
patients CMC3. Within the analyzed group an overall response
(OR) rate (CR+PR) of 64.5% (95% CI: 52.7–76.3%) was reported,
including 29.0% CR. There was no difference in the CR rate
between the patients treated with CMC5 (30%) and CMC3
(28.6%) (P = 0.9), nor in the OR rate (55.0% and 69.0%, respectively,
P = 0.3). Residual disease was identified in seven out of
18 (38.9%) patients who were in CR, including two treated with
CMC5 and five treated with CMC3 protocols. CMC-induced
grade III or IV thrombocytopenia occurred in 12 (19.4%) of
patients, including four (20%) CMC5-treated and eight (19%)
CMC3-treated patients (P = 0.8). Neutropenia grade III or IV was
observed in seven (35%) and 11 (26.2%) patients, respectively
(P = 0.8). Severe infections, including pneumonia and sepsis,
occurred more frequently after CMC5 (11 patients, 55.0%) than
CMC3 (10 patients, 28.6%) (P = 0.03) Fourteen patients died,
including six treated with CMC5 and eight treated with CMC3
(30% and 19%, respectively). Infections were the cause of death
in nine patients, including four in the CMC5 group and five in
the CMC3 group. In conclusion, our results indicate that the
CMC programme is an active combined regimen in previously
untreated B-CLL patients; its efficiency seems to be similar to
that observed earlier in B-CLL patients treated with 2-CdA as
a single agent. However, toxicity, especially after CMC5 administration,
is significant. Therefore, we recommend the CMC3
but not the CMC5 programme for further evaluation. Leukemia
(2001) 15, 1510–1516.
Keywords: cladribine; cyclophosphamide; mitoxantrone; CLL;
combined therapy; residual disease
Introduction
The newer purine analogs, fludarabine (FAMP), 2-deoxycoformycin
(DCF) and cladribine (2-chlorodeoxyadenosine, 2-
CdA), have been synthesized recently and introduced into the
treatment of low-grade lymphoid malignancies. 1–3 2-CdA is a
Correspondence: T Robak, Department of Hematology, Medical University
of Łódź, 93-513 Łódź, ul. Pabianicka 62, Poland; Fax: +48
42 6846890
The preliminary results of this study were presented at the 41st Annual
Meetingof the American Society of Hematology, San Francisco, CA,
December 1–5, 2000.
Received 27 February 2001; accepted 10 May 2001
nucleoside analogwith a substituted halogen atom at position
2 in its purine ring, which makes it resistant to deamination
by adenosine deaminase. It is mainly used in the treatment
of hairy cell leukemia, but it is also highly active in chronic
lymphocytic leukemia (CLL), with an overall response rate
(OR) and complete remission rate (CR) comparable to that
achieved with FAMP. 4–7 There are some opinions that 2-CdA
is associated with more frequent and problematic myelosuppression.
However, direct comparison of both agents in the randomized
study of CLL patients has not been published as of
this time.
Despite the fact that new purine analogs induce a higher
overall response rate and a higher CR rate in patients with
CLL, they do not influence survival time. 5,8 On the other hand,
both FAMP and 2-CdA administered as single agents can
induce immunophenotypic and molecular remission, which is
especially important in younger patients in order to qualify
these patients for bone marrow transplantation and offer the
possibility of recovery. 3,9
Combined use of purine analogs with other cytotoxic agents
may increase the CR rate and, possibly, suppress minimal
residual disease and prolongsurvival. Some preclinical studies
and early clinical reports may support such a hypothesis. 10–16
Among cytotoxic agents, alkylating drugs and anthracyclines
were the primary candidates for use in combination with
purine analogs. Synergistic action of 2-CdA with cyclophosphamide
and its derivatives has been shown both in in vitro
and in vivo experiments. 10,11 These results have been confirmed
recently by early clinical trials, which have shown that
the combination of 2-CdA with cyclophosphamide and
prednisone is feasible and active in patients with CLL and
other low-grade lymphoid malignancies. 13,14
Mitoxantrone is also a useful drugin the treatment of lowgrade
lymphomas and can be combined with purine analogs.
17–20 However, the advantage of such a combination in
patients with refractory or relapsingdisease over 2-CdA alone
has not yet been proven. Thus, the combination of 2-CdA with
cyclophosphamide and mitoxantrone seems to be the logical
conclusion of the clinical studies in which 2-CdA was administered
with each independently. In our previous study, 21 we
showed that combined treatment with 2-CdA, cyclophosphamide
and mitoxantrone (CMC programme) in heavily pretreated
CLL and other indolent lymphoma patients is an active
regimen. In this report, we present our experience with the
combination of 2-CdA with cyclophosphamide and mitoxantrone
in previously untreated patients with B-CLL.

Patients and methods
Patients
Between August 1998 and December 2000, 62 previously
untreated patients with progressive or symptomatic CLL were
treated with a combined chemotherapy consistingof 2-CdA,
cyclophosphamide and mitoxantrone. The characteristics of
the patients are shown in Table 1. All of the patients fulfilled
the National Cancer Institute-Sponsored WorkingGroup criteria
for CLL. 22 Pretreatment evaluation included examination
of medical history, physical examination, complete blood cell
count, differential count of WBC, chemical survey, bone marrow
examination and serum immunoglobulin level quantitation.
Cytogenetic analysis was not routinely performed. The
patients had peripheral lymphocytosis greater than 10 × 10 9 /l
and more than 30% lymphocytes in normal or hypercellular
bone marrow. The differences between mean values in both
groups of patients were not significant. Cell marker studies
were performed to confirm B cell origin and monoclonal proliferation.
All patients were CD5, CD19, CD20 and CD23
positive and showed monoclonality for light chain immunoglobulin
membrane surface receptors.
The clinical stage of disease was determined at the time of
initiation of the treatment accordingto Rai’s classification. 23
The distribution is shown in Table 1. Patients in stage 0, I and
II were eligible if they had evidence of active disease, including
progressive lymphocytosis, massive splenomegaly or
bulky lymphadenopathy, recurrent disease-related infections,
weight loss 10% over a 6 month period, temperature of
38°C related to disease or extreme fatigue. Patients with poor
performance status (WHO scale 4), active infection, abnormal
liver or renal function and Richter’s syndrome were excluded
from the study. The study was approved by Local Ethical Committees
and the patients had signed the informed consent
form.
Treatment modality
The doses and schedule of the treatment agents were based
on previous studies in cases of CLL relapse, refractory CLL or
low-grade lymphoma. 7,19–21
CMC in untreated CLL
T Robak et al
In the first part of the study, CMC protocol consisted of 2-
CdA administered at a dose 0.12 mg/kg in 2-h i.v. infusion for
5 (CMC5) days, mitoxantrone 10 mg/m 2 i.v. on day 1 and
cyclophosphamide 650 mg/m 2 i.v. on day 1. In the second
part of the study, 2-CdA administration was shortened to 3
days (CMC3) because of excessive hematological toxicity of
CMC5 protocol. The doses of mitoxantrone and cyclophosphamide
were the same as in the CMC5 protocol. 2-CdA
(Biodrybin) was synthesized accordingto the method of Kazimierczuk
et al 24 and was commercially available from the
Institute of Biotechnology and Antibiotics- Bioton (Warsaw,
Poland).
The cycles were repeated over 28 days for three courses. If
hematological complications (thrombocytopenia 50 × 10 9 /l,
granulocytopenia 0.5 × 10 9 /l) or severe infections developed
the drugs were re-administered at time intervals longer than
28 days, ranging from 2 to 4 months, until the increase of
hematological parameters or recovery from infections was
noted. If a response had been documented, patients were
treated until maximal response or prohibitive toxicity. If no
response or progression of the disease was observed after
three cycles, the treatment was discontinued. Packed red cells
were transfused for symptomatic anemia or prophylactically
if the hemoglobin level was lower than 7.0 g/dl. Platelets were
administered prophylactically if the platelet count was less
than 15.0 × 10 9 /l. Blood products were irradiated. In order to
prevent hyperuricemia, allopurinol (300 mg/daily) was administered.
No patients received antibiotics or antiviral agents
prophylactically. No patients received hematopoietic growth
factors prophylactically but G-CSF or GM-CSF were administered
if the absolute granulocyte count was less than 1.0 ×
10 9 /l and active infection was present.
Response criteria
Treatment effect was monitored by physical examination,
blood count evaluation and bone marrow examination before
and after every course of chemotherapy. Guidelines for
response were those developed by the NCI-Sponsored WorkingGroup.
22,25 Complete response (CR) required the absence
of symptoms and organomegaly, normal complete blood cell
count (absolute neutrophil count 1.0 × 10 9 /l, hemoglobin
1511
Table 1
Clinical characteristics of B CLL patients before CMC treatment
Characteristics All patients CMC5 CMC3
Total 62 20 42
Sex
Male 38 (61.0) 13 (65) 25 (59.5)
Female 24 (39.0) 7 (35) 17 (40.5)
Age in years, median ± s.d. (range) 62.5 (33–77) 63.5 (36–77) 61 (33–76)
Rai stage before CMC
0 1 (1.6) 1 (5) 0
I 8 (12.9) 3 (15) 5 (11.9)
II 18 (29.0) 6 (30) 12 (28.6)
III 20 (32.3) 4 (20) 16 (38.1)
IV 15 (24.2) 6 (30) 9 (21.4)
Median disease duration in months median (range) 8.9 (3.0–156.3) 14.6 (4–26) 8.2 (3.0–156.3)
Mean number of WBC × 10 9 /l (range) 84.0 (5.4–376.0) 103.2 (10.2–606.0) 82.6 (5.4–376.0)
Mean Hb concentration g/dl (range) 12.0 (4.0–17.0) 12.0 (4.0–14.0) 11.0 (5.1–17.0)
Mean number of platelets × 10 9 /l (range) 150 (28–314) 133 (15–231) 174 (28–314)
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1512
CMC in untreated CLL
T Robak et al
concentration 11.0 g/dl, platelet count 100 × 10 9 /l and
bone marrow with less than 30% lymphocytes for at least 2
months. Partial response (PR) was considered in the case of a
50% or greater decrease in the size of lymph nodes, liver and
spleen, and peripheral blood findings either identical to those
of CR or improved over pre-therapy values by at least 50%.
The patients who had not achieved CR or PR were classified
as non-responders (NR). Clinical relapse was defined accordingto
Robertson et al 9 as an increase in the absolute lymphocyte
count above 10 × 10 9 /l, more than 50% increase in the
sum of the size of at least two lymph nodes, appearance of
new lymph nodes, more than a 50% increase in the liver or
spleen below the costal margin, the new appearance of palpable
hepatosplenomegaly or development of an aggressive
lymphoma.
Immunophenotype analysis
Immunophenotypingwas performed on peripheral blood and
bone marrow by flow cytometry usinga simultaneous dualcolor
stainingtechnique before treatment and after obtaining
CR, accordingto the method described by Brugiatelli et al. 26 A
combination of phycoerythrin (PE)-conjugated and fluorescent
isothiocyanate (FITC)-conjugated monoclonal antibodies was
utilized. Residual disease was determined by co-expression of
CD5/CD19 and CD5/CD20 on B lymphocytes in conjunction
with monoclonality of surface light-chain expression on CD5-
positive B cells. The presence of more than 10% of the total
lymphocytic population co-expressingCD5/CD19 and
CD5/CD20 with monotypic light-chain expression (a : or
: ratio exceeding3:1) was considered positive for residual
disease, accordingto the criteria developed by Robertson et
al. 9
Toxicity monitoring
Hematological toxicity was evaluated according to the criteria
developed by the NCI-Sponsored WorkingGroup. 22 Druginduced
anemia, thrombocytopenia and neutropenia were
diagnosed if after the treatment course a further decrease of
hemoglobin level and/or platelets and neutrophils numbers
were observed. Other side-effects were assessed and monitored
accordingto WHO criteria. 27
Only major and moderate infections were recorded, includinglife-threateningepisodes
such as pneumonia and disseminated
infections that required oral or parenteral antibiotic
therapy, antifungal and antiviral therapy and/or hospitalization.
Fever of unknown origin (FUO) requiring parenteral
antibiotic therapy was also recorded as an infectious event.
Infections were reported as CMC related if they developed on
therapy or within 4 months of the completion of the CMC
treatment.
Statistical analysis
Statistical analysis of the differences in the percentages of
responses in patients treated with CMC3 and CMC5 were
evaluated by the 2 test. Ninety-five percent confidence intervals
for response probability were calculated usingthe
method described by Duffy and Santner. 28
Results
Sixty-two patients with B-CLL entered the study and all of
them were analyzed. The median time from the diagnosis to
CMC administration was 8.2 months (range 4–26). The
characteristics of the patients are presented in Table 1. Twenty
patients were treated accordingto CMC5 protocol and 42
received CMC3 chemotherapy. The total number of CMC
courses administered to the entire group of patients amounted
to 237 (84 CMC5 and 153 CMC3 courses). The median number
of CMC3 courses was 3.8 (range 1–6), and the median
time needed to deliver the total number of cycles was 4.6
months (range 1–8.7). The patients treated with CMC5
received from 1 to 6 (median 2.5) courses, and the median
time needed to deliver the total number of cycles was 5.7
months (range 1–10.2). In the CMC3 group 8 (19%) patients,
and in the CMC5 group 9 (45%) patients, could not reach the
total of three cycles because of early death or severe myelotoxicity.
The criteria for CR were fulfilled in 18 patients (29.0%) and
PR in 22 (35.5%), giving an overall response rate in 64.5%
(95% CI 52.7–76.3%) of total patients (Table 2). There were
no differences in the frequency of OR between the CMC5-
and the CMC3-treated groups (55% and 69%, respectively, P
= 0.3). The CR rate was also similar in both groups (30% and
28.6%, respectively) (P = 0.9). In the group treated with CMC5
the patients attainingCR received a median of three courses
(range 2–6) and in the group treated with CMC3 a median of
three courses (range 2–6) was also administered. CRs were
observed more frequently in the early stages of the disease
(Rai 0, I and II) – 11/29 (37.9%) than in the more advanced
stages (Rai III and IV) – 7/33 (21.2%) (P = 0.8).
Surface immunophenotypingby flow cytometry usingdualcolor
stainingon peripheral blood and/or bone marrow was
performed in patients who achieved CR. Residual disease was
identified in seven out of 18 (38.9%) patients who achieved
remission.
Toxicity
Myelosuppression was the major toxicity of the CMC therapy
(Table 3). Grades III and IV neutropenia were observed in 18
(29.0%) out of 62 patients and after 30 (12.7%) out of 237
CMC courses. There was no significant difference between the
frequency of severe neutropenia in the 7/20 (35%) patients
treated with CMC5 or 11/42 (26.2%) patients treated with
CMC3 regimens (P = 0.8). Hematopoietic growth factors (G-
CSF or GM-CSF) were administered after four and 13
courses, respectively.
The frequency of thrombocytopenia was similar (20% and
19%) in both groups (P = 0.8). Grade III or IV anemia was the
rarest hematological complication and was observed in only
four patients. Autoimmune hemolytic anemia (AIHA)
developed in two patients treated with CMC3. These patients
had no clinical or laboratory symptoms of this complication
before CMC treatment.
Severe infections and fever of unknown origin (FUO) requiringparenteral
antibiotic therapy occurred more often in
patients treated with the CMC5 regimen – 11 patients (55%)
than CMC3 – 10 patients (23.8%) (P = 0.03). The number of
severe infections and FUO was also more frequent after CMC5
courses – 15 (17.9%) than CMC3 courses – 12 (7.8%) (P =
0.03). Pneumonia and upper respiratory infections (sinusitis
and bronchitis) occurred in 23 patients, including12 treated
Leukemia

Table 2
CMC in untreated CLL
T Robak et al
Results of the treatment of B CLL patients with CMC accordingto the treatment protocol
1513
Rai All patients (%) CMC5 (%) CMC3 (%)
stage n = 62 n = 20 n = 42
n CR PR NR n CR PR NR n CR PR NR
0 1 1 0 0 1 1 0 0 0 0 0 0
(100.0) (100.0)
I + II 28 10 11 7 9 3 2 4 19 7 9 3
(35.7) (39.3) (26.0) (36.7) (22.2) (44.4) (36.8) (47.4) (15.8)
III + IV 33 7 11 15 10 2 3 5 23 5 8 10
(21.2) (33.3) (45.5) (20.0) (30.0) (50.0) (21.7) (34.8) (43.5)
P value a 0.8 0.4 0.4
Total 62 18 22 22 20 6 5 9 42 12 17 13
(29.0) (35.5) (35.5) (30.0) (25.0) (45.0) (28.6) (40.4) (31.0)
a
P values for responses in different Rai stages.
Table 3
Severe hematological toxicity of the CMC programme
Protocol Neutropenia Thrombocytopenia Anemia
grade III and IV grade III and IV grade III and IV
n (%) n1 (%) n (%) n1 (%) n (%) n1 (%)
CMC5 7 (35.0) 9 (10.7) 4 (20.0) 6 (7.1) 2 (10.0) 4 (4.8)
n = 20
n1 = 84
CMC3 11 (26.2) 21 (13.7) 8 (19.0) 14 (9.2) 2 (4.8) 2 (1.3)
n = 42
n1 = 153
P value for 0.8 0.9 0.7 0.8 0.8 0.2
CMC5 vs CMC3
Total 18 (29.0) 30 (10.3) 12 (19.4) 20 (8.4) 4 (6.5) 6 (2.5)
n = 62
n1 = 237
n, number of patients; n1, number of courses.
with CMC5 and 11 treated with CMC3. Herpes zoster reactivation
and herpes simplex infections were observed in 10
patients (two after CMC5 and eight after CMC3). Tuberculosis
was diagnosed in one patient after two courses of CMC5.
Other opportunistic infections were not seen.
In four patients, grade III vomiting according to the WHO
classification was observed and in one DIC syndrome
developed. Other non-hematological side-effects including
alopecia, abnormal aminotransferases, transient increased
LDH and creatinine levels were observed only very rarely
(Table 4). Secondary cancers were observed in two patients
includingone case of pulmonary cancer (adenocarcinoma)
after CMC3 in a patient without the history of tobacco
exposure and one case of malignant histiocytosis after CMC5.
Richter syndrome has not been observed to date
The intervals between CMC courses due to myelosuppression
and/or infections were prolonged from 4 to 8 weeks in
23 (37%) patients and after 38 (16%) courses, including10
patients (18 courses) treated with CMC5 and 13 patients (20
courses) treated with CMC3. In four patients (two treated with
CMC5 and two with CMC3), therapy was stopped before the
completion of three courses of treatment because of
prolonged severe myelosuppression.
Altogether, 14 (22.6%) patients died during the study,
includingsix (30%) treated with CMC5 and eight (19.0%) with
CMC3. All six patients in the CMC5 group died before completingthree
courses of treatment. In CMC3 group six out of
eight patients died before completing three courses of treatment.
The causes of death are shown in Table 5. Complications
due to infections were the cause of death in nine
patients, includingfour treated with CMC5 and five after
CMC3 therapy.
Discussion
In spite of intensive research and important progress in the
last years, CLL still remains incurable. The results of the randomized
studies published so far indicate that both FAMP and
2-CdA, applied as first-line therapy, significantly increase the
rate of complete remissions when compared to chlorambucil,
which is still regarded as the gold standard in CLL treatment. 5,8
However, neither study proved that the higher remission rate
is translated into longer survival. That is why further research
is justified, with the objective to increase the remission rate
and quality, and in this way, to influence survival time. In the
trials finished to date, alkylatingdrugs and anthracyclines with
mitoxantrone were most often combined with either FAMP or
with 2-CdA. 10–18,29,30
Our study is the first, to our knowledge, in which previously
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1514
Table 4
CMC in untreated CLL
T Robak et al
CMC-induced grade III and IV non-hematological side-effects
Side-effect Total CMC5 CMC3
n = 62 n1 = 237 n = 20 n1 = 84 n = 42 n1 = 153
n (%) n1 (%) n (%) n1 (%) n (%) n1 (%)
Infections and FUO 23 (37.1) 37 (15.6) 11 (55.0) 15 (17.9) 10 (23.8) 12 (7.8)
Vomiting grade III or IV 4 (6.5) 7 (3.0) 2 (10.0) 4 (4.8) 2 (4.8) 3 (2.0)
Alopecia 1 (1.6) 1 — 1 1
Aminotransferases increased 1 (1.6) 1 — 1 1
Creatinine increased 1 (1.6) 1 — 1 1
IHD 1 (1.6) 1 — 1 1
DIC 1 (1.6) 1 — 1 1
Secondary neoplasms 2 (3.2) 1 1 1 1 1
n, number of patients; n1, number of courses; FUO, fever of unknown origin; DIC, disseminated intravascular coagulation; IHD, ischemic
heart disease.
Table 5
Cause of death in B CLL patients treated with 2-CdA
Cause of death Total CMC5 CMC3
n = 14 n = 6 n = 8
Pneumonia 5 (35.7%) 2 (33.3%) 3 (37.5%)
Septic shock 4 (28.6%) 2 (33.3%) 2 (25.0%)
Hemorrhage 1 (7.1%) — 1 (12.5%)
Second neoplasm 2 (14.3%) 1 (16.7%) 1 (12.5%)
Not connected with CLL 2 (14.3%) 1 (16.7%) 1 (12.5%)
untreated CLL patients received two other drugs in combination
with 2-CdA: cyclophosphamide and mitoxantrone
(CMC programme). In this study, the daily doses of 2-CdA
(0.12 mg/kg) were identical in both groups, but the duration
of the treatment was different: 3 days (CMC3) or 5 days
(CMC5). The doses of cyclophosophamide and mitoxantrone
were the same in both programmes. Our study indicates that
CMC combination is active in CLL. The CR rate was 29% and
the OR rate was 64.5%. It should be emphasised, that in spite
of the large proportion of patients who have responded to
treatment, the response rate does not seem greater than in our
earlier studies with 2-CdA in monotherapy or combined with
prednisone. 7,8 It is of interest that the shortened administration
time from 5 (CMC5) to 3 (CMC3) days has not resulted in a
lower CR rate (30% and 28.6%, respectively) or overall
response rate (55% and 69%, respectively). Similarly, we
observed earlier the lack of influence of a shorter administration
time of 2-CdA within a CMC programme on the outcome
in pretreated indolent lymphoma. 21 Previous studies
revealed that the response rate was not lower when 2-CdA or
FAMP were combined with either cyclophosphamide, 14,31–33
mitoxantrone 17,34 or anthracycline. 35
Minimal residual disease (MRD) was evaluated by twocolor
immunophenotypingin the patients who fulfilled morphological
criteria for CR. MRD was identified in seven out
of 18 patients (38.9%). A similar evaluation was performed in
the CLL patients treated with 2-CdA in monotherapy and MRD
was diagnosed in five out of 17 (29.4%) patients with CR. 3
These data indicate that the combined therapy with CMC does
not appear to reduce the incidence of MRD more than 2-CdA
in monotherapy.
To the best of our knowledge, our study is the first in which
a purine analogwas combined with two other cytostatics in
patients with CLL or low-grade non-Hodgkin’s lymphoma as
first-line treatment. Such combinations were, however,
administered to earlier pretreated patients. 21,36,37 These were
the phase I/II studies that did not prove that the combination
of purine analogwith cyclophosphamide and mitoxantrone
seemed more efficient that the monotherapy with FAMP or
2-CdA.
An additional aim of our study was the evaluation of the
treatment-related toxicity of the CMC programme. We have
shown that the most important toxic effect of this combination
was myelosuppression. Grade III/IV neutropenia was observed
in 29% of the patients and severe thrombocytopenia in 19.4%
of the patients. It should be remembered, though, that myelotoxicity
is the limitingfactor for the administration of any drug
of the CMC programme when they are applied in monotherapy
or combined with other cytotoxic agents. Important myelotoxicity
of the CMC programme may indicate the necessity
of reducingthe dose of 2-CdA in this combination, and this
supports the CMC3 rather than the CMC5 programme. The
justification of such an approach has also been found in other
studies, where the dose of purine analogin combination was
lower than in monotherapy. 16–18,29,38
The infections were frequent in the patients treated with the
CMC programme and they were most commonly the cause of
death. These results are consistent with the observations from
other studies, which also indicate that infections are frequent
in patients treated with purine analogs. 39,40 It should be
emphasized that the frequency of infections was significantly
lower in patients treated with CMC3 (23.8%) than in patients
treated with CMC5 (55%) (P = 0.02). Betticher et al 41 found
that the reduction in the dose of 2-CdA from 0.7 mg/kg per
cycle to 0.5 mg/kg per cycle in pretreated patients with malignant
lymphomas did not decrease the activity of this
compound but greatly reduced the incidence of infections.
Further reduction of myelosuppression and infections may
be most likely achieved with the prophylactic use of growth
factors followingthe chemotherapy cycle. 42,43 In our study,
G-CSF was applied only as a treatment for severe infections
to the patients with neutropenia 1.0 × 10 9 /l. O’Brien et al 42
showed, however, that prophylactic administration of G-CSF
to patients treated with FAMP may reduce the incidence of
pneumonia, but does not interfere with other infections. It
should also be remembered that prophylactic administration
of hemopoietic growth factors may greatly increase the cost
Leukemia

of treatment. As an alternative, some authors are in favor of
prophylaxis with antibacterial and antiviral agents in patients
treated with purine analogs. 44,45 This approach is intended to
reduce the incidence of opportunistic infections. We have not,
however, observed in our patients infections caused by Pneumocystis
carinii or other opportunistic infections. Such an
approach should also not be recommended because of the
broad spectrum of potential infections that may necessitate the
use of numerous potentially toxic drugs. 46
In conclusion, combined treatment with 2-CdA, mitoxantrone
and cyclophosphamide (CMC programme) shows significant
therapeutic activity in previously untreated patients
with CLL. However, the toxicity of the CMC programme is
significant although it is restricted mainly to myelosuppression
and infections. The reduction of total dose of 2-CdA per cycle
in the CMC programme does not seem to decrease its antileukemic
activity but significantly reduces the risk of infections.
At present, it is not clear whether the CMC programme is more
efficient in comparison to 2-CdA in monotherapy or the combination
of 2-CdA with cyclophosphamide in previously
untreated CLL patients. Nevertheless, in our opinion, the
CMC3, but not the CMC5 programme, deserves further
evaluation.
Acknowledgements
This work was supported in part by grant No. 4P05B06019,
from KBN, Warsaw, Poland. We thank Mr Shane Gollop for
the correction of the English version of the manuscript.
References
1 Tallman MS, Hakimian D. Purine nucleoside analogs: emerging
roles in indolent lymphoproliferative disorders. Blood 1995; 86:
2463–2474.
2 Juliusson G, Liliemark J. Long-term survival following cladribine
(2-chlorodeoxyadenosine) therapy in previously treated patients
with chronic lymphocytic leukemia. Ann Oncol 1996; 7: 373–
379.
3 Robak T, Błoński JZ, Urbańska-Ryś H, Błasińska-Morawiec M,
Skotnicki AB. 2-Chlorodeoxyadenosine (Cladribine) in the treatment
of patients with chronic lymphocytic leukemia 55 years old
and younger. Leukemia 1999; 13: 518–523.
4 KeatingMJ, O’Brien S, Lerner C, Koller C, Beran M, Robertson LE,
Freireich EJ, Estey E, Kantarjian H. Long-term follow-up of patients
with chronic lymphocytic leukemia (CLL) receivingfludarabine
regimens as initial therapy. Blood 1998; 92: 1165–1171.
5 Rai KR, Peterson BL, Appelbaum FR, Kolitz J, Cheson BD, Schiffer
CA. Fludarabine compared with chlorambucil as primary therapy
for chronic lymphocytic leukemia. N Engl J Med 2000; 343:
1750–1757.
6 Delannoy A, Martiat P, Gala JL, Deneys V, Ferrant A, Bosly A,
Scheiff JM Michaux JL. 2-chlorodeoxyadenosine (CdA) for patients
with previously untreated chronic lymphocytic leukemia (CLL).
Leukemia 1995; 9: 1130–1135.
7 Robak T, Błoński JZ, Kasznicki M, Konopka L, Ceglarek B,
Dmoszyñska A, Soroka-Wojtaszko M, Skotnicki AB, Nowak W,
Dwilewicz-Trojaczek J, Tomaszewska A, Hellmann A, Lewandowski
K, Kuliczkowski K, Potoczek S, Zdziarska B, Hansz J, Kroll R,
Komarnicki M, Hołowiecki J, Grieb P. Cladribine with or without
prednisone in the treatment of previously treated and untreated B-
cell chronic lymphocytic leukaemia – updated results of the multicentre
study of 378 patients. Br J Haematol 2000; 108: 357–368.
8 Robak T, Błoński JZ, Kasznicki M, Błasińska-Morawiec M, Krykowski
E, Dmoszyńska A, Mrugała-Śpiewak H, Skotnicki AB,
Nowak W, Konopka L, Ceglarek B, Maj S, Dwilewicz-Trojaczek
J, Hellmann A, Urasiński I, Zdziarska B, Kotlarek-Haus S, Potoczek
S, Grieb P. Cladribine with prednisone versus chlorambucil with
CMC in untreated CLL
T Robak et al
prednisone as first-line therapy in chronic lymphocytic leukemia:
report of a prospective, randomized, multicenter trial. Blood 2000;
96: 2723–2729.
9 Robertson LE, Huh YO, Butler JJ, Pugh WC, Hirsch-Ginsberg C,
Stass S, Kantarjian H, KeatingMJ. Response assessment in chronic
lymphocytic leukemia after fludarabine plus prednisone: clinical,
pathologic, immunophenotypic and molecular analysis. Blood
1992; 80: 29–36.
10 Van Den Neste E, Bontemps F, Delacauw A, Cardoen S, Louviaux
I, Scheiff JM, Gillis E, Leveugle P, Deneys V, Ferrant A, Van den
Berghe G. Potentiation of antitumor effects of cyclophosphamide
derivatives in B-chronic lymphocytic leukemia cells by 2-chloro-
2deoxyadenosine. Leukemia 1999; 13: 918–925.
11 Góra-Tybor J, Robak T. Synergistic action of 2-chlorodeoxyadenosine
and cyclophosphamide on murine leukemia L1210 and P388.
Acta Haematol Pol 1993; 24: 177–182.
12 Hoffman M, Xu JC, Lesser M, Rai K. Cytotoxicity of 2-chlorodeoxyadenosine
(cladribine 2-CdA) in combination with other chemotherapy
drugs against two lymphoma cell lines. Leuk Lymphoma
1999; 33: 141–145.
13 Van Den Neste E, Louviaux I, Michaux JL, Dellannoy A, Michaux
L, Sonet A, Bosly A, Doyen C, Mineur P, Andre M, Straetmans N,
Coche E, Venet C, Duprez T, Ferrant A. Phase I/II study of 2-
chloro-2-deoxyadenosine with cyclophosphamide in patients
with pretreated B cell chronic lymphocytic leukemia and indolent
non-Hodgkin’s lymphoma. Leukemia 2000; 14: 1136–1142.
14 Laurencet FM, Zulian GB, Guetty-Alberto M, Iten PA, Betticher
DC, Alberto P. Cladribine with cyclophosphamide and prednisone
in the management of low-grade lymphoproliferative malignancies.
Br J Cancer 1999; 79: 1215–1219.
15 Kano Y, Akutsu M, Tsunoda S, Suzuki K, Ichikawa A, Furukawa
Y, Bai L, Kon K. In vitro cytotoxicity effects of fludarabine (2-Fara-A)
in combination with commonly used antileukemic agents
by isohologram analysis. Leukemia 2000; 14: 379–388.
16 Robertson LE, O’Brien S, Kantarjian H, Koller C, Beran M, Andreeff
M, Lerner S KeatingMJ. Fludarabine plus doxorubicin in previously
treated chronic lymphocytic leukemia. Leukemia 1995; 9:
943–945.
17 McLaughlin P, Hagemeister FB, Romagnera JE, Sarris AH, Pate O,
Younes A, Swan F, KeatingM, Cabanillas F. Fludarabine, mitoxantrone
and dexamethasone: an effective new regimen for indolent
lymphoma. J Clin Oncol 1996; 14: 1262–1268.
18 Saven A, Lee T, Kosty M, Piro L. Cladribine and mitoxantrone dose
escalation in indolent non-Hodgkin’s lymphoma. J Clin Oncol
1996; 14: 2139–2144.
19 Robak T, Góra-Tybor J, Urbañska-Ryś H, Krykowski E. Combination
regimen of 2-chlorodeoxyadenosine (cladribine), mitoxantrone
and dexamethasone (CMD) in the treatment of refractory and
recurrent low grade non-Hodgkin’s lymphoma. Leuk Lymphoma
1999; 32: 359–363.
20 Robak T, Góra-Tybor J, Chojnowski K. Cladribine as monotherapy
or combined with dexamethasone and idarubicin or mitoxantrone
in previously treated patients with low-grade lymphoid malignancies.
Haematologica 2000; 85: 215–216.
21 Robak T, Góra-Tybor J, Lech-Marańda E, Błoński JZ, Kasznicki M.
Cladribine in combination with mitoxantrone and cyclophosphamide
(CMC) in the treatment of heavily pretreated patients
with advanced indolent lymphoid malignancies. Eur J Haematol
2000; 66: 188–194.
22 Cheson BD, Bennett JM, Grever M, Kay N, KeatingMJ, O’Brien
S, Rai KR. National Cancer Institute-Sponsored WorkingGroup
guidelines for chronic lymphocytic leukemia: revised guidelines
for diagnosis and treatment. Blood 1996; 87: 4990–4997.
23 Rai KR, Sawitsky A, Cronkite EP, Chanana AD, Levy RN Pasternack
BS. Clinical staging of chronic lymphocytic leukemia.
Blood 1975; 46: 219–234.
24 Kazimierczuk Z, Cottam HB, Ravanliar GR, Robins RK. Synthesis
of 2-deoxytubercidin, 2-deoxyadenosin and related 2-dexynucleosides
via a novel direct stereospecific serum salt glycosylation
procedure. J Am Chem Soc 1984; 106: 6379–6382.
25 Cheson BD, Bennet MJ, Rai KR, Grever MR, Kay NE, Schiffer CA,
Oken MM, KeatingMJ, Boldt DH, Kempin SJ, Foon KA. Guidelines
for clinical protocols for chronic lymphocytic leukemia: recommendations
of the National Cancer Institute-Sponsored WorkingGroup.
Am J Hematol 1988; 29: 152–163.
1515
Leukemia

1516
CMC in untreated CLL
T Robak et al
26 Brugiatelli M, Claisse JF, Lenormand B, Marabiro F, Callea V, Malloum
K, Chevret S, Binet JL, Dighiero G, Travade P. Long term
clinical outcome of B-cell chronic lymphocytic leukaemia patients
in clinical remission phase evaluated at phenotypic level. BrJ
Haematol 1997; 97: 113–118.
27 Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results
of cancer treatment. Cancer 1981; 47: 207–214.
28 Duffy DR, Santner TJ. Confidence intervals for binomial parameter
based on multistage tests. Biometrics 1987; 43: 81–93.
29 Rummel MJ, Kafer G, Pfreundschuh M, Jager E, Reinhardt U,
Mitrou PS, Hoelzer D, Bergmann L. Fludarabine and epirubicin
in the treatment of chronic lymphocytic leukaemia: a German
multicenter phase II study. Ann Oncol 1999; 10: 183–188.
30 Zinzani PL, Magagnoli M, Moretti L, De Renzo A, Battista R, Zaccaria
A, Guardigni L, Mazza P, Marra R, Ronconi F, Lauta VM,
Bendandi M, Gherlinzoni F, Gentilini P, Ciccone F, Cellini C, Stefoni
V, Ricciuti F, Gobbi M, Tura S. Randomized trial of fludarabine
versus fludarabine and idarubicin as front line treatment in
patients with indolent or mantle-cell lymphoma. J Clin Oncol
2000; 18: 773–779.
31 O’Brien S, Kantarjian H, Beran M, Freireich E, Kornblau S, Koller
C, Lerner S, Gilbreath J, KeatingM. Fludarabine (FAMP) and cyclophosphamide
(CTX) therapy in chronic lymphocytic leukemia
(CLL). Blood 1996; 88 (Suppl. 1): 480a (Abstr. 1910.)
32 Flinn IW, Byrd JC, Morrison C, Janison J, Diehl LF, Murphy T,
Piantadosi S, Seifter C, Ambinder RF, Vogelsang G, Grever MR.
Fludarabine and cyclophosphamide with filgrastim support in
patients with previously untreated indolent lymphoid malignancies.
Blood 2000; 96: 71–75.
33 Cazin B, Binet JL, Divine M, Lepretre S, Lederlin P, Travade P,
Lemaire G, Guibon O. Oral fludarabine and cyclophosphamide
in previously untreated chronic lymphocytic leukemia. Blood
2000; 96 (Suppl. 1): 515a (Abstr. 2218).
34 O’Brien S, Kantarjian H, Beran M, Robertson LE, Freilich E,
Kornblau S, Koller C, Estey E, Lerner S, KeatingM. Fludarabine
and mitoxantrone therapy in chronic lymphocytic leukemia.
Blood 1996; 88 (Suppl. 1): 588a (Abstr. 2341).
35 Rummel MJ, Stilgenbauer S, Gamm H, Karakas T, Mitrou PS,
Doelmer H, Hoelzer D, Bergmann L. Fludarabine versus fludarabine
plus epirubicin in the treatment of chronic lymphocytic leukemia
– preliminary results of a randomized phase III multicenter
study. Blood 2000; 96 (Suppl. 1): 2946 (Abstr. 5013).
36 Bocchia M, Bigazzi C, Marconcini S, Forconi F, Marotta G, Algeri
R, Lauria F, Favorable impact of low-dose fludarabine plus epirubicin
and cyclophosphamide regimen (FLEC) as treatment for lowgrade
non-Hodgkin’s lymphomas. Hematologica 1999; 84: 716–
720.
37 Perales M, Bosch F, Esteve J, Fludarabine, cyclophosphamide and
mitoxantrone (FCM) in resistant or relapsed chronic lymphocytic
leukemia and follicular lymphoma. Ann Oncol 1999; 10 (Suppl.
3): 128 (Abstr. 462).
38 Weiss M, Spiess T, Berman E, Kempin S. Concomitant administration
of chlorambucil limits dose intensity of fludarabine in previously
treated patients with chronic lymphocytic leukemia. Leukemia
1994; 8: 1290–1293.
39 Cheson BD. Infectious and immunosuppressive complications of
purine analogtherapy. J Clin Oncol 1995; 13: 2431–2448.
40 Anaissie EJ, Kontoyiannis DP, O’Brien S, Kantarjian H, Robertson
L, Lerner S, KeatingMG. Infections in patients with chronic lymphocytic
leukemia treated with fludarabine. Ann Intern Med 1998;
129: 559–566.
41 Betticher DC, von Rohr A, Ratschiller D, Schmitz SF, Egger T, Sonderegger
T, Herrmann R, Kroner T, Zulian GB, Cavalli F, Fey MF,
Cerny T. Fewer infections, but maintained antitumor activity with
lower-dose versus standard-dose cladribine in pretreated lowgrade
non-Hodgkin’s lymphoma. J Clin Oncol 1998; 16: 850–858.
42 O’Brien S, Kantarjian H, Beran M, Koller C, Talpaz M, Lerner S,
KeatingMJ. Fludarabine and granulocyte colony-stimulatingfactor
(G-CSF) in patients with chronic lymphocytic leukemia. Leukemia
1997; 11: 1631–1635.
43 Flinn IW, Byrd JC, Morrison C, Jamison J, Diehl LF, Murphy T,
Piantadosi S, Seifter E, Ambinder RF, Vogelsang G, Grever MR.
Fludarabine and cyclophosphamide with filgrastim support in
patients with previously untreated indolent lymphoid malignancies.
Blood 2000; 96: 71–75.
44 Sudhoff T, ArningM, Schneider W. Prophylactic strategies to meet
infectious complications in fludarabine treated CLL. Leukemia
1997; 11: S38–41.
45 Byrd JC, Hargis JB, Kester KE, Hospenthal DR, Knutson SW, Diehl
LF. Opportunistic pulmonary infections with fludarabine in previously
treated patients with low-grade lymphoid malignancies: a
role for Pneumocystis carinii pneumonia prophylaxis. Am J Hematol
1995; 49: 135–142.
46 Kalil N, Cheson BD. Management of chronic lymphocytic leukaemia.
Drugs Aging 2000; 16: 9–27.
Leukemia