Rituximab With or Without Yttrium Y-90 Ibritumomab Tiuxetan in Treating Patients With Untreated Follicular Lymphoma

Phase 3

Completed

Conditions: Ann Arbor Stage II Grade 1 Contiguous Follicular Lymphoma
Ann Arbor Stage IV Grade 2 Follicular Lymphoma
Ann Arbor Stage I Grade 1 Follicular Lymphoma
Ann Arbor Stage I Grade 2 Follicular Lymphoma
Ann Arbor Stage II Grade 1 Non-Contiguous Follicular Lymphoma
Ann Arbor Stage II Grade 2 Contiguous Follicular Lymphoma
Ann Arbor Stage III Grade 1 Follicular Lymphoma
Ann Arbor Stage II Grade 2 Non-Contiguous Follicular Lymphoma
Ann Arbor Stage III Grade 2 Follicular Lymphoma
Ann Arbor Stage IV Grade 1 Follicular Lymphoma

Interventions: Other: Quality-of-Life Assessment
Biological: Rituximab
Radiation: Yttrium Y-90 Ibritumomab Tiuxetan

Registration Number: NCT02320292

Lead Sponsor: Mayo Clinic

Brief Summary: This phase III trial studies rituximab and yttrium Y-90 ibritumomab tiuxetan to see how well they work compared to rituximab alone in treating patients with untreated follicular lymphoma. Immunotherapy with monoclonal antibodies, such as nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Radioactive substances linked to monoclonal antibodies can bind to cancer cells and give off radiation which may help kill cancer cells. It is not yet known whether rituximab works better with or without yttrium Y-90 ibritumomab tiuxetan in treating follicular lymphoma.

Detailed Description: PRIMARY OBJECTIVE:

I. Test the hypothesis that a single dose of Zevalin (yttrium Y-90 ibritumomab tiuxetan) rituximab immunotherapy (RIT) will increase the complete remission (CR) rate over that achieved with standard rituximab in patients with untreated asymptomatic follicular lymphoma (FL).

SECONDARY OBJECTIVES:

I. Test the hypothesis that Zevalin RIT will improve progression-free survival. II. Test the hypothesis that Zevalin RIT will improve time to next (any) therapy and time to next chemotherapy.

CORRELATIVE RESEARCH OBJECTIVES:

I. Study the incidence of exon 2 B-cell leukemia/lymphoma 2 protein (bcl2) mutations in patients with asymptomatic follicular lymphoma (AFL).

II. Measure regulatory T cells (Tregs) and tissue monocytes in on-study FL tumor tissue.

III. Measure serum cytokines and vitamin D at on study and month 6. IV. Evaluate beta-2 microglobulin plus lactate dehydrogenase (LDH) score as a prognostic factor.

V. Measure absolute lymphocyte count (ALC), absolute monocyte count (AMC), and ALC/AMC ratio at on study and after treatment.

VI. Compare quality of life as measured by the Functional Assessment of Cancer Therapy (FACT)-Lymphoma (Lym) between arms.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM A: Patients receive rituximab intravenously (IV) on days 1, 8, 15, and 22.

ARM B: Patients receive rituximab IV on days 1 and 8 and yttrium Y-90 ibritumomab tiuxetan over 10 minutes on day 8.

After completion of study treatment, patients are followed up at 3, 6, 9, 12, 18, 24, 30, 36, 48, and 60 months and then every 12 months for 5 years.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 20

Inclusion Criteria

Histological confirmation of follicular lymphoma grades I, II diagnosed within 12 months (365 days) prior to registration; NOTE: the day of biopsy should be used as day 1 of diagnosis for this calculation
Stage I, II, III, or IV disease; NOTE: stage I disease are eligible only if the disease is not amenable to external beam radiation therapy
No indication for chemotherapy; candidate for observation
Measurable disease by tumor imaging with at least one lesion >= 1.5 cm in at least one dimension
Previously untreated; NOTE: this includes any chemotherapy or immunotherapy or RIT; patients who received corticosteroids for diseases other than lymphoma are eligible as long as prednisone dose is =< 10 mg/day
Low tumor burden as defined by Groupe d'Etudes des Lymphomes Folliculaires (GELF) criteria (2):
- No tumor mass (nodal or extranodal) >= 7 cm in one dimension on computed tomography (CT)
- Fewer than 3 (2 or less) nodal masses > 3 cm
- No systemic or B symptoms
- No splenomegaly greater than 16 cm by CT scan
- No risk of organ compression - ureteral, orbital, neurological, gastrointestinal
- No leukemic phase (> 5.0 x 10^9/L circulating FL cells in the blood as detected by complete blood count [CBC] with differential and smear)
- No cytopenias - absolute neutrophil count (ANC) < 1000 or platelets < 100,000
Meet standard criteria for RIT:
- < 25% marrow involvement with FL
- No evidence of myelodysplasia
Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, or 2
Absolute neutrophil count (ANC) >= 1500/mm^3 obtained =< 28 days prior to registration
Platelet count >= 100,000/mm^3 =< 28 days prior to registration
Hemoglobin > 10.0 g/dL =< 28 days prior to registration
Total bilirubin =< 1.5 x upper limit of normal (ULN) or if total bilirubin is > 1.5 x ULN, the direct bilirubin must be =< ULN =< 28 days prior to registration
Alkaline phosphatase =< 3 x ULN =< 28 days prior to registration
Aspartate transaminase (AST) =< 3 x ULN
Creatinine =< 2 x ULN =< 28 days prior to registration
Negative pregnancy test done =< 7 days prior to registration, for women of childbearing potential only
Provide informed written consent
Willing to travel to a radioimmunotherapy site for Zevalin, if necessary
Willing to return to the enrolling institution for follow-up (during the Active Monitoring Phase of the study); Note: during the Active Monitoring Phase of a study (i.e., active treatment and observation), participants must be willing to return to the consenting institution for follow-up
Willing to provide blood samples at baseline for correlative research purposes and tissue for central pathology review
< 25% bone marrow involvement of cellular marrow with lymphoma as determined by bilateral bone marrow aspirate and biopsy; NOTE: the percent involvement should be estimated by the hematopathologist using all of the biopsy material
Has insurance coverage or is willing to pay for protocol therapy (rituximab x 4 or Zevalin x 1)

Exclusion Criteria

Any of the following because this study involves an agent whose genotoxic, mutagenic and teratogenic effects on the developing fetus and newborn are unknown:
- Pregnant women
- Nursing women
- Men or women of childbearing potential who are unwilling to employ adequate contraception for at least three months after completing study treatment
Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment of the investigator, would make the patient inappropriate for entry into this study or interfere significantly with the proper assessment of safety and toxicity of the prescribed regimens
Patients known to be human immunodeficiency virus (HIV) positive and currently receiving antiretroviral therapy
- NOTE: These patients are excluded because it is unknown what effects prolonged B-cell depletion will have on these patient's immune system
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, uncontrolled cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
Receiving any other investigational agent that would be considered as a treatment for the lymphoma
Active other malignancy requiring treatment that would interfere with the assessments of response of the lymphoma to protocol treatment and would interfere with follow-up assessments through year 5
Presence of central nervous system (CNS) lymphoma
Known to have lymphoma related to HIV or acquired immune deficiency syndrome (AIDS)
Abnormal renal function (serum creatinine > 2 x ULN)
Received prior external beam radiation therapy for another reason to > 25% of active bone marrow
Serious non-malignant disease such as active infection or other condition which in the opinion of the investigator would compromise other protocol objectives
Major surgery other than diagnostic surgery =< 4 weeks prior to registration
Any evidence of myelodysplastic syndrome or marrow chromosomal changes suggesting myelodysplasia (-7, -5 etc)
Corticosteroid therapy at the time the patient enters the protocol; NOTE: patients using prednisone or its equivalent for adrenal failure or using =< 10 mg of prednisone/day for other benign causes are accepted
Follicular grades IIIA or IIIB are not eligible
Marrow cellularity =< 15% (as determined on all bone marrow samples)
Seropositive for or active viral infection with hepatitis B virus (HBV):
- Hepatitis B surface antigen (HBsAg) positive
- HBsAg negative, anti-hepatitis B surface antibody (HBs) positive and/or anti-hepatitis B core antibody (HBc) positive and detectable viral deoxyribonucleic acid (DNA)

Notes:

Subjects who are HBsAg negative, anti-HBs positive, and/or anti-HBc positive, but viral DNA negative are eligible
Subjects who are seropositive because of HBV vaccination are eligible (HBV surface antibody positive, HBV core antibody negative, and HBV surface antigen negative)
- Active infection with hepatitis C virus (HCV)

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm A (rituximab)	Quality-of-Life Assessment	Patients receive rituximab IV on days 1, 8, 15, and 22.
Arm B (rituximab, yttrium Y-90 ibritumomab tiuxetan)	Quality-of-Life Assessment	Patients receive rituximab IV on days 1 and 8 and yttrium Y-90 ibritumomab tiuxetan over 10 minutes on day 8.
Arm B (rituximab, yttrium Y-90 ibritumomab tiuxetan)	Rituximab	Patients receive rituximab IV on days 1 and 8 and yttrium Y-90 ibritumomab tiuxetan over 10 minutes on day 8.
Arm A (rituximab)	Rituximab	Patients receive rituximab IV on days 1, 8, 15, and 22.
Arm B (rituximab, yttrium Y-90 ibritumomab tiuxetan)	Yttrium Y-90 Ibritumomab Tiuxetan	Patients receive rituximab IV on days 1 and 8 and yttrium Y-90 ibritumomab tiuxetan over 10 minutes on day 8.

Primary Outcome Measures

Name	Time	Method
Complete Response (CR) Rate at the 6-month Disease Assessment	6 months	Will be compared between the two arms. The percentage of patients in each response category (e.g., CR, partial remission, stable disease, relapse/progressive disease) will also be tabulated by arm. The proportion of patients who have a CR at 6 months will be evaluated and compared between the two treatment regimens using a two-sided alpha=0.05 continuity corrected Cochran-Mantel-Haenszel test with stratification factors.

Secondary Outcome Measures

Name	Time	Method
Time to Chemotherapy (TTC)	Time from registration to the date of initiation of chemotherapy for follicular lymphoma, assessed up to 5 years	The distribution of time to chemotherapy will be estimated using the method of Kaplan-Meier within each arm and compared between the arms using a log-rank test. The percentage of patients free of chemotherapy at 3 years and 5 years will be estimated in each arm.
Progression-free Survival (PFS)	Time from registration to the earliest date documentation of disease progression or death due to any cause, assessed up to 5 years	The distribution of progression-free survival time will be estimated using the method of Kaplan-Meier within each arm and compared between the arms using a logrank test. The progression-free survival rates at 3 years and 5 years will be estimated in each arm.
Time to Any Therapy (TTNT)	Time from registration to the date of initiation of any treatment for follicular lymphoma, assessed up to 5 years	The distribution of time to any therapy will be estimated using the method of Kaplan-Meier within each arm and compared between the arms using a log-rank test. The percentage of patients free of any therapy at 3 years and 5 years will be estimated in each arm.
Incidence of Adverse Events	Up to 5 years	Assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. The maximum grade for each type of adverse event will be recorded for each patient, and frequency tables will be reviewed to determine patterns. Additionally, the relationship of the adverse event(s) to the study treatment will be taken into consideration. Rates of individual adverse events (grade 3 and higher) will be compared between arms using a Fisher's exact test.