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Blood, Vol. 94 No. 7 (October 1), 1999:
pp. 2217-2224
By
From the Department I of Internal Medicine, University of Cologne,
Cologne, Germany.
Eleven patients with relapsed fludarabine-resistant B-cell chronic
lymphocytic leukemia (CLL) or leukemic variants of low-grade B-cell
non-Hodgkin's lymphoma (NHL) were treated with the chimeric monoclonal
anti-CD20 antibody rituximab (IDEC-C2B8). Peripheral lymphocyte counts
at baseline varied from 0.2 to 294.3 × 109/L. During the
first rituximab infusion, patients with lymphocyte counts exceeding
50.0 × 109/L experienced a severe cytokine-release
syndrome. Ninety minutes after onset of the infusion, serum levels of
tumor necrosis factor-
RECENT META-ANALYSES have confirmed that
B-cell chronic lymphocytic leukemia (B-CLL) cannot be cured by
currently available treatment options. Advanced stage patients have a
median survival of 27 months.1 Therefore, therapeutic
approaches to CLL are being reassessed with emphasis on
laboratory-directed therapy, early enrollment of patients in clinical
trials, introduction of fludarabine into combination protocols, and
development of new drugs. Advances in the understanding of the biology
of CLL cells have identified targets for more selective immunotherapy using monoclonal antibodies (MoAbs). Clinical antitumor efficacy of
MoAbs has recently been demonstrated in patients with low-grade follicular NHL2-4 and is of interest in CLL.5-7
Fast, but transient, clearance of circulating tumor cells without major
toxicity was reported after administration of the MoAb, Ab89, in a
patient with diffuse, poorly differentiated lymphocytic lymphoma and a
white blood cell count of 110.0 × 109/L.8
Various phase I/II clinical trials were conducted investigating the
safety and efficacy of the immunoglobulin G2a (IgG2a) murine MoAb,
T101, in patients with advanced B-CLL.9 T101
binds to the CD5 antigen expressed on normal T lymphocytes, malignant T lymphocytes, and in B-CLL. The antibody caused a rapid, but transient, decrease in circulating tumor cells at different dose levels. Severe
generalized reactions were observed after intravenous bolus injection,
while toxicity was only minimal during a 50-hour infusion. More
recently, the humanized monoclonal anti-CD52 antibody Campath-1H binding to malignant cells in more than 95% of B- and T-cell lymphomas produced promising results when used in both untreated10
and pretreated CLL.7 The overall response rate was
42%.7 Toxicity was considerable with cellular
immunosuppression and subsequent opportunistic infections in most of
the heavily pretreated patients. Lower doses of Campath-1H are
associated with less pronounced side effects and are currently being
investigated for treatment of patients whose disease is still at an
early stage.
The chimeric MoAb, IDEC-C2B8 (rituximab), binds to the CD20 antigen
expressed on B lymphocytes and more than 95% of all B-cell NHL. The
effector mechanism of rituximab includes complement-mediated cell lysis
and antibody-dependent cellular cytotoxicity. In addition, rituximab
interferes with the calcium channel function of the CD20 antigen and
induces apoptosis by triggering the influx of calcium into
CD20+ cells.11 Rituximab has exhibited
significant antitumor activity in more than 300 patients with low-grade
NHL. Intravenous application at doses of 375 mg/m2 given
once weekly for 4 weeks induced complete or partial remissions in 50%
of patients with relapsed advanced low-grade follicular NHL.2,3,12
Because CD20 is expressed on malignant lymphocytes in CLL in various
densities, we initiated a monocenter clinical study investigating 375 mg/m2 rituximab weekly for 4 weeks in 11 patients with
heavily pretreated B-CLL or leukemic variants of other low-grade NHL.
The study will record that patients with lymphocyte counts exceeding
50.0 × 109/L experience a severe cytokine-release
syndrome upon the first infusion of the anti-CD20 MoAb.
Patients.
Written informed consent was obtained from all patients before study
entry. Patients had to have B-CLL according to National Cancer
Institute (NCI) criteria of any Rai stage or leukemic variants of other
low-grade NHL requiring therapy and had to have received at least 2 prior chemotherapeutic regimens, including anthracycline- and/or
fludarabine-containing schedules. Criteria for requiring therapy were
as follows: disease-related symptoms, anemia and/or thrombocytopenia,
bulky lymphadenopathy, and/or clinically relevant splenomegaly.
Patients with prolymphocytic leukemia or Richter's syndrome and those
receiving steroids were excluded. Prior treatment with rituximab was
also an exclusion criterion.
Antibody and concomitant medication.
Patients received 375 mg/m2 of the anti-CD20 MoAb rituximab
(IDEC-C2B8) once weekly for 4 weeks given as an intravenous infusion in
saline solution over a period of 3 to 10 hours. Because the first
patient with high peripheral lymphocyte counts experienced severe side
effects after attempted administration of 375 mg/m2
rituximab in 1 day, all other 10 patients were treated according to a
modified schedule with application of 50 mg rituximab on day 1, 150 mg
on day 2, and 400 to 500 mg on day 3 of the first infusion cycle. Each
dose was dissolved in 1,000 mL saline solution and the infusion was
started at a rate of 50 mL per hour. During the first hour, vital signs
were monitored every 15 minutes. If there were no adverse events during
the first hour of treatment, the infusion rate was increased by 100 mL/h every half hour up to 300 mL/h. In case of adverse events of NCI
toxicity grade II-IV, the infusion was interrupted. After the symptoms
had disappeared, infusion at half the rate was continued. If adverse
events were of grade IV toxicity, treatment was stopped and continued
the following day starting with an initial infusion rate of 50 mL/h. During the following 3 cycles, the 375 mg/m2 rituximab dose
was given in 1 day. The infusions were started at a rate of 50 mg
rituximab per hour and were increased up to 400 mg/h once tolerated
well. One thousand milligrams of acetaminophen was administered before
the beginning of each infusion. A concomitant infusion of 2,000 mL of
saline solution was given to prevent renal damage due to rapid cell
elimination. For the same reason, all patients received 300 mg
allopurinol once daily during the entire treatment period.
Patient monitoring.
Patients were monitored for safety and clinical antitumor effects using
regular medical history, physical examination, and laboratory studies
including complete and differential blood count, chemistry panel,
quantitative serum IgGs, serum complement, and urinalysis performed at
baseline, weeks 1, 2, 3, and 4, as well as 4 and 8 weeks after
completion of the last infusion. Toxicity was evaluated according to
NCI adult toxicity criteria. Standardized NCI/WG (National Cancer
Institute-Sponsored Working Group) criteria were used for assessment of
response to rituximab treatment13: complete remission was
defined as the absence of lymphadenopathy, hepatomegaly, splenomegaly,
or constitutional symptoms for at least 4 weeks after onset of
response. In addition, blood counts had to be normal and less than 30%
lymphocytes had to be present in a bone marrow biopsy. A partial
remission was characterized by a 50% reduction in blood lymphocytes
and a 50% reduction in lymphadenopathy and/or 50% reduction in
splenomegaly and/or hepatomegaly. Symptoms had to be stable for at
least 4 weeks after onset of response. Patients with progressive
disease had to present with at least 1 of the following: a greater than
50% increase in the size of at least 2 lymph nodes or new palpable
lymph nodes, a Flow cytometry.
Flow cytometric phenotyping of mononuclear cells of the peripheral
blood was performed after red blood cell lysing of blood samples
(Lysing solution; Becton Dickinson, Heidelberg, Germany). The cells
were incubated with fluorochrome (fluorescein isothiocyanate [FITC],
phycoerythrin [PE], perchlorophyll [PerCP]) conjugated mouse anti-human MoAbs (anti-CD3, anti-CD4, anti-CD5, anti-CD8, anti-CD14, anti-CD16, anti-CD19, anti-CD20, anti-CD25, anti-CD45, anti-CD56, anti-HLA-DR [Becton Dickinson]), and appropriate isotype controls for 20 minutes at 4°C. After 2 washing procedures in phosphate-buffered saline containing 0.1% bovine serum albumin and
0.01% NaN3, samples were measured on a flow cytometer
(FACSCalibur; Becton Dickinson) with a minimum of 10,000 mononuclear
cells acquired for each staining. Analysis and calculations were
performed using CellQuest and Attractors software (Becton Dickinson).
Cytokine analysis.
Cytokine levels in the serum of blood samples obtained before and
during rituximab treatment were measured by enzyme-linked immunosorbent
assay (ELISA) (interleukin-2 [IL-2], IL-4, IL-10, IL-12,
interferon- Statistical analysis.
Patients were retrospectively stratified into 2 groups according to
their peripheral lymphocyte counts at baseline. Group A comprised
patients with less than 50 × 109/L lymphocytes, while
patients with lymphocyte counts of 50 × 109/L and
higher were assigned to group B. Differences in pre and/or posttreatment laboratory values between both groups were evaluated for
statistical significance using the Student's t-test. To
compare incidence and degree of adverse events in both groups, NCI
toxicity grades of side effects were added up for all patients of 1 group; the Student's t-test was used to determine significance
of differences.
Patient characteristics.
Ten patients (4 women, 6 men) with B-CLL and 1 male patient (no. 7)
with a leukemic variant of mantle-cell NHL were treated in this study.
Patient characteristics are summarized in
Table 1. Median age was 58 years (range, 26 to 79 years). All patients had an Eastern Cooperative Oncology Group
(ECOG) performance status of 1 or 2 and active disease
requiring therapeutic intervention. Four patients had CLL Rai stage IV,
3 patients Rai stage III, 2 patients Rai stage II, and 1 patient Rai
stage I. The median time from first diagnosis to enrollment in this
study was 6.3 years (range, 2.5 to 10 years). At the time of study
entry, all patients were in second or higher relapse having received a
median of 3 prior chemotherapeutic regimens (range, 2 to 5).
Fludarabine had been applied to all patients at relapse except for
patient no. 9, who had received VACOP-B (etoposide,
doxorubicin, cyclophosphamide, vincristine, prednisone, bleomycin) as
first-line therapy followed by autologous bone marrow transplantation.
Seven weeks before treatment with rituximab, patient no. 2 had received
473 mg of the humanized anti-CD52 antibody Campath-1H, but progressed
after 6 weeks of treatment. Splenectomy had been performed in 2 cases either because of severe autoimmune thrombocytopenia (patient no. 5) or
because of a prior history of gastric cancer 5 years before onset of
the CLL (patient no. 11). Lymphocyte counts at baseline varied from 0.2 × 109/L to 294.3 × 109/L, with
CD20-expression on more than 90% of lymphocytes in all but 3 cases
(Table 1). Patients were stratified retrospectively according to their
peripheral lymphocyte counts at baseline. Group A consisted of patient
nos. 1 to 5 with lymphocyte counts less than 50.0 × 109/L, while patient nos. 6 to 11 with lymphocyte counts of
50.0 × 109/L and higher were comprised in group B. Patient no. 7 had a mantle-cell lymphoma with 68.1 × 109/L peripheral lymphocytes and stage IV disease according
to the Ann Arbor system.
Infusion schedule in patients with lymphocytosis.
Patient no. 9 was the first patient with lymphocytosis who was treated
with rituximab at our center. The 375 mg/m2 dose of the
anti-CD20 MoAb was administered in 1 day according to the infusion
schedule established for patients with advanced relapsed follicular NHL
in prior clinical trials. During the 10-hour infusion, a massive
cytokine-release syndrome was observed associated with fever, chills,
vomiting, NCI grade IV thrombocytopenia, drop of coagulation
parameters, massive elevation of lactate dehydrogenase (LDH), as well
as an increase in liver enzymes. Symptoms, as well as abnormal serum
parameters, persisted for 2 days. As a direct consequence, the infusion
regimen was changed to a fractionated schedule for all subsequent
patients with more than 10.0 × 109/L peripheral
lymphocytes: on day 1, 50 mg rituximab was administered over 5 to 7 hours; on day 2, 150 mg over the same period of time; and on day 3, the
remainder of the 375 mg/m2 dose (400 to 500 mg).
Effect of rituximab on peripheral malignant lymphocytes.
During the first infusion of rituximab, a rapid reduction of
the number of peripheral malignant lymphocytes was observed in all 11 patients irrespective of their initial tumor load
(Fig 1A). Blood samples taken 90 minutes
after onset of the infusion showed a marked depletion of tumor cells. A
total reduction of 50% to 75% of peripheral lymphocytes compared with
baseline was observed 12 hours after the onset of the rituximab
infusion (Fig 1A). Tumor cell counts gradually started to increase
again 48 to 96 hours after beginning of the first infusion.
Fluorescence-activated cell sorting (FACS) analyses indicated that all
CD19/CD20-coexpressing cells were affected. After each of the following
treatment cycles with rituximab, lymphocyte counts dropped, but the
reduction was not as pronounced as with the first infusion (data not
shown). However, tumor cell counts reached baseline values in 7 of 11 patients 4 to 6 weeks after the end of the fourth rituximab infusion.
First-dose side effects.
Despite the fractionated infusion schedule, patients with tumor cell
counts exceeding 50.0 × 109/L experienced severe side
effects during application of rituximab on day 1, resulting in a
temporary interruption of the infusion in 5 of 6 group B patients.
Incidence and severity of adverse events during the first antibody
infusion were dependent on the patients' lymphocyte counts at baseline
(Table 2). Group A patients experienced
significantly less and milder adverse reactions than patients with
lymphocyte counts exceeding 50.0 × 109/L (group B)
(P = .0017). There were no NCI grade III or IV toxicities upon
the first rituximab infusion in any of the group A patients. By
contrast, patients in group B experienced 9 grade III adverse events
and 1 NCI grade IV thrombocytopenia. The patient with the highest
peripheral lymphocyte count (294.3 × 109/L)
experienced NCI grade III dyspnea, nausea with vomiting, chills, and a
tachycardia with a heart rate up to 120/min. Most importantly, the
rituximab infusion had to be terminated to prevent further deterioration of her condition after 5 mg had been applied over a
period of 12 hours on day 1. Retreatment with 45 mg on day 2 and 50 mg
on day 3 was accompanied by nausea, chills, and fever of NCI toxicity
II-III. Side effects persisted during administration of 250 mg
rituximab on days 4 and 5, respectively. Due to the severity of the
adverse events, this particular treatment was discontinued. Fever and
chills were observed in all patients during the first infusion except
for the patient with the lowest lymphocyte count (no. 1; 0.2 × 109/L) (Table 2). During the second rituximab cycle, fever
and chills of only mild to moderate toxicity occurred again in patients
with CD20+ lymphocyte counts exceeding 50.0 × 109/L at the time of the second infusion (data not shown).
Serum cytokine levels.
At baseline, serum levels of TNF-
Clinical response.
Nine of 10 patients with CLL were evaluable for response according to
NCI response criteria for CLL. Patient no. 11 was taken off study early
because of the severity of adverse events during the first infusion.
Seven patients experienced stable disease after treatment with 4 × 375 mg/m2 rituximab. A marked reduction of
lymphocyte counts was observed in most patients lasting 4 to 6 weeks
after their fourth rituximab infusion. Then, lymphocyte counts
increased again requiring salvage treatment in 7 of 10 patients. Five
patients experienced a reduction in size of initially enlarged lymph
nodes lasting 3 weeks after the end of treatment with rituximab.
Patient no. 4 was withdrawn from therapy due to nonresponsive disease
after the third cycle of rituximab. In patient no. 8, lymphocyte counts
were reduced from 71.1 × 109/L to 12 × 109/L and remained stable for 19+ weeks. According to NCI
response criteria, this patient experienced a partial remission, which is still ongoing. Three months after completion of the fourth rituximab
infusion, patient no. 5 with the severe autoimmune-thrombocytopenia was
retreated with 4 × 375 mg/m2 rituximab.
After the first 4 MoAb infusions, his platelet counts had increased.
During rituximab retreatment, thrombocyte counts did not normalize, but
bleeding stigmata ceased and the necessity of platelet transfusion was decreased.
The following findings emerge from this study: (1) incidence and
severity of adverse events during the first infusion of rituximab in
patients with peripheral lymphocytosis are dependent on the number of
circulating CD20+ tumor cells. Patients with lymphocyte
counts exceeding 50 × 109/L experience significantly
more side effects of NCI grade III and IV toxicity than patients with
less than 50 × 109/L lymphocytes (P = .0017).
(2) Application of the first dose of rituximab to patients with high
numbers of circulating CD20+ cells results in a
cytokine-release syndrome with peaks of TNF-
Submitted March 10, 1998; accepted June 1, 1999.
The publication costs of this
article were defrayed in part by
page charge payment. This article
must therefore be hereby marked
"advertisement"
in accordance with 18 U.S.C. section
1734 solely to indicate this fact.
Address reprint requests to A. Engert, MD, PhD, Department I of
Internal Medicine, University of Cologne, Joseph-Stelzmann-Str. 9, D-50924 Cologne, Germany; e-mail: sabine.kluge{at}medizin.uni-koeln.de.
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|
TOP
ABSTRACT
INTRODUCTION
(TNF-
50% increase of splenomegaly or hepatomegaly without
evidence of transformation to a more aggressive histology, or a greater than 50% increase in the absolute number of circulating lymphocytes.
[IFN-
, IL-6, tumor necrosis factor-
)
consisting of 5 patients with lymphocyte counts less than 50 × 109/L and group B (
) of 6 patients with lymphocyte
counts greater than 50 × 109/L at baseline. (A) Relative
lymphocyte counts. (B) Relative thrombocyte counts (n = 10; patient
no. 9 was excluded from analysis because of platelet transfusion 12 hours after onset of infusion). *These differences between
posttreatment thrombocyte counts in group A and B are statistically
significant (P = .02; P = .03).
11.5 × 109/L) (Table 
the model of the Jarisch-Herxheimer reaction.
J Antimicrob Chemother
41:25, 1998