High Dose Rituximab for Initial Treatment of Indolent B-Cell Lymphomas

Phase 2

Completed

Brief Summary: The purpose of this clinical trial is to see if increased doses of rituximab are safe and effective for the initial treatment of indolent B-cell lymphomas. Rituximab (Rituxan) is a type of drug called an "antibody" that specifically targets B-cell lymphoma cells, and is approved by the FDA for the treatment of indolent B-cell non-hodgkin lymphomas and certain other types of non-hodgkin lymphomas. Standard doses currently used may not be achieving maximal efficacy. Higher doses have been shown to be safe in other clinical trials, and may offer superior efficacy to the current standard dose. This trial also employs intermittent maintenance doses of rituximab at the standard dose, which has been shown to prolong remissions and survival in patients with relapsed indolent B-cell lymphomas. This trial is designed to show that higher dose rituximab plus maintenance rituximab can achieve similarly good results to chemotherapy approaches, but without chemotherapy-related toxicity.

Detailed Description: * All participants will receive increased-dose rituximab through a vein in the arm once a week for 4 weeks (on Days 1, 8, 15, and 22 of the initial 28-day study cycle). This first cycle of study treatment is called the Induction Phase. If the participant responds well to the Induction Phase, they then may continue to the Maintenance Therapy Phase, where they will receive a lower dose of rituximab once every three months for up to 2 years.

* During the Induction Phase, the following procedures will take place before the participant receives each dose of rituximab: medical review, physical exam, performance status, and ECG. Blood tests will be drawn about 30-60 minutes after the first dose of rituximab on Day 1. Samples will be drawn immediately before each dose and again 30-60 minutes after each dose on Days 1, 8, 15 and 22.

* During the Maintenance Therapy Phase, the following procedures will take place before the participant receives each dose of rituximab: medical review, physical exam, performance status, ECG, blood tests and response assessments by CT scan.

Recruitment & Eligibility

Inclusion Criteria

Indolent B-Cell NHL of the following histologies:
1. Follicular lymphoma (grades 1-3A);
2. marginal zone lymphoma (extranodal, nodal or splenic):
  - Extranodal marginal zone lymphomas (MALT lymphomas) may not be candidates for cure with antibiotics or local radiotherapy. Patients who have failed antibiotics or local therapy are eligible for the protocol as long as they have measurable disease and are naive to chemotherapy and monoclonal antibody;
  - splenic marginal zone lymphoma patients may have received prior splenectomy as long as they have measureable disease and are naive to chemotherapy and monoclonal antibody therapy;
3. Small lymphocytic lymphoma (must have less than 5000 circulating clonal B-lymphocytes);
4. Indolent CD20+ B-cell lymphoma not otherwise specified with CD20+ expression
Measurable disease, defined as at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded) as 20mm or greater with conventional techniques or as 10mm or greater with spiral CT scan
No previous chemotherapy, antibody therapy or radioimmunotherapy for NHL. Patients previously treated with external bean radiation alone, surgery, or with antibiotics are eligible
18 years of age or older
Life expectancy of greater than 3 months
ECOG performance status of 2 or less
Adequate bone marrow function
Use of adequate contraception

Exclusion Criteria

Prior chemotherapy, monoclonal antibody therapy or radioimmunotherapy for lymphoma
Receiving any other investigational agent
Known brain metastases
History of allergic reactions attributed to compounds of similar chemical or biologic composition to rituximab
HIV positivity
Active hepatitis B infection
Candidate for curative radiotherapy, unless radiation therapy is considered too toxic (as in abdominal disease), or is refused by the patient
NYHA Classification III or IV disease
Uncontrolled intercurrent illness including, but not limited to ongoing or active infection that is not optimally treated with antibiotics, unstable angina pectoris, or psychiatric illness/social situations that would limit compliance with study requirements
Pregnant women
Individuals with a history of a different malignancy except for the following circumstances:
1. disease-free for at least 1 year and are deemed by the investigator to be at low risk for recurrence of that malignancy;
2. localized prostate cancer, prostate cancer with elevated PSA but no measurable disease on CT scans or bone scan, cervical cancer in situ; and
3. non-melanoma skin cancers

Arm && Interventions

Group	Intervention	Description
rituximab	rituximab	single-arm, open-label, interventional

Primary Outcome Measures

Name	Time	Method
Determine Complete Response Rate (CRR) of Increased Dose Rituximab in Indolent B-cell Lymphomas	after a median number of 8 maintenance cycles, up to 24 weeks	CR requires all of the following: 1. Regression to normal size on CT (≤ 1.5 cm in their greatest transverse diameter for nodes ≥ 1.5 cm before therapy). Previously involved nodes that were 1.1 to 1.5 cm in their greatest transverse diameter before treatment must have decreased to \<1 cm in their greatest transverse diameter after treatment, or by more than 75% in the sum of the products of the greatest diameters (SPD). 2. The spleen, if considered to be enlarged before therapy on the basis of a CT scan, must have regressed in size and must not be palpable on physical examination. 3. If bone marrow is known to be involved at the beginning, then repeat biopsy documents clearance

Secondary Outcome Measures

Name	Time	Method
Overall Response Rate (ORR)	after a median number of 8 maintenance cycles, up to 24 weeks	Complete Response (CR): see definition in primary outcome Partial Response (PR): 1. ≥50% decrease in SPD of up to 6 largest dominant masses 2. No new sites of disease or increase in the size of the other nodes, liver, or spleen. 3. Splenic and hepatic nodules must regress by at least 50% in the SPD. Overall Response (OR) = CR + PR.
Incidence of Severity of Infusion Reactions, Infections and Neutropenia	24 months	Toxicity grades: 1 = mild, 2 = moderate, 3 = severe, 4 = life-threatening
Progression-free Survival (PFS)	5 years	Progressive Disease (PD) or Relapsed Disease (RD): 1. Appearance of a new lesion(s) \> 1.5 cm in any axis, ≥ 50% increase in SPD of more than one node, or ≥50% increase in longest diameter of a previously identified node \> 1 cm in short axis. 2. \>50% increase from nadir in the SPD of any previous lesions PFS is number of participants who have not died or had PD or RD.

Locations (2): Massachusetts General Hospital
🇺🇸
Boston, Massachusetts, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States