Lenalidomide and Rituximab in Treating Patients With Previously Untreated Stage II, Stage III, or Stage IV Follicular Non-Hodgkin Lymphoma

PRIMARY OBJECTIVES:

I. To determine the response rate (overall and complete) to lenalidomide + rituximab in
follicular non-Hodgkin lymphoma (NHL) patients who have received no prior systemic therapy.

II. To determine the time to progression after lenalidomide + rituximab in previously
untreated patients with cluster of differentiation (CD)20+ follicular NHL.

SECONDARY OBJECTIVES:

I. To determine the toxicity profile of lenalidomide + rituximab therapy in previously
untreated patients with CD20+ follicular NHL.

II. To establish whether the therapeutic effects of lenalidomide + rituximab combination are
sufficiently promising to warrant evaluation in a subsequent randomized trial (in comparison
to rituximab alone).

III. To correlate fragment crystallizable gamma (Fcg) receptor polymorphism profiling with
response to lenalidomide + rituximab in previously untreated patients with follicular NHL.

IV. To determine the impact of lenalidomide on immune parameters in patients with previously
untreated follicular lymphoma.

V. To determine the impact of lenalidomide on angiogenic parameters in patients with
previously untreated follicular lymphoma.

VI. To correlate lymphoma-associated macrophages (LAM) and forkhead box P3 (FOXP3), granzyme
B (GzB), CD10, multiple myeloma oncogene 1 (MUM1), and B-cell lymphoma 2 (BCL2) expression
with response to rituximab + lenalidomide in previously untreated patients with follicular
lymphoma.

VII. Determine whether immune gene signatures previously identified as prognostic factors in
follicular lymphoma (FL) can be applied to paraffin-embedded tissues in rituximab treated
patients; evaluate micro ribonucleic acid (RNA) signatures associated with these gene
signatures and outcome; to validate immunohistochemical markers associated with outcome in FL
(CD68 LAMs, FOXP3, CD10, BCL6, FOXP1, MUM1); and investigate whether markers of angiogenesis
may be of value in prognosis of FL.

OUTLINE:

Patients receive lenalidomide orally (PO) once daily (QD) on days 1-21. Treatment with
lenalidomide repeats every 28 days for 12 courses in the absence of disease progression or
unacceptable toxicity. Patients also receive rituximab intravenously (IV) on days 1, 8, 15,
and 22 and on weeks 13, 21, 29, and 37 in the absence of disease progression or unacceptable
toxicity.

After completion of study treatment, patients are followed up every 4 months for 2 years and
then every 6 months for up to 8 years.

Inclusion Criteria:

- Previously untreated, histologically confirmed follicular lymphoma, World Health
Organization (WHO) classification grade 1, 2, or 3a (> 15 centroblasts per high power
field with centrocytes present) that is stage III, IV, or bulky (i.e., single mass >=
7 cm in any uni-dimensional measurement) stage II

- Bone marrow biopsies as the sole means of diagnosis are not acceptable, but they
may be submitted in conjunction with nodal biopsies; fine needle aspirates are
not acceptable for diagnosis

- Failure to submit pathology specimens within 60 days of patient registration will
be considered a major protocol violation

- Institutional flow cytometry or immunohistochemistry must confirm CD20 antigen
expression

- Low or intermediate risk by Follicular Lymphoma International Prognostic Index
(FLIPI): 0-2 risk factors

- No prior systemic therapy for NHL, including chemotherapy or immunotherapy (e.g.,
monoclonal antibody-based therapy); patients may have received involved-field
radiation therapy

- No corticosteroids within two weeks prior to study entry, except for maintenance
therapy for a non-malignant disease

- Eastern Cooperative Oncology Group (ECOG) performance status =< 2

- Measurable disease must be present either on physical examination or imaging studies;
non-measurable disease alone is not acceptable; any tumor mass > 1 cm is acceptable

- Lesions that are considered non-measurable include the following:

- Bone lesions (lesions if present should be noted)

- Ascites

- Pleural/pericardial effusion

- Lymphangitis cutis/pulmonis

- Bone marrow (involvement by NHL should be noted)

- No known central nervous system (CNS) involvement by lymphoma

- Patients with human immunodeficiency virus (HIV) infection are eligible, provided they
meet the following

- No evidence of coinfection with hepatitis B or C

- CD4+ cell count >= 400/mm^3

- No evidence of resistant strains of HIV

- If not on anti-HIV therapy, HIV viral load < 10,000 copies HIV RNA/mL

- If on anti-HIV therapy, HIV viral load < 50 copies HIV RNA/mL

- No history of acquired immune deficiency syndrome (AIDS)-defining conditions

- No evidence of active hepatitis B or C infection (i.e., no positive serology for
anti-hepatitis B core [HBc] or anti-hepatitis C virus [HCV] antibodies); hepatitis B
virus (HBV) seropositive patients (hepatitis B surface antigen positive [HBsAg +]) are
eligible if they are closely monitored for evidence of active HBV infection by HBV
deoxyribonucleic acid (DNA) testing and receive suppressive therapy with lamivudine or
other HBV suppressive therapy until 6 months after the last rituximab dose

- Patients with a history of erythema multiforme, toxic epidermal necrolysis or
Stevens-Johnson syndrome are not eligible

- Patients with uncontrolled seizures are not eligible

- Patients with an autoimmune disorder requires active immunosuppression are not
eligible

- Non-pregnant and non-nursing; 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 registration; further, they 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 starting lenalidomide; FCBP must also agree to ongoing
pregnancy testing; men must agree to use a latex condom during sexual contact with a
FCBP, even if they have had a successful vasectomy; a FCBP is a sexually mature woman
who: 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 preceding 24 consecutive months); all patients must be counseled by a trained
counselor every 28 days about pregnancy precautions and risks of fetal exposure

- No known human anti-chimeric antibody (HACA) positivity

- Absolute neutrophil count (ANC) >= 1,000/microliter

- Platelet count >= 75,000/microliter

- Creatinine clearance >= 30 mL/min unless attributable to NHL; to be calculated by
method of Cockcroft-Gault, using actual weight; maximum creatinine clearance (CrCl)
125 mL/min

- Total bilirubin =< 2 times upper limit of normal (ULN) unless attributable to NHL or
Gilbert disease