Fludarabine, Mitoxantrone and Rituximab in Relapsed or Primary Failing Advanced Follicular Non-Hodgkin's Lymphoma

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT00169208
Recruitment Status : Completed
First Posted : September 15, 2005
Last Update Posted : December 13, 2005
Information provided by:
Lymphoma Study Association

Brief Summary:
This study is a multicentric trial evaluating the efficacy of the RFM regimen in patients aged 18 to 75 years with relapsed/refractory follicular NHL.

Condition or disease Intervention/treatment Phase
Follicular Lymphoma Drug: rituximab Drug: fludarabine Drug: mitoxantrone Phase 2

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Detailed Description:

Follicular non Hodgkin's lymphoma's (FL), as defined by the REAL Classification, are usually characterized by a slowly progressive clinical course, a transient control by standard chemotherapeutic regimen and a pattern of repeated relapses until ultimately progressive and fatal disease.

Standard first line treatment for advanced FL consists of alkylating-based (CVP) or anthracycline containing regimen in association to interferon alpha (CHVP+IFN) chemotherapy. Others approaches have been developed mostly as secondary therapy including purine analogs alone or in combination with alkylators or mitoxantrone, high dose therapy with autologous peripheral stem cell transplantation and, more recently, treatment with the unconjugated chimeric anti-CD20 antibody (rituximab) to target the CD20 antigen highly expressed on follicular lymphoma cells. None of these strategies does appear to give a definitive survival advantage. Thus, in patients with FL, the design of novel combination programs is a major challenge.

Combination of fludarabine and mitoxantrone in low grade, predominantly Follicular NHL: results of phase II studies in relapsed or refractory patients Fludarabine is expected to potentiate other agents through inhibition of DNA polymerase alpha and DNA ligase and its consequent interference with the DNA repair process. The addition of mitoxantrone increases the cytotoxic effect of fludarabine in vitro. McLaughlin et al developed a combination of fludarabine, mitoxantrone and dexamethasone (FND), which was very effective in 51 patients with recurrent low-grade lymphoma (including 65% FL), with an overall response rate of 94% (47% complete response (CR) rate. The median duration of response in this phase II study was 21 months for CR patients but only 9 months for partial responders (PR) patients. The median survival and failure-free survival times from the time of entry onto the FND study were 34 and 14 months, respectively. Most major responses were evident after two to four courses of chemotherapy. The need for continuation of therapy beyond attainment of remission is suggested by early relapses among patients who had early discontinuation of therapy. The predominant toxic effects were myelosuppression and infections: neutropenia < 500/µl in 20 % of courses, thrombopenia < 50000/µl in 8 % of courses and infections in 12 % of courses. Non-hematological toxicity was modest.

FND appears to be comparable to, and less toxic than the combination of etoposide, methylprednisolone, cytarabine, and cisplatin (ESHAP), one of the most effective regimens available for patients with relapsed indolent lymphoma. Others studies have confirmed the significant efficacy and moderate toxicity profile of this combination as salvage therapy in low grade, predominantly follicular lymphoma.

Moreover, the omission of corticosteroids reduces the risk of opportunistic infections, while the activity of the combination against indolent lymphoma is maintained.

Preliminary data from rituximab studies alone or in combination with chemotherapy in relapsed or refractory low grade LNH In vitro, rituximab mediates complement dependent cytotoxicity (CDC), antibody dependent cellular cytotoxicity (ADCC) and apoptosis. However, the mechanism of in vivo anti-lymphoma effect remains largely unknown. Rituximab received approval for recurrent follicular lymphoma based on response rates of about 50% including 6% complete responses and duration of responses, which compare favorably to that of all other single agents including fludarabine and 2-CdA (15-19). Median time to progression for responders is around 13 months. Toxicity of rituximab is low and easily manageable. An 8 doses schedule did not show to confer a significant advantage in term of response rate and duration of response over the four doses schedule.

Rituximab has been shown to sensitize drug-resistant lymphoma cell lines to killing by cytotoxic drugs including fludarabine.

Thus, we may hypothesize that the combination of rituximab, fludarabine and mitoxantrone might lead to synergistic / additive induction of apoptosis through different pathways in lymphoma B-cells which maintain an indolent growth pattern.

This approach may provide a means to achieve longer progression free survival in relapsed or refractory patients with FL.

We opted for a four induction cycles of rituximab, fludarabine and mitoxantrone since:

  1. Four cycles of a combination of fludarabine and mitoxantrone are generally sufficient to assess response,
  2. the 4 doses schedule of rituximab which has been the most studied is efficient 3) The omission of dexamethasone does not appear to impair ORR and DR of a combination of fludarabine and novantrone . Recycling will start on day 28.

Subsequently responding patients according the International criteria Working group will have 2 more cycle of a combination of fludarabine and mitoxantrone but no rituximab.

Study Type : Interventional  (Clinical Trial)
Enrollment : 50 participants
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: An Open Label, Multicenter, Non Randomized Phase II Study to Evaluate Anti-Tumor Activity and Safety of a Combination of Fludarabine, Mitoxantrone and Rituximab in Relapsed or Primary Failing Advanced Follicular Non-Hodgkin's Lymphoma.
Study Start Date : April 2001
Study Completion Date : December 2006

Primary Outcome Measures :
  1. Primary objective:
  2.  to evaluate progression free survival after a combination of rituximab, fludarabine and mitoxantrone (RFM) in patients with relapsed or primary failing advanced follicular non-Hodgkin's lymphoma.

Secondary Outcome Measures :
  1. Secondary objectives:
  2.  to evaluate response to treatment: overall response rate (ORR) and complete response (CR)
  3.  to evaluate overall survival (OS)
  4.  to evaluate the duration of response and compare it to those previously obtained
  5.  to evaluate the safety profile of RFM
  6.  to monitor minimal residual disease using the molecular biological marker bcl2 in peripheral blood and bone marrow (Real Time Quantitative, PCR assay)
  7.  to evaluate quality of life with QLQ C30 form (see appendix A)

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Ages Eligible for Study:   18 Years to 75 Years   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • 18 years < age < 75 years
  • Pathologically confirmed low grade, follicular, B cell lymphoma (WHO Classification Follicular grades 1 and 2
  • Failed at least first line chemotherapy with any standard anthracycline containing regimen (see appendix C for definition of treatment failure)
  • Frozen biopsy material obtained at relapse or disease progression should be available for central pathology review and molecular biology studies
  • The lymphoma must be CD20 positive (on the biopsy material obtained at relapse or disease progression)
  • At least one measurable lesion one nodal or extranodal lesion
  • WHO performance status grade 0 or 1
  • Bulky disease at study entry according to the GELF criteria: Nodal or extranodal single mass > 7cm in its greatest diameter; systemic B-symptoms; increased LDH and beta 2 microglobulinemia (> 3mg/L); involvement of at least 3 nodal sites, each with a diameter of greater than 3 cm; splenic enlargement with margin below the umbilical line or cranio caudal diameter of greater than 20 cm; compression syndrome (ureteral, orbital, gastrointestinal), or pleural or peritoneal serous effusion.
  • Patient information and written informed consent

Exclusion Criteria:

  • Evidence of histological transformation to diffuse large B-cell lymphoma
  • > 2 prior treatment regimen
  • Chemotherapy, or other experimental anticancer treatment during the 4 weeks before inclusion
  • Any radiation therapy to the index lesion(s) during the 4 weeks before inclusion
  • Autologous stem cell transplant during the 3 months before inclusion
  • Prior treatment including fludarabine and / or mitoxantrone and / or rituximab or contra-indication to one of these products
  • Unless exempted by the Responsible Investigator, as lymphoma related: serum creatinine >2 x Institutional Upper Limit of Normal (IULN), total bilirubin >2 x IULN or AST (SGOT) >2 x IULN, alkaline phosphatase >2 x IULN
  • Low bone marrow function: absolute neutrophil count < 1500/mm3 and platelet < 100 x 109/L at study entry (unless bone marrow infiltration)
  • Clinically significant cardiac disease, as defined by history of symptomatic ventricular arrhythmias, congestive heart failure or myocardial infarction within 12 months of study entry
  • Evidence of symptomatic CNS disease
  • Known positivity for HIV, HBs antigen or hepatitis C
  • Pregnant or lactating women. Women of childbearing potential, and all men, unwilling to take appropriate contraceptive measures during and for at least 6 months after cessation of therapy
  • Patients considered for an autologous or allogenic stem transplant at time of primary treatment failure or relapse according to the rules of the respective centers
  • Any uncontrolled serious non malignant condition or infection which would likely compromise the study objectives
  • Previous evolutive malignancy within 5 years of study entry, with the exception of non-melanoma skin tumors or stage 0 (in situ) cervical carcinoma
  • Major surgery within 4 weeks prior to enrollment, unless patient has recovered from all treatment related toxicity
  • Patient under tutelage.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00169208

Service de médecine D - Maladies du Sang CHU Angers
Angers, France, 49033
Service d'Hématologie Hôpital Jean Minjoz
Besançon, France, 25030
Hôpital Henri Mondor
Créteil, France, 94010
Hôpital A. Michallon BP 217X
Grenoble, France, 38043
Service Oncologie - Centre Victor Hugo
Le Mans, France, 72015
Service d'hématologie clinique - Centre Hospitalier du Dr Schaffner
Lens, France, 62307
Hôpital Claude Huriez - Sce des Maladies du Sang - Place Verdun
Lille, France, 59037
Centre Hospitalier Lyon-sud
Lyon, France, 69310
Centre régional de lutte contre le cancer Léon Bérard
Lyon, France, 69373
Service d'hématologie Institut Paoli Calmette
Marseille, France, 13273
Service d'hématologie - Hôpital Necker
Paris, France, 75015
Service d'Hématologie Hôpital St Louis
Paris, France, 75475
Service d'hématologie clinique - Hôpital de Pontchaillou
Rennes, France, 35033
Centre Henri Becquerel
Rouen, France, 76038
Service Oncologie CHU Bretonneau
Tours, France, 37044
Service d'hématologie Institut Gustave Roussy
Villejuif, France, 94805
Sponsors and Collaborators
Lymphoma Study Association
Principal Investigator: Franck Morschhauser, MD Lymphoma Study Association
Study Chair: Charles FOUSSARD, MD French Innovative Leukemia Organisation

Additional Information:
Publications of Results:
McLaughlin P, Grillo-Lopez AJ, Maloney DG, Link BK, Levy R, Czuczman MS, Cabanillas F, Dallaire BK, White CA: Efficacy controls and long-term follow-up of patients treated with rituximab for relapsed or refractory, low-grade or follicular NHL. Blood 92:414a, 1998

Other Publications: Identifier: NCT00169208     History of Changes
Other Study ID Numbers: RFM Follicular lymphoma study
First Posted: September 15, 2005    Key Record Dates
Last Update Posted: December 13, 2005
Last Verified: September 2005

Keywords provided by Lymphoma Study Association:
lymphoma, follicular

Additional relevant MeSH terms:
Lymphoma, Follicular
Lymphoma, Non-Hodgkin
Neoplasms by Histologic Type
Lymphoproliferative Disorders
Lymphatic Diseases
Immunoproliferative Disorders
Immune System Diseases
Fludarabine phosphate
Antineoplastic Agents
Immunologic Factors
Physiological Effects of Drugs
Antirheumatic Agents
Antimetabolites, Antineoplastic
Molecular Mechanisms of Pharmacological Action
Immunosuppressive Agents
Antiviral Agents
Anti-Infective Agents
Sensory System Agents
Peripheral Nervous System Agents
Topoisomerase II Inhibitors
Topoisomerase Inhibitors
Enzyme Inhibitors