Symposium article
`
`Annals of Oncology 11 (Suppl. I): S123-S126. 2000.
`© 2000 Kluwer Academic Publishers. Printed in the Netherlands.
`
`The effect of Rituximab on patients with follicular and mantle-cell lymphoma
`
`M. Ghielmini, S.-F. Hsu Schmitz, K. Burki, G. Pichert, D. C. Betticher, R. Stupp,
`M. Wernli, A. Lohri, D. Schmitter, F. Bertoni & T. Cerny for the Swiss Group
`for Clinical Cancer Research (SAKK)
`
`Summary
`
`Background: Clinical activity of the anti CD-20 monoclonal
`antibody Rituximab has been reported in patients with follicu-
`lar lymphoma (FL) and mantle-cell lymphoma (MCL).
`Patients and methods: 120 patients with bi-dimensionally
`measurable FL or MCL (R.E.A.L. Classification) were treated
`with Rituximab 375 mg/m2/week for 4 weeks. A central path-
`ology review confirmed the diagnosis of FL in 76 of 78 and of
`MCL in 39 of 42 cases. The response was evaluated after 8
`weeks and confirmed after 12 weeks from the start of treat-
`ment.
`Results: The toxicity of the treatment was, as expected,
`grade 1-2 fever and rigors during the first infusion and mild
`asthenia during the treatment period. Serious adverse events,
`probably or possibly related to the study treatment, included
`
`four deaths (3 of cardiac origin, 1 caused by P. carinii pneumo-
`nia) and 10 further nonfatal cases, including a permanent
`agranulocytosis and one case of heart failure. Response rate at
`week 12 was 52% for FL and 22% for MCL. After treatment,
`the BCL-2 rearrangement disappeared in 15 of 29 blood but
`only in 5 of 23 bone marrow samples; BCL-1 disappeared in 5
`of 12 blood and 0 of 7 bone marrow specimens, as determined
`by PCR.
`Conclusions: Rituximab is an active agent for the treatment
`of FL, while its efficacy is modest in MCL. The effect in
`reducing minimal residual disease is more pronounced on the
`blood than it is on the bone marrow.
`
`Key words: anti CD-20 antibody, follicular
`lymphoma,
`immunotherapy, mantle-cell lymphoma, Rituximab
`
`Introduction
`
`Treatment with the anti CD-20 monoclonal antibody
`Rituximab have shown encouraging response rates in
`patients with low-grade lymphoma [1—5]. In follicular
`lymphoma (FL) a response rate of approximately 50%
`and response durations of approximately one year are
`obtained with little toxicity. In mantle-cell lymphoma 2
`studies, the first one including 13 and the second one
`including 87 patients (48 pretreated and 39 previously
`untreated), showed response rates of 35%-40%, but with
`a shorter median time to progression compared to follic-
`ular lymphoma [6, 7].
`The low complete response rates and the frequent
`observation of second responses after Rituximab suggest
`the possibility that the drug is not yet used optimally.
`Thus, the Swiss Group for Clinical Cancer Research
`(SAKK) initiated a trial with prolonged treatment dura-
`tion with the aim to improve the time to relapse and the
`proportion of complete response. In this ongoing trial,
`which has accrued 200 patients in the first 18 months,
`patients with follicular and mantle-cell lymphoma are
`randomized between a standard four-week treatment
`followed by observation or consolidation with four addi-
`tional courses of Rituximab given at two monthly inter-
`vals. This schedule was chosen based on data showing a
`
`long half-life of the drug [3-5]. We report here the
`considerable number of cases of unexpected serious and
`fatal toxicities as well as the response rates of the
`induction treatment for both follicular and mantle-cell
`lymphoma.
`
`Patients and methods
`
`Eligibility
`
`To be eligible patients need to be carrier of a biopsy proven CD-20
`positive follicular or mantle-cell lymphoma, either de novo, chemo-
`therapy resistant or relapsing after chemotherapy. Patients must be
`older than 18 and have measurable disease, defined as the presence of
`at least one lesion with 2 measurable perpendicular diameters. No
`chemotherapy or corticotherapy are allowed in the 30 days prior to
`trial entry (6 weeks if treated with nitrosureas). Written
`informed
`consent must be obtained. Exclusion criteria include a histology of
`transformation to high-grade lymphoma, evidence of symptomatic
`CNS disease, a history of significant medical conditions including
`impairment of renal or liver function, active opportunistic infection or
`known HIV or hepatitis B and C infections. After registration patients
`receive trial treatment while the original pathology specimen is sent
`for pathology review to a central pathologist. The restaging examina-
`tions are done at weeks 8 and 12 by measuring all previous lesions,
`including the extent of bone marrow infiltration if it was present at
`diagnosis.
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`Treatment
`
`Patients receive Rituximab 375 mg/m2 i.v. over three to five hours on
`week 1, 2, 3 and 4, always on the same week day (± 1 day). It is
`mandatory to administer the first Rituximab infusion during a short
`hospitalization and in all cases pre-hydration and premedication with
`allopurinol, antihistamin and paracetamol is given.
`
`Statistical methods
`
`This report is based on data from the first 120 patients entered in the
`trial. Because only data from the induction phase were used, no
`between-treatment-arms comparisons were performed. Results were
`presented as descriptive statistics or in frequency tables. Predictive
`values of baseline measurements on response were investigated using
`logistic regression.
`
`Molecular analysis of minimal residual disease
`
`PCR amplification of the t(14;18) (BCL-2 rearrangement) and t(ll;14)
`(BCL-1 rearrangement) chromosomal translocations in FL and MCL
`respectively was used to detect and monitor minimal residual disease.
`A double amplification PCR assay was used for detection of t(14;18)
`translocation-carrying cells in blood (PB) and bone marrow (BM) of
`FL patients, as previously published [8]. The presence of cells carrying
`the t(ll;14)(ql3;q32) chromosomal translocation in PB and BM of
`patients with MCL was performed using a semi-nested PCR assay [9].
`
`Analysis of lymphocyte subsets
`
`DMSO-frozen cells were thawed and washed, stained with fluorescent
`antibodies, and analyzed on a FacsCalibur machine (Becton-Dickin-
`son), using the Multiset program. The antibodies used were CD3,
`CD4, CD8, CD19, CD16+56, CD45. With a 4-color analysis on the
`lymphocyte gate, the following cells were counted. T cells (CD3+),
`T-helper (CD3+/CD4+), T-suppressor (CD3+/CD8+), NK (CD3-/
`CD16+56+) and B cells (CD19+).
`
`Results
`
`Patient characteristics
`
`Seventy-eight patients had follicular lymphoma and
`forty-two had mantle-cell lymphoma. The pathology
`review did not confirm the diagnosis of FL in 2 cases
`and the diagnosis of MCL in 3 cases. Three patients were
`retrospectively found ineligible because of inadequate
`measurability/evaluability at baseline. One patient died
`before receiving Rituximab due to tumor progression.
`Two patients (one with FL and one with MCL) should
`not have been registered because their last anticancer
`treatment was given less than twenty-eight days prior to
`start of Rituximab induction. Detailed patient charac-
`teristics are listed in Table 1.
`
`Toxicity
`
`Among 472 evaluable infusions, dose reduction was
`required in 2 patients, treatment delay in 1 and a treat-
`ment discontinuation due to toxicity in 2 cases. In one
`patient the treatment was stopped because of progres-
`
`Table I. Patient characteristics.
`
`Follicular
`(7i = 78)
`
`Mantle
`(«=42)
`
`Categorical variables
`PS <1
`No previous treatment
`> 3 previous chemotherapy regimens
`Previous CR or PR
`BM involved
`Stage III or IV
`B symptoms
`
`94%
`24%
`39%
`73%
`55%
`84%
`24%
`
`Continous variables
`Age
`Median
`Range
`Previous chemotherapy cycles
`Median
`Range
`Months since last chemotherapy
`Median
`Range
`T4 lymphocytes (106/l)
`Median
`Range
`LDH
`Median
`Range
`
`57
`31-78
`
`14
`4-56
`
`7.1
`0.5-179
`
`324
`0-2220
`
`399
`25-1196
`
`85%
`21%
`35%
`67%
`69%
`90%
`40%
`
`65
`45-83
`
`11
`2-38
`
`4.3
`0.5-61
`
`316
`0-2112
`
`401
`179-1644
`
`Table 2 Serious adverse events probably or possibly related to Ritux-
`imab treatment.
`
`Cardiovascular
`
`Haemathologic
`
`Infectious
`Respiratory
`Neurologic
`Renal
`Gastrointestinal
`Metabolic
`
`Myocardial infarction
`Myocarditis
`Hearth failure
`Sudden death
`Permanent agranulocytosis
`Transient agranulocytosis
`Haemolytic anemia
`Secondary AM L
`P carinii pneumonia
`Bronchiolitis obliterans
`Sensomotoric neuropathy
`Renal failure
`Acute abdominal pain
`Hypercalcemia
`
`sion under treatment. Mild fever was seen in 36% of
`patients during the first infusion but the incidence re-
`duced to 9%-ll% during further infusions; similarly
`rigors appeared in 18% of patients during the first
`infusion, reducing to 3%-6% subsequently. Seventeen
`patients showed a slight hypotension during the first
`infusion but this was important only in one case. Mild
`asthenia was present in approximately 20% of patients
`all along the treatment. Several unexpected serious ad-
`verse events were observed, of which 14 were judged to
`be either probably or possibly related to Rituximab
`(Table 2). Four of these patients died, three of which
`most likely because of cardiac reasons: a 77-year-old
`patient with stage IVB MCL, previously treated with
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`Table 3. Response to treatment (week 12 assessment).
`
`Follicular (n = 74) (%) Mantle (n = 36) (%)
`
`3
`49
`28
`15
`5
`
`0
`22
`36
`36
`6
`
`CR
`PR
`SD
`PD
`Missing
`
`J I
`
`Figure I. Median values of lymphocyte subsets during induction with
`Rituximab follicular and mantle-cell lymphomas.
`
`CHOP, with no cardiac history, suddenly died at home
`one week after the fourth Rituximab treatment; a non
`pre-treated 72-year-old patient with stage IIIB MCL
`and a heavy cardiac history (including two previous
`myocardial infarctions), died in hospital one week after
`the fourth Rituximab treatment due to a probable myo-
`cardial infarction with arrhythmia; a 66-year-old patient
`with stage IV MCL, pre-treated with chlorambucil, and
`with a history of COPD and coronary heart disease,
`died of rapidly progressive heart failure, one month after
`the second consolidation treatment and the post-mortem
`examination demonstrated a subacute myocarditis; and
`a 53-year-old, not previously treated patient, with a slight
`hemolytic anemia, developed a Pneumocystis carinii
`pneumonia evolving in ARDS five weeks after the
`fourth treatment and finally leading to death.
`
`Response
`
`All the FL patients were evaluable for response, while of
`the MCL patients two were not evaluable. The response
`rates at week 12 are reported in Table 3. Overall, the
`response rate was 52% for follicular lymphoma and 22%
`for mantle-cell lymphoma. A detailed analysis of the
`response status change between week 8 and week 12
`revealed that during these four weeks an improvement
`in response was seen for 7% of follicular and 3% of
`mantle-cell lymphoma patients, while a worsening of
`response status was seen in 9% of follicular and 14% of
`mantle-cell lymphoma patients. The role of a number of
`baseline values as predictors of response was evaluated,
`
`125
`
`including patient and disease characteristics, hemato-
`logic baseline values and lymphocyte subgroups. In the
`univariate analysis the presence of B symptoms, having
`received previous chemotherapy, a low hemoglobin and
`platelet value and an elevated LDH had an adverse
`prognostic value for response on FL patients, while for
`MCL patients only the hemoglobin value was predictive.
`In the multivariate analysis only the presence of B symp-
`toms and a low hemoglobin level remained significant
`for FL and no parameter remained predictive for MCL.
`The evolution of the lymphocyte subsets during and
`after treatment are reported in Figure 1. It appears that
`a significant decrease of B cells occurred after the first
`week of treatment, while T lymphocytes and their sub-
`sets remained constant.
`
`Molecular response
`
`Thirty-three of thirty-seven FL patients had t(14;18)
`PCR positive cells at baseline in either PB (« = 10) or
`PB and BM (n = 23). At restaging, conversion to neg-
`ativity of PCR was seen in the PB of 15 of 29 and in the
`BM of 5 of 23 FL cases. The search for cells carrying a
`BCL-1 rearrangement t(ll;14) in MCL patients was
`positive for 14 of 38 PB and 12 of 30 BM samples. At
`restaging conversion was seen in 5 of 12 positive PB and
`0 of 7 positive BM samples. For both rearrangements no
`correlation between molecular and clinical response
`could be established.
`
`Discussion
`
`This interim report of an ongoing randomized trial with
`Rituximab in patients with follicular and mantle-cell
`lymphoma describes the safety and efficacy of the treat-
`ment given before randomization in the first 120 patients.
`Two thirds of the cases had follicular lymphoma. For
`this disease, the trial confirms previous studies [2, 5],
`with an overall response rate of 52% and very few com-
`plete responses. We also confirm that response rate is
`independent from the amount of previous chemotherapy,
`an observation that renders this drug exceptional com-
`pared to other treatments. The almost absence of com-
`plete responses may be a sign that the drug is either not
`optimally exploited with this schedule, or that it will
`probably be best used in combination with other drugs.
`In MCL, to date no treatment have demonstrated to
`be of any help in obtaining cure or prolonging survival.
`New treatment modalities are continuously searched for
`this disease and Rituximab may be a step in this direc-
`tion. Others have found response rates of 35% [6, 7],
`which could be considered satisfactory for Rituximab
`monotherapy, but the response rate in our cohort of MCL
`is only 22%. In all the cohorts studied the majority of
`patients were pretreated, but this may not be an explan-
`ation for the low response rate, because in the present
`study denovo patients had the same response proportion
`as pretreated patients. A relative difficulty in diagnosing
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`the disease could eventually be called upon, since our
`cases were all reviewed, but in fact only three were
`found not to be compatible with the original local
`pathologist's diagnosis. Therefore, even though in the
`other two studies there was no formal pathology review,
`the probability that many of the MCL patients actually
`had a disease more sensible to Rituximab is unlikely.
`Whichever response rate will turn out correct in the
`future, the rate of success of this drug ranges between
`20% and 35% and will therefore not be, by itself, the
`solution to the treatment of mantle-cell lymphoma.
`Nevertheless the drug is active, and its role in combina-
`tion therapy for the treatment of MCL should be studied
`further.
`The molecular biology analysis results show for both
`diseases that only a minority of positive bone marrows
`became negative after monoclonal antibody treatment.
`The rates of molecular responses after chemotherapy are
`higher [10], so that the hypothesis of using Rituximab
`to minimize minimal residual disease may be too opti-
`mistic. Nevertheless, a much higher molecular response
`was seen in the blood compared to the bone marrow for
`both BCL-2 and BCL-1 translocations, confirming the
`adequacy of ongoing trials in which the monoclonal
`antibody is administered in combination with chemo-
`therapy before peripheral blood stem-cell mobilization
`and collection.
`A final consideration should be on toxicity. Even
`though the treatment was overall very well tolerated,
`with only few minor systemic side effects during treat-
`ment, the occurrence of four toxic deaths (three of which
`probably of cardiac origin) and of several other serious
`adverse events (among which a cardiac one) raise some
`concern on the safety of this drug, which was initially
`thought to be absolutely innocuous. Even though a
`possible cardiotoxicity was not known at the moment of
`the trial start, subsequent information raised the possi-
`bility that the drug could be directly cardiotoxic. Un-
`fortunately, only in one of our cases an autopsy was
`performed, but this one showed that a subacute myo-
`carditis was present as a possible cause of cardiac
`rhythm disturbance. Since our observed cases were of
`different ages, had different cardiac histories and different
`previous treatments, it is currently not possible to iden-
`tify a subset of patients at risk. It must nevertheless be
`emphasized that all patients entering clinical trials or
`receiving routine treatment with Rituximab should be
`informed that such events occurred and that medical
`advice should immediately be seaked in case of cardiac
`symptoms.
`
`Acknowledgements
`
`This study was made possible by an unrestricted research
`grant from Roche Pharma (Schweiz) AG, Basle. We thank
`Mrs M. Bacchi, statistician, Mrs U. Waltzer and P. Katz,
`data managers, and Mrs P. Tamasy and M. Gisi, labora-
`tory techniciens, for their substantial contribution to the
`success of this ongoing study.
`
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`Correspondence to:
`M. Ghielmini, MD
`Istituto Oncologico della Svizzera Italiana
`Department of Medical Oncology
`Ospedale Civico
`6900 Lugano, Switzerland
`E-mail: mghielmini(aticino.com
`
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