Non-Hodgkin's Lymphoma
Conditions
Brief summary
This is a phase I trial of the combination of bendamustine, rituximab and pixantrone in patients with relapsed/refractory B cell non-Hodgkin lymphoma. A standard 3+3 design will be used to determine the maximum tolerated dose (MTD) of the combination. A static dose of bendamustine and rituximab will be used and the dose of pixantrone will be escalated in each cohort. Pixantrone will be dosed on a 21 day cycle at 55mg/m2, 85mg/m2, and 115mg/m2 in sequential cohorts dependent on acceptable toxicity profile at each dose level. MTD will be determined based on DLTs that occur during the first 2 cycles of the drug combination. Phase II did not proceed as planned due to withdrawal of pixantrone from the US.
Detailed description
This is a phase I trial utilizing a traditional 3+3 design to evaluate maximum tolerated dose (MTD) and optimal dose schedule of pixantrone in combination with bendamustine (120mg/m2 on day 1 of each 21 day cycle) and rituximab (375mg/m2 on day 1 of each 21 day cycle). No patients will be entered on an escalated dosage level until at least 3 patients have been treated at the previous level and assessed for a dose limiting toxicity. Dose levels will be escalated in cohorts of 3 patients as long as no drug-related DLT occurs in the first 2 cycles. If one patient is observed to suffer a DLT, this cohort will be expanded to include at least 6 patients total. If less than 2 patients in the expanded cohort of 6 patients experience a DLT, dose escalation will resume. If 2 of 6 patients enrolled at the same dose level experience a DLT, the MTD has been exceeded, and the dose escalation will cease. The next lower dose will be considered the MTD. If any patient withdraws from the study prior to completing 2 cycles for reasons other than a DLT then that patient will be replaced in order to determine the MTD. If dose limiting toxicity is observed at the initial dose level in 2 patients, the MTD has been exceeded and the starting dose level will be reduced to 25mg/m2. If 1 patient experiences a DLT in the -1 dose range, the cohort will be expanded to at least 6 patients. If a second patient experiences a DLT at the -1 dose level, the trial will be closed. For part 1, those who have a confirmed diagnosis of relapsed/refractory B cell non-Hodgkin's lymphoma of any subtype will be considered eligible for enrollment. Each cycle will be 21 days. Subjects will be assessed for DLTs during the first 2 cycles of study drug. They will be assessed for response after cycle 2. Patients not experiencing a DLT during the first 2 cycles and who have stable disease or better may continue to receive up to 6 cycles of treatment with the triplet combination. If any patient withdraws from the study prior to completing 2 cycles for reasons other than a DLT then that patient will be replaced in order to determine the MTD. Phase II did not proceed as planned due to withdrawal of pixantrone from the US.
Interventions
DRUGBendamustine + Rituximab + Pixantrone
Dose escalation of pixantrone (55mg/m2, 85mg/m2 and 115mg/m2) in combination with static dose bendamustine (120mg/m2 on Day 1 of each 21 day) and rituximab (375mg/m2 on Day 1 of each 21 day cycle).
DRUGPegfilgrastim
6mg administered on Day 2 of each 21 day cycle
Sponsors
CTI BioPharma
Anne Beaven, MD
Study design
Allocation
NON_RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Dose Escalation, 3+3 design
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Part I: Subjects must have relapsed or refractory B cell NHL; 2. Part II: Subjects must have relapsed or refractory aggressive B cell NHL including follicular lymphoma (FL) grade 3, Diffuse Large B Cell Lymphoma (DLBCL), transformed NHL, mantle cell lymphoma (MCL), or other aggressive B cell NHL histology as per the WHO 2008 criteria; 3. Refractory disease (defined as persistence of evaluable disease after therapy) or relapsed disease following at least one prior treatment regimen that should include autologous stem cell transplant unless a patient was not eligible or refused prior transplant; 4. Age ≥ 18 years old; 5. Eastern Cooperative Oncology Group (ECOG) performance status of ≤2; 6. Subjects must have measurable or evaluable disease based on physical exam and/or radiographs (CT, MRI, PET) or bone marrow involvement; 7. Female subject is either post-menopausal or surgically sterilized; 8. Laboratory Values: * Absolute neutrophil count (ANC) ≥ 1.5 x 10\^9/L; lower levels accepted if due to marrow involvement by lymphoma * Platelets ≥ 75,000/mcl; lower levels accepted if due to marrow involvement by lymphoma * Total bilirubin ≤ 1.5 X institutional upper limit of normal; ≤ 3.0 ULN accepted in subjects with Gilbert's Syndrome * AST/ALT ≤ 1.5 X institutional upper limit of normal. Subjects with known liver involvement by lymphoma: AST/ALT ≤ 2 X institutional upper limit of normal * Serum creatinine \< 1.5 X institutional upper limit of normal 9. Ability to provide written informed consent obtained prior to participation in the study and any related procedures being performed
Exclusion criteria
1. No chemotherapy, radiation, biologics or immunotherapy within 2 weeks prior to registration (6 weeks if last received BCNU or mitomycin C). 2. No radioimmunotherapy within 2 months prior to registration. 3. Subjects receiving chronic, systemic treatment with corticosteroids equivalent to \> 20mg of prednisone per day. Subjects receiving replacement for adrenal insufficiency will be allowed on the study. Topical or inhaled corticosteroids are allowed. 4. Subjects with a history of another primary malignancy ≤ 3 years ago, with the exception of inactive basal, squamous cell carcinoma of the skin or superficial melanoma only requiring excision, prostate cancer with a PSA that has not increased for at least 3 months, carcinoma in situ of the cervix. 5. Major surgery ≤ 4 weeks prior to registration. Minor surgery ≤ 2 weeks prior to registration. Insertion of a vascular access device is not considered major or minor surgery. Subjects must have recovered from all surgery related toxicities to ≤ grade 1 or to baseline if subject started with \> grade 1 toxicity, not otherwise violating the above inclusion criteria. 6. Subjects who have received investigational drugs ≤ 4 weeks prior to registration. 7. Impaired Cardiac Function: * QTc \> 480 on screening ECG. * Previous history of angina pectoris or acute MI within 6 months * Congestive heart failure (New York Heart Association functional classification III-IV) or baseline MUGA/ECHO shows estimated LVEF \< 45% * Any history of torsade de pointes, ventricular fibrillation, uncontrolled ventricular tachycardia, or uncontrolled atrial fibrillation. 8. Female patients who are pregnant or breastfeeding 9. Patients with history of untreated hepatitis B or who are known carriers of hepatitis B will be excluded from this trial. All subjects will be screened prior to study entry. 10. Concurrent use of other anti-cancer agents or anti-cancer treatments.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Maximum Tolerated Dose | 4 years | Dose-limiting toxicity (DLT) assessments were performed weekly during cycles 1 and 2. A DLT was defined as any grade 3 non-hematologic toxicity that lasted longer than 48 hours, despite proper supportive care, any grade 4 non-hematologic toxicity, or any grade 3 or 4 hematologic toxicity lasting longer than 7 days. Alopecia and febrile neutropenia were not considered DLTs. Any NCI CTC (National Cancer Institute Common Terminology Criteria) v4.03 grade 5 (death) toxicity was considered a DLT. Dose Limiting Toxicities were used as the assessment criteria to determine the Maximum Tolerated Dose (MTD). MTD is presented. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Response | up to 220 days | Partial response and complete response evaluated using a modified version of the revised response criteria for malignant lymphoma by Cheson et al Complete Response (CR) • Complete disappearance of all detectable clinical and radiographic evidence of disease and disappearance of all disease-related symptoms if present prior to therapy. Complete Response Unconfirmed (CRu) meets the CR criteria, but with one or more of the following: * A residual node \> 1.5 cm in greatest transverse diameter that has regressed \>75% in the sum of the product of the diameters (SPD). Individual nodes that were previously confluent must have regressed \>75% in their SPD compared with the size of the original mass. * Indeterminate bone marrow (increased number or size of aggregates without cytologic or architectural atypia by immunohistochemistry or flow cytometry). Partial Response (PR) • A decrease of ≥ 50% in the SPD of up to six of the largest dominant nodes or nodal masses. |
| Progression Free Survival | From day 1 of treatment to disease progression, death or 5 years, whichever comes first | — |
| Toxicity | 30 days post last dose of study drug | Dose limiting toxicities plus % of patients with a clinically significant change in left ventricular ejection fraction. |
| Overall Survival | from day 1 of treatment to death | — |
Countries
United States
Participant flow
Recruitment details
The study opened November 1, 2011 and closed to accrual September 22, 2016. Subjects were recruited through the Hematology Clinic at Duke University Medical Center.
Participants by arm
| Arm | Count |
|---|---|
| Bendamustine + Rituximab + Pixantrone Bendamustine, 120mg/m2; administered first on Day 1 of each cycle. Rituximab, 375mg/m2; administered second on Day 1 of each cycle. Pixantrone, variable dosing depending on the cohort and MTD; to be administered last, 4-6 hours after bendamustine, on Day 1 of each cycle Pegfilgrastim, 6mg; administered on Day 2 of each cycle
Bendamustine + Rituximab + Pixantrone: Dose escalation of pixantrone (55mg/m2, 85mg/m2 and 115mg/m2) in combination with static dose bendamustine (120mg/m2 on Day 1 of each 21 day) and rituximab (375mg/m2 on Day 1 of each 21 day cycle). | 33 |
| Total | 33 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Screen Failure | 10 |
| Overall Study | Withdrawal by Subject | 1 |
Baseline characteristics
| Characteristic | Bendamustine + Rituximab + Pixantrone |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 14 Participants |
| Age, Categorical Between 18 and 65 years | 19 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 33 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 2 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 31 Participants |
| Region of Enrollment United States | 33 Participants |
| Sex: Female, Male Female | 10 Participants |
| Sex: Female, Male Male | 23 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 6 / 7 | 7 / 7 | 8 / 8 |
| other Total, other adverse events | 7 / 7 | 7 / 7 | 8 / 8 |
| serious Total, serious adverse events | 3 / 7 | 0 / 7 | 2 / 8 |
Outcome results
Primary
Maximum Tolerated Dose
Dose-limiting toxicity (DLT) assessments were performed weekly during cycles 1 and 2. A DLT was defined as any grade 3 non-hematologic toxicity that lasted longer than 48 hours, despite proper supportive care, any grade 4 non-hematologic toxicity, or any grade 3 or 4 hematologic toxicity lasting longer than 7 days. Alopecia and febrile neutropenia were not considered DLTs. Any NCI CTC (National Cancer Institute Common Terminology Criteria) v4.03 grade 5 (death) toxicity was considered a DLT. Dose Limiting Toxicities were used as the assessment criteria to determine the Maximum Tolerated Dose (MTD). MTD is presented.
Time frame: 4 years
Population: Over the course of 4 years, dose escalation was performed in 3 cohorts. Cohort 1 (Phase 1: Pixantrone, 55mg/m\^2) enrolled 7 people; Cohort 2 (Phase 1: Pixantrone, 85mg/m\^2) enrolled 7 people; Cohort 3 (Phase 1: Pixantrone, 115 mg/m\^2) enrolled 7 people.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Maximum Tolerated Dose | 115 milligrams per meter squared |
Secondary
Overall Response
Partial response and complete response evaluated using a modified version of the revised response criteria for malignant lymphoma by Cheson et al Complete Response (CR) • Complete disappearance of all detectable clinical and radiographic evidence of disease and disappearance of all disease-related symptoms if present prior to therapy. Complete Response Unconfirmed (CRu) meets the CR criteria, but with one or more of the following: * A residual node \> 1.5 cm in greatest transverse diameter that has regressed \>75% in the sum of the product of the diameters (SPD). Individual nodes that were previously confluent must have regressed \>75% in their SPD compared with the size of the original mass. * Indeterminate bone marrow (increased number or size of aggregates without cytologic or architectural atypia by immunohistochemistry or flow cytometry). Partial Response (PR) • A decrease of ≥ 50% in the SPD of up to six of the largest dominant nodes or nodal masses.
Time frame: up to 220 days
Population: Subjects who received at least 2 cycles of study drug were included. Data from the single patient enrolled in the phase 2 portion of the trial was included with the phase I pixantrone 115mg/m2 group because the phase 2 patient also received the 115mg/m2 dose and the combined data seems more meaningful than presenting data for 1 patient separately.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Overall Response | 2 Participants |
| Pixantrone, 85mg/m^2 | Overall Response | 2 Participants |
| Pixantrone, 115mg/m^2 | Overall Response | 5 Participants |
Secondary
Overall Survival
Time frame: from day 1 of treatment to death
Population: Groups combined to include all subjects who completed the study. This analysis was originally planned for Phase 2; there was no intent to compare dose levels in Phase 1 because there would be insufficient power to make meaningful comparisons.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Overall Survival | 7.9 months |
Secondary
Progression Free Survival
Time frame: From day 1 of treatment to disease progression, death or 5 years, whichever comes first
Population: Groups combined to include all subjects who completed the study. This analysis was originally planned for Phase 2; there was no intent to compare dose levels in Phase 1 because there would be insufficient power to make meaningful comparisons.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Progression Free Survival | 3.9 months |
Secondary
Toxicity
Dose limiting toxicities plus % of patients with a clinically significant change in left ventricular ejection fraction.
Time frame: 30 days post last dose of study drug
Population: Phase 1 subjects who received study drugs.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Toxicity | Left Ventricular Ejection Fraction | 1 Participants |
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Toxicity | Dose-Limiting Toxicity | 1 Participants |
| Bendamustine + Rituximab + Pixantrone + Pegfilgrastim | Toxicity | Other Adverse Events | 6 Participants |
| Pixantrone, 85mg/m^2 | Toxicity | Left Ventricular Ejection Fraction | 0 Participants |
| Pixantrone, 85mg/m^2 | Toxicity | Dose-Limiting Toxicity | 1 Participants |
| Pixantrone, 85mg/m^2 | Toxicity | Other Adverse Events | 6 Participants |
| Pixantrone, 115mg/m^2 | Toxicity | Dose-Limiting Toxicity | 1 Participants |
| Pixantrone, 115mg/m^2 | Toxicity | Other Adverse Events | 6 Participants |
| Pixantrone, 115mg/m^2 | Toxicity | Left Ventricular Ejection Fraction | 0 Participants |