IntroductionChronic lymphocytic leukemia (CLL) is the most frequent type of leukemia in Western countries and it accounts for approximately 25% of all leukemias. 1 Although at the present there is no curative treatment, combinations of cytotoxic agents and of immunotherapies that generate high complete remission rates hold promise for altering the natural history of this disease. [2][3][4] Alkylating agents and nucleoside analogues are 2 classes of anticancer agents important in the treatment of chronic lymphocytic leukemia. Indolent B-cell malignancies such as CLL exhibit a high DNA damage repair capacity. 5 This biologic property provides a rationale for therapeutic strategies that combine DNA-damaging cytotoxic agents, such as oxaliplatin, with an inhibitor of DNA repair such as fludarabine.Fludarabine (9-beta-D-arabinofuranosyl-2-fluoroadenine 5Ј-phosphate) is the most effective purine nucleoside analogue for the treatment of indolent lymphoproliferative disorders, including CLL, low-grade lymphoma, and prolymphocytic leukemia. 6,7 On infusion into the bloodstream, fludarabine is dephosphorylated to the respective nucleoside (F-ara-A) which is a substrate for transporters. 8 On entering the cell, fludarabine is anabolized to its triphosphate form, its major intracellular metabolite. 9 The triphosphate can then become incorporated into DNA or RNA, actions which block further synthesis. 10 Its inhibition of ribonucleotide reductase, an action that depletes the deoxynucleotide pools required for DNA repair and replication, may favor its increased incorporation into newly synthesized DNA. 11 Further, its inhibitory actions against both DNA ligase 12 and DNA primase 13 are likely to antagonize the consequences of its incorporation. The finding that it is resistant to excision 14 is likely to contribute to its effective inhibition of DNA synthesis. Finally, in vitro studies have shown that the loss of cell viability correlates directly with the level of incorporation of the analog into cellular DNA.Oxaliplatin (DACH oxalate-platinum(II); Eloxatin) is a thirdgeneration platinum compound with a different spectrum of activity and low cross-resistance with cisplatin. 15 It is currently indicated for use with fluorouracil and leucovorin for the treatment of advanced cancer of the colon or rectum. 16 Oxaliplatin has shown in vitro and in vivo supra-additive effects in combination with several other antitumor agents, including 5-fluorouracil, topoisomerase I inhibitors, thymidylate synthase inhibitors, paclitaxel, cisplatin, and carboplatin. 15,17 The mechanism of action of oxaliplatin is mediated by the formation of DNA adducts. The main types of DNA lesions induced by oxaliplatin are intrastrand crosslinks covalently binding the platinum compound to guanine residues. 18 The other type of lesions include DNA interstrand crosslinks (ICLs) and DNA protein crosslinks. 19 Oxaliplatin-DNA adducts are suggested to exert their cytotoxicity by directly inhibiting DNA and RNA synthesis and inducing apoptosis.The nonoverlapping s...