Rituximab and Combination Chemotherapy With or Without Lenalidomide in Treating Patients With Newly Diagnosed Stage II-IV Diffuse Large B Cell Lymphoma
Rituximab and Combination Chemotherapy With or Without Lenalidomide in Treating Patients With Newly Diagnosed Stage II-IV Diffuse Large B Cell Lymphoma
This randomized phase II trial studies how well rituximab and combination chemotherapy with
 or without lenalidomide work in treating patients with newly diagnosed stage II-IV diffuse
 large B cell lymphoma. Monoclonal antibodies, such as rituximab, may interfere with the
 ability of cancer cells to grow and spread. Drugs used in chemotherapy, such as
 cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone, work in
 different ways to stop the growth of cancer cells, either by killing the cells, by stopping
 them from dividing, or by stopping them from spreading. Lenalidomide may stimulate the immune
 system in different ways and stop cancer cells from growing. It is not yet known whether
 rituximab and combination chemotherapy are more effective when given with or without
 lenalidomide in treating patients with diffuse large B cell lymphoma.
PRIMARY OBJECTIVES:

 I. Progression-free survival (PFS).

 SECONDARY OBJECTIVES:

 I. Response rate (RR). II. Complete remission (CR) rate as defined by positron emission
 tomography (PET)-computed tomography (CT) criteria.

 III. Overall survival (OS).

 TERTIARY OBJECTIVES:

 I. Impact of diffuse large B cell lymphoma (DLBCL) molecular subtype on outcome.

 II. Interim PET scan results in relation to treatment outcome.

 OUTLINE: Patients are randomized to 1 of 2 treatment arms.

 ARM A: Patients receive rituximab intravenously (IV), cyclophosphamide IV, doxorubicin
 hydrochloride IV, and vincristine sulfate IV on day 1; prednisone orally (PO) on days 1-5;
 and lenalidomide PO on days 1-10. Treatment repeats every 21 days for 6 courses in the
 absence of disease progression or unacceptable toxicity.

 ARM B: Patients receive rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine
 sulfate, and prednisone as in Arm A. Treatment repeats every 21 days for 6 courses in the
 absence of disease progression or unacceptable toxicity.

 After completion of study treatment, patients are followed up every 3 months for 2 years,
 every 6 months for 1 year, and then annually for up to 7 years.
Inclusion Criteria:

 -  PRE-REGISTRATION (STEP 0)

 -  Histologically confirmed DLBCL expressing CD20 antigen; patients with transformed
 lymphoma are excluded; in this regard, patients with composite lymphoma in the
 diagnostic tissue (concomitant DLBCL and follicular or other low-grade lymphoma
 component) are excluded; however, patients with DLBCL in primary diagnostic tissue but
 a bone marrow that shows low grade or indeterminate lymphoma are eligible; patients
 with known primary mediastinal large B-cell lymphoma (PMLBCL) are excluded; similarly,
 patients with known c-myc translocation (by fluorescence in situ hybridization)
 positive DLBCL are encouraged to participate in trials specifically designed for these
 patients; however patients with known c-myc DLBC positive are NOT excluded from this
 study; c-myc testing prior to study enrollment is NOT required

 -  Stages II bulky disease (defined as mass size of more than 10 cm), stage III, or IV
 (Ann Arbor staging); patients with stage I and stage II non-bulky disease are excluded
 from this study

 -  A paraffin-embedded tumor tissue specimen from the initial diagnostic biopsy has been
 located and ready to ship to the Mayo Clinic Lymphoma Laboratory following
 pre-registration; Note: excisional tumor biopsy is preferred; core needle biopsies
 will be considered adequate if there is enough tissue for the mandatory central
 pathology review immunohistochemistry and Genomics Education Partnership (GEP);
 submission of a tumor block is preferred, but if unavailable submit alternative
 materials

 -  Eastern Cooperative Oncology Group (ECOG) performance status 0-2

 -  Previously untreated and not receiving any other agent that would be considered as a
 treatment for the lymphoma; for subjects with severe systemic symptoms, compressive
 disease, or rapidly progressing symptomatic adenopathy, are allowed for lymphoma
 associated symptom treatment with up to 1 mg/kg/day prednisone, or equivalent, for a
 maximum of 7 days is permitted prior to beginning the treatment, at the discretion of
 the investigator; a washout period does not apply

 -  No known central nervous system (CNS) lymphoma or cerebrospinal fluid involvement with
 malignant lymphoma cells; these patients are usually treated with CNS directed
 therapy; screening for cerebrospinal fluid (CSF)/CNS involvement is NOT required but
 can be performed per treating medical doctor (MD) discretion; intrathecal (IT)
 methotrexate or IT cytarabine prophylaxis in patients with negative CSF who are felt
 to be at high risk of CNS relapse is allowed per local MD discretion; this should be
 noted on the treatment form

 -  Absence of history of myocardial infarction =< 6 months, or congestive heart failure
 requiring use of ongoing maintenance therapy for life-threatening ventricular
 arrhythmias

 -  Absence of history of deep venous thrombosis/embolism, threatening thromboembolism or
 known thrombophilia; patients with a history of deep vein thrombosis(DVT)/pulmonary
 embolism (PE) or thrombophilia may participate if they are willing to be on full
 anticoagulation during the treatment if randomized to rituximab, cyclophosphamide,
 doxorubicin hydrochloride, vincristine sulfate, and prednisone (R2CHOP) arm A; full
 anticoagulation is defined as warfarin, factor X inhibitors, or low molecular weight
 heparin at therapeutic doses

 -  Patient must be able and willing to receive anticoagulation therapy with aspirin
 70-325 mg daily prophylaxis, low molecular weight heparin, factor X inhibitors or
 warfarin; patients unable or unwilling to take any prophylaxis are NOT eligible

 -  Absence of history of acquired immune deficiency syndrome (AIDS)-related conditions
 (other than the presenting DLBCL) or post-transplant lymphoproliferative disorder
 (PTLD) in immunocompromised patients; patients with human immunodeficiency virus (HIV)
 on antiretroviral therapy other than zidovudine (AZT) and/or stavudine and without
 prior AIDS defining conditions and adequate CD4 count (> 400) are eligible

 -  No other active malignancy requiring therapy such as radiation, chemotherapy, or
 immunotherapy; exceptions to this are as follows: localized non-melanotic skin cancer
 and any cancer that in the judgment of the investigator has been treated with curative
 intent and will not interfere with the study treatment plan and response assessment

 -  No history of radiation therapy to >= 25% of the bone marrow for other diseases or
 history of anthracycline therapy

 -  Patients must not be receiving erythroid stimulating agents (EPO: Procrit, Aranesp)

 -  RANDOMIZATION (STEP 1)

 -  Patient meets the eligibility criteria outlined above

 -  Site has received notification from Mayo Clinic - Rochester Division of
 Hematopathology of the central confirmation of diagnosis and tissue adequacy for
 mandatory research studies

 -  Patients must have measurable disease (at least 1 lesion of >= 1.5 cm in one diameter)
 as detected by computed tomography (CT) or the CT images of the positron emission
 tomography (PET)/CT

 -  International Prognostic Index (IPI) of 2 or greater

 -  Ejection fraction of >= 45% by either multi-gated acquisition (MUGA) scan or
 echocardiogram (ECHO)

 -  Absence of co-morbid systemic illnesses or other severe concurrent disease which, in
 the judgment of the investigator, would make the patient inappropriate for entry into
 this study or interfere significantly with the proper assessment of safety and
 toxicity of the prescribed regimens, including, but not limited to, ongoing or active
 infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
 arrhythmia, or psychiatric illness/social situations that would limit compliance with
 study requirements

 -  Absolute neutrophil count (ANC) >= 1500

 -  Platelets (PLT) >= 100,000

 -  Total bilirubin =< 1.5 x upper limit of normal (ULN) or if total bilirubin is > 1.5 x
 ULN, the direct bilirubin must be normal

 -  Alkaline (Alk.) phosphatase =< 3 x ULN unless evidence of the direct liver involvement
 by lymphoma - then =< 5 x ULN

 -  Aspartate aminotransferase (AST) =< 3 x ULN unless evidence of the direct liver
 involvement by lymphoma - then =< 5 x ULN

 -  Creatinine =< 2 x ULN or creatinine clearance (CrCl) > 30 ml/min

 -  Women must not be pregnant or breast-feeding

 -  Females of childbearing potential (FCBP) must have a negative serum or urine pregnancy
 test with a sensitivity of at least 25 mIU/mL within 10-14 days prior to and again
 within 24 hours of starting lenalidomide and must either commit to continued
 abstinence from heterosexual intercourse or begin TWO acceptable methods of birth
 control, one highly effective method and one additional effective method AT THE SAME
 TIME, at least 28 days before she starts taking lenalidomide; FCBP must also agree to
 ongoing pregnancy testing; a female of childbearing potential is any woman, regardless
 of sexual orientation or whether they have undergone tubal ligation, who meets the
 following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or
 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has
 had menses at any time in the preceding 24 consecutive months)

 -  Men must agree to use a latex condom during sexual contact with a FCBP even if they
 have had a successful vasectomy; all patients must be counseled at a minimum of every
 28 days about pregnancy precautions and risks of fetal exposure