Interest of Early Determination of Bone Marrow MRD by a Sensitive 6-Color Flow Cytometry in the Evaluation of Response: The Experience of the CLL2007FMP, An Intergroup Phase III Randomized Multicentric Trial Comparing Fludarabine Cyclophosphamide (FC) and Rituximab (FCR) Versus FC and MabCampath (FCCam) in Previously Untreated B-Chronic Lymphocytic Leukemia Patients

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1797-1797 ◽  
Author(s):  
Remi Letestu ◽  
Stéphane Leprêtre ◽  
Christine Arnoulet ◽  
Lucile Baseggio ◽  
Lydia Campos ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Residual Disease ◽  
Limit Of Detection ◽  
Lymphocytic Leukemia ◽  
Phase Iii ◽  
Color Flow ◽  
Sensitive Technique ◽  
Mutational Status ◽  
Significant Difference

Abstract Abstract 1797 Introduction: The FCGCLL/MW and GOELAMS intergroup have conducted a multicenter phase III trial, CLL2007FMP, to evaluate the efficacy of FCCam versus FCR in previously untreated medically fit CLL patients. This trial was discontinued after randomisation of 165 patients for unacceptable toxicity in the FCCam arm. A sensitive 6-color flow cytometry technique was used to evaluate the response at month 9 (M9) in blood and bone marrow and to subsequently monitor minimal residual disease (MRD). Methods and patients: 178 medically fit patients (CIRS< 6 and creatinin clearance ≥ 60 ml/min), younger than 65 years old, were enrolled. 165 patients were subsequently randomized to receive six oral courses of FC (F: 40mg/m2 d1-3 and C: 250 mg/m2 d1-3; q 28 days) in combination with either R (n=83; 375 mg/m2 i.v. d 0 at first cycle and 500 mg/m2 d1 all subsequent cycles; q 28 days) or Cam (n=82; 30 mg s/c d1-3; q 28 days). Patients were stratified according to IGHV mutational status and presence of 11q deletion. Cases with 17p deletion were excluded. Clinical response was evaluated based on iwCLL classical criteria. We established a sensitive and specific approach for the evaluation of MRD, using a 6-color flow cytometry technique with 3 combinations, including characteristic markers and light chain expression. We determined the limit of detection (LOD) of the assay by studying normal blood samples, and LOD varied from 0.5 to 0.7×10−5, depending on the combination considered. Results: The overall response rate was 87.8% in the FCR arm compared to 85.5% in the FCCam arm (p: NS). CR rates were not significantly different between the two arms with 64.6% in FCR arm and 50.6% in FCCam arm (p=.08). At M9, the rate of undetectable MRD was significantly lower in bone marrow as compared to blood but neither in blood nor bone marrow did reach a significant difference between FCR and FCCam arms. MRD was undetectable in blood in 60.2% of patients (53% of patients in the FCCAm arm and 66.7% in the FCR arm (NS)). In bone marrow samples, MRD was undetectable in 33.7% of patients (25% of patients in the FCCam arm and 41.7% in the FCR arm (NS)). The results were similar when considering exclusively the patients who reached CR. Moreover, MRD was never found detectable in blood when undetectable in bone marrow at the same time point. Therefore, irrespective of treatment arm, the bone marrow sample appeared more efficient than the blood sample for the detection of a persistent residual disease. We next combined blood and bone marrow results to define immunophenotypic remission, we considered MRD at M9 as undetectable when undetectable in bone marrow and MRD as positive when detectable either in blood or bone marrow. The rate of immunophenotypic remission was significantly lower in the FCCam arm as compared to the FCR arm (p=0.03) with our sensitive technique but, interestingly, was no longer significant when using the classical threshold of 10−4 to assess MRD status. The number of best responders, identified by MRD negativity and clinical complete response was significantly higher with FCR than with FCCam (p= 0.029). MRD was again assessed in blood at month 12 and was undetectable in 36.8% of patients in the FCCAm and 41.7% in the FCR arm (NS). All cases with positive blood MRD at M9 remained positive at M12. Among the 21 cases with positive bone marrow MRD and undetectable blood MRD at M9, only 10 explorations in blood at M12 are available at the moment but 4 cases remained undetectable. Conversely, when MRD was undetectable at M9 in both blood and bone marrow, 16/18 remained undetectable at M12, corresponding to a positive switch rate of only 11%. Conclusion: In the era of combined immuno-chemotherapy with the goal of achieving the best response, the most sensitive MRD technique is warranted. The sensitivity of 6-color flow cytometry has proved useful to uncover the differences between the two treatment arms. In this study, the evaluation of MRD in bone marrow by 6-color flow cytometry is the most sensitive technique for the early evaluation of persisting residual disease. It may not be supplanted by MRD determination in blood at M12 for the precise assessment of the immunophenotypic remission rate. Studies including sequential determinations and MRD kinetics are ongoing to determine which interpretation threshold and time-points are the best predictors of progression-free survival. Disclosures: Leblond: Roche, Genzyme: Consultancy, Membership on an entity's Board of Directors or advisory committees. Cymbalista:Roche (d) Mundipharma (e) Genzyme (e): Honoraria, Research Funding.

CLL2007FMP, a Phase III Randomized Multicentric Trial of the French Cooperative Group On CLL and WM (FCGCLL/MW) and the “Groupe Ouest-Est D'etudes Des Leucémies Aigües Et Autres Maladies Du Sang” (GOELAMS): Immunochemotherapy with Fludarabine (F), Cyclophosphamide (C), and Rituximab (R) (FCR) Yields a Significantly Better Response Than Fludarabine (F), Cyclophosphamide (C) and MabCampath (Cam) (FCCam) In Previously Untreated B-Chronic Lymphocytic Leukemia Patients as Evaluated by a Sensitive 6 Color Flow Cytometry MRD

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 698-698 ◽  
Author(s):  
Letestu Remi ◽  
Stéphane Leprêtre ◽  
Arnoulet Christine ◽  
Baseggio Lucille ◽  
Campos Lydia ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Board Of Directors ◽  
Residual Disease ◽  
Phase Iii ◽  
Advisory Committees ◽  
Color Flow ◽  
Phase Iii Trial ◽  
Mutational Status

Abstract Abstract 698 Introduction: Between 11/2007 and 01/2009, the FCGCLL/MW and the GOELAMS conducted a multicenter phase III trial, CLL2007FMP, to evaluate the efficacy of FCCam versus FCR in previously untreated medically fit patients. PFS was the primary-end-point of this trial. The trial was discontinued after randomisation of 165 patients for unacceptable toxicity in the FCCam arm. PFS and OS are not yet evaluable but as a sensitive 6 color flow cytometry technique was used to assess MRD in blood and bone marrow at month 9, we were able to evaluate the quality of the response in both arms. Methods and patients: A cohort of 178 medically fit patients (cumulative illness rating scale (CIRS) score < or = 6 and creatinine clearance ≥ 60 ml/min), younger than 65 years old, were enrolled. 165 patients were randomized to receive six oral courses of FC (F 40mg/m2 d1-3 and C 250 mg/m2 d1–3; q 28 days) in combination with either R (n=83; 375 mg/m2 i.v. d 0 at first cycle and 500 mg/m2 d1 all subsequent cycles; q 28 days) or Cam (n=82; 30 mg s/c d1-3; q 28 days). Patients were stratified according to IGHV mutational status and presence of 11q deletion. Cases with 17p deletion were excluded. The trial recruitment was discontinued because of an excess of mortality in the FCCam arm (6 deaths versus 0 in FCR arm), and the last 13 patients enrolled were not randomized. Clinical response was evaluated based on IWCLL criteria. We established a sensitive and specific approach for the evaluation of minimal residual disease (MRD) at month 9, using a 6-color flow cytometry technique with 3 combinations including characteristic markers and light chain expression. We determined the limit of detection (LOD) of the assay by studying normal blood samples, LOD varied from 0.5 to 0.7×10-5 depending on the combination considered. Result: The Overall Response Rate (ORR) was 91% in the FCR arm and 85% in the FCCam arm (ns). Clinical responses were as follows: CR (FCR: 56/80=70%, FCCam: 45/79 =59%, ns), CR I (FCR:13/FCCam: 11), PR (FCR:5/FCCam:15), and stable and progressive cases (FCR: 6/FCCam:8). When considering together CR and CR I, response rate appeared significantly higher in the FCR arm (86%) than in FCCam arm (70%) (p=0.03). MRD was assessed both in blood and bone marrow at month 9, and was undetectable in 58% patients in blood and only in 36 % in bone marrow. No patient had an undetectable MRD in marrow when detectable in blood. Similarly, MRD was detectable in bone marrow in 15 cases with histologically normal bone marrow biopsy, whereas no nodal PR had undetectable MRD. Therefore, flow cytometry MRD in bone marrow appears as the most sensitive technique for the evaluation of response. Of note, 9 patients had a very good PR with presence of a residual lymphnode, and had undetectable blood and bone marrow MRD (4 in FCCAm arm and 5 in FCR arm). When considering MRD independently from clinical response, the number of MRD negative cases was not significantly different between the two arms (FCR: 45%/FCCam: 26 %) arm. But when combining MRD negativity with clinical complete response, the number of MRD negative CR was significantly higher with FCR (40%) than with FCCam (15%)(p= 0.029). The number of courses of chemotherapy received was slightly but significantly lower in the FCCam arm. Nonetheless, this difference was not accountable for the difference in the quality of response as the number of MRD negative CR remained significantly higher with FCR than with FCCam when considering only the patients having received at least 4 courses of either chemotherapy. The quality of response was not influenced by either presence of deletion11q or mutational status as well. In conclusion, detection of MRD in bone marrow by flow cytometry is a sensitive technique for the evaluation of minimal residual disease. Combining clinical CR with flow cytometry bone marrow MRD allows detecting the best responders. In this randomized phase III trial, besides leading to a lower rate of toxicity, the FCR regimen yielded a significantly higher rate of MRD negative CR than FCCam, and therefore had a positive impact on the quality of the response. Disclosures: Veronique: roche: Consultancy, Membership on an entity's Board of Directors or advisory committees; mundipharma: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; genzyme: Membership on an entity's Board of Directors or advisory committees; celgene: Membership on an entity's Board of Directors or advisory committees; jansen: Membership on an entity's Board of Directors or advisory committees.

Novel Leukemia Associated Immunophenotype (LAIP) Absent from Normal and Regenerating Bone Marrow Identified by Multiparameter 6-Color Flow Cytometry.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 2362-2362
Author(s):  
Denis Guyotat ◽  
Daniela Olaru ◽  
Pascale Flandrin ◽  
Nathalie Nadal ◽  
Lydia Campos
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Color Flow ◽  
Significant Difference ◽  
Blast Cells ◽  
Disease Study ◽  
New Generation ◽  
Minimal Residual

Abstract Flow cytometry analysis of minimal residual disease (MRD) in acute myeloid leukemia (AML) is based on the detection of aberrant phenotypes responsible for the relapse. Until now, all studies were performed by 3 or 4 color immunostaining, allowing the identification of LAIP in 80% of cases. Moreover, no data is available regarding the existence of such phenotypes in regenerating bone marrow. The new generation of cytometers allows the study of 8 parameters that permit a better distinction of malignant from normal phenotypes. In our study we analyzed 20 bone marrow samples from allogeneic donors, 20 ALL regenerating bone marrows after chemotherapy and 53 AML samples at diagnosis. Multiparameter 4 colour and 6 colour flow cytometry was used in order to define antigen combinations which are totally absent or present at very minimal levels in normal and regenerating hematopoiesis. “Blast cells” were gated according to CD45/SSC properties.For the first time we describe by 6 color flow cytometry 47 phenotypes totally absent from “blasts” gate in all normal bone marrow (ex: CD34+DR−117+33−15+, CD34+38+33−56+19−, CD14−DR+4+11B+64+). Another 41 phenotypes were identified as presents at a frequency < 0,05% of total cells (ex: CD34+DR+117−33+15+, CD14−DR+4+11B+64−, CD34+65−56+4−16−). There was no significant difference between normal and regenerating marrows. The 4 color panel of moAbs allowed us to identify only 30 phenotypes presents at a frequency < 0,05% of total cells (ex: CD34+33−13+, CD34+117+11b+, CD34+DR−13+). 53 AML at diagnosis were studied using 6 color immunophenotyping and 58 % of phenotypes described as aberrant or infrequent in normal myeloid hematopoiesis were found in at least one AML at diagnosis in more than 1% of total cells. All AML cases show at least one LAIP but frequently we observed more than one LAIP blast subpopulation in the same sample. Some examples of LAIP observed are CD34+ 38+ 33+ 56+ 19−, CD34+ 38+ 33+ 56− 19+, CD34− DR− 117+ 33+ 15−. In conclusion our results shows that (1) the ability to clearly distinguish leukemic from the healthy cells is considerably increased by 6 color approach (8 parameters analyzed) than 4 color. (2) Furthermore that these aberrant or infrequent phenotypes in normal or regenerating bone marrow samples are identified in AML cases and can be utilized in AML minimal residual disease study. (3) Knowledge of the expression of different markers in normal hematopoietic development provides a frame of reference for identification of abnormal differentiation patterns.

Final Results of Lower Dose Fludarabine (F) and Cyclophosphamide (C), and High Dose Rituximab (R), (FCR-Lite) for Patients with Untreated Chronic Lymphocytic Leukemia (CLL).

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 2037-2037
Author(s):  
Ahmad A. Tarhini ◽  
S. Land ◽  
L. Pietragallo ◽  
A. Laman ◽  
M. Sulecki ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Response Rate ◽  
Residual Disease ◽  
Lymphocytic Leukemia ◽  
High Dose ◽  
Color Flow ◽  
Major Toxicity ◽  
Grade 3 ◽  
Age Range

Abstract Introduction Standard FCR therapy in untreated CLL patients (F-25 mg/m2 d1–3 q 4wk; C-250 mg/m2 d 1–3 q 4wk; R-500 mg/m2 d1 q 4wk for 6 cycles) was reported to have complete remissions (CR) of 70% and overall responses (OR) of 95% (J Clin Oncol2005;23:4079). The major toxicity was grade 3/4 neutropenia during 52% of treatment courses. One approach to decrease neutropenia without compromising efficacy could be by reducing the doses of F and C and increasing the dose of R. Methods We conducted a phase II study for previously untreated advanced CLL patients treated with FCR-Lite (F-20mg/m2 d1–3 q 4 wk; C-150 mg/m2 d1–3 q 4 wk; R-500mg/m2 d1 and d14 q 4wks; maintenance R-500 mg/m2 ×1 q 3 months until progression). A Simon two-stage design was used where 15 patients were accrued in the first stage and because of acceptable toxicity and response rate in stage I an additional 35 patients were treated. The primary endpoint was response rate. Results A total of 50 patients were entered into this study and 42 are currently evaluable. There were 29 male and 13 female patients with an age range of 36–85 years (median 58) treated with a total of 236 courses of FCR-Lite. All 42 patients were evaluable for toxicity. Grade 3/4 neutropenia occurred during 29 (12%) courses with two episodes of neutropenic fever. One patient had cellulitis, another had pneumonia (not neutropenic). Grade 3/4 thrombocytopenia occurred during 7 (3%) courses and grade III/IV anemia during 6 (2.5%) courses. Among the 40 evaluable patients for response, the CR rate was 85%, PR rate was 15% with an OR rate of 100%. All of the CR patients were tested by flow cytometry and had &lt;1% CD5+/CD19+ cells in their bone marrow after therapy. One patient with potential CR was excluded due to the absence of follow up bone marrow biopsy. Minimal residual disease (MRD) was tested by four color flow cytometry (sensitivity 0.01%) in 8 patients with CR (Genzyme Genetics Corp.). Seven had no evidence of MRD at 7, 8, 8, 14, 22, 25 and 30 months respectively, post CR, and one patient had 0.03% and 0.06% when tested at 12 and 18 months post CR respectively. Conclusions Our results in 42 patients suggest FCR-Lite is highly effective with considerably less grade 3/4 neutropenia than standard FCR. Complete responders had no detectable CD5+/CD19+ cells in their bone marrow following FCR-Lite. MRD testing is currently underway for all patients.

Minimal Residual Disease (MRD) By 8-Color Flow Cytometry (Flow-MRD) and IGH Clonospecific Quantitative PCR (ASO RQPCR) Reached Similar Performances for Evaluation of CLL Treatment in a Phase II Clinical Trial: Cross Validation of the Methods

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3307-3307
Author(s):  
Remi Letestu ◽  
Guillaume Cartron ◽  
Stephane Lepretre ◽  
Magali Le Garff-Tavernier ◽  
Francoise Solly ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Clinical Response ◽  
Phase Ii ◽  
Treatment Time ◽  
Residual Disease ◽  
Limit Of Detection ◽  
High Dose ◽  
Color Flow ◽  
Global Agreement

Abstract Evaluation of MRD after treatment has an increasing importance in CLL treatment. Recent studies have demonstrated that patients achieving MRD below 10-4 have significantly longer OS and/or PFS compared to subjects with positive MRD (Böttcher, JCO 2012). Additionally, in CLL patients treated by FC(R)-based regimen, 4-color flow MRD was found as effective as ASO RQ PCR for MRD evaluation down to the level of 10-4, but below that level, PCR was more sensitive (Böttcher, Leukemia 2009). The aim of our study was to investigate the sensitivity of 8-color Flow-MRD and compare it to ASO RQPCR for disease evaluation at post-treatment time-point. 140 patients with active disease were recruited in a randomized first-line phase II trial evaluating the benefit of the addition of a high-dose rituximab pre-phase to standard FCR (R-dense arm) as compared to standard FCR. Clinical response and MRD were monitored at 3 months after last cycle, Flow-MRD was performed in peripheral blood (PB) and bone marrow (BM), and RQPCR in blood only. IGH ASO RQPCR was performed in an EU-MRD laboratory according to EU-MRD guidelines. Results were expressed as 10-8, corresponding to undetectable MRD, when no specific signal was detected, 10-6 when positivity was detected below quantitative range for the patient, and specific number when residual disease was within the quantitative range. For Flow-MRD we have developed an 8-color 9-antibody panel, the analyses were performed in four centers using harmonization procedures. Flow-MRD was considered undetectable (u-MRD) when less than 10 CLL events were detected or if the percentage of CLL events was below the absolute limit of detection (LOD) of the technique established at 0.5x10-6on normal blood samples. Quantitative range was reached when at least 50 CLL events were detected (Rawstron, Leukemia 2012). 137 patients were randomized and analyzed for clinical response. Approximately 87% had MRD evaluation by Flow, ASO RQPCR or both. U-MRD was observed in 81 patients out of 121 tested by flow in blood (67%) and in 49/109 (45%) in marrow. Samples with u-MRD reached good median LOD of 0.7x10-5 and 10-5in PB and BM respectively. MRD results were concordant in PB and BM (undetectable or positive in both samples) in 84/109 patients. The discordant cases were all positive in BM and negative in PB suggesting a better sensitivity and/or informativity in marrow. Therefore, when considering as Flow-MRD positive the cases with positive MRD in PB and/or BM and as undetectable those with u-MRD in BM, Flow-CR rate was 43%. The 66 cases that were analyzed in PB using ASO RQPCR showed a global PCR-CR rate of 76.5%. Sixty patients were analyzed by both flow cytometry and ASO RQPCR in PB. Results were concordant in 49 patients (82%), either both positive (n=9) or undetectable (n=40), resulting in a good global agreement between the two techniques (Kappa coefficient: 0.50 [0.20-0.73]). The 11 cases with discrepant results are of interest as they highlight the importance of the limit of detection for interpretation of MRD results. Among the 7 patients with u-MRD by ASO RQPCR and positive Flow-MRD, 4 showed a median sensitivity of 5.10-5 by ASO RQPCR and a very low median positivity by Flow 0.0024%. Moreover, all these 7 patients had a positive Flow-MRD in BM. The last 4 discordant cases had negative Flow-MRD and positive ASO RQPCR. In 2 of them a poor LOD in Flow-MRD contrasted with a 10-5sensitivity of ASO RQPCR and positive Flow-MRD was found in BM for 2 of these patients. Finally, clinical response was evaluable in 123 patients with MRD results. Among 65 patients in CR or CRi, 16 (24.6%) were MRD positive and among 55 patients in PR or nPR, 29 (52.7%) were MRD negative. Our 8-color panel for MRD detection by flow cytometry in CLL is applicable for treatment evaluation. This work shows that lowering the limit of detection by one log renders the 8 color flow-MRD as sensitive as ASO RQPCR and that the exploration of bone marrow improves the performances of MRD detection. As previously observed using less sensitive techniques, MRD results do not superimpose clinical response. Finally, a longer follow-up will validate the clinical interest of a one-log gain of sensitivity in MRD detection for prediction of PFS and OS. Disclosures Cartron: Roche: Consultancy, Honoraria. Cymbalista:Roche: Honoraria.

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

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 2839-2839 ◽  
Author(s):  
William G. Wierda ◽  
Thomas J. Kipps ◽  
Michael J. Keating ◽  
Jennifer R. Brown ◽  
John G. Gribben ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Median Time ◽  
Response Rate ◽  
Treatment Time ◽  
Residual Disease ◽  
Lymphocytic Leukemia ◽  
Serious Adverse Events ◽  
Color Flow ◽  
Loss Of Response

Abstract 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. Cancer98:2657, 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.

Combined Fludarabine, Cyclophosphamide, and Alemtuzumab (FCC), an Active Regimen for Treated Patients with Chronic Lymphocytic Leukemia (CLL).

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 3133-3133 ◽  
Author(s):  
Marco Montillo ◽  
Sara Miqueleiz ◽  
Alessandra Tedeschi ◽  
Francesca Ricci ◽  
Eleonora Vismara ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Residual Disease ◽  
Single Agent ◽  
Lymphocytic Leukemia ◽  
Combination Regimen ◽  
Synergistic Activity ◽  
Color Flow ◽  
Grade Iii

Abstract Fludarabine (F) in combination with cyclophosphamide (C) showed a relevant advantage over single-agent F in pts with relapsed CLL. Although minimal residual disease (MRD) remains detectable in many pts achieving CR, the combination of F and C seems to reduce MRD more efficiently. Still, pts in CR eventually relapse and require treatment, demonstrating the need for improved treatments able to further reduce or eliminate MRD and induce “better quality” and thus more durable responses. Alemtuzumab (CAM), anti-CD52 monoclonal antibody, acts synergistically with F in vitro and appears to have synergistic activity in vivo. Additionally, CAM is highly effective at clearing disease from bone marrow, the usual site of residual disease following purine analogue-based treatment. Therefore, we designed a phase II study to determine feasibility and efficacy, overall response rate (ORR)-duration of response-ability at clearing MRD, of a 4-weekly combination regimen consisting of F, C, and CAM (FCC). The study population is represented by pts with B-CLL with relapsed or refractory disease after at least one line of treatment. Subcutaneous route of administration of CAM has been adopted in this trial. MRD was measured by 4-color flow cytometry in the bone marrow. The FCC regimen consisted of F 40 mg/m2/d os (d 1–3), C 250 mg/m2/d os (d 1–3) and CAM 10 mg sc (d 1–3). This combination was repeated on d 29 for up to 6 cycles. The dose of CAM was increased after the first cohort of 10 treated pts from 10 mg to 20 mg sc. Currently, 25 pts have been enrolled in this trial. Median age was 57 years (range 42–79), 15/25 (60%) were male, 23/25 (92%) were in Binet stage B or C, median number of prior treatment regimens was 2 (range 1–4). In six (24%) pts 17p deletion was detected. IgVH unmutated was observed in 17 (68%) pts. At the moment of writing 19 pts are eligible for evaluation of toxicity and response. The ORR was 79%, with 7 (37%) pts achieving CR, 7 (37%) pts a PR, 1 (5%) pt a PRn. Three pts had SD, while 1 showed progression of the disease. MRD negativity was achieved in the bone marrow of 4/15 (27%) pts. Grade III-IV neutropenia episodes were observed in 43% of the administered courses while grade III-IV thrombocytopenia episodes were detected only in 8% of cycles. Four major infections were recorded: two sustained by Mycobacterium tuberculosis (1 cutis, 1 lung), one by Nocardia (lung) and one by E. coli (sepsis). The patient with pneumonia due to M. tuberculosis died because of respiratory failure. CMV reactivation occurred in 6 pts: no CMV disease was recorded. After a median follow up of 10 m (range 1–22) 73% of responding pts did not progressed. In conclusion, results from the interim analysis of this new, 4-weekly dosing FCC regimen suggest that combination therapy with F, C and CAM is feasible, safe, and effective in treating pts with relapsed and refractory CLL, even in those patients with inherent poor prognostic factors and who had received.

NCRI CLL201 Trial: A Randomized Phase II Trial of Fludarabine, Cyclophosphamide and Mitoxantrone (FCM) with or without Rituximab in Previously Treated CLL.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 752-752 ◽  
Author(s):  
Peter Hillmen ◽  
Christopher Pocock ◽  
Dena Cohen ◽  
Kim Cocks ◽  
Hazem A. Sayala ◽  
...  
Keyword(s):  
Phase Ii ◽  
Response Rate ◽  
Phase Ii Trial ◽  
Residual Disease ◽  
Early Death ◽  
Lymphocytic Leukemia ◽  
Phase Iii ◽  
Color Flow ◽  
Randomized Phase Ii ◽  
Number Of Patients

Abstract Standard front-line therapy for chronic lymphocytic leukemia (CLL) is fludarabine plus cyclophosphamide. Adding mitoxantrone (FCM) or rituximab (FCR) appears to improve responses although no large randomized trials have been reported. We report a randomized Phase II trial of FCM and FCM-R in relapsed CLL. FCM was oral fludarabine (24mg/m2 for 5 days) and cyclophosphamide (150mg/m2 for 5 days) plus i.v. mitoxantrone (6mg/m2) on Day 1 of each cycle. FCM-R was identical with rituximab on Day 1 of each cycle (375mg/m2 cycle 1; 500mg/m2 cycles 2 to 6). Prophylaxis with aciclovir and co-trimoxazole was given. The primary end-point was response by NCI Criteria 2 months after therapy. Complete remission with incomplete marrow recovery (CR(i)) was defined according to the 2007 CLL Guidelines - clinical CR with a morphologically normal marrow but persistent cytopenias (i.e. platelets <100x109/l and/or neutrophils <1.5x109/l). In addition, minimal residual disease in the marrow was studied 2 months after therapy by four-color flow cytometry with MRD negativity defined as <0.01% CLL cells. 52 patients were entered into the trial with 26 in each arm. The median age was 65 (32–79) with 79% men. 42% had a β2m >4. The median number of prior therapies was 2 (1–6), 31 had prior fludarabine and 6 (12%) were refractory to or relapsed <6 months after fludarabine. 26/44 (59%) had unmutated VH genes (15/22 FCM-R; 11/22 FCM). 11 patients had deletion of 11q (FCM-R 5, FCM 6) and 1 patient had >20% 17p deleted cells (FCM-R). 36/52 (69%) received 4 or more cycles of therapy with no difference between FCM and FCM-R (18/26). Responses are shown in the Table. 35 SAE’s were reported in 23 patients. There was no difference in the number of patients with SAE’s between the arms (FCM 11, FCM-R 12). 6/7 patients (86%) who had 4 or more prior therapies reported an SAE, compared to 17/45 patients (38%) who had less than 4. 16 SAE’s were suspected to be related to FCM-R and 10 related to FCM. In summary, FCM-R is an effective therapy for relapsed CLL with over two-thirds of patients responding. The study design does not allow a statistical comparison between FCM and FCM-R but the results suggest that adding rituximab to FCM results in a higher complete response rate (CR + CR i = 43% for FCM-R and 13% for FCM) with more patients achieving MRD negativity (5 after FCM-R; 2 after FCM). The results of this randomised Phase II trial justify the study of FC with mitoxantrone and/or rituximab in larger randomized Phase III trials. Responses in 46 evaluable patients (remaining 6 not yet evaluable) All patients FCM FCM-R Number of patients 46 23 23 Overall response rate 29 (63%) 13 (57%) 16 (70%) CR 5 (11%) 1 (4%) 4 (17%) CR(i) 8 (17%) 2 (9%) 6 (26%) PR 16 (35%) 10 (43%) 6 (26%) SD/PD 12 (26%) 7 (30%) 5 (22%) Early Death (before assessment) 4 (9%) 2 (9%) 2 (9%) Withdrew consent (before assessment) 1 (2%) 1 (4%) 0 (0%) MRD negative 7 (15%) 2 (9%) 5 (22%)

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