NORDIC LYMPHOMA GROUP

www.nordic-lymphoma.org

2. NORDIC MANTLE CELL LYMPHOMA PHASE-II PROTOCOL:

Primary treatment with high-dose therapy and purged/unpurged autologous stem cell transplantation (ASCT), including Rituximab for induction and in-vivo purging.

WRITING COMMITTEE	NLG SUBCOMMITTEE ON MANTLE CELL LYMPHOMA: Christian H. Geisler, Denmark (chairman) Erkki Elonen, Finland Anna Johnson, Sweden Arne Kolstad, Norway
PROTOCOL SECRETARIAT & REGISTRATION	Dept. Haematology 4042 Finsen Center, Rigshospitalet DK 2100 Copenhagen, Denmark Att.: Christian Geisler Fax (45) 35 45 48 41 Email: geisler@rh.dk

Index: Page

Contact Persons……………………………. 2

Study Goals………………………………….. 3

Background………………………………….. 3

Study Objectives……………………………. 4

Trial Design………………………………….. 4

Diagnosis………………………………….. 4

Sample Size……………………………….. 4

Inclusion criteria……………………………. 5

Previous Treatment………………………… 5

Patient Registration…………………………. 5

Treatment……………………………………. 5

Tests to be done……………………………. 7

Report forms…………………………………. 8

Adverse events………………………………. 8

Response criteria……………………………. 8

Ethical aspects…………………………….… 9

Economy………………………………….. 9

Publication rules …………………………… 10

Study oveview……………………..……….. 11

Litterature……………………………………. 12

Appendix, contents of………………………. 13

Appendix (enclosed): Treatment flow charts, case report forms, guidelines and forms for pathology and molecular biology revisison.

TITLE	Primary treatment with high-dose therapy and purged/unpurged autologous stem cell transplantation (ASCT), including Rituximab for induction and in-vivo purging.
VERSION	May 2001
WRITING COMMITTEE	NLG SUBCOMMITTEE ON MANTLE CELL LYMPHOMA: Christian H. Geisler, Dept. Haematology 4042, Rigshospitalet, DK 2100 Copenhagen, Denmark Fax (45) 35 45 48 41 Email: geisler@rh.dk Erkki Elonen, Dept. Haematology, Helsinki University Central Hospital, FIN 00290 Helsinki Finland Fax: (358) 9 471 2351 Email: erkki.elonen@hu.fi Anna Johnson, Dept. Oncology, Academic Hospital, Uppsala, Sweden Fax (46) 18 611 55 28 Email: anna.johnson@onkologi.uas.se Arne Kolstad, Dept. Oncology, Tromsø University Hospital, Norway Fax: (47) 77 62 67 79 Email: kreftak@rito.no
CENTRAL PATHOLOGY REVIEW BOARD:	Denmark: Elisabeth Ralfkiær, Dept. of Pathology 5444, Rigshospitalet, University of Copenhagen 2100 Copenhagen, Denmark Fax: (45) 35456380 Email: e.ralfkiaer@rh.dk Finland: Kaarle Franssila, Dept. of Pathology, Helsinki University Central Hospital FIN 00290 Helsinki Finland Fax: (358) 9 471 5372 Email: kaarle.franssila@helsinki.fi Norway: Ruth Langholm, Dept. of Pathology, The Norwegian Radium Hospital, 0310 Oslo, Norway Fax: (47) 22 93 54 26 Email: ? Sweden: Christer Sundström, Dept. of Pathology/Cytology, Uppsala University Hospital, SE 75 185 Uppsala Sweden. Fax (46) 18 611 2665 Email:christer.sundstrom@clm.lul.se
MOLECULAR BIOLOGY	Niels Smedegaard Andersen, Rigshospitalet, Copenhagen: Telephone (45) 35 45 17 33 Telefax: (45) 35 45 48 41 Email: nanders@rh.dk
STUDY GOALS	To achieve: · Complete clinical remission pretransplant · PCR-negative stem-cell products · Molecular remission posttransplant
STUDY BACKGROUND	· Mantle cell lymphoma (MCL) is a B-cell neoplasia, clinically often with widespread disease including bone marrow infiltration and other extraonodal sites. Histomorpholocaly it is most often characterized by a diffuse lymph node infiltration of small cleaved cells. A characteristic cytogenetic aberration is detectable in most patients, the t(11;14) by which the cyclin D1 gene on chromosome 11 is brought under the control of the enhancer of the IgH gene on chromosome 14, leading to cyclin D1 protein overexpression. This may lead to an increased entry into cell cycle, but is not tumorigenic in itself (Weisenburger et al 1996). Cyclin D1-positive MCL patients have a much worse prognosis than the rare cyclin D1-negative putative MCL cases (Yatabe et al 2000), and cyclin D1 expression may be considered an important diagnostic criterion for MCL. Further cell cycle aberrations have been described in MCL patients, such as mutations involving p16 and p53, associated with worse prognosis and blastoid cytomorpho-logy (Lukas et al 1995, Dreyling et al 1997). · MCL is among the NHL entities with the poorest outlook, with a median survival of 2-3 years and a 5-year survival of 20% and hitherto no indication that this lymphoma entity is curable with any conventional treatment (Weisenburger et al 1996, NHL Classification Project 1997). In one study, treatment responders had a two-year event-free survival of less than 10% (Hiddemann et al 1998), although the responders with limited residual disease fared better. Primary high-dose therapy and autologous stem cell transplantation (ASCT) has shown promising results (Khouri et al 1998), and induction treatment using hyperCVAD (CHOP components + high-dose Cytarabine (HD-Ara-C) and Methotrexate (MTX)) appeared particularly promising. A European randomised study of primary treatment with CHOP-like therapy +/- ASCT is presently ongoing. The first Nordic MCL phase-II protocol, using maxi-CHOP for induction therapy, followed by high-dose therapy with BEAM or BEAC, showed 79% survival 3 years from the time of diagnosis (Geisler et al 2000). The 3-year failure-free survival, however, was lower (40%) due to 10 early treatment failures during induction therapy. In previously untreated patients, the toxicity of this treatment program does not exceed that of the conventional intensive therapy (Khouri et al 1998, Magni et al 2000, Geisler et al 2000). Thus, further intensification of the induction therapy is warranted and appears feasible. · Tumour-cell contamination of the stem-cell product is a prominent problem in MCL, and purging is more difficult in this disease than in other B-celll lymphomas (Andersen et al 1997). It has been shown (Jacquy et al 1999) that tumor cells are also mobilised to the blood during peripheral blood-stem-cell mobilisation, up to 1 log more than the No. of steady-state circulating tumor cells). This may explain the difficulty of effective purging in MCL. Thus, relapse after ASCT may be due to either contaminating tumor cells in the graft or resistant residual endogenous disease. · Mantle cell lymphoma cells express the CD20 antigen and the monoclonal anti-CD20 antibody Rituximab has docu-mented activity in MCL given as single drug as well as in combination with conventional chemotherapy, in both untreated and previously treated patients (Coiffier et al 1998, Foran et al 2000). Also as in-vivo purging, in combination with stem-cell mobilizing chemotherapy, Rituximab lead to a significant improvement of the purging efficacy (Magni et al 2000). · Clinical and molecular response to ASCT: In the 1. Nordic MCL study, 22 of 25 transplanted patients achieved a CR posttransplant. Of these, only 6 of 16 evaluated for molecular response were PCR-negative, leaving the majority of patients with persisting minimal residual disease (MRD), a state associated with a significant risk of clinical relapse (Andersen et al 1997). The effect of treatment with Rituximab on persisting or increasing MRD posttransplant is not known. Such treatment opens a new intervention possibility in patients with increasing PCR-signal in a quantitative PCR.
STUDY OBJECTIVES	The 2^nd Nordic Mantle Cell Lymphoma Protocol therefore plans to test: 1. the response following intensified induction chemotherapy with maxi-CHOP, Ara-C and Rituximab followed by BEAM/BEAC and autologous stem cell support. (Response definitions, see page 9) 2. The effect of in-vivo purging with Rituximab 375 mg/m^2 2 doses subsequent to mobilization with high-dose Ara-C. 3. The effect of further Rituximab treatment posttransplant in patients with an increasing PCR signal in a quantitative PCR
STUDY DESIGN SAMPLE SIZE No. OF CENTERS STUDY DURATION	Open multicenter phase-II study 50 evaluable patients 12 –15 (same as in the first Nordic MCL Protocol) 2001 – 2003
DIAGNOSIS	A histological diagnosis of mantle cell lymphoma as established by the local pathologist of each participating center Or: Small-cell malignancy with a CD5-positive CD23-negative B-cell phenotype, and a histological appearance compatible with mantle cell lymphoma. Subsequent central pathology revision, incl. cyclin-D1 staining, is mandatory.
INCLUSION CRITERIA	Patients fullfilling the diagnostic criteria, Ann Arbor stage II-IV, 18 – 65 years of age without: · Any organ dysfunction or failure that may present a risk to the patient during any phase of protocol treatment. · Chronic infections including HIV and hepatitis B · Pregnancy or lactation: At inclusion of women of child bearing age, adequate anticonception must be secured (P pills, depot injection gestagen or intra-uterine device). · Other malignancy except skin (non-melanoma) or cervix carcinoma stage 1.
PREVIOUS TREATMENT	As it is not seldom that treatment is begun on a differential diagnosis of small-cell lymphoma before the diagnosis of MCL is established, any newly diagnosed patient who has begun treatment outside protocol and has received not more than 2 cycles of any conventional dose of standard chemotherapy (e.g. CHOP, CVP) or not more than one month of continuous chlorambucil, may enter the protocol, if samples for molecular biology can still be obtained.
PATIENT REGISTRATION	· Patient Form 1 (appendix 1): Fill out and fax/mail it to the protocol secretariat, Fax (45) 35 45 48 41. Any queries concerning registration may be sent by fax or email (geisler@rh.dk) and will be answered on day by day basis. · Molecular studies at the time of diagnosis: Secure samples to be sent to the central protocol molecular laboratory in Copenhagen (Details and Molecular Form, appendix 1). Any queries concerning molecular studies may be sent by email (nanders@rh.dk) or faxed to (45) 35 45 48 41 and will be answered on day by day basis. · Central pathology revision: As soon as a patient is registered, initialize central pathology revision, by sending the Pathology Form (appendix 1) to your local pathologist.
TREATMENT (see also outline, p. 11 and Appendix including treatment flow sheets)	INDUCTION: 3 series of maxi-CHOP + Ara-C + 2 series of Rituximab. Maxi-CHOP: Cyclophosphamide 1200 mg/m^2D1 Doxorubicin 75 mg/ m^2D1 Vincristine 2 mg total D1 Prednisolone 100 mg total D1-5 The maxi CHOP should be given according to local routine. Forced diuresis and Mesna is optional. High-dose Ara-C: Patients 60 years of age or younger: Ara-C 3g/ m^2every 12 hours for 2 days as 1-hour infusions. Patients > 60 years: Ara-C 2g/ m^2every 12 hours for 2 days as 1-hour infusions. The Ara-C treatment incl. ultracortenol eyedrops should be given according to local routine The Interval between each series of maxi-CHOP and high-dose Ara-C is 3 weeks. Following each treatment it is recommended that, from day 8, the hematological values should be monitored regularly until the the WBC and platelets start to rise. Supportive treatment with platelet transfusions and with hemopoietic growth factor/ prophylactic antibiotics during the period of neutropenia and thrombocytopenia should be given according to local routine. Dose reductions of marrow-toxic drugs may be done according to local routine, or the the following guidelines may be used: If the leucocyte count is not at least 3 x 10^9/l or the platelet count not at least 150 x 10^9/l 21 days after the preceding course of chemotherapy, the dosages of CTX and doxorubicin or af Ara-C is reduced to 2/3 of initial dosage. If the leucocyte count is not at least 2 x 10^9/l or the platelet count not at least 100 x 10^9/l 21 days after the preceding course of chemotherapy, the dosages of CTX and doxorubicin or af Ara-C is reduced to 1/3 of initial dosage. If the leucocyte count is not at least 1,5 x 10^9/l or the platelet count not at least 75 x 10^9/l 21 days after the preceding course of chemotherapy, bone-marrow toxic therapy (CTX, doxorubicin, Ara-C is witheld until the count rise again. Rituximab: 375 mg/ m^2 given together with the 2^nd HD-Ara-C at day 1, 2 or 3 as wished, and with the 3^rd maxi-CHOP series at day 1. It is feasible to give maxi-CHOP + Rituximab in the outpatient setting. Rituximab will be given with standard infusion rates and following standard pretreatment with paracetamol and antihistamine treatment (see appendix 1, including treatment flow sheets) STEM CELL MOBILISATION: The 3^rd dose of HD-Ara-C is used as stem-cell mobilization. Followed from day + 5 by filgrastim 10 microg/kg s.c. once daily. IN-VIVO PURGING: Rituximab 375mg/ m^2 is given approximately at days +2 and +9 after the start of mobilising HD-Ara-C. Rituximab may be given on alternative days according to local routine. STEM CELL HARVEST: To be done according to local routine. An example of a mobilisation scheme is enclosed in the Appendix. IN-VITRO PURGING: Following stem-cell harvest, the fresh product may be subject to in-vitro purging according to local routine. Alternatively, the product may be frozen, while being assessed for tumor-cell contamination. If found contaminated, the product may be in-vitro purged upon thawing prior to reinfusion. CONSOLIDATION (optional): A 4^th course of maxi-CHOP + HD-Ara-C may be given following the stem-cell harvest, depending on local circumstances (queue in transplant unit etc). If a sufficient no. of stem cell is not reached after one mobilisation, the stem cell harvest may be repeated following this course of HD-ara-C. In that case, the Rituximab in-vivo purging should be repeated also. HIGH-DOSE THERAPY: BEAM OR BEAC*: BCNU 300 mg/m^2 (1-hour- i.v. infusion) Day 1 Etoposide 100 mg/m^2(1-hour-i.v. infusion) every 12 hours Day 2-5 Ara-C 400 mg/m^2 (24-hour i.v. infusion Day 2-5 Melphalan 140 mg/m^2(1-hour- i.v. infusion) Day 6. BEAC: As BEAM, with cyclophosphamide 6000mg/ m^2replacing melphalan according to local routine. *)Small variations of the BEAM and BEAC regimens do occur at various centres, including giving Ara-C as 1-hour infusions. The high-dose therapy should always be given according to local procedure. Filgrastim support posttransplant: Filgrastim 5 microg/kg s.c. once daily, starting day +5.. RITUXIMAB MAINTENANCE TREATMENT POSTTRANSPLANT: In patients in CR or stable VGPR, in whom 2 serial quantitative PCR assays show increasing minimal residual disease without clinical, radiological or morphological overt relapse or progression, 4 infusions of Rituximab 375 mg/ m^2may be given with one week’s interval, as an attempt to revert to a PCR negative state or at least to a decrease of the PCR signal in a quantitative assay.
TESTS TO BE DONE (SEE ALSO FLOW SHEET)	AT DIAGNOSIS: · Clinical examination, blood tests (hematology, biochemistry) · Biopsy of lymph node biopsy or other relevant material · Bone marrow aspiration and biopsy with material for - Morphology - Immunochemistry incl. cyclinD1 - Flow cytometry - Molecular biology incl. PCR for t(11;14) and cyclinD1 mRNA (in Copenhagen), as well as markers for later PCR assessment of MRD (see Appendix). · CT-scan of thorax and abdomen · Initiation of central pathology review AT RESPONSE EVALUATION: · Clinical examination, blood tests (hematology, biochemistry) · Bone marrow aspiration and biopsy with material for - Morphology - Immunochemistry incl. cyclinD1 - Flow cytometry · CT-scan of thorax and abdomen AT STEM CELL HARVEST: · Stem cells to Copenhagen for quantitative assessment of No. of tumor cells (see Appendix). POSTTRANSPLANT (6-8 WEEKS) · Clinical examination, blood tests (hematology, biochemistry) · Bone marrow aspiration and biopsy with material for - Morphology - Immunochemistry incl. cyclinD1 - Flow cytometry - Molecular biology incl. quantitative PCR for t(11;14) or CDR3 (in Copenhagen) (see Appendix). · CT-scan of thorax and abdomen CONTINUOUS CLINICAL FOLLOW-UP POSTTRANS-PLANT: EVERY 3 MONTHS FOR 3 YEARS: · Clinical examination, blood tests (hematology, biochemistry) EVERY 6 MONTHS UNTIL RELAPSE · Bone marrow aspiration and biopsy with material for - Morphology - Immunochemistry incl. cyclinD1 - Flow cytometry - Molecular biology incl. incl. quantitative PCR for t(11;14) or CDR3 (in Copenhagen) (see Appendix). · CT-scan of thorax and abdomen
REPORT FORMS	For the clinical data, 2 report forms are used: Case report form 1 covers the treatment of the first year, and case report form 2 covers the follow-up and Rituximab maintenance treatment, if given. For the molecular studies and for the initiation of the central pathology review, special forms are needed. All forms are found in appendix 1.
REPORTING ADVERSE EVENTS	If a serious adverse event occurs, the case report form must be faxed with 24 hours to the protocol secretariat (appendix ), including a letter describing the event.
RESPONSE CRITERIA	Response is defined as either CR (complete response) or PR (partial response). · CR: The disappearance of any clinically detectable sign of tumor by palpation or imaging with relevant diagnostic imaging (ultrasound, CT or MR or PET scans), a normal blood and bone marrow examination by conventional methods and no signs of B-cell monoclonality or excess of CD5+ B cells on flow cytometry. · Molecular remission is defined as a negative PCR by standard method with a sensitivity of 10^-4 to 10^-5 · PR: The reduction of detectable tumor to 50% or less of the tumor mass at the time of diagnosis. If the response is PR, not more than 20% lymphoma cells in the bone marrow may be present, as estimated by flow cytometric counting of lymphoma cells or by differential count of the bone marrow by the local pathologist. If estimated by flow cytometry, the local routine may be followed, analysing lysed or gradient separated cells. If gradient-separating or live-gating is used, a calculation of the proportion of tumour cells may be done using the propotion af mononuclear cells reported by the pathologist in the differential count of the bone marrow aspirate. · Very good PR means a tumor reduction of at least 75%. · No change/stable disease: The patient does not qualify for response as stated above. · Progressive disease: Increase in size of 25% or more of any lesion that can be observed clinically or by relevant diagnostic imaging. · Relapse: In CR occurrence of any new lesion, in PR increase in size of 25% or more of any known lesion any new pathological lesion observed clinically or by radioimaging. · Failure-free survival (FFS): Interval between registration and date of non-response, progression, relapse or death from any cause, whichever comes first. FFS will reflect all such events on an intent-treat basis. · Relapse-free survival: Interval between date of response and date of relapse or death from any cause, whichever comes first. · Post-transplant relapse-free survival: Interval between date of transplant and date of relapse or death from any cause, whichever comes first. · Survival time: Interval between registration and date of death from any cause. · Posttransplant survival time: Interval between date of transplant and date of death from any cause.
ETHICAL ASPECTS	The Declaration of Helsinki must be adhered to (version October 2000). Recent experience (Khouri et al 1998, and the first Nordic Mantle Cell Lymphoma Protocol) identifies high-dose therapy and stem cell transplantation as promising therapy in terms of prolonging survival, with acceptable toxicity. Furthermore, treatment with Rituximab in patients without very high tumor burden or lymphoma in leukemic phase with high cell counts, has rarely been associated with dangerous side effects. The patients treated with Rituximab will all have received initial chemotherapy, and are unlikely to be in a state of high tumor burden. Improvement of this treatment approach, however, is neces-sary to increase the proportion of patients who achieve com-plete remission pretransplant. Furthermore, a stem-cell pro-duct without detectable tumor cells may be a prerequisite for molecular remission posttransplant and for long-term survival.
ECONOMY	The costs of the study including Rituximab antibody for in vivo purging and maintenance treatment, will be covered by each participating centre, unless sponsor agreements can be achieved. An application for this has been submitted to Roche.
PUBLICATION RULES	Manuscripts based on this protocol will be made according to the "Vancouver System": Uniform Requirements for Manuscripts Submitted to Medical Journals (latest updated version 2000: www. Icmj.org). Authorship is based on important contributions to: · Idea, planning or modifying the protocol, collection, analysis or interpretation of data · Writing or critically revising the manuscript · Acceptance of the final manuscript. All three aspects must be covered. The chairman of the writing committee is the main responsible for accomplishing the goals of the protocol, and will also be responsible for writing the manuscript. In that case he will be 1st author. If important contributions from members of the study group warrant separate publications, the contributor in question will be first author on taht article. Members of the writing committee are expected to fulfil the above criteria and to be coauthors. Members of the Pathology Board, and molecular biologists who do important cross sectional work, will all be co-authors. As 50 patients may enter this study from 10-20 centers in the Nordic Area it cannot be guaranteed that all who contribute clinical-ly to the study, will be coauthors. All other contributors to the study will be listed in a special section of the article, including represen-tatives of all participating departments and blood banks: "Members and centres of the the Nordic Lymphoma Group". All manuscripts will be distributed to the contributors prior to submission for publication.