Conditions: Lymphocytic Leukemia, Chronic
Allocation: NON_RANDOMIZED | Intervention model: SINGLE_GROUP
Enrollment: 42
Healthy volunteers: no

Brief summary:
This single arm, open-label study will assess the safety and efficacy of low dose fludarabine and cyclophosphamide in combination with standard dose MabThera/Rituxan (rituximab) as primary therapy in elderly patients (\>/= 65 years) with chronic lymphocytic leukemia. Patients will receive six 28-day cycles of treatment with Mabthera/Rituxan (375 mg/m2 intravenously \[iv\] Day 0 of cycle 1, 500 mg/m2 iv Day 1 of cycles 2-6), fludarabine (12.5 mg/m2/d iv Days 1-3, cycles 1-6) and cyclophosphamide (150 mg/m2/d iv Days 1-3, cycles 1-6). Anticipated time on study treatment is 6 months, with a 30-month follow-up period.

Detailed description:

Arms:
arm 1: Elderly participants with chronic lymphocytic leukemia (CLL) will receive combination treatment with low-dose fludarabine and cyclophosphamide combined with standard-dose of rituximab for 6 months. Treatment is followed by a follow up period of 36 months.

Interventions: intervention 1: Cyclophosphamide intervention 2: Fludarabine intervention 3: Rituximab
Intervention descriptions: intervention 1: 150 milligrams per square meter (mg/m\^2) intravenously (IV) on Days 1-3 of each 28-day cycle for 6 cycles intervention 2: 12.5 mg/m\^2 IV on Days 1-3 of every 28-day cycle for 6 cycles intervention 3: 375 mg/m\^2 IV Day 0 of Cycle 1, 500 mg/m\^2 IV Day 1 of Cycles 2-6. Each cycle was 28 days.

Protocol document:
Prot_SAP_000.pdf: 
 
Official Title: 
A Phase II, Multicenter, Single Arm Study to Determine the 
Efficacy 
and 
Safety 
of 
Low 
Dose 
Fludarabine 
and 
Cyclophosphamide Combined with Standard Dose Rituximab as 
Primary Therapy in Elderly Untreated Patients (≥65 Years Old) 
with Chronic Lymphocytic Leukemia 
NCT Number: 
01263704 
Document Dates: 
Protocol Version A (Aug 30, 2010) 
Protocol Version B (Jan 10, 2011) 
Protocol Version C (Jan 23, 2011) 
Protocol Amendment 1 (Jan 30, 2011) 
Amendment History for Version D (Oct 6, 2011) 
Protocol Version D (Oct 6, 2011) 
Amendment History for Version E (Apr 22, 2013) 
Protocol Version E (Apr 22, 2013) 
Amendment History for Version F (May 7, 2014) 
Protocol Version F (May 7, 2014) 
 
 
 
 
 




 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 2 of 66 


 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
  
 
 
 
Author:  Prof 
 
 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 3 of 66 


 
 
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ....................................................................................... 10 
3. 
TRIAL OBJECTIVES AND PURPOSE............................................................................... 16 
3.1 
PRIMARY OBJECTIVE ................................................................................................... 17 
3.2 
SECONDARY OBJECTIVES ............................................................................................ 17 
4. 
TRIAL DESIGN ................................................................................................................... 18 
4.1 
PRIMARY AND SECONDARY END POINTS ........................................................................ 18 
4.2 
OVERALL STUDY DESIGN .............................................................................................. 18 
4.2.1 VISIT SCHEDULE AND ASSESSMENTS ............................................................................. 21 
4.3 
TRIAL TREATMENT ....................................................................................................... 23 
4.3.1  Investigational therapy ............................................................................................. 23 
4.4 
STUDY DRUG INTERRUPTION OR DISCONTINUATION ....................................................... 28 
4.5 
ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL PRODUCTS .......................... 28 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS ........................................................... 29 
5.1 
INCLUSION CRITERIA .................................................................................................... 29 
5.2 
EXCLUSION CRITERIA .................................................................................................. 29 
5.3 
INTERRUPTION OR DISCONTINUATION OF TREATMENT ................................................... 30 
6. 
TREATMENT OF SUBJECTS ............................................................................................ 33 
6.1 
TREATMENT REGIMEN .................................................................................................. 33 
6.1.1 TREATMENT ASSIGNMENT ............................................................................................ 33 
6.2 
CONCOMITANT THERAPY .............................................................................................. 33 
6.3 
TREATMENT COMPLIANCE ............................................................................................ 34 
7. 
ASSESSMENT OF EFFICACY .......................................................................................... 35 
8. 
ASSESSMENT OF SAFETY .............................................................................................. 37 
8.2 
SERIOUS ADVERSE EVENTS .......................................................................................... 41 
8.4 
Physical examinations/vital signs .............................................................................. 47 
8.5 
LABORATORY EXAMINATIONS ........................................................................................ 47 
8.6 
PHYSICAL EXAMINATIONS/VITAL SIGNS .......................................................................... 48 
9. 
STATISTICS 49 
9.1 
SAMPLE SIZE ............................................................................................................... 49 
9.2 
EFFICACY AND SAFETY EVALUATION ............................................................................. 49 
10. QUALITY CONTROL AND QUALITY ASSURANCE ......................................................... 52 
11. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ..................................................... 53 
11.1      STUDY MONITORING .................................................................................................. 53 
11.2 AUDITS ....................................................................................................................... 53 
11.3 IRB AND REGULATORY INSPECTIONS ............................................................................ 53 
12. ETHICS .............................................................................................................................. 54 
12.1    INSTITUTIONAL REVIEW BOARD ................................................................................... 54 
12.2 INFORMED CONSENT .................................................................................................... 54 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 4 of 66 


 
 
12.3 DECLARATION OF HELSINKI .......................................................................................... 55 
13. DATA HANDLING AND RECORD KEEPING .................................................................... 56 
14. FINANCING AND INSURANCE ......................................................................................... 57 
15. PUBLICATION POLICY ..................................................................................................... 58 
16. SUPPLEMENTS ................................................................................................................. 63 
APPENDIX I    RESPONSE DEFINITIONS .................................................................................... 63 
APPENDIX II    ECOG PERFORMANCE STATUS ........................................................................ 64 
APPENDIX III CALCULATED CREATININE CLEARANCE ................................................................ 65 
APPENDIX IV     ACTIVE DISEASE ............................................................................................. 65 
APPENDIX VI    FACIT-QOL .................................................................................................. 66 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 5 of 66 


 
 
LIST OF ABBREVIATIONS 
 
 
 
 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide
 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR                    
Institutional Review Board 
Infusion Related Reaction
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 6 of 66 


 
 
SYNOPSIS 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER:               ML25464 
 
DATE PROTOCOL FINAL:         30 August 2010 
 
STUDY DRUG:                                FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:                                 CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE:                              II 
 
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ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 7 of 66 


 
 
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ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 8 of 66 


 
 
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ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 9 of 66 


 
 
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ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 10 of 66 


 
 
2. Background Information 
 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
disease is often evident in this age group. Goede et al [29] reported that 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
Thurmes and colleagues [1] have shown that these comorbid conditions are in 
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients.
 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given. 
 
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate.
 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
the treatment of CLL [14]. Fludarabine is the most extensively studied purine 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
shown to be more effective than when used alone. [13,14,27,28]. In this respect 
the U.K. MRC LRF CLL4 trial  reported in 2007 [11]  compared therapy with 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 11 of 66 


 
 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  
that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
standard treatment of all CLL patients irrespective of age [11]. Similar results 
were published by the German CLL Study Group and the North American 
Intergroup [14].
 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections. 
 
Pollizzotto et al [15] investigated the influence of increasing age on the ability to 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age  70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality.
 
Table 1 
 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 (17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2
 
X 4 days 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 12 of 66 


 
 
Every 28 days ; 
4 courses 
CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
with a human IgG1 constant kappa antibody (C2B8) that reacts specifically 
with the CD20 antigen found on the surface of malignant and normal B cells 
and established B-cell lines [31,33].  The antigen is expressed at lower levels on 
chronic lymphocytic leukemia (CLL) and plasma cells [31]. CD20 is not shed 
from the surface of CD20+ cells after antibody binding and it is not 
internalized or downregulated [34].  Compared with its murine counterpart, 
Rituximab has a longer half-life in humans, interacts with human effector cells 
[34, 35], and is less immunogenic [36].
 
 
Reduced FC doses
 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-( 70 years). These are listed in Table1. 
 
 
 
 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 13 of 66 


 
 
2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
the use of this agent in CLL [37,39,40].  The original studies employed 375 
mg/m2 of Rituximab once a week for four weeks.  Subsequent studies 
suggested using this dose three times a week for four weeks for a total of 12 
doses instead of 4 doses which resulted in better overall responses [41].  Dose 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
increased or the frequency of the standard dose of 375 mg/m2 was increased 
[41, 44]. 
 
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
Byrd et al went on, to compare sequential and concurrent therapy with RF [43]. 
 
 
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
median survival has yet to be reached yet, but will be in excess of 23 months 
[44]. Three major side effects were observed: infusion related toxicity, 
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
(GCLLSG) [44] reported the treatment of 20 untreated and 11 relapsed CLL 
patients. Treatment consisted of Fludarabine administered at standard doses 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 14 of 66 


 
 
(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 
given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks.
 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections.
 
A retrospective comparative analysis of the CALGB 9712 [47] (Rituximab 
plus Fludarabine) [48] and the CALGB 9011 (Fludarabine only) studies 
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
was similar [45].
 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
patients, respectively) [24, 25]. In the untreated patients the overall response rate 
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections.
 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection. 
 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 15 of 66 


 
 
Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 
fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 21%) 
and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 16 of 66 


 
 
In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL.
 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
patient. In this regard, Foon and colleagues [50] reported a phase II single arm 
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
(20mg/m2) and Cyclophosphamide (150mg/mg2) combined with high–dose 
Rituximab (500mg/m2) given every other week during induction and later as 
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
months (range, 5.2 to 42.5 months) and none of the complete responders 
have relapsed. Grade 3/4 neutropenia was noted in 13% of the cycles of 
therapy. Another approach to reduce toxicity was to use sequential therapy 
with fludarabine (25 mg/m2 on days 1 through 5 for 6 cycles) followed by 
consolidation with Cyclophosphamide (3,000 mg/m2 administered every 3 
weeks for three cycles) and then by Rituximab 375 mg/m2 for four cycles 
(F C
R). [51]  In 36 previously untreated CLL patients an overall response of 
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
negative) and achieving molecular CRs had an excellent prognosis with a 
plateau in the response duration curve, and 90% remain in clinical CR at 5 
years. For the entire group, 5-year survival rate is 71% compared with a rate 
of 48% with the prior F C regimen (not significant P = .10). 
 
3. 
Trial Objectives and Purpose 
 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 17 of 66 


 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximabgiven as primary treatment for elderly patients with 
chronic lymphocytic leukemia.
 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic. 
 
 
3.1 
Primary Objective 
To evaluate the efficacy (Response Rate) of the combination of lower dose 
Fludarabine 12.5 mg m2/d given intravenously for three days and 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
days, combined with standard dose Rituximab (375mg/ m2 in cycle 1 and 
500 mg/m2  in cycles 2-6) for a total of 6 cycles. 
  
.
 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia grade 3, neutropenia  grade 3. 
2-       Progression Free Survival (PFS).  
3-       Time to Next Treatment (TNT).  
4-        Quality Of Life (FACIT) 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 18 of 66 


 
 
4. 
Trial Design                                                                                                             
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia grade 3, neutropenia grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     Time to Next Treatment (TNT) as defined in the protocol (see appendix I) 
4-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2  I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedureIn general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  
Up to 40 patients are planned to be enrolled during a two year period. 
This study consists of 3 periods for each study subject: A pre-treatment 
period, the treatment period and a follow up period.  


 
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Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific 
medical procedures are performed which include laboratory screening 
assessments and physical examination as well as documentation of vital 
signs. If the hematology and/or biochemistry evaluations have been 
performed within 14 days of the first dose of study drug as part of the 
screening evaluation, they need not be repeated, and the data may be used 
as the Day 1 values. Bone marrow examination including cytogenetics (FISH 
whenever possible) must have been performed within 12 months of starting 
the first dose of the study drugs. 
CT scan when done must be performed within 6 weeks of starting the first 
dose of study drugs.    
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 every 
28 days. 
Premedication: antihistamines(e.g. 2mg clemastin or promethazine 25mg I.V.) 
and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Prednison/prednisolone 
100 mg I.V. only if clinically indicated.
In the event of grade  3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 


 
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both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic monthly study- 
center visits in order to assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two 
cycles. In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation and documentation of cytopenias 
(disease or treatment related) and for any other clinical indication at the 
discretion of the investigators.  
Supportive care including blood transfusions or administration of growth 
factors G-CSF or erythropoietin is permitted at the investigators' discretion 
throughout all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination including cytogenetics, peripheral blood 
immunophenotyping (FACS), abdominal, pelvic and chest CT will be 
performed 3 to 6 months after the completion of the treatment regimen, at 
clinical progression and at any other time according to the investigators' 
discretion. 
In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 21 of 66 


 
 
subjects enrolled into the study and will be given at the dose of 15mg/m2/d 
given I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated 
and declared inadequate and inefficient. If response is evident in  5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the 
discretion of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule 
and assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days 
of the day indicated on the visit schedule, except visits 2-5 in which time 
window will be of  3 days . 
 


 
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Figure 1:   Visit schedule and assessments 
Week
 
-4 to 
0
 
1
 
3
 
5
 
7
 
9-25
Every 
4 
weeks
29
37
49
61-77 
every 12 
weeks 
89
 
101-161
 
 every 12 
weeks
 
EOS
 
Visit No.
 
1
 
2
 
3
 
4
 
5
 
6-10
 
11
 
12
13
10-13
 
14
 
15-19
 
20
 
Study period
 
preTx
 
Treatment period
 
Follow up period
 
Inc. /Excl. criteria
 
X
   
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB*
X
 
 
 
 
 
 
 
 
X
 
 
 
 
 
Physical exam
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
CBC
  
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Blood chemistry
 
X
 
X
 
 
X
 
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Beta-2 micro glob 
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level,
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
DAT***
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
FACS****
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
Hepatitis B *****
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) **
 
X
 
 
 
 
 
 
 
 
 
 
 
 
X
 
QOL
 
X
 
 
  
 
 
 
X
 
 
 
 
X
 
 
X
 
Treatment dosage
 
X
 
Ongoing data capture
 
Adverse Events
 
X
 
Ongoing data capture and up to 30 days after completion or discontinuation of 
the study
Concomitant
 
medications
X
 
Ongoing data capture
 
Comments
 
X
 
Ongoing data capture
 
Study completion
 
X
 
Complete at any time if study drug is discontinued
 
* Bone marrow examination will be performed at any clinically suspicion of 
progression/ leukemia transformation, cytopenia evaluation, or for any CR 
confirmation at investigator discretion. 
 ** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
  *** DAT will be performed at any clinical suspicion of hemolysis. 
 **** Will be performed at any clinical suspicion of progression/ leukemia 
transformation, or for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 


 
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4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 
mg/ml) diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with  25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
prednisone/prednisolone 100 mg I.V. shortly before infusion with Rituximab to 
decrease the rate and severity of acute IRR/CRS for these patients. consider 
reduced rate for first infusion or a split dosing over two days during the first 
cycle. Severe CRS: may be associated with some features of tumor lysis 
syndrome 
e.g. 
hyperuricaemia, 
hyperkalaemia, 
hypocalcaemia, 
hypophosphataemia, acute renal failure, elevated LDH and may be 


 
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associated with acute respiratory failure and death. If severe CRS manifests 
stop infusion immediately and start aggressive symptomatic treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Prednisone/prednisolone 100 mg i.v., if necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 
Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate
Mild/moderate 
> 30 mm Hg 
 
 


 
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Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more 
severe with the first infusion. In patients who were unable to tolerate the 
first infusion, cautious reintroduction of rituximab may be tried at the 
second cycle, at the investigator’s discretion. The recommended 
premedication should be given and then the patient carefully re-exposed 
to a small amount of rituximab (slow infusion of 10 mg I.V.) If a severe 
reaction occurs, the rituximab must be permanently discontinued. In 
such case patient will be treated with FC in the next cycles and data will 
be collected throughout the study period)
 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
Rituximab containing infusion bags will be labeled by the sponsor and 
collected for drug accountability. Storage conditions for study drug will be 
described on the medication label. Patients will receive the study drug 
combination for an exposure period of up to 6 months provided that in the 
opinion of the investigator the patient is benefiting from treatment with this 
study drug combination, and in the absence of any safety concerns. 
Treatment will be withheld only in the case of limiting toxicities (see below).  
As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 
10 glasses of fluids on the days they receive cyclophosphamide and  urinate 
at minimal ceasing  of bladder distention. 
DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
adequate "drug dispensing log” on Rituximab. 
 
The "drug dispensing" log for Rituximab must be kept current and should 
contain the following information: 
 


 
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o The identification of the patient (patient number) to whom Rituximab 
was administered.  
o The date(s) and quantity of Rituximab, used for the patients' treatment.  
o The date(s) and quantity of Rituximab, of empty, partial or unused 
medication.  
 
All accountability logs must be available for inspection by the monitor. Drug 
supplies (partly used and empty Rituximab infusion bags) must be available 
for inspection, at every monitoring visit. Used supplies will be destructed 
according to local site guidelines.  
 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade  3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 
following cycles. There is no dose reduction for Rituximab in this study, but 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 
• If after three weeks, the grade  3 cytopenia, 	  CLL 

, still prevails, the patient should be removed from the 
protocol with no further study drug administration. 
• If there is further grade  3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 
• If there is further grade  3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 


 
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• If there is any grade  3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine is partly (40-60%) excreted by the kidneys. If the calculated (see 
appendix III) or measured creatinine clearance is reduced to 30-60 ml/min, 
the fludarabine dose should be reduced to 50%. Patients with a creatinine 
clearance below 30 ml/min are excluded from the study. Patients who develop 
renal dysfunction (serum creatinine  1.5 mg/dL or creatinine clearance < 30 
ml/min) during treatment should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade  3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade  2, for 
up to three weeks. All subsequent cycles should then be given with a 25% 
dose reduction of fludarabine and cyclophosphamide. 
• If after three weeks, the grade  3 non-hematological, non-renal toxicity still 
persists, the patient should be removed from the protocol . 
• If there is further grade  3 non-hematological, non-renal toxicity in 
subsequent cycles despite the first 25% dose reduction treatment should 
again be delayed for up to three weeks and the dose of fludarabine and 
cyclophosphamide further reduced to 50% of the initial full dose. 
• If there is further grade  3 non-hematological, non-renal toxicity in 
subsequent cycles despite 50% dose reduction the patient should be removed 
from the protocol treatment and the study. 
4.3.5 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  


 
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 4.3.6 Blinding                                                                                                         
This is an open label trial. 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 
Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 
4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 29 of 66 


 
 
5. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). 
2. 
Previously untreated B-CLL patients  65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin  2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
Various concomitant diseases requiring chronic steroid 
administration 
7. 
Active Coomb's positive hemolytic anemia. 
8. 
Prior treatment for CLL 
9. 
 CLL in transformation (Richter syndrome). 
10.    Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix carcinoma or 
breast carcinoma) < 2 years prior to the study. 


 
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11. Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
12.    Low compliance. 
13.    Performance status: ECOG performance status 4. (see 
appendix II) 
14.   Patients who are mentally or physically unable to comply      
with all aspects of the study. 
                      
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 
 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in the         
      event of study drug discontinuation) during and at the end of the study       
      period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued. Patient will be treated with FC in the next 
cycles and data will be recorded throughout the study period. 


 
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5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4) 


 
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5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  
Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients 
who discontinue study treatment should be followed for tumor assessments 
as per standard of care, until disease progression or new cancer therapy is 
initiated.  If patients refuse to return for these visits or are unable to do so, the 
subject should be considered off-study, but a Study Evaluation Completion 
form should be completed. 
 
 
 


 
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6. 
Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of 
other concurrent investigational drugs is not allowed. The use of blood 
products (irradiated) transfusions, immunoglobulins or erythroid/myeloid 
growth factors are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration are allowed exclusively for patients with autoimmune 
hemolytic anemia and or autoimmune thrombocytopenia or as premedication 
for Rituximab . 
Premedication: Any patient considered to be at risk of infusion related 
reaction (IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should 
receive: 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 34 of 66 


 
 
Appropriate hydration starting 12-24 hours prior to initiating treatment, and 
thereafter until the risk of IRR/TLS is ruled out. Urine alkalization is at 
investigator’s discretion. 
Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Prednisone/prednisolone 100 mg 
I.V. should be given only if clinically indicated (increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended. For prevention of 
hepatitis B reactivation that needs antiviral treatment Lamivudine 100mg/day 
will be administrated for the entire duration of chemotherapy and for the six 
months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti 
HBcore (+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids if given (see above) are allowed for no more than 3 consecutive 
days. Excluding patients with autoimmune cytopenia, in which case 
prolonged period steroid administration is permitted (see above).  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


 
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7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan* for CLL patients with a CT found to be abnormal before therapy 
or alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment if the above 4 clinical 
and laboratory results demonstrate that CR has been achieved. In some 
cases, it is necessary to postpone BMB until after all the other criteria used 
to define a CR have been satisfied but, this time interval should not 
exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 36 of 66 


 
 
were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, 
this time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory 
and physical examination results will be captured on the response forms in 
the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


 
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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 
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 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 considered related to the medicinal 
[investigational] product.  Pre-existing conditions which worsen during a study 
are to be reported as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An 
adverse event is any undesirable sign, symptom or medical condition 
occurring after starting study treatment, even if the event is not considered to 
be treatment-related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. 
Clinical events occurring before starting study treatment but after signing the 
informed consent form are recorded on the Medical History/Current Medical 
Conditions Case Report Form only if the patient receives study treatment. 
Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms or require therapy, when they are 
recorded on the Adverse Events Case Report Form under the signs, 
symptoms or diagnosis associated with them. 


 
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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this 
could improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal 
daily activities; treatment or medical intervention is required in 
order to maintain survival. 
Grade 5 
Death  
AE resulting in death  
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 
cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 


 
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As a consequence, for grading of anemia and thrombocytopenia, we plan 
to apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, 
but for grading of neutropenia, the standard NCI-CTC version 3.0 
criteria, as given below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade
ANC mm3 § (nadir)
No change-9%
0
2,000
10-24%
1
1,500 and <2,000
25-49%
2
1,000 and <1,500
50-74%
3
500 and <1000
75%
4
<500
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 
Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 


 
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possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of 
hemolytic anemia secondary to fludarabine, study treatment should be 
promptly withdrawn. Full details of the hemolytic anemia should be 
recorded on the adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four 
weeks of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 
– Reasonable temporal association with drug administration 


 
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– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event 
in which the subject was at immediate risk of death at the time of the 
event; it does not refer to an event which could hypothetically have caused 
a death had it been more severe). 
– required 
in-patient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of 
the outcomes listed above 


 
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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere to the 
full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse 
event if it is clearly consistent with the suspected progression of the 
underlying cancer as defined by RECIST criteria, or other criteria as 
determined by protocol. Hospitalization due solely to the progression of 
underlying malignancy should NOT be reported as a serious adverse event.  
Clinical symptoms of progression may be reported as adverse events if the 
symptom cannot be determined as exclusively due to the progression of the 
underlying malignancy, or does not fit the expected pattern of progression for 
the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that 
the investigator may elect not to perform further disease assessments.  In 
such cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every 
effort should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the 
disease under study, it should be reported as an AE or SAE. 


 
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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious 
and which occurs during the course of the study (as defined in section 7.1.1.3 
above), regardless of the treatment arm, occurring from the enrollment visit 
(start of study screening procedures), including long term follow-up (LTFU) 
must be reported to Roche within one working day of the investigator 
becoming aware of the event (expedited reporting). The investigator must 
complete the SAE Reporting Form 
] and forward it to the SAE 
Responsible. All SAEs occurring from the enrollment period must be reported, 
(start of study screening procedures), 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an 
adverse reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
When all subjects at a particular site are off treatment as defined by the 
protocol:  
 only individual SUSAR reports originating in that particular trial 
will be forwarded to the site and associated IRB/IEC on an 
expedited basis; 
 individual SUSARs considered to be a significant safety issue 
and/or which result in Roche recommending a change to the 


 
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Informed Consent Form (ICF), will be reported in an expedited 
manner to all investigators and IRBs/IECs; 
 SUSAR reports originating from other trials using the same IMP 
will be  provided as six monthly SUSAR Reports (SSRs) to 
investigators and IRBs/IECs where long-term follow-up studies 
are carried out, unless they are considered significant.. 
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days  after the last dose of study medication. 
This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2.   
8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 


 
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Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.2 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted 
directly from the central laboratory, if applicable.  
Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 
Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, 
interruption of, discontinuation of, or any other change in a concomitant 
medication, therapy or treatment) 
 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS are in fact regarded as current 
clinical practice for CLL patients, and should therefore be collected according 
to the Visit Schedules (see Figure 1). In case of suspected hemolysis - DAT, 
reticulocyte count, serum haptoglobin, bilirubin and LDH are recommended. 
The institution will perform laboratory analyses according to the Visit 
Schedules (see Figure 1). The sponsor must be provided with a copy of the 


 
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laboratory’s certification, and a tabulation of the normal ranges for each 
parameter required. Additionally, if at any time a patient has laboratory 
parameters obtained from a different outside laboratory, the sponsor must be 
provided with a copy of the certification and a tabulation of the normal ranges 
for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 
appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 
event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  


 
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8.3 
Special tests: 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the of the disease or suspicious for 
another disease or a different type of lymphoma. 
 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
 
8.5 
Laboratory examinations 
 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
 
8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


 
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Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective prescription information. 
 
 
 
 


 
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9. 
   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 
9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
9.2 
Efficacy and Safety evaluation 
9.2.1 Efficacy analysis:  
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
Response rate include CR and PR; all other situations (eg. stable disease, 
non response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


 
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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, 
and documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. ANOVA will be used to analyse the 
changes in the components and total score of the FACIT QOL assessment. 
 


 
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9.3 
Safety Analysis: 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 , or v 2.0 for cytopenia, whenever possible. In the by-
subject analysis, a subject experiencing the same event more than once will 
be counted only once. Adverse events will be defined and summarized 
according to the worst NCI CTC grade. Adverse events leading to death or to 
discontinuation of treatment, events classified as NCI CTCAE Grade 3 or 
Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI 
CTCAE severity grade. ANOVA will be used to analyse the changes in the 
components and total score of the FACIT QOL assessments. 
 
 
 


 
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10. 
Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract 
Research Organization staff following their own internal standard operating 
procedures that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs 
and database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, 
which are returned to the investigational site for resolution.  The signed 
original and resolved Data Query Forms are kept with the CRFs at the 
investigator site, and a copy is sent to the sponsor so the resolutions can be 
entered into the database.  Quality control audits of all key safety and efficacy 
data in the database are made prior to locking the database. 


 
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11. 
    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


 
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12. 
   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement 
that the protocol and informed consent have been approved by the IRB must 
be given to the sponsor before study initiation. The name and occupation of 
the chairman and the members of the IRB must be supplied to the sponsor. 
Any amendments to the protocol, other than administrative ones, must be 
approved by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in 
the study is voluntary and that he/she may withdraw from the study at any 
time and that withdrawal of consent will not affect his/her subsequent medical 
treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a 
copy of the signed document. If the subject cannot read or sign the 
documents, oral presentation may be made or signature given by the 
subject’s legally appointed representative, if witnessed by a person not 
involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent 
has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  


 
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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


 
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13. 
Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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14. 
Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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15. 
Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other 
active investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator 
nominated by the sponsor and the steering committee at the start of the trial 
would provide any needed signature.  
 
 
 


 
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References 
1) Thurmes P, Call Timothy et al. Comorbid conditions and survival in unselected, 
newly diagnosed patients with chronic lymphocytic leukemia. Leukemia & 
Lymphoma 2008, 49: 49-56. 
2) Keating MJ, O'Brien S, Lerner S, et al. Long-term follow-up of patients with chronic 
lymphocytic leukemia (CLL) receiving fludarabine regimens as initial therapy. 
Blood. 1998; 92: 1165-1171 
3) Koehi U, Ying Yang L, Nowak B, Van Haperen R, Keating M, Plunkett W. Effect of 
combined treatment with 4-hydroperoxycyclophosphamide and fludarabine on 
cytotoxicity and repair of damaged DNA. In: Hiddemann W , editor. Acute leukemias 
VII: experimental approaches and novel therapies. Berlin: Springer-Verlag, 1998: 
555. 
4) Kawai Y, Plunkett W. DNA repair induced by 4-hydroperxycyclophosphamide 
permits fludarabine nucleotide incorporation and is associated with synergistic 
induction of apoptosis in quiescent human lymphocytes [abstract 2910]. Blood. 1999; 
(94 Suppl): 655a. 
5) Yamauchi T, Nowak BJ, Keating MJ, Plunkett W. DNA repair initiated in chronic 
lymphocytic leukemia lymphocytes by 4-hydroperoxycyclophosphamide is inhibited 
by fludarabine and clofarabine. Clin Cancer Res. 2001; 7: 3580-3589. 
6) O'Brien SM, Kantarjian HM, Cortes J, et al. Results of the fludarabine and 
cyclophosphamide combination regimen in chronic lymphocytic leukemia. J Clin 
Oncol. 2001; 19: 1414-1420. 
7) 
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8) Foran JM, Oscier D, Orchard J, et al: Pharmacokinetic study of single doses of oral 
fludarabine phosphate in patients with low-grade non-Hodgkin's lymphoma and B-
cell chronic lymphocytic leukemia. J Clin Oncol 17:1574-1579, 1999. 
9) Oscier D, Orchard J, Culligan D, et al: The bioavailability of oral fludarabine 
phosphate is unaffected by food. Hematol J 2:316-321, 2001.  
10) 5

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11) Catovsky D, Richards S, Matutes E, Oscier D, Dyer MJ, Bezares RF, Pettitt AR, 
Hamblin T, Milligan DW, Child JA, Hamilton MS, Dearden CE, Smith AG, 
Bosanquet AG, Davis Z, Brito-Babapulle V, Else M, Wade R, Hillmen P; UK 
National Cancer Research Institute (NCRI) Haematological Oncology Clinical 
Studies Group; NCRI Chronic Lymphocytic Leukaemia Working Group. Assessment 
of fludarabine plus cyclophosphamide for patients with chronic lymphocytic 
leukaemia (the LRF CLL4 Trial): a randomised controlled trial. Lancet, 2007; 
370(9583): 230-9. 
12) IW Flinn, JC Byrd and C Morrison et al., Fludarabine and cyclophosphamide with 
filgrastim support in patients with previously untreated indolent lymphoid 
malignancies, Blood 96 (2000), pp. 71–75.  
13) BF Eichhorst, R Busch, G Hopfinger et al. and for the German CLL Study Group, 
Fludarabine plus cyclophosphamide versus fludarabine alone in first-line therapy of 
younger patients with chronic lymphocytic leukemia, Blood 107 (2006), pp. 885–
891.  
14) IW Flinn, DS Neuberg and MR Grever et al., Phase III trial of fludarabine plus 
cyclophosphamide compared with fludarabine for patients with previously untreated 
chronic lymphocytic leukemia: US Intergroup Trial E2997, J Clin Oncol 25 (2007), 
pp. 793–798. 
15) Polizzotto MN, Tam CS, Milner A, Januszewicz EH, Prince HM, Westerman D, 
Wolf MM, Seymour JF. The influence of increasing age on the deliverability and 


 
ML25464 Protocol Version A, Aug 30, 2010                                                                        Page 60 of 66 


 
 
toxicity of fludarabine-based combination chemotherapy regimens in patients with 
indolent lymphoproliferative disorders. Cancer 2006; 107: 773-80. 
16) &&61
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6  et al. Low-dose oral fludarabine plus 
cyclophosphamide as first-line treatment in elderly patients with indolent non-
Hodgkin lymphoma. British Journal of Haematology, 2000; 139; 90-93. 
18) Rossi JF, Van Hoof K et al. Efficacy and safety of oral fludarabine phosphate in 
previuosly untreated patients with chronic lymphocytic leukemia. 
	+!="-+!=4 
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24) MJ Keating, S O'Brien and M Albitar et al., Early results of a chemoimmunotherapy 
regimen of fludarabine, cyclophosphamide, and rituximab as initial therapy for 
chronic lymphocytic leukemia, J Clin Oncol 23 (2005), pp. 4079–4088. 
25) W Wierda, S O'Brien and S Wen et al., Chemoimmunotherapy with fludarabine, 
cyclophosphamide, and rituximab for relapsed and refractory chronic lymphocytic 
leukemia, J Clin Oncol 23 (2005), pp. 4070–4078 
26) Bairey, O., Benjamini, O., Blickstein, D., Elis, A. & R, R. (2006) Non-Hodgkin's 
lymphoma in patients 80 years of age or older. Ann Oncol., 17, 928-934. 
27) Eichhorst, B., Busch, R., G, H. & al, e. (2006) Fludarabine plus cyclophosphamide 
versus fludarabine alone in first-line therapy of younger patients with chronic 
lymphocytic leukemia. Blood, 107, 885-891. 
28) Flinn, I., Neuberg, D., Grever, M. & al, e. (2007) Phase III trial of fludarabine plus 
cyclophosphamide compared with fludarabine for patients with previously untreated 
chronic lymphocytic leukemia: US Intergroup Trial E2997. J Clin Oncol, 25, 793-
798. 
29) Goede, V., Cramer, P., Busch, R., Eichhorst, B., Hallek, M. & GCLLSG, t. (2005) 
Distribution and impact of comorbidity in chronic lymphocytic leukemia: meta-
analysis of two phase III trials of the German CLL Study Group (GCLLSG). 
Leukemia & Lymphoma, 46. 
30) Thurmes, P., Call, T., Slager, S., Zent, C., Jenkins, G., Schwager, S., Bowen, D., 
Kay, N. & Shanafelt, T. (2008) Comorbid conditions and survival in unselected, 
newly diagnosed patients with chronic lymphocytic leukemia. Leuk Lymphoma, 49, 
49-56. 
31) Stashenko p, Nadler LM, Hardy R,Sclossman SF. Characterization of a human B 
lymphocyte-specific antigen. J Immunol 1980; 125: 1678-1685. 


 
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32) Srinivas S, Yook C, ChangV et al. Prevalence of bone marrow CD20 positivity in 
patients with multi[le myeloma. J Clin Oncol 2001;20: (abstr 2687). 
33) Reff ME,Carner K, Chambers KS et al.  Depletion of B cells in vivo by a chimeric 
mouse human monoclonal antibody to CD20/ Blood 1994; 83: 435-445. 
34) Press OW, Appelbaum F, Ledbetter JA et ak. monoclonal antibody 1F5 (anti CD20) 
serotherapy of human B cell lymphomas. Blood 1987; 69: 584-591. 
35) LoBuglio AF, Wheeler RH, Trang J et al. Mouse/human chimeric monoclonal 
antibody in man:Kinetics and immune response. Proc Natl Acad Sci USA 1989; 86: 
4220-4224. 
36) Boye J, Elter T, Engert A. An overview of the current clinical use of the anti-CD20 
monoclonal antibody rituximab. Ann Oncol 2003; 14: 520-535. 
37) Winkler U, Jensen M, Manzke O, et al: Cytokine-release syndrome in patients with 
B-cell chronic lymphocytic leukemia and high lymphocyte counts after treatment 
with an anti-CD20 monoclonal antibody (Rituximab, IDEC-C2B8). Blood 
1999;94:2217-2224. 
38) Nguyen DT, Amess JA, Doughty H, et al: IDEC-C2B8 anti-CD20 (Rituximab) 
immunotherapy in patients with low-grade non-Hodgkin’s lymphoma and 
lymphoproliferative disorders: Evaluation of response on 48 patients. Eur J Haematol 
1990;62:76-82. 
39) ForanJM, Rohatiner AZ, Cunningham D, et al. European phase II study of Rituximab 
(chimeric anti-CD20 monoclonal antibody) for patients with newly diagnosed 
mantle-cell lymphoma and previously treated mantle cell lymphoma, 
immunocytoma, and small B-cell lymphocytic lymphoma. J Clin Oncol 2000;18:317-
324. 
40) Huhn D, von Schilling C, Wilhelm M, et al: Rituximab therapy of patients with B-
cell chronic lymphocytic leukemia. Blood 2001;98:1326-1331. 
41) Byrd JC, Murphy T, Howard RS, et al. Rituximab Using A Thrice weekly dosing 
schedule in B-cell chronic lymphocytic leukemia and small lymphocytic lymphoma 
demonstrates clinical activity and acceptable toxicity. J Clin Oncol;2002;19: 2153-
2164. 
42) O'Brien SM, Kantarjian H, Cortes J, et al.  Rituximab dose escalation trial in chronic 
lymphocytic leukemia. J Clin Oncology 2001;19: 2165-2170. 
43) Byrd JC, Peterson, BL, Morrison, VA, Park, K, Jacobson, R, Hoke, E, Vardiman, 
JW, Rai, K , Schiffer, CA, Larson, PA () Randomized Phase II Study of Fludarabine 
with Concurrent Versus Sequential Treatment with Rituximab in Symptomatic, 
Untreated Patients with B-Cell Chronic Lymphocytic Leukemia: Results from 
CALGB 9712. Blood. 2003;101:6-14. 
44) Sculz H Klein SK, Rehwald U et al/ Phase II study of combined immunotherapy 
using Rituximab and Fludarabine in patients with chronic lymphocytic leukemia. 
Blood 2001; 100: 3115-3120  
 Byrd JC, Rai K, Peterson BL, et al. Addition of Rituximab to Fludarabine may 
prolong progression-free survival and overall survival in patients with previously 
untreated chronic lymphocytic leukemia: an updated retrospective comparative 
analysis of CALGB 9712 and CALGB 9011. Blood. 2005;105:49-53
 Hallek M, Chesso BD,  Kantarjian H,et al.Guidelines for the diagnosis and treatment 
of CLL: a report from the IWCLL updating the NCI-WG 1966 guidelines.
47) Rai K , B.S Bercedis, Peterson L,Appelbaum FR, Kolitz J et al Fludarabine 
Compared with Chlorambucil as Primary Therapy for Chronic Lymphocytic 
Leukemia. N Engl J Med 2000; 343:1750-1757 
48) Byrd JC, Peterson BL, Morrison VA, et al. 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 2003,101:6-14. 
49) Robak T, DmoszynkaA,Solal-Celigny P et al Rituximab plus Fludarabine and 
Cyclophosphamide prolongs progression free survival compared to Fludarabine and 
Cyclophosphamide alone in previously treated chronica lymphocytic leukemia 
j.Clin.Oncol 28:1756-1765. 
50) Foon KA, Boyiadzis M,Land SR, et al. Chemoimmunotherapy with low dose 
Fludarabine and Cyclophosphamide and high dose Rituximab in previously untreated 
patients with chronic lymphocytic leukemia.J.Clin>Oncol 2009,27:491-497 


 
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51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 












ML25464 Protocol Version B, Jan 10, 2011                                              Page  2 of 66                        
  
 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (≥65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
 
 
 
Author:  Prof 
. 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 MHA+M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 MHA+M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  3 of 66                        
  
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ...................................................................................... 10 
3. 
TRIAL OBJECTIVES AND PURPOSE.............................................................................. 17 
3.1 
PRIMARY OBJECTIVE ................................................................................................... 17 
3.2 
SECONDARY OBJECTIVES ............................................................................................ 17 
4. 
TRIAL DESIGN .................................................................................................................. 18 
4.1 
PRIMARY AND SECONDARY END POINTS ........................................................................ 18 
4.2 
OVERALL STUDY DESIGN .............................................................................................. 18 
4.2.1 VISIT SCHEDULE AND ASSESSMENTS ............................................................................. 21 
4.3 
TRIAL TREATMENT ....................................................................................................... 23 
4.3.1  Investigational therapy ............................................................................................. 23 
4.4 
STUDY DRUG INTERRUPTION OR DISCONTINUATION ....................................................... 28 
4.5 
ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL PRODUCTS .......................... 28 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS .......................................................... 29 
5.1 
INCLUSION CRITERIA .................................................................................................... 29 
5.2 
EXCLUSION CRITERIA .................................................................................................. 29 
5.3 
INTERRUPTION OR DISCONTINUATION OF TREATMENT ................................................... 30 
6. 
TREATMENT OF SUBJECTS ........................................................................................... 33 
6.1 
TREATMENT REGIMEN .................................................................................................. 33 
6.1.1 TREATMENT ASSIGNMENT ............................................................................................ 33 
6.2 
CONCOMITANT THERAPY .............................................................................................. 33 
6.3 
TREATMENT COMPLIANCE ............................................................................................ 34 
7. 
ASSESSMENT OF EFFICACY ......................................................................................... 35 
8. 
ASSESSMENT OF SAFETY ............................................................................................. 37 
8.2 
SERIOUS ADVERSE EVENTS .......................................................................................... 41 
8.4 
Physical examinations/vital signs .............................................................................. 47 
8.5 
LABORATORY EXAMINATIONS ........................................................................................ 47 
8.6 
PHYSICAL EXAMINATIONS/VITAL SIGNS .......................................................................... 48 
9. 
STATISTICS 49 
9.1 
SAMPLE SIZE ............................................................................................................... 49 
9.2 
EFFICACY AND SAFETY EVALUATION ............................................................................. 49 
10. QUALITY CONTROL AND QUALITY ASSURANCE ........................................................ 52 
11. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .................................................... 53 
11.1      STUDY MONITORING .................................................................................................. 53 
11.2 AUDITS ....................................................................................................................... 53 
11.3 IRB AND REGULATORY INSPECTIONS ............................................................................ 53 
12. ETHICS ............................................................................................................................. 54 
12.1    INSTITUTIONAL REVIEW BOARD ................................................................................... 54 
12.2 INFORMED CONSENT .................................................................................................... 54 
12.3 DECLARATION OF HELSINKI .......................................................................................... 55 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  4 of 66                        
  
 
13. DATA HANDLING AND RECORD KEEPING ................................................................... 56 
14. FINANCING AND INSURANCE ........................................................................................ 57 
15. PUBLICATION POLICY .................................................................................................... 58 
16. SUPPLEMENTS ................................................................................................................ 63 
APPENDIX I    RESPONSE DEFINITIONS .................................................................................... 63 
APPENDIX II    ECOG PERFORMANCE STATUS ........................................................................ 64 
APPENDIX III CALCULATED CREATININE CLEARANCE ................................................................ 65 
APPENDIX IV     ACTIVE DISEASE ............................................................................................. 65 
APPENDIX VI    FACIT-QOL .................................................................................................. 66 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  5 of 66                        
  
 
LIST OF ABBREVIATIONS 
 
 
 
 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide
 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR                    
Institutional Review Board 
Infusion Related Reaction
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  6 of 66                        
  
 
SYNOPSIS 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (≥65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER:               ML25464 
 
DATE PROTOCOL FINAL:         January 10, 2011 
 
STUDY DRUG:                                FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:                                 CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE:                              II 
 
     Background and rationale Chronic lymphocytic leukemia (CLL) is characteristically 
diagnosed in the older population with a median age at diagnosis ranging between 65 and 
72 years. Because the prevalence of co morbidity increases with age, concomitant disease 
is often present in this age group. Additional factors which may also  adversely affect 
treatment outcome at standard doses in elderly patients include: altered pharmacokinetics 
and poorer host  tissue tolerance ; changes in the bone marrow hematopoietic reserve and 
microenvironment leading to increased treatment related myelotoxicity and  higher rates of 
treatment related complications such as infections. As a result, elderly patients are often 
excluded from clinical trials or even from routine treatment on the basis of their age and / or 
comorbidity. Furthermore when these patients are treated, the drug doses are often 
markedly reduced in an attempt to avoid causing toxicity and complications. The challenge 
in treating elderly CLL patients relates to finding the correct balance between drug efficacy 
and toxicity and because of this optimal treatment for this group of patients is often hard to 
achieve. 
 
   Study Objectives 
The aim of this study is to evaluate the safety and efficacy (response rate) of a combination 
of low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with standard dose 
Rituximab given as primary treatment for elderly patients with chronic lymphocytic 
leukemia. 
 
   Primary end point:  -Response rate 
 
   Secondary end points: 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  7 of 66                        
  
 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- 
days),          
-
Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- Time to Next Treatment (TNT). 
- QOL 
    STUDY DESIGN: 
This is a multicenter, phase II, single arm study designed to evaluate the efficacy and 
safety of the combination of low dose Fludarabine (FLU) and Cyclophosphamide (CY) 
combined with standard dose Rituximab in elderly previously untreated CLL patients (≥ 65 
years of age). Potential study subjects will sign an informed consent prior to undergoing 
any study related procedure. Number of patients to be enrolled 40. 
    Treatment plan:  Flu 12.5mg/m2/d will be given intravenously (I.V.) for days 1-3 every 
28 days, for a total of 6 cycles. 
CY will be given I.V. at the dose of 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. 
Rituximab given before chemotherapy cycle1:  375 mg/m2  I.V.  on day 0, cycles 2-6: 500 
mg/m2 I.V. on day 1 every 28 days. 
Dose reduction or delays are recommended in case of grade ≥3 (NCI-CTC) adverse 
events. 
This study consists of 3 periods for each study subject: Pre-treatment, Treatment and 
Follow up. 
Pre-treatment period: patients will undergo screening for protocol eligibility within 28 days 
(4 weeks) of recruitment. 
Subjects who meet all the inclusion criteria and have signed an approved informed consent 
will be enrolled. 
Treatment period FLU 12.5mg/m2/d  I.V. will be given on days 1-3 every 28 days, for a total 
of 6 cycles. CY will be given (I.V.) 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. Rituximab  given before chemotherapy cycle 1:  375 mg/m2 intravenously on day 0, 
cycles 2-6:  500 mg/m2  I.V.  on day 1 every 28 days.  
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and thereafter 
only if clinically indicated. Hydrocortisone 100-500 mg I.V. (according with local common 
practice) only if clinically indicated. 
Dose reduction or delay in case of drug induced hematological toxicity grade≥ 3 level. 
During the treatment period, all patients will attend periodic monthly study center visits in 
order to assess the safety and efficacy of the treatment. 
Complete blood count will be performed on day 1 and 14 of each of the first two cycles, 
and on day 1 in the other 4 cycles, or more frequently at the investigators discretion. 
Bone marrow aspiration and biopsy and CT scan will be performed within 3-to 6 months 
after the completion of the treatment period. 
       Follow up period: All patients will be assessed for progression and survival every 3 
months via clinic visits, for a total of 30 months. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  8 of 66                        
  
 
Complete blood count and chemistry will be performed every 3 months, or more frequently 
at the investigators discretion. 
In the event of suspected progression or relapse BMB and or CT scan will be performed at 
the treating physicians' discretion. 
 
 
    Duration of study  
The duration of the treatment period is approximately 6 months. This time period is 
required to complete the therapy, to determine the safety profile of the drug combination 
and the response rate to therapy. The duration of the follow up period will be 30 months. 
The occurrence of PD will determine the duration of progression-free survival of each 
patient.    
  Recruitment period will be 24 months. 
  Inclusion criteria: 
- Diagnosis of B-CLL is established by the presence of: An absolute lymphocyte 
count>        5X109/L, typical morphology in the peripheral blood smear as seen by light 
microscopy, CLL cells must show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. Low surface immunoglobulin/CD 79b expression is also 
expected to be evident on these cells while FMC7 should be negative-are both additional 
typical features on flow cytometry (optional). 
- Previously untreated B-CLL patients ≥ 65 years old. 
- Patients requiring treatment (active Binet stage A and B, all stage C disease). 
- Written informed consent 
    Exclusion criteria: 
- Calculated or measured creatinine clearance < 30 ml/min 
- Hepatic enzymes or bilirubin > 2X ULN, unless thought to be due to CLL 
- Suspected or documented CNS involvement by CLL 
- Known HIV positivity 
- Active or uncontrolled infections, including opportunistic infection, active hepatitis B / C 
-positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
- Various concomitant diseases requiring chronic steroid administration 
- Active Coombs positive hemolytic anemia 
- Prior treatment for CLL 
- CLL with transformation (Richter syndrome). 
- Presence of active second neoplasia (excluding non-melanoma skin cancer, or in 
situ        cervix or breast carcinoma) < 2 years prior to the study. 
- Use of other investigational agents or participation in any other clinical trials < 30 days 
prior to the study. 
- Low compliance. 
- Performance status: ECOG performance status ≥4. 
- Patients who mentally or physically are unable to comply with all aspects of the study. 
 
   


ML25464 Protocol Version B, Jan 10, 2011                                              Page  9 of 66                        
  
 
 
Assessments: 
    Efficacy  
      The following evaluations will be done to record the efficacy of the treatment regimen: 
- Assessment of disease response (revised International Response Criteria:   updated 
NCI-     IWG 2008).[46].  
- Date of documentation of disease progression. 
- Bone marrow biopsy examination 
- Peripheral blood immunophenotyping by FACS. 
- Changes in ANC, Hb levels and platelets counts from baseline blood counts and 
those          done during the study period. 
- Chest, abdominal and pelvic computerized tomography 
- Physical examination for lymphadenopathy and hepato-splenomegaly 
    Safety 
The following evaluations will be recorded to assess the safety of the regimen: 
- Complete physical examination including vital signs. 
- Clinical laboratory evaluations (hematology, biochemistry) 
- Concomitant medication and procedures 
- Adverse events 
- Health outcomes assessment (any extra medical appointment)  
 
    Efficacy analysis: 
Primary efficacy will be determined by objective overall response rate. Exact tests for 
assessing these will be used to compare objective overall response rates. Kaplan Meier 
procedure will be used to characterize the duration of response for PFS and TNT. 
Summary statistics (standard deviation, mean, median, minimum and maximum) will be 
provided for the relevant variables 
 Safety Analysis: 
Data from all subjects who receive any study drug will be included in the safety analyses. 
The severity of the toxicities will be graded according to the NCI CTC v3 or v2- for cytopenia, 
whenever possible. In the by-subject analysis, a subject experiencing the same event more 
than once will be counted only once. 
Adverse events will be defined and summarized by the worst NCI CTC grade. Adverse 
events leading to death or to discontinuation of treatment, events classified as NCI CTC 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI CTC severity 
grade. 
 
STUDY DURATION: five years                                        TOTAL SAMPLE SIZE: 40


ML25464 Protocol Version B, Jan 10, 2011                                              Page  10 of 66                        
  
 
2. Background Information 
 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
reported that 
 
[29]
 
nt in this age group. Goede et al
evide
disease is often 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
onditions are in 
c
comorbid 
 
se
have shown that the
 
[1]
 
Thurmes and colleagues
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients.
 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given. 
 
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate.
 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
purine 
is the most extensively studied 
 
Fludarabine
. 
[14]
the treatment of CLL 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
 
In this respect
. 
[13,14,27,28]
alone. 
 
used
 
when
shown to be more effective than 
compared therapy with 
  
[11]
U.K. MRC LRF CLL4 trial  reported in 2007 
the 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  11 of 66                        
  
 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  
that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
. Similar results 
[11]
ge 
CLL patients irrespective of a
of all 
standard treatment 
were published by the German CLL Study Group and the North American 
.]
14
[ 
Intergroup
 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections. 
 
of increasing age on the ability to 
 
influence
the 
 
investigated
 
[15]
Pollizzotto et al 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age ≥ 70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality.
 
Table 1 
 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 
(17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
 
X 4 days 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  12 of 66                        
  
 
Every 28 days ; 
4 courses 
CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2 
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
constant kappa antibody (C2B8) that reacts specifically 
 
1
with a human IgG
with the CD20 antigen found on the surface of malignant and normal B cells 
.  The antigen is expressed at lower levels on 
[31,33]
cell lines 
-
and established B
. CD20 is not shed 
[31]
ukemia (CLL) and plasma cells 
chronic lymphocytic le
from the surface of CD20+ cells after antibody binding and it is not 
.  Compared with its murine counterpart, 
[34]
internalized or downregulated 
human effector cells 
life in humans, interacts with 
-
Rituximab has a longer half
.]
36
[ 
and is less immunogenic
, 
]
35
, 
34
[ 
 
Reduced FC doses
 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-(≥ 70 years). These are listed in Table1. 
 
 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  13 of 66                        
  
 
2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
375 
 
employed
.  The original studies 
[37,39,40]
in CLL 
the use of this agent 
of Rituximab once a week for four weeks.  Subsequent studies 
 
2
mg/m
suggested using this dose three times a week for four weeks for a total of 12 
.  Dose 
[41]
resulted in better overall responses 
 
which
doses instead of 4 doses 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
 
standard dose of 375 mg/m2 was increased
the 
increased or the frequency of 
 
].
44
, 
41
[ 
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
 
RF
therapy with 
Byrd et al went on, to compare sequential and concurrent 
.  
]
43
[ 
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
23 months 
median survival has yet to be reached yet, but will be in excess of 
major side effects were observed: infusion related toxicity, 
Three 
. 
]
44
[
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
orted the treatment of 20 untreated and 11 relapsed CLL 
rep
 
[44]
(GCLLSG) 
patients. Treatment consisted of Fludarabine administered at standard doses 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  14 of 66                        
  
 
(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 
given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks.
 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections.
 
(Rituximab 
 
[47]
 
A retrospective comparative analysis of the CALGB 9712
and the CALGB 9011 (Fludarabine only) studies 
 
[48]
 
e)
plus Fludarabin
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
.]
45
[ 
was similar
 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
. In the untreated patients the overall response rate 
) [24, 25]
patients, respectively
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections.
 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection. 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  15 of 66                        
  
 
Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 
fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 
21%) and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  16 of 66                        
  
 
In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL.
 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
reported a phase II single arm 
 
[50]
 
and colleagues
 
Foon
. In this regard, 
patient
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
dose 
–
) combined with high
2
) and Cyclophosphamide (150mg/mg
2
(20mg/m
later as 
 
) given every other week during induction and
2
Rituximab (500mg/m
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
 
(range, 5.2 to 42.5 months) and none of the complete responders
 
months
cycles of 
 
ia was noted in 13% of the
have relapsed. Grade 3/4 neutropen
therapy 
 
therapy. Another approach to reduce toxicity was to use sequential
on days 1 through 5 for 6 cycles) followed by 
 
2
with fludarabine (25 mg/m
administered every 3 
 
2
(3,000 mg/m
 
consolidation with Cyclophosphamide
for four cycles (F
 
2
eeks for three cycles) and then by Rituximab 375 mg/m
w
In 36 previously untreated CLL patients an overall response of 
  
[51]
 
R).
C
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
had an excellent prognosis with a 
molecular CRs 
 
negative) and achieving
 
response duration curve, and 90% remain in clinical CR at 5
 
plateau in the
with a rate 
 
year survival rate is 71% compared
-
years. For the entire group, 5
 .
= .10)
 
P
not significant 
C regimen (
of 48% with the prior F
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  17 of 66                        
  
 
 
3. 
Trial Objectives and Purpose 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximab given as primary treatment for elderly patients with 
chronic lymphocytic leukemia.
 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic. 
 
 
3.1 
Primary Objective 
the combination of lower dose 
of 
 
(Response Rate)
 
To evaluate the efficacy
and 
 
for three days
 
given intravenously
 
/d
2
mg m
12.5 
Fludarabine 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
in cycle 1 and 
 
2
m
 
(375mg/
 
combined with standard dose Rituximab
 
days,
 .
cycles
 
6
for a total of 
 
6)
-
in cycles 2
  
2
m
mg/
 
500
 
.
 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia ≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS).  
3-       Time to Next Treatment (TNT).  
4-        Quality Of Life (FACIT) 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  18 of 66                        
  
 
4. 
Trial Design                                                                                                              
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     Time to Next Treatment (TNT) as defined in the protocol (see appendix I) 
4-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2  I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedure. In general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  
Up to 40 patients are planned to be enrolled during a two year period. 
This study consists of 3 periods for each study subject: A pre-treatment period, 
the treatment period and a follow up period.  


ML25464 Protocol Version B, Jan 10, 2011                                              Page  19 of 66                        
  
 
 
 
Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific medical 
procedures are performed which include laboratory screening assessments 
and physical examination as well as documentation of vital signs. If the 
hematology and/or biochemistry evaluations have been performed within 14 
days of the first dose of study drug as part of the screening evaluation, they 
need not be repeated, and the data may be used as the Day 1 values. Bone 
marrow examination including cytogenetics (FISH whenever possible) must 
have been performed within 12 months of starting the first dose of the study 
drugs. 
CT scan when done, must be performed within 6 weeks of starting the first dose 
of study drugs.    
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 every 
28 days. 
Premedication: antihistamines(e.g. 2mg clemastin or promethazine 25mg I.V.) 
and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Hydrocortisone 100 -
500mg I.V.(according with local common practice only if clinically indicated. 
In the event of grade ≥ 3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  20 of 66                        
  
 
both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic monthly study- 
center visits in order to assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two cycles. 
In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation of cytopenias (disease or treatment 
related) and for any other clinical indication at the discretion of the investigators.  
Supportive care including blood transfusions or administration of growth factors 
G-CSF or erythropoietin is permitted at the investigators' discretion throughout 
all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination including cytogenetics, peripheral blood 
immunophenotyping (FACS), abdominal, pelvic and chest CT will be 
performed 3 to 6 months after the completion of the treatment regimen, at 
clinical progression and at any other time according to the investigators' 
discretion. 
In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  21 of 66                        
  
 
subjects enrolled into the study and will be given at the dose of 15mg/m2/d given 
I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated and 
declared inadequate and inefficient. If response is evident in ≥ 5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the discretion 
of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule and 
assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days of 
the day indicated on the visit schedule, except visits 2-5 in which time window 
will be of  3 days . 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  22 of 66                        
  
 
Figure 1:   Visit schedule and assessments 
Week
 
-4 to 
0
 
1
 
3
 
5
 
7
 
9-25
 
Every 
4 
weeks
 
29
37
49
61-77 
every 12 
weeks 
89
 
101-161
 
 every 12 
weeks
 
Visit No.
 
1
 
2
 
3
 
4
 
5
 
10
-
6
 
11
12
13
13
-
10
 
14
 
15-19
 
Study period
 
preTx
 
Treatment period
 
Follow up period
 
Inc. /Excl. criteria
 
X
 
 
 
 
 
 
 
 
 
 
 
Informed consent
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Disease history
 
X
 
 
 
 
 
 
 
 
 
 
 
 
BMB*
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
Physical exam
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
CBC
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Blood chemistry
 
X
 
X
 
 
X
 
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Beta-2 micro glob 
 
X
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level,
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
DAT***
  
X
 
 
 
 
 
 
 
 
X
 
 
 
 
FACS****
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
Hepatitis B *****
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) **
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
QOL
 
X
 
 
  
 
 
 
X
 
 
 
 
X
 
 
Treatment dosage
 
X
 
Ongoing data capture
 
Adverse Events
 
X
 
Ongoing data capture and up to 30 days after completion or discontinuati
the study
 
Concomitant
 
medications
 
X
 
Ongoing data capture
 
Comments
 
X
 
Ongoing data capture
 
Study completion
 
X
 
Complete at any time if study drug is discontinued
 
* Bone marrow examination will be performed at any clinically suspicion of 
progression/ leukemia transformation, cytopenia evaluation, or for any CR 
confirmation at investigator discretion. 
 ** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
  *** DAT will be performed at any clinical suspicion of hemolysis. 
 **** Will be performed at any clinical suspicion of progression/ leukemia 
transformation, or for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  23 of 66                        
  
 
 
4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 mg/ml) 
diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with ≥ 25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
Hydrocortisone 100-500 mg I.V. (according local common practice) shortly 
before infusion with Rituximab to decrease the rate and severity of acute 
IRR/CRS for these patients. consider reduced rate for first infusion or a split 
dosing over two days during the first cycle. Severe CRS: may be associated 
with some features of tumor lysis syndrome e.g. hyperuricaemia, 
hyperkalaemia, hypocalcaemia, hypophosphataemia, acute renal failure, 
elevated LDH and may be associated with acute respiratory failure and death. 


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If severe CRS manifests stop infusion immediately and start aggressive 
symptomatic treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Hydrocortisone 100-500 mg I.V. (according local common practice), if 
necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  25 of 66                        
  
 
Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate 
Mild/moderate 
> 30 mm Hg 
 
 
 
Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more 
severe with the first infusion. In patients who were unable to tolerate the 
first infusion, cautious reintroduction of rituximab may be tried at the 
second cycle, at the investigator’s discretion. The recommended 
premedication should be given and then the patient carefully re-exposed 
to a small amount of rituximab (slow infusion of 10 mg I.V.) If a severe 
reaction occurs, the rituximab must be permanently discontinued. In 
such case patient will be treated with FC in the next cycles and data will 
be collected throughout the study period)
 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
Rituximab containing infusion bags will be labeled by the sponsor and collected 
for drug accountability. Storage conditions for study drug will be described on 
the medication label. Patients will receive the study drug combination for an 
exposure period of up to 6 months provided that in the opinion of the 
investigator the patient is benefiting from treatment with this study drug 
combination, and in the absence of any safety concerns. Treatment will be 
withheld only in the case of limiting toxicities (see below).  
As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 10 
glasses of fluids on the days they receive cyclophosphamide and  urinate at 
minimal ceasing  of bladder distention. 
DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
adequate "drug dispensing log” on Rituximab. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  26 of 66                        
  
 
 
The "drug dispensing" log for Rituximab must be kept current and should 
contain the following information: 
 
o The identification of the patient (patient number) to whom Rituximab was 
administered.  
o The date(s) and quantity of Rituximab, used for the patients' treatment.  
o The date(s) and quantity of Rituximab, of empty, partial or unused 
medication.  
 
All accountability logs must be available for inspection by the monitor. Drug 
supplies (partly used and empty Rituximab infusion bags) must be available for 
inspection, at every monitoring visit. Used supplies will be destructed according 
to local site guidelines.  
 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade ≥ 3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 
following cycles. There is no dose reduction for Rituximab in this study, but 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 
• If after three weeks, the grade ≥ 3 cytopenia, NOT RELATED TO CLL BONE MARROW 
INFILTRATION, still prevails, the patient should be removed from the protocol with 
no further study drug administration. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  27 of 66                        
  
 
• If there is further grade ≥ 3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 
• If there is any grade ≥ 3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine is partly (40-60%) excreted by the kidneys. If the calculated (see 
appendix III) or measured creatinine clearance is reduced to 30-60 ml/min, 
the fludarabine dose should be reduced to 50%. Patients with a creatinine 
clearance below 30 ml/min are excluded from the study. Patients who develop 
renal dysfunction (serum creatinine ≥ 1.5 mg/dL or creatinine clearance < 30 
ml/min) during treatment should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade ≥ 3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade ≤ 2, for 
up to three weeks. All subsequent cycles should then be given with a 25% 
dose reduction of fludarabine and cyclophosphamide. 
• If after three weeks, the grade ≥ 3 non-hematological, non-renal toxicity still 
persists, the patient should be removed from the protocol . 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
subsequent cycles despite the first 25% dose reduction treatment should 
again be delayed for up to three weeks and the dose of fludarabine and 
cyclophosphamide further reduced to 50% of the initial full dose. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
subsequent cycles despite 50% dose reduction the patient should be removed 
from the protocol treatment and the study. 
4.3.5 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  28 of 66                        
  
 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  
 4.3.6 Blinding                                                                                                         This 
is an open label trial. 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 
Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 
4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  29 of 66                        
  
 
5. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). 
2. 
Previously untreated B-CLL patients ≥ 65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin ≥ 2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
Positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
7. 
Various concomitant diseases requiring chronic steroid 
administration 
8. 
Active Coomb's positive hemolytic anemia. 
9. 
Prior treatment for CLL 
10. 
 CLL in transformation (Richter syndrome). 
11. 
   Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix carcinoma or 
breast carcinoma) < 2 years prior to the study. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  30 of 66                        
  
 
12. 
Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
13. 
   Low compliance. 
14. 
   Performance status: ECOG performance status ≥4. (see 
appendix II) 
15.   Patients who are mentally or physically unable to 
comply      with all aspects of the study. 
                      
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 
 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in 
the               event of study drug discontinuation) during and at the end of the 
study             period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued. Patient will be treated with FC in the next 
cycles and data will be recorded throughout the study period. 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  31 of 66                        
  
 
5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4) 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  32 of 66                        
  
 
5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  
Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients who 
discontinue study treatment should be followed for tumor assessments as per 
standard of care, until disease progression or new cancer therapy is initiated.  
If patients refuse to return for these visits or are unable to do so, the subject 
should be considered off-study, but a Study Evaluation Completion form should 
be completed. 
 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  33 of 66                        
  
 
6. 
Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of other 
concurrent investigational drugs is not allowed. The use of blood products 
(irradiated) transfusions, immunoglobulins or erythroid/myeloid growth factors 
are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration are allowed exclusively for patients with autoimmune 
hemolytic anemia and or autoimmune thrombocytopenia or as premedication 
for Rituximab . 
Premedication: Any patient considered to be at risk of infusion related reaction 
(IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should receive: 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  34 of 66                        
  
 
Appropriate hydration starting 12-24 hours prior to initiating treatment, and 
thereafter until the risk of IRR/TLS is ruled out. Urine alkalization is at 
investigator’s discretion. 
Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. 
(according local common practice) should be given only if clinically indicated 
(increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended. For prevention of 
hepatitis B reactivation that needs antiviral treatment Lamivudine 100mg/day 
will be administrated for the entire duration of chemotherapy and for the six 
months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti HBcore 
(+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids if given (see above) are allowed for no more than 3 consecutive days. 
Excluding patients with autoimmune cytopenia, in which case prolonged period 
steroid administration is permitted (see above).  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  35 of 66                        
  
 
7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan for CLL patients with a CT found to be abnormal before therapy or 
alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment if the above 4 clinical 
and laboratory results demonstrate that CR has been achieved. In some 
cases, it is necessary to postpone BMB until after all the other criteria used 
to define a CR have been satisfied but, this time interval should not 
exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout the 
study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  36 of 66                        
  
 
were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, this 
time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory and 
physical examination results will be captured on the response forms in the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 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 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 considered related to the medicinal [investigational] 
product.  Pre-existing conditions which worsen during a study are to be reported 
as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An adverse 
event is any undesirable sign, symptom or medical condition occurring after 
starting study treatment, even if the event is not considered to be treatment-
related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. Clinical 
events occurring before starting study treatment but after signing the informed 
consent form are recorded on the Medical History/Current Medical Conditions 
Case Report Form only if the patient receives study treatment. Abnormal 
laboratory values or test results constitute adverse events only if they induce 
clinical signs or symptoms or require therapy, when they are recorded on the 
Adverse Events Case Report Form under the signs, symptoms or diagnosis 
associated with them. 


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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this could 
improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal daily 
activities; treatment or medical intervention is required in order to 
maintain survival. 
Grade 5 
Death  
AE resulting in death  
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 
cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  39 of 66                        
  
 
As a consequence, for grading of anemia and thrombocytopenia, we plan 
to apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, 
but for grading of neutropenia, the standard NCI-CTC version 3.0 
criteria, as given below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade 
ANC mm3 § (nadir) 
No change-9% 
0 
≥2,000 
10-24% 
1 
≥1,500 and <2,000 
25-49% 
2 
≥1,000 and <1,500 
50-74% 
3 
≥500 and <1000 
≥75% 
4 
<500 
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 
Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 


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possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of 
hemolytic anemia secondary to fludarabine, study treatment should be 
promptly withdrawn. Full details of the hemolytic anemia should be 
recorded on the adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four weeks 
of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 
– Reasonable temporal association with drug administration 


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– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event in 
which the subject was at immediate risk of death at the time of the event; it 
does not refer to an event which could hypothetically have caused a death 
had it been more severe). 
– required in-patient hospitalization or prolongation of existing hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of the 
outcomes listed above 


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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere to the 
full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse event 
if it is clearly consistent with the suspected progression of the underlying cancer 
as defined by RECIST criteria, or other criteria as determined by protocol. 
Hospitalization due solely to the progression of underlying malignancy should 
NOT be reported as a serious adverse event.  Clinical symptoms of progression 
may be reported as adverse events if the symptom cannot be determined as 
exclusively due to the progression of the underlying malignancy, or does not fit 
the expected pattern of progression for the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that the 
investigator may elect not to perform further disease assessments.  In such 
cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every effort 
should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the disease 
under study, it should be reported as an AE or SAE. 
 
 


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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious and 
which occurs during the course of the study (as defined in section 7.1.1.3 
above), regardless of the treatment arm, occurring from the enrollment visit 
(start of study screening procedures), including long term follow-up (LTFU) 
must be reported to Roche within one working day of the investigator 
becoming aware of the event (expedited reporting). The investigator must 
complete the SAE Reporting Form [
] and forward it to the SAE 
Responsible. All SAEs occurring from the enrollment period must be reported, 
(start of study screening procedures), 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an adverse 
reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
When all subjects at a particular site are off treatment as defined by the 
protocol:  
 only individual SUSAR reports originating in that particular trial 
will be forwarded to the site and associated IRB/IEC on an 
expedited basis; 
 individual SUSARs considered to be a significant safety issue 
and/or which result in Roche recommending a change to the 


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Informed Consent Form (ICF), will be reported in an expedited 
manner to all investigators and IRBs/IECs; 
 SUSAR reports originating from other trials using the same IMP 
will be  provided as six monthly SUSAR Reports (SSRs) to 
investigators and IRBs/IECs where long-term follow-up studies 
are carried out, unless they are considered significant.. 
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days  after the last dose of study medication. 
This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and Standards 
for Expedited Reporting, Topic E2.   
8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 


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Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.2 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted directly 
from the central laboratory, if applicable.  
Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 
Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, interruption 
of, discontinuation of, or any other change in a concomitant medication, 
therapy or treatment) 
 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS are in fact regarded as current 
clinical practice for CLL patients, and should therefore be collected according 
to the Visit Schedules (see Figure 1). In case of suspected hemolysis - DAT, 
reticulocyte count, serum haptoglobin, bilirubin and LDH are recommended. 
The institution will perform laboratory analyses according to the Visit Schedules 
(see Figure 1). The sponsor must be provided with a copy of the laboratory’s 


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certification, and a tabulation of the normal ranges for each parameter required. 
Additionally, if at any time a patient has laboratory parameters obtained from a 
different outside laboratory, the sponsor must be provided with a copy of the 
certification and a tabulation of the normal ranges for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 
appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 
event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  


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8.3 
Special tests: 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the of the disease or suspicious for 
another disease or a different type of lymphoma. 
 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination and 
vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from physical 
examinations and vital signs assessments. 
 
 
8.5 
Laboratory examinations 
 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
 
8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


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Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective prescription information. 
 
 
 
 


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9. 
   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 
9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
9.2 
Efficacy and Safety evaluation 
9.2.1 Efficacy analysis:  
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
Response rate include CR and PR; all other situations (eg. stable disease, non 
response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, and 
documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout the 
study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first treatment 
day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. ANOVA will be used to analyse the 
changes in the components and total score of the FACIT QOL assessment. 
 


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9.3 
Safety Analysis: 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 , or v 2.0 for cytopenia, whenever possible. In the by-
subject analysis, a subject experiencing the same event more than once will 
be counted only once. Adverse events will be defined and summarized 
according to the worst NCI CTC grade. Adverse events leading to death or to 
discontinuation of treatment, events classified as NCI CTCAE Grade 3 or 
Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI 
CTCAE severity grade. ANOVA will be used to analyse the changes in the 
components and total score of the FACIT QOL assessments. 
 
 
 


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10. 
Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract Research 
Organization staff following their own internal standard operating procedures 
that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs and 
database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, which 
are returned to the investigational site for resolution.  The signed original and 
resolved Data Query Forms are kept with the CRFs at the investigator site, and 
a copy is sent to the sponsor so the resolutions can be entered into the 
database.  Quality control audits of all key safety and efficacy data in the 
database are made prior to locking the database. 


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11. 
    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


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12. 
   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement that 
the protocol and informed consent have been approved by the IRB must be 
given to the sponsor before study initiation. The name and occupation of the 
chairman and the members of the IRB must be supplied to the sponsor. Any 
amendments to the protocol, other than administrative ones, must be approved 
by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in the 
study is voluntary and that he/she may withdraw from the study at any time and 
that withdrawal of consent will not affect his/her subsequent medical treatment 
or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a copy 
of the signed document. If the subject cannot read or sign the documents, oral 
presentation may be made or signature given by the subject’s legally appointed 
representative, if witnessed by a person not involved in the study, mentioning 
that the patient could not read or sign the documents. No patient can enter the 
study before his/her informed consent has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  
 


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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


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13. 
Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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14. 
Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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15. 
Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other active 
investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator nominated 
by the sponsor and the steering committee at the start of the trial would provide 
any needed signature.  
 
 
 
 
 


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Minami, H., Utsunomiya, A., Taniwaki, M., Terauchi, T., Nawano, S., 
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Seriu, T. & Hotta, T. (2006) Phase II study of oral fludarabine phosphate in 
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J.M., Lister, T.A., Vose, J., Grillo-Lopez, A., Hagenbeek, A., Cabanillas, F., 
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Carter, W., Hoppe, R. & Cannellos, J.P. (1999) Report of an international 
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24) MJ Keating, S O'Brien and M Albitar et al., Early results of a chemoimmunotherapy 
regimen of fludarabine, cyclophosphamide, and rituximab as initial therapy for 
chronic lymphocytic leukemia, J Clin Oncol 23 (2005), pp. 4079–4088. 
25) W Wierda, S O'Brien and S Wen et al., Chemoimmunotherapy with fludarabine, 
cyclophosphamide, and rituximab for relapsed and refractory chronic lymphocytic 
leukemia, J Clin Oncol 23 (2005), pp. 4070–4078 
26) Bairey, O., Benjamini, O., Blickstein, D., Elis, A. & R, R. (2006) Non-Hodgkin's 
lymphoma in patients 80 years of age or older. Ann Oncol., 17, 928-934. 
27) Eichhorst, B., Busch, R., G, H. & al, e. (2006) Fludarabine plus cyclophosphamide 
versus fludarabine alone in first-line therapy of younger patients with chronic 
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28) Flinn, I., Neuberg, D., Grever, M. & al, e. (2007) Phase III trial of fludarabine plus 
cyclophosphamide compared with fludarabine for patients with previously untreated 
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798. 
29) Goede, V., Cramer, P., Busch, R., Eichhorst, B., Hallek, M. & GCLLSG, t. (2005) 
Distribution and impact of comorbidity in chronic lymphocytic leukemia: meta-
analysis of two phase III trials of the German CLL Study Group (GCLLSG). 
Leukemia & Lymphoma, 46. 
30) Thurmes, P., Call, T., Slager, S., Zent, C., Jenkins, G., Schwager, S., Bowen, D., 
Kay, N. & Shanafelt, T. (2008) Comorbid conditions and survival in unselected, 
newly diagnosed patients with chronic lymphocytic leukemia. Leuk Lymphoma, 49, 
49-56. 
31) Stashenko p, Nadler LM, Hardy R,Sclossman SF. Characterization of a human B 
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32) Srinivas S, Yook C, ChangV et al. Prevalence of bone marrow CD20 positivity in 
patients with multi[le myeloma. J Clin Oncol 2001;20: (abstr 2687). 


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33) Reff ME,Carner K, Chambers KS et al.  Depletion of B cells in vivo by a chimeric 
mouse human monoclonal antibody to CD20/ Blood 1994; 83: 435-445. 
34) Press OW, Appelbaum F, Ledbetter JA et ak. monoclonal antibody 1F5 (anti CD20) 
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antibody in man:Kinetics and immune response. Proc Natl Acad Sci USA 1989; 86: 
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36) Boye J, Elter T, Engert A. An overview of the current clinical use of the anti-CD20 
monoclonal antibody rituximab. Ann Oncol 2003; 14: 520-535. 
37) Winkler U, Jensen M, Manzke O, et al: Cytokine-release syndrome in patients with 
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1999;94:2217-2224. 
38) Nguyen DT, Amess JA, Doughty H, et al: IDEC-C2B8 anti-CD20 (Rituximab) 
immunotherapy in patients with low-grade non-Hodgkin’s lymphoma and 
lymphoproliferative disorders: Evaluation of response on 48 patients. Eur J Haematol 
1990;62:76-82. 
39) ForanJM, Rohatiner AZ, Cunningham D, et al. European phase II study of Rituximab 
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mantle-cell lymphoma and previously treated mantle cell lymphoma, 
immunocytoma, and small B-cell lymphocytic lymphoma. J Clin Oncol 2000;18:317-
324. 
40) Huhn D, von Schilling C, Wilhelm M, et al: Rituximab therapy of patients with B-
cell chronic lymphocytic leukemia. Blood 2001;98:1326-1331. 
41) Byrd JC, Murphy T, Howard RS, et al. Rituximab Using A Thrice weekly dosing 
schedule in B-cell chronic lymphocytic leukemia and small lymphocytic lymphoma 
demonstrates clinical activity and acceptable toxicity. J Clin Oncol;2002;19: 2153-
2164. 
42) O'Brien SM, Kantarjian H, Cortes J, et al.  Rituximab dose escalation trial in chronic 
lymphocytic leukemia. J Clin Oncology 2001;19: 2165-2170. 
43) Byrd JC, Peterson, BL, Morrison, VA, Park, K, Jacobson, R, Hoke, E, Vardiman, 
JW, Rai, K , Schiffer, CA, Larson, PA () Randomized Phase II Study of Fludarabine 
with Concurrent Versus Sequential Treatment with Rituximab in Symptomatic, 
Untreated Patients with B-Cell Chronic Lymphocytic Leukemia: Results from 
CALGB 9712. Blood. 2003;101:6-14. 
44) Sculz H Klein SK, Rehwald U et al/ Phase II study of combined immunotherapy 
using Rituximab and Fludarabine in patients with chronic lymphocytic leukemia. 
Blood 2001; 100: 3115-3120  
45) Byrd JC, Rai K, Peterson BL, et al. Addition of Rituximab to Fludarabine may 
prolong progression-free survival and overall survival in patients with previously 
untreated chronic lymphocytic leukemia: an updated retrospective comparative 
analysis of CALGB 9712 and CALGB 9011. Blood. 2005;105:49-53 
46) Hallek M, Chesso BD,  Kantarjian H,et al.Guidelines for the diagnosis and treatment 
of CLL: a report from the IWCLL updating the NCI-WG 1966 guidelines. 
47) Rai K , B.S Bercedis, Peterson L,Appelbaum FR, Kolitz J et al Fludarabine 
Compared with Chlorambucil as Primary Therapy for Chronic Lymphocytic 
Leukemia. N Engl J Med 2000; 343:1750-1757 
48) Byrd JC, Peterson BL, Morrison VA, et al. 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 2003,101:6-14. 
49) Robak T, DmoszynkaA,Solal-Celigny P et al Rituximab plus Fludarabine and 
Cyclophosphamide prolongs progression free survival compared to Fludarabine and 
Cyclophosphamide alone in previously treated chronica lymphocytic leukemia 
j.Clin.Oncol 28:1756-1765. 
50) Foon KA, Boyiadzis M,Land SR, et al. Chemoimmunotherapy with low dose 
Fludarabine and Cyclophosphamide and high dose Rituximab in previously untreated 
patients with chronic lymphocytic leukemia.J.Clin>Oncol 2009,27:491-497 
51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  62 of 66                        
  
 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 


ML25464 Protocol Version B, Jan 10, 2011                                              Page  63 of 66                        
 
 
 
16. 
Supplements 
 
Appendix I    Response definitions   
 
 
of the following criteria as assessed at least 3 
 
all
requires 
= 
 
(complete remission)
 
CR
months after completion of therapy:
 
 
 
 
Absence of clonal lymphocytes in peripheral blood.
 
 
Absence of significant lymphadenopathy. (lymph nodes > 1.5 cm in diameter) by 
physical examination. CT is desirable for not palpable lymph nodes.
 
 
No hepatomegaly or splenomegaly by physical examination. (Abdominal, pelvix 
and thorax CT for subjects found to be abnormal before therapy or if physical 
examination is inconclusive.
 
 
Absence of constitutional symptoms.
 
 
.  Platelets > 100 
 
/L
9
ANC> 1.5 x 10
Blood counts above the following values: 
).
/L . Hemoglobin > 11.0 g/dL; untransfused
9
x10
 
 
Bone marrow aspirate and biopsy should be performed at least 3 months after the 
last treatment and if the above 5 clinical and laboratory results demonstrate that CR 
has been achieved.
 
Bone marrow should be analyzed  by FACS/or immunohistochemistry to demonstrate 
marrow free of B-CLL cells.
 
In some cases, it is necessary to postpone BMB until after all the other criteria to 
define a CR have been satisfied. However, this time interval should not exceed 6 
months after the last treatment.
 
 
 








 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  1 of 66                        


 
 
 
 
F. HOFFMANN-LA ROCHE LTD  
CLINICAL STUDY PROTOCOL 
PROTOCOL NUMBER ML 25464 (FCR LITE) 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA
  
 
 
PROTOCOL APPROVAL 
Protocol : 
ML25464 Version C 
Date:   January 23, 2011 
Protocol approved by:     
Medical Manager: 
 
 
Project Statistician: 
 
                                                                                                                              
 
 
This protocol is intended for use in a life-threatening indication:  Yes      No    
Confidentiality Statement 
The information contained in this document, especially unpublished data, is the 
property of the sponsor of this study (F. Hoffmann-La Roche Ltd,) or under its 
control, and therefore provided to you in confidence as an investigator, potential 
investigator or consultant, for review by you, your staff and an applicable Independent 
Ethics Committee/Institutional Review Board. It is understood that this information 
will not be disclosed to others without written authorization from Roche except to the 
extent necessary to obtain informed consent from those persons to whom the drug 
may be administered. 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  2 of 66                        


 
 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
  
 
 
 
Author:  Prof 
. 
. 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 MHA+M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 MHA+M.D.  
 M.D.  
 M.D.  
 M.D.  
.D.  


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  3 of 66                        


 
 
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ....................................................................................... 10 
3. 
TRIAL OBJECTIVES AND PURPOSE............................................................................... 17 
3.1 
PRIMARY OBJECTIVE ................................................................................................... 17 
3.2 
SECONDARY OBJECTIVES ............................................................................................ 17 
4. 
TRIAL DESIGN ................................................................................................................... 18 
4.1 
PRIMARY AND SECONDARY END POINTS ........................................................................ 18 
4.2 
OVERALL STUDY DESIGN .............................................................................................. 18 
4.2.1 VISIT SCHEDULE AND ASSESSMENTS ............................................................................. 21 
4.3 
TRIAL TREATMENT ....................................................................................................... 23 
4.3.1  Investigational therapy ............................................................................................. 23 
4.4 
STUDY DRUG INTERRUPTION OR DISCONTINUATION ....................................................... 28 
4.5 
ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL PRODUCTS .......................... 28 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS ........................................................... 29 
5.1 
INCLUSION CRITERIA .................................................................................................... 29 
5.2 
EXCLUSION CRITERIA .................................................................................................. 29 
5.3 
INTERRUPTION OR DISCONTINUATION OF TREATMENT ................................................... 30 
6. 
TREATMENT OF SUBJECTS ............................................................................................ 33 
6.1 
TREATMENT REGIMEN .................................................................................................. 33 
6.1.1 TREATMENT ASSIGNMENT ............................................................................................ 33 
6.2 
CONCOMITANT THERAPY .............................................................................................. 33 
6.3 
TREATMENT COMPLIANCE ............................................................................................ 34 
7. 
ASSESSMENT OF EFFICACY .......................................................................................... 35 
8. 
ASSESSMENT OF SAFETY .............................................................................................. 37 
8.2 
SERIOUS ADVERSE EVENTS .......................................................................................... 41 
8.4 
Physical examinations/vital signs .............................................................................. 47 
8.5 
LABORATORY EXAMINATIONS ........................................................................................ 47 
8.6 
PHYSICAL EXAMINATIONS/VITAL SIGNS .......................................................................... 48 
9. 
STATISTICS 49 
9.1 
SAMPLE SIZE ............................................................................................................... 49 
9.2 
EFFICACY AND SAFETY EVALUATION ............................................................................. 49 
10. QUALITY CONTROL AND QUALITY ASSURANCE ......................................................... 52 
11. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ..................................................... 53 
11.1      STUDY MONITORING .................................................................................................. 53 
11.2 AUDITS ....................................................................................................................... 53 
11.3 IRB AND REGULATORY INSPECTIONS ............................................................................ 53 
12. ETHICS .............................................................................................................................. 54 
12.1    INSTITUTIONAL REVIEW BOARD ................................................................................... 54 
12.2 INFORMED CONSENT .................................................................................................... 54 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  4 of 66                        


 
 
12.3 DECLARATION OF HELSINKI .......................................................................................... 55 
13. DATA HANDLING AND RECORD KEEPING .................................................................... 56 
14. FINANCING AND INSURANCE ......................................................................................... 57 
15. PUBLICATION POLICY ..................................................................................................... 58 
16. SUPPLEMENTS ................................................................................................................. 63 
APPENDIX I    RESPONSE DEFINITIONS .................................................................................... 63 
APPENDIX II    ECOG PERFORMANCE STATUS ........................................................................ 64 
APPENDIX III CALCULATED CREATININE CLEARANCE ................................................................ 65 
APPENDIX IV     ACTIVE DISEASE ............................................................................................. 65 
APPENDIX VI    FACIT-QOL .................................................................................................. 66 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  5 of 66                        


 
 
LIST OF ABBREVIATIONS 
 
 
 
 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide
 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR                    
Institutional Review Board 
Infusion Related Reaction
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  6 of 66                        


 
 
SYNOPSIS 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER:               ML25464 
 
DATE PROTOCOL FINAL:         10 January 2011 
 
STUDY DRUG:                                FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:                                 CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE:                              II 
 
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ML25464 Protocol Version C, Jan 23, 2011                                               Page  7 of 66                        


 
 
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ML25464 Protocol Version C, Jan 23, 2011                                               Page  8 of 66                        


 
 
		
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


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  9 of 66                        


 
 


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ML25464 Protocol Version C, Jan 23, 2011                                               Page  10 of 66                        


 
 
2. Background Information 
 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
disease is often evident in this age group. Goede et al [29] reported that 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
Thurmes and colleagues [1] have shown that these comorbid conditions are in 
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients.
 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given. 
 
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate.
 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
the treatment of CLL [14]. Fludarabine is the most extensively studied purine 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
shown to be more effective than when used alone. [13,14,27,28]. In this respect 
the U.K. MRC LRF CLL4 trial  reported in 2007 [11]  compared therapy with 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  11 of 66                        


 
 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  
that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
standard treatment of all CLL patients irrespective of age [11]. Similar results 
were published by the German CLL Study Group and the North American 
Intergroup [14].
 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections. 
 
Pollizzotto et al [15] investigated the influence of increasing age on the ability to 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age  70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality.
 
Table 1 
 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 (17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2
 
X 4 days 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  12 of 66                        


 
 
Every 28 days ; 
4 courses 
CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
with a human IgG1 constant kappa antibody (C2B8) that reacts specifically 
with the CD20 antigen found on the surface of malignant and normal B cells 
and established B-cell lines [31,33].  The antigen is expressed at lower levels on 
chronic lymphocytic leukemia (CLL) and plasma cells [31]. CD20 is not shed 
from the surface of CD20+ cells after antibody binding and it is not 
internalized or downregulated [34].  Compared with its murine counterpart, 
Rituximab has a longer half-life in humans, interacts with human effector cells 
[34, 35], and is less immunogenic [36].
 
 
Reduced FC doses
 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-( 70 years). These are listed in Table1. 
 
 
 
 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  13 of 66                        


 
 
2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
the use of this agent in CLL [37,39,40].  The original studies employed 375 
mg/m2 of Rituximab once a week for four weeks.  Subsequent studies 
suggested using this dose three times a week for four weeks for a total of 12 
doses instead of 4 doses which resulted in better overall responses [41].  Dose 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
increased or the frequency of the standard dose of 375 mg/m2 was increased 
[41, 44]. 
 
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
Byrd et al went on, to compare sequential and concurrent therapy with RF [43]. 
 
 
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
median survival has yet to be reached yet, but will be in excess of 23 months 
[44]. Three major side effects were observed: infusion related toxicity, 
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
(GCLLSG) [44] reported the treatment of 20 untreated and 11 relapsed CLL 
patients. Treatment consisted of Fludarabine administered at standard doses 


 
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(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 
given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks.
 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections.
 
A retrospective comparative analysis of the CALGB 9712 [47] (Rituximab 
plus Fludarabine) [48] and the CALGB 9011 (Fludarabine only) studies 
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
was similar [45].
 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
patients, respectively) [24, 25]. In the untreated patients the overall response rate 
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections.
 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection. 
 


 
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Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 
fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 21%) 
and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


 
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In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL.
 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
patient. In this regard, Foon and colleagues [50] reported a phase II single arm 
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
(20mg/m2) and Cyclophosphamide (150mg/mg2) combined with high–dose 
Rituximab (500mg/m2) given every other week during induction and later as 
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
months (range, 5.2 to 42.5 months) and none of the complete responders 
have relapsed. Grade 3/4 neutropenia was noted in 13% of the cycles of 
therapy. Another approach to reduce toxicity was to use sequential therapy 
with fludarabine (25 mg/m2 on days 1 through 5 for 6 cycles) followed by 
consolidation with Cyclophosphamide (3,000 mg/m2 administered every 3 
weeks for three cycles) and then by Rituximab 375 mg/m2 for four cycles 
(F C
R). [51]  In 36 previously untreated CLL patients an overall response of 
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
negative) and achieving molecular CRs had an excellent prognosis with a 
plateau in the response duration curve, and 90% remain in clinical CR at 5 
years. For the entire group, 5-year survival rate is 71% compared with a rate 
of 48% with the prior F C regimen (not significant P = .10). 
 
 


 
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3. 
Trial Objectives and Purpose 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximabgiven as primary treatment for elderly patients with 
chronic lymphocytic leukemia.
 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic. 
 
 
3.1 
Primary Objective 
To evaluate the efficacy (Response Rate) of the combination of lower dose 
Fludarabine 12.5 mg m2/d given intravenously for three days and 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
days, combined with standard dose Rituximab (375mg/ m2 in cycle 1 and 
500 mg/m2  in cycles 2-6) for a total of 6 cycles. 
  
.
 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia grade 3, neutropenia  grade 3. 
2-       Progression Free Survival (PFS).  
3-       Time to Next Treatment (TNT).  
4-        Quality Of Life (FACIT) 


 
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4. 
Trial Design                                                                                                             
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia grade 3, neutropenia grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     Time to Next Treatment (TNT) as defined in the protocol (see appendix I) 
4-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2  I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedureIn general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  
Up to 40 patients are planned to be enrolled during a two year period. 
This study consists of 3 periods for each study subject: A pre-treatment 
period, the treatment period and a follow up period.  


 
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Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific 
medical procedures are performed which include laboratory screening 
assessments and physical examination as well as documentation of vital 
signs. If the hematology and/or biochemistry evaluations have been 
performed within 14 days of the first dose of study drug as part of the 
screening evaluation, they need not be repeated, and the data may be used 
as the Day 1 values. Bone marrow examination including cytogenetics (FISH 
whenever possible) must have been performed within 12 months of starting 
the first dose of the study drugs. 
CT scan when done, must be performed within 6 weeks of starting the first 
dose of study drugs.    
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 every 
28 days. 
Premedication: antihistamines(e.g. 2mg clemastin or promethazine 25mg I.V.) 
and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Hydrocortisone 100 -
500mg I.V.(according with local common practice only if clinically indicated.
In the event of grade  3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 


 
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both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic twice a month in 
the first 2 months and thereafter monthly study- center visits in order to 
assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two 
cycles. In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation of cytopenias (disease or treatment 
related) and for any other clinical indication at the discretion of the 
investigators.  
Supportive care including blood transfusions or administration of growth 
factors G-CSF or erythropoietin is permitted at the investigators' discretion 
throughout all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination including cytogenetics, peripheral blood 
immunophenotyping (FACS), abdominal, pelvic and chest CT will be 
performed 3 to 6 months after the completion of the treatment regimen, at 
clinical progression and at any other time according to the investigators' 
discretion. 


 
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In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 
subjects enrolled into the study and will be given at the dose of 15mg/m2/d 
given I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated 
and declared inadequate and inefficient. If response is evident in  5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the 
discretion of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule 
and assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days 
of the day indicated on the visit schedule, except visits 2-5 in which time 
window will be of  3 days . 
 


 
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Figure 1:   Visit schedule and assessments 
Week
 
-4 to 
0
 
1
 
3
 
5
 
7
 
9-25
Every 
4 
weeks
29
37
49
61
 
73-145
 
 every 12 
weeks
 
157
 
EOS
 
Visit No.
 
1
 
2
 
3
 
4
 
5
 
6-10
 
11
12
13
14
 
15-21
 
22
 
Study period
 
preTx
 
Treatment period
 
Follow up period
 
   Inc. /Excl. criteria
 
X
   
 
 
 
 
 
 
 
 
 
 
 
Informed consent
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Disease history
 
X
 
 
 
 
 
 
 
 
 
 
 
 
BMB*
X
 
 
 
 
 
 
 
 
X
 
 
 
 
Physical exam
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
CBC
  
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Blood chemistry
 
X
 
X
 
 
X
 
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Beta-2 micro glob 
 
X
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level,
 
X
 
 
 
 
 
 
 
 
X
 
 
 
X
 
DAT***
X
 
 
 
 
 
 
 
 
X
 
 
 
 
FACS****
 
X
 
 
 
 
 
 
 
 
X
 
 
 
X
 
Hepatitis B *****
X
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) **
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
QOL
 
X
 
 
  
 
 
 
X
 
 
 
X
 
 
X
 
Treatment dosage
 
X
 
Ongoing data capture
 
Adverse Events
 
X
 
Ongoing data capture and up to 30 days after completion or 
discontinuation of the study
 
Concomitant
 
medications
 
X
 
Ongoing data capture
 
Comments
 
X
 
Ongoing data capture
 
Study completion
 
X
 
Complete at any time if study drug is discontinued
 
progression/ leukemia transformation, cytopenia evaluation, or for any CR 
confirmation at investigator discretion. 
 ** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
  *** DAT will be performed at any clinical suspicion of hemolysis. 
 **** Will be performed at any clinical suspicion of progression/ leukemia 
transformation, or for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 


 
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4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 
mg/ml) diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with  25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
Hydrocortisone 100-500 mg I.V. (according local common practice) shortly 
before infusion with Rituximab to decrease the rate and severity of acute 
IRR/CRS for these patients. consider reduced rate for first infusion or a split 
dosing over two days during the first cycle. Severe CRS: may be associated 
with some features of tumor lysis syndrome e.g. hyperuricaemia, 
hyperkalaemia, hypocalcaemia, hypophosphataemia, acute renal failure, 


 
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elevated LDH and may be associated with acute respiratory failure and death. 
If severe CRS manifests stop infusion immediately and start aggressive 
symptomatic treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Hydrocortisone 100-500 mg I.V. (according local common practice), if 
necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 


 
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Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate
Mild/moderate 
> 30 mm Hg 
 
 
 
Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more 
severe with the first infusion. In patients who were unable to tolerate the 
first infusion, cautious reintroduction of rituximab may be tried at the 
second cycle, at the investigator’s discretion. The recommended 
premedication should be given and then the patient carefully re-exposed 
to a small amount of rituximab (slow infusion of 10 mg I.V.) If a severe 
reaction occurs, the rituximab must be permanently discontinued. In 
such case patient will be treated with FC in the next cycles and data will 
be collected throughout the study period)
 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
All infusion bags will be labeled by the study nurse prior to administration and 
only the empty Rituximab infusion bags will be collected for drug 
accountability by the study monitor. Storage conditions for study drug will be 
described on the medication label. Patients will receive the study drug 
combination for an exposure period of up to 6 months provided that in the 
opinion of the investigator the patient is benefiting from treatment with this 
study drug combination, and in the absence of any safety concerns. 
Treatment will be withheld only in the case of limiting toxicities (see below).  
As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 
10 glasses of fluids on the days they receive cyclophosphamide and  urinate 
at minimal ceasing  of bladder distention. 


 
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DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
adequate "drug dispensing log” on study medication. 
 
The "drug dispensing" log for the study medication must be kept current and 
should contain the following information: 
 
o The identification of the patient (patient number) to whom the study 
medication was administered.  
o The date(s) and quantity of study medication, used for the patients' 
treatment.  
o The date(s) and quantity of study medication, of empty, partial or 
unused medication.  
 
All accountability logs must be available for inspection by the monitor. Drug 
supplies (partly used and empty Rituximab infusion bags) must be available 
for inspection, at every monitoring visit. Used supplies will be destructed 
according to local site guidelines.  
 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade  3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 
following cycles. There is no dose reduction for Rituximab in this study, but 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 


 
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• If after three weeks, the grade  3 cytopenia, 	  CLL 

, still prevails, the patient should be removed from the 
protocol with no further study drug administration. 
• If there is further grade  3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 
• If there is further grade  3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 
• If there is any grade  3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine is partly (40-60%) excreted by the kidneys. If the calculated (see 
appendix III) or measured creatinine clearance is reduced to 30-60 ml/min, 
the fludarabine dose should be reduced to 50%. Patients with a creatinine 
clearance below 30 ml/min are excluded from the study. Patients who develop 
renal dysfunction (serum creatinine  1.5 mg/dL or creatinine clearance < 30 
ml/min) during treatment should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade  3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade  2, for 
up to three weeks. All subsequent cycles should then be given with a 25% 
dose reduction of fludarabine and cyclophosphamide. 
• If after three weeks, the grade  3 non-hematological, non-renal toxicity still 
persists, the patient should be removed from the protocol . 
• If there is further grade  3 non-hematological, non-renal toxicity in 
subsequent cycles despite the first 25% dose reduction treatment should 
again be delayed for up to three weeks and the dose of fludarabine and 
cyclophosphamide further reduced to 50% of the initial full dose. 


 
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• If there is further grade  3 non-hematological, non-renal toxicity in 
subsequent cycles despite 50% dose reduction the patient should be removed 
from the protocol treatment and the study. 
4.3.5 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  
 4.3.6 Blinding                                                                                                         
This is an open label trial. 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 
Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 
4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. 


 
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5. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). ZAP 70 and CD38 are optional. 
2. 
Previously untreated B-CLL patients  65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin  2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
Positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
7. 
Various concomitant diseases requiring chronic steroid 
administration 
8. 
Active Coomb's positive hemolytic anemia. 
9. 
Prior treatment for CLL 
10. 
 CLL in transformation (Richter syndrome). 
11.    Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix carcinoma or 
breast carcinoma) < 2 years prior to the study. 


 
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12. Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
13.    Low compliance. 
14.    Performance status: ECOG performance status 4. (see 
appendix II) 
15.   Patients who are mentally or physically unable to comply      
with all aspects of the study. Upon investigator 
discretion, a psycho-geriatric evaluation will be 
performed for patients  80 years old. 
       
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 
 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in the         
      event of study drug discontinuation) during and at the end of the study       
      period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued. Patient will be treated with FC in the next 
cycles and data will be recorded throughout the study period. 


 
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5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4) 
 
 
 
5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  
Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients 
who discontinue study treatment should be followed for tumor assessments 
as per standard of care, until disease progression or new cancer therapy is 
initiated.  If patients refuse to return for these visits or are unable to do so, the 


 
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subject should be considered off-study, but a Study Evaluation Completion 
form should be completed. 
 
 
 


 
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6. 
Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of 
other concurrent investigational drugs is not allowed. The use of blood 
products (irradiated) transfusions, immunoglobulins or erythroid/myeloid 
growth factors are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration are allowed exclusively for patients with autoimmune 
hemolytic anemia and or autoimmune thrombocytopenia or as premedication 
for Rituximab . 
Premedication: Any patient considered to be at risk of infusion related 
reaction (IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should 
receive: 


 
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Appropriate hydration starting 12-24 hours prior to initiating treatment, and 
thereafter until the risk of IRR/TLS is ruled out. Urine alkalization is at 
investigator’s discretion. 
Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. 
(according local common practice)should be given only if clinically indicated 
(increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended. For prevention of 
hepatitis B reactivation that needs antiviral treatment Lamivudine 100mg/day 
will be administrated for the entire duration of chemotherapy and for the six 
months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti 
HBcore (+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids if given (see above) are allowed for no more than 3 consecutive 
days. Excluding patients with autoimmune cytopenia, in which case 
prolonged period steroid administration is permitted (see above).  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


 
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7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan for CLL patients with a CT found to be abnormal before therapy 
or alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment if the above 4 clinical 
and laboratory results demonstrate that CR has been achieved. In some 
cases, it is necessary to postpone BMB until after all the other criteria used 
to define a CR have been satisfied but, this time interval should not 
exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


 
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were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, 
this time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory 
and physical examination results will be captured on the response forms in 
the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


 
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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 
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 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 considered related to the medicinal 
[investigational] product.  Pre-existing conditions which worsen during a study 
are to be reported as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An 
adverse event is any undesirable sign, symptom or medical condition 
occurring after starting study treatment, even if the event is not considered to 
be treatment-related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. 
Clinical events occurring before starting study treatment but after signing the 
informed consent form are recorded on the Medical History/Current Medical 
Conditions Case Report Form only if the patient receives study treatment. 
Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms or require therapy, when they are 
recorded on the Adverse Events Case Report Form under the signs, 
symptoms or diagnosis associated with them. 


 
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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this 
could improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal 
daily activities; treatment or medical intervention is required in 
order to maintain survival. 
Grade 5 
Death  
AE resulting in death  
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 
cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 


 
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As a consequence, for grading of anemia and thrombocytopenia, we plan 
to apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, 
but for grading of neutropenia, the standard NCI-CTC version 3.0 
criteria, as given below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade
ANC mm3 § (nadir)
No change-9%
0
2,000
10-24%
1
1,500 and <2,000
25-49%
2
1,000 and <1,500
50-74%
3
500 and <1000
75%
4
<500
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 
Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 


 
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possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of 
hemolytic anemia secondary to fludarabine, study treatment should be 
promptly withdrawn. Full details of the hemolytic anemia should be 
recorded on the adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four 
weeks of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 
– Reasonable temporal association with drug administration 


 
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– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event 
in which the subject was at immediate risk of death at the time of the 
event; it does not refer to an event which could hypothetically have caused 
a death had it been more severe). 
– required 
in-patient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of 
the outcomes listed above 


 
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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere to the 
full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse 
event if it is clearly consistent with the suspected progression of the 
underlying cancer as defined by RECIST criteria, or other criteria as 
determined by protocol. Hospitalization due solely to the progression of 
underlying malignancy should NOT be reported as a serious adverse event.  
Clinical symptoms of progression may be reported as adverse events if the 
symptom cannot be determined as exclusively due to the progression of the 
underlying malignancy, or does not fit the expected pattern of progression for 
the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that 
the investigator may elect not to perform further disease assessments.  In 
such cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every 
effort should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the 
disease under study, it should be reported as an AE or SAE. 


 
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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious 
and which occurs during the course of the study (as defined in section 7.1.1.3 
above), occurring from the enrollment visit (start of study screening 
procedures), including long term follow-up (LTFU) must be reported to Roche 
within one working day of the investigator becoming aware of the event 
(expedited reporting). The investigator must complete the SAE Reporting 
Form [
] and forward it to the SAE Responsible. All SAEs 
occurring from the enrollment period must be reported, (start of study 
screening procedures), 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an 
adverse reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
When all subjects at a particular site are off treatment as defined by the 
protocol:  
 only individual SUSAR reports originating in that particular trial 
will be forwarded to the site and associated IRB/IEC on an 
expedited basis; 
 individual SUSARs considered to be a significant safety issue 
and/or which result in Roche recommending a change to the 


 
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Informed Consent Form (ICF), will be reported in an expedited 
manner to all investigators and IRBs/IECs; 
 SUSAR reports originating from other trials using the same IMP 
will be  provided as six monthly SUSAR Reports (SSRs) to 
investigators and IRBs/IECs where long-term follow-up studies 
are carried out, unless they are considered significant.. 
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days  after the last dose of study medication. 
This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2.   
8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 


 
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Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.2 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted 
directly from the central laboratory, if applicable.  
Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 
Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, 
interruption of, discontinuation of, or any other change in a concomitant 
medication, therapy or treatment) 
 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS and hepatitis B serology are in fact 
regarded as current clinical practice for CLL patients, and should therefore be 
collected according to the Visit Schedules (see Figure 1). In case of 
suspected hemolysis - DAT, reticulocyte count, serum haptoglobin, bilirubin 
and LDH are recommended. 


 
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The institution will perform laboratory analyses according to the Visit 
Schedules (see Figure 1). The sponsor must be provided with a copy of the 
laboratory’s certification, and a tabulation of the normal ranges for each 
parameter required. Additionally, if at any time a patient has laboratory 
parameters obtained from a different outside laboratory, the sponsor must be 
provided with a copy of the certification and a tabulation of the normal ranges 
for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 
appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 
event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  


 
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8.3 
Special tests: 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the normal behavior of the disease or 
suspicious for another disease or a different type of lymphoma. 
 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
 
8.5 
Laboratory examinations 
 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
 
8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


 
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Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective prescription information. 
 
 
 
 


 
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9. 
   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 
9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
9.2 
Efficacy and Safety evaluation 
9.2.1 Efficacy analysis:  
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
Response rate include CR and PR; all other situations (eg. stable disease, 
non response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


 
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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, 
and documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. ANOVA will be used to analyse the 
changes in the components and total score of the FACIT QOL assessment. 
 


 
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9.3 
Safety Analysis: 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/ctca
ev3.pdf 
or v 2.0 for cytopenia, whenever possible. In the by-subject analysis, a subject 
experiencing the same event more than once will be counted only once. 
Adverse events will be defined and summarized according to the worst NCI 
CTC grade. Adverse events leading to death or to discontinuation of 
treatment, events classified as NCI CTCAE Grade 3 or Grade 4, study-drug-
related events, and serious adverse events will be summarized separately. 
Laboratory data will be graded according to NCI CTCAE severity grade. 
ANOVA will be used to analyse the changes in the components and total 
score of the FACIT QOL assessments. 
 
 
 


 
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10. 
Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract 
Research Organization staff following their own internal standard operating 
procedures that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs 
and database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, 
which are returned to the investigational site for resolution.  The signed 
original and resolved Data Query Forms are kept with the CRFs at the 
investigator site, and a copy is sent to the sponsor so the resolutions can be 
entered into the database.  Quality control audits of all key safety and efficacy 
data in the database are made prior to locking the database. 


 
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11. 
    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


 
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12. 
   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement 
that the protocol and informed consent have been approved by the IRB must 
be given to the sponsor before study initiation. The name and occupation of 
the chairman and the members of the IRB must be supplied to the sponsor. 
Any amendments to the protocol, other than administrative ones, must be 
approved by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in 
the study is voluntary and that he/she may withdraw from the study at any 
time and that withdrawal of consent will not affect his/her subsequent medical 
treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a 
copy of the signed document. If the subject cannot read or sign the 
documents, oral presentation may be made or signature given by the 
subject’s legally appointed representative, if witnessed by a person not 
involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent 
has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  


 
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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


 
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13. 
Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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14. 
Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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15. 
Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other 
active investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator 
nominated by the sponsor and the steering committee at the start of the trial 
would provide any needed signature.  
 
 
 


 
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7) 
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
 !""#$%&%
'(
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%
(%()(*)
'(%
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)!+,+-!+,.
/01)) !""2$
3%&	
!2+4-!2!2 
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10) 5

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151	:5
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/	#!;!-#!;, 
11) Catovsky D, Richards S, Matutes E, Oscier D, Dyer MJ, Bezares RF, Pettitt AR, 
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16) &&61
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#4!-#4# 
17) &&61
0
6  et al. Low-dose oral fludarabine plus 
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	+!="-+!=4 
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591 !"";$%
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8''%%	
:?16)3
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Cyclophosphamide alone in previously treated chronica lymphocytic leukemia 
j.Clin.Oncol 28:1756-1765. 
50) Foon KA, Boyiadzis M,Land SR, et al. Chemoimmunotherapy with low dose 
Fludarabine and Cyclophosphamide and high dose Rituximab in previously untreated 
patients with chronic lymphocytic leukemia.J.Clin>Oncol 2009,27:491-497 


 
ML25464 Protocol Version C, Jan 23, 2011                                               Page  62 of 66                        


 
 
51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 










Amendment History 1 for Protocol ML25464 version C 
AMENDMENT HISTORY FOR PROTOCOL ML25464 
PROTOCOL AMENDMENT 1 
Date of Amendment 1: January 30, 2011 
 
Version: C 
  
Subject: Protocol Title (also synopsis)  
Reason:  
Adding a protocol nick name 
Section: Cover page and synopsis 
New text 
 
F. HOFFMANN-LA ROCHE LTD  
CLINICAL STUDY PROTOCOL 
PROTOCOL NUMBER ML 25464 (FCR LITE) 
 
PROTOCOL APPROVAL 
ML25464 Version C 
Date:   January 23, 2011 
               
 
Old text 
F. HOFFMANN-LA ROCHE LTD  
CLINICAL STUDY PROTOCOL 
PROTOCOL NUMBER ML 25464 
 
PROTOCOL APPROVAL 
ML25464 Version A and B 
Date:   January 10, 2011 August 30 2010 
 
 


Amendment History 1 for Protocol ML25464 version C 
Subject:   changes visit schedule
 
Reason for change:   
Corrections of protocol discrepancies between figure 1 and text in protocol design - 
section 4 and synopsis 
Section: 4.2.1 visit schedule and assessments 
New text 
Figure 1:   Visit schedule and assessments 
Week
 
-4 
to 0
1
 
3
 
5
 
7
 
9-25
 
Every 
4 
weeks
29
37
49
61
 
145
-
73
 
 every 12 
weeks
 
157
 
EOS
 
Visit No.
 
1
 
2
 
3
 
4
 
5
 
10
-
6
 
11
12
13
14
 
21
-
15
 
22
 
Study period
 
preTx
Treatment period
 
Follow up period
 
   Inc. /Excl. criteria
 
X
 
 
 
 
 
 
 
 
 
 
 
Informed consent
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Disease history
 
X
 
 
 
 
 
 
 
 
 
 
 
 
BMB*
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
Physical exam
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
CBC
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Blood chemistry
 
X
 
X
 
 
X
 
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Beta-2 micro glob 
 
X
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level,
 
X
 
 
 
 
 
 
 
 
X
 
 
 
X
 
DAT***
 
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
FACS****
 
X
 
 
 
 
 
 
 
 
X
 
 
 
X
 
Hepatitis B *****
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) **
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
QOL
 
X
 
 
 
 
 
 
 
X
 
 
 
X
 
 
X
 
Treatment dosage
 
X
 
Ongoing data capture
 
Adverse Events
 
X
 
Ongoing data capture and up to 30 days after completion or 
discontinuation of the study
 
Concomitant
 
medications
 
X
 
Ongoing data capture
 
Comments
 
X
 
Ongoing data capture
 
Study completion
 
X
 
Complete at any time if study drug is discontinued
 


Amendment History 1 for Protocol ML25464 version C 
* Bone marrow examination will be performed at any clinically suspicion of progression/ 
leukemia transformation, cytopenia evaluation, or for any CR confirmation at 
investigator discretion. 
 
** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
  
*** DAT will be performed at any clinical suspicion of hemolysis. 
 
**** Will be performed at any clinical suspicion of progression/ leukemia transformation, 
or for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 
 
Old text 
 
Figure 1:   Visit schedule and assessments 
Week
 
-4 
to 0
1
 
3
 
5
 
7
 
9-25
 
Every 
4 
weeks
29
37
49
61-77 
every 
12 
weeks 
89
101-161
 
 every 12 
weeks
 
EOS
 
Visit No.
 
1
 
2
 
3
 
4
 
5
 
10
-
6
 
11
12
13
13
-
10
 
14
 
15-19
 
20
 
Study period
 
preTx
 
Treatment period
 
Follow up period
 
Inc. /Excl. criteria
 
X
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB*
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
 
Physical exam
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
CBC
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Blood chemistry
 
X
 
X
 
 
X
 
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
X
 
Beta-2 micro glob 
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level,
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
DAT***
 
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
FACS****
 
X
 
 
 
 
 
 
 
 
X
 
 
 
 
X
 
Hepatitis B *****
 
X
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) **
 
X
 
 
 
 
 
 
 
 
 
 
 
 
X
 
QOL
 
X
 
 
 
 
 
 
 
X
 
 
 
 
X
 
 
X
 
Treatment dosage
 
X
 
Ongoing data capture
 


Amendment History 1 for Protocol ML25464 version C 
Adverse Events
 
X
 
Ongoing data capture and up to 30 days after completion or discontinuation of 
the study
 
Concomitant
 
medications
 
X
 
Ongoing data capture
 
Comments
 
X
 
Ongoing data capture
 
Study completion
 
X
 
Complete at any time if study drug is discontinued
 
* Bone marrow examination will be performed at any clinically suspicion of progression/ 
leukemia transformation, cytopenia evaluation, or for any CR confirmation at 
investigator discretion. 
 
** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
  
*** DAT will be performed at any clinical suspicion of hemolysis. 
 
**** Will be performed at any clinical suspicion of progression/ leukemia transformation, 
or for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 
 
Subject:   changes to steroids type 
 
Reason for change:   
Adaptation to steroids used in Israel 
 
Sections: synopsis, section 4.2  overall study design, section 4.3.1  investigational 
therapy, section  6.2  concomitant therapy 
 
New text 
 
 
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and 
thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. (according local 
common practice) only if clinically indicated. 
 
  Old  text 
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and 
thereafter only if clinically indicated. Prednisone/prednisolone 500 mg I.V. only if 
clinically indicated. 


Amendment History 1 for Protocol ML25464 version C 
 
Subject: Exclusion criteria- Hepatitis B carriers 
Reason for change:   
Recent knowledge about the risk of life threatening hepatitis B reactivation in persons 
treated with Rituximab 
Section 5.2 Exclusion criteria and synopsis 
New text 
- Active or uncontrolled infections, including opportunistic infection, active hepatitis B 
/ C 
-positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
Old text 
Active or uncontrolled infections, including opportunistic infection, active hepatitis B / C 
 
Subject: Cytopenia documentation by BMB 
Reason for change:   
Typo error correction (deletion). 
Section 4.2  Overall study design 
New text 
Bone marrow biopsy and aspiration examination will be performed before the start of 
treatment, for response documentation (3 to 6 months after the completion of treatment), 
for evaluation  of cytopenias (disease or treatment related) and for any other clinical 
indication at the discretion of the investigators.  
Old text 
Bone marrow biopsy and aspiration examination will be performed before the start of 
treatment, for response documentation (3 to 6 months after the completion of treatment), 
for evaluation  and documentation of cytopenias (disease or treatment related) and for 
any other clinical indication at the discretion of the investigators.  
 
 
Subject: Infusion bags labeling and accountability 
Section:4.3.1 Investigational therapy 
Reason for change:   
Correction according GCP rules and sponsor SOP 


Amendment History 1 for Protocol ML25464 version C 
New text 
Labels will comply with the legal requirements in Israel and be printed in Hebrew and 
English. All study drugs containing infusion bags will be labeled. All infusion bags will be 
labeled by the study nurse prior to administration and only the empty Rituximab infusion 
bags will be collected for drug accountability by the study monitor.  
 
Old text 
 
Labels will comply with the legal requirements in Israel and be printed in Hebrew and 
English. All study drugs containing infusion bags will be labeled. Rituximab  infusion 
bags will be labeled by the sponsor and will be collected for drug accountability . 
Section 4.2.1 Drug accountability 
New text 
 
Accountability and patient compliance will be assessed by maintaining adequate "drug 
dispensing log” on study medication. 
 
The "drug dispensing" log for the study medication must be kept current and should 
contain the following information: 
 
o The identification of the patient (patient number) to whom the study medication 
was administered.  
o The date(s) and quantity of study medication, used for the patients' treatment.  
o The date(s) and quantity of study medication, of empty, partial or unused 
medication.  
 
Old text 
Accountability and patient compliance will be assessed by maintaining adequate "drug 
dispensing log” on Rituximab. 
 
The "drug dispensing" log for Rituximab must be kept current and should contain the 
following information: 
 


Amendment History 1 for Protocol ML25464 version C 
o The identification of the patient (patient number) to whom Rituximab was 
administered.  
o The date(s) and quantity of Rituximab, used for the patients' treatment.  
o The date(s) and quantity of Rituximab, of empty, partial or unused medication.  
 
 
Subject: Reporting of Serious Adverse Events  
Reason for change:   
Deletion of typo error  
Section: 8.2.1 
Reporting of Serious Adverse Events (immediately reportable) 
New text 
Any clinical adverse event or abnormal laboratory test value that is serious and which 
occurs during the course of the study (as defined in section 7.1.1.3 above occurring 
from the enrollment visit (start of study screening procedures), including long term 
follow-up (LTFU) must be reported to Roche within one working day of the 
investigator becoming aware of the event (expedited reporting). 
 
Old text 
Any clinical adverse event or abnormal laboratory test value that is serious and which 
occurs during the course of the study (as defined in section 7.1.1.3 above), regardless 
of the treatment arm occurring from the enrollment visit (start of study screening 
procedures), including long term follow-up (LTFU) must be reported to Roche within 
one working day of the investigator becoming aware of the event (expedited reporting). 
 
 
 
Subject: Missing wording 
Reason for change: 
Missing wording   
 
 
 
 


Amendment History 1 for Protocol ML25464 version C 
Section 8.3  special tests 
New text 
Lymph node biopsy is recommended for definitive diagnosis of Richter transformation and 
for any rapidly progressive disease or unusual phenomena which may be suspicious of 
alteration in the normal behavior of the disease or suspicious for another disease or a 
different type of lymphoma. 
Old text 
Lymph node biopsy is recommended for definitive diagnosis of Richter transformation and 
for any rapidly progressive disease or unusual phenomena which may be suspicious of 
alteration in the of the disease or suspicious for another disease or a different type of 
lymphoma. 
 
 
Subject: Geriatric evaluation 
Reason for change:   
Increasing safety of geriatric age patient recruitment   
Section 5.2 exclusion criteria (and synopsis) 
New text 
  Patients who are mentally or physically unable to comply      with all aspects of the 
study. Upon investigator discretion, a psycho-geriatric evaluation will be performed for 
patients ≥ 80 years old. 
Old text 
Patients who are mentally or physically unable to comply      with all aspects of the 
study. 
 
 
Subject: ZAP70 and CD38 as optional tests 
Reason for change: 
To allow more information collection about possible risk factors influencing response 
 
 


Amendment History 1 for Protocol ML25464 version C 
Section: 5.1 Inclusion criteria and synopsis 
New text 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute lymphocyte 
count > 5X109 L, and typical CLL cell morphology in the peripheral blood 
smear as seen by light microscopy. CLL cells must show CD5/CD19/CD23 
positivity with light chain restriction as recorded by flow cytometry. The levels 
of surface immunoglobulin  and CD 79b are characteristically low and FMC7 is 
expected to be negative (optional). ZAP 70 and CD38 are optional. 
 
Old text 
 
1. Diagnosis of B-CLL is established by the presence of: an absolute lymphocyte 
count > 5X109 L, and typical CLL cell morphology in the peripheral blood smear 
as seen by light microscopy. CLL cells must show CD5/CD19/CD23 positivity 
with light chain restriction as recorded by flow cytometry. The levels of surface 
immunoglobulin  and CD 79b are characteristically low and FMC7 is expected to 
be negative (optional). 
 
Subject: CTCAE V.3  
Reason for change:   
Better determination(version number) of CTCAE and giving reference to CTCAE details. 
Section 9.3  Safety Analysis  
New text 
Data from all subjects who receive any study drug will be included in the safety 
analyses. The severity of the toxicities will be graded according to the NCI CTCAE v 3.0 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf 
 
Old text 
Data from all subjects who receive any study drug will be included in the safety 
analyses. The severity of the toxicities will be graded according to the NCI CTCAE v 3.0  
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   1 
 
 
AMENDMENT HISTORY FOR PROTOCOL ML25464 VERSION D 
FCR-LITE DATED 06 OCT 2011 
 
1. 
Subject:    Cytogenetics in bone marrow 
Reason for change:   
Cytogenetics in bone marrow is not performed routinely in medical centers and is not 
part of CLL assessment. 
 
Section 4.2 Overall study design 
New text: 
Pre-treatment period:… Bone marrow biopsy (FISH whenever possible) must have 
been performed within 12 months of starting the first dose of the study drugs. 
 
Old text: 
Pre-treatment period:…Bone marrow examination including cytogenetics (FISH 
whenever possible) must have been performed within 12 months of starting the first 
dose of the study drugs. 
 
New text: 
Follow up period:…Bone marrow examination, peripheral blood immunophenotyping 
(FACS), abdominal, pelvic and chest CT will be performed 3 to 6 months after the 
completion of the treatment regimen, at clinical progression and at any other time 
according to the investigators' discretion. 
Old text: 
Follow up period:…Bone marrow examination including cytogenetics, peripheral 
blood immunophenotyping (FACS), abdominal, pelvic and chest CT will be 
performed 3 to 6 months after the completion of the treatment regimen, at clinical 
progression and at any other time according to the investigators' discretion. 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   2 
 
 
Section 7 
Assessment of efficacy                                               
New text: 
Bone marrow aspiration and biopsy to assess degree of bone marrow involvement 
by CLL using FACS and immunohistochemistry, should be performed at least 3 
months after the last treatment, if the above four clinical and laboratory results 
support that CR has been achieved.  
Old text: 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment if the above 4 clinical 
and laboratory results demonstrate that CR has been achieved 
 
2. 
SUBJECT:  
Visit schedule and assessments 
Reason for change:   
The schedule was corrected to fit the text of the protocol: One pre-treatment visit, 8 
treatment visits (composed of 2 examination visits [these are titled visits 3 and 5] and 
6 treatment visits).  The Follow-up period will consist of 12 follow-up visits, once 
every 12 weeks. 
All visits in the table during which a treatment is given are marked with an X in the 
new column within the visit schedule table named – “Treatment” 
 
Section Figure 1: Visit schedule and assessments  
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   3 
 
New text: 
Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 weeks 
EOS 
Visit No. 
1 
Screening 2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical history/conditions X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
  
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   4 
 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
1 - Bone marrow biopsy must be performed within 12 months before start of treatment. BMB will be performed for progression/ lymphoma 
transformation,  cytopenia evaluation, and for treatment response within 3-6 months after completion of treatment. For any other clinical indication 
it is at the discretion of the investigator whether to perform BMB. 
2 - CT scan when done pre-treatment, must be performed within 12 weeks prior to starting the first dose of study drugs. Post therapy a 
CT scan will be performed for all CLL patients who had an abnormal CT scan prior to treatment or if physical examination is 
inconclusive - this is an optional assessment. 
3 - DAT will be performed at screening and at any clinical suspicion of hemolysis. 
4 - FACS results from up to 12 months prior to screening are relevant and no further test is necessary at screening. FACS will also be 
performed at any clinical suspicion of progression/ lymphoma transformation, or for CR confirmation at investigators' discretion. 
5 - At screening and at investigator discretion for hepatitis treatment evaluation. 
 
 
 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   5 
 
Old Text: 
Figure 1:   Visit schedule and assessments 
Week 
-4 to 
0 
1 
3 
5 
7 
9-25 
Every 
4 
weeks 
29 
37 
49 
61 
73-145 
 every 12 
weeks 
157 
EOS 
Visit No. 
1 
2 
3 
4 
5 
6-10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment period 
Follow up period 
   Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
BMB* 
X 
 
 
 
 
 
 
 
X 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
X 
 
 
X 
DAT***  
X 
 
 
 
 
 
 
 
X 
 
 
 
FACS**** 
X 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B ***** 
X 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) ** 
X 
 
 
 
 
 
 
 
X 
 
 
 
QOL 
X 
 
  
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
X 
Ongoing data capture 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or 
discontinuation of the study
Concomitant 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   6 
 
progression/ leukemia transformation, cytopenia evaluation, or for any CR confirmation at 
investigator discretion. 
 
** Abdominal, pelvic and chest CT will be performed at any clinical suspicion of progression. 
*** DAT will be performed at any clinical suspicion of hemolysis. 
**** Will be performed at any clinical suspicion of progression/ leukemia transformation, or 
for CR confirmation at investigators' discretion. 
*****At screening and at investigator discretion for hepatitis treatment evaluation. 
 
Section Exams at Screening (page 23) – comments of figure 1 
In the schedule (page 23) the following assessments were emphasized as being 
performed at screening: 
New text: 
3 - DAT will be performed at screening and at any clinical suspicion of hemolysis. 
Old Text: 
***DAT will be performed at any clinical suspicion of hemolysis. 
 
New text: 
1 - Bone marrow biopsy must be performed within 12 months before start of 
treatment. BMB will be performed for progression/ lymphoma transformation, 
cytopenia evaluation and  for treatment response within 3-6 months after 
completion of treatment. For any other clinical indication it is at the discretion 
of the investigator whether to perform BMB. 
Old Text: 
 progression/ leukemia transformation, cytopenia evaluation, or for any CR 
confirmation at investigator discretion. 
 
New text: 
4 - FACS results from up to 12 months prior to screening are relevant and no 
further test is necessary at screening. FACS will also be performed at any 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   7 
 
clinical suspicion of progression/lymphoma transformation, or for CR confirmation at 
investigators' discretion. 
Old Text: 
****Will be performed at any clinical suspicion of progression/ leukemia 
transformation, or for CR confirmation at investigators' discretion. 
 
3. 
SUBJECT:  
Dose modification for impaired renal function 
Reason for change:   
After a consultation with prinicpal investigators and after review of the Fludarabine 
investigator brochure and the CLL 8 protocol we arrived at a consensus that if  the 
calculated creatinine clearance is in the range of 30-70 mL/min  the dose of 
Fludarabine be reduced by 20%  (to 80%) and the cyclophosphamide dose be 
reduced by 25% (to 75%). 
 
SECTION  
4.3.3 Dose modification for impaired renal function 
New text:   
Fludarabine and cyclophosphomide are partly (40-60%) excreted by the kidneys. If 
the calculated (see appendix III) or measured creatinine clearance is at screening 
or during treatment is decreased to 30-70 mL/min, the dose of fludarabine  
should be reduced to 80% and the cyclophosphamide dose reduced to 75%. 
Patients with a creatinine clearance below 30 ml/min are excluded from the study.  
Old Text: 
Fludarabine is partly (40-60%) excreted by the kidneys. If the calculated (see 
appendix III) or measured creatinine clearance is reduced to 30-60 ml/min, the 
fludarabine dose should be reduced to 50%. Patients with a creatinine clearance 
below 30 ml/min are excluded from the study. 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   8 
 
4. 
SUBJECT:  
Rituximab discontinuation will result in study 
termination 
Reason for change:   
If it is impossible to continue treatment with Rituximab due to side effects, the 
patient’s participation in the study will be discontinued. 
 
SECTION 5.3.1 
Discontinuation of study drugs 
New text: 
In the case of a severe reaction to Rituximab, Rituximab will be permanently 
discontinued and the patient’s participation in the study will be discontinued.  
Old Text:     
In the case of a severe reaction to Rituximab, Rituximab will be permanently 
discontinued. Patient will be treated with FC in the next cycles and data will be 
recorded throughout the study period. 
 
5. 
SUBJECT: Delaying Rituximab treatment due to high tumor 
burden  
Reason for change:   
The option of delaying the treatment with Rituximab for up to 7 days after FC 
administration in cycle 1 has been added in case of high tumor burden. 
SECTION 
4.3.1 
 Investigational therapy  
New text: 
Consider reduced rate of Rituximab for first infusion or splitting the dose over 
two days during the first cycle. In cycle 1 the administration of Rituximab may 
be delayed up to 7 days after the administration of the Fludarabine and 
Cyclophosphomide (FC). Rituximab will be given together with FC in cycle 2, 
28 days after the administration of FC in cycle 1. 
Old Text:     
Consider reduced rate for first infusion or a split dosing over two days during the first 
cycle. 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   9 
 
6. 
SUBJECT: Patients with autoimmune hemolytic anemia 
 
Reason for change:   
Patients with autoimmune hemolytic anemia are excluded from the study and thus 
cannot receive steroids in the study. 
 
SECTION  
6.2 Concomitant therapy 
New text: 
Steroid administration is allowed exclusively for patients with autoimmune 
thrombocytopenia or as premedication for Rituximab. 
Old Text:     
Steroids administration are allowed exclusively for patients with autoimmune 
hemolytic anemia and or autoimmune thrombocytopenia or as premedication for 
Rituximab . 
 
New text: 
Steroids if given (see above) are allowed for no more than 3 consecutive days.  
Old Text:     
Steroids if given (see above) are allowed for no more than 3 consecutive days. 
Excluding patients with autoimmune cytopenia, in which  case prolonged 
period steroid administration is permitted (see above).  
 
7. 
SUBJECT:  
In situ prostate cancer does not prevent 
recruitment - Exclusion no. 11 
Reason for change:   
In addition to in situ breast and cervix cancer in situ, prostate cancer will also not 
prevent recruitment to the study. 
SECTION 5.2 & Synopsis  
Exclusion Criteria no.11 
New text: 
- Presence of active second neoplasia (excluding non-melanoma skin cancer, or in 
situ  cervix, breast or prostate carcinoma) < 2 years prior to the study. 
Old Text:     


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   10 
 
- Presence of active second neoplasia (excluding non-melanoma skin cancer, or in 
situ  cervix or breast carcinoma) < 2 years prior to the study. 
 
 
8. 
SUBJECT: CT scan prior to treatment  
Reason for change:   
CT scan prior to treatment will be accepted as baseline if performed up to 3 months 
prior to cycle 1.  
SECTION 4.2 Overall study design - Pre-treatment period 
New text: 
CT scan when done, must be performed within 12 weeks prior to starting the first 
dose of study drugs.    
Old Text:     
CT scan when done, must be performed within 6 weeks of starting the first dose of 
study drugs.    
 
9. 
SUBJECT:  
CT scan post treatment is optional 
Reason for change:   
Visit schedule needs to be updated as to the optional use of CT scan in baseline and 
response assessment.  
 
SECTION  
Figure 1 - comments 
New text: 
 CT scan when done pre treatment, must be performed within 12 weeks prior to 
starting the first dose of study drugs. Post therapy a CT scan will be 
performed for all CLL patients who had an abnormal CT scan prior to 
treatment or if physical examination is inconclusive – this is an optional 
assessment. 
Old Text:     
 Abdominal, pelvic and chest CT will be performed at any clinical suspicion of 
progression. 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   11 
 
10. 
SUBJECT:  
Performance status ≥3 as an exclusion criteria 
Reason for change:  
Due to concerns over patients safety and the desire not to include patients who 
cannot undergo this protocol the PS has been lowered. 
 
SECTION 5.2 & Synopsis Exclusion Criteria no. 14 
New text: 
Performance status: ECOG performance status ≥3 
Old Text:     
Performance status: ECOG performance status ≥4. 
 
11. 
SUBJECT:  
Reporting of Serious Adverse Events 
Reason for change:  
Clarifications were updated in the Safety section according to Roche SOPs. 
SECTION  
8.2.1 Reporting of Serious Adverse Events (immediately 
reportable) 
New text: 
None. 
Old Text:     
When all subjects at a particular site are off treatment as defined by the protocol:  
 only individual SUSAR reports originating in that particular trial will be forwarded 
to the site and associated IRB/IEC on an expedited basis; 
 individual SUSARs considered to be a significant safety issue and/or which result 
in Roche recommending a change to the Informed Consent Form (ICF), will be 
reported in an expedited manner to all investigators and IRBs/IECs; 
 SUSAR reports originating from other trials using the same IMP will be provided 
as six monthly SUSAR Reports (SSRs) to investigators and IRBs/IECs where 
long-term follow-up studies are carried out, unless they are considered significant. 
 
 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   12 
 
12. 
SUBJECT:  
Warning and Precautions 
Reason for change:   
Clarifications were updated in the Warning section regarding Fludarabine and 
Cyclophosphamide. 
SECTION  
8.6.1 Warning and Precautions 
New text: 
Safety information regarding Fludarabine and Cyclophosphamide can be found in 
the respective local MoH approved product label. 
Old Text:     
Safety information regarding Fludarabine and Cyclophosphamide can be found in 
the respective prescription information. 
 
13. 
SUBJECT:  
Destruction Process  
Reason for change:   
Section 4.3.1.2 has been added in order to detail destruction process in the site. 
SECTION  
4.3.1.2 DESTRUCTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT 
New text: 
After the monitor has reconciled study drug supplies, used supplies (partly 
used and empty Rituximab infusion bags) will be sent for destruction 
according to the site guidelines. The destruction process in the site should be 
documented. 
Old Text:     
None. 
 
SECTION 
4.5  Accountability procedures for the investigational products 
New text: 
Study drug will be prepared and dispensed by the pharmacist at the investigator’s 
institution. Drug accountability & destruction procedures are described in 
sections 4.3.1.1 & 4.3.1.2, accordingly. 
Old Text:     
Study drug will be prepared and dispensed by the pharmacist at the investigator’s institution. 


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   13 
 
14. 
SUBJECT:  
Statistics 
Reason for change:   
Changes and clarifications made by the protocol statistician. 
 
SECTION  
9.2.2 Response rate 
New text: 
 95% Confidence Interval (CI) will be calculated to the proportions of 
responders. 
Old Text:     
None 
 
New text: 
Summary statistics (standard deviation, median, minimum and maximum) will be 
provided for the relevant variables. The Paired T-test or Signed Rand Test for 
paired observations (as is appropriate) will be applied for analysing the 
changes in the components and total score of the FACIT QOL assessment. 
The data will be analyzed using the SAS ® version 9.1.3(SAS Institute, Cary 
North Carolina). 
 
Old Text:     
Summary statistics (standard deviation, median, minimum and maximum) will be 
provided for the relevant variables. ANOVA will be used to analyse the changes in 
the components and total score of the FACIT QOL assessment. 
 
SECTION  
9.3 
Safety Analysis 
New text: 
 All adverse events will be coded according to coding dictionaries (MedDRA 
version 12.1) and presented in tables by system organ class and preferred 
term. 
Old Text:    
None.  


 
Amendment History of Protocol ML25464 Version D dated 06.10.11                                                   14 
 
 
New text: 
None. 
Old Text:    
 ANOVA will be used to analyse the changes in the components and total 
score of the FACIT QOL assessments 
 
 




ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  1 of 64                        
  
 
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (≥65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA  
 
 
 
Author:  Prof 
. 
. 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 MHA+M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 MHA+M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  2 of 64                        
  
 
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ......................................................................................... 9 
3. 
TRIAL OBJECTIVES AND PURPOSE.............................................................................. 16 
3.1 PRIMARY OBJECTIVE ................................................................... 16 
3.2 SECONDARY OBJECTIVES ............................................................ 16 
4. 
TRIAL DESIGN………………………………………………………………………………….17 
4.1 PRIMARY AND SECONDARY END POINTS ........................................ 17 
4.2 OVERALL STUDY DESIGN .............................................................. 17 
4.2.1 VISIT SCHEDULE AND ASSESSMENTS ........................................... 20 
4.3 TRIAL TREATMENT ....................................................................... 23 
4.3.1 Investigational therapy………………………………………………..23 
4.4 STUDY DRUG INTERRUPTION OR DISCONTINUATION ....................... 28 
4.5 ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL 
PRODUCTS ................................................................................... 28 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS ......................................................... 29 
5.1 INCLUSION CRITERIA .................................................................... 29 
5.2 EXCLUSION CRITERIA .................................................................. 29 
5.3 INTERRUPTION OR DISCONTINUATION OF TREATMENT ................... 30 
6. TREATMENT OF SUBJECTS .............................................................................................. 32 
6.1 TREATMENT REGIMEN .................................................................. 32 
6.1.1TREATMENT ASSIGNMENT ........................................................... 32 
6.2 CONCOMITANT THERAPY .............................................................. 32 
6.3 TREATMENT COMPLIANCE ............................................................ 33 
7. 
ASSESSMENT OF EFFICACY .......................................................................................... 34 
8. 
ASSESSMENT OF SAFETY ............................................................................................. 36 
8.2 SERIOUS ADVERSE EVENTS .......................................................... 40 
8.4 Physical examinations/vital signs .................................................. 45 
8.5 LABORATORY EXAMINATIONS ....................................................... 45 
8.6 PHYSICAL EXAMINATIONS/VITAL SIGNS ......................................... 46 
9.   STATISTICS……………………………………………………………………………………46 
9.1 SAMPLE SIZE ............................................................................... 47 
9.2 EFFICACY AND SAFETY EVALUATION ............................................ 47 
10. QUALITY CONTROL AND QUALITY ASSURANCE ....................................................... 50 
11.    DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .................................................. 51 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  3 of 64                        
  
 
11.1      STUDY MONITORING ................................................................ 51 
11.2 AUDITS ........................................................................................ 51 
11.3 IRB AND REGULATORY INSPECTIONS ............................................ 51 
12.   ETHICS………………………………………………………………………………………….52 
12.1    INSTITUTIONAL REVIEW BOARD ................................................. 52 
12.2 INFORMED CONSENT .................................................................... 52 
12.3 DECLARATION OF HELSINKI ......................................................... 53 
13. DATA HANDLING AND RECORD KEEPING ................................................................... 54 
14. FINANCING AND INSURANCE ........................................................................................ 55 
15.PUBLICATION POLICY  ................................................................................................... 56 
16. SUPPLEMENTS 
 ................................................................................................... 61 
APPENDIX I    RESPONSE DEFINITIONS .................................................. 61 
APPENDIX II    ECOG PERFORMANCE STATUS ..................................... 62 
APPENDIX III CALCULATED CREATININE CLEARANCE ............................ 63 
APPENDIX IV     ACTIVE DISEASE ......................................................... 63 
APPENDIX V    BINET STAGING SYSTEM ................................................ 63 
APPENDIX VI    FACIT-QOL .............................................................. 64 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  4 of 64                        
  
 
LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR 
Institutional Review Board 
Infusion Related Reaction 
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  5 of 64                        
  
 
 
 
SYNOPSIS 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (≥65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER: 
ML25464 
 
DATE PROTOCOL FINAL: 
20 August 2011 
 
STUDY DRUG: 
 
FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:  
 
CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE: 
 
II 
 
     Background and rationale Chronic lymphocytic leukemia (CLL) is characteristically 
diagnosed in the older population with a median age at diagnosis ranging between 65 and 
72 years. Because the prevalence of co morbidity increases with age, concomitant disease 
is often present in this age group. Additional factors which may also  adversely affect 
treatment outcome at standard doses in elderly patients include: altered pharmacokinetics 
and poorer host  tissue tolerance ; changes in the bone marrow hematopoietic reserve and 
microenvironment leading to increased treatment related myelotoxicity and  higher rates of 
treatment related complications such as infections. As a result, elderly patients are often 
excluded from clinical trials or even from routine treatment on the basis of their age and / or 
comorbidity. Furthermore when these patients are treated, the drug doses are often 
markedly reduced in an attempt to avoid causing toxicity and complications. The challenge 
in treating elderly CLL patients relates to finding the correct balance between drug efficacy 
and toxicity and because of this optimal treatment for this group of patients is often hard to 
achieve. 
 
   Study Objectives 
The aim of this study is to evaluate the safety and efficacy (response rate) of a combination 
of low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with standard dose 
Rituximab given as primary treatment for elderly patients with chronic lymphocytic 
leukemia. 
 
   Primary end point:  -Response rate 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  6 of 64                        
  
 
 
   Secondary end points: 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- days),         
 - Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- Time to Next Treatment (TNT). 
- QOL 
    STUDY DESIGN: 
This is a multicenter, phase II, single arm study designed to evaluate the efficacy and 
safety of the combination of low dose Fludarabine (FLU) and Cyclophosphamide (CY) 
combined with standard dose Rituximab in elderly previously untreated CLL patients (≥ 65 
years of age). Potential study subjects will sign an informed consent prior to undergoing 
any study related procedure. Number of patients to be enrolled is 40. 
    Treatment plan:  Flu 12.5mg/m2/d will be given intravenously (I.V.) for days 1-3 every 
28 days, for a total of 6 cycles. 
CY will be given I.V. at the dose of 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. 
Rituximab will be given before chemotherapy. In cycle1:  375 mg/m2  I.V.  on day 0, cycles 
2-6: 500 mg/m2 I.V. on day 1 every 28 days. 
Dose reduction or delays are recommended in case of grade ≥3 (NCI-CTC) adverse 
events. 
This study consists of 3 periods for each study subject: Pre-treatment, Treatment and 
Follow up. 
Pre-treatment period: patients will undergo screening for protocol eligibility within 28 days 
(4 weeks) of recruitment. 
Subjects who meet all the inclusion criteria and have signed an approved informed consent 
will be enrolled. 
Treatment period FLU 12.5mg/m2/d  I.V. will be given on days 1-3 every 28 days, for a total 
of 6 cycles. CY will be given (I.V.) 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. Rituximab  given before chemotherapy cycle 1:  375 mg/m2 intravenously on day 0, 
cycles 2-6:  500 mg/m2  I.V.  on day 1 every 28 days.  
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and thereafter 
only if clinically indicated. Hydrocortisone 100-500 mg I.V. (according with local common 
practice) only if clinically indicated. 
Dose reduction or delay in case of drug induced hematological toxicity grade ≥ 3 level. 
During the treatment period, all patients will attend twice a month in the first 2 months and 
thereafter periodic monthly study center visits in order to assess the safety and efficacy of 
the treatment. 
Complete blood count will be performed on day 1 and 14 of each of the first two cycles, 
and on day 1 in the other 4 cycles, or more frequently at the investigators discretion. 
Bone marrow aspiration and biopsy and CT scan (optional) will be performed within 3-to 6 
months after the completion of the treatment period. 




ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  8 of 64                        
  
 
 
Assessments: 
    Efficacy  
      The following evaluations will be done to record the efficacy of the treatment regimen: 
- Assessment of disease response (revised International Response Criteria:   updated NCI-
     IWG 2008).[46].  
- Date of documentation of disease progression. 
- Bone marrow biopsy examination 
- Peripheral blood immunophenotyping by FACS. 
- Changes in ANC, Hb levels and platelets counts from baseline blood counts and 
those          done during the study period. 
- Chest, abdominal and pelvic computerized tomography 
- Physical examination for lymphadenopathy and hepato-splenomegaly 
    Safety 
The following evaluations will be recorded to assess the safety of the regimen: 
- Complete physical examination including vital signs. 
- Clinical laboratory evaluations (hematology, biochemistry) 
- Concomitant medication and procedures 
- Adverse events 
- Health outcomes assessment (any extra medical appointment)  
 
    Efficacy analysis: 
Primary efficacy will be determined by objective overall response rate. Exact tests for 
assessing these will be used to compare objective overall response rates. Kaplan Meier 
procedure will be used to characterize the duration of response for PFS and TNT. 
Summary statistics (standard deviation, mean, median, minimum and maximum) will be 
provided for the relevant variables 
 Safety Analysis: 
Data from all subjects who receive any study drug will be included in the safety analyses. 
The severity of the toxicities will be graded according to the NCI CTC v3 or v2- for 
cytopenia, whenever possible. In the by-subject analysis, a subject experiencing the same 
event more than once will be counted only once. 
Adverse events will be defined and summarized by the worst NCI CTC grade. Adverse 
events leading to death or to discontinuation of treatment, events classified as NCI CTC 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI CTC severity 
grade. 
 
STUDY DURATION: five years                                        TOTAL SAMPLE SIZE: 40


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  9 of 64                        
  
 
2. Background Information 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
disease is often evident in this age group. Goede et al [29] reported that 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
Thurmes and colleagues [1] have shown that these comorbid conditions are in 
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients. 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given.  
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate. 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
the treatment of CLL [14]. Fludarabine is the most extensively studied purine 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
shown to be more effective than when used alone. [13,14,27,28]. In this respect 
the U.K. MRC LRF CLL4 trial  reported in 2007 [11]  compared therapy with 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  10 of 64                        
  
 
that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
standard treatment of all CLL patients irrespective of age [11]. Similar results 
were published by the German CLL Study Group and the North American 
Intergroup [14]. 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections.  
Pollizzotto et al [15] investigated the influence of increasing age on the ability to 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age ≥ 70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality. 
 
Table 1 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 (17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days ; 
4 courses 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  11 of 64                        
  
 
CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2 
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
with a human IgG1 constant kappa antibody (C2B8) that reacts specifically 
with the CD20 antigen found on the surface of malignant and normal B cells 
and established B-cell lines [31,33].  The antigen is expressed at lower levels on 
chronic lymphocytic leukemia (CLL) and plasma cells [31]. CD20 is not shed 
from the surface of CD20+ cells after antibody binding and it is not 
internalized or downregulated [34].  Compared with its murine counterpart, 
Rituximab has a longer half-life in humans, interacts with human effector cells 
[34, 35], and is less immunogenic [36]. 
 
Reduced FC doses 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-(≥ 70 years). These are listed in Table1. 
 
 
 
 
 


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2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
the use of this agent in CLL [37,39,40].  The original studies employed 375 
mg/m2 of Rituximab once a week for four weeks.  Subsequent studies 
suggested using this dose three times a week for four weeks for a total of 12 
doses instead of 4 doses which resulted in better overall responses [41].  Dose 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
increased or the frequency of the standard dose of 375 mg/m2 was increased 
[41, 44].  
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
Byrd et al went on, to compare sequential and concurrent therapy with RF [43].   
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
median survival has yet to be reached yet, but will be in excess of 23 months 
[44]. Three major side effects were observed: infusion related toxicity, 
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
(GCLLSG) [44] reported the treatment of 20 untreated and 11 relapsed CLL 
patients. Treatment consisted of Fludarabine administered at standard doses 
(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  13 of 64                        
  
 
given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks. 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections. 
A retrospective comparative analysis of the CALGB 9712 [47] (Rituximab 
plus Fludarabine) [48] and the CALGB 9011 (Fludarabine only) studies 
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
was similar [45]. 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
patients, respectively) [24, 25]. In the untreated patients the overall response rate 
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections. 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection.  
Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  14 of 64                        
  
 
fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 21%) 
and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  15 of 64                        
  
 
In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL. 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
patient. In this regard, Foon and colleagues [50] reported a phase II single arm 
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
(20mg/m2) and Cyclophosphamide (150mg/mg2) combined with high–dose 
Rituximab (500mg/m2) given every other week during induction and later as 
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
months (range, 5.2 to 42.5 months) and none of the complete responders 
have relapsed. Grade 3/4 neutropenia was noted in 13% of the cycles of 
therapy. Another approach to reduce toxicity was to use sequential therapy 
with fludarabine (25 mg/m2 on days 1 through 5 for 6 cycles) followed by 
consolidation with Cyclophosphamide (3,000 mg/m2 administered every 3 
weeks for three cycles) and then by Rituximab 375 mg/m2 for four cycles 
(F C
R). [51]  In 36 previously untreated CLL patients an overall response of 
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
negative) and achieving molecular CRs had an excellent prognosis with a 
plateau in the response duration curve, and 90% remain in clinical CR at 5 
years. For the entire group, 5-year survival rate is 71% compared with a rate 
of 48% with the prior F
C regimen (not significant P = .10).  
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  16 of 64                        
  
 
 
3. 
Trial Objectives and Purpose 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximab given as primary treatment for elderly patients with 
chronic lymphocytic leukemia. 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic.  
 
3.1 
Primary Objective 
To evaluate the efficacy (Response Rate) of the combination of lower dose 
Fludarabine 12.5 mg m2/d given intravenously for three days and 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
days, combined with standard dose Rituximab (375mg/ m2 in cycle 1 and 
500 mg/m2  in cycles 2-6) for a total of 6 cycles.  
. 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia ≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS).  
3-       Time to Next Treatment (TNT).  
4-        Quality Of Life (FACIT) 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  17 of 64                        
  
 
4. 
Trial Design                                                                                                              
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     Time to Next Treatment (TNT) as defined in the protocol (see appendix I) 
4-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2  I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedure. In general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  
Up to 40 patients are planned to be enrolled during a two year period. 
This study consists of 3 periods for each study subject: A pre-treatment 
period, the treatment period and a follow up period.  


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  18 of 64                        
  
 
 
Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific 
medical procedures are performed which include laboratory screening 
assessments and physical examination as well as documentation of vital 
signs. If the hematology and/or biochemistry evaluations have been 
performed within 14 days of the first dose of study drug as part of the 
screening evaluation, they need not be repeated, and the data may be used 
as the Day 1 values. Bone marrow biopsy (FISH whenever possible) must 
have been performed within 12 months of starting the first dose of the study 
drugs. 
CT scan when done, must be performed within 12 weeks prior to starting the 
first dose of study drugs.    
  
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 every 
28 days. 
Premedication: antihistamines(e.g. 2mg clemastin or promethazine 25mg I.V.) 
and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Hydrocortisone 100 -
500mg I.V.(according with local common practice only if clinically indicated. 
In the event of grade ≥ 3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  19 of 64                        
  
 
both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic twice a month in 
the first 2 months and thereafter monthly study- center visits in order to 
assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two 
cycles. In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation of cytopenias (disease or treatment 
related) and for any other clinical indication at the discretion of the 
investigators.  
Supportive care including blood transfusions or administration of growth 
factors G-CSF or erythropoietin is permitted at the investigators' discretion 
throughout all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination, peripheral blood immunophenotyping (FACS), 
abdominal, pelvic and chest CT will be performed 3 to 6 months after the 
completion of the treatment regimen, at clinical progression and at any other 
time according to the investigators' discretion. 
In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  20 of 64                        
  
 
subjects enrolled into the study and will be given at the dose of 15mg/m2/d 
given I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated 
and declared inadequate and inefficient. If response is evident in ≥ 5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the 
discretion of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule 
and assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days 
of the day indicated on the visit schedule, except visits 2-5 in which time 
window will be of  3 days . 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  21 of 64                        
  
 
Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  22 of 64                        
  
 
 
 
 
1 - Bone marrow examination must be performed within 12 months before start of treatment. BMB will be performed for progression/ lymphoma 
transformation, cytopenia evaluation, and for treatment response within 3-6 months after completion of treatment. For any other clinical indication it is 
at the discretion of the investigator whether to perform BMB. 
2 - CT scan when done pre-treatment, must be performed within 12 weeks prior to starting the first dose of study drugs. Post therapy a CT 
scan will be performed for all CLL patients who had an abnormal CT scan prior to treatment or if physical examination is inconclusive - 
this is an optional assessment. 
3 - DAT will be performed at screening and at any clinical suspicion of hemolysis. 
4 - FACS results from up to 12 months prior to screening are relevant and no further test is necessary at screening. FACS will also be 
performed at any clinical suspicion of progression/ lymphoma transformation, or for CR confirmation at investigators' discretion. 
5 - At screening and at investigator discretion for hepatitis treatment evaluation. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  23 of 64                        
  
 
 
 
4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 
mg/ml) diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with ≥ 25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
Hydrocortisone 100-500 mg I.V. (according local common practice) shortly 
before infusion with Rituximab to decrease the rate and severity of acute 
IRR/CRS for these patients. Consider reduced rate of Rituximab for first 
infusion or splitting the dose over two days during the first cycle. In 
cycle 1 the administration of Rituximab may be delayed up to 7 days 
after the administration of the Fludarabine and Cyclophosphomide (FC). 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  24 of 64                        
  
 
Rituximab will be given together with FC in cycle 2, 28 days after the 
administration of FC in cycle 1. Severe CRS: may be associated with some 
features of tumor lysis syndrome e.g. hyperuricaemia, hyperkalaemia, 
hypocalcaemia, hypophosphataemia, acute renal failure, elevated LDH and 
may be associated with acute respiratory failure and death. If severe CRS 
manifests stop infusion immediately and start aggressive symptomatic 
treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Hydrocortisone 100-500 mg I.V. (according local common practice), if 
necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  25 of 64                        
  
 
Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 
Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate 
Mild/moderate 
> 30 mm Hg 
 
 
 
Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more severe with 
the first infusion. In patients who were unable to tolerate the first infusion, 
cautious reintroduction of rituximab may be tried at the second cycle, at the 
investigator’s discretion. The recommended premedication should be given 
and then the patient carefully re-exposed to a small amount of rituximab (slow 
infusion of 10 mg I.V.) If a severe reaction occurs, the rituximab must be 
permanently discontinued. In such case patient will be treated with FC in the 
next cycles and data will be collected throughout the study period) 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
All infusion bags will be labeled by the study nurse prior to administration and 
only the empty Rituximab infusion bags will be collected for drug 
accountability by the study monitor. Storage conditions for study drug will be 
described on the medication label. Patients will receive the study drug 
combination for an exposure period of up to 6 months provided that in the 
opinion of the investigator the patient is benefiting from treatment with this 
study drug combination, and in the absence of any safety concerns. 
Treatment will be withheld only in the case of limiting toxicities (see below).  
As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 
10 glasses of fluids on the days they receive cyclophosphamide and  urinate 
at minimal ceasing  of bladder distention. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  26 of 64                        
  
 
 
4.3.1.1 DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
adequate "drug dispensing log” on study medication. 
 
The "drug dispensing" log for the study medication must be kept current and 
should contain the following information: 
 
o The identification of the patient (patient number) to whom the study 
medication was administered.  
o The date(s) and quantity of study medication, used for the patients' 
treatment.  
o The date(s) and quantity of study medication, of empty, partial or 
unused medication.  
 
All accountability logs must be available for inspection by the monitor. Drug 
supplies (partly used and empty Rituximab infusion bags) must be available 
for inspection, at every monitoring visit. Used supplies will be destructed 
according to local site guidelines.  
 
4.3.1.2 DESTRUCTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT 
 
After the monitor has reconciled study drug supplies, used supplies 
(partly used and empty Rituximab infusion bags) will be sent for 
destruction according to the site guidelines. The destruction process in 
the site should be documented. 
 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade ≥ 3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 
following cycles. There is no dose reduction for Rituximab in this study, but 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  27 of 64                        
  
 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 
• If after three weeks, the grade ≥ 3 cytopenia, NOT RELATED TO CLL BONE MARROW 
INFILTRATION, still prevails, the patient should be removed from the protocol with 
no further study drug administration. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 
• If there is any grade ≥ 3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine and cyclophosphomide are partly (40-60%) excreted by the 
kidneys. If the calculated (see appendix III) or measured creatinine clearance 
is at screening or during treatment reduced to 30-70 mL/min, the 
fludarabine dose should be reduced to 80% and the cyclophosphamide 
dose will be reduced to 75%. Patients with a creatinine clearance below 30 
ml/min are excluded from the study. Patients who develop renal dysfunction 
(serum creatinine ≥ 1.5 mg/dL or creatinine clearance < 30 ml/min) during 
treatment should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade ≥ 3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade ≤ 2, for 
up to three weeks. All subsequent cycles should then be given with a 25% 
dose reduction of fludarabine and cyclophosphamide. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  28 of 64                        
  
 
• If after three weeks, the grade ≥ 3 non-hematological, non-renal toxicity still 
persists, the patient should be removed from the protocol. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
subsequent cycles despite the first 25% dose reduction treatment should 
again be delayed for up to three weeks and the dose of fludarabine and 
cyclophosphamide further reduced to 50% of the initial full dose. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
subsequent cycles despite 50% dose reduction the patient should be removed 
from the protocol treatment and the study. 
4.3.5 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  
 4.3.6 Blinding                                                                                                         
This is an open label trial. 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 
Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 
4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. Drug accountability & destruction procedures are 
described in sections 4.3.1.1 & 4.3.1.2, accordingly. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  29 of 64                        
  
 
5. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). ZAP 70 and CD38 are optional. 
2. 
Previously untreated B-CLL patients ≥ 65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin ≥ 2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
Positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
7. 
Various concomitant diseases requiring chronic steroid 
administration 
8. 
Active Coomb's positive hemolytic anemia. 
9. 
Prior treatment for CLL 
10. 
 CLL in transformation (Richter syndrome). 
11.    Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix, breast or 
prostate carcinoma) < 2 years prior to the study. 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  30 of 64                        
  
 
12. Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
13.    Low compliance. 
14.    Performance status: ECOG performance status ≥3. (see 
appendix II) 
15.   Patients who are mentally or physically unable to comply      
with all aspects of the study. Upon investigator discretion, 
a psycho-geriatric evaluation will be performed for patients 
≥ 80 years old. 
       
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 
 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in the         
      event of study drug discontinuation) during and at the end of the study       
      period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued and the patient’s participation in the study 
will be discontinued.  


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  31 of 64                        
  
 
 
5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4). 
 
5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  
Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients 
who discontinue study treatment should be followed for tumor assessments 
as per standard of care, until disease progression or new cancer therapy is 
initiated.  If patients refuse to return for these visits or are unable to do so, the 
subject should be considered off-study, but a Study Evaluation Completion 
form should be completed. 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  32 of 64                        
  
 
6. Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of 
other concurrent investigational drugs is not allowed. The use of blood 
products (irradiated) transfusions, immunoglobulins or erythroid/myeloid 
growth factors are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration is allowed exclusively for patients with 
autoimmune thrombocytopenia or as premedication for Rituximab. 
Premedication: Any patient considered to be at risk of infusion related 
reaction (IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should 
receive: 


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Appropriate hydration starting 12-24 hours prior to initiating treatment, and 
thereafter until the risk of IRR/TLS is ruled out. Urine alkalization is at 
investigator’s discretion. 
Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. 
(according local common practice) should be given only if clinically indicated 
(increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended. For prevention of 
hepatitis B reactivation that needs antiviral treatment Lamivudine 100mg/day 
will be administrated for the entire duration of chemotherapy and for the six 
months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti 
HBcore (+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids, if given (see above) are allowed for no more than 3 
consecutive days.  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


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7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan for CLL patients with a CT found to be abnormal before therapy 
or alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment, if the above four 
clinical and laboratory results support that CR has been achieved. In 
some cases, it is necessary to postpone BMB until after all the other 
criteria used to define a CR have been satisfied but, this time interval 
should not exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


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were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, 
this time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory 
and physical examination results will be captured on the response forms in 
the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 
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 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 considered related to the medicinal 
[investigational] product.  Pre-existing conditions which worsen during a study 
are to be reported as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An 
adverse event is any undesirable sign, symptom or medical condition 
occurring after starting study treatment, even if the event is not considered to 
be treatment-related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. 
Clinical events occurring before starting study treatment but after signing the 
informed consent form are recorded on the Medical History/Current Medical 
Conditions Case Report Form only if the patient receives study treatment. 
Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms or require therapy, when they are 
recorded on the Adverse Events Case Report Form under the signs, 
symptoms or diagnosis associated with them. 


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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this 
could improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal 
daily activities; treatment or medical intervention is required in 
order to maintain survival. 
Grade 5 
Death  
AE resulting in death  
 
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 


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cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 
As a consequence, for grading of anemia and thrombocytopenia, we plan to 
apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, but for 
grading of neutropenia, the standard NCI-CTC version 3.0 criteria, as given 
below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade 
ANC mm3 § (nadir) 
No change-9% 
0 
≥2,000 
10-24% 
1 
≥1,500 and <2,000 
25-49% 
2 
≥1,000 and <1,500 
50-74% 
3 
≥500 and <1000 
≥75% 
4 
<500 
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 


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Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 
possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of hemolytic 
anemia secondary to fludarabine, study treatment should be promptly 
withdrawn. Full details of the hemolytic anemia should be recorded on the 
adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four 
weeks of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 


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– Reasonable temporal association with drug administration 
– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event 
in which the subject was at immediate risk of death at the time of the 
event; it does not refer to an event which could hypothetically have caused 
a death had it been more severe). 
– required in-patient hospitalization or prolongation of existing 
hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of 
the outcomes listed above 


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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere 
to the full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse 
event if it is clearly consistent with the suspected progression of the 
underlying cancer as defined by RECIST criteria, or other criteria as 
determined by protocol. Hospitalization due solely to the progression of 
underlying malignancy should NOT be reported as a serious adverse event.  
Clinical symptoms of progression may be reported as adverse events if the 
symptom cannot be determined as exclusively due to the progression of the 
underlying malignancy, or does not fit the expected pattern of progression for 
the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that 
the investigator may elect not to perform further disease assessments.  In 
such cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every 
effort should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the 
disease under study, it should be reported as an AE or SAE. 


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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious 
and which occurs during the course of the study (as defined in section 7.1.1.3 
above), occurring from the enrollment visit (start of study screening 
procedures), including long term follow-up (LTFU) must be reported to Roche 
within one working day of the investigator becoming aware of the event 
(expedited reporting). The investigator must complete the SAE Reporting 
Form [
] and forward it to the SAE Responsible. All SAEs 
occurring from the enrolment period must be reported, (start of study 
screening procedures), 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an 
adverse reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days after the last dose of study medication. 
This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2.   
 
 


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8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.3 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted 
directly from the central laboratory, if applicable.  
Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 


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Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, 
interruption of, discontinuation of, or any other change in a concomitant 
medication, therapy or treatment) 
 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS and hepatitis B serology are in fact 
regarded as current clinical practice for CLL patients, and should therefore be 
collected according to the Visit Schedules (see Figure 1). In case of 
suspected hemolysis - DAT, reticulocyte count, serum haptoglobin, bilirubin 
and LDH are recommended. 
The institution will perform laboratory analyses according to the Visit 
Schedules (see Figure 1). The sponsor must be provided with a copy of the 
laboratory’s certification, and a tabulation of the normal ranges for each 
parameter required. Additionally, if at any time a patient has laboratory 
parameters obtained from a different outside laboratory, the sponsor must be 
provided with a copy of the certification and a tabulation of the normal ranges 
for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 
appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 


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event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  
8.3 
Special tests 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the normal behavior of the disease or 
suspicious for another disease or a different type of lymphoma. 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.5 
Laboratory examinations 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


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8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective local MoH approved product label. 
 
9.   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 


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9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
 
9.2 
Efficacy and Safety evaluation 
 
9.2.1 Efficacy analysis: 
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
95% Confidence Interval (CI) will be calculated to the proportions of 
responders. 
 
Response rate include CR and PR; all other situations (eg. stable disease, 
non response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, 
and documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. The Paired T-test or Signed Rand 
Test for paired observations (as is appropriate) will be applied for 


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analysing the changes in the components and total score of the FACIT QOL 
assessment. 
The data will be analyzed using the SAS ® version 9.1.3 (SAS Institute, 
Cary North Carolina). 
 
9.3 
Safety Analysis 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/ctca
ev3.pdf 
or v 2.0 for cytopenia, whenever possible. 
All adverse events will be coded according to coding dictionaries 
(MedDRA version 12.1) and presented in tables by system organ class 
and preferred term. 
 In the by-subject analysis, a subject experiencing the same event more than 
once will be counted only once. Adverse events will be defined and 
summarized according to the worst NCI CTC grade. Adverse events leading 
to death or to discontinuation of treatment, events classified as NCI CTCAE 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events 
will be summarized separately. Laboratory data will be graded according to 
NCI CTCAE severity grade. 
 
 
 


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10. Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract 
Research Organization staff following their own internal standard operating 
procedures that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs 
and database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, 
which are returned to the investigational site for resolution.  The signed 
original and resolved Data Query Forms are kept with the CRFs at the 
investigator site, and a copy is sent to the sponsor so the resolutions can be 
entered into the database.  Quality control audits of all key safety and efficacy 
data in the database are made prior to locking the database. 


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11.    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


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12.   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement 
that the protocol and informed consent have been approved by the IRB must 
be given to the sponsor before study initiation. The name and occupation of 
the chairman and the members of the IRB must be supplied to the sponsor. 
Any amendments to the protocol, other than administrative ones, must be 
approved by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in 
the study is voluntary and that he/she may withdraw from the study at any 
time and that withdrawal of consent will not affect his/her subsequent medical 
treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a 
copy of the signed document. If the subject cannot read or sign the 
documents, oral presentation may be made or signature given by the 
subject’s legally appointed representative, if witnessed by a person not 
involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent 
has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  


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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


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13. Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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14. Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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15.Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other 
active investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator 
nominated by the sponsor and the steering committee at the start of the trial 
would provide any needed signature.  
 
 
 


ML25464 Protocol Version D dated 06 Oct, 2011                                               Page  57 of 64                        
  
 
 
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O., Polliack, A., Berrebi, A., Israeli Study Group on CLL. (2003) Conventional 
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lymphoma in patients 80 years of age or older. Ann Oncol., 17, 928-934. 
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28) Flinn, I., Neuberg, D., Grever, M. & al, e. (2007) Phase III trial of fludarabine plus 
cyclophosphamide compared with fludarabine for patients with previously untreated 
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798. 
29) Goede, V., Cramer, P., Busch, R., Eichhorst, B., Hallek, M. & GCLLSG, t. (2005) 
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32) Srinivas S, Yook C, ChangV et al. Prevalence of bone marrow CD20 positivity in 
patients with multi[le myeloma. J Clin Oncol 2001;20: (abstr 2687). 
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38) Nguyen DT, Amess JA, Doughty H, et al: IDEC-C2B8 anti-CD20 (Rituximab) 
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39) ForanJM, Rohatiner AZ, Cunningham D, et al. European phase II study of Rituximab 
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40) Huhn D, von Schilling C, Wilhelm M, et al: Rituximab therapy of patients with B-
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41) Byrd JC, Murphy T, Howard RS, et al. Rituximab Using A Thrice weekly dosing 
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42) O'Brien SM, Kantarjian H, Cortes J, et al.  Rituximab dose escalation trial in chronic 
lymphocytic leukemia. J Clin Oncology 2001;19: 2165-2170. 
43) Byrd JC, Peterson, BL, Morrison, VA, Park, K, Jacobson, R, Hoke, E, Vardiman, 
JW, Rai, K , Schiffer, CA, Larson, PA () Randomized Phase II Study of Fludarabine 
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44) Sculz H Klein SK, Rehwald U et al/ Phase II study of combined immunotherapy 
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45) Byrd JC, Rai K, Peterson BL, et al. Addition of Rituximab to Fludarabine may 
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46) Hallek M, Chesso BD,  Kantarjian H,et al.Guidelines for the diagnosis and treatment 
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47) Rai K , B.S Bercedis, Peterson L,Appelbaum FR, Kolitz J et al Fludarabine 
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48) Byrd JC, Peterson BL, Morrison VA, et al. Randomized phase 2 study of fludarabine 
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49) Robak T, DmoszynkaA,Solal-Celigny P et al Rituximab plus Fludarabine and 
Cyclophosphamide prolongs progression free survival compared to Fludarabine and 
Cyclophosphamide alone in previously treated chronica lymphocytic leukemia 
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50) Foon KA, Boyiadzis M,Land SR, et al. Chemoimmunotherapy with low dose 
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51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 


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16. Supplements 
 
Appendix I    Response definitions    
 
CR (complete remission) = requires all of the following criteria as assessed at least 3 
months after completion of therapy: 
 
 
 
Absence of clonal lymphocytes in peripheral blood. 
 
Absence of significant lymphadenopathy. (lymph nodes > 1.5 cm in diameter) by 
physical examination. CT is desirable for not palpable lymph nodes. 
 
No hepatomegaly or splenomegaly by physical examination. (Abdominal, pelvix 
and thorax CT for subjects found to be abnormal before therapy or if physical 
examination is inconclusive. 
 
Absence of constitutional symptoms. 
 
Blood counts above the following values: ANC> 1.5 x 109/L
 .  Platelets > 100 
x109/L . Hemoglobin > 11.0 g/dL; untransfused). 
 
Bone marrow aspirate and biopsy should be performed at least 3 months after the 
last treatment and if the above 5 clinical and laboratory results demonstrate that CR 
has been achieved. 
Bone marrow should be analyzed  by FACS/or immunohistochemistry to demonstrate 
marrow free of B-CLL cells. 
In some cases, it is necessary to postpone BMB until after all the other criteria to 
define a CR have been satisfied. However, this time interval should not exceed 6 
months after the last treatment. 
 
 


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Relapse = a patient who has previously achieved CR or PR but after a period of 6 or more 
months, demonstrates evidence of disease progression 
 
Refractory disease = defined as treatment failure or disease progression within 6 months 
from the last antileukemic therapy. 
 
Progression = see above table  under PD. 
 
Progression free survival (PFS) = defined as the time from start of treatment to progression. 
 
Time to next treatment (TNT) = defined as the time from start of treatment to start of 
second-line treatment  
 
 
 
 
 
Appendix II    ECOG Performance status   
 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities. 
Up and about more than 50% of waking hours 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or 
chair 
5 
Dead 
 


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Appendix III calculated creatinine clearance 
  
 
   
 
 
 
 
Appendix IV     Active disease 
At least one of the following criteria should be met: 
1. Evidence of progressive marrow failure as manifested by the development of, 
or worsening of, anemia and/or thrombocytopenia 
2. Massive (ie, > 6 cm below the left costal margin) or progressive or 
symptomatic  splenomegaly. 
3. Massive nodes (ie, > 10 cm in longest diameter) or progressive or 
symptomatic lymphadenopathy. 
4. Progressive lymphocytosis with an increase of more than 50% over a 2-
month period or lymphocyte doubling time of less than 6 months; patients with 
initial blood lymphocyte counts of less than 30X109/L (30 000/μL) may require 
a longer observation period to determine the lymphocyte doubling time. In 
addition, factors contributing to lymphocytosis or lymphadenopathy other than 
CLL (eg, infections) should be excluded. 
5. Autoimmune anemia and/or thrombocytopenia poorly responsive to 
corticosteroides or other standard therapy. 
6. A minimum of any of the following disease-related symptoms must be 
present: a- Unintentional weight loss more than or equal to 10% within the 
previous 6 months. b- Significant fatigue (ie, ECOG PS 2 or worse; cannot 
work or unable to perform usual activities). c- Fevers of greater than 38.00C 
for 2 or more weeks without other evidence of infection. d- Night sweats for 
more than 1 month without evidence of infection. 
 
Appendix V    Binet staging system 
The areas of involvement considered for staging are as follows: 1- Head and neck, 
including the Waldeyer ring. 2- Axillae 3- Groins 4- Palpable spleen 5- Palpable liver. 
Stage A.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and up to 2 of the above 
areas involved. 
Stage B.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and organomegaly 
greater than that defined for stage A (3 or more areas). 
Stage C.  All patients who have Hb less than 10 g/dL and/or a platelets count less than 
100X 109/L, irrespective of organomegaly. 
 
 
GFR (mL/min) = 
(140-age) X weight (Kg) 
Serum cr (mg/dL) X 72 
X  0.85 (for women) 


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Appendix VI    FACIT-QOL 
 
FACIT − Fatigue Scale (Version 4) 
Below is a list of statements that other people with your illness have said are important. By 
circling one (1) number per line, please indicate how true each statement has been for you 
during the past 7 days. 
 
                                                                                                        Not     A little    Some    Quite     Very 
           At all     bit         what      a bit    much 
 
HI7     I feel fatigued 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3  
4 
HI12   I feel weak all over 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
0  
1  
2  
3   
4 
 An1   I feel listless (“washed out") . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  0  
1  
2     
3   
4 
 An2   I feel tired 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  
0  
1   
2     
3  
4 
 An3   I have trouble starting things because I am tired 
. . . . . . . . . .  0   
1  
2 
3   
4 
 An4   I have trouble finishing things because I am tired 
. . . . . . . . . 0   
1 
2   
3  
4 
 An5   I have energy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3   
4 
 An7   I am able to do my usual activities 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
 An8   I need to sleep during the day 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
An12  I am too tired to eat 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2 
3   
4 
An14  I need help doing my usual activities 
. . . . . . . . . . . . . . . . . . . . . 
. . 
0   
1 
2  
3   
4 
An15  I am frustrated by being too tired to do the things 
         I want to do 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
0  
 1  
2  
3   
4 
An16  I have to limit my social activity because I am tired 
. . . . . .   0  
1  
2  
3   
4 
 
 
 
US English 
Copyright 1987, 1997 
 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 1 of 19                                      
 
 
AMENDMENT HISTORY FOR PROTOCOL ML25464 (FCR-LITE) 
VERSION E DATED 22-Apr-2013 
 
1. Subject: Overall study design 
 Reason for change:  The option to round the dose of Rituximab and chemotherapy was 
added to fit the common practice.  
       Section 4.2 Overall study design 
              New text:  
This is a national, multicenter, phase II, single arm (not controlled), open label clinical 
trial to evaluate the efficacy and safety of the combination of low dose Flu + Cy 
combined with standard dose Rituximab Flu dosage will be given at 12.5mg/m2/d given 
I.V. together with CY150 mg/m2/d given I.V. for three days every 28 days. Rituximab 
will be given before chemotherapy  
cycle 1:  375 mg/m2  I.V. on day 0 and in cycles 2-6: 500 mg/m2 I.V. on day 1 in 
previously untreated CLL patients who are more than 65 years of age. 
Please note: All medication dosages will be rounded up to the nearest dosage 
according to the medical center routine administration procedures. 
 
               Old text:  
This is a national, multicenter, phase II, single arm (not controlled), open label clinical 
trial to evaluate the efficacy and safety of the combination of low dose Flu + Cy 
combined with standard dose Rituximab Flu dosage will be given at 12.5mg/m2/d given 
I.V. together with CY150 mg/m2/d given I.V. for three days every 28 days. Rituximab 
will be given before chemotherapy 
cycle 1:  375 mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2  I.V. on day 1 in 
previously untreated CLL patients who are more than 65 years of age. 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 2 of 19                                      
 
2. Subject : Visit schedule and assessments 
Reason for change:  The schedule of BMB was corrected to fit the text of the protocol. 
Original text in the protocol: BMB will be performed for progression/ lymphoma 
transformation, cytopenia evaluation, and for treatment response within 3-6 months 
after completion of treatment. 
              Section 4.2.1 Visit schedule and assessments 
              New text:  
Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B and C 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 3 of 19                                      
 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 6 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
 
Old text: 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 4 of 19                                      
 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
 
3. Subject: Schedule of FACS assessment 
Reason for change:  No clinical justification to perform FACS 12 mounts prior to 
screening.  
Section 4.2.1  Visit schedule and assessments: Figure 1 - Comment no. 4  
New text:  
4 - FACS results prior to screening are relevant and no further test is necessary at 
screening. 
Old text: 
4 - FACS results from up to 12 months prior to screening are relevant and no further test 
is necessary at screening. 
 
4. Subject: SAE reporting during Screening 
Reason for change:  Clarification regarding SAE reporting during Screening. 
              Section 4.2.1 Visit schedule and assessments: Figure 1 - Comment no. 6 
 
 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 5 of 19                                      
 
New text:  
6 - After signature on informed consent, but prior to initiation of study medications, 
only SAEs caused by a protocol-mandated intervention will be collected. After first 
study medication, all SAEs must be reported. 
 
Old text: 
None 
Section 8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
New text:  
Any clinical adverse event or abnormal laboratory test value that is serious and which 
occurs during the course of the study (as defined in section 8.2 above), occurring from 
the enrollment visit (start of study screening procedures), including long term follow-up 
(LTFU) must be reported to Roche within one working day of the investigator becoming 
aware of the event (expedited reporting). The investigator must complete the SAE 
Reporting Form [
] and forward it to the SAE Responsible.  
After signature on informed consent, but prior to initiation of study medications, only 
SAEs caused by a protocol-mandated intervention will be collected (e.g., SAEs related 
to invasive procedures such as biopsies, medication washout, or no treatment run-in).  
After first study medication, all SAEs must be reported.  
 
Old text: 
Any clinical adverse event or abnormal laboratory test value that is serious and which 
occurs during the course of the study (as defined in section 7.1.1.3 above), occurring 
from the enrollment visit (start of study screening procedures), including long term 
follow-up (LTFU) must be reported to Roche within one working day of the investigator 
becoming aware of the event (expedited reporting). The investigator must complete the 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 6 of 19                                      
 
SAE Reporting Form [
] and forward it to the SAE Responsible. All SAEs 
occurring from the enrolment period must be reported, (start of study screening 
procedures). 
 
5. Subject: Dose modification for other non-hematological toxicity (non renal). 
Reason for change: Prevent clinically unnecessary dose reduction of fludarabine and 
cyclophosphamide in case of grade ≥ 3 non-hematological, non-renal toxicity, not drug 
related AE (after recovery to grade ≤ 2). 
Section 4.3.4  Dose modification for other non-hematological toxicity (non renal) 
             New text:  
- 
If other grade ≥ 3, non-hematological, non-renal toxicity occurs during any cycle, study 
drugs treatment should be delayed until recovery to grade ≤ 2, for up to three weeks.  
In case of grade ≥ 3, non-hematological, non-renal toxicity, which in the investigators' 
opinion is not study drug related, dose reduction will be performed upon investigator 
discretion. In case of grade ≥ 3 non-hematological toxicity, which in the investigators' 
opinion is related to study drugs, all subsequent cycles should then be given with a 
25% dose reduction of fludarabine and cyclophosphamide. 
- 
If after three weeks, the grade ≥ 3 non-hematological, non-renal toxicity, drug related 
still persists, the patient should be removed from the protocol. 
- 
 If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug related in 
subsequent cycles despite the first 25% dose reduction treatment should again be 
delayed for up to three weeks and the dose of fludarabine and cyclophosphamide 
further reduced to 50% of the initial full dose. 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 7 of 19                                      
 
- 
If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug related in 
subsequent cycles despite 50% dose reduction the patient should be removed from the 
protocol treatment and the study. 
Old text: 
 
- If other grade ≥ 3, non-hematological, non-renal toxicity occurs during any cycle, study   
drugs treatment should be delayed until recovery to grade ≤ 2, for up to three weeks. All 
subsequent cycles should then be given with a 25% dose reduction of fludarabine and 
cyclophosphamide. 
-If after three weeks, the grade ≥ 3, non-hematological, non-renal toxicity still persists, 
the patient should be removed from the protocol.  
-If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
               subsequent cycles despite the first 25% dose reduction treatment should 
               again be delayed for up to three weeks and the dose of fludarabine and 
               cyclophosphamide further reduced to 50% of the initial full dose. 
- If there is further grade ≥ 3 non-hematological, non-renal toxicity in 
              subsequent cycles despite 50% dose reduction the patient should be removed   from 
the protocol treatment and the study. 
 
6. 
Subject: Dose modification for Weight Changes 
Reason for change: Body weights were added to screening visit and visits 2 and 4 in 
order to make dose adjustment in case of more than ± 10% change in weight. 
 
Section 4.3.5 Dose modification for Weight Changes 
New text:  
Dose of medication will be determined according to weight at screening.  
If body weight has changed at visit 2 or visit 4 by ± 10% or more, appropriate 
adjustment in dose of all medications should be performed.   


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 8 of 19                                      
 
 
Old text: 
None. 
 
              Section 4.2.1 Visit schedule and assessments 
              New text:  
Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 3 5 7 9 13 17 21 33 45 57 69 81 
93-
153 
every 
12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 3 4 5 6 
7 
8 
9 
10 11 12 13 14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Physical exam 
X 
X X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 7 
X 
X 
 
X  
 
 
 
 
 
 
 
 
 
 
 
 
CBC  
X 
X X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X X X X X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B and C 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 9 of 19                                      
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 6 
Ongoing data capture and up to 30 days after completion or 
discontinuation of the study 
Concomitant 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
 
Old text: 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 10 of 19                                    
 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
Section 4.2.1  Visit schedule and assessments: Figure 1 - Comment no. 7  
New text:  
7 - Dose of medication will be determined according to weight at screening. If body 
weight has changed at visit 2 or visit 4 by ± 10% or more, appropriate adjustment in 
dose of all medications should be performed.  
  
Old text: 
None. 
 
 
7. Subject: Inclusion criteria number 1. 
Reason for change:   In cases when atypical CLL exists the patient will only be recruited 
following the confirmation of a pathologist and the sponsor. 
Section 5.1 
 Inclusion criteria & Synopsis 
New text: 
Diagnosis of B-CLL is established by the presence of: an absolute lymphocyte count > 
5X109 L, and typical CLL cell morphology in the peripheral blood smear as seen by light 
microscopy. CLL cells must show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  and CD 79b are 
characteristically low and FMC7 is expected to be negative (optional). ZAP 70 and CD38 
are optional. Patients with different phenotype than described above can be included, 
in case the pathologist will give a written approval of B-CLL and with the approval of 
the sponsor. 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 11 of 19                                    
 
Old text: 
 
Diagnosis of B-CLL is established by the presence of: an absolute lymphocyte count > 
5X109 L, and typical CLL cell morphology in the peripheral blood smear as seen by light 
microscopy. CLL cells must show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  and CD 79b are 
characteristically low and FMC7 is expected to be negative (optional). ZAP 70 and CD38 
are optional.  
 
 
8. Subject: Exclusion criteria number 6. 
Reason for change:  permit enrollment of patients with previous exposure to HBV which 
are negative for HBS Ag and negative for presence of DNA replicates of the virus in the 
blood. 
 
Section 5.2 
 Exclusion criteria & Synopsis 
 
 
New text:  
- 
Patients with active hepatitis B or HBV surface antigen positive. 
- 
Patients with anti-HBV core antibodies (past infection with HBV) but 
who are negative for HBVsAg (either anti-HBS Ab positive or negative) 
and are positive for HBV-DNA by PCR analysis - are not eligible. 
    Old text: 
  
- 
Positive Hepatitis B Surface Ag or Hepatitis B Core Ab 
 
            Section 6.2   Concomitant therapy 
                     New text:  
Patients with anti-HBV core antibodies (past infection with HBV) but who are negative 
for HBSAg (either anti-HBVs Ab positive or negative) and had negative baseline for HBV-
DNA by PCR analysis will be given anti-viral prophylaxis during and for at least 6 months 
after the last cycle of treatment.  


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 12 of 19                                    
 
For prevention of hepatitis B reactivation that needs antiviral treatment (prophylaxis 
treatment) Lamivudine 100mg/day will be administrated for the entire duration of 
chemotherapy and for the six months afterwards. 
Old text: 
For prevention of hepatitis B reactivation that needs antiviral treatment Lamivudine 
100mg/day will be administrated for the entire duration of chemotherapy and for the six 
months afterwards. 
 
9. Subject: Assessments for hepatitis C 
Reason for change:  The assessment was mistakenly dropped in some places in the 
protocol. 
             Section 4.2.1 Visit schedule and assessments 
New text: 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 13 of 19                                    
 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B and C 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 6 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
Old text:  
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 
weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical 
history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 14 of 19                                    
 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 
Study completion 
X 
Complete at any time if study drug is discontinued 
 
            Section 8.2.3  Laboratory evaluations 
New text:  
Measurement of Complete Blood Counts, chemistry and immunological tests such as: 
serum Ig level, serum immunoellectrophoresis, DAT, peripheral and bone marrow FACS 
and hepatitis B and C serology are in fact regarded as current clinical practice for CLL 
patients, and should therefore be collected according to the Visit Schedules (see Figure 
1). 
Old text:  
Measurement of Complete Blood Counts, chemistry and immunological tests such as: 
serum Ig level, serum immunoellectrophoresis, DAT, peripheral and bone marrow FACS 
and hepatitis B serology are in fact regarded as current clinical practice for CLL patients, 
and should therefore be collected according to the Visit Schedules (see Figure 1). 
 
 
10. Subject: Cancellation of Secondary Endpoint - TNT 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 15 of 19                                    
 
Reason for change:  It was decided to remove secondary endpoint of Time to Next 
Treatment (TNT) as it was not applicable to collect the relevant data. 
Section 3.2 Synopsis 
New text:  
   Secondary end points: 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- days),       
-   Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- QOL 
 
Old text:  
   Secondary end points: 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- days),       
   
- Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- Time to Next Treatment (TNT). 
- QOL 
 
Section 3.2 Secondary Objectives 
New text:  
1-    Safety of the combination drugs given in the study population, especially in relation 
to: neutropenic fever, Infection rate, number of hospitalization days, thrombocytopenia 
≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS). 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 16 of 19                                    
 
3-        Quality Of Life (FACIT) 
Old text:  
1-    Safety of the combination drugs given in the study population, especially in relation 
to: neutropenic fever, Infection rate, number of hospitalization days, thrombocytopenia 
≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS).  
3-       Time to Next Treatment (TNT).  
4-        Quality Of Life (FACIT)  
 
Section 4.1.1 Secondary End Points 
New text:  
1-   Safety of the study drugs especially in relation to: neutropenic fever, Infection rate 
and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first day of study 
drug administration to disease progression as defined in the protocol (see appendix I) 
3-     QOL(see appendix VI) 
Old text:  
1-   Safety of the study drugs especially in relation to: neutropenic fever, Infection rate 
and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first day of study 
drug administration to disease progression as defined in the protocol (see appendix I) 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 17 of 19                                    
 
3-     Time to Next Treatment (TNT) as defined in the protocol (see appendix I) 
4-     QOL(see appendix VI) 
 
11. Subject: Drug Accountability Updates 
Reason for change:  Several updates were performed in sections 4.3.1, 4.3.1.1 & 
4.3.1.2  in order to clarify and ease the procedure of drug accountability. 
Section  4.3.1  Investigational therapy  
New text:  
Labels will comply with the legal requirements in Israel and be printed in Hebrew 
and English. All study drugs containing infusion bags will be labeled. All infusion 
bags will be labeled by the study nurse prior to administration and the 
removable part of the labels will be attached to the drug administration log, 
signed and dated by the study nurse. Storage conditions for study drug will be 
described on the medication label. Patients will receive the study drug 
combination for an exposure period of up to 6 months provided that in the opinion 
of the investigator the patient is benefiting from treatment with this study drug 
combination, and in the absence of any safety concerns. Treatment will be 
withheld only in the case of limiting toxicities (see below).  
 
Old text:  
Labels will comply with the legal requirements in Israel and be printed in Hebrew 
and English. All study drugs containing infusion bags will be labeled. All infusion 
bags will be labeled by the study nurse prior to administration and only the empty 
Rituximab infusion bags will be collected for drug accountability by the study 
monitor. Storage conditions for study drug will be described on the medication 
label. Patients will receive the study drug combination for an exposure period of 


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 18 of 19                                    
 
up to 6 months provided that in the opinion of the investigator the patient is 
benefiting from treatment with this study drug combination, and in the absence of 
any safety concerns. Treatment will be withheld only in the case of limiting 
toxicities (see below).  
 
Section  4.3.1.1 DRUG ACCOUNTABILITY 
New text:  
Accountability and patient compliance will be assessed by maintaining adequate 
"drug administration log” on study medication. 
The "drug administration" log for the study medication must be kept current and 
should contain the following information: 
o 
The identification of the patient (patient number) to whom the study 
medication was administered.  
o 
Labels of used study drugs - signed and dated by the study nurse. 
All accountability administration logs must be available for inspection by the 
monitor. Infusion bags will be destructed according to local site guidelines.  
Old text:  
Accountability and patient compliance will be assessed by maintaining adequate 
"drug dispensing log” on study medication. 
The "drug dispensing" log for the study medication must be kept current and 
should contain the following information: 
o 
The identification of the patient (patient number) to whom the study 
medication was administered.  
o 
The date(s) and quantity of study medication, used for the patients' 
treatment.  


Amendment History of Protocol ML25464 Version E dated 22 Apr 13                                   Page 19 of 19                                    
 
o 
The date(s) and quantity of study medication, of empty, partial or unused 
medication.  
 
All accountability logs must be available for inspection by the monitor. Drug 
supplies (partly used and empty Rituximab infusion bags) must be available for 
inspection, at every monitoring visit. Used supplies will be destructed according 
to local site guidelines.  
 
Section 4.3.1.2   DESTRUCTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT 
New text:  
Used supplies (infusion bags) will be sent for destruction according to the site 
guidelines. The destruction process in the site should be documented. 
Old text:  
After the monitor has reconciled study drug supplies, used supplies (partly used 
and empty Rituximab infusion bags) will be sent for destruction according to the 
site guidelines. The destruction process in the site should be documented. 
 




ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  1 of 67                        
  
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (≥65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA  
 
 
 
Author:  Prof 
. 
. 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 MHA+M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 MHA+M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  2 of 67                        
  
 
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ....................................................................................... 10 
3. 
TRIAL OBJECTIVES AND PURPOSE.............................................................................. 17 
3.1 
PRIMARY OBJECTIVE…… ............................................................................................ 17 
3.2 
SECONDARY OBJECTIVES……..................................................................................... 17 
4. 
TRIAL DESIGN………………………………………………………………………………….18 
4.1 
PRIMARY AND SECONDARY END POINTS………… ......................................................... 18 
4.2 
OVERALL STUDY DESIGN…… ...................................................................................... 18 
4.2.1  VISIT SCHEDULE AND ASSESSMENTS……….. ............................................................... 21 
4.3 
TRIAL TREATMENT….. ................................................................................................. 24 
4.3.1  Investigational therapy…………………….…………………………………………..24 
4.4 
STUDY DRUG INTERRUPTION OR DISCONTINUATION……………. .................................... 29 
4.5 
ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL PRODUCTS ......................... 30 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS ......................................................... 31 
5.1 
INCLUSION CRITERIA….. .............................................................................................. 31 
5.2 
EXCLUSION CRITERIA….. ............................................................................................ 31 
5.3 
INTERRUPTION OR DISCONTINUATION OF TREATMENT…………….. ............................... 32 
5.4 
STUDY DISCONTINUATION …………………………………………… ............................. 32 
6. TREATMENT OF SUBJECTS .............................................................................................. 35 
6.1 
TREATMENT REGIMEN….. ............................................................................................ 35 
6.1.1 TREATMENT ASSIGNMENT…….. ................................................................................... 35 
6.2 
CONCOMITANT THERAPY…… ...................................................................................... 35 
6.3 
TREATMENT COMPLIANCE……. .................................................................................... 36 
7. 
ASSESSMENT OF EFFICACY .......................................................................................... 37 
8. 
ASSESSMENT OF SAFETY ............................................................................................. 39 
8.1 
ADVERSE EVENTS ……………… ................................................................................. 39 
8.2 
SERIOUS ADVERSE EVENTS……. ................................................................................. 43 
8.3 
Special tests……………………………… ................................................................. 48 
8.4 
Physical examinations/vital signs……. ................................................................. 48 
8.5 
LABORATORY EXAMINATIONS…….. ............................................................................. 48 
8.6 
PHYSICAL EXAMINATIONS/VITAL SIGNS………… ........................................................... 49 
9.   STATISTICS………………...……………………………………………………………………49 
9.1 
SAMPLE SIZE… ........................................................................................................... 50 
9.2 
EFFICACY AND SAFETY EVALUATION……….. ............................................................... 50 
10. QUALITY CONTROL AND QUALITY ASSURANCE ....................................................... 53 
11.    DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .................................................. 54 
11.1   STUDY MONITORING .................................................................................................... 54 
11.2  AUDITS.. .................................................................................................................... 54 
11.3 IRB AND REGULATORY INSPECTIONS……….. ............................................................... 54 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  3 of 67                        
  
 
12.   ETHICS………………………………………………………………………………………….55 
12.1    INSTITUTIONAL REVIEW BOARD .................................................................................. 55 
12.2 INFORMED CONSENT….. .............................................................................................. 55 
12.3 DECLARATION OF HELSINKI……. ................................................................................. 56 
13. DATA HANDLING AND RECORD KEEPING ................................................................... 57 
14. FINANCING AND INSURANCE ........................................................................................ 58 
15.PUBLICATION POLICY  ................................................................................................... 59 
       REERENCES……………………………………………………………………………………60 
 
16. SUPPLEMENTS 
 ................................................................................................... 64 
APPENDIX I    RESPONSE DEFINITIONS .................................................................................... 64 
APPENDIX II    ECOG PERFORMANCE STATUS ....................................................................... 65 
APPENDIX III CALCULATED CREATININE CLEARANCE .............................................................. 66 
APPENDIX IV     ACTIVE DISEASE ........................................................................................... 66 
APPENDIX V    BINET STAGING SYSTEM .................................................................................. 66 
APPENDIX VI    FACIT-QOL ................................................................................................ 67 
 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  4 of 67                        
  
 
LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR 
Institutional Review Board 
Infusion Related Reaction 
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  5 of 67                        
  
 
 
 
SYNOPSIS 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (≥65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER: 
ML25464 
 
DATE PROTOCOL FINAL: 
20 August 2011 
 
STUDY DRUG: 
 
FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:  
 
CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE: 
 
II 
 
     Background and rationale Chronic lymphocytic leukemia (CLL) is characteristically 
diagnosed in the older population with a median age at diagnosis ranging between 65 and 
72 years. Because the prevalence of co morbidity increases with age, concomitant disease 
is often present in this age group. Additional factors which may also  adversely affect 
treatment outcome at standard doses in elderly patients include: altered pharmacokinetics 
and poorer host  tissue tolerance ; changes in the bone marrow hematopoietic reserve and 
microenvironment leading to increased treatment related myelotoxicity and  higher rates of 
treatment related complications such as infections. As a result, elderly patients are often 
excluded from clinical trials or even from routine treatment on the basis of their age and / or 
comorbidity. Furthermore when these patients are treated, the drug doses are often 
markedly reduced in an attempt to avoid causing toxicity and complications. The challenge 
in treating elderly CLL patients relates to finding the correct balance between drug efficacy 
and toxicity and because of this optimal treatment for this group of patients is often hard to 
achieve. 
 
   Study Objectives 
The aim of this study is to evaluate the safety and efficacy (response rate) of a combination 
of low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with standard dose 
Rituximab given as primary treatment for elderly patients with chronic lymphocytic 
leukemia. 
 
   Primary end point:  -Response rate 
 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  6 of 67                        
  
 
 
   Secondary end points: 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- days),         
- Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- QOL 
    STUDY DESIGN: 
This is a multicenter, phase II, single arm study designed to evaluate the efficacy and 
safety of the combination of low dose Fludarabine (FLU) and Cyclophosphamide (CY) 
combined with standard dose Rituximab in elderly previously untreated CLL patients (≥ 65 
years of age). Potential study subjects will sign an informed consent prior to undergoing 
any study related procedure. Number of patients to be enrolled is 40. 
    Treatment plan:  Flu 12.5mg/m2/d will be given intravenously (I.V.) for days 1-3 every 
28 days, for a total of 6 cycles. 
CY will be given I.V. at the dose of 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. 
Rituximab will be given before chemotherapy. In cycle1:  375 mg/m2  I.V.  on day 0, cycles 
2-6: 500 mg/m2 I.V. on day 1 every 28 days. 
Dose reduction or delays are recommended in case of grade ≥3 (NCI-CTC) adverse 
events. 
This study consists of 3 periods for each study subject: Pre-treatment, Treatment and 
Follow up. 
Pre-treatment period: patients will undergo screening for protocol eligibility within 28 days 
(4 weeks) of recruitment. 
Subjects who meet all the inclusion criteria and have signed an approved informed consent 
will be enrolled. 
Treatment period FLU 12.5mg/m2/d  I.V. will be given on days 1-3 every 28 days, for a total 
of 6 cycles. CY will be given (I.V.) 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. Rituximab  given before chemotherapy cycle 1:  375 mg/m2  intravenously on day 0, 
cycles 2-6:  500 mg/m2  I.V.  on day 1 every 28 days.  
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and thereafter 
only if clinically indicated. Hydrocortisone 100-500 mg I.V. (according with local common 
practice) only if clinically indicated. 
Dose reduction or delay in case of drug induced hematological toxicity grade ≥ 3 level. 
During the treatment period, all patients will attend twice a month in the first 2 months and 
thereafter periodic monthly study center visits in order to assess the safety and efficacy of 
the treatment. 
Complete blood count will be performed on day 1 and 14 of each of the first two cycles, 
and on day 1 in the other 4 cycles, or more frequently at the investigators discretion. 
Bone marrow aspiration and biopsy and CT scan (optional) will be performed within 3-to 6 
months after the completion of the treatment period. 




ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  8 of 67                        
  
 
- Use of other investigational agents or participation in any other clinical trials < 30 days 
prior to the study. 
- Low compliance. 
- Performance status: ECOG performance status ≥3. 
- Patients who mentally or physically are unable to comply with all aspects of the study. 
 
Assessments: 
    Efficacy  
      The following evaluations will be done to record the efficacy of the treatment regimen: 
- Assessment of disease response (revised International Response Criteria:   updated NCI-
     IWG 2008).[46].  
- Date of documentation of disease progression. 
- Bone marrow biopsy examination 
- Peripheral blood immunophenotyping by FACS. 
- Changes in ANC, Hb levels and platelets counts from baseline blood counts and 
those          done during the study period. 
- Chest, abdominal and pelvic computerized tomography 
- Physical examination for lymphadenopathy and hepato-splenomegaly 
    Safety 
The following evaluations will be recorded to assess the safety of the regimen: 
- Complete physical examination including vital signs. 
- Clinical laboratory evaluations (hematology, biochemistry) 
- Concomitant medication and procedures 
- Adverse events 
- Health outcomes assessment (any extra medical appointment)  
 
    Efficacy analysis: 
Primary efficacy will be determined by objective overall response rate. Exact tests for 
assessing these will be used to compare objective overall response rates. Kaplan Meier 
procedure will be used to characterize the duration of response for PFS and TNT. 
Summary statistics (standard deviation, mean, median, minimum and maximum) will be 
provided for the relevant variables 
 Safety Analysis: 
Data from all subjects who receive any study drug will be included in the safety analyses. 
The severity of the toxicities will be graded according to the NCI CTC v3 or v2- for 
cytopenia, whenever possible. In the by-subject analysis, a subject experiencing the same 
event more than once will be counted only once. 
Adverse events will be defined and summarized by the worst NCI CTC grade. Adverse 
events leading to death or to discontinuation of treatment, events classified as NCI CTC 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI CTC severity 
grade. 
 


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STUDY DURATION: five years                                        TOTAL SAMPLE SIZE: 40


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2. Background Information 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
disease is often evident in this age group. Goede et al [29] reported that 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
Thurmes and colleagues [1] have shown that these comorbid conditions are in 
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients. 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given.  
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate. 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
the treatment of CLL [14]. Fludarabine is the most extensively studied purine 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
shown to be more effective than when used alone. [13,14,27,28]. In this respect 
the U.K. MRC LRF CLL4 trial  reported in 2007 [11]  compared therapy with 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  11 of 67                        
  
 
that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
standard treatment of all CLL patients irrespective of age [11]. Similar results 
were published by the German CLL Study Group and the North American 
Intergroup [14]. 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections.  
Pollizzotto et al [15] investigated the influence of increasing age on the ability to 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age ≥ 70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality. 
 
Table 1 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 (17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days ; 
4 courses 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  12 of 67                        
  
 
CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2 
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
with a human IgG1 constant kappa antibody (C2B8) that reacts specifically 
with the CD20 antigen found on the surface of malignant and normal B cells 
and established B-cell lines [31,33].  The antigen is expressed at lower levels on 
chronic lymphocytic leukemia (CLL) and plasma cells [31]. CD20 is not shed 
from the surface of CD20+ cells after antibody binding and it is not 
internalized or downregulated [34].  Compared with its murine counterpart, 
Rituximab has a longer half-life in humans, interacts with human effector cells 
[34, 35], and is less immunogenic [36]. 
 
Reduced FC doses 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-(≥ 70 years). These are listed in Table1. 
 
 
 
 
 


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2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
the use of this agent in CLL [37,39,40].  The original studies employed 375 
mg/m2 of Rituximab once a week for four weeks.  Subsequent studies 
suggested using this dose three times a week for four weeks for a total of 12 
doses instead of 4 doses which resulted in better overall responses [41].  Dose 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
increased or the frequency of the standard dose of 375 mg/m2 was increased 
[41, 44].  
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
Byrd et al went on, to compare sequential and concurrent therapy with RF [43].   
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
median survival has yet to be reached yet, but will be in excess of 23 months 
[44]. Three major side effects were observed: infusion related toxicity, 
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
(GCLLSG) [44] reported the treatment of 20 untreated and 11 relapsed CLL 
patients. Treatment consisted of Fludarabine administered at standard doses 
(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  14 of 67                        
  
 
given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks. 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections. 
A retrospective comparative analysis of the CALGB 9712 [47] (Rituximab 
plus Fludarabine) [48] and the CALGB 9011 (Fludarabine only) studies 
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
was similar [45]. 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
patients, respectively) [24, 25]. In the untreated patients the overall response rate 
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections. 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection.  
Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  15 of 67                        
  
 
fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 21%) 
and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  16 of 67                        
  
 
In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL. 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
patient. In this regard, Foon and colleagues [50] reported a phase II single arm 
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
(20mg/m2) and Cyclophosphamide (150mg/mg2) combined with high–dose 
Rituximab (500mg/m2) given every other week during induction and later as 
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
months (range, 5.2 to 42.5 months) and none of the complete responders 
have relapsed. Grade 3/4 neutropenia was noted in 13% of the cycles of 
therapy. Another approach to reduce toxicity was to use sequential therapy 
with fludarabine (25 mg/m2 on days 1 through 5 for 6 cycles) followed by 
consolidation with Cyclophosphamide (3,000 mg/m2 administered every 3 
weeks for three cycles) and then by Rituximab 375 mg/m2 for four cycles 
(F C
R). [51]  In 36 previously untreated CLL patients an overall response of 
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
negative) and achieving molecular CRs had an excellent prognosis with a 
plateau in the response duration curve, and 90% remain in clinical CR at 5 
years. For the entire group, 5-year survival rate is 71% compared with a rate 
of 48% with the prior F
C regimen (not significant P = .10).  
 


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3. 
Trial Objectives and Purpose 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximab given as primary treatment for elderly patients with 
chronic lymphocytic leukemia. 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic.  
 
3.1 
Primary Objective 
To evaluate the efficacy (Response Rate) of the combination of lower dose 
Fludarabine 12.5 mg m2/d given intravenously for three days and 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
days, combined with standard dose Rituximab (375mg/ m2 in cycle 1 and 
500 mg/m2  in cycles 2-6) for a total of 6 cycles.  
. 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia ≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS).  
3-        Quality Of Life (FACIT) 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  18 of 67                        
  
 
4. 
Trial Design                                                                                                              
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2  I.V. on day 0 and in cycles 2-6: 500 mg/m2 I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Please note: All medication dosages will be rounded up to the nearest 
dosage according to the medical center routine administration 
procedures. 
 
 Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedure. In general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  


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Up to 40 patients are planned to be enrolled during a two year period. 
This study consists of 3 periods for each study subject: A pre-treatment 
period, the treatment period and a follow up period.  
 
Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific 
medical procedures are performed which include laboratory screening 
assessments and physical examination as well as documentation of vital 
signs. If the hematology and/or biochemistry evaluations have been 
performed within 14 days of the first dose of study drug as part of the 
screening evaluation, they need not be repeated, and the data may be used 
as the Day 1 values. Bone marrow biopsy (FISH whenever possible) must 
have been performed within 12 months of starting the first dose of the study 
drugs. 
CT scan when done, must be performed within 12 weeks prior to starting the 
first dose of study drugs.     
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 
every 28 days. 
Premedication: antihistamines (e.g. 2mg clemastin or promethazine 25mg 
I.V.) and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Hydrocortisone 100 -
500mg I.V.(according with local common practice only if clinically indicated. 
In the event of grade ≥ 3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  20 of 67                        
  
 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 
both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic twice a month in 
the first 2 months and thereafter monthly study- center visits in order to 
assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two 
cycles. In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation of cytopenias (disease or treatment 
related) and for any other clinical indication at the discretion of the 
investigators.  
Supportive care including blood transfusions or administration of growth 
factors G-CSF or erythropoietin is permitted at the investigators' discretion 
throughout all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination, peripheral blood immunophenotyping (FACS), 
abdominal, pelvic and chest CT will be performed 3 to 6 months after the 
completion of the treatment regimen, at clinical progression and at any other 
time according to the investigators' discretion. 


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In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 
subjects enrolled into the study and will be given at the dose of 15mg/m2/d 
given I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated 
and declared inadequate and inefficient. If response is evident in ≥ 5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the 
discretion of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule 
and assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days 
of the day indicated on the visit schedule, except visits 2-5 in which time 
window will be of  3 days. 
 


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Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 7 
X 
X 
 
X  
 
 
 
 
 
 
 
 
 
 
 
 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B and C 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 6 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 


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Study completion 
X 
Complete at any time if study drug is discontinued 
 
 
1 - Bone marrow examination must be performed within 12 months before start of treatment. BMB will be performed for progression/ lymphoma transformation, 
cytopenia evaluation, and for treatment response within 3-6 months after completion of treatment. For any other clinical indication it is at the discretion of the 
investigator whether to perform BMB. 
2 - CT scan when done pre-treatment, must be performed within 12 weeks prior to starting the first dose of study drugs. Post therapy a CT scan will 
be performed for all CLL patients who had an abnormal CT scan prior to treatment or if physical examination is inconclusive - this is an optional 
assessment. 
3 - DAT will be performed at screening and at any clinical suspicion of hemolysis. 
4 - FACS results prior to screening are relevant and no further test is necessary at screening. FACS will also be performed at any clinical 
suspicion of progression/ lymphoma transformation, or for CR confirmation at investigators' discretion.  
5 - At screening and at investigator discretion for hepatitis treatment evaluation. 
6 - After signature on informed consent, but prior to initiation of study medications, only SAEs caused by a protocol-mandated intervention 
will be collected. After first study medication, all SAEs must be reported. 
7 - Dose of medication will be determined according to weight at screening. If body weight has changed at visit 2 or visit 4 by ± 10% or more, 
appropriate adjustment in dose of all medications should be performed.   
 
 
 
 
 
 
 
 


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4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 
mg/ml) diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with ≥ 25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
Hydrocortisone 100-500 mg I.V. (according local common practice) shortly 
before infusion with Rituximab to decrease the rate and severity of acute 
IRR/CRS for these patients. Consider reduced rate of Rituximab for first 
infusion or splitting the dose over two days during the first cycle. In cycle 1 the 
administration of Rituximab may be delayed up to 7 days after the 
administration of the Fludarabine and Cyclophosphomide (FC). Rituximab will 
be given together with FC in cycle 2, 28 days after the administration of FC in 
cycle 1. Severe CRS: may be associated with some features of tumor lysis 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  25 of 67                        
  
 
syndrome e.g. hyperuricaemia, hyperkalaemia, hypocalcaemia, 
hypophosphataemia, acute renal failure, elevated LDH and may be 
associated with acute respiratory failure and death. If severe CRS manifests 
stop infusion immediately and start aggressive symptomatic treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Hydrocortisone 100-500 mg I.V. (according local common practice), if 
necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
 
 
 
 


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Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 
Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate 
Mild/moderate 
> 30 mm Hg 
 
 
 
Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more severe with 
the first infusion. In patients who were unable to tolerate the first infusion, 
cautious reintroduction of rituximab may be tried at the second cycle, at the 
investigator’s discretion. The recommended premedication should be given 
and then the patient carefully re-exposed to a small amount of rituximab (slow 
infusion of 10 mg I.V.) If a severe reaction occurs, the rituximab must be 
permanently discontinued. In such case patient will be treated with FC in the 
next cycles and data will be collected throughout the study period) 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
All infusion bags will be labeled by the study nurse prior to administration and 
the removable part of the labels will be attached to the drug 
administration log, signed and dated by the study nurse. Storage 
conditions for study drug will be described on the medication label. Patients 
will receive the study drug combination for an exposure period of up to 6 
months provided that in the opinion of the investigator the patient is benefiting 
from treatment with this study drug combination, and in the absence of any 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  27 of 67                        
  
 
safety concerns. Treatment will be withheld only in the case of limiting 
toxicities (see below).  
As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 
10 glasses of fluids on the days they receive cyclophosphamide and  urinate 
at minimal ceasing  of bladder distention. 
 
4.3.1.1 DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
log” on study medication.
 
administration
adequate "drug 
 
 
e study medication must be kept current 
" log for th
administration
The "drug 
and should contain the following information:
 
o The identification of the patient (patient number) to whom the 
study medication was administered.  
o Labels of used study drugs - signed and dated by the study 
nurse. 
 
logs must be available for inspection by the 
 
administration
accountability 
All 
will be destructed according to local site guidelines. 
 
Infusion bags
monitor. 
 
 
4.3.1.2 DESTRUCTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT 
 
Used supplies (infusion bags) will be sent for destruction according to the 
site guidelines. The destruction process in the site should be documented. 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade ≥ 3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 


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following cycles. There is no dose reduction for Rituximab in this study, but 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 
• If after three weeks, the grade ≥ 3 cytopenia, NOT RELATED TO CLL BONE 
MARROW INFILTRATION, still prevails, the patient should be removed from the 
protocol with no further study drug administration. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 
• If there is any grade ≥ 3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine and cyclophosphomide are partly (40-60%) excreted by the 
kidneys. If the calculated (see appendix III) or measured creatinine clearance 
is at screening or during treatment reduced to 30-70 mL/min, the fludarabine 
dose should be reduced to 80% and the cyclophosphamide dose will be 
reduced to 75%. Patients with a creatinine clearance below 30 ml/min are 
excluded from the study. Patients who develop renal dysfunction (serum 
creatinine ≥ 1.5 mg/dL or creatinine clearance < 30 ml/min) during treatment 
should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade ≥ 3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade ≤ 2, for 
up to three weeks. In case of grade ≥ 3, non-hematological, non-renal 
toxicity, which in the investigators' opinion is not study drug related, 
dose reduction will be performed upon investigator discretion. In case 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  29 of 67                        
  
 
of grade ≥ 3 non-hematological toxicity, which in the investigators' 
opinion is related to study drugs, all subsequent cycles should then be 
given with a 25% dose reduction of fludarabine and cyclophosphamide. 
• If after three weeks, the grade ≥ 3 non-hematological, non-renal toxicity, 
drug related still persists, the patient should be removed from the protocol. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug 
related in subsequent cycles despite the first 25% dose reduction treatment 
should again be delayed for up to three weeks and the dose of fludarabine 
and cyclophosphamide further reduced to 50% of the initial full dose. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug 
related in subsequent cycles despite 50% dose reduction the patient should 
be removed from the protocol treatment and the study. 
 
4.3.5 Dose modification for Weight Changes 
Dose of medication will be determined according to weight at screening.  
If body weight has changed at visit 2 or visit 4 by ± 10% or more, 
appropriate adjustment in dose of all medications should be performed.   
 
4.3.6 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  
 4.3.7 Blinding                                                                                                         
This is an open label trial. 
 
 
 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 


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Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 
 
4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. Drug accountability & destruction procedures are 
described in sections 4.3.1.1 & 4.3.1.2, accordingly. 


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5. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). ZAP 70 and CD38 are optional. Patients with 
different phenotype than described above can be included, in 
case the pathologist will give a written approval of B-CLL and 
with the approval of the sponsor. 
2. 
Previously untreated B-CLL patients ≥ 65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin ≥ 2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
- Patients with active hepatitis B or HBV surface 
antigen positive. 
- Patients with anti-HBV core antibodies (past infection 
with HBV) but who are negative for HBVsAg  (either 
anti-HBS Ab positive or negative) and are positive for 
HBV-DNA by PCR analysis - are not eligible. 


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7. 
Various concomitant diseases requiring chronic steroid 
administration 
8. 
Active Coomb's positive hemolytic anemia. 
9. 
Prior treatment for CLL 
10. 
 CLL in transformation (Richter syndrome). 
11.    Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix, breast or 
prostate carcinoma) < 2 years prior to the study. 
12. Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
13.    Low compliance. 
14.    Performance status: ECOG performance status ≥3. (see 
appendix II) 
15.   Patients who are mentally or physically unable to comply      
with all aspects of the study. Upon investigator discretion, 
a psycho-geriatric evaluation will be performed for patients 
≥ 80 years old. 
       
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 


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 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in the         
      event of study drug discontinuation) during and at the end of the study       
      period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued and the patient’s participation in the study will 
be discontinued.  
 
5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4). 
 
5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  


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Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients 
who discontinue study treatment should be followed for tumor assessments 
as per standard of care, until disease progression or new cancer therapy is 
initiated.  If patients refuse to return for these visits or are unable to do so, the 
subject should be considered off-study, but a Study Evaluation Completion 
form should be completed. 
 


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6. Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of 
other concurrent investigational drugs is not allowed. The use of blood 
products (irradiated) transfusions, immunoglobulins or erythroid/myeloid 
growth factors are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration is allowed exclusively for patients with autoimmune 
thrombocytopenia or as premedication for Rituximab. 
Premedication: Any patient considered to be at risk of infusion related 
reaction (IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should 
receive:  Appropriate hydration starting 12-24 hours prior to initiating 
treatment, and thereafter until the risk of IRR/TLS is ruled out. Urine 
alkalization is at investigator’s discretion. 


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Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. 
(according local common practice) should be given only if clinically indicated 
(increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended.  
Patients with anti-HBV core antibodies (past infection with HBV) but 
who are negative for HBSAg (either anti-HBVs Ab positive or negative) 
and had negative baseline for HBV-DNA by PCR analysis will be given 
anti-viral prophylaxis during and for at least 6 months after the last 
cycle of treatment.  
For prevention of hepatitis B reactivation that needs antiviral treatment 
(prophylaxis treatment) Lamivudine 100mg/day will be administrated for the 
entire duration of chemotherapy and for the six months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti 
HBcore (+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids, if given (see above) are allowed for no more than 3 consecutive 
days.  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


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7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan for CLL patients with a CT found to be abnormal before therapy 
or alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment, if the above four 
clinical and laboratory results support that CR has been achieved. In some 
cases, it is necessary to postpone BMB until after all the other criteria used 
to define a CR have been satisfied but, this time interval should not 
exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


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were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, 
this time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory 
and physical examination results will be captured on the response forms in 
the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 
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 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 considered related to the medicinal 
[investigational] product.  Pre-existing conditions which worsen during a study 
are to be reported as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An 
adverse event is any undesirable sign, symptom or medical condition 
occurring after starting study treatment, even if the event is not considered to 
be treatment-related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. 
Clinical events occurring before starting study treatment but after signing the 
informed consent form are recorded on the Medical History/Current Medical 
Conditions Case Report Form only if the patient receives study treatment. 
Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms or require therapy, when they are 
recorded on the Adverse Events Case Report Form under the signs, 
symptoms or diagnosis associated with them. 


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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this 
could improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal 
daily activities; treatment or medical intervention is required in 
order to maintain survival. 
Grade 5 
Death  
AE resulting in death  
 
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 


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cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 
As a consequence, for grading of anemia and thrombocytopenia, we plan to 
apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, but for 
grading of neutropenia, the standard NCI-CTC version 3.0 criteria, as given 
below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade 
ANC mm3 § (nadir) 
No change-9% 
0 
≥2,000 
10-24% 
1 
≥1,500 and <2,000 
25-49% 
2 
≥1,000 and <1,500 
50-74% 
3 
≥500 and <1000 
≥75% 
4 
<500 
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 


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Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 
possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of hemolytic 
anemia secondary to fludarabine, study treatment should be promptly 
withdrawn. Full details of the hemolytic anemia should be recorded on the 
adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four 
weeks of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 


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– Reasonable temporal association with drug administration 
– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event 
in which the subject was at immediate risk of death at the time of the 
event; it does not refer to an event which could hypothetically have caused 
a death had it been more severe). 
– required in-patient hospitalization or prolongation of existing 
hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of 
the outcomes listed above 


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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere 
to the full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse 
event if it is clearly consistent with the suspected progression of the 
underlying cancer as defined by RECIST criteria, or other criteria as 
determined by protocol. Hospitalization due solely to the progression of 
underlying malignancy should NOT be reported as a serious adverse event.  
Clinical symptoms of progression may be reported as adverse events if the 
symptom cannot be determined as exclusively due to the progression of the 
underlying malignancy, or does not fit the expected pattern of progression for 
the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that 
the investigator may elect not to perform further disease assessments.  In 
such cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every 
effort should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the 
disease under study, it should be reported as an AE or SAE. 


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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious 
and which occurs during the course of the study (as defined in section 8.2 
above), occurring from the enrollment visit (start of study screening 
procedures), including long term follow-up (LTFU) must be reported to Roche 
within one working day of the investigator becoming aware of the event 
(expedited reporting). The investigator must complete the SAE Reporting 
Form [
] and forward it to the SAE Responsible.  
After signature on informed consent, but prior to initiation of study 
medications, only SAEs caused by a protocol-mandated intervention will 
be collected (e.g., SAEs related to invasive procedures such as biopsies, 
medication washout, or no treatment run-in).  After first study 
medication, all SAEs must be reported.  
 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an 
adverse reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days after the last dose of study medication. 


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This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2.   
 
 
8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.3 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted 
directly from the central laboratory, if applicable.  


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Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 
Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, 
interruption of, discontinuation of, or any other change in a concomitant 
medication, therapy or treatment) 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS and hepatitis B and C serology are 
in fact regarded as current clinical practice for CLL patients, and should 
therefore be collected according to the Visit Schedules (see Figure 1). In case 
of suspected hemolysis - DAT, reticulocyte count, serum haptoglobin, bilirubin 
and LDH are recommended. 
The institution will perform laboratory analyses according to the Visit 
Schedules (see Figure 1). The sponsor must be provided with a copy of the 
laboratory’s certification, and a tabulation of the normal ranges for each 
parameter required. Additionally, if at any time a patient has laboratory 
parameters obtained from a different outside laboratory, the sponsor must be 
provided with a copy of the certification and a tabulation of the normal ranges 
for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 


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appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 
event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  
8.3 
Special tests 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the normal behavior of the disease or 
suspicious for another disease or a different type of lymphoma. 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
 
8.5 
Laboratory examinations 
 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


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8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective local MoH approved product label. 
 
9.   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 


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9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
 
9.2 
Efficacy and Safety evaluation 
 
9.2.1 Efficacy analysis: 
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
95% Confidence Interval (CI) will be calculated to the proportions of 
responders. 
 
Response rate include CR and PR; all other situations (eg. stable disease, 
non response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, 
and documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. The Paired T-test or Signed Rand Test 
for paired observations (as is appropriate) will be applied for analysing the 
changes in the components and total score of the FACIT QOL assessment. 


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The data will be analyzed using the SAS ® version 9.1.3 (SAS Institute, Cary 
North Carolina). 
 
9.3 
Safety Analysis 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/ctca
ev3.pdf 
or v 2.0 for cytopenia, whenever possible. 
All adverse events will be coded according to coding dictionaries (MedDRA 
version 12.1) and presented in tables by system organ class and preferred 
term. 
 In the by-subject analysis, a subject experiencing the same event more than 
once will be counted only once. Adverse events will be defined and 
summarized according to the worst NCI CTC grade. Adverse events leading 
to death or to discontinuation of treatment, events classified as NCI CTCAE 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events 
will be summarized separately. Laboratory data will be graded according to 
NCI CTCAE severity grade. 
 
 
 


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10. Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract 
Research Organization staff following their own internal standard operating 
procedures that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs 
and database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, 
which are returned to the investigational site for resolution.  The signed 
original and resolved Data Query Forms are kept with the CRFs at the 
investigator site, and a copy is sent to the sponsor so the resolutions can be 
entered into the database.  Quality control audits of all key safety and efficacy 
data in the database are made prior to locking the database. 


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11.    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  55 of 67                        
  
 
12.   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement 
that the protocol and informed consent have been approved by the IRB must 
be given to the sponsor before study initiation. The name and occupation of 
the chairman and the members of the IRB must be supplied to the sponsor. 
Any amendments to the protocol, other than administrative ones, must be 
approved by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in 
the study is voluntary and that he/she may withdraw from the study at any 
time and that withdrawal of consent will not affect his/her subsequent medical 
treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a 
copy of the signed document. If the subject cannot read or sign the 
documents, oral presentation may be made or signature given by the 
subject’s legally appointed representative, if witnessed by a person not 
involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent 
has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  


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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  57 of 67                        
  
 
13. Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  58 of 67                        
  
 
14. Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  59 of 67                        
  
 
15.Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other 
active investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator 
nominated by the sponsor and the steering committee at the start of the trial 
would provide any needed signature.  
 
 
 


ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  60 of 67                        
  
 
 
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28) Flinn, I., Neuberg, D., Grever, M. & al, e. (2007) Phase III trial of fludarabine plus 
cyclophosphamide compared with fludarabine for patients with previously untreated 
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798. 
29) Goede, V., Cramer, P., Busch, R., Eichhorst, B., Hallek, M. & GCLLSG, t. (2005) 
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30) Thurmes, P., Call, T., Slager, S., Zent, C., Jenkins, G., Schwager, S., Bowen, D., 
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32) Srinivas S, Yook C, ChangV et al. Prevalence of bone marrow CD20 positivity in 
patients with multi[le myeloma. J Clin Oncol 2001;20: (abstr 2687). 
33) Reff ME,Carner K, Chambers KS et al.  Depletion of B cells in vivo by a chimeric 
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38) Nguyen DT, Amess JA, Doughty H, et al: IDEC-C2B8 anti-CD20 (Rituximab) 
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39) ForanJM, Rohatiner AZ, Cunningham D, et al. European phase II study of Rituximab 
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40) Huhn D, von Schilling C, Wilhelm M, et al: Rituximab therapy of patients with B-
cell chronic lymphocytic leukemia. Blood 2001;98:1326-1331. 
41) Byrd JC, Murphy T, Howard RS, et al. Rituximab Using A Thrice weekly dosing 
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2164. 
42) O'Brien SM, Kantarjian H, Cortes J, et al.  Rituximab dose escalation trial in chronic 
lymphocytic leukemia. J Clin Oncology 2001;19: 2165-2170. 
43) Byrd JC, Peterson, BL, Morrison, VA, Park, K, Jacobson, R, Hoke, E, Vardiman, 
JW, Rai, K , Schiffer, CA, Larson, PA () Randomized Phase II Study of Fludarabine 
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Untreated Patients with B-Cell Chronic Lymphocytic Leukemia: Results from 
CALGB 9712. Blood. 2003;101:6-14. 
44) Sculz H Klein SK, Rehwald U et al/ Phase II study of combined immunotherapy 
using Rituximab and Fludarabine in patients with chronic lymphocytic leukemia. 
Blood 2001; 100: 3115-3120  
45) Byrd JC, Rai K, Peterson BL, et al. Addition of Rituximab to Fludarabine may 
prolong progression-free survival and overall survival in patients with previously 
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analysis of CALGB 9712 and CALGB 9011. Blood. 2005;105:49-53 
46) Hallek M, Chesso BD,  Kantarjian H,et al.Guidelines for the diagnosis and treatment 
of CLL: a report from the IWCLL updating the NCI-WG 1966 guidelines. 
47) Rai K , B.S Bercedis, Peterson L,Appelbaum FR, Kolitz J et al Fludarabine 
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48) Byrd JC, Peterson BL, Morrison VA, et al. Randomized phase 2 study of fludarabine 
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49) Robak T, DmoszynkaA,Solal-Celigny P et al Rituximab plus Fludarabine and 
Cyclophosphamide prolongs progression free survival compared to Fludarabine and 
Cyclophosphamide alone in previously treated chronica lymphocytic leukemia 
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50) Foon KA, Boyiadzis M,Land SR, et al. Chemoimmunotherapy with low dose 
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ML25464 Protocol Version E dated 22 Apr, 2013                                           Page  63 of 67                        
  
 
51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 


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16. Supplements 
 
Appendix I    Response definitions    
 
CR (complete remission) = requires all of the following criteria as assessed at least 3 
months after completion of therapy: 
 
 
 
Absence of clonal lymphocytes in peripheral blood. 
 
Absence of significant lymphadenopathy. (lymph nodes > 1.5 cm in diameter) by 
physical examination. CT is desirable for not palpable lymph nodes. 
 
No hepatomegaly or splenomegaly by physical examination. (Abdominal, pelvix 
and thorax CT for subjects found to be abnormal before therapy or if physical 
examination is inconclusive. 
 
Absence of constitutional symptoms. 
 
Blood counts above the following values: ANC> 1.5 x 109/L
 .  Platelets > 100 
x109/L . Hemoglobin > 11.0 g/dL; untransfused). 
 
Bone marrow aspirate and biopsy should be performed at least 3 months after the 
last treatment and if the above 5 clinical and laboratory results demonstrate that CR 
has been achieved. 
Bone marrow should be analyzed  by FACS/or immunohistochemistry to demonstrate 
marrow free of B-CLL cells. 
In some cases, it is necessary to postpone BMB until after all the other criteria to 
define a CR have been satisfied. However, this time interval should not exceed 6 
months after the last treatment. 
 
 


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Relapse = a patient who has previously achieved CR or PR but after a period of 6 or more 
months, demonstrates evidence of disease progression 
 
Refractory disease = defined as treatment failure or disease progression within 6 months 
from the last antileukemic therapy. 
 
Progression = see above table  under PD. 
 
Progression free survival (PFS) = defined as the time from start of treatment to progression. 
 
Time to next treatment (TNT) = defined as the time from start of treatment to start of 
second-line treatment  
 
 
 
 
 
Appendix II    ECOG Performance status   
 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities. 
Up and about more than 50% of waking hours 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or 
chair 
5 
Dead 
 


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Appendix III calculated creatinine clearance 
  
 
   
 
 
 
 
Appendix IV     Active disease 
At least one of the following criteria should be met: 
1. Evidence of progressive marrow failure as manifested by the development of, 
or worsening of, anemia and/or thrombocytopenia 
2. Massive (ie, > 6 cm below the left costal margin) or progressive or 
symptomatic  splenomegaly. 
3. Massive nodes (ie, > 10 cm in longest diameter) or progressive or 
symptomatic lymphadenopathy. 
4. Progressive lymphocytosis with an increase of more than 50% over a 2-
month period or lymphocyte doubling time of less than 6 months; patients with 
initial blood lymphocyte counts of less than 30X109/L (30 000/μL) may require 
a longer observation period to determine the lymphocyte doubling time. In 
addition, factors contributing to lymphocytosis or lymphadenopathy other than 
CLL (eg, infections) should be excluded. 
5. Autoimmune anemia and/or thrombocytopenia poorly responsive to 
corticosteroides or other standard therapy. 
6. A minimum of any of the following disease-related symptoms must be 
present: a- Unintentional weight loss more than or equal to 10% within the 
previous 6 months. b- Significant fatigue (ie, ECOG PS 2 or worse; cannot 
work or unable to perform usual activities). c- Fevers of greater than 38.00C 
for 2 or more weeks without other evidence of infection. d- Night sweats for 
more than 1 month without evidence of infection. 
 
Appendix V    Binet staging system 
The areas of involvement considered for staging are as follows: 1- Head and neck, 
including the Waldeyer ring. 2- Axillae 3- Groins 4- Palpable spleen 5- Palpable liver. 
Stage A.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and up to 2 of the above 
areas involved. 
Stage B.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and organomegaly 
greater than that defined for stage A (3 or more areas). 
Stage C.  All patients who have Hb less than 10 g/dL and/or a platelets count less than 
100X 109/L, irrespective of organomegaly. 
 
 
GFR (mL/min) = 
(140-age) X weight (Kg) 
Serum cr (mg/dL) X 72 
X  0.85 (for women) 


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Appendix VI    FACIT-QOL 
 
FACIT − Fatigue Scale (Version 4) 
Below is a list of statements that other people with your illness have said are important. By 
circling one (1) number per line, please indicate how true each statement has been for you 
during the past 7 days. 
 
                                                                                                        Not     A little    Some    Quite     Very 
           At all     bit         what      a bit    much 
 
HI7     I feel fatigued 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3  
4 
HI12   I feel weak all over 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
0  
1  
2  
3   
4 
 An1   I feel listless (“washed out") . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  0  
1 
2     
3   
4 
 An2   I feel tired 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  
0  
1   
2     
3  
4 
 An3   I have trouble starting things because I am tired 
. . . . . . . . . .  0   
1  
2 
3   
4 
 An4   I have trouble finishing things because I am tired 
. . . . . . . . . 0   
1 
2   
3  
4 
 An5   I have energy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3   
4 
 An7   I am able to do my usual activities 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
 An8   I need to sleep during the day 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
An12  I am too tired to eat 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2 
3   
4 
An14  I need help doing my usual activities 
. . . . . . . . . . . . . . . . . . . . . 
. . 
0   
1 
2  
3   
4 
An15  I am frustrated by being too tired to do the things 
         I want to do 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
0  
 1  
2  
3   
4 
An16  I have to limit my social activity because I am tired 
. . . . . .   0  
1  
2  
3   
4 
 
 
 
US English 
Copyright 1987, 1997 
 


 
Amendment History of Protocol ML25464 Version F dated 07 May, 2014                                   Page 1 of 2                                       
 
 
AMENDMENT HISTORY FOR PROTOCOL ML25464 (FCR-LITE) 
VERSION F DATED 07 May, 2014 
 
1. Subject: Interim-Analysis 
Reason for change:  It was decided to perform Interim Analysis in order to identify trends of 
response rate and safety in the study. 
 
       Section Synopsis 
            New text:  
Interim Analysis 
Interim Analysis will be conducted on all data received at database until 30 May, 2014. The 
parameters that will be analysed will include:  Primary endpoint - Overall Response rate 
(including CR and PR); Secondary endpoints - Progression Free Survival (PFS), Overall 
survival, rates of treatment related adverse events and assessment of quality of life (FACIT). 
 
              Old text:  
NA. 
 
Section 9.4 Interim Analysis 
              New text:  
Interim Analysis will be conducted on all data received at database until 30 May, 2014. The 
following parameters will be examined in the Interim Analysis: 
Primary endpoint: 
 
Overall Response rate  
Overall response rate will include CR and PR; all other situations (e.g. stable disease, non-
response, progressive disease or death from any cause) will be rated as treatment failure 
and therefore as non-responders. 


 
Amendment History of Protocol ML25464 Version F dated 07 May, 2014                                   Page 2 of 2                                       
 
 
Secondary endpoints: 
 
Progression free survival (PFS) defined as the time elapsed from first day of study drug 
administration to disease progression as defined in the protocol (Appendix I) 
 
Overall survival 
 
Safety of the study drugs especially in relation to: neutropenic fever, Infection rate and 
number of hospitalization days, thrombocytopenia ≥grade 3, neutropenia ≥grade 3 
 
Rates of treatment-related adverse effects 
 
Quality of life – by FACIT (Appendix VI)   
 
Old text: 
NA. 
 




 
ML25464 Protocol Version F dated 07 May, 2014                                           Page  1 of 68                        
  
 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE EFFICACY AND 
SAFETY OF LOW DOSE FLUDARABINE AND CYCLOPHOSPHAMIDE COMBINED WITH 
STANDARD DOSE RITUXIMAB AS PRIMARY THERAPY IN ELDERLY UNTREATED 
PATIENTS (≥65 YEARS OLD) WITH CHRONIC LYMPHOCYTIC LEUKEMIA  
 
 
 
Author:  Prof 
. 
. 
 Israel.   
Co-P.I.:  
 M.D.  
 
 M.D. 
 
 M.D.  
 MHA+M.D.  
 M.D. 
 
Steering committee:  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D . 
 MD.  
 M.D.  
 M.D.   
 M.D.  
 MHA+M.D.  
 M.D.  
 M.D.  
 M.D.  
 M.D.  


 
ML25464 Protocol Version F dated 07 May, 2014                                           Page  2 of 68                        
  
 
 
 
TABLE OF CONTENTS 
 
2. 
BACKGROUND INFORMATION ....................................................................................... 10 
3. 
TRIAL OBJECTIVES AND PURPOSE.............................................................................. 17 
3.1 
PRIMARY OBJECTIVE…… ............................................................................................ 17 
3.2 
SECONDARY OBJECTIVES……..................................................................................... 17 
4. 
TRIAL DESIGN………………………………………………………………………………….18 
4.1 
PRIMARY AND SECONDARY END POINTS………… ......................................................... 18 
4.2 
OVERALL STUDY DESIGN…… ...................................................................................... 18 
4.2.1  VISIT SCHEDULE AND ASSESSMENTS……….. ............................................................... 21 
4.3 
TRIAL TREATMENT….. ................................................................................................. 24 
4.3.1  Investigational therapy…………………….…………………………………………..24 
4.4 
STUDY DRUG INTERRUPTION OR DISCONTINUATION……………. .................................... 29 
4.5 
ACCOUNTABILITY PROCEDURES FOR THE INVESTIGATIONAL PRODUCTS ......................... 30 
5. 
SELECTION AND WITHDRAWAL OF SUBJECTS ......................................................... 31 
5.1 
INCLUSION CRITERIA….. .............................................................................................. 31 
5.2 
EXCLUSION CRITERIA….. ............................................................................................ 31 
5.3 
INTERRUPTION OR DISCONTINUATION OF TREATMENT…………….. ............................... 32 
5.4 
STUDY DISCONTINUATION …………………………………………… ............................. 32 
6. TREATMENT OF SUBJECTS .............................................................................................. 35 
6.1 
TREATMENT REGIMEN….. ............................................................................................ 35 
6.1.1 TREATMENT ASSIGNMENT…….. ................................................................................... 35 
6.2 
CONCOMITANT THERAPY…… ...................................................................................... 35 
6.3 
TREATMENT COMPLIANCE……. .................................................................................... 36 
7. 
ASSESSMENT OF EFFICACY .......................................................................................... 37 
8. 
ASSESSMENT OF SAFETY ............................................................................................. 39 
8.1 
ADVERSE EVENTS ……………… ................................................................................. 39 
8.2 
SERIOUS ADVERSE EVENTS……. ................................................................................. 43 
8.3 
Special tests……………………………… ................................................................. 48 
8.4 
Physical examinations/vital signs……. ................................................................. 48 
8.5 
LABORATORY EXAMINATIONS…….. ............................................................................. 48 
8.6 
PHYSICAL EXAMINATIONS/VITAL SIGNS………… ........................................................... 49 
9.   STATISTICS………………...……………………………………………………………………49 
9.1 
SAMPLE SIZE… ........................................................................................................... 50 
9.2 
EFFICACY AND SAFETY EVALUATION……….. ............................................................... 50 
9.3 
SAFETY ANALYSIS ………………………….................................................................. 52 
9.4 
INTERIM ANALYSIS…………………..……….. ............................................................... 52 
10. QUALITY CONTROL AND QUALITY ASSURANCE ....................................................... 53 
11.    DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .................................................. 54 
11.1   STUDY MONITORING .................................................................................................... 54 


 
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11.2  AUDITS.. .................................................................................................................... 54 
11.3 IRB AND REGULATORY INSPECTIONS……….. ............................................................... 54 
12.   ETHICS………………………………………………………………………………………….55 
12.1    INSTITUTIONAL REVIEW BOARD .................................................................................. 55 
12.2 INFORMED CONSENT….. .............................................................................................. 55 
12.3 DECLARATION OF HELSINKI……. ................................................................................. 56 
13. DATA HANDLING AND RECORD KEEPING ................................................................... 57 
14. FINANCING AND INSURANCE ........................................................................................ 58 
15.PUBLICATION POLICY  ................................................................................................... 59 
       REERENCES……………………………………………………………………………………60 
 
16. SUPPLEMENTS 
 ................................................................................................... 64 
APPENDIX I    RESPONSE DEFINITIONS .................................................................................... 64 
APPENDIX II    ECOG PERFORMANCE STATUS ....................................................................... 65 
APPENDIX III CALCULATED CREATININE CLEARANCE .............................................................. 66 
APPENDIX IV     ACTIVE DISEASE ........................................................................................... 66 
APPENDIX V    BINET STAGING SYSTEM .................................................................................. 66 
APPENDIX VI    FACIT-QOL ................................................................................................ 67 
 


 
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LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase/GPT 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase/SGOT 
ALK PHOSP 
Alkaline Phosphatase 
CBC 
Complete Blood Count 
CLL 
Chronic Lymphatic Leukemia 
CR 
Complete Remission 
CRF 
Case Report/Record Form 
CRO 
Contract Research Organization 
CT 
CY 
Computerized Tomography 
Cyclophosphamide 
FACT-CTC 
Functional Assessment of Cancer Therapy - Common Terminology 
Criteria for cancer Adverse Events 
FACS 
Flow Cytometry (Fluorescence-Activated Cell Sorting) 
DAT 
Direct Coombs Test 
FLU 
Fludarabine 
G-CSF 
Granulocyte-Colony Stimulating Factor 
Hb 
Hemoglobin 
HIV 
Human Immune deficiency Virus 
IEP 
I.V. 
Immuno-ellectrophoresis 
Intra-Venously 
Ig 
Immunoglobulin 
IRB 
IRR 
Institutional Review Board 
Infusion Related Reaction 
LDH 
Lactic Dehydrogenase 
MHO 
Medical Health Organization 
ORR 
Overall Response Rate 
PD 
Progressive Disease 
PET-CT 
Positron Emission Tomography- Computerized Tomography 
PFS 
Progression Free Survival 
P.O. 
Per Os/ by mouth/orally 
PR 
Partial Response 
QOL 
Quality Of Life 
SAE 
TLS 
Serious Adverse Event 
Tumor Lysis Syndrome 
TNT 
Time to Next Treatment 
ULN 
Upper Limit of Normal 


 
ML25464 Protocol Version F dated 07 May, 2014                                           Page  5 of 68                        
  
 
 
 
SYNOPSIS 
 
A PHASE II, MULTICENTER, SINGLE ARM STUDY TO DETERMINE THE    
EFFICACY AND   SAFETY OF LOW DOSE FLUDARABINE AND 
CYCLOPHOSPHAMIDE COMBINED WITH STANDARD DOSE RITUXIMAB AS 
PRIMARY THERAPY IN ELDERLY UNTREATED PATIENTS (≥65 YEARS OLD) 
WITH CHRONIC LYMPHOCYTIC LEUKEMIA 
 
PROTOCOL NUMBER: 
ML25464 
 
DATE PROTOCOL FINAL: 
07 May 2014 
 
STUDY DRUG: 
 
FLUDARABINE, CYCLOPHOSPHAMIDE, RITUXIMAB 
 
INDICATION:  
 
CHRONIC LYMPHOCYTIC LEUKEMIA 
 
STUDY PHASE: 
 
II 
 
     Background and rationale Chronic lymphocytic leukemia (CLL) is characteristically 
diagnosed in the older population with a median age at diagnosis ranging between 65 and 
72 years. Because the prevalence of co morbidity increases with age, concomitant disease 
is often present in this age group. Additional factors which may also  adversely affect 
treatment outcome at standard doses in elderly patients include: altered pharmacokinetics 
and poorer host  tissue tolerance ; changes in the bone marrow hematopoietic reserve and 
microenvironment leading to increased treatment related myelotoxicity and  higher rates of 
treatment related complications such as infections. As a result, elderly patients are often 
excluded from clinical trials or even from routine treatment on the basis of their age and / or 
comorbidity. Furthermore when these patients are treated, the drug doses are often 
markedly reduced in an attempt to avoid causing toxicity and complications. The challenge 
in treating elderly CLL patients relates to finding the correct balance between drug efficacy 
and toxicity and because of this optimal treatment for this group of patients is often hard to 
achieve. 
 
   Study Objectives 
The aim of this study is to evaluate the safety and efficacy (response rate) of a combination 
of low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with standard dose 
Rituximab given as primary treatment for elderly patients with chronic lymphocytic 
leukemia. 
 
   Primary end point:  -Response rate 
 


 
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   Secondary end points: 
- Safety - Special issues: incidence of neutropenic fever, hospitalizations (noo- days),         
 - Thrombocytopenia ≥grade 3, neutropenia ≥grade 3, Infection rate. 
- Progression Free Survival (PFS). 
- QOL 
    STUDY DESIGN: 
This is a multicenter, phase II, single arm study designed to evaluate the efficacy and 
safety of the combination of low dose Fludarabine (FLU) and Cyclophosphamide (CY) 
combined with standard dose Rituximab in elderly previously untreated CLL patients (≥ 65 
years of age). Potential study subjects will sign an informed consent prior to undergoing 
any study related procedure. Number of patients to be enrolled is 40. 
    Treatment plan:  Flu 12.5mg/m2/d will be given intravenously (I.V.) for days 1-3 every 
28 days, for a total of 6 cycles. 
CY will be given I.V. at the dose of 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. 
Rituximab will be given before chemotherapy. In cycle1:  375 mg/m2  I.V.  on day 0, cycles 
2-6: 500 mg/m2 I.V. on day 1 every 28 days. 
Dose reduction or delays are recommended in case of grade ≥3 (NCI-CTC) adverse 
events. 
This study consists of 3 periods for each study subject: Pre-treatment, Treatment and 
Follow up. 
Pre-treatment period: patients will undergo screening for protocol eligibility within 28 days 
(4 weeks) of recruitment. 
Subjects who meet all the inclusion criteria and have signed an approved informed consent 
will be enrolled. 
Treatment period FLU 12.5mg/m2/d  I.V. will be given on days 1-3 every 28 days, for a total 
of 6 cycles. CY will be given (I.V.) 150 mg/ m2/d on days 1-3 every 28 days, for a total of 6 
cycles. Rituximab  given before chemotherapy cycle 1:  375 mg/m2  intravenously on day 0, 
cycles 2-6:  500 mg/m2  I.V.  on day 1 every 28 days.  
Premedication: antihistamines (e.g. 2 mg clemastin or promethazine 25 mg i.v.) and 
paracetamol (500-1000 mg orally) 30 min before first infusion of Rituximab, and thereafter 
only if clinically indicated. Hydrocortisone 100-500 mg I.V. (according with local common 
practice) only if clinically indicated. 
Dose reduction or delay in case of drug induced hematological toxicity grade ≥ 3 level. 
During the treatment period, all patients will attend twice a month in the first 2 months and 
thereafter periodic monthly study center visits in order to assess the safety and efficacy of 
the treatment. 
Complete blood count will be performed on day 1 and 14 of each of the first two cycles, 
and on day 1 in the other 4 cycles, or more frequently at the investigators discretion. 
Bone marrow aspiration and biopsy and CT scan (optional) will be performed within 3-to 6 
months after the completion of the treatment period. 




 
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- Use of other investigational agents or participation in any other clinical trials < 30 days 
prior to the study. 
- Low compliance. 
- Performance status: ECOG performance status ≥3. 
- Patients who mentally or physically are unable to comply with all aspects of the study. 
 
Assessments: 
    Efficacy  
      The following evaluations will be done to record the efficacy of the treatment regimen: 
- Assessment of disease response (revised International Response Criteria:   updated NCI-
     IWG 2008).[46].  
- Date of documentation of disease progression. 
- Bone marrow biopsy examination 
- Peripheral blood immunophenotyping by FACS. 
- Changes in ANC, Hb levels and platelets counts from baseline blood counts and 
those          done during the study period. 
- Chest, abdominal and pelvic computerized tomography 
- Physical examination for lymphadenopathy and hepato-splenomegaly 
    Safety 
The following evaluations will be recorded to assess the safety of the regimen: 
- Complete physical examination including vital signs. 
- Clinical laboratory evaluations (hematology, biochemistry) 
- Concomitant medication and procedures 
- Adverse events 
- Health outcomes assessment (any extra medical appointment)  
 
    Efficacy analysis: 
Primary efficacy will be determined by objective overall response rate. Exact tests for 
assessing these will be used to compare objective overall response rates. Kaplan Meier 
procedure will be used to characterize the duration of response for PFS and TNT. 
Summary statistics (standard deviation, mean, median, minimum and maximum) will be 
provided for the relevant variables 
 Safety Analysis: 
Data from all subjects who receive any study drug will be included in the safety analyses. 
The severity of the toxicities will be graded according to the NCI CTC v3 or v2- for 
cytopenia, whenever possible. In the by-subject analysis, a subject experiencing the same 
event more than once will be counted only once. 
Adverse events will be defined and summarized by the worst NCI CTC grade. Adverse 
events leading to death or to discontinuation of treatment, events classified as NCI CTC 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events will be 
summarized separately. Laboratory data will be graded according to NCI CTC severity 
grade. 
 


 
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Interim Analysis 
Interim Analysis will be conducted on all data received at database until 30 May, 
2014. The parameters that will be analysed will include:  Primary endpoint - Overall 
Response rate (including CR and PR); Secondary endpoints – Progression Free 
Survival (PFS), Overall survival, rates of treatment related adverse events and 
assessment of quality of life (FACIT). 
 
STUDY DURATION: five years                                        TOTAL SAMPLE SIZE: 40


 
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Background Information 
 
Chronic lymphocytic leukemia (CLL) is characteristically diagnosed in older 
people with a median age at diagnosis ranging between 65 and 72 years. 
Because the prevalence of co morbidity increases with age, concomitant 
disease is often evident in this age group. Goede et al [29] reported that 
increasing numbers of more severe concomitant comorbid illnesses are 
associated with a shortened survival in patients with CLL. Most recently 
Thurmes and colleagues [1] have shown that these comorbid conditions are in 
fact less important than both the age of the patient and the disease stage, in 
predicting prognosis in untreated patients. 
Additional factors which may also  adversely affect treatment outcome in 
elderly patients include: altered pharmacokinetics and poorer host  tissue 
tolerance ; changes in bone marrow hematopoietic reserve and 
microenvironment which may lead to increased treatment related 
myelotoxicity and  higher rates complications such as infections [21,26]. As a 
result, elderly patients are often excluded from clinical trials or even from 
routine treatment at standard doses of drugs, on the basis of their age and / or 
comorbidity and when treated the drug doses are often markedly reduced 
when given.  
The basic challenge in treating elderly CLL patients appears to be related to 
finding the correct balance between treatment efficacy and drug toxicity and 
because of this, optimal treatment for older patients is hard to achieve and 
remains an open question and topic of debate. 
 
Purine analogues drugs which inhibit DNA synthesis are very effective in CLL 
and fludarabine, cladribine and pentostatin have all been used effectively in 
the treatment of CLL [14]. Fludarabine is the most extensively studied purine 
analogue in CLL and is available in tablet form as well as for intravenous use. 
When used in combination with cyclophosphamide, fludarabine has been 
shown to be more effective than when used alone. [13,14,27,28]. In this respect 
the U.K. MRC LRF CLL4 trial  reported in 2007 [11]  compared therapy with 
chlorambucil alone vs fludarabine vs fludarabine (F) alone  + 
cyclophosphamide (FC) in 777 newly diagnosed CLL patients, and showed  


 
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that  FC  achieved   superior response rates and  better  progression-free 
survival for all CLL patients  . Because of this, FC was proposed as the gold 
standard treatment of all CLL patients irrespective of age [11]. Similar results 
were published by the German CLL Study Group and the North American 
Intergroup [14]. 
However although Fludarabine - based regimes are most efficacious, they 
also appear to be more toxic, inducing more prolonged myelosuppression with 
more infections.  
Pollizzotto et al [15] investigated the influence of increasing age on the ability to 
deliver fludarabine based regimens as well as the toxicity obtained thereafter, 
in patients with indolent lymphoproliferative disorders. They reported a 
gradual increase in toxicity with advancing age especially in patients age ≥ 70 
years but still concluded that regimens were generally well tolerated and could 
be delivered safely to older patients who had a good performance status (PS). 
They noted a modestly increased degree of myelosuppression but no 
increase in the incidence of severe infectious complications or treatment-
related mortality. 
 
Table 1 
Journal  
Disease 
status 
Oral 
Fludarabine 
dose 
Oral 
Cyclophosphamide 
dose 
Patients 
age 
OR 
CR 
PR 
Hematology 
2004 (16) 
Mostly 
relapsed 
refractory 
CLPD-28 
Patients 
CLL-9 p 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days , 4 
courses 
61-85 
Median 
73.5 
NHL-
94% 
CLL- 
100% 
NHL-
35% 
CLL-
0% 
NHL-
59% 
CLL-
100% 
BJH 2007 (17) 
Untreated 
25 
patients 
SLL-8 
25mg/m2 
(total 40 mg) 
X 4 days 
150mg/m2 
X 4 days 
Every 28 days ; 
4 courses 
66-85 
Med 74 
All-
84% 
SLL-
7/8 
All-
40% 
SLL-
3/8 
All-
44% 
SLL-
4/8 


 
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CLL4 
(11) 
Untreated 
(196) 
24mg/m2 
X5 days 
150mg/m2 
X 5 days 
Every 28 dX6 
30% 
above 
age 70 
94% 
54% 
40% 
 
2.1 
Rituximab 
Since the introduction of Rituximab (Rituxan™, IDEC) (FDA Approval Letter 
Nov. 26, 1997) in the USA and shortly thereafter in Europe in 1998 
(MabThera™ (Hoffmann-LaRoche AG) for use in the treatment of CLL and 
indolent non-Hodgkins' lymphoma (NHL), it has been used extensively in the 
treatment of indolent and aggressive lymphoma, both as a single agent or 
more often in combination with chemotherapy. Today Rituximab is already 
being used to treat a variety of autoimmune disorders and by now has also 
been accepted as the model monoclonal antibody for the treatment of cancer.  
Rituximab is a chimeric mouse variable heavy and light chains (IDEC 2B8) 
with a human IgG1 constant kappa antibody (C2B8) that reacts specifically 
with the CD20 antigen found on the surface of malignant and normal B cells 
and established B-cell lines [31,33].  The antigen is expressed at lower levels on 
chronic lymphocytic leukemia (CLL) and plasma cells [31]. CD20 is not shed 
from the surface of CD20+ cells after antibody binding and it is not 
internalized or downregulated [34].  Compared with its murine counterpart, 
Rituximab has a longer half-life in humans, interacts with human effector cells 
[34, 35], and is less immunogenic [36]. 
 
Reduced FC doses 
 
There are only a few published reports (including relatively small numbers of 
CLL/SLL patients which describe the results of an FC regimen in elderly CLL 
patients-(≥ 70 years). These are listed in Table1. 
 
 
 
 
 


 
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2.2 
Use of Rituximab and Combination of Rituximab and Fludarabine 
in CLL 
 
Although initial responses to single agent treatment with Rituximab were 
low and partial responses and not complete remissions, interest continued in 
the use of this agent in CLL [37,39,40].  The original studies employed 375 
mg/m2 of Rituximab once a week for four weeks.  Subsequent studies 
suggested using this dose three times a week for four weeks for a total of 12 
doses instead of 4 doses which resulted in better overall responses [41].  Dose 
limiting toxicities of Rituximab have not been demonstrated perhaps due to 
the cost of the drug.  In this respect it should be noted that in the initial studies 
using Rituximab to treat follicular NHL, responses were much higher than in 
CLL.  This was attributed to the lower level of CD20 expression on CLL 
lymphocytes and the presence of circulating CD20 antigen.  These 
differences were partially overcome when either the dose of Rituximab was 
increased or the frequency of the standard dose of 375 mg/m2 was increased 
[41, 44].  
 
 After establishing the safety and  efficacy of standard dose Rituximab 
375 mg/m2 three times  a week  for four weeks for a total of twelve doses, 
Byrd et al went on, to compare sequential and concurrent therapy with RF [43].   
The concurrent group was therefore treated with 11 doses of Rituximab while 
the sequential cohort only received four doses. This was a randomized phase 
II trial of concurrent versus sequential Fludarabine and Rituximab with 51 and 
53 patients per arm, respectively. The overall response rate in the concurrent 
arm was 90%, including CR in 47%while in the sequential arm the overall 
response rate was 77%, with CR in 28%. The disease-free and overall 
median survival has yet to be reached yet, but will be in excess of 23 months 
[44]. Three major side effects were observed: infusion related toxicity, 
myelosuppression, and infections.  Infusion related toxicity were greatest in 
concurrent treated patients (20%) and almost not existent in the sequentially 
treated patients.  In a phase II study, the German CLL Study Group 
(GCLLSG) [44] reported the treatment of 20 untreated and 11 relapsed CLL 
patients. Treatment consisted of Fludarabine administered at standard doses 
(25mg/m2/d; days 1-5, 29-33, 57-61, 85-89) and Rituximab (375mg/m2/d) 


 
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given on days 57, 85.  The overall response rate (CR and PR) was 87% with 
a CR/CRu of 33%. The median duration of response was 75 weeks. 
Severe anemia (grade III/IV) was observed in 10% of patients, neutropenia in 
42%, and thrombocytopenia in 9%, respectively. The most frequent non-
hematologic side effects were infections (52%) and infusion-related 
symptoms.  The majority of infections were respiratory and herpes virus 
infections. 
A retrospective comparative analysis of the CALGB 9712 [47] (Rituximab 
plus Fludarabine) [48] and the CALGB 9011 (Fludarabine only) studies 
demonstrated that the addition of Rituximab to Fludarabine resulted in a 
significantly better 2 years progression free survival and overall survival 
compared to patients treated with Fludarabine alone (67% Vs 45% and 93% 
Vs 81%, respectively) and in both treatment approaches the infectious toxicity 
was similar [45]. 
The MD Anderson Cancer Center group reported a single arm study that 
utilized the combination of Rituximab, Fludarabine and Cyclophosphamide 
(FCR) in untreated and in relapsed and refractory CLL patients (224 and 177 
patients, respectively) [24, 25]. In the untreated patients the overall response rate 
was 95% with a CR rate of 70%, a nodular PR rate of 10% and a PR rate of 
15%.  Although, during the follow-up period the time to treatment was not 
reached, a calculated analysis showed that 69% of patients were projected to 
relapse at 4 years. The major toxicities were myelosupression, predominantly 
of grade 3 and 4, neutropenia (in 52% of all courses) and infections. 
 In the relapsed and refractory patients the overall response was 73% with 
25% CR, 16% nodular PR and 32% PR and a third of the complete 
responders achieved molecular remission. The median time to progression in 
responding patients was 28 months with an overall median survival time of 42 
months. About 46% of the patients completed all six intended courses and 
myelosupression was the major cause for discontinuing treatment (66% and 
18% grade 3-4 neutropenia and thrombocytopenia, respectively) with 16 % of 
the patients having major infection.  
Recently, two pivotal phase III studies (CLL8 and REACH) [49,50] evaluated 6 
cycles of rituximab (375mg/m2 on cycle-1 and 500mg/m2 on cycle 2-6) plus 


 
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fludarabine (25mg/m2 d1-3) and cyclophosphamide (250mg/m2 d1-3) 
chemotherapy compared with 6 cycles of fludarabine and cyclophosphamide 
alone. The primary endpoint of both studies was progression-free survival. 
Secondary endpoints for both studies included overall survival, event-free 
survival, duration of response, response rate and complete response. CLL8 
involved 817 patients with previously untreated (first-line) CLL and good 
physical fitness. With a median observation time of 37.7 months, statistically 
significant differences were observed in OS between the two treatment arms. 
The OS rate was 84.1% in the FCR arm versus 79 % in the FC arm (p=0.01). 
In both arms, the median OS has still not been reached. Patients who 
received rituximab together with chemotherapy had a median progression free 
survival (PFS) of 51.8 months compared to 32.3 months for those who 
received chemotherapy alone. (hazard ratio 0.56; p < 0.001). The overall 
response rate in patients receiving rituximab plus chemotherapy as first-line 
therapy was 95.1% vs. 88.4% in those receiving chemotherapy alone and with 
more complete remissions in the FCR arm (44.1 vs 21.8%; p<0.001). Severe 
(grade 3 or greater) adverse events that occurred more often in the rituximab 
arm included haematologic toxicity (56% vs. 39%), neutropenia (34% vs. 21%) 
and leukocytopenia (24% vs. 12%).  
The REACH study[49] involved 552 patients with previously treated CLL 
(second line therapy). Patients who received rituximab plus chemotherapy 
had a median PFS of 30.6 months compared to 20.6 months for those who 
received chemotherapy alone (hazard ratio 0.65; p=0.0001).  The overall 
response rate in the Rituximab-containing arm was 70% vs. 58% in those 
receiving chemotherapy alone without Rituximab. Grade 3 or greater events 
such as neutropenia (42% vs. 40%), febrile neutropenia (12% vs. 12%) and 
neoplasms (7% vs. 3%) occurred more often in the rituximab plus 
chemotherapy arm. Based on the CLL8 and REACH results the FDA 
approved the use of rituximab as first- and second-line treatment of CLL. In 
Europe, Rituximab is also approved for treatment of first and relapsing CLL 
patients. 


 
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In the light of the above literature, the combined use of Rituximab and 
Fludarabine and cyclophosphamide (FCR) is currently regarded as the gold 
standard and backbone treatment for physically fit patients with CLL. 
2.3 
Fludarabine Cyclophosphamide Rituximab (FCR) regimens for 
elderly patients with CLL 
 Due to major concerns of myleotoxicity and infection complications, this 
chemo-immunotherapy combination regimen cannot be applied safely to all 
elderly CLL patients.  To address this topic efforts are being made to establish 
novel FCR-based protocol that will be useful for the average elderly CLL 
patient. In this regard, Foon and colleagues [50] reported a phase II single arm 
study of reduced dosages of Fludarabine and Cyclophosphamide (FCR-lite).  
Fifty untreated CLL patients were treated with 6 cycles of Fludarabine 
(20mg/m2) and Cyclophosphamide (150mg/mg2) combined with high–dose 
Rituximab (500mg/m2) given every other week during induction and later as 
maintenance every 3 months for two years. The OR and CR rates were 100% 
and 79%, respectively. Median duration of complete response was 22.3 
months (range, 5.2 to 42.5 months) and none of the complete responders 
have relapsed. Grade 3/4 neutropenia was noted in 13% of the cycles of 
therapy. Another approach to reduce toxicity was to use sequential therapy 
with fludarabine (25 mg/m2 on days 1 through 5 for 6 cycles) followed by 
consolidation with Cyclophosphamide (3,000 mg/m2 administered every 3 
weeks for three cycles) and then by Rituximab 375 mg/m2 for four cycles 
(F C
R). [51]  In 36 previously untreated CLL patients an overall response of 
89% was achieved including 61% CRs. 33% achieved a molecular CR (PCR 
negative) and achieving molecular CRs had an excellent prognosis with a 
plateau in the response duration curve, and 90% remain in clinical CR at 5 
years. For the entire group, 5-year survival rate is 71% compared with a rate 
of 48% with the prior F
C regimen (not significant P = .10).  
 


 
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2. 
Trial Objectives and Purpose 
 
The aim of this study is to evaluate the safety and efficacy of a combination of 
low dose Fludarabine (FLU) and Cyclophosphamide (CY) combined with 
standard dose Rituximab given as primary treatment for elderly patients with 
chronic lymphocytic leukemia. 
The purpose of the study is to determine whether a lower dose FC combined 
with standard dose Rituximab regimen in elderly CLL patients is as effective 
as the standard FCR dose, given in most studies until now and at the same 
time to assess if it is indeed less toxic.  
 
3.1 
Primary Objective 
To evaluate the efficacy (Response Rate) of the combination of lower dose 
Fludarabine 12.5 mg m2/d given intravenously for three days and 
Cyclophosphamide 150 mg/d given intravenously for three days every 28 
days, combined with standard dose Rituximab (375mg/ m2 in cycle 1 and 
500 mg/m2  in cycles 2-6) for a total of 6 cycles.  
. 
3.2 
Secondary Objectives 
1-    Safety of the combination drugs given in the study population, especially 
in relation to: neutropenic fever, Infection rate, number of hospitalization days, 
thrombocytopenia ≥grade 3, neutropenia ≥ grade 3. 
2-       Progression Free Survival (PFS).  
3-        Quality Of Life (FACIT) 


 
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3. 
Trial Design                                                                                                              
 
4.1 
Primary and secondary end points 
Primary End Point 
Overall response rate (ORR) (CR and PR) as defined in the protocol (see 
appendix I)  
4.1.1 Secondary End Points 
1-   Safety of the study drugs especially in relation to: neutropenic fever, 
Infection rate and number of hospitalization days,  
thrombocytopenia ≥grade 3, neutropenia ≥grade 3. 
2-     Progression free survival (PFS) defined as the time elapsed from first 
day of study drug administration to disease progression as defined in the 
protocol (see appendix I) 
3-     QOL(see appendix VI) 
 
4.2 
Overall study design 
This is a national, multicenter, phase II, single arm (not controlled), open label 
clinical trial to evaluate the efficacy and safety of the combination of low dose 
Flu + Cy combined with standard dose Rituximab Flu dosage will be given at 
12.5mg/m2/d given I.V. together with CY150 mg/m2/d given I.V. for three days 
every 28 days. Rituximab will be given before chemotherapy 
cycle 1:  375 mg/m2  I.V. on day 0 and in cycles 2-6: 500 mg/m2 I.V. on day 1 
in previously untreated CLL patients who are more than 65 years of age. 
Please note: All medication dosages will be rounded up to the nearest dosage 
according to the medical center routine administration procedures. 
 
 Patients will be treated every 28 days for up to 6 cycles. Potential study 
subjects will sign an informed consent form prior to undergoing any study 
related procedure. In general, study medications should be continued until 
disease progression or drug intolerance but no more than 6 cycles. Treatment 
choices after completion of the study are at the investigators' discretion.  
Up to 40 patients are planned to be enrolled during a two year period. 


 
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This study consists of 3 periods for each study subject: A pre-treatment 
period, the treatment period and a follow up period.  
 
Pre-treatment period:  
Patients will undergo screening for protocol eligibility within 28 days (4 weeks) 
of recruitment. 
Subjects who meet all the inclusion criteria and who have signed an approved 
informed consent will be enrolled. 
Written informed consent must be obtained before any study - specific 
medical procedures are performed which include laboratory screening 
assessments and physical examination as well as documentation of vital 
signs. If the hematology and/or biochemistry evaluations have been 
performed within 14 days of the first dose of study drug as part of the 
screening evaluation, they need not be repeated, and the data may be used 
as the Day 1 values. Bone marrow biopsy (FISH whenever possible) must 
have been performed within 12 months of starting the first dose of the study 
drugs. 
CT scan when done, must be performed within 12 weeks prior to starting the 
first dose of study drugs.     
 
Treatment period 
Includes 6 months of combination treatment with low dose Fludarabine and 
Cyclophosphamide combined with standard dose of Rituximab. Flu dosage 
will be given at 12.5mg/m2/d given I.V. together with CY150 mg/m2/d I.V. for 
three days every 28 days. Rituximab given before chemotherapy cycle 1:  375 
mg/m2 I.V. on day 0 and in cycles 2-6: 500 mg/m2 intravenously on day 1 
every 28 days. 
Premedication: antihistamines (e.g. 2mg clemastin or promethazine 25mg 
I.V.) and paracetamol (500-1,000 mg orally) 30 minutes before first infusion of 
Rituximab, and thereafter only if clinically indicated. Hydrocortisone 100 -
500mg I.V.(according with local common practice only if clinically indicated. 
In the event of grade ≥ 3 hematological toxicity which in the investigators' 
opinion, is study drugs related, the administration of the next cycle should be 
delayed but not for more than 3 weeks and drug dose reduction of 25% of 


 
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both CY and F is recommended. Two dose reductions are permitted (FLU and 
CY Dose modification page 29). In cases where the delay period has been 
terminated but grade 3-4 toxicity persists, the patient should be removed from 
the protocol with no further study drug administration. 
 
During the treatment period, all patients will attend periodic twice a month in 
the first 2 months and thereafter monthly study- center visits in order to 
assess safety and efficacy of the treatment. 
Complete blood counts will be performed on day 1 and 14 of the first two 
cycles. In the next 4 cycles- on day 1 of each cycle, or more frequently at the 
investigators' discretion. 
 Bone marrow biopsy and aspiration examination will be performed before the 
start of treatment, for response documentation (3 to 6 months after the 
completion of treatment), for evaluation of cytopenias (disease or treatment 
related) and for any other clinical indication at the discretion of the 
investigators.  
Supportive care including blood transfusions or administration of growth 
factors G-CSF or erythropoietin is permitted at the investigators' discretion 
throughout all study periods. 
Follow up period 
During the follow up period, of 30 months after the completion of the study 
drugs administration, all patients will be assessed every 3 months for 
evidence of progression and documentation of survival at clinic visits. 
Complete blood count will be performed every 3 months, or more frequently at 
the investigators' discretion. 
Bone marrow examination, peripheral blood immunophenotyping (FACS), 
abdominal, pelvic and chest CT will be performed 3 to 6 months after the 
completion of the treatment regimen, at clinical progression and at any other 
time according to the investigators' discretion. 
In the event of no response (no CR nor PR) in > 5 of the initial 10 subjects 
enrolled into the study, Fludarabine dosage will be increased for all the next 


 
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subjects enrolled into the study and will be given at the dose of 15mg/m2/d 
given I.V. 
In the event of no response after the above increment in > 5 of the next 10 
subjects who received the increased dosages, the study will be terminated 
and declared inadequate and inefficient. If response is evident in ≥ 5 of the 10 
patients, the same dosages will be continued throughout the study until its 
completion. 
All further treatment decisions after completion of the study are at the 
discretion of the investigators.   
  
4.2.1 
Visit schedule and assessments 
Visit schedule 
Patient must be followed at the study center according to the visit schedule 
and assessments outlined in Figure 1.  
All routine assessments must be performed within a time window of  7 days 
of the day indicated on the visit schedule, except visits 2-5 in which time 
window will be of  3 days. 
 


 
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Figure 1:   Visit schedule and assessments 
Week 
-4 to 0 
1 
3 
5 
7 
9 
13 
17 
21 
33 
45 
57 
69 
81 
93-153 
every 12 weeks 
EOS 
Visit No. 
1 
Screening 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15-21 
22 
Study period 
preTx 
Treatment Period 
Follow up period 
Inc. /Excl. criteria 
X   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Relevant medical history/conditions 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BMB 1 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 7 
X 
X 
 
X  
 
 
 
 
 
 
 
 
 
 
 
 
CBC  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Beta-2 micro glob  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IEP,  Ig level, 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
DAT 3 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
FACS 4 
X 4 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
Hepatitis B and C 5 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging - (CT) 2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
QOL – FACIT 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
Treatment dosage 
 
X 
 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
Adverse Events 
X 6 
Ongoing data capture and up to 30 days after completion or discontinuation of the study 
Concomitant medications 
X 
Ongoing data capture 
Comments 
X 
Ongoing data capture 


 
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Study completion 
X 
Complete at any time if study drug is discontinued 
 
 
1 - Bone marrow examination must be performed within 12 months before start of treatment. BMB will be performed for progression/ lymphoma transformation, 
cytopenia evaluation, and for treatment response within 3-6 months after completion of treatment. For any other clinical indication it is at the discretion of the 
investigator whether to perform BMB. 
2 - CT scan when done pre-treatment, must be performed within 12 weeks prior to starting the first dose of study drugs. Post therapy a CT scan will 
be performed for all CLL patients who had an abnormal CT scan prior to treatment or if physical examination is inconclusive - this is an optional 
assessment. 
3 - DAT will be performed at screening and at any clinical suspicion of hemolysis. 
4 - FACS results prior to screening are relevant and no further test is necessary at screening. FACS will also be performed at any clinical suspicion of 
progression/ lymphoma transformation, or for CR confirmation at investigators' discretion.  
5 - At screening and at investigator discretion for hepatitis treatment evaluation. 
6 - After signature on informed consent, but prior to initiation of study medications, only SAEs caused by a protocol-mandated intervention will be 
collected. After first study medication, all SAEs must be reported. 
7 - Dose of medication will be determined according to weight at screening. If body weight has changed at visit 2 or visit 4 by ± 10% or more, 
appropriate adjustment in dose of all medications should be performed.   
 
 
 
 
 
 
 
 


 
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4.3 
Trial treatment 
4.3.1 
 Investigational therapy  
Fludarabine is supplied to the study investigators by the Medical Health 
Organization (MHO) as routine first line treatment in all CLL patients. 
Fludarabine is supplied as 10 mg tablets packaged in blister packs, or as 50 
mg/vial, as lyophilized powder that has to be dissolved in 2 Ml of water for 
injection, than diluted in 100 ml of saline (0/9%) given in 30 minutes.  
Cyclophosphamide is supplied to the study investigators by the MHO as a 
routine first line treatment in CLL patients. Cyclophosphamide (Endoxan) is 
supplied as 50 mg tablets packed in blister packs or as 500 mg/vial (24 
mg/ml) diluted in 100 ml of saline (0/9%) given in 30 minutes. 
Rituximab is supplied to the study investigators by the MHO as a routine first 
line treatment in CLL patients. Rituximab (Mabthera) is supplied as 100mg of 
rituximab in 10ml (10mg/ml) pack of 2 vials or 500mg of rituximab in 50ml 
(10mg/ml) pack of 1 vial. The antibody should be diluted into a final volume of 
normal saline or 5% D-glucose in water to allow for a maximal concentration 
of 4 mg/ml. Rituximab should be administrated before FC chemotherapy. 
First Infusion: Recommended initial rate is 50mg/hr; after the first 30 minutes 
increase by 50mg/hr every 30 minutes to maximum of 400 mg/hr. Subsequent 
Infusions: Initial rate 100mg/hr; increase by 100mg/hr every 30 minutes to a  
maximum of 400mg/hr 
Use extreme caution and closely monitor first infusion when treating patients 
with ≥ 25x10
9/l circulating malignant cells or high tumor burden (higher risk of 
severe cytokine release syndrome (CRS). It is recommended to administer 
Hydrocortisone 100-500 mg I.V. (according local common practice) shortly 
before infusion with Rituximab to decrease the rate and severity of acute 
IRR/CRS for these patients. Consider reduced rate of Rituximab for first 
infusion or splitting the dose over two days during the first cycle. In cycle 1 the 
administration of Rituximab may be delayed up to 7 days after the 
administration of the Fludarabine and Cyclophosphomide (FC). Rituximab will 
be given together with FC in cycle 2, 28 days after the administration of FC in 
cycle 1. Severe CRS: may be associated with some features of tumor lysis 


 
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syndrome e.g. hyperuricaemia, hyperkalaemia, hypocalcaemia, 
hypophosphataemia, acute renal failure, elevated LDH and may be 
associated with acute respiratory failure and death. If severe CRS manifests 
stop infusion immediately and start aggressive symptomatic treatment. 
If the first dose of rituximab is well tolerated, the starting flow rate for 
administration of the second and subsequent infusions will be 100 mg/hour 
and then increased gradually by 100 mg/hour intervals not to exceed 400 
mg/hour. 
If any grade 1 or 2 infusion related reactions occur during an infusion, the 
infusion should be slowed or interrupted (at the discretion of the Investigator) 
and supportive treatment instituted. The infusion rate can be increased or 
restarted on resolution of the symptoms. 
If grade 3 or 4 infusion related reactions occur during an infusion, the infusion 
has to be discontinued immediately and not restarted until resolution of the 
symptoms. Treatment can be reinitiated (at half the original infusion rate) at 
the discretion of the Investigator, but if the same adverse event appears again 
with the same severity, treatment must be permanently discontinued. 
Should bronchospasm or dyspnea occur in the patient during the infusion, the 
infusion should be stopped immediately. Medication such as anti-histamines 
or steroids should be given for symptomatic relief. The infusion should not be 
re-started until symptoms have resolved completely and should be given at 
half the original infusion rate. 
In the event of infusion related reactions to rituximab: 
• Stop rituximab infusion, treat symptoms aggressively if necessary 
• NaCl 0.9 % i.v., if necessary 
• Hydrocortisone 100-500 mg I.V. (according local common practice), if 
necessary 
• Pethidine i.v. if necessary 
• Bronchodilators/antihistamines if necessary 
• If side effects occur stop Rituximab-infusion, re-try the next day 
 
 
 
 


 
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Table 2: Reduction of Infusion Rate 
Infusion rate 
Fever 
Rigors 
Mucosal 
congestion, edema 
Drop in 
systolic blood 
Decrease to ½ if 
any of these 
events are seen 
> 38.5°C 
Mild/moderate 
Mild/moderate 
> 30 mm Hg 
 
 
 
Following the infusion the I.V. line should be kept open for medications as 
needed. If there are no complications, the line may be discontinued after one 
hour of observation. If complications occur during the rituximab infusion, the 
patient should be observed for 2 hours after the completion of the infusion. 
Infusion reactions to rituximab tend to be more common and more severe with 
the first infusion. In patients who were unable to tolerate the first infusion, 
cautious reintroduction of rituximab may be tried at the second cycle, at the 
investigator’s discretion. The recommended premedication should be given 
and then the patient carefully re-exposed to a small amount of rituximab (slow 
infusion of 10 mg I.V.) If a severe reaction occurs, the rituximab must be 
permanently discontinued. In such case patient will be treated with FC in the 
next cycles and data will be collected throughout the study period) 
 If no severe reaction occurs after 30 minutes, the full dose of rituximab 
infusion should be given. 
 
Labels will comply with the legal requirements in Israel and be printed in 
Hebrew and English. All study drugs containing infusion bags will be labeled. 
All infusion bags will be labeled by the study nurse prior to administration and 
the removable part of the labels will be attached to the drug administration 
log, signed and dated by the study nurse. Storage conditions for study drug 
will be described on the medication label. Patients will receive the study drug 
combination for an exposure period of up to 6 months provided that in the 
opinion of the investigator the patient is benefiting from treatment with this 
study drug combination, and in the absence of any safety concerns. 
Treatment will be withheld only in the case of limiting toxicities (see below).  


 
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As administration of cyclophosphamide may cause hemorrhagic cystitis and 
even urinary bladder malignancy, patients will be instructed to drink at least 
10 glasses of fluids on the days they receive cyclophosphamide and  urinate 
at minimal ceasing  of bladder distention. 
 
4.3.1.1 DRUG ACCOUNTABILITY 
 
Accountability and patient compliance will be assessed by maintaining 
adequate "drug administration log” on study medication.
 
 
The "drug administration" log for the study medication must be kept current 
and should contain the following information:
 
o The identification of the patient (patient number) to whom the 
study medication was administered.  
o Labels of used study drugs - signed and dated by the study 
nurse. 
 
All accountability administration logs must be available for inspection by the 
monitor. Infusion bags will be destructed according to local site guidelines. 
 
 
4.3.1.2 DESTRUCTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT 
 
Used supplies (infusion bags) will be sent for destruction according to the site 
guidelines. The destruction process in the site should be documented. 
 
4.3.2 Dose modification for hematological toxicity 
Dose modifications will not be made during the first cycle of therapy. During 
the flowing cycles modifications of the treatment schedule will only be made 
as follows: 
• If at day 1 of any cycle, there is a grade ≥ 3 cytopenia (See hematological 
toxicity section 8), NOT RELATED TO BONE MARROW INFILTRATION DUE 
TO CLL, treatment should be delayed for up to three weeks and then given 
with a 25% dose reduction of fludarabine and cyclophosphamide in the 
following cycles. There is no dose reduction for Rituximab in this study, but 
drug administration will be delayed for the same time period as for fludarabine 
and cyclophosphamide. 


 
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• If after three weeks, the grade ≥ 3 cytopenia, NOT RELATED TO CLL BONE 
MARROW INFILTRATION, still prevails, the patient should be removed from the 
protocol with no further study drug administration. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles, despite the first 
25% dose reduction treatment should again be delayed for up to three weeks 
and the dose of fludarabine and cyclophosphamide further reduced to 50% of 
the full initial dose. 
• If there is further grade ≥ 3 cytopenia in subsequent cycles despite the 50% 
drugs dose reduction the patient should be removed from the protocol with no 
further treatment. 
• If there is any grade ≥ 3 neutropenia with infection during any cycle, G-CSF 
should be administered and G-CSF should than be given in all subsequent 
cycles prophylactically. 
 
4.3.3 Dose modification for impaired renal function 
Fludarabine and cyclophosphomide are partly (40-60%) excreted by the 
kidneys. If the calculated (see appendix III) or measured creatinine clearance 
is at screening or during treatment reduced to 30-70 mL/min, the fludarabine 
dose should be reduced to 80% and the cyclophosphamide dose will be 
reduced to 75%. Patients with a creatinine clearance below 30 ml/min are 
excluded from the study. Patients who develop renal dysfunction (serum 
creatinine ≥ 1.5 mg/dL or creatinine clearance < 30 ml/min) during treatment 
should go off protocol treatment. 
 
4.3.4 Dose modification for other non-hematological toxicity (non 
renal). 
• If other grade ≥ 3 non-hematological, non-renal toxicity occurs during any 
cycle, study drugs treatment should be delayed until recovery to grade ≤ 2, for 
up to three weeks. In case of grade ≥ 3, non-hematological, non-renal toxicity, 
which in the investigators' opinion is not study drug related, dose reduction will 
be performed upon investigator discretion. In case of grade ≥ 3 non-
hematological toxicity, which in the investigators' opinion is related to study 
drugs, all subsequent cycles should then be given with a 25% dose reduction 
of fludarabine and cyclophosphamide. 


 
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• If after three weeks, the grade ≥ 3 non-hematological, non-renal toxicity, 
drug related still persists, the patient should be removed from the protocol. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug 
related in subsequent cycles despite the first 25% dose reduction treatment 
should again be delayed for up to three weeks and the dose of fludarabine 
and cyclophosphamide further reduced to 50% of the initial full dose. 
• If there is further grade ≥ 3 non-hematological, non-renal toxicity, drug 
related in subsequent cycles despite 50% dose reduction the patient should 
be removed from the protocol treatment and the study. 
 
4.3.5 Dose modification for Weight Changes 
Dose of medication will be determined according to weight at screening.  
If body weight has changed at visit 2 or visit 4 by ± 10% or more, appropriate 
adjustment in dose of all medications should be performed.   
 
4.3.6 Treatment assignment 
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reutilized.  
 4.3.7 Blinding                                                                                                         
This is an open label trial. 
 
 
 
 
4.4 
Study drug interruption or discontinuation                                             
4.4.1 Discontinuation of study drugs 
Events that will be considered as reasons for study drugs 
discontinuation are described in section 5.3 
In addition, patient follow-up information must still be recorded (also in the 
event of study drug discontinuation) during and at the end of the study period. 


 
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4.4.2 Study Discontinuation  
Events that will be considered as reasons for study discontinuation are 
described in section 5.3 
 
4.5 
Accountability procedures for the investigational products 
Study drug will be prepared and dispensed by the pharmacist at the 
investigator’s institution. Drug accountability & destruction procedures are 
described in sections 4.3.1.1 & 4.3.1.2, accordingly. 


 
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4. Selection and Withdrawal of Subjects                           
    
5.1 
 Inclusion Criteria 
1. 
Diagnosis of B-CLL is established by the presence of: an absolute 
lymphocyte count > 5X109 L, and typical CLL cell morphology in the 
peripheral blood smear as seen by light microscopy. CLL cells must 
show CD5/CD19/CD23 positivity with light chain restriction as 
recorded by flow cytometry. The levels of surface immunoglobulin  
and CD 79b are characteristically low and FMC7 is expected to be 
negative (optional). ZAP 70 and CD38 are optional. Patients with 
different phenotype than described above can be included, in case 
the pathologist will give a written approval of B-CLL and with the 
approval of the sponsor. 
2. 
Previously untreated B-CLL patients ≥ 65 years old. 
3. 
Patients requiring treatment (active Binet classification stage A and 
B, all stage C disease).(appendixes IV and V) 
4. 
Written informed consent 
 
5.2 
 Exclusion Criteria 
1. 
Calculated or measured creatinine clearance < 30 ml/min 
2. 
Hepatic enzymes or bilirubin ≥ 2X ULN, unless thought to 
be due to CLL. 
3. 
Suspected or documented CNS involvement by CLL 
4. 
Known HIV positivity 
5. 
Active or uncontrolled infections, including opportunistic 
infection and active hepatitis B / C 
6. 
- Patients with active hepatitis B or HBV surface antigen 
positive. 
- Patients with anti-HBV core antibodies (past infection with 
HBV) but who are negative for HBVsAg  (either anti-HBS 
Ab positive or negative) and are positive for HBV-DNA by 
PCR analysis - are not eligible. 


 
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7. 
Various concomitant diseases requiring chronic steroid 
administration 
8. 
Active Coomb's positive hemolytic anemia. 
9. 
Prior treatment for CLL 
10. 
 CLL in transformation (Richter syndrome). 
11.    Presence of active second neoplasia (excluding non-
melanoma   skin cancer, or in situ cervix, breast or 
prostate carcinoma) < 2 years prior to the study. 
12. Use of other investigational agents or participation in any 
other clinical trials < 30 days prior to the study. 
13.    Low compliance. 
14.    Performance status: ECOG performance status ≥3. (see 
appendix II) 
15.   Patients who are mentally or physically unable to comply      
with all aspects of the study. Upon investigator discretion, 
a psycho-geriatric evaluation will be performed for patients 
≥ 80 years old. 
       
 
5.3 
 Interruption or Discontinuation of Treatment 
5.3.1 Discontinuation of study drugs 
The following events will be considered as reasons for discontinuation. 
 
Interruption of study drug/s for longer than 3 consecutive weeks. 
 
Adverse events, including study drugs induced active 
autoimmune haemolytic anemia. 
 
Patient with large cell transformation (Richter syndrome). 
 
Disease progression as defined at any time during study drug therapy. 
 
Treatment with other chemotherapeutic or investigational anti-neoplastic 
drugs 
 
Intolerable adverse effects that are judged by the investigator to be either 
physically or psychologically detrimental to the patient. Unresolved or 
recurrent (more than twice) grade 3 or 4 toxicity. 


 
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 
The reason for discontinuation should be recorded in the CRF and in the 
subject’s medical records. The sponsor is to be notified of all 
discontinuations related to study medication. 
 
In addition, patient follow-up information will be recorded (also in the         
      event of study drug discontinuation) during and at the end of the study       
      period. 
 
In the case of a severe reaction to Rituximab, Rituximab will be 
permanently discontinued and the patient’s participation in the study will 
be discontinued.  
 
5.3.2 Interruption of study drugs 
In the event of grade 3 or 4 toxicity, or increase of creatinine>1.5 or GFR of 
less than 30ml/min study drug will be interrupted for no more than 3 weeks 
(see sections 4.3.2-4.3.4). 
 
5.4 
Study Discontinuation  
The following events are considered as study discontinuation: 
 
Death 
 
Participation in another investigational drug trial 
 
Loss to follow-up 
 
Patient withdrawal of  consent 
 
Major violation of the study protocol- such as eligibility criteria.  
In these cases, no patient follow-up will be recorded. 
 
Administrative problems 
 
In the event of no response after dosage increment in > 5 of the next 10 
subjects who received the increased dosage.(see chapter 4.2). 
The section for “Study Completion” in the CRF must be completed for all 
patients. The reason for early discontinuation should be given, even if the 
patient refuses to return for a final visit. Patients who discontinue prematurely 
due to significant study drug related adverse events (AEs) should continue to 
be followed until resolution of the AE or up to 30 days after discontinuation. 
The relevant sections of the CRF should be completed as appropriate.  


 
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Patients who discontinue the study drugs for any reason should be scheduled 
for a visit within 30 days from drug discontinuation at which time all the 
assessments listed for the final visit should be performed (see figure 1).   
Patients lost to follow up should be recorded as such on the CRF.  Patients 
who discontinue study treatment should be followed for tumor assessments 
as per standard of care, until disease progression or new cancer therapy is 
initiated.  If patients refuse to return for these visits or are unable to do so, the 
subject should be considered off-study, but a Study Evaluation Completion 
form should be completed. 
 


 
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6. Treatment of Subjects                                                       
 
6.1 
 Treatment regimen 
 Patients will receive FLU , CY and Rituximab combination for an exposure 
period of up to 6 months- defined as the  treatment period. Dosage, dose 
regimen and route of administration are detailed in 4.3-4.4  
 
6.1.1 Treatment assignment  
Informed consent must be obtained before any testing for the purpose of 
determining a patient’s eligibility is performed. Each patient will be assigned a 
unique patient number. Once assigned, numbers for any non-evaluable or 
discontinued patient will not be reused.  
 
6.2 
Concomitant therapy 
In general, concomitant medications and therapies deemed necessary for the 
supportive care and safety of the patient are permitted in this study, provided 
their use is documented in the patient records and on the appropriate Case 
Report Form. The administration of any anticancer agents including 
chemotherapy and biologic agents is NOT permitted. Similarly, the use of 
other concurrent investigational drugs is not allowed. The use of blood 
products (irradiated) transfusions, immunoglobulins or erythroid/myeloid 
growth factors are permitted at investigator's discretion.  
Transfusion-associated graft versus host disease prevention using irradiated 
blood products is mandatory. 
Steroids administration is allowed exclusively for patients with autoimmune 
thrombocytopenia or as premedication for Rituximab. 
Premedication: Any patient considered to be at risk of infusion related 
reaction (IRR) or TLS (=patients with lymphocytosis > 25,000mm3) should 
receive:  Appropriate hydration starting 12-24 hours prior to initiating 
treatment, and thereafter until the risk of IRR/TLS is ruled out. Urine 
alkalization is at investigator’s discretion. 


 
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Antihistamines (e.g. 2 mg clemastin or promethazine 25mg i.v.) and 
paracetamol (500-1,000 mg orally) 30 min before first infusion of Rituximab, 
and thereafter only if clinically indicated. Hydrocortisone 100-500 mg I.V. 
(according local common practice) should be given only if clinically indicated 
(increased risk of IRR). 
Pneumocystis carinii pneumonitis prophylaxis with trimethoprim 160mg-
sulfamethoxasole 800 mg twice a day, twice a week, for the treatment period 
and for the next 6 months of follow up are recommended.  
Patients with anti-HBV core antibodies (past infection with HBV) but who are 
negative for HBSAg (either anti-HBVs Ab positive or negative) and had 
negative baseline for HBV-DNA by PCR analysis will be given anti-viral 
prophylaxis during and for at least 6 months after the last cycle of treatment.  
For prevention of hepatitis B reactivation that needs antiviral treatment 
(prophylaxis treatment) Lamivudine 100mg/day will be administrated for the 
entire duration of chemotherapy and for the six months afterwards. 
Hepatitis B serology will be: HBsAg+, Anti HBcore and anti-HBsAg 
Treatment is recommended for: HBsAg+ (carriers), or HBVsAg (-), anti 
HBcore (+) and anti-HBVsAg (-).  
Any use of concomitant medication must be captured in the concomitant 
medication CRF. Administration of Blood products must also be captured as 
concomitant medication on CRF. 
Steroids, if given (see above) are allowed for no more than 3 consecutive 
days.  
 
6.3 
Treatment compliance 
Number of FLU and CY vials administrated I.V to every subject in every study 
site, will be captured on CRF. 
Number of Rituximab containing infusion bags administrated to every subject 
in every study site, will be captured on CRF  
 
 


 
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7. Assessment of efficacy                                               
The primary efficacy parameter to be assessed will be response rate.  
Response rate include CR and PR; all others (eg. stable disease, non 
response, progressive disease or death from any cause should be rated as 
treatment failure.) 
An overall objective assessment of all measurable and non-measurable 
response parameters will be performed according to the Visit Schedules (see 
Figure 1).  
Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix I: [46]. 
 Peripheral blood immunophenotyping by FACS for absence of clonal 
lymphocytes. 
 Physical examination - lymph node examination and measurements for 
absence of significant (>1.5 cm in diameter), as well as the presence of 
hepatomegaly and splenomegaly.  
 CT scan for CLL patients with a CT found to be abnormal before therapy 
or alternatively if physical examination is inconclusive. 
  Complete blood count for ANC, platelets and hemoglobin levels. Blood 
counts have to be above the following values: ANC> 1.5 X 109/L. platelets 
> 100X 109/L. Hemoglobin > 11.0 g/dL. 
 
Bone marrow aspiration and biopsy to assess degree of bone marrow 
involvement by CLL using FACS and immunohistochemistry, should be 
performed at least 3 months after the last treatment, if the above four 
clinical and laboratory results support that CR has been achieved. In some 
cases, it is necessary to postpone BMB until after all the other criteria used 
to define a CR have been satisfied but, this time interval should not 
exceed 6 months after the last treatment. 
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
A single laboratory should perform all evaluations for all patients recruited in 
the same site. All the above studies must account for disease parameters that 


 
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were present at baseline and must use the same techniques as used at 
baseline. All the above mentioned assessments should be performed within 7 
days of the scheduled day of assessment (see Figure 1). 
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
Bone marrow examination can be postponed until after the above clinical and 
laboratory examinations used to define a CR have been satisfied. However, 
this time interval should not exceed 6 months after the last treatment.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate. Current laboratory 
and physical examination results will be captured on the response forms in 
the CRF.  
Progression free survival is defined as the interval from the first study drug 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator discretion. Progression will be 
captured on the response form CRF. 
Time to next treatment is defined as the interval between the first study drug 
treatment day to the first day of starting the next treatment. 
In general, second-line treatment decisions follow the same indications as 
those used for initiation of first-line treatment. 
Re-treatment day will be captured on the treatment form CRF. 
QOL questionnaires (FACIT) will be completed by study subjects at: 
screening visit and at visits number: 11,14 and at the end of study. 
Questionnaires will be captured on the QOL forms CRF. 
CT Scan – In order to prevent contrast nephropathy, patients   with GFR < 
60ml/min or   diabetes mellitus, hydration is  recommended and if possible 
acetylcystein (600 mg in bolus pre CT and 1,200 mg orally twice a day for 48 
hours after CT) should be given . Hospitalization for this procedure is 
recommended.  


 
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8. Assessment of Safety   
Safety assessments will consist of evaluating adverse events and serious 
adverse events, laboratory parameters including hematology, chemistry, vital 
signs, physical examinations, and documentation of all concomitant 
medications and/or therapies. 
8.1 
Adverse events 
According to the International Conference of Harmonization [ICH], an AE is 
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 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 considered related to the medicinal 
[investigational] product.  Pre-existing conditions which worsen during a study 
are to be reported as AEs. 
 
Information about all adverse events, whether volunteered by the patient, 
discovered by investigator questioning, or detected through physical 
examination, laboratory test or other means, will be collected and recorded on 
the Adverse Event Case Report Form and followed as appropriate. An 
adverse event is any undesirable sign, symptom or medical condition 
occurring after starting study treatment, even if the event is not considered to 
be treatment-related.  
Medical conditions/diseases present before starting study treatment are only 
considered adverse events if they worsen after starting study treatment. 
Clinical events occurring before starting study treatment but after signing the 
informed consent form are recorded on the Medical History/Current Medical 
Conditions Case Report Form only if the patient receives study treatment. 
Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms or require therapy, when they are 
recorded on the Adverse Events Case Report Form under the signs, 
symptoms or diagnosis associated with them. 


 
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8.1.2 Grading and reporting of adverse events 
All adverse events will be graded according the NCI-CTC scale version 3.0 
Anemia and thrombocytopenia should be graded according to NCI-CTC scale 
version 2.0- the criteria for patients in leukemia studies (see assessment of 
toxicity below for details), and reported in detail as indicated on the CRF 
  
Adverse events not listed on the CTCAE should be graded as follows:   
CTC Grade 
Equivalent To: 
Definition 
Grade 1 
Mild 
Discomfort noticed but no disruption of normal daily activity  
Grade 2 
Moderate 
Discomfort sufficient to reduce or affect daily activity; no 
treatment or medical intervention is indicated although this 
could improve the overall well-being or symptoms of the subject 
Grade 3 
Severe 
Inability to work or perform normal daily activity; treatment or 
medical intervention is indicated in order to improve the overall 
well-being or symptoms; delaying the onset of treatment is not 
putting the survival of the subject at direct risk. 
Grade 4 
Life threatening/ 
disabling 
An immediate threat to life or leading to a permanent mental or 
physical conditions that prevents work or performing normal 
daily activities; treatment or medical intervention is required in 
order to maintain survival. 
Grade 5 
Death  
AE resulting in death  
 
8.1.3 Assessment of Toxicity 
The evaluation of potential treatment-induced toxicity in patients with 
advanced CLL may be quite difficult requiring careful consideration of both the 
manifestations of the underlying disease, as well as adverse reactions to the 
therapy under study. Some of the conventional criteria for toxicity are not 
applicable especially under circumstances of progressive bone marrow failure 
from the CLL itself. 
 
8.1.4 Hematological Toxicity 
The evaluation of hematological toxicity in patients with CLL must consider 
the high frequency of hematological compromise already present at the 
initiation of therapy. Therefore the standard criteria used for solid tumors 


 
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cannot be applied directly; many patients would be considered to have grade 
II to IV hematological toxicity at presentation. 
As a consequence, for grading of anemia and thrombocytopenia, we plan to 
apply the NCI-CTC version 2.0 criteria for patients in leukemia studies, but for 
grading of neutropenia, the standard NCI-CTC version 3.0 criteria, as given 
below. 
 
Table 3: NCI-CTC Grading scale for hematological toxicity for  
patients in this study 
 
Decrease in platelets*or 
Hb# from pretreatment 
value (%). 
Grade 
ANC mm3 § (nadir) 
No change-9% 
0 
≥2,000 
10-24% 
1 
≥1,500 and <2,000 
25-49% 
2 
≥1,000 and <1,500 
50-74% 
3 
≥500 and <1000 
≥75% 
4 
<500 
  
 
Grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening 
* if platelets were < 20,000mm3 [<20 x109/L] prior to therapy, the patient is 
inevaluable for toxicity in platelets 
# baseline and subsequent Hb determinations must be performed before any 
given infusion 
§ if ANC was < 1,000 prior to therapy, the patient is inevaluable for toxicity in 
ANC. 
 
Platelets: 
If at any level of decrease the platelet count is < 20,000 mm3, this is 
considered grade 4 toxicity, unless a severe or life-threatening decrease in 
the initial platelet count (e.g. < 20,000 mm3) was present before treatment in 
which case the patient is inevaluable for toxicity referable to platelet counts. 
Hemoglobin: 
Baseline and subsequent Hb determinations must be performed before any 
given infusions. 


 
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Fludarabine has been reported to exacerbate or precipitate autoimmune 
hemolytic anemia and patients should be monitored carefully for this 
condition. If a rapid decrease of hemoglobin occurs during therapy, the 
possibility of fludarabine- or autoantibody-induced hemolysis should be 
considered and appropriate diagnostic tests (LDH, bilirubin, α2-haptoglobin, 
reticulocytes, Coombs-test) be performed. In particular, a Coomb’s test 
should be performed for: 
 Any grade 3 or 4 anemia (Hb < 8 g/dL) 
 A Hb < 10 g/dL sustained for > 2 weeks 
 A drop in Hb of 3 g/dL in one week (while pts are receiving weekly 
blood tests) 
 Any patient requiring a blood transfusion 
If, in the judgment of the treating physician, there is evidence of hemolytic 
anemia secondary to fludarabine, study treatment should be promptly 
withdrawn. Full details of the hemolytic anemia should be recorded on the 
adverse event pages of the CRF. 
Neutrophils: 
Absolute neutrophil count (ANC) is used to assess the toxicity of the myeloid 
lineage. Other decreases in the white blood cell count, or in circulating 
lymphocytes, are not to be  considered, since a decrease in the white blood 
cell count is a desired therapeutic end point. If the ANC was < 1,000/ mm3 [<1 
x109/L] prior to therapy, the patient is inevaluable for toxicity referable to the 
ANC. 
Any Adverse Event occurring by the time of study completion (within four 
weeks of last drug intake) must be recorded on the Adverse Event CRF page. 
8.1.5 Drug-Adverse event relationship 
The causality relationship of study drug to the adverse event will be assessed 
by the investigator as either: 
Yes or No 
If there is a reasonable suspected causal relationship to the study medication, 
i.e. there are facts (evidence) or arguments to suggest a causal relationship, 
drug-event relationship should be assessed as Yes. 
The following criteria should be considered in order to assess the relationship 
as Yes: 


 
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– Reasonable temporal association with drug administration 
– It may or may not have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– Known response pattern to suspected drug 
– Disappears or decreases on cessation or reduction in dose 
– Reappears on rechallenge 
 
The following criteria should be considered in order to assess the relationship 
as No: 
– It does not follow a reasonable temporal sequence from administration of 
the drug. 
– It may readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered to 
the subject. 
– It does not follow a known pattern of response to the suspected drug. 
– It does not reappear or worsen when the drug is readministered. 
 
8.2 
Serious adverse events 
A serious adverse event is any experience that suggests a significant hazard, 
contraindication, side effect or precaution.  It is any Adverse Event that at any 
dose fulfils at least one of the following criteria: 
– is fatal; (results in death; NOTE: death is an outcome, not an event)  
– is Life-Threatening (NOTE: the term "Life-Threatening" refers to an event 
in which the subject was at immediate risk of death at the time of the 
event; it does not refer to an event which could hypothetically have caused 
a death had it been more severe). 
– required in-patient hospitalization or prolongation of existing 
hospitalization; 
– results in persistent or significant disability/incapacity; 
– is a congenital anomaly/birth defect; 
– is medically significant or requires intervention to prevent one or other of 
the outcomes listed above 


 
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**The term sudden death should be used only when the cause is of a 
cardiac origin as per standard definition.  The terms death and sudden 
death are clearly distinct and must not be used interchangeably. 
The study will comply with all local regulatory requirements and adhere 
to the full requirements of the ICH Guideline for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic 
E2 
Other safety findings may require expedited reporting depending on local 
legislation, e.g. a major safety finding from a newly completed animal study 
(such as carcinogenicity). 
Progression of underlying malignancy is not reported as an adverse 
event if it is clearly consistent with the suspected progression of the 
underlying cancer as defined by RECIST criteria, or other criteria as 
determined by protocol. Hospitalization due solely to the progression of 
underlying malignancy should NOT be reported as a serious adverse event.  
Clinical symptoms of progression may be reported as adverse events if the 
symptom cannot be determined as exclusively due to the progression of the 
underlying malignancy, or does not fit the expected pattern of progression for 
the disease under study. 
Symptomatic deterioration may occur in some subjects.  In this situation, 
progression is evident in the subject’s clinical symptoms, but is not supported 
by the tumor measurements.  Or, the disease progression is so evident that 
the investigator may elect not to perform further disease assessments.  In 
such cases, the determination of clinical progression is based on symptomatic 
deterioration.  These determinations should be a rare exception as every 
effort should be made to document the objective progression of underlying 
malignancy. 
If there is any uncertainty about an adverse event being due only to the 
disease under study, it should be reported as an AE or SAE. 


 
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8.2.1 Reporting of Serious Adverse Events (immediately reportable) 
Any clinical adverse event or abnormal laboratory test value that is serious 
and which occurs during the course of the study (as defined in section 8.2 
above), occurring from the enrollment visit (start of study screening 
procedures), including long term follow-up (LTFU) must be reported to Roche 
within one working day of the investigator becoming aware of the event 
(expedited reporting). The investigator must complete the SAE Reporting 
Form [
 and forward it to the SAE Responsible.  
After signature on informed consent, but prior to initiation of study medications, 
only SAEs caused by a protocol-mandated intervention will be collected (e.g., 
SAEs related to invasive procedures such as biopsies, medication washout, 
or no treatment run-in).  After first study medication, all SAEs must be 
reported.  
 
Related Serious Adverse Events MUST be collected and reported regardless 
of the time elapsed from the last study drug administration, even if the study 
has been closed. Suspected Unexpected Serious Adverse Reactions 
(SUSARs) are reported to investigators at each site and associated IRB/IEC  
when the following conditions occur: 
 The event must be a SAE.  
 There must be a certain degree of probability that the event is an 
adverse reaction from the administered drug.  
 The adverse reaction must be unexpected, that is to say, not foreseen 
in the SPC text (Summary of Product Characteristics (for an authorized 
medicinal product) or the Investigator’s Brochure (for an unauthorized 
medicinal product).  
Unrelated Serious Adverse Events must be collected and reported during the 
study and for up to 30 days after the last dose of study medication. 


 
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This study adheres to the definition and reporting requirements of ICH 
Guideline for Clinical Safety Data Management, Definitions and 
Standards for Expedited Reporting, Topic E2.   
 
 
8.2.2 Treatment and Follow-up of AEs 
During the study period and up to 30 days after completion or discontinuation 
of the study, continue to follow up AEs as follows: 
Related AEs:  Follow until one of the following occurs: 
– Resolved or improved to baseline 
– Relationship is reassessed as unrelated 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated severe or life threatening AEs: Follow until one of the following 
occurs: 
– Resolved or improved to baseline 
– Severity improved to Grade 2 
– Death 
– Start of new anti-cancer regimen  
– Investigator confirms that no further improvement can be expected  
– Clinical or safety data will no longer be collected, or final database closure 
Unrelated Grade 1 or Grade 2 AEs: Follow up to 30 days after completion or 
discontinuation of the study. 
The final outcome of each adverse event must be recorded on the CRF  
 
8.2.3 Laboratory evaluations 
Laboratory test results will be recorded on the laboratory results form of the 
CRF, or appear on electronically produced laboratory reports submitted 
directly from the central laboratory, if applicable.  


 
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Any laboratory result abnormality fulfilling the criteria for a serious adverse 
event (SAE) should be reported as such, in addition to being recorded as an 
AE in the CRF. 
Any treatment-emergent abnormal laboratory result which is clinically 
significant, i.e., meeting one or more of the following conditions, should be 
recorded as a single diagnosis on the adverse event page in the CRF: 
 Accompanied by clinical symptoms 
 Leading to a change in study medication (e.g. dose modification, 
interruption or permanent discontinuation) 
 Requiring a change in concomitant therapy (e.g. addition of, 
interruption of, discontinuation of, or any other change in a concomitant 
medication, therapy or treatment) 
No special laboratory or tests are required to be performed for the purpose of 
the study.  Measurement of Complete Blood Counts, chemistry and 
immunological tests such as: serum Ig level, serum immunoellectrophoresis, 
DAT, peripheral and bone marrow FACS and hepatitis B and C serology are 
in fact regarded as current clinical practice for CLL patients, and should 
therefore be collected according to the Visit Schedules (see Figure 1). In case 
of suspected hemolysis - DAT, reticulocyte count, serum haptoglobin, bilirubin 
and LDH are recommended. 
The institution will perform laboratory analyses according to the Visit 
Schedules (see Figure 1). The sponsor must be provided with a copy of the 
laboratory’s certification, and a tabulation of the normal ranges for each 
parameter required. Additionally, if at any time a patient has laboratory 
parameters obtained from a different outside laboratory, the sponsor must be 
provided with a copy of the certification and a tabulation of the normal ranges 
for that laboratory.     
At any time during the study, abnormal laboratory parameters which are 
clinically relevant (e.g. require dose modification and/or interruption of study 
drug, lead to clinical symptoms or signs or require therapeutic intervention), 
whether specifically requested in the protocol or not, must be recorded on the 


 
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appropriate Comment CRF page in addition to the appropriate laboratory CRF 
page. When abnormal laboratory values or test results constitute an adverse 
event (i.e., induces clinical signs/symptoms or requires therapy) they must be 
recorded on the Adverse Events CRF. 
 
When, in the opinion of the investigator, other clinical laboratory evaluations 
may be relevant for assessing the patient’s status, they will be completed and 
entered into the database as appropriate.  
8.3 
Special tests 
PET-CT will be performed in case of suspected Richter transformation. 
Lymph node biopsy is recommended for definitive diagnosis of Richter 
transformation and for any rapidly progressive disease or unusual phenomena 
which may be suspicious of alteration in the normal behavior of the disease or 
suspicious for another disease or a different type of lymphoma. 
 8.4 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no case report forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
 
8.5 
Laboratory examinations 
 
8.5.1 Hematology 
Hematological evaluations (CBC) are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 


 
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8.5.2 Blood chemistry 
The following blood chemistry results are regarded as clinical practice for CLL 
patients and should therefore be collected according to the Visit Schedules 
(see Figure 1). 
Serum creatinine, ALT, AST, alkaline Phosphatase, LDH, bilirubin. globulin, 
serum immunoellectrophoresis and beta-2 microglobulin. 
 
8.6 
Physical examinations/vital signs 
A physical examination including vital signs will be performed according to the 
Visit Schedules (see Figure 1). Information about the physical examination 
and vital signs must be present in the source documentation at the study site. 
Significant findings present prior to the start of study drug must be included in 
the Relevant Medical History/Current Medical Conditions CRF. Significant 
findings made after the start of study drug which meet the definition of an 
adverse event must be recorded on the Adverse Event Case Report Form. 
There are no Case Report Forms to capture routine normal findings from 
physical examinations and vital signs assessments. 
 
8.6.1 Warning and Precautions 
No evidence available at the time of the approval of this study protocol 
indicated that special warnings or precautions were appropriate regarding 
Rituximab, other than those noted in the Investigators’ Brochure. 
Safety information regarding Fludarabine and Cyclophosphamide can be 
found in the respective local MoH approved product label. 
 
9.   Statistics 
Subjects’ age, weight, height and other continuous demographic and baseline 
variables will be summarized using descriptive statistics (mean, standard 
deviation, minimum and maximum), while performance status, gender, and 
other categorical variables will be summarized with frequency tabulations.  
 


 
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9.1 
Sample size 
This is a single arm phase II study. The number of subjects planed to be 
enrolled into the study is 40. Such a low number of patients as in most phase 
II studies) constitute an underpowered study for revealing any statistical 
significance, but is indeed clinically meaningful. So, the sample size chosen 
for this study was based on clinical considerations. 
Those patients achieving PR or CR by the study medication will be regarded 
as responders. All the others (stable disease, progressive disease or death 
from any cause) will be regarded as non responders. Determining the ratio of 
responders versus non responders, even if not statistically significant, will still 
be clinically meaningful. 
 
9.1.1 Data analysis 
Categorical data will be presented as frequencies and percentages.  For 
continuous data, mean, standard deviation, median, 25th and 75th percentiles, 
minimum, and maximum will be presented.    
 
9.2 
Efficacy and Safety evaluation 
 
9.2.1 Efficacy analysis: 
All analyses will be according to the intention to treat principle. 
 
9.2.2 Response rate 
The primary efficacy parameter to be assessed will be response rate 
determined by objective overall response rate.  
The primary endpoint is a binary variable where each patient is classified as a 
responder or not responder. 
95% Confidence Interval (CI) will be calculated to the proportions of 
responders. 
 
Response rate include CR and PR; all other situations (eg. stable disease, 
non response, progressive disease or death from any cause) will be rated as 
treatment failure and therefore as non responders. 


 
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Response rate will be assessed according the updated (2008) NCI-WG 
guidelines defined in appendix 1: 
 Peripheral blood FACS for lymphocytes clonality. 
  Physical examination for lymph node examination and measurements, 
and documentation of the presence of hepatomegaly and splenomegaly. 
  Blood count for ANC, platelets and hemoglobin levels.  
 Bone marrow aspiration and biopsy for bone marrow involvement by CLL 
cells using FACS immunophenotyping or immunohistochemistry.  
 Patient interview for the presence of constitutional symptoms throughout 
the study.  
All above mentioned efficacy (response) parameters will be performed at 
screening and at least 3 months after completing study drug administration for 
response documentation.  
All known disease (measurable, and non measurable) parameters must be 
accounted for when assessing objective response rate.  
Progression free survival is defined as the interval between the first 
treatment day to the first sign of disease progression. 
Progressive disease (PD) will be assessed according the updated (2008) NCI-
WG guidelines defined in appendix I. If needed, BMB will be performed for 
suspected progression at the investigator's discretion. Progression will be 
captured on the response form CRF. 
A Kaplan-Meier method will be used to estimate median PFS and 90% 
confidence interval.      
QOL questionnaires will be completed by study subjects at: screening visit 
and visits number: 11, 14, and end of study. Questionnaires will be captured 
on the QOL forms CRF. 
 Summary statistics (standard deviation, median, minimum and maximum) will 
be provided for the relevant variables. The Paired T-test or Signed Rand Test 
for paired observations (as is appropriate) will be applied for analysing the 
changes in the components and total score of the FACIT QOL assessment. 


 
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The data will be analyzed using the SAS ® version 9.1.3 (SAS Institute, Cary 
North Carolina). 
 
9.3 
Safety Analysis 
 
Data from all subjects who receive any study drug will be included in the 
safety analyses. The severity of the toxicities will be graded according to the 
NCI CTCAE v 3.0 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/ctca
ev3.pdf 
or v 2.0 for cytopenia, whenever possible. 
All adverse events will be coded according to coding dictionaries (MedDRA 
version 12.1) and presented in tables by system organ class and preferred 
term. 
 In the by-subject analysis, a subject experiencing the same event more than 
once will be counted only once. Adverse events will be defined and 
summarized according to the worst NCI CTC grade. Adverse events leading 
to death or to discontinuation of treatment, events classified as NCI CTCAE 
Grade 3 or Grade 4, study-drug-related events, and serious adverse events 
will be summarized separately. Laboratory data will be graded according to 
NCI CTCAE severity grade. 
 
9.4 Interim Analysis 
Interim Analysis will be conducted on all data received at database until 
30 May, 2014. The following parameters will be examined in the Interim 
Analysis: 
 
Primary endpoint: 
 Overall Response rate  
Overall response rate will include CR and PR; all other situations 
(e.g. stable disease, non-response, progressive disease or death 
from any cause) will be rated as treatment failure and therefore as 
non-responders. 
 
 
 


 
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Secondary endpoints: 
 
 Progression free survival (PFS) defined as the time elapsed from 
first day of study drug administration to disease progression as 
defined in the protocol (Appendix I) 
 Overall survival 
 Safety of the study drugs especially in relation to: neutropenic 
fever, Infection rate and number of hospitalization days, 
thrombocytopenia ≥grade 3, neutropenia ≥grade 3 
 Rates of treatment-related adverse effects 
 Quality of life – by FACIT (Appendix VI)  
 
 


 
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10. Quality Control and Quality Assurance 
 
Data from the CRFs are entered into the study database by Contract 
Research Organization staff following their own internal standard operating 
procedures that have been reviewed and approved by the sponsor. 
Subsequently, the entered data are systematically checked by Data 
Management staff, using error messages printed from validation programs 
and database listings.  Obvious errors are corrected by Data Management 
personnel.  Other errors or omissions are entered on Data Query Forms, 
which are returned to the investigational site for resolution.  The signed 
original and resolved Data Query Forms are kept with the CRFs at the 
investigator site, and a copy is sent to the sponsor so the resolutions can be 
entered into the database.  Quality control audits of all key safety and efficacy 
data in the database are made prior to locking the database. 


 
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11.    Direct Access to Source Data/Documents 
 
11.1      Study monitoring 
The monitoring visits will enable the sponsor or the monitor acting on his 
behalf, to assess the study’s progress status, to verify data  accuracy and 
degree of completeness of the CRFs, to ensure the protocol as well as local 
regulations are being followed, that the investigator is fulfilling his obligations 
and to correct errors in the CRFs compared to the source documents. The 
investigators' will authorize the monitor, at a mutually convenient time during 
the study to periodically review all of the CRFs and the related parts of 
administrative, medical and laboratory files of each participant in the study. 
The CRFs must be filled out before the monitoring visits. 
 
11.2  Audits 
During the study, people belonging to the sponsor quality assurance group 
may visit the investigator site in order to audit the study. The purpose of this 
visit is to check that the study is carried out according to Good Clinical 
Practices. Before conducting an audit, the monitor will contact the investigator 
in order to agree upon a mutually suitable date. The investigator and his team 
are required to cooperate with the auditors and to grant them access to the 
patients’ medical files and to the study documents (CRFs and investigator’s 
binders). 
 
11.3  IRB and regulatory inspections 
A regulatory authority may also wish to conduct an inspection (during the 
study or even after its completion). If an inspection is requested by a 
regulatory authority, the investigator must inform the sponsor immediately that 
this request has been made.


 
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12.   Ethics 
 
12.1    Institutional Review Board 
Before implementing this study, the protocol, the proposed informed consent 
form and other information to subjects, must be reviewed by a properly 
constituted Institutional Review Board (IRB). A signed and dated statement 
that the protocol and informed consent have been approved by the IRB must 
be given to the sponsor before study initiation. The name and occupation of 
the chairman and the members of the IRB must be supplied to the sponsor. 
Any amendments to the protocol, other than administrative ones, must be 
approved by this committee. 
 
12.2 
  Informed consent 
The investigator must explain to each subject (or legally authorized 
representative) the nature of the study, its purpose, the procedures involved, 
the expected duration, the potential risks and benefits involved and any 
discomfort it may entail. Each subject must be informed that participation in 
the study is voluntary and that he/she may withdraw from the study at any 
time and that withdrawal of consent will not affect his/her subsequent medical 
treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written 
statement, written in non-technical language. The subject should read and 
consider the statement before signing and dating it, and should be given a 
copy of the signed document. If the subject cannot read or sign the 
documents, oral presentation may be made or signature given by the 
subject’s legally appointed representative, if witnessed by a person not 
involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent 
has been obtained. 
The informed consent form is considered to be part of the protocol, and must 
be submitted by the investigator with it for IRB approval.  


 
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12.3 
  Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the 
Declaration of Helsinki which can be accessed via the website of the World 
Medical Association at http://www.wma.net/e/policy/17-c e.html. 


 
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13. Data Handling and Record Keeping  
 
The information obtained from the execution of the protocol will be listed on 
the CRFs provided by the sponsor. 
The CRFs must be filled out on a timely basis, signed and dated by the 
investigator or a co-investigator named by the former and clinically 
responsible for the patient during the study. 
 
The completed CRFs will be collected by the sponsor. The investigator must 
remit one CRF for every participant in his center for a time period of 15 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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14. Financing and Insurance 
 
Financing and insurance will be addressed in the future in a separate 
agreement. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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15.Publication Policy 
 
Any formal presentation or publication of data from this trial will be considered 
as a joint publication by the investigator(s) and appropriate sponsor’s 
personnel. Authorship will be determined by mutual agreement taking in 
consideration that the group of PI's will prepare the manuscript and write it 
initially and decide which member of steering committee and which other 
active investigators who provided cases will be involved. 
 It is a multicenter study, and it is mandatory that the first publication is based 
on data from all centers, analyzed as stipulated in the protocol, by the sponsor 
statisticians, and not by the investigators. Investigators participating in 
multicenter studies agree not to present data gathered from one center or a 
small group of centers before the full publication, unless formally agreed to by 
all other investigators and the PI's and steering committee. 
The investigator may be required to sign the clinical study report, if it is to be 
used in a registration submission to the health authorities of some countries. 
For multicenter studies only the coordinating (principle) investigator 
nominated by the sponsor and the steering committee at the start of the trial 
would provide any needed signature.  
 
 
 


 
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32) Srinivas S, Yook C, ChangV et al. Prevalence of bone marrow CD20 positivity in 
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JW, Rai, K , Schiffer, CA, Larson, PA () Randomized Phase II Study of Fludarabine 
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44) Sculz H Klein SK, Rehwald U et al/ Phase II study of combined immunotherapy 
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45) Byrd JC, Rai K, Peterson BL, et al. Addition of Rituximab to Fludarabine may 
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49) Robak T, DmoszynkaA,Solal-Celigny P et al Rituximab plus Fludarabine and 
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51) Lamana N,Jurcic JG,Noy A et al sequential therapy with Fludarabine,high dose 
Cyclophosphamide and Rituximab in previously untreated patients with chronic 
lymphocytid leukemia produces high quality responses: Molecular remisiions predict 
fordurable complete response.J.Clin.Oncol>2009,27:491-497. 
 
 
 


 
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16. Supplements 
 
Appendix I    Response definitions    
 
CR (complete remission) = requires all of the following criteria as assessed at least 3 
months after completion of therapy: 
 
 
 
Absence of clonal lymphocytes in peripheral blood. 
 
Absence of significant lymphadenopathy. (lymph nodes > 1.5 cm in diameter) by 
physical examination. CT is desirable for not palpable lymph nodes. 
 
No hepatomegaly or splenomegaly by physical examination. (Abdominal, pelvix 
and thorax CT for subjects found to be abnormal before therapy or if physical 
examination is inconclusive. 
 
Absence of constitutional symptoms. 
 
Blood counts above the following values: ANC> 1.5 x 109/L
 .  Platelets > 100 
x109/L . Hemoglobin > 11.0 g/dL; untransfused). 
 
Bone marrow aspirate and biopsy should be performed at least 3 months after the 
last treatment and if the above 5 clinical and laboratory results demonstrate that CR 
has been achieved. 
Bone marrow should be analyzed  by FACS/or immunohistochemistry to demonstrate 
marrow free of B-CLL cells. 
In some cases, it is necessary to postpone BMB until after all the other criteria to 
define a CR have been satisfied. However, this time interval should not exceed 6 
months after the last treatment. 
 
 


 
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Relapse = a patient who has previously achieved CR or PR but after a period of 6 or more 
months, demonstrates evidence of disease progression 
 
Refractory disease = defined as treatment failure or disease progression within 6 months 
from the last antileukemic therapy. 
 
Progression = see above table  under PD. 
 
Progression free survival (PFS) = defined as the time from start of treatment to progression. 
 
Time to next treatment (TNT) = defined as the time from start of treatment to start of 
second-line treatment  
 
 
 
 
 
Appendix II    ECOG Performance status   
 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities. 
Up and about more than 50% of waking hours 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or 
chair 
5 
Dead 
 


 
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Appendix III calculated creatinine clearance 
  
 
   
 
 
 
 
Appendix IV     Active disease 
At least one of the following criteria should be met: 
1. Evidence of progressive marrow failure as manifested by the development of, 
or worsening of, anemia and/or thrombocytopenia 
2. Massive (ie, > 6 cm below the left costal margin) or progressive or 
symptomatic  splenomegaly. 
3. Massive nodes (ie, > 10 cm in longest diameter) or progressive or 
symptomatic lymphadenopathy. 
4. Progressive lymphocytosis with an increase of more than 50% over a 2-
month period or lymphocyte doubling time of less than 6 months; patients with 
initial blood lymphocyte counts of less than 30X109/L (30 000/μL) may require 
a longer observation period to determine the lymphocyte doubling time. In 
addition, factors contributing to lymphocytosis or lymphadenopathy other than 
CLL (eg, infections) should be excluded. 
5. Autoimmune anemia and/or thrombocytopenia poorly responsive to 
corticosteroides or other standard therapy. 
6. A minimum of any of the following disease-related symptoms must be 
present: a- Unintentional weight loss more than or equal to 10% within the 
previous 6 months. b- Significant fatigue (ie, ECOG PS 2 or worse; cannot 
work or unable to perform usual activities). c- Fevers of greater than 38.00C 
for 2 or more weeks without other evidence of infection. d- Night sweats for 
more than 1 month without evidence of infection. 
 
Appendix V    Binet staging system 
The areas of involvement considered for staging are as follows: 1- Head and neck, 
including the Waldeyer ring. 2- Axillae 3- Groins 4- Palpable spleen 5- Palpable liver. 
Stage A.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and up to 2 of the above 
areas involved. 
Stage B.  Hb 10 g/dL or more and platelets 100X 10
9/L or more and organomegaly 
greater than that defined for stage A (3 or more areas). 
Stage C.  All patients who have Hb less than 10 g/dL and/or a platelets count less than 
100X 109/L, irrespective of organomegaly. 
 
 
GFR (mL/min) = 
(140-age) X weight (Kg) 
Serum cr (mg/dL) X 72 
X  0.85 (for women) 


 
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Appendix VI    FACIT-QOL 
 
FACIT − Fatigue Scale (Version 4) 
Below is a list of statements that other people with your illness have said are important. By 
circling one (1) number per line, please indicate how true each statement has been for you 
during the past 7 days. 
 
                                                                                                        Not     A little    Some    Quite     Very 
           At all     bit         what      a bit    much 
 
HI7     I feel fatigued 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3  
4 
HI12   I feel weak all over 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
0  
1  
2  
3   
4 
 An1   I feel listless (“washed out") . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  0  
1 
2     
3   
4 
 An2   I feel tired 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  .  
0  
1   
2     
3  
4 
 An3   I have trouble starting things because I am tired 
. . . . . . . . . .  0   
1  
2 
3   
4 
 An4   I have trouble finishing things because I am tired 
. . . . . . . . . 0   
1 
2   
3  
4 
 An5   I have energy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2  
3   
4 
 An7   I am able to do my usual activities 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
 An8   I need to sleep during the day 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0  
1  
2  
3   
4 
An12  I am too tired to eat 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
0  
1  
2 
3   
4 
An14  I need help doing my usual activities 
. . . . . . . . . . . . . . . . . . . . . 
. . 
0   
1 
2  
3   
4 
An15  I am frustrated by being too tired to do the things 
         I want to do 
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An16  I have to limit my social activity because I am tired 
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US English 
Copyright 1987, 1997