Clinical trial NCT01805557: Phase II Randomized Study With R-DHAP +/- Bortezomib as Induction Therapy in Relapsed/Refractory Diffuse Large B-cell Lymphoma (DLBCL) Patients Eligible to Transplantation. BR-DHAP Versus R-DHAP.
Official title: Phase II Randomized Study With R-DHAP +/- Bortezomib as Induction Therapy in Relapsed/Refractory Diffuse Large B-cell Lymphoma (DLBCL) Patients Eligible to Transplantation. BR-DHAP Versus R-DHAP.
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE2
PHASE3
Conditions: Diffuse Large B-cell Lymphoma Refractory
Diffuse Large B-cell Lymphoma Recurrent
Keywords: Diffuse Large B-cell Lymphoma (DLBCL)
Bortezomib
Lead sponsor: Fondazione Italiana Linfomi - ETS
Sponsor class: OTHER
Collaborators: name: Janssen Pharmaceutica
name: Janssen-Cilag Ltd.
name: Centro di Riferimento per l'Epidemiologia e la Prev. Oncologica Piemonte
First posted: 2013-03-06
Enrollment: 108
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The probability to achieve CR with R-chemotherapy in patients failing a rituximab containing first line regimen is quite low, in particular in cases with non GCB profile. The bioCORAL trial suggest that ABC subset have a dismal outcome whichever the induction treatment. Thus it can be argued the addition of new molecule to the RDHAP regimen could be of value. Bortezomib appears the best candidate in this setting as ABC subtypes constitutively express NFkb, which is the target of bortezomib itself. Data from the literature suggest an encouraging activity of R-chemo+ bortezomib in non GCB-derived DLBCL, although in small series. Thus, the addition of bortezomib is here justified by the need to circumvent constitutional resistance to chemotherapy. Published experience of the association between bortezomib and cytarabine are also encouraging with acceptable cumulative toxicity.

Detailed description: This is a prospective, multicenter, two-arm randomized phase II screening trial34 in young patients (18-65 years) affected by relapsed/refractory Diffuse Large B-cell Lymphoma (DLBCL) at diagnosis, eligible to high-dose therapy.

Aim of the study is to to assess whether the addition of Bortezomib to R-DHAP is more promising than standard R-DHAP, as induction therapy before high dose chemotherapy with ASCT with respect to response and safety. Patients will be randomized at first relapse between: a) the standard salvage therapy Rituximab in association to DHAP every 28 days (R-DHAP) for 4 cycles and b) Bortezomib in association to the same regimen (BR-DHAP). In both arms the induction therapy is followed by autologous stem cell transplantation or, if indicated, by allogeneic stem cell transplant.

A patient is considered evaluable if it is possible to assess response by PET after 4 cycle or, if a patient withdraws from the study for PD, before completion of study treatment.

After providing written informed consent, patients will be evaluated for eligibility during a 21-day screening period. If they continue to meet eligibility criteria, they will be randomized to receive the first dose of BR-DHAP or R-DHAP .

Eligibility criteria: Inclusion Criteria:

1. Age 18-65
2. Relapsed/refractory disease after receiving one line of standard chemoimmunotherapy (R-CHOP, GA-CHOP, R-CHOP like)
3. Diffuse Large B-cell Lymphoma at relapse. Patient has to be re-biopsied prior to study entry. If this is harmful for the patient, the patient can be enrolled if archivial tumor sample and block from first diagnosis are available.
4. No prior Bortezomib therapy
5. Measurable and/or evaluable disease
6. Any Ann Arbor stage and IPI group at relapse
7. Performance status \< 2 according to ECOG scale unless due to lymphoma
8. No Central Nervous System (CNS) disease (meningeal and/or brain involvement by lymphoma)
9. Adequate hematological counts: ANC \> 1.5 x 109/L, Hgb \> 9 g/dl (transfusion independent), Platelet count \> 75 x 109/L (transfusion independent), with the exception of cytopenia due to lymphoma bone marrow involvement
10. HIV negativity, HCV negativity, HBV negativity or patients with HBcAb +, HBsAg -, HBs Ab+/- with HBV-DNA negativity (in these patients Lamivudine prophylaxis is mandatory)
11. Normal liver function (ALP, AST, ALT, GGT, conjugated bilirubin total \< 2 x ULN) if not related to lymphoma
12. Normal kidney function (creatinine clearance \> 45 ml/min)
13. Cardiac ejection fraction \> 50% (MUGA scan or echocardiography)
14. Normal lung function
15. Absence of active opportunistic infections
16. Non peripheral neuropathy or active neurological non neoplastic disease of CNS
17. Non major surgical intervention prior 3 months to randomization if not due to lymphoma and/or no other disease life-threatening that can compromise chemotherapy treatment
18. Disease free of prior malignancies other than lymphoma for \> 3 years with exception of currently treated squamous cell and basal cell carcinoma of the skin or carcinoma in situ of the cervix or breast
19. Life expectancy \> 6 months
20. No psychiatric illness that precludes understanding concepts of the trial or signing informed consent
21. Written informed consent
22. Women must be:

    * postmenopausal for at least 1 year (must not have had a natural menses for at least 12 months)
    * surgically sterile (have had a hysterectomy or bilateral oophorectomy, tubal ligation, or otherwise be incapable of pregnancy),
    * abstinent (at the discretion of the investigator/per local regulations), or
    * if sexually active, be practicing a highly effective method of birth control (eg, prescription oral contraceptives, contraceptive injections, contraceptive patch, intrauterine device, double-barrier method (eg, condoms, diaphragm, or cervical cap, with spermicidal foam, cream, or gel, male partner sterilization) as local regulations permit, before entry, and must agree to continue to use the same method of contraception throughout the study. They must also be prepared to continue birth control measures for at least 12 months after terminating treatment.
23. Women of childbearing potential must have a negative serum or urine beta-human chorionic gonadotropin (beta-hCG) pregnancy test at screening
24. Men must agree to use an acceptable method of contraception (for themselves or female partners as listed above) for the duration of the study. Men must agree to use a double barrier method of birth control and to not donate sperm during the study and for 3 months after receiving the last dose of study drug.

Exclusion criteria:

1. Diagnosis of Lymphoblastic Lymphoma, Burkitt Lymphoma, Non Hodgkin Lymphoma CD20 negative, Mantle Cell Lymphoma, Follicular Lymphoma g I-II-IIIa-IIIb, Primary Mediastinal Lymphoma
2. Age \> 65 years
3. Patients ineligible to high-dose chemotherapy
4. Performance status \> 2 according to ECOG scale if not due to lymphoma
5. Patient has known or suspected hypersensitivity or intolerance to Rituximab
6. Patient has received an experimental drug or used an experimental medical device within 4 weeks before the planned start of treatment. Concurrent participation in non-treatment studies is allowed, if it will not interfere with participation in this study.
7. CNS disease (meningeal and/or brain involvement by lymphoma)
8. History of clinically relevant liver or renal insufficiency; significant cardiac, vascular, pulmonary, gastrointestinal, endocrine, neurologic, rheumatologic, hematologic, psychiatric, or metabolic disturbances
9. Uncontrolled diabetes (if receiving antidiabetic agents, subjects must be on a stable dose for at least 3 months before first dose of study drug
10. Uncontrolled or severe cardiovascular disease including myocardial infarction within six months of enrollment, New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, clinically significant pericardial disease, or cardiac amyloidosis
11. Cardiac ejection fraction \< 50% (MUGA scan or echocardiography)
12. Creatinine clearance \< 45 ml/min
13. Presence of major neurological disorders
14. HIV positivity, HCV positivity, HBV positivity with the exception of patients with HBcAb +, HbsAg -, HBs Ab+/- with HBV-DNA negative
15. Active opportunistic infection
16. Major surgical intervention prior 3 months to randomization if not due to lymphoma and/or other disease life-threatening that can compromise chemotherapy treatment
17. Prior malignancies other than lymphoma in the last 3 years with exception of currently treated squamous cell and basal cell carcinoma of the skin or carcinoma in situ of the cervix or breast
18. Life expectancy \< 6 months
19. Any other coexisting medical or psychological condition that would preclude participation in the study or compromise ability to give informed consent.
20. If female, the patient is pregnant or breast-feeding.

Primary outcomes:
measure: Complete Response (CR) Rate
timeFrame: At the end of the induction phase (6 months)
Secondary outcomes:
measure: Overall Response Rate (ORR)
timeFrame: At the end of the induction phase (6 months)
measure: Overall Survival (OS)
timeFrame: 36 months
measure: Number of Patients With Treatment-Related Adverse Events (AEs)/Serious Adverse Events (SAEs) as a Measure of Safety
timeFrame: 12 months
measure: Mobilizing potential
timeFrame: 6 months
measure: Number of Patients completing ASCT
timeFrame: 12 months
Other outcomes:
Locations:
city: Meldola
country: Italy
facility: Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori-Ematologia
state: Forlì-Cesena
city: Rozzano
country: Italy
facility: Clinica Humanitas
state: Milano
city: Milano
country: Italy
facility: ASST Grande Ospedale Metropolitano Niguarda - SC Ematologia
state: MI
city: Aviano
country: Italy
facility: CRO Aviano
state: Pordenone
city: Gallarate
country: Italy
facility: ASST Valle Olona
state: Varese
city: Alessandria
country: Italy
facility: A.O. SS. Antonio e Biagio e C. Arrigo
city: Ancona
country: Italy
facility: Clinica di ematologia AOU Umberto I Ospedali Riuniti
city: Brescia
country: Italy
facility: ASST Spedali Civili di Brescia - Ematologia
city: Cagliari
country: Italy
facility: Ospedale Businco - SC Ematologia e CTMO
city: Genova
country: Italy
facility: Ematologia 1 Ospedale S. Martino
city: Milano
country: Italy
facility: SC Ematologia - Trapianto di midollo osseo Fond. IRCCS Istituto Nazionale Tumori
city: Novara
country: Italy
facility: SCDU Ematologia - Università del Piemonte Orientale
city: Padova
country: Italy
facility: Ospedale S. Antonio
city: Parma
country: Italy
facility: U.O. Complessa di Ematologia Ospedale di Parma
city: Piacenza
country: Italy
facility: Ospedale Civile Guglielmo da Saliceto
city: Ravenna
country: Italy
facility: Osp. S. Maria delle Croci
city: Reggio Calabria
country: Italy
facility: Grande Ospedale Metropolitano Bianchi Melacrino Morelli - Ematologia
city: Reggio Emilia
country: Italy
facility: AO Arcispedale S.Maria Nuova Ematologia
city: Rimini
country: Italy
facility: Osp. degli Infermi Divisione di Oncologia
city: Roma
country: Italy
facility: A.O. Universitaria S. Andrea
city: Terni
country: Italy
facility: SC Oncoematologia con autotrapianto AO Santa Maria
city: Torino
country: Italy
facility: AOU Citta della Salute e della Scienza di Torino - Ematologia Universitaria
city: Torino
country: Italy
facility: AOU Citta della Salute e della Scienza di Torino-SC Ematologia
city: Udine
country: Italy
facility: Azienda Ospedaliero - Universitaria di Udine
Study officials:
affiliation: SC Ematologia 2-AO Città della Salute e della Sienza-Molinette
name: Umberto Vitolo, MD
role: STUDY_DIRECTOR
References: