Chronic lymphocytic leukemia

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Jon Arnason, MD
Beth Israel Deaconess Medical Center
Boston, MA
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Sanjai Sharma, MD
Sequoia Regional Cancer Center
Visalia, CA

Are you looking for a regimen but can't find it here? It is possible that we've moved it to the historical regimens page. If you still can't find it, please let us know so we can add it!
Note: there are several regimens on this page that are specific to small lymphocytic lymphoma (SLL). The vast majority of the regimens here were evaluated in CLL or in mixed populations of CLL and SLL patients.

84 regimens on this page
122 variants on this page


Guidelines

ASBMT

ESMO

"How I Treat"

International Workshop on Chronic Lymphocytic Leukemia (iwCLL)

Older

NCCN

First-line therapy, randomized data

Acalabrutinib monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Byrd et al. 2021 (ACE-CL-001 untreated) 2014-2015 Phase 1/2
Sharman et al. 2020 (ELEVATE TN) 2015-2017 Phase 3 (E-RT-switch-ooc) 1. Acalabrutinib & Obinutuzumab Not reported
2. Chlorambucil & Obinutuzumab Superior PFS
Median PFS: NYR vs 22.6 mo
(HR 0.20, 95% CI 0.13-0.30)

Note: Byrd et al. 2021 reports on a treatment-naive cohort from a trial that mostly enrolled patients in relapse.

Targeted therapy

Continued indefinitely

References

  1. ELEVATE TN: Sharman JP, Egyed M, Jurczak W, Skarbnik A, Pagel JM, Flinn IW, Kamdar M, Munir T, Walewska R, Corbett G, Fogliatto LM, Herishanu Y, Banerji V, Coutre S, Follows G, Walker P, Karlsson K, Ghia P, Janssens A, Cymbalista F, Woyach JA, Salles G, Wierda WG, Izumi R, Munugalavadla V, Patel P, Wang MH, Wong S, Byrd JC. Acalabrutinib with or without obinutuzumab versus chlorambucil and obinutuzmab for treatment-naive chronic lymphocytic leukaemia (ELEVATE TN): a randomised, controlled, phase 3 trial. Lancet. 2020 Apr 18;395(10232):1278-1291. link to original article link to PMC article contains dosing details in abstract PubMed NCT02475681
  2. ACE-CL-001 untreated: Byrd JC, Woyach JA, Furman RR, Martin P, O'Brien S, Brown JR, Stephens DM, Barrientos JC, Devereux S, Hillmen P, Pagel JM, Hamdy A, Izumi R, Patel P, Wang MH, Jain N, Wierda WG. Acalabrutinib in treatment-naive chronic lymphocytic leukemia. Blood. 2021 Jun 17;137(24):3327-3338. link to original article link to PMC article contains dosing details in abstract PubMed NCT02029443

Acalabrutinib & Obinutuzumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Sharman et al. 2020 (ELEVATE TN) 2015-2017 Phase 3 (E-RT-switch-ooc) 1. Acalabrutinib Not reported
2. Chlorambucil & Obinutuzumab Superior PFS
Median PFS: NYR vs 22.6 mo
(HR 0.10, 95% CI 0.06-0.17)

Targeted therapy

  • Acalabrutinib (Calquence) 100 mg PO twice per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 2: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 3 to 7: 1000 mg IV once on day 1

28-day cycles

References

  1. ELEVATE TN: Sharman JP, Egyed M, Jurczak W, Skarbnik A, Pagel JM, Flinn IW, Kamdar M, Munir T, Walewska R, Corbett G, Fogliatto LM, Herishanu Y, Banerji V, Coutre S, Follows G, Walker P, Karlsson K, Ghia P, Janssens A, Cymbalista F, Woyach JA, Salles G, Wierda WG, Izumi R, Munugalavadla V, Patel P, Wang MH, Wong S, Byrd JC. Acalabrutinib with or without obinutuzumab versus chlorambucil and obinutuzmab for treatment-naive chronic lymphocytic leukaemia (ELEVATE TN): a randomised, controlled, phase 3 trial. Lancet. 2020 Apr 18;395(10232):1278-1291. link to original article link to PMC article contains dosing details in abstract PubMed NCT02475681

Alemtuzumab monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hillmen et al. 2007 (CAM 307) 2001-2004 Phase 3 (E-RT-switch-ooc) Chlorambucil Superior PFS1
Median PFS: 15 vs 12 mo
(aHR 0.58, 95% CI 0.43-0.77)

1Median PFS is not reported in the manuscript and is estimated from the K-M curve (Figure 1A)
This regimen was intended for patients who were at least 18 years old with flow cytometry–confirmed diagnosis of B-cell CLL, Rai stage I through IV with evidence of progression according to the National Cancer Institute Working Group (NCI-WG) 1996 criteria, no previous chemotherapy for CLL, a life expectancy of at least 12 weeks, WHO performance status of 0 to 2, and adequate renal and liver function.

Targeted therapy

  • Alemtuzumab (Campath) by the following criteria:
    • Starting dose: 3 mg IV once per day
    • If tolerated in terms of infusion reactions: 10 mg IV once per day
    • If tolerated in terms of infusion reactions: 30 mg IV once per day
    • Once 30 mg dose is tolerated: 30 mg IV over 2 hours, 3 times per week

Supportive medications

12- to 16-week course; total course varies depending on reference

References

  1. CAM 307: Hillmen P, Skotnicki AB, Robak T, Jaksic B, Dmoszynska A, Wu J, Sirard C, Mayer J. Alemtuzumab compared with chlorambucil as first-line therapy for chronic lymphocytic leukemia. J Clin Oncol. 2007 Dec 10;25(35):5616-23. Epub 2007 Nov 5. link to original article contains dosing details in abstract PubMed NCT00046683

Bendamustine monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Knauf et al. 2009 2002-2006 Phase 3 (E-RT-switch-ic) Chlorambucil Superior PFS
Median PFS: 21.6 vs 8.3 mo
Zhou et al. 2022 (SIM-79-001) 2009-2016 Phase 3 (E-switch-ic) Chlorambucil Superior PFS
Median PFS: 16.5 vs 9.6 mo

This regimen was intended for previously untreated CLL patients up to 75 years of age with Binet stage B or C disease in need for treatment per the NCI-WG guidelines or IWCLL guidelines.

Chemotherapy

28-day cycle for 6 cycles

References

  1. Knauf WU, Lissichkov T, Aldaoud A, Liberati A, Loscertales J, Herbrecht R, Juliusson G, Postner G, Gercheva L, Goranov S, Becker M, Fricke HJ, Huguet F, Del Giudice I, Klein P, Tremmel L, Merkle K, Montillo M. Phase III randomized study of bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukemia. J Clin Oncol. 2009 Sep 10;27(26):4378-84. Epub 2009 Aug 3. link to original article contains dosing details in manuscript PubMed
    1. Update: Knauf WU, Lissitchkov T, Aldaoud A, Liberati AM, Loscertales J, Herbrecht R, Juliusson G, Postner G, Gercheva L, Goranov S, Becker M, Fricke HJ, Huguet F, Del Giudice I, Klein P, Merkle K, Montillo M. Bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukaemia: updated results of a randomized phase III trial. Br J Haematol. 2012 Oct;159(1):67-77. Epub 2012 Aug 4. link to original article PubMed
  2. Retrospective: Kolibaba KS, Sterchele JA, Joshi AD, Forsyth M, Alwon E, Beygi H, Kennealey GT. Demographics, treatment patterns, safety, and real-world effectiveness in patients aged 70 years and over with chronic lymphocytic leukemia receiving bendamustine with or without rituximab: a retrospective study. Ther Adv Hematol. 2013 Jun;4(3):157-71. link to PMC article PubMed
  3. SIM-79-001: Zhou D, Xu W, Ma H, Zhao C, Hu Y, Zhao Y, Wu D, Zhao X, He Y, Yan J, Wang C, Meng F, Jin J, Zhang X, Yu K, Hu J, Lv Y. Bendamustine versus chlorambucil in treatment of chronic lymphocytic leukaemia in China: a randomized, open-label, parallel-controlled, phase III clinical trial. Invest New Drugs. 2022 Apr;40(2):349-360. Epub 2022 Jan 15. link to original article contains dosing details in manuscript PubMed NCT01109264

Bendamustine & Rituximab (BR)

BR: Bendamustine & Rituximab
R-B: Rituximab & Bendamustine

Regimen variant #1, 6 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Fischer et al. 2012 (GCLLSG CLL2M untreated) 2007-2008 Phase 2
Eichhorst et al. 2016 (GCLLSG CLL10) 2008-2011 Phase 3 (E-switch-ic) FCR Seems to have inferior PFS
Michallet et al. 2018 (MABLE) 2010-2014 Phase 3b (E-switch-ic) R-Clb Superior PFS
Median PFS: 39.6 vs 29.9 mo
(HR 0.52, 95% CI 0.34-0.81)
Tam et al. 2022 (SEQUOIACLL) 2017-2019 Phase 3 (C) Zanubrutinib Inferior PFS

Biomarker eligibility criteria

  • SEQUOIACLL: No 17p deletion

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 0 or 1
    • Cycle 2 onwards: 500 mg/m2 IV once on day 1

28-day cycle for up to 6 cycles

Regimen variant #2, 6 cycles with maintenance rituximab

Study Years of enrollment Evidence Comparator Comparative Efficacy
Wang et al. 2022 (SHINE) 2013-2014 Phase 3 (C) BR & Ibrutinib Seems to have inferior PFS

Note: the cycle timing changes during rituximab maintenance; the dosing does not change.

Chemotherapy

  • Bendamustine as follows:
    • Cycles 1 to 6: 90 mg/m2 IV once per day on days 1 & 2

Targeted therapy

28-day cycle for 6 cycles, then 8-week cycle for 12 cycles

References

  1. GCLLSG CLL2M untreated: Fischer K, Cramer P, Busch R, Böttcher S, Bahlo J, Schubert J, Pflüger KH, Schott S, Goede V, Isfort S, von Tresckow J, Fink AM, Bühler A, Winkler D, Kreuzer KA, Staib P, Ritgen M, Kneba M, Döhner H, Eichhorst BF, Hallek M, Stilgenbauer S, Wendtner CM. Bendamustine in combination with rituximab for previously untreated patients with chronic lymphocytic leukemia: a multicenter phase II trial of the German Chronic Lymphocytic Leukemia Study Group. J Clin Oncol. 2012 Sep 10;30(26):3209-16. Epub 2012 Aug 6. link to original article contains dosing details in manuscript PubMed NCT00274989
  2. Retrospective: Kolibaba KS, Sterchele JA, Joshi AD, Forsyth M, Alwon E, Beygi H, Kennealey GT. Demographics, treatment patterns, safety, and real-world effectiveness in patients aged 70 years and over with chronic lymphocytic leukemia receiving bendamustine with or without rituximab: a retrospective study. Ther Adv Hematol. 2013 Jun;4(3):157-71. link to PMC article PubMed
  3. GCLLSG CLL10: Eichhorst B, Fink AM, Bahlo J, Busch R, Kovacs G, Maurer C, Lange E, Köppler H, Kiehl M, Sökler M, Schlag R, Vehling-Kaiser U, Köchling G, Plöger C, Gregor M, Plesner T, Trneny M, Fischer K, Döhner H, Kneba M, Wendtner CM, Klapper W, Kreuzer KA, Stilgenbauer S, Böttcher S, Hallek M; International Group of Investigators; GCLLSG. First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol. 2016 Jul;17(7):928-42. Epub 2016 May 20. link to original article PubMed NCT000769522
  4. MABLE: Michallet AS, Aktan M, Hiddemann W, Ilhan O, Johansson P, Laribi K, Meddeb B, Moreno C, Raposo J, Schuh A, Ünal A, Widenius T, Bernhardt A, Kellershohn K, Messeri D, Osborne S, Leblond V. Rituximab plus bendamustine or chlorambucil for chronic lymphocytic leukemia: primary analysis of the randomized, open-label MABLE study. Haematologica. 2018 Apr;103(4):698-706. Epub 2018 Feb 1. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01056510
  5. Alliance A041202: Woyach JA, Ruppert AS, Heerema NA, Zhao W, Booth AM, Ding W, Bartlett NL, Brander DM, Barr PM, Rogers KA, Parikh SA, Coutre S, Hurria A, Brown JR, Lozanski G, Blachly JS, Ozer HG, Major-Elechi B, Fruth B, Nattam S, Larson RA, Erba H, Litzow M, Owen C, Kuzma C, Abramson JS, Little RF, Smith SE, Stone RM, Mandrekar SJ, Byrd JC. Ibrutinib regimens versus chemoimmunotherapy in older patients with untreated CLL. N Engl J Med. 2018 Dec 27;379(26):2517-2528. Epub 2018 Dec 1. link to original article contains dosing details in abstract link to PMC article PubMed NCT01886872
  6. SHINE: Wang ML, Jurczak W, Jerkeman M, Trotman J, Zinzani PL, Belada D, Boccomini C, Flinn IW, Giri P, Goy A, Hamlin PA, Hermine O, Hernández-Rivas JÁ, Hong X, Kim SJ, Lewis D, Mishima Y, Özcan M, Perini GF, Pocock C, Song Y, Spurgeon SE, Storring JM, Walewski J, Zhu J, Qin R, Henninger T, Deshpande S, Howes A, Le Gouill S, Dreyling M; SHINE Investigators. Ibrutinib plus Bendamustine and Rituximab in Untreated Mantle-Cell Lymphoma. N Engl J Med. 2022 Jun 30;386(26):2482-2494. Epub 2022 Jun 3. link to original article PubMed NCT01776840
  7. SEQUOIACLL: Tam CS, Brown JR, Kahl BS, Ghia P, Giannopoulos K, Jurczak W, Šimkovič M, Shadman M, Österborg A, Laurenti L, Walker P, Opat S, Chan H, Ciepluch H, Greil R, Tani M, Trněný M, Brander DM, Flinn IW, Grosicki S, Verner E, Tedeschi A, Li J, Tian T, Zhou L, Marimpietri C, Paik JC, Cohen A, Huang J, Robak T, Hillmen P. Zanubrutinib versus bendamustine and rituximab in untreated chronic lymphocytic leukaemia and small lymphocytic lymphoma (SEQUOIA): a randomised, controlled, phase 3 trial. Lancet Oncol. 2022 Aug;23(8):1031-1043. Epub 2022 Jul 7. link to original article contains dosing details in abstract PubMed NCT03336333
  8. ACE-CL-311: NCT03836261
  9. CRISTALLO: NCT04285567
  10. GAIA: NCT02950051

Bendamustine & Rituximab (BR) & Ibrutinib

BR & Ibrutinib: Bendamustine, Rituximab, Ibrutinib

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Wang et al. 2022 (SHINE) 2013-2014 Phase 3 (E-esc) BR Seems to have superior PFS
Median PFS: 80.6 vs 52.9 mo
(HR 0.75, 95% CI 0.59-0.96)

Note: the cycle timing changes during rituximab maintenance; the dosing does not change.

Chemotherapy

  • Bendamustine as follows:
    • Cycles 1 to 6: 90 mg/m2 IV once per day on days 1 & 2

Targeted therapy

28-day cycle for 6 cycles, then 8-week cycles

References

  1. SHINE: Wang ML, Jurczak W, Jerkeman M, Trotman J, Zinzani PL, Belada D, Boccomini C, Flinn IW, Giri P, Goy A, Hamlin PA, Hermine O, Hernández-Rivas JÁ, Hong X, Kim SJ, Lewis D, Mishima Y, Özcan M, Perini GF, Pocock C, Song Y, Spurgeon SE, Storring JM, Walewski J, Zhu J, Qin R, Henninger T, Deshpande S, Howes A, Le Gouill S, Dreyling M; SHINE Investigators. Ibrutinib plus Bendamustine and Rituximab in Untreated Mantle-Cell Lymphoma. N Engl J Med. 2022 Jun 30;386(26):2482-2494. Epub 2022 Jun 3. link to original article contains dosing details in manuscript PubMed NCT01776840

Cladribine & Cyclophosphamide (CC)

CC: Cladribine, Cyclophosphamide

Regimen variant #1, 0.36/650

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2006 (PALG CLL2) 1998-2003 Phase 3 (E-esc) 1. Cladribine Might have superior CR rate
2. CMC Seems to have inferior CR rate

Chemotherapy

Supportive medications

  • No routine prophylactic antibiotics, antiviral agents, or growth factor administration was planned.

28-day cycle for up to 6 cycles

Regimen variant #2, 0.36/750

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2010 (PALG-CLL3) 2004-2007 Phase 3 (E-switch-ic) FC Did not meet primary endpoint of CR rate

Chemotherapy

Supportive medications

  • "No routine prophylaxis with antibiotics, antiviral agents, or growth factors."

28-day cycle for up to 6 cycles

References

  1. PALG CLL2: Robak T, Blonski JZ, Gora-Tybor J, Jamroziak K, Dwilewicz-Trojaczek J, Tomaszewska A, Konopka L, Ceglarek B, Dmoszynska A, Kowal M, Kloczko J, Stella-Holowiecka B, Sulek K, Calbecka M, Zawilska K, Kuliczkowski K, Skotnicki AB, Warzocha K, Kasznicki M; PALG. 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 Adult Leukemia Group (PALG CLL2). Blood. 2006 Jul 15;108(2):473-9. Epub 2006 Mar 21. link to original article contains dosing details in manuscript PubMed
    1. Update: Robak T, Blonski JZ, Gora-Tybor J, Calbecka M, Dwilewicz-Trojaczek J, Boguradzki P, Dmoszynska A, Kowal M, Kloczko J, Piszcz J, Stella-Holowiecka B, Sulek K, Kuliczkowski K, Potoczek S, Warzocha K, Lech-Maranda E, Skotnicki AB, Piotrowska M, Moskwa A, Zawilska K, Jamroziak K. Long-term results of the Polish Adult Leukemia Group PALG-CLL2 phase III randomized study comparing cladribine-based combinations in chronic lymphocytic leukemia. Leuk Lymphoma. 2014 Mar;55(3):606-10. Epub 2013 Nov 14. link to original article PubMed
  2. PALG-CLL3: Robak T, Jamroziak K, Gora-Tybor J, Stella-Holowiecka B, Konopka L, Ceglarek B, Warzocha K, Seferynska I, Piszcz J, Calbecka M, Kostyra A, Dwilewicz-Trojaczek J, Dmoszyñska A, Zawilska K, Hellmann A, Zdunczyk A, Potoczek S, Piotrowska M, Lewandowski K, Blonski JZ. Comparison of cladribine plus cyclophosphamide with fludarabine plus cyclophosphamide as first-line therapy for chronic lymphocytic leukemia: a phase III randomized study by the Polish Adult Leukemia Group (PALG-CLL3 Study). J Clin Oncol. 2010 Apr 10;28(11):1863-9. Epub 2010 Mar 8. link to original article contains dosing details in manuscript PubMed

Chlorambucil & Obinutuzumab (GClb)

GClb: GA101 (Obinutuzumab) & Chlorambucil

Regimen variant #1, 6 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Goede et al. 2014 (GCLLSG CLL11) 2010-2012 Phase 3 (E-RT-esc) 1. Chlorambucil Superior OS
Median OS: NYR vs NYR
(HR 0.41, 95% CI 0.23-0.74)
2. Chlorambucil & Rituximab Superior PFS
Moreno et al. 2018 (iLLUMINATE) 2014-2015 Phase 3 (E-RT-switch-ooc) Ibrutinib & Obinutuzumab Inferior PFS

Chemotherapy

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycle for 6 cycles

Regimen variant #2, 12 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Fischer et al. 2019 (GCLLSG CLL14) 2015-2016 Phase 3 (C) Venetoclax & Obinutuzumab Inferior PFS

Note: Obinutuzumab is only given for the first six cycles.

Chemotherapy

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycle for 12 cycles

References

  1. GCLLSG CLL11: Goede V, Fischer K, Busch R, Engelke A, Eichhorst B, Wendtner CM, Chagorova T, de la Serna J, Dilhuydy MS, Illmer T, Opat S, Owen CJ, Samoylova O, Kreuzer KA, Stilgenbauer S, Döhner H, Langerak AW, Ritgen M, Kneba M, Asikanius E, Humphrey K, Wenger M, Hallek M. Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions. N Engl J Med. 2014 Mar 20;370(12):1101-10. Epub 2014 Jan 8. link to original article contains dosing details in manuscript PubMed NCT01010061
    1. Update: Goede V, Fischer K, Engelke A, Schlag R, Lepretre S, Casado Montero LF, Montillo M, Fegan C, Asikanius E, Humphrey K, Fingerle-Rowson G, Hallek M. Obinutuzumab as frontline treatment of chronic lymphocytic leukemia: updated results of the CLL11 study. Leukemia. 2015 Jul;29(7):1602-4. Epub 2015 Jan 30. link to original article PubMed
  2. iLLUMINATE: Moreno C, Greil R, Demirkan F, Tedeschi A, Anz B, Larratt L, Simkovic M, Samoilova O, Novak J, Ben-Yehuda D, Strugov V, Gill D, Gribben JG, Hsu E, Lih CJ, Zhou C, Clow F, James DF, Styles L, Flinn IW. Ibrutinib plus obinutuzumab versus chlorambucil plus obinutuzumab in first-line treatment of chronic lymphocytic leukaemia (iLLUMINATE): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2019 Jan;20(1):43-56. Epub 2018 Nov 30. link to original article contains dosing details in abstract PubMed NCT02264574
  3. GCLLSG CLL14: Fischer K, Al-Sawaf O, Bahlo J, Fink AM, Tandon M, Dixon M, Robrecht S, Warburton S, Humphrey K, Samoylova O, Liberati AM, Pinilla-Ibarz J, Opat S, Sivcheva L, Le Dû K, Fogliatto LM, Niemann CU, Weinkove R, Robinson S, Kipps TJ, Boettcher S, Tausch E, Humerickhouse R, Eichhorst B, Wendtner CM, Langerak AW, Kreuzer KA, Ritgen M, Goede V, Stilgenbauer S, Mobasher M, Hallek M. Venetoclax and obinutuzumab in patients with CLL and coexisting conditions. N Engl J Med. 2019 Jun 6;380(23):2225-2236. Epub 2019 Jun 4. link to original article contains dosing details in manuscript PubMed NCT02242942
    1. Update: Al-Sawaf O, Zhang C, Tandon M, Sinha A, Fink AM, Robrecht S, Samoylova O, Liberati AM, Pinilla-Ibarz J, Opat S, Sivcheva L, Le Dû K, Fogliatto LM, Niemann CU, Weinkove R, Robinson S, Kipps TJ, Tausch E, Schary W, Ritgen M, Wendtner CM, Kreuzer KA, Eichhorst B, Stilgenbauer S, Hallek M, Fischer K. Venetoclax plus obinutuzumab versus chlorambucil plus obinutuzumab for previously untreated chronic lymphocytic leukaemia (CLL14): follow-up results from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2020 Sep;21(9):1188-1200. link to original article PubMed
    2. Update: Al-Sawaf O, Zhang C, Lu T, Liao MZ, Panchal A, Robrecht S, Ching T, Tandon M, Fink AM, Tausch E, Schneider C, Ritgen M, Böttcher S, Kreuzer KA, Chyla B, Miles D, Wendtner CM, Eichhorst B, Stilgenbauer S, Jiang Y, Hallek M, Fischer K. Minimal Residual Disease Dynamics after Venetoclax-Obinutuzumab Treatment: Extended Off-Treatment Follow-up From the Randomized CLL14 Study. J Clin Oncol. 2021 Dec 20;39(36):4049-4060. Epub 2021 Oct 28. link to original article link to PMC article PubMed
  4. CR108428: NCT03462719
  5. UNITY-CLL: NCT02612311

Chlorambucil & Ofatumumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hillmen et al. 2015 (COMPLEMENT 1) 2008-2011 Phase 3 (E-RT-esc) Chlorambucil Superior PFS
Median PFS: 22.4 vs 13.1 mo
(HR 0.57, 95% CI 0.45-0.72)

Chemotherapy

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once on day 8
    • Cycle 2 onwards: 1000 mg IV once on day 1

Supportive medications

28-day cycle for a minimum of 3 cycles, and then given until best response up to a maximum of 12 cycles

References

  1. COMPLEMENT 1: Hillmen P, Robak T, Janssens A, Babu KG, Kloczko J, Grosicki S, Doubek M, Panagiotidis P, Kimby E, Schuh A, Pettitt AR, Boyd T, Montillo M, Gupta IV, Wright O, Dixon I, Carey JL, Chang CN, Lisby S, McKeown A, Offner F; COMPLEMENT 1 Study Investigators. Chlorambucil plus ofatumumab versus chlorambucil alone in previously untreated patients with chronic lymphocytic leukaemia (COMPLEMENT 1): a randomised, multicentre, open-label phase 3 trial. Lancet. 2015 May 9;385(9980):1873-83. Epub 2015 Apr 13. link to original article contains dosing details in abstract PubMed NCT00748189
    1. Update: Offner F, Robak T, Janssens A, Govind Babu K, Kloczko J, Grosicki S, Mayer J, Panagiotidis P, Schuh A, Pettitt A, Montillo M, Werner O, Vincent G, Khanna S, Hillmen P. A five-year follow-up of untreated patients with chronic lymphocytic leukaemia treated with ofatumumab and chlorambucil: final analysis of the Complement 1 phase 3 trial. Br J Haematol. 2020 Sep;190(5):736-740. Epub 2020 Mar 31. link to original article PubMed

Chlorambucil & Rituximab (RClb)

RClb: Rituximab & Chlorambucil
CLB-R: ChLoramBucil & Rituximab

Regimen variant #1, Clb 0.5 mg/kg q2wk

Study Years of enrollment Evidence Comparator Comparative Efficacy
Goede et al. 2014 (GCLLSG CLL11) 2010-2012 Phase 3 (E-esc) 1. Chlorambucil Superior PFS
2. Chlorambucil & Obinutuzumab Inferior PFS

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

28-day cycle for 6 cycles

Regimen variant #2, Clb 8 mg/m2/d, 1 week out of 4

Study Years of enrollment Evidence
Foà et al. 2014 (ML21445) 2008-2013 Non-randomized portion of phase 2 RCT

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 3: 375 mg/m2 IV once on day 1
    • Cycle 4 onwards: 500 mg/m2 IV once on day 1

28-day cycle for up to 8 cycles

Subsequent treatment

Regimen variant #3, Clb 10 mg/m2/d, 1 week out of 4

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hillmen et al. 2014 (NCRI CLL208) 2007-2009 Phase 2
Michallet et al. 2018 (MABLE) 2010-2014 Phase 3b (E-switch-ic) BR Inferior PFS

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

28-day cycle for 6 cycles

Subsequent treatment

  • NCRI CLL208; Patients not achieving CR: Optional chlorambucil x up to 6 cycles
  • MABLE; Patients not achieving CR: Optional chlorambucil x up to 6 cycles or until CR

References

  1. GCLLSG CLL11: Goede V, Fischer K, Busch R, Engelke A, Eichhorst B, Wendtner CM, Chagorova T, de la Serna J, Dilhuydy MS, Illmer T, Opat S, Owen CJ, Samoylova O, Kreuzer KA, Stilgenbauer S, Döhner H, Langerak AW, Ritgen M, Kneba M, Asikanius E, Humphrey K, Wenger M, Hallek M. Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions. N Engl J Med. 2014 Mar 20;370(12):1101-10. Epub 2014 Jan 8. link to original article contains dosing details in manuscript PubMed NCT01010061
    1. Update: Goede V, Fischer K, Engelke A, Schlag R, Lepretre S, Casado Montero LF, Montillo M, Fegan C, Asikanius E, Humphrey K, Fingerle-Rowson G, Hallek M. Obinutuzumab as frontline treatment of chronic lymphocytic leukemia: updated results of the CLL11 study. Leukemia. 2015 Jul;29(7):1602-4. Epub 2015 Jan 30. link to original article PubMed
  2. ML21445: Foà R, Del Giudice I, Cuneo A, Del Poeta G, Ciolli S, Di Raimondo F, Lauria F, Cencini E, Rigolin GM, Cortelezzi A, Nobile F, Callea V, Brugiatelli M, Massaia M, Molica S, Trentin L, Rizzi R, Specchia G, Di Serio F, Orsucci L, Ambrosetti A, Montillo M, Zinzani PL, Ferrara F, Morabito F, Mura MA, Soriani S, Peragine N, Tavolaro S, Bonina S, Marinelli M, De Propris MS, Starza ID, Piciocchi A, Alietti A, Runggaldier EJ, Gamba E, Mauro FR, Chiaretti S, Guarini A. Chlorambucil plus rituximab with or without maintenance rituximab as first-line treatment for elderly chronic lymphocytic leukemia patients. Am J Hematol. 2014 May;89(5):480-6. Epub 2014 Feb 18. link to original article contains dosing details in manuscript PubMed EudraCT 2008-001612-20
  3. NCRI CLL08: Hillmen P, Gribben JG, Follows GA, Milligan D, Sayala HA, Moreton P, Oscier DG, Dearden CE, Kennedy DB, Pettitt AR, Nathwani A, Varghese A, Cohen D, Rawstron A, Oertel S, Pocock CF. Rituximab plus chlorambucil as first-line treatment for chronic lymphocytic leukemia: Final analysis of an open-label phase II study. J Clin Oncol. 2014 Apr 20;32(12):1236-41. Epub 2014 Mar 17. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00532129
  4. MABLE: Michallet AS, Aktan M, Hiddemann W, Ilhan O, Johansson P, Laribi K, Meddeb B, Moreno C, Raposo J, Schuh A, Ünal A, Widenius T, Bernhardt A, Kellershohn K, Messeri D, Osborne S, Leblond V. Rituximab plus bendamustine or chlorambucil for chronic lymphocytic leukemia: primary analysis of the randomized, open-label MABLE study. Haematologica. 2018 Apr;103(4):698-706. Epub 2018 Feb 1. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01056510

Cladribine monotherapy

Regimen variant #1, 0.6 mg/kg

Study Years of enrollment Evidence Comparator Comparative Efficacy
Mulligan et al. 2014 1997-2004 Phase 3 (E-switch-ic) 1. Chlorambucil
2. Fludarabine
Superior PFS
Robak et al. 2006 (PALG CLL2) 1998-2003 Phase 3 (C) 1. CC Might have inferior CR rate
2. CMC Inferior CR rate

Note: Dosing details for Mulligan et al. 2014 were not available in the abstract.

Chemotherapy

Supportive medications

  • No routine prophylactic antibiotics, antiviral agents, or growth factor administration was planned.

28-day cycle for up to 6 cycles

Regimen variant #2, 0.7 mg/m2

Study Years of enrollment Evidence
Saven et al. 1995 1988-1993 Phase 2

Chemotherapy

  • Cladribine (Leustatin) 0.1 mg/m2/day IV continuous infusion over 7 days, started on day 1 (total dose per cycle: 0.7 mg/m2)

28 to 35-day cycles, repeated until maximum response or limiting toxicity

References

  1. Saven A, Lemon RH, Kosty M, Beutler E, Piro LD. 2-Chlorodeoxyadenosine activity in patients with untreated chronic lymphocytic leukemia. J Clin Oncol. 1995 Mar;13(3):570-4. link to original article contains dosing details in abstract PubMed
  2. PALG CLL2: Robak T, Blonski JZ, Gora-Tybor J, Jamroziak K, Dwilewicz-Trojaczek J, Tomaszewska A, Konopka L, Ceglarek B, Dmoszynska A, Kowal M, Kloczko J, Stella-Holowiecka B, Sulek K, Calbecka M, Zawilska K, Kuliczkowski K, Skotnicki AB, Warzocha K, Kasznicki M; Polish Adult Leukemia Group. 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 Adult Leukemia Group (PALG CLL2). Blood. 2006 Jul 15;108(2):473-9. Epub 2006 Mar 21. link to original article contains dosing details in manuscript PubMed
    1. Update: Robak T, Blonski JZ, Gora-Tybor J, Calbecka M, Dwilewicz-Trojaczek J, Boguradzki P, Dmoszynska A, Kowal M, Kloczko J, Piszcz J, Stella-Holowiecka B, Sulek K, Kuliczkowski K, Potoczek S, Warzocha K, Lech-Maranda E, Skotnicki AB, Piotrowska M, Moskwa A, Zawilska K, Jamroziak K. Long-term results of the Polish Adult Leukemia Group PALG-CLL2 phase III randomized study comparing cladribine-based combinations in chronic lymphocytic leukemia. Leuk Lymphoma. 2014 Mar;55(3):606-10. Epub 2013 Nov 14. link to original article PubMed
  3. Mulligan SP, Karlsson K, Strömberg M, Jønsson V, Gill D, Hammerström J, Hertzberg M, McLennan R, Uggla B, Norman J, Wallvik J, Sundström G, Johansson H, Brandberg Y, Liliemark J, Juliusson G; Scandinavian Lymphoma Group; ALLG. Cladribine prolongs progression-free survival and time to second treatment compared to fludarabine and high-dose chlorambucil in chronic lymphocytic leukemia. Leuk Lymphoma. 2014 Dec;55(12):2769-77. Epub 2014 Apr 16. link to original article PubMed

FCA

FCA: Fludarabine, Cyclophosphamide, Alemtuzumab
FCCam: Fludarabine, Cyclophosphamide, Campath (Alemtuzumab)

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Geisler et al. 2014 (HOVON-68) 2006-2010 Phase 3 (E-esc) FC Superior PFS
PFS36: 53% vs 37%
Lepretre et al. 2012 (GOELAMS CLL2007FMP) 2007-2009 Phase 3 (E-switch-ic) FCR Did not meet primary endpoint of PFS36

Note: GOELAMS CLL2007FMP was halted prematurely due to excess mortality. In HOVON-68, this regimen was intended for patients with previously untreated CLL diagnosed and in need of treatment according to the National Cancer Institute guidelines, 18 to 75 years of age, with WHO performance status less than 3 and no severe comorbidities, with high-risk CLL as defined by the presence of either unmutated IGHV, 17p deletion, 11q deletion, or trisomy 12 by FISH.

Chemotherapy

Targeted therapy

  • Alemtuzumab (Campath) as follows:
    • Cycle 1: 30 mg SC once per day on days -1, 0, and 1
    • Cycle 2 onwards: 30 mg SC once on day 1

Supportive medications

28-day cycle for 6 cycles

References

  1. GOELAMS CLL2007FMP: Lepretre S, Aurran T, Mahé B, Cazin B, Tournilhac O, Maisonneuve H, Casasnovas O, Delmer A, Leblond V, Royer B, Corront B, Chevret S, Delépine R, Vaudaux S, Van Den Neste E, Béné MC, Letestu R, Cymbalista F, Feugier P. Excess mortality after treatment with fludarabine and cyclophosphamide in combination with alemtuzumab in previously untreated patients with chronic lymphocytic leukemia in a randomized phase 3 trial. Blood. 2012 May 31;119(22):5104-10. Epub 2012 Feb 14. link to original article PubMed NCT00564512
  2. HOVON-68: Geisler CH, van T' Veer MB, Jurlander J, Walewski J, Tjønnfjord G, Itälä Remes M, Kimby E, Kozak T, Polliack A, Wu KL, Wittebol S, Abrahamse-Testroote MC, Doorduijn J, Ghidey Alemayehu W, van Oers MH. Frontline low-dose alemtuzumab with fludarabine and cyclophosphamide prolongs progression-free survival in high-risk CLL. Blood. 2014 May 22;123(21):3255-62. Epub 2014 Apr 15. link to original article contains dosing details in manuscript PubMed NTR529

FCR

FCR: Fludarabine, Cyclophosphamide, Rituximab
R-FC: Rituximab, Fludarabine, Cyclophosphamide

Regimen variant #1, 25/250/375-500

Study Years of enrollment Evidence Comparator Comparative Efficacy Comparative Toxicity
Keating et al. 2005 1999-2001 Phase 2
Hallek et al. 2010 (GCLLSG CLL8) 2003-2006 Phase 3 (E-RT-esc) FC Superior OS1
Median OS: NYR vs 86 mo
(HR 0.68, 95% CI 0.54-0.89)
Equivalent HRQoL
Herling et al. 2020 (GCLLSG CLL7) 2005-2010 Phase 3 (E-esc) Observation Superior EFS
Median EFS: NYR vs 18.5 mo
(HR 0.22, 95% CI 0.15-0.33)
Lepretre et al. 2012 (GOELAMS CLL2007FMP) 2007-2009 Phase 3 (C) FCCam Did not meet primary endpoint of PFS36
Eichhorst et al. 2016 (GCLLSG CLL10) 2008-2011 Phase 3 (C) BR Inconclusive whether non-inferior PFS
Shanafelt et al. 2019 (ECOG E1912) 2014-2016 Phase 3 (C) Ibrutinib & Rituximab Inferior OS

1Reported efficacy for GCLLSG CLL8 is based on the 2016 update.

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 0
      • Alternate dosing in ECOG E1912: 50 mg/m2 IV once on day 1, then 325 mg/m2 IV once on day 2
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 6 cycles

Regimen variant #2, 25/250/500

Study Years of enrollment Evidence Comparator Comparative Efficacy
Awan et al. 2014 (LUCID) 2006-NR Phase 3 (C) FCR+L Did not meet primary endpoint of CR rate

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV over at least 10 to 30 minutes once per day on days 2 to 4
    • Cycle 2 to 6: 25 mg/m2 IV over at least 10 to 30 minutes once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV over at least 10 to 30 minutes once per day on days 2 to 4
    • Cycle 2 to 6: 250 mg/m2 IV over at least 10 to 30 minutes once per day on days 1 to 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 50 mg/m2 IV over 4 hours once on day 1, then 450 mg/m2 IV once on day 3
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 6 cycles

Regimen variant #3, 20/150/375-500 ("FCR-Lite")

Study Years of enrollment Evidence
Foon et al. 2009 2003-2007 Phase 2

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 20 mg/m2 IV over 30 minutes once per day on days 2 to 4
    • Cycles 2 to 6: 20 mg/m2 IV over 30 minutes once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 150 mg/m2 IV over 60 minutes once per day on days 2 to 4
    • Cycles 2 to 6: 150 mg/m2 IV over 60 minutes once per day on days 1 to 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1, then 500 mg/m2 IV once on day 14
    • Cycles 2 to 6: 500 mg/m2 IV once per day on days 1 & 14

Supportive medications

28-day cycle for 6 cycles

Subsequent treatment

Regimen variant #4, 40/250/375-500, oral FC

Study Years of enrollment Evidence
Dartigeas et al. 2017 (CLL 2007 SA) 2007-2014 Non-randomized portion of RCT

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1, then 500 mg/m2 IV once on day 14
    • Cycle 2: 500 mg/m2 IV once per day on days 1 & 14
    • Cycles 3 & 4: 500 mg/m2 IV once on day 1

1-month cycle for 4 cycles

Subsequent treatment

Regimen variant #5, 25/250/375

Study Years of enrollment Evidence
Tam et al. 2006 2000-2005 Phase 2

Chemotherapy

Targeted therapy

28-day cycle for up to 6 cycles or "attainment of maximum response"

Regimen variant #6, 24/150/375-500, oral FC

Study Years of enrollment Evidence Comparator Comparative Efficacy
Munir et al. 2017 (ADMIRE) 2009-2012 Randomized Phase 2B (C) FCM-R Did not meet primary endpoint of CR rate
Howard et al. 2017 (ARCTICCLL) 2009-2012 Randomized Phase 2B (C) FCM-miniR Superior CR rate

Note: in contrast to other variants, FC is given over 5 days not 3. ARCTIC should not be confused with the trial by the same name in NSCLC.

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

28-day cycle for 6 cycles

References

  1. Keating MJ, O'Brien S, Albitar M, Lerner S, Plunkett W, Giles F, Andreeff M, Cortes J, Faderl S, Thomas D, Koller C, Wierda W, Detry MA, Lynn A, Kantarjian H. Early results of a chemoimmunotherapy regimen of fludarabine, cyclophosphamide, and rituximab as initial therapy for chronic lymphocytic leukemia. J Clin Oncol. 2005 Jun 20;23(18):4079-88. Epub 2005 Mar 14. link to original article contains dosing details in manuscript PubMed
    1. Update: Tam CS, O'Brien S, Wierda W, Kantarjian H, Wen S, Do KA, Thomas DA, Cortes J, Lerner S, Keating MJ. Long-term results of the fludarabine, cyclophosphamide, and rituximab regimen as initial therapy of chronic lymphocytic leukemia. Blood. 2008 Aug 15;112(4):975-80. Epub 2008 Apr 14. link to original article link to PMC article PubMed
    2. Update: Thompson PA, Tam CS, O'Brien SM, Wierda WG, Stingo F, Plunkett W, Smith SC, Kantarjian HM, Freireich EJ, Keating MJ. Fludarabine, cyclophosphamide, and rituximab treatment achieves long-term disease-free survival in IGHV-mutated chronic lymphocytic leukemia. Blood. 2016 Jan 21;127(3):303-9. Epub 2015 Oct 22. link to original article link to PMC article PubMed
  2. Tam CS, Wolf M, Prince HM, Januszewicz EH, Westerman D, Lin KI, Carney D, Seymour JF. Fludarabine, cyclophosphamide, and rituximab for the treatment of patients with chronic lymphocytic leukemia or indolent non-Hodgkin lymphoma. Cancer. 2006 Jun 1;106(11):2412-20. link to original article contains dosing details in manuscript PubMed
  3. Foon KA, Boyiadzis M, Land SR, Marks S, Raptis A, Pietragallo L, Meisner D, Laman A, Sulecki M, Butchko A, Schaefer P, Lenzer D, Tarhini A. Chemoimmunotherapy with low-dose fludarabine and cyclophosphamide and high dose rituximab in previously untreated patients with chronic lymphocytic leukemia. J Clin Oncol. 2009 Feb 1;27(4):498-503. Epub 2008 Dec 15. link to original article contains dosing details in manuscript PubMed
    1. Update: Foon KA, Mehta D, Lentzsch S, Kropf P, Marks S, Lenzner D, Pietragallo L, Sulecki M, Tarhini A, Boyiadzis M. Long-term results of chemoimmunotherapy with low-dose fludarabine, cyclophosphamide and high-dose rituximab as initial treatment for patients with chronic lymphocytic leukemia. Blood. 2012 Mar 29;119(13):3184-5. link to original article PubMed
  4. GCLLSG CLL8: Hallek M, Fischer K, Fingerle-Rowson G, Fink AM, Busch R, Mayer J, Hensel M, Hopfinger G, Hess G, von Grünhagen U, Bergmann M, Catalano J, Zinzani PL, Caligaris-Cappio F, Seymour JF, Berrebi A, Jäger U, Cazin B, Trneny M, Westermann A, Wendtner CM, Eichhorst BF, Staib P, Bühler A, Winkler D, Zenz T, Böttcher S, Ritgen M, Mendila M, Kneba M, Döhner H, Stilgenbauer S; International Group of Investigators; German Chronic Lymphocytic Leukaemia Study Group. Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial. Lancet. 2010 Oct 2;376(9747):1164-74. link to original article contains dosing details in manuscript PubMed NCT00281918
    1. Update: Fischer K, Bahlo J, Fink AM, Goede V, Herling CD, Cramer P, Langerbeins P, von Tresckow J, Engelke A, Maurer C, Kovacs G, Herling M, Tausch E, Kreuzer KA, Eichhorst B, Böttcher S, Seymour JF, Ghia P, Marlton P, Kneba M, Wendtner CM, Döhner H, Stilgenbauer S, Hallek M. Long-term remissions after FCR chemoimmunotherapy in previously untreated patients with CLL: updated results of the CLL8 trial. Blood. 2016 Jan 14;127(2):208-15. Epub 2015 Oct 20. link to original article PubMed
    2. HRQoL analysis: Kutsch N, Busch R, Bahlo J, Mayer J, Hensel M, Hopfinger G, Hess G, von Grünhagen U, Wendtner CM, Maria Fink A, Fischer K, Hallek M, Eichhorst B. FCR front-line therapy and quality of life in patients with chronic lymphocytic leukemia. Leuk Lymphoma. 2017 Feb;58(2):399-407. Epub 2016 Jun 29. link to original article PubMed
  5. GOELAMS CLL2007FMP: Lepretre S, Aurran T, Mahé B, Cazin B, Tournilhac O, Maisonneuve H, Casasnovas O, Delmer A, Leblond V, Royer B, Corront B, Chevret S, Delépine R, Vaudaux S, Van Den Neste E, Béné MC, Letestu R, Cymbalista F, Feugier P. Excess mortality after treatment with fludarabine and cyclophosphamide in combination with alemtuzumab in previously untreated patients with chronic lymphocytic leukemia in a randomized phase 3 trial. Blood. 2012 May 31;119(22):5104-10. Epub 2012 Feb 14. link to original article PubMed NCT00564512
  6. GCLLSG CLL7: Herling CD, Cymbalista F, Groß-Ophoff-Müller C, Bahlo J, Robrecht S, Langerbeins P, Fink AM, Al-Sawaf O, Busch R, Porcher R, Cazin B, Dreyfus B, Ibach S, Leprêtre S, Fischer K, Kaiser F, Eichhorst B, Wentner CM, Hoechstetter MA, Döhner H, Leblond V, Kneba M, Letestu R, Böttcher S, Stilgenbauer S, Hallek M, Levy V. Early treatment with FCR versus watch and wait in patients with stage Binet A high-risk chronic lymphocytic leukemia (CLL): a randomized phase 3 trial. Leukemia. 2020 Aug;34(8):2038-2050. Epub 2020 Feb 18. link to original article link to PMC article PubMed NCT00275054
  7. LUCID: Awan FT, Hillmen P, Hellmann A, Robak T, Hughes SG, Trone D, Shannon M, Flinn IW, Byrd JC; LUCID trial investigators. A randomized, open-label, multicentre, phase 2/3 study to evaluate the safety and efficacy of lumiliximab in combination with fludarabine, cyclophosphamide and rituximab versus fludarabine, cyclophosphamide and rituximab alone in subjects with relapsed chronic lymphocytic leukaemia. Br J Haematol. 2014 Nov;167(4):466-77. Epub 2014 Aug 8. link to original article contains dosing details in manuscript PubMed NCT00391066
  8. GCLLSG CLL10: Eichhorst B, Fink AM, Bahlo J, Busch R, Kovacs G, Maurer C, Lange E, Köppler H, Kiehl M, Sökler M, Schlag R, Vehling-Kaiser U, Köchling G, Plöger C, Gregor M, Plesner T, Trneny M, Fischer K, Döhner H, Kneba M, Wendtner CM, Klapper W, Kreuzer KA, Stilgenbauer S, Böttcher S, Hallek M; International Group of Investigators; German CLL Study Group. First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol. 2016 Jul;17(7):928-42. Epub 2016 May 20. link to original article PubMed NCT000769522
  9. ADMIRE: Munir T, Howard DR, McParland L, Pocock C, Rawstron AC, Hockaday A, Varghese A, Hamblin M, Bloor A, Pettitt A, Fegan C, Blundell J, Gribben JG, Phillips D, Hillmen P. Results of the randomized phase IIB ADMIRE trial of FCR with or without mitoxantrone in previously untreated CLL. Leukemia. 2017 Oct;31(10):2085-2093. Epub 2017 Apr 20. link to original article contains dosing details in manuscript PubMed ISRCTN42165735
  10. ARCTIC: Howard DR, Munir T, McParland L, Rawstron AC, Milligan D, Schuh A, Hockaday A, Allsup DJ, Marshall S, Duncombe AS, O'Dwyer JL, Smith AF, Longo R, Varghese A, Hillmen P. Results of the randomized phase IIB ARCTIC trial of low-dose rituximab in previously untreated CLL. Leukemia. 2017 Nov;31(11):2416-2425. Epub 2017 Mar 24. link to original article contains dosing details in supplement PubMed ISRCTN16544962
  11. CLL 2007 SA: Dartigeas C, Van Den Neste E, Léger J, Maisonneuve H, Berthou C, Dilhuydy MS, De Guibert S, Leprêtre S, Béné MC, Nguyen-Khac F, Letestu R, Cymbalista F, Rodon P, Aurran-Schleinitz T, Vilque JP, Tournilhac O, Mahé B, Laribi K, Michallet AS, Delmer A, Feugier P, Lévy V, Delépine R, Colombat P, Leblond V; CLL 2007 SA investigators; FILO. Rituximab maintenance versus observation following abbreviated induction with chemoimmunotherapy in elderly patients with previously untreated chronic lymphocytic leukaemia (CLL 2007 SA): an open-label, randomised phase 3 study. Lancet Haematol. 2018 Feb;5(2):e82-e94. Epub 2017 Dec 20. link to original article contains dosing details in abstract PubMed NCT00645606
  12. ECOG E1912: Shanafelt TD, Wang XV, Kay NE, Hanson CA, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M. Ibrutinib-rituximab or chemoimmunotherapy for chronic lymphocytic leukemia. N Engl J Med. 2019 Aug 1;381(5):432-443. link to original article contains dosing details in manuscript PubMed NCT02048813
    1. Update: Shanafelt TD, Wang XV, Hanson CA, Paietta EM, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M, Kay NE. Long-term outcomes for ibrutinib-rituximab and chemoimmunotherapy in CLL: updated results of the E1912 trial. Blood. 2022 Jul 14;140(2):112-120. link to original article PubMed
  13. ACE-CL-311: NCT03836261
  14. CRISTALLO: NCT04285567
  15. GAIA: NCT02950051

FCR (Rituximab and hyaluronidase)

FCR: Fludarabine, Cyclophosphamide, Rituximab hyaluronidase

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Assouline et al. 2016 (SAWYER) 2012-2013 Randomized Phase 1b (E-RT-switch-ic) FCR Not reported

Note: other variants include oral fludarabine and/or cyclophosphamide; to be completed.

Chemotherapy

Targeted therapy

28-day cycle for up to 6 cycles

References

  1. SAWYER: Assouline S, Buccheri V, Delmer A, Gaidano G, Trneny M, Berthillon N, Brewster M, Catalani O, Li S, McIntyre C, Sayyed P, Badoux X. Pharmacokinetics, safety, and efficacy of subcutaneous versus intravenous rituximab plus chemotherapy as treatment for chronic lymphocytic leukaemia (SAWYER): a phase 1b, open-label, randomised controlled non-inferiority trial. Lancet Haematol. 2016 Mar;3(3):e128-38. link to original article contains dosing details in manuscript PubMed NCT01292603

Fludarabine & Alemtuzumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Elter et al. 2011 (CAM 314) 2004-2008 Phase 3 (E-esc) Fludarabine Superior OS
Median OS: NYR vs 52.9 mo
(HR 0.65, 95% CI 0.45-0.94)

Chemotherapy

Targeted therapy

28-day cycle for up to 6 cycles

References

  1. CAM 314: Elter T, Gercheva-Kyuchukova L, Pylylpenko H, Robak T, Jaksic B, Rekhtman G, Kyrcz-Krzemień S, Vatutin M, Wu J, Sirard C, Hallek M, Engert A. Fludarabine plus alemtuzumab versus fludarabine alone in patients with previously treated chronic lymphocytic leukaemia: a randomised phase 3 trial. Lancet Oncol. 2011 Dec;12(13):1204-13. Epub 2011 Oct 10. link to original article contains dosing details in abstract PubMed NCT00086580

Ibrutinib monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
O'Brien et al. 2013 (PCYC-1102 untreated) 2010-2012 Phase 1b/2
Farooqui et al. 2014 (NHLBI 12-H-0035) 2011-2014 Phase 2
Burger et al. 2015 (RESONATE-2) 2013-NR Phase 3 (E-RT-switch-ooc) Chlorambucil Superior OS1
OS60: 83% vs 68%
(HR 0.45, 95% CI 0.27-0.76)
Woyach et al. 2018 (Alliance A041202) 2013-2016 Phase 3 (E-switch-ooc) BR Superior PFS
PFS24: 87% vs 74%
(HR 0.39, 95% CI 0.26-0.58)
Ibrutinib & Rituximab Did not meet primary endpoint of PFS
(HR 1.00, 95% CI 0.62-1.62)
Burger et al. 2018 (MDACC 2013-0703) 2013-2017 Phase 3 (C) Ibrutinib & Rituximab Did not meet primary endpoint of PFS
Langerbeins et al. 2022 (CLL12) 2014-2019 Phase 3 (E-esc) Placebo Superior EFS
Median EFS: NYR vs 47.8 mo
(HR 0.25, 95% CI 0.14-0.43)

1Reported efficacy for RESONATE-2 is based on the 2019 update.
PCYC-1102 was intended for elderly patients. Although both 420 mg and 840 mg doses were planned, the 840 mg cohort was closed due to findings of comparable efficacy in other studies. RESONATE-2 was intended for patients older than 65 years. CLL12 was intended for patients with asymptomatic Binet stage A CLL.

Biomarker eligibility criteria

  • NHLBI 12-H-0035: TP53 aberrations

Targeted therapy

28-day cycles

References

  1. PCYC-1102 untreated: O'Brien S, Furman RR, Coutre SE, Sharman JP, Burger JA, Blum KA, Grant B, Richards DA, Coleman M, Wierda WG, Jones JA, Zhao W, Heerema NA, Johnson AJ, Izumi R, Hamdy A, Chang BY, Graef T, Clow F, Buggy JJ, James DF, Byrd JC. Ibrutinib as initial therapy for elderly patients with chronic lymphocytic leukaemia or small lymphocytic lymphoma: an open-label, multicentre, phase 1b/2 trial. Lancet Oncol. 2014 Jan;15(1):48-58. Epub 2013 Dec 10. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01105247
    1. Update: Byrd JC, Furman RR, Coutre SE, Burger JA, Blum KA, Coleman M, Wierda WG, Jones JA, Zhao W, Heerema NA, Johnson AJ, Shaw Y, Bilotti E, Zhou C, James DF, O'Brien S. Three-year follow-up of treatment-naïve and previously treated patients with CLL and SLL receiving single-agent ibrutinib. Blood. 2015 Apr 16;125(16):2497-506. Epub 2015 Feb 19. link to original article link to PMC article PubMed
    2. Update: O'Brien S, Furman RR, Coutre S, Flinn IW, Burger JA, Blum K, Sharman J, Wierda W, Jones J, Zhao W, Heerema NA, Johnson AJ, Luan Y, James DF, Chu AD, Byrd JC. Single-agent ibrutinib in treatment-naïve and relapsed/refractory chronic lymphocytic leukemia: a 5-year experience. Blood. 2018 Apr 26;131(17):1910-1919. Epub 2018 Feb 2. link to original article link to PMC article PubMed
    3. Update: Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum K, Sharman JP, Wierda W, Zhao W, Heerema NA, Luan Y, Liu EA, Dean JP, O'Brien S. Ibrutinib Treatment for First-Line and Relapsed/Refractory Chronic Lymphocytic Leukemia: Final Analysis of the Pivotal Phase Ib/II PCYC-1102 Study. Clin Cancer Res. 2020 Aug 1;26(15):3918-3927. Epub 2020 Mar 24. link to original article link to PMC article PubMed
  2. NHLBI 12-H-0035: Farooqui MZ, Valdez J, Martyr S, Aue G, Saba N, Niemann CU, Herman SE, Tian X, Marti G, Soto S, Hughes TE, Jones J, Lipsky A, Pittaluga S, Stetler-Stevenson M, Yuan C, Lee YS, Pedersen LB, Geisler CH, Calvo KR, Arthur DC, Maric I, Childs R, Young NS, Wiestner A. Ibrutinib for previously untreated and relapsed or refractory chronic lymphocytic leukaemia with TP53 aberrations: a phase 2, single-arm trial. Lancet Oncol. 2015 Feb;16(2):169-76. Epub 2014 Dec 31. link to original article contains dosing details in abstract link to PMC article PubMed NCT01500733
  3. RESONATE-2: Burger JA, Tedeschi A, Barr PM, Robak T, Owen C, Ghia P, Bairey O, Hillmen P, Bartlett NL, Li J, Simpson D, Grosicki S, Devereux S, McCarthy H, Coutre S, Quach H, Gaidano G, Maslyak Z, Stevens DA, Janssens A, Offner F, Mayer J, O'Dwyer M, Hellmann A, Schuh A, Siddiqi T, Polliack A, Tam CS, Suri D, Cheng M, Clow F, Styles L, James DF, Kipps TJ; RESONATE-2 Investigators. Ibrutinib as initial therapy for patients with chronic lymphocytic leukemia. N Engl J Med. 2015 Dec 17;373(25):2425-37. Epub 2015 Dec 6. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01722487
    1. Update: Barr PM, Robak T, Owen C, Tedeschi A, Bairey O, Bartlett NL, Burger JA, Hillmen P, Coutre S, Devereux S, Grosicki S, McCarthy H, Li J, Simpson D, Offner F, Moreno C, Zhou C, Styles L, James D, Kipps TJ, Ghia P. Sustained efficacy and detailed clinical follow-up of first-line ibrutinib treatment in older patients with chronic lymphocytic leukemia: extended phase 3 results from RESONATE-2. Haematologica. 2018 Sep;103(9):1502-1510. Epub 2018 Jun 7. link to original article link to PMC article PubMed
    2. Update: Burger JA, Barr PM, Robak T, Owen C, Ghia P, Tedeschi A, Bairey O, Hillmen P, Coutre SE, Devereux S, Grosicki S, McCarthy H, Simpson D, Offner F, Moreno C, Dai S, Lal I, Dean JP, Kipps TJ. Long-term efficacy and safety of first-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study. Leukemia. 2020 Mar;34(3):787-798. Epub 2019 Oct 18. link to original article link to PMC article PubMed
  4. Alliance A041202: Woyach JA, Ruppert AS, Heerema NA, Zhao W, Booth AM, Ding W, Bartlett NL, Brander DM, Barr PM, Rogers KA, Parikh SA, Coutre S, Hurria A, Brown JR, Lozanski G, Blachly JS, Ozer HG, Major-Elechi B, Fruth B, Nattam S, Larson RA, Erba H, Litzow M, Owen C, Kuzma C, Abramson JS, Little RF, Smith SE, Stone RM, Mandrekar SJ, Byrd JC. Ibrutinib regimens versus chemoimmunotherapy in older patients with untreated CLL. N Engl J Med. 2018 Dec 27;379(26):2517-2528. Epub 2018 Dec 1. link to original article contains dosing details in abstract link to PMC article PubMed NCT01886872
  5. MDACC 2013-0703: Burger JA, Sivina M, Jain N, Kim E, Kadia T, Estrov Z, Nogueras-Gonzalez GM, Huang X, Jorgensen J, Li J, Cheng M, Clow F, Ohanian M, Andreeff M, Mathew T, Thompson P, Kantarjian H, O'Brien S, Wierda WG, Ferrajoli A, Keating MJ. Randomized trial of ibrutinib vs ibrutinib plus rituximab in patients with chronic lymphocytic leukemia. Blood. 2019 Mar 7;133(10):1011-1019. Epub 2018 Dec 7. link to original article contains dosing details in abstract link to PMC article PubMed NCT02007044
  6. CLL12: Langerbeins P, Zhang C, Robrecht S, Cramer P, Fürstenau M, Al-Sawaf O, von Tresckow J, Fink AM, Kreuzer KA, Vehling-Kaiser U, Tausch E, Müller L, Eckart MJ, Schlag R, Freier W, Gaska T, Balser C, Reiser M, Stauch M, Wendtner CM, Fischer K, Stilgenbauer S, Eichhorst B, Hallek M. The CLL12 trial: ibrutinib vs placebo in treatment-naïve, early-stage chronic lymphocytic leukemia. Blood. 2022 Jan 13;139(2):177-187. link to original article contains dosing details in abstract PubMed NCT02863718
  7. GCLLSG CLL17: NCT04608318
  8. SYMPATICO: NCT03112174

Ibrutinib & Obinutuzumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Moreno et al. 2018 (iLLUMINATE) 2014-2015 Phase 3 (E-RT-switch-ooc) G-Clb Superior PFS
Median PFS: NYR vs 19 mo
(HR 0.23, 95% CI 0.15-0.37)

Targeted therapy

  • Ibrutinib (Imbruvica) 420 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycles

References

  1. iLLUMINATE: Moreno C, Greil R, Demirkan F, Tedeschi A, Anz B, Larratt L, Simkovic M, Samoilova O, Novak J, Ben-Yehuda D, Strugov V, Gill D, Gribben JG, Hsu E, Lih CJ, Zhou C, Clow F, James DF, Styles L, Flinn IW. Ibrutinib plus obinutuzumab versus chlorambucil plus obinutuzumab in first-line treatment of chronic lymphocytic leukaemia (iLLUMINATE): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2019 Jan;20(1):43-56. Epub 2018 Nov 30. link to original article contains dosing details in abstract PubMed NCT02264574
  2. ECOG-ACRIN EA9161: NCT03701282
  3. Alliance A041702: NCT03737981

Ibrutinib & Rituximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Shanafelt et al. 2019 (ECOG E1912) 2014-2016 Phase 3 (E-RT-switch-ooc) FCR Superior OS1
OS60: 95% vs 89%
(HR 0.47, 95% CI 0.25-0.89)

1Reported efficacy is based on the 2022 update.

Targeted therapy

28-day cycles

References

  1. ECOG E1912: Shanafelt TD, Wang XV, Kay NE, Hanson CA, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M. Ibrutinib-rituximab or chemoimmunotherapy for chronic lymphocytic leukemia. N Engl J Med. 2019 Aug 1;381(5):432-443. link to original article contains dosing details in manuscript link to PMC article PubMed NCT02048813
    1. Update: Shanafelt TD, Wang XV, Hanson CA, Paietta EM, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M, Kay NE. Long-term outcomes for ibrutinib-rituximab and chemoimmunotherapy in CLL: updated results of the E1912 trial. Blood. 2022 Jul 14;140(2):112-120. link to original article PubMed

Obinutuzumab monotherapy

Regimen variant #1, standard-dose (1000 mg)

Study Years of enrollment Evidence Comparator Comparative Efficacy
Byrd et al. 2015 (GAGE) 2011-NR Randomized Phase 2 (C) Obinutuzumab; high-dose Might have inferior ORR rate

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycle 2 onwards: 1000 mg IV once on day 1

Supportive medications

21-day cycle up to 8 cycles

Regimen variant #2, high-dose (2000 mg)

Study Years of enrollment Evidence Comparator Comparative Efficacy
Byrd et al. 2015 (GAGE) 2011-NR Randomized Phase 2 (E-esc) Obinutuzumab; standard-dose Might have superior ORR rate

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1, option A: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once on day 3, then 2000 mg IV once per day on days 8 & 15
    • Cycle 1, option B: 100 mg IV once on day 1, then 1900 mg IV once on day 2, then 2000 mg IV once per day on days 8 & 15
    • Cycle 2 onwards: 2000 mg IV once on day 1

Supportive medications

21-day cycle up to 8 cycles

References

  1. GAGE: Byrd JC, Flynn JM, Kipps TJ, Boxer M, Kolibaba KS, Carlile DJ, Fingerle-Rowson G, Tyson N, Hirata J, Sharman JP. Randomized phase 2 study of obinutuzumab monotherapy in symptomatic, previously untreated chronic lymphocytic leukemia. Blood. 2016 Jan 7;127(1):79-86. Epub 2015 Oct 15. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01414205

Observation

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Dighiero et al. 1998 (FRE-CLL-85) 1985-1990 Phase 3 (C) 1. Chlorambucil Seems to have inferior PFS
2. Chlorambucil & Prednisone Inferior PFS
Hoechstetter et al. 2017 (GCLLSG CLL1) 1997-2004 Phase 3 (C) Fludarabine Inferior PFS
Herling et al. 2020 (GCLLSG CLL7) 2005-2010 Phase 3 (C) FCR Inferior EFS
Langerbeins et al. 2022 (CLL12) 2014-2019 Phase 3 (C) Ibrutinib Inferior EFS

No active treatment, also known as "watchful waiting".

References

  1. FRE-CLL-85: Dighiero G, Maloum K, Desablens B, Cazin B, Navarro M, Leblay R, Leporrier M, Jaubert J, Lepeu G, Dreyfus B, Binet JL, Travade P. Chlorambucil in indolent chronic lymphocytic leukemia: French Cooperative Group on Chronic Lymphocytic Leukemia. N Engl J Med. 1998 May 21;338(21):1506-14. link to original article contains dosing details in manuscript PubMed
  2. GCLLSG CLL7: Herling CD, Cymbalista F, Groß-Ophoff-Müller C, Bahlo J, Robrecht S, Langerbeins P, Fink AM, Al-Sawaf O, Busch R, Porcher R, Cazin B, Dreyfus B, Ibach S, Leprêtre S, Fischer K, Kaiser F, Eichhorst B, Wentner CM, Hoechstetter MA, Döhner H, Leblond V, Kneba M, Letestu R, Böttcher S, Stilgenbauer S, Hallek M, Levy V. Early treatment with FCR versus watch and wait in patients with stage Binet A high-risk chronic lymphocytic leukemia (CLL): a randomized phase 3 trial. Leukemia. 2020 Aug;34(8):2038-2050. Epub 2020 Feb 18. link to original article link to PMC article PubMed NCT00275054
  3. GCLLSG CLL1: Hoechstetter MA, Busch R, Eichhorst B, Bühler A, Winkler D, Eckart MJ, Vehling-Kaiser U, Schimke H, Jäger U, Hurtz HJ, Hopfinger G, Hartmann F, Fuss H, Abenhardt W, Blau I, Freier W, Müller L, Goebeler M, Wendtner CM, Bahlo J, Fischer K, Bentz M, Emmerich B, Döhner H, Hallek M, Stilgenbauer S. Early, risk-adapted treatment with fludarabine in Binet stage A chronic lymphocytic leukemia patients: results of the CLL1 trial of the German CLL study group. Leukemia. 2017 Dec;31(12):2833-2837. Epub 2017 Aug 14. link to original article PubMed NCT00262782
  4. CLL12: Langerbeins P, Zhang C, Robrecht S, Cramer P, Fürstenau M, Al-Sawaf O, von Tresckow J, Fink AM, Kreuzer KA, Vehling-Kaiser U, Tausch E, Müller L, Eckart MJ, Schlag R, Freier W, Gaska T, Balser C, Reiser M, Stauch M, Wendtner CM, Fischer K, Stilgenbauer S, Eichhorst B, Hallek M. The CLL12 trial: ibrutinib vs placebo in treatment-naïve, early-stage chronic lymphocytic leukemia. Blood. 2022 Jan 13;139(2):177-187. link to original article contains dosing details in abstract PubMed NCT02863718

Venetoclax & Obinutuzumab

VG: Venetoclax & Gazyva (Obinutuzumab)

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Fischer et al. 2019 (GCLLSG CLL14) 2015-2016 Phase 3 (E-RT-switch-ooc) Chlorambucil & Obinutuzumab Superior PFS1
Median PFS: NYR vs 36.4 mo
(HR 0.33, 95% CI 0.25-0.45)

1Reported efficacy is based on the 2021 update.
Note: Obinutuzumab is only given for the first six cycles.

Targeted therapy

  • Venetoclax (Venclexta) as follows:
    • Cycle 1: 20 mg PO once per day on days 22 to 28
    • Cycle 2: 50 mg PO once per day on days 1 to 7, then 100 mg PO once per day on days 8 to 14, then 200 mg PO once per day on days 15 to 21, then 400 mg PO once per day on days 22 to 28
    • Cycles 3 to 12: 400 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycle for 12 cycles

References

  1. GCLLSG CLL14: Fischer K, Al-Sawaf O, Bahlo J, Fink AM, Tandon M, Dixon M, Robrecht S, Warburton S, Humphrey K, Samoylova O, Liberati AM, Pinilla-Ibarz J, Opat S, Sivcheva L, Le Dû K, Fogliatto LM, Niemann CU, Weinkove R, Robinson S, Kipps TJ, Boettcher S, Tausch E, Humerickhouse R, Eichhorst B, Wendtner CM, Langerak AW, Kreuzer KA, Ritgen M, Goede V, Stilgenbauer S, Mobasher M, Hallek M. Venetoclax and obinutuzumab in patients with CLL and coexisting conditions. N Engl J Med. 2019 Jun 6;380(23):2225-2236. Epub 2019 Jun 4. link to original article contains dosing details in manuscript PubMed NCT02242942
    1. Update: Al-Sawaf O, Zhang C, Tandon M, Sinha A, Fink AM, Robrecht S, Samoylova O, Liberati AM, Pinilla-Ibarz J, Opat S, Sivcheva L, Le Dû K, Fogliatto LM, Niemann CU, Weinkove R, Robinson S, Kipps TJ, Tausch E, Schary W, Ritgen M, Wendtner CM, Kreuzer KA, Eichhorst B, Stilgenbauer S, Hallek M, Fischer K. Venetoclax plus obinutuzumab versus chlorambucil plus obinutuzumab for previously untreated chronic lymphocytic leukaemia (CLL14): follow-up results from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2020 Sep;21(9):1188-1200. link to original article PubMed
    2. Update: Al-Sawaf O, Zhang C, Lu T, Liao MZ, Panchal A, Robrecht S, Ching T, Tandon M, Fink AM, Tausch E, Schneider C, Ritgen M, Böttcher S, Kreuzer KA, Chyla B, Miles D, Wendtner CM, Eichhorst B, Stilgenbauer S, Jiang Y, Hallek M, Fischer K. Minimal Residual Disease Dynamics after Venetoclax-Obinutuzumab Treatment: Extended Off-Treatment Follow-up From the Randomized CLL14 Study. J Clin Oncol. 2021 Dec 20;39(36):4049-4060. Epub 2021 Oct 28. link to original article link to PMC article PubMed
  2. EVOLVE CLL/SLL: NCT04269902

Zanubrutinib monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Tam et al. 2022 (SEQUOIACLL) 2017-2019 Phase 3 (E-switch-ooc) BR Superior PFS
Median PFS: NYR vs NYR
(HR 0.42, 95% CI 0.28-0.63)

Biomarker eligibility criteria

  • SEQUOIACLL: No 17p deletion

Targeted therapy

28-day cycles

References

  1. SEQUOIACLL: Tam CS, Brown JR, Kahl BS, Ghia P, Giannopoulos K, Jurczak W, Šimkovič M, Shadman M, Österborg A, Laurenti L, Walker P, Opat S, Chan H, Ciepluch H, Greil R, Tani M, Trněný M, Brander DM, Flinn IW, Grosicki S, Verner E, Tedeschi A, Li J, Tian T, Zhou L, Marimpietri C, Paik JC, Cohen A, Huang J, Robak T, Hillmen P. Zanubrutinib versus bendamustine and rituximab in untreated chronic lymphocytic leukaemia and small lymphocytic lymphoma (SEQUOIA): a randomised, controlled, phase 3 trial. Lancet Oncol. 2022 Aug;23(8):1031-1043. Epub 2022 Jul 7. link to original article contains dosing details in abstract PubMed NCT03336333

First-line therapy, non-randomized or retrospective data

Alemtuzumab & Methylprednisolone

Regimen

Study Years of enrollment Evidence
Pettitt et al. 2012 (NCRI CLL206) 2006-2008 Phase 2

Biomarker eligibility criteria

  • TP53 deletion

Targeted therapy

  • Alemtuzumab (Campath) as follows:
    • Cycle 1: 3 mg IV once on day 1, then 10 mg IV once on day 3, then 30 mg IV once per day on days 5, 8, 10, 12, 15, 17, 19, 22, 24, 26 (three times per week; increased as tolerated)
    • Cycles 2 to 4: 30 mg SC once per day on days 1, 3, 5, 8, 10, 12, 15, 17, 19, 22, 24, 26 (three times per week)

Glucocorticoid therapy

28-day cycle for 4 cycles

References

  1. NCRI CLL206: Pettitt AR, Jackson R, Carruthers S, Dodd J, Dodd S, Oates M, Johnson GG, Schuh A, Matutes E, Dearden CE, Catovsky D, Radford JA, Bloor A, Follows GA, Devereux S, Kruger A, Blundell J, Agrawal S, Allsup D, Proctor S, Heartin E, Oscier D, Hamblin TJ, Rawstron A, Hillmen P. Alemtuzumab in combination with methylprednisolone is a highly effective induction regimen for patients with chronic lymphocytic leukemia and deletion of TP53: final results of the National Cancer Research Institute CLL206 trial. J Clin Oncol. 2012 May 10;30(14):1647-55. Epub 2012 Apr 9. link to original article contains dosing details in manuscript PubMed NCT00292760

AVO

AVO: Acalabrutinib, Venetoclax, Obinutuzumab

Regimen

Study Years of enrollment Evidence
Davids et al. 2021 (DFCI 18-226) 2018-2019 Phase 2

Note: detailed venetoclax dosing was not available in the abstract.

Targeted therapy

28-day cycles

References

  1. DFCI 18-226: Davids MS, Lampson BL, Tyekucheva S, Wang Z, Lowney JC, Pazienza S, Montegaard J, Patterson V, Weinstock M, Crombie JL, Ng SY, Kim AI, Jacobson CA, LaCasce AS, Armand P, Arnason JE, Fisher DC, Brown JR. Acalabrutinib, venetoclax, and obinutuzumab as frontline treatment for chronic lymphocytic leukaemia: a single-arm, open-label, phase 2 study. Lancet Oncol. 2021 Oct;22(10):1391-1402. Epub 2021 Sep 14. link to original article PubMed NCT03580928

Bendamustine & Obinutuzumab

G-B: Gazyva (Obinutuzumab), Bendamustine

Regimen

Study Years of enrollment Evidence Efficacy
Brown et al. 2015 (GALTON) 2011-NR Phase 1b, 20 pts ORR: 90%
Sharman et al. 2020 (GIBB) 2015-2016 Phase 2 CR rate: 50%

Chemotherapy

  • Bendamustine as follows:
    • Cycle 1: 90 mg/m2 IV once per day on days 2 & 3
    • Cycles 2 to 6: 90 mg/m2 IV once per day on days 1 & 2

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

Supportive medications

28-day cycle for 6 cycles

References

  1. GALTON: Brown JR, O'Brien S, Kingsley CD, Eradat H, Pagel JM, Lymp J, Hirata J, Kipps TJ. Obinutuzumab plus fludarabine/cyclophosphamide or bendamustine in the initial therapy of CLL patients: the phase 1b GALTON trial. Blood. 2015 Apr 30;125(18):2779-85. Epub 2015 Mar 13. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01300247
  2. GIBB: Sharman JP, Burke JM, Yimer HA, Boxer MA, Babu S, Li J, Mun Y, Danilov AV; GIBB study investigators. Phase 2, multicenter GIBB study of obinutuzumab plus bendamustine in previously untreated patients with chronic lymphocytic leukemia. Leuk Lymphoma. 2021 Apr;62(4):791-800. Epub 2020 Nov 26. link to original article contains dosing details in abstract PubMed NCT02320487

CFAR

CFAR: Cyclophosphamide, Fludarabine, Alemtuzumab, Rituximab

Regimen

Study Years of enrollment Evidence Efficacy
Parikh et al. 2011 2005-2008 Phase 2 ORR: 92%

Note that the doses of cyclophosphamide and fludarabine are lower than in the r/r CFAR regimen.

Chemotherapy

Targeted therapy

Supportive medications

28-day cycle for 6 cycles

References

  1. Parikh SA, Keating MJ, O'Brien S, Wang X, Ferrajoli A, Faderl S, Burger J, Koller C, Estrov Z, Badoux X, Lerner S, Wierda WG. Frontline chemoimmunotherapy with fludarabine, cyclophosphamide, alemtuzumab, and rituximab for high-risk chronic lymphocytic leukemia. Blood. 2011 Aug 25;118(8):2062-8. Epub 2011 Jul 12. link to original article link to PMC article contains dosing details in manuscript PubMed

G-FC

G-FC: Gazyva (Obinutuzumab), Fludarabine, Cyclophosphamide

Regimen

Study Years of enrollment Evidence
Brown et al. 2015 (GALTON) 2011-NR Non-randomized

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 25 mg/m2 IV once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 250 mg/m2 IV once per day on days 1 to 3

Supportive medications

28-day cycle for 6 cycles

References

  1. GALTON: Brown JR, O'Brien S, Kingsley CD, Eradat H, Pagel JM, Lymp J, Hirata J, Kipps TJ. Obinutuzumab plus fludarabine/cyclophosphamide or bendamustine in the initial therapy of CLL patients: the phase 1b GALTON trial. Blood. 2015 Apr 30;125(18):2779-85. Epub 2015 Mar 13. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01300247

HDMP-R

HDMP-R: High Dose, MethylPrednisolone & Rituximab

Regimen

Study Years of enrollment Evidence
Castro et al. 2009 NR Phase 2

Glucocorticoid therapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 total divided over 2 days IV once on days 1 & 2, then 375 mg/m2 IV once per day on days 8, 15, 22
    • Cycles 2 & 3: 375 mg/m2 IV once per day on days 1, 8, 15, 22

Supportive medications

28-day cycle for 3 cycles

References

  1. Castro JE, James DF, Sandoval-Sus JD, Jain S, Bole J, Rassenti L, Kipps TJ. Rituximab in combination with high-dose methylprednisolone for the treatment of chronic lymphocytic leukemia. Leukemia. 2009 Oct;23(10):1779-89. Epub 2009 Aug 20. link to original article contains dosing details in abstract link to PMC article PubMed

Ibrutinib & Venetoclax

VI: Ventoclax & Ibrutinib

Regimen

Study Years of enrollment Evidence
Jain et al. 2019 (MDACC 2015-0860) 2016-2018 Phase 2

Note: the starting dose and escalation schedule of venetoclax are not clearly specified in the manuscript; the authors were contacted for clarification and informed us that they used the FDA-recommended dosing, which is replicated here.

Targeted therapy

  • Ibrutinib (Imbruvica) 420 mg PO once per day
  • Venetoclax (Venclexta) as follows:
    • Cycle 4: 20 mg PO once per day on days 1 to 7, then 50 mg PO once per day on days 8 to 14, then 100 mg PO once per day on days 15 to 21, then 200 mg PO once per day on days 22 to 28
    • Cycle 5 onwards: 400 mg PO once per day

28-day cycle for up to 24 cycles

References

  1. MDACC 2015-0860: Jain N, Keating M, Thompson P, Ferrajoli A, Burger J, Borthakur G, Takahashi K, Estrov Z, Fowler N, Kadia T, Konopleva M, Alvarado Y, Yilmaz M, DiNardo C, Bose P, Ohanian M, Pemmaraju N, Jabbour E, Sasaki K, Kanagal-Shamanna R, Patel K, Jorgensen J, Garg N, Wang X, Sondermann K, Cruz N, Wei C, Ayala A, Plunkett W, Kantarjian H, Gandhi V, Wierda W. Ibrutinib and venetoclax for first-line treatment of CLL. N Engl J Med. 2019 May 30;380(22):2095-2103. link to original article contains dosing details in abstract PubMed NCT02756897

Ibrutinib, Venetoclax, Obinutuzumab

Regimen

Study Years of enrollment Evidence
Rogers et al. 2020 (OSU-14266) 2015-2017 Phase 2

Targeted therapy

  • Ibrutinib (Imbruvica) as follows:
    • Cycle 2 onwards: 420 mg PO once per day
  • Venetoclax (Venclexta) as follows:
    • Cycle 3: 20 mg PO once per day on days 1 to 7, then 50 mg PO once per day on days 8 to 14, then 100 mg PO once per day on days 15 to 21, then 200 mg PO once per day on days 22 to 28
    • Cycles 4 to 14: 400 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 8: 1000 mg IV once on day 1

28-day cycles

References

  1. OSU-14266: Rogers KA, Huang Y, Ruppert AS, Abruzzo LV, Andersen BL, Awan FT, Bhat SA, Dean A, Lucas M, Banks C, Grantier C, Heerema NA, Lozanski G, Maddocks KJ, Valentine TR, Weiss DM, Jones JA, Woyach JA, Byrd JC. Phase II Study of Combination Obinutuzumab, Ibrutinib, and Venetoclax in Treatment-Naïve and Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2020 Nov 1;38(31):3626-3637. Epub 2020 Aug 14. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02427451

Idelalisib & Rituximab

Regimen

Study Years of enrollment Evidence
O'Brien et al. 2015 (Study 101-08) 2010-NR Phase 2

In a letter dated 3/21/2016, Gilead states that idelalisib should not be used for first line treatment of CLL.

Targeted therapy

28-day cycle for 12 cycles

Subsequent treatment

  • Patients who had not progressed could continue on an extension study

References

  1. Study 101-08: O'Brien SM, Lamanna N, Kipps TJ, Flinn I, Zelenetz AD, Burger JA, Keating M, Mitra S, Holes L, Yu AS, Johnson DM, Miller LL, Kim Y, Dansey RD, Dubowy RL, Coutre SE. A phase 2 study of idelalisib plus rituximab in treatment-naïve older patients with chronic lymphocytic leukemia. Blood. 2015 Dec 17;126(25):2686-94. Epub 2015 Oct 15. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01203930

iFCR

iFCR: ibrutinib, Fludarabine, Cyclophosphamide, Rituximab

Regimen

Study Years of enrollment Evidence
Davids et al. 2019 (DFCI 14-296) 2014-2018 Phase 2

Note: Patients with undetectable minimal residual disease in bone marrow after 2 years were required to discontinue treatment, after a protocol amendment.

Targeted therapy

  • Ibrutinib (Imbruvica) as follows:
    • Cycle 0 (pre-phase): 420 mg PO once per day on days 1 to 7
    • Cycle 1 onwards: 420 mg PO once per day
  • Rituximab (Rituxan)
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Chemotherapy

28-day cycles (see note)

References

  1. DFCI 14-296: Davids MS, Brander DM, Kim HT, Tyekucheva S, Bsat J, Savell A, Hellman JM, Bazemore J, Francoeur K, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng S, Crombie J, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Fisher DC, Brown JR; Blood Cancer Research Partnership of the Leukemia & Lymphoma Society. Ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial treatment for younger patients with chronic lymphocytic leukaemia: a single-arm, multicentre, phase 2 trial. Lancet Haematol. 2019 Aug;6(8):e419-e428. Epub 2019 Jun 14. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02251548

Lenalidomide & Rituximab (R2)

Regimen variant #1

Study Years of enrollment Evidence
James et al. 2014 (CRC014) 2008-NR Phase 2

Targeted therapy

  • Lenalidomide (Revlimid) with escalation in the absence of grade 2 or higher toxicities as follows:
    • Cycle 1: 2.5 mg PO once per day on days 1 to 7, then 5 mg PO once per day on days 8 to 21
    • Cycle 2: 5 mg PO once per day on days 1 to 21
    • Subsequent cycles: 10 mg PO once per day on days 1 to 21
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 31 & 33
    • Cycle 2: 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • Subsequent cycles: 375 mg/m2 IV once on day 1

Supportive medications

35-day cycle for 1 cycle, then 28-day cycle for up to 6 cycles

Regimen variant #2

Study Years of enrollment Evidence
Fowler et al. 2014 (MDACC 2008-0042) 2008-2011 Phase 2

This combination was only studied in SLL (as opposed to CLL). Lenalidomide is dose-escalated to avoid tumor flare.

Targeted therapy

28-day cycle for up to 12 cycles

References

  1. CRC014: James DF, Werner L, Brown JR, Wierda WG, Barrientos JC, Castro JE, Greaves A, Johnson AJ, Rassenti LZ, Rai KR, Neuberg D, Kipps TJ. Lenalidomide and rituximab for the initial treatment of patients with chronic lymphocytic leukemia: a multicenter clinical-translational study from the Chronic Lymphocytic Leukemia Research Consortium. J Clin Oncol. 2014 Jul 1;32(19):2067-73. Epub 2014 May 27. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00628238
  2. MDACC 2008-0042: Fowler NH, Davis RE, Rawal S, Nastoupil L, Hagemeister FB, McLaughlin P, Kwak LW, Romaguera JE, Fanale MA, Fayad LE, Westin JR, Shah J, Orlowski RZ, Wang M, Turturro F, Oki Y, Claret LC, Feng L, Baladandayuthapani V, Muzzafar T, Tsai KY, Samaniego F, Neelapu SS. Safety and activity of lenalidomide and rituximab in untreated indolent lymphoma: an open-label, phase 2 trial. Lancet Oncol. 2014 Nov;15(12):1311-8. Epub 2014 Oct 15. link to original article contains dosing details in abstract link to PMC article PubMed NCT00695786

O-FC

O-FC: Ofatumumab, Fludarabine, Cyclophosphamide

Regimen

Study Years of enrollment Evidence
Wierda et al. 2011 (407 Study) 2007-NR Phase 2

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1
    • Cycles 2 to 6: 500 mg or 1000 mg IV once on day 1

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 25 mg/m2 IV once per day on days 1 to 3 (note: there was ambiguity in Wierda et al. 2011 about whether both fludarabine and cyclophosphamide are given three days per cycle, or whether fludarabine is given once per cycle and only cyclophosphamide is given three days per cycle)
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV once per day on days 2 to 4
    • Cycle 2 to 6: 250 mg/m2 IV once per day on days 1 to 3

Supportive medications

28-day cycle for 6 cycles

References

  1. 407 Study: Wierda WG, Kipps TJ, Dürig J, Griskevicius L, Stilgenbauer S, Mayer J, Smolej L, Hess G, Griniute R, Hernandez-Ilizaliturri FJ, Padmanabhan S, Gorczyca M, Chang CN, Chan G, Gupta I, Nielsen TG, Russell CA; 407 Study Investigators. Chemoimmunotherapy with O-FC in previously untreated patients with chronic lymphocytic leukemia. Blood. 2011 Jun 16;117(24):6450-8. Epub 2011 Apr 15. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00410163

PCO

PCO: Pentostatin, Cyclophosphamide, Ofatumumab

Regimen

Study Years of enrollment Evidence
Shanafelt et al. 2013 (MC0983 arm 1) 2010-2011 Phase 2
Strati et al. 2016 (MC0983 arm 2) 2011-2012 Phase 2
Tedeschi et al. 2015 2011-2013 Phase 2

Chemotherapy

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once on day 8
    • Cycles 2 to 6: 1000 mg IV once on day 1

Supportive medications

21-day cycle for 6 cycles

Subsequent treatment

References

  1. MC0983 arm 1: Shanafelt T, Lanasa MC, Call TG, Beaven AW, Leis JF, LaPlant B, Bowen D, Conte M, Jelinek DF, Hanson CA, Kay NE, Zent CS. Ofatumumab-based chemoimmunotherapy is effective and well tolerated in patients with previously untreated chronic lymphocytic leukemia (CLL). Cancer. 2013 Nov 1;119(21):3788-96. Epub 2013 Aug 6. Erratum in: Cancer. 2014 Mar 15;120(6):926. Dosage error in article text. link to original article link to PMC article contains dosing details in manuscript PubMed NCT01024010
  2. Tedeschi A, Rossi D, Motta M, Quaresmini G, Rossi M, Coscia M, Anastasia A, Rossini F, Cortelezzi A, Nador G, Scarfò L, Cairoli R, Frustaci AM, Dalceggio D, Picardi P, De Paoli L, Orlandi E, Rambaldi A, Massaia M, Gaidano G, Montillo M; Rete Ematologica Lombarda–CLL Workgroup. A phase II multi-center trial of pentostatin plus cyclophosphamide with ofatumumab in older previously untreated chronic lymphocytic leukemia patients. Haematologica. 2015 Dec;100(12):e501-4. Epub 2015 Aug 20. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01681563
  3. MC0983 arm 2: Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. Lancet Haematol. 2016 Sep;3(9):e407-14. Epub 2016 Aug 1. link to original article contains dosing details in abstract PubMed NCT01024010

PCR

PCR: Pentostatin, Cyclophosphamide, Rituximab

Regimen variant #1, 2/600/100->375

Study Years of enrollment Evidence
Kay et al. 2007 2002-2005 Phase 2
Shanafelt et al. 2007 NR Phase 2

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 100 mg/m2 IV once on day 1, then 375 mg/m2 IV once per day on days 3 & 5
    • Cycles 2 to 6: 375 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 6 cycles

Regimen variant #2, 4/600/375

Study Years of enrollment Evidence
Samaniego et al. 2015 (MDACC 2004-0818) 2005-NR Phase 2

This regimen was specifically studied in SLL, not CLL.

Chemotherapy

Targeted therapy

Supportive medications

21-day cycle for 6 cycles

References

  1. Kay NE, Geyer SM, Call TG, Shanafelt TD, Zent CS, Jelinek DF, Tschumper R, Bone ND, Dewald GW, Lin TS, Heerema NA, Smith L, Grever MR, Byrd JC. Combination chemoimmunotherapy with pentostatin, cyclophosphamide, and rituximab shows significant clinical activity with low accompanying toxicity in previously untreated B chronic lymphocytic leukemia. Blood. 2007 Jan 15;109(2):405-11. Epub 2006 Sep 28. link to original article contains dosing details in abstract link to PMC article PubMed
  2. Shanafelt TD, Lin T, Geyer SM, Zent CS, Leung N, Kabat B, Bowen D, Grever MR, Byrd JC, Kay NE. Pentostatin, cyclophosphamide, and rituximab regimen in older patients with chronic lymphocytic leukemia. Cancer. 2007 Jun 1;109(11):2291-8. link to original article PubMed
  3. MDACC 2004-0818: Samaniego F, Hagemeister F, Romaguera JE, Fanale MA, Pro B, McLaughlin P, Rodriguez MA, Neelapu SS, Fayad L, Younes A, Feng L, Berkova Z, Khashab T, Sehgal L, Vega-Vasquez F, Kwak LW. Pentostatin, cyclophosphamide and rituximab for previously untreated advanced stage, low-grade B-cell lymphomas. Br J Haematol. 2015 Jun;169(6):814-23. Epub 2015 Mar 31. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00496873

RCC

RCC: Rituximab, Cladribine, Cyclophosphamide

Regimen

Study Years of enrollment Evidence
Robak et al. 2018 (PALG CLL4) 2009-2011 Non-randomized portion of RCT

Targeted therapy

Chemotherapy

28-day cycle for 6 cycles

Subsequent treatment

References

  1. PALG CLL4: Robak T, Błoński J, Skotnicki AB, Piotrowska M, Wróbel T, Rybka J, Kłoczko J, Bołkun Ł, Budziszewska BK, Walczak U, Uss A, Fidecka M, Smolewski P. Rituximab, cladribine, and cyclophosphamide (RCC) induction with rituximab maintenance in chronic lymphocytic leukemia: PALG - CLL4 (ML21283) trial. Eur J Haematol. 2018 May;100(5):465-474. Epub 2018 Mar 22. link to original article PubMed NCT00718549

Rituximab monotherapy

Regimen

Study Years of enrollment Evidence
Hainsworth et al. 2003 2000-2001 Phase 2
Williams et al. 2016 (RESORT substudy) 2003-2008 Non-randomized portion of RCT

Targeted therapy

  • Rituximab (Rituxan) 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • In Hainsworth et al. 2003, optional alternate initial dosing for patients with WBC count greater than 100 x 109/L: 100 mg IV once on day 1, with remainder of the 375 mg/m2 dosage given on day 2

Supportive medications

4-week course

Subsequent treatment

References

  1. Hainsworth JD, Litchy S, Barton JH, Houston GA, Hermann RC, Bradof JE, Greco FA; Minnie Pearl Cancer Research Network. Single-agent rituximab as first-line and maintenance treatment for patients with chronic lymphocytic leukemia or small lymphocytic lymphoma: a phase II trial of the Minnie Pearl Cancer Research Network. J Clin Oncol. 2003 May 1;21(9):1746-51. link to original article PubMed
  2. RESORT substudy: Williams ME, Hong F, Gascoyne RD, Wagner LI, Krauss JC, Habermann TM, Swinnen LJ, Schuster SJ, Peterson CG, Sborov MD, Martin SE, Weiss M, Ehmann WC, Horning SJ, Kahl BS; Eastern Cooperative Oncology Group. Rituximab extended schedule or retreatment trial for low tumour burden non-follicular indolent B-cell non-Hodgkin lymphomas: Eastern Cooperative Oncology Group Protocol E4402. Br J Haematol. 2016 Jun;173(6):867-75. Epub 2016 Mar 11. link to original article contains dosing details in abstract link to PMC article PubMed NCT01406782

Ruxolitinib monotherapy

Regimen

Study Years of enrollment Evidence
Jain et al. 2017 (MDACC 2013-0044) 2014-2015 Phase 2

Note: this was a trial focused on symptom control, not efficacy.

Targeted therapy

References

  1. MDACC 2013-0044: Jain P, Keating M, Renner S, Cleeland C, Xuelin H, Gonzalez GN, Harris D, Li P, Liu Z, Veletic I, Rozovski U, Jain N, Thompson P, Bose P, DiNardo C, Ferrajoli A, O'Brien S, Burger J, Wierda W, Verstovsek S, Kantarjian H, Estrov Z. Ruxolitinib for symptom control in patients with chronic lymphocytic leukaemia: a single-group, phase 2 trial. Lancet Haematol. 2017 Feb;4(2):e67-e74. Epub 2017 Jan 11. link to original article contains dosing details in abstract link to PMC article PubMed NCT02131584

Zanubrutinib & Obinutuzumab

Regimen

Study Years of enrollment Evidence
Tam et al. 2020 2016-NR Phase 1b, >20 pts in this subgroup

Targeted therapy

  • Zanubrutinib (Brukinsa) 160 mg PO twice per day or 320 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycles

References

  1. Tam CS, Quach H, Nicol A, Badoux X, Rose H, Prince HM, Leahy MF, Eek R, Wickham N, Patil SS, Huang J, Prathikanti R, Cohen A, Elstrom R, Reed W, Schneider J, Flinn IW. Zanubrutinib (BGB-3111) plus obinutuzumab in patients with chronic lymphocytic leukemia and follicular lymphoma. Blood Adv. 2020 Oct 13;4(19):4802-4811. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02569476

Consolidation and/or maintenance after first-line therapy

Alemtuzumab monotherapy

Regimen variant #1, 6-week course

Study Years of enrollment Evidence
Varghese et al. 2017 (NCRN CLL 207) 2006-2010 Phase 2

Preceding treatment

Targeted therapy

  • Alemtuzumab (Campath) 30 mg SC once per day on days 1, 3, 5, 8, 10, 12, 15, 17, 19, 22, 24, 26, 29, 31, 33, 36, 38, 40 (three times per week)

6-week course

Regimen variant #2, 12-week course

Study Years of enrollment Evidence Comparator Comparative Efficacy
Wendtner et al. 2004 (GCLLSG CLL4B) NR Phase 3 (E-esc) Observation Superior PFS1

1Reported efficacy is based on the 2009 update.
Note: this study closed early due to high rates of infections in the experimental arm.

Preceding treatment

  • F x 6 or FC x 6

Targeted therapy

  • Alemtuzumab (Campath) as follows:
    • Day 1: 3 mg SC once
    • Day 2, if 3 mg dose is well tolerated: 10 mg SC once
    • Day 3 onwards, if 10 mg dose is well tolerated: 30 mg SC once on day 3, then SC 3 times per week

12-week course

References

  1. GCLLSG CLL4B: Wendtner CM, Ritgen M, Schweighofer CD, Fingerle-Rowson G, Campe H, Jäger G, Eichhorst B, Busch R, Diem H, Engert A, Stilgenbauer S, Döhner H, Kneba M, Emmerich B, Hallek M; German CLL Study Group. Consolidation with alemtuzumab in patients with chronic lymphocytic leukemia (CLL) in first remission--experience on safety and efficacy within a randomized multicenter phase III trial of the German CLL Study Group (GCLLSG). Leukemia. 2004 Jun;18(6):1093-101. link to original article contains dosing details in manuscript PubMed
    1. Update: Schweighofer CD, Ritgen M, Eichhorst BF, Busch R, Abenhardt W, Kneba M, Hallek M, Wendtner CM. Consolidation with alemtuzumab improves progression-free survival in patients with chronic lymphocytic leukaemia (CLL) in first remission: long-term follow-up of a randomized phase III trial of the German CLL Study Group (GCLLSG). Br J Haematol. 2009 Jan;144(1):95-8. Epub 2008 Oct 30. link to original article PubMed
  2. NCRN CLL207: Varghese AM, Howard DR, Pocock C, Rawstron AC, Follows G, McCarthy H, Dearden C, Fegan C, Milligan D, Smith AF, Gregory W, Hillmen P; NCRI CLL Sub-Group. Eradication of minimal residual disease improves overall and progression-free survival in patients with chronic lymphocytic leukaemia, evidence from NCRN CLL207: a phase II trial assessing alemtuzumab consolidation. Br J Haematol. 2017 Feb;176(4):573-582. Epub 2016 Dec 29. link to original article contains dosing details in abstract PubMed

Lenalidomide monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Fink et al. 2017 (GCLLSG CLLM1) 2012-2016 Phase 3 (E-esc) Observation Superior PFS
Median PFS: NYR vs 13.3 mo
(HR 0.17, 95% CI 0.07-0.38)

Note that while the NCT record reports dose increases beyond 15 mg PO once per day, the abstract states that 15 mg PO once per day was the "target dose".

Preceding treatment

  • GCLLSG CLLM1: "Chemoimmunotherapy"

Targeted therapy

  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 5 mg PO once per day
    • If tolerated, Cycles 2 to 6: 10 mg PO once per day
    • If tolerated, Cycle 7 onwards: 15 mg PO once per day

28-day cycles

References

  1. GCLLSG CLLM1: Fink AM, Bahlo J, Robrecht S, Al-Sawaf O, Aldaoud A, Hebart H, Jentsch-Ullrich K, Dörfel S, Fischer K, Wendtner CM, Nösslinger T, Ghia P, Bosch F, Kater AP, Döhner H, Kneba M, Kreuzer KA, Tausch E, Stilgenbauer S, Ritgen M, Böttcher S, Eichhorst B, Hallek M. Lenalidomide maintenance after first-line therapy for high-risk chronic lymphocytic leukaemia (CLLM1): final results from a randomised, double-blind, phase 3 study. Lancet Haematol. 2017 Oct;4(10):e475-e486. Epub 2017 Sep 12. link to original article contains dosing details in abstract PubMed NCT01556776

Observation

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Wendtner et al. 2004 (GCLLSG CLL4B) NR Phase 3 (C) Alemtuzumab Inferior PFS1
Hochster et al. 2009 (ECOG E1496) NR Phase 3 (C) Rituximab Inferior PFS
Michallet et al. 2010 2001-2007 Phase 3 (C) 1. Cy/TBI, then auto HSCT
2. BEAM, then auto HSCT
Inferior EFS
Sutton et al. 2011 (Auto-LLC 2001) 2001-2007 Phase 3 (C) Cy/TBI, then auto HSCT Inferior EFS
Foà et al. 2014 (ML21445) 2008-2013 Randomized Phase 2 (C) Rituximab Might have inferior PFS
Greil et al. 2016 (AGMT CLL-8a) 2010-2013 Phase 3 (C) Rituximab Inferior PFS
Fink et al. 2017 (GCLLSG CLLM1) 2012-2016 Phase 3 (C) Lenalidomide Inferior PFS
Dartigeas et al. 2017 (CLL 2007 SA) 2007-2014 Phase 3 (C) Rituximab Inferior PFS

1Reported efficacy for GCLLSG CLL4B is based on the 2009 update.
No further treatment; used as a comparator arm. GCLLSG CLL4B closed early due to high rates of infections in the experimental arm

Preceding treatment

References

  1. GCLLSG CLL4B: Wendtner CM, Ritgen M, Schweighofer CD, Fingerle-Rowson G, Campe H, Jäger G, Eichhorst B, Busch R, Diem H, Engert A, Stilgenbauer S, Döhner H, Kneba M, Emmerich B, Hallek M; German CLL Study Group. Consolidation with alemtuzumab in patients with chronic lymphocytic leukemia (CLL) in first remission--experience on safety and efficacy within a randomized multicenter phase III trial of the German CLL Study Group (GCLLSG). Leukemia. 2004 Jun;18(6):1093-101. link to original article PubMed
    1. Update: Schweighofer CD, Ritgen M, Eichhorst BF, Busch R, Abenhardt W, Kneba M, Hallek M, Wendtner CM. Consolidation with alemtuzumab improves progression-free survival in patients with chronic lymphocytic leukaemia (CLL) in first remission: long-term follow-up of a randomized phase III trial of the German CLL Study Group (GCLLSG). Br J Haematol. 2009 Jan;144(1):95-8. Epub 2008 Oct 30. link to original article PubMed
  2. ECOG E1496: Hochster H, Weller E, Gascoyne RD, Habermann TM, Gordon LI, Ryan T, Zhang L, Colocci N, Frankel S, Horning SJ. Maintenance rituximab after cyclophosphamide, vincristine, and prednisone prolongs progression-free survival in advanced indolent lymphoma: results of the randomized phase III ECOG1496 Study. J Clin Oncol. 2009 Apr 1;27(10):1607-14. Epub 2009 Mar 2. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00003204
  3. Michallet M, Dreger P, Sutton L, Brand R, Richards S, van Os M, Sobh M, Choquet S, Corront B, Dearden C, Gratwohl A, Herr W, Catovsky D, Hallek M, de Witte T, Niederwieser D, Leporrier M, Milligan D; EBMT Chronic Leukemia Working Party. Autologous hematopoietic stem cell transplantation in chronic lymphocytic leukemia: results of European intergroup randomized trial comparing autografting versus observation. Blood. 2011 Feb 3;117(5):1516-21. Epub 2010 Nov 24. link to original article PubMed
  4. Auto-LLC 2001: Sutton L, Chevret S, Tournilhac O, Diviné M, Leblond V, Corront B, Leprêtre S, Eghbali H, Van Den Neste E, Michallet M, Maloisel F, Bouabdallah K, Decaudin D, Berthou C, Brice P, Gonzalez H, Chapiro E, Radford-Weiss I, Leporrier N, Maloum K, Nguyen-Khac F, Davi F, Lejeune J, Merle-Béral H, Leporrier M; Société Française de Greffe de Moelle et de Thérapie Cellulaire; Groupe Français d'étude de la Leucémie Lymphoïde Chronique. Autologous stem cell transplantation as a first-line treatment strategy for chronic lymphocytic leukemia: a multicenter, randomized, controlled trial from the SFGM-TC and GFLLC. Blood. 2011 Jun 9;117(23):6109-19. Epub 2011 Mar 15. link to original article PubMed NCT00931645
  5. ML21445: Foà R, Del Giudice I, Cuneo A, Del Poeta G, Ciolli S, Di Raimondo F, Lauria F, Cencini E, Rigolin GM, Cortelezzi A, Nobile F, Callea V, Brugiatelli M, Massaia M, Molica S, Trentin L, Rizzi R, Specchia G, Di Serio F, Orsucci L, Ambrosetti A, Montillo M, Zinzani PL, Ferrara F, Morabito F, Mura MA, Soriani S, Peragine N, Tavolaro S, Bonina S, Marinelli M, De Propris MS, Starza ID, Piciocchi A, Alietti A, Runggaldier EJ, Gamba E, Mauro FR, Chiaretti S, Guarini A. Chlorambucil plus rituximab with or without maintenance rituximab as first-line treatment for elderly chronic lymphocytic leukemia patients. Am J Hematol. 2014 May;89(5):480-6. Epub 2014 Feb 18. link to original article contains dosing details in manuscript PubMed EudraCT 2008-001612-20
  6. AGMT CLL-8a: Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. Lancet Haematol. 2016 Jul;3(7):e317-29. Epub 2016 Jun 16. link to original article contains dosing details in abstract PubMed NCT01118234
  7. GCLLSG CLLM1: Fink AM, Bahlo J, Robrecht S, Al-Sawaf O, Aldaoud A, Hebart H, Jentsch-Ullrich K, Dörfel S, Fischer K, Wendtner CM, Nösslinger T, Ghia P, Bosch F, Kater AP, Döhner H, Kneba M, Kreuzer KA, Tausch E, Stilgenbauer S, Ritgen M, Böttcher S, Eichhorst B, Hallek M. Lenalidomide maintenance after first-line therapy for high-risk chronic lymphocytic leukaemia (CLLM1): final results from a randomised, double-blind, phase 3 study. Lancet Haematol. 2017 Oct;4(10):e475-e486. Epub 2017 Sep 12. link to original article contains dosing details in abstract PubMed NCT01556776
  8. CLL 2007 SA: Dartigeas C, Van Den Neste E, Léger J, Maisonneuve H, Berthou C, Dilhuydy MS, De Guibert S, Leprêtre S, Béné MC, Nguyen-Khac F, Letestu R, Cymbalista F, Rodon P, Aurran-Schleinitz T, Vilque JP, Tournilhac O, Mahé B, Laribi K, Michallet AS, Delmer A, Feugier P, Lévy V, Delépine R, Colombat P, Leblond V; CLL 2007 SA investigators; FILO. Rituximab maintenance versus observation following abbreviated induction with chemoimmunotherapy in elderly patients with previously untreated chronic lymphocytic leukaemia (CLL 2007 SA): an open-label, randomised phase 3 study. Lancet Haematol. 2018 Feb;5(2):e82-e94. Epub 2017 Dec 20. link to original article contains dosing details in abstract PubMed NCT00645606

Ofatumumab monotherapy

Regimen

Study Years of enrollment Evidence
Strati et al. 2016 (MC0983 arm 2) 2011-2012 Phase 2

Preceding treatment

Targeted therapy

28-day cycle for 6 cycles

References

  1. MC0983 arm 2: Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. Lancet Haematol. 2016 Sep;3(9):e407-14. Epub 2016 Aug 1. link to original article contains dosing details in abstract PubMed NCT01024010

Rituximab monotherapy

Regimen variant #1, 1 year

Study Years of enrollment Evidence Comparator Comparative Efficacy
Foà et al. 2014 (ML21445) 2008-2013 Randomized Phase 2 (E-esc) Observation Might have superior PFS
Robak et al. 2018 (PALG CLL4) 2009-2011 Phase 3b (E-esc) Observation Seems to have superior PFS

Note: dosing details for PALG CLL4 were not available in the abstract.

Preceding treatment

Targeted therapy

8-week cycle for 6 cycles

Regimen variant #2, 2 years, given q3mo

Study Years of enrollment Evidence Comparator Comparative Efficacy
Bosch et al. 2009 2005-2007 Phase 2
Greil et al. 2016 (AGMT CLL-8a) 2010-2013 Phase 3 (E-esc) Observation Superior PFS
Median PFS: 47 vs 35.5 mo
(HR 0.50, 95% CI 0.33-0.75)

Preceding treatment

Targeted therapy

3-month cycle for 8 cycles (2 years)

Regimen variant #3, 2 years, given q8wk

Study Years of enrollment Evidence Comparator Comparative Efficacy
Dartigeas et al. 2017 (CLL 2007 SA) 2007-2014 Phase 3 (E-esc) Observation Superior PFS
Median PFS: 59.3 vs 49 mo
(HR 0.55, 95% CI 0.40-0.75)

Note the higher dose used here.

Preceding treatment

Targeted therapy

8-week cycle for up to 13 cycles (2 years)

Regimen variant #4, 2 years, given q6mo

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hainsworth et al. 2003 2000-2001 Phase 2
Hochster et al. 2009 (ECOG E1496) NR Phase 3 (E-esc) Observation Superior PFS

ECOG E1496 included patients with SLL, but they were grouped into an "other" non-follicular lymphoma category.

Preceding treatment

Targeted therapy

Supportive medications

6-month cycle for 4 cycles (2 years)

Regimen variant #5, indefinite 375 mg/m2 q3mo

Study Years of enrollment Evidence Comparator Comparative Efficacy
Williams et al. 2016 (RESORT substudy) 2003-2008 Phase 3 (C) Rituximab salvage Seems to have superior TTTF

Intended for patients with SLL.

Preceding treatment

Targeted therapy

13-week cycles

Regimen variant #6, indefinite 500 mg/m2 q3mo

Study Years of enrollment Evidence
Foon et al. 2009 2003-2007 Phase 2

Preceding treatment

Targeted therapy

3-month cycles

References

  1. Hainsworth JD, Litchy S, Barton JH, Houston GA, Hermann RC, Bradof JE, Greco FA; Minnie Pearl Cancer Research Network. Single-agent rituximab as first-line and maintenance treatment for patients with chronic lymphocytic leukemia or small lymphocytic lymphoma: a phase II trial of the Minnie Pearl Cancer Research Network. J Clin Oncol. 2003 May 1;21(9):1746-51. link to original article PubMed
  2. Foon KA, Boyiadzis M, Land SR, Marks S, Raptis A, Pietragallo L, Meisner D, Laman A, Sulecki M, Butchko A, Schaefer P, Lenzer D, Tarhini A. Chemoimmunotherapy with low-dose fludarabine and cyclophosphamide and high dose rituximab in previously untreated patients with chronic lymphocytic leukemia. J Clin Oncol. 2009 Feb 1;27(4):498-503. Epub 2008 Dec 15. link to original article contains dosing details in manuscript PubMed
    1. Update: Foon KA, Mehta D, Lentzsch S, Kropf P, Marks S, Lenzner D, Pietragallo L, Sulecki M, Tarhini A, Boyiadzis M. Long-term results of chemoimmunotherapy with low-dose fludarabine, cyclophosphamide and high-dose rituximab as initial treatment for patients with chronic lymphocytic leukemia. Blood. 2012 Mar 29;119(13):3184-5. link to original article PubMed
  3. ECOG E1496: Hochster H, Weller E, Gascoyne RD, Habermann TM, Gordon LI, Ryan T, Zhang L, Colocci N, Frankel S, Horning SJ. Maintenance rituximab after cyclophosphamide, vincristine, and prednisone prolongs progression-free survival in advanced indolent lymphoma: results of the randomized phase III ECOG1496 Study. J Clin Oncol. 2009 Apr 1;27(10):1607-14. Epub 2009 Mar 2. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00003204
  4. Bosch F, Abrisqueta P, Villamor N, Terol MJ, González-Barca E, Ferra C, González Diaz M, Abella E, Delgado J, Carbonell F, García Marco JA, Escoda L, Ferrer S, Monzó E, González Y, Estany C, Jarque I, Salamero O, Muntañola A, Montserrat E. Rituximab, fludarabine, cyclophosphamide, and mitoxantrone: a new, highly active chemoimmunotherapy regimen for chronic lymphocytic leukemia. J Clin Oncol. 2009 Sep 20;27(27):4578-84. Epub 2009 Aug 24. link to original article contains dosing details in manuscript PubMed EudraCT 2005-001569-33
    1. Update: Abrisqueta P, Villamor N, Terol MJ, González-Barca E, González M, Ferrà C, Abella E, Delgado J, García-Marco JA, González Y, Carbonell F, Ferrer S, Monzó E, Jarque I, Muntañola A, Constants M, Escoda L, Calvo X, Bobillo S, Montoro JB, Montserrat E, Bosch F. Rituximab maintenance after first-line therapy with rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) for chronic lymphocytic leukemia. Blood. 2013 Dec 5;122(24):3951-9. Epub 2013 Oct 11. link to original article contains dosing details in manuscript PubMed
  5. ML21445: Foà R, Del Giudice I, Cuneo A, Del Poeta G, Ciolli S, Di Raimondo F, Lauria F, Cencini E, Rigolin GM, Cortelezzi A, Nobile F, Callea V, Brugiatelli M, Massaia M, Molica S, Trentin L, Rizzi R, Specchia G, Di Serio F, Orsucci L, Ambrosetti A, Montillo M, Zinzani PL, Ferrara F, Morabito F, Mura MA, Soriani S, Peragine N, Tavolaro S, Bonina S, Marinelli M, De Propris MS, Starza ID, Piciocchi A, Alietti A, Runggaldier EJ, Gamba E, Mauro FR, Chiaretti S, Guarini A. Chlorambucil plus rituximab with or without maintenance rituximab as first-line treatment for elderly chronic lymphocytic leukemia patients. Am J Hematol. 2014 May;89(5):480-6. Epub 2014 Feb 18. link to original article contains dosing details in manuscript PubMed EudraCT 2008-001612-20
  6. RESORT substudy: Williams ME, Hong F, Gascoyne RD, Wagner LI, Krauss JC, Habermann TM, Swinnen LJ, Schuster SJ, Peterson CG, Sborov MD, Martin SE, Weiss M, Ehmann WC, Horning SJ, Kahl BS; Eastern Cooperative Oncology Group. Rituximab extended schedule or retreatment trial for low tumour burden non-follicular indolent B-cell non-Hodgkin lymphomas: Eastern Cooperative Oncology Group Protocol E4402. Br J Haematol. 2016 Jun;173(6):867-75. Epub 2016 Mar 11. link to original article contains dosing details in abstract link to PMC article PubMed NCT01406782
  7. AGMT CLL-8a: Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. Lancet Haematol. 2016 Jul;3(7):e317-29. Epub 2016 Jun 16. link to original article contains dosing details in abstract PubMed NCT01118234
  8. CLL 2007 SA: Dartigeas C, Van Den Neste E, Léger J, Maisonneuve H, Berthou C, Dilhuydy MS, De Guibert S, Leprêtre S, Béné MC, Nguyen-Khac F, Letestu R, Cymbalista F, Rodon P, Aurran-Schleinitz T, Vilque JP, Tournilhac O, Mahé B, Laribi K, Michallet AS, Delmer A, Feugier P, Lévy V, Delépine R, Colombat P, Leblond V; CLL 2007 SA investigators; FILO. Rituximab maintenance versus observation following abbreviated induction with chemoimmunotherapy in elderly patients with previously untreated chronic lymphocytic leukaemia (CLL 2007 SA): an open-label, randomised phase 3 study. Lancet Haematol. 2018 Feb;5(2):e82-e94. Epub 2017 Dec 20. link to original article contains dosing details in abstract PubMed NCT00645606
  9. PALG CLL4: Robak T, Błoński J, Skotnicki AB, Piotrowska M, Wróbel T, Rybka J, Kłoczko J, Bołkun Ł, Budziszewska BK, Walczak U, Uss A, Fidecka M, Smolewski P. Rituximab, cladribine, and cyclophosphamide (RCC) induction with rituximab maintenance in chronic lymphocytic leukemia: PALG - CLL4 (ML21283) trial. Eur J Haematol. 2018 May;100(5):465-474. Epub 2018 Mar 22. link to original article PubMed NCT00718549

Relapsed or refractory, randomized data

Acalabrutinib monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Byrd et al. 2015 (ACE-CL-001 r/r) 2014-NR Phase 1/2 ORR: 95%
Byrd et al. 2021 (ACE-CL-006) 2015-2017 Phase 3 (E-switch-ic) Ibrutinib Non-inferior PFS
Median PFS: 38.4 vs 38.4 mo
(HR 1.00, 95% CI 0.79-1.27)
Ghia et al. 2020 (ASCEND) 2017-2018 Phase 3 (E-RT-switch-ooc) Investigator's choice of:
1. BR
2. Idelalisib & Rituximab
Superior PFS
Median PFS: NYR vs 16.5 mo
(HR 0.31, 95% CI 0.20-0.49)

Biomarker eligibility criteria

  • ACE-CL-006: del(17)(p13.1) or del(11)(q22.3)

Prior treatment criteria

  • ACE-CL-006 & ASCEND: At least 1 prior systemic therapy

Targeted therapy

Continued indefinitely

References

  1. ACE-CL-001 r/r: Byrd JC, Harrington B, O'Brien S, Jones JA, Schuh A, Devereux S, Chaves J, Wierda WG, Awan FT, Brown JR, Hillmen P, Stephens DM, Ghia P, Barrientos JC, Pagel JM, Woyach J, Johnson D, Huang J, Wang X, Kaptein A, Lannutti BJ, Covey T, Fardis M, McGreivy J, Hamdy A, Rothbaum W, Izumi R, Diacovo TG, Johnson AJ, Furman RR. Acalabrutinib (ACP-196) in relapsed chronic lymphocytic leukemia. N Engl J Med. 2016 Jan 28;374(4):323-32. Epub 2015 Dec 7. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02029443
  2. ASCEND: Ghia P, Pluta A, Wach M, Lysak D, Kozak T, Simkovic M, Kaplan P, Kraychok I, Illes A, de la Serna J, Dolan S, Campbell P, Musuraca G, Jacob A, Avery E, Lee JH, Liang W, Patel P, Quah C, Jurczak W. ASCEND: Phase III, Randomized Trial of Acalabrutinib Versus Idelalisib Plus Rituximab or Bendamustine Plus Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2020 Sep 1;38(25):2849-2861. Epub 2020 May 27. link to original article contains dosing details in manuscript PubMed NCT02970318
  3. ACE-CL-006: Byrd JC, Hillmen P, Ghia P, Kater AP, Chanan-Khan A, Furman RR, O'Brien S, Yenerel MN, Illés A, Kay N, Garcia-Marco JA, Mato A, Pinilla-Ibarz J, Seymour JF, Lepretre S, Stilgenbauer S, Robak T, Rothbaum W, Izumi R, Hamdy A, Patel P, Higgins K, Sohoni S, Jurczak W. Acalabrutinib Versus Ibrutinib in Previously Treated Chronic Lymphocytic Leukemia: Results of the First Randomized Phase III Trial. J Clin Oncol. 2021 Nov 1;39(31):3441-3452. Epub 2021 Jul 26. link to original article contains dosing details in manuscript link to PMC article PubMed NCT02477696

Bendamustine monotherapy

Regimen variant #1, 70 mg/m2

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2016 (Aptevo 16201) 2011-2013 Randomized Phase 2 (C) Bendamustine & Otlertuzumab Seems to have inferior PFS

Chemotherapy

  • Bendamustine 70 mg/m2 IV over 30 minutes once per day on days 1 & 2

28-day cycle for 6 cycles

Regimen variant #2, 100 mg/m2

Study Years of enrollment Evidence Comparator Comparative Efficacy
Niederle et al. 2013 (WiSP RI05) 2001-2006 Phase 3 (E-switch-ic) Fludarabine Seems to have non-inferior PFS

Chemotherapy

28-day cycle for up to 8 cycles

Regimen variant #3, 120 mg/m2

Study Years of enrollment Evidence
Friedberg et al. 2008 2003-2005 Phase 2
Kahl et al. 2010 2005-2007 Phase 2

Chemotherapy

21-day cycle for 6 to 8 (Kahl et al. 2010) or up to 12 (Friedberg et al. 2008) cycles

References

  1. Friedberg JW, Cohen P, Chen L, Robinson KS, Forero-Torres A, La Casce AS, Fayad LE, Bessudo A, Camacho ES, Williams ME, van der Jagt RH, Oliver JW, Cheson BD. Bendamustine in patients with rituximab-refractory indolent and transformed non-Hodgkin's lymphoma: results from a phase II multicenter, single-agent study. J Clin Oncol. 2008 Jan 10;26(2):204-10. Erratum in: J Clin Oncol. 2008 Apr 10;26(11) 1911. link to original article contains dosing details in manuscript PubMed
  2. Kahl BS, Bartlett NL, Leonard JP, Chen L, Ganjoo K, Williams ME, Czuczman MS, Robinson KS, Joyce R, van der Jagt RH, Cheson BD. Bendamustine is effective therapy in patients with rituximab-refractory, indolent B-cell non-Hodgkin lymphoma: results from a multicenter study. Cancer. 2010 Jan 1;116(1):106-14. link to original article contains dosing details in manuscript link to PMC article PubMed
  3. Retrospective: Kolibaba KS, Sterchele JA, Joshi AD, Forsyth M, Alwon E, Beygi H, Kennealey GT. Demographics, treatment patterns, safety, and real-world effectiveness in patients aged 70 years and over with chronic lymphocytic leukemia receiving bendamustine with or without rituximab: a retrospective study. Ther Adv Hematol. 2013 Jun;4(3):157-71. link to PMC article PubMed
  4. WiSP RI05: Niederle N, Megdenberg D, Balleisen L, Heit W, Knauf W, Weiß J, Freier W, Hinke A, Ibach S, Eimermacher H. Bendamustine compared to fludarabine as second-line treatment in chronic lymphocytic leukemia. Ann Hematol. 2013 May;92(5):653-60. Epub 2013 Jan 23. link to original article contains dosing details in manuscript PubMed NCT01423032
  5. Aptevo 16201: Robak T, Hellmann A, Kloczko J, Loscertales J, Lech-Maranda E, Pagel JM, Mato A, Byrd JC, Awan FT, Hebart H, Garcia-Marco JA, Hill BT, Hallek M, Eisenfeld AJ, Stromatt SC, Jaeger U. Randomized phase 2 study of otlertuzumab and bendamustine versus bendamustine in patients with relapsed chronic lymphocytic leukaemia. Br J Haematol. 2017 Feb;176(4):618-628. Epub 2016 Dec 15. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01188681

Bendamustine & Rituximab (BR)

BR: Bendamustine & Rituximab
R-B: Rituximab & Bendamustine

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Fischer et al. 2011 (GCLLSG CLL2M r/r) 2006-2007 Phase 2
Michallet et al. 2018 (MABLE) 2010-2014 Phase 3 (E-switch-ic) R-Clb Superior CR rate1
Chanan-Khan et al. 2015 (HELIOS) 2012-2014 Phase 3 (C) BR & Ibrutinib Inferior OS2
Zelenetz et al. 2017 (Tugela) 2012-2014 Phase 3 (C) BR & Idelalisib Inferior PFS
Seymour et al. 2018 (MURANO) 2014-2015 Phase 3 (C) Venetoclax & Rituximab Inferior OS
Ghia et al. 2020 (ASCEND) 2017-2018 Phase 3 (C) Acalabrutinib Inferior PFS

1Reported efficacy is for 2L patients only.
2Reported efficacy for HELIOS is based on the 2020 update.

Prior treatment criteria

  • ASCEND: At least 1 prior systemic therapy

Chemotherapy

  • Bendamustine 70 mg/m2 IV once per day on days 1 & 2
    • HELIOS gave 1st cycle on days 2 & 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 0
      • HELIOS gave on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

28-day cycle for up to 6 cycles

References

  1. GCLLSG CLL2M r/r: Fischer K, Cramer P, Busch R, Stilgenbauer S, Bahlo J, Schweighofer CD, Böttcher S, Staib P, Kiehl M, Eckart MJ, Kranz G, Goede V, Elter T, Bühler A, Winkler D, Kneba M, Döhner H, Eichhorst BF, Hallek M, Wendtner CM; GCLLSG. Bendamustine combined with rituximab in patients with relapsed and/or refractory chronic lymphocytic leukemia: a multicenter phase II trial of the German Chronic Lymphocytic Leukemia Study Group. J Clin Oncol. 2011 Sep 10;29(26):3559-66. Epub 2011 Aug 15. link to original article contains dosing details in manuscript PubMed NCT00274989
  2. Retrospective: Kolibaba KS, Sterchele JA, Joshi AD, Forsyth M, Alwon E, Beygi H, Kennealey GT. Demographics, treatment patterns, safety, and real-world effectiveness in patients aged 70 years and over with chronic lymphocytic leukemia receiving bendamustine with or without rituximab: a retrospective study. Ther Adv Hematol. 2013 Jun;4(3):157-71. link to PMC article PubMed
  3. HELIOS: Chanan-Khan A, Cramer P, Demirkan F, Fraser G, Silva RS, Grosicki S, Pristupa A, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Pylypenko H, Loscertales J, Avigdor A, Rule S, Villa D, Samoilova O, Panagiotidis P, Goy A, Mato A, Pavlovsky MA, Karlsson C, Mahler M, Salman M, Sun S, Phelps C, Balasubramanian S, Howes A, Hallek M; HELIOS investigators. Ibrutinib combined with bendamustine and rituximab compared with placebo, bendamustine, and rituximab for previously treated chronic lymphocytic leukaemia or small lymphocytic lymphoma (HELIOS): a randomised, double-blind, phase 3 study. Lancet Oncol. 2016 Feb;17(2):200-11. Epub 2015 Dec 5. link to original article contains dosing details in abstract PubMed NCT01611090
    1. Update: Fraser G, Cramer P, Demirkan F, Silva RS, Grosicki S, Pristupa A, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Pylypenko H, Loscertales J, Avigdor A, Rule S, Villa D, Samoilova O, Panagiotidis P, Goy A, Pavlovsky MA, Karlsson C, Hallek M, Mahler M, Salman M, Sun S, Phelps C, Balasubramanian S, Howes A, Chanan-Khan A. Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma. Leukemia. 2019 Apr;33(4):969-980. Epub 2018 Oct 12. link to original article link to PMC article PubMed
    2. Update: Fraser GAM, Chanan-Khan A, Demirkan F, Santucci Silva R, Grosicki S, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Loscertales J, Avigdor A, Rule S, Samoilova O, Pavlovsky MA, Goy A, Mato A, Hallek M, Salman M, Tamegnon M, Sun S, Connor A, Nottage K, Schuier N, Balasubramanian S, Howes A, Cramer P. Final 5-year findings from the phase 3 HELIOS study of ibrutinib plus bendamustine and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma. Leuk Lymphoma. 2020 Dec;61(13):3188-3197. Epub 2020 Aug 6. link to original article link to PMC article PubMed
  4. Tugela: Zelenetz AD, Barrientos JC, Brown JR, Coiffier B, Delgado J, Egyed M, Ghia P, Illés Á, Jurczak W, Marlton P, Montillo M, Morschhauser F, Pristupa AS, Robak T, Sharman JP, Simpson D, Smolej L, Tausch E, Adewoye AH, Dreiling LK, Kim Y, Stilgenbauer S, Hillmen P. Idelalisib or placebo in combination with bendamustine and rituximab in patients with relapsed or refractory chronic lymphocytic leukaemia: interim results from a phase 3, randomised, double-blind, placebo-controlled trial. Lancet Oncol. 2017 Mar;18(3):297-311. Epub 2017 Jan 28. link to original article link to PMC article contains dosing details in abstract PubMed NCT01569295
  5. MABLE: Michallet AS, Aktan M, Hiddemann W, Ilhan O, Johansson P, Laribi K, Meddeb B, Moreno C, Raposo J, Schuh A, Ünal A, Widenius T, Bernhardt A, Kellershohn K, Messeri D, Osborne S, Leblond V. Rituximab plus bendamustine or chlorambucil for chronic lymphocytic leukemia: primary analysis of the randomized, open-label MABLE study. Haematologica. 2018 Apr;103(4):698-706. Epub 2018 Feb 1. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01056510
  6. MURANO: Seymour JF, Kipps TJ, Eichhorst B, Hillmen P, D'Rozario J, Assouline S, Owen C, Gerecitano J, Robak T, De la Serna J, Jaeger U, Cartron G, Montillo M, Humerickhouse R, Punnoose EA, Li Y, Boyer M, Humphrey K, Mobasher M, Kater AP. Venetoclax-rituximab in relapsed or refractory chronic lymphocytic leukemia. N Engl J Med. 2018 Mar 22;378(12):1107-1120. link to original article contains dosing details in manuscript PubMed NCT02005471
    1. Update: Kater AP, Seymour JF, Hillmen P, Eichhorst B, Langerak AW, Owen C, Verdugo M, Wu J, Punnoose EA, Jiang Y, Wang J, Boyer M, Humphrey K, Mobasher M, Kipps TJ. Fixed duration of venetoclax-rituximab in relapsed/refractory chronic lymphocytic leukemia eradicates minimal residual disease and prolongs survival: post-treatment follow-up of the MURANO phase III study. J Clin Oncol. 2019 Feb 1;37(4):269-277. Epub 2018 Dec 3. link to original article PubMed
    2. Update: Kater AP, Wu JQ, Kipps T, Eichhorst B, Hillmen P, D'Rozario J, Assouline S, Owen C, Robak T, de la Serna J, Jaeger U, Cartron G, Montillo M, Dubois J, Eldering E, Mellink C, Van Der Kevie-Kersemaekers AM, Kim SY, Chyla B, Punnoose E, Bolen CR, Assaf ZJ, Jiang Y, Wang J, Lefebure M, Boyer M, Humphrey K, Seymour JF. Venetoclax Plus Rituximab in Relapsed Chronic Lymphocytic Leukemia: 4-Year Results and Evaluation of Impact of Genomic Complexity and Gene Mutations From the MURANO Phase III Study. J Clin Oncol. 2020 Dec 1;38(34):4042-4054. Epub 2020 Sep 28. link to original article link to PMC article PubMed
    3. Update: Seymour JF, Kipps TJ, Eichhorst BF, D'Rozario J, Owen CJ, Assouline S, Lamanna N, Robak T, de la Serna J, Jaeger U, Cartron G, Montillo M, Mellink C, Chyla B, Panchal A, Lu T, Wu JQ, Jiang Y, Lefebure M, Boyer M, Kater AP. Enduring undetectable MRD and updated outcomes in relapsed/refractory CLL after fixed-duration venetoclax-rituximab. Blood. 2022 Aug 25;140(8):839-850. link to original article PubMed
  7. ASCEND: Ghia P, Pluta A, Wach M, Lysak D, Kozak T, Simkovic M, Kaplan P, Kraychok I, Illes A, de la Serna J, Dolan S, Campbell P, Musuraca G, Jacob A, Avery E, Lee JH, Liang W, Patel P, Quah C, Jurczak W. ASCEND: Phase III, Randomized Trial of Acalabrutinib Versus Idelalisib Plus Rituximab or Bendamustine Plus Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2020 Sep 1;38(25):2849-2861. Epub 2020 May 27. link to original article contains dosing details in manuscript PubMed NCT02970318

Bendamustine & Rituximab (BR) & Ibrutinib

BR & Ibrutinib: Bendamustine, Rituximab, Ibrutinib
IBR: Ibrutinib, Bendamustine, Rituximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Brown et al. 2015 (PCYC-1108) 2011-NR Phase 2
Chanan-Khan et al. 2015 (HELIOS) 2012-2014 Phase 3 (E-RT-esc) BR Superior OS1
Median OS: NYR vs NYR
(HR 0.61, 95% CI 0.455-0.82)

1Reported efficacy for HELIOS is based on the 2020 update.
Note: PCYC-1108 also evaluated FCR-ibrutinib (non-randomized) but accrual to that arm was extremely low and it was prematurely discontinued.

Chemotherapy

  • Bendamustine as follows:
    • Cycles 1 to 6: 70 mg/m2 IV once per day on days 1 & 2
      • HELIOS gave 1st cycle on days 2 & 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
      • PCYC-1108 gave the option of splitting the dose between days 1 & 2
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1
  • Ibrutinib (Imbruvica) 420 mg PO once per day

28-day cycles

References

  1. PCYC-1108: Brown JR, Barrientos JC, Barr PM, Flinn IW, Burger JA, Tran A, Clow F, James DF, Graef T, Friedberg JW, Rai K, O'Brien S. The Bruton tyrosine kinase inhibitor ibrutinib with chemoimmunotherapy in patients with chronic lymphocytic leukemia. Blood. 2015 May 7;125(19):2915-22. Epub 2015 Mar 9. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01292135
  2. HELIOS: Chanan-Khan A, Cramer P, Demirkan F, Fraser G, Silva RS, Grosicki S, Pristupa A, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Pylypenko H, Loscertales J, Avigdor A, Rule S, Villa D, Samoilova O, Panagiotidis P, Goy A, Mato A, Pavlovsky MA, Karlsson C, Mahler M, Salman M, Sun S, Phelps C, Balasubramanian S, Howes A, Hallek M; HELIOS investigators. Ibrutinib combined with bendamustine and rituximab compared with placebo, bendamustine, and rituximab for previously treated chronic lymphocytic leukaemia or small lymphocytic lymphoma (HELIOS): a randomised, double-blind, phase 3 study. Lancet Oncol. 2016 Feb;17(2):200-11. Epub 2015 Dec 5. link to original article contains dosing details in abstract PubMed NCT01611090
    1. Update: Fraser G, Cramer P, Demirkan F, Silva RS, Grosicki S, Pristupa A, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Pylypenko H, Loscertales J, Avigdor A, Rule S, Villa D, Samoilova O, Panagiotidis P, Goy A, Pavlovsky MA, Karlsson C, Hallek M, Mahler M, Salman M, Sun S, Phelps C, Balasubramanian S, Howes A, Chanan-Khan A. Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma. Leukemia. 2019 Apr;33(4):969-980. Epub 2018 Oct 12. link to original article link to PMC article PubMed
    2. Update: Fraser GAM, Chanan-Khan A, Demirkan F, Santucci Silva R, Grosicki S, Janssens A, Mayer J, Bartlett NL, Dilhuydy MS, Loscertales J, Avigdor A, Rule S, Samoilova O, Pavlovsky MA, Goy A, Mato A, Hallek M, Salman M, Tamegnon M, Sun S, Connor A, Nottage K, Schuier N, Balasubramanian S, Howes A, Cramer P. Final 5-year findings from the phase 3 HELIOS study of ibrutinib plus bendamustine and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma. Leuk Lymphoma. 2020 Dec;61(13):3188-3197. Epub 2020 Aug 6. link to original article link to PMC article PubMed

Bendamustine & Rituximab (BR) & Idelalisib

BR & Idelalisib: Bendamustine, Rituximab, Idelalisib

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Zelenetz et al. 2017 (Tugela) 2012-2014 Phase 3 (E-esc) BR Superior PFS
Median PFS: 20.8 vs 11.1 mo
(HR 0.33, 95% CI 0.25-0.44)

Chemotherapy

  • Bendamustine as follows:
    • Cycles 1 to 6: 70 mg/m2 IV once per day on days 1 & 2

Targeted therapy

28-day cycles

References

  1. Tugela: Zelenetz AD, Barrientos JC, Brown JR, Coiffier B, Delgado J, Egyed M, Ghia P, Illés Á, Jurczak W, Marlton P, Montillo M, Morschhauser F, Pristupa AS, Robak T, Sharman JP, Simpson D, Smolej L, Tausch E, Adewoye AH, Dreiling LK, Kim Y, Stilgenbauer S, Hillmen P. Idelalisib or placebo in combination with bendamustine and rituximab in patients with relapsed or refractory chronic lymphocytic leukaemia: interim results from a phase 3, randomised, double-blind, placebo-controlled trial. Lancet Oncol. 2017 Mar;18(3):297-311. Epub 2017 Jan 28. link to original article contains dosing details in abstract link to PMC article PubMed NCT01569295

Duvelisib monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Flinn et al. 2018 (DUO) 2014-2015 Phase 3 (E-RT-switch-ooc) Ofatumumab Superior PFS
Median PFS: 13.3 vs 9.9 mo
(HR 0.52)

Targeted therapy

28-day cycles

References

  1. DUO: Flinn IW, Hillmen P, Montillo M, Nagy Z, Illés Á, Etienne G, Delgado J, Kuss BJ, Tam CS, Gasztonyi Z, Offner F, Lunin S, Bosch F, Davids MS, Lamanna N, Jaeger U, Ghia P, Cymbalista F, Portell CA, Skarbnik AP, Cashen AF, Weaver DT, Kelly VM, Turnbull B, Stilgenbauer S. The phase 3 DUO trial: duvelisib vs ofatumumab in relapsed and refractory CLL/SLL. Blood. 2018 Dec 6;132(23):2446-2455. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02004522

FCR

FCR: Fludarabine, Cyclophosphamide, Rituximab
R-FC: Rituximab, Fludarabine, Cyclophosphamide

Regimen variant #1

Study Years of enrollment Evidence Comparator Comparative Efficacy
Awan et al. 2014 (LUCID) 2006-NR Phase 3 (C) FCR+L Did not meet primary endpoint of CR rate

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV over at least 10 to 30 minutes once per day on days 2 to 4
    • Cycles 2 to 6: 25 mg/m2 IV over at least 10 to 30 minutes once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV over at least 10 to 30 minutes once per day on days 2 to 4
    • Cycles 2 to 6: 250 mg/m2 IV over at least 10 to 30 minutes once per day on days 1 to 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 50 mg/m2 IV over 4 hours once on day 1, then 450 mg/m2 IV once on day 3
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 6 cycles

Regimen variant #2

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2010 (REACH) 2003-2007 Phase 3 (E-RT-esc) FC Superior PFS
Median PFS: 30.6 vs 20.6 mo
(HR 0.65)

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 25 mg/m2 IV once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 250 mg/m2 IV once per day on days 1 to 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 6 cycles

Regimen variant #3

Study Years of enrollment Evidence
Wierda et al. 2005 1999-2001 Phase 2

Chemotherapy

  • Fludarabine (Fludara) as follows:
    • Cycle 1: 25 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 25 mg/m2 IV once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) as follows:
    • Cycle 1: 250 mg/m2 IV once per day on days 2 to 4
    • Cycles 2 to 6: 250 mg/m2 IV once per day on days 1 to 3

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 6: 500 mg/m2 IV once on day 1

Supportive medications

28-day cycle for up to 6 cycles

Regimen variant #4

Study Years of enrollment Evidence
Tam et al. 2006 2000-2005 Phase 2

Chemotherapy

Targeted therapy

28-day cycle for up to 6 cycles or "attainment of maximum response"

References

  1. Wierda W, O'Brien S, Wen S, Faderl S, Garcia-Manero G, Thomas D, Do KA, Cortes J, Koller C, Beran M, Ferrajoli A, Giles F, Lerner S, Albitar M, Kantarjian H, Keating M. Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab for relapsed and refractory chronic lymphocytic leukemia. J Clin Oncol. 2005 Jun 20;23(18):4070-8. Epub 2005 Mar 14. link to original article contains dosing details in manuscript PubMed
    1. Update: Badoux XC, Keating MJ, Wang X, O'Brien SM, Ferrajoli A, Faderl S, Burger J, Koller C, Lerner S, Kantarjian H, Wierda WG. Fludarabine, cyclophosphamide, and rituximab chemoimmunotherapy is highly effective treatment for relapsed patients with CLL. Blood. 2011 Mar 17;117(11):3016-24. Epub 2011 Jan 18. link to original article link to PMC article PubMed
  2. Tam CS, Wolf M, Prince HM, Januszewicz EH, Westerman D, Lin KI, Carney D, Seymour JF. Fludarabine, cyclophosphamide, and rituximab for the treatment of patients with chronic lymphocytic leukemia or indolent non-Hodgkin lymphoma. Cancer. 2006 Jun 1;106(11):2412-20. link to original article contains dosing details in manuscript PubMed
  3. REACH: Robak T, Dmoszynska A, Solal-Céligny P, Warzocha K, Loscertales J, Catalano J, Afanasiev BV, Larratt L, Geisler CH, Montillo M, Zyuzgin I, Ganly PS, Dartigeas C, Rosta A, Maurer J, Mendila M, Saville MW, Valente N, Wenger MK, Moiseev SI. Rituximab plus fludarabine and cyclophosphamide prolongs progression-free survival compared with fludarabine and cyclophosphamide alone in previously treated chronic lymphocytic leukemia. J Clin Oncol. 2010 Apr 1;28(10):1756-65. Epub 2010 Mar 1. link to original article contains dosing details in manuscript PubMed content property of HemOnc.org NCT00090051
  4. LUCID: Awan FT, Hillmen P, Hellmann A, Robak T, Hughes SG, Trone D, Shannon M, Flinn IW, Byrd JC; LUCID trial investigators. A randomized, open-label, multicentre, phase 2/3 study to evaluate the safety and efficacy of lumiliximab in combination with fludarabine, cyclophosphamide and rituximab versus fludarabine, cyclophosphamide and rituximab alone in subjects with relapsed chronic lymphocytic leukaemia. Br J Haematol. 2014 Nov;167(4):466-77. Epub 2014 Aug 8. link to original article contains dosing details in manuscript PubMed NCT00391066

Fludarabine monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Johnson et al. 1996 1990-1992 Phase 3 (E-de-esc) CAP Seems to have superior ORR
Niederle et al. 2013 (WiSP RI05) 2001-2006 Phase 3 (C) Bendamustine Seems to have non-inferior PFS

Note: this is an experimental arm that did not meet its primary endpoint; included here because it was eventually used to establish this regimen as a standard comparator.

Chemotherapy

28-day cycle for up to 6 to 12 cycles

References

  1. Johnson S, Smith AG, Löffler H, Osby E, Juliusson G, Emmerich B, Wyld PJ, Hiddemann W; FRE-CLL. Multicentre prospective randomised trial of fludarabine versus cyclophosphamide, doxorubicin, and prednisone (CAP) for treatment of advanced-stage chronic lymphocytic leukaemia. Lancet. 1996 May 25;347(9013):1432-8. link to original article contains dosing details in abstract PubMed
  2. WiSP RI05: Niederle N, Megdenberg D, Balleisen L, Heit W, Knauf W, Weiß J, Freier W, Hinke A, Ibach S, Eimermacher H. Bendamustine compared to fludarabine as second-line treatment in chronic lymphocytic leukemia. Ann Hematol. 2013 May;92(5):653-60. Epub 2013 Jan 23. link to original article contains dosing details in manuscript PubMed NCT01423032

Ibrutinib monotherapy

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Byrd et al. 2013 (PCYC-1102 relapsed) 2010-2011 Phase 2 (RT)
Farooqui et al. 2014 (NHLBI 12-H-0035) 2011-2014 Phase 2, <20 pts
Byrd et al. 2014 (RESONATE) 2012-2013 Phase 3 (E-RT-switch-ooc) Ofatumumab Superior PFS1
Median PFS: 44.1 vs 8.1 mo
(HR 0.15, 95% CI 0.11-0.20)
O'Brien et al. 2016 (RESONATE-17) 2013 Phase 2
Huang et al. 2018 (CR102604) 2013-2015 Phase 3 (E-switch-ooc) Rituximab Superior OS
OS24: 79.8% vs 57.6%
(HR 0.45, 95% CI 0.22-0.90)
Sharman et al. 2021 (GENUINE) 2015-2016 Phase 3 (C) Ibrutinib & Ublituximab Seems to have inferior ORR
Byrd et al. 2021 (ACE-CL-006) 2015-2017 Phase 3 (C) Acalabrutinib Non-inferior PFS
Brown et al. 2022 (ALPINE) 2018-2019 Phase 3 (C) Zanubrutinib Inferior ORR

1Reported efficacy for RESONATE is based on the second 2019 update.
Note: Both 420 mg and 840 mg doses were investigated in PCYC-1102: "the similar response in the two dose groups provide support for the use of the 420-mg dose of ibrutinib for relapsed CLL." The others used the 420 mg dose.

Biomarker eligibility criteria

  • RESONATE-17: 17p deletion
  • GENUINE: 17p deletion, 11q deletion, or TP53 mutation
  • ACE-CL-006: del(17)(p13.1) or del(11)(q22.3)

Prior treatment criteria

  • ACE-CL-006 & ALPINE: At least 1 prior systemic therapy

Targeted therapy

Continued indefinitely

References

  1. PCYC-1102 relapsed: Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum KA, Grant B, Sharman JP, Coleman M, Wierda WG, Jones JA, Zhao W, Heerema NA, Johnson AJ, Sukbuntherng J, Chang BY, Clow F, Hedrick E, Buggy JJ, James DF, O'Brien S. Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med. 2013 Jul 4;369(1):32-42. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01105247
    1. Update: Byrd JC, Furman RR, Coutre SE, Burger JA, Blum KA, Coleman M, Wierda WG, Jones JA, Zhao W, Heerema NA, Johnson AJ, Shaw Y, Bilotti E, Zhou C, James DF, O'Brien S. Three-year follow-up of treatment-naïve and previously treated patients with CLL and SLL receiving single-agent ibrutinib. Blood. 2015 Apr 16;125(16):2497-506. Epub 2015 Feb 19. link to original article link to PMC article PubMed
    2. Update: O'Brien S, Furman RR, Coutre S, Flinn IW, Burger JA, Blum K, Sharman J, Wierda W, Jones J, Zhao W, Heerema NA, Johnson AJ, Luan Y, James DF, Chu AD, Byrd JC. Single-agent ibrutinib in treatment-naïve and relapsed/refractory chronic lymphocytic leukemia: a 5-year experience. Blood. 2018 Apr 26;131(17):1910-1919. Epub 2018 Feb 2. link to original article link to PMC article PubMed
    3. Update: Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum K, Sharman JP, Wierda W, Zhao W, Heerema NA, Luan Y, Liu EA, Dean JP, O'Brien S. Ibrutinib Treatment for First-Line and Relapsed/Refractory Chronic Lymphocytic Leukemia: Final Analysis of the Pivotal Phase Ib/II PCYC-1102 Study. Clin Cancer Res. 2020 Aug 1;26(15):3918-3927. Epub 2020 Mar 24. link to original article link to PMC article PubMed
  2. RESONATE: Byrd JC, Brown JR, O'Brien S, Barrientos JC, Kay NE, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Devereux S, Barr PM, Furman RR, Kipps TJ, Cymbalista F, Pocock C, Thornton P, Caligaris-Cappio F, Robak T, Delgado J, Schuster SJ, Montillo M, Schuh A, de Vos S, Gill D, Bloor A, Dearden C, Moreno C, Jones JJ, Chu AD, Fardis M, McGreivy J, Clow F, James DF, Hillmen P; the RESONATE Investigators. Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med. 2014 Jul 17;371(3):213-23. Epub 2014 May 31. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01578707
    1. Update: Brown JR, Hillmen P, O'Brien S, Barrientos JC, Reddy NM, Coutre SE, Tam CS, Mulligan SP, Jaeger U, Barr PM, Furman RR, Kipps TJ, Cymbalista F, Thornton P, Caligaris-Cappio F, Delgado J, Montillo M, De Vos S, Moreno C, Pagel JM, Munir T, Burger JA, Chung D, Lin J, Gau L, Chang B, Cole G, Hsu E, James DF, Byrd JC. Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL. Leukemia. 2018 Jan;32(1):83-91. Epub 2017 Jun 8. link to original article link to PMC article PubMed
    2. Update: Byrd JC, Hillmen P, O'Brien S, Barrientos JC, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Barr PM, Furman RR, Kipps TJ, Thornton P, Moreno C, Montillo M, Pagel JM, Burger JA, Woyach JA, Dai S, Vezan R, James DF, Brown JR. Long-term follow-up of the RESONATE phase 3 trial of ibrutinib vs ofatumumab. Blood. 2019 May 9;133(19):2031-2042. Epub 2019 Mar 6. link to original article link to PMC article PubMed
    3. Update: Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Kipps TJ, Moreno C, Montillo M, Burger JA, Byrd JC, Hillmen P, Dai S, Szoke A, Dean JP, Woyach JA. Final analysis from RESONATE: Up to six years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol. 2019 Dec;94(12):1353-1363. Epub 2019 Oct 13. link to original article link to PMC article PubMed
  3. NHLBI 12-H-0035: Farooqui MZ, Valdez J, Martyr S, Aue G, Saba N, Niemann CU, Herman SE, Tian X, Marti G, Soto S, Hughes TE, Jones J, Lipsky A, Pittaluga S, Stetler-Stevenson M, Yuan C, Lee YS, Pedersen LB, Geisler CH, Calvo KR, Arthur DC, Maric I, Childs R, Young NS, Wiestner A. Ibrutinib for previously untreated and relapsed or refractory chronic lymphocytic leukaemia with TP53 aberrations: a phase 2, single-arm trial. Lancet Oncol. 2015 Feb;16(2):169-76. Epub 2014 Dec 31. link to original article contains dosing details in abstract link to PMC article PubMed NCT01500733
  4. RESONATE-17: O'Brien S, Jones JA, Coutre SE, Mato AR, Hillmen P, Tam C, Österborg A, Siddiqi T, Thirman MJ, Furman RR, Ilhan O, Keating MJ, Call TG, Brown JR, Stevens-Brogan M, Li Y, Clow F, James DF, Chu AD, Hallek M, Stilgenbauer S. Ibrutinib for patients with relapsed or refractory chronic lymphocytic leukaemia with 17p deletion (RESONATE-17): a phase 2, open-label, multicentre study. Lancet Oncol. 2016 Oct;17(10):1409-1418. Epub 2016 Sep 13. link to original article contains dosing details in abstract PubMed NCT01744691
  5. Retrospective: Ryan CE, Sahaf B, Logan AC, O'Brien S, Byrd JC, Hillmen P, Brown JR, Dyer MJ, Mato AR, Keating MJ, Jaglowski S, Clow F, Rezvani AR, Styles L, Coutre SE, Miklos DB. Ibrutinib efficacy and tolerability in patients with relapsed chronic lymphocytic leukemia following allogeneic HCT. Blood. 2016 Dec 22;128(25):2899-2908. link to original article link to PMC article PubMed
  6. CR102604: Huang X, Qiu L, Jin J, Zhou D, Chen X, Hou M, Hu J, Hu Y, Ke X, Li J, Liang Y, Liu T, Lv Y, Ren H, Sun A, Wang J, Zhao C, Salman M, Sun S, Howes A, Wang J, Wu P, Li J. Ibrutinib versus rituximab in relapsed or refractory chronic lymphocytic leukemia or small lymphocytic lymphoma: a randomized, open-label phase 3 study. Cancer Med. 2018 Apr;7(4):1043-1055. Epub 2018 Mar 13. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01973387
  7. GENUINE: Sharman JP, Brander DM, Mato AR, Ghosh N, Schuster SJ, Kambhampati S, Burke JM, Lansigan F, Schreeder MT, Lunin SD, Zweibach A, Shtivelband M, Travis PM, Chandler JC, Kolibaba KS, Sportelli P, Miskin HP, Weiss MS, Flinn IW. Ublituximab plus ibrutinib versus ibrutinib alone for patients with relapsed or refractory high-risk chronic lymphocytic leukaemia (GENUINE): a phase 3, multicentre, open-label, randomised trial. Lancet Haematol. 2021 Apr;8(4):e254-e266. Epub 2021 Feb 22. link to original article contains dosing details in abstract PubMed NCT02301156
  8. ACE-CL-006: Byrd JC, Hillmen P, Ghia P, Kater AP, Chanan-Khan A, Furman RR, O'Brien S, Yenerel MN, Illés A, Kay N, Garcia-Marco JA, Mato A, Pinilla-Ibarz J, Seymour JF, Lepretre S, Stilgenbauer S, Robak T, Rothbaum W, Izumi R, Hamdy A, Patel P, Higgins K, Sohoni S, Jurczak W. Acalabrutinib Versus Ibrutinib in Previously Treated Chronic Lymphocytic Leukemia: Results of the First Randomized Phase III Trial. J Clin Oncol. 2021 Nov 1;39(31):3441-3452. Epub 2021 Jul 26. link to original article contains dosing details in manuscript link to PMC article PubMed NCT02477696
  9. ALPINE: Brown JR, Hillmen P, Eichhorst B, Lamanna N, O'Brien S, Tam CS, Qiu L, Kazmierczak M, Zhou K, Šimkovič M, Mayer J, Gillespie-Twardy A, Shadman M, Ferrajoli A, Ganly PS, Weinkove R, Salmi T, Wu K, Novotny W, Jurczak W. CLL-115 First Interim Analysis of ALPINE Study: Results of a Phase 3 Randomized Study of Zanubrutinib vs Ibrutinib in Patients With Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL). Clin Lymphoma Myeloma Leuk. 2022 Oct;22 Suppl 2:S266. link to original article PubMed NCT03734016

Idelalisib & Ofatumumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Jones et al. 2017 (GS-US-312-0119) 2012-2014 Phase 3 (E-esc) Ofatumumab Superior PFS
Median PFS: 16.3 vs 8 mo
(HR 0.27, 95% CI 0.19-0.39)

Targeted therapy

  • Idelalisib (Zydelig) 150 mg PO twice per day
  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 1000 mg IV once per day on days 1, 8, 15, 22
    • Cycles 3 to 6: 1000 mg IV once on day 1

28-day cycle for 6 cycles

References

  1. GS-US-312-0119: Jones JA, Robak T, Brown JR, Awan FT, Badoux X, Coutre S, Loscertales J, Taylor K, Vandenberghe E, Wach M, Wagner-Johnston N, Ysebaert L, Dreiling L, Dubowy R, Xing G, Flinn IW, Owen C. Efficacy and safety of idelalisib in combination with ofatumumab for previously treated chronic lymphocytic leukaemia: an open-label, randomised phase 3 trial. Lancet Haematol. 2017 Mar;4(3):e114-e126. link to original article contains dosing details in abstract PubMed NCT01659021

Idelalisib & Rituximab

Regimen variant #1, finite duration

Study Years of enrollment Evidence Comparator Comparative Efficacy
Furman et al. 2014 (GS-US-312-0116) 2012-2013 Phase 3 (E-RT-esc) Rituximab Superior PFS
PFS6: 93% vs 46%
(aHR 0.15, 95% CI 0.08-0.28)

Targeted therapy

21-day cycle for 1 cycle, then 28-day cycle for up to 17 cycles (18 cycles total)

Subsequent treatment

  • Upon progression: Idelalisib can be increased to 300 mg PO twice per day

Regimen variant #2, indefinite

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ghia et al. 2020 (ASCEND) 2017-2018 Phase 3 (C) Acalabrutinib Inferior PFS

Prior treatment criteria

  • ASCEND: At least 1 prior systemic therapy

Targeted therapy

  • Idelalisib (Zydelig) 150 mg PO twice per day
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 3: 500 mg/m2 IV once per day on days 1 & 15
    • Cycles 4 to 6: 500 mg/m2 IV once on day 1

14-day cycle for 1 cycle, then 28-day cycles

References

  1. GS-US-312-0116: Furman RR, Sharman JP, Coutre SE, Cheson BD, Pagel JM, Hillmen P, Barrientos JC, Zelenetz AD, Kipps TJ, Flinn I, Ghia P, Eradat H, Ervin T, Lamanna N, Coiffier B, Pettitt AR, Ma S, Stilgenbauer S, Cramer P, Aiello M, Johnson DM, Miller LL, Li D, Jahn TM, Dansey RD, Hallek M, O'Brien SM. Idelalisib and rituximab in relapsed chronic lymphocytic leukemia. N Engl J Med. 2014 Mar 13;370(11):997-1007. Epub 2014 Jan 22. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01539512
    1. Update: Sharman JP, Coutre SE, Furman RR, Cheson BD, Pagel JM, Hillmen P, Barrientos JC, Zelenetz AD, Kipps TJ, Flinn IW, Ghia P, Eradat H, Ervin T, Lamanna N, Coiffier B, Pettitt AR, Ma S, Tausch E, Cramer P, Huang J, Mitra S, Hallek M, O'Brien SM, Stilgenbauer S. Final results of a randomized, phase III study of rituximab with or without idelalisib followed by open-label idelalisib in patients with relapsed chronic lymphocytic leukemia. J Clin Oncol. 2019 Jun 1;37(16):1391-1402. Epub 2019 Apr 17. link to original article PubMed
  2. ASCEND: Ghia P, Pluta A, Wach M, Lysak D, Kozak T, Simkovic M, Kaplan P, Kraychok I, Illes A, de la Serna J, Dolan S, Campbell P, Musuraca G, Jacob A, Avery E, Lee JH, Liang W, Patel P, Quah C, Jurczak W. ASCEND: Phase III, Randomized Trial of Acalabrutinib Versus Idelalisib Plus Rituximab or Bendamustine Plus Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2020 Sep 1;38(25):2849-2861. Epub 2020 May 27. link to original article contains dosing details in manuscript PubMed NCT02970318

Ofatumumab monotherapy

Regimen variant #1, 2 cycles

Study Years of enrollment Evidence
Österborg et al. 2015 (GEN416) 2009-2011 Phase 2

Patients in this trial were fludarabine refractory and had previously received ofatumumab; this is a re-treatment trial.

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 2000 mg IV once per day on days 1, 8, 15, 22

Supportive medications

28-day cycle for 2 cycles

Subsequent treatment

  • Patients with SD or better could proceed to ofatumumab maintenance

Regimen variant #2, 6 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Coiffier et al. 2007 2004-2006 Phase 1/2
Wierda et al. 2010 (Hx-CD20-406) 2006-NR Phase 2 (RT)
Österborg et al. 2016 (Novartis 114242) 2011-NR Phase 3 (E-switch) Physician's choice Did not meet primary endpoint of PFS
Byrd et al. 2014 (RESONATE) 2012-2013 Phase 3 (C) Ibrutinib Inferior PFS1
Jones et al. 2017 (GS-US-312-0119) 2012-2014 Phase 3 (C) Idelalisib & Ofatumumab Inferior PFS
Flinn et al. 2018 (DUO) 2014-2015 Phase 3 (C) Duvelisib Inferior PFS

1Reported efficacy for RESONATE is based on the second 2019 update.
Note: this regimen is sometimes described as 300 mg IV once on day 1, then 2000 mg IV once per week for 7 weeks, then 2000 mg IV once every 4 weeks for 16 weeks. To our knowledge, this regimen was not tested as an experimental arm in an RCT prior to becoming a standard comparator arm.

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 2000 mg IV once per day on days 1, 8, 15, 22
    • Cycles 3 to 6: 2000 mg IV once on day 1

Supportive medications

  • Prednisolone (Millipred) 100 mg (or equivalent) PO once, prior to infusions 1, 2, and 9 (question whether this was a typo), reduced to lower doses if initial infusions well-tolerated

28-day cycle for 6 cycles

Regimen variant #3, 12 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ghia et al. 2017 (P07714) 2012-NR Phase 3 (C) Dinaciclib Not reported

Note: this trial was terminated early and no statistical tests were performed; note also that cycle 3 is "skipped".

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 2000 mg IV once per day on days 1, 8, 15, 22
    • Cycle 3: no treatment
    • Cycles 4 to 12: 2000 mg IV once on day 1

28-day cycle for 12 cycles

References

  1. Coiffier B, Lepretre S, Pedersen LM, Gadeberg O, Fredriksen H, van Oers MH, Wooldridge J, Kloczko J, Holowiecki J, Hellmann A, Walewski J, Flensburg M, Petersen J, Robak T. Safety and efficacy of ofatumumab, a fully human monoclonal anti-CD20 antibody, in patients with relapsed or refractory B-cell chronic lymphocytic leukemia: a phase 1-2 study. Blood. 2008 Feb 1;111(3):1094-100. Epub 2007 Nov 14. link to original article PubMed
  2. Hx-CD20-406: Wierda WG, Kipps TJ, Mayer J, Stilgenbauer S, Williams CD, Hellmann A, Robak T, Furman RR, Hillmen P, Trneny M, Dyer MJ, Padmanabhan S, Piotrowska M, Kozak T, Chan G, Davis R, Losic N, Wilms J, Russell CA, Osterborg A; Hx-CD20-406 Study Investigators. Ofatumumab as single-agent CD20 immunotherapy in fludarabine-refractory chronic lymphocytic leukemia. J Clin Oncol. 2010 Apr 1;28(10):1749-55. Epub 2010 Mar 1. link to original article contains dosing details in abstract link to PMC article PubMed NCT00349349
    1. Subgroup analysis: Wierda WG, Padmanabhan S, Chan GW, Gupta IV, Lisby S, Osterborg A; Hx-CD20-406 Study Investigators. Ofatumumab is active in patients with fludarabine-refractory CLL irrespective of prior rituximab: results from the phase 2 international study. Blood. 2011 Nov 10;118(19):5126-9. Epub 2011 Aug 19. link to original article link to PMC article PubMed
    2. Update: Österborg A, Jewell RC, Padmanabhan-Iyer S, Kipps TJ, Mayer J, Stilgenbauer S, Williams CD, Hellmann A, Furman RR, Robak T, Hillmen P, Trnêný M, Dyer MJ, Piotrowska M, Kozak T, Gupta IV, Phillips JL, Goldstein N, Struemper H, Losic N, Lisby S, Wierda WG; Hx-CD20-406 Study Investigators. Ofatumumab monotherapy in fludarabine-refractory chronic lymphocytic leukemia: final results from a pivotal study. Haematologica. 2015 Aug;100(8):e311-4. Epub 2015 Mar 13. link to original article link to PMC article PubMed
  3. RESONATE: Byrd JC, Brown JR, O'Brien S, Barrientos JC, Kay NE, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Devereux S, Barr PM, Furman RR, Kipps TJ, Cymbalista F, Pocock C, Thornton P, Caligaris-Cappio F, Robak T, Delgado J, Schuster SJ, Montillo M, Schuh A, de Vos S, Gill D, Bloor A, Dearden C, Moreno C, Jones JJ, Chu AD, Fardis M, McGreivy J, Clow F, James DF, Hillmen P; the RESONATE Investigators. Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med. 2014 Jul 17;371(3):213-23. Epub 2014 May 31. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01578707
    1. Update: Brown JR, Hillmen P, O'Brien S, Barrientos JC, Reddy NM, Coutre SE, Tam CS, Mulligan SP, Jaeger U, Barr PM, Furman RR, Kipps TJ, Cymbalista F, Thornton P, Caligaris-Cappio F, Delgado J, Montillo M, De Vos S, Moreno C, Pagel JM, Munir T, Burger JA, Chung D, Lin J, Gau L, Chang B, Cole G, Hsu E, James DF, Byrd JC. Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL. Leukemia. 2018 Jan;32(1):83-91. Epub 2017 Jun 8. link to original article link to PMC article PubMed
    2. Update: Byrd JC, Hillmen P, O'Brien S, Barrientos JC, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Barr PM, Furman RR, Kipps TJ, Thornton P, Moreno C, Montillo M, Pagel JM, Burger JA, Woyach JA, Dai S, Vezan R, James DF, Brown JR. Long-term follow-up of the RESONATE phase 3 trial of ibrutinib vs ofatumumab. Blood. 2019 May 9;133(19):2031-2042. Epub 2019 Mar 6. link to original article link to PMC article PubMed
    3. Update: Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Kipps TJ, Moreno C, Montillo M, Burger JA, Byrd JC, Hillmen P, Dai S, Szoke A, Dean JP, Woyach JA. Final analysis from RESONATE: Up to six years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol. 2019 Dec;94(12):1353-1363. Epub 2019 Oct 13. link to original article link to PMC article PubMed
  4. Retrospective: Moreno C, Montillo M, Panayiotidis P, Dimou M, Bloor A, Dupuis J, Schuh A, Norin S, Geisler C, Hillmen P, Doubek M, Trněný M, Obrtlikova P, Laurenti L, Stilgenbauer S, Smolej L, Ghia P, Cymbalista F, Jaeger U, Stamatopoulos K, Stavroyianni N, Carrington P, Zouabi H, Leblond V, Gomez-Garcia JC, Rubio M, Marasca R, Musuraca G, Rigacci L, Farina L, Paolini R, Pospisilova S, Kimby E, Bradley C, Montserrat E. Ofatumumab in poor-prognosis chronic lymphocytic leukemia: a Phase 4, non--interventional, observational study from the European Research Initiative on Chronic Lymphocytic Leukemia. Haematologica. 2015 Apr;100(4):511-6. Epub 2015 Jan 16. link to original article link to PMC article PubMed
  5. GEN416: Österborg A, Wierda WG, Mayer J, Hess G, Hillmen P, Schetelig J, Schuh A, Smolej L, Beck C, Dreyfus B, Hellman A, Kozlowski P, Pfreundschuh M, Rizzi R, Spacek M, Phillips JL, Gupta IV, Williams V, Jewell RC, Nebot N, Lisby S, Dyer MJ. Ofatumumab retreatment and maintenance in fludarabine-refractory chronic lymphocytic leukaemia patients. Br J Haematol. 2015 Jul;170(1):40-9. Epub 2015 Mar 30. link to original article contains dosing details in manuscript PubMed NCT00802737
  6. Novartis 114242: Österborg A, Udvardy M, Zaritskey A, Andersson PO, Grosicki S, Mazur G, Kaplan P, Steurer M, Schuh A, Montillo M, Kryachok I, Middeke JM, Kulyaba Y, Rekhtman G, Gorczyca M, Daly S, Chang CN, Lisby S, Gupta I. Phase III, randomized study of ofatumumab versus physicians' choice of therapy and standard versus extended-length ofatumumab in patients with bulky fludarabine-refractory chronic lymphocytic leukemia. Leuk Lymphoma. 2016 Sep;57(9):2037-46. Epub 2016 Jan 19. link to original articlePubMed NCT01313689
    1. Update: Miklos U, Strugov V, Lewerin C, Grosicki S, Mazur G, Steurer M, Montillo M, Kryachok I, Middeke JM, Rekhtman G, Stefanelli T, Vincent G, Govindaraju S, Österborg A. Five-year survival follow-up of a phase III randomised trial comparing ofatumumab versus physicians' choice for bulky fludarabine-refractory chronic lymphocytic leukaemia: a short report. Br J Haematol. 2020 May;189(4):689-693. Epub 2020 Jan 28. link to original article PubMed
  7. GS-US-312-0119: Jones JA, Robak T, Brown JR, Awan FT, Badoux X, Coutre S, Loscertales J, Taylor K, Vandenberghe E, Wach M, Wagner-Johnston N, Ysebaert L, Dreiling L, Dubowy R, Xing G, Flinn IW, Owen C. Efficacy and safety of idelalisib in combination with ofatumumab for previously treated chronic lymphocytic leukaemia: an open-label, randomised phase 3 trial. Lancet Haematol. 2017 Mar;4(3):e114-e126. link to original article contains dosing details in abstract PubMed NCT01659021
  8. P07714: Ghia P, Scarfò L, Perez S, Pathiraja K, Derosier M, Small K, McCrary Sisk C, Patton N. Efficacy and safety of dinaciclib vs ofatumumab in patients with relapsed/refractory chronic lymphocytic leukemia. Blood. 2017 Mar 30;129(13):1876-1878. Epub 2017 Jan 26. link to original article PubMed NCT01580228
  9. DUO: Flinn IW, Hillmen P, Montillo M, Nagy Z, Illés Á, Etienne G, Delgado J, Kuss BJ, Tam CS, Gasztonyi Z, Offner F, Lunin S, Bosch F, Davids MS, Lamanna N, Jaeger U, Ghia P, Cymbalista F, Portell CA, Skarbnik AP, Cashen AF, Weaver DT, Kelly VM, Turnbull B, Stilgenbauer S. The phase 3 DUO trial: duvelisib vs ofatumumab in relapsed and refractory CLL/SLL. Blood. 2018 Dec 6;132(23):2446-2455. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02004522

O-FC

O-FC: Ofatumumab, Fludarabine, Cyclophosphamide

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2016 (COMPLEMENT 2) 2008-NR Phase 3 (E-RT-esc) FC Superior PFS
Median PFS: 28.9 vs 18.8 mo
(HR 0.67, 95% CI 0.51-0.88)

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once on day 8
    • Cycles 2 to 6: 1000 mg IV once on day 1

Chemotherapy

Supportive medications

28-day cycle for 6 cycles

References

  1. COMPLEMENT 2: Robak T, Warzocha K, Govind Babu K, Kulyaba Y, Kuliczkowski K, Abdulkadyrov K, Loscertales J, Kryachok I, Kłoczko J, Rekhtman G, Homenda W, Błoński JZ, McKeown A, Gorczyca MM, Carey JL, Chang CN, Lisby S, Gupta IV, Grosicki S. Ofatumumab plus fludarabine and cyclophosphamide in relapsed chronic lymphocytic leukemia: results from the COMPLEMENT 2 trial. Leuk Lymphoma. 2017 May;58(5):1084-1093. Epub 2016 Oct 12. link to original article contains dosing details in manuscript PubMed NCT00824265

Rituximab monotherapy

Regimen variant #1, 4-week course

Study Years of enrollment Evidence Comparator Comparative Efficacy
McLaughlin et al. 1998 1995-1996 Phase 2
Williams et al. 2016 (RESORT substudy) 2003-2008 Phase 3 (E-de-esc) Rituximab maintenance Seems to have inferior TTTF

Preceding treatment

Targeted therapy

4-week course

Regimen variant #2, 8 doses

Study Years of enrollment Evidence Comparator Comparative Efficacy
Furman et al. 2014 (GS-US-312-0116) 2012-2013 Phase 3 (C) Idelalisib & Rituximab Inferior PFS

Note: Reported efficacy is based on the 2019 update.

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycles 2 to 8: 500 mg/m2 IV once on day 1

14-day cycle for 4 cycles, then 21-day cycle for 4 cycles

Regimen variant #3, 8 doses alternate schedule

Study Years of enrollment Evidence Comparator Comparative Efficacy
Huang et al. 2018 (CR102604) 2013-2015 Phase 3 (C) Ibrutinib Seems to have inferior OS

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1, then 500 mg/m2 IV once on day 15
    • Cycle 2: 500 mg/m2 IV once per day on days 1 & 15
    • Cycles 3 to 6: 500 mg/m2 IV once on day 1

28-day cycle for 6 cycles

References

  1. McLaughlin P, Grillo-López AJ, Link BK, Levy R, Czuczman MS, Williams ME, Heyman MR, Bence-Bruckler I, White CA, Cabanillas F, Jain V, Ho AD, Lister J, Wey K, Shen D, Dallaire BK. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol. 1998 Aug;16(8):2825-33. link to original article contains dosing details in manuscript PubMed
  2. GS-US-312-0116: Furman RR, Sharman JP, Coutre SE, Cheson BD, Pagel JM, Hillmen P, Barrientos JC, Zelenetz AD, Kipps TJ, Flinn I, Ghia P, Eradat H, Ervin T, Lamanna N, Coiffier B, Pettitt AR, Ma S, Stilgenbauer S, Cramer P, Aiello M, Johnson DM, Miller LL, Li D, Jahn TM, Dansey RD, Hallek M, O'Brien SM. Idelalisib and rituximab in relapsed chronic lymphocytic leukemia. N Engl J Med. 2014 Mar 13;370(11):997-1007. Epub 2014 Jan 22. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01539512
    1. Update: Sharman JP, Coutre SE, Furman RR, Cheson BD, Pagel JM, Hillmen P, Barrientos JC, Zelenetz AD, Kipps TJ, Flinn IW, Ghia P, Eradat H, Ervin T, Lamanna N, Coiffier B, Pettitt AR, Ma S, Tausch E, Cramer P, Huang J, Mitra S, Hallek M, O'Brien SM, Stilgenbauer S. Final results of a randomized, phase III study of rituximab with or without idelalisib followed by open-label idelalisib in patients with relapsed chronic lymphocytic leukemia. J Clin Oncol. 2019 Jun 1;37(16):1391-1402. Epub 2019 Apr 17. link to original article PubMed
  3. RESORT substudy: Williams ME, Hong F, Gascoyne RD, Wagner LI, Krauss JC, Habermann TM, Swinnen LJ, Schuster SJ, Peterson CG, Sborov MD, Martin SE, Weiss M, Ehmann WC, Horning SJ, Kahl BS; Eastern Cooperative Oncology Group. Rituximab extended schedule or retreatment trial for low tumour burden non-follicular indolent B-cell non-Hodgkin lymphomas: Eastern Cooperative Oncology Group Protocol E4402. Br J Haematol. 2016 Jun;173(6):867-75. Epub 2016 Mar 11. link to original article contains dosing details in abstract link to PMC article PubMed NCT01406782
  4. CR102604: Huang X, Qiu L, Jin J, Zhou D, Chen X, Hou M, Hu J, Hu Y, Ke X, Li J, Liang Y, Liu T, Lv Y, Ren H, Sun A, Wang J, Zhao C, Salman M, Sun S, Howes A, Wang J, Wu P, Li J. Ibrutinib versus rituximab in relapsed or refractory chronic lymphocytic leukemia or small lymphocytic lymphoma: a randomized, open-label phase 3 study. Cancer Med. 2018 Apr;7(4):1043-1055. Epub 2018 Mar 13. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01973387

Venetoclax & Rituximab

VenR: Venetoclax & Rituximab

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Seymour et al. 2018 (MURANO) 2014-2015 Phase 3 (E-RT-switch-ooc) BR Superior OS1
OS48: 85.3% vs 66.8%
(HR 0.41, 95% CI 0.26-0.65)

1Reported efficacy is based on the 2020 update.

Targeted therapy

  • Venetoclax (Venclexta) as follows:
    • Week 1: 20 mg PO once per day
    • Week 2: 50 mg PO once per day
    • Week 3: 100 mg PO once per day
    • Week 4: 200 mg PO once per day
    • Week 5 onwards: 400 mg PO once per day
  • Rituximab (Rituxan) as follows:
    • Week 6: 375 mg/m2 IV once on day 1
    • Weeks 10, 14, 18, 22, 26: 500 mg/m2 IV once on day 1

Up to 2-year course

References

  1. MURANO: Seymour JF, Kipps TJ, Eichhorst B, Hillmen P, D'Rozario J, Assouline S, Owen C, Gerecitano J, Robak T, De la Serna J, Jaeger U, Cartron G, Montillo M, Humerickhouse R, Punnoose EA, Li Y, Boyer M, Humphrey K, Mobasher M, Kater AP. Venetoclax-rituximab in relapsed or refractory chronic lymphocytic leukemia. N Engl J Med. 2018 Mar 22;378(12):1107-1120. link to original article contains dosing details in manuscript PubMed NCT02005471
    1. Update: Kater AP, Seymour JF, Hillmen P, Eichhorst B, Langerak AW, Owen C, Verdugo M, Wu J, Punnoose EA, Jiang Y, Wang J, Boyer M, Humphrey K, Mobasher M, Kipps TJ. Fixed duration of venetoclax-rituximab in relapsed/refractory chronic lymphocytic leukemia eradicates minimal residual disease and prolongs survival: post-treatment follow-up of the MURANO phase III study. J Clin Oncol. 2019 Feb 1;37(4):269-277. Epub 2018 Dec 3. link to original article PubMed
    2. Update: Kater AP, Wu JQ, Kipps T, Eichhorst B, Hillmen P, D'Rozario J, Assouline S, Owen C, Robak T, de la Serna J, Jaeger U, Cartron G, Montillo M, Dubois J, Eldering E, Mellink C, Van Der Kevie-Kersemaekers AM, Kim SY, Chyla B, Punnoose E, Bolen CR, Assaf ZJ, Jiang Y, Wang J, Lefebure M, Boyer M, Humphrey K, Seymour JF. Venetoclax Plus Rituximab in Relapsed Chronic Lymphocytic Leukemia: 4-Year Results and Evaluation of Impact of Genomic Complexity and Gene Mutations From the MURANO Phase III Study. J Clin Oncol. 2020 Dec 1;38(34):4042-4054. Epub 2020 Sep 28. link to original article link to PMC article PubMed
    3. Update: Seymour JF, Kipps TJ, Eichhorst BF, D'Rozario J, Owen CJ, Assouline S, Lamanna N, Robak T, de la Serna J, Jaeger U, Cartron G, Montillo M, Mellink C, Chyla B, Panchal A, Lu T, Wu JQ, Jiang Y, Lefebure M, Boyer M, Kater AP. Enduring undetectable MRD and updated outcomes in relapsed/refractory CLL after fixed-duration venetoclax-rituximab. Blood. 2022 Aug 25;140(8):839-850. link to original article PubMed

Zanubrutinib monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Brown et al. 2022 (ALPINE) 2018-2019 Phase 3 (E-switch-ic) Ibrutinib Superior ORR
ORR: 78.3% vs 62.5%

Prior treatment criteria

  • ALPINE: At least 1 prior systemic therapy

Targeted therapy

28-day cycles

References

  1. ALPINE: Brown JR, Hillmen P, Eichhorst B, Lamanna N, O'Brien S, Tam CS, Qiu L, Kazmierczak M, Zhou K, Šimkovič M, Mayer J, Gillespie-Twardy A, Shadman M, Ferrajoli A, Ganly PS, Weinkove R, Salmi T, Wu K, Novotny W, Jurczak W. CLL-115 First Interim Analysis of ALPINE Study: Results of a Phase 3 Randomized Study of Zanubrutinib vs Ibrutinib in Patients With Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL). Clin Lymphoma Myeloma Leuk. 2022 Oct;22 Suppl 2:S266. link to original article PubMed NCT03734016

Relapsed or refractory, non-randomized or retrospective data

Alemtuzumab monotherapy

Regimen variant #1

Study Years of enrollment Evidence
Keating et al. 2002 1998 Phase 2 (RT)
Rai et al. 2002 NR-1994 Phase 2 (RT)

Note: total course varies depending on reference.

Targeted therapy

  • Alemtuzumab (Campath) by the following criteria:
    • Starting dose: 3 mg IV once per day
    • If tolerated in terms of infusion reactions: 10 mg IV once per day
    • If tolerated in terms of infusion reactions: 30 mg IV once per day
    • Once 30 mg dose is tolerated: 30 mg IV over 2 hours, 3 times per week

Supportive medications

12- to 16-week course

Regimen variant #2

Study Years of enrollment Evidence
Lozanski et al. 2004 NR Phase 2 (RT)

Targeted therapy

  • Alemtuzumab (Campath) 3 mg IV once on day 1, then 10 mg IV once on day 2, then 30 mg IV once on day 3, then 30 mg IV 3 days per week

Supportive medications

  • G-CSF or GM-CSF per institutional protocol
  • Trimethoprim-Sulfamethoxazole (Bactrim DS) 160/800 mg PO 3 times per week during therapy and continued for 6 months after treatment is complete
  • Acyclovir (Zovirax) 800 mg PO three times per day during therapy and continued for 6 months after treatment is complete; similar medication can be used if intolerant of acyclovir

12-week course

References

  1. Keating MJ, Flinn I, Jain V, Binet JL, Hillmen P, Byrd J, Albitar M, Brettman L, Santabarbara P, Wacker B, Rai KR. Therapeutic role of alemtuzumab (Campath-1H) in patients who have failed fludarabine: results of a large international study. Blood. 2002 May 15;99(10):3554-61. link to original article contains dosing details in abstract PubMed
  2. Rai KR, Freter CE, Mercier RJ, Cooper MR, Mitchell BS, Stadtmauer EA, Santábarbara P, Wacker B, Brettman L. Alemtuzumab in previously treated chronic lymphocytic leukemia patients who also had received fludarabine. J Clin Oncol. 2002 Sep 15;20(18):3891-7. link to original article contains dosing details in abstract PubMed
  3. Lozanski G, Heerema NA, Flinn IW, Smith L, Harbison J, Webb J, Moran M, Lucas M, Lin T, Hackbarth ML, Proffitt JH, Lucas D, Grever MR, Byrd JC. Alemtuzumab is an effective therapy for chronic lymphocytic leukemia with p53 mutations and deletions. Blood. 2004 May 1;103(9):3278-81. Epub 2004 Jan 15. link to original article contains dosing details in abstract PubMed

Alemtuzumab & Rituximab

Regimen

Study Years of enrollment Evidence
Faderl et al. 2003 NR Phase 2

Targeted therapy

  • Alemtuzumab (Campath) 3 mg IV once on day 1, then 10 mg IV once on day 2, then 30 mg IV once on day 3 of week 1, then 30 mg IV once per day on days 10, 12, 17, 19, 24, 26 (i.e. days 3 and 5 of weeks 2 to 4)
  • Rituximab (Rituxan) 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • For patients with WBC count greater than 50 x 109/L, the first dose was split into 100 mg/m2 IV once on day 1, then 275 mg/m2 IV once on day 2

Supportive medications

28-day cycle for 1 to 2 cycles depending on response and toxicity

References

  1. Faderl S, Thomas DA, O'Brien S, Garcia-Manero G, Kantarjian HM, Giles FJ, Koller C, Ferrajoli A, Verstovsek S, Pro B, Andreeff M, Beran M, Cortes J, Wierda W, Tran N, Keating MJ. Experience with alemtuzumab plus rituximab in patients with relapsed and refractory lymphoid malignancies. Blood. 2003 May 1;101(9):3413-5. Epub 2003 Jan 9. link to original article contains dosing details in abstract Pubmed

Bendamustine & Ofatumumab

BendOfa: Bendamustine & Ofatumumab

Regimen

Study Years of enrollment Evidence Efficacy
Cortelezzi et al. 2013 (GIMEMA CLL0809) 2010-2011 Phase 2 ORR: 72% (95% CI, 57–84%)

Chemotherapy

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once on day 7
    • Cycle 2 onwards: 1000 mg IV once on day 1

Supportive medications

28-day cycle up to 6 cycles

References

  1. GIMEMA CLL0809: Cortelezzi A, Sciumè M, Liberati AM, Vincenti D, Cuneo A, Reda G, Laurenti L, Zaja F, Marasca R, Chiarenza A, Gritti G, Orsucci L, Storti S, Angelucci E, Cascavilla N, Gobbi M, Mauro FR, Morabito F, Fabris S, Piciocchi A, Vignetti M, Neri A, Rossi D, Giannarelli D, Guarini A, Foà R. Bendamustine in combination with ofatumumab in relapsed or refractory chronic lymphocytic leukemia: a GIMEMA multicenter phase II trial. Leukemia. 2014 Mar;28(3):642-8. Epub 2013 Nov 13. link to original article contains dosing details in manuscript PubMed NCT01244451

CFAR

CFAR: Cyclophosphamide, Fludarabine, Alemtuzumab, Rituximab

Regimen

Study Years of enrollment Evidence Efficacy
Badoux et al. 2011 (MDACC DM02-593) 2002-2006 Phase 2 ORR: 65%

Chemotherapy

Targeted therapy

Supportive medications

28-day cycle for 6 cycles

References

  1. MDACC DM02-593: Badoux XC, Keating MJ, Wang X, O'Brien SM, Ferrajoli A, Faderl S, Burger J, Koller C, Lerner S, Kantarjian H, Wierda WG. Cyclophosphamide, fludarabine, alemtuzumab, and rituximab as salvage therapy for heavily pretreated patients with chronic lymphocytic leukemia. Blood. 2011 Aug 25;118(8):2085-93. Epub 2011 Jun 13. link to original article contains dosing details in abstract link to PMC article PubMed NCT01082939

DFCR

DFCR: Duvelisib, Fludarabine, Cyclophosphamide, Rituximab

Regimen

Study Years of enrollment Evidence
Davids et al. 2020 (DFCI 14-193) 2014-2016 Phase 1b/2

This is the phase 2 dosing.

Targeted therapy

Chemotherapy

28-day cycle for up to 26 cycles (2 years)

References

  1. DFCI 14-193: Davids MS, Fisher DC, Tyekucheva S, McDonough M, Hanna J, Lee B, Francoeur K, Montegaard J, Odejide O, Armand P, Arnason J, Brown JR. A phase 1b/2 study of duvelisib in combination with FCR (DFCR) for frontline therapy for younger CLL patients. Leukemia. 2021 Apr;35(4):1064-1072. Epub 2020 Aug 20. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02158091

Fludarabine & Alemtuzumab

FluCam: Fludarabine & Campath (Alemtuzumab)

Regimen

Study Years of enrollment Evidence
Elter et al. 2005 NR Phase 2

Chemotherapy

Targeted therapy

  • Alemtuzumab (Campath) as follows:
    • Cycle 1: 3 mg IV once on day 1, then 10 mg IV once on day 2, then 30 mg IV once on day 3
    • Cycles 2 to 6: 30 mg IV once per day on days 1 to 3

Supportive medications

  • Trimethoprim/Sulfamethoxazole 960 mg (paper did not specify which component was 960 mg) PO once per day, started on day 1 and continued at least 2 months after treatment is complete
  • Valacyclovir (Valtrex) 500 mg PO twice per day, started on day 1 and continued at least 2 months after treatment is complete
    • If patients experienced CMV (cytomegalovirus) reactivation, valacyclovir was replaced by (val)ganciclovir 500 mg PO or IV three times per day
  • Fluconazole (Diflucan) 100 mg PO once per day, started if patients had evidence of fungal infection, continued until resolution
  • Acetaminophen (Tylenol) 1000 mg PO once on day 1, prior to first dose of Alemtuzumab (Campath), then with subsequent doses if clinically indicated
  • Clemastine (Tavist) 2 mg IV once on day 1, prior to first dose of Alemtuzumab (Campath), then with subsequent doses if clinically indicated
  • Prednisone (Sterapred) 100 mg IV once on day 1, prior to first dose of Alemtuzumab (Campath), then with subsequent doses if clinically indicated
  • For patients with WBC count greater than 50 x 109/L, bulky disease, or history of hyperuricemia: Allopurinol (Zyloprim) 300 mg PO once on day 1, prior to first dose of Alemtuzumab (Campath), and used later if clinically indicated

28-day cycle for 6 cycles

References

  1. Elter T, Borchmann P, Schulz H, Reiser M, Trelle S, Schnell R, Jensen M, Staib P, Schinköthe T, Stützer H, Rech J, Gramatzki M, Aulitzky W, Hasan I, Josting A, Hallek M, Engert A. Fludarabine in combination with alemtuzumab is effective and feasible in patients with relapsed or refractory B-cell chronic lymphocytic leukemia: results of a phase II trial. J Clin Oncol. 2005 Oct 1;23(28):7024-31. Epub 2005 Sep 6. link to original article contains dosing details in abstract PubMed

Fludarabine & Ibrutinib

Regimen

Study Years of enrollment Evidence
Pleyer et al. 2020 (NIH 15-H-0172) 2015-2019 Phase 2

Chemotherapy

Targeted therapy

28-day cycles

References

  1. NIH 15-H-0172: Pleyer C, Tian X, Rampertaap S, Mu R, Soto S, Superata J, Gaglione E, Sun C, Lotter J, Stetler-Stevenson M, Yuan CM, Maric I, Pittaluga S, Rosenzweig S, Fleisher T, Wiestner A, Ahn IE. A phase II study of ibrutinib and short-course fludarabine in previously untreated patients with chronic lymphocytic leukemia. Am J Hematol. 2020 Nov;95(11):E310-E313. Epub 2020 Sep 8. link to original article contains dosing details in manuscript link to PMC article PubMed NCT02514083

Fludarabine & Prednisone

Regimen

Study Years of enrollment Evidence
O'Brien et al. 1993 1988-1991 Phase 2

Chemotherapy

Glucocorticoid therapy

28-day cycles

References

  1. O'Brien S, Kantarjian H, Beran M, Smith T, Koller C, Estey E, Robertson LE, Lerner S, Keating M. Results of fludarabine and prednisone therapy in 264 patients with chronic lymphocytic leukemia with multivariate analysis-derived prognostic model for response to treatment. Blood. 1993 Sep 15;82(6):1695-700. link to original article contains dosing details in abstract PubMed
    1. Update: Keating MJ, O'Brien S, Lerner S, Koller C, Beran M, Robertson LE, Freireich EJ, Estey E, Kantarjian H. Long-term follow-up of patients with chronic lymphocytic leukemia (CLL) receiving fludarabine regimens as initial therapy. Blood. 1998 Aug 15;92(4):1165-71. link to original article PubMed

HDMP-R

HDMP-R: High Dose, MethylPrednisolone, Rituximab

Regimen variant #1, 3 cycles

Study Years of enrollment Evidence
Castro et al. 2008 NR Phase 2, <20 pts

Glucocorticoid therapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1, 3, 5, 8, 17, 22
    • Cycles 2 & 3: 375 mg/m2 IV once per day on days 1, 7, 14, 21

28-day cycle for 3 cycles

Regimen variant #2, 6 cycles

Study Years of enrollment Evidence
Pileckyte et al. 2011 NR in abstract Phase 2

Glucocorticoid therapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 50 mg IV once on day 1, then 150 mg IV once on day 2, then remainder of a 375 mg/m2 dose IV once on day 3, then 500 mg/m2 IV once on day 5
    • Cycles 2 to 6: 500 mg/m2 IV once per day on days 1 & 5

Supportive medications

21-day cycle for 6 cycles

References

  1. Castro JE, Sandoval-Sus JD, Bole J, Rassenti L, Kipps TJ. Rituximab in combination with high-dose methylprednisolone for the treatment of fludarabine refractory high-risk chronic lymphocytic leukemia. Leukemia. 2008 Nov;22(11):2048-53. Epub 2008 Aug 28. link to original article link to PMC article contains dosing details in manuscript PubMed
  2. Pileckyte R, Jurgutis M, Valceckiene V, Stoskus M, Gineikiene E, Sejoniene J, Degulys A, Zvirblis T, Griskevicius L. Dose-dense high-dose methylprednisolone and rituximab in the treatment of relapsed or refractory high-risk chronic lymphocytic leukemia. Leuk Lymphoma. 2011 Jun;52(6):1055-65. link to original article contains dosing details in abstract PubMed

Ibrutinib & Ofatumumab

Regimen variant #1, concurrent ibrutinib and ofatumumab

Study Years of enrollment Evidence
Jaglowski et al. 2015 (PCYC-1109-CA) 2011-2012 Phase 2

This study to patients who had failed two or more prior therapies, or had Richter's transformation.

Targeted therapy

  • Ibrutinib (Imbruvica) 420 mg PO once per day
  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 2000 mg IV once per day on days 1, 8, 15, 22
    • Cycles 3 to 6: 2000 mg IV once on day 1

28-day cycles

Regimen variant #2, ibrutinib lead-in

Study Years of enrollment Evidence
Jaglowski et al. 2015 (PCYC-1109-CA) 2011-2012 Phase 2

This study to patients who had failed two or more prior therapies, or had Richter's transformation.

Targeted therapy

  • Ibrutinib (Imbruvica) 420 mg PO once per day
  • Ofatumumab (Arzerra) as follows:
    • Cycle 2: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 3: 2000 mg IV once per day on days 1, 8, 15, 22
    • Cycles 4 to 7: 2000 mg IV once on day 1

28-day cycles

Regimen variant #3, ofatumumab lead-in

Study Years of enrollment Evidence
Jaglowski et al. 2015 (PCYC-1109-CA) 2011-2012 Phase 2

This study to patients who had failed two or more prior therapies, or had Richter's transformation.

Targeted therapy

  • Ibrutinib (Imbruvica) as follows:
    • Cycle 3 onwards: 420 mg PO once per day
  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 2000 mg IV once per day on days 8, 15, 22
    • Cycle 2: 2000 mg IV once per day on days 1, 8, 15, 22
    • Cycles 3 to 6: 2000 mg IV once on day 1

28-day cycles

References

  1. PCYC-1109-CA: Jaglowski SM, Jones JA, Nagar V, Flynn JM, Andritsos LA, Maddocks KJ, Woyach JA, Blum KA, Grever MR, Smucker K, Ruppert AS, Heerema NA, Lozanski G, Stefanos M, Munneke B, West JS, Neuenburg JK, James DF, Hall N, Johnson AJ, Byrd JC. Safety and activity of BTK inhibitor ibrutinib combined with ofatumumab in chronic lymphocytic leukemia: a phase 1b/2 study. Blood. 2015 Aug 13;126(7):842-50. Epub 2015 Jun 26. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01217749

Ibrutinib & Rituximab

Regimen

Study Years of enrollment Evidence
Burger et al. 2014 (MDACC 2011-0785) 2012 Phase 2

This study was open to patients with high-risk CLL (del17p or TP53 mutation, PFS less than 36 months from initial therapy, or relapsed CLL with del11q). Only 4 patients in the published study were untreated.

Targeted therapy

28-day cycles

References

  1. MDACC 2011-0785: Burger JA, Keating MJ, Wierda WG, Hartmann E, Hoellenriegel J, Rosin NY, de Weerdt I, Jeyakumar G, Ferrajoli A, Cardenas-Turanzas M, Lerner S, Jorgensen JL, Nogueras-González GM, Zacharian G, Huang X, Kantarjian H, Garg N, Rosenwald A, O'Brien S. Safety and activity of ibrutinib plus rituximab for patients with high-risk chronic lymphocytic leukaemia: a single-arm, phase 2 study. Lancet Oncol. 2014 Sep;15(10):1090-9. Epub 2014 Aug 20. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01520519
    1. Update: Jain P, Keating MJ, Wierda WG, Sivina M, Thompson PA, Ferrajoli A, Estrov Z, Kantarjian H, O'Brien S, Burger JA. Long-term follow-up of treatment with ibrutinib and rituximab in patients with high-risk chronic lymphocytic leukemia. Clin Cancer Res. 2017 May 1;23(9):2154-2158. Epub 2016 Oct 19. link to original article link to PMC article PubMed

Ibrutinib, Venetoclax, Obinutuzumab

Regimen

Study Years of enrollment Evidence
Rogers et al. 2020 (OSU-14266) 2015-2017 Phase 2

Targeted therapy

  • Ibrutinib (Imbruvica) as follows:
    • Cycle 2 onwards: 420 mg PO once per day
  • Venetoclax (Venclexta) as follows:
    • Cycle 3: 20 mg PO once per day on days 1 to 7, then 50 mg PO once per day on days 8 to 14, then 100 mg PO once per day on days 15 to 21, then 200 mg PO once per day on days 22 to 28
    • Cycles 4 to 14: 400 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 8: 1000 mg IV once on day 1

28-day cycles

References

  1. OSU-14266: Rogers KA, Huang Y, Ruppert AS, Abruzzo LV, Andersen BL, Awan FT, Bhat SA, Dean A, Lucas M, Banks C, Grantier C, Heerema NA, Lozanski G, Maddocks KJ, Valentine TR, Weiss DM, Jones JA, Woyach JA, Byrd JC. Phase II Study of Combination Obinutuzumab, Ibrutinib, and Venetoclax in Treatment-Naïve and Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2020 Nov 1;38(31):3626-3637. Epub 2020 Aug 14. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02427451

Idelalisib monotherapy

Regimen

Study Years of enrollment Evidence
Brown et al. 2014 (Gilead 101-02) 2008-2011 Phase 1, >20 pts
Gopal et al. 2014 (DELTA) 2011-2012 Phase 2 (RT)

Targeted therapy

Continued indefinitely

References

  1. DELTA: Gopal AK, Kahl BS, de Vos S, Wagner-Johnston ND, Schuster SJ, Jurczak WJ, Flinn IW, Flowers CR, Martin P, Viardot A, Blum KA, Goy AH, Davies AJ, Zinzani PL, Dreyling M, Johnson D, Miller LL, Holes L, Li D, Dansey RD, Godfrey WR, Salles GA. PI3Kd inhibition by idelalisib in patients with relapsed indolent lymphoma. N Engl J Med. 2014 Mar 13;370(11):1008-18. Epub 2014 Jan 22. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01282424
    1. Update: Abstract: Ajay K. Gopal, MD, Brad S. Kahl, MD, Sven de Vos, MD, PhD, Nina D. Wagner-Johnston, MD, Stephen J. Schuster, MD, Wojciech Jurczak, MD, PhD, Ian W. Flinn, MD, PhD, Christopher R. Flowers, MD, Peter Martin, MD, Andreas Viardot, MD, Kristie A. Blum, MD, Andre Goy, MD, Andrew Davies, BM PhD, Pier Luigi Zinzani, MD, Martin H. Dreyling, MD, PhD, Leanne M. Holes, Bess Sorensen, PhD, Wayne R. Godfrey, MD and Gilles Andre Salles, MD, PhD. Mature Follow up from a Phase 2 Study of PI3K-Delta Inhibitor Idelalisib in Patients with Double (Rituximab and Alkylating agent)-Refractory Indolent B-Cell Non-Hodgkin Lymphoma (iNHL). ASH Annual Meeting 2014, Abstract 1708 link to abstract
  2. Gilead 101-02: Brown JR, Byrd JC, Coutre SE, Benson DM, Flinn IW, Wagner-Johnston ND, Spurgeon SE, Kahl BS, Bello C, Webb HK, Johnson DM, Peterman S, Li D, Jahn TM, Lannutti BJ, Ulrich RG, Yu AS, Miller LL, Furman RR. Idelalisib, an inhibitor of phosphatidylinositol 3-kinase p110d, for relapsed/refractory chronic lymphocytic leukemia. Blood. 2014 May 29;123(22):3390-7. Epub 2014 Mar 10. link to original article link to PMC article PubMed NCT00710528

Lenalidomide monotherapy

Regimen variant #1

Study Years of enrollment Evidence
Chanan-Khan et al. 2006 2004-2006 Phase 2

Targeted therapy

  • Lenalidomide (Revlimid) 5 mg PO once per day, escalated by 5 mg every 1 to 2 weeks to a target maximum dose of 25 mg PO once per day on days 1 to 21

Supportive medications

28-day cycles

Regimen variant #2

Study Years of enrollment Evidence
Ferrajoli et al. 2008 (MDACC 2005-0175) 2005-2007 Phase 2

Targeted therapy

  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 10 mg PO once per day
    • Cycle 2: 15 mg PO once per day
    • Cycle 3: 20 mg PO once per day
    • Cycle 4 onwards: 25 mg PO once per day

28-day cycles

Regimen variant #3

Study Years of enrollment Evidence
Witzig et al. 2009 (CC-5013-NHL-001) 2005-2006 Phase 2, <20 patients in this subgroup

Patients studied in this trial and in this subgroup had a diagnosis of SLL.

Targeted therapy

28-day cycles

References

  1. Chanan-Khan A, Miller KC, Musial L, Lawrence D, Padmanabhan S, Takeshita K, Porter CW, Goodrich DW, Bernstein ZP, Wallace P, Spaner D, Mohr A, Byrne C, Hernandez-Ilizaliturri F, Chrystal C, Starostik P, Czuczman MS. Clinical efficacy of lenalidomide in patients with relapsed or refractory chronic lymphocytic leukemia: results of a phase II study. J Clin Oncol. 2006 Dec 1;24(34):5343-9. Epub 2006 Nov 6. link to original article contains dosing details in abstract PubMed
  2. MDACC 2005-0175: Ferrajoli A, Lee BN, Schlette EJ, O'Brien SM, Gao H, Wen S, Wierda WG, Estrov Z, Faderl S, Cohen EN, Li C, Reuben JM, Keating MJ. Lenalidomide induces complete and partial remissions in patients with relapsed and refractory chronic lymphocytic leukemia. Blood. 2008 Jun 1;111(11):5291-7. Epub 2008 Mar 11. link to original article link to PMC article PubMed NCT00267059
  3. CC-5013-NHL-001: Witzig TE, Wiernik PH, Moore T, Reeder C, Cole C, Justice G, Kaplan H, Voralia M, Pietronigro D, Takeshita K, Ervin-Haynes A, Zeldis JB, Vose JM. Lenalidomide oral monotherapy produces durable responses in relapsed or refractory indolent non-Hodgkin's Lymphoma. J Clin Oncol. 2009 Nov 10;27(32):5404-9. Epub 2009 Oct 5. link to original article contains dosing details in manuscript PubMed NCT00179673

Lenalidomide & Ofatumumab

Regimen variant #1

Study Years of enrollment Evidence
Vitale et al. 2016 (MDACC 2009-0283) 2010-2011 Phase 2

Targeted therapy

  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 10 mg PO once per day on days 9 to 28
    • Cycle 2 to 24: 10 mg PO once per day
  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once per day on days 8, 15, 22
    • Cycles 3 to 6, 8, 10, 12, 14, 16, 18, 20, 22, 24: 1000 mg IV once on day 1

Supportive medications

28-day cycle for 24 cycles

Subsequent treatment

  • Patients with a sustained PR or CR were allowed to continue treatment with lenalidomide monotherapy indefinitely

References

  1. MDACC 2009-0283: Vitale C, Falchi L, Ten Hacken E, Gao H, Shaim H, Van Roosbroeck K, Calin G, O'Brien S, Faderl S, Wang X, Wierda WG, Rezvani K, Reuben JM, Burger JA, Keating MJ, Ferrajoli A. Ofatumumab and Lenalidomide for Patients with Relapsed or Refractory Chronic Lymphocytic Leukemia: Correlation between Responses and Immune Characteristics. Clin Cancer Res. 2016 May 15;22(10):2359-67. Epub 2016 Jan 5. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01002755

Lenalidomide & Rituximab (R2)

Regimen variant #1

Study Years of enrollment Evidence
Chanan-Khan et al. 2006 2004-2006 Phase 2

Note: this lenalidomide dosing was the result of a mid-protocol amendment due to TLS in two of the first 29 patients enrolled.

Targeted therapy

  • Lenalidomide (Revlimid) 5 mg PO once per day, escalated by 5 mg every 1 to 2 weeks to a target maximum dose of 25 mg PO once per day on days 1 to 21
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1, 8, 15
    • Cycle 2 onwards: 375 mg/m2 IV once per day on days 1 & 15

Supportive medications

  • Allopurinol (Zyloprim) 300 mg PO once per day, starting 2 to 3 days prior to chemotherapy, and continued up to a total of 14 days

28-day cycles

Regimen variant #2

Study Years of enrollment Evidence
Badoux et al. 2013 (MDACC 2007-0208) 2008-2009 Phase 2

Targeted therapy

  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 10 mg PO once per day on days 9 to 28
    • Cycle 2 onwards: 10 mg PO once per day on days 1 to 28
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • Cycle 2: no rituximab given
    • Cycles 3 to 12: 375 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 12 cycles

Subsequent treatment

  • Responders: Lenalidomide could continue indefinitely

References

  1. Chanan-Khan A, Miller KC, Musial L, Lawrence D, Padmanabhan S, Takeshita K, Porter CW, Goodrich DW, Bernstein ZP, Wallace P, Spaner D, Mohr A, Byrne C, Hernandez-Ilizaliturri F, Chrystal C, Starostik P, Czuczman MS. Clinical efficacy of lenalidomide in patients with relapsed or refractory chronic lymphocytic leukemia: results of a phase II study. J Clin Oncol. 2006 Dec 1;24(34):5343-9. Epub 2006 Nov 6. link to original article contains dosing details in manuscript PubMed
  2. MDACC 2007-0208: Badoux XC, Keating MJ, Wen S, Wierda WG, O'Brien SM, Faderl S, Sargent R, Burger JA, Ferrajoli A. Phase II Study of Lenalidomide and Rituximab As Salvage Therapy for Patients With Relapsed or Refractory Chronic Lymphocytic Leukemia. J Clin Oncol. 2013 Feb 10;31(5):584-91. Epub 2012 Dec 26. link to original article contains dosing details in manuscript link to PMC article PubMed NCT00759603

Obinutuzumab monotherapy

Regimen

Study Years of enrollment Evidence
Salles et al. 2012 (GAUGUIN) 2008-2009 Phase 1/2

Note: Dose here is the phase II dose reported in the Cartron et al. 2014 update.

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 1000 mg IV once per day on days 1, 8, 15
    • Cycle 2 onwards: 1000 mg IV once on day 1

Supportive medications

  • Acetaminophen (Tylenol) 650 to 1000 mg PO once on cycle 1 day 1; 30 minutes prior to Obinutuzumab (Gazyva), repeat for those at risk of tumor lysis or with history of reaction
  • Antihistamine (no drug or dose specified) PO once on cycle 1 day 1; 30 minutes prior to Obinutuzumab (Gazyva), repeat for those at risk of tumor lysis or with history of reaction
  • For patients at "high risk" of severe infusion reaction, including those with a history of severe rituximab reactions: Corticosteroids (no drug/dose/route specified) once on cycle 1 day 1, prior to Obinutuzumab (Gazyva)

21-day cycle for up to 8 cycles

References

  1. GAUGUIN: Salles G, Morschhauser F, Lamy T, Milpied N, Thieblemont C, Tilly H, Bieska G, Asikanius E, Carlile D, Birkett J, Pisa P, Cartron G. Phase 1 study results of the type II glycoengineered humanized anti-CD20 monoclonal antibody obinutuzumab (GA101) in B-cell lymphoma patients. Blood. 2012 May 31;119(22):5126-32. Epub 2012 Mar 19. link to original article PubMed NCT00517530
    1. Subgroup analysis: Morschhauser FA, Cartron G, Thieblemont C, Solal-Céligny P, Haioun C, Bouabdallah R, Feugier P, Bouabdallah K, Asikanius E, Lei G, Wenger M, Wassner-Fritsch E, Salles GA. Obinutuzumab (GA101) monotherapy in relapsed/refractory diffuse large B-cell lymphoma or mantle-cell lymphoma: results from the phase II GAUGUIN study. J Clin Oncol. 2013 Aug 10;31(23):2912-9. Epub 2013 Jul 8. link to original article contains dosing details in manuscript PubMed
    2. Subgroup analysis: Salles GA, Morschhauser F, Solal-Céligny P, Thieblemont C, Lamy T, Tilly H, Gyan E, Lei G, Wenger M, Wassner-Fritsch E, Cartron G. Obinutuzumab (GA101) in patients with relapsed/refractory indolent non-Hodgkin lymphoma: results from the phase II GAUGUIN study. J Clin Oncol. 2013 Aug 10;31(23):2920-6. Epub 2013 Jul 8. link to original article contains dosing details in manuscript PubMed
    3. Subgroup analysis: Cartron G, de Guibert S, Dilhuydy MS, Morschhauser F, Leblond V, Dupuis J, Mahe B, Bouabdallah R, Lei G, Wenger M, Wassner-Fritsch E, Hallek M. Obinutuzumab (GA101) in relapsed/refractory chronic lymphocytic leukemia: final data from the phase 1/2 GAUGUIN study. Blood. 2014 Oct 2;124(14):2196-202. Epub 2014 Aug 20. link to original article contains dosing details in manuscript PubMed

OFAR

OFAR: Oxaliplatin, Fludarabine, Ara-C (Cytarabine), Rituximab

Regimen

Study Years of enrollment Evidence
Tsimberidou et al. 2008 2004-2006 Phase 1/2

Note: this is the dosing used in the phase II portion.

Chemotherapy

  • Oxaliplatin (Eloxatin) 25 mg/m2 IV over 2 hours once per day on days 1 to 4
  • Fludarabine (Fludara) 30 mg/m2 IV once per day on days 2 & 3, administered within 30 minutes of completion of oxaliplatin
  • Cytarabine (Ara-C) 1000 mg/m2 IV over 2 hours once per day on days 2 & 3, 4 hours after fludarabine started

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV over 4 to 6 hours once on day 3
    • Cycles 2 to 6: 375 mg/m2 IV over 4 to 6 hours once on day 1

Supportive medications

28-day cycle for up to 6 cycles

References

  1. Tsimberidou AM, Wierda WG, Plunkett W, Kurzrock R, O'Brien S, Wen S, Ferrajoli A, Ravandi-Kashani F, Garcia-Manero G, Estrov Z, Kipps TJ, Brown JR, Fiorentino A, Lerner S, Kantarjian HM, Keating MJ. Phase I-II study of oxaliplatin, fludarabine, cytarabine, and rituximab combination therapy in patients with Richter's syndrome or fludarabine-refractory chronic lymphocytic leukemia. J Clin Oncol. 2008 Jan 10;26(2):196-203. link to original article contains dosing details in manuscript PubMed

PCR

PCR: Pentostatin, Cyclophosphamide, Rituximab

Regimen

Study Years of enrollment Evidence
Lamanna et al. 2006 2001-2004 Phase 2

Chemotherapy

Targeted therapy

Supportive medications

21-day cycle for 6 cycles

References

  1. Lamanna N, Kalaycio M, Maslak P, Jurcic JG, Heaney M, Brentjens R, Zelenetz AD, Horgan D, Gencarelli A, Panageas KS, Scheinberg DA, Weiss MA. Pentostatin, cyclophosphamide, and rituximab is an active, well-tolerated regimen for patients with previously treated chronic lymphocytic leukemia. J Clin Oncol. 2006 Apr 1;24(10):1575-81. Epub 2006 Mar 6. link to original article contains dosing details in manuscript PubMed

R-BAC

R-BAC: Rituximab, Bendamustine, Ara-C (Cytarabine)

Regimen

Study Years of enrollment Evidence
Visco et al. 2013 2010-2012 Pilot, <20 patients reported

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycle 2 onwards: 500 mg/m2 IV once on day 1

Chemotherapy

  • Bendamustine 70 mg/m2 IV once per day on days 1 & 2
  • Cytarabine (Ara-C) 800 mg/m2 IV over 2 hours once per day on days 1 to 3, beginning 2 hours after bendamustine

Supportive medications

  • Primary prophylaxis with granulocyte colony-stimulating factor was routinely used starting from Day 5 after chemotherapy completion, and lasting for 3 to 6 days or until neutrophil count recovery.

28-day cycle for up to 4 cycles

References

  1. Visco C, Finotto S, Pomponi F, Sartori R, Laveder F, Trentin L, Paolini R, Di Bona E, Ruggeri M, Rodeghiero F. The combination of rituximab, bendamustine, and cytarabine for heavily pretreated relapsed/refractory cytogenetically high-risk patients with chronic lymphocytic leukemia. Am J Hematol. 2013 Apr;88(4):289-93. Epub 2013 Feb 28. link to original article contains dosing details in manuscript PubMed

Ruxolitinib monotherapy

Regimen

Study Years of enrollment Evidence
Jain et al. 2017 (MDACC 2013-0044) 2014-2015 Phase 2, <20 pts in this subgroup

Note: this was a trial focused on symptom control, not efficacy.

Targeted therapy

References

  1. MDACC 2013-0044: Jain P, Keating M, Renner S, Cleeland C, Xuelin H, Gonzalez GN, Harris D, Li P, Liu Z, Veletic I, Rozovski U, Jain N, Thompson P, Bose P, DiNardo C, Ferrajoli A, O'Brien S, Burger J, Wierda W, Verstovsek S, Kantarjian H, Estrov Z. Ruxolitinib for symptom control in patients with chronic lymphocytic leukaemia: a single-group, phase 2 trial. Lancet Haematol. 2017 Feb;4(2):e67-e74. Epub 2017 Jan 11. link to original article contains dosing details in manuscript link to PMC article PubMed NCT02131584

Venetoclax monotherapy

Regimen variant #1, standard lead-in

FDA-recommended dose
Study Years of enrollment Evidence Efficacy
Roberts et al. 2015 (M12-175) 2011-2014 Phase 1/2 (RT) ORR: 79%
Stilgenbauer et al. 2016 (M13-982) 2013-2014 Phase 2 (RT) ORR: 79% (95% CI, 70.5-87)
Jones et al. 2017 (M14-032 ibrutinib cohort) 2014-2016 Phase 2 (RT) ORR: 65% (95% CI 53-74)
Coutre et al. 2018 (M14-032 idelalisib cohort) 2014-NR Phase 2 (RT) ORR: 67%

This is the dosing schedule used in the phase II expansion cohort of M12-175. See papers for supportive care details during initial dosing.

Biomarker eligibility criteria

  • M13-982: 17p deletion

Targeted therapy

  • Venetoclax (Venclexta) as follows:
    • Week 1: 20 mg PO once per day
    • Week 2: 50 mg PO once per day
    • Week 3: 100 mg PO once per day
    • Week 4: 200 mg PO once per day
    • Week 5 onwards: 400 mg PO once per day

Continued indefinitely

Regimen variant #2, modified lead-in

Study Years of enrollment Evidence Efficacy
Coutre et al. 2018 (M14-032 idelalisib cohort) 2014-NR Phase 2 ORR: 67%

This dosing schedule was intended for high-risk patients with "clinical signs of progression during screening." See paper for supportive care details during initial dosing.

Targeted therapy

  • Venetoclax (Venclexta) as follows:
    • Day 1: 20 mg PO once per day
    • Days 2 & 3: 50 mg PO once per day
    • Days 4 to 7: 100 mg PO once per day
    • Week 2: 200 mg PO once per day
    • Week 3 onwards: 400 mg PO once per day

Continued indefinitely

References

  1. M12-175: Roberts AW, Davids MS, Pagel JM, Kahl BS, Puvvada SD, Gerecitano JF, Kipps TJ, Anderson MA, Brown JR, Gressick L, Wong S, Dunbar M, Zhu M, Desai MB, Cerri E, Heitner Enschede S, Humerickhouse RA, Wierda WG, Seymour JF. Targeting BCL2 with venetoclax in relapsed chronic lymphocytic leukemia. N Engl J Med. 2016 Jan 28;374(4):311-22. Epub 2015 Dec 6. link to original article contains dosing details in manuscript link to PMC article PubMed NCT01328626
  2. M13-982: Stilgenbauer S, Eichhorst B, Schetelig J, Coutre S, Seymour JF, Munir T, Puvvada SD, Wendtner CM, Roberts AW, Jurczak W, Mulligan SP, Böttcher S, Mobasher M, Zhu M, Desai M, Chyla B, Verdugo M, Heitner Enschede S, Cerri E, Humerickhouse R, Gordon G, Hallek M, Wierda WG. Venetoclax in relapsed or refractory chronic lymphocytic leukaemia with 17p deletion: a multicentre, open-label, phase 2 study. Lancet Oncol. 2016 Jun;17(6):768-78. Epub 2016 May 10. link to original article contains dosing details in abstract PubMed NCT01889186
    1. Update: Stilgenbauer S, Eichhorst B, Schetelig J, Hillmen P, Seymour JF, Coutre S, Jurczak W, Mulligan SP, Schuh A, Assouline S, Wendtner CM, Roberts AW, Davids MS, Bloehdorn J, Munir T, Böttcher S, Zhou L, Salem AH, Desai M, Chyla B, Arzt J, Kim SY, Verdugo M, Gordon G, Hallek M, Wierda WG. Venetoclax for patients with chronic lymphocytic leukemia with 17p deletion: results from the full population of a phase II pivotal trial. J Clin Oncol. 2018 Jul 1;36(19):1973-1980. Epub 2018 May 1. link to original article PubMed
  3. M14-032 ibrutinib cohort: Jones JA, Mato AR, Wierda WG, Davids MS, Choi M, Cheson BD, Furman RR, Lamanna N, Barr PM, Zhou L, Chyla B, Salem AH, Verdugo M, Humerickhouse RA, Potluri J, Coutre S, Woyach J, Byrd JC. Venetoclax for chronic lymphocytic leukaemia progressing after ibrutinib: an interim analysis of a multicentre, open-label, phase 2 trial. Lancet Oncol. 2018 Jan;19(1):65-75. Epub 2017 Dec 12. link to original article link to PMC article PubMed NCT02141282
  4. M14-032 idelalisib cohort: Coutre S, Choi M, Furman RR, Eradat H, Heffner L, Jones JA, Chyla B, Zhou L, Agarwal S, Waskiewicz T, Verdugo M, Humerickhouse RA, Potluri J, Wierda WG, Davids MS. Venetoclax for patients with chronic lymphocytic leukemia who progressed during or after idelalisib therapy. Blood. 2018 Apr 12;131(15):1704-1711. Epub 2018 Jan 5. link to original article contains dosing details in supplement link to PMC article PubMed NCT02141282

Zanubrutinib & Obinutuzumab

Regimen

Study Years of enrollment Evidence
Tam et al. 2020 2016-NR Phase 1b, >20 pts in this subgroup

Targeted therapy

  • Zanubrutinib (Brukinsa) 160 mg PO twice per day or 320 mg PO once per day
  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 100 mg IV once on day 1, then 900 mg IV once on day 2, then 1000 mg IV once per day on days 8 & 15
    • Cycles 2 to 6: 1000 mg IV once on day 1

28-day cycles

References

  1. Tam CS, Quach H, Nicol A, Badoux X, Rose H, Prince HM, Leahy MF, Eek R, Wickham N, Patil SS, Huang J, Prathikanti R, Cohen A, Elstrom R, Reed W, Schneider J, Flinn IW. Zanubrutinib (BGB-3111) plus obinutuzumab in patients with chronic lymphocytic leukemia and follicular lymphoma. Blood Adv. 2020 Oct 13;4(19):4802-4811. link to original article link to PMC article contains dosing details in manuscript PubMed NCT02569476

Consolidation and/or maintenance after subsequent lines of therapy

FC, then allo HSCT

FC: Fludarabine & Cyclophosphamide

Regimen

Study Years of enrollment Evidence
Dreger et al. 2010 (GCLLSG CLL3X) 2001-2007 Phase 2

Chemotherapy

Immunotherapy

Stem cells transfused on day 0

References

  1. GCLLSG CLL3X: Dreger P, Döhner H, Ritgen M, Böttcher S, Busch R, Dietrich S, Bunjes D, Cohen S, Schubert J, Hegenbart U, Beelen D, Zeis M, Stadler M, Hasenkamp J, Uharek L, Scheid C, Humpe A, Zenz T, Winkler D, Hallek M, Kneba M, Schmitz N, Stilgenbauer S; German CLL Study Group. Allogeneic stem cell transplantation provides durable disease control in poor-risk chronic lymphocytic leukemia: long-term clinical and MRD results of the German CLL Study Group CLL3X trial. Blood. 2010 Oct 7;116(14):2438-47. Epub 2010 Jul 1. link to original article contains dosing details in manuscript PubMed NCT00281983
    1. Update: Dreger P, Schnaiter A, Zenz T, Böttcher S, Rossi M, Paschka P, Bühler A, Dietrich S, Busch R, Ritgen M, Bunjes D, Zeis M, Stadler M, Uharek L, Scheid C, Hegenbart U, Hallek M, Kneba M, Schmitz N, Döhner H, Stilgenbauer S. TP53, SF3B1, and NOTCH1 mutations and outcome of allotransplantation for chronic lymphocytic leukemia: six-year follow-up of the GCLLSG CLL3X trial. Blood. 2013 Apr 18;121(16):3284-8. Epub 2013 Feb 22. link to original article PubMed
    2. Update: Krämer I, Stilgenbauer S, Dietrich S, Böttcher S, Zeis M, Stadler M, Bittenbring J, Uharek L, Scheid C, Hegenbart U, Ho A, Hallek M, Kneba M, Schmitz N, Döhner H, Dreger P. Allogeneic hematopoietic cell transplantation for high-risk CLL: 10-year follow-up of the GCLLSG CLL3X trial. Blood. 2017 Sep 21;130(12):1477-1480. Epub 2017 Jul 17. link to original article PubMed

Fludarabine & TBI, then allo HSCT

Regimen

Study Years of enrollment Evidence
Sorror et al. 2005 1997-2003 Phase 2

Chemotherapy

Radiotherapy

GVHD prophylaxis

  • Cyclosporine 6.25 mg/kg PO twice per day starting 4 to 6 hours after transplant, tapered at day 100 over 80 days (if no GVHD)
  • Mycophenolate mofetil (CellCept) 15 mg/kg PO twice per day starting 4 to 6 hours after transplant, tapered at day 40 over 56 days (if no GVHD)

Immunotherapy

Stem cells transfused on day 0

References

  1. Sorror ML, Maris MB, Sandmaier BM, Storer BE, Stuart MJ, Hegenbart U, Agura E, Chauncey TR, Leis J, Pulsipher M, McSweeney P, Radich JP, Bredeson C, Bruno B, Langston A, Loken MR, Al-Ali H, Blume KG, Storb R, Maloney DG. Hematopoietic cell transplantation after nonmyeloablative conditioning for advanced chronic lymphocytic leukemia. J Clin Oncol. 2005 Jun 1;23(16):3819-29. Epub 2005 Apr 4. link to original article PubMed
    1. Update: Sorror ML, Storer BE, Sandmaier BM, Maris M, Shizuru J, Maziarz R, Agura E, Chauncey TR, Pulsipher MA, McSweeney PA, Wade JC, Bruno B, Langston A, Radich J, Niederwieser D, Blume KG, Storb R, Maloney DG. Five-year follow-up of patients with advanced chronic lymphocytic leukemia treated with allogeneic hematopoietic cell transplantation after nonmyeloablative conditioning. J Clin Oncol. 2008 Oct 20;26(30):4912-20. Epub 2008 Sep 15. link to original article link to PMC article PubMed

Fludarabine, Busulfan, ATG, then allo HSCT

Regimen

Study Years of enrollment Evidence
Slavin et al. 1998 NR Phase 2
Schetelig et al. 2003 1998-2001 Phase 2

Chemotherapy

Immunosuppressive therapy

  • ATG-Fresenius 10 mg/kg IV once per day on days -4 to -1 (4 consecutive days)

Immunotherapy

Stem cells transfused on day 0

References

  1. Slavin S, Nagler A, Naparstek E, Kapelushnik Y, Aker M, Cividalli G, Varadi G, Kirschbaum M, Ackerstein A, Samuel S, Amar A, Brautbar C, Ben-Tal O, Eldor A, Or R. Nonmyeloablative stem cell transplantation and cell therapy as an alternative to conventional bone marrow transplantation with lethal cytoreduction for the treatment of malignant and nonmalignant hematologic diseases. Blood. 1998 Feb 1;91(3):756-63. link to original article contains dosing details in manuscript PubMed
  2. Schetelig J, Thiede C, Bornhauser M, Schwerdtfeger R, Kiehl M, Beyer J, Sayer HG, Kroger N, Hensel M, Scheffold C, Held TK, Hoffken K, Ho AD, Kienast J, Neubauer A, Zander AR, Fauser AA, Ehninger G, Siegert W; Cooperative German Transplant Study Group. Evidence of a graft-versus-leukemia effect in chronic lymphocytic leukemia after reduced-intensity conditioning and allogeneic stem-cell transplantation: the Cooperative German Transplant Study Group. J Clin Oncol. 2003 Jul 15;21(14):2747-53. link to original article contains reference to protocol PubMed

Fludarabine, Cyclophosphamide, ATG, then allo HSCT

Regimen

Study Years of enrollment Evidence
Dreger et al. 2010 (GCLLSG CLL3X) 2001-2007 Phase 2

Chemotherapy

Immunosuppressive therapy

  • ATG-Fresenius 10 mg/kg/day IV on days -4 to -1 (4 consecutive days)

Immunotherapy

Stem cells transfused on day 0

References

  1. GCLLSG CLL3X: Dreger P, Döhner H, Ritgen M, Böttcher S, Busch R, Dietrich S, Bunjes D, Cohen S, Schubert J, Hegenbart U, Beelen D, Zeis M, Stadler M, Hasenkamp J, Uharek L, Scheid C, Humpe A, Zenz T, Winkler D, Hallek M, Kneba M, Schmitz N, Stilgenbauer S; German CLL Study Group. Allogeneic stem cell transplantation provides durable disease control in poor-risk chronic lymphocytic leukemia: long-term clinical and MRD results of the German CLL Study Group CLL3X trial. Blood. 2010 Oct 7;116(14):2438-47. Epub 2010 Jul 1. link to original article contains dosing details in manuscript PubMed NCT00281983
    1. Update: Dreger P, Schnaiter A, Zenz T, Böttcher S, Rossi M, Paschka P, Bühler A, Dietrich S, Busch R, Ritgen M, Bunjes D, Zeis M, Stadler M, Uharek L, Scheid C, Hegenbart U, Hallek M, Kneba M, Schmitz N, Döhner H, Stilgenbauer S. TP53, SF3B1, and NOTCH1 mutations and outcome of allotransplantation for chronic lymphocytic leukemia: six-year follow-up of the GCLLSG CLL3X trial. Blood. 2013 Apr 18;121(16):3284-8. Epub 2013 Feb 22. link to original article PubMed
    2. Update: Krämer I, Stilgenbauer S, Dietrich S, Böttcher S, Zeis M, Stadler M, Bittenbring J, Uharek L, Scheid C, Hegenbart U, Ho A, Hallek M, Kneba M, Schmitz N, Döhner H, Dreger P. Allogeneic hematopoietic cell transplantation for high-risk CLL: 10-year follow-up of the GCLLSG CLL3X trial. Blood. 2017 Sep 21;130(12):1477-1480. Epub 2017 Jul 17. link to original article PubMed

Observation

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Greil et al. 2016 (AGMT CLL-8a) 2010-2013 Phase 3 (C) Rituximab Inferior PFS
van Oers et al. 2015 (PROLONG) 2010-2014 Phase 3 (C) Ofatumumab Inferior PFS

No further treatment offered to patients in their second or third CR or PR; prior treatment was not specified in PROLONG.

Preceding treatment

References

  1. PROLONG: van Oers MH, Kuliczkowski K, Smolej L, Petrini M, Offner F, Grosicki S, Levin MD, Gupta I, Phillips J, Williams V, Manson S, Lisby S, Geisler C; PROLONG study investigators. Ofatumumab maintenance versus observation in relapsed chronic lymphocytic leukaemia (PROLONG): an open-label, multicentre, randomised phase 3 study. Lancet Oncol. 2015 Oct;16(13):1370-9. Epub 2015 Sep 13. link to original article contains dosing details in manuscript PubMed NCT00802737
    1. Update: van Oers M, Smolej L, Petrini M, Offner F, Grosicki S, Levin MD, Davis J, Banerjee H, Stefanelli T, Hoever P, Geisler C. Ofatumumab maintenance prolongs progression-free survival in relapsed chronic lymphocytic leukemia: final analysis of the PROLONG study. Blood Cancer J. 2019 Dec 4;9(12):98. link to original article link to PMC article PubMed
  2. AGMT CLL-8a: Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. Lancet Haematol. 2016 Jul;3(7):e317-29. Epub 2016 Jun 16. link to original article contains dosing details in abstract PubMed NCT01118234

Ofatumumab monotherapy

Regimen variant #1

Study Years of enrollment Evidence Comparator Comparative Efficacy
van Oers et al. 2015 (PROLONG) 2010-2014 Phase 3 (E-RT-esc) Observation Superior PFS
Median PFS: 29.4 vs 15.2 mo
(HR 0.50, 95% CI 0.38-0.66)

Treatment offered to patients in their second or third CR or PR; prior treatment was not specified.

Targeted therapy

  • Ofatumumab (Arzerra) as follows:
    • Cycle 1: 300 mg IV once on day 1, then 1000 mg IV once on day 7
    • Cycles 2 to 13: 1000 mg IV once on day 1

Supportive medications

8-week cycle for up to 13 cycles (2 years)

Regimen variant #2

Study Years of enrollment Evidence
Österborg et al. 2015 (GEN416) 2009-2011 Phase 2

Preceding treatment

Targeted therapy

Supportive medications

Monthly cycle for up to 24 cycles (2 years)

References

  1. GEN416: Österborg A, Wierda WG, Mayer J, Hess G, Hillmen P, Schetelig J, Schuh A, Smolej L, Beck C, Dreyfus B, Hellman A, Kozlowski P, Pfreundschuh M, Rizzi R, Spacek M, Phillips JL, Gupta IV, Williams V, Jewell RC, Nebot N, Lisby S, Dyer MJ. Ofatumumab retreatment and maintenance in fludarabine-refractory chronic lymphocytic leukaemia patients. Br J Haematol. 2015 Jul;170(1):40-9. Epub 2015 Mar 30. link to original article contains dosing details in manuscript PubMed NCT00802737
  2. PROLONG: van Oers MH, Kuliczkowski K, Smolej L, Petrini M, Offner F, Grosicki S, Levin MD, Gupta I, Phillips J, Williams V, Manson S, Lisby S, Geisler C; PROLONG study investigators. Ofatumumab maintenance versus observation in relapsed chronic lymphocytic leukaemia (PROLONG): an open-label, multicentre, randomised phase 3 study. Lancet Oncol. 2015 Oct;16(13):1370-9. Epub 2015 Sep 13. link to original article contains dosing details in manuscript PubMed NCT00802737

Placebo

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Chanan-Khan et al. 2017 (CONTINUUM) 2009-2015 Phase 3 (C) Lenalidomide Did not meet primary endpoint of OS

No active antineoplastic treatment offered to patients with at least partial response to second-line therapy.

References

  1. CONTINUUM: Chanan-Khan AA, Zaritskey A, Egyed M, Vokurka S, Semochkin S, Schuh A, Kassis J, Simpson D, Zhang J, Purse B, Foà R. Lenalidomide maintenance therapy in previously treated chronic lymphocytic leukaemia (CONTINUUM): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Haematol. 2017 Nov;4(11):e534-e543. Epub 2017 Sep 25. link to original article PubMed NCT00774345

Rituximab monotherapy

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Greil et al. 2016 (AGMT CLL-8a) 2010-2013 Phase 3 (E-esc) Observation Superior PFS
Median PFS: 47 vs 35.5 mo
(HR 0.50, 95% CI 0.33-0.75)

Preceding treatment

Targeted therapy

3-month cycle for 8 cycles (2 years)

References

  1. AGMT CLL-8a: Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. Lancet Haematol. 2016 Jul;3(7):e317-29. Epub 2016 Jun 16. link to original article contains dosing details in abstract PubMed NCT01118234

Prognosis

These are various staging and risk prediction systems that are in approximate chronological order.

Original Rai staging (1975)

  • Stage 0: bone marrow and blood lymphocytosis only
  • Stage I: lymphocytosis with enlarged nodes
  • Stage II: lymphocytosis with enlarged spleen or liver or both
  • Stage III: lymphocytosis with anemia
  • Stage IV: lymphocytosis with thrombocytopenia
  1. Rai KR, Sawitsky A, Cronkite EP, Chanana AD, Levy RN, Pasternack BS. Clinical staging of chronic lymphocytic leukemia. Blood. 1975 Aug;46(2):219-34. link to original article PubMed

Binet staging (1981)

  • Group A: no anemia, no thrombocytopenia, less than three involved areas
  • Group B: no anemia, no thrombocytopenia, three or more involved areas (counting as one each of the following: axillary, cervical, inguinal, lymph nodes, whether unilateral or bilateral, spleen and liver)
  • Group C: anemia (hemoglobin less than 10 g/dL) and/or thrombocytopenia (platelets less than 100 x 109/L)
  1. Binet JL, Auquier A, Dighiero G, Chastang C, Piguet H, Goasguen J, Vaugier G, Potron G, Colona P, Oberling F, Thomas M, Tchernia G, Jacquillat C, Boivin P, Lesty C, Duault MT, Monconduit M, Belabbes S, Gremy F. A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer. 1981 Jul 1;48(1):198-206. link to original article PubMed

Risk by cytogenetics

  • Classic NEJM paper establishing abnormal karyotype as an adverse prognostic marker
  1. Han T, Ozer H, Sadamori N, Emrich L, Gomez GA, Henderson ES, Bloom ML, Sandberg AA. Prognostic importance of cytogenetic abnormalities in patients with chronic lymphocytic leukemia. N Engl J Med. 1984 Feb 2;310(5):288-92. to original article PubMed
  • Large retrospective series looking at cytogenetic complexity
  1. Baliakas P, Jeromin S, Iskas M, Puiggros A, Plevova K, Nguyen-Khac F, Davis Z, Rigolin GM, Visentin A, Xochelli A, Delgado J, Baran-Marszak F, Stalika E, Abrisqueta P, Durechova K, Papaioannou G, Eclache V, Dimou M, Iliakis T, Collado R, Doubek M, Calasanz MJ, Ruiz-Xiville N, Moreno C, Jarosova M, Leeksma AC, Panayiotidis P, Podgornik H, Cymbalista F, Anagnostopoulos A, Trentin L, Stavroyianni N, Davi F, Ghia P, Kater AP, Cuneo A, Pospisilova S, Espinet B, Athanasiadou A, Oscier D, Haferlach C, Stamatopoulos K; ERIC, the European Research Initiative on CLL. Cytogenetic complexity in chronic lymphocytic leukemia: definitions, associations, and clinical impact. Blood. 2019 Mar 14;133(11):1205-1216. Epub 2019 Jan 2. link to original article PubMed

Risk by lymphocyte doubling time

  1. Montserrat E, Sanchez-Bisono J, Viñolas N, Rozman C. Lymphocyte doubling time in chronic lymphocytic leukaemia: analysis of its prognostic significance. Br J Haematol. 1986 Mar;62(3):567-75. link to original article PubMed
  2. Molica S, Alberti A. Prognostic value of the lymphocyte doubling time in chronic lymphocytic leukemia. Cancer. 1987 Dec 1;60(11):2712-6. link to original article PubMed

Risk by FISH

  • Classic 2000 NEJM paper establishing that 17p deletion has the worst prognosis:
  1. Döhner H, Stilgenbauer S, Benner A, Leupolt E, Kröber A, Bullinger L, Döhner K, Bentz M, Lichter P. Genomic aberrations and survival in chronic lymphocytic leukemia. N Engl J Med. 2000 Dec 28;343(26):1910-6. link to original article PubMed
  • This article and abstract explore the significance of 13q deletions in more detail:
  1. Van Dyke DL, Shanafelt TD, Call TG, Zent CS, Smoley SA, Rabe KG, Schwager SM, Sonbert JC, Slager SL, Kay NE. A comprehensive evaluation of the prognostic significance of 13q deletions in patients with B-chronic lymphocytic leukaemia. Br J Haematol. 2010 Feb;148(4):544-50. Epub 2009 Nov 6. link to original article link to PMC article PubMed
  2. Abstract: Claudia Haferlach, Melanie Zenger, Vera Grossmann, Frank Dicker, Sabine Jeromin, Alexander Kohlmann, Susanne Schnittger, Wolfgang Kern, Torsten Haferlach. The Impact of Homozygosity and Size of the 13q Deletion in Patients with CLL. Blood 2012 120:3892 abstract 3892 link to abstract

Risk by TP53 mutation

  1. Zenz T, Eichhorst B, Busch R, Denzel T, Häbe S, Winkler D, Bühler A, Edelmann J, Bergmann M, Hopfinger G, Hensel M, Hallek M, Döhner H, Stilgenbauer S. TP53 mutation and survival in chronic lymphocytic leukemia. J Clin Oncol. 2010 Oct 10;28(29):4473-9. Epub 2010 Aug 9. link to original article PubMed

Risk by CD38 expression

  1. Damle RN, Wasil T, Fais F, Ghiotto F, Valetto A, Allen SL, Buchbinder A, Budman D, Dittmar K, Kolitz J, Lichtman SM, Schulman P, Vinciguerra VP, Rai KR, Ferrarini M, Chiorazzi N. Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood. 1999 Sep 15;94(6):1840-7. link to original article PubMed
  2. Review: Malavasi F, Deaglio S, Damle R, Cutrona G, Ferrarini M, Chiorazzi N. CD38 and chronic lymphocytic leukemia: a decade later. Blood. 2011 Sep 29;118(13):3470-8. link to original article link to PMC article PubMed

Risk by ZAP-70 expression (2003)

  1. Crespo M, Bosch F, Villamor N, Bellosillo B, Colomer D, Rozman M, Marcé S, López-Guillermo A, Campo E, Montserrat E. ZAP-70 expression as a surrogate for immunoglobulin-variable-region mutations in chronic lymphocytic leukemia. N Engl J Med. 2003 May 1;348(18):1764-75. link to original article PubMed

Prognostic scoring system using molecular and cytogenetic features (2012)

  1. Rossi D, Rasi S, Spina V, Bruscaggin A, Monti S, Ciardullo C, Deambrogi C, Khiabanian H, Serra R, Bertoni F, Forconi F, Laurenti L, Marasca R, Dal-Bo M, Rossi FM, Bulian P, Nomdedeu J, Del Poeta G, Gattei V, Pasqualucci L, Rabadan R, Foà R, Dalla-Favera R, Gaidano G. Integrated mutational and cytogenetic analysis identifies new prognostic subgroups in chronic lymphocytic leukemia. Blood. 2013 Feb 21;121(8):1403-12. Epub 2012 Dec 13. link to original article link to PMC article PubMed

CLL-IPI (2016)

  1. International CLL-IPI working group. An international prognostic index for patients with chronic lymphocytic leukaemia (CLL-IPI): a meta-analysis of individual patient data. Lancet Oncol. 2016 Jun;17(6):779-90. Epub 2016 May 13. link to original article PubMed

Prognostic scoring system using clinical features (2019)

  1. Soumerai JD, Ni A, Darif M, Londhe A, Xing G, Mun Y, Kay NE, Shanafelt TD, Rabe KG, Byrd JC, Chanan-Khan AA, Furman RR, Hillmen P, Jones J, Seymour JF, Sharman JP, Ferrante L, Mobasher M, Stark T, Reddy V, Dreiling LK, Bhargava P, Howes A, James DF, Zelenetz AD. Prognostic risk score for patients with relapsed or refractory chronic lymphocytic leukaemia treated with targeted therapies or chemoimmunotherapy: a retrospective, pooled cohort study with external validations. Lancet Haematol. 2019 Jul;6(7):e366-e374. Epub 2019 May 17. Erratum in: Lancet Haematol. 2019 Jul;6(7):e348. link to original article link to PMC article PubMed

Investigational agents