Biaxin Based Antibiotic Therapy in Previously Untreated, Advanced Stage Indolent Lymphoma

The primary objective of this study is to evaluate a biaxin (clarithromycin)-based
antibiotic therapy in previously untreated patients with indolent lymphoma who do not
require active lymphoma therapy (utilizing GELF criteria,). This is the primary objective
Response rate (CR + PR) stratified for Follicular/Non-Follicular disease.

The secondary objectives of this study are to understand the biologic correlates of indolent
lymphoma biaxin (clarithromycin) response and progression:

Response rate (CR + PR) according to H. pylori positive or negative (RR with a confidence
interval will be estimated for each subset). Immunohistochemistry in all diagnostic biopsy
specimens: Lymphocyte- Activated Macrophage (CD68) and other selected markers to clarify
tumor infiltrating cells. Peripheral blood mononuclear cell (PBMCs) studies to evaluate
possible HDAC (histone deacetylase) inhibition with biaxin (clarithromycin) therapy.

Inclusion Criteria:

- Histologically confirmed diagnosis of follicular lymphoma: grades I, II, or IIIA, or
non-follicular lymphoma: lymphoplasmacytoid lymphoma, small lymphocytic lymphoma,
marginal B-cell lymphoma, or MALT lymphoma (as defined in the WHO classification1) as
reviewed by a hematopathologist at Memorial Hospital.

- Staging fulfills criteria for no initial treatment according to GELF criteria for
advanced stage disease. None of the following should be present:

- A nodal or extranodal mass with a diameter of >7 cm,

- Involvement of at least three nodal sites [each with a diameter of >3 cm],

- Systemic symptoms,

- Symptomatic splenomegaly,

- Ureteral compression.

- No prior treatment for lymphoma is permitted.

- Measurable disease is required.

- Karnofsky performance status > 70%

- The patient may not have a previous history of radiation therapy.

- Patient or guardian must be able to sign voluntary written consent.

- Male or female patients 18 years of age or greater.

Exclusion Criteria:

- Allergy to biaxin (clarithromycin), erythromycin, or other macrolide antibiotic.
Patients requiring use of ergot derivatives, pimozide, cisapride, or astemizole;
combination with ranitidine bismuth citrate should not be used in patients with
history of acute porphyria or CrCl <25 mL/minute.

- Prior treatment with Biaxin (clarithromycin) during the prior 6 months.

- Histologic diagnosis of follicular grade 3B or aggressive non-Hodgkin's lymphoma.

- Histologic evidence of transformation from low grade/indolent NHL to aggressive NHL.

- Prior treatment for non-Hodgkin's lymphoma.

- Regional lymphoma (peripheral stages I and II) eligible for involved field
irradiation.

- GELF criteria21 for institution of systemic chemotherapy, which includes:

- A nodal or extranodal mass with a diameter of >7 cm,

- Involvement of at least three nodal sites [each with a diameter of >3 cm],

- Systemic symptoms,

- Symptomatic splenomegaly,

- Ureteral compression.

- Patients with a known history of HIV, Hepatitis B or C seropositivity.

- Patients who require therapy with systemic corticosteroids.

- Prior history of malignancy within the past five years or a concurrent malignancy,
with the exceptions of cutaneous basal cell carcinoma or carcinoma in situ of the
uterine cervix.

- Pregnant or lactating women, since imaging cannot be done in this setting.18