CLL3R protocol, Revision date: Status: active Page 1 of 71

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1 The value of autografting in patients with high-risk chronic lymphocytic leukemia. A randomized phase III intergroup trial. - CLL3R protocol of the German CLL Study Group (GCLLSG) - A joint study of the GCLLSG, the Medical Research Council (MRC), the French Cooperative Group on CLL and the Societé Francais de Greffe de Moelle (SFGM), and the Chronic Leukemia Working Party (CLWP) of European Blood and Marrow Transplant Group (EBMT) Writing Committee: R. Arnold, Berlin R. Brand, Leiden G. Brittinger, Essen D. Bunjes, Ulm P. Corradini, Milan H. Dö hner, Ulm P. Dreger, Hamburg B. Emmerich, Munich J. Esteve, Barcelona H. Greinix, Vienna M. Hallek, Munich B. Hertenstein, Hannover U. Jäger, Vienna E. Kimby, Huddinge W. Knauf, Berlin M. Kneba, Kiel R. Kuse, Hamburg M. Mauricette, Lyon D. Milligan, Birmingham E. Montserrat, Barcelona D. Niederwieser, Leipzig S. Richards, Oxford V. Runde, Essen Study Coordinators: PD Dr. P. Dreger Abteilung Hämatologie AK St. Georg Lohmühlenstr Hamburg Tel: /2005 Fax: E mail: peter.dreger@ak-stgeorg.lbk-hh.de Dr. M. Michallet Service d Hematologie Hopital Eduard Herriot Place d Arsonval F Lyon cedex 03, France Fax: E mail: mauricette.michallet@chu-lyon.fr Study Office: Studienzentrale der CLL-Studien Genzentrum der Ludwig-Maximilians-Universität Feodor-Lynen-Str München Tel: Fax: E mail: CLLSTUDIE@LRZ.UNI-muenchen.de Biometry: A. van Biezen (Data Manager) R. Brand (Statistician) Department of Hematology, L.U.M.C, Albinusdreef 2, NL-2333 ZA Leiden, Netherland Tel : Fax : E.Mail : clwpebmt@lumc.nl _ CLL3R protocol, Revision date: Status: active Page 1 of 71

2 Phase-III-Studie zur Effektivitä t der autologen Stammzelltransplantation in der Rezidivtherapie der chronischen lymphatischen Leukä mie - CLL3R-Protokoll der Deutschen CLL-Studiengruppe in Zusammenarbeit mit der EBMT - SYNOPSIS Art der Studie Offene, prospektiv randomisierte, multizentrische Phase-III-Studie. Die CLL3R-Studie stellt den deutschen Teil einer europäischen Studie zur randomisierten Prüfung des Stellenwertes der ASCT in der Therapie der CLL dar. Primä re Studienziele Ereignisfreies Ü berleben nach Randomisation: ASCT im Vergleich zum Standardvorgehen (=wait & watch). Ereignis = Tod oder Progression. Progression = Entstehen neuer Läsionen oder Zunahme vorbestehender Läsionen um >50%. Gezeigt werden soll eine Verbesserung des 5y-EFS von <30% auf 50%, Power 90%. Sekundä re Studienziele (* = CLL3R-spezifische Studienziele) Gesamtüberleben Zeit bis zum Therapieversagen (= Zeit bis zur erneuten Therapiebedürftigkeit) Toxizität und Durchführbarkeit der ASCT in Abhängigkeit vom Zeitpunkt ihres Einsatzes Lebensqualität mit/ohne ASCT* Qualitative und quantitative Analyse sowie prognostische Bedeutung des molekularen Ansprechens* Zytogenetische Subgruppenanalyse* Standardisierter Vergleich zu ASCT als Teil der Primärtherapie (CLL3-Studie)* Standardisierter Vergleich zu intensivierter konventioneller Rezidivtherapie (CLL6-Studie)* Patientenzahl und Studiendauer 300 Patienten; Rekrutierungszeitraum <48 Monate. In Deutschland kann mit >20 Patienten pro Jahr gerechnet werden (= Rezidive aus CLL4 und Patienten mit Rezidiv nach Therapie auß erhalb der DCLLSG-Studien, die für eine SCT qualifizieren) Einschlußkriterien Patienten mit (rezidivierter) B-CLL in Remission* sowie Alter Jahre Allgemeinzustand nach ECOG-Kriterien 0-1 keine Einschränkung wesentlicher Organfunktionen schriftliche Einverständniserklärung (* Frührezidive nach CLL4/Fludarabin-haltiger Primärtherapie dürften diesen Status nur selten erreichen und sollten eher einem allogenen Therapieansatz zugeführt werden (=CLL3X-Protokoll der DCLLSG/EBMT)) CLL3R protocol, Revision date: Status: active Page 2 of 71

3 Behandlungsplan 1. Nach Erreichen einer Remission (VGPR/CR gemäß NIH sowie periphere Lymphozytenzahl <10x10 9 /l) durch freigestellte Standardchemotherapie (empfohlen bei Vortherapie mit F/FC: CHOP; bei Vortherapie mit Alkylanz: F/FC): Randomisierung ASCT vs. W&W 2. PBSC-Mobilisierung in beiden Armen: ASCT: Dexa-BEAM+G-CSF; W&W: CY3+G-CSF. 3. Sammeln peripherer Blutstammzellen und fakultative ex-vivo B-Zell-Depletion des Transplantates (>2x10 6 /kg CD34+ Zellen im B-Zell-depletierten Endprodukt plus >2x10 6 /kg CD34+ Zellen ungepurgt als Backup). 4. ASCT-Arm: Hochdosistherapie (TBI/CY) und Stammzellreinfusion. 5. Nachuntersuchungen für beide Arme: Infektions-, Toxizitäts- und QOL-Anamnese, physikalische Untersuchung, Blutbild, Immunphänotypisierung und molekulargenetische Untersuchung alle 4 Monate nach Abschluß der jeweiligen Therapie bis zum Erreichen des primären Endpunkts. Bei der ersten Untersuchung zusätzlich zytologische, histomorphologische, immunphänotypische und molekulargenetische Analyse einer KM-Biopsie. 6. Rezidiv/Progreß im ASCT-Arm: Therapie freigestellt. Rezidiv im W&W-Arm: Frühzeitige ASCT anstreben (nicht bis zur Therapiebedürftigkeit abwarten!). Remissionsinduktion z.b. mit Dexa-BEAM. Randomisation, Datenverwaltung und klinische Betreuung: Meldung der Patienten und Randomisierungsersuchen über die Studienzentrale der DCLLSG in München: Studienzentrale der CLL-Studien Genzentrum der Ludwig-Maximilians-Universitä t Feodor-Lynen-Str München Tel: Fax: E mail: CLLSTUDIE@LRZ.UNI-muenchen.de Das Studienzentrale leitet die Meldung an das zentrale EBMT-Randomisierungsbüro (CTSU, Oxford), welches die Randomisierung anhand einer DCLLSG-spezifischen Randomisierungsliste vornimmt. Mitteilung des Randomisierungsergebnisses an das behandelnde Zentrum durch die Studienzentrale Dokubö gen werden vom behandelnden Zentrum der Studienzentrale zugeleitet, von wo aus der Datentransfer an das EBMT Data Center in Leiden erfolgt. Klinische Betreuung und Studienleitung für den Bereich der DCLLSG: PD Dr. P. Dreger Abteilung Hämatologie AK St. Georg Lohmühlenstr Hamburg Tel: /2005 Fax: E mail: peter.dreger@ak-stgeorg.lbk-hh.de CLL3R protocol, Revision date: Status: active Page 3 of 71

4 Synopsis der CLL3R-Studie der DCLLSG 11/2002 B-CLL; untreated or 1st relapse; stage B, C, or progessive A, <65 years any 1st/2nd line treatment CR/PR R Endpoints Mobilisation (Dexa-BEAM/G) TBI/CY + ASCT Relapse wait & watch (mobilisation optional) Relapse 1 EFS 2 - OS - TTTF - Toxicity - QOL allo-sct (CLL3X) CLL3R protocol, Revision date: Status: active Page 4 of 71

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6 Content Synopsis and flow sheets Background and rationale Objectives of the study Indications and patient eligibility Trial design and registration procedure Treatment schedule PBSC collection Myeloablative regimens Toxicity and supportive care Treatment of progressive disease after randomisation Clinical evaluation Reasons for going off study Evaluation criteria Patient registration after randomization Forms and procedures for collecting data Reporting severe adverse events Statistical considerations Independent data monitoring committee Quality assurance Ethical considerations Bibliography Appendix A: Patient information and consent form Appendix B: Registration form Appendix C: Binet staging system Appendix D: Central assessment: Serum thymidine kinase, ß -2-microglobuline Appendix E: Central assessment: Cytogenetics Appendix F: Central assessment: Minimal residual disease Appendix G: Signatures Appendix H: Case report forms Appendix J: Reporting severe adverse events Appendix K: Ethics committee s approval Appendix L: Patient insurance CLL3R protocol, Revision date: Status: active Page 6 of 71

7 1 BACKGROUND AND RATIONALE 1.1 Introduction Chronic lymphocytic leukemia (CLL), the most frequent adult leukemia in western countries is a clonal hematopoietic disorder with proliferation and accumulation of small lymphocytes of B lineage (1-3). Since the median age at diagnosis is 65 years, in many patients CLL will not affect life expectancy although the disease is incurable with conventional treatment. However, in patients with an advanced stage (B or C according to the Binet classification (1) ) with adverse prognostic factors, such as high leukocyte count, diffuse bone marrow infiltration, short lymphocyte doubling time (LDT), unfavourable cytogenetics, or elevated beta-2 microglobulin, survival time is considerably reduced (4-14). Although CLL is usually a disease of the elderly, it is increasingly diagnosed in younger people. A recent report indicates that about 20 % of patients are less than 55 years old (15). CLL in younger adults has no major distinctive features, the prognostic factors are the same as those to older patients and median survival is less than three years for young patients with advanced CLL (15). 1.2 Therapeutic Approaches Conventional chemotherapy The choice of therapy for CLL in stages B and C remains difficult with median survival time of 5 years and 22 months respectively (16). The disease can be treated with alkylating agents with or without prednisolone (16). The addition of anthracyclines may improve the outlook but the median survival remained less than 4 and 6 years for stages C and B respectively (16,17). Comparative studies between the use of chlorambucil with or without corticosteroids (18-20) and alkylating agent-based regimens (22-25) have not demonstrated superiority of any one regimen for stages B and C. The majority of the responses observed with these different regimens are partial remissions (18-26). More recently,fludarabine (27-34), 2-chlorodeoxyadenosine (2CDA) (35,36) and deoxycorfomycin (37), have been explored in previously treated CLL patients. Increasingly purine analogues are being used as initial therapy for CLL patients (29,37,38). Randomised comparisons between fludarabine and other therapeutic regimens (39-42) have demonstrated that fludarabine achieved more complete responses. A recent report of the response to fludarabine regimens as initial therapy of 174 patients with CLL has shown a median survival of 63 months and for responders, a median time to progression of 31 months. Patients who were refractory to fludarabine had a median survival of only 48 weeks (43). These results justify the consideration of innovative dose-intensive therapies (44). CLL3R protocol, Revision date: Status: active Page 7 of 71

8 Taken together, the available information clearly demonstrates the survival time in patients with CLL and adverse prognostic features is considerably reduced. Since this is not acceptable in particular for younger individuals, treatment modalities are required which have the potential to provide long-term remissions or completely eradicate the disease. To date, the only potentially curative approach for CLL is high-dose therapy followed by autologous or allogeneic stem cell transplantation Allogeneic stem cell transplantation (SCT) Although allotransplantation adds immunotherapeutic to cytotoxic effects and may, thus, be a curative treatment for CLL, its use in patients with this disease has been difficult and contentious. This is partly to do with the fact that many patients with CLL are older and/or have indolent disease which does not justify aggressive treatment. Apart from the donor problem, however, the main reason is the high toxicity associated with allografting for this particular indication. Even in well experienced centers, the treatment-related mortality (TRM) of allogeneic SCT in patients with CLL has been reported to be as high as 36% (45,46,47). This figure further increases if registry data are taken into account. A recent update of the EBMT database comprising 188 allografted patients with CLL disclosed a TRM of 49% at 36 months post transplant, which is clearly more than after standard indications such as acute leukemia or chronic myeloid leukemia (CML) (48-50). The causes of these discouraging results are not completely clear, but patients age, selection of poor risk patients with advanced disease and extensive pretreatment, and the CLL-associated incompetence of the immune system may all contribute to the high TRM observed. The recent development of conditioning regimens with reduced intensity may help to improve the tolerability of allo-sct in patients with CLL (51-62). Taken together, the information available to date is too limited to justify the investigation of allografting for CLL in a large phase-iii multicenter study Autologous stem cell transplantation In contrast to allogeneic transplantation, autografting of patients with CLL has dramatically increased over the past years and is now the preferred type of transplant with 370 cases in the EBMT database and a growing number of published single center series (49, 53-59). Due to the ability to mobilize peripheral blood stem cells and other improvements of supportive therapy, the mortality of the procedure is low and was clearly below 10% in High-dose radio-chemotherapy followed by autologous SCT can induce or maintain long-term complete remissions. Nevertheless, in most series a steady decline of the event-free survival curve is observed due to continuous CLL3R protocol, Revision date: Status: active Page 8 of 71

9 relapses occurring up to 5 years post transplant, and it is still not clear if autografting can be curative in at least certain subsets of patients with CLL. The probability of relapse varies greatly between different series and this may depend on differences in patient selection and perhaps also on technical details such as the stem cell source and purging. Due to the low toxicity of the procedure, the outcome of autografted patients is characterized by 3-year overall survival figures of more than 75% and, thus, is generally superior to that after allotransplantation. The largest single-center series of patients treated with SCT for CLL has been reported by the Dana- Farber Cancer Center. One-hundred-fifty-two patients with advanced CLL underwent myeloablative therapy including total body irradiation (TBI) and cyclophosphamide followed by reinfusion of autologous BM purged with anti-b-cell monoclonal antibodies and complement. There were 8 treatment-related deaths (5%). With a median follow-up of about 30 months, only 14 patients have relapsed, but additional 63 patients (of 136 with a marker available) show persistent disease at the molecular level (55). At the University of Kiel, 54 patients with poor-risk CLL have been reinfused with immunomagnetically purged PBPC grafts following preparation with TBI/CY. Engraftment was delayed in patients receiving BM (n=3) but prompt (ANC >0.5 x10 9 /L after 9 [8-13] days and platelets >20 x10 9 /L after 10 [7-214] days) in patients restored with PBPC (n=42). Two patients experienced procedure-related deaths, and one of 7 patients with recurrent disease died due to progressive disease. With a median follow-up of 12 (3-84 months) the 7-year event-free survival is 85%. The EBMT has recently updated data on the outcome of 370 autologous transplants from the EBMT registry (59). The median age was 50 years. The median interval between diagnosis and transplant was 30 months. At time of transplant, 32% of patients were in complete remission. Purging was performed in 48% of the cases. The 2-year probability of survival was 82 %. The 2-year risk of transplant-related mortality (TRM) was 10%. Although a number of single-center or multicenter SCT studies have been performed or are currently underway, the impact of autologous SCT on the prognosis of CLL is still unproven. For this purpose, the EBMT in cooperation with national study groups from France, Germany, the Nordic countries, Spain, and the UK has developed the concept of a prospective randomized trial to CLL3R protocol, Revision date: Status: active Page 9 of 71

10 study the influence of first- or second-line autologous SCT on the course of poor-risk CLL. 1.3 Study rationale For high risk CLL patients who have achieved a good response after one or two lines of treatment, no further treatment is presently the standard. Autologous HSCT has given promising results according to the forgoing informations, but remains to be evaluated. Thus, the purpose of the present trial is to evaluate the efficacy of consolidating SCT in patients having achieved remission after standard chemotherapy in terms of event-free and overall survival. 2 OBJECTIVES AND ENDPOINTS This is a prospective randomised phase III Intergroup study aimed to compare no further treatment until required (arm 0) with autologous stem cell transplantation (SCT) (arm 1) in adult high risk CLL patients who have reached a complete remission (CR), a very good partial remission (VGPR) or a nodular partial remission (NPR) after first or second line therapy. The CLL3R (=GCLLSG) part of this study shares the eligibility criteria, treatment design, primary endpoints, essential secondary endpoints, evaluation criteria, and central analysis with the main study, but aims at evaluation of additional secondary endpoints. 2.1 Primary endpoint Event-free survival (EFS) from randomisation (see 8.3 for definition) 2.2 Secondary endpoints (* analyses restricted to CLL3R/GCLLSG patients) Overall survival from randomisation Time to disease-requiring therapy from time of remission (Treatment-free survival TFS) Quality of life analysis (QOL) Toxicity and feasibility of 1 st line versus later SCT Quantitative analysis and prognostic impact of molecular response* Prognostic impact of cytogenetics and mutational status* Comparison to historical controls (CLL3 study)* CLL3R protocol, Revision date: Status: active Page 10 of 71

11 3 INDICATIONS AND PATIENT ELIGIBILITY 3.1 Inclusion criteria All patients with symptomatic B-CLL (CD19+/CD5+/CD23+; Binet stage B and C, or progressive A) are eligible for the randomisation provided they have reached a Complete Remission (CR), a Very Good Partial Remission (VGPR), or Nodular Partial Remission (NPR) assessed by bone marrow biopsy after first or second line treatment (see sections through 8.1.4). In addition, the following criteria must be met for inclusion into the CLL3R study: presence of a clonal CDRIII rearrangement which can be detected by PCR age years ECOG performance status 0-1 normal organ function as defined by - creatinine clearance >60mL/min - SGOT, SGPT, and bilirubine <2x normal - normal cardiac function as assessed by ECG and echocardiografic examination - Pulmonary tests (VCin, FEV1, TLCO) >50% of predicted written informed consent 3.2 Exclusion criteria age >65 years ECOG >1 Richter's syndrome, T-CLL, NHL other than B-CLL serious localized or systemic infections Rai stages 0-II, stable Binet stage A (asymptomatic disease) concomitant malignant disease impaired organ function, uncontrolled diabetes, uncontrolled hypertension lactating or pregnant women or those of childbearing potential not using a reliable contraceptive method infection with HIV, HBV, or HCV current alcohol or drug abuse inability to understand the scope of the study and intent of treatment. Dementia or altered mental status that would prohibit understanding informed consent planned allograft CLL3R protocol, Revision date: Status: active Page 11 of 71

12 4 TRIAL DESIGN AND RANDOMISATION PROCEDURE 4.1 General design This is an open randomised, multicenter phase III, Intergroup study. Two hundred and seventy eligible CLL patients will be randomised and registered. The patient will be followed until death. The randomisation will be done at the moment of the response (CR, VGPR or NPR, see for definition). The treatment given before randomisation will be left at the discretion of the individual participating centre. Any therapy leading to CR, VGPR or NPR will be acceptable including monoclonal antibodies, such as rituximab (CD20) and alemtuzumab (CD52). If participation in this trial is intended, randomization should be performed as soon as CR/VGPR/NPR are achieved. Patients randomized to arm 0 may be further treated conventionally to maximum response, whereas patients randomized to arm 1 should proceed to mobilization without further conventional treatment to avoid compromising mobilization. After meeting all the eligibility criteria, written informed consent is required prior to the patient s participation in the trial according to ICH/EU GCP, and national/local regulations. 4.2 Randomisation The randomisation is between Treatment arm 0 (No further Treatment until required) and Treatment arm 1 (Autologous Stem Cell Transplantation). Randomisation will be stratified according to the status at the randomisation: Stratification 1-1 = patient in first CR, VGPR or NPR after one line of therapy. Stratification 2-2 = patient in second CR, VGPR or NPR after a second line of therapy. Stratification 2-1 = patient in first CR, VGPR or NPR after a second line of therapy. The randomisation is performed by the central EBMT randomisation office (CTSU, Oxford) via the GCLLSG study office in Munich. Any participating centre can request a randomisation to the GCLLSG Munich office by telephone or fax using the GCLLSG Registration forms ( Meldebogen und Ein-/Ausschluß kriterien ). The GCLLSG office will forward the Registration data to the CLWP data centre in Leiden and a randomisation request to the CTSU CLL3R protocol, Revision date: Status: active Page 12 of 71

13 which allocates a trial number based on a stratified, balanced block allocation. Then, the CTSU enters a new record using the PRoMISe system into the study database via internet thus, fixing the patient ID in the central database. The CTSU will inform the patient s centre via the GCLLSG Munich office using the Randomisation Characteristics form. The contact details of the randomisation service are : Studienzentrale der CLL-Studien Genzentrum der Ludwig-Maximilians-Universitä t Feodor-Lynen-Str München Tel: Fax: E mail: CLLSTUDIE@LRZ.UNI-muenchen.de 5 TREATMENT SCHEDULE 5.1 Peripheral Blood Stem Cells (PBSC) harvest Stem Cell Mobilisation Following treatment with fludarabine, it is recommended to delay PBSC mobilisation (at least 2 months) from the last course of fludarabine. The recommended mobilization schedule is : - Cyclophosphamide 2g/m² iv day1 with Mesna (100% of the dose of Cyclophosphamide iv) - G-CSF (Lenograstim) 150 µg/m²/day sc days Apheresis days 11, 12, ± 13 (or when WBC > 2 x 10 9 /l) An alternative schedule for mobilization only for patients randomised in the autograft arm (arm 1) is Dexa-BEAM: - Dexamethasone 3 x 8 mg (days 1to 10) - BCNU 60 mg/m² (day 2) - Etoposide 75 mg/m² (days 4 to 7) - Cytarabine 100 mg/m² q12 h (days 4 to 7) - Melphalan 20 mg/m² (day 3) CLL3R protocol, Revision date: Status: active Page 13 of 71

14 - Lenograstim 150µg/m²/day sc day 11 until the last day of apheresis - Apheresis days 19ff (or when WBC > 5 x 10 9 /l) This schedule must not be used for patients randomised in the arm 0 even if they are harvested Stem cell collection PBSC collections will be performed on 2 to 4 consecutive days following the hematopoietic recovery phase as soon as the leukocyte counts have reached 2 x 10 9 /l or as soon as the peripheral CD34+ counts exceed 2 x 10 7 /l. The PBSC harvest should contain at least CD34+ cells > 2 x 10 6 /kg body weight (or > 4 x 10 6 /kg if purging is planned) and/or CFU-GM > 5 x 10 4 /kg body weight. If these numbers are not met after four collections the patient will be considered as a failure for mobilization and the mobilization will be discontinued. There is an option for a second attempt at mobilisation when the blood count has recovered and the bone marrow is normocellular. Autologous bone marrow harvest will only be performed in case of failure to harvest enough peripheral blood stem cells Purging. Purging (negative and/or positive selection) of PBSC is permitted but must be recorded. 5.2 Myeloablative regimens Two standard types of pretransplant regimens are recommended: TBI/Cyclophosphamide: Cyclophosphamide 60 mg/kg body weight on 2 consecutive days (+ Mesna) + fractionated total Body Irradiation (ftbi). The schedule for ftbi should be one with which the transplant centre is familiar. Doses may vary from 11 to 14.4 Gy BEAM BCNU 300 mg/m² day -6, Cytosine Arabinoside 400mg/m² and Etoposide 200mg/m² days-5 to -2 and Melphalan 140 mg/m² day -1. The use of granulocyte colony-stimulating factor is allowed after transplantation. CLL3R protocol, Revision date: Status: active Page 14 of 71

15 5.3 Toxicity and supportive care All treatment schedules used in this protocol cause pancytopenia and can induce septic or hemorrhagic complications. Note: Unexpected toxicity and toxic death should be reported to the study coordinator immediately, refer to section Attempts should be made prior and during chemotherapy/radiotherapy to control any medical problems, such as bleeding, infection and metabolic abnormalities according to the individual standards of the participating centre. Electrolyte abnormalities should be checked and monitored. All patients will receive platelet transfusions, whenever necessary, to avoid hemorrhages. Patients with fever should receive empiric broad spectrum antibiotics. Antibiotics should be given as prescribed by the sensitivity studies, whenever a pathogen has been isolated. Protective environment and digestive tract decontamination are strongly recommended for prophylaxis of infections during stem cell transplantation. 5.4 Treatment of progressive disease after randomisation Arm 0: The recommended treatment in case of relapse/progressive disease is early autologous SCT after remission induction with a second/third-line regimen, such as monoclonals, Dexa-BEAM etc. Arm 1: The treatment of relapse is left at the discretion of the investigator. 6 CLINICAL EVALUATION, LABORATORY TESTS AND FOLLOW-UP Patients in the study will have the following data collected (see summary table): 6.1 Before randomisation The following will be performed within 15 days before the randomisation but after CR/VGPR/NPR has been established: signed and dated informed consent CLL3R protocol, Revision date: Status: active Page 15 of 71

16 medical history and physical examination: WHO performance status, liver and spleen size, lymph node enlargement, dermal infiltration, fever, documented sepsis, hemorrhages blood count (hematocrit and hemoglobin, platelet count, WBC and differential) bone marrow aspiration and biopsy : (% lymphocytes) basic clinical chemistry immunophenotyping of leukemic cells by flow cytometry* serum thymidine kinase and ß 2-microglobulin* interphase cytogenetics* molecular genetics (PCR-amplificable CDR3 rearrangement, mutational status)* abdominal ultrasound examination ECG, echocardiography, lung function tests virus serology (HIV, HBV, HCV, CMV, EBV, VZV, HSV) thoracoabdominal CT scan pregnancy test * STK/ß 2M, cytogenetics and CDR3 assessment should be performed centrally in Munich (STK/ß 2M), Ulm (cytogenetics), and Kiel (CDR3), respectively, using the central diagnosis forms (Appendix D-F). In order to facilitate assessment of these diagnostic/prognostic markers, these tests should be performed prior to conventional salvage treatment for induction of remission if participation in this trial is intended. 6.2 During high-dose therapy and immediate post transplant hospitalization Infection assessments Mucositis assessment Uric acid, creatinine, electrolytes, liver function tests (bilirubin, transaminases, alkaline phosphatase) at least once weekly Adverse event assessment (non-hematological toxicity according to CTC-NCIC-criteria) ANC nadir (bottom and duration) Day ANC >0.5x10 9 /L Day platelets >20x10 9 /L Transfusion assessment (packed RBC, platelets) CLL3R protocol, Revision date: Status: active Page 16 of 71

17 6.3 During the first year post randomisation (Follow-up Form) Four months after the completion of therapy: interview and physical examination blood counts (hemoglobin, platelet count, WBC and differential), blood chemistry (uric acid, creatinine, electrolytes, bilirubin, transaminases, alkaline phosphatase) bone marrow aspiration and biopsy immunologic phenotyping in blood and bone marrow (CD5, CD20, CD19, CD23, CD38, Kappa/Lambda) Arm 1 only: molecular genetics (PCR-amplificable CDR3 rearrangement) in PB (+BM if available). Every four months for autografted and non autografted patients only during 4 years or until progression: interview and physical examination blood counts (hemoglobin, platelet count, WBC and differential), blood chemistry (uric acid, creatinine, electrolytes, bilirubin, transaminases, alkaline phosphatase) immunologic phenotyping in blood (CD5, CD 20, CD 19, CD 23, CD38, Kappa/Lambda) Arm 1 only: molecular genetics (PCR-amplificable CDR3 rearrangement) in PB (+BM if available). 6.4 At progression blood and bone marrow examination, with immunophenotyping, molecular genetics and cytogenetics identification of any type of extra-medullary localisation (CT scan) CLL3R protocol, Revision date: Status: active Page 17 of 71

18 6.5 Summary table Study schedule visit Screening Randomisation Informed consent X Day 0 Mobilisation period Transplantation period (from transplant to end of hospitalisation) 4 years after randomisation After 4 years Medical History/ Interview X Every 4 months Every 6 months Physical examination (1) X X Daily Every 4 months Every 6 months Temperature X Daily Daily WHO performance status Bone marrow aspiration and biopsy X X At month +4; at relapse Immunophenotyping (2,3) X Every 4 months Every 6 months STK/ß 2M assessment (3) X Cytogenetics (3) X At relapse At relapse Molecular genetics (3) X Every 4 months Every 6 months Hematocrit and hemoglobin X Daily Daily Every 4 months Every 6 months Platelets X Daily Daily Every 4 months Every 6 months WBC and differential X Daily Daily Every 4 months Every 6 months CD34+ monitoring Blood chemistry (3) X X Once weekly or more often HIV, HBV, HCV serology ECG Chest X-rays X X X CT Scan X At relapse Adverse events reporting X X X X QOL assessment X Every 4 months (1) : Including liver and spleen size, liver enlargement, dermal infiltration, documented sepsis and hemorrhages. (2) : CD5, CD 20, CD 19, CD 23, CD38, Kappa/Lambda (3) : STK/ß 2M, cytogenetics and CDR3 assessment should be performed centrally in Munich (STK/ß 2M), Ulm (cytogenetics), and Kiel (CDR3), respectively, using the central diagnosis forms (Appendix D-F). In order to facilitate assessment of these diagnostic/prognostic markers, these tests should be performed prior to conventional salvage treatment for induction of remission if participation in this trial is intended. (4) at screening only : Fibrinogene and other coagulation factors, prothrombin time, calcium, phosphate, glucose, alkaline phosphatase, albumine at screening and at all other visits : Electrolytes, uric acid, creatinine, transaminases X CLL3R protocol, Revision date: Status: active Page 18 of 71

19 7 REASONS FOR GOING OFF STUDY After completion of treatment according to the protocol patients will be monitored until relapse, progression, or death from any cause (= event in terms of the primary objective). The patient has to be taken off protocol and regarded as a treatment failure if one of the following criteria is met (individual stopping criteria) ineligibility for inclusion patient s demand or non-compliance excessive toxicity major protocol violation (other treatments than those described in 5.0) lost to follow-up PBSC harvest is for any reason definitely unsuccessful (arm 1 only) progressive disease prior to SCT (arm 1 only) Although no longer on protocol treatment, every attempt will be made to follow up these patients for survival and progression-free survival. 8 CRITERIA OF EVALUATION 8.1 Evaluation of response (before randomisation) Complete Remission (CR) [Cheson et al. 1996] Is defined by a bone marrow containing < 30% lymphocytes (normal immunophenotype) and a cellularity of at least 20% with maturation of all cell lines (including an hemoglobin which should be >6.8 mmol/l (11 g/dl), a neutrophil count >1.5 x 10 9 /l and platelets >100 x 10 9 /l), and a blood lymphocytosis <5 x 10 9 /l. Extramedullary leukemia, such as CNS involvement, leukemic infiltration of the skin, hepatosplenomegaly or lymphadenopathy exceeding 1.5 cm dimension should not be present. All CR criteria should be met at the time of randomisation Very Good Partial Remission (VGPR) or Nodular Partial Remission (NPR) A VGPR is characterised by a bone marrow containing <50% lymphocytes, with a blood lymphocytosis of <10 x 10 9 /l, hemoglobin >6.8 mmol/l (11 g/dl), platelets >100 x 10 9 /l, and neutrophils >1.5 x 10 9 /l. A NPR is characterised by the same parameters than VGPR with CLL3R protocol, Revision date: Status: active Page 19 of 71

20 nodular infiltration of lymphocytes in bone marrow assessed by bone marrow biopsy Criteria of progression/relapse Progression following a CR, a VGPR or NPR is defined as reappearance of leukaemic cells in the blood (>10x109/l) or the finding of more than 50% lymphocytes in the BM, increase of lymph nodes or of other manifestations by more than 50% Criteria for therapy-requiring disease Presence of at least one of the following symptoms: B symptoms symptomatic or progressive lymphomas symptomatic splenomegaly progressive reduction of hemoglobin and/or thrombocytes which in the view of the clinician requires treatment. 8.2 Evaluation of toxicity Adverse events and side effects All adverse events will be recorded on the case report forms; the investigator will decide if those events are transplant-related (unrelated, unlikely, possible, probably or almost definitely) and his decision will be recorded on the forms for all adverse events. Adverse events definitely not transplant related will not be considered as side effects or toxicity, but recorded separately General evaluation of side effects Hematological toxicity will be assessed on the basis of at least weekly blood counts. Non hematological acute side effects will be assessed and reported separately according to the common toxicity criteria defined by the CTC-NCIC. A link to download CTC criteria is provided on the CTEP web site: CLL3R protocol, Revision date: Status: active Page 20 of 71

21 8.2.3 Serious adverse events Serious adverse events are defined as any undesirable experience occurring to a patient, whether or not considered related to the investigational arm, that is any of the following: - Life-threatening - permanently disabling - Death SERIOUS ADVERSE EVENTS SHOULD BE IMMEDIATELY REPORTED ACCORDING TO THE PROCEDURE DETAILED IN THIS PROTOCOL, refer to annex 6. Toxic death is defined as death due to toxicity. This must be reported on the follow-up form. The cause of death must be reported as toxicity. The evaluation of toxic deaths is independent of the evaluation of response (patients can die from toxicity after a complete assessment of the response to therapy). 8.3 Endpoint evaluation Primary endpoint event-free survival from randomisation (EFS) For evaluation of EFS, relapse, progression, or death from any cause are regarded as events (see 8.1.3) Secondary endpoints time to therapy-requiring disease (TFS) For evaluation of TFS, persistence/ recurrence of symptomatic disease or death from any cause are regarded as events (see 8.1.4). overall survival from randomisation (OS) For evaluation of OS, death from any cause is regarded as event. toxicity and feasibility of 1 st line versus later SCT Toxicity is evaluated by assessment of the following parameters: - treatment-related mortality - treatment-related morbidity CLL3R protocol, Revision date: Status: active Page 21 of 71

22 - serious or unexpected adverse event assessment (see 8.2) Feasibility is evaluated by assessment of the following parameters: - toxicity - proportion of eligible patients completing the protocol successfully - proportion of patients who have to be taken off protocol due to individual stopping criteria (see section 7) Quality of life analysis (QOL) QOL is evaluated by using the forms placed at at defined time points before and after treatment according to the protocol (see 6.5.) Quantitative analysis and prognostic impact of molecular response Molecular response is evaluated by assessment of the following parameters: - proportion of protocol-treated patients achieving molecular remission (= oligo- or polyclonal CDR3 rearrangement [PCR-amplification using consensus primers for the VH and J regions with Genescan analysis] - level of residual disease using allele-specific primers with TaqMan quantification Prognostic impact of cytogenetics and mutational status is evaluated by correlating outcome per arm with the results of pretreatment analyses of FISH caryotype and mutational status (Sequencing of FR1-IgH PCR products). Comparison to historical controls (CLL3) is performed by comparing the outcome of the present series with that of historical populations undergoing upfront SCT (CLL3 study of the GCLLSG) using the GCLLSG data base. 9 PATIENT REGISTRATION AFTER RANDOMISATION Patient registration/randomisation will only be accepted from authorised investigators. All patients will be registered after the randomisation. The Registration Form must be sent to the GCLLSG office Munich (see 3.1.1). CLL3R protocol, Revision date: Status: active Page 22 of 71

23 10 FORMS AND PROCEDURES FOR COLLECTING DATA Case report forms must be completed according the following schedule: 10.1 After randomisation Baseline data must be reported using the Follow up form ( During and after treatment (every 4 months after randomisation) For autotransplanted patients (arm 1) : Follow up form For not autotransplanted patients (arm 0) : Follow up form 11 REPORTING ADVERSE EVENTS Upon occurrence of a Serious Adverse Event (SAE) a SAE Form must be completed and returned to the study coordinator ( 12 STATISTICAL CONSIDERATIONS For patients having stage B, C or progressive A disease in the age group > 15 and 65 years, the event-free survival (EFS) at 5 years after randomisation without further treatment can be expected to be approximately about 30 % at best. Autologous stem cell transplantation will hopefully lead to an EFS 5 years after randomisation of 50%. To detect a absolute difference of 20% using a two-sided significance level of 0.05 and a power of 0.90 requires 134 patients in each arm. So altogether about 270 patients have to be randomised. Randomisation will be stratified according to (1) participating groups and (2) first or second line treatment. After randomisation of 100 patients the data will be examined by the CLL3R protocol, Revision date: Status: active Page 23 of 71

24 Independent Data Monitoring Committee (IDMC) to check the feasibility and safety of the protocol. After randomisation of 200 patients a formal interim analysis will be applied with respect to overall survival from randomisation and EFS from randomisation and reported to the IDMC, which will recommend modification or stopping of the trial only if, in their view, there is proof beyond reasonable doubt that for all, or for some types of patients, one treatment is clearly indicated or clearly contra-indicated. 13 INDEPENDENT DATA MONITORING COMMITTEE (IDMC) An IDMC will be appointed. Toxicity data will be discussed at each meeting of the EBMT CLWP, but efficacy results will not be presented at group meetings before the trial is closed to recruitment. 14 QUALITY ASSURANCE 14.1 EBMT and GCLLSG data bases Data forms will be entered in the database of the EBMT Data Centre Leiden as well as in the GCLLSG data base. Computerised and manual consistency checks will be performed on newly entered forms; query forms will be issued in case of inconsistencies. Consistent forms will be validated by the Data Manager to be entered on the master database. Inconsistent forms will be kept "on hold" until full resolution of inconsistencies On site quality control On site quality control will only be performed in case of a high incidence of inconsistencies. 15 ETHICAL CONSIDERATIONS 15.1 Patient protection The responsible investigator will ensure that this study is conducted in agreement with either the declaration of Helsinki (Version of Edinburgh, October 7, 2000) or the laws and CLL3R protocol, Revision date: Status: active Page 24 of 71

25 regulations of the country, whichever provides the greatest protection of the patient. The protocol has been written and the study will be conducted according to the ICH Harmonised Tripartite Guideline for Good Clinical Practice, issued by the European Union. The protocol must be approved by the responsible Ethics Committee. A copy of the informed consent form (with patient information sheet) must be submitted to the Ethics Committee together with the protocol for written approval. Written approval of the protocol and informed consent by the responsible Ethics Committee must be obtained prior to recruitment of patients to the study by each participating investigator. The investigator must inform the Ethics Committee of all subsequent protocol amendments, which must be approved by the Committee Subject identification The investigator must ensure that the patient's anonymity is maintained. On the case report forms or other documents submitted to the study office patients should be identified by their initials, birth date, and a unique study patient number only. Documents which are not for submission to the study office (e.g. signed informed consent forms) should be kept in strict confidence by the investigator Informed consent All patients will be informed of the aims of the study, the possible adverse events, the procedures and possible hazards to which he/she will be exposed, and the mechanism of treatment allocation. They will be informed as to the strict confidentiality of their patient data, but that their medical records may be reviewed for trial purposes by authorised individuals other than their treating physician. It will be emphasised that the participation is voluntary and that the patient is allowed to refuse further participation in the protocol, whenever he/she wants. This will not prejudice the patient's subsequent care. Documented informed consent must be obtained for all patients included in the study, before they are registered. This must be done in accordance with the national and local regulatory requirements. For European Union member states, the informed consent procedure must conform to the ICH guidelines on Good Clinical Practice. CLL3R protocol, Revision date: Status: active Page 25 of 71

26 15.4 Reporting and recording of data The investigator must arrange for the retention of the patient identification codes for at least 15 years after the completion or discontinuation of the trial. Patient files and other source data pertaining to the conduct of the study must be kept for the maximum period of time permitted by the institution Insurance A patient insurance has been taken out by the EBMT Chronic Leukemia Working Party for Working Party studies including this protocol with the Gerling Industrie-Service GmbH Nord-Ost, Harvestehuder Weg 25, Hamburg; Germany (Probandenversicherung gemäß AMG 40). Contract-No.: CLL3R protocol, Revision date: Status: active Page 26 of 71

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28 18. Sawitsky A, Rai KR, Glidewell O et al. Comparison of daily versus intermittent chlorambucil and prednisone therapy in the treatment of patients with chronic lymphocytic leukemia. Blood 50: 1049, Knospe WH, Loeb V, Huguley CM et al. Bi-weekly chlorambucil of chronic lymphocytic leukemia. Cancer 33: 555, Keller JW, Knospe WH, Raney M et al. Treatment of chronic lymphocytic leukemia using chlorambucil and prednisone with or without cycle-active consolidation chemotherapy. Cancer 58: 1185, Montserrat E, Alcala A, Parody R et al. Treatment of chronic lymphocytic leukemia in advanced stages-a randomized trial comparing chlorambucil plus prednisone versus cyclophosphamide, vincristine and prednisone. Cancer 56: 2369, Raphael B, Andersen JW, Silber R et al. Comparison of chlorambucil and prednisone as initial treatment for chronic lymphocytic leukemia. Long-term follow-up of an Eastern Cooperative Oncology Group randomized clinical trial. J Clin Oncol 9: 770, French Cooperative Group on Chronic Lymphocytic Leukemia. Is the CHOP regimen a good treatment for advanced CLL? Results from two randomized clinical trials. Leuk Lymphoma 13: 449, Keating MJ, Scouros M, Murphy S et al. Multiple agent chemotherapy (POACH) in previously treated and untreated patients with chronic lymphocytic leukemia. Leukemia 2: 391, Keating MJ, Hester JP, McCredie KB et al. Long-term results of CAP therapy in chronic lymphocytic leukemia. Leuk Lymphoma 2: 391, Kempin S, Lee BJ III, Thaler HT et al. Combination chemotherapy of advanced chronic lymphocytic leukemia : the M-2 protocol (vincristine, BCNU, cyclophosphamide, melphalan and prednisone). Blood 60: 1110, Keating MJ, Kantarjian MJ, O Brien S et al. Fludarabine : a new agent with marked cytoreductive activity in untreated chronic lymphocytic leukaemia. J Clin Oncol 9: 44, Keating MJ, O'Brien S, Kantarjian H et al. Long-term follow-up of patients with chronic lymphocytic leukemia treated with fludarabine as single agent. Blood 81: 2878, O Brien S, Kantarjian H, Beran M et al. Results of fludarabine and prednisone therapy in 264 patients with chronic lymphocytic leukemia with multivariate analysis-derived prognostic model for response to treatment. Blood 82: 1695, Robertson LE, O Brien S, Kantarjian H et al. A 3-day schedule of fludarabine in previously treated chronic lymphocytic leukemia. Leukemia 9: 1444, Hiddemann W, Rottmann R, Woermann B et al. Treatment of advanced chronic lymphocytic leukemia by fludarabine- Results of a clinical phase II study. Ann Hematol 63: 1, Montserrat E, Lopez-Lorenzo JL, Manso F et al. Fludarabine in resistant or relapsing B-cell chronic lymphocytic leukemia The spanish Group experience. Leuk Lymphoma 21: 467, Gjedde SB, Hansen MM. Salvage therapy with fludarabine in patients with progressive B- chronic lymphocytic leukemia. Leuk Lymphoma 21: 317, Puccio CA, Mittelman A, Lichtman SM et al. A loading dose/continuous infusion schedule of fludarabine phosphate in chronic lymphocytic leukemia. J Clin Oncol 9: 1562, Juliusson G, Elmhorn-Rosenborg A, Liliemark J. Response to 2-chlorodeoxyadenosine in patients with B- cell chronic lymphocytic leukemia resistant to fludarabine. N Eng J Med 327: 1056, Saven A, Carrera CJ, Carson DA et al. 2 Chlorodeoxyadenosine treatment of refractory chronic CLL3R protocol, Revision date: Status: active Page 28 of 71