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Leukemias
Chronic Lymphocytic Leukemia:
Recent Advances in Diagnosis and Treatment
Brian L. Abbott

Leukemia/Lymphoma Program, University of Colorado Health Science Center, Aurora, Colorado, USA

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Key Words. CLL • Chronic lymphocytic leukemia • Rituximab • ZAP70

Learning Objectives
After completing this course, the reader will be able to:
1. Discuss prognostic markers for CLL, including ZAP70 expression, IgVH rearrangements, and CD38 expression.
2. Describe the latest chemotherapy regimens for CLL, including combinations containing nucleoside analogues and
monoclonal antibodies.
3. Describe appropriate indications for initiation of treatment for CLL.

CME Access and take the CME test online and receive 1 AMA PRA category 1 credit at CME.TheOncologist.com

Abstract
Chronic lymphocytic leukemia (CLL) is a low-grade B-
lineage lymphoid malignancy but may have more het-
erogeneity than previously thought. Many cases require
no treatment at all because of an indolent course, while
other patients become symptomatic or develop signs of
rapid progression. Treatment is usually noncurative
and is directed at reducing the symptoms. Some molec-
ular risk features may help delineate, at initial diagno-
sis, which patients will have a more aggressive course.
Newer CLL treatment regimens incorporating purine
nucleoside analogues and monoclonal antibodies have
increased the rate of molecular complete remissions,
which may lead to better survival times. Reduced inten-
sity allogeneic transplant conditioning regimens have
made the potentially curative modality more widely
available. All these treatments have significant risks
for infectious complications, which must be carefully
weighed against the risks posed by the underlying dis-
ease. A proposed risk-based treatment algorithm is dis-
cussed. The Oncologist 2006;11:21–30

Diagnosis and Staging ent in up to 4% of elderly individuals, and most of these

Chronic lymphocytic leukemia (CLL) is predominantly a cases do not ever progress to meet the diagnostic criteria of
disease of older individuals; most patients are older than 50 CLL [3]. CLL may present as a lymph node–based disease,
at the time of initial diagnosis [1, 2]. Furthermore, the dis- called small lymphocytic lymphoma (SLL), and the treat-
ease often has slow progression, so many of these patients ment is generally the same as for CLL. However, CLL may
ultimately succumb to other medical problems rather than also present in up to 5% of patients with large-cell (Rich-
to CLL. Additionally, a monoclonal lymphocytosis is pres- ter’s) transformation in the lymph nodes, requiring more
Correspondence: Brian L. Abbott, M.D., Leukemia/Lymphoma Program, University of Colorado Health Science Center, 1665 N. Ursula
Street, Room CP-2254, (P.O. Box 6510 Mail Stop F-704), Aurora, Colorado 80010, USA. Telephone: 720-848-0300; Fax: 720-848-
0360; e-mail: Brian.Abbott@uchsc.edu Received June 29, 2005; accepted for publication October 14, 2005. ©AlphaMed Press 1083-
7159/2006/$12.00/0

The Oncologist 2006;11:21–30 www.TheOncologist.com

22
aggressive treatment with large-cell lymphoma regimens
and with often poor outcome.
The most common presenting symptom in CLL is
lymph node swelling, while smaller numbers of patients
report “B” symptoms (fever, weight loss, or night sweats),
and 25% of patients are asymptomatic. The most com-
mon physical findings with CLL include lymphadenopa-
thy (87%), splenomegaly (54%), and hepatomegaly (14%).
Occasionally, laboratory abnormalities are seen in newly
diagnosed CLL. About 10% of patients present with a
Coombs-positive autoimmune hemolytic anemia. Ten per-
cent of patients may have hypogammaglobulinemia, and
another 15% may have hypergammaglobulinemia or even a
monoclonal gammopathy. Most asymptomatic patients are
identified on the basis of an absolute lymphocytosis on rou-
tine complete blood count.
A bone marrow aspirate and biopsy are necessary for
full diagnostic and prognostic information. Bone marrow
findings in CLL include normal to high cellularity with a
B lymphocyte population that is monoclonal for kappa or
lambda light chain expression. The immunophenotype
of this lymphocyte population includes the pathognomic
coexpression of CD5 and CD19, as well as positivity for
CD20, CD21, CD23, and CD24. Several variable immu-
nophenotypic findings with prognostic importance, dis-
cussed later, include CD38 expression and intracellular
expression of zeta-associated protein (ZAP70). Bone mar-
row should also be sent for cytogenetics, and a fluorescence
in situ hybridization (FISH) panel for common chromo-
somal abnormalities (del[17p], del[11q22-23], del[13q14],
and trisomy 12) should be done in order to provide superior
prognostic information.
Important diseases to exclude include mantle cell leuke-
mia/lymphoma, hairy cell leukemia, and prolymphocytic
leukemia (PLL). Mantle cell leukemia/lymphoma is dis-
tinguished from CLL by CD23 negativity and intracellular
cyclin D1 expression, by immunohistochemistry or flow
cytometry, and the presence of t(11;14), by cytogenetics and/
or FISH. Hairy cell leukemia and PLL are morphologically
distinct from CLL and lack expression of CD5. Splenic mar-
ginal zone lymphoma (SMZL) with circulating villous lym-
phocytes may also mimic CLL, with bone marrow involve-
ment, a serum monoclonal protein spike, and an indolent
course. However, SMZL cells are generally morphologi-
cally distinct from CLL lymphocytes, with a plasmacytoid
basophilic cytoplasm, and also express CD11c [4]. Rapidly
enlarging lymph nodes should be biopsied to exclude the
presence of Richter’s transformation, which would require
more aggressive treatment than nontransformed CLL/SLL.
The earliest systems of CLL risk stratification rely on the
measurement of disease bulk at initial diagnosis (Table 1).
Advances in CLL
Rai et al. reported a staging system that includes lymphade-
nopathy, splenogmegaly, anemia, and thrombocytopenia
as markers of progressive disease bulk, from stage 0 to 4
[5]. Binet et al. reported a simplified staging system that
relies on the number of enlarged lymph nodes and the pres-
ence of anemia or thrombocytopenia for stages A–C [6].
With both staging systems, patients with the most advanced
stage have a predicted survival duration of 1–2 years, while
Table 1. Chronic lymphocytic leukemia (CLL) diagnosis,
staging, and risk stratification
Diagnostic criteria (all of the following)
1. Lymphocytes > 5 × 109/l
2. Duration of lymphocytosis >2 months
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3. Bone marrow lymphocytes > 30%
4. Flow cytometry findings in the majority
of lymphocytes
i. Kappa or lambda monoclonality
ii. CD5+, CD19+, CD23+, CD20 weak or positive
iii. Cyclin D1 negative, CD22 weak or negative
Staging at diagnosis (Rai system)
0. Lymphocytosis
1. Lymph node enlargement
2. Spleen enlargement
3. Hemoglobin < 11 g/dl
4. Platelets < 100,000/μl
Staging at diagnosis (Binet system)
1. Lymphocytosis
2. Lymph node enlargement in > 3 areas
3. Cytopenia: hemoglobin < 10 g/dl or platelets
<100,000/μl
High-risk features for CLL
1. CD38 expression in > 30% of lymphocytes
2. ZAP70 expression in > 30% of lymphocytes
3. Unmutated (germline) IgVH gene
4. High-risk cytogenetic abnormalities
a. 14q changes
b. 11q changes
c. 17p depletion
d. Trisomy 12
5. Rai stage 3 or 4 or Binet stage C
6. Doubling time of lymphocyte count <12 months
7. Elevated beta-2 microglobulin
8. Elevated serum thymidine kinase
9. Presence of large-cell transformation
(Richter’s syndrome)
Abbreviations: IgVH, immunoglobulin heavy chain;
ZAP70, zeta-associated protein.
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patients with the lowest stage of disease have a median sur-
vival time of over 10 years. Staging for patients in suspected
relapse is individualized and based on the sites of initial dis-
ease involvement. The Rai and Binet staging systems have
not been validated in large studies for relapsed patients, and
the prognosis for these patients is probably more correlated
with their molecular risk features as well as duration of pre-
vious remission.
Prognostic Factors
Several biologic markers have been associated with a more
aggressive form of CLL. These include rapid lymphocyte
doubling time, cytogenetic findings, serum beta-2 micro-
globulin (B2M), CD38 expression, unmutated (germline)
immunoglobulin heavy chain gene, and ZAP70 expression.
Rapid lymphocyte doubling time is usually defined as the
doubling of peripheral blood absolute lymphocyte count
(ALC) in less than 12 months. Montserrat et al. reported
a median survival time of over 118 months for patients
with slow lymphocyte doubling times, while patients with
rapid doubling times had a median survival time of only
61 months [7], which is independent of Rai stage [8]. B-
cell CLL/lymphoma 2 (BCL2) expression is associated
with a shorter survival time in CLL [9]. Conflicting data
exist regarding whether an elevated serum B2M level is an
independent adverse prognostic feature [10, 11]. Elevated
serum thymidine kinase has been identified as a risk factor
for more aggressive disease [12].
CD38 is a cell surface molecule frequently expressed
on leukemic cells in patients who experienced relatively
early CLL progression [13]. The threshold for consider-
ing a case CD38-positive is expression in more than 30%
of cells by flow cytometry. CD38 positivity is associated
with significantly shorter overall survival and progres-
sion-free survival times [14], and also a poor response
to fludarabine (Fludara® ; Berlex Laboratories, Wayne,
NJ, http://www.berlex.com) [15]. Ghia et al. reported that
patients with CD38 + CLL had a 75% probability of pro-
gression at a median follow-up of 90 months, compared
with 13% probability in patients without CD38 expres-
sion [16].
The absence of immunoglobulin heavy chain (IgVH)
mutations, also termed germline IgVH, is also associated
with a high risk for early progression [17–19]. However, a
test for the detection of IgVH mutations is not widely avail-
able. Expression of the intracellular signaling molecule
ZAP70 has been identified in a majority of CLL cases with-
out IgVH mutations, and ZAP70 expression is highly pre-
dictive of patients with more rapid disease progression and
death [20, 21]. Prospective trials are ongoing to determine
whether the treatment of patients with ZAP70 + CLL in a
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23
more aggressive fashion will improve clinical outcomes.
Caution is warranted in interpreting results from ZAP70
assays, as intracellular flow cytometry can be a difficult
assay to perform reproducibly even in experienced labora-
tories. Thus, ZAP70 analysis remains a prognostic tool of
uncertain clinical use.
Several cytogenetic changes have been associated with
poorer survival in newly diagnosed CLL patients. Doh-
ner et al. reported the most extensive study of cytogenet-
ics in CLL [22]. The most unfavorable feature was dele-
tion of 17p, which was present in 7% of patients, who had
a median survival time of 32 months. An intermediate risk
was associated with the deletion of 11q [22, 23], the site of
the ataxia-telangectasia (ATM) gene, which was present
in 18% of patients (median survival time of 79 months).
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Certain cytogenetic changes were associated with a more
favorable prognosis, including 13q14 deletion, present in
approximately half of patients (median survival time of 133
months), and trisomy 12, present in 16% of patients (median
survival time of 114 months). Also, the development of 17p
deletion is associated with abnormalities in the tumor sup-
pressor gene p53 and is more likely to occur as a clonal evo-
lution after initial diagnosis [23]. Panels of FISH probes
for common abnormalities may be used in the diagnosis of
CLL, since metaphase cytogenetics may be difficult in the
largely quiescent cells of CLL.
Treatment
Indications for Treatment
CLL is a disease that is often monitored for a number of
years without treatment. Because of the lack of data dem-
onstrating that early treatment of asymptomatic CLL results
in any survival benefit, the National Cancer Institute Work-
ing Group (NCIWG) has published recommended criteria
for treatment initiation [24]. These guidelines include the
development of “B” symptoms (weight loss > 10% within 6
months, fevers for 2 weeks, night sweats, or extreme fatigue),
worsening anemia and/or thrombocytopenia, autoimmune
cytopenias, progressive splenomegaly, progressive lymph-
adenopathy, and lymphocyte doubling time of 6 months.
The choice of first-line treatment depends on the
patient’s risk factors. Younger patients or those with higher
stages or with adverse prognostic factors may benefit from
more aggressive combination regimens and consideration
for allogeneic transplant early in their disease course, as this
is the only potentially curative therapy. Currently, no pro-
spective data exist to support the early treatment of patients
with adverse prognostic features, although it seems likely
that attainment of complete molecular remission may lead
to longer survival. Thus, any aggressive treatment should
24
preferably be offered through a clinical trial when possible.
Older patients and patients with no identifiable molecular
adverse prognostic features are less likely to ever require
treatment. When treatment is indicated in these patients,
goals of therapy should focus on minimizing the disease
symptoms while avoiding excessive risk for treatment-
related toxicity.
The treatment of relapse requires careful analysis of a
patient’s risk factors, response to prior therapy, duration of
response, and comorbid medical conditions. If the previous
duration of response was > 3–5 years, consideration may be
given to repeating the previous treatment. For shorter remis-
sions, therapy should be modified. For young patients with
short remissions (< 1–2 years), allogeneic transplantation
may be considered following retreatment and attainment of
complete remission. For older or sicker patients, palliation
should be used, with treatments less likely to induce myelo-
suppression or infectious risk.
Chemotherapy
In previous decades, CLL therapy consisted primarily of
alkylating agents, such as chlorambucil (Leukeran®; Glaxo-
SmithKline, Philadelphia, http://www.gsk.com). One limi-
tation of this treatment is a 2.5-fold greater risk for second-
ary acute myeloid leukemia in patients with prior exposure
to alkylating agents [25]. For older patients seeking pal-
liation of disease symptoms, alkylating agents may have a
useful therapeutic role, although there is no demonstrable
survival benefit with any therapy in this patient population.
Multiagent therapy is not indicated, as there is additional
risk for toxicity without proven benefit. The chemotherapy
regimen of cyclophosphamide, vincristine (Oncovin®; Eli
Lilly and Company, Indianapolis, http://www.lilly.com),
and prednisone (Deltasone®; Pfizer Pharmaceuticals, New
York, http://www.pfizer.com) (CVP) was compared with
chlorambucil and prednisone, and no difference in survival
was noted after 7 years of follow-up [26].
Purine Nucleoside Analogues
Purine nucleoside analogues, such as fludarabine (FAMP),
pentostatin (2-deoxycoformycin; Nipent®; SuperGen, Inc.,
Pleasanton, CA, http://www.supergen.com), and cladribine
(2-CDA, 2-chlorodeoxyadenosine; Leustatin®; Ortho Bio-
tech Products, L.P., Bridgewater, NJ, http://www.orthobio-
tech.com), are highly active agents in the treatment of CLL.
Fludarabine as a single agent was shown to have remark-
able activity in a range of indolent lymphoid malignancies
refractory to other treatments, including up to a 100% com-
plete remission rate in relapsed CLL [27]. Fludarabine was
shown to be superior to chlorambucil in a major intergroup
study, with a higher response rate and longer disease-free
Advances in CLL
interval [28]. Single-agent fludarabine also has response
rates superior to those of several combination regimens,
such as cyclophosphamide, doxorubicin (Adriamycin® ;
Bedford Laboratories, Bedford, OH, http://www.bedford-
labs.com), vincristine, and prednisone (CHOP) and CVP,
in previously untreated CLL [29]. Keating et al. reported
long-term results from 174 patients following initial treat-
ment with fludarabine [30]. The overall response rate was
78%, and the median survival time was 63 months. Among
responders, the median survival time was 74 months, and
the median time to progression was 31 months.
The incorporation of fludarabine into combination
regimens has resulted in further improvements in response
rates. With the addition of cyclophosphamide to fluda-
rabine (FC regimen), O’Brien et al. reported an overall
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response rate >80% in previously untreated CLL patients,
and the median duration of response was not reached at 41
months [31]. Hallek et al. reported the results from 29 pre-
viously treated patients with advanced CLL using the FC
regimen [32]. Five of 29 (17%) had complete responses and
24 of 29 (83%) had partial responses. The addition of ritux-
imab (Rituxan® ; Genentech, Inc., South San Francisco,
CA, http://www.gene.com) (FCR regimen) appears to have
further improved response rates, as discussed below.
Other purine nucleoside analogues also have demon-
strated activity against primary and refractory CLL. Pen-
tostatin has demonstrated efficacy against CLL, both as a
single agent [33, 34] and in combination regimens [35, 36].
Pentostatin regimens may be given in a single day, mak-
ing them more convenient than the multiday infusions of
fludarabine, and they may have less myelosuppression than
fludarabine. Cladribine has been studied in several small
trials [37–40]. Clofarabine (Clolar®; Genzyme Oncology,
Cambridge, MA, http://www.genzyme.com) is a newly
approved nucleoside analogue indicated for the treatment
of pediatric leukemia; trials are ongoing to determine its
efficacy in CLL. In vitro cytotoxicity data show that clo-
farabine may be superior to cladribine in CLL cell lines
[41]. Overall, the other nucleoside analogues appear to have
roughly similar clinical efficacy as fludarabine, as summa-
rized in Table 2, but there is a lack of randomized studies
comparing nucleoside analogues.
Toxicities of nucleoside analogues are relatively fre-
quent and may be occasionally severe. These include
myelosuppression, which may predispose to a variety of
infections, including infection by bacteria and fungi. There
is also significant lymphosuppression, necessitating the
use of Pneumocystis carinii and herpes simplex infection
prophylaxis. Autoimmune hemolytic anemia has been
reported. Long-term hematopoietic stem cell damage may
also persist, as evidenced by the occasional difficulty in
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Table 2. Selected trials using purine nucleoside analogues and combinations in the treatment of chronic lymphocytic leukemia (CLL)
No. of
Study CLL status Agents patients CR mCR TTF
Rai et al. [28] Untreated F 170 20% NR 25 months
Schulz et al. [50] Untreated FR 20 25% NR 19 months
Byrd et al. [47] Untreated F→R (sequential) 53 28% NR >23 months
Untreated F+R (concurrent) 51 47% NR >23 months
O’Brien et al. [31] Untreated FC 128 35% 8% >41 months
a
Keating et al. [52] Untreated FCR 224 70% 99% 69% at 4 years
Wierda et al. [53] Relapsed FCR 177 25% 8% 39 months
Wierda et al. [58] Relapsed FCRA (CFAR) 31 23% NR NR
Bosch [70] Relapsed FCM 60 50% 17% 19 months
Saven et al. [40] Untreated 2-CDA 20 25% NR >8 months
Byrd et al. [51] Refractory 2-CDA 28 0% 0% NR

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Montillo et al. [39] Relapsed 2-CDA/C 29 38% NR 12 months
Johnson et al. [33] Refractory P 29 8% NR NR
Weiss et al. [35] Relapsed P/C 23 17% NR NR
Weiss et al. [49] Relapsed PCR 13 31% NR NR
a
As evaluated by flow cytometry.
Abbreviations: 2-CDA, cladribine; C, cyclophosphamide; CR, complete remission; F, fludarabine; FC, fludarabine, cyclo-
phosphamide; FCM, fludarabine, cyclophosphamide, mitoxantrone; FCR, fludarabine, cyclophosphamide, rituximab; FCRA
(CFAR), fludarabine, cyclophosphamide, rituximab, alemtuzumab; FR, fludarabine, rituximab; NR, not reported; PCR, pento-
statin, cyclophosphamide, rituximab; mCR, molecular complete remission; P, pentostatin; R, rituximab; TTF, time to treatment
failure (among complete responders).

mobilization of autologous stem cells in some prior recipi-
ents of nucleoside analogues [42, 43]. Finally, there are rare
reports of secondary acute myeloid leukemia following
nucleoside analogue treatment [44].
Immunotherapy
Rituximab
Rituximab is a humanized murine monoclonal antibody
that binds CD20 and has activity against most B-lineage
lymphoid malignancies, including CLL. Most studies in
CLL have used higher rituximab doses than those used
in lymphoma treatment because of lower CD20 density
on CLL cells [45, 46]. Single-agent rituximab has rather
limited efficacy in CLL. Rituximab has been added to the
fludarabine [47] and fludarabine plus cyclophosphamide
(FCR) [48] regimens, as well as the pentostatin plus cyclo-
phosphamide (PCR) regimen [49] (Table 1). The addition
of rituximab to fludarabine (FR regimen) has been shown
to produce higher overall and complete response rates [50],
as well as longer disease-free and overall survival times in
previously untreated CLL patients [51]. The FCR regimen
produces a high complete remission rate in both previously
untreated [52] and relapsed CLL patients [53]. Common
side effects of this regimen include infections and cytope-
nias; antibiotic prophylaxis for herpes simplex, fungi, bac-
teria, and Pneumocystis is often recommended.
Alemtuzumab
Alemtuzumab (Campath®; Berlex Laboratories, Wayne,
NJ, http://www.berlex.com) is a monoclonal antibody
against CD52, an antigen expressed on lymphocytes (B,
T, and NK cells), monocytes, and some granulocytes. It
is approved for treatment of relapsed CLL and has been
reviewed elsewhere [54]. Rates of molecular complete
remission approach 38% using alemtuzumab in fludara-
bine-refractory patients [55, 56]. Alemtuzumab has also
been studied in combinations with rituximab [57] and with
the FCR combination [58]. Trials are also studying the use
of alemtuzumab as a consolidative treatment following ini-
tial combination therapy.
Subcutaneous administration of alemtuzumab is better
tolerated than i.v. administration [59]. Comparable serum
antibody levels were found with s.c. administration, and
efficacy was similar. Immediate side effects of s.c. alem-
tuzumab injection are predominantly local, including
localized erythema, and the potentially severe infusional
side effects such as fever and chills are rare. Longer-term
side effects of alemtuzumab relate to its profound immuno-
suppression, leading to a relatively high rate of infectious

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26
complications, including cytomegalovirus reactivation and
Epstein-Barr virus lymphoproliferative disease.
Other Immunotherapies
Denileukin deftitox (Ontak®; Ligand Pharmaceuticals, San
Diego, CA, http://www.ligand.com) is an interleukin-2 (IL2)
and diphtheria toxin fusion protein that targets CD25, which
is part of the IL2 receptor complex. It is approved for the treat-
ment of cutaneous T cell lymphoma (CTCL) but not CLL.
While CD25 is primarily expressed on normal and malig-
nant T lymphocytes, there is evidence that this agent also has
efficacy in B lineage CLL. A phase II study of denileukin
deftitox in 12 fludarabine-refractory CLL patients revealed
that 11 patients had a reduction in their circulating CLL cells,
and six of these reductions were greater than 95% [60]. Other
immunotherapies in clinical development include: anti-
CD23 (Lumiliximab® ; Biogen-IDEC, Cambridge, MA,
http://www.biogenidec.com), anti-CD22 (Epratuzumab®;
Immunomedics, Morris Plains, NJ, http://www.immuno-
medics.com), apolizumab (Hu1D10, anti–HLA-DR; Protein
Design Labs, Fremont, CA, http://www.pdl.com), and anti-
CD80 (anti-B7, IDEC-114; Biogen-IDEC).
Hematopoietic Cell Transplantation
Allogeneic
Allogeneic hematopoietic cell transplantation (HCT) is
the only curative CLL treatment. Until recently, allogeneic
HCT relied on myeloablative doses of chemoradiotherapy,
which made the treatment unacceptably risky for the major-
ity of CLL patients. The largest reported long-term experi-
ence of myeloablative allogeneic HCT for CLL was reported
by Khouri et al. [61]. Twenty-eight patients were treated
for CLL with allogeneic HCT and myeloablative doses of
cyclophosphamide and total body irradiation (TBI). The
investigators reported 5-year progression-free survival
rates of 78% for previously untreated patients and 31% for
chemotherapy-refractory patients. However, the mortal-
ity rate at 100 days was 11%. These results demonstrate the
potentially curative nature of allogeneic transplantation for
CLL and also suggest that delaying allotransplant until the
development of refractory disease may result in worse clini-
cal outcomes.
Nonmyeloablative Allogeneic
The role of dose escalation in allogeneic transplantation
has been called into question, and many investigators sug-
gest that allogeneic antileukemic effects represent the most
important therapeutic aspect in CLL. In nonmyeloablative,
or reduced-intensity, approaches, using immunosuppres-
sive doses of purine nucleoside analogues and relatively
Advances in CLL
low doses of either an alkylating agent or irradiation, rates
of engraftment similar to fully ablative conditioning regi-
mens have been achieved with lower rates of early toxicity
[62, 63]. Representative nonmyeloablative transplant clini-
cal trials are summarized in Table 3. Excellent rates of dis-
ease response, including molecular remissions, have been
reported for CLL, as summarized in Table 4.
Early evidence suggests that the graft versus leukemia
(GVL) effect is present against disease with poor prognos-
tic factors. Ritgen et al. report that seven of nine patients
with unmutated (germline) IgH genes remained in molec-
ular complete remission (assessed by polymerase chain
reaction) at a median of 25 months after nonmyeloablative
allotransplantation [64]. Further proof of a GVL effect
is demonstrated by the induction of complete remission
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of CLL in many patients with persistent disease follow-
ing the administration of donor leukocyte infusion [65].
Finally, allotransplant recipients experiencing chronic
graft-versus-host disease (GVHD) have a significantly
lower risk for CLL relapse than patients experiencing no
GVHD [66].
Autologous
Studies involving autologous transplantation and high-dose
chemotherapy for CLL have failed to demonstrate a survival
advantage despite initial high rates of complete molecular
response [67]. This may be due in part to intrinsic chemore-
sistance of CLL, lack of a steep dose-response curve, or the
reinfusion of malignant cells in the thawed hematopoietic
progenitor cell product. Purging strategies with monoclo-
nal antibodies have not improved survival, and infectious
complications are frequent [68, 69]. In view of limited effi-
cacy, the use of autotransplantation in CLL cannot be rec-
ommended outside the context of a clinical trial.
Conclusions: A Risk-Based Treatment
Approach
Recent advances in the management of CLL include molec-
ular diagnostic techniques, nucleoside analogue combina-
tion regimens, monoclonal antibodies, and nonmyeloabla-
tive allogeneic stem cell transplantation. Improvements in
diagnostic techniques, such as molecular cytogenetics to
detect ZAP70 expression and the absence of IgVH rear-
rangements, may help target aggressive therapy to high-risk
patients, although it remains unproven whether this will
result in higher rates of long-term survival.
If indications for treatment exist, patients should gener-
ally be offered the opportunity to participate in a clinical
trial. In the absence of a clinical trial, first-line therapy in
healthy patients usually involves a combination regimen
containing a nucleoside analogue, such as a fludarabine.
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Table 3. Selected allogeneic hematopoietic cell transplantation trials with purine analogue conditioning regimens
No. of
Study Agents patients GVHD prophylaxis aGVHD TRM
Slavin et al. [63] Busulfan/fludarabine/ATG 26 CSA 46% 15%
Schetelig [78] Busulfan/fludarabine/ATG 30 CSA + MMF or MTX 56% 13%
Khouri et al. [61] Fludarabine/cyclophosphamide/ 20 Tac/MTX 20% 5%
rituximab
Childs [74] Fludarabine/cyclophosphamide 12 CSA 60% 13%
Pedrazolli [75] Fludarabine/cyclophosphamide 17 CSA/MTX 29% 9%
Corradini [79] Fludarabine/cyclophosphamide/ 45 CSA/MTX 47% 13%
thiotepa
Carella [76] Fludarabine/cyclophosphamide 15 CSA/MTX 47% 27%
Liu [77] Mitoxantrone/Ara-C/Pentostatin 25 NR 32% NR
Abbreviations: aGVHD, acute graft-versus-host disease, grade 2–4; Ara-C, cytarabine; ATG, antithymocyte globulin; CSA,

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cyclosporine A; GVHD, graft-versus-host disease; MMF, mycophenolate mofetil; MTX, methotrexate; NR, not reported; Tac,
tacrolimus; TRM, treatment-related mortality.

Table 4. Selected nonmyeloablative allogeneic hematopoietic cell transplantation trials including patients with chronic lym-
phocytic leukemia
Study Conditioning regimen CR mCR
Schetelig [78] Busulfan/fludarabine/ATG 12/30 8/30
Corradini [79] Fludarabine/cyclophosphamide/thiotepa 3/4 2/4
McSweeney [80] Fludarabine/TBI 4/8 3/8
Khouri et al. [61] Fludarabine/cyclophosphamide with or without rituximab 2/2 NR
Ritgen et al. [64] Fludarabine/cyclophosphamide 8/9 7/9
Abbreviations: ATG, antithymocyte globulin; CR, complete response; mCR, molecular complete remission; NR, not reported;
TBI, total body irradiation.

Older patients with indications for treatment may receive
chlorambucil and prednisone. Younger patients with no
comorbidities and high-risk disease attributes may be
candidates for a more intense combination, such as FCR
or PCR, which increase the likelihood of attaining a com-
plete molecular remission. In first remission, patients are
generally followed until demonstrating signs of relapse.
Following retreatment with a relapse therapy, such as
alemtuzumab, appropriate patients may be considered for
nonmyeloablative allogeneic transplantation if a suitable
matched sibling donor is available. Nontransplant candi-
dates may be followed until additional relapse occurs and,
when treatment is again indicated, may receive retreatment
with a previously administered regimen or investigational
agents in a clinical trial. All these treatments have risks for
significant infectious complications, which must be care-
fully weighed against the risks of their CLL. With recent
improvements in prognostic features and treatments, the
management of CLL is now much more challenging and
rewarding than in past decades.
Disclosure of Potential Conflicts
of Interest
The author indicates no potential conflicts of interest.

References 4 Catovsky D, Matutes E. Splenic lymphoma with circulating villous

lymphocytes/splenic marginal-zone lymphoma. Semin Hematol
1 Foon KA, Rai KR, Gale RP. Chronic lymphocytic leukemia: new insights
1999;36:148–154.
into biology and therapy. Ann Intern Med 1990;113:525–539.
5 Rai KR, Sawitsky A, Cronkite EP et al. Clinical staging of chronic lym-
2 O’Brien S, del Giglio A, Keating M. Advances in the biology and treat-
ment of B-cell chronic lymphocytic leukemia. Blood 1995;85:307–318. phocytic leukemia. Blood 1975;46:219–234.

3 Ghia P, Prato G, Scielzo C et al. Monoclonal CD5+ and CD5- B-lympho- 6 Binet JL, Auquier A, Dighiero G et al. A new prognostic classification
cyte expansions are frequent in the peripheral blood of the elderly. Blood of chronic lymphocytic leukemia derived from a multivariate survival
2004;103:2337–2342. analysis. Cancer 1981;48:198–206.

www.TheOncologist.com
28
7 Montserrat E, Sanchez-Bisono J, Vinolas N et al. Lymphocyte doubling
time in chronic lymphocytic leukaemia: analysis of its prognostic signifi-
cance. Br J Haematol 1986;62:567–575.
8 Molica S, Alberti A. Prognostic value of the lymphocyte doubling time in
chronic lymphocytic leukemia. Cancer 1987;60:2712–2716.
9 Faderl S, Keating MJ, Do KA et al. Expression profile of 11 proteins and
their prognostic significance in patients with chronic lymphocytic leuke-
mia (CLL). Leukemia 2002;16:1045–1052.
10 Spati B, Child JA, Kerruish SM et al. Behaviour of serum beta 2-micro-
globulin and acute phase reactant proteins in chronic lymphocytic leukae-
mia. A multicentre study. Acta Haematol 1980;64:79–86.
11 Molica S, Levato D, Cascavilla N et al. Clinico-prognostic implications
of simultaneous increased serum levels of soluble CD23 and beta2-
microglobulin in B-cell chronic lymphocytic leukemia. Eur J Haematol
1999;62:117–122.
12 Hallek M, Langenmayer I, Nerl C et al. Elevated serum thymidine kinase
levels identify a subgroup at high risk of disease progression in early, non-
smoldering chronic lymphocytic leukemia. Blood 1999;93:1732–1737.
13 Damle RN, Wasil T, Fais F et al. Ig V gene mutation status and CD38
expression as novel prognostic indicators in chronic lymphocytic leuke-
mia. Blood 1999;94:1840–1847.
14 Jelinek DF, Tschumper RC, Geyer SM et al. Analysis of clonal B-cell
CD38 and immunoglobulin variable region sequence status in relation to
clinical outcome for B-chronic lymphocytic leukaemia. Br J Haematol
2001;115:854–861.
15 Del Poeta G, Maurillo L, Venditti A et al. Clinical significance of CD38
expression in chronic lymphocytic leukemia. Blood 2001;98:2633–2639.
16 Ghia P, Guida G, Stella S et al. The pattern of CD38 expression defines a
distinct subset of chronic lymphocytic leukemia (CLL) patients at risk of
disease progression. Blood 2003;101:1262–1269.
17 Hamblin TJ, Davis Z, Gardiner A et al. Unmutated Ig V(H) genes are
associated with a more aggressive form of chronic lymphocytic leukemia.
Blood 1999;94:1848–1854.
18 Lin K, Sherrington PD, Dennis M et al. Relationship between p53 dys-
function, CD38 expression, and IgV(H) mutation in chronic lymphocytic
leukemia. Blood 2002;100:1404–1409.
19 Krober A, Seiler T, Benner A et al. V(H) mutation status, CD38 expression
level, genomic aberrations, and survival in chronic lymphocytic leuke-
mia. Blood 2002;100:1410–1416.
20 Crespo M, Bosch F, Villamor N et al. ZAP-70 expression as a surrogate
for immunoglobulin-variable-region mutations in chronic lymphocytic
leukemia. N Engl J Med 2003;348:1764–1775.
21 Wiestner A, Rosenwald A, Barry TS et al. ZAP-70 expression identifies
a chronic lymphocytic leukemia subtype with unmutated immunoglobu-
lin genes, inferior clinical outcome, and distinct gene expression profile.
Blood 2003;101:4944–4951.
22 Dohner H, Stilgenbauer S, Benner A et al. Genomic aberrations and sur-
vival in chronic lymphocytic leukemia. N Engl J Med 2000;343:1910–
1916.
23 Thornton PD, Gruszka-Westwood AM, Hamoudi RA et al. Characterisa-
tion of TP53 abnormalities in chronic lymphocytic leukaemia. Hematol J
2004;5:47–54.
24 Cheson BD, Bennett JM, Grever M et al. National Cancer Institute-
sponsored Working Group guidelines for chronic lymphocytic leuke-
mia: revised guidelines for diagnosis and treatment. Blood 1996;87:
4990–4997.
Advances in CLL
25 Robertson LE, Estey E, Kantarjian H et al. Therapy-related leukemia and
myelodysplastic syndrome in chronic lymphocytic leukemia. Leukemia
1994;8:2047–2051.
26 Raphael B, Andersen JW, Silber R et al. Comparison of chlorambucil and
prednisone versus cyclophosphamide, vincristine, and prednisone as ini-
tial treatment for chronic lymphocytic leukemia: long-term follow-up of
an Eastern Cooperative Oncology Group randomized clinical trial. J Clin
Oncol 1991;9:770–776.
27 Redman JR, Cabanillas F, Velasquez WS et al. Phase II trial of fludarabine
phosphate in lymphoma: an effective new agent in low-grade lymphoma.
J Clin Oncol 1992;10:790–794.
28 Rai KR, Peterson BL, Appelbaum FR et al. Fludarabine compared with
chlorambucil as primary therapy for chronic lymphocytic leukemia.
N Engl J Med 2000;343:1750–1757.
29 Leporrier M, Chevret S, Cazin B et al. Randomized comparison of fluda-
rabine, CAP, and ChOP in 938 previously untreated stage B and C chronic
lymphocytic leukemia patients. Blood 2001;98:2319–2325.
Downloaded from www.TheOncologist.com by on September 23, 2010
30 Keating MJ, O’Brien S, Lerner S et al. Long-term follow-up of patients
with chronic lymphocytic leukemia (CLL) receiving fludarabine regi-
mens as initial therapy. Blood 1998;92:1165–1171.
31 O’Brien SM, Kantarjian HM, Cortes J et al. Results of the fludarabine and
cyclophosphamide combination regimen in chronic lymphocytic leuke-
mia. J Clin Oncol 2001;19:1414–1420.
32 Hallek M, Schmitt B, Wilhelm M et al. Fludarabine plus cyclophospha-
mide is an efficient treatment for advanced chronic lymphocytic leukae-
mia (CLL): results of a phase II study of the German CLL Study Group. Br
J Haematol 2001;114:342–348.
33 Johnson SA, Catovsky D, Child JA et al. Phase I/II evaluation of pento-
statin (2’-deoxycoformycin) in a five day schedule for the treatment of
relapsed/refractory B-cell chronic lymphocytic leukaemia. Invest New
Drugs 1998;16:155–160.
34 Ho AD, Thaler J, Stryckmans P et al. Pentostatin in refractory chronic
lymphocytic leukemia: a phase II trial of the European Organization for
Research and Treatment of Cancer. J Natl Cancer Inst 1990;82:1416–
1420.
35 Weiss MA, Maslak PG, Jurcic JG et al. Pentostatin and cyclophospha-
mide: an effective new regimen in previously treated patients with chronic
lymphocytic leukemia. J Clin Oncol 2003;21:1278–1284.
36 Waselenko JK, Grever MR, Beer M et al. Pentostatin (Nipent) and chlo-
rambucil with granulocyte-macrophage colony-stimulating factor support
for patients with previously untreated, treated, and fludarabine-refrac-
tory B-cell chronic lymphocytic leukemia. Semin Oncol 2000;27(suppl
5):44–51.
37 Robak T, Blonski JZ, Kasznicki M et al. Cladribine with prednisone ver-
sus chlorambucil with prednisone as first-line therapy in chronic lympho-
cytic leukemia: report of a prospective, randomized, multicenter trial.
Blood 2000;96:2723–2729.
38 Robak T, Blonski JZ, Kasznicki M et al. Cladribine combined with cyclo-
phosphamide is highly effective in the treatment of chronic lymphocytic
leukemia. Hematol J 2002;3:244–250.
39 Montillo M, Tedeschi A, O’Brien S et al. Phase II study of cladribine and
cyclophosphamide in patients with chronic lymphocytic leukemia and
prolymphocytic leukemia. Cancer 2003;97:114–120.
40 Saven A, Lemon RH, Kosty M et al. 2-Chlorodeoxyadenosine activity
in patients with untreated chronic lymphocytic leukemia. J Clin Oncol
1995;13:570–574.
OTncologist
he ®
Abbott
41 Lindemalm S, Liliemark J, Gruber A et al. Comparison of cytotoxicity
of 2-chloro- 2’-arabino-fluoro-2’-deoxyadenosine (clofarabine) with
cladribine in mononuclear cells from patients with acute myeloid and
chronic lymphocytic leukemia. Haematologica 2003;88:324–332.
42 Tournilhac O, Cazin B, Lepretre S et al. Impact of frontline fludara-
bine and cyclophosphamide combined treatment on peripheral blood
stem cell mobilization in B-cell chronic lymphocytic leukemia. Blood
2004;103:363–365.
43 Lysak D, Koza V, Steinerova K et al. Mobilization of peripheral blood
stem cells in CLL patients after front-line fludarabine treatment. Ann
Hematol 2005;84:456–461.
44 Lam CC, Ma ES, Kwong YL. Therapy-related acute myeloid leukemia
after single-agent treatment with fludarabine for chronic lymphocytic
leukemia. Am J Hematol 2005;79:288–290.
45 Keating M, O’Brien S. High-dose rituximab therapy in chronic lympho-
cytic leukemia. Semin Oncol 2000;6(suppl 12):86–90.
46 O’Brien SM, Kantarjian H, Thomas DA et al. Rituximab dose-escalation
trial in chronic lymphocytic leukemia. J Clin Oncol 2001;19:2165–2170.
47 Byrd JC, Peterson BL, Morrison VA et al. Randomized phase 2 study of
fludarabine with concurrent versus sequential treatment with rituximab
in symptomatic, untreated patients with B-cell chronic lymphocytic leu-
kemia: results from Cancer and Leukemia Group B 9712 (CALGB 9712).
Blood 2003;101:6–14.
48 Lamanna N, Weiss MA, Maslak PG et al. Sequential therapy with fluda-
rabine, high dose cyclophosphamide, and rituximab induces a high inci-
dence of complete response in patients with chronic lymphocytic leuke-
mia (CLL). Proc Am Soc Clin Oncol 2003;22:580.
49 Weiss MA, Lamanna N, Maslak PG et al. Pentostatin, cyclophosphamide
and rituximab (PCR therapy): a new active regimen for previously treated
patients with chronic lymphocytic leukemia (CLL). Proc Am Soc Clin
Oncol 2003;22:580.
50 Schulz H, Klein SK, Rehwald U et al. Phase 2 study of a combined immu-
nochemotherapy using rituximab and fludarabine in patients with chronic
lymphocytic leukemia. Blood 2002;100:3115–3120.
51 Byrd JC, Rai KR, Peterson BL et al. The addition of rituximab to fluda-
rabine significantly improves progression-free and overall survival in
previously untreated chronic lymphocytic leukemia (CLL) patients. Proc
Am Soc Hematol 2003;102:245a.
52 Keating MJ, O’Brien S, Albitar M et al. Early results of a chemoim-
munotherapy regimen of fludarabine, cyclophosphamide, and ritux-
imab as initial therapy for chronic lymphocytic leukemia. J Clin Oncol
2005;23:4079–4088.
53 Wierda W, O’Brien S, Wen S et al. Chemoimmunotherapy with fluda-
rabine, cyclophosphamide, and rituximab for relapsed and refractory
chronic lymphocytic leukemia. J Clin Oncol 2005;23:4070–4078.
54 Moreton P, Hillmen P. Alemtuzumab therapy in B-cell lymphoprolifera-
tive disorders. Semin Oncol 2003;30:493–501.
55 O’Brien SM, Kantarjian HM, Thomas DA et al. Alemtuzumab as treat-
ment for residual disease after chemotherapy in patients with chronic lym-
phocytic leukemia. Cancer 2003;98:2657–2663.
56 Lozanski G, Heerema NA, Flinn IW et al. Alemtuzumab is an effective
therapy for chronic lymphocytic leukemia with p53 mutations and dele-
tions. Blood 2004;103:3278–3281.
57 Faderl S, Thomas DA, O’Brien S et al. Experience with alemtuzumab plus
rituximab in patients with relapsed and refractory lymphoid malignan-
cies. Blood 2003;101:3413–3415.
58 Weirda W, Faderl S, O’Brien S et al. Combined cyclophosphamide, fluda-
www.TheOncologist.com
29
rabine, alemtuzumab, and rituximab (CFAR) is active for relapsed/refrac-
tory patients with CLL. Blood 2004;104:101a.
59 Hale G, Rebello P, Brettman LR et al. Blood concentrations of alemtu-
zumab and antiglobulin responses in patients with chronic lymphocytic
leukemia following intravenous or subcutaneous routes of administra-
tion. Blood 2004;104:948–955.
60 Frankel AE, Fleming DR, Hall PD et al. A phase II study of DT fusion pro-
tein denileukin diftitox in patients with fludarabine-refractory chronic
lymphocytic leukemia. Clin Cancer Res 2003;9:3555–3561.
61 Khouri IF, Keating MJ, Saliba RM et al. Long-term follow-up of patients
with CLL treated with allogeneic hematopoietic transplantation. Cyto-
therapy 2002;4:217–221.
62 Giralt S, Estey E, Albitar M et al. Engraftment of allogeneic hemato-
poietic progenitor cells with purine analog-containing chemotherapy:
harnessing graft-versus-leukemia without myeloablative therapy. Blood
1997;89:4531–4536.
63 Slavin S, Nagler A, Naparstek E et al. Nonmyeloablative stem cell trans-
Downloaded from www.TheOncologist.com by on September 23, 2010
plantation 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;91:756–763.
64 Ritgen M, Stilgenbauer S, von Neuhoff N et al. Graft-versus-leukemia
activity may overcome therapeutic resistance of chronic lymphocytic leu-
kemia with unmutated immunoglobulin variable heavy-chain gene status:
implications of minimal residual disease measurement with quantitative
PCR. Blood 2004;104:2600–2602.
65 Rondon G, Giralt S, Huh Y et al. Graft-versus-leukemia effect after allo-
geneic bone marrow transplantation for chronic lymphocytic leukemia.
Bone Marrow Transplant 1996;18:669–672.
66 Dreger P, Brand R, Hansz J et al. Treatment-related mortality and graft-
versus-leukemia activity after allogeneic stem cell transplantation for
chronic lymphocytic leukemia using intensity-reduced conditioning.
Leukemia 2003;17:841–848.
67 Milligan DW, Fernandes S, Dasgupta R et al. Results of the MRC pilot
study show autografting for younger patients with chronic lymphocytic
leukemia is safe and achieves a high percentage of molecular responses.
Blood 2005;105:397–404.
68 Altes A, Sierra J, Esteve J et al. CD34+-enriched-CD19+-depleted autolo-
gous peripheral blood stem cell transplantation for chronic lymphopro-
liferative disorders: high purging efficiency but increased risk of severe
infections. Exp Hematol 2002;30:824–830.
69 Trneny M, Salkova J, Karban J et al. Combined therapeutic modality with
rituximab, fludarabine and cyclophosphamide followed by high dose ther-
apy with autologous stem cell transplantation (ASCT) leads to excellent
response rate and high probability of molecular remission in chronic lym-
phocytic leukemia (CLL) patients. Proc Am Soc Hematol 2002;100:3176a.
70 Bosch F, Ferrer A, Lopez-Guillermo A et al. Fludarabine, cyclophospha-
mide and mitoxantrone in the treatment of resistant or relapsed chronic
lymphocytic leukaemia. Br J Haematol 2002;119:976–984.
71 Saven A, Lemon RH, Kosty M et al. 2-Chlorodeoxyadenosine activity
in patients with untreated chronic lymphocytic leukemia. J Clin Oncol
1995;13:570–574.
72 Byrd JC, Peterson B, Piro L et al. A phase II study of cladribine treatment
for fludarabine refractory B cell chronic lymphocytic leukemia: results
from CALGB study 9211. Leukemia 2003;17:323–377.
73 Khouri IF, Saliba RM, Giralt SA et al. Nonablative allogeneic hematopoi-
etic transplantation as adoptive immunotherapy for indolent lymphoma :
low incidence of toxicity, acute graft-versus-host disease, and treatment-
related mortality. Blood 2001;98:3595–3599.
30
74 Childs R, Clave E, Contentin N et al. Engraftment kinetics after nonmye-
loablative allogenic peripheral blood stem cell transplantation: full donor
T-cell chimerism precedes alloimmune responses. Blood 1999;94:3234–
3241.
75 Pedrazzoli P, Da Prada GA, Giorgiani G et al. Allogeneic blood stem cell
transplantation alter a reduced-intensity, preparative regimen: a pilot
study in patients with refractory malignancies. Cancer 2002;94:2409–
2415.
76 Carella AM, Cavaliere M, Lerma E et al. Autografting followed by
nonmyeloablative immunosuppressive chemotherapy and allogeneic
peripheral-blood hematopoietic ítem cell transplantation as treatment of
resistant Hodgkin’s disease and non-Hodgkin’s lymphoma. Clin Oncol
2000;18:3918–3924.
77 Liu D, Sieter K, Ciao JW. Map Regimen: A Novel Non-Myeloablative
Conditioning Regimen of Mitoxantrone, Ara-C, and Pentostatin (MAP
Advances in CLL
Regimen) for Hematological Malignancies. Proc Am Soc Hematology
2002:2451(poster).
78 Schetelig J, Thiede C, Bomhauser M et al. Evidence of a graft-versus-leu-
kemia effect in chronic hymphocytic leukemia after reduced-intensity
conditioning and allogeneic stem cell transplantation: the Cooperative
German Transplant Study Group. J Clin Oncol 2003;21:2747–2753.
79 Corradini P, Tarella C, Olivieri A et al. Reduced-intensity conditioning
followed by allografting of hematopoietic cells can produce clinical and
molecular remissions in patients with poor-risk hematologic malignan-
cies. Blood 2002;99:75–82.
80 McSweeney PA, Niederwieser D, Shizuru JA et al. Hematopoietic cell
transplantation in older patients with hematologic malignancies: replac-
ing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood
2001;97:3390–3400.
Downloaded from www.TheOncologist.com by on September 23, 2010
OTncologist
he ®
 Chronic Lymphocytic Leukemia: Recent Advances in Diagnosis and Treatment
Brian L. Abbott
Oncologist 2006;11;21-30
DOI: 10.1634/theoncologist.11-1-21
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