Bortezomib, Rituximab, and Dexamethasone With or Without Temsirolimus in Treating Patients With Untreated or Relapsed Waldenstrom Macroglobulinemia or Relapsed or Refractory Mantle Cell or Follicular Lymphoma

Study Overview
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Brief Summary
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This randomized phase I/II trial studies the side effects and the best dose of temsirolimus when given together with bortezomib, rituximab, and dexamethasone and to see how well they work compared to bortezomib, rituximab, and dexamethasone alone in treating patients with untreated or relapsed Waldenstrom macroglobulinemia or relapsed or refractory mantle cell or follicular lymphoma. Bortezomib and temsirolimus may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Bortezomib may also stop the growth of cancer cells by blocking blood flow to the tumor. Monoclonal antibodies, such as rituximab, can block cancer growth in difference 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. Drugs used in chemotherapy, such as dexamethasone, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It is not yet known whether bortezomib, rituximab, and dexamethasone are more effective with temsirolimus in treating non-Hodgkin lymphoma.

Detailed Description
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PRIMARY OBJECTIVES: I. To determine the maximum tolerated dose (MTD) of temsirolimus in combination with bortezomib, rituximab, dexamethasone in patients with relapsed Waldenstrom's macroglobulinemia and relapsed/refractory mantle cell, follicular, marginal zone or small lymphocytic lymphoma. (Phase I) II. To evaluate whether the addition of temsirolimus to the regimen of bortezomib, rituximab, dexamethasone improves progression-free survival in patients with previously untreated or relapsed Waldenstrom's macroglobulinemia. (Phase II) SECONDARY OBJECTIVES: I. To define and describe the toxicities of temsirolimus in combination with bortezomib, rituximab, and dexamethasone. (Phase I) II. To evaluate time to progression of bortezomib, rituximab, dexamethasone +/- temsirolimus in patients. (Phase II) III. To evaluate major and minor response by 6 cycles of therapy of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Phase II) IV. To evaluate time to response and duration of response of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Phase II) V. To evaluate toxicity of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Phase II) VI. To evaluate time to next therapy of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Phase II) VII. To evaluate overall survival of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Phase II) VIII. To describe treatment-related fatigue, physical and functional well-being during and after treatment. (Phase II) IX. To compare the change in treatment related fatigue, physical and functional well-being over 6 cycles of bortezomib, rituximab, dexamethasone +/- temsirolimus. (Quality of Life) X. To prospectively assess health-related quality of life longitudinally (pre-treatment to 3 year follow-up assessment) among trial participants. (Quality of Life) XI. To describe treatment-related peripheral neuropathy associated with bortezomib neurotoxicity. (Quality of Life) OUTLINE: This is a phase I, dose-escalation study of temsirolimus followed by a randomized phase II study. PHASE I: Patients receive temsirolimus intravenously (IV) over 30-60 minutes on days 1, 8, 15, and 22; rituximab IV over 30-60 minutes on days 1, 8, 15, and 22 (of courses 1 and 4 only); and bortezomib IV or subcutaneously (SC) and dexamethasone orally (PO) on days 1, 8, and 15. Courses repeat every 28 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. PHASE II: Patients are randomized to 1 of 2 treatment arms. ARM I: Patients receive rituximab IV over 30-60 minutes on days 1, 8, 15, and 22 (of courses 1 and 4 only) and bortezomib IV or SC and dexamethasone PO on days 1, 8, and 15. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive temsirolimus IV over 30-60 minutes on days 1, 8, 15, and 22 and rituximab, bortezomib, and dexamethasone as in arm I. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. After completion of study therapy, patients are followed up every 3 months for 2 years, every 6 months for 3 years, and then yearly for 5 years.

Official Title
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A Randomized Phase I/II Study of Bortezomib, Rituximab, Dexamethasone and Temsirolimus in Patients With Relapsed Waldenstrom Macroglobulinemia and Relapsed/Refractory Mantle Cell, Follicular, Marginal Zone or Small Lymphocytic Lymphomas (Phase I), and Untreated/Relapsed Waldenstrom Macroglobulinemia (Phase II)

Conditions
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Recurrent Follicular Lymphoma, Recurrent Mantle Cell Lymphoma, Recurrent Marginal Zone Lymphoma, Recurrent Non-Hodgkin Lymphoma, Recurrent Small Lymphocytic Lymphoma, Recurrent Waldenstrom Macroglobulinemia, Refractory Follicular Lymphoma, Refractory Mantle Cell Lymphoma, Refractory Marginal Zone Lymphoma, Refractory Non-Hodgkin Lymphoma, Refractory Small Lymphocytic Lymphoma

Intervention / Treatment
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* Drug: Bortezomib
* Drug: Dexamethasone
* Other: Laboratory Biomarker Analysis
* Other: Quality-of-Life Assessment
* Biological: Rituximab
* Drug: Temsirolimus


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically proven diagnosis For phase I portion (Arm A, B, C and D), patients must have of one of the following: Relapsed Waldenstrom's macroglobulinemia Relapsed/refractory mantle cell lymphoma; previous treatment with at least one standard regimen and no longer responsive to that regimen Relapsed/refractory follicular lymphoma; previous treatment with at least one standard regimen and no longer responsive to that regimen Relapsed/refractory marginal zone lymphoma; previous treatment with at least one standard regimen and no longer responsive to that regimen Relapsed/refractory small lymphocytic lymphoma; previous treatment with at least one standard regimen and no longer responsive to that regimen For phase II portion (Arm E and F), patients must have a diagnosis of symptomatic Waldenstrom's macroglobulinemia, either untreated or relapsed, confirmed by the presence of all of the following: Bone marrow lymphoplasmacytosis with >= 10% lymphoplasmatic cells (measured within 28 days prior to registration) OR Aggregates or sheets of one of the following: lymphocytes, plasma cells or lymphoplasmacytic cells on the bone marrow biopsy (measured within 28 days prior to registration) Measurable disease defined as a quantitative immunoglobulin M (IgM) monoclonal protein of >= 1000 mg/dL obtained within 28 days prior to registration Cluster of differentiation 20 (CD20) positive bone marrow or lymph node by immunohistochemistry or flow cytometry obtained within 28 days prior to registration Lymph node biopsy must be done =< 28 days prior to registration if used as an eligibility criterion for study entry Serum protein electrophoresis (SPEP) is required to be performed within 28 days prior to registration Additional requirements for Waldenstrom's macroglobulinemia (WM) patients (phase I and II): In addition to measurable disease, patients must have symptomatic disease defined by one or more of the following: Laboratory studies defining eligibility (hemoglobin [Hgb], platelet count, viscosity) must have been obtained within 28 days prior to registration; if more than one test was obtained, the most recent one will be utilized Hemoglobin =< 11 g/dL Hyperviscosity syndrome or measured viscosity level of >= 4 centipoise NOTE: for these patients it is strongly recommended that they undergo therapeutic plasmapheresis prior to initiation of therapy Platelet count < 100,000/mm^3 Symptomatic lymphadenopathy, splenomegaly, or hepatomegaly Constitutional symptoms including fever, night sweats, or unexplained weight loss (at least 10% of body weight in < 6 months) Symptomatic cryoglobulinemia Additional requirements for WM patients (phase I): Patients must have received previous treatment with at least one standard regimen and are no longer responsive to that regimen There must have been at least 21 days since the last regimen and patient must have recovered from any previous treatment-related toxicity to =< grade 1 Additional requirements for WM patients (phase II): For previously treated patients, no more than 4 prior regimens are allowed If last regimen is with rituximab there must have been at least 6 months since last rituximab dose, and if without rituximab there must have been at least 3 months since last regimen For all phase I patients, there must have been at least 21 days since last regimen and any previous non-hematologic treatment related toxicity must have resolved to =< grade 1 Patients must not be receiving concurrent steroids > 10 mg prednisone (or equivalent) per day Prior irradiation is allowed if >= 28 days prior to registration have elapsed since the date of last treatment Fasting serum cholesterol =< 300 mg/dL OR =< 7.75 mmol/L AND fasting triglycerides =< 2.5 x institutional upper limit of normal (ULN), within 28 days prior to registration NOTE: in case one or both of these thresholds are exceeded, the patient can only be included after initiation of appropriate lipid lowering medication; patients cannot be enrolled if they do not meet these criteria on or off lipid lowering medication; patients must start lipid lowering medication and cholesterol and triglycerides must be below said levels before study entry Patients must not have had prior exposure to mammalian target of rapamycin (m-TOR) inhibitors (sirolimus, temsirolimus, everolimus) Women must not be pregnant or breast-feeding; all females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months) Women of childbearing potential and sexually active males must use an accepted and effective method of contraception throughout the study and for 8 weeks following discontinuation of everolimus Patients must have no history of prior malignancy except for adequately treated basal cell or squamous cell skin cancer or in-situ cervical cancer; the patient may also have had other cancer for which the patient was curatively treated with surgery alone and from which the patient has been disease free for >= 5 years Platelets >= 75,000 mm^3 Neutrophils >= 1,000 mm^3 Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) and serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) =< 2.5 x institutional ULN Direct bilirubin =< 1.5 mg/dL Serum creatinine =< 2.5 mg/dL Patients must be tested for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) within 28 days of registration and will not be eligible if found to be positive Patients must not have any severe and/or uncontrolled medical condition or other conditions that could affect their participation in the study, including, but not restricted to: Symptomatic congestive heart failure of New York Heart Association class III or IV Unstable angina pectoris, symptomatic congestive heart failure, myocardial infarction within 3 months of start of study treatment, serious uncontrolled cardiac arrhythmia or any other clinically significant heart disease Severely impaired lung function as defined as spirometry and diffusing capacity of the lung for carbon monoxide (DLCO) (corrected for Hgb) that is < 50% of the normal predicted value and/or oxygen (O2) saturation < 88% at rest on room air Active (acute or chronic) or uncontrolled severe infections Patients must have Eastern Cooperative Oncology Group (ECOG)-American College of Radiology Imaging Network (ACRIN) performance status of =< 2 Patients must not have grade 2 or higher neuropathy Patients must not have concurrent use of angiotensin-converting enzyme (ACE) inhibitors (angioedema), and no concurrent use of strong cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A4) inducers and inhibitors

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 I (rituximab, bortezomib, dexamethasone)<br>Patients receive rituximab IV over 30-60 minutes on days 1, 8, 15, and 22 (of courses 1 and 4 only) and bortezomib IV or SC and dexamethasone PO on days 1, 8, and 15. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. | Drug: Bortezomib<br>* Given IV or SC<br>* Other names: Velcade;Drug: Dexamethasone<br>* Given PO<br>* Other names: ZoDex;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>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 II (temsirolimus, rituximab, bortezomib, dexamethasone)<br>Patients receive temsirolimus IV over 30-60 minutes on days 1, 8, 15, and 22 and rituximab, bortezomib, and dexamethasone as in arm I. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. | Drug: Bortezomib<br>* Given IV or SC<br>* Other names: Velcade;Drug: Dexamethasone<br>* Given PO<br>* Other names: ZoDex;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Other: Quality-of-Life Assessment<br>* Ancillary studies<br>* Other names: Quality of Life Assessment;Biological: Rituximab<br>* Given IV<br>* Other names: Truxima;Drug: Temsirolimus<br>* Given IV<br>* Other names: Torisel;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Phase I: The Maximum Tolerated Dose (MTD) of Temsirolimus in Combination With Bortezomib, Rituximab and Dexamethasone | Temsirolimus in combination with bortezomib, rituximab, dexamethasone were to be escalated using a standard 3+3 design. The MTD was defined as the highest dose level at which no more than 0 in 3 or 1 in 6 participants experienced a dose-limiting toxicity (DLT) during the first 28-day cycle of treatment. | Assessed during cycle 1 (28 days) | 
| Phase II: Progression-free Survival | Progression-free survival is defined as the time from randomization to progression or death, whichever occurred first. Progression is evaluated based on Recommended Response Criteria for Waldenstrom's Macroglobulinemia. Progression is defined as at least 25% increase in serum monoclonal IgM protein by electrophoresis confirmed by a second measurement at any time, as well as an absolute increase of the M-spike by 0.5g/dL, or progression of clinically significant findings due to disease, (i.e. anemia, thrombocytopenia, leukopenia, bulky adenopathy/organomegaly or symptoms of disease) or hyperviscosity, neuropathy, symptomatic cryoglobulinemia, or amyloidosis attributable to WM. | Assessed every 3 months if <2 years from study entry, every 6 months if 2-5 years from study entry, and annually if 6-10 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Phase II: Time to Progression | Time to progression is defined as the time from randomization to disease progression. Progression is evaluated based on Recommended Response Criteria for Waldenstrom's Macroglobulinemia. Progression is defined as at least 25% increase in serum monoclonal IgM protein by electrophoresis confirmed by a second measurement at any time, as well as an absolute increase of the M-spike by 0.5g/dL, or progression of clinically significant findings due to disease, (i.e. anemia, thrombocytopenia, leukopenia, bulky adenopathy/organomegaly or symptoms of disease) or hyperviscosity, neuropathy, symptomatic cryoglobulinemia, or amyloidosis attributable to WM. | Assessed every 3 months if <2 years from study entry, every 6 months if 2-5 years from study entry, and annually if 6-10 years | 
| Phase II: Major Response Rate | Response is evaluated based on Recommended Response Criteria for Waldenstrom's Macroglobulinemia (WM). Major response is defined as complete response (CR), near CR (nCR), very good partial remission (VGPR), or partial response (PR). CR: Disappearance of monoclonal protein by immmunofixation; no histologic evidence of bone marrow involvement, resolution of any adenopathy/organomegaly, or signs or symptoms attributable to WM Near CR (nCR): As for CR except that immunofixation is still positive VGPR: At least 90% reduction of serum monoclonal protein using serum protein electrophoresis (SPEP) PR: At least 50% reduction of serum monoclonal concentration on protein electrophoresis and at least a decrease in adenopathy/organomegaly (confirmed by original mode of imaging). No new signs or symptoms of active disease. | Assessed at cycle 6 | 
| Phase II: Minor Response Rate | Response is evaluated based on Recommended Response Criteria for Waldenstrom's Macroglobulinemia (WM). Minor response is defined as achieving minor response (MR) or better (including complete response [CR], near CR (nCR), very good partial remission [VGPR], partial response [PR] and MR). CR: Disappearance of monoclonal protein by immmunofixation; no histologic evidence of bone marrow involvement, resolution of any adenopathy/organomegaly, or signs or symptoms attributable to WM nCR: As CR except that immunofixation is still positive VGPR: At least 90% reduction of serum monoclonal protein using serum protein electrophoresis PR: At least 50% reduction of serum monoclonal concentration on protein electrophoresis and at least a decrease in adenopathy/organomegaly (confirmed by original mode of imaging). No new signs or symptoms of active disease. MR: At least 25% but less than 50% reduction of serum monoclonal protein and no new signs or symptoms of active disease. | Assessed at cycle 6 | 
| Phase II: Time to Response | Time to response is defined as the time from randomization to documentation of response. Response is evaluated based on Recommended Response Criteria for Waldenstrom's Macroglobulinemia (WM). Response is defined as complete response (CR), near CR (nCR), very good partial remission (VGPR), partial response (PR) or minor response (MR). CR: Disappearance of monoclonal protein by immmunofixation; no histologic evidence of bone marrow involvement, resolution of any adenopathy/organomegaly, or signs or symptoms attributable to WM nCR: As CR except that immunofixation is still positive VGPR: >=90% reduction of serum monoclonal protein using serum protein electrophoresis PR: >=50% reduction of serum monoclonal concentration on protein electrophoresis and at least a decrease in adenopathy/organomegaly (confirmed by original mode of imaging). No new signs or symptoms of active disease. MR: >=25% but <50% reduction of serum monoclonal protein. No new signs or symptoms of active disease | Assessed every 3 months if <2 years of study entry, every 6 months if 2-5 years of study entry, and annually if 6-10 years | 
| Phase II: Duration of Response | Duration of response is defined as the time from documentation of response to disease progression. Response evaluation will be based on the Recommended Response Criteria for Waldenstrom's Macroglobulinemia (WM). Response is defined as complete response (CR), near CR (nCR), very good partial remission (VGPR), partial response (PR) or minor response (MR). Progression is defined as at least 25% increase in serum monoclonal IgM protein by electrophoresis confirmed by a second measurement at any time, as well as an absolute increase of the M-spike by 0.5g/dL, or progression of clinically significant findings due to disease, or hyperviscosity, neuropathy, symptomatic cryoglobulinemia, or amyloidosis attributable to WM. | Assessed every 3 months if <2 years of study entry, every 6 months if 2-5 years of study entry, and annually if 6-10 years | 
| Phase II: Time to Next Therapy | Time to next therapy is defined as duration from the end of protocol treatment to the initiation of next therapy, censored at date last known alive without initiation of next therapy. | Assessed every 3 months if <2 years of study entry, every 6 months if 2-5 years of study entry, and annually if 6-10 years | 
| Phase II: Overall Survival | Overall survival is defined as the time from randomization to date of death or date last known alive. | Assessed every 3 months if <2 years of study entry, every 6 months if 2-5 years of study entry, and annually if 6-10 years |