R-ABVD vs ABVD-RT in Early Stage Hodgkin's Lymphoma

Sponsor

Fondazione Michelangelo (Other)

Overall Status

Terminated

CT.gov ID

NCT00992030

Collaborator

(none)

112

Enrollment

Locations

Arms

113.9

Duration (Months)

10.2

Patients Per Site

0.1

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Combined modality therapy has then emerged as the standard of care for limited-stage Hodgkin's lymphoma and doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy that is devoid of alkylating agents and associated with a low potential for gonadal toxicity and leukemogenesis, is currently considered a gold standard. Nevertheless, the disadvantage to combine radiotherapy to ABVD is represented by late cardiovascular events (myocardial dysfunction and coronary or valvular disease), especially when the heart is within the radiation field; bleomycin pulmonary toxicity also is increased in conjunction with RT and secondary tumors, in particular in the RT fields. This study aims at treating patients with limited disease with multiagent chemotherapy alone, without irradiation, and using radiotherapy only for relapses.

Condition or Disease	Intervention/Treatment	Phase
Hodgkin Lymphoma	Drug: Rituximab Radiation: Involved field irradiation	Phase 3

Detailed Description

Limited-stage Hodgkin lymphoma is a highly curable disease, with expected long-term disease-free and overall survival rates close to 90% and 95%, respectively. This success has come at a cost of long-term treatment-related toxicity, such that the patients who live beyond 10 to 15 years are more likely to die from late complications of treatment than from the disease itself. In the last decades efforts to improve long-term results have been made by developing curative strategies aimed to reduce toxicity while maintaining high cure rates. Based on the observation that systemic chemotherapy can control occult sites of the disease, thereby eliminating the requirement for staging laparotomy, in the last years the use of combined modalities that allowed a reduction of number of cycles of chemotherapy and of radiation field size and doses, thus reducing late toxicity was investigated in various clinical trials. Combined modality therapy has then emerged as the standard of care for limited-stage Hodgkin's lymphoma and doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy that is devoid of alkylating agents and associated with a low potential for gonadal toxicity and leukemogenesis, is currently considered the gold standard. Nevertheless, optimal treatment is still a question of debate and current investigations are now taking into consideration to further reduce long-term toxicity. Actually two main options are available. The first option combines radiotherapy to ABVD chemotherapy, with the aim to maximize disease control. Using 4 cycles of ABVD followed by involved field radiotherapy at 36 Gy, Bonadonna and coworkers first documented a 94% freedom-from-progression and a 94% overall survival rate, respectively. The disadvantage with this approach is represented by late cardiovascular events (myocardial dysfunction and coronary or valvular disease), especially when the heart is within the radiation field; bleomycin pulmonary toxicity also is increased in conjunction with RT and secondary tumors, in particular in the RT fields. Whether these risks will be lower with fewer chemotherapy cycles, lower RT doses, or both has been studied in many clinical trials that have demonstrated that smaller radiation fields and lower doses are important, but a key unanswered question is whether RT can be eliminated completely in limited-stage patients. The second option therefore consists of chemotherapy with ABVD alone, with the aim to eliminate the late effects of radiotherapy. This approach have resulted in an absolute increase of the failure rate in the order of 8% (from approximately 4% up to 12%). However, the majority of relapsing patients achieves a durable disease control with a second-line radiation-containing combined approach, and shows an overall survival rate superimposable to that of patients receiving upfront combined strategy with chemo-radiotherapy. We thus designed a study aimed at treating patients with limited disease with multiagent chemotherapy alone, without irradiation, and using radiotherapy only for relapses. In fact, it has recently been reported that the addition of Rituximab (a monoclonal antibody directed against the CD20 B-cell antigens) to ABVD significantly increases the antilymphoma activity of ABVD alone in advanced-stage Hodgkin's lymphoma and in absence of added toxicity. In conclusion, rituximab-supplemented ABVD (R-ABVD) given to early-stage Hodgkin's lymphoma might represent a radiation-free regimen capable of increasing long-term disease control of ABVD alone, while avoiding the late effects of radiotherapy.

The primary objective of this study is to evaluate whether the R-ABVD therapy (ARM A) is not worse than the standard therapy of ABVD-RT (ARM B) in patients with limited Hodgkin's lymphoma. In this trial a maximum inferiority of 8% of the 3-year Failure Free Survival rate (FFS) in ARM A with respect to ARM B is considered acceptable to assess that ARM A is not worse than ARM B.

Study Design

Study Type:

Interventional

Actual Enrollment :

112 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Phase III Study Comparing Rituximab-supplemented ABVD (R-ABVD) With ABVD Followed by Involved-field Radiotherapy (ABVD-RT) in Limited Stage (Stage I-IIA With no Areas of Bulk) Hodgkin's Lymphoma

Study Start Date :

Sep 1, 2009

Actual Primary Completion Date :

Mar 1, 2019

Actual Study Completion Date :

Mar 1, 2019

Arms and Interventions

Arm	Intervention/Treatment
Experimental: ARM A Rituximab plus ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) for 4 cycles	Drug: Rituximab I.V. infusion weekly x 6 weeks at a dose of 375 mg/m2 Other Names: Drug: rituximab Drug: ABVD regimen Drug: doxorubicin hydrocloride Drug: bleomycin Drug: vinblastine Drug: dacarbazine
Active Comparator: ARM B ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) for 4 cycles followed by involved field irradiation	Radiation: Involved field irradiation Radiation therapy, limited to initially involved nodal sites, will start within four weeks from the last cycle of ABVD chemotherapy and after complete restaging with TAC total-body and PET total-body. The planned total dose is 30,6 Gy. Other Names: Drug: ABVD regimen Drug: doxorubicin hydrochloride Drug: bleomycin Drug: vinblastine Drug: dacarbazine Radiation: radiation therapy

Arm

Intervention/Treatment

Experimental: ARM A

Rituximab plus ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) for 4 cycles

Drug: Rituximab

I.V. infusion weekly x 6 weeks at a dose of 375 mg/m2

Other Names:

Drug: rituximab

Drug: ABVD regimen

Drug: doxorubicin hydrocloride

Drug: bleomycin

Drug: vinblastine

Drug: dacarbazine

Active Comparator: ARM B

ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) for 4 cycles followed by involved field irradiation

Radiation: Involved field irradiation

Radiation therapy, limited to initially involved nodal sites, will start within four weeks from the last cycle of ABVD chemotherapy and after complete restaging with TAC total-body and PET total-body. The planned total dose is 30,6 Gy.

Other Names:

Drug: ABVD regimen

Drug: doxorubicin hydrochloride

Drug: bleomycin

Drug: vinblastine

Drug: dacarbazine

Radiation: radiation therapy

Outcome Measures

Primary Outcome Measures

3-year failure free survival. Failure is defined as disease progression during treatment, achievement of less than complete remission (CR) after the total planned therapy, relapse during follow-up or death from any cause. [Three-year failure free survival from randomization]

Secondary Outcome Measures

Event-free survival including, besides failures, late serious treatment-related events [7 years from randomization]
Overall survival, all causes included [7 year from randomozation]

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

History of histologically confirmed classical Hodgkin lymphoma (cHL)
Limited-stage disease defined as stage I or IIA with no areas of bulky disease
Measurable disease according to the Cheson criteria
Age >=18 years
Adequate bone marrow reserve (ANC >= 1,500/uL, Platelet > 100,000/uL)
LVEF >= 50% by MUGA scan or echocardiogram
Serum creatinine < 2 mg/dl, serum bilirubin < 2 mg/dl, AST or ALT <2x ULN
Bi-dimensionally measurable disease
Use of effective means of contraception
Signed informed consent form

Exclusion Criteria:

Lymphocyte predominant HL
Prior chemotherapy or radiation therapy
Severe pulmonary disease as judged by the PI including COPD and asthma
Presence of CNS lymphoma
Concomitant malignancies or previous malignancies (exception made for adequately treated basal or squamous cell carcinoma of the skin)
Active infection requiring treatment with intravenous therapy
Known HIV infection
Active hepatitis B or C
Pregnancy or lactation and women of child bearing age who are not practicing adequate contraception

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	UT MD Anderson Cancer Center	Houston	Texas	United States	77030
2	Ospedali Riuniti Umberto I	Ancona		Italy	60020
3	Ospedali Riuniti	Bergamo		Italy	24100
4	Policlinico S. Orsola Malpighi	Bologna		Italy	40138
5	Ospedale Roberto Binaghi	Cagliari		Italy	09126
6	Azienda Ospedaliera Vittorio Emanuele Ferrarotto	Catania		Italy	95124
7	Fondazione IRCCS Istituto Nazionale Tumori	Milano		Italy	20133
8	Azienda Ospedaliero Universitaria S. Luigi Gonzaga	Orbassano		Italy	10043
9	Gianpietro Semenzato	Padova		Italy	35128
10	Ospedali Riuniti Villa Sofia Cervello	Palermo		Italy	90146
11	Ospedale San Carlo	Potenza		Italy	85100