Epcoritamab and Rituximab for First-line Follicular Lymphoma

Study Overview
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Brief Summary
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The purpose of this study is to determine how effective and safe the combination of rituximab and epcoritamab is in treating patients with Follicular Lymphoma (FL) and who have not received other treatments for their lymphoma. The names of the study drugs involved in this study are: Rituximab (a type of monoclonal antibody therapy) Epcoritamab (a T-cell bispecific antibody)

Detailed Description
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This is an open-label, multicenter, phase II study to evaluate the efficacy and safety of epcoritamab and rituximab for patients with untreated follicular lymphoma (FL). Epcoritamab brings T cells and follicular lymphoma cells close together and activates the T cells to kill the lymphoma cells. Rituximab activates the immune system to kill the lymphoma cells. The U.S. Food and Drug Administration (FDA) has not approved epcoritamab as a treatment for any disease. The U.S. Food and Drug Administration (FDA) has approved rituximab as a treatment option for follicular lymphoma (FL). The research study procedures include screening for eligibility, study treatment with evaluations, blood tests, bone marrow biopsies, and Computerized Tomography (CT) scans and Positron Emission Tomography (PET) scans. Participants will receive study treatment for approximately 9-10 months and will be followed for up to 10 years. It is expected that about 35 people will take part in this research study. Genmab and AbbVie are supporting this research study by providing one of the study drugs, Epcoritamab. Genmab is providing funding for the study.

Official Title
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A Phase 2 Study of Epcoritamab and Rituximab for First-line Treatment of Follicular Lymphoma

Conditions
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Low Grade Non-Hodgkin's Lymphoma, Adult, Follicular Lymphoma

Intervention / Treatment
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* Drug: Epcoritamab
* Drug: Rituximab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically confirmed diagnosis of CD20+ FL (grade 1-3A) with review of the diagnostic pathology specimen at one of the participating institutions. Patients with current or prior histologic transformation are excluded. No prior systemic therapy for FL. Prior treatment with radiation therapy or short course steroids is allowed. Meets at least one criterion to begin treatment based on the modified GELF (Groupe d'Etude des Lymphomes Folliculaires) criteria: Symptomatic adenopathy Organ function impairment due to disease involvement, including cytopenias due to marrow involvement (WBC <1.5x109/L; absolute neutrophil count [ANC] <1.0x109/L, Hgb <10g/dL; or platelets <100x109/L) Constitutional symptoms (defined as persistent fevers >100.4 F, shaking chills, drenching night sweats, or loss of >10% of body weight within a 6 month period) Any nodal or extranodal tumor mass >7 cm in maximum diameter >3 nodal sites of involvement >3 cm Local compressive symptoms or imminent risk thereof Splenomegaly (craniocaudal diameter > 16cm on CT imaging) Clinically significant pleural or peritoneal effusion Leukemic phase (>5x109/L circulating malignant cells) Rapid generalized disease progression Renal infiltration Bone lesions Patients cannot be in need of urgent cytoreductive chemotherapy (in the opinion of the treating investigator). Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. (Appendix A) Age ≥18 years. Adequate hematologic and organ function: Absolute neutrophil count > 1.0x109/L unless due to marrow involvement by lymphoma in which case ANC must be >0.5x109/L Platelets > 75 x109/L, unless due to marrow involvement by lymphoma, in which case platelets must be >50 x109/L Estimated CrCl (Cockcroft Gault) ≥ 45ml/min Total bilirubin < 1.5 X ULN, unless Gilbert syndrome, in which case direct bilirubin must be < 1.5 x ULN AST/ALT < 2.5 X ULN, unless documented liver involvement by lymphoma, in which case AST/ALT must be <5 x ULN Ability to understand and the willingness to sign a written informed consent document. Willingness to provide a pre-treatment tumor sample by core needle or excisional surgical biopsy. A fresh biopsy is strongly encouraged, but an archival sample is acceptable if the following provisions are met: 1) availability of a tumor-containing formalin-fixed, paraffin-embedded (FFPE) tissue block, 2) if the tumor containing FFPE tissue block cannot be provided in total, sections from this block should be provided that are freshly cut and mounted on positively-charged glass slides. Preferably, 25 slides should be provided; if not possible, a minimum of 15 slides is required. Exceptions to this criterion may be made with approval of the Sponsor-Investigator. Willingness to remain abstinent or to use two effective contraceptive methods that result in a failure rate of <1% per year from screening until: (a) at least 3 months after pre-treatment with rituximab or 12 months after the last dose of epcoritamab, whichever is longer, if the patient is a male or (b) until at least 18 months after pre-treatment with rituximab or 12 months after the last dose of epcoritamab, whichever is longer, if patient is a female. Examples of contraceptive methods with a failure rate of <1% per year include: Tubal ligation, male sterilization, hormonal implants, established proper use of hormonal contraceptives that inhibit ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices. Alternatively, two methods (e.g., two barrier methods such as a condom and a cervical cap) may be combined to achieve a failure rate of <1% per year. Barrier methods must always be supplemented with the use of a spermicide. Exclusion Criteria: Patients who require systemic immunosuppressive therapy for an ongoing medical condition will be excluded. For corticosteroids, patients receiving a prednisone dose of >10 mg daily (or equivalent) will not be eligible. A short course of steroids (up to 14 days) for symptom palliation is allowed, in which case patients should be off steroids prior to treatment start. Patients with bulky cervical adenopathy that is compressing the upper airway or could result in significant airway compression during a tumor flare event. Patients with stage I follicular lymphoma Patients who are candidates for radiation therapy with curative intent (in the opinion of the treating investigator) Patients, who have had a major surgery or significant traumatic injury within 4 weeks of start of study drug, patients who have not recovered from the side effects of any major surgery (defined as requiring general anesthesia). Active HBV (DNA PCR-positive) or hepatitis C (RNA PCR-positive infection). Subjects with evidence of prior HBV but who are PCR-negative are permitted in the trial but should receive prophylactic antiviral therapy. Subjects who received treatment for HCV that was intended to eradicate the virus may participate if hepatitis C RNA levels are undetectable. Known history of seropositivity for human immunodeficiency virus (HIV). Note: HIV testing is required at screening only if required per local health authorities or institutional standards. Known active bacterial, viral, fungal, mycobacterial, parasitic, or other infection (excluding fungal infections of nail beds) at trial enrolment or significant infections within 2 weeks prior to the first dose of epcoritamab. Prior history of another malignancy (except for non-melanoma skin cancer or in situ cervical or breast cancer) unless disease free for at least 2 years. Patients should not have received immunization with attenuated live vaccine within one week of study entry or during study period. Patients who have any severe and/or uncontrolled medical conditions or other conditions that could affect their participation in the study or limit adherence to study requirements. Patients with any one of the following currently on or in the previous 6 months will be excluded: myocardial infarction, congenital long QT syndrome, torsade de pointes, unstable angina, coronary/peripheral artery bypass graft, cardiac arrhythmia (CTCAE grade 3 or higher), clinically significant ECG abnormalities, or cerebrovascular accident. Patients with New York Heart Association Class III or IV heart failure or known ejection fraction of <45%. Inability to comply with protocol mandated hospitalizations and restrictions. Patients who are pregnant, breast-feeding, or intending to become pregnant during the study. Prior solid organ or allogeneic stem cell transplantation. History of known or suspected hemophagocytic lymphohistiocytosis (HLH). History of autoimmune disease, including but not limited to myocarditis, pneumonitis, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis, Sjögren's syndrome, Guillain-Barré syndrome, multiple sclerosis, vasculitis, or glomerulonephritis. • Patients with a remote history of, or well controlled, autoimmune disease who meet above criteria may be eligible to enroll after consultation with the Sponsor-Investigator. History of severe allergic or anaphylactic reactions to anti-CD20 mAb therapy or known allergy or intolerance to any component or excipient of epcoritamab. Vaccination with live vaccines within 28 days prior to the first dose of epcoritamab. Active CNS lymphoma Neuropathy > grade 2. (CTCAE) Treatment with CAR-T therapy within 100 days prior to first dose of epcoritamab. Treatment with an investigational drug within 4 weeks or 5 half-lives, whichever is longer, prior to the first dose of epcoritamab. Chemotherapy and other non-investigational anti-neoplastic agents (except CD20 mAbs) within 4 weeks or 5 half-lives (whichever is shorter) prior to the first dose of epcoritamab. Screening 12-lead ECG showing a baseline QTcF >470 msec.

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: Epcoritamab + Rituximab<br>Participants will undergo study procedures as outlined: PET/CT scans at baseline and after cycles 2, 5, and 9 of treatment. Cycle 1: Days -14, -7, 1, 8 of 6 week cycle: Predetermined dose of Rituximab. Days 1, 8, 15, 22 of 6 week cycle: Predetermined dose of Epcoritamab. (Day 15 of Epcoritamab dosage will be administered in the hospital.) Cycles 2 - 3: --Days 1, 8, 15, 22 of 4 week cycle: Predetermined dose of Epcoritamab. Cycles 4 - 9: Day 1 of 4 week cycle: Predetermined dose of Epcoritamab. Day 15 of 4 week cycle: Predetermined dose of Epcoritamab. Surveillance imaging (PT/CT scans) at months 13, 18, and 24 after initiation of treatment. Follow up visits for up to 5 years. | Drug: Epcoritamab<br>* T-cell bispecific antibody, via subcutaneous injection<br>* Other names: DuoBody-CD3xCD20, GEN3013;Drug: Rituximab<br>* Chimeric anti-CD20 monoclonal antibody, via IV infusion<br>* Other names: Rituxan, MabThera;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| End of Treatment (EOT) Complete Metabolic Response (CMR) Rate | EOT CMR rate defined as the proportion of participants achieving CR per PET/CT Lugano 2014 criteria (protocol appendix B) at the EOT assessment: PET-CT, score 1, 2, or 3 with or without a residual mass on a 5-point scale (5PS). | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Best Partial Metabolic Response (PMR) Rate | Best PMR rate defined as the proportion of participants achieving PR per Lugano 2014 criteria (protocol appendix B) ever on treatment: PET-CT Score 4 or 5 with reduced uptake compared with baseline and residual mass(es) of any size or on CT, ≥ 50% decrease in SPD of up to 6 target measurable nodes and extranodal sites; no increase in non-measured lesions; spleen if enlarged must have regressed by >50% in length beyond normal. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days | 
| Best Objective Metabolic Response (OMR) Rate | Best OMR rate defined as the proportion of participants achieving CR or partial response (PR) per Lugano 2014 criteria (protocol appendix B) ever on treatment. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days | 
| EOT Partial Metabolic Response (PMR) Rate | EOT PMR rate defined as the proportion of participants achieving PR per PET/CT Lugano 2014 criteria (protocol appendix B) at the EOT assessment: PET-CT Score 4 or 5 with reduced uptake compared with baseline and residual mass(es). | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days | 
| EOT Objective Metabolic Response (OMR) Rate | EOT OMR rate defined as the proportion of participants achieving CR or partial response (PR) per PET/CT Lugano 2014 criteria (protocol appendix B) at the EOT assessment. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days | 
| 2-year Duration of Response (DOR) | 2-year DOR is a probability estimated using the Kaplan Meier method; DOR is defined as the time measurement criteria are met for CR or PR (whichever is first recorded) per Lugano 2014 criteria (protocol Appendix B) until the first date that recurrent or progressive disease is objectively documented, or death due to any cause. CR and PR participants without events reported are censored at the last disease evaluation. | 2 years | 
| 2-year Duration of Complete Response (DOCR) | 2-year DOCR is a probability estimated using the Kaplan Meier method; DOCR is defined as the time measurement criteria are met for CR per Lugano 2014 criteria (protocol Appendix B) until the first date that recurrent or progressive disease is objectively documented, or death due to any cause. CR participants without events reported are censored at the last disease evaluation. | 2 years | 
| 2-year Progression-free Survival (PFS) | 2-year PFS is a probability estimated using the Kaplan Meier method; PFS is defined as the duration of time from study entry to documented disease progression (PD) or death. PD defined by Lugano 2014 criteria (protocol Appendix B). | 2 years | 
| 2-year Time-to-Next Treatment (TTNT) | 2-y TTNT is a probability estimated using the Kaplan Meier method; TTNT is defined as the duration of time from the first dose of treatment until the time of initiation of new therapy, or censored at the date of last contact. | 2 years | 
| 2-year Overall Survival (OS) | 2-year OS is a probability estimated using the Kaplan-Meier method; OS is defined as the time from study entry to death, or censored at date last known alive. | 2 years | 
| Incidence of Histological Transformation | Histological transformation was defined as participants who have a biopsy showing diffuse large B-cell lymphoma (DLBCL). Incidence is the number of participants with histological transformation during or after treatment. | up to 10 years | 
| Number of Participants with Cytokine Release Syndrome (CRS) by Grade | All grade CRS AEs regardless of attribution based on American Society of Transplantation and Cellular Therapy [ASTCT] Consensus grading as reported on case report forms are counted and maximum grade tabulated. Incidence by grade is then tabulated as the number of participants ever experiencing maximum grade during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Grade 3-5 Treatment-Related CRS Rate | All grade 3-5 CRS AEs with attribution of probably, possibly or definitely-related to treatment based on American Society of Transplantation and Cellular Therapy [ASTCT] Consensus grading as reported on case report forms were counted. Rate is the proportion of treated participants experiencing at least one treatment-related grade 3-5 CRS AE of any type during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Number of Participants with Neurotoxicity by Grade | All grade neurotoxicity AEs regardless of attribution based on CTCAEv5 as reported on case report forms are counted and maximum grade tabulated. Incidence by grade is then tabulated as the number of participants ever experiencing maximum grade during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Grade 3-5 Treatment-Related Neurotoxicity Rate | All grade 3-5 neurotoxicity AEs with attribution of probably, possibly or definitely-related to treatment based on CTCAEv5 as reported on case report forms were counted. Rate is the proportion of treated participants experiencing at least one treatment-related grade 3-5 neurotoxicity AE of any type during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Grade 3-5 Toxicity Rate | All grade 3-5 AEs regardless of attribution based on CTCAEv5 as reported on case report forms were counted. Rate is the proportion of treated participants experiencing at least one grade 3-5 AE of any type during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Grade 3-5 Treatment-Related Toxicity Rate | All grade 3-5 AEs with attribution of probably, possibly or definitely-related to treatment based on CTCAEv5 as reported on case report forms were counted. Rate is the proportion of treated participants experiencing at least one treatment-related grade 3-5 AE of any type during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 
| Grade 2-5 Treatment-Related Toxicity Rate | All grade 2-5 AEs with attribution of probably, possibly or definitely-related to treatment based on CTCAEv5 as reported on case report forms were counted. Rate is the proportion of treated participants experiencing at least one treatment-related grade 2-5 AE of any type during the time of observation. | (Cycle 1 = 36 days, cycle 2-12 = 21 days), up to 267 days + 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Immunotherapy, Follicular Lymphoma, Low-grade Non-Hodgkin's Lymphoma