Clinical trial NCT00795613: Positron Emission Tomography (PET)-Adapted Chemotherapy In Advanced Hodgkin Lymphoma (HL)
Official title: Multicenter Clinical Study With Early Treatment Intensification In Patients With High- Risk Hodgkin Lymphoma, Identified As FDG-PET Scan Positive After 2 Conventional ABVD Courses
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: PHASE2
Conditions: HODGKIN LYMPHOMA
Keywords: PET
Lead sponsor: Ospedale Santa Croce-Carle Cuneo
Sponsor class: OTHER
Collaborators: name: GITIL (GRUPPO ITALIANO TERAPIE INNOVATIVE NEI LINFOMI)
name: Consorzio Mario Negri Sud
First posted: 2008-11-21
Enrollment: 450
Sex: ALL
Minimum age (years): 18
Maximum age (years): 60
Standard ages: ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The purpose of this multicenter clinical trial is to assess the clinical impact of dose intensification performed very early during treatment in a subset of poor prognosis, advanced-stage Hodgkin Lymphoma patients, defined as PET-positive after two courses of conventional adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy.

Detailed description: Version number 1.0 Date 07.05.0808

Study Title

A phase-II clinical trial for assessing the clinical impact of a global strategy utilizing early FDG-PET imaging for a risk-adapted therapy in untreated, advanced Hodgkin Lymphoma (aHL).

Short study title PET-adapted chemotherapy in advanced HL

Start and end dates of study Start date: July 2008

Patients will be recruited during four calendar years and will be followed at least for three years.

Registration of the patients All patients with newly diagnosed Hodgkin's Lymphoma, presenting with advanced disease (stage II B-IV B) should be registered at the WEB site of the study whatever treatment is planned.

Primary outcome measure 3-year progression free survival (PFS).

Secondary endpoint 3-year event free survival (EFS) of all the registered patients whatever the treatment assigned. Events are deaths from any cause, disease progression, secondary cancer, late serious treatment-related events.

- Feasibility of the program for the entire population of advanced-stage HL patients admitted to GITIL institutions

Clinical Phase Phase II

Study design A multicentre clinical trial for assessing the clinical impact of a global strategy utilizing early FDG-PET imaging after 2 cycles of ABVD for a risk-adapted, single patient tailored therapy for all the newly diagnosed, aHL patients admitted to GITIL haematological centers .

Statistical aspects 450 patients could be recruited in GITIL centres in 4 years. Thirty-five percent of these could be expected to have a PET-2 positive after 2 ABVD courses (135 patients). Roughly half of these latter could likely be salvaged by BEACOPPescal. or R-BEACOPPescal. therapy. Since the 3-y PFS of aHL patients treated with the ABVD is 70% we could expect to cure, with this approach, about 85% of these patients. In order to demonstrate a benefit of this strategy over conventional ABVD treatment, with the Simon optimal two-stage design and an alpha error of 0.05 and a power of 90%, a minimum of 150 patients needs to be enrolled. In order to establish an advantage of R-BEACOPP esc. over BEACOPPescal. Approximately 135 patients are needed in the arm of PET-positive patients.

Analysis will be intention-to-treat. Standard time-to-event statistics tests will be carried out, including Kaplan-Meier survival curves, log rank test, and Cox proportional hazards models. Chi square test and analysis of variance will be adopted for univariate analysis with mathematical transformation to approach normality as appropriate. The formal level of significance for P-values is set at 0.05 (two-tailed).

Interim analysis and safety aspects A first interim analysis is planned one year after study onset in order to check the morbidity and mortality of the program. Because of the rarity of the disease, no formal statistical boundaries are established as stopping rules. The results of the interim analysis will be evaluated by the Data Safety and Monitoring Board (DSMB). The Chairman of the DSMB will advise the Steering Committee (ST) as to the any action to be taken for safety reasons (i.e., premature study closure and protocol modification). The DSMB will also establish and communicate to the ST and the CRO its own rules and requirements to optimize the quantity and quality of information to be periodically received to monitor adequately all safety aspects.

Initial treatment for 2 cycles ABVD (cycle repeats every 28 days) This will be given at full dose and on schedule, regardless of blood count. Growth factors may be used at the discretion of investigators but are not routinely advised.

PET Reviewing Committee A central panel for PET reviewing (PET-RC) will be established. The members will be seven nuclear medicine experts. The operational aspects of the validation of PET diagnoses will be managed by the National Institute of Nuclear Physics in Turin using an already existing and functioning web-site. Upon receipt of PET-2 records, along with PET baseline studies via web, the PET-RC members are bound to send the reviewed studies to the Central Data Center (CDC) within 5 days from the data of receipt of the studies from the local PET enter. The image exchange will be performed by uploading the records of PET-2 (PET after 2 cycles of ABVD) and PET-0 (baseline PET) in the .dycom format in the web site dedicated.Only the positive and "minimally positive" PET scan will be reviewed. The final judgment of a reviewed defined as "positive" or "negative" study will be supplied from the CDC to the local GITIL center on the basis of the first three reviewed studies arrived to CDC

After 2 cycles, PET negative patients (Arm B) continue with ABVD (for 4 cycles) ABVD as above, every 28 days for 4 further cycles Patients in Arm B with a positive PET at the end of ABVD treatment. Patients with a positive PET at the end of ABVD chemotherapy should undergo, whenever is possible, a confirmatory biopsy; in patients with a proven resistant disease DHAP (x1 or x2) should be given in order to collect a sufficient number of CD 34+ cells; later they proceed to a classical high-dose sequential chemotherapy (HDS) with: cyclophosphamide 4 gr./m2 , ARA-c 4 gr./m2/day for 4 days, VP 16 2 gr./m2, followed by autologous stem cell transplantation (ASCT) with BEAM conditioning regimen

Consolidation Radiotherapy (Arm B) Patients treated with traditional ABVD x 6 cycles (PET-negative arm) will be re-evaluated at the end of chemotherapy with PET. Patients with a negative final PET scan will be randomized to undergo consolidation radiotherapy or not on the initial bulky lesion(s) or on the residual disease. Radiotherapy will be given with an "involved field technique, at the dose of 30 Gy. No radiotherapy is planned in patients with residual mass that was not an initial bulky lesion.

After 2 cycles, PET positive patients (Arm A) will be randomized to 4 escalated BEACOPP or 4 escalated R-BEACOPP administration for 4 cycles. Peripheral Blood Stem Cell (PBSC) will be collected after the first BEACOPP (or R-BEACOPP) course

After 4 cycles of escalated BEACOPP or escalated R-BEACOPP patients with PET negative will continue with baseline BEACOPP or baseline R-BEACOPP (for further 4 cycles )

After 4 cycles of escalated BEACOPP or escalated R-BEACOPP patients with positive PET will undergo salvage treatment with DHAP (x 1 or x 2) followed by double autologous stem cell transplantation (ASCT) or, in presence of a suitable HLA-matched stem cell donor, with a single ASCT (BEAM) followed by RIC allogeneic bone marrow transplantation .

Allogeneic Reduced-Intensity transplant:

Thiotepa 5 mg/Kg every 12 hours for 2 doses (day -5); cyclophosphamide 30 mg/kg (days -4 and -3); fludarabine 30 mg/ms (days -4 and -3); allogeneic stem cell transplantation with 4 - 8 X 106 CD34+ cells/kg from related donors (day 0).

GVHD prophylaxis:

Cyclosporin A (CSA), adjusted to 200-300 ng/ml blood levels, and short course methotrexate (10 mg/ms day +1, 8 mg/ms day + 3 and +6). CSA is administered at full dose through day +100 and, if GVHD does not occur, the dose is tapered by 10% every week thereafter

Treatment duration Approx 10-11 months for PET-2+ patients and 6 months for PET-2 negative patients

Eligibility criteria: Inclusion Criteria:

* Patients with advanced classical Hodgkin Lymphoma according to the World Health Organization classification
* Aged 18-60
* Not previously treated
* Stages IIB to IV B
* All IPS prognostic groups
* Patients who have signed an informed consent form

Exclusion Criteria:

* Patients aged more than 60.
* Concomitant or previously treated neoplastic disorder less than 5 year before the diagnosis of Hodgkin's lymphoma.
* Psychiatric disorders
* Uncontrolled infectious disease
* Impaired cardiac (EF \< 50%) , renal (creatinine clearance \< 60 ml/m)
* HIV, HBV DNA, HCV RNA positive markers
* Pregnancy and lactation
* Patients with uncompensated diabetes mellitus and fasting glucose levels over 200 mg/dl

Primary outcomes:
measure: progression-free survival (PFS)
timeFrame: 3 year
Secondary outcomes:
measure: event-free survival (EFS)
timeFrame: 3 year
Other outcomes:
Locations:
city: Tel Hashomer
country: Israel
facility: The Chaim Sheba Medical Center
city: Monza
country: Italy
facility: Ospedale S. Gerardo
state: Milano
city: Orbassano
country: Italy
facility: A.O. Universitaria S. Luigi Gonzaga
state: Torino
city: Ancona
country: Italy
facility: A.O. Universitaria Ospedali Riuniti Osp. Umberto I
city: Bergamo
country: Italy
facility: Ospedali Riuniti
city: Bolzano
country: Italy
facility: Ospedale Generale Regionale Bolzano
city: Cagliari
country: Italy
facility: Ospedale Roberto Binaghi
city: Catania
country: Italy
facility: A.O. Universitaria Osp. Vittorio Emanuele E Ferrarotto
city: Cuneo
country: Italy
facility: Azienda Ospedaliera S. Croce E Carle
city: Genova
country: Italy
facility: Azienda Ospedaliera Universitaria S. Martino
city: Milano
country: Italy
facility: Ospedale S. Raffaele Turro
city: Milano
country: Italy
facility: Irccs - Istituto Nazionale Dei Tumori (Int)
city: Milano
country: Italy
facility: Irccs Istituto Nazionale Dei Tumori (Int)
city: Napoli
country: Italy
facility: A.O. Universitaria Federico Ii
city: Padova
country: Italy
facility: Azienda Ospedaliera
city: Palermo
country: Italy
facility: Azienda Ospedaliera V. Cervello
city: Perugia
country: Italy
facility: Ospedale Silvestrini-S.Andrea Delle Fratte
city: Potenza
country: Italy
facility: Ospedale S. Carlo
city: Roma
country: Italy
facility: A.O. Universitaria Policlinico Tor Vergata
city: Roma
country: Italy
facility: Azienda Ospedaliera San Camillo-Forlanini
city: Torino
country: Italy
facility: Ospedale Mauriziano Umberto I
city: Torino
country: Italy
facility: A.O. Universitaria S. Giovanni Battista-Molinette
city: Verona
country: Italy
facility: Ospedale Policlinico G.B. Rossi
city: Vicenza
country: Italy
facility: Ospedale Di Vicenza
Study officials:
affiliation: A.S.O. S.CROCE E CARLE-HEMATOLOGY DEPT. - VIA M. COPPINO 26-12100 CUNEO ITALY
name: ANDREA GALLAMINI, MD
role: STUDY_CHAIR
References:
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citation: Gallamini A, Rossi A, Patti C, Picardi M, Romano A, Cantonetti M, Oppi S, Viviani S, Bolis S, Trentin L, Gini G, Battistini R, Chauvie S, Sorasio R, Pavoni C, Zanotti R, Cimminiello M, Schiavotto C, Viero P, Mule A, Fallanca F, Ficola U, Tarella C, Guerra L, Rambaldi A. Consolidation Radiotherapy Could Be Safely Omitted in Advanced Hodgkin Lymphoma With Large Nodal Mass in Complete Metabolic Response After ABVD: Final Analysis of the Randomized GITIL/FIL HD0607 Trial. J Clin Oncol. 2020 Nov 20;38(33):3905-3913. doi: 10.1200/JCO.20.00935. Epub 2020 Sep 18.
citation: Gallamini A, Tarella C, Viviani S, Rossi A, Patti C, Mule A, Picardi M, Romano A, Cantonetti M, La Nasa G, Trentin L, Bolis S, Rapezzi D, Battistini R, Gottardi D, Gavarotti P, Corradini P, Cimminiello M, Schiavotto C, Parvis G, Zanotti R, Gini G, Ferreri AJM, Viero P, Miglino M, Billio A, Avigdor A, Biggi A, Fallanca F, Ficola U, Gregianin M, Chiaravalloti A, Prosperini G, Bergesio F, Chauvie S, Pavoni C, Gianni AM, Rambaldi A. Early Chemotherapy Intensification With Escalated BEACOPP in Patients With Advanced-Stage Hodgkin Lymphoma With a Positive Interim Positron Emission Tomography/Computed Tomography Scan After Two ABVD Cycles: Long-Term Results of the GITIL/FIL HD 0607 Trial. J Clin Oncol. 2018 Feb 10;36(5):454-462. doi: 10.1200/JCO.2017.75.2543. Epub 2018 Jan 23.