# Outpatient-Based Therapy of Oral Fludarabine and Subcutaneous Alemtuzumab for Asian Patients with Relapsed/Refractory Chronic Lymphocytic Leukemia

Authors: William Y. K. Hwang; Claire Dearden; Yvonne S. M. Loh; Yeh C. Linn; Sim L. Tien; Gerrard K. H. Teoh; Gee F. How; Kee K. Heng; Yeow T. Goh; Lai H. Lee
Journal: Advances in Hematology
 (2009)

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## Abstract

Background. Intravenous alemtuzumab and fludarabine are effective in combination for the treatment of chronic lymphocytic leukemia (CLL), but require hospital visits for intravenous injection. We performed a pilot study to assess the safety and efficacy of outpatient-based oral fludarabine with subcutaneous alemtuzumab (OFSA) for the treatment of relapsed/refractory CLL. Results. Depending on their response, patients were given two to six 28-day cycles of subcutaneous alemtuzumab 30 mg on days 1,3, and 5 and oral fludarabine 40 mg/m2/day for 5 days. Median patient age was 74. The lymphocyte counts of all five patients fell after the 1st cycle of treatment and reached normal/low levels on completion of 2 to 6 cycles of therapy. Platelet counts and hemoglobin were unaffected. All five patients achieved complete hematological remission, while two attained minimal residual disease negativity on 4-color flow cytometry. Conclusions. Our OFSA regimen was effective in elderly Asian patients with relapsed/refractory CLL, and it should be investigated further.


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## Body

## 1. Background

Chronic  lymphoproliferative  disorders  are considered rare in Asian countries. A recent
3-year study of 342 consecutive leukemia patients from 2 regional hospitals in
Hong Kong, however, showed that (CLL) was diagnosed in 19% of Chinese patients with leukemia [1].
Alemtuzumab has just been approved as a single agent for first-line therapy of
chronic lymphocytic leukemia [2]. Intravenous
alemtuzumab administered in combination with fludarabine has been shown to be
an effective chemoimmunotherapy regimen in CLL, even among patients with
relapsed or refractory disease who were unresponsive to prior therapy with
either agent alone [3, 4].
However, both these drugs had to be given intravenously. Subcutaneous (SC) administration of
alemtuzumab can reduce the occurrence of acute infusion-related reactions while
maintaining therapeutic efficacy comparable to that of intravenous alemtuzumab
[5, 6]. Moreover, oral fludarabine has been made
available, and is found to be as effective as the intravenous combination even
in combination therapy [7]. Based on these findings, we conducted a single
arm pilot clinical study to study the safety and efficacy of subcutaneous
alemtuzumab in combination with oral fludarabine for the treatment of CLL, in
order to provide patients with a self-administered outpatient-based regimen for
treatment of relapsed/recurrent CLL.


## 2. Patients and Methods

Patients with relapsed or
refractory CLL with failure of at least one prior chemotherapy regimen were eligible
to enroll in this study, which was approved by the Institutional Review Board of
the Singapore General Hospital. Response
to therapy was assessed based on the National Cancer Institute Working Group
criteria (NCI-WG) [8]. Evaluation of B cell clonality and minimal
residual disease (MRD) was performed on bone marrow specimens by both DNA
methods (consensus immunoglobulin heavy-chain polymerase chain reaction) [9]
as well as flow cytometry (estimated sensitivity of 0.01%) [10]
after every 2 cycles of treatment. Oral
fludarabine and subcutaneous alemtuzumab (OFSA) chemotherapy comprised
induction and consolidation cycles as outlined in Figure 1 and were given in 28
day cycles, whenever feasible. In the
first induction cycle, patients were given self-administered SC alemtuzumab 10 mg, 20 mg, 30 mg and 30 mg in dose escalation on days 1, 3, 5 and 8,
respectively, together with oral fludarabine 40 mg/m2/day for 5 days
of each 28-day cycle. For cycle 2 of
induction, SC alemtuzumab 30 mg was given three times on days 1, 3, and 5
together with oral fludarabine 40 mg/m2/day for 5 days of each
cycle. Patients were premedicated with
steroids (100 mg hydrocortisone) just before the first dose of alemtuzumab of
the first cycle. Depending upon response,
patients received 2 to 6 cycles of induction: if complete remission (CR) was
attained without MRD negativity on four-color flow cytometry and IgH clonality
assays, consolidation therapy was given comprising SC alemtuzumab 30 mg on day 1 and oral fludarabine
40 mg/m2/day for 5 days of each cycle. Therapy was discontinued if molecular CR with
MRD negativity was attained. No more
than 6 cycles of therapy, whether for induction or consolidation, were
administered (Figure 1). Patients were given oral cotrimoxazole and acyclovir
prophylaxis. Cytomegalovirus (CMV) antigen (Ag) titers were assayed for
patients with fever and all blood products were irradiated and filtered. Oral paracetamol 1 g and chlorpheniramine
were given before alemtuzumab injections.
IV hydrocortisone 100 mg was administered before test dose
administration during the first induction cycle; with monitoring of blood
pressure, heart rate and temperature were performed every 15 minutes for 1 hour
after.Figure 1
OFSA Treatment
schedule. CR: Complete remission, MRD: Minimal residual disease.


## 3. Results

### 3.1. Patient Characteristics

As shown on Table1, patients were all males
with median age of 72 years (range, 60–81 years), some
with other comorbidities. All 5 patients
had received at least 2 prior lines of therapy, 4 of whom had received
fludarabine alone or in combination with other chemotherapy. Recruitment was limited to five patients by
the funding available for this pilot study.
The CLL-FISH panel revealed 11q23 (consistent with ATM gene deletion)
and trisomy 12 abnormalities in 2 patients; in both cases, trisomy 12 was also
revealed using conventional cytogenetics, with additional rearrangement of
chromosome 13 in one patient and multiple structural abnormalities in the other
(Table 1). The FISH panel also revealed
17p13.1 deletion (consistent with p53 deletion) in one patient, 13q14 deletion
in one patient, whereas one patient had no chromosomal aberrations. In the
latter patient with no detectable chromosomal abnormalities by FISH,
conventional cytogenetics revealed translocations between chromosomes 13 and
17. FISH analysis was used for
prognostication and not for measurement of residual disease or clonal evolution
and was not repeated after completion of therapy.Table 1
Patient characteristics, treatment duration, and response.
ParametersPatient no.1Patient no.2Patient no.3Patient no.4Patient no.5SexMaleMaleMaleMaleMaleAge, years7270816074ComorbiditiesUreteric stoneBenign prostatic hypertrophyThyroiditis, hepatitis B carrierDiabetes mellitus, hypt stomach ulcer, hernia
operationPrevious chemotherapyCVP, FCCP, FCCVP, FCPC, FFISH abnormalities(Del)11q22.3 (deletion ofATM),
trisomy 12None(Del)11q22.3 (deletion ofATM), trisomy 12(Del)13q14 (deletion ofRB1 and D13S25)(Del)17p13.1 (deletion ofp53)Conventional (metaphase) cytogenetics analysisNumerous structural rearrangements in 7 of 20
cells; trisomy 12 in 5 other cellst(13;17); loss of Y chromosome in 5 other cellsTrisomy 12; structural rearrangement on chromosome
13 in 1 of 20 cellsLoss of Y chromosome in 3 cellsComplex structural rearrangements in 2 of 18 cellsNo. of induction cycles4222*6No. of consolidation cycles20000ResponseCRCRCRPR*PRMRD-negativityNoYesYesNoNoC = cyclophosphamide; CP = chlorambucil and prednisolone; CR = complete
response; CVP = cyclophosphamide, vincristine and prednisolone; F = fludarabine; FC = fludarabine and cyclophosphamide; FISH =
fluorescence in situ hybridization; MRD = minimal residual disease; PR =
partial response.Patient* was lost to follow-up and did not complete
protocol-specified therapy.


### 3.2. Response to Therapy

All 5 patients responded to therapy; 2
patients achieved a partial response (PR), 2 had an MRD-negative CR and one had
an MRD-positive CR (Table1). Patient no.  1
received 4 cycles of induction followed by 2 cycles of consolidation therapy
and subsequently achieved a MRD-positive CR. Patients no.  2 and no.  3 achieved a
MRD-negative CR after completing only 2 cycles of induction therapy, and treatment
was therefore halted. Patient no. 4 was
lost to follow-up after 2 cycles of induction therapy and did not complete
therapy. However, he returned to the
clinic 6 months later and had relapsed, whereupon he was given melphalan
therapy, to which he did not respond.
OFSA combination therapy was then reinitiated off-protocol, leading the
patient to achieve an MRD-positive CR. Patient no.  5 achieved clearance of blood
and marrow lymphocytosis albeit the persistence of a palpably enlarged spleen
after 6 cycles of induction chemotherapy.
He remained MRD positive. He did
not receive consolidation as the trial allowed only for 6 cycles of
therapy. The median duration of
follow-up for the 5 patients was 11 months (range, 8–13 months).


### 3.3. Leukocyte Response and Side Effects

The mean lymphocyte counts of all patients fell from
a mean baseline value of 63,610/μL to
42,610/μL
after the first cycle of treatment and further decreased to 1,500/μL after completion of 2 to 6 cycles of
therapy. Two patients developed neutropenia,
as defined by an absolute neutrophil count of less than 1,000/μL (one of whom
had a neutrophil  count <500/μL),
but both recovered promptly after granulocyte-colony stimulating factor (G-CSF)
administration. The platelet counts
(mean 114,000/μL prior to and 111,400/μL after therapy) and hemoglobin levels
(mean 11.7 g/dL before and 11.6 g/dL after therapy) remained unaffected, and no
patient required platelet or red cell transfusion support during the
study. CMV reactivation did not occur,
but 2 patients developed rapidly reversible neutropenic sepsis requiring
empiric antibiotics and transient administration of G-CSF. More than 4 months after completing the
trial, Patient no. 1 had recurrence of peripheral blood prolymphocytosis and
disease-related cytopenias with concurrent chryseobacterium meningosepticum
infection of the blood, to which he finally succumbed. Excluding the initial
admission, none of the patients required hospitalization during the period of
the trial, except for Patient no. 1 and Patient no. 4 who were hospitalized for
concomitant infection and recurrence of disease 4 to 6 months after completion
of therapy.


## 3.1. Patient Characteristics

As shown on Table1, patients were all males
with median age of 72 years (range, 60–81 years), some
with other comorbidities. All 5 patients
had received at least 2 prior lines of therapy, 4 of whom had received
fludarabine alone or in combination with other chemotherapy. Recruitment was limited to five patients by
the funding available for this pilot study.
The CLL-FISH panel revealed 11q23 (consistent with ATM gene deletion)
and trisomy 12 abnormalities in 2 patients; in both cases, trisomy 12 was also
revealed using conventional cytogenetics, with additional rearrangement of
chromosome 13 in one patient and multiple structural abnormalities in the other
(Table 1). The FISH panel also revealed
17p13.1 deletion (consistent with p53 deletion) in one patient, 13q14 deletion
in one patient, whereas one patient had no chromosomal aberrations. In the
latter patient with no detectable chromosomal abnormalities by FISH,
conventional cytogenetics revealed translocations between chromosomes 13 and
17. FISH analysis was used for
prognostication and not for measurement of residual disease or clonal evolution
and was not repeated after completion of therapy.Table 1
Patient characteristics, treatment duration, and response.
ParametersPatient no.1Patient no.2Patient no.3Patient no.4Patient no.5SexMaleMaleMaleMaleMaleAge, years7270816074ComorbiditiesUreteric stoneBenign prostatic hypertrophyThyroiditis, hepatitis B carrierDiabetes mellitus, hypt stomach ulcer, hernia
operationPrevious chemotherapyCVP, FCCP, FCCVP, FCPC, FFISH abnormalities(Del)11q22.3 (deletion ofATM),
trisomy 12None(Del)11q22.3 (deletion ofATM), trisomy 12(Del)13q14 (deletion ofRB1 and D13S25)(Del)17p13.1 (deletion ofp53)Conventional (metaphase) cytogenetics analysisNumerous structural rearrangements in 7 of 20
cells; trisomy 12 in 5 other cellst(13;17); loss of Y chromosome in 5 other cellsTrisomy 12; structural rearrangement on chromosome
13 in 1 of 20 cellsLoss of Y chromosome in 3 cellsComplex structural rearrangements in 2 of 18 cellsNo. of induction cycles4222*6No. of consolidation cycles20000ResponseCRCRCRPR*PRMRD-negativityNoYesYesNoNoC = cyclophosphamide; CP = chlorambucil and prednisolone; CR = complete
response; CVP = cyclophosphamide, vincristine and prednisolone; F = fludarabine; FC = fludarabine and cyclophosphamide; FISH =
fluorescence in situ hybridization; MRD = minimal residual disease; PR =
partial response.Patient* was lost to follow-up and did not complete
protocol-specified therapy.


## 3.2. Response to Therapy

All 5 patients responded to therapy; 2
patients achieved a partial response (PR), 2 had an MRD-negative CR and one had
an MRD-positive CR (Table1). Patient no.  1
received 4 cycles of induction followed by 2 cycles of consolidation therapy
and subsequently achieved a MRD-positive CR. Patients no.  2 and no.  3 achieved a
MRD-negative CR after completing only 2 cycles of induction therapy, and treatment
was therefore halted. Patient no. 4 was
lost to follow-up after 2 cycles of induction therapy and did not complete
therapy. However, he returned to the
clinic 6 months later and had relapsed, whereupon he was given melphalan
therapy, to which he did not respond.
OFSA combination therapy was then reinitiated off-protocol, leading the
patient to achieve an MRD-positive CR. Patient no.  5 achieved clearance of blood
and marrow lymphocytosis albeit the persistence of a palpably enlarged spleen
after 6 cycles of induction chemotherapy.
He remained MRD positive. He did
not receive consolidation as the trial allowed only for 6 cycles of
therapy. The median duration of
follow-up for the 5 patients was 11 months (range, 8–13 months).


## 3.3. Leukocyte Response and Side Effects

The mean lymphocyte counts of all patients fell from
a mean baseline value of 63,610/μL to
42,610/μL
after the first cycle of treatment and further decreased to 1,500/μL after completion of 2 to 6 cycles of
therapy. Two patients developed neutropenia,
as defined by an absolute neutrophil count of less than 1,000/μL (one of whom
had a neutrophil  count <500/μL),
but both recovered promptly after granulocyte-colony stimulating factor (G-CSF)
administration. The platelet counts
(mean 114,000/μL prior to and 111,400/μL after therapy) and hemoglobin levels
(mean 11.7 g/dL before and 11.6 g/dL after therapy) remained unaffected, and no
patient required platelet or red cell transfusion support during the
study. CMV reactivation did not occur,
but 2 patients developed rapidly reversible neutropenic sepsis requiring
empiric antibiotics and transient administration of G-CSF. More than 4 months after completing the
trial, Patient no. 1 had recurrence of peripheral blood prolymphocytosis and
disease-related cytopenias with concurrent chryseobacterium meningosepticum
infection of the blood, to which he finally succumbed. Excluding the initial
admission, none of the patients required hospitalization during the period of
the trial, except for Patient no. 1 and Patient no. 4 who were hospitalized for
concomitant infection and recurrence of disease 4 to 6 months after completion
of therapy.


## 4. Discussion

There are several noteworthy observations from
this study. Four of the 5 patients
responded to this combination regimen despite failing previous fludarabine
treatment and 2 attained a MRD negative status.
Importantly, this combination regimen was capable of inducing responses
(1 CR, 1 MRD-negative CR, 1 PR) even in patients with poor-risk cytogenetic
abnormalities such as 11q and 17p deletions; this finding is consistent with
recent reports from the UK CLL02 study of SC alemtuzumab with or without oral
fludarabine in patients with relapsed/refractory CLL [11]. Although no preemptive therapy or CMV
prophylaxis in the form of IV ganciclovir or oral valganciclovir was given,
symptomatic CMV reactivation was not observed.
This could be because of small patient numbers. Overall, the SC alemtuzumab and oral
fludarabine combination regimen was well tolerated and induced promising
responses in elderly patients with relapsed CLL, including achievement of MRD
negativity in 2 patients. Importantly,
this regimen provided elderly Asian patients (four of whom were more than 70
years of age) with a reasonably well-tolerated, self-administered,
outpatient-based treatment of relapsed/recurrent CLL. With a median age of
patients' population of 74 years (range, 60–81 years), this report provides
evidence that the association of fludarabine and alemtuzumab is feasible also
in a select group of elderly Asian patients. These
responses are also comparable to those observed with patients from Western
countries, who are treated with alemtuzumab and fludarabine combinations. In light of these encouraging results, the
OFSA regimen should be extended to larger multicenter clinical trials.Competing Interests
CD is a paid
speaker and consultant for Bayer-Schering. WH has received research funding for
this study from Bayer-Schering. The clinical trial was supported by a
research grant from Schering AG. The
other authors have no competing interests to declare.Authors' Contributions
WH conceived of the study, coordinated in its design and drafted the
manuscript. CD participated in
manuscript revisions. YSL, YCL,  and TSL contributed patients and participated in
coordination of the study. GKT participated in design of the study. LHL
provided helpful advice and facilitated the conduct of the study. All authors
read and approved the final manuscript.



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