Conditions: Marginal Zone B-cell Lymphoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 78
Healthy volunteers: no

Brief summary:
Splenic Marginal Zone Lymphoma (SMZL) is a well-defined low-grade B-cell lymphoma,considered as a rare neoplasm accounting for about 2% of all non-Hodgkin's lymphomas (NHL) and represents for most cases of otherwise unclassifiable chronic lymphoid B-cell cluster of differentiation antigen 5 (CD5)-lymphoproliferative disorders. SMZL is characterized by an almost exclusive involvement of the spleen and bone marrow and in about 25% of cases the disease pursues an aggressive course and most patients die of lymphoma progression within 3-4 years.

Retrospective studies have indicated that purine analogous achieved very high response rates in both naïve and pre-treated patients. Moreover, the introduction of the anti-cluster of differentiation antigen 20 (CD20) humanized antibody rituximab, either used alone or in combination with chemotherapy has been reported to be very effective in producing a rapid clearance of neoplastic cells.

Detailed description:
Prospective, multicenter, open-label, phase II study, designed to determine efficacy and safety of a Chemo-immunotherapy with the combination of bendamustine + rituximab in patients with splenic marginal zone lymphoma.

Study Population: previously untreated (except for splenectomy and/or antiviral therapy for Hepatitis C Virus (HCV) infection) and symptomatic Splenic Marginal Zone patients.

Objectives: evaluation of the efficacy and the safety of R-Bendamustine in symptomatic Splenic Marginal Zone Lymphoma patients.

Primary Objective: efficacy of R-Bendamustine measured by Complete Response rate. Complete response rate defined as regression to normal size on CT of organomegaly (spleen, liver, lymph nodes); normalization of the blood counts and no evidence of circulating clonal cells, and no evidence or minor (≤ 5%) Bone Marrow (BM) infiltration detected by immunohistochemistry (IHC).

Treatment: The R-Bendamustine regimen consisted of 28-day cycle. Patients achieving a complete response (CR) after 3 cycles received only one more cycle of R-Bendamustine, while those achieving a partial response (PR) received 3 additional cycles of R-Bendamustine; if less than PR patients were withdrawn from the study

Arms:
arm 1: Induction Phase (Cycle 1 to Cycle 3 ):

Bendamustine 90 mg/sqm i.v. d1 \& d2\* Rituximab 375 mg/m2 i.v. d1\*\*

Extended Phase (Cycle 4 to Cycle 6):

Bendamustine 90 mg/sqm i.v. d1 \& d2\* Rituximab 375 mg/m2 i.v. d1

From Cycle 4 to Cycle 6, every 4 weeks, depending on the response after the first 3 Cycles

\*Or days 2-3 according to institutional/patient/physician preference

\*\*Administration of Rituximab during cycle 1 and cycle 2 can be postponed to day 8 or 14 in case of risk of tumor lysis syndrome (TLS)

Interventions: intervention 1: Bendamustine and Rituximab
Intervention descriptions: intervention 1: None

Protocol document:
Prot_SAP_000.pdf: 
 
IELSG-36 – Version 5.1 – November 22, 2017 
 
 
 
BRISMA  
Bendamustine and Rituximab for the treatment of 
Splenic Marginal Zone Lymphoma  
The IELSG-36 phase II prospective study 
 
EudraCT Number 2011-000880-28 
 
 
 
 
Study Chair 
Alessandro Maggi, Emilio Iannitto 
Co-chairpersons 
Catherine THIEBLEMONT, Carlos MONTALBAN  
Study coordination and data management   FIL - Fondazione Italiana Linfomi 
 
 
 
Statistical advice 
Luigi Marcheselli 
Uffici studi FIL, Modena 
 
 
Central Lab. France 
LYSA-P - Hôpital Henri Mondor 
51, avenue du Maréchal de Lattre de Tassigny 
Bat R RDC Haut, F-94010 Créteil  
Centre Hospitalier Lyon Sud - Laboratoire d’hématologie-Bât 3D 
Chemin du Grand Revoyet, F-69310 Pierre-Bénite 
 
 
Central Lab. Italy 
Dipartimento di Scienze per la promozione della salute 
Sez. Anatomia patologica, Università di Palermo 
Via del Vespro 127, I-90129 Palermo 
 
Dott. Simone Ferrero/Dott.ssa Daniela Drandi 
AOU “Città della Salute e della Scienza” di Torino, presidio “Molinette” 
Laboratorio di ematologia 1 U Prof. Boccadoro 
Via Genova 3, P.T. padiglione giallo, 10126 Torino   
 
 
Trial contacts 
Study Coordinators 
 
 
 
LYSA: Catherine THIEBLEMONT – Rémy GRESSIN  
FIL: Alessandro MAGGI, Emilio IANNITTO – Andrés FERRERI – Massimo 
FEDERICO 
 
Writing Committee 
 
E. Iannitto, C. Thieblemont, C. Montalban, L. Baseggio,F. C. Bastard, F. Berger, 
M. Bellei, B. Coiffier, F. Davi, M. Federico, F. P. Felman, M. Ferrarini, AMJ 
Ferreri, J. Feuillard, V. Franco R. Garand, S. LeGouill, T. Molina, L. Marcheselli 
F. Morschhauser, N. Mounier, M.E. Noguera, M. Parrens,  J.F. Rossi, A. 
Traverse-Glehen 
Central Review 
LYSA: T. Molina, F. Berger, A. Traverse-Glehen, M. Parrens, P. Felman, R. 
Garand, M.E. Noguera, J. Feuillard, L. Baseggio, C. Bastard, F. Davi 
FIL: V. Franco, E. Iannitto, AM. Florena, M. Paulli, G. Fraternali Orcioni, S. 
Ascani, C. Tripodo, M. Ferrarini, S. Zupo, S. Ferrero, D. Drandi, M. Ponzoni 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
Contact addresses for the trial organization 
 
Contact information in France (LYSA centers) 
Investigator Coordinator in France 
Catherine Thieblemont 
Hôpital Saint-Louis 
Service d’hémato-oncologie- Coquelicot 6.  
1, avenue C. Vellefaux - F-75010 Paris 
Tel: +33 1 42 49 92 36 
Fax: +33 1 42 49 96 41 
catherine.thieblemont@sls.aphp.fr 
Coordination centre for France 
Fabienne Morand 
LYSARC 
Centre Hospitalier Lyon-Sud - Secteur Sainte Eugénie 
Pavillon 6 D – F-69495 Pierre Bénite Cedex 
Tel: +33 4 72 66 93 33 
Fax: +33 4 26 07 40 55 
IELSG36@lysarc.org 
LYSA-P (centralization of material for histology review) 
Nadine Vailhen 
Hôpital Henri Mondor 
51, avenue du Maréchal de Lattre de Tassigny  
BatR RDC Haut - F-94010 Creteil  
Tel: +33 1 49 81 37 48 
Fax: +33 1 49 81 37 47 
nadine.vailhen@lysarc.org 
Centralization  of slides for cytology review (and immune-phenotype) 
Pascale Felman 
Pascale Felman  
Centre Hospitalier Lyon Sud 
Centre de Biologie et d’anatomie Pathologique Sud 
– Bât. 3D 
Laboratoire d’hématologie cellulaire 
F-69310 Pierre-Bénite 
Tel: +33 4 78 86 11 76 
Fax: +33 4 78 86 33 40 
pascale.felman@chu-lyon.fr 
Centralized lab for DNA extraction 
Anne-Laure Borrel 
Carole Charlot 
Centre Hospitalier Lyon Sud 
Laboratoire de biologie moléculaire et hématologie 
Centre de Biologie Sud, Espace J. Monot, Etage 1 
Chemin du Grand Revoyet - F-69310 Pierre-Bénite 
Tel: +33 4 72 66 93 33 
Fax:  +33 4 72 66 93 71 
anne-laure.borrel@lysarc.org 
 
Centralized lab for MRD 
Frederic Davi + Maria Elena Noguera 
Frederic Davi 
Hopital La Pitié Salpetrière 
Inserm U 543, Service d'hématologie biologique - 
47-83, boulevard de l'Hôpital  
F-75651 Paris Cedex 13 
Maria-Elena Noguera 
Hopital Saint-Louis 
Laboratoire Central d’hématologie 
Nouveau Saint-Louis – Secteur Vert Porte 1 
Unité de cytologie immunologie – 1er étage 
1, avenue C. Vellefaux - F-75010 Paris 
Tel: +33 1 42 16 01 93 
 
 
 
 
Tel :  +33 1 42 49 92 32 
Fax:  +33 1 42 49 92 43 
 
fred.davi@psl.aphp.fr 
 
 
 
 
maria-elena.noguera@sls.aphp.fr 
 
Contact information in Italy (FIL centers) 
Scientific director 
Emilio Iannitto, emilio.iannitto@gmail.com 
Investigator Coordinator in Italy 
 
 
Alessandro Maggi 
Presidio ospedaliero G. Moscati; UOC di Ematologia 
Via per Martina Franca (Poggio Galeso) 
I-74100 Taranto 
 
Tel: +39 099 458 5788 
 
alessandro.maggi@asl.taranto.it 
Coordination centre for Italy 
Monica Bellei/Marina Cesaretti 
FIL, Dipartimento di Oncologia, Ematologia e 
Patologie dell’Apparato Respiratorio 
Università di Modena e Reggio Emilia 
C.O.M. - Centro Oncologico Modenese 
Via del Pozzo 71 - I-41124 Modena 
Tel: +39 059 442 40 20 
Tel:    +39 059 422 31 65  
Fax: +39 059 422 36 02 
monica.bellei@filinf.it 
mcesaretti@filinf.it 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
 
Centralization of material for histology review 
Claudio Tripodo 
Università di Palermo 
Dip. di Scienze per la promozione della salute 
Sezione Anatomia patologica 
Via del Vespro 129 - I-90127 Palermo 
Tel: +39 091 655 35 46 
Fax: +39 091 655 35 49 
tripodo@unipa.it 
Centralization of slides for cytology review 
Claudio Tripodo 
Università di Palermo 
Dip. di Scienze per la promozione della salute 
Sezione Anatomia patologica 
Via del Vespro 129 - I-90127 Palermo 
Fax: +39 091 655 44 02 
Tel: +39 091 655 44 03 
 
+39 091 655 44 05 
tripodo@unipa.it  
Centralized lab for flow-cytometry immunophenotype and DNA extraction 
 
 
 
AOU “Città della Salute e della Scienza” di Torino, 
presidio “Molinette”, Laboratorio di ematologia 1 U 
Prof. Boccadoro, Via Genova 3, P.T. padiglione giallo, 
10126 Torino   
 
 
Tel: +39.011.6334220 
Tel: +39.011.6336884 
 
 
Simone Ferrero 
Daniela Drandi 
simone.ferrero@unito.it 
daniela.drandi@unito.it 
 


 
IELSG-36 – Version 5.1 – November 22, 2017 
TABLE OF CONTENTS 
 
Table of contents ...................................................................................................................... 4 
Synopsis .................................................................................................................................... 1 
1 
INTRODUCTION AND STUDY RATIONALE ............................................................................. 7 
1.1 
Disease Background: Splenic Marginal Zone Lymphoma ................................................................ 7 
1.2 
Drug background .............................................................................................................................. 8 
1.2.1 
Bendamustine ..................................................................................................................... 8 
1.2.2 
Rituximab .......................................................................................................................... 10 
1.3 
Rationale ........................................................................................................................................ 11 
1.3.1 
Rationale for combining drugs ......................................................................................... 11 
1.3.2 
Rationale for performing the study .................................................................................. 11 
2 
OBJECTIVES ........................................................................................................................ 11 
2.1 
Primary Objective........................................................................................................................... 11 
2.2  
Secondary Objectives ..................................................................................................................... 11 
3 
INVESTIGATIONAL PLAN ..................................................................................................... 12 
3.1 
Overall study design and plan of the study.................................................................................... 12 
3.2 
Study population ............................................................................................................................ 12 
3.2.1 
Inclusion criteria ............................................................................................................... 12 
3.2.2 
Exclusion criteria ............................................................................................................... 13 
4 
STUDY TREATMENT ............................................................................................................ 14 
4.1 
Clinical Trial Materials .................................................................................................................... 14 
4.1.1 
Bendamustine ................................................................................................................... 14 
4.1.2 
Rituximab .......................................................................................................................... 14 
4.2 
Preparation, Handling and Storage of Study Drugs ....................................................................... 14 
4.3 
Drug Supply and storage ................................................................................................................ 15 
4.4 
Drug Accountability ........................................................................................................................ 15 
4.5 
Treatment Plan .............................................................................................................................. 15 
4.5.1 
Induction Phase ................................................................................................................ 15 
4.5.2 
Extended Phase ................................................................................................................ 15 
4.6 
Dose modification or interruption ................................................................................................. 16 
4.6.1 
Bendamustine dose modification ..................................................................................... 16 
4.6.2 
Rituximab dose modification ............................................................................................ 17 
4.7 
Concomitant Treatment................................................................................................................. 17 
4.7.1 
Recommended concomitant therapy ............................................................................... 17 
4.7.2 
Permitted concomitant therapy ....................................................................................... 17 
4.7.3 
Prohibited concomitant therapy ...................................................................................... 17 
5 
Registration and enrollment procedures ............................................................................. 19 
5.1 
Patient registration ........................................................................................................................ 19 
5.2 
Central review of diagnosis ............................................................................................................ 19 
5.3 
Duration of Patients Participation ................................................................................................. 19 
5.4 
Discontinuation of Treatment ........................................................................................................ 19 
5.5 
Completion of Treatment .............................................................................................................. 19 
5.6 
Withdrawal from the Study ........................................................................................................... 19 
6 
STUDY PROCEDURES .......................................................................................................... 21 
6.1 
Disease Evaluation ......................................................................................................................... 21 
6.1.1 
Staging .............................................................................................................................. 21 
6.2 
Investigation at Baseline (following informed consent to trial entry) ........................................... 21 
6.3 
Investigation before each course ................................................................................................... 22 
6.4 
Investigation at restaging after the third course (week 10-12) ..................................................... 22 
6.5 
Investigation after the fourth course (Early Complete Responders End of Treatment) (week 14-
16) .................................................................................................................................................. 23 
6.6 
Investigation after the sixth course (Late Responders End of Treatment) (week 22-24) .............. 23 


 
IELSG-36 – Version 5.1 – November 22, 2017 
6.7 
Investigation During Follow-Up ..................................................................................................... 24 
6.8 
Summary tables of required investigations ................................................................................... 25 
6.9  
Schedule of blood samples for MRD and cytogenetics ................................................................. 26 
7 
EFFICACY MEASUREMENT AND PARAMETERS .................................................................... 26 
7.1 
Efficacy measurement.................................................................................................................... 26 
7.2 
Efficacy parameters ....................................................................................................................... 26 
7.2.1 
Primary endpoints ............................................................................................................ 26 
7.2.2 
Secondary endpoints ........................................................................................................ 27 
8 
SAFETY MEASUREMENT AND PARAMETERS........................................................................ 28 
8.1 
Safety measurements .................................................................................................................... 28 
8.2 
Safety parameters .......................................................................................................................... 28 
8.2.1 
Adverse Events (AE) .......................................................................................................... 28 
8.2.1.1 Adverse Event reporting ................................................................................................... 28 
8.2.1.2 Definition of Adverse Event .............................................................................................. 28 
8.2.1.3 Abnormal laboratory values defined as Adverse Events .................................................. 28 
8.2.2 
Serious Adverse Events (SAE) ........................................................................................... 29 
8.2.2.1 SAE reporting to Regulatory Authorities and Ethic Committees ...................................... 29 
8.3 
Classification of severity ................................................................................................................ 29 
8.4 
Classification of relationship/causality of Adverse Events (SAE/AE) to study drug(s) ................... 30 
8.5 
Monitoring of Adverse Event and period of observation .............................................................. 30 
8.6 
Safety contact information ............................................................................................................ 30 
9 
STATISTICAL METHODS ...................................................................................................... 31 
9.1 
Parameter specifications and sample size calculation................................................................... 31 
9.2 
Analysis plan................................................................................................................................... 31 
10 PUBLICATION POLICY ......................................................................................................... 32 
11 ETHICAL ASPECTS ............................................................................................................... 32 
11.1 Investigator Responsibilities .......................................................................................................... 32 
11.2 Ethical and Administrative considerations .................................................................................... 32 
11.3 Independent Ethics Committee or Institutional Review Board (IEC/IRB) ...................................... 32 
11.4 Informed Consent .......................................................................................................................... 33 
11.5 Privacy of Personal Data ................................................................................................................ 34 
11.6 Data Quality Assurance .................................................................................................................. 34 
11.7 Record Retention ........................................................................................................................... 34 
11.8 On Site Audits ................................................................................................................................. 34 
12 STUDY ACKNOWLEDGEMENT ............................................................................................. 35 
13 REFERENCES ....................................................................................................................... 36 
APPENDIX A 
Guidelines for Diagnosis review 
APPENDIX B 
World Medical Association Declaration of Helsinki 
APPENDIX C 
WHO performance status scale 
APPENDIX D 
SMZL Diagnostic and Staging Work-Up 
APPENDIX E 
Ann Arbor Staging – Cotswolds Reccomendations 
APPENDIX F 
Cumulative Illness Rating Scale (CIRS) 
APPENDIX G 
Fondazione Italiana Linfomi (Onlus) SMZL score 
APPENDIX H 
New York Heart Association Classification Of Cardiac Disease 
APPENDIX I 
Creatinine Clearance Calculation 
APPENDIX J 
Common Terminology Criteria for Adverse Events 
APPENDIX K 
Suggested Body Surface Area Calculation 
APPENDIX L 
Instruction for Preparation and Handling of BENDAMUSTINE 
APPENDIX M 
Guidelines for Management of Biological Material 
APPENDIX N 
Description of MRD, and molecular, genetic and cytogenetic investigations 
APPENDIX O 
Guidelines for the use of granulocyte colony stimulating factor 
APPENDIX P 
Procedures for AE, SAE and SUSAR reporting 


 
IELSG-36 – Version 5.1 – November 22, 2017 
APPENDIX Q           FDG-PET reviewing 
 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
1 
SYNOPSIS 
 
Name 
BRISMA 
 
 
Protocol Title 
Bendamustine and Rituximab for the treatment of Splenic Marginal Zone 
Lymphoma. The IELSG-36 phase II prospective study. 
 
 
Protocol Version 
VERSION 5.1 – 22 NOVEMBER, 2017 
 
 
Investigational product 
Bendamustine and Rituximab 
 
 
Sponsor 
IELSG 
 
 
Study Phase 
II 
 
 
Study Design 
Multicenter open label two stage phase II study  
 
 
Principal Investigators 
France: Catherine Thieblemont, Remi Gressin  
Italy: Alessandro Maggi, Emilio Iannito, Andres JM Ferreri, Massimo Federico 
 
 
Centers 
France:  LYSA 
centers n = 13 
Italy:  
FIL 
centers n = 50 
 
 
Statistician 
Luigi Marcheselli 
Uffici studi FIL, Modena 
 
 
 
Central Review 
France 
Italy 
- Histology 
T. Molina, F. Berger, A. Traverse-Glehen, M. 
Parrens, 
V. Franco, E. Iannitto, AM. Florena, M. Paulli, 
G. Fraternali Orcioni, S. Ascani, MA. Piris 
- Cytology 
P. Felman, R. Garand, ME Noguera 
C. Tripodo, M. Ferrarini, S. Ferrero, D. Drandi 
- Flow Cytometry 
ME Noguera, J. Feuillard, L. Baseggio 
S. Zupo, M. Ponzoni, S. Ferrero, D. Drandi 
- MRD, Cytogenetic 
ME Noguera, .F Davi, C. Bastard 
 
 
 
Study Population 
Previously untreated (except for splenectomy and/or antiviral therapy for HCV 
infection) and symptomatic Splenic Marginal Zone patients. 
 
 
Objectives 
 
Evaluation of the efficacy and the safety of R-Bendamustine in symptomatic 
Splenic Marginal Zone Lymphoma patients. 
 
 
Primary Objective 
 
Efficacy of R-Bendamustine measured by Complete Response rate 
Complete response rate defined as regression to normal size on CT of 
organomegaly (spleen, liver, lymph nodes); normalization of the blood counts 
and no evidence of circulating clonal cells, and no evidence or minor (≤ 5%) BM 
infiltration detected by immunohistochemistry. 
 
* Analysis of minimal residual disease by Flow cytometry and by quantitative Taq Man PCR (RQ-
PCR) targeting clonal IgVH antiCDR3 to evaluate response status and a potential impact on 
progression free survival and long-term remission of patients will be incorporated as research 
evaluation but will be not influence nor the response evaluation nor influence the management of the 
patient.
Secondary Objectives 
 
Efficacy measured by 
· Overall Response Rate (ORR) (Complete response + Partial response) 
· Safety and tolerability measured by toxicities of R-Bendamustine evaluated 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
2 
by assessment of laboratory parameters and adverse events coded with NCI 
Common Toxicity Criteria, version 4.0 (Appendix F) 
· 3-year Progression Free Survival (PFS), defined as the time from entry into 
the study until reappearance of cytopenia associated with disease 
progression (autoimmune, hypersplenism) or lymphoma relapse/progression 
with enlarged lymph node(s) or spleen if present, histologic transformation or 
death as a result of any cause 
· Duration Of Response (DOR), is defined for all patients who achieved a 
response (CR and PR) and is measured from the time of response until the 
date of first documentation of progression or relapse. 
· 3-year Event Free Survival (EFS), measured from the time from study entry 
until appearance of any of the following event: any treatment failure 
including disease progression/relapse, or initiation of new anti-lymphoma 
therapy or death 
· Time to Next Treatment (TTNT), defined as the time from the end of the 
chemo-immunotherapy course to the day of next treatment commencement 
irrespective of cause 
· 3-year Overall Survival (OS), defined as the time from date of treatment start 
into the study until the date of death irrespective of cause. Patients who have 
not died at the time of end of the whole study, and patients who are lost to 
follow up, will be censored at the date of the last contact 
· Risk of histological transformation 
· 5 year-PFS and - OS 
 
 
Study design 
Multicentric Phase II study 
 
 
Treatment 
 
Immuno-Chemotherapy 
All patients will be treated with 4-6 cycles of R-Bendamustine every 4 weeks, 
depending on the response after 3 cycles 
Standard Doses: 
R- Bendamustine 
 
Dose (mg/m²) 
Days 
BENDAMUSTINE 
I.V.  
90 
1 and 2* 
RITUXIMAB 
I.V. 
375 
1§ 
* 
Or days 2-3 according to institutional/patient/physician preference 
§ 
Administration of Rituximab during cycle 1 and 2 can be postponed to day 8 or 14 in case of 
risk of tumor lysis syndrome e.g. marked splenomegaly or lymphocytosis above 10.000 
lymphocytes/mm3 
 
The use of G-CSF for prophylaxis is recommended according to EORTC 
guidelines (appendix O); either filgrastim, lenograstim or peg-filgrastim can be 
used. It is recommended to prescribe anti-infectious agents for all patients with 
valaciclovir 500 mg/d and trimetroprim/cotrimoxazole 400mg/d during all the 
chemotherapy. 
 
A centralized PET scan evaluation will be performed; the anonymized PET scan 
images will be collected and preserved for the entire duration of the study at 
the LYSARC (Resp. Romain Ricci, Coordinator Imaging LYSARC, CHU Henri 
Mondor Créteil, Service de Médecine Nucléaire). The images will be evaluated 
by a group of expert nuclear medicine (Dr. Salim Kanoun, Service de Medecine 
Nucleaire  IUCT-ONCOPoLE, Institut C. Regaud, Toulouse, France and Dr. Michel 
Meignan, LYSA Imaging, Hopitaux Universitaires Henri Mondor, Créteil, France) 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
3 
to analyze the clinical response of the patients. 
 
 
 
 
Response Criteria (according to Matutes et al, Leukemia 2008) 
·
Complete Response (CR) all the following criteria must be fulfilled: 
1. Resolution of organomegaly 
2. Normalization of the blood counts (Hb >12 g/dL; Plt >100.000/mm3; 
Absolute Neutrophils Count (ANC) > 1500/mm3; no evidence of circulating 
clonal B-cells- 
3. No evidence of BM infiltration  
 
·
Partial Response (PR) 
≥ 50% improvement in the disease manifestations that should include: 
1. Resolution or decrease in spleen size. 
2. Improvement on cytopenias. 
3. Resolution or decrease in lymphoadenopathy if present. 
4. BM should show a decrease in the level of lymphoid infiltration and 
improvement of the haematopoietic reserve. 
 
·
No response (NR) and progressive disease (PD) 
1. Less than 10% improvement on the disease manifestations or 
deterioration by increase >50% of measurable signs of the disease from 
nadir, respectively. 
 
 
Study flow-chart 
 
 
 
Inclusion criteria 
 
·
Initial diagnosis of CD20+ Splenic Marginal Zone Lymphoma morphology 
confirmed by histology, cytology, immunophenotype (chromosomal 
abnormalities by quantitative multiplex PCR of short fluorescent fragments 
(QMPSF) is optional) according to WHO 2008 classification of Lymphoma 
criteria or according to the recommendation of the Splenic Lymphoma 
Group (Matutes et al. Leukemia 2008) for non splenectomized patient. 
1. If patients not splenectomised: diagnosis on bone marrow biopsy 
(histology 
and 
immunohystochemistry), 
and 
blood 
(cytology, 
immunophenotype), chromosomal abnormalities by QMPSF optional.  
2. If patients splenectomised diagnosis on spleen, bone marrow biopsy 
(histology 
and 
immunohistochemistry), 
and 
blood 
(cytology, 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
4 
immunophenotype) chromosomal abnormalities by QMPSF optional. 
 
·
No previous treatment with immunotherapy or chemotherapy or 
radiotherapy unless pretreatment by monocorticotherapy. 
 
 
·
Patients requiring a treatment with at least one of the following situation: 
1) Symptomatic SMZL in not splenectomized patients  
a) Bulky (arbitrarily defined as ≥6 cm below left costal margin) or 
progressive 
or 
painful 
splenomegaly, 
without 
enlarged 
lymphoadenopathy, with or without cytopenia, not eligible for 
splenectomy or not willing splenectomy 
b) One of the following symptomatic/progressive cytopenias: Hb <10 
g/dL, or Plat <80.000/mm3, or ANC <1.000/mm3, whatever the reason 
(autoimmune or hypersplenism or bone marrow infiltration) not 
eligible for splenectomy or not willing splenectomy 
c) SMZL with enlarged lymphoadenopathy or involvement of extranodal 
sites with or without cytopenia 
2) Symptomatic disease in SMZL splenectomised patients with rapidly 
raising lymphocyte counts, development of lymphadenopaty or 
involvement of extranodal sites.  
3) SMZL with concomitant hepatitis C infection who have not responded or 
are relapsed after Interferon and/or Ribavirin. 
·
Clinically and/or radiologically confirmed measurable disease before 
treatment start. 
·
Aged ≥ 18 yo at time of initial diagnosis and ≤ 80 yo. 
·
Eastern Cooperative Oncology Group [ECOG] performance status 0-2 
(Appendix C). 
·
Minimum life expectancy of >6 months. 
·
Voluntary signed informed consent before performance of any study related 
procedure not part of normal medical care, with the understanding that 
consent may be withdrawn by the patient at any time without prejudice to 
future medical care. 
·
The following laboratory values at screening: 
1. Absolute 
neutrophil 
count 
(ANC) 
³1.000/mm3 
and 
Platelets 
³100.000/mm3, unless these abnormalities are related to bone marrow 
infiltration or to hypersplenism. 
2. Aspartate transaminase (AST) £2 x ULN; Alanine transaminase (ALT) £2 x 
ULN; total bilirubin £1.5 x ULN. 
3. Creatinine clearance ≥ 10 ml/min (as calculated by the Cockcroft-Gault 
formula - Appendix I). 
·
All patients must: 
1. Agree to abstain from donating blood while taking study drug therapy 
and following discontinuation of study drug therapy. 
2. Agree not to share study medication with another person. 
3. Agree to use an adequate method of contraception for women of 
childbearing potential during the study treatment and until 12 months 
after the end of the study treatment. 
4. Agree to use an adequate method of contraception for men during the 
study treatment and until 6 months after the end of the study treatment 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
5 
Exclusion criteria  
·
Any type of lymphoma other than SMZL.  
·
Patients with proven biopsy of histological transformation. 
·
Contraindication to any drug contained in the chemotherapy regimen. 
·
Myocardial infarction during last 3 months or unstable coronary disease or 
uncontrolled chronic symptomatic congestive heart insufficiency NYHA III – 
IV (Appendix H). 
·
Uncontrolled hypertension. 
·
Uncontrolled diabetes mellitus as defined by the investigator. 
·
Active systemic infection requiring treatment.  
·
Previously known HIV positive serology. 
 
·
Active hepatitis B virus infection (presence of antigen HBS+; in case of 
presence of antibody anti HBC+ and anti HBS+, controls should be organized 
according to guidelines of AASLD and l’EASL). 
·
Active and previously untreated HCV infection. 
·
Prior history of malignancies other than lymphoma within 3 years (except for 
complete resection of basal cell carcinoma, squamous cell carcinoma of the 
skin, or in situ malignancy). Patients previously diagnosed with prostate 
cancer are eligible if  (1) their disease was T1-T2a, N0, M0, with a Gleason 
score £7, and a prostate specific antigen (PSA) £10 ng/mL prior to initial 
therapy, (2) they had definitive curative therapy (ie, prostatectomy or 
radiotherapy) ³2 years before Day 1 of Cycle 1, and (3) at a minimum 2 years 
following therapy they had no clinical evidence of prostate cancer, and their 
PSA was undetectable if they underwent prostatectomy or <1 ng/mL if they 
did not undergo prostatectomy. 
·
Major surgery within 30 days before the inclusion in the study 
·
A positive Coombs test without haemolysis or an autoimmune hemolytic 
anemia is not an exclusion criterion. 
·
Impaired renal function with creatinine clearance <10 ml/min. 
·
Severe chronic obstructive pulmonary disease with hypoxemia. 
·
Medical condition requiring long-term use (>1 months) of systemic 
corticosteroids. 
·
Serious medical or psychiatric illness likely to interfere with participation in 
this clinical study. 
·
Prior participation in another study with experimental drug during the last 4 
months. 
·
Pregnant or currently breast-feeding woman. 
 
Procedures  
At baseline  
·
General baseline assessment: Demographic (date of birth, gender, height, 
weight, body surface area). Relevant clinical history (general and disease-
specific, including concurrent illnesses and therapies at the time of study 
entry). All patients will undergo a thorough scrutiny for the presence of 
comorbidity.  
·
Complete physical examination: (including peripheral lymphnodes, 
Waldeyer ring, size of liver and spleen measured as cm below costal margin). 
EGOG performance status. Laboratory: Complete blood count. 
·
Complete biochemistry: Complete blood count (haemoglobin, RBC, WBC 


 
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6 
and differential), Coagulation assessment (PTT, PT, ATIII, XDP, fibrinogen) 
AST, ALT, serum albumin, serum alkaline phosphatase, GGT, total bilirubin, 
creatinine, creatinine clearance, Na, K, Ca, LDH, total serum protein with 
serum protein electrophoresis, Beta2 microglobulin. Serology for HIV, B and 
C Hepatitis. Coomb’s test, Serum IgG, IgM, IgA (urine and serum 
Immunofixation if a monoclonal component is suspected), serum glucose, 
Mantoux screening test or QuantiFERON. 
 
·
Tumor assessment: Chest and abdomen CT-scan with iodine contrast (CT 
scan of head, neck, pelvis if clinically indicated); PET scan is highly 
recommended, to be performed according to local policies and to discretion 
of the physician in charge. Bone marrow trephine biopsy, bone marrow and 
peripheral blood smears to be centralized for central review (bone marrow if 
no blood infiltration). Results of flow cytometry on bone marrow and 
peripheral blood also to be centralized for central review. Biopsy of 
suspicious extranodal sites to be centralized for central review. If clinically 
indicated, abdomen ultrasounds with spleen measurement.  
·
Any other exam if clinically indicated. Cardiac function: 12 Lead ECG (only in 
case of abnormal ECG or history of cardiac disorder, LVEF by 
Echocardiography or Isotopic method if applicable to be performed). 
·
Scoring through application of CIRS scale (Appendix F) for history and 
concomitant diseases.  
Are optional:  
·
ESR, Fe, BUN/urea, uric acid, transferrin, serum ferritin, urine analysis.  
·
Investigation for Minimal Residual Disease by Flow cytometry and by 
quantitative Taq Man PCR (RQ-PCR) targeting clonal IgVH, chromosomal 
abnormalities by QMPSF is centralized. Peripheral blood samples for 
molecular, genetic and cytogenetic investigations is also centralized (bone 
marrow if no blood infiltration) 
During the study, please refer to the study procedure table. 
 
Expected number 
of patients 
N = 65 
 
Statistical consideration 
 
For the purposes of the study an efficacy and a safety population are defined. 
All patients receiving at least one dose of study medication will be considered 
for the safety population (SP). Only patients who receive at least two courses of 
RB combination and undergo procedures for response assessment will be 
considered for the efficacy population (EP). Sample size is calculated on the EP. 
SAMPLE SIZE CALCULATION 
We anticipated a CR rate of 80% and computed that, a sample size of 53 
valuable patients would provide 90% power at the overall 5% (2-sided) 
significance level to detect a CR rate >60% (null hypothesis, 60%; alternative 
hypothesis, 80%) Assuming a drop-out of 10% and that about 10% of cases 
entered into the study could be refused after the final histologic revision a total 
of 65 patients will be included 
ANALYSIS PLAN 
INTERIM ANALYSIS at 19 valuable patients 
FINAL ANALYSIS 
at 53 valuable patients 
 
 
Estimated study duration 
·
Duration of recruitment is estimated at 2 years  


 
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7 
·
Duration of follow-up phase: 5 years after last patient treated 
·
Estimation of total duration: 7 years 
Planned start             
of recruitment 
 
Second semester 2012 
 
 
1 
INTRODUCTION AND STUDY RATIONALE 
 
 
1.1 
Disease Background: Splenic Marginal Zone Lymphoma 
 
Splenic Marginal Zone Lymphoma (SMZL) is a well defined low-grade B-cell lymphoma, ranking as a 
distinct entity in the WHO (World Health Organization) classification1. Although it is considered as a rare 
neoplasm accounting for about 2% of all non Hodgkin’s lymphomas (NHL) it is estimated represents for 
most cases of otherwise unclassifiable chronic lymphoid B-cell CD5-lymphoprolipherative disorders2.  
The peak of incidence is in the sixth decade with an almost equal female/male ratio.  SMZL is 
characterized by an almost exclusive involvement of the spleen and bone marrow3-5. Peripheral blood 
involvement is usually scanty and in about half of cases the circulating neoplastic lymphocytes display a 
characteristic villous appearance. Signs and symptoms are mostly related to the development of 
peripheral cytopenias and or to the abdominal discomfort associated with the presence of a huge 
splenomegaly5-11. The definite diagnosis rely on spleen histology which is considered the gold standard 
diagnostic assay1,12. Recently, to avoid a major surgical procedure for mere diagnostic purposes in 
otherwise healthy subjects, the Splenic Lymphoma Group proposed guidelines for the diagnosis of 
SMZL based on the merging of bone marrow and peripheral blood picture with immunophenotypic and 
cytogenetic data13,14 (Appendix D). SMZL affects the elderly with a median age of 70 years, the median 
survival exceeds ten years and most patients can be effectively managed for many years with a 
watchful waiting policy. Yet in about 25% of cases the disease pursues an aggressive course and most 
patients die of lymphoma progression within 3-4 years. Some presenting features on diagnosis have 
been shown to have a significant prognostic value (extranodal involvement; high lymphocyte count; 
anemia; lymphonode involvement; thrombocytopenia) and when they develop during the course of the 
disease are harbinger of disease progression6-8,11. The Intergruppo Italiano Linfomi (IIL) have proposed a 
clinical score based on three parameters15: anemia, elevated LDH values and hypoalbuminemia 
(Appendix G). Patients showing two or more of the above adverse prognostic factors have a median life 
expectancy of less than five years. For the time being, there is not a prospectively validated therapy for 
SMZL and splenectomy has been deemed to be the therapeutic approach most effective in patients 
complaining signs and symptoms secondary to hyperpslenism. However, though almost all patients 
achieve a clinical response after splenectomy they eventually relapse or progress. Moreover, most of 
SMZL patients are elderly and show comorbities that classify them as poor surgical risk16-18. For these 
patient or those who show a spread of the disease to lymphonodes or other extranodal sites or others 
adverse prognostic factors, a systemic treatment may be appropriate. Retrospective studies have 
indicated that alkylating-agents monotherapy do not produce any clinical benefit while purine analogs 
(i.e. fludarabine, cladribine, and pentostatine) achieved very high response rates in both naïve and pre-
treated patients19-21. Moreover, the introduction of the anti-CD20 humanized antibody rituximab, either 
used alone or in combination with chemotherapy has been reported to be very effective in producing a 
rapid clearance of neoplastic cells. Treatment of such patients with rituximab both alone or in 
combination with chemotherapy has shown remarkable responses22-30.  
In 2005 the IIL started a prospective phase II trial to verify the efficacy of rituximab in combination with 
COMP (Cyclophosphamide, Oncovin, Myocet, Prednisone) chemotherapy, as front-line therapy for 
SMZL patients, in terms of response, survival, and safety. To be included in the trial, patients should had 
a diagnosis of SMZL supported by spleen histology or by a combination of bone marrow and peripheral 
blood morphologic and immunophenotipic data; patients should also be untreated for lymphoma and 
have active disease defined by the presence of at least one of the following: Hb <10g/dl; plt 


 
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8 
<100.000/mmc, symptomatic splenomegaly, elevated LDH, B symptoms, extrasplenic disease, LDT <12 
months. The preliminary results of this study have been presented at 2007 ASH meeting31. The most 
important findings were an ORR of 100% with 63% of CR. The results have been recently update, 
confirming on 63 patients an 85% ORR with 63% CR rate, and a 82% PFS at three years. However, the 
toxicity profile showed a 24% haematological toxicity WHO 3-4 and one patients died of therapy-related 
cardiac failure while in CR.  
1.2 
Drug background 
 
1.2.1 
Bendamustine 
 
Bendamustine was synthesized in 1963 in what was then the German Democratic Republic32. There, it 
was widely used, but not widely studied. When the Iron Curtain fell and the Federal Republic of 
Germany was reunited, investigators began to study bendamustine’s mechanism of action and its 
clinical activity. Although the early studies were plagued with problems, clear evidence of activity 
against low-grade lymphoproliferative disorders previously treated with other alkylating agents began 
to emerge, largely in the absence of significant toxicity33-38. More recently, several large, well designed 
and well-conducted trials39-41 have provided intriguing data that not only have allowed investigators 
outside of Germany to consider the potential role of bendamustine in the treatment of 
lymphoproliferative disorders in the future, but have also led the Food and Drug Adminstration (FDA) of 
the United States to approve bendamustine for the treatment of CLL and indolent B-cell non-Hodgkin 
lymphoma (NHL), thus providing clinicians a “new” treatment option for their patients right now42.  
 
Bendamustine Clinical Pharmacology 
 
Mechanism of Action 
The bendamustine molecule is composed of 3 structural elements: a mechlorethamine (nitrogen 
mustard) group, a benzimidazole ring, and a butyric acid side chain42. The mechlorethamine (nitrogen 
mustard) group is similar to other alkylators like cyclophosphamide and chlorambucil. The 
benzimidazole ring, which replaces the benzene ring present in chlorambucil, is unique and is similar in 
structure to some purine analogs such as 2-chlorodeoxyadenosine. This observation has led some to 
hypothesize that bendamustine may have purine analog activity as well, but no evidence for 
antimetabolite functionality has been confirmed. Although an alkylator itself, bendamustine displays 
distinct preclinical activity. DNA breaks induced by bendamustine are significantly greater in number 
than those produced by cyclophosphamide or carmustine and are more durable than those associated 
with melphalan, cyclophosphamide, or carmustine34,43. This extensive DNA damage leads to inefficient 
DNA repair mechanisms, resulting in inhibition of checkpoint control. The resultant cell cycle changes 
culminate in mitotic catastrophe, another pathway leading to cell death44. Furthermore, bendamustine 
activates a base-excision DNA-repair pathway, rather than an alkyltransferase DNA repair mechanism 
like other alkylating agents. This observation suggests that bendamustine may be less susceptible to 
alkylguanyl transferase expression–based drug resistance45.  
 
Bendamustine Pharmacokinetic Parameters And Drug Metabolism 
 
Absorption 
Not applicable, since bendamustine is administered by intravenous route. 
 
Distribution 
Bendamustine undergoes first-pass metabolism, primarily in the liver by the action of cytocrome p450 
enzyme complex. Bendamustine is highly protein bound (> 95%), primarily to albumin. Protein binding 
is not affected by advanced age, low serum albumin levels or presence of advanced tumor. However, 


 
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9 
only free, unbound bendamustine is active. After intravenous administration of bendamustine volume 
of distribution at steady state is 19,8 L. 
 
Metabolism and Excretion 
Elimination of bendamustine is rapid and occurs predominantly by the renal route, with peak 
metabolite concentrations found in the urine one hour after administration; only a small amount of the 
drug is eliminated by the liver. Mean total clearance was reported to be 49.6 L/h and to be independent 
of dosage over the range 0.5 to 5 mg/kg. Elimination is biphasic with a half-life (t1/2α) of 6 to 10 
minutes, and a termination half-life (t1/2β) of approximately 30 minutes. Bendamustine is eliminated 
primary by renal route and therefore should not be given to patients in whom renal function is 
compromised (glomerular filtration rate <10ml/min). Bendamustine is also contraindicated in patients 
with severe hepatic damage, since primary metabolism occurs in the liver. There are at present no 
published data on placental transfer or excretion in breast milk of bendamustine. 
 
Bendamustine Preclinical And Clinical Data 
 
Preclinical studies demonstrate bendamustine’s activity in cancer cells that are resistant to other 
alkylating agents. Alkylator-resistant human B-CLL cells are less resistant to bendamustine46 and there is 
clinical evidence that bendamustine retains activity when other alkylators fail47,48. The overall remission 
rate was 56%, with a median duration of remission of 42.7 months. Several studies of bendamustine-
based therapy in patients with relapsed and refractory low-grade lymphomas report overall remission 
rates from 48% to 97%34,42-45. Thus, both preclinical and clinical data suggest that bendamustine may 
have properties distinct from other alkylating agents. These observations informed the design of larger 
studies that extend these preliminary observations. 
 
Several experiences have been published related to the use of bendamustine as a single or combined 
agent in low-grade lymphomas. As a single agent, bendamustine was administered to 52 evaluable 
patients with relapsed or refractory low-grade lymphomas at a dose of 120 mg/m2 on the first 2 days of 
a 21-day cycle49. The median age of the patients was 63 years (range, 36-82 years), and all patients had 
been previously exposed to alkylating agents. The overall response rate (ORR) was 73%, and 11% 
achieved complete remission (CR). The regimen appeared to be remarkably well tolerated, and only 3 
patients developed grade 3 or 4 toxicity, both grade 3 neutropenia. This study and similar studies 
conducted in Europe suggest activity of bendamustine against low grade lymphoma in the absence of 
debilitating or unmanageable toxicity39. To help confirm these preliminary observations, a North 
American study was organized to test the safety and efficacy of bendamustine in rituximab refractory 
patients with indolent and transformed non-Hodgkin lymphoma. Patients enrolled on this study were 
defined as rituximab-refractory if they failed to respond or progressed within 6 months of previous 
treatment with rituximab. This multicenter trial enrolled 77 patients, and 76 patients were treated with 
bendamustine 120 mg/m2 on the first 2 consecutive days of a 21-day cycle. Nineteen patients required 
dose reductions. The incidence of grade 3-4 neutropenia was 54% and of grade 3-4 thrombocytopenia 
was 25%. Non-hematologic toxicities were common, but generally mild with grade 1-2 nausea in 68% 
and grade 1-2 fatigue in 42%. No patient developed alopecia or mucositis. Although these patients were 
frequently relapsed from combination chemotherapy regimens, and 20% had transformed disease, the 
ORR was 77%, and 34% achieved CR.41 Interestingly, the ORR in patients with alkylator-resistant 
disease was 61%, and it was 62% in the 8 patients with fludarabine-refractory disease. For all patients, 
the median progression-free survival (PFS) was 7.1 months. The results of the study performed by 
Friedberg et al confirm earlier findings and clearly establish bendamustine as a safe and effective 
treatment for relapsed and refractory low-grade lymphomas. Although remission rates were high, 
however, the duration of remission was relatively short. Thus, bendamustine has been combined with 
other active agents to determine whether results could be improved. Although its efficacy and safety 


 
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10 
profile in the treatment of low-grade lymphoma would have been enough to consider rituximab in 
combination with bendamustine, preclinical studies also suggest a degree of synergism with the 
combination against lymphoma cell lines and in severe combined immunodeficient mice with Daudi 
xenografts50. Therefore, rituximab has been combined with bendamustine (BR) for the treatment of 
low-grade lymphoma in some recent clinical trials. A study from Germany accrued 63 patients with 
relapsed or refractory low-grade non-Hodgkin lymphoma for treatment with BR. Rituximab 375 mg/m2 
was administered on Day 1, and bendamustine was administered at a dose of 90 mg/m2 on Days 2 and 
3 of a 28-day treatment cycle37. Rituximab was also infused 1 week before the first treatment cycle and 
4 weeks after the fourth and final treatment cycle. The median age of the patients was 64 years (range, 
40 to 81 years). The beta-2 microglobulin level was >2 mg/dL in 48%, and the lactate dehydrogenase 
level was >240 U/L in 24% of assessable patients. Toxicity was graded according to World Health 
Organization (WHO) guidelines and was largely limited to myelosuppression (16% grade 3-4 leukopenia) 
and nausea (102 of 136 treatment cycles complicated by grade 1 nausea). Hematopoietic growth 
factors were allowed on the study, but none was used. The ORR rate to BR on this study was 90%, and 
60% achieved a CR. Patients with relapsed mantle cell lymphoma had an ORR of 75%, and 50% achieved 
CR. These remissions were also reasonably durable, with a median progression-free survival of 24 
months. The median PFS in patients with mantle cell lymphoma was 18 months. The remarkable results 
of the German study of BR prompted a confirmatory study in North America. The treatment regimen 
was identical to the German study, but toxicity was graded according to the National Cancer Institute’s 
Common Terminology Criteria (NCI-CTC). Sixty-seven patients with relapsed or refractory low-grade 
non-Hodgkin lymphoma were enrolled in this trial, and 66 patients were treated with BR41. This 
population of patients had a median age of 60 years (range, 40-84 years) and was similar to the German 
cohort. The efficacy results of the North American Trial were also very similar to those of the German 
trial. Both studies demonstrate excellent activity against low-grade lymphomas across multiple 
histologic subtypes. The 2 studies differed in their assessment and reporting of toxicity, leading to 
apparent discrepancies in their respective toxicity results. In the German study, toxicity was reported as 
a function of events per treatment cycle, whereas in the North American study toxicity was reported as 
a function of study participants. Grade 3-4 leukopenia was reported in 16% of treatment cycles in the 
former study, and in 30% of study participants in the latter study. The discrepancy is more than just in 
the way toxicity was reported. Therefore, the toxicity in the 2 trials is not as easily compared as the 
response rates are. Nonetheless, severe adverse events were uncommon in both studies. 
 
Considering this treatment option bendamustine is neither a new drug, nor a biologically targeted 
agent. Yet it has unique activity against lymphoproliferative disorders, and its favorable side-effect 
profile makes it amenable for use in combination with other agents. 
 
 
1.2.2 
Rituximab  
 
Rituximab is a mouse/human chimaeric IgG1-k monoclonal antibody that targets the CD20 antigen 
found on the surface of malignant and normal B lymphocytes.18 
Although not fully elucidated, the cytotoxic effects of rituximab on CD20-positive malignant B cells 
appears to involve complement-dependent cytotoxicity, antibody-dependent cellular cytotoxicity and 
induction of apoptosis.19-20 
Rituximab has demonstrated efficacy in patients with various lymphoid malignancies, including indolent 
and aggressive forms of B-cell NHL and B-cell chronic lymphocytic leukaemia (CLL).21-27 However few are 
the data on the use of rituximab alone or in combination in patients with Splenic Marginal Zone 
Lymphoma. Since approval of rituximab, treatment of such patients with rituximab both alone or in 
combination with chemotherapy has shown remarkable responses. In literature six retrospective 
studies adding up 52 patients are reported. The overall response rate both in refractory/relapsed and 


 
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11 
treatment naive cases was rather high ranging from 88% to 100%. Worth noting the prompt and 
marked shrinkage of splenomegaly and the amelioration of the peripheral cytopenias, mostly registered 
within the third course of therapy. Treatment with rituximab is generally well tolerated, particularly in 
terms of adverse haematological effects and serious or opportunistic infections relative to standard 
chemotherapy. 
 
1.3 
Rationale 
 
1.3.1 
Rationale for combining drugs 
 
Preclinical and recent clinical studies suggest a degree of synergism using the combination 
bendamustine and rituximab in the treatment of low-grade lymphoma demonstrating remarkable 
results. 
 
1.3.2 
Rationale for performing the study 
 
To investigate the role of bendamustine in combination with rituximab in a peculiar subset of low-grade 
lymphoma. 
 
 
2 
OBJECTIVES 
 
 
2.1 
Primary Objective 
 
To evaluate the complete response rate obtained with bendamustine in combination with rituximab in 
previously untreated splenic marginal zone lymphoma (SMZL). 
 
 
2.2  
Secondary Objectives 
 
·
To evaluate Overall Response Rate (ORR) (Complete response + Partial response) 
·
To evaluate safety and tolerability measured by toxicities of R-Bendamustine (by assessment of 
laboratory parameters and adverse events coded with NCI Common Toxicity Criteria, version 4.0) 
·
To evaluate 3-year Progression Free Survival (PFS) 
·
To evaluate Duration Of Response (DOR) 
·
To evaluate 3-year Event Free Survival (EFS) 
·
To evaluate Time To Next Treatment (TTNT) 
·
To evaluate 3-year Overall Survival (OS) 
·
To evaluate risk of histological transformation  
·
To evaluate 5 year-PFS and - OS 


 
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12 
3 
INVESTIGATIONAL PLAN 
 
 
3.1 
Overall study design and plan of the study 
 
This is a prospective, multicenter phase II trial designed to determine efficacy and safety of a Chemo-
immunotherapy with the combination of bendamustine + rituximab in patients with splenic marginal 
zone lymphoma. 
The study design is presented in the figure below: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.2 
Study population 
 
Male and women patients (age ≥ 18 yo and ≤ 80 yo) are eligible for this clinical trial if they have B-cell 
splenic marginal zone lymphoma in first line treatment. 
Specific inclusion and exclusion criteria for enrolling subjects in this study are described in the following 
sections. 
 
3.2.1 
Inclusion criteria 
 
·
Initial diagnosis of CD20+ Splenic Marginal Zone Lymphoma (According to WHO 2008 classification 
of Lymphoma) morphology confirmed by histology, cytology, and immunophenotype (Chromosomal 
abnormalities by QMPSF is optional) or according to the recommendation of the Splenic Lymphoma 
Group13 for non splenectomized patient. 
1. If patients not splenectomised: diagnosis on bone marrow biopsy (histology and 
immunohistochemistry) and blood (cytology and immunophenotype 
- chromosomal 
abnormalities by QMPSF is optional)  
2. If patients splenectomised diagnosis on spleen, bone marrow biopsy (histology and 
immunophenotype), and blood (cytology and immunophenotype - chromosomal abnormalities 
by QMPSF optional)  
·
No previous treatment with immunotherapy or chemotherapy or radiotherapy unless pretreatment 
by monocorticotherapy. 


 
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13 
·
Patients requiring a treatment with at least one of the following situation: 
1) Symptomatic SMZL in not splenectomized patients  
a) Bulky (arbitrarily defined as ≥ 6 cm below left costal margin) or progressive or painful 
splenomegaly, without enlarged lymphoadenopathy with or without cytopenia, not eligible 
for splenectomy or not willing splenectomy. 
b) one of the following symptomatic/progressive cytopenias: Hb < 10 g/dL, or Plat < 
80.000/mm3, or neutropenia < 1.000/mm3, whatever the reason (autoimmune or 
hypersplenism or bone marrow infiltration) not eligible for splenectomy or not willing 
splenectomy. 
c) SMZL with enlarged lymphoadenopathy or involvement of extranodal sites, with or without 
cytopenia. 
2) Symptomatic disease in SMZL splenectomised patients with rapidly raising lymphocyte counts, 
development of lymphadenopathy or involvement of extranodal sites. 
3) SMZL with concomitant hepatitis C infection who have not responded to or are relapsed after 
Interferon and/or Ribavirin  
·
Clinically and / or radiologically confirmed measurable disease before treatment start. 
·
Aged ≥ 18 yo at time of initial diagnosis and ≤ 80 yo. 
·
Eastern Cooperative Oncology Group [ECOG] performance status 0-2 (Appendix C). 
·
Minimum life expectancy of > 6 months. 
·
Voluntary signed informed consent before performance of any study related procedure not part of 
normal medical care, with the understanding that consent may be withdrawn by the patient at any 
time without prejudice to future medical care. 
·
The following laboratory values at screening: 
1. Absolute neutrophil count (ANC) ³1.000/mm3 and Platelets ³100.000/mm3, unless these 
abnormalities are related to bone marrow infiltration or to hypersplenism. 
2. Aspartate transaminase (AST) £2 x ULN; Alanine transaminase (ALT) £2 x ULN; Total bilirubin £1.5 
x ULN. 
3. Creatinine clearance ≥ 10 ml/min (as calculated by the Cockcroft-Gault formula – Appendix I). 
·
All patients must: 
1. Agree to abstain from donating blood while taking study drug therapy and following 
discontinuation of study drug therapy. 
2. Agree not to share medication with another person. 
3. Agree to practice an adequate method of contraception for women of childbearing potential 
during the study treatment and until 12 months after the end of the study treatment. 
4. Agree to practice an adequate method of contraception for men during the study treatment and 
until 6 months after the end of the study treatment. 
 
3.2.2 
Exclusion criteria 
 
Potential patients who meet any of the following criteria will be excluded from participating in the 
study: 
·
Any type of lymphoma other than SMZL. 
·
Patients with proven biopsy of histological transformation. 
·
Contraindication to any drug contained in the chemotherapy regimen. 
·
Myocardial infarction during last 3 months or unstable coronary disease or uncontrolled chronic 
symptomatic congestive heart insufficiency NYHA III – IV (Appendix H). 
·
Uncontrolled hypertension. 
·
Uncontrolled diabetes mellitus as defined by the investigator.  
·
Active systemic infection requiring treatment.  
·
Previously known HIV positive serology. 


 
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14 
·
Active hepatitis B virus infection (presence of antigen HBS+; in case of presence of antibody anti 
HBC+ and anti HBS+, controls should be organized according to guidelines of AASLD and l’EASL). 
·
Active and previously untreated HCV infection. 
·
Prior history of malignancies other than lymphoma within 3 years (except for complete resection of 
basal cell carcinoma, squamous cell carcinoma of the skin, or in situ malignancy). Patients previously 
diagnosed with prostate cancer are eligible if  (1) their disease was T1-T2a, N0, M0, with a Gleason 
score £ 7, and a prostate specific antigen (PSA) £ 10 ng/mL prior to initial therapy, (2) they had 
definitive curative therapy (ie, prostatectomy or radiotherapy) ³ 2 years before Day 1 of Cycle 1, and 
(3) at a minimum 2 years following therapy they had no clinical evidence of prostate cancer, and 
their PSA was undetectable if they underwent prostatectomy or < 1 ng/mL if they did not undergo 
prostatectomy. 
·
Major surgery within 30 days before the inclusion in the study. 
·
A positive Coombs test without haemolysis or an autoimmune hemolytic anemia is not an exclusion 
criterion. 
·
Impaired renal function with creatinine clearance <10 ml/min.  
·
Severe chronic obstructive pulmonary disease with hypoxemia. 
·
Medical condition requiring long-term use (>1 months) of systemic corticosteroids. 
·
Serious medical or psychiatric illness likely to interfere with participation in this clinical study. 
·
Prior participation in another study with experimental drug during the last 4 months. 
·
Pregnant or currently breast feeding women. 
 
 
4 
STUDY TREATMENT 
 
 
4.1 
Clinical Trial Materials 
 
4.1.1 
Bendamustine 
 
Bendamutine (Bendamustine Hydrochloride) is an antineoplastic agent available for I.V. use only. 
Packaging - Bendamustine will be provided as lyophilized powder. Two different packaging could be 
provided, depending on the calculated Body Surface Area (BSA) of the patient. 
Two different packaging exist : 
26 mL Type I brown glass vial with rubber stopper and aluminium flip-off cap for single use only 
contains 25 mg of bendamustine hydrochloride. Supplied in packs of 1 vial. 
60 mL Type I brown glass vial with rubber stopper and aluminium flip-off cap for single use only 
contains 100 mg of bendamustine hydrochloride. Supplied in packs of 1 vial. 
Shelf life - 3 years. 
 
4.1.2 
Rituximab 
 
Rituximab is a mouse/human chimeric monoclonal antibody formulated for I.V. administration. The 
rituximab antibody is produced by a Chinese hamster ovary transfectoma. 
 
 
4.2 
Preparation, Handling and Storage of Study Drugs 
 
Bendamustine: will be supplied in packs of 5 vials each. 
Bendamustine may be stored up to 25°C with excursions permitted up to 30°C (see USP Controlled 
Room Temperature). Retain in original package until time of use to protect from light. Bendamustine 


 
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15 
contains no antimicrobial preservative. The admixture should be prepared as close as possible to the 
time of patient administration. After reconstitution and dilution the chemical stability has been proved 
during 3,5 hours at temperature of 25°C and during 2 days in a range of temperature between 2°C and 
8°C in polyethylene bags. Administration of bendamustine must be completed within this period. 
Bendamustine solution should be prepared and handled according to the instructions provided in 
Appendix L. 
Rituximab: for rituximab admixture preparation and handling please refer to the Standard Medical 
Practice. 
 
 
4.3 
Drug Supply and storage 
 
As rituximab will be administrated according to the marketing authorization, it will not be supplied by 
the sponsor and will be provided by the local pharmacies.  
Bendamustine will be supplied by Mundipharma. 
At the study site, all investigational study drugs will be stored in a locked, safe area to prevent 
unauthorized access. The study drug should be stored at room temperature away from direct sunlight 
and protected from excessive heat and cold. 
 
Packs of bendamustine vials shouldn’t be stored at above 25°C. 
The product is a protein - HANDLE GENTLY AND AVOID FOAMING. The avoidance of foaming during 
product handling, preparation and administration is important, as foaming may lead to the de-naturing 
of the product proteins. All transfer procedures require strict adherence to aseptic techniques, 
preferably in a laminar flow hood.  
 
 
4.4 
Drug Accountability 
 
The Investigator or designee is responsible for taking an inventory of each shipment of study drug 
(Rituximab and Bendamustine in France, Bendamustine only outside France), and comparing it with the 
accompanying study drug accountability form. The Investigator will verify the accuracy of the 
information on the form, sign and date it, retain a copy in the study file. 
 
4.5 
Treatment Plan 
 
4.5.1 
Induction Phase 
 
Rituximab – Bendamustine (R-B): cycles 1 to 3: (week 0, 4, 8) 
Rituximab: 375 mg/sqm i.v. day 1* 
Bendamustine: 90 mg/sqm iv days 1-2 or days 2-3 according to institutional/patient/physician choice 
Treatment will be administered on a 28-day cycle basis.  
* Administration of rituximab during cycle 1 and 2 can be postponed to day 8 or day 14 in case of risk 
of tumor lysis syndrome: i.e. marked splenomegaly or lymphocytosis above 10.000 lymphocytes/µl. 
 
4.5.2 
Extended Phase 
 
Rituximab – Bendamustine (R-B): cycles 4 to 6: (week 12, 16, 20) 
Rituximab: 375 mg/sqm i.v. day 1 
Bendamustine: 90 mg/sqm iv days 1-2 or days 2-3 according to institutional/patient/physician choice. 
Treatment will be administered on a 28-day cycle basis.  


 
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16 
Patients will be treated with 3 courses of R-Bendamustine and then restaged. If in PR patients will 
proceed to the next extended phase with 3 more R-B courses. If in CR only one more R-Bendamustine 
course will be delivered. Patients with clinical response less than PR will go off the study. Patients in CR 
or PR at the end of the third course of R-Bendamustine and who proceeded to the extended phase will 
be considered to have completed the chemio-immunotherapy program and will undergo final restaging 
after 4 courses or after 6 courses (24 weeks) of R-Bendamustine treatment patients respectively. 
 
Treatment plan schema 
 
 
Bendamustine 90 mg/m2, i.v. days 1 and 2 
 
 
Rituximab 375 mg/m2, i.v. day 1 (1st and 2nd cycle Day 8 when indicated) 
 
Restaging 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Week 
0 
 1 
 
 
4 
 
 
 
8 
 
 
 
12 
 
 
 
16 
 
 
 
20 
Cycle 
1 
 
 
 
2 
 
 
 
3 
 
 
 
4 
 
 
 
5 
 
 
 
6 
 
INDUCTION PHASE 
 
EXTENDED PHASE 
 
 
A centralized PET scan evaluation will be performed; the anonymized PET scan images will be collected 
and preserved for the entire duration of the study at the LYSARC (Resp. Romain Ricci). The images will 
be evaluated by a group of expert nuclear medicine to analyze the clinical response of the patients (See 
APPENDIX Q). 
 
 
4.6 
Dose modification or interruption 
At the end of each course of R-B patients will be evaluated for possible toxicities that may have 
occurred during the cycle. Toxicities are to be assessed according to the National Cancer Institute 
Common Toxicity Criteria for Adverse Events (NCI CTCAE), Version 4.0 (see Appendix J). 
 
4.6.1 
Bendamustine dose modification 
 
Patients will start R-B every 28 days. Bendamustine administration should be delayed (after 7 days, on 
Day +35 of each cycle) in the event of Grade 4 hematologic toxicity or clinically significant ≥ Grade 2 
non-hematologic toxicity. 
For patients started on treatment with neutropenia or thrombocytopenia due to hypersplenism or to 
SMZL bone marrow infiltration (see section inclusion criteria 3.2.1) the R-B will be delivered every 28 
days if neutrophils and platelet values match those at pre-treatment. If neutrophils and platelet values 
are lower than those at pre-treatment, R-B must be delayed (after 7days, on Day +35 of each cycle). 
In case of neutropenia (<1.000/mm3) at day +28, even if it is consequence of bone marrow infiltration 
and/or hypersplenism, subsequent cycles will be administered with G-CSF or PegGCSF support (see 
section 4.7.2). 
Once non-hematologic toxicity has recovered to ≤ Grade 1 and/or the blood counts have improved 
[Absolute Neutrophil Count (ANC) ≥1.000/mm3, platelets ≥75.000/mm3], Bendamustine can be 
reinitiated at the discretion of the treating physician. In addition, dose reduction may be warranted. 
 


 
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17 
Dosing will be delayed up to 4 weeks until the criteria for reinitiating therapy are met. Patients who did 
not meet these criteria after a 4-week delay will be removed from protocol therapy. 
 
4.6.2 
Rituximab dose modification 
 
Rituximab administration and dose modification must follow labeling instructions and guidelines. Please 
refer to the approved product label for instructions. 
Patients who develop severe infusion reactions should have rituximab infusion discontinued and 
supportive care measures as medically indicated (e.g. fluids, vasopressors, oxygen, bronchodilators, 
paracetamol, etc.). In most cases, the infusion can be resumed at 50% reduction rate (e.g. from 100 
mg/hr to 50 mg/hr) when symptoms have completely resolved. Patients requiring close monitoring 
during first and all subsequent infusions include those pre-existing cardiac and pulmonary conditions, 
those with prior clinically significant cardiopulmonary adverse events, and whose with high numbers of 
circulating malignant cells (>25 x 109/l) with or without evidence of high tumor burden. 
 
 
4.7 
Concomitant Treatment 
 
4.7.1 
Recommended concomitant therapy 
 
During treatment are recommended as concomitant therapy: 
Patients will receive prophylactic treatment with valciclovir 500 mg/d and trimetroprim/Cotrimoxazole 
double strengths (one tablet twice daily, given three times per week, Monday, Tuesday, Wednesday) 
untill the completion of the last Rituximab-Bendamustine cycle. 
If cutaneous toxicity appears, an amendment will be written in order to give Bactrim only in patients 
with low level of CD4. 
In patients HBcAb+, prophylaxis against hepatitis B reactivation with Lamivudine 100 mg/die from the 
start of the treatment to one year after the end of the treatment. 
All concomitant medications for medical conditions other than B-NHL are permitted, as clinically 
Indicated. 
All supportive therapies other than anti-cancer treatment needed for the management of patients 
enrolled in this study are permitted. 
 
4.7.2 
Permitted concomitant therapy 
 
The following medications and support therapies that may be used if needed during this study: 
Prophylaxis with levofloxacine or ciprofloxacine and fluconazole/itraconazole will be administrated in 
case of neutropenia <1.000/mm3. Platelets and red blood cell transfusion are allowed, if needed, and 
will be given in case of Hb <8 g/dl or Plt <10.000/mm3. 
Erytropoietin therapy is allowed according to ASH/ASCO guidelines. G-CSF or PegG-CSF Is allowed and 
will be given according to primary physician decision. 
Immunoglobulin assay is advisable during induction therapy and follow-up; immunoglobulin 
replacement therapy is advisable in case of IgG level <0.3-0.5 gr/dl and frequent infectious events. 
Premedication for rituximab infusion with paracetamol and diphenhydramine should be considered 
before each infusion of rituximab, because it may reduce infusion reactions. 
 
4.7.3 
Prohibited concomitant therapy 
 
The following medications and supportive therapies are prohibited at all times: 
·
Any antineoplastic agent other than those planned by the study program; 


 
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18 
·
Any experimental agent. 
·
Allopurinol. 
·
Vaccination against yellow fever. 
 


 
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19 
5 
REGISTRATION AND ENROLLMENT PROCEDURES 
 
 
5.1 
Patient registration 
Following confirmation of eligibility and written informed consent, patients should be registered online 
at www.filinf.it, in the BRISMA dedicated section. An email of confirmation will be sent to the 
investigator and to each country coordination center, as well as the central labs that have on charge the 
diagnosis review. 
 
 
5.2 
Central review of diagnosis 
 
Once the patient is registered into the trial he/she enters the Screening phase that consists in the 
central review of diagnosis. All patients will be centrally reviewed before starting therapy. For review 
procedures details refer to Appendix A and M. 
 
 
5.3 
Duration of Patients Participation 
 
Patients will be treated for up to a total of 4-6 cycles R-B and unless removed from study for failure to 
respond after 3 courses or toxicity. 
All responding patients will be followed-up until disease progression or death for a maximum of 60 
months.  
 
 
5.4 
Discontinuation of Treatment 
 
A patient should be discontinued from study treatment if: 
·
The investigator believes that for safety reasons (e.g., adverse event) it is in the best interest of the 
subject to stop treatment; 
·
The subject has disease progression at any time; 
·
The subject has grade 4 hematologic toxicity or clinically significant ≥ Grade 2 non-hematologic 
toxicity for > 4 weeks. 
 
 
5.5 
Completion of Treatment 
 
A subject will be considered as having completed the study if he/she has completed all assessments of 
the treatment phase and follow-up. 
Subjects who discontinue study treatment due to lack of efficacy are also considered to have completed 
the study. 
 
 
5.6 
Withdrawal from the Study 
 
A subject will be withdrawn from the study for any of the following reasons: 
·
Lost at follow up 
·
Withdrawal of consent 
·
Discontinuation of study treatment (final assessments will be obtained) if applicable. 


 
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20 
When a subject withdraws before completing the study, the reason for withdrawal is to be documented 
on the CRF and in the source document. 


 
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21 
6 
STUDY PROCEDURES 
 
 
6.1 
Disease Evaluation  
 
6.1.1 
Staging 
 
Staging will be done according to the modified Ann Arbor staging system (see Appendix E) 
 
 
6.2 
Investigation at Baseline (following informed consent to trial entry) 
 
All patients must satisfy all the inclusion criteria and none of exclusion criteria listed in section 3 and 
sign informed consent has to be obtained before any non routine baseline evaluation is conducted. 
Results of procedures performed as part of standard medical care before signing the informed consent 
may be used as part of the screening evaluation if performed within 2 months of beginning of therapy 
for laboratory tests, imaging studies, and bone marrow biopsy and aspirate and within 12 months for 
spleen histology. 
 
All the following are required during screening phase 
Diagnosis with:  
·
Spleen biopsy for splenectomized patients 
·
Bone marrow biopsy for immuno-histochemistry analysis (and optional bone marrow aspirate with 
cytology analysis and flow cytometry) 
·
Peripheral blood smears: WBC differential, identification and percentage of lymphoma cells with or 
without villous lymphocytes 
·
Flow cytometry peripheral blood (CD3, CD4, CD8, CD19, CD20, CD5, CD10, CD23, CD11c, FMC7, SIg, 
SIgM, SIgG, SIgD, K, L; CD22, CD43, CD103, CD25, CD123) 
For Central diagnosis review (Appendix M-N), the following material should be centralized in each 
country with local report. 
o Paraffin embedded tumour tissue will be sent (spleen and bone marrow biopsy). 
o Slides of peripheral blood smears (+/- bone marrow aspirate optional). 
o Flow cytometry results on Peripheral Blood and/or bone marrow. 
·
Relevant medical history 
·
Patient characteristics: age, gender, weight, height, body surface area, CIRS scale, history of the 
Lymphoma  
·
Concomitant diseases and treatment and use of an adequate method of contraception 
·
Recent clinical history (B symptoms) 
·
Physical examination (size of the spleen, of lymph nodes, sign of organ involvement) 
·
ECOG performance status 
·
Chest and abdomen CT scan; CT scan of the head, neck and pelvis at the discretion of the treating 
physician. 
·
FDG-PET; recommended (according to local policies and if clinically indicated at discretion of treating 
physician). 
·
ECG; echocardiogram or blood pool cardioscintigraphy are optional 
·
Hematology (hemoglobin, RBC, reticulocytes, WBC and differential, platelets)  
·
Serum LDH 
·
Beta-2-microglobulin 
·
Coombs test 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
22 
·
Serum protein electrophoresis and immunofixation 
·
Blood chemistry (AST, ALT, serum alkaline phosphatase, GGT, total bilirubin, creatinine, creatinine 
clearance, Na, K, Ca, uric acid, total protein, albumin, serum glucose) 
·
Coagulation assessment (PTT, PT, ATIII, XDP, fibrinogen) 
·
Blood serology (HIV, HBV, HCV) 
·
Mantoux screening test or QuantiFERON 
·
Blood sample and bone marrow for MRD 
·
Scoring through application of CIRS scale for history and concomitant disease (see Appendix F) 
 
All the following are optional but strongly recommended  
·
ESR, Fe, BUN/urea, transferring serum ferritin, urine analysis. 
·
Investigation for chromosomal abnormalities by QMPSF. Peripheral blood samples for molecular, 
genetic and cytogenetic investigations to be centralized (bone marrow if no blood infiltration). 
Cytogenetics investigations should consist in evaluation of copy number abnormalities by QMPSF for 
patient without histological evaluation + IGVH status 
 
 
6.3 
Investigation before each course 
 
·
Physical examination (PS, spleen size).  
·
Use of an adequate method of contraception. 
·
Collection of adverse events during the month after the last dose of study drug administration. 
·
Hematology (Whole blood cell counts and differential). 
·
Blood chemistry (AST, ALT, serum alkaline phosphatase, total bilirubin, creatinine, Na, K). 
 
 
6.4 
Investigation at restaging after the third course (week 10-12) 
 
·
Physical examination (size of spleen, liver and lymph nodes, signs of organ involvement).  
·
Use of an adequate method of contraception. 
·
ECOG performance status. 
·
Chest and abdomen CT scan; CT scan of the head, neck and pelvis at the discretion of the treating 
physician. 
·
Hematology (hemoglobin, RBC, reticolocytes, WBC and differential, platelets. 
·
Peripheral blood smears: WBC differential, identification and percentage of lymphoma cells with or 
without villous lymphocytes.  
·
Serum LDH. 
·
Beta-2-microglobulin. 
·
Coombs test if documented as positive during the screening phase.  
·
Serum protein electrophoresis and immunofixation. 
·
Flow cytometry peripheral blood (CD3, CD4, CD8, CD19, CD20, CD5, CD10, CD23, CD11c, FMC7, SIg, 
SIgM, SIgG, SIgD, K, L; CD22, CD43, CD103, CD25, CD123). 
·
Bone marrow aspirate with cytology analysis and flow cytometry. 
·
Bone marrow biopsy (only if it was abnormal at baseline visit). 
·
Serum biochemistry (AST, ALT, serum alkaline phosphatase, total bilirubin, creatinine, Na, K, Ca, uric 
acid, total protein, albumin, serum glucose).  
·
Blood sample and bone marrow for MRD 
 
 
 


 
IELSG-36 – Version 5.1 – November 22, 2017 
 
23 
6.5 
Investigation after the fourth course (Early Complete Responders End of 
Treatment) (week 14-16) 
 
The end treatment visit for those patients who turned out to be in complete remission after the third 
course, will include collection of adverse events during the month after the last dose of study drug 
administration; in this visit will be evaluated: 
·
Physical examination 
·
Use of an adequate method of contraception until 12 months for women and 6 months for men 
after the end of the study treatment 
·
ECOG performance status 
·
Hematology (hemoglobin, RBC, WBC and differential, platelets) 
·
Blood sample and bone marrow for MRD 
·
Blood chemistry (AST, ALT, serum alkaline phosphatase, GGT, total bilirubin, BUN, creatinine, Na, K, 
Ca, uric acid, total protein, albumin, serum glucose). 
·
FDG-PET; if documented as “positive” during the screening phase, after at least 45 day from the last 
dose of study administration. 
 
 
6.6 
Investigation after the sixth course (Late Responders End of Treatment) 
(week 22-24) 
 
The end treatment visit for those patients who turned out to be in partial response after the third 
course, will include end of treatment procedures and collection of adverse events during the month 
after the last dose of study drug administration; in this visit will be evaluated: 
·
Physical examination (size of spleen, liver and lymph nodes, signs of organ involvement) 
·
Use of an adequate method of contraception until 12 months for women and 6 months for men 
after the end of the study treatment 
·
ECOG performance status 
·
Hematology (hematocrit, hemoglobin, RBC WBC and differential, Platelets. 
·
Flow cytometry peripheral blood (CD3, CD4, CD8, CD19, CD20, CD5, CD10, CD23, CD11c, FMC7, SIg, 
SIgM, SIgG, SIgD, K, L; CD22, CD43, CD103, CD25, CD123) 
·
Bone marrow aspirate with cytology analysis and flow cytometry 
·
Bone marrow biopsy (only if it was abnormal at baseline visit) 
·
Blood chemistry (AST, ALT, serum alkaline phosphatase, total bilirubin, BUN, creatinine, Na, K, Ca, 
uric acid, total protein, albumin, serum glucose) 
·
Serum LDH 
·
Beta-2-microglobulin 
·
Blood sample and bone marrow for MRD 
·
Chest and abdomen computer tomography; CT of the head, neck and pelvis at the discretion of the 
treating physician 
·
FDG-PET; if documented as “positive” during the screening phase, after at least 45 day from the last 
dose of study administration. 
·
Additional assessments if necessary according to the local standards and if clinically indicated at the 
discretion of the treating physician. 
 
 


 
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24 
6.7 
Investigation During Follow-Up 
 
After the completion of the end of treatment evaluation all patients will enter in the follow up phase. 
The follow-up phase will end in case of dead or progressive disease. 
Follow-up clinical examination for all patients after the completion of the chemo-immunotherapy, will 
be scheduled once a year for 5 years.  
 
·
Hematology (hematocrit, hemoglobin, RBC WBC and differential, Platelets. 
·
Flow cytometry peripheral blood (CD3, CD4, CD8, CD19, CD20, CD5, CD10, CD23, CD11c, FMC7, SIg, 
SIgM, SIgG, SIgD, K, L; CD22, CD43, CD103, CD25, CD123) 
·
Blood chemistry (AST, ALT, serum alkaline phosphatase, total bilirubin, BUN, creatinine, Na, K, Ca, 
uric acid, total protein, albumin, serum glucose) 
·
Serum LDH 
·
Beta-2-microglobulin 
·
Blood sample and bone marrow for MRD 
·
Chest and abdomen computer tomography; CT of the head, neck and pelvis at the discretion of the 
treating physician 
·
Use of an adequate method of contraception during the 12 first months for women and 6 first 
months for men after the end of the study treatment 
·
Additional assessments if necessary according to the local standards and if clinically indicated at the 
discretion of the treating physician. 
 
 
Patients will be evaluated through the study phases for possible toxicities and delays in dosing: dose 
modification will be made as required according to dose modification rules identified in section 4.6. 
Patients who discontinued study drug due to toxicity will have end of treatment procedures completed 
and enter in the follow up phase. 
Additional assessments have to be performed according to the local standards and if clinically indicated 
at the discretion of the treating physician. 


 
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25 
6.8 
Summary tables of required investigations 
 
 
Before 
treatment 
start 
First 3 cycles 
After 4th 
cycles 
(only 
patients in 
CR after 3rd  
cycle) 
After 6th 
cycles 
(only 
patients in 
PR after 3rd  
cycle) 
Follow-up 
visits 
(once a year 
for 5 years)  
Before 
each cycle 
After 3rd 
cycle 
Informed Consent 
X 
 
 
 
 
 
Centr. Diagnostic review (a, b) 
X 
 
 
 
 
 
Patient characteristics (c) 
X 
 
 
 
 
 
Phys. Examination  
X 
X 
X 
X 
X 
X 
ECOG PS 
X 
X 
X 
X 
X 
 
Adverse events 
 
Continuous report until one month after the end of treatment 
 
Electro-cardiogram 
X 
 
 
 
 
 
Echocardiography or Isotopic 
method if applicable (d) 
X 
 
 
 
 
 
Chest, abdomen +/- head, neck 
and pelvis CT scan (e)  
X 
 
X 
 
X 
 
Abdominal Ultrasound (e) 
x 
 
 
 
 
X (every 6 
months) 
FDG-PET (f) 
X 
 
 
X 
X 
 
Coombs D and I 
X 
 
X 
 
 
 
HIV, 
HBV, 
HCV 
serologies, 
Mantoux 
screening 
test 
or 
QuantiFERON 
X 
 
 
 
 
 
Serum electrophoresis and Ig (g) 
X 
 
X 
 
X 
X (every 6 
months) 
Beta 2 microglobulin 
X 
 
X 
 
X 
 
LDH 
X 
 
X 
 
X 
 
Serum biochemistry (h) 
X 
X 
X 
X 
X 
 
Haematology (i) 
X 
X 
X 
X 
X 
X 
Coagulation assessment (j) 
X 
 
 
 
 
 
Peripheral blood samples for 
QMPFS and IGVH status (k) 
X 
 
 
 
 
 
Flow Cytometry (on peripheral 
blood) (l) 
X 
 
X 
 
X 
X (every 6 
months 
Peripheral blood smears (m) 
X 
 
X 
 
X 
X (every 6 
months) 
BoneMarrow 
Biopsy/aspirate 
(n) 
X 
 
X only if 
abnormal at 
baseline 
 
X only if 
abnormal at 
baseline 
X  
Method of contraception (o) 
X 
X 
X 
X 
X 
X 
 
a) Histological/cytological diagnostic. In France local histological diagnostic used for inclusion and central histological 
diagnostic review done post treatment start.  
b) Biological material (Bone marrow biopsy and smears; peripheral blood smears; pathology review) + 
immunoistochemical on BM 
c) Age, gender, weight, height, body surface area, relevant medical history, CIRS scale, history of the Lymphoma  
d) In case of cardiac abnormality on ECG or history 
e) If clinically indicated 
f)
Baseline PET is recommended. PET should be repeated, if positive at baseline, after the completion of 
chemoimmunotherapy  
g) Serum  and urine Immunofixation if a monoclonal component  peak is suspected 
h) Serum chemistry to include AST, ALT, serum alkaline phosphatase, GGT, total bilirubin, creatinine, creatinine 
clearance, Na, K, Ca, uric acid, total protein, albumin, serum glucose 
i)
hemoglobin, RBC, reticulocytes, WBC and differential, platelets  
j)
PTT, PT, ATIII, XDP, fibrinogen 
k) Optional, 


 
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26 
l)
Flow cytometry investigation in peripheral blood and bone marrow samples (CD3, CD4, CD8, CD19, CD20, CD5, CD10, 
CD23, CD11c, FMC7, SIg, SIgM, SIgG, SIgD, K, L; CD22, CD43, CD103, CD25, CD123) 
m) Every six months 
n) Every 12 months for five years 
o) Use of an adequate method of contraception during the 12 first months for women and 6 first months for men after 
the end of the study treatment 
 
6.9  
Schedule of blood samples for MRD and cytogenetics 
 
 
7 
EFFICACY MEASUREMENT AND PARAMETERS 
 
 
7.1 
Efficacy measurement 
 
Patients receiving at least 2 courses of R-BENDA will be considered the Efficacy Population (EP). 
 
 
7.2 
Efficacy parameters 
 
7.2.1 
Primary endpoints 
 
Efficacy of R-Bendamustine measured by Complete Response rate. 
Complete response rate will be assessed by means of CT-scan, Immunophenotype in blood and bone 
marrow (PET-scan optional). 
 
The recently published recommendations of an International experts panel13 will be applied. Response 
criteria will be determined as follows: 
Complete response (CR) requires the disappearance of all evidence of disease 
a. Regression to normal size on CT of organomegaly (splenomegaly, hepatomegaly and 
lymphoadenopathies) 
b. Normalization of the blood counts (Hb >12 g/dl; platelets >100.000/mm3; neutrophils >1.500/mm3 
and no evidence of circulating clonal B-cells) 


 
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27 
c. No evidence or minor (<5%) BM infiltration detected by immunohistochemistry.  
Partial response (PR) requires regression of 50% or greater in the measurable disease manifestations 
and no new sites of disease. This should include: resolution or decrease in spleen size, improvement on 
cytopenias and resolution or decrease in lymphadenopathy if present. Bone Marrow should show a 
decrease in the level of lymphoid infiltration and improvement of the haemopoietic reserve. 
No response (NR) and progressive disease (PD) less than 10% improvement on the disease 
manifestations or deterioration, by increase >50%, of measurable signs of the disease from nadir- 
Relapsed disease: Reappearance of any measurable sign of the disease. 
A patient is defined as a responder if she/he has a complete or partial response. Patients without 
response assessment (due to whatever reason) will be considered as non-responders. 
 
7.2.2 
Secondary endpoints 
 
v Overall Response Rate (ORR) (Complete response + Partial response) 
v Safety and tolerability measured by toxicities of R-Bendamustine evaluated by assessment of 
laboratory parameters and adverse events coded with NCI Common Toxicity Criteria, version 4.0 
(Appendix J). 
v 3-year Progression Free Survival (PFS), defined as the time from entry into the study until 
reappearance of cytopenia or lymphoma relapse/ progression with enlarged lymph node(s) or 
spleen if present, histologic transformation or death as a result of any cause. Responding patients, 
patients who are lost to follow up, who withdrawal the consent or drop-out due to adverse event 
will be censored at their last assessment date. Patients died due to tumor will be considered in 
progression. Patients died for any other cause will be censored to the death date. 
v Duration of Response (DR), is defined for all patients who achieved a response (CR and PR) and is 
measured from the time of response until the date of first documentation of progression or relapse. 
Patients without relapse or progression will be censored at their last assessment date. Patients died 
due to tumor will be considered in progression. Patients died for any other cause will be censored to 
the death date. 
v 3-year Event Free Survival (EFS), will be measured from the day of treatment start to the date of 
documentation of one of the following events: any treatment failure including disease progression, 
or discontinuation of treatment for any reason (eg, disease progression, toxicity, patient preference, 
initiation of new treatment without documented progression, or death). Responding patients, 
patients who are lost to follow up, who withdrawal the consent or drop-out due to adverse event 
will be censored at their last assessment date. 
v Time To Next Treatment (TTNT), defined as the time from the end of the chemo-immunotherapy 
course to the day of next treatment commencement irrespective of cause 
v 3-year Overall Survival (OS), defined as the time from the date of treatment start into the study 
until the date of death irrespective of cause. Patients who have not died at the time of end of the 
whole study, and patients who are lost to follow up, will be censored at the date of the last contact 
v Risk of histological transformation 
v 5-year -PFS and -OS 
 
The overall response rate and the rate of the single response type (CR and PR) will be estimated with 
the 95% confidence interval. 
Time to event data (PFS, DR, TTNT, OS) will be estimated using the Kaplan-Meier method. 
The curves will be plotted and the 95% confidence interval for median time will be calculated. 


 
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8 
SAFETY MEASUREMENT AND PARAMETERS 
 
 
8.1 
Safety measurements 
 
All patients who have received at least one dose of study medication will be considered the Safety 
Population (SP) and will be evaluated for toxicity from the time of their first drug administration. When 
toxicity occurs, it should be graded according to the NCI Common Toxicity Criteria, version 4.0 
(Appendix J). 
Any clinically significant abnormalities persisting at the end of the study will be followed by the 
investigator until resolution or until reaching a clinically stable endpoint. 
The study will include the evaluations of safety and tolerability as described in the following sections.  
 
 
8.2 
Safety parameters 
 
8.2.1 
Adverse Events (AE) 
 
Adverse events will be reported by the subject (or, when appropriate, by a caregiver, surrogate, or the 
subject’s legally acceptable representative) for the duration of the study. 
Clinical Laboratory Tests 
All laboratory tests should be performed at the laboratory of the investigational site or other certificate 
laboratories according to physician decision. 
Any clinically significant abnormalities persisting at the end of the study will be followed by the 
investigator until resolution or until reaching a clinically stable endpoint. 
 
8.2.1.1 Adverse Event reporting 
 
Timely, accurate, and complete reporting and analysis of safety information from clinical studies are 
crucial for the protection of subjects and are mandated by regulatory agencies worldwide. 
 
8.2.1.2 Definition of Adverse Event 
 
An adverse event (AE) is any noxious, unintended, or untoward medical occurrence occurring at any 
dose that may appear or worsen in a subject during the course of a study. It may be a new intercurrent 
illness, a worsening concomitant illness, an injury, or any concomitant impairment of the subject’s 
health, including laboratory test values (as specified by the criteria below), regardless of etiology. Any 
medical condition that was present prior to study treatment and that remains unchanged or improved 
should not be recorded as an AE. If there is a worsening of that medical condition this should be 
considered an AE. A diagnosis or syndrome should be recorded on the AE page of the Case Report Form 
rather than the individual signs or symptoms of the diagnosis or syndrome. 
All AEs will be recorded by the Investigator(s) from the time of signing the informed consent through 
the end of the designated follow-up period. 
 
8.2.1.3 Abnormal laboratory values defined as Adverse Events 
 
An abnormal laboratory value is considered to be an AE if the laboratory abnormality is characterized 
by any of the following: 
·
Results in discontinuation from the study. 


 
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·
Requires treatment, modification/interruption of study drug dose, or any other therapeutic 
intervention. 
·
Is judged by the Investigator(s) to be of significant clinical importance. 
If a laboratory abnormality is one component of a diagnosis or syndrome, then only the diagnosis or 
syndrome should be recorded on the AE page of the CRF. If the abnormality was not a part of a 
diagnosis or syndrome, then the laboratory abnormality should be recorded as the AE. 
 
8.2.2 
Serious Adverse Events (SAE) 
 
A serious adverse event (SAE) is any AE which: 
·
Results in death 
·
Is life-threatening (i.e., in the opinion of the Investigator(s) the subject is at immediate risk of death 
from the AE) 
·
Requires inpatient hospitalization or prolongation of existing hospitalization 
·
Results in persistent or significant disability/incapacity (a substantial disruption of the subject’s 
ability to conduct normal life functions) 
·
Is a congenital anomaly/birth defect 
·
Constitutes an important medical event: important medical events are defined as those occurrences 
that may not be immediately life threatening or result in death, hospitalization, or disability, but may 
jeopardize the subject or require medical or surgical intervention to prevent one of the other 
outcomes listed above. Medical and scientific judgment should be exercised in deciding whether 
such an AE should be considered serious. 
Events not considered to be SAEs are hospitalizations which: were planned before entry into the clinical 
study; are for elective treatment of a condition unrelated to the studied indication or its treatment; 
occur on an emergency outpatient basis and do not result in admission (unless fulfilling other criteria 
above); are part of the normal treatment or monitoring of the studied indication and are not associated 
with any deterioration in condition. 
If an AE is considered serious, both the AE pages of the CRF and the SAE Report Form must be 
completed. 
For each SAE, the Investigator(s) will provide information on severity, start and stop dates, relationship 
to study drug, action taken regarding study drug, and outcome. 
 
8.2.2.1 SAE reporting to Regulatory Authorities and Ethic Committees  
 
The pharmacovigilance team (see section 8.6) will inform relevant Regulatory Authorities and the Ethics 
Committee: 
a) of all relevant information about serious unexpected adverse events suspected to be related to the 
study medication that are fatal or life threatening as soon as possible, and in any case no later than 
seven days after knowledge of such a case. Relevant follow-up information for these cases will 
subsequently be submitted within an additional eight days. 
b) of all other serious unexpected events suspected to be related to the study medication as soon as 
possible, but within a maximum of fifteen days of first knowledge by the investigator(s). 
 
 
8.3 
Classification of severity 
 
For both AEs and SAEs, the investigator(s) must assess the severity of the event. The severity of adverse 
events (AEs) will be graded on a scale of 1 to 5 according to the National Cancer Institute (NCI) Common 
Terminology Criteria for Adverse Events Version 4.0 (NCI CTCAE). The NCI CTCAE V4.0 can be viewed on-
line at the following NCI web site (http://ctep.cancer.gov/reporting/ctc.html). 


 
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If a specific event is not included in the NCI CTCAE toxicity scale, the following scale should be used to 
grade the event: 
1. Mild: Awareness of sign, symptom, or event, usually transient, requiring no special treatment and 
generally not interfering with usual daily activities. 
2. Moderate: Discomfort that causes interference with usual activities; usually ameliorated by basic 
therapeutic maneuvers. 
3. Severe: Incapacitating with inability to do usual activities or significantly affects clinical status and 
warrants intervention. Hospitalization may or may not be required. 
4. Life-threatening: Immediate risk of death; requires hospitalization and clinical intervention. 
5. Death. 
 
 
8.4 
Classification of relationship/causality of Adverse Events (SAE/AE) to 
study drug(s) 
 
The Investigator(s) must determine the relationship between the administration of study drug and the 
occurrence of an AE/SAE as Not Suspected or Suspected as defined below: 
v Not suspected: The temporal relationship of the adverse event to study drug administration makes a 
causal relationship unlikely or remote, or other medications, therapeutic interventions, or 
underlying conditions provide a sufficient explanation for the observed event. 
v Suspected: The temporal relationship of the adverse event to study drug administration makes a 
causal relationship possible, and other medications, therapeutic interventions, or underlying 
conditions do not provide a sufficient explanation for the observed event. 
 
 
8.5 
Monitoring of Adverse Event and period of observation 
 
Adverse events, both serious and non–serious, and death that occur during the patient’s study 
participation will be recorded in the source documents. All SAEs should be monitored until they are 
resolved or are clearly determined to be due to a patient’s stable or chronic condition or intercurrent 
illness(es). 
 
 
8.6 
Safety contact information  
 
PHARMACOVIGILANCE 
Safety phone number 
Safety Fax/e-mail 
International Extranodal Lymphoma 
Study Group 
Oncology Institute of Southern Switzerland 
CH-6500 Bellinzona – Switzerland 
 
 
Ph.: 0041 91 811 9040  
 
 
E-mail: ielsg@ticino.com  
Fax: 0041 91 811 9182 
 
 
Procedures for AE, SAE and SUSAR reporting are listed in Appendix P. 


 
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9 
STATISTICAL METHODS 
 
 
The primary objective of the study is to demonstrate a clinical benefit in Complete remission Rate (CR) 
with Rituximab-Bendamustine association in patients with splenic marginal zone lymphoma and splenic 
lymphoma. Complete Remission was used to determine the sample size of the study. 
There are no established data in splenic marginal zone lymphoma patients in first line treatment. The 
CR rate with rituximab and different chemotherapy regimens in previous studies ranged from 40 to 
80%. Comparison data for the study design and sample size calculations come from a median of those 
reported from different studies. The median expected CR rate for splenic marginal zone with the same 
characteristics indicated into the study and treated with standard rituximab + chemotherapy may be 
estimated to be approximately 60%. We would consider a positive result to increase CR rate from 60% 
to 80%. 
This phase II study has been designed according to Simon’s two-stage Optimal Design, since it is the 
design that minimizes the expected sample size given a 'bad' response rate. 
 
 
9.1 
Parameter specifications and sample size calculation 
 
Parameters 
v Standard proportion of CRR: p0 (null hypothesis) = 0.6 
v Minimum required CRR for the new regimen: p1 (alternative hypothesis) = 0.80 
v Alpha error (two sided) = 0.05 
v Beta error (power) = 0.9 
 
Sample size 
v Potential recruitment = thirty-four patients/year 
v # Valuable patients required = 53 
v Drop out 10% 
v Refused after central histological review 10% 
v 65 subjects (total) 
v Estimated study duration 7 years 
 
 
9.2 
Analysis plan 
 
9.2.1 Analysis populations 
The Safety Population consists of all enrolled patients who received at least one dose of study agent. 
The Efficacy Population consists of enrolled patients who completed at least two cycles of treatment. 
Number per protocol sample is defined. 
 
9.2.2 Interim analysis 
An interim analysis will be performed after recruitment of the first 19 valuable patients. Aim of this 
analysis is to determine preliminary the activity of the treatment. 
 
9.2.3 Parameters of efficacy 
The analysis of efficacy parameter will be performed according to the Intent to Treat principle. 
 
9.2.4 Assessment of safety 
Safety analysis will be based on all enrolled patients who received at least one dose of study agent. 
Adverse events, including toxicities, will be analyzed calculating the number and percentage of patients 
with event. 


 
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10 
PUBLICATION POLICY  
 
 
The results of this study will be submitted for publication in peer reviewed journals and for 
presentation at appropriate scientific meetings. In terms of the main clinical output the study chairs 
(Emilio Iannitto, Catherine Thieblemont) will be alternating the first the second and the last author; the 
pathological outputs will be led by the relevant pathologists with the study chairs alternating between 
last and penultimate author. Other contributors will be included as authors according to their input into 
the study. No publication of any results will occur without the agreement of the study chairs. 
 
 
11 
ETHICAL ASPECTS 
 
 
11.1 
Investigator Responsibilities 
 
The investigator is responsible for ensuring that the clinical study is performed in accordance with the 
protocol, current ICH guidelines on Good Clinical Practice (GCP), and applicable regulatory 
requirements. 
GCP is an international ethical and scientific quality standard for designing, conducting, recording, and 
reporting studies that involve the participation of human subjects. Compliance with this standard 
provides public assurance that the rights, safety, and well being of study subjects are protected, 
consistent with the principles that originated in the Declaration of Helsinki (Appendix B), and that the 
clinical study data are credible. 
 
 
11.2 
Ethical and Administrative considerations 
 
The study will be submitted for approval to the relevant Ethical Committee in each country/institution. 
Copies of the approval letter kept on file at IELSG. Before entering patients into the study, clinicians 
must ensure that the protocol has received clearance from their Local Research Ethics Committee. The 
patient's consent to participate in the study should be obtained for all cases, after a written full 
explanation has been given of the treatment. PATIENT INFORMATION FORMS and INFORMED CONSENT 
FORMS must be prepared by the principal investigator in each country/institution following the 
requirements of the local Regulatory Authorities and ECs. The right of a patient to refuse to participate 
without giving reasons must be respected. After the patient has entered the part A of the study the 
clinician must remain free to give alternative treatment to that specified in the protocol at any stage if 
it is felt to be in the patient's best interests. The reason for giving such alternative treatment must be 
recorded and the patient should remain in the study for the purposes of follow-up and data analysis. 
Similarly, the patient must remain free to withdraw at any time from protocol treatment without giving 
reasons and without prejudicing further treatment. A clinical trial liability insurance which applies 
specifically to this study will be provided. 
 
 
11.3 
Independent Ethics Committee or Institutional Review Board (IEC/IRB) 
 
Before the start of the study, the investigator will provide the IEC/IRB with current and complete copies 
of the following documents: 
·
Final protocol and, if applicable, amendments 
·
Informed consent form (and any other written materials to be provided to the subjects) 


 
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33 
·
Investigator’s Brochure (or equivalent information) and amendments 
·
Information on compensation for study-related injuries or payment to subjects for participation in 
the study, if applicable 
·
Investigator’s curriculum vitae or equivalent information (unless not required, as documented by 
IEC/IRB) 
·
Information regarding funding, institutional affiliations, other potential conflicts of interest, and 
incentives for subjects 
·
Any other documents that the IEC/IRB requests to fulfill its obligation 
 
During the study the investigator will send the following documents to the IEC/IRB for their review and 
approval, where appropriate:  
·
Protocol amendments 
·
Revision(s) to informed consent form and any other written materials to be provided to subjects 
·
If applicable, new or revised subject recruiting materials approved by the sponsor 
·
Revisions to compensation for study-related injuries or payment to subjects for participation in the 
study, if applicable 
·
Investigator’s Brochure amendments or new edition(s) 
·
Summaries of the status of the study (at least annually or at intervals stipulated in guidelines of the 
IEC/IRB) 
·
Reports of adverse events that are serious, unlisted, and associated with the investigational drug 
·
New information that may affect adversely the safety of the subjects or the conduct of the study 
·
Deviations from or changes to the protocol to eliminate immediate hazards to the subjects 
·
Report of deaths of subjects under the investigator's care 
·
Notification if a new investigator is responsible for the study at the site. 
·
Any other requirements of the IEC/IRB 
 
For protocol amendments that increase subject risk, the amendment and applicable informed consent 
form revisions must be submitted promptly to the IEC/IRB for review and approval before 
implementation of the change(s). 
At least once a year, the IEC/IRB will be informed about the clinical ongoing of this clinical study. 
This request should be documented in writing. 
At the end of the study, the investigator (or sponsor where required) will notify the IEC/IRB about the 
study completion. 
 
 
11.4 
Informed Consent 
 
Each subject (or a legally acceptable representative) must give written consent according to local 
requirements after the nature of the study has been fully explained. The consent form must be signed 
before performance of any study-related activity. The consent form that is used must be approved by 
the reviewing IEC/IRB. The informed consent should be in accordance with principles that originated in 
the Declaration of Helsinki, current ICH and GCP guidelines, applicable regulatory requirements, and 
sponsor policy. 
Before entry into the study, the investigator or an authorized member of the investigational staff must 
explain to potential subjects or their legally acceptable representatives the aims, methods, reasonably 
anticipated benefits, and potential hazards of the study, and any discomfort it may entail. 
Subjects will be informed that their participation is voluntary and that they may withdraw consent to 
participate at any time. They will be informed that choosing not to participate will not affect the care 
the subject will receive for the treatment of his/her disease. Subjects will be told that alternative 
treatments are available if they refuse to take part and that such refusal will not prejudice future 
treatment. 


 
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34 
The subject or legally acceptable representative will be given sufficient time to read the informed 
consent form and the opportunity to ask questions. After this explanation and before entry to the 
study, consent should be appropriately recorded by means of either the subject's or his/her legally 
acceptable representative's dated signature. After having obtained the consent, a copy of the informed 
consent form must be given to the subject. 
If the subject or legally acceptable representative is unable to read or write, an impartial witness should 
be present for the entire informed consent process (which includes reading and explaining all written 
information) and personally date and sign the informed consent form after the oral consent of the 
subject or legally acceptable representative is obtained. 
 
 
11.5 
Privacy of Personal Data 
 
The collection and processing of personal data from subjects enrolled in this study will be limited to 
those data that are necessary to investigate the efficacy, safety, quality, and utility of the investigational 
product(s) used in this study. 
These data must be collected and processed with adequate precautions to ensure confidentiality and 
compliance with applicable data privacy protection laws and regulations. 
The investigator ensures that the personal data will be processed fairly and lawfully collected for 
specified, explicit, and legitimate purposes and not further processed in a way incompatible with these 
purposes adequate, relevant, and not excessive in relation to said purposes; accurate and, where 
necessary, kept current. 
Explicit consent for the processing of personal data will be obtained from the participating subject (or 
his/her legally acceptable representative) before collection of data. Such consent should also address 
the transfer of the data to other entities and to other countries. 
The subject has the right to request through the investigator access to his/her personal data and the 
right to request rectification of any data that are not correct or complete. Reasonable steps should be 
taken to respond to such a request, taking into consideration the nature of the request, the conditions 
of the study, and the applicable laws and regulations. 
 
 
11.6 
Data Quality Assurance 
 
Steps to be taken to ensure the accuracy and reliability of data include the selection of qualified 
investigators and appropriate study centers, review of protocol procedures with the investigator and 
associated personnel before the study. Written instructions will be provided for collection, preparation, 
and shipment of blood, plasma, and urine samples. CRF completion guidelines will be provided and 
reviewed with study personnel before the start of the study. Investigator will permit trial-related 
monitoring, providing direct access to source documents/data. 
 
 
11.7 
Record Retention 
 
The results of the study will be reported in a Clinical study Report generated by the investigator and will 
contain all data from all investigational sites. 
Data recorded on the CRFs (electronic record of data) on site www.filinf.it will be considered to be the 
source data for analyses. 
 
 
11.8 
On Site Audits 
Investigator/institution will permit trial-related audits, providing direct access to source 
documents/data. 


 
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35 
12 
STUDY ACKNOWLEDGEMENT 
 
 
PROTOCOL IELSG 36 (BRISMA) 
 
 
BENDAMUSTINE AND RITUXIMAB FOR THE TREATMENT OF SPLENIC MARGINAL ZONE LYMPHOMA: 
THE IELSG36 PHASE II PROSPECTIVE STUDY. 
 
As investigator for this study, I understand that this protocol contains information that is confidential 
and proprietary to IELSG. I have received and read the above mentioned protocol and agree that it 
contains all necessary details for carrying out the study as described; I will conduct this protocol as 
outlined therein. 
I will provide copies of this protocol and access to all information furnished by IELSG to study personnel 
under my supervision. I will discuss this material with them to ensure that they are fully informed about 
the investigational product and the study. I agree to keep accurate records on all patients information 
(CRFs and Patients’s informed consent statement) and all other information collected during the study 
for a minimum period of 10 years. 
I agree not to publish all or any part of the results of the study carried out under this protocol, without 
the prior written consent of IELSG. 
All parties agree to ensure direct access to examine, analyse, verify and reproduce source data / 
documents, and reports from all trial related sites for the purpose of monitoring and auditing, and 
inspection by domestic and foreign regulatory authorities. 
 
 
 
 
 
 
 
 
 
 
 
 
Investigator (printed name)  
 
Signature  
 
 
Date 
 
 
 
 
Prof. Dr. med. Franco Cavalli 
 
 
 
 
IELSG Representative 
 
 
Signature 
 
 
Date 


 
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36 
13 
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APPENDIX A - Guidelines for diagnosis review  
 
In order to assure the high quality and consistent pathology diagnosis, a centralized diagnosis review is 
included in this trial, to be performed during the Screening phase of the study, i.e. before therapy start. 
Paraffine embedded tissue block, bone marrow trephine biopsy, peripheral blood smears/bone marrow 
aspirate, flow-cytometry results on peripheral blood and marrow will be centrally reviewed separately 
for LYSA and FIL centers. 
For timeline of review processes refer to group specific guidelines detailed in Appendix M. 
 
Diagnosis will be established according to WHO classification for splenectomized cases1 and according 
to the Splenic Lymphoma Group recommendations for non splenectomized cases13, with full support of 
immunohistochemistry.  
 
Where indicated, chromosomal translocation will be investigated using appropriate molecular genetic 
and cytogenetic methods. In suspected cases of SMZL with CD5 positivity, at (11;14) must be eliminated 
by FISH. 
 
For each enrolled patient, the paraffin embedded tissue block should be sent to collecting centres (see 
contact addresses for the trial organization for LYSA and FIL centers) for processing; the block will be 
returned as soon as possible. If for local reasons, it is not possible to release the paraffin embedded 
tissue block, the following specimens should be submitted to collecting centres: one slide stained with 
H&E and 14 unstained sections (for immunohistochemistry and FISH), of each tumor bioptic sample 
(bone marrow, spleen, lymphonode). 
For each enrolled patient, peripheral blood smears/bone marrow aspirate should be sent to collecting 
centres (see contact addresses for the trial organization for LYSA and FIL centers). The slides will be 
returned as soon as possible.  


 
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40 
Summary Table 
Flow-cytometry local results 
on peripheral blood and 
bone marrow aspirate will be 
reviewed during the 
screening phase 
(percentages and 
histograms; provide 
caryotype when performed 
locally). 
LYSA 
FIL 
 
Spleen 
Bone 
Marrow 
Peripheral 
Blood 
Spleen 
Bone 
Marrow 
Peripheral 
Blood 
Histology 
LYSA-P 
LYSA-P 
 
Palermo 
Palermo 
 
Cytology 
 
Slides of BM 
aspirate sent 
for review to 
Hôpital Lyon 
Sud  or 
Hôpital Saint 
Louis - 
laboratoire 
hematologie 
Slides of 
blood 
smears sent 
for review to 
Hôpital Lyon 
Sud  or 
Hôpital Saint 
Louis - 
laboratoire 
hematologie 
 
Slides of BM 
aspirate sent 
for review to 
Palermo 
Slides of 
blood 
smears sent 
for review to 
Palermo 
Immuno-phenotype 
 
 
Local results 
sent for 
review to 
Lyon Sud  or 
Hôpital Saint 
Louis - 
laboratoire 
hematologie 
Palermo 
Palermo 
Local results 
sent for 
review to 
Palermo 
Cytogenetics 
 
 
Blood 
samples on 
paxgene sent 
to Lyon for 
DNA 
extraction 
further 
analysis of 
QMPFS and 
IGVH status 
(analysis 
post 
inclusion) 
 
Blood 
samples in 
EDTA sent to 
Genova for 
DNA 
extraction 
and further 
analysis 
(FISH and 
IGVH status; 
(analysis 
post 
inclusion) 
Blood 
samples in 
EDTA sent to 
Genova for 
DNA 
extraction 
and  further 
analysis 
(FISH and 
IGVH status; 
analysis post 
inclusion) 


 
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APPENDIX B - World Medical Association 
Declaration of Helsinki 
Ethical Principles for 
Medical research involving Human Subjects 
 
Adopted by the 18th WMA General Assembly, 
 Helsinki, Finland, June 1964, and amended by the: 
29th WMA General Assembly, Tokyo, Japan, October 1975 
35th WMA General Assembly, Venice, Italy, October 1983 
41st WMA General Assembly, Hong Kong, September 1989 
48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 
52nd WMA General Assembly, Edinburgh, Scotland, October 2000  
53rd WMA General Assembly, Washington 2002 (Note of Clarification on paragraph 29 added) 
55th WMA General Assembly, Tokyo 2004 (Note of Clarification on Paragraph 30 added) 
59th WMA General Assembly, Seoul, October 2008 
 
INTRODUCTION  
1.
The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of 
ethical principles for medical research involving human subjects, including research on identifiable 
human material and data.  
The Declaration is intended to be read as a whole and each of its constituent paragraphs should 
not be applied without consideration of all other relevant paragraphs.  
2.
Although the Declaration is addressed primarily to physicians, the WMA encourages other 
participants in medical research involving human subjects to adopt these principles.  
3.
It is the duty of the physician to promote and safeguard the health of patients, including those who 
are involved in medical research. The physician's knowledge and conscience are dedicated to the 
fulfilment of this duty.  
4.
The Declaration of Geneva of the WMA binds the physician with the words, "The health of my 
patient will be my first consideration," and the International Code of Medical Ethics declares that, 
"A physician shall act in the patient's best interest when providing medical care."  
5.
Medical progress is based on research that ultimately must include studies involving human 
subjects. Populations that are underrepresented in medical research should be provided 
appropriate access to participation in research.  
6.
In medical research involving human subjects, the well-being of the individual research subject 
must take precedence over all other interests.  
7.
The primary purpose of medical research involving human subjects is to understand the causes, 
development and effects of diseases and improve preventive, diagnostic and therapeutic 
interventions (methods, procedures and treatments). Even the best current interventions must be 
evaluated continually through research for their safety, effectiveness, efficiency, accessibility and 
quality.  
8.
In medical practice and in medical research, most interventions involve risks and burdens.  
9.
Medical research is subject to ethical standards that promote respect for all human subjects and 
protect their health and rights. Some research populations are particularly vulnerable and need 
special protection. These include those who cannot give or refuse consent for themselves and 
those who may be vulnerable to coercion or undue influence.  
10. Physicians should consider the ethical, legal and regulatory norms and standards for research 
involving human subjects in their own countries as well as applicable international norms and 
standards. No national or international ethical, legal or regulatory requirement should reduce or 
eliminate any of the protections for research subjects set forth in this Declaration. 
 


 
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BASIC PRINCIPLES FOR ALL MEDICAL RESEARCH  
11. It is the duty of physicians who participate in medical research to protect the life, health, dignity, 
integrity, right to self-determination, privacy, and confidentiality of personal information of 
research subjects.  
12. Medical research involving human subjects must conform to generally accepted scientific 
principles, be based on a thorough knowledge of the scientific literature, other relevant sources of 
information, and adequate laboratory and, as appropriate, animal experimentation. The welfare of 
animals used for research must be respected.  
13. Appropriate caution must be exercised in the conduct of medical research that may harm the 
environment.  
14. The design and performance of each research study involving human subjects must be clearly 
described in a research protocol. The protocol should contain a statement of the ethical 
considerations involved and should indicate how the principles in this Declaration have been 
addressed. The protocol should include information regarding funding, sponsors, institutional 
affiliations, other potential conflicts of interest, incentives for subjects and provisions for treating 
and/or compensating subjects who are harmed as a consequence of participation in the research 
study. The protocol should describe arrangements for post-study access by study subjects to 
interventions identified as beneficial in the study or access to other appropriate care or benefits.  
15. The research protocol must be submitted for consideration, comment, guidance and approval to a 
research ethics committee before the study begins. This committee must be independent of the 
researcher, the sponsor and any other undue influence. It must take into consideration the laws 
and regulations of the country or countries in which the research is to be performed as well as 
applicable international norms and standards but these must not be allowed to reduce or eliminate 
any of the protections for research subjects set forth in this Declaration. The committee must have 
the right to monitor ongoing studies. The researcher must provide monitoring information to the 
committee, especially information about any serious adverse events. No change to the protocol 
may be made without consideration and approval by the committee.  
16. Medical research involving human subjects must be conducted only by individuals with the 
appropriate scientific training and qualifications. Research on patients or healthy volunteers 
requires the supervision of a competent and appropriately qualified physician or other health care 
professional. The responsibility for the protection of research subjects must always rest with the 
physician or other health care professional and never the research subjects, even though they have 
given consent.  
17. Medical research involving a disadvantaged or vulnerable population or community is only justified 
if the research is responsive to the health needs and priorities of this population or community and 
if there is a reasonable likelihood that this population or community stands to benefit from the 
results of the research.  
18. Every medical research study involving human subjects must be preceded by careful assessment of 
predictable risks and burdens to the individuals and communities involved in the research in 
comparison with foreseeable benefits to them and to other individuals or communities affected by 
the condition under investigation.  
19. Every clinical trial must be registered in a publicly accessible database before recruitment of the 
first subject.  
20. Physicians may not participate in a research study involving human subjects unless they are 
confident that the risks involved have been adequately assessed and can be satisfactorily managed. 
Physicians must immediately stop a study when the risks are found to outweigh the potential 
benefits or when there is conclusive proof of positive and beneficial results.  
21. Medical research involving human subjects may only be conducted if the importance of the 
objective outweighs the inherent risks and burdens to the research subjects.  
22. Participation by competent individuals as subjects in medical research must be voluntary. Although 
it may be appropriate to consult family members or community leaders, no competent individual 
may be enrolled in a research study unless he or she freely agrees.  


 
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23. Every precaution must be taken to protect the privacy of research subjects and the confidentiality 
of their personal information and to minimize the impact of the study on their physical, mental and 
social integrity.  
24. In medical research involving competent human subjects, each potential subject must be 
adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, 
institutional affiliations of the researcher, the anticipated benefits and potential risks of the study 
and the discomfort it may entail, and any other relevant aspects of the study. The potential subject 
must be informed of the right to refuse to participate in the study or to withdraw consent to 
participate at any time without reprisal. Special attention should be given to the specific 
information needs of individual potential subjects as well as to the methods used to deliver the 
information. After ensuring that the potential subject has understood the information, the 
physician or another appropriately qualified individual must then seek the potential subject's 
freely-given informed consent, preferably in writing. If the consent cannot be expressed in writing, 
the non-written consent must be formally documented and witnessed.  
25. For medical research using identifiable human material or data, physicians must normally seek 
consent for the collection, analysis, storage and/or reuse. There may be situations where consent 
would be impossible or impractical to obtain for such research or would pose a threat to the 
validity of the research. In such situations the research may be done only after consideration and 
approval of a research ethics committee.  
26. When seeking informed consent for participation in a research study the physician should be 
particularly cautious if the potential subject is in a dependent relationship with the physician or 
may consent under duress. In such situations the informed consent should be sought by an 
appropriately qualified individual who is completely independent of this relationship.  
27. For a potential research subject who is incompetent, the physician must seek informed consent 
from the legally authorized representative. These individuals must not be included in a research 
study that has no likelihood of benefit for them unless it is intended to promote the health of the 
population represented by the potential subject, the research cannot instead be performed with 
competent persons, and the research entails only minimal risk and minimal burden.  
28. When a potential research subject who is deemed incompetent is able to give assent to decisions 
about participation in research, the physician must seek that assent in addition to the consent of 
the legally authorized representative. The potential subject's dissent should be respected.  
29. Research involving subjects who are physically or mentally incapable of giving consent, for 
example, unconscious patients, may be done only if the physical or mental condition that prevents 
giving informed consent is a necessary characteristic of the research population. In such 
circumstances the physician should seek informed consent from the legally authorized 
representative. If no such representative is available and if the research cannot be delayed, the 
study may proceed without informed consent provided that the specific reasons for involving 
subjects with a condition that renders them unable to give informed consent have been stated in 
the research protocol and the study has been approved by a research ethics committee. Consent to 
remain in the research should be obtained as soon as possible from the subject or a legally 
authorized representative.  
30. Authors, editors and publishers all have ethical obligations with regard to the publication of the 
results of research. Authors have a duty to make publicly available the results of their research on 
human subjects and are accountable for the completeness and accuracy of their reports. They 
should adhere to accepted guidelines for ethical reporting. Negative and inconclusive as well as 
positive results should be published or otherwise made publicly available. Sources of funding, 
institutional affiliations and conflicts of interest should be declared in the publication. Reports of 
research not in accordance with the principles of this Declaration should not be accepted for 
publication.  
 
 
 
 


 
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ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH MEDICAL CARE  
31. The physician may combine medical research with medical care only to the extent that the 
research is justified by its potential preventive, diagnostic or therapeutic value and if the physician 
has good reason to believe that participation in the research study will not adversely affect the 
health of the patients who serve as research subjects.  
32. The benefits, risks, burdens and effectiveness of a new intervention must be tested against those 
of the best current proven intervention, except in the following circumstances:  
33. The use of placebo, or no treatment, is acceptable in studies where no current proven intervention 
exists; or  
34. Where for compelling and scientifically sound methodological reasons the use of placebo is 
necessary to determine the efficacy or safety of an intervention and the patients who receive 
placebo or no treatment will not be subject to any risk of serious or irreversible harm. Extreme care 
must be taken to avoid abuse of this option.  
35. At the conclusion of the study, patients entered into the study are entitled to be informed about 
the outcome of the study and to share any benefits that result from it, for example, access to 
interventions identified as beneficial in the study or to other appropriate care or benefits.  
36. The physician must fully inform the patient which aspects of the care are related to the research. 
The refusal of a patient to participate in a study or the patient's decision to withdraw from the 
study must never interfere with the patient-physician relationship.  
37. In the treatment of a patient, where proven interventions do not exist or have been ineffective, 
the physician, after seeking expert advice, with informed consent from the patient or a legally 
authorized representative, may use an unproven intervention if in the physician's judgement it 
offers hope of saving life, re-establishing health or alleviating suffering. Where possible, this 
intervention should be made the object of research, designed to evaluate its safety and efficacy. In 
all cases, new information should be recorded and, where appropriate, made publicly available.  
 


 
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APPENDIX C - WHO performance status scale 
 
 
Grade 
Performance scale 
0 
Able to carry out all normal activity without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to 
carry out light work 
2 
Ambulatory and capable of all self-care but unable to carry out any 
work; up and about more than 50% of waking hours 
3 
Capable of only limited self-care; confined to bed or chair more than 
50% of waking hours 
4 
Completely disabled; cannot carry on any self-care; totally confined to 
bed or chair 
 
 
 
 
APPENDIX D - SMZL Diagnostic and Staging Work-Up 
(Source: Matutes et al., Splenic marginal zone lymphoma proposals for a revision of diagnostic, staging 
and therapeutic criteria. 
Leukemia, 22(3):487-495, 2008) 
 
 
Diagnostic and staging workup 
(1) 
Full Blood count (FBC) with differential counts, reticulocytes, Coomb’s 
test and autoimmune screen (ANA, anti-DNA, AMA, anti-thyroid, 
rheumatoid factor) 
(2) 
Renal and liver biochemistry including calcium levels and LDH 
(3) 
Serum and urine Igs and B-2 microglobulin 
(4) 
Serology for hepatitis C (if positive, reverse transcriptase-PCR for HCV 
RNA in the blood) and virus genotyping, when possible 
(5) 
HIV serology should be investigated, with the limitations due to specific 
countries policies 
(6) 
Review of blood morphology and flow cytometry (if circulating 
lymphoma cells) 
(7) 
BM aspirate with morphology and flow cytometry and trephine biopsy 
with immunohistochemistry (IHC). BM aspirate in the absence of 
trephine biopsy and immunohistochemistry may have a low diagnostic 
value. 
(8) 
Computerized tomography scan of the abdomen and chest 
 
 
 


 
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APPENDIX E 
Ann Arbor staging* - Cotswolds recommendations** 
(Sources: * Carbone PP, Kaplan HS, Musshoff K, et al. Report of the committee on Hodgkin's disease staging 
classification. Cancer. Res. 31:1860-1861, 1971. ** Lister TA, Crowther D, Sutcliffe SB, et al. Staging for Hodgkin's 
disease. Report of a committee convened todiscuss the evaluation and staging of patients with Hodgkin's disease: 
Cotswolds meeting. J. Clin. Oncol. 7:1630-1636,1989 [Erratum J. Clin. Oncol. 8:1602, 1990]) 
 
Stage I: involvement of a single lymphatic region (I), or localized involvement of a single extralymphatic 
organ or site (IE). 
Stage II: involvement of two or more lymphatic regions on the same side of diaphragm (II) or localized 
involvement of an extralymphatic organ or site and one or more lymph node regions the same side of 
diaphragm (IIE). 
Stage III: involvement of two or more lymphatic regions on both sides of diaphragm (III) which may also 
be accompanied either by localized involvement of an extralymphatic organ or site (IIIE), or by 
involvement of the spleen (IIIS). 
Stage IV: Diffuse or disseminated involvement of one or more extralymphatic organs or tissue, with or 
without associated lymph node involvement. 
Bone marrow or liver involvement will always be considered as stage IV. 
 
Lymphatic structures include lymph nodes, spleen, thymus, Waldeyer’s ring including tonsils. The 
lymphatic regions are defined according to Ann Arbor as (a) clinical enlargement of a node when 
alternative pathology may reasonably be ruled out (suspicious nodes should always be biopsied if 
treatment decisions are based on their involvement) ; and (b) enlargement on plain radiograph, CT 
scan, or lymphography. 
Localized involvement of an extralymphatic site (extranodal site or E-lesion) is diagnosed when the 
involvement is small enough to be in principle accessible for curative radiotherapy (thereby excluding 
diffuse organ involvement corresponding to stage IV). 
 
Criteria for “B” symptoms 
The presence of (a) unexplained weight loss of more than 10% of the body weight during the 6 months 
before initial staging investigation and/or (b) unexplained, persistent, or recurrent fever with 
temperatures above 38°C during the previous month and/or (c) recurrent drenching night sweats 
during the previous months is denoted by the suffix letter ‘B’. ‘A’ indicates the absence of these 
symptoms.  
 
Criteria for bulk disease 
The bulk of palpable lymph nodes will be defined by the largest dimension (cm) of the single largest 
Iymph node or conglomerate node mass in each region of involvement. A node or nodal mass must be 
10 cm or greater to be recorded as "bulky". 
A mediastinal mass will be defined as "bulky" on a postero-anterior chest radiograph, when the 
maximum width is equal or greater than one-third of the internal transverse diameter of the thorax at 
the T5-T6 level. The chest radiography should be taken with maximal inspiration in the upright position 
at a source-skin distance of 2 m. 
 
Spleen bulky is arbitrarily defined as spleen ≥6 cm below left costal margin. 


 
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APPENDIX F - Cumulative Illness Rating Scale (CIRS) 
(Source: Parmelee, P.A., et al., Validation of the Cumulative Illness Rating Scale in a geriatric residential 
population. J Am Geriatr Soc, 1995. 43(2): p. 130-7) 
 
Comorbidity indices 
CIRS 
Items 
1.
Cardiac (heart only)  
2.
Hypertension (rating is based on severity; affected systems are rated separately) 
3.
Vascular (blood, blood vessels and cells, marrow, spleen, lymphatics) 
4.
Respiratory (lungs, bronchi, trachea below the larynx) 
5.
EENT (eye, ear, nose, throat, larynx) 
6.
Upper gastrointestinal (esophagus, stomach, duodenum, biliary and pancreatic trees; do 
no include diabetes) 
7.
Lower gastrointestinal (intestines, hernias) 
8.
Hepatic (liver only) 
9.
Renal (kidneys only) 
10. Other genitourinary (ureters, bladder, urethra, prostate, genitals) 
11. Musculo-skeletal-integumentary (muscles, bone, skin) 
12. Neurological (brain, spinal cord, nerves; do not include dementia) 
13. Endocrine-Metabolic (includes diabetes, diffuse infections, infections, toxicity) 
14. Psychiatric/Behavioral (includes depression, anxiety, agitation, psychosis, not dementia) 
 
 
Weights 
All systems weighted from 0 to 4: 
0 = None 
no impairment to that organ/system 
1 = Mild 
 
Impairment does not interfere with normal activity; treatment may not be 
required; prognosis is excellent (examples: skin lesions, hernias, hemorrhoids) 
2 = Moderate 
Impairment interferes with normal activity; treatment is needed; prognosis is 
good (examples: gallstones, diabetes, fractures) 
3 = Severe 
Impairment is disabling; treatment is urgently needed; prognosis is guarded 
(examples: respectable carcinoma, pulmonary emphysema, congestive heart 
failure) 
4 = Extremely severe 
Impairment is life threatening; treatment is urgent or of no avail; prognosis is 
grave 
(examples: 
myocardial 
infarction, 
cerebrovascular 
accident, 
gastrointestinal bleeding, embolus) 
Final score 
Sum of weights assigned to each system 
 
 
APPENDIX G 
Fondazione Italiana Linfomi Onlus (FIL) SMZL score 
(Source: Arcaini et al., Splenic marginal zone lymphoma: a prognostic model for clinical use. Blood, 107:4643-
4649, 2006) 
 
Parameters 
Score 
 
a) Heamoglobin 
< 12 gr/dL 
b) LDH 
> ULN 
c) Albumin 
< 3.5 gr/dL 
 
Low Risk 
non adverse factor 
Intermediate Risk 
1 adverse factor 
High Risk 
2-3 adverse factors 


 
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APPENDIX H 
New York Heart Association Classification Of Cardiac Disease 
(Source: The Criteria Committee of the New York Heart Association, Inc. : Diseases of the heart and blood vessels; 
Nomenclature and criteria for diagnosis, 6th Ed. Boston: Little, Brown; 1964) 
 
The following table presents the NYHA classification of cardiac disease: 
Class Functional Capacity 
Objective 
Assessment 
I 
Patients with cardiac disease but without resulting limitations of 
physical activity. Ordinary physical activity does not cause undue fatigue 
palpitation, dyspnea, or anginal pain. 
No objective 
evidence of 
cardiovascular 
disease. 
II 
Patients with cardiac disease resulting in slight limitation of physical 
activity. They are comfortable at rest. Ordinary physical activity results 
in fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence 
of minimal 
cardiovascular 
disease. 
III 
Patients with cardiac disease resulting in marked limitation of physical 
activity. They are comfortable at rest. Less than ordinary activity causes 
fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence 
of moderately severe 
cardiovascular 
disease. 
IV 
Patients with cardiac disease resulting in inability to carry on any 
physical activity without discomfort. Symptoms of heart failure or the 
angina syndrome may be present even at rest. If any physical activity is 
undertaken, discomfort is increased. 
Objective evidence 
of severe 
cardiovascular 
disease. 
 
 
 
 
APPENDIX I - Creatinine Clearance Calculation  
(Source: Cockroft DW, Gault MH, Prediction of creatinine clearance from serum creatinine. Nephron 16, 31-41, 
1976) 
 
Creatinine clearance for men and women will be calculated according to the Cockcroft-Gault formula as 
follows: 
 
 
[(140−age)× weight (kg)] 
In men 
--------------------------------------------  
 
[72 × creatinine (mg/dL)] 
 
 
 
 [(140−age)× weight (kg)] 
In women 
-------------------------------------------- 
 
[72 × creatinine (mg/dL)] × 0.85 
 
 
Note 
Age (in years), weight (in kg), serum-creatinine (in mg/dL) 
72 (normalized to 72 kg body weight and a body surface of 1.72 m2) 


 
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APPENDIX J 
Common Terminology Criteria for Adverse Events 
 
In the present study, adverse events and/or adverse drug reactions will be recorded according to the: 
 
Common Terminology Criteria for Adverse Events (CTCA), version 4.0. 
 
At the time this protocol was issued, the full CTC document was available on the NCI web site, at the 
following address: http://ctep.cancer.gov/reporting/ctc.html.  
 
 
 
 
APPENDIX K - Suggested Body Surface Area Calculation 
(Source: Mosteller RD., Simplified calculation of body-surface area. N Engl J Med, 317:1098, 1987) 
 
 
BSA should be determinated using the appropriate following calculation: 
 
BSA = 
Ht(inches)xWt(lbs)
3131
 
 
 
OR 
 
 
BSA = 
Ht(cm)xWt(kg)
3600
 
 
 
 
 
 


 
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APPENDIX L 
Instruction for Preparation and Handling of Bendamustine 
 
Refer to the clinical trial protocol for details about the dose and dose schedule. 
Bendamustine should not be administered to patients with known hypersensitivity to 
bendamustine or mannitol.   
 
A licensed pharmacist or a properly trained designee will prepare all doses of bendamustine. It 
is very important that the exact dose is accurately dispensed and administered. If possible, the 
same person should prepare all doses (on all dosing days). Bendamustine will be administered 
only to eligible subjects under the supervision of the investigator or identified 
subinvestigator(s). 
 
Calculation of Dose 
The amount (in mg) of bendamustine to be administered will be determined based on body 
surface area (BSA). BSA will be calculated based on body weight and height using a standard 
calculation (Appendix K, Suggested Body Surface Area Calculation). The bendamustine dose 
will not be corrected for obese subjects. The dose should be calculated on Day 1 of each cycle 
and remain consistent during an individual cycle. The dose administered should remain 
consistent across cycles unless a notable change in weight (e.g., loss or gain of ı10%) is 
documented during the Day 1 weight assessment of the cycle, in which case the subject’s dose 
should be recalculated at that time. In the event of bendamustine-associated toxicity during 
the study, the dose may be decreased according to the dose reduction schedules provided in 
Section 4.6.1. 
 
Reconstruction and Dilution 
Reconstruction 
Reconstitute each vial containing 25 mg bendamustine hydrochloride in 10 ml water for 
injection by shaking; 
Reconstitute each vial containing 100 mg bendamustine hydrochloride in 40 ml water for 
injection by shaking. 
The reconstituted concentrate contains 2.5 mg bendamustine hydrochloride per ml and 
appears as a clear colourless solution 
Dilution 
As soon as a clear solution is obtained (usually after 5-10 minutes) dilute the total 
recommended dose immediately with 0.9% NaCl solution to produce a final volume of about 
500 ml. 
Bendamustine must be diluted with 0.9% NaCl solution and not with any other injectable 
solution. 


 
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Administration of bendamustine 
The final admixture is stable 3.5 hours when stored at room temperature (25°C) and room 
light. Administration of bendamustine must be completed within this period. 
The administration of bendamustine, reconstituted and diluted according to the above 
prescriptions will be accomplished by slow I.V. infusion in an out- or in-patient setting over 
approximately 30 to 60 minutes).  
 
CAUTION: DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS 
 
Discarding of Vials and Syringe 
After administration all materials that have been used for preparation should be disposed of 
according to standard practices. Any unused solution should be discarded according to institutional 
procedures for antineoplastics. 
All unused vials must be saved for reconciliation by the study monitor. A log must be kept of all 
disposed materials.  
 
Procedures to follow in case of body contact 
Inhalation: if inhaled, remove to fresh air. If breathing becomes difficult, call a physician. 
Skin: in case of skin contact, flush with copious amounts of water for at least 15 minutes. 
Remove contaminated clothing and shoes. 
Ingestion: if swallowed, wash out mouth with water provided person is conscious. Call a 
physician. 
Eyes: in case of contact with eyes, flush with copious amount of water for at least 15 minutes. 
Assure adequate flushing by separating eyelids 
Always contact the investigator after any form of body contact.  
 
 
 
 
 
 
 
 
 


 
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APPENDIX M 
Guidelines for Management of Biological Material 
 
The consent process allows for paraffin embedded blocks of tumour (bone marrow, spleen), peripheral 
blood smears, anticoagulated blood samples and anticoagulated bone marrow samples, serum 
(collectively defined in this protocol as study material) to be submitted for central histology review, 
cytogenetic analysis and immunoglobulin gene repertoire and mutation analysis.  
 
1. 
LYSA Centers 
 
SAMPLES FOR PATHOLOGY REVIEW OF SPLEEN/BONE MARROW 
The pathological diagnosis of SMZL should have been first performed locally and will be used for the 
inclusion.  
A central review of the diagnosis will be then organized by the LYSA-P Institute for each patient 
included in the trial. Diagnosis will be established according to WHO classification for splenectomized 
cases1 and according to the Splenic Lymphoma Group recommendations for non splenectomized 
cases13,  with full support of immunohistochemistry. At patient screening, the investigator will be 
requested to join with the form of inclusion a copy of the histopathological report where the name and 
address of the pathologist having diagnosed the lymphoma will be easily identified. However, in the 
case where no histopathological report is available, the name and address of the initial pathologist as 
well as the report number will have to be indicated on the inclusion form.  
The LYSA-P Institute will then organize and centralize the collection of the bone marrow biopsy and 
spleen (if available) material. At reception of the material, routinely stained sections will be performed 
and an appropriate panel of antibodies according to morphological aspects will be applied.  
Tissue microarray (TMA) will also be constructed. Three tissue cylinders representative of tumor regions 
with a diameter of 0.6 mm will be punched from the paraffin embedded tissue and transferred into a 
recipient paraffin block using a manual tissue arrayer (Beecher Instruments). Reactive lymphoid tissues 
will also be included in the TMA blocks, as a control and two twin TMA blocks will be prepared, 
according to the procedure used in the LYSA-P. 
The prepared stained slides will be reviewed by a panel of pathologist based on expert 
hematopathologists who will establish a consensus diagnosis. When the review process is achieved and 
the tissue array performed, a pathological report is sent to the initial pathologist as well as the 
investigator of the inclusion centre. The remaining material is sent back to the initial pathologist. 
The LYSA-P will make the commitment to respect the legal requirements for the collection, preparation 
and  storage of the samples. 
 
SAMPLES FOR CYTOLOGY REVIEW ON BLOOD AND BONE MARROW ASPIRATE 
At screening, peripheral blood smears (2 stained slides + 1 blank slide) and bone marrow aspirate (2 
stained slides + 1 blank slide) will be shipped with the completed traceability form in a pre-paid 
enveloped by regular mail. 
 
 
 
SAMPLES FOR MINIMAL RESIDUAL DISEASE (MRD) 
Flow-cytometry immunophenotype and IgVH gene rearrangement (antiCDR3) analyses (molecular B cell 
clonality assay ) will be performed on the peripheral blood and the bone marrow aspirate at baseline 
(screening phase),  at each restaging phases, at end of the treatment and at intervals (one a year) 
during follow up. 
For FACS analyses, 5 ml x 2 EDTA blood and 3 ml x 1 EDTA bone marrow will be required and will be 
sent by DHL to guarantee a delivery in 48h in centralized lab with a shipment form. 


 
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For IgVh gene rearrangement (antiCDR3) analyses, collection of blood samples and bone marrow for 
DNA preparation is required, with 10 ml x 1 on EDTA or on paxgene tube for blood at baseline 
(screening phase), at each restaging phases, at end of the treatment and at intervals during follow up. A 
special isolation tube (PAXgene tube) and labels will be provided by LYSARC. This PAXgene tube will be 
send on the day of collection by regular mail at room temperature.  
 
The results of MRD will be not incorporated into the response evaluation nor influence the 
management of the patient. 
 
 
SAMPLES FOR QMPFS  
A specific informed consent form will be used to allow the collection of blood samples for DNA 
preparation. It is highly recommended to collect blood samples (10 ml on EDTA or on paxgene tube) at 
diagnosis in all patients of each LYSA center.  
A special isolation tube (the same PAXgene tube used for IgVH at baseline) and labels will be provided 
by LYSARC. This PAXgene tube will be sent on the day of collection by regular mail at room 
temperature.  
 
 
Address of shipping  
Cytology review on blood and bone marrow aspirate 
Centre Hospitalier Lyon Sud 
Centre de Biologie et d’anatomie Pathologique Sud – Bât. 3D 
Laboratoire d’hématologie cellulaire - Pascale Felman  
F-69310 Pierre-Bénite 
 
Hôpital Saint Louis 
Laboratoire Central d’hématologie - Maria-Elena Noguera 
Nouveau Saint-Louis – Secteur Vert Porte 1 
Unité de cytologie immunologie – 1er étage 
1, avenue C. Vellefaux - F-75010 Paris 
 
DNA – MRD for molecular biology and QMPSF 
Centre Hospitalier Lyon Sud  
Laboratoire de biologie moléculaire et Hématologie 
Centre de Biologie Sud – Espace Jacques Monot – Etage 1 
Chemin du Grand Revoyet – F-69310 Pierre-Bénite 
% Please, complete the information sheet “BRISMA – Etude LYSARC – Envoi par la poste –– tube 
PAXgene"  and send this information sheet with PAXgene tube in Lyon Sud Hospital by post office.  
 
All the samples will be immediately coded if they are not yet, or identification will be controlled at 
reception (date of sampling and number of inclusion in the study).  
DNA will be extracted and provided to the concerned labs. 
 
Flow cytometry - MRD 
Maria-Elena Noguera 
Hopital Saint-Louis 
Laboratoire Central d’hématologie 
Nouveau Saint-Louis – Secteur Vert Porte 1 
Unité de cytologie immunologie – 1er etage 


 
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54 
1, avenue C. Vellefaux - F-75010 Paris 
 
% Please, complete the information sheet “BRISMA – Etude LYSARC – Envoi par courrier –– tube 
EDTA"  and send this information sheet with EDTA tube in Saint-Louis.  
 


 
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2. 
FIL Centers 
 
SAMPLES FOR PATHOLOGY REVIEW OF SPLEEN/BONE MARROW 
A central review of the diagnosis will be organized by the co-ordinator for each patient included in the 
trial, in order to confirm the diagnosis by using the 2008 WHO classification.  
The review of diagnosis will be performed up-front, during the screening phase, after patient’s 
registration in the trial and before treatment start. 
At patient screening, a copy of the histopathological report where the name and address of the 
pathologist having diagnosed the lymphoma will be easily identified. However, in the case where no 
histopathological report is available, the name and address of the initial pathologist as well as the 
report number will have to be indicated on the inclusion form.  
The centralized collection of the tumor material will be routinely stained sections and an appropriate 
panel of antibodies will be applied.  
The slides will be reviewed by a panel of pathologist who will establish a consensus diagnosis. When the 
review process is achieved, a pathological report is sent to the initial pathologist as well as the 
investigator of the inclusion centre. Once the study is completed, the stained sections and remaining 
material is sent back to the initial pathologist. 
 
SAMPLES FOR CYTOLOGY REVIEW ON BLOOD AND BONE MARROW ASPIRATE 
At screening, peripheral blood smears and bone marrow aspirate will be shipped with A SHIPMENT 
FORM provided to accompany the study material and a courier service (prepaid way-bill) will be 
activated to guarantee delivery of these within 48 hours.  
 
SAMPLES FOR IGVH  STATUS 
If the blocks are available, tissue sections will be used from paraffin block for IgVh status.  
 
Address of shipping  
Dott. Claudio TRIPODO 
ANATOMIA PATOLOGICA 
Policlinico 
Via del Vespro 129 
I-90127 Palermo 
 
 
 


 
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APPENDIX N 
Description of Minimal Residual Disease, and molecular, 
genetic and cytogenetic investigations 
 
1. 
LYSA Centers 
·
Minimal residual Disease (MRD) 
There are strong hints from recently published data that minimal residual disease (MRD) detection may 
play a role as a prognostic factor in patients with small B cell lymphomas such as mantle cell lymphoma. 
Nothing has been reported in Splenic Marginal Zone lymphoma. But this method could help to assess 
the status of complete response because evaluation of response in SMZL may not be easy even if 
criteria have been published (Matutes et al. 2008).  
Aim of MRD analysis within this study protocol is the monitoring of MRD by Flow cytometry and by 
quantitative Taq Man PCR (RQ-PCR) targeting clonal IgVH (antiCDR3) to evaluate the prognostic impact 
of MRD on progression free survival and long-term remission of patients with splenic marginal zone 
lymphoma.  
FACS analysis will be performed at baseline, after C4, after C6 and every year, to evaluate the B cell 
background during treatment with Rituximab. Therefore it is essential to send heparin blood/ bone 
marrow for FACS analysis together with EDTA blood/ bone marrow for FACS analysis at every time point 
of MRD investigation. 
The real time PCR method is sensitive enough to detect a lymphoma cell in the background of 104-105 
normal cells. PCR-analysis will be performed from peripheral blood (10 ml EDTA blood) and bone 
marrow (3-5 ml EDTA bone marrow aspirate). As a prerequisite for molecular assessment of MRD using 
RQ-PCR peripheral blood and bone marrow has to be sent before start of any treatment to determine 
the individual patient-specific DNA-sequence of the malignant clone. It will then realized at the 
timepoint than FACS analysis (C4, C6, and once a year). 
Flow-cytometry immunophenotype and IgVH gene rearrangement analyses  (molecular B cell clonality 
assay ) will be performed on the peripheral blood and the bone marrow aspirate at  baseline (screening 
phase),  at each restaging phases, at end of the treatment and at intervals during follow up. 
The results of MRD will be not incorporated into the response evaluation nor influence the 
management of the patient. 
 
Chromosomal abnormalities by QMPSF– C. Bastard 
Analysis of chromosomal copy number abnormalities will be performed from DNA extracted from blood 
collected at baseline: +3 ; del7 ; +12 ; +18 
In Centre Henri Becquerel - Laboratoire de Génétique Oncologique - rue d'Amiens - F-76038 Rouen - 
Telephone +33 2 32 08 25 77 
Immunoglobulin heavy-chain variable-region (IgVH ) gene mutation analysis – F. Davi 
Analysis of IgVH genes expressed by tumor cells will be undertaken for both mutational status and 
repertoire evaluation. Nucleotide sequence of IgVH genes will be performed according to standardized 
protocols (Ghia et al., Leukemia, 2007, 21:1). Briefly, clonal IgVH  rearrangements will be amplified 
from genomic DNA (0,5-2 micrograms) using 5’ primers corresponding to the framework 1 (or peptide 
leader) region and 3’ primers corresponding to the J genes. PCR products will be sequenced directly or 
after cloning if necessary. Sequence analysis including identification of the closest germline gene 
counterpart, distribution and characteristics of somatic mutations will be performed using dedicated 
bioinformatic tools (IMGT V-QUEST, IgBlast). 
In Hôpital Pitié Salpêtrière- Inserm U 543, Service d'hématologie biologique - 47-83, boulevard de 
l'Hôpital – F-75651 PARIS Cedex 13 
 
 


 
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2. 
FIL Centers 
 
Flow cytometry immunophenotype, Chromosomal abnormalities and Immunoglobulin 
heavy-chain variable-region (IgVH) gene mutation analysis – S. Ferrero/D. Drandi. 
Heparined or EDTA peripheral blood (20 ml) and heparined or EDTA bone marrow aspirate  (5-10 ml) 
will be sent by express shipment (24H delivery) to the Laboratory of hematology 1, U Prof. Boccadoro, 
Turin. 
 
Address of shipping 
 
Dott. Simone Ferrero/Dott.ssa Daniela Drandi 
AOU “Città della Salute e della Scienza” di Torino, presidio “Molinette” 
Laboratorio di ematologia 1 U Prof. Boccadoro 
Via Genova 3, P.T. padiglione giallo, 10126 Torino   
 
Flow-cytometry immunophenotype and IgVH gene rearrangement analyses (molecular B cell clonality 
assay) will be performed on the peripheral blood and the bone marrow aspirate at  baseline (screening 
phase), at each restaging phases, at end of the treatment and at intervals during follow up. Cytogenetic 
assessment and IgVH mutation analyses will be performed at baseline only. Table 6.8 of the protocol 
summarises the time schedule of the required investigations (row g,h). 
Samples 
Mononuclear cells (MNC) will be isolated from peripheral blood and /or bone marrow aspirate by ficoll 
hypaque density gradient centrifugation. MNC will be splitted in three aliquots to perform the following 
different analysis: flow cytometry, cytogenetic assessment, molecular analysis (B cell clonality assay and 
IgVH mutation analysis).  
 
Flow cytometry 
Immunophenotype analysis by flow cytometry will be performed on fresh MNC using the following 
monoclonal antibodies (moAb): CD3+, CD4+, CD8+, CD19+, CD20+, CD5+, CD10+, CD23+, CD11c+, 
FMC7+, CD103, CD25, SIg, SIgM, SIgG, SIgD, K, L). CD22+, CD43+, Cd103+, CD25+, CD123+. Four color 
stainings will be performed using moAb conjugated with four different fluorochromes and using 
FACSalibur cytometer (BD biosciences). The acquired data will be analyzed by Cell Quest software. 
Chromosomal abnormalities 
Analysis of chromosomal abnormalities will be performed from DNA extracted from MNC from 
periphera blood or bone marrow aspirates (only in the case of peripheral blood without neoplastic 
cells): +3 ; del7 ; +12 ; +18. 
Molecular analysis 
The detection of IgVH gene rearrangements (B cell clonality assay) will be performed by fluorochrome 
labeled PCR as described in the protocol BIOMED 2 PCR (Leukemia 2003 17: 2257-2317). The 
fluorochrome labeled PCR products will be analyzed by GeneScanning analysis using ABI prism 3100 
Avant Genetic Analyser. GeneScanning analysis of IgVH rearrangements have been developed for B cell 
clonality studies with a sensitive of clonal populations of >1%, (not for detection of subclones <1%). 
 
Immunoglobulin heavy-chain variable-region (IgVH) gene mutation analysis will be performed as 
described in Dono M et al. J Immunol. 2000 Jun 1;164(11):5596-604. Briefly, clonal IgVH 
rearrangements will be amplified from genomic DNA using 5’ primers corresponding to the VH leaders 
or VH framework 1 region and 3’ primers corresponding to the JH genes. PCR products will be 
sequenced directly by Sanger method using ABI prism 3100 Avant Genetic Analyser. Sequence analysis 
including identification of the closest germline gene counterpart, distribution and characteristics of 
somatic mutations will be performed using dedicated bioinformatic tools (IMGT V-QUEST, IgBlast). 
 
 


 
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APPENDIX O 
Guidelines for the use of granulocyte colony stimulating factor 
(source: Aapro MS, Bohlius J, Cameron DA, Dal Lago L, Donnelly JP, Kearney N, Lyman GH, Pettengell R, Tjan-Heijnen VC, Walewski J, Weber 
DC, Zielinski C: European Organisation for Research and Treatment of Cancer. 2010 update of EORTC guidelines for the use of granulocyte-
colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative 
disorders and solid tumours. Eur J Cancer. Jan;47(1):8-32 , 2011) 
Algorithm to decide the use of primary prophylaxis of FN (Febrile neutropenia) with G-CSF (Granulocyte 
Colony Stimulating Factor). Start prophylaxis with G-CSF in the first cycle 24-72 hours after the end of 
the first cycle of chemotherapy and continue for subsequent cycles (when appropriate re-evaluated in 
each cycle). Secondary prophylaxis: start G-CSF if there was an event linked to neutropenia in the 
previous cycle. 
        
 
 
 
Step 1 
Assess frequency of FN associated with planned chemotherapy regimen 
FN risk ≥ 20% 
FN risk 10-20% 
FN risk < 10% 
Step 2 
Assess factors that increase the frequency/risk of FN§ 
High risk 
 
Age > 65 years 
Increased risk  
Advanced disease 
(level I and II 
 
History of prior FN 
evidence) 
 
No antibiotic prophylaxis, no G-CSF use 
Other factors 
 
Poor performance and /or nutritional status 
(level III and 
 
Female gender 
IV evidence) 
 
Haemoglobin <12g/dL 
 
 
 
Liver, renal or cardiovascular disease 
Step 3
Define the patient’s overall FN risk for planned chemotherapy regimen 
Overall FN risk ≥20% 
Overall FN risk < 20% 
Prophylactic G-CSF 
recommended 
G-CSF use not 
indicated 
§ The risk of febrile neutropenia associated with rituximab therapy bendamustine is considered 10% 
(source: Knauf WU, Lissichkov T, Aldaoud A, Liberati A, Loscertales J, Herbrecht R,Juliusson G, Postner G, Gercheva L, 
Goranov S, Becker M, Fricke HJ, Huguet F, DelGiudice I, Klein P, Tremmel L, Merkle K, Montillo M: Phase III randomized 
study of bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukemia. J 
Clin Oncol. Sep 10;27(26):4378-84, 2009) 


 
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APPENDIX P 
Procedures for AE, SAE and SUSAR reporting
Patients will be instructed by the investigator to report the occurrence of any AE. The 
investigator assesses and records all AEs observed during the AE reporting period  (i.e. from 
inclusion until 30 days after end of treatment).
AEs are coded with the NCI Common Terminology Criteria for Adverse Events (CTCAE) v4.0 
(appendix J) and assigned a grade (from 1 = mild to 5 = death related to AE) as well as a 
relationship (suspected vs not suspected)  to trial treatment.
Any SAE must be reported within 24 hours (working days) by completing the “SAE Report form” 
and sending it by fax/email attachment to IELSG Study Coordination:
IELSG Study Coordination
Oncology Institute of Southern Switzerland
Ospedale San Giovanni
CH - 6500 Bellinzona
Phone 0041 91 811 9040
Fax
0041 91 811 9182
E-mail ielsg@ticino.com
SAE reporting period is from inclusion until 30 days after end of treatment.
The SAE outcome must be reported within 2 weeks after definitive assessment by completing 
the “SAE Report form” and sending it by fax/email attachment again to IELSG Coordinating 
Center.
The investigator according to local regulations will inform local authorities (ethic committees). 
The physician responsible for patient care should organize any supplementary investigation of 
serious adverse events based on the clinical judgement on the likely causing factors. These 
means include seeking a further opinion from a specialist in the field of the adverse event. If a 
patient dies, any post mortem finding including histopathology must be provided.
The sponsor (IELSG) shall be responsible for ensuring that any SAEs are appropriately 
reported to the relevant health authorities according to applicable laws and regulations in each 
country where the Study will be conducted and to perform any additional activities.
 
 
 
 
 
 


 
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APPENDIX Q 
 
FDG-PET reviewing
 
In the literature, many published reviews and the guidelines by the main onco-hematological scientific 
associations consider it is still controversial to role the 18F-FDG PET in the staging/restaging of the 
MALT lymphomas, recommending a standard radiological approach with contrast enhanced CT. 
However, recent clinical meta-analysis (Treglia G, Hematol Oncol 2015) and retrospective study 
(carrillo-Cruz E, Hematol Oncol) seems to indicate a potential clinical role of 18F-FDG PET or PET/CT in 
the initial evaluation of patients with SMZL. 
In particular, the meta-analysis study adds significant novelty in this setting, underlining that MALT 
lymphomas are 18F-FDG-avid tumours in most of the cases, in particular in those with primary head-
and-neck and bronchial locations.  
Moreover, the retrospective study suggest that PET/CT has a high sensitivity in newly diagnosed 
patients with MZL and therefore can be useful in the staging of patients with nodal and extranodal 
subtypes. The technique is more sensitive than a CT scan at initial staging, mainly in cases with 
extranodal involvement. Although a larger number of patients will be required to further confirm these 
data, the study can conclude that PET/CT is a valuable imaging tool for both staging and response 
assessment in patients with NMZL and MALT lymphoma. 
 
Also the analysis of clinical response conducted in IELSG36/BRISMA study has clearly demonstrated that 
the classic criteria based on physical examination and CT scan are far for being accurate. Particularly in 
patients showing a small splenomegaly as only sign of residual disease at the end of treatment it is very 
difficult differentiate complete responses from partial responses. 
 
Due to these considerations, a centralized PET scan evaluation will be performed; the anonymized PET 
scan images will be collected and preserved for the entire duration of the study at the LYSARC (Resp. 
Romain Ricci, Coordinator Imaging LYSARC, CHU Henri Mondor Créteil, Service de Médecine Nucléaire). 
The images will be evaluated by a group of expert nuclear medicine to analyze the clinical response of 
the patients (Dr. Salim Kanoun, Service de Medecine Nucleaire  IUCT-ONCOPoLE, Institut C. Regaud, 
Toulouse, France and Dr. Luc Fornecker, Service d'Oncologie et d'Hématologie, Hôpitaux Universitaires 
de Strasbourg, Strasbourg, France). 
The primary objective of this ancillary study was to evaluate the role of 18FDG/PET in SMZL at diagnosis 
for staging and as predictor of the treatment outcome including the response to treatment, the 
progression free survival and the time to next treatment.  


 
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The secondary objectives are the prognostic value of interim and post-R-benda PET and the prognostic 
value of the metabolic volume associated with biological markers.