ZR2 Versus R2 Regimen in the Treatment of Newly Diagnosed Follicular Lymphoma

Zanubrutinib Combined With Rituximab and Lenalidomide (ZR2) Versus R2 Regimen in the Treatment of Newly Diagnosed Follicular Lymphoma: A Randomized, Multicenter, Open-Label Phase II Clinical Study

Primary Objective: To compare the complete response rate (CR rate) after induction treatment between the ZR2 regimen and the R2 regimen.

Secondary Objectives: To compare the objective response rate (ORR) after induction treatment, progression-free survival (PFS), progression of disease within 24 months (POD24) rate, duration of response (DOR), overall survival (OS), treatment-related adverse events (AEs), and patient quality of life between the two groups.

Exploratory Objectives: To compare the histological .transformation (HT) rate at disease progression, minimal residual disease (MRD) negativity rate, changes in tumor microenvironment (TME) biomarkers, and the relationship between genetic biomarkers and efficacy/prognosis between the two groups; to further reveal the unique pattern of systemic immune status remodeling by the ZR2 regimen and identify potential efficacy-predictive biomarkers.

Study Nature Interventional study Study Design Prospective, randomized controlled, exploratory, multicenter clinical study Sample Size 100 cases Principal Investigator Professor Zhou Keshu Sponsor The Affiliated Cancer Hospital of Zhengzhou University Treatment Regimens (4 weeks per cycle) ZR2 Group
- Induction Treatment (6 cycles): Zebutinib 160mg bid starting from C1D1; Rituximab 375mg/m² on Day 1; Lenalidomide 20mg qd on Days 1-21.
- Maintenance Treatment: Rituximab 375mg/m² on Day 1 (once every 8 weeks for 2 years); Lenalidomide ;ZR2 Group
- Induction Treatment (6 cycles): Zebutinib 160mg bid starting from C1D1; Rituximab 375mg/m² on Day 1; Lenalidomide 20mg qd on Days 1-21.
- Maintenance Treatment: Rituximab 375mg/m² on Day 1 (once every 8 weeks for 2 years); Lenalidomide 10mg qd on Days 1-21 (once every 4 weeks for 12 times).

R2 Group
- Induction Treatment (6 cycles): Rituximab 375mg/m² on Day 1; Lenalidomide 20mg qd on Days 1-21.
- Maintenance Treatment: Rituximab 375mg/m² on Day 1 (once every 8 weeks for 2 years); Lenalidomide 10mg qd on Days 1-21 (once every 4 weeks for 12 times).

Note: Patients who achieve PR during the first 6 cycles of induction treatment may receive an additional 3 to 6 cycles of lenalidomide 20mg until CR is achieved; thereafter, during maintenance treatment, lenalidomide 10mg PO qd is administered on Days 1-21 (once every 4 weeks for 12 times).

Study Endpoints:Primary Endpoint: CR rate after induction treatment (assessed by the 2014 Lugano Classification for Non-Hodgkin Lymphomas).

Secondary Endpoints: ORR after induction treatment; PFS; POD24 rate; OS; DOR; treatment-related AEs; patient quality of life.

Exploratory Endpoints: HT rate at disease progression; MRD negativity rate; changes in TME biomarkers; relationship between genetic biomarkers and efficacy/prognosis.

Follow-up Schedule:All patients will be followed up for 2 years after completing treatment, once every 3 months.

Study Overview

• Status: Not yet recruiting
• Conditions: Follicular Lymphomas
• Intervention / Treatment: Drug: Zanubrutinib+R2; Drug: R2

• Study Type: Interventional
• Enrollment (Estimated): 100
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Keshu Zhou Zhou; Phone Number: 13674902391; Email: drzhouks77@163.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

1. Voluntarily participate in the clinical study; fully understand and comprehend this study and sign the Informed Consent Form (ICF); willing to follow and capable of completing all study steps;
2. According to the 5th edition of the WHO classification of hematological and lymphoid tumors, diagnosed as CD20+ classic FL (grade 1-3a FL) by histology, and no previous anti-FL treatment has been received;
3. Age ≥ 18 years;
4. Judged by the investigator, the subject must urgently need to receive systemic treatment, based on meeting at least one GELF criterion;
5. At least one measurable lesion [longest diameter (LDi) ≥ 15mm, lymph node lesion LDi ≥ 10mm, evaluated according to the 2014 Lugano efficacy criteria];

6. The subject has at least one measurable target lesion:

   i. PET/CT scan shows positive PET lesion, or ii. CT scan or MRI shows > 1 measurable lymph node lesion (long axis > 1.5 cm) or > 1 measurable extranodal lesion (long axis > 1.0 cm);

7. ECOG performance status is 0-2;
8. Expected survival period > 3 months;
9. Adequate organ function and bone marrow function, without severe heart, lung, liver, kidney and immune deficiencies (no blood transfusion, granulocyte colony-stimulating factor or other medical support drugs within 7 days before starting this study): hemoglobin (HB) ≥ 60 g/L; absolute neutrophil count (ANC) ≥ 5×109/L; platelets (PLT) ≥ 50×109/L; aspartate aminotransferase (AST/SGOT) and alanine aminotransferase (ALT/SGPT) ≤ 5×ULN; total bilirubin (TBIL) ≤ 1.5×ULN; creatinine clearance rate (Ccr) ≥ 40 ml/min (estimated by Cockcroft-Gault formula); left ventricular ejection fraction (LVEF) ≥ lower limit of normal value.
10. Patients with reproductive potential must agree to use effective contraceptive measures (dual methods, such as condom + oral contraceptive), and avoid pregnancy or make their partners pregnant during the treatment period and within 12 months after the last administration.

Exclusion Criteria:

1. The subject has a history of systemic anti-leukemia treatment for FL (including any curative radiotherapy for the purpose of cure);
2. The subject has a history of aggressive B-cell lymphoma or has currently undergone histological transformation to DLBCL;
3. FL 3b;
4. The subject had suspected or confirmed primary CNS tumor at screening or had evidence of known CNS involvement;
5. The subject has a history of severe allergic reaction or immediate severe allergic reaction to any component or excipient of zanubrutinib, lenalidomide, or rituximab;
6. Has other tumors that affect the study medication or interfere with the results;
7. Received live vaccine within 28 days before treatment;
8. Has reproductive capacity and is unwilling to use effective contraceptive measures;
9. Pregnant or lactating women;
10. Known human immunodeficiency virus (HIV) infection, or any serological status indicating active hepatitis B or hepatitis C virus infection: 1) HBV DNA positive. Positive for hepatitis B surface antigen (HBsAg) or serologically positive for hepatitis B core antibody (HBcAb), if HBV DNA is undetectable and is willing to undergo monthly HBV reactivation monitoring, then can be enrolled. 2) HCV antibody positive. For patients with HCV antibody, if HCV RNA is undetectable, then can be enrolled;
11. Severe coagulation disorders and severe damage to organs such as heart, brain, lungs, liver, and kidneys;
12. Had a history of deep vein thrombosis (DVT) or pulmonary embolism (PE) within the past 12 months; has any life-threatening disease, medical condition, or organ system dysfunction that the subject considers may affect the safety of the subject or cause study risks.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: ZR2; 6 cycles (each cycle lasting 4 weeks): From cycle 1 to cycle 6 (daily), patients received 160 mg of Zanubrutinib twice daily by mouth; From cycle 1 to cycle 6 (on the first day), patients received 375 mg/m2 of Rituximab once every 4 weeks by intravenous injection; From cycle 1 to cycle 6, patients received 20 mg of Lenalidomide once daily by mouth from day 1 to day 21 (if the CrCl was less than 60 mL/min in the previous 2 cycles, the dose was reduced to 10 mg; if this dose was tolerated, it was increased to 20 mg in cycles 3 to 6); After 6 cycles, patients who achieved CR or PR continued to receive the following treatment in cycles 7 to 24: From cycle 7 to cycle 24, patients received 375 mg/m2 of Rituximab once every 8 weeks by intravenous injection (i.e., on the first day of every 2 cycles); From cycle 7 to cycle 18, patients received 10 mg of Lenalidomide once daily by mouth from day 1 to day 21.	Drug: Zanubrutinib+R2; 6 cycles (each cycle lasting 4 weeks): From cycle 1 to cycle 6 (daily), patients received 160 mg of Zanubrutinib twice daily by mouth; From cycle 1 to cycle 6 (on the first day), patients received 375 mg/m2 of Rituximab once every 4 weeks by intravenous injection; From cycle 1 to cycle 6, patients received 20 mg of Lenalidomide once daily by mouth from day 1 to day 21 (if the CrCl was less than 60 mL/min in the previous 2 cycles, the dose was reduced to 10 mg; if this dose was tolerated, it was increased to 20 mg in cycles 3 to 6); After 6 cycles, patients who achieved CR or PR continued to receive the following treatment in cycles 7 to 24: From cycle 7 to cycle 24, patients received 375 mg/m2 of Rituximab once every 8 weeks by intravenous injection (i.e., on the first day of every 2 cycles); From cycle 7 to cycle 18, patients received 10 mg of Lenalidomide once daily by mouth from day 1 to day 21.
Active Comparator: R2; R2, 6 cycles (each 4 weeks as one cycle): During the first 6 cycles (from the 1st day to the 6th week), receive rituximab 375 mg/m2 every 4 weeks by intravenous injection; from the 1st day to the 21st day of the 1st to 6th cycles, receive lenalidomide 20 mg once daily by oral administration (if the CrCl was less than 60 mL/min in the previous 2 cycles, reduce it to 10 mg; if this dose is tolerated, increase it to 20 mg in the 3rd to 6th cycles); After 6 cycles, patients who achieved CR or PR continue to receive the following administration: In the 7th to 24th cycles, receive rituximab 375 mg/m2 every 8 weeks by intravenous injection (i.e., administer every 1st day of every 2 cycles); From the 7th to the 18th cycle, from the 1st day to the 21st day, receive lenalidomide 10 mg once daily by oral administration. Note: Patients who achieved PR within the first 6 cycles can receive an additional 3 to a maximum of 6 cycles of lenalidomide 20 mg until achieving CR.	Drug: R2; R2, 6 cycles (each 4 weeks as one cycle): During the first 6 cycles (from the 1st day to the 6th week), receive rituximab 375 mg/m2 every 4 weeks by intravenous injection; from the 1st day to the 21st day of the 1st to 6th cycles, receive lenalidomide 20 mg once daily by oral administration (if the CrCl was less than 60 mL/min in the previous 2 cycles, reduce it to 10 mg; if this dose is tolerated, increase it to 20 mg in the 3rd to 6th cycles); After 6 cycles, patients who achieved CR or PR continue to receive the following administration: In the 7th to 24th cycles, receive rituximab 375 mg/m2 every 8 weeks by intravenous injection (i.e., administer every 1st day of every 2 cycles); From the 7th to the 18th cycle, from the 1st day to the 21st day, receive lenalidomide 10 mg once daily by oral administration. Note: Patients who achieved PR within the first 6 cycles can receive an additional 3 to a maximum of 6 cycles of lenalidomide 20 mg until achieving CR.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
CR rate	24weeks

Collaborators and Investigators

• Sponsor: KeshuZhou

Publications and helpful links

General Publications

• [1] Jacobsen E. Follicular lymphoma: 2023 update on diagnosis and management. Am J Hematol. 2022. 97(12): 1638-1651. [2] Ghione P, Palomba ML, Ghesquieres H, et al. Treatment patterns and outcomes in relapsed/refractory follicular lymphoma: results from the international SCHOLAR-5 study. Haematologica. 2023. 108(3): 822-832. [3] Casulo C, Byrtek M, Dawson KL, et al. Early Relapse of Follicular Lymphoma After Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone Defines Patients at High Risk for Death: An Analysis From the National LymphoCare Study. J Clin Oncol. 2015. 33(23): 2516-22. [4] Day JR, Larson MC, Durani U, et al. Treatment patterns and outcomes in follicular lymphoma with POD24: an analysis from the LEO Consortium. Blood Adv. 2025. 9(5): 1013-1023. [5] Sarkozy C, Trneny M, Xerri L, et al. Risk Factors and Outcomes for Patients With Follicular Lymphoma Who Had Histologic Transformation After Response to First-Line Immunochemotherapy in the PRIMA Trial. J Clin Oncol. 2016. 34(22): 2575-82. [6] Lu G, Middleton RE, Sun H, et al. The myeloma drug lenalidomide promotes the cereblon-dependent destruction of Ikaros proteins. Science. 2014. 343(6168): 305-9. [7] Ramsay AG, Clear AJ, Fatah R, Gribben JG. Multiple inhibitory ligands induce impaired T-cell immunologic synapse function in chronic lymphocytic leukemia that can be blocked with lenalidomide: establishing a reversible immune evasion mechanism in human cancer. Blood. 2012. 120(7): 1412-21. [8] Morschhauser F, Nastoupil L, Feugier P, et al. Six-Year Results From RELEVANCE: Lenalidomide Plus Rituximab (R(2)) Versus Rituximab-Chemotherapy Followed by Rituximab Maintenance in Untreated Advanced Follicular Lymphoma. J Clin Oncol. 2022. 40(28): 3239-3245. [9] Küppers R. Mechanisms of B-cell lymphoma pathogenesis. Nat Rev Cancer. 2005. 5(4): 251-62. [10] Cheng G, Ye ZS, Baltimore D. Binding of Bruton's tyrosine kinase to Fyn, Lyn, or Hck through a Src homology 3 domain-mediated interactio

Study record dates

Study Major Dates

• Study Start (Estimated): March 23, 2026
• Primary Completion (Estimated): March 23, 2030
• Study Completion (Estimated): March 23, 2030

Study Registration Dates

• First Submitted: March 24, 2026
• First Submitted That Met QC Criteria: March 29, 2026
• First Posted (Actual): April 1, 2026

Study Record Updates

• Last Update Posted (Actual): April 1, 2026
• Last Update Submitted That Met QC Criteria: March 29, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neoplasms; Immune System Diseases; Neoplasms by Histologic Type; Lymphatic Diseases; Lymphoproliferative Disorders; Immunoproliferative Disorders; Lymphoma, Non-Hodgkin; Lymphoma; Hemic and Lymphatic Diseases; Lymphoma, Follicular
• Other Study ID Numbers: 2025-776-003

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No