In vivo kinetics of the genotoxic and cytotoxic activities of cladribine and clofarabine.

The aim of the present in vivo study was to determine the kinetics of the genotoxic and cytotoxic activities of cladribine and clofarabine in mouse normoblasts using flow cytometry. Mice in groups of five were treated with cladribine or clofarabine. Blood samples were obtained from the mouse tails before treatment and every 8 hr posttreatment for 72 hr. These samples were cytometrically scored for micronucleated reticulocytes (RETs), and the percentage of RETs was determined. The results showed that clofarabine and cladribine have early cytotoxic effects that are related to the genotoxic effects reported in previous studies; the drugs have both complex long-lasting genotoxic and cytotoxic kinetic activity, with similar profiles that suggest a relationship between the genotoxic and cytotoxic parameters. The initial genotoxkinetics timing of clofarabine is equivalent to those of difluorodeoxycytidine, likely because both agents inhibit DNA polymerase. Clofarabine shows a higher genotoxic and cytotoxic efficiency than cladribine, in agreement with previous results.

Chronic cladribine administration increases amyloid beta peptide generation and plaque burden in mice.

BACKGROUND: The clinical uses of 2-chloro-2'-deoxyadenosine (2-CDA) or cladribine which was initially prescribed to patients with hematological and lymphoid cancers is now extended to treat patients with multiple sclerosis (MS). Previous data has shown that 2-CDA has high affinity to the brain and readily passes through the blood brain barrier reaching CSF concentrations 25% of that found in plasma. However, whether long-term administration of 2-CDA can lead to any adverse effects in patients or animal models is not yet clearly known. METHODOLOGY: Here we show that exposure of 2-CDA to CHO cells stably expressing wild-type APP751 increased generation and secretion of amyloid ß peptide (Aß) in to the conditioned medium. Interestingly, increased Aß levels were noticed even at non-toxic concentrations of 2-CDA. Remarkably, chronic treatment of APdE9 mice, a model of Alzheimer's disease with 2-CDA for 60 days increased amyloid plaque burden by more than 1-fold. Increased Aß generation appears to result from increased turnover of APP as revealed by cycloheximide-chase experiments. Additionally, surface labeling of APP with biotin and immunoprecipitation of surface labeled proteins with anti-biotin antibody also indicated increased APP at the cell surface in 2-CDA treated cells compared to controls. Increased turnover of APP by 2-CDA in turn might be a consequence of decreased protein levels of PIN 1, which is known to regulate cis-trans isomerization and phosphorylation of APP. Most importantly, like many other oncology drugs, 2-CDA administration led to significant delay in acquiring a reward-based learning task in a T maze paradigm. CONCLUSIONS: Taken together, these data provide compelling evidence for the first time that chronic 2-CDA administration can increase amyloidogenic processing of APP leading to robustly increased plaque burden which may be responsible for the observed deficits in learning skills. Thus chronic treatment of mice with 2-CDA can have deleterious effects in vivo.

Alternative methods of cladribine administration.

Nucleoside derivative cladribine treatment in hairy cell leukemia (HCL) is a rare example of treatment success in cancer. In fact, HCL is generally responsive to single-agent cladribine and only a minority of patients are refractory. Cladribine was originally administered intravenously as a continuous infusion at a dose of 0.1 mg/kg/day for 7 consecutive days. Subsequently cladribine has been administered intravenously, as a 2 h infusion for 5 consecutive days or weekly for 7 weeks, or subcutaneously. These regimens are all very effective but often show relevant toxicity. The subcutaneous route is easier to administer and may increase compliance of the patient. We have had the opportunity to investigate the efficacy and toxicity of subcutaneous cladribine given at the dose of 0.1 mg/kg/day for 5 or 7 days as a single course in newly diagnosed HCL requiring treatment, in an ongoing Italian multicenter clinical trial. Overall responses have been no different in the two arms, while a much lower infection rate was observed when cladribine was given at the lowest dose. Subcutaneous administration may be deemed a very convenient route since it does not require hospitalization. A reduced dosage of cladribine may also be advantageous since it may be associated with reduced toxicity and may set the dose needed for combinations with antibody treatments.

Cladribine alone and in combination with cyclophosphamide or cyclophosphamide plus mitoxantrone in the treatment of progressive chronic lymphocytic leukemia: report of a prospective, multicenter, randomized trial of the Polish Adult Leukemia Group (PALG CLL2).

In this prospective randomized trial, we compared the efficacy and toxicity of cladribine (2-CdA) alone to 2-CdA combined with cyclophosphamide (CC) or cyclophosphamide and mitoxantrone (CMC) in untreated progressive chronic lymphocytic leukemia (CLL). Study end points were complete response (CR), overall response, minimal residual disease (MRD), progression-free survival, overall survival, and toxicity. From January 1, 1998 to December 31, 2003, 508 patients from 15 hematology departments were randomized. Compared with 2-CdA, CMC induced higher CR rate (36% vs 21%, P = .004), and a trend for higher CR rate with CC was observed (29% vs 21%, P = .08). Furthermore, the percentage of patients who were in CR and were MRD negative was higher in CMC compared with 2-CdA (23% vs 14%, P = .042). There were no differences in overall response, progression-free survival, and overall survival among treatment groups. Grade 3/4 neutropenia occurred more frequently in CC (32%) and CMC (38%) than in 2-CdA (20%) (P = .01 and P = .004, respectively). Infections were more frequent in CMC compared with 2-CdA (40% vs 27%, P = .02). In conclusion, CMC used in first-line treatment of CLL results in a higher CR rate and suppresses MRD more efficiently than 2-CdA monotherapy, although associates with increased toxicity. No important differences in efficacy and toxicity were found between CC and 2-CdA regimens.

Cytotoxic effects of cladribine and tezacitabine toward HL-60.

The aim of the study was to determine the relation between the cytotoxic and cytostatic effects of tezacitabine and cladribine on a HL-60 cell line and the time of exposure of cells to these drugs. Cell viability and induction of apoptosis were assessed using flow cytometry methods. Apoptosis was confirmed by direct microscopic observation. Growth inhibition was examined by cell counting. After 24 h incubation tezacitabine was equally or less toxic compared to cladribine. However, toxicity of tezacitabine strongly rose after 48 h incubation leading to massive cell death at doses much lower than those of cladribine. Assessment of the effect of increased exposure time on the clinical efficacy of tezacitabine is indicated.

In vitro cytotoxic effect of proteasome inhibitor bortezomib in combination with purine nucleoside analogues on chronic lymphocytic leukaemia cells.

OBJECTIVE: The anti-tumour in vitro activity of proteasome inhibitor bortezomib (PS-341, VELCADE) in combination with purine nucleoside analogues, cladribine (2-CdA) and fludarabine (FA) was tested in lymphocytes derived from 26 patients with B-cell chronic lymphocytic leukaemia (B-CLL). METHODS: Cell viability was assessed by propidium iodide staining, and apoptosis by annexin-V and caspase activation flow cytometry assays. Additionally, expression of the apoptosis-regulating proteins Bax, Bak, Bid, Bcl-w, Bcl-2, XIAP and Mcl-1 was evaluated in B-CLL lymphocytes. RESULTS: Bortezomib alone induced significant, dose-dependent cytotoxicity starting from the low concentration 2.5 nm, inducing apoptosis of B-CLL cells. Combination of this agent with 2-CdA or FA resulted in an increase of cytotoxicity when compared with that mediated by single drugs. The observed increase was especially evident when 5 nm of bortezomib were combined with suboptimal doses of 2-CdA or FA. The combination index (CI) was 0.87 for bortezomib + 2-CdA and 0.82 for bortezomib + FA, indicating an evident additive effect of these combinations. Moreover, B-CLL cells were more sensitive to proteasome inhibitor used alone or combined with 2-CdA or FA comparing to CD3+ lymphocytes. Corresponding to enhanced apoptosis, the expression levels of several apoptosis-regulating proteins were altered. The most pronounced changes were down-regulation of XIAP and up-regulation of Bid proteins by the combination of bortezomib with either 2-CdA or FA. CONCLUSIONS: This study suggest that the in vitro cytotoxic effect through proteasome inhibition by bortezomib can be increased substantially with low doses of the purine nucleoside analogues, 2-CdA and FA, and that this effect on B-CLL cell is selectively higher than on normal, CD3-positive lymphocytes.

Durable response but prolonged cytopenia after cladribine treatment in relapsed patients with indolent non-Hodgkin's lymphomas: results of a Japanese phase II study.

We conducted a phase II study to evaluate the efficacy and safety of cladribine (2-chlorodeoxyadenosine [2-CdA]) for patients with refractory or relapsed indolent B-cell lymphoma or mycosis fungoides. Forty-five patients were enrolled, and 43 patients, including 34 with follicular lymphoma, were eligible. 2-CdA was given by continuous intravenous infusion at a dose of 0.09 mg/kg daily for 7 consecutive days, and this schedule was repeated every 4 weeks up to a maximum of 6 cycles. The overall and complete response rates were 58.1% (25/43; 90% confidence interval, 44.5%-70.9%) and 14.0% (6/43), respectively. The disease progression-free proportions of all 43 eligible and all 25 responding patients at 2 years were 30.3% and 48.1%, respectively. Neutropenia and thrombocytopenia of grade 3 or 4 were observed in 53.3% and 37.8% of patients, respectively, with prolonged cytopenia observed in patients with increased numbers of treatment cycles. Nonhematologic toxicities of grade 3 or greater included diarrhea, arrhythmia, malaise, and gastrointestinal bleeding in 1 patient each, an increase in glutamic-pyruvic transaminase level in 2 patients, and infection in 5 patients. Two treatment-related deaths were observed. Four patients developed myelodysplastic syndrome (MDS) at 13 months to 2 years after completion of the 2-CdA treatments. 2-CdA is an active agent with acceptable toxicity for refractory or relapsed indolent lymphoma; however, prolonged myelosuppression and the potential development of MDS should be carefully monitored.

The influence of 2-chlorodeoxyadenosine (2-CdA) on the adenine energy charge and glutathione content of human erythrocytes.

We have examined the effect of exposure of human erythrocytes to the new chemotherapy drug 2-chlorodeoxyadenosine (2-CdA, cladribine), focusing on the glutathione (GSH and GSSG) content and the adenine energy charge (AEC). Incubation of erythrocytes with 0.1-5 microg/ml 2-CdA induced no significant change in the reduced or total glutathione level or in the AMP and ATP concentrations. The ADP concentration increased slightly and the AEC value is in the range typical of healthy organisms. Incubation of erythrocytes with 2-CdA also caused cell shape changes, converting most of the cells to echinocytes.

Treatment of indolent non-Hodgkin's lymphoma with cladribine as single-agent therapy and in combination with mitoxantrone.

The term indolent in describing a non-Hodgkin's lymphoma (NHL) generally refers to a group of B-cell NHLs composed of predominantly small cells that make up several categories, including follicular lymphoma, small lymphocytic lymphoma, and lymphoma of mucosa-associated lymphoid tissue. Most patients with follicular lymphoma respond to therapy, and the average survival time in large series is approximately 10 years. Patients who achieve a complete remission with initial treatment have an approximately 25% chance of remaining free of disease for 10 years. However, this means that more than 80% of patients will require salvage therapy. Cladribine is a newer purine analogue and is of particular interest because it is resistant to deamination by adenosine deaminase. It is cytotoxic to both proliferating and resting lymphocytes, making it an attractive agent for the treatment of indolent NHL. In this review article, we summarize the current treatment approaches for indolent NHL and the results of cladribine monotherapy studies in Japan and cladribine studies in Germany that have focused on a combination therapy with mitoxantrone. Cladribine is a potent inhibitor of DNA repair. The combination of a DNA-damaging agent with an inhibitor of DNA repair constitutes the rationale for combining cladribine with mitoxantrone. A German study has demonstrated that the combination of reduced-dose cladribine and mitoxantrone is a highly active regimen with favorable toxicity profiles. Cladribine is highly effective as a single agent and in combination with mitoxantrone in the treatment of indolent NHL, and its availability broadens the range of therapeutic options for indolent NHL.

2-Chloro-2'-deoxyadenosine synergistically enhances azidothymidine cytotoxicity in azidothymidine resistant T-lymphoid cells.

This report presents quantitative analysis of the synergistic interaction of azidothymidine (AZT) and cladribine (CdA) in human H9-lymphoid cell lines sensitive and resistant to AZT (H9-araC cells). H9-araC cells obtained by cultivation of H9 cells in the presence of 0.5 microM arabinosyl-cytosine (araC) had lower deoxycytidine kinase and thymidine kinase (TK) activities and expressed cross-resistance to araC and AZT. The IC(50) values of AZT and CdA were calculated by using median-effect analysis and CalcuSyn software. The IC(50) values were 0.44 and 0.82 microM for CdA and 67.8 and 30,310 microM for AZT in H9 and H9-araC cells, respectively. However, when the drugs were used in combination the IC(50) values of CdA and AZT were reduced to 0.12 and 15.5 microM in H9 cells and to 0.19 and 24.9 microM in H9-araC cells, respectively. Calculation of dose reduction index (DRI) indicated that at 50-90% growth inhibition level, the combination of the drugs caused 3.6-5.8- and 4.1-11.5-fold reduction in the dose of CdA and 4.4-37.6- and > 1000-fold reduction in the dose of AZT in H9 and H9-araC cells, respectively. The combination index (CI) values simulated from these data suggested synergistic to very strong synergistic lymphocytotoxic effects of AZT combined with CdA. These findings suggest the potential usefulness of a double-targeted approach for designing efficacious therapeutics for the kinase deficient drug resistant tumors.

Histomorphometry of nuclei of proximal convoluted tubules epithelium of kidney of experimental animals after Cladribine (2-CdA) administration.

The area of the section of nuclei of the epithelium cells lining the proximal convoluted tubules of the kidney of white Wistar rats was examined. The animals were given Cladribine (2-CdA) subcutaneously at the dosages of 0.07 mg/kg b.w./24 h for seven days and 0.1 mg/kg b.w./24 h for 6 days in three courses with 5 weeks' break between each. The animals were killed in each instance, 24 hours after the last dose of the drug and 4 weeks after the last dose. The mean area of the section of the cell's nuclei was measured in projection microscope. Results of the examination were counted statistically. In experimental groups I and III the surface areas of the proximal tubules epithelium nuclei cross-sections are smaller than in the control grous. In the experimental groups II and IV the surface areas of the proximal tubules epithelium nuclei cross-sections are bigger than in the control group.

Histomorphology of renal corpuscles of kidney of experimental animals after Cladribine (2-CdA) administration.

The renal corpuscles of the kidney of white Wistar rats was examined. The animals were given Cladribine (2-CdA) subcutaneously at the dosages of 0.07 mg/kg b.w./24 h for 7 days and 0.1 mg/kg b.w./24 h for 6 days in 3 courses with 5 weeks' break between each. The animals were killed in each instance, 24 hours after the last dose of the drug and 4 weeks after the last dose. The kidney samples were taken for histological and histochemical examination, then stained with hematoxylin and eosin, using the Masson's, PAS, and Feulgen's methods. In all of the groups, changes were observed but the intensity differed, with widening or narrowing of the urinary space, thickening of the basement membrane of the parietal layer of the Bowman's capsule and the basement membrane of capillaries, and density changes in capillary vessels. Hyperaemia in renal glomeruli and in all parenchyma, and infiltrations around the tubules and renal glomeruli, were also observed.

Histomorphology of renal proximal convoluted tubules of kidney of experimental animals after Cladribine (2-CdA) administration.

The proximal convoluted tubules of the kidney of the white Wistar rats were examined. The animals were given Cladribine (2-CdA) sub-cutaneously at the dose: 0.07 mg/kg b.w./24 h for 7 days and 0.1 mg/kg b.w./24 h for 6 days in 3 courses, with 5 weeks' break between each. The animals were killed in each instance 24 hours after the last dose of the drug, and 4 weeks after the last dose. The kidney's samples were taken for histological and histochemical examination and were stained with hematoxylin and eosin, using the Masson's, the PAS's, and the Feulgen's method. In experimental group I, we observed few changes (in comparison to the control group): cells of the epithelium of some of the proximal convoluted tubules were however, puffy. In a few tubules we observed some unknown substance and the lumen of some of these tubules was narrowed. In experimental group II, a few proximal convoluted tubules and their lumen were wider with an unknown substance within. We also observed hydropic degeneration. The brush border of these tubules was a little lower than in control group. In experimental group III, the cells of the epithelium of proximal convoluted tubules rested on a thicker basement membrane, the lumen of most of the proximal convoluted tubules being narrow and filled with some unknown substance. In experimental group IV, the lumen of the tubules was a little wider, and the epithelial cells were smaller than in the control group, thus the lumen of the tubules was wider. In the cytoplasm of epithelial cells we observed numerous PAS(+) granules. The low brush border appeared damaged.

The ultrastructure of kidney renal corpuscles of experimental animals after Cladribine (2-CdA) administration.

The renal glomeruli of the kidney of white Wistar rats were examined. The animals were given Cladribine (2-CdA) subcutaneously at dosages of 0.07 mg/kg b.m./24 h for 7 days and 0.1 mg/kg b.m./24 h for 6 days in 3 courses with 5 weeks' break between each. The animals were killed in each instance, 24 hours after the last dose of the drug or 4 weeks after the last dose. The kidney samples were taken for ultrastructural examination. In all of the groups, changes were observed but the intensity differed: widening or narrowing of the urinary space, thickening of the basement membrane of the parietal layer of the Bowman's capsule and the basement membrane of capillaries, and density changes in capillary vessels as well as infiltrations around the renal glomeruli. Most changes were observed in experimental group IV: the picnotic nuclei of epithelium, widening and fusion of the foot processes of podocytes (the narrowing of the filtration spaces) and numerous invaginations of the nuclear envelope of damaged podocytes.

Ultrastructure of kidney renal proximal convoluted tubules of experimental animals after Cladribine (2-CdA) administration.

The proximal convoluted tubules of the kidney of white Wistar rats were examined. The animals were given Cladribine (2-CdA) subcutaneously at dosages of 0.07 mg/kg b.m./24 h for 7 days and 0.1 mg/kg b.m./24 h for 6 days in three courses with 5 weeks' break between each. The animals were decapitated 24 hours after the last dose of the drug and 4 weeks after the last dose. The kidney samples were taken for ultrastructural examination. Giving Cladribine at the dose of 0.1 mg/kg b.m./24 h for 7 successive days does not lead to instant changes in the ultrastructure of the proximal convoluted tubules. Changes noticed 4 weeks after Cladribine administration are the following: decrease in amount of mitochondria, the presence of numerous vacuoles, changes in the structure of the brush border, presence of numerous glycogen granules, and the presence of a diluted cytoplasm around the nucleus. Giving 2-CdA at the dose of 0.07 mg/kg b.m./24 h for 6 days in three courses leads to similar changes in proximal convoluted tubules with more extensive damages of the brush border. These were no more intensive after 4 weeks' break in Cladribine administration.

Phase II study of cladribine (2-chlorodeoxyadenosine) in relapsed or refractory adult T-cell leukemia-lymphoma.

Adult T-cell leukemia-lymphoma (ATL) is a retrovirus-associated T-cell malignancy with an extremely poor prognosis; the median survival time of ATL patients with the acute or lymphoma type is less than 1 year with various combination chemotherapies. Cladribine (2-chlorodeoxyadenosine; 2-CdA), a purine analog resistant to degradation by adenosine deaminase, has shown definitive clinical activity against various lymphoid malignancies, including hairy cell leukemia, indolent lymphoma, and cutaneous T-cell lymphoma. An in vitro study showed the sensitivity of T-lymphoblastoid cell lines to cladribine, and a preceding Japanese phase I study of cladribine showed that 1 refractory patient with ATL achieved an objective response. To evaluate the therapeutic efficacy of cladribine in treating ATL, we conducted a multicenter phase II study. The plan was to administer cladribine to 30 ATL patients as 0.09 mg/kg per day by 7-day continuous intravenous infusion every 4 weeks for up to 3 courses. Before the planned interim analysis, 16 patients with relapsed or refractory ATL were enrolled, 15 of whom were eligible. Only 1 of the 15 eligible patients showed an objective response (overall response rate, 7%; 90% confidence interval, 0% to 28%), and 11 patients (73%) showed progressive disease, mostly during the first course of treatment. Because the upper limit of the 90% confidence interval of the overall response rate did not reach 30% in the interim analysis, the Independent Monitoring Committee advised us to discontinue patient enrollment. In conclusion, cladribine is not worthy of further investigation for the treatment of ATL.

Efficacy of 2-chlorodeoxyadenosine in refractory factor VIII inhibitors in persons without hemophilia.

The authors examined the efficacy of 2-chlorodeoxyadenosine (2-CDA) in the treatment of refractory inhibitors to factor VIII in persons without hemophilia. The drug was administered to 6 patients at a dose of 0.1 mg/kg as a 24-hour continuous infusion for a total of 7 days each cycle. An average of 3 immunosuppressive regimens per patient had been administered prior to enrollment in this study. The median inhibitor titer against human and porcine factor VIII before treatment with 2-CDA was 31 Bethesda units (BUs) and 9 BU, respectively. The median inhibitor titer against human and porcine factor VIII after treatment was 3.5 BU and 1.5 BU, respectively. The median time to reach nadir inhibitor titer in this study was 137 days, whereas the median time to reach a 50% increase in factor VIII was 117 days. No major toxicity was observed in any patient in this study. Patients with acquired inhibitors to factor VIII refractory to conventional immunosuppressive therapy may respond favorably to 2-CDA.

Exposure-disease continuum for 2-chloro-2'-deoxyadenosine (2-CdA), a prototype teratogen: induction of lumbar hernia in the rat and species comparison for the teratogenic responses.

BACKGROUND: The purine analog 2-chloro-2'-deoxyadenosine (2-CdA) caused ocular and limb defects in the mouse and rabbit. The current study examined the teratogenic potential of this drug in the rat and compared the adverse developmental outcomes with the other species. METHODS: Timed-pregnant Sprague-Dawley rats were given a single intraperitoneal injection of various doses of 2-CdA ranging from 5-60 mg/kg, at gestational day (GD) 9.5 and GD 14. 2-CdA concentrations in maternal serum and embryos were measured by HPLC and termed fetuses were prepared for teratological examination. RESULTS: Full-litter resorption was seen in dams receiving 50 mg/kg of 2-CdA at GD 9.5, whereas post-implantation loss was significantly increased and fetal weights significantly reduced at 40 mg/kg. Gross examination of the surviving fetuses revealed microphthalmia, a shortened body trunk and lumbar hernia, manifested by a soft mass protrusion at the lumbar region on one or both sides of the spine. Incidence of these defects increased in a dose-dependent fashion. Histological examination indicated that the hernia was associated with hypoplasia of the body wall, poorly developed skeletal muscle bundles surrounding the vertebral column in the lumbar region, and an absence of the lateral muscle groups that allowed protrusion of the abdominal viscera. The lumbar hernia was generally accompanied by spina bifida, deformed ribs and a wide spectrum of soft tissue-abnormalities that included kidney, genitourinary and heart defects. At GD 14, exposure to 2-CdA at 60 mg/kg produced oligodactyly in one of six litters. CONCLUSIONS: 2-CdA produced similar ocular defects in the rat and mouse, although the incidence was much lower in the former species. In contrast, the drug-induced lumbar hernia was only seen in the rat. These apparent disparities were not readily explained by species differences in pharmacokinetic parameters. the similarities between the teratological features of 2-CdA-induced lumbar hernia in the rat and the clinical description of lumbocostovertebral syndrome, however, may provide a key to unlock the etiology of this rare birth defect in humans.

Cladribine combined with cyclophosphamide and mitoxantrone as front-line therapy in chronic lymphocytic leukemia.

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/m2 on day 1 and cyclophosphamide at 650 mg/m2 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.

Does intensive treatment with high dose chlorambucil and prednisone as first line and cladribine as second line influence the survival of the patients with chronic lymphocytic leukemia?

Cladribine (2-CdA) and fludarabine are the new purine analogs introduced in the treatment of chronic lymphocytic leukemia (CLL). Despite the high response rate, their influence on survival is still uncertain. The aim of this study was a retrospective analysis and comparison of the response rate and survival of CLL patients treated with high dose chlorambucil (HDChl) as first and 2-CdA as second line, with an historical group of patients never treated with purine analogs who received standard doses of chlorambucil (SDChl). We analyzed 347 patients with CLL treated between January 1985 and January 2000. Group A (190 patients) received HDChl (12 mg/m(2) ) with prednisone (P) 30 mg/m(2) daily for 7 days monthly as first line and in refractory or early relapsed patients 2-CdA (0.12 mg/kg/day) for 5 days with or without P (30mg/m(2) ) as second line. Group B (157 patients) received continuous SDChl (4-8 mg/m(2) /day) and P as first line and COP or CHOP as second line. The overall response rate (OR) for the first line was 48,4% in group A and 38,9% in group B (p=0.09). 148 patients in group A and 52 in group B received the second line treatment and the second OR was 19.6% and 13.5%, respectively (p=0.4). At the time of analysis, 124 patients died in group A and 139 in group B. Median survival was 65 months and 50 months, respectively. In group A, survival was longer in advanced Rai stage patients (p=0.001) but in early Rai stage was similar for both groups (p=0.4). We suggest that intensive treatment with HDChl as first line and 2-CdA as second line should be applied in more advanced rather than in less advanced stages of CLL until the final results of randomized clinical trials are available.