Phase II Venetoclax, Obinutuzumab and Bendamustine in High Tumor Burden Follicular Lymphoma as Front Line Therapy
Condition: Follicular Lymphoma; Non-Hodgkin's Lymphoma Follicular; Non-Hodgkin's Lymphoma, Adult High Grade
MeSH terms: Lymphoma; Lymphoma, Follicular; Lymphoma, Non-Hodgkin
Intervention: Induction Venetoclax; Maintenance Venetoclax
Intervention description: 1 cycle = 28 days.
Cycle 1-6: Obinutuzumab IV. Cycle 1, Day 1 obinutuzumab 100 mg and Cycle 1, Day 2 obinutuzumab 900 mg for total dose of 1000 mg. On Cycle 1, Day 8 and Day 15 obinutuzumab 1000 mg. Starting with Cycle 2, obinutuzumab 1000 mg on Day 1 only of each cycle.
Cycle 1-6: Bendamustine 90 mg/m² IV on Days 1 and 2 of each cycle over 15 minutes after obinutuzumab.
Cycle 2-6: Venetoclax 800 mg by mouth daily on Days 1-10 administered before obinutuzumab and/or bendamustine.; Patients whose disease is the same or improved will receive venetoclax 800 mg by mouth daily for 24 cycles (1 cycle=1 month) and obinutuzumab 1000 mg IV every 2 months for 12 cycles. Patients with no evidence of disease will receive obinutuzumab 1000 mg IV every 2 months for 12 cycles.
Intervention MeSH terms: Venetoclax
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 56.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: High Tumor Burden Follicular Lymphoma; Venetoclax; Obinutuzumab; Bendamustine; Bcl-2 Family Protein Inhibitor; Monoclonal Antibody

Summary:

      Patients with high tumor burden, low grade follicular lymphoma that has never been treated,
      will receive venetoclax in combination with obinutuzumab and bendamustine.

      Venetoclax is an oral Bcl-2 family protein inhibitor. It targets the B-cell lymphoma 2
      (BCL-2) protein, which supports cancer cell growth and is overexpressed in many patients with
      follicular lymphoma. Venetoclax may help to slow down the growth of cancer or may cause
      cancer cells to die.

      The purpose of this study is to see whether adding venetoclax to obinutuzumab and
      bendamustine improves the response (the tumor shrinks or disappears) in patients with
      follicular lymphoma.

      As of 9/5/2018, a higher than expected incidence of tumor lysis syndrome (TLS) was
      experienced among patients receiving venetoclax, obinutuzumab and bendamustine on Cycle 1,
      Day 1 of treatment. TLS is caused by the fast breakdown of cancer cells. These patients
      developed an increase in some of their blood tests (uric acid, phosphorus, potassium and/or
      creatinine). They received a medication called rasburicase and continued with treatment. It
      is unclear if the TLS was due to the venetoclax or the standard treatment of obinutuzumab and
      bendamustine. For the remaining patients, venetoclax will start on Cycle 2, Day 1 (previously
      Cycle 1, Day 1).

      As of 9/16/2021, additional maintenance therapy has been suspended for those patients who
      remain on study. These patients will not receive any further treatment and will move on to
      the two year survival follow-up.
    

Eligibility criteria:

        -  Patient must have a histologically confirmed (biopsy-proven) diagnosis of follicular
             B-cell non-Hodgkin lymphoma (WHO classification: follicular center grades 1, 2, and 3a
             [3b patients are not eligible]), with no evidence of transformation to large cell
             histology.

          -  Patient must meet criteria for High Tumor Burden (higher risk) as defined by either
             the Groupe D'Etude des Lymphomes Follicularies (GELF) criteria [at least one
             criterion] OR the follicular lymphoma international prognostic index (FLIPI) [score of
             3, 4, or 5].

          -  Patient must have Stage II, III or IV disease.

          -  Baseline measurements and evaluations (PET/ CT) must be obtained within 10 weeks of
             randomization to the study. Patient must have at least one objective measurable
             disease parameter.

          -  Age ≥ 18 years.

          -  Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.

          -  Ability to understand and willingness to sign Institutional Review Board
             (IRB)-approved informed consent.

          -  Willing to provide mandatory tissue samples (if sufficient tissue available) for
             research purposes.

          -  Adequate organ function as measured by the following criteria:

               -  Absolute Neutrophil Count (ANC) ≥ 1000/mm³

               -  Hemoglobin ≥ 8 g/dL

               -  Platelets ˃75,000/mm³

               -  Creatinine clearance ≥ 50 mL/min, calculated with the use of 24-hour creatinine
                  clearance or by Cockcroft-Gault formula

               -  Total Bilirubin ≤ 1.5x Upper Limit of Normal (ULN) or ≤ 3x ULN for patients with
                  documented Gilbert's syndrome

               -  Aspartate aminotransferase (AST)/ alanine aminotransferase (ALT) ≤ 2.5x ULN

               -  Alkaline Phosphatase <5x ULN

          -  All females of childbearing potential (not surgically sterilized and between menarche
             and 1 year post menopause) must have a blood or urine test to rule out pregnancy
             within 2 weeks prior to registration.

          -  Women must not be pregnant or breastfeeding.

          -  Patient must have had no prior chemotherapy, radiotherapy or immunotherapy for
             lymphoma. For purposes of this trial, prednisone or other corticosteroids used for
             non-lymphomatous conditions will not be considered as prior chemotherapy. In addition,
             a prior/recent short course (<2 weeks) of steroids for symptom relief of
             lymphoma-related symptoms will not make a patient ineligible.

          -  Patient must have no recent history of malignancy except for adequately treated basal
             cell or squamous cell skin cancer, Stage I melanoma of the skin, or in situ cervical
             cancer. Individuals in documented remission without treatment for ≥ 2 years prior to
             enrollment may be included at the discretion of the investigator.

          -  Patient must have no active, uncontrolled infections.

          -  Patients must be tested for hepatitis B virus (HBV), hepatitis B surface antigen
             (HBsAg+) and hepatitis C (HCV) antibody within 6 weeks of registration. Patients who
             are chronic carriers of HBV with positive HBsAg+ and positive HCV serology are
             excluded, as chemotherapy and B-cell depleting therapy have been associated with virus
             reactivation and fulminant hepatitis. NOTE: Patients with a past or resolved HBV
             infection (defined as the presence of hepatitis B core antibody [anti-HBc] and absence
             of HBsAg) may be included if HBV DNA is undetectable. If enrolled, patients must be
             willing to undergo monthly HBV DNA testing. Patients with positive HCV antibody must
             be negative for HCV by polymerase chain reaction (PCR) to be eligible for study
             participation.

          -  HIV positive patients are not excluded, but to enroll, must meet all of the below
             criteria:

               -  HIV is sensitive to antiretroviral therapy.

               -  Must be willing to take effective antiretroviral therapy if indicated.

               -  No history of CD4 prior to or at the time of lymphoma diagnosis <300 cells/mm³.

               -  No history of AIDS-defining conditions.

               -  If on antiretroviral therapy, must not be taking zidovudine or stavudine.

               -  Must be willing to take prophylaxis for Pneumocystis jiroveci pneumonia during
                  therapy and until at least 2 months following the completion of therapy or until
                  the CD4 cells recover to over 250 cells/mm³, whichever occurs later.

          -  Evidence of significant, uncontrolled concomitant diseases that could affect
             compliance with the protocol or interpretation of results or that could increase risk
             to the patient.

          -  No major surgery within 2 weeks prior to cycle 1, other than for diagnosis.

          -  A condition that precludes oral route of administration (venetoclax).

          -  No known allergies to both xanthine oxidase inhibitors and rasburicase.

          -  Patient must not require the use of warfarin (because of potential drug-drug
             interactions that may potentially increase the exposure of warfarin). Blood thinners
             of other classes are permitted.

          -  Patient may not receive the following agents within 7 days prior to the first dose of
             venetoclax:

               -  Strong and moderate CYP3A inhibitors

               -  Strong and moderate CYP3A inducers

               -  Consumed grapefruit, grapefruit products, Seville oranges (including marmalade
                  containing Seville oranges), or star fruit within 3 days prior to the first dose
                  of venetoclax.

          -  Patient must not have serious medical or psychiatric illness likely to interfere with
             participation in this clinical study.