Agatolimod Sodium, Rituximab, and Yttrium Y 90 Ibritumomab Tiuxetan in Treating Patients With Recurrent or Refractory Non-Hodgkin Lymphoma

Study Overview
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Brief Summary
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RATIONALE: Biological therapies, such as agatolimod sodium, may stimulate the immune system in different ways and stop cancer cells from growing. Monoclonal antibodies, such as rituximab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Radiolabeled monoclonal antibodies, such as yttrium Y 90 ibritumomab tiuxetan, can find cancer cells and carry cancer-killing substances to them without harming normal cells. Giving agatolimod sodium together with rituximab and yttrium Y 90 ibritumomab tiuxetan may kill more cancer cells. PURPOSE: This phase I/II trial is studying the side effects and best dose of agatolimod sodium when given together with rituximab and yttrium Y 90 ibritumomab tiuxetan and to see how well it works in treating patients with recurrent or refractory non-Hodgkin lymphoma.

Detailed Description
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PRIMARY OBJECTIVES: I. To determine the maximum tolerated dose of CpG 7909 that can be delivered in four doses (days 6, 13, 20, 27) for patients with relapsed CD20+ non-Hodgkin's lymphoma. (Phase I) II. To assess the toxicity of CpG 7909 when combined with rituximab and Y-90 Zevalin in patients with lymphoma. (Phase I) III. To assess the overall response rate (CR + PR) of this regimen in relapsed diffuse large B cell lymphoma. (Phase II) IV. To assess the toxicity of the treatment regimen in patients with relapsed diffuse large B cell lymphoma. (Phase II) V. To assess the time to progression and duration of response in patients with relapsed diffuse large B cell lymphoma. (Phase II) SECONDARY OBJECTIVES: I. To report the response rate (complete remission + complete remission unconfirmed + partial remission) in this patient population after CpG 7909, rituximab, and Y-90 Zevalin. (Phase I) II. To compare the biodistribution of In-111 Zevalin radioimmunoconjugate scans before and after CpG 7909. (Phase I) III. To determine the HAMA/HACA rate in patients treated with this regimen. (Phase I) IV. To determine if CpG 7909 when given in the context of rituximab and Y-90 Zevalin can stimulate immune effector cells in the blood and tumor tissue. (Phase I) OUTLINE: This is a dose escalation study of agatolimod sodium followed by a phase II study. PHASE I (patients with relapsed, refractory, or residual CD20+ non-Hodgkin lymphoma [closed to accrual as of 10/29/07]): Patients receive rituximab IV on days 1, 8 and 15, agatolimod sodium IV over 2 hours on days 6, 13, 20, and 27, and yttrium Y 90 ibritumomab tiuxetan* IV over 10 minutes on day 15 in the absence of disease progression and unacceptable toxicity. *NOTE: Patients receive indium In 111 ibritumomab tiuxetan IV over 10 minutes on days 1 and 8. Patients undergo whole-body gamma camera imaging, single-photon emission computed tomography/CT scans, and blood sampling after each dose of indium In 111 ibritumomab tiuxetan to determine biodistribution. If biodistribution is acceptable, patients receive yttrium Y 90 ibritumomab tiuxetan. PHASE II (patients with relapsed, refractory, or residual diffuse large B-cell lymphoma): Patients receive agatolimod sodium at the MTD as determined in phase I. Patients receive rituximab and yttrium Y 90 ibritumomab tiuxetan as in phase I. *NOTE: Patients receive indium In 111 ibritumomab tiuxetan IV over 10 minutes on day 8. Patients undergo whole-body gamma camera imaging and blood sampling after each dose of indium In 111 ibritumomab tiuxetan to determine biodistribution. After completion of study treatment, patients are followed periodically for up to 5 years.

Official Title
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A Phase I/II Trial of CpG 7909, Rituximab Immunotherapy, and Y-90 Zevalin Radioimmunotherapy for Patients With Previously Treated CD20+ Non-Hodgkin Lymphoma

Conditions
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Adult Non-Hodgkin Lymphoma, Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue, Nodal Marginal Zone Lymphoma, Recurrent Adult Diffuse Large Cell Lymphoma, Recurrent Grade 1 Follicular Lymphoma, Recurrent Grade 2 Follicular Lymphoma, Recurrent Grade 3 Follicular Lymphoma, Recurrent Mantle Cell Lymphoma, Recurrent Marginal Zone Lymphoma, Recurrent Small Lymphocytic Lymphoma, Splenic Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia

Intervention / Treatment
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* Drug: Agatolimod Sodium
* Radiation: Indium In-111 Ibritumomab Tiuxetan
* Other: Laboratory Biomarker Analysis
* Procedure: Radionuclide Imaging
* Biological: Rituximab
* Procedure: Single Photon Emission Computed Tomography
* Radiation: Yttrium Y-90 Ibritumomab Tiuxetan


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: The following histologic types by REAL classification and International Working Formulation (IWF) when applicable (NOTE: Closed to accrual as of 10/29/07): Small lymphocytic lymphoma; Lymphoplasmacytoid lymphoma; Follicular center lymphoma, follicular grades 1, 2, and 3; Extranodal marginal zone B cell lymphoma of MALT type; Nodal marginal zone B cell lymphoma The following histologic types by REAL classification and International Working Formulation (IWF) when applicable: Diffuse large cell; Transformed lymphoma Less than 25% bone marrow involvement of cellular marrow with lymphoma as determined by bilateral bone marrow aspirate and biopsy (the percent involvement should be estimated by the hematopathologist using all of the biopsy material) There is no limit on the number of prior therapies (patients who have previously received rituximab are eligible) Bi-dimensionally measurable disease: The patients must have >= 1 lesion that has a single diameter of >= 2 cm Absolute neutrophil count >= 1500/mm^3 Platelet count >= 150,000 Total lymphocyte count < 5000/mm^3 only for patients with small lymphocytic lymphoma HGB >= 8 Biopsy-proven relapsed, refractory, or residual CD20+ non-Hodgkin's lymphomas; previous biopsies =<6 months prior to treatment on this protocol will be acceptable as long as there has not been intervening therapy; if the patient has received therapy for NHL between the time of the last biopsy and this protocol, then a re-biopsy is necessary ECOG performance status (PS) 0, 1, or 2 Expected survival >= 3 months Willingness to provide all biologic specimens as required by the protocol Total bilirubin =< 2 x ULN mg/dL (if abnormal, direct bilirubin =< 1.5 x ULN) Exclusion Criteria: Prior myeloablative therapies with autologous or allogeneic bone marrow transplantation or peripheral blood stem cell support Prior radioimmunotherapy including Y-90 Zevalin or 131-Iodine anti-B1 antibody or Lym-1 Presence of CNS lymphoma 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 Another active primary malignancy Known HAMA/HACA (Human anti-mouse or anti-chimeric antibodies) Myelodysplastic syndrome or marrow chromosomal changes suggesting myelodysplasia Pregnant women Nursing women Men or women of childbearing potential who are unwilling to employ adequate contraception (condoms, diaphragm, birth control pills, injections, intrauterine device [IUD], surgical sterilization, abstinence, etc.) Failed stem cell collection Marrow cellularity =< 15% (as determined on all bone marrow samples) Known to have lymphoma related to HIV or AIDS (these patients are excluded because it is unknown what effects prolonged B-cell depletion will have on these patient's immune system) G-CSF or GM-CSF therapy =< 1 week prior to study registration (pegylated filgrastim =< 3 weeks) Myelosuppressive chemotherapy =< 3 weeks prior to study registration (=< 6 weeks if rituximab, nitrosourea, or Mitomycin C) Skin rash (such as Stevens-Johnson's syndrome or toxic epidermal necrolysis) with prior rituximab therapy should not be entered on this study because of the risk of reoccurrence of that skin toxicity Abnormal renal function (serum creatinine > 2 mg/dL) Pre-existent clinical autoimmune or antibody mediated diseases, including systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, Sjogren's syndrome, and autoimmune thrombocytopenia (patients that have no clinical symptoms of these diseases, but merely have previously detected antibodies are eligible) Received prior external beam radiation therapy to > 25% of active bone marrow Corticosteroid therapy at the time the patient enters the protocol; patients using prednisone or its equivalent for adrenal failure or using < 20mg of prednisone/day for other benign causes are accepted

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm I<br>See Detailed Description | Drug: Agatolimod Sodium<br>* Given IV<br>* Other names: ProMune;Radiation: Indium In-111 Ibritumomab Tiuxetan<br>* Given IV<br>* Other names: indium In 111 ibritumomab tiuxetan;Other: Laboratory Biomarker Analysis<br>* Correlative study<br>Procedure: Radionuclide Imaging<br>* Undergo imaging scans<br>* Other names: SCINTIGRAPHY;Biological: Rituximab<br>* Given IV<br>* Other names: RTXM83;Procedure: Single Photon Emission Computed Tomography<br>* Undergo imaging scans<br>* Other names: Tomography, Emission-Computed, Single-Photon;Radiation: Yttrium Y-90 Ibritumomab Tiuxetan<br>* Given IV<br>* Other names: yttrium Y90 ibritumomab tiuxetan;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Maximum Tolerated Dose of CpG 7909 as Determined Using the Number of Participants With a DLT at Each Dose Level | Participants will be treated in cohorts of 6 patients at each dose level of CpG 7909 (0.08 mg/kg, 0.16 mg/kg, 0.32 mg/kg, 0.48 mg/kg) and observed for at least 10 weeks post treatment. If at most one of the 6 patients experiences a dose limiting toxicity (DLT), a new cohort of 6 patients will be treated at the next higher dose level. A DLT for this study is defined as patients with one of the following: Absolute neutrophil counts or platelet counts below 10*10^9/L for 14 days Absolute neutrophil counts greater than 0.5 or less than 1*10^9/L Platelet counts greater than 10 or less than 50*10^9/L for 28 days. Any grade 3 non-hematologic toxicity not explainable by another obvious cause as assessed using the Common Terminology Criteria for Adverse Events (CTCAE) v3.0. We are reporting the number of DLTs at each of the dose levels. The maximum tolerated dose will be 0.48 mg/kg or the largest dose level where 1 or fewer participants reports a dose limiting toxicity. | at least 10 weeks post treatment up to 3 months. | 
| Tumor Response | Complete Response (CR): No measurable or nonmeasurable disease. No symptoms of Lymphoma. Non-palpable spleen, if palpable at baseline. Histologically negative bone marrow, if positive at baseline. All nodes <1.5 cm in transverse diameter. Partial Response (PR): greater than 50% decrease from baseline in the sum of the products of the longest perpendicular diameters of the six largest dominant lesions. No new lesions We are reporting the number of participants that attained a status of CR or PR. | Evaluations occur every three months up to a year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression-free Survival | The Progression-free survival (PFS) is defined as the time from registration to progression or death due to any cause. The distribution of PFS will be estimated using the method of Kaplan-Meier. | Up to 1 year from treatment start date | 
| Duration of Response | Duration of response (DoR) will be calculated from the documentation of response until the date of progression in the subset of patients who respond. | Up to 1 year from treatment start date |