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Safety and Efficacy of Sequential Treatment With a Combination of Rituximab, Fludarabine and Cyclophosphamide Followed by Zevalin (Rituximab and Y-Ibritumomab Tiuxetan) - A Phase I/II Study for Treatment of Patients With Relapsed Indolent and Transformed CD20-Positive B-Cell Non-Hodgkin's-Lymphoma Ineligible for High-Dose Chemo(Radio)Therapy Supported by Autologous Peripheral Blood Stem-Cells


Phase 1/Phase 2
50 Years
75 Years
Open (Enrolling)
Both
Lymphoma

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Trial Information

Safety and Efficacy of Sequential Treatment With a Combination of Rituximab, Fludarabine and Cyclophosphamide Followed by Zevalin (Rituximab and Y-Ibritumomab Tiuxetan) - A Phase I/II Study for Treatment of Patients With Relapsed Indolent and Transformed CD20-Positive B-Cell Non-Hodgkin's-Lymphoma Ineligible for High-Dose Chemo(Radio)Therapy Supported by Autologous Peripheral Blood Stem-Cells


OBJECTIVES:

Primary

- Determine the dose-limiting toxicity and maximum tolerated dose of rituximab and
yttrium Y 90 (^90Y) ibritumomab tiuxetan when administered with rituximab as
radioimmunotherapy after rituximab, fludarabine, and cyclophosphamide in patients with
relapsed indolent, mantle cell, or transformed CD20-positive B-cell non-Hodgkin's
lymphoma.

Secondary

- Determine the overall survival in patients treated with this regimen.

- Determine time to progression and event-free survival in patients treated with this
regimen.

- Determine partial and complete response rates in patients treated with this regimen.

- Determine time to maximal response in patients treated with this regimen.

- Determine response duration in patients treated with this regimen.

- Determine the feasibility of additional antineoplastic treatment following disease
relapse after treatment with rituximab and ^90Y ibritumomab tiuxetan in these patients.

OUTLINE: This is a prospective, nonrandomized, multicenter, phase I dose-escalation study of
yttrium Y 90 (^90Y) ibritumomab tiuxetan followed by a phase II open-label study.

- Phase I:

- Chemoimmunotherapy: Patients receive rituximab IV on day 1 and fludarabine IV over
30 minutes and cyclophosphamide IV over 60 minutes on days 1-3. Treatment repeats
every 4 weeks for up to 3 courses in the absence of disease progression. Four
weeks after the first day of the last chemoimmunotherapy course, patients receive
1 dose of rituximab IV alone. Patients with disease progression are removed from
the study. Patients with stable disease proceed to radioimmunotherapy 8-12 weeks
after the first day of the last chemoimmunotherapy course.

- Radioimmunotherapy: Patients receive rituximab IV and an imaging dose of indium In
III ibritumomab tiuxetan IV over 10 minutes on day 1. Patients then undergo
imaging. If dosimetry is acceptable, patients receive rituximab IV and ^90Y
ibritumomab tiuxetan IV over 10 minutes on day 8.

Cohorts of 3-6 patients receive escalating doses of ^90Y ibritumomab tiuxetan until the
maximum tolerated dose (MTD) is determined. The MTD is defined as the dose preceding that at
which 2 of 3 or 2 of 6 patients experience dose-limiting toxicity.

- Phase II: Patients receive chemoimmunotherapy and radioimmunotherapy as in phase I, at
the MTD determined in phase I.

Treatment continues in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed periodically for up to 2 years.

PROJECTED ACCRUAL: A total of 12 patients will be accrued for this study.

Inclusion Criteria


DISEASE CHARACTERISTICS:

- Histologically confirmed CD20-positive B-cell non-Hodgkin's lymphoma (NHL), including
any of the following subtypes:

- Indolent NHL, including any of the following:

- Follicular

- Lymphoplasmacytoid

- Marginal zone

- Mantle cell NHL

- Transformed B-cell NHL

- In at least first relapse with an indication for systemic antineoplastic treatment,
as defined by the following:

- Local or constitutional (B-) symptoms

- Hypersplenism due to splenic involvement

- Bulky disease (> 7.5 cm in diameter)

- Impending medical problems derived from rapid disease progression within the
past 6 months, as defined by an observed or anticipated > 50% increase in the
sum of the areas calculated from multiplying the greatest perpendicular
diameters of each lesion

- Measurable lesions of lymphoma infiltration

- Medically ineligible for high-dose treatment followed by autologous stem cell support

- Adequate bone marrow cellularity (> 15% of marrow area covered by hematopoiesis)

- No CNS, leptomeningeal, spinal cord, or testes lymphoma involvement

- No lymphoma lesion mandating emergency radiotherapy

- No clinical, cytological, cytogenetic, or histopathologic indication of
myelodysplastic syndrome

- If there is bone marrow infiltration detected prior to chemoimmunotherapy, patient
must undergo a repeat bone marrow biopsy prior to planned treatment with
radioimmunotherapy to verify the level of bone marrow infiltration is < 25%

PATIENT CHARACTERISTICS:

- ECOG performance status 0-2

- Life expectancy ≥ 3 months

- Absolute neutrophil count > 1,500/mm³

- Platelet count > 150,000/mm³

- Hemoglobin > 9 g/dL

- Creatinine < 1.5 times upper limit of normal (ULN)

- Bilirubin < 2 times ULN

- ALT and AST < 2 times ULN

- Albumin > 2.5 g/dL

- INR < 1.5

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception during and for ≥ 12 months after
completion of study treatment

- No concurrent severe and/or uncontrolled medical disease that would preclude study
compliance, including any of the following:

- Uncontrolled diabetes

- Congestive heart failure

- Chronic renal disease

- Active uncontrolled infection

- No bleeding risks or disorders, including any of the following:

- CNS abnormalities suggesting an increased susceptibility for hemorrhage,
including recent history of stroke as demonstrated by cranial contrast-enhanced
CT scan

- Severe arrhythmia or uncontrolled hypertension

- Myocardial infarction within the past 6 months

- Diabetic retinopathy with history of symptomatic hemorrhage

- Known and potentially active gastrointestinal bleeding foci

- Concurrent anticoagulant medication that must be continued even with platelet
count < 20,000/mm³ (e.g., following mitral valve replacement, anti-phospholipid
syndrome, or recurrent venous thromboembolism)

- Other congenital or acquired hemorrhagic diatheses

- No ongoing autoimmune hemolytic anemia

- No known presence of anti-murine antibody reactivity

- No known hypersensitivity to murine or chimeric antibodies or proteins

- No known HIV infection

- No psychiatric illness that would preclude study requirements

- No other malignant disorder within the past 10 years except basal cell carcinoma of
the skin or carcinoma in situ of the cervix

PRIOR CONCURRENT THERAPY:

- See Disease Characteristics

- Recovered from prior therapy

- No more than 4 prior systemic anti-lymphoma regimens (including single-agent
rituximab)

- At least 2 months since prior systemic anti-lymphoma treatment (including
single-agent rituximab)

- No prior radioimmunotherapy

- No prior autologous or allogeneic hematopoietic stem cell transplantation

- No prior treatment with purine analogues that has not resulted in remission for > 1
year

- No prior anti-CD20 radioimmunoconjugate therapy

- More than 5 years since prior radiotherapy to extensive fields covering lymph node
regions on both sides of the diaphragm or > 50% of the spinal column

- More than 4 weeks since prior surgery

- No concurrent oral anticoagulant therapy

Type of Study:

Interventional

Study Design:

Allocation: Non-Randomized, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

Dose-limiting toxicity

Safety Issue:

Yes

Principal Investigator

Christian Peschel, MD

Investigator Role:

Study Chair

Investigator Affiliation:

Technische Universität München

Authority:

Germany: Paul-Ehrlich-Institut

Study ID:

CDR0000515982

NCT ID:

NCT00397800

Start Date:

June 2005

Completion Date:

May 2013

Related Keywords:

  • Lymphoma
  • recurrent grade 1 follicular lymphoma
  • recurrent grade 2 follicular lymphoma
  • Waldenstrom macroglobulinemia
  • recurrent mantle cell lymphoma
  • recurrent marginal zone lymphoma
  • extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue
  • nodal marginal zone B-cell lymphoma
  • splenic marginal zone lymphoma
  • Lymphoma
  • Lymphoma, Non-Hodgkin
  • Lymphoma, B-Cell

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