Zucca, et al DOI: /JCO

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1 The Addition of Rituximab to Chlorambucil Produces Superior Event-Free Survival in the Treatment of Patients with Extranodal Marginal Zone B-Cell Lymphoma: 5-Year Analysis of The IELSG-19 Randomized Study. Zucca, et al DOI: /JCO The information provided may not reflect the complete protocol or any previous amendments or modifications. As described in the Information for Contributors ( only specific elements of the most recent version of the protocol are requested by JCO. The protocol information is not intended to replace good clinical judgment in selecting appropriate therapy and in determining drug doses, schedules, and dose modifications. The treating physician or other health care provider is responsible for determining the best treatment for the patient. ASCO and JCO assume no responsibility for any injury or damage to persons or property arising out of the use of these protocol materials or due to any errors or omissions. Individuals seeking additional information about the protocol are encouraged to consult with the corresponding author directly.

2 MULTICENTER RANDOMIZED TRIAL OF CHLORAMBUCIL VERSUS CHLORAMBUCIL PLUS RITUXIMAB VERSUS RITUXIMAB ALONE IN EXTRANODAL MARGINAL ZONE B- CELL LYMPHOMA OF MUCOSA ASSOCIATED LYMPHOID TISSUE (MALT LYMPHOMA) Trial Chairpersons Statistician Study Coordination and Data Management Dr. Emanuele Zucca, Bellinzona (CH) Prof. Franco Cavalli, Bellinzona (CH) Dr. Emilio Montserrat, Barcelona (E) Dr. Catherine Thieblemont, Lyon (F) Dr. Giovanni Martinelli, Milan (I) Prof. Peter Johnson, Southampton (UK) Dr. Maurizio Martelli, Roma (I) Dr. Valter Torri Istituto di Ricerche Farmacologiche Mario Negri Milan (I) Cristina Morinini, Monica Trovesi IELSG Coordinating Centre Oncology Institute of Southern Switzerland Ospedale San Giovanni CH-6500 Bellinzona, Switzerland Phone: / 9060 Fax: [email protected] Activation date December 31, 2002 Version no January 13, 2009

3 TRIAL CHAIRPERSONS Dr. Emanuele Zucca Oncology Institute of Southern Switzerland, Ospedale San Giovanni CH-6500 Bellinzona, Switzerland Phone: / Fax: [email protected] Dr. Emilio Montserrat Clínic Hospital Universitari, Servicio de Hematologia Villarroel, 170 E Barcelona, Spain Phone: Fax: [email protected] Dr. Catherine Thieblemont Centre Hospitalier Lyon Sud, Service d Hématologie F Lyon Pierre Bénite Cedex, France Phone: Fax: [email protected] Dr. Giovanni Martinelli Istituto Europeo di Oncologia, Divisione di Ematoncologia Clinica Via Ripamonti 435 I Milan, Italy Phone: Fax: [email protected] Prof. Peter Johnson Southampton General Hospital, Cancer Research UK Oncology Unit Southampton SO16 6YD Phone: Fax: [email protected] Dr. Maurizio Martelli (IIL) Dip. Di Biotecnologie Cellulari ed Ematologia Università degli studi La Sapienza Via Benevento 6 I Roma Phone: Fax: [email protected] STATISTICIAN: Dr. Valter Torri Istituto di Ricerche Farmacologiche Mario Negri, Department of Oncology Via Eritrea 62 I Milan, Italy Phone: Fax: [email protected] IELSG 19 PROTOCOL version n page 2

4 TABLE OF CONTENTS 1 Background and introduction Objectives of the trial General objectives End points Primary endpoint (on which the sample size is calculated) Secondary endpoints Trial Design Patient selection criteria Inclusion criteria Exclusion criteria Randomization procedure Therapeutic regimens, drug supply, expected toxicity, dose modifications Treatment plan Drug supply Drug toxicity and dose reduction Expected toxicity Expected Adverse Events with Chlorambucil Expected Adverse Events with Rituximab Dose modifications Premature treatment withdrawal Unexpected adverse event Serious Adverse Event (SAE) Definition of adverse event Definition of serious adverse event Reporting of serious adverse events Clinical evaluation, laboratory tests and follow-up Before treatment start During treatment After the end of treatment (Follow-up) Summary table of timing of investigations during treatment Pathology review Criteria of evaluation Definition of measurable or evaluable lesion Criteria for response definition Assessment and definition of tumor response in gastric MALT lymphomas Analysis of toxicity Treatment failure Statistical considerations Statistical design and sample size Randomization and stratifications Analysis of outcome Definition of survival endpoints Interim Analysis Ethical considerations Administrative considerations Insurance Study acknowledgement References /. IELSG 19 PROTOCOL version n page 3

5 APPENDIX A Informed consent document APPENDIX B ECOG Performance Status Scale APPENDIX C Ann Arbor Staging System Lugano Staging System for Gastrointestinal (GI) Lymphomas APPENDIX D The International Prognostic Index (IPI) APPENDIX E Response criteria APPENDIX F Toxicity Criteria APPENDIX G Modalities of infusion of Rituximab APPENDIX H Participating centres...39 APPENDIX I Molecular biology ancillary study (optional)...40 ADDENDUM ADDENDUM ADDENDUM CASE RECORD FORMS (CRFs) WHEN TO SUBMIT FORMS REGISTRATION AND RANDOMIZATION FORM (2 parts) ON-STUDY FORM (3 parts) TREATMENT FORM (week 1-6 / week 9-22) RESTAGING FORM FOLLOW-UP FORM SERIOUS ADVERSE EVENT REPORT FORM SERIOUS ADVERSE EVENT FOLLOW-UP FORM WITHDRAWAL FORM IELSG 19 PROTOCOL version n page 4

6 1 BACKGROUND AND INTRODUCTION The group of MALT (mucosa-associated lymphoid tissue) non-hodgkin s lymphomas (NHLs) comprises a number of low-grade extranodal B-cell lymphomas that share similar clinical, pathologic, immunologic and molecular features. This condition has been widely accepted only in recent years and has been included in the REAL/WHO classification as a specific entity, the extranodal marginal-zone B-cell lymphoma of MALT-type (1,2). The most frequent localization is represented by the stomach, however MALT lymphomas can arise virtually in any extranodal site (3-5) and account for approximately 8% of all non-hodgkin s lymphoma (6). Despite abundant literature on histological, clinical and biologic features of MALT lymphoma, results of controlled trials to define the optimal therapy have not yet been published. There are few published studies specifically reporting treatment outcome for MALT lymphoma and also the more recent studies often refer to retrospective series of irradiation and chemotherapy, with no significant difference in outcome between patients who received different initial treatments (7). The overall survival rates range between 80% to 95% at 5 years, but the progression-free-survival is significantly shorter, especially for patients presenting with advanced stage or unfavorable international prognostic index (IPI) (3, 8). For localized gastric MALT lymphoma there is increasing evidence indicating that antibiotics can be effectively employed as the sole initial treatment: more than half of the treated patients achieve a histological regression of the gastric lymphoma following eradication of H. pylori (9-12). However, it is still unknown whether H. pylori eradication will definitely cure the lymphoma. It has been shown that PCR-detectable B-cell monoclonality may persist after the disappearance of histological evidence of MALT lymphoma, suggesting that H. pylori eradication suppresses but does not eradicate the lymphoma clone (3-5, 13-14). Moreover, no treatment guidelines exist for the management of patients with nongastric lymphoma, for those with gastric MALT lymphoma who fail antibiotic treatment or for the subset of gastric cases in which no evidence of H. pylori can be found. A choice can be made between conventional oncological modalities, including chemotherapy, radiotherapy and surgery, alone or in combination. Unfortunately, there are no published randomized studies to help the decision (3-4). For localized disease, local treatment (either radiotherapy or surgery) will usually achieve excellent disease control (8, 15-18). However, at least a quarter of patients has disseminated disease at presentation, usually with involvement of multiple mucosal sites (3, 19). Chemotherapy has never been adequately evaluated in MALT lymphomas either because it was not administered or given after surgery or radiotherapy. Some scanty data suggesting the efficacy of chlorambucil in low grade gastric lymphoma can be found in the older literature (20). A French non-randomized trial has tested the activity of chemotherapy with single alkylating agents in MALT lymphomas (21). In this study, 24 patients, 17 with stage I and 7 with stage IV disease were given continous oral administration of cyclophosphamide, 100 mg/day, or chlorambucil, 6 mg/day (median treatment duration: 18 months; range: 8-24 months). A 75% complete remission (CR) rate was reported. Five patients relapsed, all in initial sites, one of them with large-cell transformation. The projected 5-year event-free and overall survivals were 50% and 75%, respectively (21). IELSG 19 PROTOCOL version n page 5

7 Therefore analogous with follicular lymphomas and other nodal low-grade lymphomas (22), chemotherapy with single alkylating agents can be considered as standard approach in the MALT lymphoma patients who do not respond to local therapy (23) and in those with disseminated disease. However, in non-malt indolent lymphomas, combination chemotherapy, including the recently developed regimens based on fludarabine, is often advocated, at least in the cases with more advanced disease (22), whilst in MALT lymphoma, optimal therapy remains to be determined and the poor progression-free-survival in advanced stage patients suggests the need to develop new systemic treatment strategies for this disease (3, 8, 23) Rituximab is a chimerical monoclonal antibody directed against the B-cell lineagespecific antigen CD20 which is expressed on 80% of non-hodgkin s lymphoma. Its activity relies on different mechanisms of action. The antibody has demonstrated efficacy against CD20-positive follicular lymphoma, using a well tolerated and brief (weekly, for four cycles) schedule. There is no a defined maximum tolerated dose and additional research is being done on different doses and schedules of Rituximab. Furthermore there is increasing evidence that maintainance treatment may be of benefit (25-27). A preliminary result from a phase II trial of the International Extranodal Lymphoma Study Group indicates that the anti-cd20 antibody Rituximab may also have a significant clinical activity in relapsing or H. pylori-negative gastric MALT lymphoma, as well as in non-gastric MALT lymphomas (28). There is a powerful rationale for combining Rituximab treatment with chemotherapeutic agents that have also shown efficacy in NHL, since the mechanisms of action are distinct and there is also evidence that Rituximab may sensitize chemoresistant tumor cells to the actions of cytotoxic drugs. Indeed, several trials combining Rituximab with combination chemotherapy (most often the CHOP regimen) have suggested an efficacy advantage in both indolent and aggressive B- cell NHLs, with no significant additional toxicity (29-33). More recently, Martinelli et al. showed that the association of Rituximab and Chlorambucil is feasible, safe and very active treatment modality for low grade lymphomas (mainly of follicular type) either as first line therapy or at relapse (34). In this study, the treatment plan consisted of oral Chlorambucil 6 mg/m 2 /d on days 1-42, followed from day 56, by administration for 14 consecutive days, every 28 days, for four cycles. Rituximab 375 mg/m 2 was given iv on day 1, 8, 15, 22 during the first month (four weekly doses) and then on day 1 of each of the following cycles (four additional doses on days 56, 84, 112, 140). It is very likely that this combination will also be effective in MALT lymphoma. This will be the first randomized trial evaluating whether the addition of Rituximab to Chlorambucil will improve the outcome in extranodal MALT lymphomas. IELSG 19 PROTOCOL version n page 6

8 2 OBJECTIVES OF THE TRIAL 2.1 General objectives Aim of the study is to assess the therapeutic activity and safety of the combination of Chlorambucil and Rituximab in MALT lymphomas and to determine whether the addition of Rituximab to Chlorambucil will improve the outcome of MALT lymphoma in comparison to treatment with Chlorambucil alone. In April 2006, a third arm of treatment was added to compare the antitumor activity and safety of rituximab alone vs chlorambucil alone. 2.2 End-points Since the very indolent natural history of marginal zone lymphoma, it is very unlikely that any difference in overall survival will be large enough to be detected in a study with a realistic size and expected accrual. For this reason the endpoints will be (see also Section 9): Primary endpoint (on which the sample size is calculated) Event-free-survival (EFS) (failure or death from any cause) for all patients Secondary endpoints Complete and partial remission rates for all patients Response duration (time to relapse or progression) for responder patients Progression-free-survival (PFS) (disease progression or death from lymphoma: for all patients. Overall survival for all patients Acute and long-term toxicity IELSG 19 PROTOCOL version n page 7

9 3 TRIAL DESIGN This is a multicenter randomized phase III trial. DIAGNOSIS OF CD20+ MALT lymphoma ELIGIBILITY CRITERIA any extranodal site de novo or relapsed any stage measurable or evaluable disease REGISTRATION & STRATIFICATION RANDOMIZATION 1 : 1 : 6 ARM A Chlorambucil 6 mg/m 2 daily p.o for 42 consecutive days (weeks 1-6) ARM B Chlorambucil 6 mg/m 2 daily p.o for 42 consecutive days (weeks 1-6) + Rituximab 375 mg/m 2 iv on days 1, 8, 15, 22 during the first month (4 weekly doses) ARM C Rituximab 375 mg/m 2 iv on days 1, 8, 15, 22 during the first month (4 weekly doses) RESTAGING (week 7-8) NON-RESPONDER PATIENTS progressive disease (PD) RESPONDER PATIENTS complete remission (CR) complete remission undetermined (CRu) partial remission (PR) stable disease (SD) OFF TRIAL ARM A Chlorambucil 6 mg/m 2 daily p.o for 14 consecutive days every 28 days for 4 cycles (weeks 9-10, 13-14, 17-18, 21-22) ARM B Chlorambucil 6 mg/m 2 daily p.o for 14 consecutive days every 28 days for 4 cycles (weeks 9-10, 13-14, 17-18, 21-22) + Rituximab 375 mg/m 2 iv on day 1 of each of the following Chlorambucil cycles (4 doses on days 56, 84, 112 and 140) ARM C Rituximab 375 mg/m 2 iv every 28 days (4 doses on days 56, 84, 112 and 140) IELSG 19 PROTOCOL version n page 8

10 4 PATIENT SELECTION CRITERIA 4.1 Inclusion criteria To be eligible for inclusion in this trial, patients must fulfill all the following criteria: 1. histologically proven diagnosis of CD20-positive marginal zone B-cell lymphoma of MALT type arisen at any extranodal site 2. any stage (Ann Arbor I-IV) (see Appendix C) 3. either de novo, or relapsed disease following local therapy (including surgery, radiotherapy and antibiotics for H. pylori-positive gastric lymphoma)* 4. no evidence of histologic transformation to a high grade lymphoma 5. measurable or evaluable disease 6. age > life expectancy of at least 1 year 8. ECOG performance status 0-2 (see Appendix B) 9. no prior diagnosis of neoplasm within 5 years, except cervical intraepithelial neoplasia type 1 (CIN1) or localized non-melanomatous skin cancer 10. no prior chemotherapy 11. no prior immunotherapy with any anti-cd20 monoclonal antibody 12. no prior radiotherapy in the last 6 weeks 13. no corticosteroids during the last 28 days, unless prednisone chronically administered at a dose <20 mg/day for indications other than lymphoma or lymphoma-related symptoms 14. no evidence of clinically significant cardiac disease, as defined by history of symptomatic ventricular arrhytmias, congestive heart failure or myocardial infarction within 12 months before study entry 15. no evidence of symptomatic central nervous system (CNS) disease 16. no impairment of bone marrow function (WBC >3.0x10 9 /L, ANC >1.5x10 9 /L, PLT >100x10 9 /L), unless due to lymphoma involvement 17. no major impairment of renal function (serum creatinine <1,5x upper normal) or liver function (ASAT/ALAT <2,5 upper normal, total bilirubin <2,5x upper normal), unless due to lymphoma involvement 18. no evidence of active opportunistic infections 19. no known HIV infection 20. no active HBV and/or HCV infection 21. no pregnant or lactating status 22. appropriate contraceptive method in women of childbearing potential or men 23. absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial 24. informed consent must be given according to national/local regulations before randomization (see Appendix A) 4.2 Exclusion criteria None * See ADDENDUM 1 page 37 IELSG 19 PROTOCOL version n page 9

11 5 RANDOMIZATION PROCEDURE Patients will be centrally randomized at the IELSG Coordination and Data Management Office. A filled registration/randomization form (see CRFs) should be submitted by fax (or e- mail) on working days to: IELSG Study Coordination and Data Management Office: Fax: [email protected] Patients fulfilling the eligibility criteria will then be randomized and a notification of the allocation arm will be sent back within 48 hours to the investigator. Treatment should start within 15 days from randomization. Arm A: Chlorambucil alone Arm B: Rituximab plus Chlorambucil Arm C: Rituximab alone For all the three arms, after the first 6 weeks, a restaging procedure, including all previous positive disease parameters, will be repeated. Responder patients and those with stable disease (see Section 9) will continue on trial while non-responders (PD) will go off trial. IELSG 19 PROTOCOL version n page 10

12 6 THERAPEUTIC REGIMENS, EXPECTED TOXICITY, DOSE MODIFICATIONS 6.1 Treatment plan Arm A Chlorambucil 6 mg/m 2 daily p.o for 42 consecutive days (weeks 1-6). After restaging, responder patients (CR, CRu, PR) and those with stable disease will receive Chlorambucil 6 mg/m 2 daily p.o for 14 consecutive days every 28 days for 4 cycles (weeks 9-10, 13-14, 17-18, 21-22) Week Chlorambucil 6 mg/m 2 /day Y Y Y Y Y Y Y Y Y Y Y Y Y Y Arm B Chlorambucil 6 mg/m 2 given as in arm A. Rituximab 375 mg/ m 2 iv on day 1, 8, 15, 22 during the first month (4 weekly doses). After restaging, on day 1 of each of the following Chlorambucil cycles (4 doses on days 56, 84, 112 and 140). Rituximab is administered according to the manifacturer s instructions (see Appendix G). It is mandatory to administer the first Rituximab infusion during a short hospitalization. Do not administer Rituximab as an intravenous push or bolus. Week Chlorambucil 6 mg/m 2 /day Rituximab 375 mg/m 2 on days 1, 8, 15, 22, 56, 84, 112, 140 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Arm C Rituximab 375 mg/ m 2 iv on day 1, 8, 15, 22 during the first month (4 weekly doses). After restaging, 4 doses every 28 days (on days 56, 84, 112 and 140). Rituximab is administered according to the manifacturer s instructions (see Appendix G). It is recommended to administer the first Rituximab infusion during a short hospitalization. Do not administer Rituximab as an intravenous push or bolus. Week Rituximab 375 mg/m 2 on days 1, 8, 15, 22, 56, 84, 112, 140 Y Y Y Y Y Y Y Y IELSG 19 PROTOCOL version n page 11

13 For all the three arms, after the first 6 weeks, a restaging procedure, including all previous positive disease parameters, will be repeated. Responder patients and those with stable disease (see Section 9) will continue on trial while patients with disease progression will go off study. 6.2 Drug supply Chlorambucil is considered standard treatment, it is commercially available worldwide and will be provided by each participating institute. Rituximab (Mabthera ) will be supplied by Roche International Ltd. Roche International will prepare Rituximab vials labeled as IELSG19-Study Drug and will send them to the local/national Roche representatives, who will provide the investigators with the drug. IELSG 19 PROTOCOL version n page 12

14 7 DRUG TOXICITY AND DOSE REDUCTION 7.1 Expected toxicity Expected Adverse Events with Chlorambucil The main side effect of Chlorambucil is myelosuppression, usually reversible; gastrointestinal toxicity is observed rarely with nausea, diarrhoea and stomatitis. Lung fibrosis (generally reversible), liver toxicity with jaundice and irreversible pancytopenias have been reported usually in association with drug overdose. Skin reactions (rash) have been reported, too. Rare cases of secondary myeloid leukemia have been reported in patients treated with continuous long-term administration of the compound Expected Adverse Events with Rituximab (see also Appendix G) The main side effects of the drug could be the following. Likely Fever > 38.5 C Rigors, which can be severe Hypotension Bone and joint pain Rare Allergic reactions, evolving in rare cases to anaphylactic shock Bronchospasm Tumor lysis syndrome with acute renal failure, particularly in patients with a WBC> 50 x 109/L Acute cardiac failure, particularly in patients with a previous history of cardiac disease Cytokine release syndrome with dyspnea In case of mild symptoms (for example fever below 38.5 C or rigors, not life threatening edemas, absolute blood pressure fall up to 30 mm Hg) the Rituximab infusion should be stopped and the patient should be monitored until the symptom has clearly improved or disappeared. The infusion may then be continued but at half of the previous rate. In case of more important side effects like bronchospasm or anaphylactic shock, the treatment should be stopped and more active measures should be undertaken such as administration of alpha-adrenergic drugs, additional antihistamine and any other medically indicated support measures. Premedication with oral/iv paracetamol and/or antihistaminics should be given according to the manifacturer s instructions and to the single institution IELSG 19 PROTOCOL version n page 13

15 experience. Avoid as far as possible, the administration of corticosteroids: their effect is anyway delayed and could interfere with the evaluation of response. 7.2 Dose modifications Chlorambucil: If any hematological toxicity of grade 3-4 occurs during the initial 6-week cycle of Chlorambucil or during the successive 2-week cycle, then the following cycle will be given with a 33% reduction of the dose (i.e. at 4 mg/m 2 /d). If tolerated, subsequent dose increase (up to the prescribed dose) is reccommanded. The administration of Chlorambucil should be delayed (1 week) in case of non complete recovery from hematological toxicity of the previous course (i.e. WBC <3.0 G/l, ANC <1.0 G/l, PLT<100 G/l). Rituximab: No dose reduction is allowed for Rituximab in Arm B and C. In Arm B, if Chlorambucil has to be delayed (see above) then also Rituximab will be delayed to keep its admninistration on day 1 of each Chlorambucil cycle. 7.3 Premature treatment withdrawal Patients will go off study in case of disease progression while on treatment, in case of unacceptable toxicity (serious adverse event). In any of these cases the patient will be considered as having had treatment failure from the moment of the withdrawal. In the case of patient s choice to withdraw, it will be censored but not regarded as an event (i.e. not treatment failure). Subsequent therapies for patients in progression or in relapse are at the discretion of the treating physician. As a general guideline, patients should be considered as "off protocol therapy" if: All treatments prescribed by the protocol are discontinued One of the components of the protocol therapy is stopped, and modifications not prescribed by the protocol are also brought to any of the other components (dose increase, schedule modifications) An anticancer agent (or treatment modality) is added to the protocol therapy 7.4 Unexpected adverse event One of the main aims of this trial is to assess the safety and tolerability of the programmed administration schedule. It is the investigator s responsibility to record and report all adverse events observed during and after treatment. IELSG 19 PROTOCOL version n page 14

16 8 SERIOUS ADVERSE EVENTS (SAE) 8.1 Definition of adverse event Patients will be instructed by the investigator to report the occurrence of any adverse event. An adverse event is any undesirable event occurring during the trial, whether or not considered drug related, and includes any side effect, injury, toxicity, or sensitivity reactions. It also includes any undesirable clinical or laboratory change, which does not commonly occur in the patient. An adverse event may occur under therapy and follow-up. 8.2 Definition of serious adverse event A serious adverse event includes any event that is: Fatal: includes all deaths up to 30 days after cessation of treatment. Deaths occurring later are only to be considered as SAE if they are not related to the tumor. Life-threatening: means that the patient was at immediate risk of death from the event as it occurred. It does not include an event that, had it occurred in a more serious form, might have caused death. Disabling: includes persistent or relevant disability or incapacity occurring during or after treatment. Requires inpatient hospitalization: defined as hospital admission required for treatment of the adverse event. Hospital admission for scheduled elective surgery would not be a serious adverse event. Prolonged hospitalization: due to a serious disease not necessarily related to the tumor is also considered as SAE. Cancer: any new malignancy other than a relapse of the current tumor. Congenital anomaly Important medical events: are those which may not be immediately lifethreatening, but are clearly of major clinical significance. They may jeopardize the subject, and may not require intervention to prevent one of the other serious outcomes. Grade 4 toxicity except for: hematological toxicity, alopecia and mucositis 8.3 Reporting of serious adverse events Any SAE must be reported within 24 hours (working days) by completing the SAE Report form (see CRFs) and sending it by fax to IELSG Study Coordinating Center ( ) and to the local Roche representative. The SAE outcome must be reported within 2 weeks after definitive assessment by completing the SAE Follow-up form (see CRFs) and sending it by fax to IELSG Coordinating Center ( ). The investigator according to local regulations will inform local authorities (ethics committees) IELSG 19 PROTOCOL version n page 15

17 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. 9 CLINICAL EVALUATION, LABORATORY TESTS AND FOLLOW-UP Baseline evaluations are to be conducted within 1 week prior to the administration of a study agent. Scans and X-rays must be done within 4 weeks prior to the start of therapy. In the event that the patient s condition begins to deteriorate, laboratory evaluations should be repeated within 48 hours prior to the initiation of the next therapy cycle. 9.1 Before treatment start History and complete physical examination with measurement of all palpable disease. Bone marrow aspirate and biopsy Complete blood count (CBC) with differential white count Serum creatinine, glucose, Na, K, ASAT, ALAT, alkaline phosphatase, gamma GT, total bilirubin, uric acid, LDH, beta2-microglobulin, and serum protein electrophoresis. HBV and HCV, serology. Should HBV or HCV serology result positive, determine HBV-DNA or HCV-RNA, respectively. Imaging studies within 1 month prior to start therapy, including: Chest X-ray, CT scan of chest, abdomen and pelvis. CT of the head and neck district when required. Endoscopic and/or echoendoscopic examination when required (e.g., stomach, intestine or lung localizations) with multiple random biopsies. Electrocardiogram (ECG) 9.2 During treatment Full blood count with differential white count, creatinine, uric acid, gamma GT, ASAT and ALAT on weeks 3, 5, 7, 9, 13, 17, 21, 25. Repeat imaging studies of all disease parameters and determination of LDH, beta2-microglobulin, serum protein electrophoresis (if abnormal before treatment) during weeks 7-8 and at the end of treatment. Repeat endoscopic examinations and biopsy (if disease parameters) during weeks 7-8 and at the end of treatment. IELSG 19 PROTOCOL version n page 16

18 9.3 After the end of treatment (Follow-up) The follow-up controls should be assessed every 4 months for 2 years, then every 6 months for 3 years and then annually for at least 5 years and should include: Complete physical examination. Full blood count with differential white count, serum creatinine, ASAT, ALAT, alkaline phosphatase, LDH, beta2-microglobulin, and serum protein electrophoresis. Chest X-ray, abdomen ultrasound Repeat additional imaging and/or endoscopic studies required to evaluate all initial disease parameters Repeat bone marrow aspirate and biopsy if involved at diagnosis. 9.4 Summary table of timing of investigations during treatment Week PE X X X X X X CBC X X X X X X X X X X X X X X X X Biochemistry X X 1 X 1 X 1 X 1 X 1 X 1 X 1 X HIV, HBV, HCV X Bone marrow X X X Chest X-ray X X X CT scan X X X Other Imaging Examination X X X Endoscopy X X X ECG X PE: Physical examination with measurement of all palpable disease. CBC: complete blood count with differential white count. Biochemistry: serum glucose, creatinine, Na, K, uric acid, ASAT, ALAT, alkaline phosphatase, gamma-gt, total bilirubin, LDH, beta2-microglobulin, serum protein electrophoresis. (X 1 ) : repeat only creatinine, uric acid, ASAT, ALAT, gamma-gt. Standard HIV, HBV, HCV serology. Bone marrow examination: including bone marrow biopsy and aspirate with immunophenotypic analysis. To be repeated after week 6 and week 24 of therapy if involved at diagnosis. CT scan: including scan of the chest, abdomen and pelvis. Head and neck scan when required. To be repeated after week 6 and week 24 of therapy if disease parameter. Other imaging examinations: echography, RMN, PET, scintigraphic imaging, when required for special clinical conditions. To be repeated after week 6 and week 24 of therapy if disease parameter. Endoscopy: endoscopy or echoendoscopy examination when required, with multiple random biopsies. To be repeated after week 6 and week 24 of therapy if disease parameter. IELSG 19 PROTOCOL version n page 17

19 10 PATHOLOGY REVIEW The local pathologist of each center participating in this trial has to be informed by the local investigator about the trial protocol, particularly about data and sample processing. A IELSG panel of expert pathologists will review all cases. After examination by the local pathologist, 2 stained sections from routinely processed histological material (H&E, Giemsa) and at least 15 unstained sections (optional if paraffin block submitted) must be sent for central pathology review to the IELSG Lymphoma Review Center (LRC) at the IELSG Coordinating Center, together with a copy of the original pathology report(s) including diagnosis, classification and immunophenotyping result. In case of doubt the LRC may request paraffin embedded material to complement the analysis. IELSG 19 PROTOCOL version n page 18

20 11 CRITERIA OF EVALUATION Response to treatment will be evaluated after 6 weeks and 24 weeks of therapy. All patients who have received at least two Rituximab infusions (weeks 1 and 2) or two weeks of treatment with chlorambucil for Arm A will be considered evaluable for response. Response criteria are defined according to the NCI standardized response criteria for non-hodgkin s lymphoma (36) (See Appendix E) Definition of measurable or evaluable lesion Bidimensionally measurable lesions Examples of such lesions evaluated by clinical examination or imaging tools include: a skin nodule or superficial lymph node > 5 mm a lung lesion surrounded by aerated lung (on CT scan at least one diameter > 15 mm). a lesion of the liver or of the soft tissues, lymph nodes and masses investigated by CT scan or ultrasound (at least one diameter > 15 mm). Evaluable lesions Bidimensionally measurable lesions with the largest diameter below the cut-off defined in measurable lesions Unidimensionally measurable lesions Diffuse liver and/or spleen involvement with hepatomegaly and/or splenomegaly. Bone marrow and peripheral blood involvement. Ascitic, pleural and pericardial effusions Not evaluable lesions Not evaluable lesions include any osseous lesions Criteria for response definition Ideally, all bidimensionally measurable lesions should be measured at each protocol required staging procedure (see Appendix E). When multiple lesions are present, this may not be possible and, under such circumstances, up to 6 measurable target lesions, which are representative of all organs involved should be selected for measurement, giving the priority to bidimensionally measurable target lesions. Serial evidence of appreciable change documented by radiography or photography must be obtained and must be available for subsequent review. The assessment must be objective. Complete response (CR). Disappearance of all detectable clinical and radiographic evidence of disease, disappearance of all disease-related symptoms, if present before therapy, and normalization of those biochemical abnormalities definitely assignable to NHL. Regression of all lymph nodes and nodal masses to normal ( 1.5 cm in their greatest transverse diameter for nodes > 1.5 cm before IELSG 19 PROTOCOL version n page 19

21 therapy and to 1 cm for nodes that were cm. Regression by more than 75% in the sum of the products of the greatest diameters). Partial response (PR). Decrease by at least 50% in SPD of the six largest measurable lesions. It is not necessary for all lesions to have regressed to qualify for partial response, but no lesion should have progressed and no new lesion should appear. Stable disease (SD). Is defined as less than a PR but is not progressive disease Progressive disease (PD). Defined as 50% increase from nadir in the size of at least one bidimensionally measurable lesion or appearance of any new lesion during or at the end of therapy. The occurrence of pleural effusion or ascites is also considered as progressive disease if this is substantiated by positive cytology. Pathological fracture or collapse of bone is not necessarily evidence of disease progression. Evaluable not measurable disease will be assessed for complete response (complete disappearance) of all known disease. Spleen and liver, if considered to be enlarged before therapy on the basis of a CT scan must have regressed in size and must not be palpable on physical examination. Disappearance of bone marrow involvement as evaluated by bone marrow aspirate and trephine biopsy or progressive disease/relapse (appearance of any new lesion not previously identified or any size increase in existing lesions) Assessment and definition of tumor response in gastric MALT lymphomas The response should be assessed with both endoscopy and histology Definition of complete histologic regression is obtained when the postreatment biopsies showed no sign of remaining lymphoma but instead an empty tunica propria with small basal clusters of lymphocytes and scattered plasma cells. Partial histologic regression is defined as post-treatment biopsy samples revealing either focal atypical lymphoid cells or lymphoepithelial destruction and an empty tunica propria as signs of lymphoma regression. Relapse of the underlying gastric MALT lymphoma was diagnosed whenever lymphoepithelial lesions were again present after the patient had entered CR Analysis of toxicity All patients who have received at least one dose of either Rituximab or Chlorambucil will be evaluable for toxicity from the time of their first drug administration. When a toxicity occurs, it should be graded according to the NIH Common Toxicity Criteria (see Appendix F) 11.5 Treatment failure Whenever toxicity, progression, patient refusal, death or any other reason induces a premature termination of the study treatment. IELSG 19 PROTOCOL version n page 20

22 12 STATISTICAL CONSIDERATIONS 12.1 Statistical design and sample size Primary endpoint (on which the sample size is calculated) is the event-free-survival (failure or death from any cause) for all patients. The event-free survival for the patients treated with Chlorambucil was assumed to be 50% at 5 years, so 182 patients (91 per arm) were judged be required to show a 20% improvement with a 5% significance level (two-sided) and 80% power. With an assumed adjustment of 10% for non-evaluable patients, the anticipated recruitment was stated to be 200 patients. Based on the results of an interim analysis (February 2005) the recruitment was prolonged up to a total of 250 patients. In April 2006, when 250 patients have already been enrolled in the study, a third arm of treatment with rituximab alone has been introduced (see Amendment 2). A randomization among chlorambucil alone, chlorambucil plus rituximab and rituximab alone will be performed with an allocation ratio of 1 : 1 : 6. Therefore, the recruitment of further 200 patients is required in order to achieve a total enrolment of approximately 450 patients which, with an assumed adjustment of 10% for non-evaluable patients, will allow the analysis of approximately 400 patients (approximately 130 patients for each trial arm). With this design the study will be powered to compare each of the 2 experimental arms against chlorambucil alone. Indeed the analysis of chlorambucil vs chlorambucil + rituximab in the first 250 patients will be reported first and later another analysis will be done with the rituximab arm and the updated results of the 2 first arms. The recruitment of all study patients (approximately 450) will have to be completed before any report. The above statement has been made taking into account that: The event rate in the control group (chlorambucil alone) is 50% at 5 years The size of the difference to be detected should be 20% The type I error (alpha) and type II (beta) are respectively 5% and 20% The proposed test statistic to be used is the Log rank test The expected patient entry rate since the study re-opening (based on the ongoing study) should be about 90 patients per year. Thus, the duration of the accrual would be of approximately 3 years. The duration of follow up after end of accrual would be 10 years 12.2 Randomization and stratification Patients will be centrally randomized at the IELSG Central Office. A minimization technique will be used in order to balance the randomization according to the following factors: tumor site (gastrointestinal versus non-gastrointestinal) presence of nodal disease versus no lymph node involvement previously treated versus untreated International Prognostic Index (IPI) (low / low-intermediate risk versus intermediate-high / high risk) (see Appendix D) IELSG 19 PROTOCOL version n page 21

23 12.3 Analysis of outcome Efficacy analysis will be done on an intent-to-treat basis. Survival curves will be estimated using the Kaplan-Meier method and the Log rank test will be used to compare outcome of the different treatment arms Definition of survival endpoints Event free survival (EFS), for all patients, is defined as the interval between the time of entry onto trial and failure or death from any cause. Overall survival (OS), for all patients, is measured from entry onto trial until death from any cause. Progression free interval (PFS), for all patients, is taken from the time of entry onto study until disease progression or death from NHL. Duration of response, for patients who achieved complete or partial response, is measured from the first assessment that documents the response to the date of relapse Interim Analysis A formal interim analysis will be performed after recruitment of the first 80 patients. Aim of this analysis is to determine the feasibility of the study and any major difference of outcome (recurrence rate and severe toxicity) between the randomized arms. The interim analysis will be performed by an Independent Data and Safety Monitoring Board (DSMB) whose responsibility is to establish the early stopping rule to be used and the frequency and timing of the analyses as well as the significance levels to be used for each analyses. A second formal interim analysis will be performed after recruitment of the first 80 patients, after introduction of the third treatment arm of rituximab alone, again with the purpose of determining any major outcome differences among the study arms. IELSG 19 PROTOCOL version n page 22

24 13 ETHICAL CONSIDERATIONS The responsible investigator will inform the patient about the present knowledge of the drug and the study with special reference to know activity and toxicity. The patient is allowed to refuse the treatment either before or at any time during the trial. Before the patient is entered into the trial, his/her consent has to be obtained according to local guidelines. The trial has to be approved by the responsible Ethical Committee of every participating institutions. The trial is to be performed in accordance with the declaration of Helsinky. Patients will be treated according to Good Clinical Practice (GCP) standard. 14 ADMINISTRATIVE CONSIDERATIONS 14.1 Insurance Patients from Switzerland, Italy, Spain, United Kingdom, Canada, Australia, Belgium, France enrolled in this trial are covered by a clinical trial liability insurance, which applies exclusively to this clinical trial. IELSG 19 PROTOCOL version n page 23

25 15 STUDY ACKNOWLEDGEMENT 15.1 PROTOCOL IELSG 19 MULTICENTER RANDOMIZED TRIAL OF CHLORAMBUCIL VERSUS CHLORAMBUCIL PLUS RITUXIMAB IN EXTRANODAL MARGINAL ZONE B- CELL LYMPHOMA OF MUCOSA ASSOCIATED LYMPHOID TISSUE (MALT LYMPHOMA) 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), drug transportation, 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, analyze, 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 IELSG 19 PROTOCOL version n page 24

26 15.2 For Institutions which start participation in the study after May 15, 2006 PROTOCOL IELSG 19 MULTICENTER RANDOMIZED TRIAL OF CHLORAMBUCIL VERSUS CHLORAMBUCIL PLUS RITUXIMAB VERSUS RITUXIMAB ALONE IN EXTRANODAL MARGINAL ZONE B-CELL LYMPHOMA OF MUCOSA ASSOCIATED LYMPHOID TISSUE (MALT LYMPHOMA) 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), drug transportation, 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, analyze, 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 IELSG 19 PROTOCOL version n page 25

27 16 REFERENCES 1. Harris NL, Jaffe ES, Stein H et al, A revised European American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84: Isaacson PG, Müller-Hermelink HK, Piris MA, et al. Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue(malt lymphoma). In: Jaffe ES, Harris NL, Stein H, Vardiman JW (Eds.), World Health Organization Classification of Tumors. Pathology and Genetics.of Tumours of Haematopoietic and Lymphoid Tissuesds. IARC Press, Lyon 2001; pp Cavalli F, Isaacson PG, Gascoyne RD, Zucca E, MALT Lymphomas, Hematology (Am Soc Hematol Educ Program) 2001; Zucca E, Bertoni F, Roggero E, Cavalli F. The gastric marginal zone B-cell lymphoma of MALT type. Blood. 2000;96: Isaacson P. Gastric MALT lymphoma: from concept to cure. Ann Oncol. 1999;10: Non-Hodgkin s Lymphoma Classification Project, A clinical evaluation of the International Lymphoma Study Group classification of non-hodgkin s lymphoma. Blood 1997; 89: Pinotti G, Zucca E, Roggero E et al, Clinical features, treatment and outcome in a series of 93 patients with low-grade gastric MALT lymphoma. Leuk Lymphoma 1997; 26: Hitchcock S, Ng AK, Fisher DC, et al. Treatment outcome of mucosa-associated lymphoid tissue/marginal zone non-hodgkin's lymphoma. Int J Radiat Oncol Biol Phys 2002;52: Roggero E, Zucca E, Pinotti G et al, Eradication of Helicobacter pylori infection in primary low-grade gastric lymphoma of mucosa associated lymphoid tissue. Ann Intern Med 1995; 122: Neubauer A, Thiede C, Morgner A et al, Cure of Helicobacter pylori infection and duration of remission of low-grade gastric MALT lymphoma. J Natl Cancer Inst 1997; 89: Ruskone Formestraux A, Lavergne A, Aegerter PH et al. Predictive factors for regression of gastric MALT lymphoma after anti-helicobacter pylori treatment. Gut. 2001;48: Steinbach G, Ford R, Glober G, et al. Antibiotic treatment of gastric lymphoma of mucosa-associated lymphoid tissue: an uncontrolled trial. Ann Intern Med. 1999;131: Bertoni F, Conconi A, Capella C, et al. Molecular follow-up in gastric mucosa-associated lymphoid tissue lymphomas: early analysis of the LY03 cooperative trial. Blood 2002;99: Thiede C, Wundisch T, Alpen B, et al. Long-term persistence of monoclonal B cells after cure of Helicobacter pylori infection and complete histologic remission in gastric mucosa-associated lymphoid tissue B-cell lymphoma. J Clin Oncol. 2001;19: Schechter NR, Portlock CS, Yahalom J. Treatment of mucosa-associated lymphoid tissue lymphoma of the stomach with radiation alone. J Clin Oncol. 1998;16: Fung CY, Grossbard ML, Linggood RM, et al. Mucosa-associated lymphoid tissue lymphoma of the stomach: long term outcome after local treatment. Cancer. 1999;85: Tsang RW, Gospodarowicz MK, Pintilie M, et al. Stage I and II MALT lymphoma: results of treatment with radiotherapy. Int J Radiat Oncol Biol Phys 2001;50: Cogliatti SB, Schmid U, Schumacher U, et al. Primary B-cell gastric lymphoma: a clinicopathological study of 145 patients. Gastroenterology. 1991;101: Thieblemont C, Berger F, Dumontet C, et al. Mucosa-associated lymphoid tissue lymphoma is a disseminated disease in one third of 158 patients analyzed. Blood. 2000;95: Richards MA, Gregory WM, Hall P, et al. Management of localized non-hodgkin's lymphoma: the experience at St. Bartholomew's Hospital Hematol Oncol. 1989;7: Hammel P, Haioun C, Chaumette MT, et al. Efficacy of single-agent chemotherapy in low-grade B- cell mucosa-associated lymphoid tissue lymphoma with prominent gastric expression. J Clin Oncol. 1995;13: Gupta RK, Lister TA. Current management of follicular lymphoma. Curr Opin Oncol 1996;8: IELSG 19 PROTOCOL version n page 26

28 23. Levy M, Copie-Bergman C, Traulle C, et al. Conservative treatment of primary gastric low-grade B- cell lymphoma of mucosa-associated lymphoid tissue: predictive factors of response and outcome. Am J Gastroenterol 2002;97: McLaughlin P, Grillo-Lopez AJ, Link BK, et al. Rituximab chimeric anti-cd20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol 1998;16: Ghielmini M, et al. Maintenance treatment with 2-monthly Rituximab after standard weekly x4 Rituximab induction significantly improves event-free survival in patients with follicular lymphoma. (Proceedings of the 8th Conference on Malignant Lymphoma). Ann Oncol 2002 (Suppl), in press. 26. Piro LD, White CA, Grillo-Lopez AJ, et al. Extended Rituximab (anti-cd20 monoclonal antibody) therapy for relapsed or refractory low-grade or follicular non-hodgkin's lymphoma. Ann Oncol 1999;10: Hainsworth JD. Rituximab as first-line and maintenance therapy for patients with indolent non- Hodgkin's lymphoma: interim follow-up of a multicenter phase II trial. Semin Oncol 2002; 29 (1 Suppl 2): Conconi A, Martinelli G, Thieblemont C, et al. Clinical activity of rituximab in extranodal matginal zone B-cell lymphoma of MALT type. Blood 2003; 102(8): Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-b-cell lymphoma. N Engl J Med 2002; 346(4): Vose JM, Link BK, Grossbard ML, et al. Phase II study of rituximab in combination with chop chemotherapy in patients with previously untreated, aggressive non-hodgkin's lymphoma. J Clin Oncol 2001;19: Czuczman MS, Fallon A, Mohr A, et al. Rituximab in combination with CHOP or fludarabine in lowgrade lymphoma. Semin Oncol 2002;29(1 Suppl 2): Emmanouilides C, Rosen P, Telatar M, et al. Excellent tolerance of rituximab when given after mitoxantrone/cyclophosphamide: an effective and safe combination for indolent non-hodgkin's lymphoma. Clin Lymphoma 2000;1: Howard OM, Gribben JG, Neuberg DS, et al. Rituximab and CHOP induction therapy for newly diagnosed mantle-cell lymphoma: molecular complete responses are not predictive of progressionfree survival. J Clin Oncol 2002;20: Martinelli G, Laszlo D, Mancuso P et al. Rituximab plus chlorambucil in low-grade non-hodgkin s lymphomas (NHL): A pilot study. (Proceedings of the 8th Conference on Malignant Lymphoma). Ann Oncol 2002 (Suppl), in press. 35. Common Toxicity Criteria Manual (PDF) [Updated August 18,1999], CTC v. 2.0 Reference document available at /forms/ctcmanual_v4_ pdf 36. Cheson BD, Horning SJ, Coiffier B, et al. Report of an international workshop to standardize response criteria for non-hodgkin's lymphomas. NCI Sponsored International Working Group. J Clin Oncol 1999;17: (erratum in J Clin Oncol 2000;18:2351) IELSG 19 PROTOCOL version n page 27

29 APPENDIX A CONSENSO INFORMATO PER LA PARTECIPAZIONE ALLO STUDIO IELSG 19: STUDIO MULTICENTRICO RANDOMIZZATO DI TRATTAMENTO CON CHLORAMBUCIL DA SOLO verso CHLORAMBUCIL + RITUXIMAB verso RITUXIMAB DA SOLO IN PAZIENTI AFFETTI DA LINFOMA A CELLULE B DELLA ZONA MARGINALE (MZL) EXTRANODALI (LINFOMA MALT) Iniziali e N del/la paziente N cartella : Perché Le è stato proposto di partecipare a questo studio? E stato/a informato/a che nella sua malattia, il linfoma a linfociti di tipo B della zona marginale (cosiddetto linfoma MALT), il trattamento convenzionale è rappresentato da un farmaco chiamato CHLORAMBUCIL, i cui benefici ed i cui effetti collaterali sono ben noti da anni. Più recentemente, è stato sviluppato un altro farmaco molto attivo in questa malattia che si chiama RITUXIMAB. Per questo motivo Le è stata offerta la possibilità di partecipare ad uno studio che si propone di valutare e confrontare l efficacia antitumorale e gli effetti collaterali dei due farmaci utilizzati singolarmente e della combinazione degli stessi in un solo programma terapeutico. Quali sono le caratteristiche di questo nuovo farmaco? Il RITUXIMAB non appartiene alla categoria dei citostatici abitualmente impiegati nella terapia di questi linfomi. Si tratta, invece, di un anticorpo monoclonale fabbricato con tecniche di ingegneria genetica. E' una sostanza che ha caratteristiche analoghe a quelle degli anticorpi prodotti normalmente dal nostro organismo per eliminare particelle, microorganismi o cellule tumorali, riconosciuti come estranei. Il RITUXIMAB è stato studiato in modo da riconoscere come estranei e distruggere i linfociti di tipo B e quindi anche le cellule linfomatose. Fino ad oggi, nel mondo, migliaia di pazienti affetti da altri tipi di linfoma a cellule B sono già stati trattati con questo farmaco che ha mostrato un effetto antitumorale in un importante numero di casi. In Svizzera il RITUXIMAB è disponibile in commercio e il suo impiego è stato approvato dagli organismi competenti nel trattamento di diversi tipi di linfoma. Qual è lo scopo di questo studio? Gli obiettivi principali di questo studio sono di verificare se: L associazione del RITUXIMAB alla chemioterapia con CHLORAMBUCIL è più efficace della chemioterapia con CHLORAMBUCIL da solo. Il trattamento con RITUXIMAB da solo è più efficace della chemioterapia con CHLORAMBUCIL da solo E prevista la partecipazione di circa 450 pazienti trattati in diversi centri nel mondo. Che trattamento riceverà se partecipa allo studio? Questo è uno studio randomizzato. Ciò vuol dire che esistono tre possibili trattamenti (CHLORAMBUCIL da solo, CHLORAMBUCIL+RITUXIMAB, RITUXIMAB da solo) e che l assegnazione a uno di questi trattamenti è casuale. Nel primo caso, il programma terapeutico prevede la somministrazione di CHLORAMBUCIL per bocca ogni giorno per 6 settimane. Al termine è necessario ripetere alcuni esami per valutare la risposta ottenuta. In caso di risposta o di stabilità della malattia, si proseguirà con una somministrazione per 15 giorni ogni mese per quattro mesi. Nel secondo caso, alla terapia già descritta verrà aggiunto il RITUXIMAB, una dose alla settimana per 4 settimane e, dopo gli esami di rivalutazione, il primo giorno di ciascun ciclo mensile per 4 mesi. Il RITUXIMAB verrà somministrato nel corso di un infusione endovenosa della durata di 3-5 ore. La prima dose verrà somministrata durante una degenza ospedaliera di 2-3 giorni, le successive in regime ambulatoriale. Nel terzo caso, la terapia consisterà nella somministrazione del solo RITUXIMAB, una dose alla settimana per 4 settimane e, dopo gli esami di rivalutazione, una volta ogni 28 giorni IELSG 19 PROTOCOL version n page 28

30 per 4 mesi. Il RITUXIMAB verrà somministrato nel corso di un infusione endovenosa della durata di 3-5 ore in regime ambulatoriale La durata minima della Sua partecipazione sarà quindi di 6 settimane e durerà fino a un massimo di 24 settimane Il trattamento verrà interrotto in caso di progressione della malattia, comparsa di effetti collaterali inaccettabili o per una Sua decisione. Quali sono i rischi? Nei pazienti trattati fino ad oggi, i principali effetti collaterali osservati a seguito della somministrazione di RITUXIMAB sono stati febbre di grado lieve e brividi, limitati, nella maggioranza dei casi, alla prima somministrazione del farmaco. Più raramente vengono lamentati dolori ossei, calo di pressione mancanza di respiro e mal di testa. In rari casi pazienti già affetti da malattie di cuore hanno presentato, dopo la somministrazione di RITUXIMAB, complicanze cardiache gravi. Se, in passato, lei avesse avuto problemi cardiaci sarebbe sconsigliabile la Sua partecipazione allo studio. Alcuni pazienti hanno sviluppato infezioni virali nuove e anche gravi, o hanno mostrato un peggioramento di infezioni virali croniche già presenti, in seguito al trattamento con Rituximab in combinazione con chemioterapia o come parte di un programma di trapianto di midollo. In alcuni casi queste infezioni sono occorse anche un anno dopo il trattamento con il Rituximab e sono state letali. Tra queste va inclusa una rarissima (meno di un caso ogni 10'000 pazienti) ma grave infezione virale chiamata leucoencefalopatia progressiva multifocale, che può causare un danno cerebrale. Due pazienti con Lupus eritematoso sistemico (una malattia reumatologica) trattati con Rituximab e altri farmaci che sopprimono le difese immunitarie, hanno sviluppato questa malattia e ne sono morti. Non è chiaro se il trattamento con Rituximab possa avere aumentato il rischio di questa infezione che si può manifestare con perdita di memoria, difficoltà di pensiero e perdita della vista. Nel caso si presentassero questi sintomi o anche altri sintomi neurologici come difficoltà nel camminare e nei movimenti, siete pregati di informare immediatamente il vostro medico. Inoltre, sono stati segnalati alcuni casi di pazienti trattati con chemioterapia e Rituximab che hanno avuto delle perforazioni gastrointestinali, per questo motivo vi preghiamo di informare il vostro medico se avete dolore addominale o qualsiasi altro sintomo gastrointestinale. Non essendo noti i possibili effetti sul feto, le donne in età fertile dovranno sottoporsi a un test di gravidanza prima di iniziare il trattamento. Durante lo studio l allattamento non è permesso e tutti i pazienti (sia di sesso maschile che femminile) dovranno adottare un metodo anticoncezionale, meccanico o ormonale per i soggetti femminili e meccanico per quelli maschili, che dovrà essere proseguito per 3 mesi dopo la fine dello studio. Qual è il beneficio? Il trattamento con RITUXIMAB ha già dimostrato di essere efficace contro alcune forme di linfoma e attivo nel linfoma MALT. Sulla base di queste premesse, è possible che il solo RITUXIMAB o l associazione di RITUXIMAB e CLORAMBUCILE sia più attiva della sola terapia con CLORAMBUCILE, soprattutto nella prevenzione delle recidive di linfoma MALT. Questo risultato, tuttavia, non può in alcun modo essere garantito. Che cosa succederà nel corso dello studio? Prima di iniziare la terapia, verrà sottoposto/a ad una serie di accertamenti per definire la diffusione della sua malattia (esame clinico, esami del sangue, controlli radiologici, biopsia ossea e aspirato midollare, biopsie di tessuto tumorale) e la Sua funzione cardiaca (elettrocardiogramma). Verrà inoltre effettuato un prelievo di sangue per la ricerca di anticorpi anti-virus dell epatite B e C e anti- HIV (virus dell immunodeficienza umana acquisita). Gli esami utili per valutare la Sua malattia (parametri di malattia) verranno ripetuti dopo 6 settimane e dopo 24 settimane dall inizio del trattamento, per valutare la risposta. Durante il trattamento, per controllare la comparsa di effetti collaterali, verranno inoltre effettuati controlli settimanali degli esami del sangue, l esame fisico ed eventuali esami supplementari. Potrà, inoltre, essere necessaria la somministrazione di terapie di supporto per ridurre i sintomi dovuti agli effetti collaterali. I materiali prelevati (prelievi di sangue e midollo osseo, biopsie del tumore) potranno essere analizzati per scopi di ricerca da laboratori autorizzati dal gruppo promotore, sia durante lo studio, sia in futuro. Naturalmente è garantito l anonimato del materiale nonché la confidenzialità dei IELSG 19 PROTOCOL version n page 29

31 risultati da esso eventualmente ottenuti, e la sua autorizzazione all uso di questo materiale potrà essere ritirata in qualunque momento lei lo desideri. Quali sono le altre possibili terapie? L altra possibile terapia consiste nella somministrazione di una chemioterapia convenzionale (o in casi particolari di una radioterapia convenzionale) come discusso con il suo medico oncologo. I suoi diritti. In caso di cattiva tollerabilità del trattamento, di peggioramento della malattia o per qualsiasi altra ragione, qualora il medico responsabile ritenga che ciò risulti a Suo vantaggio, il trattamento verrà sospeso e potrà essere sostituito con un altro trattamento adeguato. Se durante lo studio nuovi dati dovessero emergere, lei verrà informato/a e il gruppo promotore dello studio, IELSG (Gruppo Internazionale di Studio dei Linfomi Extranodali), potrà decidere, insieme al suo medico responsabile, di chiudere lo studio a beneficio dei pazienti. A sua volta dovrà informare il suo oncologo in merito alle cure fornite da un altro medico e a qualsiasi farmaco che assume. La partecipazione allo studio non comporta alcun costo supplementare: tutti gli esami ed accertamenti previsti fanno parte delle indagini abituali, previste per il controllo della Sua malattia. Il RITUXIMAB verrà fornito gratuitamente dalla casa farmaceutica produttrice (Roche). Le sarà concesso, conformemente alle disposizioni vigenti in Svizzera, qualsiasi indennizzo, pieno ed integrale, che si rendesse necessario qualora dovesse subire danni rinconducibili alla sua partecipazione a questo studio. A questo proposito l International Extranodal Lymphoma Study Group (IELSG), promotore di questo studio, dispone di un assicurazione specifica per studi clinici. Il medico di oncologia potrà fornirle tutte le informazioni necessarie. Le è stato spiegato che la sua partecipazione a questo studio è volontaria e che potrà rifiutarsi di partecipare senza pregiudicare l assistenza medica fornitale. Inoltre in qualunque momento dello studio Lei lo desideri, potrà interrompere il trattamento. In questo caso Le verrà chiesto di fare ancora un esame medico finale per la Sua sicurezza. Il medico responsabile è disponibile a rispondere a qualsiasi domanda in ogni momento; troverà i numeri utili sul cartoncino degli appuntamenti. La Sua documentazione clinica potrà essere esaminata da persone autorizzate dal centro promotore IELSG, o da rappresentanti delle autorità regolatorie, o dal comitato etico, per una verifica della correttezza dei dati e delle procedure di studio. In ogni caso verrà mantenuta la confidenzialità sui Suoi dati e la Sua identità non verrà rivelata in alcuna pubblicazione scientifica. Per rispondere a qualunque ulteriore informazione Le fosse necessaria quale paziente partecipante a studi di ricerca, è stato istituito un Servizio di Consulenza indipendente al seguente indirizzo: Ufficio del Farmacista Cantonale Via Maspoli 6850 Mendrisio Tel.: 091 / IELSG 19 PROTOCOL version n page 30

32 Dichiaro di esser stato/a informato/a sulle caratteristiche dello studio propostomi, di essere d accordo di partecipare allo stesso e di aver avuto tempo sufficiente per prendere liberamente la mia decisione.. (Firma del/la paziente). (Data). (Firma del medico responsabile). (Data). (Firma del/la testimone). (Data) IELSG 19 PROTOCOL version n page 31

33 APPENDIX B ECOG Performance Status Scale Score Description 0 Fully active, able to carry on all pre-disease performance without restriction. 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work. 2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of working hours. 3 Capable of only limited selfcare, confined to bed or chair more than 50% of working hours. 4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair. IELSG 19 PROTOCOL version n page 32

34 APPENDIX C Ann-Arbor Staging System Stage Description I II III IV Involvement of single lymph-node region (I) or localized involvement of a single extra-lymphatic organ or site (IE) Involvement of two or more lymph-node regions on the same side of the diaphragn (II), or localized involvement of a single associated extra-lymphatic organ or site and its regional nodes with or without other lymph-node regions on the same side of the diaphragm (IIE). Involvement of lymph-node regions on both sides of the diaphragm (III) that may also be accompanied by localized involvement of an extra-lymhatic organ or site (IIIE), by involvement of the spleen (IIIS) or both (IIIE+S). Disseminated (multifocal) involvement of one or more extralymphatic organs with or without associated lymph-node involvement or isolated extra-lymphatic organ involvement with distant (non regional) nodal involvement. The B designation is given to those patients with (1) unexplained loss of more than 10% of body weight in the 6 months before diagnosis, or (2) unexplained fever with temperatures above 38 C or (3) drenching night sweats. Lugano Staging System for Gastrointestinal (GI) Lymphomas Stage Description I II IIE IV Tumor confined to GI tract. Single primary site or multiple, non contiguous lesions. Tumor extending into abdomen from primary GI site. Nodal involvement. II1: local (paragastric in cases of gastric lymphoma and para-intestinal for intestinal lymphoma) II2: distant (mesenteric in the case of an intestinal primary, otherwise: para-aortic, para-caval, pelvic, inguinal) Penetration of serosa to involve adjacent organs or tissues. Note: enumerate actual site of involvement; e.g. IIE (pancreas), IIE (large intestine), IIE (post-abdominal wall). Where there is both nodal involvement and penetration to involve adjacent organs, stage should be denoted using both a subscript (1 or 2) and e; e.g. II1E (pancreas) Disseminated extranodal involvement of a GI-tract lesion with supra-diaphragmatic nodal involvement. IELSG 19 PROTOCOL version n page 33

35 APPENDIX D The International Prognostic Index (IPI) Prognostic Factors for Survival in International Index Patients Age (< 60 years vs > 60 years) Serum LDH level (< normal vs > normal) Performance status (0,1 vs 2-4) Tumor stage (I/II vs III/IV) Extranodal involvement (< 1 site vs > 1 site) The International Prognostic Index Risk factors Risk groups 0,1 Low (L) 2 Low-intermediate (LI) 3 High-intermediate (HI) 4,5 High (H) IELSG 19 PROTOCOL version n page 34

36 APPENDIX E Response criteria Response Rate Physical Examination Lymph Nodes Lymph Node Masses Bone Marrow CR Normal Normal Normal Normal CRu Normal Normal Normal Indeterminate Normal Normal > 75% decrease Normal or Indeterminate PR Normal Normal Normal Positive Normal 50% decrease 50% decrease Irrelevant Decrease in liver/ spleen 50% decrease 50% decrease Irrelevant Relapse/ Enlarging liver/ New or Reappearance Progression spleen/new sites increased New or increased IELSG 19 PROTOCOL version n page 35

37 APPENDIX F Toxicity criteria In the present study, toxicities will be recorded according to the International Common Toxicity Criteria (CTC), version 3.0. The full CTC document is available on the NIH web site, at the following address (April 2006): IELSG 19 PROTOCOL version n page 36

38 APPENDIX G Modalities of infusion of Rituximab Rituximab (MabThera ) is provided in 100 mg (10 ml) and 500 mg (50 ml) pharmaceutical grade vials at a concentration of 10 mg of protein/ml. Vials should be stored in the refrigerator at 2-8 C. Do not freeze or store at room temperature. Dilution The drug should be diluted under a laminar flow cabinet. The prescribed dose of Rituximab should be diluted in the amount of ml NaCl 0.9% needed to achieve a final concentration of 1 to 4 mg/ml rituximab. The product is a protein: HANDLE GENTLY TO AVOID FOAMING! Avoiding foaming during product handling, preparation and administration is important, as foaming could cause the denaturation of the proteins. Prepared infusion solutions of rituximab are stable for 24 hours in the refrigerator (2-8 C) and at room temperature for additional 12 hours. Premedication Patients known to be at risk of tumor lysis syndrome should be well hydrated and treated with Allopurinol (300 mg per os) or a suitable alternative treatment for hours before the first dose of therapy. It is recommended that the first administration of drug is taken as inpatient. We recommend an overnight hydration with ml of fluids. One hour before treatment start: 1g Paracetamol per os intravenous antihistamine (for example 1-2 vials = 2-4 mg Tavegyl) Administration of treatment While administering the drug for the first time, all the necessary equipment for the treatment of anaphylactic shock should be readily available. IELSG 19 PROTOCOL version n page 37

39 ADMINISTRATION OF THE FIRST TREATMENT During the first treatment with Rituximab, the infusion speed, in case of no toxicity, can be gradually increased every half hour up to a maximum of 400 mg/h according to the following scheme. The use of an electronic infusion pump is recommended. If WBC 50 X 10 9 /l 0-30 minutes 50 mg/h minutes 100 mg/h minutes 150 mg/h minutes 200 mg/h minutes 250 mg/h minutes 300 mg/h minutes 350 mg/h to the end 400 mg/h Rinse the line with 500 ml NaCl 0.9% in 1/2 hour In case of complications Stop immediately the treatment, wait until symptoms have disappeared and continue the treatment at half the previous rate. ADMINISTRATION OF THE FOLLOWING TREATMENTS For patients having experienced a life treatening cytokine release syndrome (severe dyspnea, hypotension, confusion) the following infusion must as well be administered as inpatient, and only after complete resolution of all pathological signs and symptoms. If the first treatment was well tolerated, the speed of the subsequent treatment can be increased as following: 0-60 minutes 100 mg/h minutes 200 mg/h minutes 300 mg/h 120 to the end 400 mg/h Rinse the line with 500 ml NaCl 0.9% in 1/2 hour In case of complications Proceed as described above IELSG 19 PROTOCOL version n page 38

40 APPENDIX H Participating centres IOSI Oncology Institute of Southern Switzerland Ospedale San Giovanni CH-6500 Bellinzona, Switzerland Kantonsspital Onkologie / Hämatologie CH-9007 St. Gallen, Switzerland Inselspital Institut für Medizinische Onkologie CH-3010 Bern, Switzerland Clínic Hospital Universitari Servicio de Hematologia Villarroel, 170 E Barcelona, Spain Centre Hospitalier Lyon Sud Service d Hématologie F Lyon Pierre Bénite Cedex, France Istituto Europeo di Oncologia Divisione di Ematoncologia Clinica Via Ripamonti 435 I Milan, Italy Italian Lymphoma Intergroup (IIL) c/o Dipartimento di Oncologia ed Ematologia Università di Modena e Reggio Emilia COM 4 piano Policlinico via del Pozzo 71 I Modena, Italy Southampton General Hospital Cancer Research UK Oncology Unit University of Southampton Tremona Road Southampton SO16 6YD, UK Peter MacCallum Cancer Institute Division of Haematology / Medical Oncology Locked Bag 1, A Beckett St. Melbourne VIC 8006, Australia Princess Margaret Hospital University Health Network Department of Radiation Oncology 610 University Avenue Toronto Ontario M5G 2M9, Canada IELSG 19 PROTOCOL version n page 39

41 Molecular biology ancillary study (optional) APPENDIX I Lymphoma-containing material at diagnosis and material from follow-up biopsies should be collected for molecular biology studies. The polymerase chain reaction (PCR) assay for the rearrangement of the immunoglobulin heavy chain genes will be performed to provide a molecular marker to evaluate the follow-up biopsies, especially in primary gastric localisations, as already applied in the previous LY03/IELSG 3 trial (Ref. 13). The presence of the t(11;18)(q21;q21) translocation may have a prognostic significance (Ref. 2) and will be evaluated by reverse-transcription polymerase chain reaction (RT-PCR) assay on RNA derived from the diagnostic biopsies. Aliquots of DNA for molecular biology studies will be stocked. Whenever it is possible, three unstained slides will be also collected. METHODS OF TISSUE SAMPLE COLLECTION Using liquid nitrogen The specimen is put in a sterile Nunc vial and submerged in liquid nitrogen; store at 80 C. Using RNAlater TM (Ambion) Tissue collection RNA stabilization solution The dissected fresh tissue is submerged in approximately 5 volumes of RNAlater (p.e, 0.5 g of tissue in 2.5 ml of solution). With RNAlater, RNA will be stable for one day at 37 C, one week at 25 C, one month at 4 C, or indefinitely at 20 C. Using cell culture medium Operation specimens should be immersed in culture medium or in sterile balanced salt solution, such as isotonic sodium chloride. Tissue retains viability for 2-3 days. Samples have to be shipped immediately. Paraffin-embedded material Two 1.5 ml Eppendorf tubes are prepared: one for DNA extraction and one for RNA extraction. They are prepared with five 10µm sections of tumour-containing paraffin-embedded sections. Please note for RNA extraction: use RNAse-free microcentrifuge tube and clean the microtome blades with acetone. For both DNA and RNA, extra-care has to be taken to avoid cross-contamination among the different samples. Separate parts of the blade should be used for cutting different blocks; the same part of the blade must not be used to cut more than one block. BLOOD SAMPLE COLLECTION Heparin is the anticoagulant of choice. EDTA may also be used. Five ml peripheral blood in EDTA and bone marrow aspirate sample in EDTA at study entry have to be collected. Follow up molecular studies are only appropriate for those patients with a marker at diagnosis. Cells pellet can be extracted from blood and bone marrow samples and stored at -80 C. Protocol to extract pellet from blood for DNA analysis 1. Transfer the anticoagulated blood in a 50 ml sterile Falcon vial 2. Add 10 ml of Lysis Buffer (0.32 M sucrose, 10 mm Tris-HCl ph 7.5, 5 mm MgCl 2, 1% Triton X-100) 3. Vortex 4. Centrifuge 3000 rpm for Discard the supernatant 6. Add 10 ml of Lysis Buffer 7. Vortex 8. Centrifuge 3000 rpm for Discard the supernatant 10. Add 10 ml of PBS 1x; 11. Vortex 12. Centrifuge 3000 rpm for Discard the supernatant 14. Put the pellet at -80 C. SAMPLE SHIPMENT Before the sample shipment each investigator should contact the IELSG Coordinating Office ([email protected]) in order to arrange the shipment details. IELSG 19 PROTOCOL version n page 40

42 ADDENDUM 1 MARCH 31, Version 3.1 This addendum refers to the interpretation of the Inclusion Criteria and clarifies the eligibility criteria for gastric MALT lymphoma. The following patients with gastric MALT lymphoma can be entered: 1. H. pylori-negative cases, either de novo (non pre-treated) or at relapse following local therapy (i.e., surgery, radiotherapy or antibiotics). 2. H. pylori-positive cases at diagnosis, who failed antibiotic therapy, including patients with: clinical (endoscopic) and histological evidence of disease progression at any time post H. pylori eradication stable disease with persistent lymphoma at 1 year post H. pylori eradication relapse (without H. pylori re-infection), after a remission patients who failed either first line antibiotics or further local treatment (surgery or radiotherapy) IELSG 19 PROTOCOL version n page 41

43 ADDENDUM 2 MAY 15, Version 3.2 Addition of a third arm (Rituximab alone) in the study IELSG 19 Based on the results of the interim analysis, which showed no difference in response rate and toxicity between the two study arms of Chlorambucil alone vs. Chlorambucil plus Rituximab and on the now published data on the activity of Rituximab alone in extranodal marginal non-lymphoma of MALT type, this amendment to the IELSG 19 study is implemented: - A third treatment arm (namely, arm C with the administration of Rituximab alone), is introduced. - Randomization will proceed with a 1:1:6 allocation until a total additional number of approximately new 150 patients will be recruited in each of the three arms. - The protocol version nr. 3.1, May 15, 2006, is provided, which takes into account these changes. - A new version of the informed consent form, will have to be prepared by the local investigators according to the local EC and authorities requirements. - Patients randomized in arm C will receive Rituximab 375mg/m2 i.v. on day 1,8,15, 22, 56, 84,112 and 140 as described on page 11 of the study protocol (version 3.1). Rituximab will be supplied by Roche International Ltd. in labeled vials and will be distributed by the local/national Roche representatives. IELSG 19 PROTOCOL version n page 42

44 ADDENDUM 3 APRIL 9, Version 3.3 Update of the stability and storage instructions of rituximab According to the Roche Investigator s Brochure 12 th version, Feb. 2007, R , page 23, we have modified the APPENDIX G (page 37) as follows: Prepared infusion solutions of rituximab are stable for 24 hours in the refrigerator (2-8 C) and at room temperature for additional 12 hours. AUGUST 12, 2008 Version 3.4 This addendum refers to a minor amendment due to a typographical error Appendix G (page 38) the double reference If WBC 50 X 10 9 /l on the table has been cancelled. JANUARY 13, 2009 Version This addendum refers to a non substantial amendment regarding the modalities of dilution of the drug According to Roche instructions as reported on the Summary of product characteristics (page 61) we have updated the dilution modalities. Appendix G (page 37) has been modified as follows: The prescribed dose of Rituximab should be diluted in the amount of ml NaCl 0.9% needed to achieve a final concentration of 1 to 4 mg/ml rituximab. IELSG 19 PROTOCOL version n page 43