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Introduction: Fludarabine (F) is the most effective single agent for chronic lymphocytic leukemia, and the combination of fludarabine and mitoxantrone (M) has demonstrated excellent activity. Rituximab (R), added to the regimen, demonstrated benefit in progression-free survival and overall survival, despite low CD20 antigen expression in CLL. GM-CSF has been shown to enhance CLL cell kill by rituximab significantly; possible mechanisms include enhancement of CD20 antigen expression and augmentation of recruitment of effector cells involved in ADCC. Thus priming cells with GM-CSF, followed by rituximab in combination with a fludarabine-based regimen should give the best chance of a durable clinical remission in previously untreated patients with CLL. In this non-controlled, prospective single arm phase II study, we evaluate the safety and efficacy of the FMR + GMCSF combination. Methods: Patients received rituximab 375 mg/m2 IV on day -1 of only the first cycle, followed by mitoxantrone 12 mg/m2 on day +1 and fludarabine 25 mg/m2 on days 1–3 of each cycle. GM-CSF 250 mcg/m2 was administered on days 9–15, followed by rituximab 375 mg/m2 IV on day 15. Cycles were repeated every 28 days for a maximum 6 cycles in the absence of disease progression or unacceptable toxicity. Results: 11 patients (3 female, 8 male), median age 57 (range 44–82) were enrolled with intent to treat. 3 patients completed only 1 cycle of chemotherapy: 2 patients were unable to tolerate rituximab; 1 patient with PD after 1 cycle of therapy, was found to have Richter’s transformation and died of complications related to subsequent treatment. 8 remaining patients received 6 cycles of chemotherapy; these 8 patients were evaluated for response. At median F/U 16m (range 3–26m), ORR was 87.5% (2 CR, 1 CRu, 4 PR), 1 patient with SD. Median time to progression in all patients was 7.5m (range 2m–19m). Of the 3 patients achieving CR, 1 patient progressed at 19m, 1 patient progressed at 15m, and the patient achieving CRu has not yet had documented progression. None of these patients have required further treatment. Toxicities were primarily hematologic. Each patient experienced at least one episode of grade 3/4 neutropenia despite routine administration of GMCSF, with significant neutropenia resulting from 45% of all completed cycles. However, there were only 3 episodes (5.9%) of febrile neutropenia. There were no grade 3/4 episodes of anemia or thrombocytopenia. One patient developed a local reaction to GM-CSF after cycle 4, and was changed to G-CSF for the final 2 cycles. Five episodes of infusion reactions were reported with rituximab; these were generally mild, but resulted in stopping infusions in 2 cases. Conclusion: FMR + GM-CSF is an active regimen with acceptable toxicity in patients with CLL and warrants further investigation. Direct comparison of safety profile and efficacy to the fludarabine, cyclophosphamide, rituximab regimen requires further analysis.

Background: Immune ablation with autologous stem cell transplant has been studied in small phase I/II trials with modest success. However, the administration of granulocyte colony-stimulating factor (G-CSF) has led to disease flare in a number of patients. Immunoablative dosing of cyclophosphamide (CTX) without stem cell rescue has been beneficial in a variety of autoimmune disorders, including CIDP, lupus, and myasthenia gravis, as well as inducing durable complete responses in patients with severe aplastic anemia. Therefore, we attempted this method in patients with intractable MS. Methods: Patients were hospitalized; treatment was initiated with CTX at 50 mg/kg/day for four consecutive days. Patients were supported with adequate hydration and forced diuresis to prevent hemorrhagic cystitis. G-CSF was started 6 days after the completion of chemotherapy at 5 mcg/kg/day until the absolute neutrophil count (ANC) >1000 per UL for 2 consecutive days. Patients received supportive transfusions to maintain a hemoglobin of >8gm/dL and platelet count of >10 thousand/UL. Antibiotic therapy was administered per institutional guidelines for febrile neutropenia. Results: Four of planned 10 patients with definite MS, median age 26 (range 23–37), have been treated since February, 2005. All had progressive neurologic decline refractory to standard therapy and also to moderate-dose intermittent pulse IV CTX (1 gm/m2 total dose per cycle) with concurrent IV glucocorticoids. They had received a median of 6.5 (range 3–8) prior cycles, to a total median dose 15,600 (range 10,000–20,000) mg of CTX. The median duration of hospitalization was 19.5 (range 16–21) days. Hematologic toxicity was of short duration, and all patients became neutropenic on day 9. Median duration of neutropenia was 11 (range 7–15) days, with grade IV neutropenia lasting a median of 10.5 (range 6–12) days. Two of 4 patients developed grade III anemia requiring packed red blood cell transfusions; no patient developed grade IV anemia. All patients required supportive transfusions with platelets for grade IV thrombocytopenia, lasting a median of 4.5 (range 2–8) days. Treatment was well tolerated, without serious non-hematologic adverse events. The most common side effect was nausea, mild in 2 patients and moderate in 1 patient. 2 patients experienced diarrhea. 1 patient developed hematuria requiring cystoscopy and bladder irrigation. Three of 4 patients received IV antibiotics for neutropenic fevers; no sources of infection were identified. One patient developed reactivation of oral herpetic lesions despite prophylactic acyclovir. One patient had self-limited mild stomatitis. All patients experienced improvement of neurologic functions, two were clinically dramatic; 3 patients also had dramatic improvement of MRI findings. Conclusion: This is the first report of immune ablation in recalcitrant MS using high dose cyclophosphamide without stem cell rescue. Despite multiple previous CTX doses, all 4 patients responded clinically to high dose therapy, and treatment was remarkably well tolerated with short duration of hematologic toxicity. No disease relapses occurred during chemotherapy or administration of G-CSF. Further follow-up and additional patients are required to evaluate long-term efficacy and late toxicities.