Bendamustine and Rituximab for the Treatment of Splenic Marginal Zone Lymphoma

Bendamustine and Rituximab for the Treatment of Splenic Marginal Zone Lymphoma. The International Extranodal Lymphoma Study Group (IELSG) 36 Phase II Prospective Study

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.

Study Overview

• Status: Completed
• Conditions: Marginal Zone B-cell Lymphoma
• Intervention / Treatment: Drug: Bendamustine and Rituximab

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).

• Study Type: Interventional
• Enrollment (Actual): 78
• Phase: Phase 2

Contacts and Locations

Study Locations

• France
  • Creteil, France
    • Créteil (Hôpital Henri Mondor)
  • Dijon, France
    • Dijon (CHU de Dijon - Hôpital d'Enfants)
  • Grenoble, France
    • Grenoble cedex 9 (CHU Michallon)
  • Le Kremlin Bicetre, France
    • Le Kremlin Bicêtre (Hôpital Bicêtre)
  • Le Mans, France
    • Le Mans (C.H. Le Mans)
  • Lille, France
    • Lille cedex (CHRU Lille - Hôpital Claude Huriez)
  • Lyon Sud, France
    • Pierre Benite
  • Nancy, France
    • Vandoeuvre-les-Nancy cedex (CHU Brabois)
  • Nantes, France
    • Nantes cedex 01 (CHU de Nantes - Hôtel Dieu)
  • Paris, France
    • Paris cedex 10 (Hôpital Saint-Louis)
  • Pessac, France
    • Pessac cedex (Centre François Magendie)
  • Rouen, France
    • Rouen (Centre Henri Becquerel)
• Italy
  • Alessandria, Italy
    • Ospedale Civile Ss. Antonio E Biagio
  • Ancona, Italy
    • A.O. Universitaria Ospedali Riuniti - Ospedale Umberto I Di Ancona
  • Cagliari, Italy
    • Ospedale Armando Businco
  • Genova, Italy
    • A.O. Universitaria S. Martino Di Genova
  • Meldola, Italy
    • Irst - Istituto Scientifico Romagnolo Per Lo Studio E La Cura Dei Tumori - Sede Di Meldola (Fc)
  • Milano, Italy
    • Irccs Fondazione Centro S. Raffaele Del Monte Tabor
  • Modena, Italy
    • A.O. Universitaria Policlinico Di Modena
  • Palermo, Italy
    • A.O. "V. Cervello"
  • Palermo, Italy
    • A.O. Universitaria Policlinico Giaccone
  • Parma, Italy
    • A.O. Universitaria Di Parma
  • Piacenza, Italy
    • AUSL di Piacenza
  • Ravenna, Italy
    • Ospedale S. Maria Delle Croci Di Di Ravenna
  • Reggio Calabria, Italy
    • Ospedale Bianchi - Melacrino - Morelli
  • Reggio Emilia, Italy
    • Ospedale Di S. Maria Nuova-Irccs
  • Rionero, Italy
    • Irccs Centro Di Riferimento Oncologico Di Basilicata (Crob)
  • Roma, Italy
    • Irccs Istituto Dermatologico S. Gallicano (Ifo)
  • Terni, Italy
    • Azienda Ospedaliera "S. Maria"
  • Varese, Italy
    • Ospedale Di Circolo E Fondazione Macchi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Initial diagnosis of CD20+ Splenic Marginal Zone Lymphoma morphology confirmed by histology, cytology, immunophenotype (chromosomal abnormalities by quantitative multiplex Polymerase Chain Reaction (PCR) of short fluorescent fragments (QMPSF) is optional) according to World Health Organization (WHO) 2008 classification of Lymphoma criteria or according to the recommendation of the Splenic Lymphoma Group for non splenectomized patient.

  1. If patients not splenectomised: diagnosis on bone marrow biopsy (histology and immunohistochemistry), 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, immunophenotype) chromosomal abnormalities by QMPSF optional.
• No previous treatment with immunotherapy or chemotherapy or radiotherapy unless pretreatment by mono corticotherapy.

• Patients requiring a treatment with at least one of the following situation:

  1. Symptomatic SMZL in not splenectomized patients

     1. 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
     2. 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
     3. 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 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
• 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) ≥1.000/mm3 and Platelets ≥100.000/mm3, unless these abnormalities are related to bone marrow infiltration or to hypersplenism.
  2. Aspartate transaminase (AST) ≤2 x upper limit of normal (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)

Exclusion Criteria:

• 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 hepatitis B surface (HBS)+; in case of presence of antibody anti hepatitis B core antigen (HBC)+ and anti HBS+, controls should be organized according to guidelines of American Association for the Study of Liver Disease (AASLD) and European Association for the Study of the Liver (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) ≥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 Prostate Specific Antigen(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 month) 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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Bendamustine and Rituximab; 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)

Drug: Bendamustine and Rituximab

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
CT-scan of organomegaly (spleen-liver-lymph nodes)	up to 24 weeks

Collaborators and Investigators

• Sponsor: International Extranodal Lymphoma Study Group (IELSG)
• Investigators: Study Chair: Emilio Iannitto, MD, Presidio ospedaliero G. Moscati; UOC di Ematologia - Taranto

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2012
• Primary Completion (Actual): December 1, 2020
• Study Completion (Actual): December 1, 2020

Study Registration Dates

• First Submitted: July 26, 2016
• First Submitted That Met QC Criteria: July 28, 2016
• First Posted (Estimate): August 2, 2016

Study Record Updates

• Last Update Posted (Actual): June 7, 2021
• Last Update Submitted That Met QC Criteria: June 4, 2021
• Last Verified: June 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Immune System Diseases; Neoplasms by Histologic Type; Neoplasms; Lymphoproliferative Disorders; Lymphatic Diseases; Immunoproliferative Disorders; Lymphoma, Non-Hodgkin; Lymphoma, B-Cell; Lymphoma; Lymphoma, B-Cell, Marginal Zone; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Antirheumatic Agents; Antineoplastic Agents; Immunologic Factors; Antineoplastic Agents, Alkylating; Alkylating Agents; Antineoplastic Agents, Immunological; Bendamustine Hydrochloride; Rituximab
• Other Study ID Numbers: IELSG 36