Prospective Identification of Significant Prognostic Factors in Patients Treated With Fludarabine, Cyclophosphamide, and Rituximab (FCR) as Initial Therapy for Chronic Lymphocytic Leukemia.
Phase: PHASE2
Conditions: Chronic Lymphocytic Leukemia, Leukemia
Sponsor: M.D. Anderson Cancer Center

Protocol Page
Prospective Identification of Significant Prognostic Factors in Patients Treated with 
Fludarabine, Cyclophosphamide, and Rituximab (FCR) as Initial Therapy for 
Chronic Lymphocytic Leukemia.
2008-0431
Core Protocol Information
Short Title 
Identifying Prognostic Factors in Frontline FCR for Patients with 
CLL
Study Chair: 
William G. Wierda
Additional Contact:
Andrea L. Booker
Sheri L. Allred
Leukemia Protocol Review Group
Additional Memo Recipients:
Recipients List
OPR Recipients (for OPR use only)
None
Study Staff Recipients
Ana B. Ayala
Dora E. Villarreal-Reyes
Minerva A. Griffin
Troy R. Gilchrist
Department:
Leukemia
Phone:
713-745-0428
Unit:
0428
Study Manager:
Ana B. Ayala
Full Title: 
Prospective Identification of Significant Prognostic Factors in 
Patients Treated with Fludarabine, Cyclophosphamide, and 
Rituximab (FCR) as Initial Therapy for Chronic Lymphocytic 
Leukemia.
Public Description:
N/A
Protocol Type:
Standard Protocol
Protocol Phase:
Phase II
Version Status:
Activated -- Closed to new patient entry as of 08/05/2019
Version:
16
Document Status:
Saved as "Final"
Submitted by:
Sheri L. Allred--7/17/2019 9:56:07 AM
OPR Action:
Accepted by:  Felicia Young -- 7/22/2019 4:13:36 AM
Which Committee will review this protocol?
 The Clinical Research Committee - (CRC)

Protocol Body
 
  

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Prospective Identification of Significant Prognostic Factors 
in Patients Treated with Fludarabine, Cyclophosphamide, 
and Rituximab (FCR) as Initial Therapy for Chronic 
Lymphocytic Leukemia 
 
Version 2 
 
July 9, 2008 
 
William G. Wierda, M.D.,Ph.D. 
Associate Professor of Medicine 
Department of Leukemia 
Division of Cancer Medicine 
UT MD Anderson Cancer Center 
1515 Holcombe Blvd., Unit 428 
Houston, TX  77030 
(713) 745-0428 (ph) 
(713) 794-1602 (fax) 

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July 9, 2008 
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Full Title:  
Prospective Identification of Significant Prognostic Factors in 
Patients Treated with Fludarabine, Cyclophosphamide, and 
Rituximab (FCR) as Initial Therapy for Chronic Lymphocytic 
Leukemia 
 
Short Title: 
Identifying Prognostic Factors in Frontline FCR for Patients 
with CLL 
 
1.0 
OBJECTIVES 
 
1.1 
Primary Objective: 
The primary objective of the study is to prospectively evaluate new and traditional 
prognostic factors and evaluate associations with complete remission (CR) in 
frontline patients treated with FCR. 
 
1.2 
Secondary Objectives: 
1. To prospectively evaluate new and traditional prognostic factors and evaluate 
associations with overall response and time to failure in frontline patients 
treated with FCR. 
2. To prospectively determine the minimal residual disease (MRD)-free rate in 
bone marrow of patients treated with frontline FCR and to evaluate prognostic 
factors for MRD. 
3. To assess the pharmacokinetics of rituximab in patients treated with frontline 
FCR. 
 
2.0 
BACKGROUND 
 
2.1 
Chronic lymphocytic leukemia (CLL) is the most common leukemia in the United 
States and Western hemisphere.  It is a disease of the aging population; the 
median age at diagnosis is 72 and over two-thirds of patients with CLL are over 
60 years of age.  Both the incidence and prevalence of this disease increase with 
age.  The natural history for individuals with this disease is diverse.  Generally, 
patients with early Rai stage (stage 0, low-risk) have a median expected survival 
of more than 10 years.  Those with evidence of marrow failure manifested by 
anemia (stage III) or thrombocytopenia (stage IV) (Rai high-risk) have an 
estimated median survival of only 2 years.  In patients with intermediate-risk 
disease (Rai stage I and II) the estimated median survival is 7 years. 
 
2.2 
There is remarkable clinical diversity in patients with CLL.  Following diagnosis, 
some patients have smoldering, asymptomatic disease that may not progress for 
many years; others are diagnosed with advanced stage, or early stage disease 
that rapidly progresses, causing symptoms and/or bone marrow failure and 
require treatment.  Prognostic factors for time to treatment and survival 
potentially include mutation status of the immunoglobulin heavy chain variable 
gene (IgVH); expression of ZAP-70; expression of CD38; plasma level of 2M 
and soluble CD23; and presence of chromosome abnormalities such as 17p 

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deletion and 11q deletion by fluorescence in situ hybridization (FISH) analysis.  
Thus far, these factors have been identified in retrospective analyses of highly 
selected patient populations.  There is limited if any prospective validation 
available for any of the factors.  Nevertheless, factors may help delineate 
patients with smoldering versus progressive disease, thereby providing tools to 
identify patients for whom early treatment clinical trials may be indicated.  They 
also may prove useful in directing selection of treatment agents; however, 
prospective clinical trials to evaluate these issues are needed. 
 
Studies from the Cancer and Leukemia Group B (CALGB) and the French 
cooperative group demonstrated that immediate or early treatment did not 
prolong survival for patients with early-stage disease treated with chlorambucil1,2.  
However, these results were likely influenced by inclusion of patients with 
smoldering CLL and by inadequate treatment.  To readdress this issue, a large 
US Intergroup trial is will be initiated comparing early versus delayed treatment 
with fludarabine with rituximab for high-risk patients defined as having an 
unmutated IgVH gene (>98% homology to germline).  Given available data for 
prognostic factors and status of therapies for patients with CLL, we continue to 
follow clinical guidelines for initiating therapy in patients with active and 
progressive disease.  These guidelines were recently updated by the 
International Workshop on CLL3 and are consistent with the 1996 National 
Cancer Institute-Working Group (NCI-WG) guidelines4. 
 
2.3 
Clinical research employs a response-driven approach for clinical trial 
development.  This approach is based on the observation that patients who 
achieve complete remission (CR) live longer than those who achieve partial 
remission (PR), or those who fail treatment.  In general, clinical trials aim to 
increase the CR rate and demonstrate prolonged remission duration with the 
expectation that this will correlate with improved survival. 
 
Response to treatment has been assessed in clinical trials by the NCI-WG 
criteria published 10 years ago4.  CR requires no evidence of disease on physical 
examination or microscopic examination of blood (ALC <4,000/L) and bone 
marrow (<30% lymphocytes, no nodules), and recovery of hemoglobin, 
neutrophil, and platelet counts.  Recently, more sensitive tests to evaluate 
residual disease than microscopic exam have become available, specifically 
multi-color flow cytometry and allele-specific polymerase chain reaction (PCR) for 
the immunoglobulin heavy chain variable gene (IgVH).  In some patients 
achieving CR by NCI-WG criteria, one or both of these methods can demonstrate 
residual disease, referred to as minimal residual disease (MRD), usually in the 
bone marrow.  Patients free of MRD following treatment have a longer remission 
duration and longer survival5.  Therefore, in addition to improving CR rates, 
investigators are focusing on eliminating MRD.  The initial treatment of patients 
with CLL represents the best opportunity to achieve CR. 
 

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2.4 
Historically, palliative treatment consisted of an alkylating agent, most commonly 
chlorambucil, or alkylating agent-based combination.  This treatment typically 
was intermittent and protracted, resulting in PRs.  With alkylating agent-based 
therapy, the CR rate is less than 10%, the overall response (OR) rate is 
approximately 50-60%, and estimated median survival is 50-70 months. 
 
2.5 
Fludarabine is the most extensively studied purine analogue for the treatment of 
patients with CLL.  Randomized, phase III frontline clinical trials have evaluated 
fludarabine versus single-agent chlorambucil or alkylating agent-based 
combinations for chemotherapy-naïve patients6-8.  The US Intergroup trial 
randomized 509 patients to treatment with fludarabine, chlorambucil, or the 
combination8.  The combination arm was closed early due to unacceptable 
toxicity.  The CR rate for patients in the fludarabine arm was 20% versus 4% in 
the chlorambucil arm (p<0.001).  In addition, the OR rates were 63% and 37% for 
the fludarabine and chlorambucil arms, respectively.  The median remission 
duration for patients who received fludarabine was 25 months, nearly double that 
of patients on the chlorambucil arm.  Despite a significantly higher CR rate and 
longer remission duration with fludarabine, overall survival (OS) was not different. 
 
2.6 
Fludarabine inhibits excision repair of DNA inter-strand cross-links induced by 
cyclophosphamide, thereby enhancing activity and giving a rationale for 
combining these agents9.  Results of three large randomized phase III trials 
comparing efficacy of combined fludarabine and cyclophosphamide (FC) versus 
single-agent fludarabine or chlorambucil have been reported.  In the German 
CLL Study Group CLL4 trial, previously untreated patients younger than 65 years 
with indications for treatment were randomized to receive 6 courses of 
fludarabine (F) at the standard dose versus fludarabine and cyclophosphamide 
(FC) at 30mg/m2 and 250mg/m2, respectively, daily for 3 days of each 4-week 
course10.  There were 328 randomized patients evaluable for response; FC 
produced significantly higher CR (24%) and OR (95%) rates compared to 
fludarabine (7% CR; 83% OR).  The median progression-free survival (PFS) for 
patients treated with FC was 48 versus 20 months for F (p=0.001).  The median 
treatment-free survival for patients treated with FC versus F was 37 versus 25 
months (p=0.001).  The median OS was not reached in both arms.  There was an 
increase in the incidence of myelosuppression with the FC combination; 
however, there was no increase in the incidence of infection.  Results of the 
Intergroup E2997 and UK Leukemia Research Fund (LRF) CLL4 trials comparing 
FC to fludarabine have also been reported11,12.  There were no age restrictions in 
these randomized, phase III trials; both confirmed superior efficacy for the FC 
combination over F or chlorambucil in chemotherapy-naïve patients with CLL.  
Treatment with FC resulted in higher CR and OR rates and longer remission 
duration.  No trial has shown survival advantage for frontline treatment with FC. 
 
2.7 
Rituximab, the mAb that targets CD20, is approved by the US FDA for patients 
with relapsed low-grade non-Hodgkin’s lymphoma13.  Relatively low levels of 
CD20 are expressed on CLL cells, compared to normal B or neoplastic B cells of 

Protocol 2008-0431 
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other lymphomas.  In addition, soluble CD20 has been demonstrated in plasma 
of patients with CLL; this may inhibit the capacity of rituximab to bind to CLL 
cells, thereby resulting in rapid clearance and negatively affecting 
pharmacokinetics14.  Standard-dose rituximab (375mg/m2 weekly for 4 weeks) 
has very limited activity for patients with CLL giving an overall response rate of 
12% in patients with CLL/SLL in the pivotal trial with no compete responders13,15.  
Dose intense16 and dose-dense17 single-agent rituximab has been shown to 
increase efficacy. 
 
2.8 
Rituximab enhances the activity of purine analogue-based therapies and has 
been incorporated into chemoimmunotherapy regimens.  The randomized, phase 
II multi-institutional CALGB 9712 trial evaluated the activity of concurrent versus 
sequential fludarabine and rituximab as initial treatment of patients with CLL18.  
Induction consisted of either 6 courses of standard-dose fludarabine (sequential 
group) or standard-dose fludarabine with rituximab (concurrent group).  At the 
end of a 2-month observation period, responders and patients with stable 
disease in both groups received an additional 4 weekly doses of rituximab.  This 
phase II trial demonstrated a significantly higher CR rate of 47% for the 
concurrent group versus 28% for the sequential group.  The OR rate and PFS 
were not significantly different between the two groups.  All patients in this study 
received rituximab; the concurrent group received 2.5 times the cumulative dose 
given to the sequential group.  Subsequently, an analysis of all patients treated in 
the CALGB 9712 trial compared to an historical group of chemotherapy-naive 
patients treated with single-agent fludarabine in the randomized CALGB 9011 
trial (no rituximab) demonstrated statistically significantly higher CR and OR 
rates, 2-year disease-free survival, and 2-year OS, favoring patients who 
received frontline fludarabine and rituximab19. 
 
The combination of fludarabine, cyclophosphamide, and rituximab (FCR) has 
been evaluated in both chemotherapy-naïve and previously treated patients with 
CLL20,21.  In 224 previously untreated patients with CLL, the CR rate with FCR 
was 70% and the OR rate was 95%, with most patients having no detectable 
disease by two-color flow cytometry evaluation of the bone marrow at the end of 
therapy20.  Over 40% of complete responders were free of disease in the bone 
marrow by PCR testing for the clonal IgVH gene.  The projected failure-free 
survival at 4 years was 69%.  This was the highest response rate reported for 
any regimen in previously untreated patients with CLL.  The long-term follow-up 
of this frontline trial was recently updated.  The median remission duration for 
300 patients treated with FCR was 66 months 22.  An early report of a large, 
phase III randomized clinical trial of FCR versus FC done in Europe indicates 
that the response rate, including complete response and progression-free 
survival are superior for FCR in previously untreated patients.  The FCR regimen 
has become the standard frontline regimen.  Clinical trials done at MDACC to 
improve the activity have included FCR3, consisting of FCR with 3 doses of 
rituximab with each course of treatment, and FCMR, consisting of FCR with 
mitoxantrone.  Neither of these two trials showed improvement in response rate 

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or progression-free survival compared to the historic group of 300 patients 
treated with FCR. 
 
2.9 
Bone marrow is the usual site of involvement in patients with residual disease 
after purine analog-based therapy.  Eliminating residual disease may improve 
remission duration and overall outcome5,23.   
 
A report of 91 previously treated patients with CLL who received alemtuzumab 
demonstrated eradication of residual disease in the blood and bone marrow in 
20%5.  Minimal residual disease was evaluated by four-color flow cytometry and 
those patients who were negative for residual disease in the bone marrow had 
longer PFS and OS compared with those who had residual disease.  The OS for 
the 18 patients who were free of detectable residual disease was 84% at 60 
months.  A focus of clinical investigation continues to be the elimination of 
minimal residual disease with the expectation that this will correlate with 
improved remission duration and survival. 
 
2.10 Treatment regimen has an impact on the significance of prognostic factors in 
frontline therapy in predicting response and time-to-event endpoints.  Therefore, 
it is important to evaluate the newer prognostic factors in patients treated 
uniformly with a specific treatment regimen. This clinical trial will prospectively 
evaluate the newer prognostic factors, including IgVH mutation status, ZAP70 
expression, CD38 expression, CD49d expression, thymidine kinase, and 
chromosome abnormalities by FISH analysis along with traditional prognostic 
factors such as age, beta-2 microglobulin, Rai stage, etc, to identify which are 
significant, independent predictors of treatment endpoints including response 
(CR) to treatment and TTF.  We will evaluate for MRD and determine the MRD-
free rate with the FCR regimen using standardized, validated assays.  We will 
also develop prognostic models and nomograms for these endpoints.  Also, we 
will evaluate pharmacokinetics of rituximab in the FCR regimen in order to more 
rationally dose rituximab in chemoimmunotherapy regimens.  Finally, we will 
characterize immune reconstitution following frontline FCR treatment. 
 
3.0 
BACKGROUND DRUG INFORMATION  
 
3.1 
Fludarabine phosphate (Fludara) 
Fludarabine phosphate is commercially available as a standard treatment 
for patients with CLL.  Fludarabine is a purine analogue that inhibits DNA 
synthesis by inhibition of DNA polymerase, ribonucleotide reductase, and 
DNA primase. 
 
3.1.1 How Supplied: Sterile, 50 mg prepared as a white lyophilized 
powder with sodium hydroxide to adjust pH. 
 
3.1.2 Solution Preparation: Fludarabine for injection should be prepared 
for parenteral use by aseptically adding Sterile Water for Injection 

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USP.  When reconstituted with 2mL of Sterile Water for Injection, 
USP, the solid cake should fully dissolve in 15 seconds or less; 
each mL of the resulting solution will contain 25 mg of fludarabine 
phosphate, 25 mg of mannitol, and sodium hydroxide to adjust the 
pH to 7.7.  The pH range for the final product is 7.2 – 8.2.  In clinical 
studies, the product has been diluted in 100 cc or 125 cc of 5% 
Dextrose Injection USP or 0.9% Sodium Chloride USP. 
 
Reconstituted Fludarabine for Injection contains no antimicrobial 
preservative and thus should be used within 8 hours of 
reconstitution.  Care must be taken to assure the sterility of 
prepared solutions.  Parenteral drug products should be inspected 
visually for particulate matter and discoloration prior to 
administration. 
 
Handling and Disposal: Procedures for proper handling and 
disposal should be considered.  Consideration should be given to 
handling and disposal according to guidelines issued for cytotoxic 
drugs.  Several guidelines on this subject have been published.  
There is no general agreement that all of the procedures 
recommended in the guidelines are necessary or appropriate.   
 
Caution should be exercised in the handling and preparation of 
Fludarabine for Injection solution.  The use of latex gloves and 
safety glasses is recommended to avoid exposure in case of 
breakage of the vial or other accidental spillage.   If the solution 
contacts the skin or mucous membrane, wash thoroughly with soap 
and water; rinse eyes thoroughly with plain water.  Avoid exposure 
by inhalation or by direct contact of the skin or mucous membranes.   
 
3.1.3 Stability: Fludarabine phosphate is relatively stable in aqueous 
solution.  Over a pH range of approximately 4.5 to 8 in aqueous 
buffer solutions stored at 65C, approximately 11% decomposition 
occurred in one day.  From this pH profile, the optimum pH was 
determined to be approximately 7.7. 
 
At concentration of 25 mg/ml in distilled water stored at room 
temperature in normal laboratory light, fludarabine phosphate 
exhibited less than 20% decomposition in 16 days. 
 
Diluted to concentration of 1 mg/ml in 5% dextrose injection, USP, 
or in 0.9 sodium chloride injection, USP, less than 3% 
decomposition occurred in 16 days at room temperature under 
normal laboratory light. 
 

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CAUTION: The single-use lyophilized dosage form contains no 
antibacterial preservatives.  Therefore, it is advised that the 
reconstituted product be discarded eight hours after reconstitution. 
 
3.1.4 Route of Administration: Intravenous. 
 
3.2 
Cyclophosphamide (Cytoxan) 
Cyclophosphamide is commercially available and has activity in treating a 
variety of malignancies.  Cyclophosphamide is an alkylating agent that 
prevents cell division by cross-linking DNA strands and decreasing DNA 
synthesis.  It is a cell cycle phase non-specific agent.  Cyclophosphamide 
is a prodrug that must be metabolized to active metabolites in the liver. 
 
Expected toxicities include myelosuppression.  Cystitis can be caused by 
cyclophosphamide and can be dose limiting.   
 
3.2.1 How Supplied: Supplied in quantities of 100 mg, 200 mg, 500 mg, 1 
gm, an 2 gm for intravenous use.  Maximum concentration is 20 
mg/ml.:  
 
3.2.2 Solution Preparation: This is per standard pharmacy practice. 
 
3.2.3 Stability: Room temperature stability is 48 hrs.  Refrigeration 
stability is 28 days. 
 
3.2.4 Route of Administration: Intravenous 
 
3.3 
Rituximab (Rituxan®) 
Rituximab is commercially available and is an approved treatment for low-
grade lymphoma.  Rituximab is a monoclonal antibody that binds to CD20. 
 
3.3.1 Clinical Formulation 
Clinical supplies for this study will be manufactured by Genentech 
Incorporated in South San Francisco, CA. 
 
Rituximab will be provided to the clinical sites packaged in single 
use 10 mL (100mg) and 50 mL (500mg) Type I glass vials at a 
concentration of 10 mg of protein per mL.  The product is 
formulated in 7.35 mg/mL sodium citrate buffer, containing 7 mg/mL 
polysorbate 80, 9.0 mg/mL sodium chloride and Sterile Water for 
Injection.  The pH is adjusted to 6.5. 
 
Rituximab may be produced by the mammalian (Chinese Hamster 
Ovary) cell suspension culture in a nutrient medium containing 100 
mg/mL of the antibiotic gentamicin.  The antibiotic is not detectable 
in the final product. 

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3.3.2 Storage 
Rituximab for clinical use should be stored in a secure refrigerator 
at 2-8C. 
 
3.3.3 Reconstitution and Dilution of rituximab 
 
Using a sterile syringe and a 21 gauge or larger needle, transfer the 
necessary amount of rituximab from the vial into a partially filled IV 
pack containing sterile, pyrogen-free 0.9% Sodium Chloride, USP 
(saline solution).  The final concentration of rituximab should be 1 
mg/mL.  Mix by inverting the bag gently.   
 
4.0 
PATIENT ELIGIBILITY 
 
4.1 
Patients will have a diagnosis of CLL, SLL, or CD20+ low-grade 
lymphoproliferative disorder. 
 
4.2 
All patients with untreated Rai stage III-IV are eligible for this protocol.  
Prior single-agent rituximab treatment is permitted. 
- OR - 
 
 
Patients with untreated Rai stage 0-II who meet one or more criteria for 
active disease as defined by the International Working Group for CLL 
(IWCLL).  Prior single-agent rituximab treatment is permitted. 
 
4.3 
Patients must have an ECOG performance status of 0-3. 
 
4.4 
Patients must have adequate renal and hepatic function (creatinine 
<2mg%, bilirubin <2mg%).  Patients with renal or liver dysfunction due to 
organ infiltration by lymphocytes may be eligible after discussion with the 
study chairman. 
 
4.5 
Patients may not receive other concurrent chemotherapy, radiotherapy, or 
immunotherapy.  Localized radiotherapy to an area not compromising 
bone marrow function does not apply.   
 
4.6 
Patients must be 16 years of age or older. 
 
4.7 
Patients must sign informed consent indicating that they are aware of the 
investigational nature of this study according to the policies of the 
UTMDACC IRB.  
 
5.0 
TREATMENT PLAN 
 

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5.1 
The following are recommended prophylactic medications.  For individuals 
who are allergic, an equivalent replacement may be identified. 
 
Allopurinol 300 mg PO daily for the first 7 days of course 1 is 
recommended for tumor lysis prophylaxis. 
 
Valacyclovir 500 mg PO daily for all 6 courses and for at least 2 months 
after completion of treatment is recommended for herpes virus 
prophylaxis. 
 
PCP prophylaxis may be given at the discretion of the treating physician 
but is recommended for recent or concurrent corticosteroid use. 
 
Growth factors (neutrophil, erythrocyte, platelet) may be used at the 
discretion of the treating physician. 
 
5.2 
Since transient hypotension has been reported during rituximab infusions, 
withholding anti-hypertensive medications the day of the rituximab infusion 
is recommended. 
 
Suggested pre-medication for rituximab: two tablets [375 mg or 500 mg] of 
acetaminophen orally and 25 to 50 mg diphenhydramine hydrochloride 
orally or intravenously will be administered prior to starting each infusion 
of rituximab.  Use of corticosteroids will be at the discretion of the treating 
physician with intent to minimize the infusion-related reactions.  Other pre-
medications may be appropriate based on the physician or patient 
experience. 
 
Recommended rituximab administration is according to the standard 
practice regarding rate of IV infusion, escalation of infusion, and 
precautions.  Suggested administration is as follows: the initial dose rate 
at the time of the first rituximab infusion should be 50 mg/hr for the first 
half hour.  If no toxicity is seen, the dose rate may be escalated gradually 
(50 mg/hour increments at 30-minute intervals) to a maximum of 500 
mg/hr.  If the first dose of rituximab is well tolerated, the starting flow rate 
for the administration of courses 2-6 will be 100 mg/hour then increased 
gradually (100 mg/hour increments at 30-minute intervals) not to 
exceed 600 mg/hr. 
 
 
                                                                                  Mucosal  
 
 
 
 
 
 
   
                   Congestion/ 
     % 
Drop in 
Dose Rate 
          Fever    or    Rigors   or   
 Edema        or   Systolic BP 
Decrease to ½     > 38.5C      Mild/Moderate   Mild/Moderate    >30 mm Hg 
 

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During the rituximab infusion, the patient’s vital signs (blood pressure, 
pulse, respiration, temperature) should be monitored.  Available at the 
bedside prior to rituximab administration will be appropriate measures for 
management of anaphylactic reactions. 
 
Patients may experience transient fever and rigors with infusion of 
chimeric anti-CD20 (rituximab) antibody.  When these side effects are 
noted, the antibody infusion should be slowed or interrupted, the patient 
should be observed and the severity of the side effects should be 
evaluated.  The patient should be treated according to the best available 
local practices and procedures.  Following observation, when the patient’s 
symptoms improve, the infusion should be continued, initially, at half the 
previous rate (see table below).  Upon resolution of all side effects and in 
the judgment of the investigator, the patient’s dose may be gradually 
escalated (50 mg/hr increments at 30 minute intervals) to a maximum rate 
of 300 mg/hr.  Following the antibody infusion, the IV line should be kept 
open for medications, as needed.  If complications occur during the 
rituximab infusion, the patient should be observed for two hours after the 
completion of the infusion. 
 
First Dose – Week 1 
 
The first dose of rituximab will be 375 mg/m2.  All patients will receive the 
same first dose. 
 
Subsequent doses will be 500 mg/m2 for all patients combined with 
fludarabine and cyclophosphamide. 
 
5.3 
Suggested premedication for fludarabine and cyclophosphamide:  
ondansetron 8 mg IV or 10 mg PO or equivalent. 
 
Course 1 of FC + rituximab-Week 1: 
AGENT 
DOSE 
DAY 
ROUTE 
TIME 
Fludarabine 
Cyclophosphamide 
Rituximab 
25 mg/m2/day 
250 mg/m2/day 
375 mg/m2/day 
2-4 
2-4 
1 
I.V. 
I.V. 
I.V. 
5-30 minutes 
5-30 minutes 
4-6 hours 
 
Courses 2-6 of FC + rituximab - Weeks 5, 9, 13, 17, 21: 
AGENT 
DOSE 
DAY 
ROUTE 
TIME 
Fludarabine 
Cyclophosphamide 
Rituximab 
25 mg/m2/day 
250 mg/m2/day 
500 mg/m2/day 
1-3 
1-3 
1 
I.V. 
I.V. 
I.V. 
5-30 minutes 
5-30 minutes 
4-6 hours 
 
Cyclophosphamide will be given after the dose of fludarabine.  Rituximab 
may start two hours before fludarabine.  Courses will be repeated every 4 
– 6 weeks, depending on neutrophil and platelet recovery. 

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5.4 
Dose modifications: 
 
Dose modifications will be at the discretion of the treating physician.  
Modification of rituximab dose is not recommended.  Dose reduction 
should be considered for elderly (>69 yr) patients and patients with renal 
impairment.  Recommended dose levels for fludarabine and 
cyclophosphamide are as follows: 
 
Fludarabine 
Cyclophosphamide 
-2 
-1 
0 
17.5 x 3 
175 x 3 
20 x 3 
200 x 3 
25 x 3 
250 x 3 
 
5.5 
Patients will receive fludarabine phosphate 25 mg/m2 I.V. over 5-30 
minutes daily for 3 days.  Cyclophosphamide 250 mg/m2 will be given I.V. 
over 5-30 minutes daily for 3 days.  Rituximab will be given as in section 
5.0.  Courses will be repeated every 4 – 6 weeks, depending on neutrophil 
and platelet count recovery.  Response evaluation will be conducted after 
completion of 3 and 6 courses. 
 
5.6 
Patients achieving a stable partial response or demonstrating continued 
response after 3 courses will be given an additional 3 courses.  No patient 
will receive more than 6 courses. 
 
5.7 
Patients demonstrating progressive disease or no response after 3 
courses will come off study treatment. 
 
5.8 
Dose adjustment to the next lower level is recommended if pneumonia, 
septicemia, or other life-threatening infection occurs with any course.  If 
recovery of the platelet count to the level of prior to treatment exceeds 35 
days the recommended dose will be decreased 1 level.  If grade 3 or 4 
toxicities to other organ systems develop, the dose level recommended 
will be lowered 1 or 2 levels respectively. 
 
6.0 
PRETREATMENT EVALUATION 
 
6.1 
Patients will have a complete history and physical. 
 
6.2 
Laboratory studies will include CBC, platelet count, differential count, 
chemical survey (bilirubin, creatinine, albumin, LDH), -2 microglobulin, 
bone marrow aspirate and biopsy with samples sent for morphology. 
  
6.3 
Prognostic factors will be characterized including IgVH gene family and 
mutation status; leukemia cell expression of ZAP-70, CD38, and CD49d; 
thymidine kinase; chromosome abnormalities by FISH (13q del, +12, 11q 
del, and 17p del); soluble CD20, CD52, and CD23; and p53 expression.  
Because IgVH and ZAP-70 are thought not to change with time, they do 

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not need to be repeated if done subsequent to diagnosis, before 
treatment.  Evaluation of all other prognostic factors will be done within 3 
months of enrollment on this trial.  Blood or bone marrow may be used to 
evaluate these prognostic factors. 
 
6.4 
Optional blood (20 ml) will be taken to isolate and store pretreatment 
mononuclear cells, DNA, RNA, and plasma.  Optional bone marrow will be 
taken (5 ml) to isolate and store cells, DNA, RNA and marrow plasma.  
Gene methylation analyses will be performed on these pre-treatment 
samples to correlate with treatment outcome. 
 
6.5 
Any appropriate radiological and radioisotope examinations should be 
performed as clinically indicated. 
 
7.0 
EVALUATION DURING STUDY 
 
7.1 
Patients will be followed with CBC, platelet count and differential every 1 – 
2 weeks for the first course and q2 – 4 weeks during therapy thereafter.  
An SMA (bilirubin, creatinine, albumin, LDH) will be repeated every 1-3 
months as clinically indicated.  Physical examination every follow-up visit 
at MDACC. 
 
7.2 
Prior to course 4 and 2 months after course 6 (or last course for 
individuals stopping treatment early) a full evaluation will be performed for 
response assessment, including CBC, platelet and differential count, SMA 
(bilirubin, creatinine, albumin, LDH), and bone marrow aspiration and 
biopsy with samples sent for morphologic and flow cytometry analyses.  
Blood will be evaluated for soluble CD20 and soluble CD52.  CT scans of 
neck, chest, abdomen, and pelvis are recommended at end of treatment 
response assessment.  In patients achieving CR, nodular PR, or PR, 
blood or bone marrow will be evaluated for MRD by 4-color flow cytometry 
or molecular evaluation for the clonal IgVH gene.  Preferentially, this will be 
done on bone marrow, but may be done on blood if necessary. 
 
7.3 
Repeat response assessments by physical examination, blood counts, 
and bone marrow evaluation, including for MRD will be done 6, 12, and 24 
months after last treatment course.  Evaluation for MRD may be done on 
blood.  Blood or marrow for MRD evaluation may be taken by referring 
physician and mailed to UTMDACC.  Follow-up will be annually thereafter 
and bone marrow examinations will be done at the discretion of the 
treating physician for those visits. 
 
7.3 
Myelosuppression and associated complications are expected events 
during leukemia therapy and are part of the treatment success (marrow 
emptying of leukemia cells).  Therefore, myelosuppression and associated 
complications such as fever, infections, bleeding, and related 

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hospitalizations, will not be reported as individual ADRs, but will be 
summarized in the updated and final reports. 
 
7.4 
Optional blood (10 ml) may be taken to determine rituximab levels prior to 
rituximab dose with each course and on day 4 (2 days) of course 1 and 
day 3 (1 day) of courses 2-6.  Optional blood may be taken by referring 
physician in a green-top (heparin) or yellow-top (ACD) tube and mailed to 
UTMDACC. 
 
7.5 
Optional blood (10 ml) may be taken at response assessment (end of 
treatment) and follow-up visits after completion of treatment to monitor for 
immune reconstitution.  Immune reconstitution samples will be evaluated 
for T cell and normal B cell populations, T cell receptor repertoire, T cell 
functional subsets defined by multi-color flow cytometry. Optional blood 
may be taken by referring physician in a green-top (heparin) or yellow-top 
(ACD) tube and mailed to UTMDACC. 
 
 
7.6 
When patients relapse, every attempt will be made to repeat the 
prognostic factor assessment at relapse: ZAP-70 expression, CD38 
expression, CD49d expression, thymidine kinase, beta-2 microglobulin, 
and FISH. 
 
8.0 
RESPONSE CRITERIA 
 
SITE 
CR 
PR 
Nodes* 
None 
> 50% decrease 
Liver/Spleen 
Not palpable 
> 50% decrease 
Symptoms 
None 
N/A 
PMN 
>1,500/l 
> 1,500/l or >50% 
improvement from 
baseline 
Platelets 
> 100,000/l 
>100,000/l or > 50% 
improvement from 
baseline 
Hemoglobin 
(untransfused) 
>11,0 g/dl 
>11.0 g/dl or >50% 
improvement from 
baseline 
Lymphocytes 
<4,000/l 
>50% decrease 
Bone Marrow 
     Aspirate** 
 
     Biopsy 
 
<30% lymphocytes 
 
No lymphocyte infiltrate 
 
N/A for PR 
 
< 30% lymphocytes with 
residual disease on 
biopsy for nodular PR 
* CT scan of neck, chest, abdomen, and pelvis to confirm CR is recommended. 

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** Evaluation for MRD will be performed either by 4-color flow cytometry or by molecular 
evaluation. 
 
9.0 
REMOVAL FROM STUDY 
 
 
9.1 
Progressive or Relapsed Disease 
 
Progressive disease (PD) will be characterized by at least one of the 
following: 
 
a. 
> 50% increase in the sum of the products of at least two nodes on 
two consecutive examinations two weeks apart (at least one node 
must be > 2 cm).  Appearance of new palpable lymph nodes. 
 
b. 
> 50% increase in the size of liver and/or spleen as determined by 
measurement below the respective costal margin; appearance of 
palpable hepatomegaly or splenomegaly, which was not previously 
present. 
 
c. 
> 50% increase in absolute number of circulating lymphocytes and 
at least 10,000/l. 
 
9.2 
Intolerable treatment-related side effects. 
 
9.3 
Patient request. 
 
9.4 
Patients will be removed from study if they receive treatment, such as for 
MRD.  In these cases, they will be removed from this study and their time-
to-event status will remain censored.  They will be followed and evaluated 
for survival. 
 
10.0 STATISTICAL CONSIDERATIONS 
The primary objective of the study is to prospectively evaluate new and 
traditional prognostic factors and validate associations with complete remission 
(CR) in frontline patients treated with FCR.  CR is defined by NCI Working Group 
/ International Working Group for CLL criteria as no evidence of disease on 
physical examination (no adenopathy or organomegaly) or microscopic 
examination of blood (ALC <4,000/L) and bone marrow (<30% lymphocytes, no 
lymphoid nodules), and recovery of hemoglobin, neutrophil, and platelet counts 
3,4.  Response by these criteria will be conducted after completion of 3 and 6 
courses.  Each planned course is 4 weeks; courses may be delayed for 
myelosuppression.  No patient will receive more than 6 courses.  Patients who 
demonstrate progressive disease or no response after 3 courses will come off 
treatment and will be counted as treatment failures. 
 
The secondary objectives for the study are: 

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1. To prospectively evaluate new and traditional prognostic factors and validate 
associations with overall response and time to failure in frontline patients 
treated with FCR. 
2. To prospectively determine the minimal residual disease (MRD)-free rate in 
bone marrow of patients treated with frontline FCR and to evaluate prognostic 
factors for MRD. 
3. To assess the pharmacokinetics of rituximab in patients treated with frontline 
FCR. 
 
FCR regimen is the standard frontline regimen.  Historical data for 300 previously 
untreated patients with CLL indicate that the CR rate after 6 courses of FCR was 
72%, overall response rate was 95%.  Prognostic factors for CR include 
traditional ones such as age, beta-2 microglobulin, Rai stage, etc and the newer 
ones such as IgVH mutation status, ZAP70 expression, CD38 expression, CD49d 
expression, thymidine kinase, and chromosome abnormalities by FISH analysis. 
Prognostic factors will be characterized including IgVH gene family and mutation 
status; leukemia cell expression of ZAP-70, CD38, and CD49d; thymidine kinase; 
chromosome abnormalities by FISH (13q del, +12, 11q del, and 17p del); soluble 
CD20, CD52, and CD23; and p53 expression.  In the current study, we will 
prospectively evaluate these newer prognostic factors, along with the traditional 
ones, in 300 patients with CLL treated frontline with FCR. 
 
Sample size  
The sample size calculation was based on fitting a multiple logistic regression 
model for the binary endpoint of CR with various prognostic factors as covariates.  
For each new prognostic factor of interest, let  be the percent prevalence in CLL 
patients, and  P1 and P0 be the probability of CR in patients with and without the 
expression (or mutation) of the factor.  We then computed the power of detecting 
this difference between P0 and P1 with a sample size of 300 patients, after 
adjusting for the association between this factor and other prognostic factors in 
the same model.  The prevalence level for the factor of interest,, was also taken 
into account in the computation.  Table 1 below shows the power calculation 
results for each of the newer prognostic factors of interest, assuming a sample 
size of 300 and an R-Squared of 0.40 obtained from the multiple regression of 
the factor of interest on other prognostic factors.  For example, given the these 
assumptions and assuming a 48% prevalence level of ZAP-70 in CLL patients, 
we could achieve 79% power at a two-sided 0.05 significance level to detect a 
change in CR rate from 0.80 for patients without ZAP-70 expression to 0.57 for 
patients with ZAP-70 expression.  PASS 2005 was used for all sample size 
calculations.   
 
Table 1.  Power calculations assuming a sample size of 300 and an R-squared of 
0.40 from the multiple regression of the factor of interest on other prognostic 
factors using PASS 2005 software. 

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Prognostic Factors 
% in CLL patients () 
CR within each 
group (%) 
Power 
ZAP-70 expression 
 
 
0.79 
No 
52 
80 
 
Yes 
48 
57 
 
 
 
 
 
CD38 expression 
 
 
0.77 
No 
80 
81 
 
Yes 
20 
59 
 
 
 
 
 
IgVH 
 
 
0.77 
Unmutated 
66 
84 
 
Mutated 
34 
66 
 
 
 
 
 
17p deletion 
 
 
0.89 
No 
91 
70 
 
Yes 
9 
31 
  
 
No interim analysis for futility is planned since all drugs are FDA approved and 
the FCR combination is a standard treatment regimen for frontline patients. 
 
Analysis Plan 
Descriptive statistics, such as frequency (percentage) or median (range), will 
used to summarize the prognostics factors.  Intent-to-treat analysis will be 
conducted for the primary endpoint of CR.  The CR rates, along with 95% 
confidence intervals, will be estimated in all patients and in subgroups 
categorized by prognostic factors.  A multiple logistic regression model will be fit 
to assess the predictive effect of newer (eg, ZAP-70, IgVH, CD38 expression and 
17p deletion, etc.) and traditional prognostic factors (eg, age, beta-2 
microglobulin, Rai stage, etc.) on CR.  Shrinkage estimates will be used in the 
final fitted model. Based on this final fitted model, a nomogram will be developed 
as a tool to predict the probability of CR for each individual patient.  The 
nomogram provides a graphical presentation of the effect of each covariate in the 
fitted model and it can be used to calculate the probability of CR for an individual 
patient by adding the points associated with each prognostic factor.  For model 
validation, we will assess both discrimination and calibration capabilities.  
Discrimination refers to the ability of the model to rank patients by their risk, such 
that patients with higher probability of CR should be more likely to experience 
CR.  The discrimination will be quantified using the area under the ROC curve.  
We will measure the calibration of the model through visual examination of plots 
of predicted vs. actual probabilities.  Bootstrapping will be used to generate the 
calibration plot and obtain more generalizable estimates of expected future 
performance. 
 
Time to failure (TTF) is defined as the time from start of treatment to disease 
progression or death or lost of follow-up, which ever occurs first.  Kaplan-Meier 

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plots will be used to assess the probability of failure-free survival and log-rank 
tests will be performed to assess the difference in TTF between subgroups of 
patients.  A multiple Cox proportional hazards model will be fit for TTF, with 
newer and traditional prognostic factors as potential covariates.  Shrinkage 
estimates will be used in the final fitted model. Similarly as in the case for CR, a 
nomogram for the TTF will be developed and calibrated24.  Calculating the 
concordance index for censored data will assess the discrimination ability of the 
model.  Again, in order to adjust for the bias associated with evaluating the 
performance of a model on the same group of patients used to build the 
nomogram, the assessment of calibration and discrimination was repeated for 
500 bootstrapped samples. 
 
Similar methods described above for analyzing CR will be used to assess overall 
response (OR) or minimal residual disease (MRD)-free rate in bone marrow.  
Descriptive statistics will be used to summarize pharmacokinetics of rituximab.  
 
Missing data 
 
Firstly, we will analyze complete data only, ie, patient with any missing covariate 
will not be included in the model fitting. Secondly, we will perform multiple 
imputations for missing data, assuming missing completely at random (MCAR). 
We will then assess the results from both methods and determine whether the 
result is severely biased when ignoring missing data.  
 
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