Successful treatment of extranodal Hodgkin's lymphoma in a patient with longstanding hairy cell leukemia

Purine analogs, particularly pentostatin and cladribine, are highly effective in hairy cell leukemia (HCL). Both of these drugs induce responses in approximately 80-95% of patients. However, it is not yet determined if treatment with these drugs can induce second malignancies. Hodgkin's lymphoma is very rare as a second malignancy and there are only 3 reported cases concerning the association of this lymphoma with HCL. We describe a patient with longstanding HCL in complete remission after cladribine, in whom extranodal Hodgkin's lymphoma appeared 8 years after the diagnosis of HCL. Magnetic resonance imaging revealed diffuse intra-osseal neoplastic infiltration of the corpora of the whole spinal column and extra-osseal propagation from the fifth thoracic vertebra into the spinal canal with spinal cord compression. Histological and immunohistochemical analysis of the extradural tumor, which was completely excised, disclosed nodular sclerosis Hodgkin's lymphoma with typical Reed-Sternberg cells that were positive for CD30, CD15, bcl-6, Ki67, p53, EBV LPM-1 and IgG, and negative for CD45, CD20, DBA44, kappa, lambda light chains and IgM. In addition, immunohistochemical analysis of the bone marrow in 1999 showed infiltration with positivity for IgM and negative for kappa light chains and IgG. These findings (expression of different immunoglobulins and light chains on the cells) suggest an independent origin of these 2 B-cell neoplasms. After neurosurgery the patient received 6 courses of the MP-ABVD protocol and achieved a complete remission, which has lasted 16 months thus far.

Long-term analysis of the palliative benefit of 2-chlorodeoxyadenosine for myelofibrosis with myeloid metaplasia

OBJECTIVE

Therapeutic splenectomy in myelofibrosis with myeloid metaplasia (MMM) may result in extreme thrombocytosis and leukocytosis and accelerated hepatomegaly. We previously described initial palliative benefit from 2-chlorodeoxyadenosine (2-CdA) in such instances. The purpose of this study is to provide long-term follow-up on the durability of response in the initial cohort and in additional subsequent cases.

METHODS

We retrospectively identified patients with histologically confirmed MMM who had palliative therapy with 2-CdA. Clinical characteristics and information on subsequent clinical course were abstracted at the time of diagnosis of MMM and at initiation of 2-CdA therapy until death.

RESULTS

To date, we have used 2-CdA as palliative therapy in 14 patients with MMM. After a median of four cycles of therapy, responses for hepatomegaly occurred in 56% of patients, thrombocytosis 50%, leukocytosis 55%, and anemia 40%. Cytopenias were frequent but usually transient and without clinical consequence. Responses occurred usually by the second cycle; median duration of response was 6 months (range, 2-19) after completion of 2-CdA therapy.

CONCLUSION

This study confirmed relevant and frequently durable palliation of symptoms in about half the patients. 2-CdA is a reasonable palliative option in postsplenectomy patients with MMM who have problematic myeloproliferation.

Treatment of hairy cell leukemia with 2-chlorodeoxyadenosine (2-CdA): long-term follow-up of the Northwestern University experience

2-Chlorodeoxyadenosine (2-CdA), a purine analog, has become universally accepted as the agent of choice in treating hairy cell leukemia (HCL). However, few studies have reported long-term outcomes after 2-CdA treatment. Between January 1990 and June 2003, 86 consecutive patients with HCL were treated with a single 7-day course of 2-CdA by continuous infusion at a dose of 0.1 mg/kg per day. Of the 86 patients (mean age: 49 years), 67 patients (79%) achieved a complete remission (CR); 18 patients (21%) achieved a partial remission (PR); and 1 patient's response was unable to be assessed. The progression-free survival (PFS) for initial relapse after 12 years was 54%. At a median follow-up of 9.7 years (range, 0.3-13.8 years), 31 (36%) of 85 patients relapsed. There were 23 relapsed patients treated with a second cycle of 2-CdA; 2 patients were treated with alternative agents; and 6 patients were observed. Of the 23 relapsed patients retreated with 2-CdA, 12 (52%) achieved a CR and 7 (30%) patients achieved a PR (overall response rate: 83%). The overall survival (OS) rate after 12 years was 87%. There were 15 patients (17%) who developed other malignancies. Long-term follow-up of up to 14 years (median: 9.7 years) showed an excellent PFS and OS for HCL patients after 2-CdA treatment.

Epstein-Barr virus positive large B-cell lymphoma arising in a patient previously treated with Cladribine for hairy cell leukemia

We describe the case of a patient treated with 2-chloro-2'-deoxyadenosine, CdA or Cladribine for hairy cell leukemia who subsequently developed an Epstein Barr virus (EBV)-positive polymorphous large B-cell lymphoma (p-LBCL). The time interval between Cladribine therapy and development of p-BCL was 11 months and morphologically resembled an EBV-positive post transplant lymphoproliferative disorder (PTLD). Molecular genetic studies for EBV-clonality by Southern blot hybridization showed a clonal population of infected cells, implying that this was an EBV induced lesion. The chronology of events suggest that Cladribine, a purine analog which has been previously described to induce long-lasting immunodeficiency, can, in some cases, weaken the host defense mechanism to a level at which an innocuous EBV infection may transform the normal lymphoid cells into an aggressive neoplasm. Unlike most methotrexate-related lymphoproliferative disorders (LPDs), which undergo spontaneous remission after discontinuation of therapy, LPDs secondary to purine analogs often fails to resolve after discontinuation of therapy and requires additional therapy. Our patient was treated with rituximab following the diagnosis of p-LBCL, with the goal of improving the pancytopenia to permit chemotherapy. However, the patient failed to show any dramatic improvements in counts, developed systemic symptoms and progressive ascites. He expired 3 weeks after a second dose of rituximab. Cladribine is a potent immunosuppressive agent and should be included with the list of immunosuppressive agents that may be associated with EBV-related B-cell lymphoproliferative disorders.

The place of cladribine in the treatment of chronic lymphocytic leukemia: a 10-year experience in Poland

Cladribine (2-CdA) is structurally similar to another purine analog, fludarabine (FA), recently accepted in several centers as the first-line treatment in chronic lymphocytic leukemia (CLL). Unfortunately, there is less experience with the use of 2-CdA than with FA in patients with CLL in the majority of Western countries. In the last decade we performed several phase II studies and two phase III randomized trials to evaluate the activity and toxicity of 2-CdA in previously treated and untreated patients with CLL. We have also compared the results of Polish studies with the data presented by other investigators. Similarly to FA this agent has been found to be more effective in previously untreated CLL than in patients refractory to or relapsed after conventional therapy with alkylating agents. In different studies the overall response (OR) rate ranged from 70 to 85% and complete response (CR) from 10 to 47%. Higher CR and OR rates in CLL patients treated with 2-CdA and prednisone than with chlorambucil and prednisone were confirmed in our multicenter, randomized study. Subsequently, we performed a multicenter, randomized study comparing 2-CdA alone with a combination of 2-CdA and cyclophosphamide (CC) or cyclophosphamide and mitoxantrone (CMC). Our updated results seem to indicate that the CC program used as a first-line therapy in CLL gives higher CR and OR and better elimination of minimal residual disease (MRD) than 2-CdA alone. CC is also less myelotoxic than CMC. More recently, we have undertaken a phase II study to determine the efficacy and toxicity of 2-CdA combined with the anti-CD20 monoclonal antibody rituximab in CLL and other refractory or relapsed indolent lymphoproliferative disorders. The preliminary results seem to be better than in similar patients previously treated in our institution with 2-CdA alone. In conclusion, the studies performed in the last decade in Poland and other countries have shown that 2-CdA used alone or in combination with other agents is, similarly to FA, a highly active and relatively safe agent in previously treated and untreated patients with CLL.

A phase I trial of gemcitabine plus cladribine in patients with advanced hematologic malignant diseases

PURPOSE

Gemcitabine and cladribine (2CdA) are nucleoside analogues that decrease DNA synthesis via inhibition of ribonucleotide reductase; the combination could be additive or synergistic. We conducted a dose escalation study to establish the maximum tolerable doses (MTD) of gemcitabine and 2CdA when given in combination in patients with advanced hematologic malignancies and to describe the toxicity profile of this combination.

PATIENTS AND METHODS

A total of 45 patients with advanced hematologic diseases were enrolled into two groups. Group A had adequate baseline hematopoiesis, defined as absolute neutrophil count (ANC) >1 x 10(9)/l and platelet count >50 x 10(9)/l. Group B did not meet these criteria. Hematologic dose-limiting toxicity (DLT) for group A was defined as grade 4 neutropenia or thrombocytopenia lasting >28 days; group B was not evaluated for hematologic toxicity. Nonhematologic DLT was defined similarly for both groups. Death occurring during the first cycle of treatment was considered a DLT event only if it was related to drug toxicity. Gemcitabine was administered as a 4-h intravenous infusion once every 28 days. 2CdA was administered over 1 h daily for the first 3 days of each 28-day cycle.

RESULTS

The MTD was not reached in either group. Myelosuppression was common, but not dose-limiting. Febrile neutropenia and infections were also common, particularly in group B, and judged in most cases to be due to bone marrow failure at baseline. Nonhematologic toxicities were generally mild, and skin rash, the most frequently observed, was dose-limiting in one patient enrolled in each group. Four deaths (three during the first cycle of treatment) occurred at the highest dose level tested in group B (gemcitabine 5000 mg/m2 and 2CdA 16 mg/m2). Although only one of these deaths was dose-limiting by stated criteria, this dose level did not appear to be safely tolerated in this patient population. Several responses were observed in patients with Hodgkin's disease.

CONCLUSIONS

The combination of gemcitabine and 2CdA is feasible in patients with hematologic malignancies. Phase II studies of this combination should be considered, particularly in patients with Hodgkin's disease.

Cutaneous adverse reaction to 2-chlorodeoxyadenosine with histological flame figures in patients with chronic lymphocytic leukaemia

INTRODUCTION

2-Chlorodeoxyadenosine (cladribine or 2-CdA) is a purine analogue that has been used successfully in hairy cell leukaemia (HCL). Moreover, it has been increasingly used to treat chronic lymphoproliferative syndromes and paediatric acute myeloid leukaemia. Cutaneous side-effects associated with this drug have seldom been described in cases of HCL.

PATIENTS AND METHODS

We describe three patients with chronic lymphocytic leukaemia that presented generalized skin eruptions after treatment with 2-CdA.

RESULTS

All patients had advanced disease, receiving 2-CdA as a second or third line chemotherapy. Skin lesions were severe and chemotherapy had to be discontinued. Histological examination of skin biopsies showed an eosinophil-rich infiltrate with flame figures, similar to what is observed in Wells' syndrome (eosinophilic cellulitis). Corticosteroids were effective to control the eruptions.

CONCLUSIONS

Cutaneous adverse reactions associated with 2-CdA have seldom been observed in the treatment of HCL. However, as this purine analogue has been used in more advanced cases these may be more frequent and severe. The pathophysiology of these lesions is unclear, but it is probably related to drug-induced change in T-cell imbalance in severely immunosuppressed patients.

?Smouldering systemic mastocytosis?

Mastocytoses are a heterogenous group of diseases characterized by proliferation and accumulation of mast cells in the skin and other organs. They are subdivided into cutaneous mastocytoses; systemic forms, which may appear with or without skin lesions; mast cell sarcomas and extracutaneous, localized, benign mastocytomas. Systemic mastocytoses apart from the skin mainly involve bone marrow, gastrointestinal tract, bones, lymph nodes, spleen and liver. Whereas indolent forms of systemic mastocytosis are mainly treated with antihistamines, glucocorticosteroids and PUVA therapy, the more aggressive forms, including mast cell leukemia, often require cytostatic chemotherapy. A 53-year old patient with beginning "smoldering systemic mastocytosis" failed to respond to high-dose systemic glucocorticosteroids and interferon-alpha. Treatment with cladribine led to an impressive improvement of skin lesions, a significant decrease in tryptase serum levels and stabilization of bone marrow infiltrates.

Occurrence of a myelodysplastic syndrome (MDS) during first-line 2-chloro-deoxyadenosine (2-CDA) treatment of a low-grade gastrointestinal MALT lymphoma. Case report and review of the literature

While myelodysplastic syndrome (MDS) and acute leukemia (AL) are well-known secondary diseases after administration of chemotherapy, particularly alkylating agents, they have only rarely been reported in the context of purine analog treatment. In all cases there was an interval of several months before onset of the secondary disease and cytogenetic analyses showed typical chromosomal aberrations. We report the case of a 68-year old male Caucasian with low-grade lymphoma who developed a MDS during ongoing first-line treatment with the purine analog 2-CDA (Cladribine). Furthermore, a normal karyotype was present initially and at all consecutive control evaluations. Thus, this case represents another rare report of an evolution of purine analog treatment-associated MDS; the absence of cytogenetic aberrations might suggest a different mechanism in the pathogenesis of this secondary disease.

High incidence of complications after 2-chloro-2'-deoxyadenosine combined with cyclophosphamide in patients with advanced lymphoproliferative malignancies

The combination of purine analogs with alkylating agents is able to produce a synergistic antitumoral effect. However, the addition of immunosuppressive and DNA-targeting agents might increase purine analog-related complications. The risk for serious complications was evaluated in 38 patients treated with 2-chloro-2'-deoxyadenosine (CDA) and cyclophosphamide (CP). The diagnoses were chronic lymphocytic leukemia (CLL) in 15, Waldenström's macroglobulinemia in 4, mantle cell lymphoma in 6, follicular non-Hodgkin's lymphoma (NHL) in 10, and other low-grade NHL in 3 patients. All patients were pretreated (median: 2 lines, range: 1-5) and 23 (61%) were refractory. The patients received a median of two courses (range: 1-5) of 5.6 mg/m(2) CDA, followed by a median of 200 mg/m(2) CP, for 3 days. The response rate was 51% [complete remission (CR): 14%, partial remission (PR): 38%]. Grade 3/4 infections occurred in 16 (42%) patients. Dose-limiting cytopenias were seen in 22 (58%) patients. In 12 (32%) patients, autoimmune manifestations developed requiring treatment in most of them. Second cancers arose in five (13%) patients (myelodysplastic syndrome/acute myelocytic leukemia in three, lung cancer in two). Multivariate analysis showed that cytopenias, gender (F), prior radiotherapy, and age (>65 years) predicted for the complications seen after CDA-CP. To conclude, because of the high incidence of complications, caution is warranted in selecting patients with advanced lymphoid malignancies for the CDA-CP protocol.

Long-term follow-up of front-line treatment of hairy cell leukemia with 2-chlorodeoxyadenosine

BACKGROUND AND OBJECTIVES

Although remission of hairy cell leukemia (HCL) after treatment with 2-chlorodeoxyadenosine (2-CdA) appears to be long lasting, few reports currently provide results from follow-up exceeding 5 years.

DESIGN AND METHODS

We reviewed our HCL patients treated with front-line 2-CdA (by 2-hour infusion) either for 5 consecutive days at 0.14 mg/kg/day (daily subset, n=21) or once a week at 0.14 mg/kg for 5 cycles (weekly subset, n=16).

RESULTS

Of the 37 eligible patients, 30 (81%) achieved complete response (CR) and 7 (19%) partial response (PR) (overall response rate, 100%); identical response rates were recorded in the daily and weekly subsets. After a median follow-up of 122 months (range, 54-156), the overall relapse rate was 27% (8/30): 24% (4/17) had relapsed in the subset treated daily whereas 30% (4/13) had done so in the subset treated weekly (p=ns). The projected 13-year overall and the relapse-free survivals are 96% and 52%, respectively. In terms of hematologic toxicity, the weekly 2-CdA schedule was associated with significantly fewer cases of grade 3-4 neutropenia.

INTERPRETATION AND CONCLUSIONS

In HCL patients, a single dose of 2-CdA induces a long-term CR. Over 90% of patients are alive 13 years later and over 50% of patients appear to be clinically cured by this treatment. The weekly schedule seems to be a safer option for neutropenic HCL patients, while apparently providing equivalent results in terms of response rates and long-term outcome.

2-Chloro-deoxyadenosine induces durable complete remission in Castleman's disease but may accelerate its transformation to non-Hodgkin's lymphoma

There is currently no consensus on the best treatment for unresectable hyaline-vascular variant or for multicentric Castleman's disease (MCD), because none of the reported regimens have consistently produced complete response or durable remission in the majority of patients In the present study, we report on the use of 2-CdA (2-chloro-deoxyadenosine) in three patients, two of them with MCD and one with unresectable hyaline-vascular type disease. Relapse-free survival of the responding patients was 24 and 20 months. Later, both patients evolved to non-Hodgkin's lymphoma (NHL) (diffuse large B-cell lymphoma and peripheral T-cell NHL, respectively). 2-CdA typically causes a long-lasting state of immunodeficiency and the profound influence of this drug on the immune system has raised questions concerning the emergence of secondary neoplasms after its use. Therefore, it is reasonable to conclude that: 1) 2-CdA can induce durable complete remission in MCD patients but unfortunately it cannot cure the disease; 2) the possibility that 2-CdA may accelerate the transformation of MCD to NHL cannot be ruled out.

[Bone marrow fibrosis during therapy of hairy cell leukemia]

The influence of Cladribin therapy to bone marrow fibrosis in patients with hairy cell leukemia was studied. Eighteen patients were included in the study; bone marrow fibrosis was graded 0-4 according to the quantity and pattern of distribution of reticulin. The grade of bone marrow fibrosis was established before the therapy and then in 12- and 24-month intervals. Patients showed complete remission after the therapy and remarkable reduction of bone marrow fibrosis.

Cladribine therapy for systemic mastocytosis

Patients with systemic mastocytosis (SM) can suffer from disabling symptoms related to mast cell mediator release or mast cell infiltration, requiring mast cell eradication. In the present absence of any curative therapy, a recent case report describing the efficacy of cladribine showed promising results. In a pilot study, the efficacy of cladribine (0.10-0.13 mg/kg in a 2-hour infusion, days 1-5; repeated at 4-8 weeks until 6 cycles) was studied. Ten patients with SM with severe symptoms were treated. Four patients were classified as having indolent or smoldering mastocytosis, 3 as having aggressive systemic mastocytosis, and 3 as having SM with an accompanying hematologic malignancy. Nine patients received 6 courses, 1 patient stopped because of toxicodermia. All responded concerning signs, symptoms, and mast cell parameters (serum tryptase and urinary histamine metabolite excretion), although none achieved a complete remission. Prolonged follow-up is required, as response is ongoing in most cases. One patient relapsed within 11 months and showed a second response. Side effects were mainly related to bone marrow suppression. Single-agent cladribine is an effective and relatively safe treatment for severe systemic mastocytosis. The optimal dose and schedule need to be explored.

Histological examination of the retinal ganglion layer in rabbits after experimental administration of the new immunosuppressive medicine--Cladribine

The experiment was carried out on rabbit females of New Zealand breed weighing about 3 kg. Animals from the experimental group received Cladribine according to the schema of experimental treatment in the hairy cell leukemia and rabbits from the experimental group II--according to the schema of experimental treatment in multiple sclerosis. Specimens of retina were collected for histological examinations in the light microscope. It was revealed that administration of Cladribine in the dose corresponding to the therapeutic dose used in human for the treatment of the hairy cell leukemia and multiple sclerosis does not cause evident morphological changes in retinal ganglion cells on the level of light microscope.

Ultrastructural changes of retinal ganglion cells in rabbits of New Zealand breed after experimental administration of 2-CDA (Cladribine)

The experiment was carried out on rabbit females of New Zealand breed weighing about 3 kg. The animals from the experimental group received. Cladribine in the dose of 0.1 mg/kg for 7 days. Specimens of retina were collected for ultrastructural examinations. It was revealed that administration of Cladribine in the dose corresponding to the therapeutic dose used in human for the treatment of the hairy cell leukemia causes morphological changes in ultrastructure of retinal ganglion cells which are classified as reversible in cytophysiology. The necessity of periodic, regular ophthalmological examinations during Cladribine treatment was indicated.

Histological examination of the lacrimal gland after experimental administration of Cladribine

The experiment was carried out on female rabbits of New Zealand breed weighing about 3 kg. The rabbits from experimental group I received Cladribine in the dose corresponding to the schema of treatment in the hairy cell leukemia and the animals from the experimental group II the dose corresponding to the experimental treatment in multiple sclerosis. The lacrimal glands were collected for histological examinations in the light microscope. It was observed that administration of Cladribine in the dose corresponding to the therapeutic dose used in the therapy of hairy cell leukemia could have caused morphological changes in the lacrimal gland, but the medicine administered in therapeutic doses in experimental therapy of multiple sclerosis does not cause morphological changes in the structure of the lacrimal gland on the level of the light microscope.

Influence of the new medicine--2-CDA (Cladribine) on the ultrastructure of the extrabulbar segment of the optic nerve in rabbits of New Zealand breed

Experiments were carried out on the rabbits of New Zealand breed weighting about 3 kg. Rabbits from the experimental group received Cladribine in the dose of 0.07 mg/kg/24 h each morning subcutaneously for 6 days, three cycles with 5-week intervals. Specimens of the optic nerve were stained according to the Reynold's method and observed in Tesla BS-500 transmission electron microscope. Results achieved from examinations of slides in experimental group indicate that Cladribine administered in the dose corresponding to therapeutic dose used in humans for experimental treatment of sclerosis multiplex does not cause the damage of extrabulbar segment of optic nerve in experimental animals. The achieved results suggest necessity of new research works regarding the eye structures of mesenchymal origin.

Histological examination of the extrabulbar segment of the optic nerve in experimental animals after administration of Cladribine

The experiment was carried out on rabbits, females of New Zealand breed, weighting about 3 kg. Rabbits from the experimental group I received Cladribine in the dose corresponding to the schema of the experimental treatment in the hairy cell leukemia and animals from the experimental group II, the dose corresponding to the experimental treatment in multiple sclerosis. The optic nerves were collected for histological examinations in the light microscope. It appeared that administration of Cladribine in the dose corresponding to the therapeutic dose used in therapy of hairy cell leukemia and sclerosis multiplex does not cause evident morphological changes in the extrabulbar segment of the optic nerve on the level of the light microscope.

A multicenter, open, non-comparative, phase II study of the combination of cladribine (2-chlorodeoxyadenosine), cytarabine, and G-CSF as induction therapy in refractory acute myeloid leukemia - a report of the Polish Adult Leukemia Group (PALG)

OBJECTIVES

To evaluate the efficacy and toxicity of cladribine (2-chlorodeoxyadenosine, 2-CdA), cytarabine (Ara-C), and granulocyte-colony stimulating factor (G-CSF) (CLAG) regimen in refractory acute myeloid leukemia (AML) in the multicenter phase II study.

METHODS

The induction chemotherapy consisted of 2-CdA 5 mg/m2, Ara-C2 g/m2, and G-CSF. In the case of partial remission (PR), a second CLAG was administered. Patients in complete remission (CR) received two consolidation courses based on HD Ara-C, mitoxantrone or idarubicine, with or without 2-CdA.

RESULTS

Fifty-eight patients from 11 centers were registered; 50 primary resistant and eight early relapsed (CR1 < 6 months). CR was achieved in 29 (50%) patients, 19 (33%) were refractory, and 10 (17%) died early. Forty of 50 primary resistant patients received daunorubicin (DNR) and Ara-C as the first-line induction therapy (DA-7), 10 received additional 2-CdA (DAC-7). The CR rates after CLAG were 58% and 10%, respectively in each group (P = 0.015). Five of six patients with myelodysplastic syndrome (MDS)/AML achieved CR. Hematologic toxicity was the most prominent toxicity of this regimen. The overall survival (OS, 1 yr) for the 58 patients as a whole, and the 29 patients in CR were 42% and 65%, respectively. Disease-free survival (DFS, 1 yr) was 29%. Only first-line induction treatment with DA-7 significantly influenced the probability of CR after CLAG. None of the analyzed factors significantly influenced DFS and OS.

CONCLUSION

CLAG regimen has significant anti-leukemic activity and an acceptable toxicity in refractory AML. The addition of 2-CdA to the first-line induction treatment may worsen the results of salvage with CLAG. The high CR rate in patients with MDS preceding AML deserves further observation.

Cutaneous reactions in hairy cell leukaemia treated with 2-chlorodeoxyadenosine and allopurinol

The purine nucleoside analogue 2-chlorodeoxyadenosine (2-CdA) is currently considered by many as first-line therapy for hairy cell leukaemia. Cutaneous reactions have occasionally been reported with this drug, particularly if used with allopurinol. We report a high frequency of skin reactions in 15 consecutive patients with hairy cell leukaemia treated with 17 courses of 2-CdA. These reactions occurred only in those receiving allopurinol and, in two patients, were severe enough to warrant steroid therapy. The routine concomitant use of allopurinol is therefore not recommended in this setting.