Dr. Nagourney's Blog

Chronic Lymphocytic Leukemia (CLL) - Model for Functional Profiling

By Robert A. Nagourney, MD

Among the most common forms of leukemia in adults is chronic lymphocytic leukemia CLL.

This neoplasm usually arises in a subset of lymphocytes known as B-cells. However, T-cell variants also occur.

The disease presents clinically as an elevation of the circulating lymphocytes. This may be associated with enlarged lymph nodes, splenomegaly or liver enlargement.

The decision to treat patients is largely based upon clinical staging systems know as the Rai or Binet classifications. Low risk patients can often be observed without treatment, while more aggressive presentations (such as those associated with anemia and low platelet counts) require intervention.

More recently, molecular determinants of aggressiveness have been applied in the prognosis of this disease. These include: CD38, VH gene mutation and Zap 70. Additional findings include ATM mutations, principally in the T-cell and pro-lymphocytic variants.

For more than 40 years, the treatment of choice for this disease was oral chlorambucil.

Although effective, chlorambucil resulted in the development of resistance and was associated with rather significant myelosuppression over time. The introduction of fludarabine (FAMP) and 2-CDA revolutionized the management of this disease —providing high response rates with relatively tolerable toxicities.

The introduction of 2-CDA and fludarabine in the 1980s offered an opportunity for our laboratory to examine drug interactions in CLL patients.

Combining the alkylating agents (of which, chlorambucil is a member) with 2-CDA revealed synergy (supra- additvity) in 100 percent of the CLL samples we studied (Nagourney, R; et al. British Journal of Cancer, 1993).

Based on this observation, we began treating patients with CLL and related lymphoid malignancies with a combination of Cytoxan and 2-CDA, resulting in dramatic and durable remissions. 

O’Brian, Keating and other investigators at the MD Anderson then undertook this work (using fludarabine), providing for the most effective treatment for CLL in today’s literature.

Unfortunately, a percentage of patients who receive this combination develop deep myelo-suppression. Therefore, the administration of this combination requires careful monitoring by the physician.

One of the most interesting aspects of the high activity observed for fludarabine was the capacity of this “anti-metabolite” to induce cell death in short term cultures of CLL cells.

It was well known that CLL cells were not highly proliferative, yet the anti-metabolite class of drugs was specifically designed to stop cell proliferation at the level of DNA synthesis. We realized that 2-CDA and Fludarabine had to be killing cells, not preventing their growth.

This conundrum provided an opportunity for us to test a related anti-metabolite in this disease.

We chose cytarabine (Ara-C), a drug not considered an effective treatment for CLL (e.g. low proliferative rate, no likelihood of DNA synthesis inhibition, no likelihood of cytotoxicity). To our delight, low doses or Ara-C proved highly effective in controlling even the most advanced cases of CLL as we then reported.

CLL became one of our favored models for the study of human tumor biology, enabling us to study drug responses at the molecular level.

Many of the observations that we made in this hematologic malignancy granted us insights that we continue to apply in solid tumors today.

As always, I appreciate your thoughts and comments.