Bendamustine Hydrochloride and Rituximab With or Without Bortezomib Followed by Rituximab With or Without Lenalidomide in Treating Patients With High-Risk Stage II, Stage III, or Stage IV Follicular Lymphoma

OBJECTIVES:

Primary

- To compare the complete remission rate in patients with high-risk follicular lymphoma
receiving induction therapy comprising bendamustine hydrochloride and rituximab with vs
without bortezomib.

- To compare the 1-year post-induction disease-free survival rate in patients receiving
continuation therapy comprising rituximab with vs without lenalidomide.

Secondary

- To determine the 3-year progression-free survival and the 5-year overall survival of
these patients.

- To evaluate patient-reported outcomes at baseline and during treatment to determine
differences in symptom palliation, treatment-related symptoms, and overall
health-related quality of life.

- To examine the association between baseline FLIPI information and outcome of these
patients.

- To examine the association between baseline and end-of-treatment patient comorbidities
assessed by the Cumulative Illness Rating Scale (CIRS) and outcome.

- To create an image and tissue bank including serial PET/CT scans, diagnostic
paraffin-embedded tissue, germline DNA, and serial blood and bone marrow samples
sufficient to support proposed and future studies of tumor and host characteristics that
may predict for clinical outcome, including treatment arm effects, and enhance existing
prognostic indices. (exploratory)

OUTLINE: Patients are stratified according to FLIPI-1score (1 or 2 vs 3 vs 4 or 5) and GELF
tumor burden (low vs high). Patients are randomized to 1 of 3 treatment arms.

- Arm I: Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1
hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of
disease progression or unacceptable toxicity.

Beginning 4 weeks after the completion of induction therapy, patients receive rituximab IV on
day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or
unacceptable toxicity.

- Arm II: Patients receive rituximab IV on day 1; bortezomib IV on days 1, 4, 8, and 11;
and bendamustine hydrochloride IV over 1 hour on days 1 and 4. Treatment repeats every
28 days for 6 courses in the absence of disease progression or unacceptable toxicity.

Beginning 4 weeks after the completion of induction therapy, patients receive rituximab as in
arm I.

- Arm III: Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1
hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of
disease progression or unacceptable toxicity.

Immediately after completing induction therapy, patients receive oral lenalidomide on days
1-21. Treatment repeats every 4 weeks for 13 courses in the absence of disease progression or
unacceptable toxicity. Beginning 4 weeks after the completion of induction therapy, patients
receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of
disease progression or unacceptable toxicity.

Quality of life (including fatigue, neurotoxicity, anxiety, and depression) is assessed by
questionnaire at baseline and periodically during study therapy.

Blood, bone marrow, and tissue samples may be collected periodically for correlative studies
and for a repository.

After completion of study therapy, patients are followed up periodically for 15 years.

DISEASE CHARACTERISTICS:

- Histologically confirmed (biopsy-proven) diagnosis of follicular B-cell non-Hodgkin
lymphoma with no evidence of transformation to large cell histology

- Patients having both diffuse and follicular architectural elements are eligible
if the histology is predominantly follicular (i.e., ≥ 50% of the cross-sectional
area) and there is no evidence of transformation to a large cell histology

- Diagnostic confirmation (i.e., core needle or excisional lymph node biopsy)
required if the interval since tissue diagnosis of low-grade malignant lymphoma
is > 24 months

- Bone marrow biopsy alone not acceptable

- Stage II, III, or IV AND grade 1, 2, or 3a disease

- Must meet criteria for High Tumor Burden (higher risk) as defined by either the Groupe
D'Etude des Lymphomes Follicularies (GELF) criteria OR the follicular lymphoma
international prognostic index (FLIPI) as defined below:

- Patient must meet ≥ 1 of the following GELF criteria:

- Nodal or extranodal mass ≥ 7 cm

- At least 3 nodal masses > 3.0 cm in diameter

- Systemic symptoms due to lymphoma or B symptoms

- Splenomegaly with spleen > 16 cm by CT scan

- Evidence of compression syndrome (e.g., ureteral, orbital, gastrointestinal)
or pleural or peritoneal serous effusion due to lymphoma (irrespective of
cell content)

- Leukemic presentation (≥ 5.0 x 10^9/L malignant circulating follicular
cells)

- Cytopenias (polymorphonuclear leukocytes < 1.0 X 10^9/L, hemoglobin < 10
g/dL, and/or platelets < 100 x 10^9/L)

- Patient must have a FLIPI-1 score of 3, 4, or 5 (1 point per criterion below):

- Age ≥ 60 years

- Stage III-IV disease

- Hemoglobin level < 12 g/dL

- > 4 nodal areas

- Serum LDH level above normal

- At least 1 objective measurable disease parameter

- Baseline measurements and evaluations (PET and CT) obtained within 6 weeks of
randomization

- Measurable disease in the liver is required if the liver is the only site of
lymphoma

PATIENT CHARACTERISTICS:

- See Disease Characteristics

- ECOG performance status 0-2

- ANC ≥ 1,500/mm³ (includes neutrophils and bands)

- Platelet count ≥ 100,000/mm³

- Creatinine ≤ 2.0 mg/dL

- AST and ALT ≤ 5 x upper limit of normal (ULN)

- Alkaline phosphatase ≤ 5 x ULN

- Total bilirubin ≤ 1.5 x ULN (patients with known Gilbert disease should contact the
study PI)

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use 2 effective methods (1 highly effective and 1 additional
effective method) of contraception ≥ 28 days before, during, and for ≥ 28 days after
completing study treatment

- HIV-positive patients must meet all of the following criteria:

- HIV is sensitive to antiretroviral therapy

- Must be willing to take effective antiretroviral therapy if indicated

- No history of CD4 < 300 cells/mm³ prior to or at the time of lymphoma diagnosis

- No history of AIDS-defining conditions

- If on antiretroviral therapy, must not be taking zidovudine or stavudine

- Must be willing to take prophylaxis for Pneumocystis jiroveci pneumonia (PCP)
during therapy and ≥ 2 months following completion of study therapy or until the
CD4 cells recover to over 250 cells/mm³

- No recent history of malignancy except for adequately treated basal cell or squamous
cell skin cancer, in situ cervical cancer, or other cancer for which the patient has
been disease-free for ≥ 2 years

- No active, uncontrolled infections (afebrile for > 48 hours off antibiotics)

- No ≥ grade 2 neuropathy

- No myocardial infarction within the past 6 months

- No NYHA class III-IV heart failure, uncontrolled angina, severe uncontrolled
ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active
conduction system abnormalities

- No serious medical or psychiatric illness likely to interfere with participation in
this clinical study

- No known hypersensitivity to boron or mannitol

- No chronic carriers of hepatitis B virus (HBV) with positive hepatitis surface antigen
(HBsAg +)

- Patients with a prior history of HBV infection, but immune, with only IgG
hepatitis core antibody positive (HBcAb+), must receive antiviral prophylaxis
(e.g., lamivudine 100 mg po daily) for ≥ 1 week prior to course 1 and throughout
induction and continuation therapy and for ≥ 12 months after the last rituximab
dose

- Must register into the mandatory RevAssist® program and be willing and able to comply
with the requirements of RevAssist® (for patients randomized to arm III)

PRIOR CONCURRENT THERAPY:

- No prior chemotherapy, radiotherapy, or immunotherapy for lymphoma

- Prednisone or other corticosteroids used for non-lymphomatous conditions will not
be considered as prior chemotherapy

- A prior/recent short course (< 2 weeks) of steroids for symptom relief of
lymphoma-related symptoms is allowed