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

Study Overview
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Brief Summary
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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
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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.

Official Title
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The Asymptomatic Follicular Lymphoma (AFL) Trial: A Phase III Study of Single-Agent Rituximab Immunotherapy Versus Zevalin Radioimmunotherapy for Patients With New, Untreated Follicular Lymphoma Who Are Candidates for Observation

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

Intervention / Treatment
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* Other: Quality-of-Life Assessment
* Biological: Rituximab
* Radiation: Yttrium Y-90 Ibritumomab Tiuxetan


Participation Criteria
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Eligibility Criteria
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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)

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
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Arm A (rituximab)<br>Patients receive rituximab IV on days 1, 8, 15, and 22. | Other: Quality-of-Life Assessment<br>* Ancillary studies<br>* Other names: Quality of Life Assessment;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;|
| Experimental: Arm B (rituximab, yttrium Y-90 ibritumomab tiuxetan)<br>Patients receive rituximab IV on days 1 and 8 and yttrium Y-90 ibritumomab tiuxetan over 10 minutes on day 8. | Other: Quality-of-Life Assessment<br>* Ancillary studies<br>* Other names: Quality of Life Assessment;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;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 |
| --- | --- | --- |
| Complete Response (CR) Rate at the 6-month Disease Assessment | 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. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression-free Survival (PFS) | 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 from registration to the earliest date documentation of disease progression or death due to any cause, assessed up to 5 years | 
| Time to Any Therapy (TTNT) | 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. | Time from registration to the date of initiation of any treatment for follicular lymphoma, assessed up to 5 years | 
| Time to Chemotherapy (TTC) | 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. | Time from registration to the date of initiation of chemotherapy for follicular lymphoma, assessed up to 5 years | 
| Incidence of Adverse Events | 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. | Up to 5 years |