2-Chlorodeoxyadenosine Dose Escalation
in Nonhematologic Malignancies
By Alan Saven, Hajime Kawasaki, Carlos J. Carrera, Thomas Waltz, Brian Copeland,
Jack Zyroff, Michael Kosty, Dennis A. Carson, Ernest Beutler, and Lawrence D. Piro
Purpose: We performed a dose-escalation study of
2-chlorodeoxyadenosine (2-CdA) in solid tumors to de-
termine the maximum-tolerated dose (MTD) and define
its toxicity profile at higher doses.
Patients and Methods: Twenty-one patients, seven
with malignant astrocytoma, twelve with metastatic
melanoma, and two with metastatic hypernephroma,
were enrolled onto the study. Patients were entered onto
cohorts that received 0.10, 0.15, or 0.20 mg/kg/d of 2-
CdA by continuous intravenous infusion for 7 days every
28 days. 2-CdA levels were determined by radioim-
munoassay. In tumor tissue samples, deoxycytidine ki-
nase (dCK) levels were measured by both enzyme activ-
ity and immunoreactive protein analysis.
Results: Of seven patients treated with 2-CdA at 0.1
mg/kg/d, one experienced grade 3 or 4 myelotoxicity.
Of 11 patients treated at 0.15 mg/kg/d, four experi-
enced myelotoxicity, two after a single course of 2-CdA.
All three patients who received 2-CdA at 0.2 mg/kg/d
2-CHLORODEOXYADENOSINE (2-CdA) is a purine
substrate analog resistant to degradation by adenosine
deaminase. Previous studies in a variety of both T- and
B-cell lymphoid malignancies have shown 2-CdA to be
an effective new agent with a favorable toxicity profile.1"
When administered as a single agent by a continuous in-
travenous infusion for 7 days in the treatment of hema-
tologic malignancies, 0.1 mg/kg/d was found to be the
optimal dose. Myelosuppression, mainly thrombocyto-
penia, is the dose-limiting toxicity that occurs in approx-
imately 25% of patients.2' 4 No conventional chemotherapy
toxicities, including alopecia, nausea or vomiting, cardio-
pulmonary, renal, hepatic, or neurotoxicity, have been
observed at this dose of 2-CdA.
The goals of this study were to establish the maximum-
tolerated dose (MTD), the toxicity profile, and the re-
sponse rates of 2-CdA at escalating dose levels in patients
with a variety of nonhematologic malignancies. In selected
patients, 2-CdA levels were measured by radioimmu-
noassay in the serum and CSF to determine blood-brain
barrier penetration. In tumor tissue samples, deoxycyti-
dine kinase (dCK) levels were measured by both enzyme
activity and immunoreactive protein analysis to establish
the relationship between these two methodologies of dCK
determination and also the possible correlation of tumor
responsiveness to 2-CdA with dCK expression.
The solid tumors included were residual and recurrent
malignant astrocytoma, metastatic malignant melanoma,
and metastatic renal cell carcinoma. The rationale for the
Journalof Clinical Oncology, Vol 11, No 4 (April), 1993: pp 671-678
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Copyright © 2017 American Society of Clinical Oncology. All rights reserved.
experienced myelosuppression. Neurologic events oc-
curred in two patients, both with malignant melanoma.
Two of seven patients (28.6%) with astrocytomas ob-
tained partial responses with a median duration of 8
months. 2-CdA penetrated the blood-brain barrier. An
association was found between dCK levels as measured
by enzymatic activity and immunoreactive proteins, but
this did not correlate with 2-CdA tumor responsiveness.
Conclusion: The MTD for 2-CdA delivered as a 7-day
intravenous infusion in patients with nonhematologic
malignancies was determined to be 0.1 mg/kg/d, the
same as the MTD for patients with hematologic malig-
nancies. There was no clinical correlation with dCK
expression and response to 2-CdA. The responses noted
in patients with malignant astrocytoma warrant further
phase II study.
J Clin Oncol 11:671-678. © 1993 by American Society
of Clinical Oncology.
inclusion of patients with melanoma in this study was
based on in vitro studies of two human melanoma cell
lines that showed that they are highly sensitive to deoxy-
9
adenosine congeners' and express high levels of dCK, the
activating enzyme for 2-CdA. Because 2-CdA is highly
6
effective in the treatment of hairy cell leukemia, an in-
1 2
terferon-sensitive malignancy,1- the possibility that it
might have activity in other interferon-sensitive malig-
13
nancies created further rationale for a trial in melanoma
1 4
as well as the rationale for including renal cell carcinoma.
Astrocytomas were included because of their uniformly
poor prognosis and the need for new effective systemic
therapies.
From the Divisions of Hematology/Oncology and Neurosurgery,
DepartmentsofRadiology and MolecularandExperimentalMedicine,
Ida M. and Cecil H. Green CancerCenter,Scripps ClinicandResearch
Foundation,and The Scripps Research Institute;and the Department
of Medicine, University of CaliforniaSan Diego, La Jolla, CA.
Submitted September 22, 1992; accepted November 24, 1992.
This is publication no. 7356-MEM from The Scripps Research
Institute, La Jolla,CA.
Supported in part by National Institutes ofHealth, Bethesda, MD,
grants no. RR00833, GM-23200, andFOR-00028003, the Sam Stein
and Rose Stein Charitable Trust Fund, and R&W Johnson Phar-
maceutical Institute, Raritan,NJ.
Address reprint requests to Lawrence D. Piro,MD, Scripps Clinic
and Research Foundation, 10666 N Torrey Pines Rd, La Jolla, CA
92037.
© 1993 by American Society of Clinical Oncology.
0732-183X/93/1104-0012$3.00/0
671
672
PATIENTS AND METHODS
Eligibility Criteria
Patients with residual or recurrent malignant astrocytomas after
definitive surgery and irradiation with measurable or assessable disease
as evident on computerized axial tomographic (CAT) scans or mag-
netic resonance imaging (MRI) scans of the brain and patients with
measurable or assessable metastatic malignant melanoma and met-
astatic renal cell carcinoma were eligible. For patients with metastatic
malignant melanoma or metastatic renal cell carcinoma, the presence
of untreated cranial metastases was an exclusion criterion. Cranial
metastases, once treated and stable for 3 months, did not result in
patient exclusion. All patients were required to be older than 18
years, have a life expectancy greater than 2 months, have a Karnofsky
performance status > 60,"1have adequate renal (serum creatinine <
2.0 mg/dL) and hepatic function (bilirubin, alkaline phosphatase,
AST, and ALT < 2 X normal) unless caused by metastatic disease,
and be available for follow-up evaluation. Informed consent was ob-
tained and the study was approved by our institutional review board.
Radioimmunoassay of 2-CdA in Serum and CSF
In selected patients, 2-CdA concentrations in serum and CSF were
measured by radioimmunoassay using polyclonal rabbit antiserum
raised against 2-chloroadenosine conjugated to bovine serum albu-
min.' [8-'H]CdA (Moravek Biochemicals, Brea, CA) was used as the
competitive ligand. 2-CdA levels were derived from a standard curve
for each patient constructed by adding known amounts of unlabeled
2-CdA to pretreatment serum or CSF.
dCK Enzyme Activity and Immunoreactive Protein
Whenever feasible, at the time of definitive surgery or at disease
recurrence, samples of tumor tissue were frozen for subsequent dCK
assays. Cytosol extracts were prepared by freeze-thaw lysis and cen-
trifugation at 12,000g for 10 minutes. Enzymatic activity of dCK
was measured by a modified anion exchange disc filter method.'"
Reaction mixtures contained dithiothreitol 10 mmol/L, NaF 15
mmol/L, MgCI2 10 mmol/L, adenosine triphosphate (ATP) 10 mmol/
L, deoxyuridine I mmol/L, cytidine I mmol/L, and [3 H]deoxy-
cytidine 10 1gmol/L in a Tris-hydrochloric acid 50 mmol/L buffer at
pH 7.5. Assays were initiated by the addition of an extract that con-
tained 20 to 50 ,g of protein. Protein concentrations in the tumor
cytosol extracts were determined by reaction with Coomassie Blue
(Sigma, St Louis, MO),17 and the dCK activity was expressed as pmol
of dCMP/min/mg of protein. Immunoreactive dCK was detected on
protein blots after polyacrylamide gel electrophoresis using rabbit
polyclonal antiserum against purified dCK-maltose binding protein
fusion protein expressed in Escherichiacoli.'0 Autoradiographic sig-
nals were quantitated by densitometry using a calibration curve de-
rived from known amounts of purified, cloned dCK.
Drug Formulation
2-CdA was supplied'6 by Ortho Pharmaceutical Corporation (Rar-
itan, NJ) and recrystallized before its use. 2-CdA was supplied to the
pharmacy as a 0.1% solution (1 mg/mL) of pyrogen-free 2-CdA in
sterile 0.9% sodium chloride (NaCI). The desired dosage (0.10 to 0.20
mg/kg/d) was added to 0.9% NaCI solution to make a total volume
(drug plus diluent) of 100 mL and infused through central venous
access using an infusional pump device (Pharmacia Deltec Cadd, St
Paul, MN) or 500 mL of 0.9% NaCI for inpatients admitted to our
General Clinical Research Center.
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SAVEN ET AL
Treatment Plan
Patients were entered onto cohorts that received 0.10, 0.15, or 0.20
mg/kg of 2-CdA per day by continuous intravenous infusion for 7
days every 28 days. Dose escalation occurred in cohorts, not in in-
dividual patients. Courses were repeated until maximum response
or prohibitive toxicity was encountered. The final patient in each
cohort completed at least two courses of treatment before patients
were enrolled in subsequent dose levels. If there was a greater than
50% reduction in the pretreatment absolute neutrophil or platelet
count, then 2-CdA was withheld until the absolute neutrophil count
and platelet count were greater than 75% of the pretreatment value,
9
or >1,500 cells/ML and >100 x 10 /L, respectively. The initiation
of 2-CdA therapy was delayed in the presence of active infection.
Dose Escalation and MTD
A minimum of three patients were treated at each dose level. Dose
escalation was halted if grade 3 or grade 4 hematologic or nonhe-
matologic toxicity" was encountered in two or more patients at any
dose level. If only one patient developed grade 3 or 4 toxicity, five
additional patients were entered at that particular dose level. If two
or more of the five patients developed grade 3 or 4 toxicity, dose
escalation was halted. The MTD was defined as the dose level im-
mediately below that level that produced grade 3 or 4 toxicity in
more than one third of the patients treated. If any patients showed
tumor responsiveness, then additional patients would be treated at
the MTD.
Toxicity
Hematologic and nonhematologic toxicity was evaluated according
to standard criteria. 20 Grade 3 or 4 toxicity was determined to be
significant. Grade 3 leukopenia was an absolute neutrophil count of
500 to 1,000 cells/uL and grade 4 leukopenia was less than 500 cells/
ML. Grade 3 thrombocytopenia was a platelet count 25 to 50 X 109/
L and grade 4 thrombocytopenia was less than 25 X 109/L.
Response Criteria
For malignant astrocytomas, responses were determined according
to the criteria proposed by Macdonald et al. 21 A complete response
required the disappearance of all enhancing tumor on consecutive
CAT or MRI scans at least I month apart, off corticosteroids, and
neurologically stable or improved. A partial response was defined as
a > 50% decrease in size (largest cross-sectional area) of enhancing
tumor on consecutive CAT or MRI scans at least 1 month apart,
cortico-steroids stable or reduced, and neurologically stable or im-
proved. All other tumor responses were designated as no response.
For malignant melanoma and renal cell carcinoma, a complete
response was defined as the disappearance of all evidence of disease,
clinically and with imaging studies, for at least I month. A partial
response was defined as a 50% decrease in the product of the per-
pendicular diameters of the indicator lesion(s) with no new area of
malignancy for at least I month. All other categories of tumor response
were defined as no responses.
Statistical Analysis
Fisher's exact test was used for the statistical comparison of bi-
nomial proportions, and confidence intervals were determined by a
standard technique.
2-CHLORODEOXYADENOSINE DOSE ESCALATION
RESULTS
Patient Characteristics
Twenty-one patients, 12 males and nine females, were
enrolled onto the study and all were assessable. Median
age was 54 years with a range of 33 to 76 years. Seven
patients had malignant astrocytoma, 12 had metastatic
malignant melanoma, and two had metastatic malignant
renal cell carcinoma.
Seven patients (three with melanoma, two with astro-
cytoma, and two with renal cell carcinoma) received 18
courses of 2-CdA at 0.10 mg/kg/d. The range of courses
received by patients in this cohort was one to four with a
median of three. In six of these seven patients progressive
disease, and not myelosuppression, prevented further ad-
ministration of 2-CdA. Eleven patients (five with astro-
cytoma and six with melanoma) received 21 courses of
2-CdA at 0.15 mg/kg/d with a median of two courses and
a range of one to five. Three patients, all with melanoma,
received four courses of 2-CdA at 0.20 mg/kg/d with
"amedian of one course and a range of one to two. In all,
"atotal of 44 courses of 2-CdA were administered to 21
patients.
The histologic diagnoses, previous therapies, and tox-
icities of the patients enrolled onto the study are listed in
Table 1.
Toxicity
General
No alopecia, nausea, vomiting, cardiopulmonary, renal,
or hepatic toxicity occurred as a result of 2-CdA therapy.
Bone Marrow Suppression
0.10 mg 2-CdA/kg/d. Patient no. 3, with widely met-
astatic melanoma and an extensive prior exposure to bi-
ologic response modifiers, interleukin-2 with lymphocyte-
activated killer cells and subsequently with interferon, ex-
perienced grade 4 thrombocytopenia on his second course
of therapy. No further myelosuppression was documented
in the additional six patients treated at this dose. Thus,
one of seven patients and one of 18 courses of 2-CdA
experienced myelosuppression (Table 1).
0.15 mg 2-CdA/kg/d. The third patient, patient no.
10, treated at this dose level experienced grade 3 neutro-
penia and concomitant fever that necessitated hospital-
ization for empiric intravenous antibiotics after the second
course of 2-CdA. An additional five patients were then
treated, two of whom developed myelotoxicity. Patient
no. 12 had protracted grade 3 neutropenia and grade 4
thrombocytopenia that lasted 5 months and required in-
termittent RBCs and platelet support after five cycles of
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673
2-CdA. Patient no. 14 had reversible grade 3 neutropenia
and chills in association with Proteusmirabilisbacteremia.
When the myelotoxicity of 2-CdA at the next dose level,
0.20 mg/kg/d, was found to be prohibitive, three addi-
tional patients were treated at 0.15 mg/kg/d; a single pa-
tient, patient no. 18, developed grade 4 neutropenia and
grade 4 thrombocytopenia complicated by fever and de-
hydration that required inpatient admission for intrave-
nous fluids. Thus, four of 11 patients and five of 22 2-
CdA courses experienced severe life-threatening myelo-
suppression. Two of these four patients experienced my-
elosuppression after a single course of 2-CdA, whereas
two patients experienced myelosuppression with subse-
quent courses, one with course 2 and the other after
course 4.
0.20 mg 2-CdA/kg/d. All three patients treated at this
dose developed myelosuppression after their first course
of 2-CdA: patient no. 19 with grade 4 neutropenia, patient
no. 20 with grade 4 neutropenia and grade 4 thrombo-
cytopenia, and patient no. 21 with grade 3 neutropenia.
Myelosuppression was more frequent in those patients
with a prior exposure to systemic chemotherapy. Five of
the eight patients (63%) who developed myelosuppression
had prior chemotherapy versus two of 13 patients (15.3%)
without myelosuppression who had prior chemotherapy;
P = .041 (Fisher's exact test). Four of the eight patients
(50%) with myelosuppression had received prior biologic
therapies (interferon, interleukin-2, or lymphocyte-acti-
vated killer cells). It is of interest that all patients with
previous biologic therapy treatment developed myelosup-
pression.
Infectious Complications
Two patients, both with metastatic melanoma, expe-
rienced infectious complications. Patient no. 14 developed
a P mirabilis bacteremia from an undefined source and
patient no. 21 developed dermatomal herpes zoster.
Neurotoxicity
Two patients developed neurologic events after the ad-
ministration of 2-CdA. Patient no. 14, with adult-onset
diabetes mellitus and metastatic melanoma previously
treated with cisplatin chemotherapy complicated by oto-
toxicity, developed grade 3 neutropenia and P mirabilis
bacteremia 7 days after the completion of a single course
of 2-CdA at 0.15 mg/kg/d for 7 days. The infection was
treated with intravenous cefotaxime and ampicillin, an-
tibiotics not associated with neurotoxicity. Thirty-four
days after this infection he developed a sensorimotor
polyneuropathy that involved predominantly his lower
extremities and prevented ambulation. A lumbar puncture
674 SAVEN ET AL

Table 1. Dose of 2-CdA, Diagnosis, Prior Therapy, and Myelosuppression

Myelosuppression 2-CdA Cycle Number

Patient
No. Diagnosrs Prior Treatment 1 2 3 4 5

Dose of 2-CdA: 0.10 mg/kg/d x 7 days

1 Astrocytomoa, low-grade Surgery, XRT
2 Astroctyoma, GBM Surgery, chemo
(thioguanine, BCNU)
3 Melanoma Chemo (DTIC), biol (IL-2/ T (4)
LAK, IL-2/interferon)
4 Melanoma None
5 Melanoma Surgery, chemo (cisplatin,
DTIC, BCNU)
6 Renal cell cancer Surgery, XRT
7 Renal cell cancer None

Total 017 1/5 0/4 0/2 = 1/18

Dose of 2-CdA: 0.15 mg/kg/d x 7 days

8 Astrocytoma, GBM Surgery, XRT
9 Astrocytoma, GBM Surgery, XRT
10 Astrocytoma, GBM Surgery, chemo N (3)
(procarbazine, VCR,
BCNU)
11 Astrocytomao, GBM Surgery, XRT
12 Astrocytoma, GBM Surgery, XRT *

* N (3), T (4)
13 Melanoma XRT
14 Melanoma Chemo (cisplatin), biol N (3)
(interferon)
15 Melanoma XRT
16 Melanoma Untreated
17 Melanoma Surgery, XRT
18 Melanoma Untreated N (4) N (4), T (4)

Total 2/11 2/8 0/1 0/1 1/1 =5/22

Doses of 2-CdA: 0.20 mg/kg/d x 7 days

19 Melanoma Chemo (cisplatin), biol N (4)
(interferon)
20 Melanoma Chemo (cisplatin, BCNU, N (4), T (4)
DTIC), biol (IL-2)
21 Melanoma Surgery, XRT N (3)

Total 3/3 0/1 3/4

Abbreviations: GBM, glioblastoma multiforme; XRT, irradiation; chemo, chemotherapy; BCNU, carmustine; DTIC, dacarbazine; VCR, vincristine; biol,
biologic response modifiers; IL-2, interleukin-2; LAK, lymphocyte-activated killer cells; N (3), grade 3 neutropenia = absolute neutrophil count 500-
1,000 cells/pL; N (4), grade 4 neutropenia = absolute neutrophil count < 500 cells/Lt; T (3), grade 3 thrombocytopenia = platelet count 25-50 X 109/
L; T (4), grade 4 thrombocytopenia = platelet count < 25 x 109/L.
*No myelosuppression.

showed a normal CSF glucose level and an elevated pro-
tein level, but no malignant cells were noted. A sural nerve
biopsy showed demyelination only. The neuropathy im-
proved and the patient was able to ambulate unassisted.
Possible causes for the neuropathy include a Guillain-
Barr6 syndrome after a serious infection and/or a 2-CdA-
induced exacerbation of a pre-existing cisplatin or diabetic
neuropathy.
Patient no. 21, with widespread metastatic melanoma,
developed a Brown-Sequard syndrome with progressive
coma and paraplegia 3 weeks after the completion of the
second course of 2-CdA at 0.20 mg/kg/d for 7 days and
a preceding herpes zoster infection of the trigeminal
nerve. MRI scans of the craniospinal axis showed no
extradural or intradural metastases. CSF showed normal
glucose and protein levels. An autopsy was denied. Po-
tential causes of the neuropathy include direct 2-CdA-
induced neurotoxicity, a paraneoplastic effect of meta-

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2-CHLORODEOXYADENOSINE DOSE ESCALATION 675

static malignant melanoma, or a causal role for the pre-

ceding herpes zoster infection.
MTD
Four of 11 patients (36%) experienced myelotoxicity at
a 2-CdA dose level of 0.15 mg/kg/d: patient no. 10 de-
veloped neutropenic fever that necessitated hospitalization
for empiric antibiotics, patient no. 12 became pancyto-
penic and required protracted RBC and platelet support,
patient no. 14's neutropenia was complicated by P mir-
abilis bacteremia, and patient no. 18 also became pan-
cytopenic and dehydrated, which required hospitalization.
Given the severity and clinical consequences of both the
neutropenia and thrombocytopenia observed at this dose
level together with its early onset, two patients in their
first course of therapy, and its protracted nature in a single
patient, this magnitude of myelosuppression was deemed
significant and prohibitive. Also, as previously described,
a single patient (patient no. 14) in this cohort with met-
astatic malignant melanoma developed a peripheral neu-
ropathy. At a dose of 0.20 mg/kg/d, three of three treated
patients (100%), all with metastatic malignant melanoma,
developed myelotoxicity after their first course of therapy;
a single patient (patient no. 14) developed a neurologic
event. Accordingly, the toxicity associated with the 0.20
mg/kg/d 2-CdA dosage was deemed unacceptable.
The small numbers of patients who experienced my-
elosuppression do not permit an accurate distinction to
be made between maximal dose defined by acute toxicity
versus cumulative toxicity. However, there seemed to be
a trend toward cumulative myelotoxicity after repeated
courses of 2-CdA. At the 0.1 mg/kg/d and 0.15 mg/kg/d
doses of 2-CdA, two of 18 patients (both at the 0.15 mg/
kg/d dose) experienced myelosuppression after one course
of therapy, whereas three of 12 patients (one at 0.10 and
two at 0.15 mg/kg/d) experienced myelosuppression after
the second or subsequent courses of 2-CdA administration;
P = .30 (Fisher's exact test). All three patients treated at
0.2 mg/kg/d had significant myelosuppression after their
first course of 2-CdA.
Therefore, the MTD was established to be 0.10 mg/kg/
d. At this dose level, one of seven patients (14%) experi-
2-CdA
in CSF
(nM)
0 0.05 0.10 0.15 0.20
2-CdA Intravenous Infusion (mg/kg per day)
Fig 1. The relationship between CSF concentration of 2-CdA and
intravenous drug dose.
the 50% inhibition of growth (ID50) for some human ma-
lignant lymphoblast cell lines incubated with 2-CdA in
vitro.1, 22 These concentrations of 2-CdA are similar to
those achieved in chronic lymphocytic leukemia patients
at the same dose and schedule.2
2-CdA CSF concentrations were measured in three as-
trocytoma patients who received different dosages of drug.
Spinal fluid concentrations of 2-CdA increased from 2.2
to 24.7 nmol/L as the infusion dosage was increased from
0.1 to 0.2 mg/kg/d. The relationship between 2-CdA in-
travenous infusion dose and its CSF concentration is
shown in Fig 1.
dCK Enzymatic and Immunoreactive Activities
dCK was measured enzymatically and by quantitative
immunoassay in tumor biopsy samples from two patients
with astrocytoma and from six patients with metastatic
Table 2. dCK Enzymatic and Immunoreactive Activities
in Tumor Biopsy Samples
dCK Activity dCK Protein
Tumor Type Patient No. (pmol/minlmg) (ng/mg of protein)

enced myelotoxicity, and no neurotoxicity was observed. Astrocytomo 1 ND 22.70*

This is the same MTD previously established in hema- 10 ND 10.43
Melanoma 14 0.39 132.18
tologic malignancies.
17 0.49 171.06
18 0.15 74.20
Serum and CSF Concentrationsof 2-CdA
19 0.46 220.98
Serum concentrations of 2-CdA were measured in pa- 20 0.32 82.94
tients who received 0.1 mg/kg/d by continuous intrave- 21 0.64 132.26
nous administration. 2-CdA concentrations ranged from Abbreviation: ND, none detected.
6.9 to 46 nmol/L (mean, 20 nmol/L), which far exceeds *Partial response obtained.

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676 SAVEN ET AL

melanoma (Table 2). Enzyme activity was present in all

the melanoma samples (mean, 0.41 pmol/min/mg pro-
tein; range, 0.15 to 0.64), but could not be detected in the
astrocytoma biopsy extracts. Immunoreactive dCK pro-
tein was more abundant in melanoma (mean, 135.6 ng/
mg cytosol protein; range, 74.2 to 221) than in the two
astrocytoma specimens analyzed (10.43 and 22.70 ng/mg
cytosol protein). Among the melanoma biopsy samples
assayed by both methods there was a correlation between
dCK enzymatic activity and immunoreactive protein.
However, there was no clinical correlation with dCK
expression and clinical response to 2-CdA in the mela-
noma patients treated. It is of interest that the astrocytoma
patient (patient no. 1) with the higher dCK protein content
achieved a partial response after administration of 2-CdA.

Responses and Response Duration

Two patients, both with malignant astrocytomas,
achieved partial responses. Patient no. 1, with a grade 2
astrocytoma previously treated with multiple surgeries and
irradiation, achieved a partial response of 7 months. He
received four cycles of 2-CdA at 0.10 mg/kg/d (Fig 2).
Patient no. 12, with a glioblastoma multiforme also pre-
viously treated with both surgery and irradiation, received
five cycles of 2-CdA at 0.15 mg/kg/d, achieved a partial
response of 9 months duration (Fig 3). No patients with
metastatic malignant or metastatic renal cell carcinoma
responded.
Thus, the overall response rate was two of 21 (9.5%)
for all patients treated (95% confidence interval for this
proportion was 0.3% to 32.5%) and two of seven (28.6%)
for the malignant astrocytoma patients treated (95% con-
fidence interval was 0.8% to 73.1%), with a median re-
sponse duration of 8 months.
Fig 2. Coronal MRI scans of the brain with intravenous contrast
(gadopentetate dimeglumine) before (A) and after (B) 2-CdA treat-
ment. (A) Irregular and dense tumor enhancement is identified in the
splenium and posterior body of the corpus callosum with cephalad
extension into the cingulate gyrus. A craniotomy defect is also ob-
served. (B) A coronal image at the identical slice location after 2-CdA
treatment shows resolution of tumor enhancement.
Fig 3. Axial spin echo MRI images (A,B) and sagittal TI -weighted
images (C,D) were obtained before (A,C) and after (B,D) 2-CdA treat-
ment. (A) Axial spin echo image before treatment shows a 5-cm cystic
neoplasm in the right posterior temporal lobe with extensive sur-
rounding edema. (B) An identical slice after 2-CdA treatment shows
complete regression of the edema and shrinkage of the cyst. (C) Sag-
ittal Ti-weighted image before treatment again shows cystic tumor
with marked swelling of the entire temporal lobe. (D) An identical
slice after 2-CdA treatment shows complete regression of the temporal
lobe swelling, with restoration of a normal sulcal pattern. The cyst is
smaller in size and higher in signal intensity, possibly related to de-
creasing free water concentration with a secondary increase in the
protein concentration.
DISCUSSION
2-CdA is a purine nucleoside with major activity in
lymphoid malignancies. It was postulated that the MTD
for patients with nonhematologic malignancies might be
higher than for patients with hematologic malignancies
because of potentially greater bone marrow reserve. How-
ever, as with hematologic malignancies, 0.10 mg/kg/d by
continuous intravenous infusion for 7 days seems to be
the MTD. Myelosuppression, both leukopenia and
thrombocytopenia, was the dose-limiting toxicity. Prior
exposure to biologic response modifiers seemed to pre-
dispose patients to the development ofmyelosuppression,
perhaps through their antiproliferative actions or through
an effect on the bone marrow supporting stroma.
Fludarabine and 2'-deoxycoformycin (pentostatin) are two
other purine analogs effective in the treatment of lymphoid

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2-CHLORODEOXYADENOSINE DOSE ESCALATION
malignancies. In the early phase I studies of pentostatin,
severe life-threatening neurologic, renal, hepatic, and bone
marrow toxicities were encountered.2 3 Likewise, fludarabine
has a similar spectrum of toxicity when administered by
continuous intravenous infusion at high dosage. Delayed
neurotoxicity with a progressive clinical course that consisted
of optic neuritis, cortical blindness, altered mental status,
and generalized seizures complicated high-dose fludarabine
therapy.24 Neuropathologic findings at autopsy in these pa-
tients included progressive demyelination25 and a diffuse,
necrotizing leukoencephalopathy that was most severe in
the occipital lobes.26 Neurotoxicity is uncommon with the
low doses of fludarabine now used.
In this study with 2-CdA, neurologic events occurred
in two patients, both with malignant melanoma and ex-
tensive prior therapy. A causal role for delayed neurotox-
icity seems plausible in the patient treated at 0.2 mg/kg/
d for 7 days, although in the absence of an autopsy other
possible causes cannot be absolutely excluded. The cause
for the peripheral neuropathy in the second patient, treated
at 0.15 mg/kg/d for a single course, cannot be absolutely
established because of other associated conditions. How-
ever, when 2-CdA was administered at much higher doses
(0.4 to 0.5 mg/kg for 7 to 14 days) combined with total-
body irradiation and cyclophosphamide (60 mg/kg on 2
successive days) in preparation for bone marrow trans-
plantation, both neurotoxicity and nephrotoxicity were
encountered.7 The neurologic symptoms occurred weeks
after the discontinuation of 2-CdA. It is unknown whether
these toxicities were directly caused by the high doses of
2-CdA or by its combination with total-body irradiation
and cyclophosphamide. Because 2-CdA prevents repair
of DNA strand breaks 27 there could have been synergism
between it and the irradiation and/or alkylating agent.
2-CdA was found to penetrate the blood-brain barrier
and increased CSF concentrations were shown with suc-
cessive intravenous dose escalation of the drug.
dCK, in the crucial first step of intracellular activation
of 2-CdA, catalyzes the phosphorylation of 2-CdA. Levels
of dCK may be prognostically important in the treatment
of malignancies with deoxynucleoside antimetabolites that
are phosphorylated by this enzyme, eg, cytarabine and 2-
CdA. The level of dCK may also be a useful indicator of
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