ORIGINAL ARTICLE: CLINICAL

Cladribine combined with cyclophosphamide and mitoxantrone is anactive salvage therapy in advanced non-Hodgkin’s lymphoma

TADEUSZ ROBAK, EWA LECH-MARANDA, AGNIESZKA JANUS, JERZY BLONSKI,

AGNIESZKA WIERZBOWSKA, & JOANNA GORA-TYBOR

Department of Hematology, Medical University of Lodz, Poland

(Received 22 January 2007; revised 20 March 2007; accepted 21 March 2007)

AbstractThe aim of this study was to determine the feasibility, efficacy and toxicity of the combined therapy consisting of cladribine(2-CdA), mitoxantrone and cyclophosphamide (CMC regimen) in patients with refractory or relapsed non-Hodgkin’slymphoma (NHL). Thirty six patients, 14 with mantle cell lymphoma (MCL), 10 with diffuse large B-cell lymphoma(DLBCL), 5 with follicular lymphoma (FL), 3 with small lymphocytic lymphoma (SLL), and 4 with T-cell lymphoma wereenrolled to the study. The CMC protocol consisted of 2-CdA at a dose of 0.12 mg/kg in a 2-hour infusion on days 1 through3, mitoxantrone 10 mg/m2 i.v. on day 1 and cyclophosphamide 650 mg/m2 i.v. on day 1. The CMC courses were repeated atintervals of 4 weeks. Thirty three patients were available for evaluation of response. Overall response rate (OR) was 58%(95% CI, 41 – 75%). Seven patients (21%; 95% CI, 7 – 35%) achieved a complete response (CR) and 12 patients (36%;95% CI, 20 – 52%) achieved a partial response (PR). Seven of 19 patients with CR/PR are still in remission with a medianfollow-up of 3 months (range, 2 – 17 months). The median failure-free survival (FFS) was 5 months (range, 2 – 17 months).The median overall survival (OS) for the entire group was 9 months (range, 0.1 – 77 months). There was a significantdifference in OS between responders and nonresponders after CMC therapy (log rank test, P¼ 0.015). When differentdisease status before CMC treatment was considered, a trend toward longer survival of recurrent patients was observed (logrank test, P¼ 0.08). Grade 3 – 4 neutropenia developed in 14 (39%) patients, and 16 episodes (15%) of grade 3 – 4 infectionswere observed. Grade 3 – 4 thrombocytopenia or anemia was seen in 9 patients (25%) and 10 patients (28%), respectively.The results of our study show that the CMC regimen is effective salvage therapy with acceptable toxicity in heavily pretreatedpatients with NHL including MCL and DLBCL.

Keywords: Lymphoma, 2-CdA, mitoxantrone, cyclophosphamide, DLBCL, MCL

Introduction

Cladribine (2-chlorodeoxyadenosine, 2-CdA) used

as a single agent showed remarkable activity in both

previously treated and untreated patients with low

grade non-Hodgkin’s lymphoma (LG-NHL) [1,2].

In relapsed or refractory LG-NHL patients, 2-CdA

induced durable responses with overall response

(OR) rates ranging from 32% to 76% and complete

response (CR) rates between 10% and 38% [3 – 13].

Combined use of 2-CdA with cyclophosphamide and

its derivatives showed synergistic action in both in

vitro and in vivo experiments [14 – 16]. Mitoxan-

trone and anthracyclines are also useful drugs in the

treatment of LG-NHL and can be combined with

purine nucleoside analogs. These agents potentiated

the antineoplastic activity of 2-CdA in preclinical

studies [17].

Recent data indicate that 2-CdA in combination

with cyclophosphamide or mitoxantrone produce

higher response rates in indolent lymphoid malig-

nancies compared with 2-CdA monotherapy [18 –

24]. Thus, combination treatment with 2-CdA,

cyclophosphamide and mitoxantrone (CMC pro-

gramme) seems to be the logical conclusion of the

clinical studies in which 2-CdA was administered

with each independently. In our previous studies we

showed that the CMC regimen was an active

treatment in chronic lymphocytic leukaemia (CLL)

[25,26] and that it had significant activity and

Correspondence: Tadeusz Robak, Department of Hematology, Medical University of Lodz, Poland. E-mail: robaktad@csk.am.lodz.pl

Leukemia & Lymphoma, June 2007; 48(6): 1092 – 1101

ISSN 1042-8194 print/ISSN 1029-2403 online � 2007 Informa UK Ltd.

DOI: 10.1080/10428190701361216

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

acceptable toxicity in heavily pre-treated patients

with other LG-NHL [27].

In this report, we present the up-dated results of

our study evaluating the feasibility, efficacy and

toxicity of the CMC regimen in patients with

refractory or relapsed NHL, including mantle cell

lymphoma (MCL) and diffuse large B-cell lym-

phoma (DLBCL).

Patients and methods

Patients

The study comprised 36 adult patients with relapsed

or refractory NHL treated in the Department of

Hematology, Medical University of Lodz, Poland,

between December 1999 and March 2006. The

study was approved by the local ethics committee.

Informed consent was obtained from all patients and

patients’ confidentiality was preserved in accordance

with the Polish regulations for studies of human

subjects. The diagnosis was based on the World

Health Organization (WHO) classification for NHL

[28]. Pre-treatment medical evaluation consisted of a

complete history and physical examination, blood

morphology and chemistry, including lactic dehy-

drogenase (LDH) level, bone marrow biopsy, com-

puted tomographic scan of the chest, abdomen and

pelvis, ECG and echocardiograms. The extent of the

disease was categorized according to the Ann Arbor

classification, and performance status was assessed

using criteria of the Eastern Cooperative Oncology

Group (ECOG). All patients entering the study were

at least 18 years old, had ECOG performance status

between 0 – 2 with a life expectancy greater than 3

months, and at least one area of measurable disease.

They had to be free of active infections and did not

receive radiation or chemotherapy within at least 3

weeks before entering this study. All patients had

previously received at least one chemotherapy regi-

men and had either failed to respond (refractory

disease) or developed progressive disease after the

discontinuation of previous treatment (recurrent

disease). The median number of previous regimens

was 2 (range 1 – 4). Exclusion criteria of the study

were prior malignancy, Richter’s syndrome, active

infections including HIV infection, any significant

organ dysfunction, i.e., elevated creatinine (42 mg/

dl), elevated total bilirubin (42 mg/dl), elevated

transaminases or alkaline phosphatase (426 normal

values), left ventricular ejection fraction (LVEF)

555% and symptoms of heart failure (New York

Heart Association Grade III or IV). Pregnant or

lactating women were also excluded. The pre-

treatment characteristics of the patients are shown

in Table I.

Treatment

The treatment consisted of 2-CdA (cladribine) given

at a dose of 0.12 mg/kg/day in a 2-h intravenous

infusion for 3 consecutive days, mitoxantrone

10 mg/m2 on Day 1 and cyclophosphamide

650 mg/m2 on Day 1 (CMC regimen). 2-CdA

(Biodribin) was commercially available from the

Institute of Biotechnology and Antibiotics, Bioton,

Warsaw, Poland. If a response was documented, then

patients were treated until maximal response was

achieved or prohibitive toxicity occurred. If no

response or disease progression was observed after

two cycles, the treatment was stopped. The cycles were

repeated usually at 28 days intervals. In patients who

developed an infection or a drug-induced cytopenia

(a platelet count 5506109 l71 and/or a neutrophil

count 51.06109 l71), CMC therapy was interrupted

until recovery of haematological parameters (at least

Grade 2 toxicity according to the WHO Criteria) or

recovery from infection was observed. The treatment

was re-administered at time intervals longer than 4

weeks, ranging from 5 to 8 weeks.

To prevent hyperuricemia, allopurinol (300 mg

daily) was given. No prophylactic antibiotics, anti-

viral agents, or haematopoietic growth factors were

Table I. Clinical characteristics of NHL patients before CMC

treatment.

Number of patients 36

Age, median (range) 59 (19 – 83)

Sex (male/female) 23/13

Histology

Mantle cell lymphoma 14

Diffuse large B-cell lymphoma 10

Follicular lymphoma 5

Small lymphocytic lymphoma 3

T-cell lymphomas* 4

Ann Arbor stage III, IV (%) 32 (89)

B-symptoms (%) 23 (64)

Extranodal involved sites 41 (%) 15 (42)

Elevated LDH (%) 27 (75)

Bone marrow involvement (%) 21 (58)

Bulky disease (410 cm) (%) 6 (17)

Elevated b2-microglobulin (%) 33 (92)

Disease status before CMC treatment

Refractory 21

Recurrent 15

Prior courses of chemotherapy

1 regimen 17

2 regimes 9

3 or more regimens 10

Prior radiotherapy 3

Median white cell count 6109 l71 (range) 9.5 (1.5 – 152.0)

Median neutrophil count 6109 l71 (range) 3.72 (0.5 – 26.2)

Median haemoglobin g/dl (range) 11.6 (7.3 – 15.3)

Median platelets count 6109 l71 (range) 161 (27 – 434)

*T-cell lymphomas included anaplastic large T-cell lymphoma,

Sezary syndrome, angioimmunoblastic lymphoma, T-cell lympho-

blastic lymphoma.

Cladribine, cyclophosphamide, and mitoxantrone in NHL 1093

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

given. However, patients received granulocyte-col-

ony stimulating factor (G-CSF) if the absolute

granulocyte count was 51.06 109 l71 and an active

infection was present.

Response criteria

Response criteria were defined according to NCI

sponsored International Working Group [28].

Complete response (CR) was defined as disappear-

ance of all disease manifestations by physical

examination, bone marrow biopsy, imaging studies

and normalisation of all laboratory values, lasting at

least 2 months with no development of any new

lesions. Partial response (PR) was defined as a

reduction of at least 50% in all the involved areas of

disease, lasting for at least 2 months. The duration

of response was computed from the time of onset of

CR or PR to the time of relapse, last follow-up, or

death. Patients who had not achieved CR or PR

were classified as non-responders. If CR was

achieved, no further therapy was administered; in

the case of PR, CMC treatment was continued up

to 6 cycles. Non-responders were put on another

treatment.

Toxicity monitoring

Toxicity was monitored and assessed according to

the WHO Criteria [29]. Blood counts, creatinine,

bilirubin, GOT, GPT, ECG, urinalysis and general

physical examination were serially evaluated and

recorded. Treatment induced anaemia, thrombocy-

topenia and neutropenia were diagnosed if after any

treatment course a further decrease of haemoglobin

level and/or platelets and neutrophil counts were

observed.

Only major and moderate infections that required

oral or parenteral antibiotics, antiviral or antifungal

therapy and/or hospitalisation were recorded. Fever

of unknown origin (FUO) requiring parenteral

antibiotics therapy was also recorded as an infectious

event. Infections were reported as CMC treatment

related if they developed on therapy or within 4

weeks of the completion of the CMC therapy.

Statistical analysis

Statistical analysis of the differences in the percentages

of NHL patients’ response was evaluated using the

chi-square test. Ninety-five percent confidence inter-

vals for response probability were calculated using the

method described by Duffy and Santner [30]. Failure

free survival (FFS) and overall survival (OS) curves

were calculated using the method of Kaplan and

Meier [31] and compared between groups using the

log-rank test. FFS was measured from the onset of CR

or PR achievement to the time of disease recurrence.

OS was determined from the onset of treatment until

the last follow-up evaluation or death from any cause.

The duration of response was calculated from the

onset of CR or PR achievement to the time of

recurrence, last follow-up or death.

Results

Thirty-six patients with refractory or relapsed NHL

were enrolled into the study and 33 of them were

available for evaluation of response. There were 14

patients with mantle cell lymphoma (MCL), 10 with

diffuse large B-cell lymphoma (DLBCL), 5 with

follicular lymphoma (FL), 3 with small lymphocytic

lymphoma (SLL) and 4 with T-cell lymphomas.

Their characteristics are presented in Table I. All

patients received at least one standard chemotherapy

regimen and had failed to respond or progressed after

an initial response. The median number of previous

regimens administered was 2 (range 1 – 4 regimens

per patient) and the median disease duration before

the CMC therapy was 13.5 months (range 3.6 – 163

months). Twenty-one (58%) patients had refractory

disease after prior therapy, and 15 (42%) were

recurrent. Most of the patients experienced advanced

disease before entering the study, 32 (89%) patients

had disease stage III/IV, 27 (75%) elevated serum

LDH, 33 (92%) elevated b2-microglobulin levels,

and 21 (58%) bone marrow involvement. In total,

104 courses of the CMC regimen were given to the

entire group. All 33 patients, who were available for

response assessment, received at least two CMC

courses. The median number of CMC courses was 3

(range 2 – 6 courses).

Response and survival

Response and survival analysis was based on disease

status in September 2006. Nineteen patients re-

sponded (58%; 95% CI, 41 – 75%) to the CMC

treatment. Seven patients (21%; 95% CI, 7 – 35%)

achieved a CR and 12 patients (36%; 95% CI, 20 –

52%) achieved a PR. The remaining 14 patients

(42%; 95% CI, 25 – 59%) had either stable or

progressive disease.

The response to CMC treatment according to

different histological diagnosis is presented in

Table II. Overall response (OR) was obtained in

7 patients (54%; 95% CI 27 – 81%) with MCL,

in 5 patients (62.5%; 95% CI 29 – 96%) with

DLBCL. The OR was also obtained in 2 patients

(40%) with FL, in 3 patients (100%) with SLL, and 2

patients (50%) with T-cell lymphoma. There were no

statistically significant differences in response to

1094 T. Robak et al.

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

CMC within different NHL histological subtypes.

When different disease status (refractory or recurrent)

before the CMC therapy was considered, no sig-

nificant differences was found in terms of OR rates.

Detailed characteristics of the patients who re-

sponded to the CMC therapy are shown in Table III.

Seven of 19 patients who achieved a CR or a PR are

still in remission at the time of this report with a

median follow-up of 3 months (range 2 – 17 months).

The median failure-free survival (FFS) of responders

was 5 months (range 2 – 17 months).

The median overall survival (OS) for the entire

group of 36 patients was 9 months (range 0.1 – 77

months), and the median OS for responders was 12.5

months (range 3 – 77 months). There was a signifi-

cant difference in overall survival between responders

and non-responders after the CMC therapy (log rank

test, P¼ 0.015) (Figure 1). When different disease

status before CMC was considered, no significant

differences were found between refractory and

recurrent patients in FFS (log rank test, P¼ 0.1);

however, in terms of OS, a trend toward longer

survival of recurrent patients was observed (log rank

test, P¼ 0.08) (Figure 2).

During the whole period of follow-up, 25 patients

died, including 17 deaths from the disease progres-

sion, three treatment related deaths (one septic shock

after the 1st cycle, and two septic shocks after the 3rd

cycle), and five deaths from other causes. Of five

deaths that were not related to the treatment, two were

caused by infectious complications and occurred

during the further chemotherapy given after comple-

tion of participation in this study, one patient died

because of stroke during the follow-up period, and

two deaths were caused by circulatory failure; one

patient had a myocardial infarction and left ventricular

failure after the 1st cycle, and the second patient had

left ventricular failure during further chemotherapy

given due to disease progression. Among 25 deaths,

three were recorded as early deaths before completing

two CMC cycles; one patient died due to septic shock

after the 1st cycle, a second suffered a myocardial

infarction and left ventricular failure after the 1st

cycle, and the third patient died because of disease

progression. These three patients were not considered

for response assessment.

Toxicity

The major toxicity was myelosuppression. Severe

neutropenia (Grade 3 – 4 according to the WHO

classification) was observed in 14 patients (39%) and

in total 32 episodes (31%) were seen during all 104

CMC courses. Sixteen episodes (15%) of Grade 3 – 4

infections were observed, including nine cases of

severe pneumonia, two herpes zoster infections, one

case of influenza-like syndrome, and three episodes

of fever of unknown origin (FUO). Four cases of

pneumonia were microbiologically documented and

were caused by Gram-positive micro-organisms,

mainly Streptococci. Pneumonia caused by Pneumo-

cystis carinii or other opportunistic micro-organisms

were not documented. The intervals between CMC

courses due to myelosuppression and/or infections

were prolonged from 2 to 8 weeks in 15 (45%)

patients. There were three treatment related deaths.

These patients died from severe pneumonia compli-

cated by septic shock and agranulocytosis; one

patient died after the first cycle, and two patients

after the third cycle. Grade 3 – 4 thrombocytopenia

or anaemia was observed in nine patients (25%) and

10 patients (28%), respectively. Vomiting of Grade 3

was observed in four patients (11%) and alopecia in

five patients (14%). Toxicity of the CMC therapy is

summarised in Table IV.

Late haematological and non-haematological toxi-

cities were also observed in the study group. Four

weeks after the completion of the CMC therapy,

Grade 3 – 4 neutropenia was observed in six patients

(18%) with the median value of 2.36 109 l71 (range

0.4 – 10.0). Grade 3 – 4 thrombocytopenia or anae-

mia was observed in six patients (18%) and two

patients (6%), respectively. The median platelets

count was 1196 109 l71 (range 11 – 3986 109 l71),

and the median haemoglobin level was 11.3 g/dl

(range 6.6 – 14.7 g/dl). Late Grade 3 – 4 infections,

Table II. Response rate and response duration of 33 NHL patients.

Type of lymphoma No. of patients OR (%) CR (%)

No. of CMC courses,

median (range)

Median response duration

in months (range)

Mantle cell lymphoma 13 7 (54) 1 (8) 3 (2 – 6) 6 (2 – 16)

Diffuse large B-cell lymphoma 8 5 (62.5) 2 (25) 2 (2 – 6) 4 (2 – 17)

Follicular lymphoma 5 2 (40) 1 (20) 3 (2 – 4) 8 (3 – 13)

Small lymphocytic lymphoma 3 3 (100) 2 (67) 4 (2 – 4) 6 (4 – 27)

T-cell lymphoma* 4 2 (50) 1 (25) 2.5 (2 – 4) 3.5 (2 – 5)

Total 33 19 (58) 7 (21) 3 (2 – 6) 4 (2 – 27)

*T-cell lymphomas included anaplastic large T-cell lymphoma, Sezary syndrome, angioimmunoblastic lymphoma, T-cell lymphoblastic

lymphoma. OR, overall response; CR, complete response.

Cladribine, cyclophosphamide, and mitoxantrone in NHL 1095

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

Tab

leII

I.C

har

acte

rist

ics

of

pat

ien

tsw

ho

resp

on

ded

toC

MC

ther

apy.

Pat

ien

tn

o.

Dia

gn

osi

s

An

nA

rbo

rst

age

bef

ore

CM

C

Dis

ease

stat

us

bef

ore

CM

C

Pri

or

trea

tmen

t

(No

.o

fco

urs

es)

No

.of

CM

Cco

urs

es

Tim

eb

etw

een

firs

t

and

last

CM

C(m

on

ths)

Res

po

nse

toC

MC

Du

rati

on

of

resp

on

se(m

on

ths)

1M

CL

IVre

curr

ent

CH

OP

(4)

65

PR

16

2M

CL

IVre

frac

tory

CH

OP

(5)

33

CR*

3{

3M

CL

IVre

frac

tory

CH

OP

(6)

33

PR

4

4M

CL

IVre

curr

ent

CO

P(4

)C

HO

P(3

)4

5P

R*

6{

5M

CL

III

refr

acto

ryC

HO

P(6

)2

1P

R*

2{

6M

CL

IVre

frac

tory

CO

P(6

)3

3P

R9

7M

CL

III

refr

acto

ryC

OP

(6)

34

PR

12

8D

LB

CL

IVre

curr

ent

CH

OP

(9)

22

PR*

2{

9D

LB

CL

IVre

curr

ent

CH

OP

(4)

CH

OP

-Ble

o(6

)2

1C

R*

17{

10

DL

BC

LIV

recu

rren

tC

HO

P(3

)C

HO

P-B

leo

(3)

DH

AP

(2)

21

PR*

3{

11

DL

BC

LIV

recu

rren

tC

HO

P(4

)C

HO

P-B

leo

(6)

IMV

PIG

(6)

65

CR

11

12

DL

BC

LIV

refr

acto

ryC

HO

P(4

)D

HA

P(1

)3

3P

R3

13

FL

IIre

curr

ent

CH

OP

(6)

Rit

(2)

43

PR

3{

14

FL

III

recu

rren

tC

HO

P(1

2)

Rit

ux

(4)

45

CR

13{

15

SL

LII

Ire

frac

tory

CO

P(5

)C

HO

P(4

)Id

aþ

2-C

DA

(2)

43

PR

6

16

SL

LIV

refr

acto

ryC

OP

(4)

CH

OP

(6)

2-C

DA

(2)

21

CR

4

17

SL

LII

Ire

curr

ent

CO

P(1

2)

Idaþ

2C

DA

(3)

44

CR

16

18

AIL

DII

Ire

frac

tory

CH

OP

(4)

33

PR

2

19

T-L

LII

refr

acto

ryC

HO

P(5

)2

1C

R*

5{

*P

atie

nts

aliv

e,in

CR

/PR

.{ P

atie

nts

aliv

e.

MC

L,

man

tle

cell

lym

ph

om

a;D

LB

CL

,d

iffu

sela

rge

B-c

ell

lym

ph

om

a;F

L,

follic

ula

rly

mp

ho

ma;

SL

L,

smal

lly

mp

ho

cyti

cly

mp

ho

ma;

AIL

D,

angio

imm

un

ob

last

icly

mp

ho

ma;

T-L

L,

T-c

ell

lym

ph

ob

last

icly

mp

ho

ma;

CH

OP

,cy

clo

ph

osp

ham

ide,

do

xoru

bic

in,

vin

cris

tin

e,p

red

nis

on

e;B

leo

,b

leo

myc

in;

Ida,

idar

ub

icin

;R

it,

ritu

xim

ab;

2-C

dA

,cl

adri

bin

e;D

HA

P,

dex

amet

has

on

e,

do

xo

rub

icin

,cy

tara

bin

e,p

red

nis

on

e.

1096 T. Robak et al.

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

which occurred beyond 4 weeks after the last CMC

cycle and before the beginning of subsequent

chemotherapy, were observed in six patients (18%).

During the follow-up period, secondary cancers or

acute myeloid leukaemia (AML) were not observed

in any of the patients.

Discussion

In this study we report on the efficacy and toxicity of

the CMC regimen in patients with relapsed or

refractory NHL. We evaluated here a heterogeneous

group of 36 patients, most of whom were diagnosed

with MCL (14/36) and DLBCL (10/36). The results

suggest a good level of anti-tumour activity and an

acceptable tolerance of the CMC regimen. Among

33 evaluated patients, an overall response rate was

58%, including 21% of patients who achieved a CR.

The results are comparable to those previously

reported by us, with an overall response rate of

48.6% and a CR rate of 12.1% in the group of heavily

pre-treated patients with indolent lymphoid malig-

nancies (19 patients with CLL and 14 with LG-

NHL) [27].

Cladribine has been reported to be active as the

first-line therapy or in the first relapse among

patients with MCL achieving a response rate of

58% [9,10]. It is noteworthy that patients refractory

to 2-CDA did not respond to other salvage

therapies like CHOP or Dexa-BEAM. Rummel

et al. [23] reported later on increased efficacy of

the combination treatment with reduced-dose of

2-CdA and mitoxantrone in previously untreated

or relapsed patients with MCL. They achieved a

response rate of 100% with a CR rate of 44%.

2-CdA is a potent inhibitor of DNA repair and

mitoxantrone acts as a DNA-damaging agent. Thus,

simultaneous use of these drugs enhances their anti-

tumour activity [22]. High response rates to the

combined chemotherapy observed by Rummel et al.

in MCL patients confirm its superiority to mono-

therapy. Another purine analog, fludarabine, has

been also shown to be effective in the treatment of

low-grade lymphomas, and in particular of MCL

[32,33]. Similar to 2-CdA, fludarabine seems to be

more active if it is combined with cyclophospha-

mide or cyclophosphamide and mitoxantrone

[32,33]. The German Low-Grade Lymphoma

Study Group obtained an overall response rate of

46% in relapsed or refractory MCL patients who

received combination therapy with fludarabine,

cyclophosphamide and mitoxantrone [34]. Recent

studies have indicated that the addition of mono-

clonal antibody, rituximab, may increase the clinical

effectiveness of standard chemotherapy [34 – 37].

Forstpointner et al. [34] achieved a higher overall

Figure 1. Kaplan – Meier overall survival (OS) curve for responders and non-responders to CMC treatment.

Cladribine, cyclophosphamide, and mitoxantrone in NHL 1097

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

response rate (79% vs. 58%), a higher complete

remission rate (33% vs. 13%), and a superior

overall survival at 2 years (90% vs. 70%) in

relapsed/refractory LG-NHL patients treated with

rituximab combined with chemotherapy (R-FMC)

compared with that of those who received che-

motherapy alone (FCM). It may be therefore

speculated that the addition of rituximab to the

Figure 2. Kaplan – Meier failure-free survival (FFS) (A) and overall survival (OS) (B) curves for NHL patients refractory or recurrent to prior

CMC treatment.

1098 T. Robak et al.

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

CMC therapy could also improve the prognosis of

heavily pre-treated NHL patients. The addition of

rituximab may render tumour cells susceptible to

apoptosis and enhance the effect of subsequent

chemotherapy.

One of the most interesting observations in our

study is the results obtained for DLBCL patients.

Five patients (62.5%) responded to the CMC

treatment, and two of them achieved a CR despite

refractoriness to previous treatment regimens. In our

study, one patient with a CR after the CMC

treatment received subsequently high dose therapy

followed by autologous stem cell transplantation

(autoSCT) and remained in remission for 15 months.

Although purine analogs in monotherapy were

reported to be ineffective against high grade lympho-

mas [38], promising results have been obtained for

combination chemotherapy. Fludarabine combined

with dexamethasone, cytosine arabinoside and cis-

platinum (FluDAP) showed high activity in relapsed/

refractory aggressive NHL patients [39], while the

combination of fludarabine with cyclophosphamide

was effective in the treatment of refractory peripheral

T-cell lymphoma concurrent with DLBCL [40]. Our

results suggest that CMC therapy could be used in

the treatment of refractory or relapsed patients with

high grade lymphomas. Moreover, patients who

respond to CMC treatment could then be considered

for autologous haematopoietic stem cell transplanta-

tion [41 – 43].

An additional aim of our study was the evaluation

of the treatment-related toxicity of the CMC therapy.

We have shown that the major toxicity of this

regimen was myelosuppression. It was manifested

with 39% of Grade 3 – 4 neutropenia, complicated

with 16 episodes (15%) of Grade 3 – 4 infections.

Grade 3 – 4 thrombocytopenia was observed in 25%

and anaemia in 28% of patients. However, it has

been reported that cladribine alone induces Grade

3 – 4 neutropenia in 17%, and Grade 3 – 4 thrombo-

cytopenia in 2% of patients [9,10]. The main reason

for myelotoxicity was the use of the CMC regimen in

heavily pre-treated patients. Additionally, the dose of

mitoxantrone (10 mg/m2) we used was high and

higher than the dose (8 mg/m2) used by Forstpoint-

ner et al. [34,37]. They also observed neutropenia in

40% of the pre-treated patients; however, the

incidence of Grade 3 – 4 neutropenia and thrombo-

cytopenia was significantly lower [34,37]. Late

toxicity was also mainly manifested by Grade 3 – 4

neutropenia and infections observed in 18% of

patients. Further reduction of myelosuppression

and infections may be most likely achieved with the

prophylactic use of growth factors following che-

motherapy cycle as well as antibacterial and antiviral

agents. Additionally, myelosuppression could be

diminished by reducing the dose of mitoxantrone to

8 mg/m2.

Based on these results, it can be concluded that the

combination of 2-CdA, mitoxantrone and cyclophos-

phamide is a highly effective salvage therapy for

relapsed or refractory NHL patients, in particular, for

those with MCL and DLBCL. However, the toxicity

of the CMC treatment is significant, although it is

restricted mainly to myelosuppression and infections.

The CMC regimen can be considered a valuable

treatment choice for heavily pre-treated NHL pa-

tients; however, a prospective, randomized study

comparing the efficacy of the CMC regimen with

cladribine alone should be undertaken.

References

1. Robak T, Korycka A, Kasznicki M, Wrzesien-Kus A,

Smolewski P. Purine nucleoside analogues for the treatment

of hematological malignancies: pharmacology and clinical

applications. Curr Cancer Drug Targets 2005;5:424 – 444.

2. Tallman MS, Hakimian D. Purine nucleoside analogs:

emerging roles in indolent lymphoproliferative disorders.

Blood 1995;86:2463 – 2474.

3. Kay AC, Saven A, Carrera CJ, Carson DA, Thurston D,

Beutler E, et al. 2-chlorodeoxyadenosine treatment of low-

grade non-Hodgkin’s lymphomas. J Clin Oncol 1992;10:371 –

377.

4. Betticher DC, von Rohr A, Ratschiller D, Schmitz SF,

Egger T, Sonderegger T, et al. Fewer infections but

maintained antitumor activity with lower-dose versus standard

dose caldribine in pretreated low grade non-Hodgkin’s

lymphoma. J Clin Oncol 1998;16:850 – 859.

5. Liliemark J, Porwit A, Juliusson G. Intermittent infusion

cladribine (CdA) in previously treated patients with low-grade

non-Hodkin’s lymphoma. Leuk Lymphoma 1997;25:313 –

318.

Table IV. Severe toxicity of CMC treatment.

Toxicity (Grade 3 – 4 according to WHO) Number of patients, N¼36 (%) Number of cycles, N¼104 (%)

Neutropenia 14 (39) 32 (31)

Thrombocytopenia 9 (25) 15 (14)

Anaemia 10 (28) 17 (16)

Infections and FUO* 10 (25) 16 (15)

Vomiting 4 (11) 5 (5)

Alopecia 5 (14) 6 (6)

*FUO, fever of unknown origin.

Cladribine, cyclophosphamide, and mitoxantrone in NHL 1099

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

6. Robak T, Gora-Tybor J, Krykowski E, Walewski JA,

Borawska A, Płu_zanska A, et al. Activity of 2-chlorodeox-

yadenosine (Cladribine) in 2-hour intravenous infusion in 94

previously treated patients with low-grade non-Hodgkin’s

lymphoma. Leuk Lymphoma 1997;26:99 – 105.

7. Tulpule A, Schiller G, Harvey-Buchanan LA, Lee M,

Espina BM, Khan AU, et al. Cladribine in the treatment of

advanced relapsed or refractory low and intermediate grade

non-Hodgkin’s lymphoma. Cancer 1998;83:370 – 376.

8. Ogura M, Morishima Y, Kobayashi Y, Uike N, Sugai S,

Chou T, et al. Durable response but prolonged cytopenia after

cladribine treatment in relapsed patients with indolent non-

Hodgkin’s lymphomas: results of Japanese phase II study. Int J

Haematol 2004;80:267 – 277.

9. Rummel MJ, Chow KU, Jager E, Leimer L, Hossteld DK,

Bergmann L, et al. Intermittent 2-hour infusion of cladribine

as first-line therapy or in first relapse of progressive advanced

low-grade and mantle cell lymphomas. Leuk Lymphoma

1999;82:957 – 964.

10. Rummel MJ, Chow KU, Jager E, Hossfeld DK, Bergmann L,

Peters HD, et al. Treatment of mantle-cell lymphomas with

intermittent two-hour infusion of cladribine as first-line

therapy or in first relapse. Ann Oncol 1999;10:115 – 117.

11. Kong LR, Huang CF, Hakimian D, Variakojis D, Klein L,

Kuzel TM, et al. Long term follow-up and late complications of

2-chlorodeoxyadenosine in previously treated, advanced in-

dolent non-Hodgkin’s lymphoma. Cancer 1998;82:957 – 964.

12. Saven A, Emanuele S, Kosty M, Kozioł J, Ellison D, Piro L.

2-chlorodeoxyadenosine activity in patients with utreated in-

dolent non-Hodgkin’s lymphoma. Blood 1995;86:1710 – 1716.

13. Fridrik M, Jager G, Kienzer HR, Hausmaninger H, Oppitz P,

Krieger O, et al. Efficacy and toxicity of 2-chlorodeoxyade-

nosine (Cladribine)– 2 h infusion for 5 days – as first-line

treatment for advanced low-grade non-Hodgkin’s lymphoma.

Eur J Cancer 1998;34:1560 – 1564.

14. Van Den Neste E, Bontemps F, Delacauw A, Cardoen S,

Louviaux I, Scheiff JM, et al. Potentiation of antitumor effects

of cyclophosphamide derivatives in B-chronic lymphocytic

leukemia cells by 2-chloro-20-deoxyadenosine. Leukemia

1999;13:918 – 925.

15. Gora-Tybor J, Robak T. Synergistic action of 2-chlorodeox-

yadenosine and cyclophosphamide on murine leukemia L1210

and P388. Acta Haematol Pol 1993;24:177 – 182.

16. Hoffman M, Xu JC, Lesser M, Rai K. Cytotoxicity of 2-

chlorodeoxyadeosine (cladribine – 2-CdA) in combination

with other chemotherapy drugs against two lymphoma cell

lines. Leuk Lymphoma 1999;33:141 – 145.

17. Szmigielska-Kapłon A, Ciesielska E, Smigiero L, Robak T.

Anthracyclines potentiate activity against murine leukemias

L1210 and P388 in vivo and in vitro. Eur J Haematol

2002;68:370 – 375.

18. Laurencet FM, Ballabeni P, Rufener B, Hess U, Cerny T,

Fey M, et al. The multicenter trial SAKK 37/95 of cladribine,

cyclophosphamide and prednisone in the treatment of

chronic lymphocytic leukemias and low-grade non-Hodgkin’s

lymphomas. Acta Haematol 2007;117:40 – 47.

19. Van den Neste E, Louviaux I, Michaux JL, Delnnoy A,

Michaux L, Sonet A, et al. Phase I/II study of 2-chloro-2-

deoxyadenosine with cyclophosphamide in patients with

pretreated B-cell chronic lymphocytic leukemia and indolent

non-Hodgkin’s lymphoma. Leukemia 2000;14:1136 – 1142.

20. Kalinka E, Wajs JJ, Sułek KS, Blasinska-Morawiec M,

Centkowski P, Ceglarek B, et al. Randomized comparison of

cladribine single (C) or in combination with cyclophospha-

mide (CC) and COP in previously untreated low-grade B-cell

non-Hodgkin lymphoma patients. Blood 2006;108 (Suppl

1):703a (abstract 2481).

21. Robak T, Gora-Tybor J, Urbanska-Rys H, Krykowski E.

Combination regimen of 2-chlorodeoxyadenosine (cladri-

bine), mitoxantrone and dexamethasone (CMD) in the

treatment of refractory and recurrent low-grade non Hodg-

kin’s lymphoma. Leuk Lymphoma 1999;32:359 – 368.

22. Armitage JO, Tobinai K, Hoelzer D, Rummel MJ. Treatment

of indolent non-Hodgkin’s lymphoma with cladribine as

single-agent therapy and in combination with mitoxantrone.

Int J Hematol 2004;79:311 – 321.

23. Rummel MJ, Chow KU, Karakas T, Jager E, Mezger J, von

Grunhagen U, et al. Reduced dose cladribine (2-CdA) plus

mitoxantrone is effective in the treatment of mantle cell and

low-grade non-Hodgkin’s lymphoma. Eur J Cancer

2002;38:1739 – 1746.

24. Robak T, Gora-Tybor J, Chojnowski K. Cladribine as

monotherapy or combined with dexamethasone and idarubi-

cin or mitoxantrone in previously treated patients with low

grade lymphoid malignancies. Haematologica 2000;85:215 –

216.

25. Robak T, Błonski JZ, Kasznicki M, Gora-Tybor J, Dwilewicz-

Trojaczek J, Boguradzki P, et al. Cladribine combined with

cyclophosphamide and mitoxantrone as front-line therapy

in chronic lymphocytic leukemia. Leukemia 2001;15:1510 –

1516.

26. Robak T, Błonski JZ, Gora-Tybor J, Jamroziak K, Dwilewicz-

Trojaczek J, Tomaszewska A, et al. Cladribine alone and in

combination with cyclophosphamide or cyclophosphamide

plus mitoxantrone in the treatment of progressive chronic

lymphocytic leukemia: report of a prospective, multicenter

randomized trial of the Polish Adults Leukemia Group (PALG

CLL 2). Blood 2006;108:473 – 479.

27. Robak T, Gora-Tybor J, Lech-Maranda E, Błonski JZ,

Kasznicki M. Cladribine in combination with mitoxantrone

and cyclophsophamide (CMC) in the treatment of heavily

pretreated patients with advanced indolent lymphoid malig-

nancies. Eur J Haematol 2000;66:188 – 194.

28. Cheson BD, Horning SJ, Coiffier B, Shipp MS, Fisher RI,

Connors JM, et al. Report of an international workshop to

standardize response criteria for non-Hodgkin’s lymphomas. J

Clin Oncol 1999;17:1244 – 1253.

29. Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting

results of cancer treatment. Cancer 1981;47:207 – 214.

30. Duffy DR, Santner TJ. Confidence intervals binomial para-

meter based on multistage tests. Biometrics 1987;47:207 –

214.

31. Kaplan EL, Meier P. Nonparametric estimation from in-

complete observations. J Am Stat Assoc 1958;53:457 –

481.

32. Cohen BJ, Moskowitz C, Straus D, Noy A, Mednick E,

Zelenetz A. Cyclophosphamide fludarabine (CCF) is active in

the treatment of mantle cell lymphoma. Leuk Lymphoma

2001;42:1015 – 1022.

33. Thomas DW, Owen RG, Johnson SAN, Hillmen P,

Seymour JF, Wolf MM, Rule SAJ. Superior quality and

duration of response among patients with mantle cell

lymphoma treated with fludarabine and cyclophosphamide

with or without rituximab compared with prior responses to

CHOP. Leuk Lymphoma 2005;46:549 – 552.

34. Forspointer R, Dreyling M, Repp R, Hermann S, Hanel A,

Metzner B, et al. The addition of rituximab to a combination

of fludarabine, cyclophosphamide, mitoxantrone (FCM)

significantly increases the response rate and prolongs

survival as compared with FCM alone in patients with

relapsed and refractory follicular and mantle cell lymphomas:

results of a prospective randomized study of the German

Low-Grade Lymphoma Study Group. Blood 2004;104:

3064 – 3071.

1100 T. Robak et al.

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.

35. Robak T, Smolewski P, Cebula B, Blonski JZ. Rituximab

combined with cladribine or with cladribine and cyclopho-

sphamide in heavily pretreated patients with indolent lympho-

proliferative disorders and mantle cell lymphoma. Cancer

2006;107:1542 – 1550.

36. Robak T. Rituximab plus purine nucleoside analogs in the

treatment of indolent lymphoid malignancies. Am J Cancer

2005;4:279 – 292.

37. Forspointner R, Unterhalt M, Dreyling M, Bock HP, Repp R,

Wandt H, et al. Maintenance therapy with rituximab leads to a

significant prolongation of response duration after salvage

therapy with a combination of rituximab, fludarabine,

cyclophosphmide and mitoxantrone (R-FCM) in patients

with recurring and refractory follicular and mantle cell

lymphomas: results of a prospective randomized study of the

German Low Grade Lymphoma Study Group (GLSG). Blood

2006;108:4003 – 4008.

38. Redman JR, Cabanillas F, Velasquez WS, Mc Laughlin P,

Hagemeister FB, Swan F Jr, et al. Phase II trial of fludarabine

phosphate in lymphoma an effective new agent in low-grade

lymphoma. J Clin Oncol 1992;10:790 – 794.

39. Child JA, Johnson SA, Rule S, Smith GM, Morgan GJ,

Johnson PW, et al. FLUDAP: salvage chemotherapy for

relapsed/refractory aggressive non-Hodgkin’s lymphoma.

Leuk Lymphoma 2000;37:309 – 317.

40. Yamaguchi M, Kotani T, Nkamura Y, Ueda M. Successful

treatment of refractory peripheral T-cell lymphoma with a

combination of fludarabine and cyclophosphamide. Int J

Hematol 2006;83:450 – 453.

41. Villanueva ML, Vose JM. The role of hematopoietic stem cell

transplantation in non-Hodgkin lymphoma. Clin Adv Hema-

tol Oncol 2006;4:521 – 530.

42. Van Besien K. The evolving role of autologous and allogeneic

stem cell transplantation in follicular lymphoma. Blood Rev

2006;20:235 – 244.

43. Laudi N, Arora M, Burns L, McGlave P, Miller J, Bohac G,

et al. Efficacy of high-dose therapy and hematopoietic stem

cell transplantation for mantle cell lymphoma. Am J Hematol

2006;81:519 – 524.

Cladribine, cyclophosphamide, and mitoxantrone in NHL 1101

Leu

k L

ymph

oma

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f M

inne

sota

on

05/1

5/13

For

pers

onal

use

onl

y.