Lymphoproliferative Disorders
`research paper
`Fludarabine + prednisone ± α-interferon followed or not by α-interferon
`maintenance therapy for previously untreated patients with chronic lymphocytic
`leukemia: long term results of a randomized study
`FRANCESCA R. MAURO, PIERLUIGI ZINZANI, FRANCESCO ZAJA, MASSIMO GENTILE, MARIA LUCE VEGNA, VITTORIO STEFONI, LUCIANA MARIN, RENATO FANIN,
`MICHELE BACCARANI, SANTE TURA, FRANCO MANDELLI
`
`Background and Objectives. Fludarabine is an effective
`therapy for patients with chronic lymphocytic leukemia (CLL)
`and interferon-α (IFN-α) has been reported to have anti-
`leukemic activity in CLL patients. A randomized study was
`designed to evaluate whether the addition of IFN-α to a
`first-line treatment with fludarabine and prednisone could
`increase the response rate in patients with advanced CLL
`and whether IFN-α given as maintenance therapy could
`improve the duration of response.
`Design and Methods. One hundred and thirty-three
`patients were randomized to receive fludarabine (25
`mg/m2/i.v, days 9-13) and prednisone (20 mg/m2, days 1,
`3, 5, 7 and 14 and 40 mg/m2, days 9-13) (arm A: 66
`patients) or in addition to the same schedule, IFN-α (2
`MUI/sc, days 1, 3, 5, 7, 9, 11, 13 and 15) (arm B: 67
`patients). Seventy-eight patients responsive to therapy
`entered the post-remission phase of the study in which 41
`patients were randomized to receive IFN-α (3 MUI three
`times a week) and 37 to clinical observation.
`Results. A similar response rate (complete responses +
`partial responses) was observed in the 2 arms: 86% for arm
`A and 84% for arm B (p = 0.4). A longer response duration
`was observed in patients who achieved a complete response
`(p = 0.001) and in patients who received maintenance ther-
`apy with IFN-α (p < 0.05). However, the quality of response
`was the only significant and independent factor influencing
`response duration (p < 0.01). No benefits in terms of infec-
`tion-related mortality and morbidity could be ascribed to
`IFN-α administration.
`Interpretation and Conclusions. In previously untreated
`CLL patients with advanced disease a high response rate is
`obtained from first-line fludarabine and prednisone and no
`benefit is derived from the addition of IFN-α to this regimen.
`The achievement of a good quality response to therapy was
`the only independent predictor of a prolonged response.
`
`Key words: chronic lymphocytic leukemia, treatment,
`fludarabine, α-interferon.
`
`Haematologica 2003; 88:1348-1357
`http://www.haematologica.org/2003_12/1348.htm
`
`©2003, Ferrata Storti Foundation
`
`From the Dept. of Cell Biotechnology and Hematology, Università “La Sapien-
`za” di Roma (FRM, MG, MLV, FM); Istituto di Ematologia ed Oncologia “L. & A.
`Seragnoli”, Università di Bologna (PLZ, VS, MB, ST); Istituto di Ematologia,
`Università di Udine (FZ, LM, RF), Italy.
`
`Correspondence: Francesca R. Mauro, Dipartimento di Biotecnologie Cellulari
`ed Ematologia, University “La Sapienza”, via Benevento 6, 00161 Rome, Italy.
`E-mail: mauro@bce.med.uniroma1.it
`
`During the last 10 years three prospective random-
`
`ized studies have demonstrated that fludarabine
`therapy is superior to CAP (cyclophosphamide, dox-
`orubicin, and prednisone),1 CHOP (cyclophosphamide,
`vincristine, doxorubicin, and prednisone)2 and chloram-
`bucil3 as first-line treatment of patients with chronic
`lymphocytic leukemia (CLL). However, most patients
`relapse after 2-4 years suggesting that fludarabine has
`a very effective debulking activity, but that it is not cura-
`tive: residual disease represents the main cause of
`relapse.
`Interferon-α (IFN-α) is a biological agent with multi-
`ple properties including inhibition of cell proliferation
`and modulation of cellular immunity.4-5 IFN-α has been
`shown to have an anti-tumor effect in different hema-
`tologic malignancies, in particular multiple myeloma,
`non-Hodgkin’s lymphoma and hairy cell leukemia.6-12
`During the late eighties, several clinical trials evaluated
`the anti-tumor activity of IFN-α, given at variable dos-
`es and for different durations, as a single agent in CLL
`patients with different clinical pictures. While only lim-
`ited activity was recorded in patients previously treated
`and with advanced disease,13-16 a higher response rate
`was observed in untreated patients with early disease.17-
`22 Furthermore, some authors reported a therapeutic ben-
`efit of IFN-α given as post-remission therapy.23,24
`A synergistic effect of IFN-α with several cytotoxic
`drugs has been documented in vitro25 and favorable clin-
`ical results in patients with low grade lymphoma have
`been described.26 Positive clinical results were reported
`by Mandelli et al.27 and by Molica et al.28 in small series
`of CLL patients with advanced disease treated with a
`regimen including chlorambucil, prednisone and IFN-α.
`On the basis of the anti-leukemic activity shown by
`IFN-α given alone or in combination with cytotoxic
`drugs and considering its potential immuno-modulato-
`ry properties, a multicenter study was designed to eval-
`uate the therapeutic effect of IFN-α in previously
`untreated CLL patients with advanced disease. The study
`was characterized by two randomized phases. In the first
`phase, the activity and toxicity of two induction sched-
`ules, fludarabine and prednisone with or without IFN-α,
`were evaluated. The primary objective of this first part of
`the study, which included 134 CLL patients, was to eval-
`uate whether the addition of IFN-α could increase the
`response rate. In the second phase, patients who
`achieved a response to induction therapy were random-
`ized to receive IFN-α as maintenance therapy or no
`treatment. The primary objective of this second part of
`
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`haematologica/journal of hematology vol. 88(12):december 2003
`
`WCK1045
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`

`
`Maintenance therapy for previously untreated patients with CLL
`
`the study, which included 78 CLL patients, was to
`evaluate whether the administration of IFN-α as
`maintenance therapy could improve the response
`duration. Herein, we report, the results of this study.
`
`Design and Methods
`
`Patients
`One hundred and thirty-four patients with
`untreated progressive or advanced CLL were pro-
`spectively enrolled into a randomized clinical trial
`between March 1993 and December 1998. Patients
`were recruited from three Italian hematologic cen-
`ters: Dipartimento di Biotecnologie Cellulari ed
`Ematologia, University “La Sapienza” of Rome (74
`patients), Istituto di Ematologia ed Oncologia “L. &
`A. Seragnoli”, University of Bologna (32 patients),
`and Istituto di Ematologia, University of Udine (28
`patients).
`
`Pre-study evaluation and eligibility criteria
`All patients fulfilled the National Cancer Insti-
`tute-Sponsored Working-Group diagnostic criteria
`for CLL.29 At baseline, peripheral blood lymphocytes
`were characterized by immunophenotyping and
`morphology as previously described.30 The stage of
`the disease was assessed according to Rai’s classi-
`fication.31 Pre-treatment work-up included a med-
`ical history, physical examination, complete periph-
`eral blood (PB) cell count with differential, bone
`marrow (BM) aspiration and biopsy, Ig quantifica-
`tion, liver and renal function tests and radiograph-
`ic examination (computerized tomography scans,
`ultrasounds).
`Eligibility criteria included: age 65 years or less, no
`prior treatment, advanced stage (III-IV) or interme-
`diate stage (I-II) with one or more clinical signs of
`active disease. Exclusion criteria included: prior
`treatment; autoimmune cytopenia; history of other
`malignancies within 2 years prior to study entry
`(except for adequately treated carcinoma in situ of
`the cervix; basal or squamous cell skin cancer);
`active infection requiring systemic therapy, human
`immunodeficiency virus infection, hepatitis B or C;
`history of uncontrolled hypertension, severe cardiac,
`pulmonary, or neurological disease; uncontrolled
`metabolic disorder; any co-existing medical or psy-
`chological condition that would preclude participa-
`tion in the study or compromise ability to give
`informed consent.
`The protocol was approved by the local ethics
`committee. All patients gave written informed con-
`sent before enrollment into the study which was
`carried out in accordance with the Good Clinical
`Practice precepts.
`
`Treatment plan
`Eligible patients were centrally randomized to one
`of the two induction treatments (arm A or arm B).
`
`Randomization was balanced for each participating
`center and stratified according to the following fac-
`tors: institution, stage and bone marrow histology.
`Arm A: fludarabine (Fludara®; kindly given by Scher-
`ing SpA) associated with prednisone.
`Fludarabine: 25 mg/m2 i.v. for 5 consecutive
`days, on days 9 to 13;
`Prednisone: 20 mg/m2 orally on days 1, 3, 5, 7
`and 14.
`Prednisone: 40 mg/m2 orally from day 9 to day
`13.
`Arm B: fludarabine associated with prednisone as in
`arm A with the addition of IFN-α as follows:
`IFN-α: (lymphoblastoid IFN-α; Wellferon®, kind-
`ly given by Glaxo-Wellcome) 2 MUI on days 1, 3,
`5, 7, 9, 11, 13 and 15.
`
`Both regimens were administered every 4 weeks
`for a total number of 6 courses. Patients achieving
`a complete or partial response (CR or PR) according
`to NCI criteria were considered for the second ran-
`domized part of the study, the post-remission phase.
`Patients were randomized to two post-remission
`approaches (arm C or arm D).
`Arm C: IFN-α: 3 MUI three times a week until dis-
`ease progression
`Arm D: no therapy.
`Randomization was stratified according to 3 fac-
`tors: institution, prior induction therapy and quali-
`ty of response. All study treatments were carried
`out on an outpatient basis and IFN-α was self-
`administered subcutaneously.
`
`Dose modifications
`In the presence of severe (III-IV grade according
`to WHO criteria) hematologic toxicity, the start of
`the subsequent course was delayed. In the case of
`severe cytopenias persisting for more than 2 weeks,
`treatment was discontinued, while, in the presence
`of moderate cytopenias, fludarabine and IFN-α dos-
`es were reduced by 50%. Treatment was withheld in
`the presence of grade III-IV non-hematologic WHO
`toxicity or major infection until the patient had
`recovered from toxicity or infection. In the case of
`recovery after more than 2 weeks or no recovery,
`patients were withdrawn from the study.
`
`Supportive care
`During fludarabine treatment and for at least 1
`year after therapy discontinuation, trimethoprim-
`sulphamethoxazole was given three times a week
`for Pneumocystis carinii prophylaxis. No granulo-
`cyte colony-stimulating factor (G-CSF) administra-
`tion was planned in the presence of neutropenia.
`Patients requiring blood transfusions were given
`irradiated products. To prevent flu-like symptoms,
`paracetamol was administered 30 minutes prior to
`IFN-α.
`
`haematologica/journal of hematology vol. 88(12):december 2003
`
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`

`
`F. R. Mauro et al.
`
`Table 1. Patients’ characteristics.
`
`No. of
`patients
`134 (%)
`
`FLU+PDN FLU+PDN p
`+IFN-α value
`67 (%)
`67 (%)
`
`Gender
`Male
`Female
`
`94 (70)
`40 (30)
`
`Median age (yrs.)
`range
`
`54
`34-65
`
`Median time from 12.6
`diagnosis (months)
`range
`0-103
`
`49 (73)
`18 (27)
`
`52.3
`34-64
`
`12.6
`
`0-98
`
`45 (67)
`22 (33)
`
`NS
`
`55.7
`37-65 < 0.01
`
`13.0
`
`NS
`
`0 -103
`
`Rai stage
`I+II
`III+IV
`
`117 (87)
`18 (13)
`
`58 (87)
`10 (13)
`
`59 (88) NS
`8 (12)
`
`Median
`hemoglobin (g/dL)
`range
`7.1-17.4
`
`13
`
`13
`
`12.9
`
`NS
`
`7.1-17.4
`
`7.8-16.0
`
`Median
`lymphocytes
`(×109/L)
`range
`
`Median platelets
`(×109/L)
`range
`
`67
`
`67
`
`67
`
`NS
`
`2-315
`
`2-315
`
`9-167
`
`157
`
`145
`
`166
`
`NS
`
`70-410
`
`70-410
`
`72-318
`
`Bone marrow histology
`diffuse
`58(43)
`non-diffuse
`76(57)
`
`LDH
`normal
`elevated
`
`94(70)
`40(30)
`
`NS: not significant.
`
`28(42)
`39(58)
`
`45(67)
`22(33)
`
`30(45)
`37(55)
`
`49(73)
`18(27)
`
`NS
`
`NS
`
`Response and toxicity evaluation
`Response to induction therapy was assessed
`according to NCI criteria.29 Response duration was
`measured from the time of achievement of the
`response to the time of disease progression. Disease
`progression was based on the presence on two
`monthly consecutive evaluations of one or more of
`the following disease-related signs: ≥ 50% increase
`in the absolute number of circulating lymphocytes
`(minimum number: at least 5000/µL); ≥ 50%
`increase of the size of spleen, liver and lymph-nodes
`(minimum diameter: at least 2 cm). Disease trans-
`formation was considered in the presence of a his-
`tologic diagnosis of lymphoma and in the case of an
`increase of the prolymphocyte rate ≥55% (prolym-
`phocytoid transformation). Autoimmune hemolytic
`anemia was considered to have developed when
`
`there were clinical signs of hemolysis associated
`with a positive Coombs’ test. Toxicity was evaluat-
`ed according to WHO criteria. Toxicity was sepa-
`rately recorded and evaluated in the two phases of
`the study, during the induction therapy and the
`post-remission phase, from response to the start of
`a second line therapy.
`
`Statistical analysis
`Statistical analysis included an evaluation of the
`response rate, of the actuarial time to progression
`probability and of the actuarial survival probability.
`The corrected χ2 test was applied to compare
`groups. Survival curves were calculated according to
`Kaplan and Meier32 from the time of first random-
`ization and from the time of second randomization
`to death, and compared with the log-rank test.33
`Response duration was calculated from the time of
`response to the time of disease progression or death.
`The prognostic significance of the following para-
`meters: gender (male vs female), age (≤55 vs >55
`years), time from CLL diagnosis to treatment (≤12 vs
`>12 months), stage according to the Rai classifica-
`tion (I+II vs III+IV), peripheral blood lymphocyte
`count (≤60 vs >60×109/L), LDH value (normal vs ele-
`vated), rate of peripheral blood lymphocyte reduc-
`tion after the second course of induction therapy
`(≤25 vs >25%), BM histology (non-diffuse vs dif-
`fuse), induction therapy regimen (fludarabine +
`prednisone vs fludarabine + prednisone + IFN-α:
`arm A vs arm B), on the probability of achieving a
`response was analyzed. Furthermore, the prognos-
`tic significance on response duration and survival
`duration of these same parameters, quality of
`response (CR vs PR) and type of post-remission
`approach (IFN-α vs no treatment) was evaluated.
`In order to evaluate the relative significance of
`prognostic factors emerging as such from the uni-
`variate analysis, the multiple regression model of
`Cox was applied.34
`
`Results
`
`Clinical features of patients
`The median age of the 134 CLL patients entered
`into the study was 54 years (range: 34-65 years).
`The median duration of CLL before the start of treat-
`ment was 12.6 months. More than two-thirds of
`patients were males and 13% had Rai stage III-IV
`disease. The median hemoglobin value was 13 g/dL,
`the median lymphocyte count 67×109/L and the
`median platelet count 157×109/L. The patients’
`characteristics are reported in Table 1.
`
`Induction therapy
`Sixty-seven patients were randomized to receive
`fludarabine and prednisone (arm A) and 67 were
`randomized to receive fludarabine, prednisone and
`IFN-α (arm B). The baseline clinical features of the
`
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`

`
`Maintenance therapy for previously untreated patients with CLL
`
`Table 2. Response to therapy by induction therapy
`arm.
`
`No. of patients FLU+PDN
`133 (%)
`66 (%)
`
`p
`FLU+PDN
`+IFN-α 67 (%) value
`
`Overall
`responses
`
`CR
`
`PR
`
`113 (85)
`
`57 (86)
`
`56 (84)
`
`NS
`
`50 (38)
`
`30 (45)
`
`20 (30)
`
`NS
`
`63 (47)
`
`27 (41)
`
`36 (54)
`
`NS: not significant.
`
`two groups of patients did not differ except for the
`higher median age (p < 0.01) of patients random-
`ized to receive no IFN-α (Table 1).
`Response to induction therapy. One patient in
`whom the immunologic characteristics did not ful-
`fill the criteria for a CLL diagnosis was retrospec-
`tively excluded from the study. No protocol devia-
`tions were recorded in the induction phase. Thus,
`response was assessed in 133 patients. The overall
`
`response rate (CR+PR) was 85% (113 patients) with
`no statistically significant differences between the
`two arms (arm A, fludarabine, prednisone: 86% vs
`arm B, fludarabine, prednisone and IFN-α: 84%; p
`= 0.4).
`A higher, though not significantly so, CR rate was
`observed in patients treated with fludarabine and
`prednisone compared to patients treated with these
`two drugs and IFN-α (45% vs 30%; p = 0.08) (Table
`2).
`Age, gender, prior CLL duration, LDH value, BM
`histology, PB lymphocyte count, and the introduc-
`tion of IFN-α in the induction regimen, showed no
`significant effect on the probability of achieving a
`response (CR+PR) while only 2 factors showed a sig-
`nificant and independent effect on the probability
`of achieving a response (CR+PR): the baseline ini-
`tial Rai stage (p = 0.05) and the rate of lymphocyte
`reduction, ≤25% or >25%, recorded after the sec-
`ond course of therapy (p = 0.01) (Table 3).
`
`Post-induction phase
`Second randomized phase of the study: IFN-αvs
`no therapy. Seventy-eight of the 113 patients who
`had a response (69%) were subsequently random-
`ized to receive maintenance treatment with IFN-α
`(arm C: 41 patients) or only clinical observation (arm
`
`Table 3. Significant and independent prognostic factors for the probability of achieving a response, response dura-
`tion and survival probability (in parentheses non-significant variables).
`
`Probability of achieving a response
`(Age, gender, Rai stage, prior CLL
`duration, LDH value, BM histology,
`PB lymphocyte count, induction therapy regimen,
`rate of peripheral blood lymphocyte reduction
`after the second course of induction therapy)
`
`Response duration probability
`(Age, gender, prior CLL duration, LDH value,
`BM histology, Rai stage, PB lymphocyte count,
`induction therapy regimen, rate of peripheral blood
`lymphocyte reduction after the second course of
`induction therapy and post-remission approach)
`
`1st
`randomized
`phase
`(133 pts)
`
`2nd
`randomized
`phase
`(78 pts)
`
`1st
`Survival probability
`(Gender, prior CLL duration, LDH value, BM histology, randomized
`PB lymphocyte count, the induction therapy regimen,
`phase
`the quality of response, the rate of lymphocyte reduction, (133 pts)
`recorded after the second course of therapy)
`
`Independent prognostic factors
`
`p
`
`CI 95%
`
`Rai stage: I+II vs III+IV
`
`0.05 0.99-27.99
`
`Pb Lymph. % reduction
`after 2nd course: ≤25 vs >25%
`
`0.01 1.49-29.5
`
`Response to induction: CR vs PR < 0.01 1.31-4.06
`
`Age: ≤55 vs >55 years
`
`< 0.05 0.98-3.97
`
`Rai stage: I+II vs III+IV
`
`0.05 0.96-4.40
`
`(In addition to the above mentioned variables,
`the administration of IFN-α as maintenance therapy)
`
`2nd
`randomized
`phase
`(78 pts)
`
`Age: ≤55 vs >55 years
`
`0.01 1.36-14.33
`
`Rai stage: I+II vs III+IV
`
`0.01 1.33-14.11
`
`haematologica/journal of hematology vol. 88(12):december 2003
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`

`
`25 (68)
`12 (32)
`
`18 (49)
`19 (51)
`
`27 (73)
`10 (27)
`
`19 (51)
`18 (49)
`
`Gender
`Male
`Female
`
`58 (74)
`20 (26)
`
`33 (80)
`8 (20)
`
`Time to therapy
`≤ 1 yr
`>1 yr
`
`35 (48)
`43 (52)
`
`17 (41)
`24 (59)
`
`Rai stage
`I-II
`III-IV
`
`63 (81)
`15 (19)
`
`36 (88)
`5 (12)
`
`Induction therapy
`FLU + PDN
`38 (49)
`FLU + PDN
`40 (51)
`+ IFN-α
`
`Response to induction
`CR
`33 (42)
`PR
`45 (58)
`
`NS: not significant.
`
`19 (46)
`22 (54)
`
`18 (44)
`23 (56)
`
`15 (41)
`22 (59)
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`NS
`
`(actuarial progression-free survival at 12 months,
`arm C vs arm D: 60% vs 48%; p < 0.05) (Figure 1)
`and patients who achieved a CR after induction
`therapy (actuarial progression-free survival at 12
`months, CR vs PR: 75% vs 45%; p = 0.001) (Figure
`2). However, in the multivariate analysis the quali-
`ty of response (p < 0.01) emerged as the only sig-
`nificant and independent factor for response dura-
`tion while IFN-α showed no independent prognos-
`tic significance (Table 3).
`Patients not included in the second randomized
`phase of the study. Thirty-five patients (31%) who
`responded to induction therapy were not included
`in the second phase of the study. Sixteen patients
`(14%) were considered not eligible: 4 because of an
`infection (HBV hepatitis: 2 patients; Listeria mono-
`cytogenes infection: 1 patient; HVZ: 1 patient), 6
`because of persistent cytopenia, 1 with autoimmune
`hemolytic anemia, 2 with a non-hematologic neo-
`plasia, 2 showing a persistent liver enzyme increase,
`1 with a cerebral hemorrhage.
`Nineteen patients who responded (17%) were
`excluded from the second randomization. The rea-
`sons for the protocol deviation in the second phase
`of the study were: one patient with residual marked
`splenomegaly underwent splenectomy, 14 young
`patients (median age 50 years) underwent an autol-
`ogous stem cell transplantation and 4 patients
`refused the second randomization.
`
`Survival and factors predicting survival
`Causes of death. The median follow-up was 51
`months. At the time of the analysis, 41 patients
`(31%) had died. The main cause of death was CLL
`progression (51%); other causes of death were
`infection (15%), Richter’s transformation (15%),
`second malignancy (12%), acute myeloid leukemia
`(5%) and myocardial infarction (2%). A patient
`included in arm A died during induction therapy
`because of pneumonia. The introduction of IFN-α at
`any time of the treatment approach was not signif-
`icantly related to an increased mortality or to a spe-
`cific cause of death.
`
`Prognostic factors for survival
`The overall actuarial survival probability at 6 years
`was 55%. The survival probability for the two induc-
`tion arm groups was not significantly different (at
`6 years, arm A: 57% vs arm B: 51%; p = 0.3). While
`gender, prior CLL duration, LDH value, BM histology,
`PB lymphocyte count, the introduction of IFN-α in
`the induction regimen, the quality of response, and
`the rate of lymphocyte reduction, (≤25% or >25%
`recorded after the second course of therapy) showed
`no significant effect on survival duration, age (p
`< 0.05) and Rai stage (p = 0.05) emerged as the only
`significant and independent parameters influencing
`survival probability (Table 3). When the survival
`probability of the 78 responsive patients included in
`
`F. R. Mauro et al.
`
`Table 4. Characteristics of patients included in the
`2nd randomized phase of the study.
`
`p
`Clinical
`IFN
`No. of
`observation value
`therapy
`patients
`78 (%) 41 pts. (%) 37 pts. (%)
`
`Median age
`
`55
`
`56
`
`54
`
`D: 37 patients). The baseline characteristics of
`patients were well balanced between the two treat-
`ment groups (Table 4).
`The reason for early (≤6 months) IFN-α discon-
`tinuation in 8 patients (20%) was IFN-α-related
`toxicity including: neurotoxicity (5 patients), per-
`sistent febrile flu-like syndrome (2 patients) and
`persistent thrombocytopenia (1 patient). The rea-
`sons for late (>6 months) IFN-α discontinuation
`were a life-threatening car accident in 2 patients, a
`second malignancy in 2 patients (liver: 1 patient;
`kidney: 1 patient) and an interstitial pneumonia of
`unknown origin in 1 patient. Two cases of der-
`matomal herpes-varicella zoster
`(HVZ) were
`observed after IFN-α discontinuation. After a medi-
`an time of 27 months of IFN-α treatment (range: 6-
`59 months), 7 responder patients refused to con-
`tinue IFN-α administration. The actuarial median
`response duration of the 78 randomized patients
`was 14 months.
`While age, gender, prior CLL duration, LDH value,
`BM histology, Rai stage, PB lymphocyte count, the
`rate of lymphocyte reduction, ≤25% or >25%,
`recorded after the second course of therapy and the
`type of the induction regimen, showed no signifi-
`cant effect on the response duration, a significant-
`ly longer response duration was shown by 2 groups
`of patients: patients randomized to receive IFN-α
`
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`Maintenance therapy for previously untreated patients with CLL
`
`Figure 1. Actuarial progression-free survival of
`78 patients who responded to FLU + PDN ± IFN-
`αa according to the post-remission approach:
`IFN-αa (41 patients) or clinical observation (37
`patients).
`
`p<.05
`
`clinical
`observation
`
`IFN-αa
`
`0
`
`10
`
`20
`
`30
`
`40
`
`50
`
`60
`
`70
`
`months
`
`Figure 2. Actuarial progression-free survival of
`78 patients who responded to FLU + PDN ± IFN-
`αa according to the quality of response after
`induction therapy:CR (33 patients) or PR (45
`patients).
`
`p = 0.001
`
`PR
`
`CR
`
`1.00
`
`0.75
`
`0.50
`
`0.25
`
`0.00
`
`1.00
`
`0.75
`
`0.50
`
`0.25
`
`probability
`
`probability
`
`0.00
`
`0
`
`10
`
`20
`
`30
`
`40
`
`50
`
`60
`
`70
`
`the second randomized phase of the study was sep-
`arately analyzed, gender, prior CLL duration, LDH
`value, BM histology, PB lymphocyte count, the intro-
`duction of IFN-α in the induction regimen, the qual-
`ity of response, the rate of lymphocyte reduction
`(≤25% or >25% recorded after the second course of
`
`therapy) and the administration of IFN-α as main-
`tenance therapy showed no significant effect on
`survival duration, while, again, age (p = 0.01) and Rai
`stage (p = 0.01), emerged as significant and inde-
`pendent factors (Table 3).
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`haematologica/journal of hematology vol. 88(12):december 2003
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`F. R. Mauro et al.
`
`Toxicity
`The main toxicities observed during induction
`therapy were myelosuppression and infections
`which occurred with no significant differences in
`the two arms. After the 729 administered courses of
`fludarabine + prednisone ± IFN-α, we observed 46
`cases (6%) of severe granulocytopenia (WHO grade
`III-IV), 7 episodes (0.9%) of fever of unknown ori-
`gin (FUO) and 10 cases (1.4%) of pneumonia. A case
`of interstitial pneumonia with negative broncho-
`alveolar lavage, 2 cases of Listeria monocytogenes
`sepsis, 6 cases of dermatomal HVZ and 7 of herpes
`simplex were observed during induction therapy. In
`2 patients, a reactivation of viral hepatitis (HBV)
`was observed. One patient had a cerebral hemor-
`rhage after completion of therapy. During the first
`course of induction therapy 4 patients who received
`IFN-α in addition to fludarabine and prednisone
`reported flu-like symptoms.
`Persisting cytopenia (granulocytopenia in 5 cases
`and anemia in 1 patient) and the occurrence of an
`IgM autoimmune hemolytic anemia in 1 patient
`after 5 courses of fludarabine and prednisone, were
`the reasons for exclusion from the second random-
`ization for 7 patients. Toxicity in patients random-
`ized to receive IFN-α as maintenance therapy has
`already been reported in the post-induction phase
`section. Among patients randomized to clinical
`observation, 1 developed an IgG autoimmune
`hemolytic anemia 10 months after discontinuation
`of fludarabine and prednisone and 2 developed der-
`matomal HVZ.
`
`Richter’s syndrome, acute leukemia and
`second malignancies
`No statistically significant differences in the rates
`of Richter’s syndromes and solid tumors were
`observed in patients who at any time of their treat-
`ment course received or not IFN-α. At a median
`time of 16 months (range: 10-26 months) after the
`start of therapy, a histologic diagnosis of Richter’s
`syndrome had been made in 8 patients (6%) and
`included 7 cases of non-Hodgkin’s lymphoma
`(nodal: 2 patients; gastric: 1 patient; BM: 1 patient;
`skin: 1 patient; otorhinolaryngologic: 1 patient;
`orbit: 1 patient) and 1 case of Hodgkin’s lymphoma
`(cervical nodes and mediastinum). An acute myeloid
`leukemia (AML) was diagnosed in 2 patients (1.5%)
`at 12 and 28 months after the start of therapy. AML
`was not considered directly related to the treatment
`study since in both cases it occurred after the start
`of a subsequent chemotherapeutic approach that
`included alkylating agents. The first patient, a 57-
`year old female, was treated with fludarabine +
`prednisone and then with IFN-α which was discon-
`tinued after 5 months because of CLL progression.
`Six months after starting a second-line treatment
`with chlorambucil a diagnosis of AML was made.
`The second case of AML was observed in a 55-year
`
`old patient who after fludarabine and prednisone
`therapy, underwent peripheral blood stem cell mobi-
`lization with high dose cyclophosphamide and then
`an autologous stem cell transplantation which was
`followed 16 months later by AML associated with
`lung cancer.
`Four patients developed a second cancer during
`the induction therapy (fludarabine plus prednisone:
`2 patients; fludarabine plus prednisone and IFN-α:
`2 patients). In 2 cases there was no evidence of the
`tumor (liver, lung) in the baseline radiographic
`exams, while in the other 2 cases, the tumor
`involved organs not explored during the pre-thera-
`py work-up (stomach, larynx).
`Five patients developed a second malignancy (kid-
`ney: 2 patients; bladder: 1 patient; colon: 1 patient;
`melanoma: 1 patient) at a median time of 26
`months (range: 12-37 months) after the start of
`therapy. The concomitant occurrence of two malig-
`nancies during the follow-up was observed in 3
`patients (lung carcinoma + AML; kidney carcinoma
`+ NHL; bladder carcinoma + parotid adenoma).
`
`Discussion
`
`This study was carried out in previously untreat-
`ed CLL patients with advanced disease to evaluate
`the therapeutic benefit of the combination of IFN-
`α with a regimen including fludarabine and pred-
`nisone, and the role of IFN-α as maintenance ther-
`apy in prolonging the response duration.
`Our results indicate that no therapeutic benefit is
`obtained by the addition of IFN-α to the fludarabine
`and prednisone regimen, since no difference was
`observed in terms of response rate between the two
`induction arm groups, being 86% for patients treat-
`ed with fludarabine and prednisone and 84% for
`those treated with the same schedule combined
`with IFN-α. The high overall response rates compare
`favorably with those previously reported by other
`studies in which fludarabine was administered as a
`single agent, associated with prednisone or with
`cyclophosphamide.1-3; 35-38
`While the introduction of IFN-α in the induction
`regimen had no impact, Rai stage and the rate of
`lymphocyte reduction (≤ 25% or > 25% after the
`second course of therapy) emerged as significant
`and independent predictive factors of the probabil-
`ity of achieving a response to therapy. These find-
`ings suggest that patients with advanced stages of
`CLL and a less than 25% reduction of PB lympho-
`cytes after two courses of therapy represent a sub-
`set of poor responders who should be shifted to an
`intensified therapeutic approach, such as fludara-
`bine associated with synergistic drugs and/or mon-
`oclonal antibodies.36,38,39
`Patients randomized to receive IFN-α as mainte-
`nance therapy and patients who achieved a CR
`showed a significantly longer response duration.
`
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`Maintenance therapy for previously untreated patients with CLL
`
`However, the multivariate analysis showed that the
`quality of the response was the only significant and
`independent factor influencing the duration of
`response. This finding, also reported by other stud-
`ies,35,37 shows that a prolonged response in CLL
`results from a good quality response.
`The mechanism of action of IFN-α in CLL is not
`yet fully understood. Different effects have been
`ascribed to IFN-α: an influence on cell survival
`through a modulation of bcl-2 protein expression40,41
`or through the reduction of tumor necrosis fac-
`tor,42–44 and changes in expression of adhesion mol-
`ecules influencing the recirculation and homing of
`B cells.45,46 Morabito et al.47 observed that IFN-α
`enabled CLL cells to increase their in vitro resistance
`to fludarabine–induced cell death in some samples,
`while in others it produced a synergistic effect with
`fludarabine. It has been assumed by several
`authors40,48,49 that the anti-tumor activity of IFN-α
`could be ascribed to the activation of natural killer
`and T-cell mediated cytotoxicity. Thus, the signifi-
`cant depletion of T lymphocytes, usually recorded
`in CLL patients treated with fludarabine or fludara-
`bine and prednisone,35,37 may have hampered the
`activation of the immune-mediated cytotoxicity by
`IFN-α and this could help to explain the absence of
`a therapeutic effect of IFN-α during the induction
`therapy. On the other hand, the evidence of a ther-
`apeutic effect of IFN-α given as post-remission
`therapy could be explained by the restoration of the
`T-lymphocyte count and by the lower leukemic bur-
`den.
`A beneficial effect of IFN-α given as maintenance
`therapy has been reported in CLL patients who had
`achieved a prior response to chlorambucil23 or flu-
`darabine.24 Furthermore, Ferrara et al.50 also report-
`ed an advantage of interferon given as maintenance
`therapy in a study including 45 CLL patients ran-
`domized to receive IFN-α or no treatment after
`achieving a response to the MiNa protocol (vin-
`cristine, cyclophosphamide, melphalan, pepti-
`chemio, and prednisone). No benefits were report-
`ed by O’Brien et al.51 in 31 CLL patients treated with
`IFN-α after first-line or second-line therapy with
`fludarabine (30 patients) or with chlorambucil +
`prednisone (1 patient). It is worth noting that in the
`latter study, only patients who, after 6 months of
`IFN-α therapy, showed a tumor response or a sta-
`ble disease with at