Randomized Phase II Trial of Rituximab With Either Pentostatin or Bendamustine for Multiply Relapsed or Refractory Hairy Cell Leukemia
Phase: PHASE2
Conditions: Hairy Cell Leukemia
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
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Abbreviated title: Ben-R vs. Pen-R in HCL
NIH Protocol Number: 10-C-0025 
Version Date: 09/06/2022
NCT#: NCT01059786
Randomized Phase II Trial of Rituximab with Either Pentostatin or Bendamustine for 
Multiply Relapsed or Refractory Hairy Cell Leukemia 
NCI Principal Investigator
Robert J. Kreitman, M.D., LMB, CCR 
National Cancer Institute (NCI), NIH 
9000 Rockville Pike, Building 37/5124b 
Bethesda, MD 20892
Phone: 301-480-6187
Email: kreitmar@mail.nih.gov
Investigational Agents: none
Commercial Agents: Pentostatin (Nipent™), Bendamustine (Treanda®) and Rituximab 
(Rituxan®) 

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
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PRÉCIS
Background

Hairy cell leukemia (HCL) is highly responsive to purine analogs cladribine and 
pentostatin, without evidence of cure.  Neither is standard after 2 courses, due to 
cumulative marrow and T-cell toxicity and declining remission rates and durations. 
Once resistant, patients after multiple relapses can die of disease-related cytopenias.  

Rituximab alone in 51 patients from 5 trials who had cytopenias and at least 1 prior 
purine analog resulted in 10 complete + 10 partial remissions (CR+PR= ORR 39%).

Rituximab with cladribine gives high CR rates in 1st or 2nd line, but is not standard.  

While cladribine use is more common for 1st and 2nd line, pentostatin is often used for 
subsequent treatment because of < 100% cross-resistance.  

Retrospective published data for pentostatin plus rituximab in HCL include 7 of 7 
responses with 6 (86%) CRs, and there are no prospective data.  

Recombinant immunotoxins targeting CD25 (LMB-2) and CD22 (BL22 and HA22) are 
highly active in purine analog resistant HCL. Palliative pentostatin-rituximab is often 
used off-protocol for patients with immunogenicity needing more therapy.

Bendamustine is approved for early treatment of CLL, and is effective with rituximab 
for relapsed/refractory CLL.  Its use in HCL is unreported.

CRs with minimal residual disease (MRD) by immunohistochemistry of bone marrow 
biopsy (BMBx IHC), can relapse early.  Tests for HCL MRD in blood or marrow 
include flow cytometry (FACS) or PCR using consensus primers.  The most sensitive 
MRD test in HCL is real-time quantitative PCR using sequence-specific primers (RQ-
PCR).  

Of 5 HCL-specific trials listed on Cancer.gov, 2 are phase II trials of cladribine + 
rituximab in 1st and 2nd line (1 randomized at NIH, 1 non-randomized at MDA), and 
3 NIH phase I-II trials of recombinant immunotoxins BL22, HA22 and LMB-2.
Objective

Primary:  To determine if pentostatin + rituximab and bendamustine + rituximab are 
each associated with adequate response rates (ORR=PR+CR) in patients with relapsed 
HCL, and, if so, to select which combination is likely to be superior.
Eligibility 

HCL needing therapy, either > 2 prior courses of purine analog, 1 course purine 
analog plus >1 course rituximab if < 1 year response to the 1 course purine analog, 
diagnosis of HCL variant (HCLv), or unmutated IGHV4-34+expressing HCL/HCLv.

Prior treatment, ineligibility for, or patient refusal of recombinant immunotoxin.
Design 

Rituximab 375 mg/m2 on day 1, 15 for 6 x 28-day cycles (all 72 patients).

Initial tolerability study: 12 patients receive rituximab + bendamustine (nonrandom), 
including 6 at 70 mg/m2 and 6 at 90 mg/m2 of bendamustine.

Randomize: 1) 28 patients to bendamustine 90 mg/m2/day, days 1 and 2 each cycle
2) 28 patients to pentostatin 4 mg/m2 days 1 and 15 of each cycle.

Abbreviated Title: Ben-R vs. Pen-R in HCL
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
Non-randomize: up to 4 patients to receive either bendamustine 90 mg/m2/day, days 
1 and 2 each cycle or pentostatin 4 mg/m2 days 1 and 15 of each cycle.

Statistics:  If > 14/28 respond, can conclude with 90% power that response > 40% in 
that arm.  >80% probability of selecting the better arm if true response probability is 
approximately 40-50% on the inferior arm and >15% higher on the superior arm. 

Stratify to equalize the % of patients/arm refractory to last course of purine analog.

Accrual Ceiling:  72 evaluable participants

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TABLE OF CONTENTS
PRÉCIS...........................................................................................................................................2
TABLE OF CONTENTS ................................................................................................................4
STATEMENT OF COMPLIANCE ................................................................................................6
1
INTRODUCTION ...............................................................................................................6
1.1
Study Objectives..........................................................................................................6
1.2
Background and Rationale...........................................................................................7
1.3
Rationale....................................................................................................................16
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT ...................................................19
2.1
Eligibility Criteria......................................................................................................19
2.2
Screening Evaluation.................................................................................................21
2.3
Participant Registration and Status Update Procedures.............................................22
2.4
Baseline evaluation....................................................................................................24
3
STUDY IMPLEMENTATION .........................................................................................25
3.1
Study Design..............................................................................................................25
3.2
Drug Administration..................................................................................................27
3.3
Dose Modifications....................................................................................................27
3.4
Study Calendar...........................................................................................................29
3.5
Protocol Evaluation ...................................................................................................34
3.6
Concurrent Therapies.................................................................................................35
3.7
Radiation Therapy Guidelines ...................................................................................36
3.8
Cost and Compensation .............................................................................................36
3.9
Criteria for Removal from Protocol Therapy and Off Study Criteria .......................36
4
SUPPORTIVE CARE .......................................................................................................37
4.1
Infections/Fever and Neutropenia..............................................................................37
4.2
Blood product support ...............................................................................................37
4.3
Cytokine Support.......................................................................................................37
4.4
Tumor lysis syndrome ...............................................................................................37
4.5
Infusion reactions.......................................................................................................38
4.6
Skin reactions related to bendamustine .....................................................................38
5
DATA COLLECTION AND EVALUATION .................................................................38
5.1
Data Collection ..........................................................................................................38
5.2
Response Criteria.......................................................................................................39
5.3
Toxicity Criteria.........................................................................................................41
5.4
Sample Storage, tracking and disposition..................................................................41
6
CORRELATIVE STUDIES FOR RESEARCH ...............................................................44
6.1
Blood and bone marrow samples...............................................................................44
7
STATISTICAL CONSIDERATIONS ..............................................................................47
8
COLLABORATIVE AGREEMENTS..............................................................................50
8.1
Cooperative Research and Development Agreement (CRADA) ..............................50
9
HUMAN SUBJECTS PROTECTIONS............................................................................50
9.1
Rationale for Subject selection ..................................................................................50

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9.2
Participation of Children............................................................................................50
9.3
Participation of Subjects Unable to Consent .............................................................50
9.4
Evaluation of Benefits and Risks/Discomforts..........................................................50
9.5
Risk/Benefit Analysis ................................................................................................51
9.6
Consent Process and Documentation.........................................................................52
10
NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN
53
10.1
Definitions .................................................................................................................53
10.2
OHSRP Office of Compliance and Training / IRB Reporting ..................................53
10.3
NCI Clinical Director Reporting ...............................................................................54
10.4
NIH Required Data and Safety Monitoring Plan.......................................................54
11
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL 
COLLABORATORS.....................................................................................................................54
11.1
Definitions .................................................................................................................54
11.2
Reporting of Serious Adverse Events Associated with Rituximab ...........................55
11.3
Adverse Events of Special Interest (AESI) ...............................................................55
11.4
MedWatch 3500A Reporting Guidelines: .................................................................56
11.5
Product Complaint Reporting....................................................................................57
11.6
Safety Reporting Requirements for IND Exempt Studies (Genentech information) 57
11.7
Requirements for reporting to Teva for patients getting bendamustine ....................58
12
REGULATORY AND OPERATIONAL CONSIDERATIONS......................................59
12.1
Study Discontinuation and Closure ...........................................................................59
12.2
Quality Assurance and Quality Control.....................................................................59
12.3
Conflict of Interest Policy..........................................................................................59
12.4
Confidentiality and Privacy .......................................................................................60
13
PHARMACEUTICAL INFORMATION .........................................................................61
13.1
Bendamustine ............................................................................................................61
13.2
Pentostatin (Nipent)...................................................................................................61
13.3
Rituximab (Rituxan) from Genentech .......................................................................61
14
REFERENCES ..................................................................................................................63
15
APPENDICES ...................................................................................................................70
15.1
Appendix A:  Performance Status Criteria ................................................................70
15.2
Appendix B:  New York Heart Association Classification .......................................71
15.3
Appendix C:  Guidelines for Rituximab Preparation and Administration ................72
15.4
Appendix D: Local Physician Information................................................................76

Abbreviated Title: Ben-R vs. Pen-R in HCL
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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Conference on 
Harmonisation Good Clinical Practice (ICH GCP) and the following: 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies 
(45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR 
Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who 
are responsible for the conduct, management, or oversight of NIH-funded clinical trials 
have completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant 
materials will be submitted to the Institutional Review Board (IRB) for review and 
approval.  Approval of both the protocol and the consent form must be obtained before 
any participant is enrolled.  Any amendment to the protocol will require review and 
approval by the IRB before the changes are implemented to the study.  In addition, all 
changes to the consent form will be IRB-approved; an IRB determination will be made 
regarding whether a new consent needs to be obtained from participants who provided 
consent, using a previously approved consent form.
1
INTRODUCTION
1.1
STUDY OBJECTIVES
1.1.1
Primary Objective
Primary:  To determine if pentostatin + rituximab and bendamustine + rituximab 
are each associated with adequate response rates (ORR=PR+CR) in patients with 
relapsed HCL, and, if so, to select which combination is likely to be superior.
1.1.2
Secondary Objectives
To compare rituximab plus either pentostatin or bendamustine in terms of MRD-
free survival, disease-free survival, overall survival and toxicity, including to 
CD4+ T-cells.
To compare the 2 regimens in crossover when used after failure of the 1st 
regimen.
To determine if MRD levels and tumor markers (soluble CD25 and CD22, and 
RQ-PCR) correlate with response and clinical endpoints, and if bone marrow 
MRI signal correlates with BMBx results, and whether these tests could in some 
cases possibly replace BMBx.
To study the mechanism of thrombocytopenia after purine analog plus 
rituximab.
To study HCL biology by cloning, sequencing and characterizing monoclonal 
immunoglobulin rearrangements, and other genes.

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1.2
BACKGROUND AND RATIONALE
1.2.1
Treatment of HCL with cladribine  
The most commonly used purine analog for HCL, particularly for 1st and 2nd line 
treatment, is cladribine, also called 2-chloro-2’-deoxyadenosine, or CdA.  
Deoxycytidine kinase phosphorylates cladribine to CdATP, which incorporates 
into DNA, leading to DNA strand breaks and inhibition of DNA synthesis [1].  
CdATP 
also 
inhibits 
ribonucleotide 
reductase, 
leading 
to 
decreased 
concentrations of deoxyribonucleotides and further inhibition of DNA synthesis 
[2].  The resistance of cladribine to adenosine deaminase (ADA) allows low 
catabolism and increased potency [3].  Cladribine induces complete remission 
(CR) rates of 75-87%, overall response rates (ORR) of 90-100%, and 4 year disease 
free survivals (DFS) of 79-84% [4-7].  A full course of cladribine may be 
administered over 5-7 days either by continuous infusion, daily 2-hr infusions, or 
by subcutaneous injection [5, 8-12].  
1.2.2
 HCL Epidemiology and diagnosis  
HCL is an indolent B-cell leukemia comprising 2% of all leukemias [13, 14], or 
approximately 900 of the 44,000 new cases of leukemia/year in the US [15].  
Patients present with pancytopenia and splenomegaly, and the malignant cells 
have cytoplasmic projections resembling hairs [16, 17].  By flow cytometry, B-cell 
antigens FMC7, CD11c, CD20, CD22 and surface immunoglobulin are strongly 
positive, and in the typical or classic form, CD103, CD25 and CD123 are also 
positive [18-20].   The median survival of HCL without effective treatment is 
about 4 years [21], and early treatments including splenectomy and interferon 
were of modest benefit [22].  Treatment of HCL was revolutionized with the 
advent of purine analog therapy in the late 1980s.  
1.2.3
Pentostatin treatment of HCL  
Pentostatin is less commonly used for early treatment of HCL since it is usually 
administered every other week, usually for 3-6 months [23-26].  Nevertheless, the 
CR rates of 72-89% [23, 27-32] were indistinguishable from those achieved by 
cladribine, and responses appeared as durable.  Toxicities from pentostatin and 
cladribine are similar, including neutropenia and fever usually within the first 
month [33, 34], depressions of CD4+ T-cells for 40-52 months [35, 36], and 
neuropathy long-term [5, 7, 37].  HCL patients sometimes receive pentostatin after 
failure of cladribine, due to anecdotal reports of complete remission to cladribine 
[31, 38-40] or pentostatin [41] alone after failure of the other purine analog.  In 
summary, while pentostatin is rarely used for 1st and 2nd line treatment of HCL, 
it is often used for later treatment when purine analog is needed.
1.2.4
 Lack of evidence for cure in HCL  
With over 20 years elapsing since the introduction of purine analogs for the 
treatment of HCL, there has been no plateau on the disease-free survival curves 
[5, 6, 33, 42, 43].  Moreover, while 3rd and 4th CRs are common with repeated 

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courses of purine analogs, the CR rates decline significantly with each successive 
course, whether or not the same purine analog is used [5, 43].  Because a single 
course of cladribine or pentostatin is reported to suppress CD4+ lymphocytes 
below the lower limit of normal for a median of 40 or 54 months, respectively [35, 
36], it may not be safe to use repeated courses of purine analogs alone to maintain 
HCL patients, particularly at short intervals.  Clearly, it would be desirable to 
lengthen the interval needed between purine analog courses by increasing 
efficacy, and by using alternative agents which are effective but less toxic, either 
sequentially or in combination. 
1.2.5
Rituximab for HCL  
Rituximab is a genetically engineered, chimeric murine/human monoclonal 
antibody directed against the CD20 antigen found on the surface of normal and 
malignant pre-B and mature B cells.  The antibody is an IgGR1
R κ immunoglobulin 
containing murine light-and heavy-chain variable region sequences and human 
constant region sequences.  Rituximab is composed of two heavy chains of 451 
amino acids and two light chains of 213 amino acids (based on cDNA analysis) 
and has an approximate molecular mass of 145 kD.  Rituximab has a binding 
affinity for the CD20 antigen of ~8.0 nM.  Rituximab kills cells by inducing 
apoptosis and mediating either complement or antibody dependent cytotoxicity 
(ADCC or CDC) [44].  HCL cells are strongly CD20 positive [18].  Case reports 
[45-49] documented efficacy of rituximab in HCL.  CR rates among the 6 reported 
rituximab studies in HCL (10-25 patients each, total 97) vary from 10 to 54% [50-
55].  However, in the 51 patients from 5 studies who demonstrated a need for 
treatment based on cytopenias and who had at least 1 prior purine analog, there 
were 10 (20%) CRs and 10 (20%) PRs [50-54].  In the largest single trial enrolling 
24 such patients, there were 3 (13%) CRs and 3 (13%) PRs [52].  Rituximab was 
usually administered by 4-8 weekly doses of 375 mg/m2 and some patients 
required more than 4 doses to respond [53].  Toxicities of rituximab in non-
Hodgkin’s 
lymphoma 
(NHL) 
were 
infusion-related 
(hypotension, 
bronchospasm, rhinitis, pruritus, rash, urticaria, and tumor-pain) and decreased 
with repeated dosing [56].  Rituximab appears well tolerated in HCL but the 
number of patients reported in the above trials are few.
1.2.6
Other treatments for HCL  
Other agents with significant systemic efficacy in HCL include the recombinant 
immunotoxin LMB-2 targeting CD25 [57, 58], and BL22, targeting CD22 [59, 60].  
LMB-2 and BL22 have been tested in patients with inadequate response to prior 
purine analogs.  In a recent phase II trial, BL22 induced CR in 25% patients after 
a single cycle, and in 47% of 36 patients after 1-10 cycles. HA22, a high affinity 
variant of BL22, has completed multicenter phase I clinical testing in HCL, with 
NIH enrolling 21 of 28 patients.  The unconfirmed response rate on this trial 
includes 12 (43%) CRs and 10 (36%) PRs out of 28 patients.  HA22 is being 
prepared for a pivotal trial in HCL.

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1.2.7
Minimal residual disease in HCL  
The criteria for CR in HCL generally require absence of HCL cells in the blood 
and bone marrow by Wright and H/E stains, and also normalization of 
neutrophils, platelets and hemoglobin to 1500/mm3, 100,000/mm3, and 11-12 
g/dl, respectively [5, 7].  In patients in CR, MRD in the BMBx by 
immunohistochemistry (IHC) has been defined as a ratio of CD20+ or DBA-44+ 
cells to T cells of at least 1, most of the CD20+ or DBA-44+ cells having 
morphology consistent with HCL, and HCL cells undetectable by non-
immunologic methods (i.e. H/E staining)  [61, 62].  Patients with MRD had 
shorter relapse free survivals compared to those in CR without MRD after either 
cladribine or pentostatin [61].  The estimated 4-year relapse-free survival was 55% 
in patients with MRD compared to 88% in patients without MRD.  Tallman et al. 
reported that 13 and 26% of patients treated with cladribine and pentostatin, 
respectively, had MRD by this definition.  The sensitivity of bone marrow biopsy 
immunohistochemistry (BMBx IHC) has not been published for HCL, but is 
considered to be 1% [63], and based on the definition above, would depend on 
the number of CD3+ normal T-cells [61].  Bastie et al. reported an association 
between > 5% DBA-44+ cells in the bone marrow 5 months after cladribine and 
relapse [64].  Ellison et al. reported that MRD, defined as > 5 CD20+ or DBA-44+ 
cells in the BMBx IHC, was as high as 50% after cladribine [65].  Early reports 
suggested that IHC of BMBx was more sensitive than flow cytometry of marrow 
aspirate and blood [66], but more recent data [67-69] with highly sensitive 4-color 
flow cytometry suggest the opposite.  Flow cytometry was reported to be more 
sensitive for detecting MRD than conventional PCR using consensus primers to 
immunoglobulin heavy chain (IgH) rearrangements, which are monoclonal and 
unique for each patient [69].  While consensus PCR can detect 1 HCL cell in 103-
104 normal cells [70], flow cytometry can detect 1 in 104-105 [69].  To improve the 
sensitivity of PCR detection, the IgH rearrangements were cloned and a sequence-
specific probe and primer were used for real-time quantitative PCR (RQ-PCR).  
This method, able to detect 1 HCL cell in 106 normal cells [71], is the most sensitive 
method of MRD detection in HCL.  Data quantifying the risk of clinical relapse 
after detection of MRD are lacking using methods other than BMBx IHC. 
1.2.8
Combination of purine analog with rituximab for HCL  
Rituximab combined with either fludarabine [72], or pentostatin [73] has been 
reported for CLL.  Rituximab combined with cladribine has been reported as 
effective in treating indolent non-Hodgkin’s lymphoma (NHL) [74], mantle cell 
lymphoma [75], and CLL [76].  In a retrospective review, 3 HCL patients received 
cladribine plus rituximab and 5 received pentostatin plus rituximab after prior 
therapy with purine analogs [77].  One patient receiving pentostatin plus 
rituximab achieved PR, and the remaining patients had CR without MRD.  In an 
updated retrospective report, 12 patients received purine analog plus rituximab 
[43], including 7 with concurrent rituximab plus pentostatin every 2 weeks, 1 with 
rituximab following pentostatin by 1 month, 2 with cladribine plus rituximab 

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given weekly, and 1 with rituximab following cladribine by 2 months.  Of the 12 
patients, 11 (92% CRs) and 1 PR were achieved, and in no cases were the 
responses less than the previous line of therapy.  Of the 12 patients, combination 
purine analog plus rituximab was administered as 2nd, 3rd, 4th and 6th line therapy 
in 5, 5, 1 and 1 patients, respectively [43].  This report included neither duration 
of treatment nor duration of response for patients receiving pentostatin plus 
rituximab.  It also did not state whether the 1 of 12 patients with PR had received 
pentostatin or cladribine with rituximab, but based on the earlier 2007 report [77], 
it may be assumed that this patient had pentostatin.  Thus, published 
retrospective data for pentostatin plus rituximab includes 6 CRs and 1 PR out of 
7 patients.  There are no prospective data of pentostatin plus rituximab for HCL.  
A phase II trial is currently underway at MD Anderson where patients receive 1st 
or 2nd-line cladribine by 2 hour i.v. infusion for days 1-5, followed by 8 weekly 
doses of rituximab beginning on day ~28 [63].  Approximately 28 out of 44 
planned patients have been accrued to this trial, and of the first 13 patients, all 
had CR, including 12 (92%) without MRD [63].  In late March 2009, a prospective 
randomized trial opened at NCI where patients receive cladribine on day 1 and 8 
weekly doses of rituximab beginning either on day 1 or at least 6 months later 
when MRD is detected in the blood.   This trial has quickly accrued 11 patients as 
of August 2009.  These 2 cladribine-rituximab trials are only for 1st and 2nd line 
treatment and are the only HCL-specific trials listed on Cancer.gov besides trials 
testing BL22, HA22 and LMB-2.  There are no non-immunotoxin trials for 
multiply relapsed HCL.
1.2.9
Unpublished NCI/LMB data for pentostatin plus rituximab in HCL  
In view of the lack of response durability data for patients receiving pentostatin 
plus rituximab, we decided to collect such data on patients prescreened for or 
already treated with recombinant immunotoxins.  Of 9 such patients who 
received combination pentostatin-rituximab, response and response duration 
data were available for 7.  The 7 patients previously received 1-6 (median 2) 
courses of purine analog and were treated with 4-8 (median 6) doses of DCFR.  
Since bone marrow biopsies were not prospectively obtained on these patients, 
the 3 endpoints evaluable for these 7 patients included PR, hematologic remission 
(HR), and MRD-free HR.  With respect to normal blood counts, HR required 
achievement of neutrophils > 1500/mm3, platelets > 100/mm3, and Hgb > 11 for 
at least 4 weeks.  PR required HR or at least 50% improvement in neutrophils, 
platelets and Hgb.  MRD-free HR required negative blood flow cytometry in 
addition to other criteria of HR.  Of the 7 evaluable patients, 6 (86%) achieved 
MRD-free HR and therefore by definition HR and PR as well.  Three (42%) of 7 
patients remain in MRD-free CR after 6.3-30 (median 6.9) months.  The duration 
of response for the 7 patients is 0-34.5 (median 8.7) months for PR, the same for 
HR, and 0-30.5 (median 6.0) months for MRD-free HR.  Thus, while the number 
of patients followed was limited, the multiply relapsed HCL patients had high 
response rates to DCFR, but response durations were usually limited.  This 

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suggests that in the multiply relapsed patient population, it might be feasible to 
compare response durations produced by DCFR vs. a comparison regimen.
1.2.10 Bendamustine mechanism of action and pharmacology  
Bendamustine, synthesized in the 1960s in East Germany, has structural features 
of both an alkylating drug and a purine analog (Figure 1) [78]. Bendamustine 
interacts with DNA in a way which is non-cross resistant with other alkylators 
including cyclophosphamide, carmustine and melphalan [79]. The lack of cross-
resistance between bendamustine and other cytotoxic drugs suggested a unique 
mechanism, or perhaps a combination of mechanisms of action [80]. The specific 
mechanisms of cytotoxicity identified for bendamustine include 1) activation of 
DNA-damage stress responses and apoptosis, 2) inhibition of mitotic 
checkpoints, 3) induction of mitotic catastrophe, 4) activation of a DNA repair 
pathway involving base excisions, 5) p53-dependent stress pathway initiation 
leading to apoptosis, and 6) downregulation of genes needed for mitotic 
checkpoint regulation [80]. Using lymphoma cell lines, bendamustine was 
synergistic with either cladribine [81] or rituximab [78].  The mean elimination 
half-life of bendamustine is 49 minutes [82]. 
Figure 1:  Structure of purine analogs and Bendamustine
O
OH
HOCH2
N
N
N
Cl
N
NH2
O
OH
HOCH2
N
N
N
N
N
N
N
CH3
COOH
N
Cl
Cl
Bendamustine
Nitrogen mustard
Cladribine
Pentostatin
Benzimidazole
Ring

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1.2.11 Treatment of CLL with Bendamustine with or without rituximab 
In a randomized study of 319 previously untreated CLL patients, response rates 
were 68% for bendamustine vs. 31% for chlorambucil (p < 0.0001) [83], leading to 
approval of bendamustine for newly diagnosed CLL.  In this trial, median 
remission duration was 22 vs. 8 months. The dose of bendamustine used was 100 
mg/m2 days 1-2 every 4 weeks for 6 cycles, and was associated with grade 3-4 
toxicity in 40% of patients, including grade 3-4 infections in 8% [83].  A phase II 
CLL trial of bendamustine 70 mg/m2 days 1-2 plus rituximab 375 mg/m2 day 1, 
with rituximab 500 mg/m2 for repeat cycles, was associated with an ORR of 77% 
and CR rate of 15% in the 62 of the 81 patients treated who were evaluable for 
response [78, 84].  On this trial there were 3 deaths due to infection, including 1 
pneumonia, 1 sepsis after diagnosis of Richter’s syndrome and 1 urosepsis.  An 
interesting finding from this trial was high response rates in subsets of patients 
with 
poor 
prognostic 
factors, 
including 
unmutated 
immunoglobulin 
rearrangements, del(11q22), and del(17p13).  
1.2.12 Treatment of NHL with Bendamustine alone  
For relapsed/refractory indolent NHL, bendamustine was administered at 120 
mg/m2 days 1-2 every 3 weeks.  The ORR was 73% with 11% CRs out of 52 
patients, median response duration 16 months [85].  Five daily doses of 60 mg/m2 
induced a CR rate of 15% with ORR 82% and CR rate 15%.  Of 74 evaluable 
patients with relapsed/refractory indolent and transformed NHL who received 
bendamustine 120 mg/m2 days 1-2 every 3 weeks x6-12 cycles, the ORR was 77% 
with 34% CR + CR-unconfirmed (CRu) [86].  Even in the alkylator-refractory 
patients, the ORR was 61%, indicating non-cross resistance with alkylating 
agents.  Median response duration was 8.3 months for indolent and 4.2 months 
for transformed NHL.  A pivotal trial in 100 patients with rituximab-refractory 
indolent NHL was conducted with the same dose and schedule for 6-8 cycles [78].  
An ORR of 84% with 32% CR+CRu was achieved, and the median response 
duration was 9.3 months.  
1.2.13 Bendamustine + rituximab for indolent NHL  
Bendamustine 90 mg/m2 days 1-2 plus rituximab 375 mg/m2 every 4 weeks x4 
cycles for rituximab-naïve indolent NHL achieved an ORR of 90% with 60% CRs 
[87].  The median PFS was 24 months, and toxicity included (% of cycles) grade 
3-4 leukopenia (16%), thrombocytopenia (3%) and anemia (1%).  A follow-up 
multicenter US trial treated 66 relapsed patients with rituximab 375 mg/m2 day 
1 and bendamustine 90 mg/m2 days 2-3 every 28 days x4-6 cycles [88].  The ORR 
was 92% with 41% CRs, 14% CRu, and median duration of response 21 months.  
A randomized phase III trial compared bendamustine + rituximab with R-CHOP 
in 315 evaluable patients with untreated indolent and mantle cell NHL [78].  
Preliminary analysis of this trial shows similar response rates (ORR 93% vs 93%, 
CRs 47% vs 42%, respectively.   However, toxicity favors bendamustine + 

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13
rituximab with lower rates of alopecia (16% vs 94%) and grade 3-4 leukopenia 
(16% vs 41%).  
1.2.14 Secondary malignancies with bendamustine  
With toxicity and response showing promising results with and without 
bendamustine, some investigators have been concerned about the risk of 
secondary malignancies.  This is particularly appropriate because of the 
combined alkylators and purine analog structural and functional attributes of 
bendamustine.  Two cases each in NHL were reported of myelodysplastic 
syndrome (MDS) and of myelomonocytic leukemia were reported [78, 86].  It is 
not clear that these few cases represent an increase risk over and above what was 
expected from their prior therapy.  
Figure 2:  Response of HCL to Bendamustine
1.2.15 Preliminary data on bendamustine in HCL  
Although there are no published results of bendamustine in HCL patients at this 
time, a 57 year old male HCL patient waiting to be enrolled on the HA22 protocol 
began single-agent bendamustine through his local physician.  This patient had 
previously received treatment with cladribine, splenectomy, rituximab and 
pentostatin.  At the time bendamustine was begun, the patient had a large 
abdominal mass attributed to HCL, a circulating HCL count of 730 cells/mm3, 
and was transfusion dependent for platelets and red cells.  As shown Figure 2 
above, the transfusion dependence for platelets was resolved after 2 cycles and 
for red cells after the 4th cycle.  The circulating malignant count is 0-1.1 cells/mm3, 
ANC
CELLS / mm3 x 10-3
CELLS / mm3 x 10-3
0.0
0.5
1.0
1.5
C1
C2
C3
C4
C5
C6
C7
PLATELETS
0
50
100
150
200
C1
C2
C3
C4
C5
C6
C7
HGB
DAYS SINCE BEGINNING BENDAMUSTINE
0
50
100
150
200
250
g/dl
8
10
C1
C2
C3
C4
C5
C6
C7
HCL
HCL PT HBJ, Bendamustine 90 mg/m
2 d1, 2 
/mm3
/mm3
0
200
400
600
800
C1
C2
C3
C4
C5
C6
C7

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14
a nearly 99.9% response.  Thus, while this patient has not achieved CR, 
bendamustine was clearly associated with a lifesaving response and was 
relatively well tolerated.  This suggests that bendamustine might have activity in 
HCL.  Moreover, activity might be enhanced when combined with rituximab.
1.2.16 Safety profile of rituximab  
No dose-limiting effects were observed in the Phase I/II studies.  Reported 
adverse events including fever, chills, headache, nausea, vomiting, rhinitis, 
asthenia, and hypotension, occurred primarily during rituximab infusions and 
typically responded to an interruption of the infusion and resumption at a slower 
rate.  
Fatal Infusion Reactions:  Severe and fatal cardiopulmonary events, including 
angioedema, hypoxia, pulmonary infiltrates, acute respiratory distress 
syndrome, myocardial infarction, and cardiogenic shock, have been reported.  
These severe reactions typically occurred during the first infusion with time to 
onset of 30-120 minutes.
Cardiac Events:  Patients with preexisting cardiac conditions, including 
arrhythmia and angina, have had recurrences of these cardiac events during 
rituximab infusions.
Tumor Lysis Syndrome:  Tumor lysis syndrome, some with fatal outcome, has 
been reported and is characterized in patients with a high number of circulating 
malignant cells (≥25,000 ul) by rapid reduction in tumor volume, renal 
insufficiency, 
hyperkalemia, 
hypocalcemia, 
hyperuricemia, 
and 
hyperphosphatemia.
Renal Events:  Rituximab has been associated with severe renal toxicity 
including acute renal failure requiring dialysis, and in some cases has led to 
death.  Renal toxicity has occurred in patients with high numbers of circulating 
malignant cells (≥25,000/mm2 ) or high tumor burden who experience tumor 
lysis syndrome and in patients administered concomitant cisplatin.
Mucocutaneous Reactions:  Severe bullous skin reactions, including fatal cases 
of toxic epidermal necrolysis and paraneoplastic pemphigus, have been reported 
in patients treated with rituximab.  The onset of reaction has varied from 1 to 13 
weeks following rituximab exposure.
Hematologic Events:  In clinical trials, Grade 3 and 4 cytopenias were reported 
in 48% of patients treated with rituximab; these include: lymphopenia (40%), 
neutropenia (6%), leukopenia (4%), anemia (3%), and thrombocytopenia (2%).  
The median duration of lymphopenia was 14 days (range, 1 to 588 days) and of 
neutropenia was 13 days (range, 2 to 116 days).  A single occurrence of transient 
aplastic anemia (pure red cell aplasia) and two occurrences of hemolytic anemia 
following Rituximab therapy were reported.  In addition, there have been a 
limited number of postmarketing reports of prolonged pancytopenia, marrow 
hypoplasia, and late onset neutropenia.

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Infectious Events:  Rituxan induced B-cell depletion in 70% to 80% of patients 
with NHL and was associated with decreased serum immunoglobulins in a 
minority of patients; the lymphopenia lasted a median of 14 days (range, 1-588 
days).  Infectious events occurred in 31% of patients: 19% of patients had 
bacterial infections, 10% had viral infections, 1% had fungal infections, and 6% 
were unknown infections.  Serious infectious events (Grade 3 or 4), including 
sepsis, occurred in 2% of patients.
Hepatitis B Reactivation:  Hepatitis B virus (HBV) reactivation with fulminant 
hepatitis, hepatic failure, and death has been reported in some patients with 
hematologic malignancies treated with rituximab.  The majority of patients 
received rituximab in combination with chemotherapy.  The median time to the 
diagnosis of hepatitis was approximately four months after the initiation of 
rituximab and approximately one month after the last dose.
Other Serious Viral Infections:  The following additional serious viral 
infections, either new, reactivated or exacerbated, have been identified in clinical 
studies or postmarketing reports. The majority of patients received Rituxan in 
combination with chemotherapy or as part of a hematopoietic stem cell 
transplant. These viral infections included JC virus (progressive multifocal 
leukoencephalopathy 
{PML}), 
cytomegalovirus, 
herpes 
simplex 
virus, 
parvovirus B19, varicella zoster virus, West Nile virus, and hepatitis C. In some 
cases, the viral infections occurred up to one year following discontinuation of 
Rituxan and have resulted in death.
Progressive multifocal leukoencephalopathy (PML).  PML is a rare disease 
caused by the reactivation of latent JC virus in the brain.  Immunosuppression 
allows reactivation of the JC virus which causes demyelination and destruction 
of oligodendrocytes resulting in death or severe disability.  Rare cases of PML, 
some resulting in death, have been reported in patients with hematologic 
malignancies who have received rituximab.  The majority of these patients had 
received rituximab in combination with chemotherapy or as part of a 
hematopoietic stem cell transplant.  Cases of PML resulting in death have also 
been reported following the use of rituximab for the treatment of autoimmune 
diseases. The reported cases had multiple risk factors for PML, including the 
underlying 
disease 
and 
long-term 
immunosuppressive 
therapy 
or 
chemotherapy. Most cases of PML were diagnosed within 12 months of their last 
infusion of rituximab.  Physicians should consider PML in any patient presenting 
with new onset neurologic manifestations. Consultation with a neurologist, 
brain MRI, and lumbar puncture should be considered as clinically indicated.  In 
patients who develop PML, rituximab should be discontinued and reductions or 
discontinuation of any concomitant chemotherapy or immunosuppressive 
therapy should be considered.
Bowel Obstruction and Perforation:  Abdominal pain, bowel obstruction and 
perforation, in some cases leading to death, were observed in patients receiving 
Rituxan in combination with chemotherapy for DLBCL. In post-marketing 

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reports, which include both patients with low-grade or follicular NHL and 
DLBCL, the mean time to onset of symptoms was 6 days (range 1−77) in patients 
with documented gastro-intestinal perforation. Complaints of abdominal pain, 
especially early in the course of treatment, should prompt a thorough diagnostic 
evaluation and appropriate treatment.
Immunogenicity: Patients may develop a human anti-chimeric antibody 
(HACA) response with rituximab treatment. The clinical significance of this is 
unclear.
Additional Safety Signals:  The following serious adverse events have been 
reported to occur in patients following completion of rituximab infusions: 
arthritis, disorders of blood vessels (vasculitis, serum sickness and lupus-like 
syndrome), eye disorders (uveitis and optic neuritis), lung disorders including 
pleuritis and scarring of the lung (bronchiolitis obliterans), that may result in 
fatal outcomes, and fatal cardiac failure.
Additional details:  The investigator brochure contains additional details 
regarding rituximab safety.
1.3
RATIONALE
1.3.1
Randomized trial of rituximab with either pentostatin or bendamustine
It has now been over 20 years since the advent of purine analogs for HCL [4, 89].  
During these last 20 years, purine analogs have kept HCL patients alive without 
evidence for cure [33].  Therefore, it should not be surprising that multiply 
relapsed HCL is becoming an increasingly common problem.  While many of these 
patients have been successfully salvaged with immunotoxin therapy [57, 59, 60, 
90], other patients have produced neutralizing antibodies or are for other reasons 
ineligible for this new therapy.  The rationale for a randomized trial of pentostatin 
plus rituximab vs bendamustine plus rituximab is based on the following:  1) Since 
the Intergroup trial comparing interferon with pentostatin [27], there has not been 
a randomized trial comparing different agents for HCL, and therefore most 
treatment recommendations are based on comparisons of small single-arm trials 
with varying patient populations and inherent bias.  2)  The combination of purine 
analog with rituximab offers very high CR rates and the combination of cladribine 
plus rituximab is already being tested in the 1st and 2nd line setting [43, 63].  3) 
Because pentostatin is < 100% cross-resistant with cladribine [41] and pentostatin 
use is much less common in the 1st and 2nd line setting, pentostatin may be the 
more appropriate purine analog to combine with rituximab in the multiply 
relapsed setting.  4) While published retrospective data on 7 patients suggest that 
pentostatin plus rituximab is highly active even in patients with multiple relapses 
[43], there has never been a prospective trial of this combination in HCL, and 
therefore such a trial needs to be done. 5) While bendamustine with or without 
rituximab has been reported as effective and well tolerated in a variety of 
hematologic malignancies [78, 83, 85-88], its use has never been reported in HCL.  
6) While examining the activity of pentostatin plus rituximab and bendamustine 

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17
plus rituximab in separate cohorts of the same patient population, it would be 
highly useful and practical to randomize patients to these arms and determine if 
one regimen is better than the other.
1.3.2
Endpoints by which to evaluate pentostatin + rituximab and bendamustine + 
rituximab
The initial goal of this trial is simply to determine the response rates in each arm 
separately, and specifically to determine if response is higher than the 39% 
expected with rituximab alone.  Once each arm meets its accrual goals, the best 
regimen may be selected using a selection design, described in more detail in the 
statistical section.  Briefly, there is at least 80% probability of selecting the correct 
arm if the differences in rates of response are at least 15%, i.e. 40% vs. 55%, 45 vs. 
60%, and 50% vs. 65%.  Using a 2-tailed p-value to compare rates of response, there 
is at least 80% power to discriminate 36-39% differences in response rates, 
providing the response rates being compared are between 18 and 82%.  While ORR 
(CR+PR) is normally used to compare arms, more stringent measures of response 
can be used if necessary, including CR or MRD-free CR rates, and rates of response 
lasting at least 6 months.  Thus, despite the limited patient numbers, this trial is 
reasonably sized to determine a difference between the 2 regimens.  If no 
difference is observed, the trial will still be very valuable since other factors could 
guide physicians on which regimen to use for a given patient.
1.3.3
Need to stratify patients with regard to prior purine analog resistance
In randomized trials of this size, it is possible to stratify for one variable so that the 
data will have bias minimized.  It was felt that the most important risk factor 
would be whether or not patients were refractory to purine analog.  This 
stratification will also include patients with untreated poor-risk disease, namely 
HCLv and unmutated IGHV4-34+ HCL. 
1.3.4
Rationale for feasibility of accrual goals
We have a large and growing multiply relapsed patient population which should 
be eligible for this trial.  A recent survey of 98 patients treated with LMB-2, BL22 
or HA22 indicated the following:  1) 44 patients could have received combination 
purine analog-rituximab after immunotoxin, 2) 18 patients have already received 
a purine analog after immunotoxin, many of them pentostatin-rituximab, and 3) 
34 patients are likely to need pentostatin-rituximab or a similar regimen in the next 
1-2 years.  Of approximately 100 patients prescreened for immunotoxin protocols, 
about 10 patients are now in need of a regimen like pentostatin-rituximab and 
many more are being followed for anticipated need soon.   We consider this trial 
much easier to accrue for compared to the randomized trial of cladribine with or 
without rituximab for 1st and 2nd line treatment of HCL.  This trial has accrued 11 
patients in under 5 months, 5 of whom were newly diagnosed and 6 of whom had 
one prior course of cladribine.  It is far easier to find patients with several courses 
of purine analogs and/or prior rituximab who would be eligible for this trial, since 
most patient calls we receive are in this category.  

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1.3.5
Lack of potential conflict with other HCL trials  
At this time there are no HCL-specific clinical trials for multiply relapsed HCL 
except those within LMB, namely LMB-2 (06-c-0150), BL22 (09-c-0076) and HA22 
(07-c-0130).  The HA22 phase I protocol has completed accrual and we plan to open 
a phase II HCL trial at NIH while planning proceeds on an international pivotal 
trial in HCL.  The BL22 trial is only for patients who have had prior LMB-2, BL22 
or HA22 without immunogenicity who could benefit by more BL22, a small patient 
population.  The LMB-2 trial is mainly for patients with prior HUS with BL22, also 
a small population.  Patients with prior immunotoxin may not enroll on the HA22 
trial.  Patients with antibodies, either pre-existing or post immunotoxin, are not 
eligible for our immunotoxin trials.  Therefore, this trial fills a large gap in our 
HCL program where a significant percentage of our patients may continue 
treatment on a protocol whereas otherwise they could not.
1.3.6
Following tumor markers in HCL patients  
We have developed several novel assays quantifying tumor burden in HCL, 
including soluble IRTA [91, 92] and soluble CD22 (sCD22).  The sCD22 assay may 
be particularly appropriate for following HCL, especially in patients with limited 
expression of CD25 as in HCLv.  While soluble CD20 (cCD20) has been described 
[93, 94], this marker would be difficult to assess because it would bind to rituximab 
which has a long half-life.  sCD22 does not bind to rituximab and may be a 
sensitive indicator of extent of response and predicting early relapse.  We already 
have considerable tumor marker data after treatment with rituximab, cladribine, 
and/or immunotoxins, and believe such data after the agents on this trial will be 
very useful.  We have also determined MRD by PCR using sequence-specific 
primers (RQ-PCR), and plan to prospectively study protocol patients with this 
assay.  Finally, to correlate bone marrow MRI signal with bone marrow biopsy, 
patients will obtain cervical and thoracic spine MRI at baseline and at bone 
marrow restaging time points, when feasible.  The MRI signal in HCL is abnormal 
at baseline, remains abnormal immediately after achievement of completely 
remission due to enhance production of normal blood cells, and eventually 
becomes more normal.  A secondary research objective is to define this correlation 
in a large number of patients and time points, and to determine when after 
achievement of CR the MRI normalizes.  If the correlation is strong, an MRI may 
be useful in the future to determine if patients might be relapsing or in long term 
CR.  
1.3.7
Mechanism of thrombocytopenia after purine analog and rituximab
We have found that patients have an immediate and usually short-lived 
thrombocytopenia (median ~50,000 cells/mm3) after receiving purine analog 
followed by rituximab the same day [95, 96].  We have not seen significant 
bleeding associated and it is not clear whether platelet margination or 
consumption is occurring.  To investigate the mechanism of this interaction, we 

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19
are prospectively drawing coagulation studies as well as plasma which can be 
used later for cytokine assessment.
1.3.8
Relationship of this trial to current research performed in LMB  
The Laboratory of Molecular Biology (LMB) is currently developing recombinant 
immunotoxins for treating several forms of cancer, and the most successful trials 
have been performed in patients with HCL [57-60].  A major and increasing focus 
of the lab is in studying MRD after treatment for HCL using the highly sensitive 
RQ-PCR assay, and this assay has already been used to study MRD after purine 
analog and rituximab [71].  The lab is also studying the biology of HCL through 
patient samples obtained, and has the largest molecular database of HCL patients 
reported [97-99].  Patient recruitment for HCL trials has been very strong and the 
growing population of untreated patients seeking advice indicates that a trial 
earlier in the disease would also accrue well at NIH.  In addition to the RQ-PCR 
assay in the LMB which needs to be tested after agents other than immunotoxins, 
the Laboratory of Pathology has excellent tools for studying HCL MRD, including 
flow cytometry, consensus PCR, and immunohistochemistry [69, 71].  Finally, this 
trial can benefit the LMB immunotoxin program by giving patients an option for 
treatment should immunotoxin not work or be complicated by immunogenicity.  
We believe these improved options will enhance our accrual for all HCL trials. 
1.3.9
 Inclusion of patients with HCLv or unmutated IGHV4-34+ HCL
Patients with HCLv or unmutated IGHV4-34+ HCL have been shown to have poor 
response to cladribine alone for newly diagnosed disease, with ORR <50% and CR 
<10%, and overall survival from diagnosis is much shorter as well [100]. These 
patients are not eligible for BRAF/MEK therapy since they are always wild-type 
for the BRAF V600E mutation [101] We are able to get these patients into complete 
remission with 1st or 2nd line treatment with cladribine and rituximab.  While these 
remissions can last several years, they often relapse with clinically more aggressive 
disease.  Patients with multiply relapsed HCLv or unmutated IGHV4-34+ HCL 
have benefitted by this protocol using either Bendamustine-rituximab or 
Pentostatin-rituximab, but often relapse with more rapidly progressive 
disease.  We believe these patients should be eligible for this protocol regardless 
of prior therapy. They may be stratified within the existing stratification for 
resistant HCL/HCLv. 
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT
2.1
ELIGIBILITY CRITERIA
2.1.1
Inclusion Criteria
2.1.1.1
Evidence of HCL by flow cytometry of blood or a solid (lymph node) mass, 
confirmed by the Laboratory of Pathology, NCI, including positivity for CD19, 
CD22, CD20, and CD11c.  Patients with flow cytometry consistent with HCL 

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variant (HCLv) are eligible, including those with CD25 and/or CD103 negative 
disease.
2.1.1.2
BMBx or BMA consistent with HCL, confirmed by NIH Laboratory of Pathology, 
NCI, or the Department of Laboratory Medicine, Clinical Center, NIH, unless the 
diagnosis can be confirmed from a solid (lymph node) mass.
2.1.1.3
Treatment indicated based on demonstration of at least one of the following no 
more than 4 weeks from the time of enrollment, and no less than 6 months after 
prior cladribine and no less than 4 weeks after other prior treatment, if applicable.  

Neutropenia (ANC < 1000 cells/µl).

Anemia (Hgb < 10g/dL).

Thrombocytopenia (Plt < 100,000/µl).

Absolute lymphocyte count (ALC) of >5,000 cells/µL

Symptomatic splenomegaly.

Enlarging lymph nodes > 2cm. 

Repeated infections requiring oral or i.v. antibiotics.

Increasing lytic bone lesions
Patients who have eligible blood counts within 4 weeks from enrollment will not 
be considered ineligible if subsequent blood counts prior to enrollment fluctuate 
and become ineligible up until the time of enrollment.
2.1.1.4
One of the following:

At least 2 prior courses of purine analog

1 prior course of purine analog plus >1 course of rituximab if the 
response to the course of purine analog lasted < 1 year.

Diagnosis of HCL variant (HCLv)

Unmutated (>98% homology to germline) IGHV4-34+expressing 
HCL/HCLv
2.1.1.5
ECOG performance status [102] of 0-3 (see Appendix A).
2.1.1.6
Patients must be able to understand and give informed consent.
2.1.1.7
Creatinine < 1.5 or creatinine clearance > 60 ml/min.  
2.1.1.8
Bilirubin < 2 unless consistent with Gilbert’s (total/direct > 5), ALT and AST < 3 
x upper limits of normal.
2.1.1.9
No other therapy (i.e. chemotherapy, interferon) for 4 weeks prior to study entry, 
or cladribine for 6 months prior to study entry, unless progressive disease more 
than 2 months after cladribine is documented.
2.1.1.10 Age at least 18
2.1.1.11 Men and women of reproductive potential must agree to use an acceptable 
method of birth control during treatment and for twelve months after completion 
of treatment.

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2.1.1.12 Patients must be willing to co-enroll in the investigator’s companion protocol 10-
C-0066 titled “Collection of Human Samples to Study Hairy Cell and other 
Leukemias, and to Develop Recombinant Immunotoxins for Cancer Treatment”.
2.1.2
Exclusion Criteria
2.1.2.1
Presence of active untreated infection
2.1.2.2
Uncontrolled coronary disease or NYHA class III-IV heart disease (see Appendix 
B).
2.1.2.3
Known infection with HIV, hepatitis B or C.
2.1.2.4
Pregnant or lactating women.
2.1.2.5
Presence of active 2nd malignancy requiring treatment.  2nd malignancies with 
low activity which do not require treatment (i.e. low grade prostate cancer, basal 
cell or squamous cell skin cancer) do not constitute exclusions.
2.1.2.6
Inability to comply with study and/or follow-up procedures.
2.1.2.7
Presence of CNS disease
2.1.2.8
Patients with history of non-response to both pentostatin plus rituximab and to 
bendamustine plus rituximab.
2.1.2.9
Receipt of a live vaccine within 4 weeks prior to randomization.  Efficacy and/or 
safety of immunization during periods of B-cell depletion have not been 
adequately studied.  It is recommended that a patient’s vaccination record and 
possible requirements be reviewed. The patient may have any required 
vaccination/booster administered at least 4 weeks prior to the initiation of study 
treatment.  Review of the patient’s immunization status for the following 
vaccinations is recommended:  tetanus; diphtheria; influenza; Pneumococcal 
polysaccharide; Varicella; measles, mumps and rubella (MMR); and hepatitis B.  
Patients who are considered to be at high risk for hepatitis B virus (HBV) 
infection and for whom the investigator has determined that immunization is 
indicated should complete the entire HBV vaccine series at least 4 weeks prior to 
participation in the study.  
2.1.3
Recruitment Strategies
Recruitment of patients from outside NIH is facilitated by multiple ongoing trials at NIH. 
Many 
patients 
find 
about 
NIH 
trials 
from 
NIH 
websites, 
such 
as 
https://clinicaltrials.gov/ or NIH social media, or from other patients through social 
media.  
2.2
SCREENING EVALUATION 
2.2.1
Screening activities performed prior to obtaining informed consent
Minimal risk activities that may be performed before the subject has signed a consent 
include the following: 

Email, written, in person or telephone communications with prospective subjects 

Review of existing medical records to include H&P, laboratory studies, etc. 

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
Review of existing MRI, x-ray, or CT images

Review of existing photographs or videos
Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes.
A waiver of consent for these activities has been requested in Section 9.6.2.
2.2.2
Screening activities performed after a consent for screening has been signed
The following activities will be performed only after the subject has signed the consent 
for this study for screening. Assessments performed at outside facilities or on another 
NIH protocol within the timeframes below may also be used to determine eligibility once 
a patient has signed the consent.
2.2.3
Tests and procedures for evaluation (needed for eligibility)
2.2.3.1
Within 6 months before starting drug

BMBx with IHC for CD20 and CD3. BMBx must have been done since last prior 
therapy and at least 6 months after prior cladribine.

BMA for FACS and PCR (if evaluable).  Blood PCR should be done at the same 
time as BMA PCR.
2.2.3.2
Within 3 months before starting drug

Hepatitis B (HBcAB and HBsAg), hepatitis C and HIV test

24hour urine for creatinine clearance 

Direct bilirubin, total bilirubin, UPEP and SPEP
2.2.3.3
Within 7 days before starting drug

Pregnancy test (urine or serum).  Women of childbearing potential must have a 
negative pregnancy test.

CBC with differential

Chemistries including acute care panel (sodium, potassium, chloride, CO2, 
glucose, creatinine, and BUN), mineral panel (calcium, magnesium, phosphorus 
and albumin), hepatic panel (AST, ALT, bilirubin, alkaline phosphatase), lipid 
panel (cholesterol, triglycerides, HDL, LDH), direct bilirubin, total protein, 
creatine kinase (CK), uric acid, LDH, and urinalysis

History & Physical with documented performance status
2.3
PARTICIPANT REGISTRATION AND STATUS UPDATE PROCEDURES
Registration and status updates (e.g. when a participant is taken off protocol therapy and 
when a participant is taken off-study) will take place per CCR SOP ADCR-2, CCR 
Participant 
Registration 
& 
Status 
Updates 
found 
at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825.

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2.3.1
Treatment Assignment and Randomization/Stratification Procedures  
Cohorts
Number
Name
Description
1
Cohort 1
(Dose escalation)
Patients with HCL needing therapy, HCLv or 
unmutated IGHV4-34+ HCL/HCLv enrolled directly 
to Arm 1 or 2 for initial tolerability study; patients 
with relapse/no response may crossover to receive 
rituximab + pentostatin (Arm 4). (Up to 12 evaluable 
patients) (closed)
2
Cohort 2
(Dose expansion; 
randomized)
Patients with HCL needing therapy, HCLv or 
unmutated IGHV4-34+ HCL/HCLv to be 
randomized, stratified based upon response to prior 
purine analog, and to be enrolled to Arm 3 or 4; 
patients with relapse/no response may crossover to 
the other arm. (Up to evaluable 56 patients; 28 in each 
arm)
3
Cohort 3
(Dose expansion; 
non-randomized)
Patients with HCL needing therapy, HCLv or 
unmutated IGHV4-34+ HCL/HCLv with prior non-
response to either pentostatin plus rituximab or to 
bendamustine plus rituximab not to be randomized 
and to be enrolled directly to Arm 3 or Arm 4 (Up to 
4 evaluable patients)
Arms
Number
Name
Description
1
Arm 1
Rituximab +bendamustine at 70 mg/m2 for initial 
tolerability study (closed)
2
Arm 2
Rituximab +bendamustine at 90 mg/m2 for initial 
tolerability study (closed)
3
Arm 3
Rituximab + bendamustine (at the tolerated dose)
4
Arm 4
Rituximab + pentostatin
Stratifications
Name
Distinct Options
Notes
Response to previous 
purine analog
Refractory to therapy
Non-refractory to therapy
Refractory to therapy also 
includes untreated poor-risk 
disease, namely HCLv and 
unmutated IGHV4-34+ HCL 
(i.e., unknown)
Randomization and Arm Assignment

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At the time of registration for treatment, patients with HCL needing therapy, HCLv or 
unmutated IGHV4-34+ HCL/HCLv are assigned to:

Cohort 1: 12 patients in this cohort will not be randomized and will be assigned to 
Arms 1 or 2 for initial tolerability studies.

Cohort 2: 56 patients in this cohort are randomized on a 1:1 basis to Arm 3 or 4, to 
begin either bendamustine plus rituximab or pentostatin plus rituximab, 
stratifying for prior response to purine analog. The randomization will be 
performed by CRO personnel using randomization assignments generated by the 
study statistician. The Pharmacy Department will be notified of the treatment 
assignment once the patient is randomized. Patients who relapse from or have no 
response to one arm may cross over to the other arm providing they meet initial 
eligibility criteria.  Patients with progressive disease to one arm may cross over to 
the other arm at least 2 months after the last dose of purine analog, while those 
with stable disease after one arm may cross over to the other arm at least 6 months 
after the last dose of purine analog.

Cohort 3: Four patients in this cohort, with history of non-response to either 
pentostatin plus rituximab or to bendamustine plus rituximab will not be 
randomized and will receive the other regimen on protocol but will not be 
considered for the primary endpoint of the study.   
2.4
BASELINE EVALUATION
2.4.1.1
At the time of enrollment for treatment

Blood for cloning and sequence immunoglobulin rearrangements.
2.4.1.2
Within 6 months before drug

MRI Cervical and Thoracic (C- and T-) Spine to correlate the status of the BMBx 
with the vertebral BMA signal by MRI.  May be cancelled at the discretion of the 
PI, including if patient unable to get MRI at NIH and not covered by insurance 
outside NIH.
2.4.1.3
Within 3 months before drug

Thrombin time, Free T4 & T3, D-dimer, beta-2 microglobulin

24-hour urine for protein if measurable

EKG

Echocardiogram and stress test

Pulmonary Function Test (PFTs)

CT neck-pelvis or abdominal MRI.

Abdominal Ultrasound (U/S) will be done to exclude lymph nodes potentially 
impacting the biliary tree, and for baseline spleen size which can be subsequently 
followed by spleen U/S.
2.4.1.4
Within 2 weeks before drug

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
Blood FACS, and citrate tube for consensus PCR, IgG, IgA, IgM, haptoglobin, 
Ferritin, fibrinogen PT, PTT, Lipid panel (HDL, LDL, Cholesterol, Triglyceride), 
GGT, CRP, TSH, Triiodothyronine, Amylase, Lipase.
2.4.1.5
Within 1 week before drug

TBNK (B-cell, CD4_CD8+ and NK cells) Pre Tx draw will suffice for cycle 1. May 
skip pre-cycle blood FACS if neg x1.  TBNK needed only on patients at NIH.

EKG
2.4.1.6
Within 0-1 days before drug

CBC, diff 

Acute care panel, mineral panel, hepatic panel, LDH, direct bilirubin, CK, uric 
acid, and total protein.

Urinalysis

TBNK

Any of these tests performed for screening purposes (Section 2.2.3.3) within 0-1 
days before drug may also count for baseline purposes.
3
STUDY IMPLEMENTATION
3.1
STUDY DESIGN  
3.1.1
Overview  
This is a randomized study of pentostatin plus rituximab versus bendamustine plus 
rituximab for multiply relapsed HCL.  The primary objective of the study is to determine 
if response in each arm is higher than the 39% expected from rituximab alone, and to 
determine which regimen might be better. To determine whether the proposed dose of 
bendamustine plus rituximab is well tolerated in HCL, 6 non-randomized patients will 
initially receive bendamustine 70 mg/m2 days 1-2 plus rituximab 375 mg/m2 days 1 and 
15 for six 4-week cycles.  An additional 6 patients will receive the same regimen with 90 
rather than 70 mg/m2 of bendamustine. Randomization will begin using the higher of 
the 2 dose levels of bendamustine providing 5-6 of the 6 patients can tolerate the 6 cycles 
without delays > 4 weeks.  If neither dose level is tolerated to this extent, the trial may 
need to be amended prior to randomization.  If tolerance of the 90 mg/m2 dose level of 
bendamustine is acceptable, subsequent patients will be randomized to receive either this 
dose of bendamustine + rituximab (n=28), or pentostatin 4 mg/m2 plus rituximab 375 
mg/m2 days 1, and 15 for six 4-week cycles (n=28).  Once randomization begins, patients 
will be stratified to equalize the percent of patients in each arm who were refractory to 
their last course of purine analog, meaning lack of response lasting at least 1 year.  This 
stratification will also include patients with untreated poor-risk disease, namely HCLv 
and unmutated IGHV4-34+ HCL.
3.1.1.1
Crossover
Patients who relapse from or have no response to one arm may cross over to the other 
arm providing they meet initial eligibility criteria.  Patients with progressive disease to 1 
arm may cross over to the other arm at least 2 months after the last dose of purine analog, 

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while those with stable disease after 1 arm may cross over to the other arm at least 6 
months after the last dose of purine analog.  Up to four patients with a history of non-
response to 1 arm before enrollment may be treated in the other arm without being 
randomized, and will not be able to cross over.  These non-randomized patients will not 
be considered for the primary endpoint of the study.
3.1.2
Schema
3.1.3
Definition of MRD positivity  
To determine MRD rates for the secondary endpoints, the following 3 CLIA-certified 
MRD tests will be used:

Blood FACS and consensus PCR

Bone marrow aspirate (BMA) FACS and consensus PCR 

Bone marrow biopsy immunohistochemistry (BMBx IHC)

Patients will be considered blood MRD-free providing the blood 
FACS is negative and the blood counts are consistent with CR (ANC 
> 1500/mm3, Plt > 100,000/mm3, and Hgb > 11 g/dL).  MRD in the 
BMBx by IHC is defined as a ratio of CD20+ cells to T cells of at least 
1, and most of the CD20+ cells having morphology consistent with 
HCL.  FACS uses multicolor flow cytometry to specifically identify 
and quantify HCL cells based on expression of CD19, CD22, CD20, 
CD11c, CD103, and restricted (lambda or kappa) light chains.  Flow 
cytometry studies which are not positive (i.e. suspicious for MRD) 
will be considered negative for protocol purposes.  Blood consensus 
PCR is reported as clonal rearrangement present (positive) or 
polyclonal rearrangement pattern present (negative).  While MRD 
generally refers to HCL detected while a patient is in CR, patients 
with more than minimal disease in the BMBx, who by definition are 
not in CR, will also be considered MRD+ by IHC.  Patients not in CR 
due to positive BMBx may be MRD-free by blood tests.  Thus, blood 
MRD-free survival is usually shorter than, but could be equal to or 
longer than disease-free survival.
Cy1
Cy2
Cy3
Cy4             Cy5           Cy6
| | | | | | | | | | | |
D1
D15 D1
D15 D1
D15 D1
D15
Bendamustine 70 mg/m2 d1,2  (n=6)
Bendamustine 90 mg/m2 d1,2 (n=6+28)
Rituximab 375 mg/m2 d1, 15
Crossover:  For relapse or 
progression (exploratory)
Prior refractory to BenR/PenR: 
Opposite regimen (n=0-6)
Cy1
Cy2
Cy3
Cy4            Cy5            Cy6
| | | | | | | | | | | |
D1
D15 D1
D15 D1
D15 D1
D15   D1    D15   D1     C15
Pentostatin 4 mg/m2 d1,15     (n=28)
Rituximab 375 mg/m2 d1,15

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3.1.4
Additional tests for MRD  

RQ-PCR of blood, while extremely sensitive for MRD, will not be 
used for protocol decisions since it is not CLIA certified and its 
clinical relevance needs additional study.  
3.2
DRUG ADMINISTRATION 
Participants will receive treatments at NIH. 
3.2.1
Bendamustine by 30-60 minute infusion days 1-2 at 70 mg/m2/dose for 1st 6 
patients, and 90 mg/m2/dose for additional patients.
3.2.2
Pentostatin 4 mg/m2 by rapid (<45 min) infusion days 1 and 15.  
3.2.3
Rituximab 375 mg/m2 i.v. infusion days 1 and 15.  When rituximab is given on the 
same day as bendamustine or pentostatin, it will be given after the other drug.  
Actual body weight measured within 4 weeks prior to initial treatment will be 
used for calculations of body surface area. See Appendix C:  Guidelines for 
Rituximab Preparation and Administration for infusion times. 
3.2.4
Cycles will repeat every 28 days (+/- 2 days).
3.2.5
The day 15 dose of Pentostatin and/or Rituximab may be given on day 13 or 14 if 
needed for logistical reasons.
3.3
DOSE MODIFICATIONS 
3.3.1
Dosing may be delayed up to 4 weeks for toxicity or logistical reasons, including 
inability of the patient to get to clinic.
3.3.2
Patients with excessive delay (delay > 4 weeks) or dose-limiting toxicity (DLT) are 
off-treatment and may be followed but not retreated with the current regimen. 
They will receive the cross-over regimen if and when eligible.
3.3.3
Treatment with rituximab or bendamustine may not be dose-reduced.  Rituximab 
infusion should be interrupted for severe reactions, e.g., rapid tumor lysis.  
Treatment 
of 
infusion-related 
symptoms 
with 
diphenhydramine 
and 
acetaminophen is recommended.  Additional treatment with bronchodilators or 
IV saline may be indicated.  Epinephrine, antihistamines, and corticosteroids 
should be available for immediate use in the event of a hypersensitivity reaction 
to rituximab (e.g., anaphylaxis).  In most cases, the infusion can be resumed at a 
50% reduction in rate (e.g., from 100mg/hr to 50mg/hr) when symptoms and 
laboratory abnormalities have completely resolved.  Patients with anaphylaxis or 
hypersensitivity reactions to rituximab may receive desensitization using 
standard methods [103], but otherwise should be removed from treatment.
3.3.4
If creatinine resolves to grade >1, the following pentostatin doses should be used: 
If eGFR is:
>40 and <60: treat with 3 mg/m2 of pentostatin 
>20 and <40: treat with 2 mg/m2 of pentostatin 

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<20: treat with 1 mg/m2 of pentostatin
eGFR may be obtained from CRIS or it may be calculated using the following 
formula:
(140-age)(weight in Kg)(0.85 if female)
 (72)(Serum creatinine in mg/dL)
3.3.5
DLT criteria:  Grade III-IV bendamustine, pentostatin or rituximab related toxicity 
except:

Grade 3-4 hematologic toxicity resolving in 8 weeks.

Grade 3-4 lymphopenia, leukopenia, or CD4 reduction.

Hematologic toxicity managed with platelet transfusion and/or 
other support.

Grade 3 toxicity resolving within the 4-week allowable treatment 
delay.

Grade 4 AST, ALT and GGT for < 5 days 

Allergic reactions prevented by desensitization.

Grade 3-4 tumor lysis syndrome with significant decrease in tumor 
burden. Patients may continue without dose reduction providing 
laboratory abnormalities resolve to grade 0-1 or baseline within the 
4-week allowable delay. 
3.3.6
Infusions should be discontinued in the event of serious or life-threatening 
cardiac arrhythmias.  Subjects who develop clinically significant arrhythmias 
which are not dose-limiting should undergo cardiac monitoring during and after 
subsequent infusions.

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3.4
STUDY CALENDAR
3.4.1
Randomization and Initial Crossover Treatment Calendar
Randomization and Initial Crossover Treatment
Treatment
Screening/Baseline (time interval before drug)
Cycles 1-6
Time point
6 
months
3 
months
2 
weeks
1 
week
0-1 
days
Anytime 
D1
D2
D3
D5
D15
Pre 
Cycle 
4 (at 
NIH)
End 
of 
Tx12
Treatment
Bendamustine
X
X
Pentostatin
X
X
Rituximab
X
X
Procedures
NIH Advance 
Directives Form
X11
Bone Marrow 
Biopsy/aspiration1, 
Blood PCR2
X
X
X
Echocardiogram, stress 
test, PFTs
X
HCL Imaging4
X
X5
X
EKG
X
X7
X
X
History & Physical
X7
X
X
MRI Cervical and 
Thoracic Spine3
X
X
X
Laboratory Evaluations
HBsAg, HBcAB, & 
HCV, HIV
X
24hr urine protein, 
creatinine clearance 
and protein
X

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Randomization and Initial Crossover Treatment
Treatment
Screening/Baseline (time interval before drug)
Cycles 1-6
Time point
6 
months
3 
months
2 
weeks
1 
week
0-1 
days
Anytime 
D1
D2
D3
D5
D15
Pre 
Cycle 
4 (at 
NIH)
End 
of 
Tx12
Direct bilirubin, UPEP 
and SPEP
X
Thrombin time, Free T4 
& T3, D-dimer, Beta-2 
microglobulin
X
Pregnancy test (if 
relevant)
X
IgG, IgA, IgM, IFE13, 
haptoglobin, ferritin, 
fibrinogen, PT, PTT, 
Lipid panel, GGT, CRP, 
TSH, Triiodothyronine, 
Amylase, Lipase
X
X
X
TBNK
X
X
X7
X7, 15
X7
X7
CBC, diff
X
X
X
X7
X7
X7
X15
X
X
Chemistries8
X
X
X7
X7,14
X
X
Urinalysis
X
X
X7
Research Evaluations15
Blood for cloning and 
sequencing 
immunoglobulin 
rearrangements15
X
Blood FACS 
X7
X6
X
X
Coagulation labs 9 and 
Cytokine labs10
X7,15
X7,15
1 At NIH, aspirate for FACS, PCR-molecular diagnostics, and RQ-PCR.
2 Blood PCR should be done at the same time as BMA PCR.

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3 MRI of C- and T-Spine (only at NIH) Spine to correlate marrow uptake in vertebra with response status, may be cancelled at discretion 
of PI.
4 CT neck-pelvis or abdominal MRI for Baseline Evaluation.  If no nodes, subsequent imaging may be done with spleen or abdominal U/S, 
abdominal MRI, or CT. If nodes >2cm in short axis are present, subsequent imaging should include CT or MRI of that area.
5 Pre-cycle 2 and 3 on patients at NIH
6 Pre-cycle FACS, may be done 0-4 days before drug, and FACS may be skipped if negative x1.  
7 When patients are at NIH
8 Chemistries=Acute Care Panel, Mineral Panel, Hepatic Panel, lipid panel, total protein, direct bilirubin, CK, Uric Acid. Precycle day 1 
chemistries may be done 0-2 days before drug. 
9 Cycle 1: Coagulation labs: Thrombomodulin, P-selectin, plasminogen activator inhibitor type 1, vWF activity, vWF antigen, d-dimer, 
fibrin degradation products (FDP), fibrinogen, retic, LDH, and haptoglobin, to be drawn day1 and 2 (1st 5 on ice)
10 Cycle 1:  Sodium Heparin Green Top Tubes for cytokines are drawn Pre-Bendamustine or Pre-Pentostatin, Pre-Rituximab, and 2, 4 and 
8 (each +/- 1) hours from the start of the Rituximab Infusion, then next AM, each to be placed in Dr. Kreitman’s bin in the refrigerator 
until picked up by Research Nurse or other appropriate staff. Draw 1 extra if rigors or temp >38.3.
11 As indicated in Section 9.3, all subjects ≥ age 18 will be offered the opportunity to complete an NIH advance directives form.  This should 
be done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained.  The completion 
of the form is strongly recommended but is not required.
12 End of treatment visit will occur approximately 30 days after the last dose of study drug. If the patient cannot return to the Clinical 
Center for this visit, a request will be made to collect required clinical labs from a local physician or laboratory.  If this is not possible, 
patients may be assessed by telephone for symptoms.  
13 IFE, Serum immunofixation electrophoresis and free light chains when drawn at NIH.
14 Acute Care Panel only for patients receiving Pentostatin; it may be done 0-2 days before receiving Pentostatin. Patients receiving 
Bendamustine do not need chemistries on day 15.
15 Samples collected during the course of this study will be stored, tracked, and disposed of as specified in investigator’s companion 
protocol, 10-C-0066, on which all subjects will be co-enrolled.

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3.4.2
Follow-up Calendar (for patients waiting to cross over or patients who have not developed progressive disease).
Follow-up
Time point
9mo
1yr1
15mo1
1.5yrs1
21mo1
2yr1
27mo1
2.5yrs1
>2.5yrs1
Procedures
Bone Marrow 
Biopsy/aspiration, 
Blood PCR2
X
X
X4,5
MRI Cervical and 
Thoracic Spine 3
X
X
X
HCL Imaging6
X
X
X4
EKG
X
X
X4
Laboratory Evaluations
GGT, PT, PTT, 
fibrinogen, IFE11, 
quantitative 
immunoglobulins, 
lipid panel, CRP, 
ferritin, TSH, Free 
T3, Free T4, 
amylase, lipase, 
haptoglobin
X
X
X4
TBNK10
X
X
X
X
X8
CBC, diff
X
X
X
X
X
X
X
X
X8
Urinalysis, 
chemistries7
X
X
X4
Research Evaluations12
Blood FACS
X
X
X
X
X9
1From the beginning of initial treatment, acceptable time windows for follow up procedures may be +/- 1 month up to 1.5 y, then +/- 
2 mo. Time points will remain from initial treatment even if end of treatment is before the 6-month time point. 
2At NIH, aspirate for FACS, PCR-molecular diagnostics, and RQ-PCR. Blood PCR should be done at the same time as BMA PCR.

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3MRI of C- and T-Spine (only at NIH) Spine to correlate marrow uptake in vertebra with response status, may be cancelled at discretion 
of PI.
4Continue every 2 years
5May delete bone marrow if not in CR.
6CT neck-pelvis or abdominal MRI needed only for baseline. If no nodes, subsequent imaging may be done with spleen or abdominal 
U/S, abdominal MRI, or CT.  If nodes >2cm in short axis are present, subsequent imaging should include CT or MRI of that area
and imaging is optional if no spleen at baseline.
7Chemistries=Acute Care Panel, Mineral Panel, Hepatic Panel, LDH, total protein, CK, Uric Acid
8Continue every 6 months for those in CR, otherwise every 3 months
9Continue every year
10When patients are at NIH
11IFE, Serum immunofixation electrophoresis and free light chains when drawn at NIH
12 Samples collected during the course of this study will be stored, tracked, and disposed of as specified in investigator’s companion 
protocol, 10-C-0066, on which all subjects will be co-enrolled.

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3.5
PROTOCOL EVALUATION
3.5.1
Evaluation during study 

Day 1 and 2 of 1st cycle (if at NIH): Coagulation labs (Thrombomodulin, P-selectin, 
plasminogen activator inhibitor type 1, vWF activity, vWF antigen, d-dimer, fibrin 
degradation products {FDP}, fibrinogen, retic, LDH, and haptoglobin, 1st 5 on ice) 
are drawn days 1 and 2.  

Sodium Heparin Green Top Tubes for cytokines are drawn Pre-Bendamustine or 
Pre-Pentostatin, Pre-Rituximab, and 2, 4 and 8 (each +/- 1) hours from the start of 
the Rituximab Infusion, then next AM. Draw 1 extra cytokine sample if rigors or 
temp >38.3. 
Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting 
samples (the Friday before is preferred).
For sample pickup, page 102-11964.
For immediate help, call 240-760-6180 (main blood processing core number) or, if 
no answer, 240-760-6190 (main clinical pharmacology lab number).
For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov.
The samples will be processed, barcoded, and stored in Dr. Figg’s lab until 
requested by the investigator. See 5.4.3 for additional details. 

Days 0-1 and 14-15 (i.e., the day of or the day before the day 15 dose) of each cycle 
and every week for the first cycle:  CBC, diff

0-2 days before each cycle: Acute care panel, mineral panel, hepatic panel, total 
protein, CK, uric acid, LDH, direct bilirubin, urinalysis

0-4 days before each cycle: blood FACS (until negative) 

0-2 days before Day 15 of each cycle: CBC with diff and acute care panel

Prior to Cycle 4, then 4-8 weeks after last dose of arm (end of treatment restaging): 
Blood citrate tube for consensus PCR, BMBx with IHC for CD20 and CD3, and 
bone marrow aspirate (BMA, if obtainable) for FACS, PCR, and RQ-PCR.  

Prior to Cycle 4 and at end of treatment restaging: CT or other imaging study of 
spleen and any other site of known disease, acute care panel, mineral panel, 
hepatic panel, total protein, uric acid, Lipid panel, GGT, PT, PTT, fibrinogen, 
quantitative immunoglobulins, creatinine kinase (CK), CRP, ferritin, TSH, Free T3, 
Free T4, amylase, lipase, haptoglobin, and urinalysis. Acceptable time windows 
for all post 6-mo time points (even CBCs) should be +/- 1 month up to 1.5 y, then 
+/- 2 months, unless individual change needed for logistical reasons.

At end of treatment restaging: CBC with diff.

At end of treatment restaging: blood FACS, and if patient is at NIH, TBNK (B-cells, 
CD4+, CD8+, and NK cells).

Cervical and Thoracic (C- and T-) Spine MRI with each restaging that includes 
BMBx, so that the status of the BMBx can be correlated with the vertebral BMA 
signal by MRI.  May be cancelled at the discretion of the PI

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
EKG- Pre cycle 4 and at 4-8 weeks after last dose (end of treatment)

History and Physical- Pre-Cycle 4 and 4-8 weeks after last dose of drug (end of 
treatment).
3.5.2
Evaluations during the follow up period
All end of treatment time points (even CBCs) should occur +/- 1 month up to 1.5 years 
after initial treatment, then +/- 2 months.
3.5.2.1
Yearly for 2 years (i.e. 1.5 and 2.5 years after initial treatment), then every 2 years

Blood citrate (4-6 ml blue top) tube for consensus PCR

BMBx with IHC for CD20 and CD3, and bone marrow aspirate (BMA, if 
obtainable) for FACS, PCR, and RQ-PCR.  (while in CR)

Cervical and Thoracic (C- and T-) Spine MRI with each restaging that includes 
BMBx, so that the status of the BMBx can be correlated with the vertebral BMA 
signal by MRI.  May be cancelled at the discretion of the PI

CT or other imaging study of spleen and any other site of known disease, 

acute care panel, mineral panel, hepatic panel, total protein, uric acid, Lipid panel, 
GGT, PT, PTT, fibrinogen, quantitative immunoglobulins, creatinine kinase (CK), 
CRP, ferritin, TSH, Free T3, Free T4, amylase, lipase, haptoglobin, and urinalysis.

EKG
3.5.2.2
9 months after initial treatment, then every 3 months. If in CR, every 6 months 
after 2.5 years after treatment

CBC with diff.
3.5.2.3
1, 1.5, 2, and 2.5 years after initial treatment, then yearly (also 6 months after 
initial treatment if end of treatment evaluation occurred prior to 5 months after 
initial treatment) 

Blood FACS 

TBNK (B-cells, CD4+, CD8+, and NK cells (if patient is at NIH).
If patient progresses during follow up period and has already undergone or will not 
undergo crossover treatment, or otherwise begins other treatment, or voluntarily 
withdraws from follow-up testing, an annual phone call (or other contact) will be made 
to patient or their treating physician to assess survival and obtain data about other 
treatments (dates and names of treatments) and response.
3.6
CONCURRENT THERAPIES
3.6.1
Patients may not receive other treatments for HCL while on treatment or in the 
active follow-up portion of the study. If splenectomy is done after initial 
randomization regimen, then progressive disease will need to be documented 
using a post-splenectomy baseline, prior to cross-over.
3.6.2
This research study protocol allows the subject to receive up to 16 infusions of 
rituximab.  Even if the treatment is shown to be of benefit, additional infusions of 

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rituximab beyond that allowed in the protocol cannot be given to the subject while 
she/he is participating in this study.
3.7
RADIATION THERAPY GUIDELINES
Radiation therapy for HCL is not permitted while on protocol unless follow-up portion 
of the study, i.e., while patients are off of active follow-up testing and being followed for 
survival. 
3.8
COST AND COMPENSATION
3.8.1
Costs
NIH does not bill health insurance companies or participants for any research or related 
clinical care that participants receive at the NIH Clinical Center. 
3.8.2
Compensation
Participants will not be compensated on this study.
3.8.3
Reimbursement
The NCI will cover the costs of some expenses associated with protocol participation.  
Some of these costs may be paid directly by the NIH and some may be reimbursed to the 
participant/guardian as appropriate.  The amount and form of these payments are 
determined by the NCI Travel and Lodging Reimbursement Policy.
3.9
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA
Prior to removal from study, effort must be made to have all subjects complete a safety 
visit approximately 30 days following the last dose of study therapy.
3.9.1
Criteria for removal from protocol therapy (off treatment), for either arm  

Subject has completed cross-over treatment

Progressive disease or DLT and ineligible for future cross-over treatment

Intercurrent illness or medical circumstances

Radiation therapy or other treatment for HCL other than splenectomy

Voluntary withdrawal from treatment regimen

PI determines further treatment on this study is not in patient’s best interest

Patients may still be eligible for crossover after going off-treatment from their 
randomized regimen.

Patients who are off-treatment but still on-study will be followed as per the 
schedule in Sections 3.4 and 3.5, until they begin alternative therapy or 
voluntarily withdrawal from follow-up testing.  Thereafter, they may be followed 
on-study for survival and other secondary endpoints.

Positive pregnancy test
3.9.2
Off Study Criteria  

Voluntary patient withdrawal from study

Death

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
Non-compliance with study treatment and/or testing, or lost to follow-up, at 
discretion of PI

Screen failure

Patients in long-term CR may become temporarily ‘lost to follow-up’ but may 
intend to eventually follow-up with restaging, and taking them off study 
prematurely might greatly compromise the long-term objectives of the study.  
Therefore, patients may be reported as ‘lost to follow-up’ and unavailable for 
follow-up testing, but may continue to be followed once contact resumes.  Regular 
communication with patients will be maintained to minimize this occurrence.
4
SUPPORTIVE CARE
4.1
INFECTIONS/FEVER AND NEUTROPENIA
Febrile Neutropenia is a common side-effect of pentostatin or bendamustine which 
require empiric antibiotics, either as an inpatient or outpatient. Hematopoietic growth 
factors may be used if clinically indicated.  Fever is also common with rituximab and may 
be treated symptomatically and with interrupting or with decreasing the infusion rate, as 
detailed in 13.3.2.  
4.2
BLOOD PRODUCT SUPPORT
Symptomatic anemia should be treated with appropriate red blood cell support. 
Transfusion is generally recommended if the hemoglobin falls below 8g/dL, but lower 
levels are acceptable particularly for younger patients.  Recombinant erythropoietin may 
also be used.  Platelets are generally given when the platelet count is < 10,000/mm3 or 
when there is bleeding.  
4.3
CYTOKINE SUPPORT
Prophylactic filgrastim (G-CSF) or sargramostim (GM-CSF) is not indicated for 
chemotherapy in HCL but may be used in special situations, for example, when patients 
have serious neutropenic infections and it is considered desirable to resolve the 
neutropenia as soon as possible.
4.4
TUMOR LYSIS SYNDROME
Although 
tumor 
lysis 
syndrome, 
with 
fever, 
hyperkalemia, 
hyperuricemia, 
hypocalcemia, hyperphosphatemia, and decreased renal function have been reported in 
CLL with rituximab, this syndrome has not been reported in HCL with pentostatin or 
rituximab.  Tumor lysis syndrome associated with bendamustine treatment has been 
reported in patients in clinical trials and in spontaneous reports. The onset tends to be 
within the first treatment cycle of bendamustine and, without intervention, may lead to 
acute renal failure and death. Preventive measures include maintaining adequate volume 
status, and close monitoring of serum chemistry, particularly potassium and uric acid 
levels. Allopurinol has also been used prior to or at the beginning of bendamustine 
therapy. However, there may be an increased risk of severe skin toxicity when 
bendamustine and allopurinol are administered concomitantly.  This protocol will not 

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mandate prophylaxis for this syndrome.  Patients should be followed closely particularly 
during the first week of treatment when the chance of tumor lysis syndrome would be 
highest.
4.5
INFUSION REACTIONS
Patients receiving rituximab, particularly those with high concentrations of circulating 
malignant cells, commonly have infusional toxicities including fever, chills, nausea and 
vomiting, dyspnea, hypotension, and palpitations.  Infusional reactions with rituximab 
have been observed in HCL as well as other malignancies, and are best managed by 
slowing or interrupting the rate of infusion.  
4.6
SKIN REACTIONS RELATED TO BENDAMUSTINE
Skin reactions have been reported in clinical trials and post-marketing spontaneous 
reports. These events have included rash, toxic skin reactions, and bullous exanthema. 
Some events occurred when bendamustine was given in combination with other 
anticancer agents, so the precise relationship of the skin reactions to bendamustine 
treatment is uncertain.
In a study of bendamustine (90 mg/m2) in combination with rituximab (study SDX-105-
02), 1 case of TEN occurred. TEN has been associated with treatment with rituximab. 
Spontaneous reports of SJS and TEN, some fatal, have been reported when bendamustine 
was administered concomitantly with allopurinol and other medications known to cause 
these syndromes. The relationship to bendamustine cannot be determined.
When skin reactions occur, they may be progressive and increase in severity with further 
treatment. Therefore, patients with skin reactions should be monitored closely. If skin 
reactions are severe or progressive, bendamustine treatment should be withheld or 
discontinued.
5
DATA COLLECTION AND EVALUATION
5.1
DATA COLLECTION 
5.1.1
Documentation of dosage and timing of drug administration
5.1.2
Outside laboratory, radiologic, and pathology results will be faxed to the PI and 
entered into the database at NIH
5.1.3
The original signed consent goes to Medical Records; copy placed in research 
record
5.1.4
NIH labs and tests will be downloaded into the database
5.1.5
A pre-existing (baseline) laboratory abnormality will be considered the last one 
obtained prior to the first dose of drug, unless the PI considers an abnormality of 
higher grade occurring within 100 days prior to the first dose to be a truer baseline.
5.1.6
Patients beginning crossover treatment will be assessed for new baseline signs and 
symptoms.  

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5.1.7
All adverse events (AEs) will be collected except grade 1 events which are 
unrelated or unlikely related to the research.
The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-
compliant data capture system provided by the NCI CCR and ensuring data 
accuracy, consistency and timeliness. The principal investigator, associate 
investigators/research nurses and/or a contracted data manager will assist with 
the data management efforts. Primary and final analyzed data will have identifiers 
so that research data can be attributed to an individual human subject participant.
All adverse events, including clinically significant abnormal findings on 
laboratory evaluations, regardless of severity, will be followed until return to 
baseline or stabilization of event. 
Document AEs from the first dose of any study drug through 30 days after the last 
dose of any study drug. Beyond 30 days after the last dose of study drug, only 
adverse events which are serious and related to the study drug need to be 
recorded.
Patients treated both inside and outside of NIH will require source documentation 
regarding dosage and timing of drug administration.  For patients treated outside 
NIH, results of lab, radiology and pathology tests should be faxed to the PI.   Data 
from NIH will be located in the CRIS.  Data managers can enter the data from both 
sources electronically into the database.  
An abnormal laboratory value will be considered an AE only if the laboratory 
abnormality is characterized by any of the following:
o
Results in discontinuation from the study
o
Is associated with clinical signs or symptoms
o
Requires treatment or any other therapeutic intervention
o
Is associated with death or another serious adverse event, including 
hospitalization.
o
Is judged by the Investigator to be of significant clinical impact, i.e., at least 
possibly related to drug.
AEs need not be collected retroactively after the 30 day time point after the last dose, even 
if the patient subsequently receives crossover treatment.
End of study procedures: Data will be stored according to HHS, FDA regulations, and 
NIH Intramural Records Retention Schedule as applicable. 
5.2
RESPONSE CRITERIA
5.2.1
Rules for response assessment

No G-CSF or GM-CSF at least 4 weeks before major response.

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
No transfusions at least 4 weeks before major response.

Hgb requirement for major response may be dropped if iron stores 
are low (ferritin ≤ 20)

Isolated low blood counts do not indicate relapse or lack of response 
unless they are consistently low, i.e. at least 2 low counts > 1 week 
apart.

For determining response durations, if a given response (i.e. PR, CR 
or MRD-negative CR) appears to end but then later resumes in the 
absence of intervening therapy, it will be considered to have 
continued.
5.2.2
Complete remission (CR):  All of the following for at least 4 weeks

Absolute neutrophil count (ANC) ≥ 1500/mm3

Platelets ≥ 100,000/mm3

Hgb ≥ 11 g/dL

Spleen non-palpable below the costal margin, or not below costal 
margin on CT.

Circulating HCL cells either non-visible on Wright stain or < 1% by 
flow cytometry

Lymph nodes ≤ 2 cm by short axis, unless larger lymph nodes not 
due to HCL

Absence of hairy cells on BM aspirate smears and H/E stain of the 
bone marrow biopsy negative for HCL  The date CR begins will be 
either the date of the BMBx or the date at which normal blood counts 
remain adequate for at least 4 weeks off growth factors or 
transfusions without 2 unacceptable CBCs in a row, whichever 
comes last.

CR with MRD in the BMBx by IHC is defined as CR and a ratio of 
CD20+ cells to T cells of at least 1, and most of the CD20+ cells having 
morphology consistent with HCL.  

CR with MRD in the peripheral blood is defined as CR and a positive 
peripheral blood FACS or PCR.  Suspicious flow is considered 
negative per protocol.

Patients meeting all criteria for CR except minimum levels of ANC, 
platelets and Hgb will be considered CR if MRD is absent by BMBx 
IHC and by flow cytometry of blood and bone marrow.
5.2.3
Partial Response (PR):  All of the following for at least 4 weeks

Neutrophils  1,500/µL or 50% improvement over baseline. 

Platelets 100,000/µL or 50% improvement over baseline. 

Hgb  11.0 g/dL or 50% improvement over baseline.  For patients 
who are transfusion-dependent at baseline, Hgb of  9.0 g/dL. 

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
 50% decrease in circulating malignant HCL count from the 
pretreatment baseline. 

 50% reduction in sum of products of perpendicular diameters or 
decrease to ≤ 2 cm in evaluable (> 2cm) lymphadenopathy. 

 50% reduction in extent of spleen below costal margin by CT or 
physical exam, if abnormal at baseline.  
5.2.4
Progressive disease (PD):  Any of the following

50% increase in sum of products of perpendicular diameters of 
evaluable (> 2cm) lymphadenopathy or appearance of new 
evaluable lymph nodes > 2 cm. 

50% increase in extent of spleen below costal margin by CT or 
physical exam, if abnormal at baseline.  

50% increase in the absolute number of circulating malignant 
lymphocytes.  

The baseline for determination of PD for the purpose of best 
response to each arm of the protocol will be the patient’s baseline 
prior to beginning that arm of the protocol.  However, the baseline 
for determination of PD for the purpose of crossing over will be the 
lowest (nadir) tumor burden achieved.  That baseline, if after 
enrollment, should not be assessed less than 27 days after beginning 
the last cycle.  
5.2.5
Stable disease (SD):  None of the above
5.3
TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of 
each participant while on the study.  The descriptions and grading scales found in the 
revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will 
be utilized for AE reporting.  All appropriate treatment areas should have access to a 
copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be downloaded 
from 
the 
CTEP 
web 
site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).
5.4
SAMPLE STORAGE, TRACKING AND DISPOSITION  
Samples will be ordered in CRIS and tracked through Clinical Trial Data Management 
system.  Should a CRIS screen not be available, the CRIS downtime procedures will be 
followed.  Samples will not be sent outside NIH without appropriate approvals and/or 
agreements, if required.
5.4.1
Description of data/specimens  
Blood and bone marrow samples
5.4.2
Timeframe and location of storage 

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
Samples will be stored and cataloged longer than a year, in alarmed freezers at  
a number of locations, including Frederick, MD, in NCI contracted space and 
Building 37. 

Confidentiality:  Patient names or identifiers will not be used in publications 
resulting from testing of patient samples. Other than described above, no 
germline testing will be done which may impact disease risk in the patient’s 
relatives.  Studies will only be done if the subject provides consent for future 
use and the studies to be done have been approved by the IRB.

Samples at Leidos Biomedical Research, Inc. laboratory in Frederick will be 
tracked in a secure electronic database.
The PI will record any loss or unanticipated destruction of samples as a deviation. 
Reports will be made per the requirements of Section 10.2.1.
5.4.3
Sample Handling, Data Collection and Sample Disposition for the Blood 
Processing Core (BPC)
5.4.3.1
Sample Data Collection
Samples collected during the course of this study will be stored, tracked, and disposed of 
as specified in investigator’s companion protocol, 10-C-0066, on which all subjects will be 
co-enrolled.
Samples collected from patients enrolled prior to Amendment U may be stored, tracked 
and disposed of as specified in investigator’s companion protocol, 10-C-0066.
All samples sent to the Blood Processing Core (BPC) will be barcoded, with data entered 
and stored in the Labmatrix utilized by the BPC. This is a secure program, with access to 
Labmatrix limited to defined Figg lab personnel, who are issued individual user 
accounts. Installation of Labmatrix is limited to computers specified by Dr. Figg. These 
computers all have a password restricted login screen. 
Labmatrix creates a unique barcode ID for every sample and sample box, which cannot 
be traced back to patients without Labmatrix access. The data recorded for each sample 
includes the patient ID, name, trial name/protocol number, time drawn, cycle time point, 
dose, material type, as well as box and freezer location. Patient demographics associated 
with the clinical center patient number are provided in the system. For each sample, there 
are notes associated with the processing method (delay in sample processing, storage 
conditions on the ward, etc.).
5.4.3.2
Sample Storage and Destruction
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -80C 
according to stability requirements.  These freezers are located onsite in the BPC and 
offsite at NCI Frederick Central Repository Services in Frederick, MD. Visitors to the 
laboratory are required to be accompanied by laboratory staff at all times. 
Access to stored clinical samples is restricted. Samples will be stored until requested by 
a researcher named on the protocol. All requests are monitored and tracked in Labmatrix. 
All researchers are required to sign a form stating that the samples are only to be used 

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for research purposes associated with this trial (as per the IRB approved protocol) and 
that any unused samples must be returned to the BPC. It is the responsibility of the NCI 
Principal Investigator to ensure that the samples requested are being used in a manner 
consistent with IRB approval.
Following completion of this study, samples will remain in storage as detailed above. 
Access to these samples will only be granted following IRB approval of an additional 
protocol, granting the rights to use the material. 
If, at any time, a patient withdraws from the study and does not wish for their existing 
samples to be utilized, the individual must provide a written request. Following receipt 
of this request, the samples will be destroyed (or returned to the patient, if so requested). 
Sample barcodes are linked to patient demographics and limited clinical information. 
This information will only be provided to investigators listed on this protocol, via 
registered use of the Labmatrix. It is critical that the sample remains linked to patient 
information such as race, age, dates of diagnosis and death, and histological information 
about the tumor, in order to correlate genotype with these variables.
5.4.4
Procedures for storage and disposition of serum specimens at the Clinical Support 
Laboratory, Leidos Biomedical Research, Inc.in Frederick, MD

The Clinical Support Laboratory, Leidos Biomedical Research, Inc.-Frederick, 
processes and cryopreserves samples in support of IRB-approved, NCI clinical 
trials.  The laboratory is CLIA certified for anti-IL15 and certain cytokine 
measurements and all laboratory areas operate under a Quality Assurance Plan 
with documented Standard Operating Procedures that are reviewed annually.  
Laboratory personnel are assessed for competency prior to being permitted to 
work with patient samples.  Efforts to ensure protection of patient information 
include:

The laboratory is located in a controlled access building and laboratory doors are 
kept locked at all times. Visitors to the laboratory are required to be accompanied 
by laboratory staff at all times.  

Hard copy records or electronic copies of documents containing patient 
information are kept in the locked laboratory or other controlled access locations.   

An electronic database is used to store information related to patient samples 
processed by the laboratory.  

The database resides on a dedicated program server that is kept in a central, locked 
computer facility.  

The facility is supported by two IT specialists who maintain up to date security 
features including virus and firewall protection.  

Program access is limited to specified computers as designated by the laboratory 
director.  Each of these computers has a password restricted login screen.  

The database sample entry program itself is accessed through a password 
protected entry screen.  

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
The database program has different levels of access approval to limit unauthorized 
changes to specimen records and the program maintains a sample history.  

Upon specimen receipt each sample is assigned a unique, sequential laboratory 
accession ID number.  All products generated by the laboratory that will be stored 
either in the laboratory freezers or at a central repository facility are identified by 
this accession ID.

Inventory information will be stored at the vial level and each vial will be labeled 
with both a sample ID and a vial sequence number.  

Vial labels do not contain any personal identifier information.   

Samples are stored inventoried in locked laboratory freezers and are routinely 
transferred to the NCI-Frederick repository facilities for long term storage.  

Access to stored clinical samples is restricted.  Investigators establish sample 
collections under “Source Codes” and the investigator responsible for the 
collections, the protocol Principal Investigator, specifies who has access to the 
collection.  Specific permissions will be required to view, input or withdraw 
samples from a collection. 

Sample withdrawal requests submitted to approved laboratory staff by anyone 
other than the repository source code owner are submitted to the source code 
owner for approval.  The repository facility will also notify the Source Code holder 
of any submitted requests for sample withdrawal.  

It is the responsibility of the Source Code holder (the NCI Principal Investigator) 
to ensure that samples requested and approved for withdrawal are being used in 
a manner consistent with IRB approval.  

The Clinical Support Laboratory does perform testing services that may be 
requested 
by 
clinical 
investigators 
including, 
but 
not 
limited 
to, 
immunophenotyping by flow cytometry and cytokine testing using ELISA or 
multiplex platforms.  

When requests are submitted by the NCI investigator for shipment of samples 
outside of the NIH it is the policy of the laboratory to request documentation that 
appropriate approvals and/or agreements are  in place to cover  the specimen 
transfer.  The laboratory does not provide patient identifier information as part of 
the transfer process but may, at the discretion of the NCI investigator, group 
samples from individual patients when that is critical to the testing process.   

The NCI investigator responsible for the sample collection is responsible for 
ensuring appropriate IRB approvals are in place. Samples will not be sent outside 
NIH without appropriate approvals and/or agreements, if required.
6
CORRELATIVE STUDIES FOR RESEARCH 
6.1
BLOOD AND BONE MARROW SAMPLES
Note: Samples collected during the course of this study will be stored, tracked, and 
disposed of as specified in investigator’s companion protocol, 10-C-0066, on which all 
subjects will be co-enrolled.

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Tissue 
Sample 
Type
Test
Lab
Volume
Tube
Storage
Timing
Blood
Blood FACS
Flow Lab
B1B58
18cc
3- Na 
Heparin
Room 
Temperature
Pre-treatment
D1 of each cycle x 
6
Pre-cycle 4 
Restaging, 
end of -treatment 
restaging
Post-treatment;
with every bone 
marrow, every 6 
months x 2 years 
then yearly
Blood
LDH
Main Lab: 
Chemistry
6cc
1- 
Lithium 
Heparin 
Room 
Temperature
Pre-treatment
Cycle 1- D1-D2,
(D3 and D5 if at 
NIH)
D1 of each cycle x 
6
Pre-cycle 4 
Restaging
4-8 week post-
treatment 
restaging,
Post-treatment;
Every year x 2 
years, then every 
2 years if in CR 
otherwise 
continue yearly.
Blood
P-selectin, 
plasminogen 
activator 
inhibitor type 1, 
vWF activity, 
vWF antigen, 
thrombomodulin, 
d-Dimer, FDP, 
fibrinogen, 
Main Lab 
Coagulation
13.5cc
3- Na-
Citrate
On Ice
Cycle 1- D1-D2
(D3 and D5 if at 
NIH)

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Tissue 
Sample 
Type
Test
Lab
Volume
Tube
Storage
Timing
Blood
Haptoglobin
Main Lab: 
Chemistry
6cc
1-
Lithium 
Heparin 
Room 
Temperature
Pre-treatment 
Cycle 1- D1-D2
(D3 and D5 if at 
NIH)
Pre-cycle 4 
Restaging
4-8 week post-
treatment 
restaging
Post-treatment;
Every year x 2 
years, then every 
2 years if in CR 
otherwise 
continue yearly.
Blood
Reticulocytes
Main Lab: 
Hematology
4.5cc
1-EDTA
Room 
Temperature
Cycle 1- D1-D2
(D3 and D5 if at 
NIH)
Blood
Cloning and 
sequence 
immunoglobulin 
rearrangements
Kreitman or 
Figg Lab, 
please page 
designated 
person in 
orders to 
pick up.
5 green 
top 
tubes x 
3 sets
 Na- 
Heparin 
(total of 
15 tubes)
Room 
Temperature
3 sets drawn on 
different days 
prior to starting 
treatment if at 
NIH
Blood
Cytokines
Kreitman or 
Figg Lab, 
please page 
designated 
person in 
orders to 
pick up.
2cc
6ml Na- 
Heparin 
tube
Room 
Temperature
Pre-Bendamustine 
or Pre-
Pentostatin, Pre-
Rituximab, and 2, 
4 and 8 (each +/- 
1) hours from the 
start of the 
Rituximab 
Infusion, then 
next AM. Draw 1 
extra cytokine 
sample if rigors or 
temp >38.3.

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Tissue 
Sample 
Type
Test
Lab
Volume
Tube
Storage
Timing
Note: Samples collected during the course of this study will be stored, tracked, and disposed of as 
specified in investigator’s companion protocol, 10C0066, on which all subjects will be co-enrolled.
7
STATISTICAL CONSIDERATIONS

The primary objective of this randomized phase II trial is to determine if  the 
combination of pentostatin + rituximab and the combination of bendamustine + 
rituximab is associated with an adequate clinical response rate (PR+CR) in 
patients with relapsed hairy cell leukemia (HCL) and, if so, to select for further 
investigation, the combination which is likely to be superior.

Data from 51 patients who were similar to the patients to be enrolled on this 
study have exhibited a 39% response rate (20/51 responses) to rituximab alone.  
As such, since each arm would be testing a combination of agents which would 
include rituximab, it would be desirable to rule out a response rate which is 
somewhat greater than 39%.

Prior to randomization, 12 patients will be treated with bendamustine + 
rituximab at 2 dose levels and evaluated for toxicity in order to determine if each 
combination is safe for use in subsequent patients. Randomization will begin 
using the higher of the 2 dose levels of bendamustine providing 5-6 of the 6 
patients can tolerate the 6 cycles without delays > 4 weeks.  If neither dose level 
is tolerated to this extent, the trial may need to be amended prior to 
randomization, or accrual will be discontinued.

Patients will be stratified according to whether they are purine analog refractory 
vs. sensitive vs. unknown.  Within the refractory category will be patients with 
untreated poor-risk disease, namely HCLv and unmutated IGHV4-34+ HCL.

Patients will be randomized between bendamustine + rituximab or pentostatin 
+ rituximab. For each arm of the trial, the  study will be conducted using an 
optimal two-stage phase II design (Simon R, Controlled Clinical Trials 10:1-10, 
1989), in order to rule out an unacceptably low 40% clinical response rate 
(PR+CR; p0=0.40)  in favor of a higher response rate of 65% (p1=0.65). With 
alpha=0.10 (probability of accepting a poor treatment=0.10) and beta = 0.10 
(probability of rejecting a good treatment=0.10), the study will initially enroll 13 
evaluable (randomized) patients onto each arm, and if 0-5 of the 13 on a given 
arm have a clinical response (CR+PR), then no further patients will be accrued 
to that arm. If 6 or more the first 13 have a response, then accrual would continue 
until a total of 28 evaluable patients have enrolled on that arm. As it may take 
several weeks to determine if a patient has experienced a clinical response, a 
temporary pause in the accrual to the trial may be necessary to ensure that 
enrollment to the second stage is warranted. If there are 6-14 clinical responses 

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in 28 patients on an arm, this would be an uninterestingly low response rate, 
while if there were 15 or more responses in 28 patients on that arm, then this 
would be considered a sufficiently interesting response rate. Under the null 
hypothesis (40% response rate), the probability of early termination for each arm 
is 57%.

If accrual stops early to one arm because of insufficient activity, patients will 
continue to be accrued in a non-randomized fashion to the other arm. If both 
arms end accrual early, neither combination would be pursued further. If 28 
patients are treated on each arm, and if one arm has at least 15 responses and the 
other does not, then only the arm with 15 or more responses would be worthy 
of further study. If both arms have at least 15 responses, then a selection design 
approach will be used to determine which of the two combinations is worthy of 
further investigation. Using this approach, the arm with the greater total number 
of responses (CR+PR) will be selected for further study. If there is a tie in the 
number of responses, then secondary criteria, such as the number of CRs, the 
duration of response, or the amount of toxicity noted will be used to select the 
superior arm. Taking into consideration the two-stage nature of the design, the 
following table provides the probability that the truly superior arm will be 
selected following the rule stated above:
True response probability in
Inferior arm
Superior arm 
Probability of correctly selecting the superior arm
0.40
0.55
87.0%
0.40
0.60
93.3%
0.40
0.65
97.1%
0.45
0.55
77.2%
0.45
0.60
87.0%
0.45
0.65
93.5%
0.50
0.60
77.4%
0.50 
0.65
87.2%

Thus, with 28 patients on each arm, the inferior arm having a true 40-50% 
response rate, and the superior arm having a true response rate of 55-65%, there 
is at least a 77% probability of correctly selecting the superior arm.

To select the best arm, ORR (PR+CR) would normally be used, but more 
stringent measures of response could be used to discriminate the 2 arms, 
including CR rate, MRD-free CR rate, and rates of patients who have a 6 month 
duration of response.  

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
The study is being designed as a selection trial. Only large differences, on the 
order of 35% to 40% or more, can be detected between the arms with 80% power 
(2-way p=0.05).

Accrual was expected to be 16-24 patients per year; however, that has not held 
true. Instead, the accrual has been about 6 per year and is likely to continue at 
that rate. There are 3 groups of patients in the study: 
1.
Twelve evaluable non-randomized patients in the Dose Escalation 
group
2.
Fifty-six evaluable randomized patients in the Dose Expansion 
group
3.
Four evaluable patients who were previously refractory to therapy 
or untreated with poor-risk disease in the Dose expansion, non-
randomized group.
At this rate, 72 evaluable patients will be enrolled in approximately 12 years. The 
accrual ceiling is set at 200, which includes patients consented for screening and 
enrolled.    

The trial would be a single-institution trial at NIH.  

The most important secondary endpoint of the study is to compare rituximab 
plus either pentostatin or bendamustine in terms of MRD-free survival and 
disease-free survival, and toxicity, including to CD4+ T-cells. Patients will also 
be followed for overall survival.

Another secondary endpoint is to compare the 2 regimens in crossover when 
used after failure of the 1st regimen.  It may be determined whether the 1st 
regimen in each patient was more effective than the 2nd regimen, or vice versa, 
and it may also be determined whether one regimen is better than the other in 
crossover, considering all patients crossed over.  However, it is recognized that 
this endpoint is only exploratory since crossover is not universal and not at a 
fixed time.

Other secondary endpoints on this study include: 1) To determine if MRD levels 
and tumor markers (soluble CD25 and CD22, and RQ-PCR) correlate with 
response and clinical endpoints, and could possibly replace BMBx, 2) to correlate 
bone marrow MRI signal with bone marrow biopsy, patients will obtain cervical 
and thoracic spine MRI at baseline and at bone marrow restaging time points, 
when feasible, 3) To enhance the study of HCL biology by cloning, sequencing 
and characterizing monoclonal immunoglobulin rearrangements, and other 
genes, and 4) To study the mechanism of thrombocytopenia after purine analog 
plus rituximab.  These endpoints would be considered exploratory.

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8
COLLABORATIVE AGREEMENTS
8.1
 COOPERATIVE RESEARCH AND DEVELOPMENT AGREEMENT (CRADA)
CRADA #02753 between Genentech and NCI was executed 11/8/2012 and amended 
11/3/2017. CTA #00819 between NCI and Cephalon was executed on 07/20/2017.
9
HUMAN SUBJECTS PROTECTIONS 
9.1
RATIONALE FOR SUBJECT SELECTION
Both men and women and members of all races and ethnic groups are eligible for this 
trial.  Pregnant women are not allowed to enroll because both bendamustine and 
pentostatin may pose significant risks to the fetus.
9.2
PARTICIPATION OF CHILDREN  
Children will not be eligible for this study.  HCL is a disease of adults, not children, and 
it is unlikely that any children will be diagnosed. 
9.3
PARTICIPATION OF SUBJECTS UNABLE TO CONSENT
Adults unable to give consent are excluded from enrolling in the protocol.  However, re-
consent may be necessary and there is a possibility, though unlikely, that subjects could 
become decisionally impaired. For this reason and because there is a prospect of direct 
benefit from research participation (Section 9.5), all subjects ≥ age 18 will be offered the 
opportunity to fill in their wishes for research and care, and assign a substitute decision 
maker on the “NIH Advance Directive for Health Care and Medical Research 
Participation” form so that another person can make decisions about their medical care 
in the event that they become incapacitated or cognitively impaired during the course of 
the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team 
(ACAT) for evaluation to assess ongoing capacity of the subjects and to identify an LAR, 
as needed.
Please see Section 9.6.1 for consent procedure.
9.4
EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS
9.4.1
Potential benefits  
Purine analog in combination with rituximab may lead to durable responses including 
CR in patients.  
9.4.2
Risks/discomforts
Purine analogs have many toxicities, some of which can be long term.  Rituximab has 
mainly short-term toxicities and could select for cells deficient in apoptosis and render 
patients unresponsive to rituximab and other agents when they relapse later in their 
disease course.  Moreover, it is possible that the risk of infection may increase with use of 
rituximab with purine analog.

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9.5
RISK/BENEFIT ANALYSIS  
Patients are multiply relapsed from purine analog and have either received or are 
ineligible for immunotoxin treatment.  They will have limited options and may obtain 
better response to purine analog plus rituximab as compared with purine analog or 
rituximab alone.
9.5.1
Risks from Study Procedures
9.5.1.1
Blood draws
Side effects of blood draws include pain and bruising, lightheadedness, and rarely, 
fainting.
9.5.1.2
Urine collection
There is no physical risk involved with urine collection.
9.5.1.3
Bone marrow aspirate and/or biopsy
Bone marrow biopsy is minimally invasive and is typically a very safe procedure. Usually 
hipbone is numbed with anesthesia. Using a needle, the solid and liquid portion of bone 
marrow is taken out. This procedure causes some pain. Very rarely, infection or bleeding 
may occur at the needle site.
9.5.1.4
Local anesthesia
Bone marrow biopsy may be done under local anesthesia. Potential side effects of local 
anesthesia include drowsiness, headaches, blurred vision, twitching muscles or 
shivering, continuing numbness, weakness or pins and needles sensation.
9.5.1.5
Echocardiogram
There is no physical risk involved with echocardiogram. Side effects of an 
echocardiogram are discomfort from the transducer being firmly placed against the chest.
9.5.1.6
Electrocardiogram
Some skin irritation can occur where the ECG/EKG electrodes are placed. The test is 
completely painless, and generally takes less than a minute to perform.
9.5.1.7
Stress test
A stress test is generally safe, and complications are rare. Risks of complication include 
hypotension, arrhythmias, or myocardial infarction.
9.5.1.8
Pulmonary function tests (PFTs)
PFTs are usually safe for most people. Risks of complication include dizziness, asthma 
attack, or collapsed lung.
9.5.1.9
Ultrasound
No physical risks are associated with ultrasound procedures.
9.5.1.10 Imaging

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In addition to the radiation risks discussed below, CT scans may include the risks of an 
allergic reaction to the contrast. Participants might experience hives, itching, headache, 
difficulty breathing, increased heartrate and swelling.
9.5.1.11 MR Imaging
The risks of MR imaging are relatively small.
Participants undergoing gadolinium enhanced MRIs may also be at risk for kidney 
damage. MRIs include the additional risk of damage to hearing.
9.5.2
Risks from Radiation Exposure
On this study, patients will receive up to four CT scans (including screening). The total 
radiation dose for research purposes will be approximately 5.2 rem. The risk of getting 
cancer from the radiation exposure in this study is 0.5% and of getting a fatal cancer is 
0.3%.
9.6
CONSENT PROCESS AND DOCUMENTATION  
The informed consent document will be provided as a physical or electronic document 
to the participant or consent designee(s) as applicable for review prior to consenting.  A 
designated study investigator will carefully explain the procedures and tests involved in 
this study, and the associated risks, discomforts and benefits. In order to minimize 
potential coercion, as much time as is needed to review the document will be given, 
including an opportunity to discuss it with friends, family members and/or other 
advisors, and to ask questions of any designated study investigator. A signed informed 
consent document will be obtained prior to entry onto the study.
The initial consent process as well as re-consent, when required, may take place in person 
or remotely (e.g., via telephone or other NIH approved remote platforms used in 
compliance with policy, including HRPP Policy 303) per discretion of the designated 
study investigator and with the agreement of the participant/consent designee(s).  
Whether in person or remote, the privacy of the subject will be maintained. Consenting 
investigators (and participant/consent designee, when in person) will be located in a 
private area (e.g., clinic consult room). When consent is conducted remotely, the 
participant/consent designee will be informed of the private nature of the discussion and 
will be encouraged to relocate to a more private setting if needed.
Consent will be documented with required signatures on the physical document (which 
includes the printout of an electronic document sent to participant) or as described below, 
with a manual (non-electronic) signature on the electronic document. When required, 
witness signature will be obtained similarly as described for the investigator and 
participant.
Manual (non-electronic) signature on electronic document:
When a manual signature on an electronic document is used for the documentation of 
consent at the NIH Clinical Center, this study will use the following to obtain the required 
signatures:

Adobe platform (which is not 21 CFR Part 11 compliant); or,  

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
iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of 
the approved consent document on screens at their respective locations (if remote 
consent); the same screen may be used when in the same location but is not required.  
Both the investigator and the participant will sign the document using a finger, stylus or 
mouse. 
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent 
Process for additional information (e.g., verification of participant identity when 
obtaining 
consent 
remotely) 
found 
at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825
9.6.1
Consent Process for Adults Who Lack Capacity to Consent to Research 
Participation
For participants addressed in Section 9.3, an LAR will be identified consistent with Policy 
403 and informed consent obtained from the LAR, as described in Section 9.6.
9.6.2
Request for Waiver of Consent for Screening Activities
Prior to the subject signing the consent for this study pre-screening activities listed in 
Section 2.2.1 may be performed. 
We request a waiver of consent for these activities as they involve only minimal risk to 
the subjects.  A waiver will not adversely affect the rights and welfare of the subjects 
given that the activities are only intended to determine suitability for screening for 
participation in research protocols.  These activities could not practicably be carried out 
without the waiver as central recruiting services, utilized in the NIH Clinical Center, 
perform pre-screening activities for multiple studies and obtaining consent for each one 
is beyond their resources.  The subjects will be provided with additional pertinent 
information after participation as they will be informed whether or not they are eligible 
to sign a consent for additional screening.
10 NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING 
PLAN 
10.1 DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&
Guidance-800Series-ComplianceandResearchEventReportingRequirements.
10.2 OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING
10.2.1 Expedited Reporting 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and 
Policy 
802 
Non-Compliance 
Human 
Subjects 
Research 
found 
at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&
Guidance-800Series-ComplianceandResearchEventReportingRequirements.

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10.2.2 IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found 
at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&
Guidance-800Series-ComplianceandResearchEventReportingRequirements. 
10.3 NCI CLINICAL DIRECTOR REPORTING
Problems expeditiously reported to the OHSRP in the NIH eIRB system will also be 
reported to the NCI Clinical Director/designee; therefore, a separate submission for these 
reports is not necessary.  
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email unless they are due to progressive disease.  
To report these deaths, please send an email describing the circumstances of the death to  
NCICCRQA@mail.nih.gov within one business day of learning of the death.
10.4 NIH REQUIRED DATA AND SAFETY MONITORING PLAN
10.4.1 Principal Investigator/Research Team 
The clinical research team will meet on a regular basis (weekly) when patients are being 
actively treated on the trial to discuss each patient. Decisions about dose level enrollment 
and dose escalation if applicable will be made based on the toxicity data from prior 
patients. 
All data will be collected in a timely manner and reviewed by the principal investigator 
and members of the research team. Events meeting requirements for expedited reporting 
as described in Section 10.2.1 will be submitted within the appropriate timelines.
The principal investigator will review adverse event and response data on each patient 
to ensure safety and data accuracy. The principal investigator will personally conduct or 
supervise the investigation and provide appropriate delegation of responsibilities to 
other members of the research staff. 
11 SAFETY 
REPORTING 
CRITERIA 
TO 
THE 
PHARMACEUTICAL 
COLLABORATORS
11.1 DEFINITIONS
11.1.1 Adverse Event 
Any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product and which does not necessarily have a causal 
relationship with this treatment. An adverse event (AE) can therefore be any unfavorable 
and unintended sign (including an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of a medicinal (investigational) product, whether or 
not related to the medicinal (investigational) product (ICH E6 (R2)).

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11.1.2 Serious Adverse Event (SAE)
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following:

Death,

A life-threatening adverse event (see Section 11.1.3)
o
Inpatient hospitalization or prolongation of existing hospitalization

Persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions

A congenital anomaly/birth defect.

Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered a serious adverse drug experience 
when, based upon appropriate medical judgment, they may jeopardize the patient 
or subject and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition.
11.1.3 Life-threatening 
An adverse event or suspected adverse reaction is considered "life-threatening" if, in the 
view of either the investigator or sponsor, its occurrence places the patient or subject at 
immediate risk of death. It does not include an adverse event or suspected adverse 
reaction that, had it occurred in a more severe form, might have caused death. 
(21CFR312.32).
11.2 REPORTING OF SERIOUS ADVERSE EVENTS ASSOCIATED WITH RITUXIMAB  

All serious adverse events (SAEs) regardless of causality to rituximab (this 
applies to both expected and unexpected events) should be recorded on a 
MedWatch 3500A Form and faxed to:
Genentech Drug Safety 
Tel:
(888) 835-2555
Fax:
(650) 225-4682 or (650) 225-4683
Forward all SAEs also to the IRB and PI as directed in Section 10.2.
11.3 ADVERSE EVENTS OF SPECIAL INTEREST (AESI)
Adverse events of special interest for this study include the following:

Cases of potential drug-induced liver injury that include an elevated ALT or AST 
in combination with either an elevated bilirubin or clinical jaundice, as defined by 
Hy’s law:
o
Treatment-emergent ALT or AST > 3 ´ ULN in combination with total 
bilirubin > 2 ´ ULN
o
Treatment-emergent ALT or AST > 3 ´ ULN in combination with clinical 
jaundice

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
Data related to a suspected transmission of an infectious agent by the study drug 
(STIAMP), as defined below:
Any organism, virus, or infectious particle (e.g., prion protein transmitting transmissible 
spongiform encephalopathy), pathogenic or non-pathogenic, is considered an infectious 
agent.  A transmission of an infectious agent may be suspected from clinical symptoms 
or laboratory findings that indicate an infection in a patient exposed to a medicinal 
product.  This term applies only when a contamination of the study drug is suspected.
11.4 MEDWATCH 3500A REPORTING GUIDELINES:  

In addition to completing appropriate patient demographic and suspect 
medication information, the report should include the following information 
within the Event Description (section 5) of the MedWatch 3500A form:
o
Treatment regimen (dosing frequency, combination therapy)
o
Protocol description (and number, if assigned)
o
Description of event, severity, treatment, and outcome if known
o
Supportive laboratory results and diagnostics
o
Investigator’s assessment of the relationship of the adverse event to each 
investigational product and suspect medication

Follow-up information.  Additional information may be added to a previously 
submitted report by any of the following methods:
o
Adding to the original MedWatch 3500A report and submitting it as follow-
up
o
Adding supplemental summary information and submitting it as follow-
up with the original MedWatch 3500A form 
o
Summarizing new information and faxing it with a cover letter including 
subject identifiers (i.e. D.O.B. initial, subject number), protocol description 
and number, if assigned, suspect drug, brief adverse event description, and 
notation that additional or follow-up information is being submitted (The 
patient identifiers are important so that the new information is added to the 
correct initial report)
o
Occasionally Genentech may contact the reporter for additional 
information, clarification, or current status of the subject for whom and 
adverse event was reported.  For questions regarding SAE reporting, you 
may contact the Genentech Drug Safety representative noted above.

Study Drug Relationship.  The investigator will determine which events are 
associated with the use of the study drugs.  For reporting purposes, an AE 
should be regarded as possibly related to the use of the investigational product 
if the investigator believes:
o
There is a clinically plausible time sequence between onset of the AE and 
rituximab administration; and/or
o
There is a biologically plausible mechanism for rituximab causing or 
contributing to the AE; and
o
The AE cannot be attributed solely to concurrent/underlying illness, other 
drugs, or procedures.

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11.5
 PRODUCT COMPLAINT REPORTING
11.5.1 Product Complaint
Any written or oral information received from a complainant that alleges deficiencies 
related to identity, quality, safety, strength, purity, reliability, durability, effectiveness or 
performance of a product after it has been released and distributed to the commercial 
market or clinical trial.
11.5.2 Reporting of Product Complaint

For all Investigator Initiated Studies (interventional and non-interventional):
Product Complaints with an AE (adverse event) should be reported via email/fax 
to: usds_aereporting-d@gene.com OR 650-238-6067

Product Complaints without an AE should call via:
PC Hotline Number: (800) 334-0290 (M-F: 5 am to 5 pm PST)

For 
Non-Interventional 
Investigator 
Initiated 
Studies: 
us.clinops.sae@tevapharm.com
All complaints must be filed within 1 business day for pre-approved products and 15 calendar 
days for approved products. Complaints can be reported using a Medwatch, CIOMS or any 
Genentech-approved reporting form (same as SAEs, AESI etc.).
11.6 SAFETY REPORTING REQUIREMENTS FOR IND EXEMPT STUDIES (GENENTECH 
INFORMATION)

For Investigator Sponsored IND Exempt Studies, there are some reporting 
requirements for the FDA in accordance with the guidance set forth in 21 CFR 
314.80.

Postmarketing 15-Day “Alert Report”:  The Sponsor-Investigator is required to 
notify the FDA of any fatal or life-threatening adverse event that is unexpected 
and assessed by the investigator to be possibly related to the use of Rituximab. 
An unexpected adverse event is one that is not already described in the 
Investigator Brochure. Such reports are to be submitted to the FDA (2 copies) 
at the following address: Central Document Room, 12229 Wilkins Avenue, 
Rockville, MD 20852.

All Postmarketing 15-Day “Alert Reports” submitted to the FDA by the 
Sponsor-Investigator must also be faxed to:  Genentech Drug Safety, Fax:(650) 
225-4682 or (650) 225-4683, (Please use the safety reporting fax cover sheet 
attached to this document for your fax transmission. Also provided on Rituxan 
CD-ROM).

For questions related to safety reporting, contact:  Genentech Drug Safety, 
Tel:1-888-835-2555 or Fax: (650) 225-4682 or (650) 225-4683 (Please use the 
safety reporting fax cover sheet attached to this document for your fax 
transmission).  

Principal investigator contact information and fax #:  Robert J. Kreitman, M.D., 
Chief, Clinical Immunotherapy Section, Laboratory of Molecular Biology 

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(LMB), Centers for Cancer Research (CCR), National Cancer Institute (NCI), 
NIH (9000 Rockville Pike, Bethesda, MD  20892), building 37/5124b, Phone 
301-480-6187, email kreitmar@mail.nih.gov
11.7 REQUIREMENTS FOR REPORTING TO TEVA FOR PATIENTS GETTING BENDAMUSTINE

“Serious Adverse Event or Adverse Drug Reaction (AE/ADR)” means any 
AE/ADR occurring at any dose that results in any of the following outcomes:
(a) Death;
(b) A life-threatening AE/ADR (i.e., the patient/subject was, in the view of 
the initial reporter/investigator, at immediate risk of death from the 
AE/ADR as it occurred. It does not refer to an AE/ADR that 
hypothetically might have caused death if more severe);
(c) Inpatient hospitalization or prolongation of existing hospitalization (i.e., 
hospitalization was required to treat or diagnose the AE/ADR; excludes 
hospitalization for unrelated reasons);
(d) A persistent or significant disability or incapacity (disability here means 
that there is a substantial disruption of a person’s ability to conduct 
normal life functions;
(e) A congenital anomaly/birth defect.
(f) An important medical event (i.e., AEs/ADRs that might not be 
immediately life-threatening, or result in death or hospitalization might 
be considered serious when, based upon appropriate medical and 
scientific judgment, they might jeopardize the patient/subject or might 
require medical or surgical intervention to prevent one of the other 
serious outcomes listed above);
(g) Any suspected transmission via a medicinal product of an infectious 
agent; 

Sponsor-Investigator shall use his/her judgment to determine the relationship 
between the Serious Adverse Drug Experience and the Study Drug.

Institution shall notify the IRB and Teva within 15 business days, by facsimile 
at 215-619-3825 or Email to us.clinops.sae.tevapharm.com, upon learning of the 
occurrence during the Study of:
(a) All Serious AE/ADRs, regardless of causality;
(b) Any exposure of a pregnant Study participant to the Study Drug within 
thirty (30) days of exposure;
(c) A female partner of a male Study participant becoming pregnant within 
thirty (30) days of exposure; 
(d) Any medical event which may reasonably be believed to impair the 
integrity, validity or ongoing viability of the Study.

All such occurrences listed in this section shall be reported to Teva using the 
MedWatch 3500A Form 

In the event the IRB requests additional safety information from Sponsor-
Investigator, Sponsor-Investigator shall notify Teva of such request within 15 
business days.

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12 REGULATORY AND OPERATIONAL CONSIDERATIONS
12.1 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study 
participants, investigator, funding agency, and regulatory authorities.  If the study is 
prematurely terminated or suspended, the Principal Investigator (PI) will promptly 
inform study participants and the Institutional Review Board (IRB) and will provide the 
reason(s) for the termination or suspension.  Study participants will be contacted, as 
applicable, and be informed of changes to study visit schedule.
 Circumstances that may warrant termination or suspension include, but are not limited 
to:

Determination of unexpected, significant, or unacceptable risk to participants

Demonstration of efficacy that would warrant stopping   

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the IRB.
12.2 QUALITY ASSURANCE AND QUALITY CONTROL
The clinical site will perform internal quality management of study conduct, data and 
biological specimen collection, documentation and completion.  An individualized 
quality management plan will be developed to describe a site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry 
system and data QC checks that will be run on the database will be generated. Any 
missing data or data anomalies will be communicated to the site(s) for 
clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that 
the clinical trial is conducted and data are generated and biological specimens are 
collected, documented (recorded), and reported in compliance with the protocol, 
International Conference on Harmonisation Good Clinical Practice (ICH GCP), and 
applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good 
Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source 
data/documents, and reports for the purpose of monitoring and auditing, and inspection 
by local and regulatory authorities.
12.3 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical.  Therefore, any actual conflict of interest of persons 
who have a role in the design, conduct, analysis, publication, or any aspect of this trial 

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will be disclosed and managed. Furthermore, persons who have a perceived conflict of 
interest will be required to have such conflicts managed in a way that is appropriate to 
their participation in the design and conduct of this trial.  The study leadership in 
conjunction with the National Cancer Institute has established policies and procedures 
for all study group members to disclose all conflicts of interest and will establish a 
mechanism for the management of all reported dualities of interest.
12.4 CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating 
investigators, their staff, and the sponsor(s). This confidentiality is extended to cover 
testing of biological samples and genetic tests in addition to the clinical information 
relating to participants. Therefore, the study protocol, documentation, data, and all other 
information generated will be held in strict confidence. No information concerning the 
study or the data will be released to any unauthorized third party without prior written 
approval. 
All research activities will be conducted in as private a setting as possible.
The study monitor, representatives of the Institutional Review Board (IRB), and/or 
regulatory agencies may inspect all documents and records required to be maintained by 
the investigator, including but not limited to, medical records (office, clinic, or hospital) 
and pharmacy records for the participants in this study. The clinical study site will permit 
access to such records.
The study participant’s contact information will be securely stored at the clinical site for 
internal use during the study. At the end of the study, all records will continue to be kept 
in a secure location for as long a period as dictated by the reviewing IRB or Institutional 
policies.
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be stored at the NCI CCR. This will not include the participant’s contact 
or identifying information. Rather, individual participants and their research data will be 
identified by a unique study identification number. The study data entry and study 
management systems used by the clinical site and by NCI CCR research staff will be 
secured and password protected. At the end of the study, all study databases will be 
archived at the NIH.
To further protect the privacy of study participants, a Certificate of Confidentiality has 
been issued by the National Institutes of Health (NIH).  This certificate protects 
identifiable research information from forced disclosure. It allows the investigator and 
others who have access to research records to refuse to disclose identifying information 
on research participation in any civil, criminal, administrative, legislative, or other 
proceeding, whether at the federal, state, or local level. By protecting researchers and 
institutions from being compelled to disclose information that would identify research 
participants, Certificates of Confidentiality help achieve the research objectives and 
promote participation in studies by helping assure confidentiality and privacy to 
participants.

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13 PHARMACEUTICAL INFORMATION
13.1 BENDAMUSTINE
Please, refer to package insert.
13.1.1 Source
Bendamustine is commercially available under the name of Treanda and obtained from 
Teva Pharmaceutical Industries Ltd. 
13.1.2 Administration Procedures  
Bendamustine is administered as a 30-60-minute intravenous (IV) infusion.  Precautions 
should be taken to avoid extravasation, including monitoring of the intravenous infusion 
site for redness, swelling, pain, infection and necrosis during and after the 
administration.
13.2 PENTOSTATIN (NIPENT) 
Please, refer to package insert.
13.2.1 Source
Pentostatin is commercially available under the trade name Nipent, and will be obtained 
from commercial sources from the Clinical Center Pharmacy. 
13.2.2 Administration Procedures  
Pentostatin may be given intravenously by bolus injection or diluted in a larger volume 
(25 to 50 mL) with 5% dextrose injection or 0.9% sodium chloride injection. Dilution of 
the entire contents of a reconstituted vial with 25 mL or 50 mL provides a pentostatin 
concentration of 0.33 mg/mL or 0.18 mg/mL, respectively, for the diluted solutions.  
Although the dose level of pentostatin is 4 mg/m2, patients who are at least 2.5 m2 will 
only receive a maximum of 10 mg total dose.
13.3 RITUXIMAB (RITUXAN) FROM GENENTECH 
Please, refer to package insert.
13.3.1 Source
Rituximab will be provided free of charge by Genentech and Biogen IDEC. The 
Sponsor/Investigator of the study will ensure maintenance of complete and accurate 
records of the receipt, dispensation, and disposal or return of all study drug in accordance 
with 21 Code of Federal Regulations (C.F.R.), Part 312.57 and 312.62 and Genentech 
requirements. 
13.3.2 Administration Procedures  

DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS. Infusion and 
hypersensitivity 
reactions 
may 
occur. 
 
Premedication, 
consisting 
of 
acetaminophen and diphenhydramine, should be considered before each infusion 
of rituximab.  Premedication may attenuate infusion-related events. Since 
transient hypotension may occur during rituximab infusion, consideration should 

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be given to withholding anti-hypertensive medications 12 hours prior to rituximab 
infusion.  See Appendix C in Section  15.3 for more information.  

First Infusion: The rituximab solution for infusion should be administered 
intravenously at an initial rate of 50 mg/hr. Rituximab should not be mixed or 
diluted with other drugs. If hypersensitivity or infusion-related events do not 
occur, escalate the infusion rate in 50 mg/hr increments every 30 minutes, to a 
maximum of 400 mg/hr.  

Rituximab infusion should be interrupted for severe reactions.  In most cases, the 
infusion can be resumed at a 50% reduction in rate (e.g., from 100mg/hr to 
50mg/hr) when symptoms have completely resolved.  Most patients who have 
experienced non-life-threatening infusion-related reactions have been able to 
complete the full course of rituximab therapy

Subsequent Infusions: If the subject tolerated the first infusion well, subsequent 
rituximab infusions can be administered at an initial rate of 100 mg/hr, and 
increased by 100 mg/hr increments at 30-minute intervals, to a maximum of 400 
mg/hr as tolerated.  If the first infusion was not well tolerated, the guidelines for 
the first infusion should be followed for the subsequent infusions.

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
14 REFERENCES
1.
Beutler E: Cladribine (2-chlorodeoxyadenosine). Lancet 1992, 340(8825):952-956.
2.
Carson DA, Kaye J, Seegmiller JE: Differential sensitivity of human leukemic T cell 
lines and B cell lines to growth inhibition by deoxyadenosine. J Immunol 1978, 
121(5):1726-1731.
3.
Carson DA, Kaye J, Seegmiller JE: Lymphospecific toxicity in adenosine deaminase 
deficiency and purine nucleoside phosphorylase deficiency: possible role of 
nucleoside kinase(s). Proceedings of the National Academy of Sciences of the United 
States of America 1977, 74(12):5677-5681.
4.
Piro LD, Carrera CJ, Carson DA, Beutler E: Lasting remissions in hairy-cell leukemia 
induced by a single infusion of 2-chlorodeoxyadenosine. N Engl J Med 1990, 
322(16):1117-1121.
5.
Saven A, Burian C, Koziol JA, Piro LD: Long-term follow-up of patients with hairy 
cell leukemia after cladribine treatment. Blood 1998, 92(6):1918-1926.
6.
Goodman GR, Burian C, Koziol JA, Saven A: Extended follow-up of patients with 
hairy cell leukemia after treatment with cladribine. J Clin Oncol 2003, 21(5):891-896.
7.
Cheson BD, Sorensen JM, Vena DA, Montello MJ, Barrett JA, Damasio E, Tallman M, 
Annino L, Connors J, Coiffier B et al: Treatment of hairy cell leukemia with 2-
chlorodeoxyadenosine via the Group C protocol mechanism of the National Cancer 
Institute: a report of 979 patients. J Clin Oncol 1998, 16(9):3007-3015.
8.
Robak T, Blasinska-Morawiec M, Krykowski E, Hansz J, Komarnicki M, Kazimierczak 
M, Konopka L, Maj S, Hellmann A, Zaucha JM et al: 2-chlorodeoxyadenosine (2-CdA) 
in 2-hour versus 24-hour intravenous infusion in the treatment of patients with 
hairy cell leukemia. Leuk Lymphoma 1996, 22(1-2):107-111.
9.
von Rohr A, Schmitz SF, Tichelli A, Hess U, Piguet D, Wernli M, Frickhofen N, 
Konwalinka G, Zulian G, Ghielmini M et al: Treatment of hairy cell leukemia with 
cladribine (2-chlorodeoxyadenosine) by subcutaneous bolus injection: a phase II 
study. Ann Oncol 2002, 13(10):1641-1649.
10.
Juliusson G, Heldal D, Hippe E, Hedenus M, Malm C, Wallman K, Stolt CM, Evensen 
SA, Albertioni F, Tjonnfjord G et al: Subcutaneous injections of 2-
chlorodeoxyadenosine for symptomatic hairy cell leukemia. J Clin Oncol 1995, 
13(4):989-995.
11.
Sonderegger T, Betticher DC, Cerny T, Lauterburg BH: Pharmacokinetics of 2-chloro-
2 '-deoxyadenosine administered subcutaneously or by continuous intravenous 
infusion. Cancer Chemother Pharmacol 2000, 46(1):40-42.
12.
Damasio EE, Resegotti L, Masoudi B, Bruni R, Cerri R, Isaza A, Clavio M, Risso M, 
Rossi E, Spriano M et al: Five day intermittent vs seven day continuous 2-
chlorodeoxyadenosine infusion for the treatment of hairy cell leukemia. A study by 
Italian Group for the Hairy Cell Leukemia. Recenti Prog Med 1998, 89(2):68-73.
13.
Bouroncle BA: Thirty-five years in the progress of hairy cell leukemia. Leuk 
Lymphoma 1994, 14 Suppl 1:1-12.
14.
Kreitman RJ, Cheson BD: Malignancy: Current Clinical Practice: Treatment of 
Hairy Cell Leukemia at the Close of the 20th Century. Hematology (Amsterdam, 
Netherlands) 1999, 4(4):283-303.

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
64
15.
Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ: Cancer statistics, 2007. CA: a 
cancer journal for clinicians 2007, 57(1):43-66.
16.
Sharpe RW, Bethel KJ: Hairy cell leukemia: diagnostic pathology. Hematol Oncol Clin 
North Am 2006, 20(5):1023-1049.
17.
Cawley JC: The pathophysiology of the hairy cell. Hematol Oncol Clin North Am 2006, 
20(5):1011-1021.
18.
Robbins BA, Ellison DJ, Spinosa JC, Carey CA, Lukes RJ, Poppema S, Saven A, Piro 
LD: Diagnostic application of two-color flow cytometry in 161 cases of hairy cell 
leukemia. Blood 1993, 82(4):1277-1287.
19.
Matutes E, Oscier D, Montalban C, Berger F, CalletBauchu E, Dogan A, Felman P, 
Franco V, Iannitto E, Mollejo M et al: Splenic marginal zone lymphoma proposals for 
a revision of diagnostic, staging and therapeutic criteria. Leukemia 2008, 22(3):487-
495.
20.
Matutes E: Immunophenotyping and differential diagnosis of hairy cell leukemia. 
Hematol Oncol Clin North Am 2006, 20(5):1051+.
21.
Golomb HM, Catovsky D, Golde DW: Hairy cell leukemia: a clinical review based on 
71 cases. Ann Intern Med 1978, 89(5 Pt 1):677-683.
22.
Habermann TM: Splenectomy, interferon, and treatments of historical interest in 
hairy cell leukemia. Hematol Oncol Clin North Am 2006, 20(5):1075-1086.
23.
Kraut EH, Bouroncle BA, Grever MR: Pentostatin in the treatment of advanced hairy 
cell leukemia. J Clin Oncol 1989, 7(2):168-172.
24.
Grem JL, King SA, Cheson BD, Leyland-Jones B, Wittes RE: Pentostatin in hairy cell 
leukemia: treatment by the special exception mechanism. J Natl Cancer Inst 1989, 
81(6):448-453.
25.
Spiers AS, Moore D, Cassileth PA, Harrington DP, Cummings FJ, Neiman RS, Bennett 
JM, MJ OC: Remissions in hairy-cell leukemia with pentostatin (2'-
deoxycoformycin). N Engl J Med 1987, 316(14):825-830.
26.
Spiers AS, Parekh SJ: Complete remission in hairy cell leukaemia achieved with 
pentostatin [letter]. Lancet 1984, 1(8385):1080-1081.
27.
Grever M, Kopecky K, Foucar MK, Head D, Bennett JM, Hutchison RE, Corbett WE, 
Cassileth PA, Habermann T, Golomb H et al: Randomized comparison of pentostatin 
versus interferon alfa-2a in previously untreated patients with hairy cell leukemia: 
an intergroup study. J Clin Oncol 1995, 13(4):974-982.
28.
Flinn IW, Kopecky KJ, Foucar MK, Head D, Bennett JM, Huchison R, Corbett W, 
Cassileth P, Habermann T, Golomb H et al: Long-term follow-up of remission 
duration, mortality, and second malignancies in hairy cell leukemia patients treated 
with pentostatin. Blood 2000, 96(9):2981-2986.
29.
Johnston JB, Eisenhauer E, Wainman N, Corbett WEN, Zaentz SD, Daeninck P: Long-
term outcome following treatment of hairy cell leukemia with pentostatin (Nipent): 
A National Cancer Institute of Canada Study. Semin Oncol 2000, 27(2):32-36.
30.
Rafel M, Cervantes F, Beltran JM, Zuazu F, Hernandez Nieto L, Rayon C, Garcia 
Talavera J, Montserrat E: Deoxycoformycin in the treatment of patients with hairy 
cell leukemia: results of a Spanish collaborative study of 80 patients. Cancer 2000, 
88(2):352-357.
31.
Maloisel F, Benboubker L, Gardembas M, Coiffier B, Divine M, Sebban C, Blanc M, 
Abgrall JF, Lederlin P, Harousseau JL et al: Long-term outcome with pentostatin 

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
65
treatment in hairy cell leukemia patients. A French retrospective study of 238 
patients. Leukemia 2003, 17(1):45-51.
32.
Else M, Ruchlemer R, Osuji N, DelGiudice I, Matutes E, Woodman A, Wotherspoon A, 
Swansbury J, Dearden C, Catovsky D: Long remissions in hairy cell leukemia with 
purine analogs - A report of 219 patients with a median follow-up of 12.5 years. 
Cancer 2005, 104(11):2442-2448.
33.
Fanta PT, Saven A: Hairy cell leukemia. Cancer treatment and research 2008, 142:193-
209.
34.
Cannon T, Mobarek D, Wegge J, Tabbara IA: Hairy cell leukemia: Current concepts. 
Cancer Invest 2008, 26(8):860-865.
35.
Seymour JF, Kurzrock R, Freireich EJ, Estey EH: 2-chlorodeoxyadenosine induces 
durable remissions and prolonged suppression of CD4+ lymphocyte counts in 
patients with hairy cell leukemia. Blood 1994, 83(10):2906-2911.
36.
Seymour JF, Talpaz M, Kurzrock R: Response duration and recovery of CD4+ 
lymphocytes following deoxycoformycin in interferon-alpha-resistant hairy cell 
leukemia: 7- year follow-up. Leukemia 1997, 11(1):42-47.
37.
Cheson BD, Vena DA, Foss FM, Sorensen JM: Neurotoxicity of purine analogs: a 
review. J Clin Oncol 1994, 12(10):2216-2228.
38.
Saven A, Piro LD: Complete remissions in hairy cell leukemia with 2-
chlorodeoxyadenosine after failure with 2'-deoxycoformycin. Ann Intern Med 1993, 
119(4):278-283.
39.
Piro LD, Ellison DJ, Saven A: The Scripps Clinic experience with 2-
chlorodeoxyadenosine in the treatment of hairy cell leukemia. Leuk Lymphoma 1994, 
14 Suppl 1:121-125.
40.
Mercieca J, Matutes E, Emmett E, Coles H, Catovsky D: 2-Chlorodeoxyadenosine in 
the treatment of hairy cell leukaemia: differences in response in patients with and 
without abdominal lymphadenopathy. Br J Haematol 1996, 93(2):409-411.
41.
Chadha P, Rademaker AW, Mendiratta P, Kim B, Evanchuk DM, Hakimian D, Peterson 
LC, Tallman MS: Treatment of hairy cell leukemia with 2-chlorodeoxyadenosine (2-
CdA): long-term follow-up of the Northwestern University experience. Blood 2005, 
106(1):241-246.
42.
Grever MR: Pentostatin: Impact on outcome in hairy cell leukemia. Hematol Oncol 
Clin N Amer 2006, 20(5):1099-1108.
43.
Else M, Dearden CE, Matutes E, Garcia-Talavera J, Rohatiner AZ, Johnson SA, 
O'Connor NT, Haynes A, Osuji N, Forconi F et al: Long-term follow-up of 233 patients 
with hairy cell leukaemia, treated initially with pentostatin or cladribine, at a 
median of 16 years from diagnosis. Br J Haematol 2009, 145:733-740.
44.
Villamor N, Montserrat E, Colomer D: Mechanism of action and resistance to 
monoclonal antibody therapy. Semin Oncol 2003, 30(4):424-433.
45.
Zinzani PL, Ascani S, Piccaluga PP, Bendandi M, Pileri S, Tura S: Efficacy of 
rituximab in hairy cell leukemia treatment. J Clin Oncol 2000, 18(22):3875-3877.
46.
Hagberg H: Chimeric monoclonal anti-CD20 antibody (rituximab)--an effective 
treatment for a patient with relapsing hairy cell leukaemia. Med Oncol 1999, 
16(3):221-222.
47.
Hoffman M, Auerbach L: Bone marrow remission of hairy cell leukaemia induced by 
rituximab (anti-CD20 monoclonal antibody) in a patient refractory to cladribine. Br 
J Haematol 2000, 109(4):900-901.

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
66
48.
Sokol L, Agosti SJ: Simultaneous manifestation of chronic lymphocytic leukemia 
(CLL) and hairy cell leukemia (HCL). American Journal of Hematology 2004, 
75(2):107-109.
49.
Pollio F, Pocali B, Palmieri S, Morabito P, Scalia G, Del Vecchio L, Ferrara F: 
Rituximab: a useful drug for a repeatedly relapsed hairy cell leukemia patient. Ann 
Hematol 2002, 81(12):736-738.
50.
Hagberg H, Lundholm L: Rituximab, a chimaeric anti-CD20 monoclonal antibody, in 
the treatment of hairy cell leukaemia. Br J Haematol 2001, 115(3):609-611.
51.
Lauria F, Lenoci M, Annino L, Raspadori D, Marotta G, Bocchia M, Forconi F, Gentili 
S, La Manda M, Marconcini S et al: Efficacy of anti-CD20 monoclonal antibodies 
(Mabthera) in patients with progressed hairy cell leukemia. Haematologica 2001, 
86(10):1046-1050.
52.
Nieva J, Bethel K, Saven A: Phase 2 study of rituximab in the treatment of 
cladribine-failed patients with hairy cell leukemia. Blood 2003, 102(3):810-813.
53.
Thomas DA, O'Brien S, Bueso-Ramos C, Faderl S, Keating MJ, Giles FJ, Cortes J, 
Kantarjian HM: Rituximab in relapsed or refractory hairy cell leukemia. Blood 2003, 
102(12):3906-3911.
54.
Angelopoulou MK, Pangalis GA, Sachanas S, Kokoris SI, Anargyrou K, Galani Z, 
Kalpadakis C, Vassilakopoulos TP: Outcome and toxicity in relapsed hairy cell 
leukemia patients treated with rituximab. Leuk Lymphoma 2008, 49(9):1817-1820.
55.
Zenhausern R, Simcock M, Gratwohl A, Hess U, Bargetzi M, Tobler A: Rituximab in 
patients with hairy cell leukemia relapsing after treatment with 2-
chlorodeoxyadenosine (SAKK 31/98). Haematol Hematol J 2008, 93(9):1426-1428.
56.
McLaughlin P, GrilloLopez AJ, Link BK, Levy R, Czuczman MS, Williams ME, 
Heyman MR, BenceBruckler I, White CA, Cabanillas F et al: Rituximab chimeric Anti-
CD20 monoclonal antibody therapy for relapsed indolent lymphoma: Half of 
patients respond to a four-dose treatment program. Journal of Clinical Oncology 
1998, 16(8):2825-2833.
57.
Kreitman RJ, Wilson WH, Robbins D, Margulies I, Stetler-Stevenson M, Waldmann TA, 
Pastan I: Responses in refractory hairy cell leukemia to a recombinant immunotoxin. 
Blood 1999, 94:3340-3348.
58.
Kreitman RJ, Wilson WH, White JD, Stetler-Stevenson M, Jaffe ES, Waldmann TA, 
Pastan I: Phase I trial of recombinant immunotoxin Anti-Tac(Fv)-PE38 (LMB-2) in 
patients with hematologic malignancies. J Clin Oncol 2000, 18:1614-1636.
59.
Kreitman RJ, Wilson WH, Bergeron K, Raggio M, Stetler-Stevenson M, FitzGerald DJ, 
Pastan I: Efficacy of the Anti-CD22 Recombinant Immunotoxin BL22 in 
Chemotherapy-Resistant Hairy-Cell Leukemia. New Engl J Med 2001, 345(4):241-
247.
60.
Kreitman RJ, Squires DR, Stetler-Stevenson M, Noel P, Fitzgerald DJ, Wilson WH, 
Pastan I: Phase I trial of recombinant immunotoxin RFB4(dsFv)-PE38 (BL22) in 
patients with B-cell malignancies. J Clin Oncol 2005, 23(27):6719-6729.
61.
Tallman MS, Hakimian D, Kopecky KJ, Wheaton S, Wollins E, Foucar K, Cassileth PA, 
Habermann T, Grever M, Rowe JM et al: Minimal residual disease in patients with 
hairy cell leukemia in complete remission treated with 2-chlorodeoxyadenosine or 2- 
deoxycoformycin and prediction of early relapse. Clin Cancer Res 1999, 5(7):1665-
1670.

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
67
62.
Catovsky D, Matutes E, Talavera JG, Oconnor NTJ, Johnson SA, Emmett E, Corbett L, 
Swansbury J: Long term results with 2'deoxycoformycin in hairy cell leukemia. Leuk 
Lymphoma 1994, 14 Suppl 1:109-113.
63.
Ravandi F, Jorgensen JL, O'Brien S M, Verstovsek S, Koller CA, Faderl S, Giles FJ, 
Ferrajoli A, Wierda WG, Odinga S et al: Eradication of minimal residual disease in 
hairy cell leukemia. Blood 2006, 107(12):4658-4662.
64.
Bastie JN, CazalsHatem D, Daniel MT, MF DA, Rabian CL, Glaisner S, NoelWalter MP, 
Dabout D, Flandrin G, Dombret H et al: Five years follow-up after 2-chloro 
deoxyadenosine treatment in thirty patients with hairy cell leukemia: Evaluation of 
minimal residual disease and CD4+lymphocytopenia after treatment. Leuk 
Lymphoma 1999, 35(5-6):555-565.
65.
Ellison DJ, Sharpe RW, Robbins BA, Spinosa JC, Leopard JD, Saven A, Piro LD: 
Immunomorphologic analysis of bone marrow biopsies after treatment with 2-
chlorodeoxyadenosine for hairy cell leukemia. Blood 1994, 84(12):4310-4315.
66.
Konwalinka G, Schirmer M, Hilbe W, Fend F, Geisen F, Knoblechner A, Petzer A, 
Thaler J: Minimal residual disease in hairy-cell leukemia after treatment with 2- 
chlorodeoxyadenosine. Blood Cells Mol Dis 1995, 21(2):142-151.
67.
Bengio R, Narbaitz M, Palacios F, Scolnik M, Sarmiento M: Hairy cell leukemia. An 
alternative method for the detection of minimal residual disease using flow 
cytometry. Medicina Buenos Aires 2000, 60:71-76.
68.
Bengio R, Narbaitz MI, Sarmiento MA, Palacios MF, Scolnik MP: Comparative 
analysis of immunophenotypic methods for the assessment of minimal residual 
disease in hairy cell leukemia. Haematologica 2000, 85(11):1227-1229.
69.
Sausville JE, Salloum R, Sorbara L, Kingma DW, Raffeld M, Kreitman RJ, Imus PD, 
Venzon D, Stetler-Stevenson M: Minimal residual disease detection in hairy cell 
leukemia. Comparison of flow cytometric immunophenotyping with clonal analysis 
using consensus primer polymerase chain reaction for the heavy chain gene. Am J 
Clin Pathol 2003, 119:213-217.
70.
Cervetti G, Galimberti S, Andreazzoli F, Fazzi R, Cecconi N, Caracciolo F, Petrini M: 
Rituximab as treatment for minimal residual disease in hairy cell leukaemia. 
European Journal of Haematology 2004, 73(6):412-417.
71.
Arons E, Margulies I, Sorbara L, Raffeld M, Stetler-Stevenson M, Pastan I, Kreitman RJ: 
Minimal residual disease in hairy cell leukemia patients assessed by clone-specific 
polymerase chain reaction. Clin Cancer Res 2006, 12(9):2804-2811.
72.
Byrd JC, Peterson BL, Morrison VA, Park K, Jacobson R, Hoke E, Vardiman JW, Rai K, 
Schiffer CA, Larson RA: Randomized phase 2 study of fludarabine with concurrent 
versus sequential treatment with rituximab in symptomatic, untreated patients with 
B-cell chronic lymphocytic leukemia: results from Cancer and Leukemia Group B 
9712 (CALGB 9712). Blood 2003, 101(1):6-64.
73.
Tsiara SN, Kapsali HD, Chaidos A, Christou L, Bourantas KL: Treatment of 
resistant/relapsing chronic lymphocytic leukemia with a combination regimen 
containing deoxycoformycin and rituximab. Acta Haematologica 2004, 111(4):185-
188.
74.
Robak T, Smolewski P, UrbanskaRys H, GoraTybor J, Blonski JZ, Kasznicki M: 
Rituximab followed by cladribine in the treatment of heavily pretreated patients 
with indolent lymphoid malignancies. Leukemia & Lymphoma 2004, 45(5):937-944.

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
68
75.
Robak T, Smolewski P, Cebula B, SzmigielskaKaplon A, Chojnowski K, Blonski JZ: 
Rituximab combined with cladribine or with cladribine and cyclophosphamide in 
heavily pretreated patients with indolent lymphoproliferative disorders and mantle 
cell lymphoma. Cancer 2006, 107(7):1542-1550.
76.
Robak T, Smolewski P, Cebula B, Grzybowska-Izydorczyk O, Blonski JZ: Rituximab 
plus cladribine with or without cyclophosphamide in patients with relapsed or 
refractory chronic lymphocytic leukemia. Eur J Haematol 2007, 79(2):107-113.
77.
Else M, Osuji N, Forconi F, Dearden C, Del Giudice I, Matutes E, Wotherspoon A, 
Lauria F, Catovsky D: The role of rituximab in combination with pentostatin or 
cladribine for the treatment of recurrent/refractory hairy cell leukemia. Cancer 
2007, 110(10):2240-2247.
78.
Cheson BD, Rummel MJ: Bendamustine: rebirth of an old drug. J Clin Oncol 2009, 
27(9):1492-1501.
79.
Strumberg D, Harstrick A, Doll K, Hoffmann B, Seeber S: Bendamustine 
hydrochloride activity against doxorubicin-resistant human breast carcinoma cell 
lines. Anticancer Drugs 1996, 7(4):415-421.
80.
Leoni LM, Bailey B, Reifert J, Bendall HH, Zeller RW, Corbeil J, Elliott G, Niemeyer 
CC: Bendamustine (Treanda) displays a distinct pattern of cytotoxicity and unique 
mechanistic features compared with other alkylating agents. Clin Cancer Res 2008, 
14(1):309-317.
81.
Chow KU, Boehrer S, Geduldig K, Krapohl A, Hoelzer D, Mitrou PS, Weidmann E: In 
vitro induction of apoptosis of neoplastic cells in low-grade non-Hodgkin's 
lymphomas using combinations of established cytotoxic drugs with bendamustine. 
Haematologica 2001, 86(5):485-493.
82.
Rasschaert M, Schrijvers D, Van den Brande J, Dyck J, Bosmans J, Merkle K, 
Vermorken JB: A phase I study of bendamustine hydrochloride administered once 
every 3 weeks in patients with solid tumors. Anticancer Drugs 2007, 18(5):587-595.
83.
Knauf WU, Lissichkov T, Aldaoud A, Liberati A, Loscertales J, Herbrecht R, Juliusson 
G, Postner G, Gercheva L, Goranov S et al: Phase III randomized study of 
bendamustine compared with chlorambucil in previously untreated patients with 
chronic lymphocytic leukemia. J Clin Oncol 2009, 27(26):4378-4384.
84.
Maddocks KJ, Lin TS: Update in the management of chronic lymphocytic leukemia. J 
Hematol Oncol 2009, 2:29.
85.
Heider A, Niederle N: Efficacy and toxicity of bendamustine in patients with relapsed 
low-grade non-Hodgkin's lymphomas. Anticancer Drugs 2001, 12(9):725-729.
86.
Friedberg JW, Cohen P, Chen L, Robinson KS, Forero-Torres A, La Casce AS, Fayad 
LE, Bessudo A, Camacho ES, Williams ME et al: Bendamustine in patients with 
rituximab-refractory indolent and transformed non-Hodgkin's lymphoma: results 
from a phase II multicenter, single-agent study. J Clin Oncol 2008, 26(2):204-210.
87.
Rummel MJ, Al-Batran SE, Kim SZ, Welslau M, Hecker R, Kofahl-Krause D, Josten 
KM, Durk H, Rost A, Neise M et al: Bendamustine plus rituximab is effective and has 
a favorable toxicity profile in the treatment of mantle cell and low-grade non-
Hodgkin's lymphoma. J Clin Oncol 2005, 23(15):3383-3389.
88.
Robinson KS, Williams ME, van der Jagt RH, Cohen P, Herst JA, Tulpule A, 
Schwartzberg LS, Lemieux B, Cheson BD: Phase II multicenter study of 
bendamustine plus rituximab in patients with relapsed indolent B-cell and mantle 
cell non-Hodgkin's lymphoma. J Clin Oncol 2008, 26(27):4473-4479.

Abbreviated Title: Ben-R vs. Pen-R in HCL
Version Date: 09/06/2022
69
89.
Kraut EH, Bouroncle BA, Grever MR: Low-dose deoxycoformycin in the treatment of 
hairy cell leukemia. Blood 1986, 68(5):1119-1122.
90.
Kreitman RJ, Stetler-Stevenson M, Margulies I, Noel P, FitzGerald DJP, Wilson WH, 
Pastan I: Phase II trial of recombinant immunotoxin RFB4(dsFv)-PE38 (BL22) in 
patients with hairy cell leukemia. J Clin Oncol 2009, 27(18):2983-2990.
91.
Ise T, Maeda H, Santora K, Xiang L, Kreitman RJ, Pastan I, Nagata S: Immunoglobulin 
superfamily receptor translocation associated 2 protein on lymphoma cell lines and 
hairy cell leukemia cells detected by novel monoclonal antibodies. Clin Cancer Res 
2005, 11:87-96.
92.
Ise T, Kreitman RJ, Pastan I, Nagata S: Sandwich ELISAs for soluble immunoglobulin 
superfamily receptor translocation-associated 2 (IRTA2)/FcRH5 (CD307) proteins 
in human sera. Clin Chem Lab Med 2006, 44(5):594-602.
93.
Manshouri T, Do KA, Wang X, Giles FJ, O'Brien SM, Saffer H, Thomas D, Jilani I, 
Kantarjian HM, Keating MJ et al: Circulating CD20 is detectable in the plasma of 
patients with chronic lymphocytic leukemia and is of prognostic significance. Blood 
2003, 101(7):2507-2513.
94.
Giles FJ, Vose JM, Do KA, Johnson MM, Manshouri T, Bociek G, Bierman PJ, O'Brien 
SM, Keating MJ, Kantarjian HM et al: Circulating CD20 and CD52 in patients with 
non-Hodgkin's lymphoma or Hodgkin's disease. Br J Haematol 2003, 123(5):850-857.
95.
Kreitman RJ, Wilson W, Calvo KR, Arons E, Roth L, Sapolsky J, Zhou H, Raffeld M, 
Stetler-Stevenson M: Cladribine with immediate rituximab for the treatment of 
patients with variant hairy cell leukemia. Clin Cancer Res 2013, 19(24):6873-6881.
96.
Burotto M, Stetler-Stevenson M, Arons E, Zhou H, Wilson W, Kreitman RJ: 
Bendamustine and Rituximab in Relapsed and Refractory Hairy Cell Leukemia. 
Clin Cancer Res 2013, 19(22):6313-6321.
97.
Arons E, Suntum T, Margulies I, Yuan C, Stetler-Stevenson M, Kreitman RJ: PRAME 
expression in hairy cell leukemia. Leukemia research 2008, 32(9):1400-1406.
98.
Arons E, Sunshine J, Suntum T, Kreitman RJ: Somatic hypermutation and VH gene 
usage in hairy cell leukemia. Br J Haematol 2006, 133(5):504-512.
99.
Arons E, Suntum T, Sunshine J, Stetler-Stevenson M, Kreitman RJ: Immunoglobulin 
Light Chain Repertoire in Hairy Cell Leukemia. Leukemia research 2007, 31:1239-
1244.
100.
Arons E, Suntum T, Stetler-Stevenson M, Kreitman RJ: VH4-34+ hairy cell leukemia, a 
new variant with poor prognosis despite standard therapy. Blood 2009, 
114(21):4687-4695.
101.
Xi L, Arons E, Navarro W, Calvo KR, Stetler-Stevenson M, Raffeld M, Kreitman RJ: 
Both variant and IGHV4-34-expressing hairy cell leukemia lack the BRAF V600E 
mutation. Blood 2012, 119(14):3330-3332.
102.
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP: 
Toxicity and response criteria of the Eastern Cooperative Oncology Group. 
American journal of clinical oncology 1982, 5(6):649-655.
103.
Hong DI, Bankova L, Cahill KN, Kyin T, Castells MC: Allergy to monoclonal 
antibodies: cutting-edge desensitization methods for cutting-edge therapies. Expert 
review of clinical immunology 2012, 8(1):43-52; quiz 53-44.

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15 APPENDICES
15.1 APPENDIX A:  PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Descriptions
100
Normal, no complaints, no 
evidence of disease.
0
Normal activity.  Fully active, 
able to carry on all pre-disease 
performance without 
restriction.
90
Able to carry on normal activity; 
minor signs or symptoms of 
disease.
80
Normal activity with effort; 
some signs or symptoms of 
disease.
1
Symptoms, but ambulatory.  
Restricted in physically 
strenuous activity, but 
ambulatory and able to carry 
out work of a light or sedentary 
nature (e.g., light housework, 
office work).
70
Cares for self, unable to carry on 
normal activity or to do active 
work.
60
Requires occasional assistance, 
but is able to care for most of 
his/her needs.
2
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry 
out any work activities.  Up 
and about more than 50% of 
waking hours.
50
Requires considerable assistance 
and frequent medical care.
40
Disabled, requires special care 
and assistance.
3
In bed >50% of the time.  
Capable of only limited self-
care, confined to bed or chair 
more than 50% of waking 
hours.
30
Severely disabled, 
hospitalization indicated.  Death 
not imminent.
20
Very sick, hospitalization 
indicated. Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to 
bed or chair.
10
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.

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15.2 APPENDIX B:  NEW YORK HEART ASSOCIATION CLASSIFICATION
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity 
does not cause undue fatigue, palpitation, or dyspnea 
(shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but 
ordinary physical activity results in fatigue, palpitation, or 
dyspnea.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, 
but less than ordinary activity causes fatigue, palpitation, or 
dyspnea.
Class IV (Severe)
Unable to carry out any physical activity without 
discomfort. Symptoms of cardiac insufficiency at rest. If any 
physical activity is undertaken, discomfort is increased.

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15.3 APPENDIX C:  GUIDELINES FOR RITUXIMAB PREPARATION AND ADMINISTRATION
How Supplied
Rituximab will be supplied in 50-mL vials containing 500 mg of antibody (50 mL of 
solution) at a concentration of 10 mg/mL and 10-mL vials containing 100 mg of antibody 
(10 mL of solution) at a concentration of 10mg/ML.  Rituximab vials are sterile, 
preservative-free, and intended for single use only.  
Stability and Storage
Rituximab is biologically and chemically stable at 2C to 8C (36F to 46F) and has a 
proposed shelf-life stability of 30 months.  Once reconstituted into IV bags, rituximab is 
chemically stable for up to 24 hours at 2C to 8C (36F to 46F), followed by up to 
24 hours at room temperature (23C).  However, since rituximab solutions do not contain 
preservative, diluted solutions should be stored refrigerated (2°C to 8°C).  No 
incompatibilities between rituximab and polyvinylchloride or polyethylene bags have 
been observed.  Rituximab vials should be protected from direct sunlight.  Rituximab 
vials are intended for single use only.  Do not use beyond the expiration date stamped on 
the carton. 
Dose Calculation 
1.
Before the first infusion only, calculate the subject’s body surface area (BSA).  
Actual body weight measured within 4 weeks prior to initial treatment with 
rituximab will be used for calculation of body surface area.
2.
Calculate the dose to be administered.  The formula for the dose calculation is as 
follows:
(Subject BSA in m2) (375 mg/ 
m2)
                    10 mg/mL
= 
___ mL 
(volume 
of 
rituximab 
for 
reconstitution) 
3.
The same volume of rituximab for reconstitution will be used for each subsequent 
infusion.
Preparation of Rituximab for Intravenous Administration (First Infusion)
1.
Using aseptic technique, withdraw the necessary amount of rituximab and dilute 
to a final concentration of 1 to 4 mg/mL into an infusion bag containing either 
0.9% Sodium Chloride, USP, or 5% Dextrose in Water, USP.  It is recommended 
that a dilution of 2 mg/mL be used for ease in calculating dose.  Gently invert the 
bag to mix the solution.  Discard any unused portion left in the vial.  Parenteral 

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drug products should be inspected visually for particulate matter and 
discoloration prior to administration.  
2.
DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS.  Do not 
infuse rituximab concomitantly with another IV solution or other IV medications.
3.
The first infusion of rituximab should be administered IV at an initial rate of 
50 mg/hr.  If hypersensitivity or infusion-related reactions do not occur, the 
infusion rate can be escalated in 50 mg/hr increments every 30 minutes, to a 
maximum of 400 mg/hr.  Such an infusion schedule is listed below for a 1000mg 
total dose:
Time
(Minutes)
Infusion Rate
(mg/h)
Dose in 30 
minutes
(mg)
Cumulative Dose
(mg)
0-30
50
25
25
31-60
100
50
75
61-90
150
75
150
91-120
200
100
250
121-150
250
125
375
151-180
300
150
525
181-210
350
175
700
212-240
400
200
900
241-255*
400
200
1000
*Should complete at 255 minutes (4h 15min) to complete a 1000mg total dose.
4.
Infusion and hypersensitivity reactions may occur.  Premedication consisting of 
acetaminophen and diphenhydramine should be considered before each infusion 
of rituximab.  Premedication may attenuate infusion reactions.  Since transient 
hypotension may occur during rituximab infusion, consideration should be given 
to withholding antihypertensive medications 12 hours before rituximab infusion.  
5.
If a hypersensitivity (non-IgE-mediated) or an infusion reaction develops, the 
infusion rate should be reduced to half that rate, i.e. from 100 mg/h to 50 mg/h.  
Subjects who experience a moderate to severe infusion related reaction (fever, 
chills, or hypotension) should have their infusion interrupted immediately and 
should receive aggressive symptomatic treatment.  The infusion should not be 
restarted before all the symptoms have disappeared and then the infusion can 
continue at one-half the previous rate.
6.
After the end of infusion, the intravenous line should remain in situ for at least 1 
hour in order to be able to administer drugs intravenously if necessary. If there are 
no adverse events during this period of time, the intravenous line may be 
removed.

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Preparation of Rituximab for Subsequent Intravenous Infusions
1.
Using aseptic technique, withdraw the necessary amount of rituximab and dilute 
to a final concentration of 1 to 4 mg/mL into an infusion bag containing either 
0.9% Sodium Chloride, USP, or 5% Dextrose in Water, USP.  It is recommended 
that a dilution of 2 mg/mL be used for ease in calculating dose.  Gently invert the 
bag to mix the solution.  Discard any unused portion left in the vial.  Parenteral 
drug products should be inspected visually for particulate matter and 
discoloration prior to administration. 
2.
DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS.  Do not 
infuse rituximab concomitantly with another IV solution or other IV medications. 
Rituximab infusions should be made through a dedicated line. 
3.
If the subject tolerated the first infusion well, subsequent study drug infusions can 
be administered at an initial rate of 100 mg/hr and increased by 100 mg/hr 
increments at 30-minute intervals to a maximum of 400 mg/hr as tolerated.  Such 
an infusion schedule is listed below.  If the subject did not tolerate the first infusion 
well, the above guidelines for the first infusion should be followed for subsequent 
infusions.
Time
(Minutes)
Infusion Rate
(mg/h)
Dose in 30 
minutes
(mg)
Cumulative Dose
(mg)
0-30
100
50
50
31-60
200
100
150
61-90
300
150
300
91-120
400
200
500
121-150
400
200
700
151-180
400
200
900
181-195*
400
200
1000
Should complete at 195 minutes (3h 15 min) to complete a 1000mg total dose
4.
Infusion and hypersensitivity reactions may occur.  Premedication consisting of 
acetaminophen and diphenhydramine should be considered before each infusion 
of rituximab.  Premedication may attenuate infusion reactions.  Since transient 
hypotension may occur during rituximab infusion, consideration should be given 
to withholding antihypertensive medications 12 hours before rituximab infusion.  
5.
If a hypersensitivity (non-IgE-mediated) or an infusion reaction develops, the 
infusion rate should be reduced to half that rate, i.e. from 100 mg/h to 50 mg/h.  
Subjects who experience a moderate to severe infusion related reaction (fever, 

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chills, or hypotension) should have their infusion interrupted immediately and 
should receive aggressive symptomatic treatment.  The infusion should not be 
restarted before all the symptoms have disappeared and then the infusion can 
continue at one-half the previous rate.
6.
After the end of infusion, the intravenous line should remain in situ for at least 1 
hour in order to be able to administer drugs intravenously if necessary. If there are 
no adverse events during this period of time, the intravenous line may be 
removed.

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15.4 APPENDIX D: LOCAL PHYSICIAN INFORMATION
Note: This list is no longer applicable, but it is being kept for historical purposes.
Physician Name 
Facility Name
Facility Address
Facility Contact 
Number
Elizabeth Bengtson, MD
Dartmouth 
College
1 Medical Center Dr. 
Lebanon, NH 03756
603-650-5529
Pamela Oster, MD
Fremont-
Rideout Cancer 
Center
618 5th Street
Marysville, CA 95901
530-749-4400
Michael Crump, MD
Princess 
Margaret 
Cancer Centre
610 University Ave, 
Toronto, ON 
Canada M5G 2M9
416-946-4501
Philip Kuriakose, MD
Henry Ford 
West 
Bloomfield 
Hospital
6777 West Maple Rd.
West Bloomfield 
Township, MI 48322
800-436-7936
Paul Hendrie, MD
University of 
Washington/ 
Seattle Cancer 
Care Alliance*
825 Eastlake Ave. E
PO Box 19023
Seattle, WA 98109
206-541-6426