title: Cladribine with immediate rituximab for the treatment of patients with variant hairy cell leukemia.
abstract: OBJECTIVE
  In contrast with the classic form, variant hairy cell leukemia (HCLv) responds poorly to single-agent purine analogs, expresses unmutated BRAF, has shorter overall survival, and lacks effective standard therapy. No treatment has achieved a high complete remission (CR) rate even in small series, and of 39 reported cases from six studies, overall response rate after cladribine was 44% with 8% CRs. Rituximab has been found to increase the sensitivity of malignant cells to cladribine, suggesting that combination with cladribine might improve response in HCLv. To test this hypothesis, patients with HCLv were treated with simultaneous cladribine and rituximab.
  
  
  METHODS
  Patients with HCLv with 0 to 1 prior courses of cladribine received cladribine 0.15 mg/kg for days 1 to 5, with eight weekly doses of rituximab 375 mg/m(2) beginning day 1. Restaging was performed, and minimal residual disease (MRD) in blood and marrow was quantified using PCR, immunohistochemistry, and flow cytometry.
  
  
  RESULTS
  By 6 months, 9 (90%) of 10 patients achieved CR, compared with 3 (8%) of 39 reported cases treated with cladribine alone (P < 0.0001). Of the 9 CRs, 8 remain free of MRD at 12 to 48 (median 27) months of follow-up. No dose-limiting toxicities were observed when beginning cladribine and rituximab on the same day, although most patients required short-term steroids to prevent and treat rituximab infusion reactions. Cytopenias in CRs resolved in 7 to 211 (median 34) days without major infections.
  
  
  CONCLUSIONS
  Although cladribine alone lacks effectiveness for early or relapsed HCLv, cladribine with immediate rituximab achieves CRs without MRD and is feasible to administer.
authors.affiliation: Authors' Affiliations: Laboratories of Molecular Biology, Pathology, and Metabolism Branch, National Cancer Institute; and Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, Maryland.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Kreitman
authors.forename: Wyndham
authors.initials: W
authors.lastname: Wilson
authors.forename: Katherine R
authors.initials: KR
authors.lastname: Calvo
authors.forename: Evgeny
authors.initials: E
authors.lastname: Arons
authors.forename: Laura
authors.initials: L
authors.lastname: Roth
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Sapolsky
authors.forename: Hong
authors.initials: H
authors.lastname: Zhou
authors.forename: Mark
authors.initials: M
authors.lastname: Raffeld
authors.forename: Maryalice
authors.initials: M
authors.lastname: Stetler-Stevenson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000911:Antibodies, Monoclonal / Q000008:administration & dosage*; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage; D017338:Cladribine / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007143:Immunoglobulin Heavy Chains / Q000235:genetics; D007943:Leukemia, Hairy Cell / Q000188:drug therapy* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D012074:Remission Induction; D000069283:Rituximab; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D007143:Immunoglobulin Heavy Chains; D017338:Cladribine; D000069283:Rituximab