Clinical Protocol A PHASE II MULTICENTER NON-RANDOMIZED …filinf.it/wp-content/uploads/2010/02/Bril-06-protocollo... · 2020. 9. 18. · RELAPSED/REFRACTORY INDOLENT NON FOLLICULAR

1

Clinical Protocol

A PHASE II MULTICENTER NON-RANDOMIZED STUDY TO ASSESS SAFETY, TOXICITY AND CLINICAL ACTIVITY OF THE

ASSOCIATION OF BORTEZOMIB (VELCADE) WITH RITUXIMAB IN RELAPSED/REFRACTORY INDOLENT NON FOLLICULAR AND

MANTLE-CELL NON HODGKIN LYMPHOMA

Study ID IIL-BRIL06 Phase II

VELCADE® (bortezomib) for Injection INVESTIGATOR SPONSOR Gruppo Italiano Multiregionale per le Leucemie e i Linfomi (GIMURELL) ONLUS Address: corso Vittorio Emanuele II, 68 - 10122 Torino, phone +390115623887, fax +390115620756 Secretary: Sig.ra Lina De Masi, SC Ematologia 2, ASO S. Giovanni Battista, corso Bramante, 88 - 10126 Torino; phone: +390116335937/+390116335611; fax no.:+390116335611; e-mail: [email protected] STUDY COORDINATORS 1. Umberto Vitolo, M.D. (Principal Investigator) Address: SC Ematologia, Azienda Sanitaria Ospedaliera S. Giovanni Battista – TORINO Phone no.: 0039-011-6335937/6335550 Fax no.: 0039-011-6335611

2. Pierluigi Zinzani, M.D. (Co-investigator) Address: Cattedra di Ematologia, Istituto L e A Seragnoli, Università degli Studi – BOLOGNA Phone no.: 0039-051-6363680 Fax no.: 0039-051-398973

3. Patrizia Pregno, M.D. (Co-Investigator) Address: SC Ematologia, Azienda Sanitaria Ospedaliera S. Giovanni Battista – TORINO Phone no.: 0039-011-6335934 Fax no.: 0039-011-6335550

VELCADE: Clinical Protocol Sample

WRITING COMMITTEE AND SCIENTIFIC SUPPORT Intergruppo Italiano Linfomi (IIL)

1. Dr. Umberto Vitolo, Dr.ssa Patrizia Pregno, Prof. Eugenio Gallo, SC Ematologia,

Azienda Ospedaliera S. Giovanni Battista, Torino 2. Dr. Marco Ladetto, Cattedra di Ematologia, Università degli Studi di Torino,

Torino 3. Prof. Pier Luigi Zinzani, Cattedra di Ematologia, Università di Bologna, Bologna 4. Prof. Luca Baldini, Dipartimento di Ematologia ed Oncologia, Osp. Maggiore,

Milano 5. Prof. Angelo Michele Carella, Divisione di Ematologia I, Osp. San Martino,

Genova 6. Prof. Mario Lazzarino, Divisione di Oncoematologia, Policlinico San Matteo,

Pavia 7. Dr. Alessandro Levis, SC Ematologia, ASO SS Antonio e Biagio, Alessandria 8. Dr. Maurizio Martelli, Cattedra di Ematologia, Università La Sapienza, Roma 9. Prof.ssa Enrica Morra, U.O. Ematologia, Ospedale Niguarda Cà Granda, Milano 10. Dr. Giuseppe Rossi, SC Ematologia, ASO Spedali Civili, Brescia

REFERENCE LABORATORY FOR MOLECULAR BIOLOGY Responsible: Marco Ladetto, M.D. Address: Cattedra di Ematologia, Università degli Studi di Torino, Azienda Ospedaliera S. Giovanni Battista – TORINO Phone no.: 0039-011-6336884/6335329 Fax no.: 0039-011- 6963737 BIOMETRY

Responsible: Giovannino Ciccone, M.D. - Torino

Manuela Ceccarelli, M.D. - Torino

Annalisa Chiappella, M.D. - Torino Address: SCDU Epidemiologia dei Tumori – Università degli Studi di Torino e Azienda Sanitaria Ospedaliera S. Giovanni Battista – TORINO Phone no.: 0039-011-6336857 Fax no.: 0039-011- 6706692

HISTOPATOLOGY

Responsible: Stefano Pileri, M.D. – Anatomia Patologica, Istituto L e A Seragnoli, Università di Bologna – Bologna

Domenico Novero, M.D. – Anatomia Patologica II, Torino

Version 09/01/2007 2


Fabio Facchetti, M.D. – Anatomia Patologica, Brescia

PHARMACOVIGILANCE

Responsible: Alessandro Levis, M.D. – SC. Ematologia, Azienda Ospedaliera S.

Antonio e Biagio, Alessandria

Date: [09/01/2007 Emendamento N° 1]

Confidentiality Statement The information in this document contains trade secrets and commercial information that are privileged or confidential and may not be disclosed unless such disclosure is required by applicable law or regulations. In any event, persons to whom the information is disclosed must be informed that the information is privileged or confidential and may not be further disclosed by them. These restrictions on disclosure will apply equally to all future information supplied to you that is indicated as privileged or confidential.

Version 09/01/2007 3


TABLE OF CONTENTS

INVESTIGATOR AGREEMENT................................................................................................ 6 1. INTRODUCTION................................................................................................................... 7

1.1. Background ........................................................................................................... 7 1.2. Overall Rationale for the Study ........................................................................... 21

2. OBJECTIVES ...................................................................................................................... 22 3. OVERVIEW OF STUDY DESIGN....................................................................................... 22

3.1 Study Design ........................................................................................................ 23 4. STUDY POPULATION ........................................................................................................ 24

4.1 General Considerations........................................................................................ 25 4.2. Inclusion Criteria.................................................................................................. 25 4.3. Exclusion Criteria ............................................................................................... 26

5. DOSAGE AND ADMINISTRATION..................................................................................... 28 5.1. Drug Administration............................................................................................. 28 5.2. Dose Modification and Delay............................................................................... 29 5.3. VELCADE Dose Modifications for Neuropathic Pain or Peripheral

Sensory Neuropathy .................................................................................. 30 5.4. RITUXIMAB dose modification............................................................................ 32

6. COMPLIANCE..................................................................................................................... 33 7. CONCOMITANT THERAPY................................................................................................ 33

7.1. Permitted Therapy............................................................................................... 33 7.2. Prohibited Therapy .............................................................................................. 34

8. STUDY EVALUATIONS ...................................................................................................... 34 8.1. Study Procedures................................................................................................ 34 8.2.Statistical considerations and Sample size .......................................................... 39 8.3. Safety Evaluations............................................................................................... 42

9. SUBJECT COMPLETION/WITHDRAWAL.......................................................................... 43 9.1. Completion .......................................................................................................... 43 9.2. Discontinuation of Treatment .............................................................................. 43 9.3. Withdrawal From the Study ................................................................................. 43

10. ADVERSE EVENT REPORTING...................................................................................... 44 10.1. Definitions.......................................................................................................... 44 10.2. Procedures ........................................................................................................ 46

11. STUDY DRUG INFORMATION ........................................................................................ 47 11.1. Physical Description of Study Drug(s)............................................................... 47

Version 09/01/2007 4


11.2. Packaging.......................................................................................................... 48 11.3.Labeling .............................................................................................................. 48 11.4.Preparation and Handling................................................................................... 48 11.5. Drug Accountability ........................................................................................... 48

12. ETHICAL ASPECTS.......................................................................................................... 49 12.1. Study-Specific Design Considerations .............................................................. 49 12.2.Regulatory Ethics Compliance ........................................................................... 49 12.3.Independent Ethics Committee or Institutional Review Board (IEC/IRB)........... 49

13.ADMINISTRATIVE REQUIREMENTS ............................................................................... 52 13.1.Data Quality Assurance...................................................................................... 52 13.2.Record Retention ............................................................................................... 53 13.3.On-Site Audits .................................................................................................... 53

14. REFERENCES.................................................................................................................. 54 15. ATTACHMENTS................................................................................................................ 54

Attachment 1: performance status scales24 ............................................................... 58 Attachment 2: WHO CLASSIFICATION FOR lymphoma .......................................... 60 Attachment 3: Instructions for the Preparation and Handling of VELCADE

Injections .................................................................................................... 63 Attachment 3: (Continued):Instructions for the Preparation and Handling of

VELCADE Injections .................................................................................. 64 Attachment 4: dispensing information for rituximab (idec-c2b8) ................................ 65 Attachment 5: Neurotoxicity Questionnaire25 ............................................................. 68 Attachment 6: Creatinine Clearance Calculation ....................................................... 69 Attachment 7: New York Heart Association Classification of Cardiac

Disease26.................................................................................................... 70 Attachment 8: Suggested Body Surface Area Calculation......................................... 71

Attachment 9: Related Biological Studies .................................................................. 71

Version 09/01/2007 5


INVESTIGATOR AGREEMENT I have read this protocol and agree that it contains all necessary details for carrying out this study. I will conduct the study as outlined herein and will complete the study within the time designated.

I will provide copies of the protocol and all pertinent information to all individuals responsible to me who assist in the conduct of this study. I will discuss this material with them to ensure that they are fully informed regarding the study drug and the conduct of the study.

Investigator’s Signature Date

Name of Investigator (Typed or Printed) Institution, Address* Phone Number* Investigator-Sponsor Signature* Date (where required)

Name of Coordinating Investigator (Typed or Printed) Institution * If the address or phone number of the investigator changes during the course of the study, written notification will be provided by the investigator to the sponsor and will not require protocol amendment(s).

Version 09/01/2007 6


1. INTRODUCTION

VELCADE is a small molecule proteasome inhibitor developed as a novel agent to treat human malignancies.1 VELCADE is currently approved by the United States Food and Drug Administration (FDA) for the treatment of patients with multiple myeloma who have received at least 1 prior line of therapies and have demonstrated disease progression on the last therapy.2

By inhibiting a single molecular target, the proteasome, VELCADE affects multiple signaling pathways. The antineoplastic effect of VELCADE likely involves several distinct mechanisms, including inhibition of cell growth and survival pathways, induction of apoptosis, and inhibition of expression of genes that control cellular adhesion, migration, and angiogenesis. Thus, the mechanisms by which VELCADE elicits its antitumor activity may vary among tumor types, and the extent to which each affected pathway is critical to the inhibition of tumor growth could also differ. VELCADE has a novel pattern of cytotoxicity in National Cancer Institute (NCI) in vitro and in vivo assays.3 In addition, VELCADE has shown cytotoxic activity in a variety of xenograft tumor models, both as a single agent and in combination with chemotherapy and radiation.4-8 Notably, VELCADE induces apoptosis in cells that over express bcl-2, a genetic trait that confers unregulated growth and resistance to conventional chemotherapeutics.9

VELCADE is thought to be efficacious in multiple myeloma via its inhibition of nuclear factor κB (NF-κB) activation, its attenuation of interleukin-6 (IL-6)-mediated cell growth, a direct apoptotic effect, and possibly anti-angiogenic and other effects.10

1.1. Background 1.1.1. VELCADE BACKGROUND

VELCADE is a specific proteasome inhibitor. VELCADE is

approved in Europe for the treatment of multiple myeloma subjects

Version 09/01/2007 7


who have received at least one prior therapy and who have already

undergone or are unsuitable for bone marrow transplantation1. The

drug is currently being tested in a variety of other hematologic and solid tumors.

By inhibiting a single molecular target, the proteasome, VELCADE affects multiple signalling pathways. The anti-neoplastic effect of VELCADE likely involves several distinct mechanisms, including inhibition of cell growth and survival pathways, induction of apoptosis, and inhibition of expression of genes that control cellular adhesion, migration, and angiogenesis. Thus, the mechanisms by which VELCADE elicits its anti-tumor activity may vary among tumor types, and the extent to which each affected pathway is critical to the inhibition of tumor growth could also differ. VELCADE has a novel pattern of cytotoxicity in National Cancer

Institute (NCI) in vitro and in vivo assays2. In addition, VELCADE

has shown cytotoxic activity in a variety of xenograft tumor models, both as a single agent and in combination with chemotherapy and

radiation3-8

. Notably, VELCADE induces apoptosis in cells that over express bcl-2, a genetic trait that confers unregulated growth and

resistance to conventional chemotherapeutics.9

VELCADE is thought to be efficacious in multiple myeloma via its inhibition of nuclear factor κB (NF-κB) activation, its attenuation of interleukin-6 (IL-6)-mediated cell growth, a direct apoptotic effect,

and possibly anti-angiogenetic and other effects.10

Nonclinical Studies

Nonclinical Pharmacology

Pharmacokinetic (PK) and pharmacodynamic studies were conducted in the rat and cynomolgus monkey. Upon intravenous (IV) bolus administration, VELCADE displays a rapid distribution phase (t

1/2α < 10 minutes) followed by a longer elimination phase

(t1/2β

5-15 hours). VELCADE has a large volume of distribution

Version 09/01/2007 8


(range 5-50 L/kg). The plasma PK profile is well described by a 2-compartment model.

The pharmacodynamic action of VELCADE is well established and can be measured through an ex vivo assay (20S proteasome

activity).11

This assay was used to determine the duration of drug effect in lieu of the PK data in the early preclinical toxicology studies as well as to set a guide for dose escalation in humans.

Following dosing with VELCADE in rats and cynomolgus monkeys, proteasome inhibition in peripheral blood had a half-life less than 24 hours, with proteasome activity returning to pretreatment baseline within 24 hours in monkey and within 48 to 72 hours in rat after a single dose of VELCADE. Further, intermittent but high inhibition (> 70%) of proteasome activity was better tolerated than sustained inhibition.

Nonclinical Toxicity

Single-dose IV toxicity studies were conducted with VELCADE in mouse, rats, dogs, and monkeys to establish the single-dose maximum tolerated dose (MTD). The MTDs were 0.25 mg/kg (1.5 mg/m2) and 0.067 mg/kg (0.8 mg/m2) in the 2 most sensitive species, rats and monkeys, respectively.

Repeat-dose multi-cycle toxicity studies of 3 and 6 months in the rat and 9 months in the monkey, each with 8-week recovery periods, were conducted to characterize the chronic toxicity of VELCADE when administered by the clinical route and regimen of administration. The MTD in the 6-month rat study was 0.10 mg/kg (0.6 mg/m2) and the key target organs were the gastrointestinal (GI) tract, hematopoietic, and lymphoid systems. The MTD in the 9-month monkey study was 0.05 mg/kg (0.6 mg/m2) and the key target organs were the GI tract, hematopoietic and lymphoid systems, peripheral nervous system, and kidney. Full or partial reversibility was observed for each of the toxicities described to date.

In general, the nature of the toxicity of VELCADE is similar across species, and target organs of toxicity in animals have been largely

Version 09/01/2007 9


predictive of human toxicity. The doses used in the pivotal repeat-dose studies are in the same order of magnitude of the clinical dose of 1.3 mg/m². The toxicity of VELCADE in animals is characterized by a steep dose-response with mortality seen at dosages above the MTD. The cause of death at acutely lethal dosages is considered to be related to cardiovascular (CV) effects of hypotension and vascular changes with initial physiologically significant heart rate elevation, which preceded a profound hypotension and eventual bradycardia. The cause of death in long-term studies has been attributed to GI or hematologic toxicity. The pharmacologic effects of VELCADE on the CV system have been extensively characterized. It has been demonstrated that indirect effects on CV function occur only at acutely lethal dosages and are abrogated by routine supportive care.

Additional detailed information regarding the non clinical pharmacology and toxicology of VELCADE may be found in the Investigator Brochure.

Clinical Studies

Clinical Pharmacokinetics and Pharmacodynamics

The clinical pharmacology characterization of VELCADE has been determined from Phase 1 studies in subjects with solid tumours and hematologic malignancies, and confirmed in Phase 2 studies in subjects with multiple myeloma.

In subjects with solid tumours, the mean terminal elimination half-life of VELCADE was 9.06 hours. The mean maximum plasma concentration (Cmax) and area under the curve (AUClast) after the first dose (1.3 mg/m2) of VELCADE were 173 ng/mL and 48.2 h*ng/mL, respectively. The average clearance of VELCADE following a single 1.3 mg/m2 dose was 49.0 L/h. However, the AUClast increased to 81.0 h*ng/mL after the third dose in the first cycle as a result of a reduction in systemic clearance to 28.2 L/h with a consequent increase in elimination half-life to 16.6 hours. Clinical experience has shown that the change in clearance does not

Version 09/01/2007 10


result in overt toxicity from accumulation in this multidose regimen in humans. Formal pharmacokinetic studies are currently ongoing.

In subjects with advanced malignancies, the maximum pharmacodynamic effect (inhibition of 20S activity) occurred within

1-hour post dose. At the therapeutic dose of 1.3 mg/m2

in subjects with multiple myeloma, the mean proteasome inhibition at 1 hour post dose was approximately 61%.

The time course of proteasome inhibition in subjects is characterized by maximum inhibition observed within the first hour after administration, followed by partial recovery of proteasome activity over the next 6 to 24 hours to within 50% of the pretreatment activity. On the Day 1, 4, 8, and 11 schedule, variable (10%-30%) levels of proteasome inhibition have been observed at next scheduled dosing. In theory, this advantage allows cells to recover proteasome activity for normal cellular housekeeping functions between doses.

The relationship between VELCADE plasma concentrations and proteasome inhibition can be described by a maximum effect (E

max)

model. The Emax

curve is initially very steep, with small changes in

plasma VELCADE concentration over the range of 0.5 to 2.0 ng/mL relating to large increases in the percent inhibition (0-60%). After that, a plateau occurs where marginal increases of proteasome inhibition are observed in spite of large changes in plasma VELCADE concentrations.

Clinical Experience

Clinical studies have been conducted in 3 clinical research programs, one sponsored by the clinical development partners (J&J and Millennium (MPI), one by investigator-initiated studies, and the third by the U.S. NCI.

The overall goal of the MPI Phase 1 program was to determine the MTD and dose-limiting toxicity (DLT) of VELCADE in a number of therapeutic settings involving subjects with various advanced

Version 09/01/2007 11


malignancies. In the 3-week schedule of VELCADE monotherapy (4 doses, given on Days 1, 4, 8, and 11 of a 21-day treatment cycle), the DLT occurred at 1.56 mg/m2/dose (3 subjects with Grade 3 diarrhoea and 1 with peripheral sensory neuropathy).12 Therefore, the MTD at this schedule was at least 1.3 mg/m2/dose. In a 35-day treatment cycle with 4 once-weekly doses of VELCADE monotherapy, the MTD was 1.6 mg/m2/dose and DLT included hypotension, tachycardia, diarrhea, and syncope13. In a 42-day treatment cycle of VELCADE administered twice a week for 4 weeks with 2 weeks rest in subjects with advanced hematologic malignancies, the MTD was 1.04 mg/m² per dose and DLTs were

hyponatremia and hypokalemia.14

In Phase I clinical studies, anti-tumor activity was reported in subjects with, multiple myeloma, Waldenström’s Macroglobulinemia, non-Hodgkins lymphoma, squamous cell carcinoma of the nasopharynx, bronchoalveolar carcinoma of the lung, renal cell carcinoma, and prostate cancer.

The safety and efficacy of VELCADE in subjects with pretreated multiple myeloma were investigated in two Phase II clinical studies, studies M34100-024 (subjects with first relapse) and M34100-025 (subjects with second or greater relapse and refractory to their primary therapy). In M34100-025, 202 heavily pre-treated subjects with refractory multiple myeloma after at least 1 previous treatments

received VELCADE, 1.3 mg/m2

on Days 1, 4, 8, and 11 of a 21-day treatment cycle for 8 cycles (24 weeks of therapy). The European Group for Blood and Marrow Transplant (EBMT) response criteria,

as described by Blade15

were used to determine disease response. These responses were confirmed by an independent review committee. Complete responses (CRs) were observed in 10% of subjects, including some cases in which M-protein was not detected by immunofixation. Partial response (PR) or CR was observed in 27% of subjects, and the overall response rate (CR, PR, and minor response (MR) combined) was 35%. Of the 69 subjects who were 65 years or older, the response rate (CR + PR) for those who had

Version 09/01/2007 12


response data was 19%. Seventy percent (70%) of subjects experienced an M-protein reduction of 25% or more. Responses occurred early (median time to response was 6 weeks) and were durable (median duration of response was 12 months). Median time to progression for all subjects was 7 months and median overall survival (OS) was 16 months. The therapy was well tolerated and the incidence of Grade 4 adverse events was relatively low. The most common adverse events were Grade 1 to 2 GI adverse events, including nausea, vomiting, diarrhea, and constipation. Severe myelosuppression was uncommon. Thrombocytopenia (Grade 3 to 4 in 31% of subjects) occurred primarily in subjects with low baseline platelet counts, and was transient. The most clinically significant adverse event was a cumulative, dose-related peripheral sensory neuropathy managed by treatment interruptions and dose

modifications. 16, 17

In the M34100-025 study, subject self-reported questionnaires (European Organization for Research and Treatment of Cancer [EORTC] QLQ-C30, EORTC QLQ-MY24 [24 item myeloma-specific extension module], and the Functional Assessment of Chronic Illnesses – Fatigue [FACIT-F] scales; were administered at the screening visit and Day 1 of Cycles 3, 5, 7, and at the end of the study. In subjects with CR or PR, improvement from baseline on global quality of life, disease symptoms, pain, fatigue, and physical functioning was observed.

The M34101-039 APEX study, a randomized, Phase 3 study comparing VELCADE with high-dose Dexamethasone in 669 subjects with multiple myeloma after 1 to 3 prior lines of therapy was halted at the time of the interim analysis because of a statistically significant improvement in time to disease progression (TTP) in favour of the VELCADE arm. In this study, the

experimental arm received VELCADE 1.3 mg/m2

on Days 1, 4, 8, and 11 every 3 weeks, for 8 cycles (24 weeks) followed by a less

dose-intense therapy of weekly VELCADE 1.3 mg/m2

on Days 1, 8, 15, and 22 every 5 weeks (15 weeks), for 3 additional cycles.

Version 09/01/2007 13


Following a preplanned interim analysis of TTP, the Dexamethasone arm was halted and all subjects randomised to dexamethasone were offered VELCADE. Subjects treated with VELCADE had higher response rates, a longer time to progression and a longer survival than subjects treated with dexamethasone. The combined CR and

PR were 38% versus 18%.18

Preliminary data on VELCADE in newly diagnosed multiple myeloma is available from an ongoing, multicenter, Phase 2 study of VELCADE alone or in combination with dexamethasone. These early data indicate a 75% overall response rate and a 33% CR rate in

previously untreated subjects.19

In addition to myeloma, VELCADE has also shown promising activity in the treatment of selected types of non Hodgkin lymphoma. Several single agent phase II clinical trials in lymphoma patients have demonstrated that VELCADE has reproducible activity in mantle cell lymphoma and follicular lymphoma with some suggestion of activity in marginal zone lymphoma.28, 29, 31

The safety and efficacy of VELCADE in subjects with pretreated indolent non Hodgkin lymphoma and mantle cell lymphoma were investigated in a phase II clinical study by O’Connor and collegues.27 Twenty-four patients were included and treated with VELCADE 1,5 mg/m2 on days 1, 4, 8 and 11 . The overall response rate was 58% with a duration between +3 and +24 months. The drug was welle tolerated with only one grade IV toxicity (hyponatremia).

The WMCTG Trial 03-248, a multicenter phase II study, assessed the use of VELCADE as a single agent in 27 patients with Waldentrom’s macroglobulinemia. All patients received 6-8 cycles

of VELCADE 1.3 mg/m2

on days 1, 4, 8, and 11. The overall response rate was 84.6% . The therapy was well tolerated with grade III/IV toxicities as follows: neutropenia 15%, sensory neuropathies 12%, trombocytopenia 8%.30

Version 09/01/2007 14


1.1.2. RITUXIMAB BACKGROUND Rituximab is a genetically engineered chimeric murine/human monoclonal antibody directed against the CD20 antigen expressed on the surface of normal and malignant B-lymphocytes. Rituximab is approved by the Health Authorities for the treatment of patients with relapsed or refractory, low grade or follicular CD20+ , B- cell NHL CD 20 regulates early steps in cell cycles initiation and differentiation and possibly functions as a calcium ion channel. Rituximab bind to the antigen CD20 located on pre-B and mature B- lymphocytes. CD 20 is also expressed on greater than 90% of B-cell NHL cells, but it is not found on stem cells, pro-B cells, plasmacells or other normal tissues. Cd20 does not shed from CD20+ cells after antibody binding: does not modulates, internalized, or down regulate upon antibody binding, nor does it circulate free in the plasma. Though the main mechanism of action of rituximab appear to be through complement-dependent cytotoxicity, some data also suggest direct induction of apoptosis in cell line models and down regulation of bcl-2 in vivo.

In an open label, multicenter, pivotal clinical study, rituximab alone was administrated to 166 subjects with low grade or follicular, CD20+ B-cell NHL that had relapsed or was non-responsive to previous therapy. Rituximab was infused intravenously at 375 mg/m2 once weekly for 4 doses. The overall response rate (ORR) reported was 48% ( 6% CR and 42% PR). The median time to onset of response was 50 days, the median TTP was 9 months, and the Median duration of response was 11.2 months23.

Other rituximab clinical studies have included an expanded regimen (once weekly for 8 doses); treatment to bulky disease; treatment intermediate and high grade lymphomas; retreatment to patients who previously responded to rituximab; rituximab in combination with different types of chemotherapy (R-CHOP, R-CVP, R-FND, R-FCM), interferon and radiotherapy. In 57 patients with indolent lymphoma who had previously responded to single agent rituximab and subsequently progressed, the RR following retreatment with 4 weekly doses of rituximab was 40%. These data indicate that

Version 09/01/2007 15


patients who have responded to rituximab can respond again, though the response rate may be lower with retreatment. Extensive data have confirmed the benefit of combination therapy with rituximab and conventional chemotherapy especially in the aggressive lymphomas. In these studies, rituximab generally was well tolerated. The majority of adverse reactions were infusion related, mild to moderate and occurred during the first infusion.

1.1.3. ASSOCIATION OF RITUXIMAB AND VELCADE BACKGROUND The promising activity of VELCADE as single agent in low grade lymphoma patients in small studies has led to a number of larger multicenter trials with VELCADE in combination with Rituximab in mantle-cell lymphoma, follicular lymphoma and marginal zone lymphoma.27

Pre-clinical studies have shown a synergistic effect of the addition of Rituximab to VELCADE on lymphoma cell lines.28,29

A randomized phase II study investigated the response rate of VELCADE plus Rituximab weekly or twice-weekly in patients with relapsed follicular lymphoma or marginal zone lymphoma. Patients received VELCADE 1,3 mg/2 on days 1,4,8 and 11 of a 21 day cycle (Arm A) or VELCADE 1,6 mg/2 on days 1, 8, 15 and 22 of a 35 day cycle (Arm B). Rituximab 375 mg/m2 weekly for 4 doses was added in both arms. (81 patients were ernolled and were evaluable for response. Overall response rate was 51% in Arm A and 54% in Arm B Response rate were similar in patients who previously received rituximab compared to the total study population. Treatment was well tolerated in both arms with better results in Arm B: Grade >3 toxicities were seen in 54% patinets in arm A and 18% patients in arm B.31,32

A phase I/II trial by Leonard and collegues analyzed the use of VELCADE in association with Rituximab and CHOP in diffuse large B cell and mantle-cell lymphoma, treatment naive xx. In this phase I study of dose finding patients receveid CHOP-21 + Rituximab (375 mg/m2 each cycle) plus VELCADE 0,7 mg/m2

Version 09/01/2007 16


(Arm 0), 1,0 mg/m2 (Arm 1) or 1,3 mg/m2 (Arm 2) on days 1 and 4 of each cycle. 16 Diffuse large cell lymphoma patients and 4 mantle-cell lymphoma patients were included. The treatment was generally well tolerated . peripheral neuropathy >2 occurred in 10% of patients. Intent to treat overall response rate was 95% with 80% Cr/Cru and 80% of patients alive without progression.33

Studies using VELCADE as monotherapy and in combination with other chemotherapy agents are continuing. Further details on clinical studies of VELCADE may be found in the Investigator Brochure

and in preliminary clinical data presentations5, 8, 12, 16-22

.

Potential Risks of VELCADE

Over 33,000 subjects have been exposed to VELCADE. Most common side effects of VELCADE (i.e., incidence ≥30%) observed in subjects are weakness, fatigue, and general discomfort; gastrointestinal effects such as constipation, diarrhea, nausea, vomiting and anorexia, which may result in dehydration and/or weight loss; fever; peripheral neuropathy (including painful sensations or numbness and tingling in hands and feet that may not get better after discontinuation of VELCADE); thrombocytopenia that may increase the risk of bleeding, and anemia. Very common side effects of VELCADE (i.e., incidence 10–29%) observed in subjects are neutropenia that may increase the risk of infection; abdominal pain; dyspepsia; nasopharyngitis; arthralgias; myalgias; skin rash that can be erythematous, pruritic and display leukocytoclastic vasculitis at biopsy (an uncommon event is toxic epidermal necrolysis); rigors; hypotension; dizziness; fluid retention; pain in limbs and bones; paresthesia; dysesthesia; dyspnea; cough; epistaxis; headache; blurred vision; changed sense of taste; insomnia; anxiety; herpes zoster, and lower respiratory/lung infections including pneumonia. Common side effects of VELCADE (i.e., incidence 1–9%) observed in subjects are lymphopenia; pancytopenia; palpitations; tachycardia; bradycardia; atrial fibrillation; angina pectoris; acute onset of congestive heart failure including pulmonary edema

Version 09/01/2007 17


(subjects with risk factors for, or existing, heart disease should be closely monitored); pleural effusion; tinnitus; conjunctivitis; abdominal distension; oral and esophageal mucositis; oropharyngeal and esophageal candidiasis; superficial fungal infections of the skin and nails; upper and lower gastrointestinal bleeding; hemoptysis; bronchitis; sinusitis; urinary tract infection; gastroenteritis; skin infections; sepsis; hyponatremia; hyperglycemia; hypoglycemia (Subjects on oral antidiabetic agents may require close monitoring of their blood sugar levels); dehydration; pulmonary embolism; orthostatic hypotension; syncope; convulsions; renal failure; hematuria; depression; confusion; increases in serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transpepsidase (GGT) and alkaline phosphatase. Uncommon side effects of VELCADE (i.e., incidence <1%) observed in subjects are febrile neutropenia; atrial flutter; new onset of decreased left ventricular ejection fraction; cardiogenic shock; hearing impairment; ileus paralytic/small bowel obstruction; upper gastrointestinal hemorrhage; oral mucosal petechiae; liver injury including abnormal liver function tests, hyperbilirubinemia, hepatitis, and liver failure (reported in subjects receiving multiple concomitant medications and with serious underlying medical conditions); drug hypersensitivity reactions including angioedema; injection site reaction; aspergillosis; cerebral hemorrhage; tumor lysis syndrome; severe muscle weakness and paralysis; and severe, life threatening, or fatal acute diffuse infiltrative pulmonary disease of unknown etiology such as pneumonitis, interstitial pneumonia, and Acute Respiratory Distress Syndrome (ARDS). These pulmonary events were seen more often in patients treated in Japan. Fatal ARDS has been reported in a study of VELCADE in combination with high-dose cytarabine delivered by continuous infusion and daunorubicin, in patients with relapsed acute myeloid leukemia. Isolated cases of QT-interval prolongation have been reported, but are not thought to be related to VELCADE treatment. Complications arising from these VELCADE toxicities may result in death.

Version 09/01/2007 18


The effect of VELCADE on reproduction and its safety in pregnancy are unknown. Laboratory tests show that VELCADE may damage DNA therefore it is possible that VELCADE may cause infertility in men and women. Further details on the potential risks of VELCADE may be found in the Investigator Brochure.

Potential Risks of RITUXIMAB

The most serious adverse reactions with rituximab include: infusion reactions, Tumor lysis syndrome, mucocutaneous reactions, hypersensitivity reactions, cardiac arhytmias

And angina, and renal failure. Administration of rituximab weekly for 8 doses resulted in higher rates of grade 3 and 4 overall adverse events (70%) compared with weekly doses for 4 weeks 857%). The incidence of clinically significant abdominal pain, anemia, dyspnea, hypotension and neutropenia was higher in subjects with bulky disease ( lesions > 10 cm) vs subjects with lesions < 10 cm. During retreatment with rituximab the incidence of grade 3 and 4 adverse events was similar to the experience of patients receiving the first treatment (58% and 57% respectively).

Mild to moderate infusion reactions consisting of fever and chill/rigors occurred in the majority of patients during the first infusion. Other frequent infusion reaction symptoms included nausea, pruritus, angioedema, asthenia, hyypotension, headache, bronchospasm, throat irritaion, rhinitis, urticaria, rash, vomiting, myalgia, dizziness and hypertension. These reactions generally occurred within 30 to 120 minutes of beginning the first infusion and resolved with slowing or interruption of the rituximab infusion and with supportive care.

Rituximab induced B-cell depletion in 70-80%of patients and was associated with decrease serum immunoglobulins in a minority of subjects, infections events occurred in 31% of patients. Grade 3 and

Version 09/01/2007 19


4 infectious events including sepsis occurred in 25 of patients. Grade 3 and 4 cytopenia were reported in 485 of subjects, a single occurrence of transient aplastic anemia and 2 occurrence of hemolytic anemia were reported. In addition, there have been a limited number of postmarketing reports of pancytopenia, marrow hypoplasia and late onset neutropenia ( defined as occurring 40 days after the last dose of rituximab) in patients with hematological malignancies. Grade 3 and 4 cardiac events including hypotension and rare fatal cardiac failure with symptomatic onset after rituximab administration have been reported. Pulmonary events were experienced by 38% of patients. The most common respiratory adverse events were increased cough, rhinitis, bronchospasm, dyspnea and sinusitis. In addition, immune/autoimmune events have been reported including uveitis, optic neuritis ( in a subject with systemic vasculitis), pleuritis ina subject with lupus-like syndrome, serum sickness with with polyarticular arthritis and vasculitis with rash.

Hepatitis B virus (HBV) reactivation with fulminant hepatitis, hepatic failure and death has been reported in some patients with hematological malignancies treated with rituximab. The majority of patients received rituximab in combination with chemotherapy. The median time to the diagnosis of hepatitis was approximately 4 months after the beginning of rituximab and approximately 1 month after the last dose. Carriers of hepatitis B should be closely monitored for clinical and laboratory signs of active HBV infection and for signs of hepatitis during and for up to several months following rituximab therapy. In patients who develop viral hepatitis, rituximab and any concomitant chemotherapy should be discontinued and appropriate treatment including antiviral drugs should be initiated.

Less common adverse events (>1% and <5%) reported from clinical studies included agitation anorexia, hypokinesia, hyperstesia, hypoglicemia, injection site pain, insomnia, lacrimation disorder, malaise, nervousness, neuritis, neuropathy, paresthesia, somnolence, vertigo and weight decrease.

Version 09/01/2007 20


1.2. Overall Rationale for the Study Although the majority of patients with indolent non Hodgkin’s lymphoma (follicular and non follicular) initially respond to chemotherapy, recurrence of the disease is common and there is a need to explore new active drugs to control the disease and prolong the response duration. One of the most active drug is the anti-CD20 monoclonal antibody Rituximab. When Rituximab is used as a single drug in relapsed or refractory indolent lymphoma for 4 weekly doses, overall response rate (ORR) was 48% with complete remission rate of 6%; however median duration of response do not exceed 12 months22. However most of the patients included in that study had follicular lymphoma and only a small subset of patients had indolent non-follicular lymphoma. In these patients the ORR was significantly lower, only 12%. Extended doses of Rituximab up to 8 increase the ORR, but without a significant advantage in CR or response duration. Re-treatment with Rituximab in patients who relapsed after Rituximab therapy is safe and patients may respond as well as those Rituximab naive.

The 26S proteasome plays a vital role in degrading regulatory proteins that govern cell cycle, transcription factor activation and apoptosis. Proteasome inhibitor PS –341 (bortezomib) has been shown well tolerated and active in multiple myeloma.

Few preliminary data suggest a clinical activity of Bortezomib in relapsed/ refractory indolent or mantle cell lymphoma. Recently in vitro and animal studies have shown that the administration of Bortezomib prior to rituximab exposure induces apoptosis, cell growth arrest and makes NHL cell lines more susceptible to rituximab activity and in vivo administration in mice of bortezomib with rituximab was more effective in controlling lymphoma growth than each single drug alone.

The two drugs do not happen to have an overlapping toxicity. Thus, it seems to be worthwhile to explore the effectiveness of combination of bortezomib with rituximab.

Version 09/01/2007 21


This study aimed to assess safety, toxicity and clinical activity of the association of bortezomib along with Rituximab as salvage therapy in patients with relapsed or refractory advantage stage Rituximab naïve or sensitive indolent non follicular and mantle cell l.ymphoma.

2. OBJECTIVES Primary Objective

To demonstrate a statistical benefit in overall response rate (ORR) of the Bortezomib/Rituximab association in relapsed /refractory indolent non-follicular and mantle cell non-Hodgkin lymphoma patients that was naïve or sensitive to rituximab

Secondary Objectives

1) To evaluate the Complete Response (CR) rate of

relapsed/refractory indolent non-follicular and mantle cell

non-Hodgkin lymphoma patients treated with the

Bortezomib/Rituximab association

2) To evaluate the efficacy of the Bortezomib/Rituximab

association to prolong 2-year failure-free survival (FFS) rate

compared to historical standard treatment

3) To assess the safety of Bortezomib/Rituximab association in

relapsed/refractory indolent non follicular and mantle cell non

Hodgkin lymphoma patients

4) To evaluate overall survival of the patients treated with

Bortezomib/Rituximab association

3. OVERVIEW OF STUDY DESIGN

Version 09/01/2007 22


This is a open label, non randomized, phase II , multicenter, prospective trial to evaluate the efficacy and safety of the combination of bortezomib and rituximab in patients with relapsed or refractory rituximab naïve or sensitive indolent non-follicular and mantle cell non-Hodgkin’s lymphoma. Despite of the availability of treatment for this disease, this study is justified because no known therapies are really curative and it is necessary to look for new treatment options to improve the clinical outcome and prognosis of relapsed indolent lymphoma. This study is designed for patients not eligible for high-dose chemotherapy and autologous stem cells transplantation.

A total of 48 patients are expected to participate into the study and it is expected that there will be 24 months of accrual and the trial will end two months after the end of the last patient treatment. A follow-up phase will follow for 24 months.

3.1 Study Design The study is divided in 3 phases:

1.A pretreatment (screening) phase of approximately 28 days Patients will be evaluated before to be enrolled in the study as requires according the staging rules.

2.An open label non randomized multicenter treatment phase. The investigator will assess patient response to therapy using efficacy measurements and disease response criteria. Patients will be evaluated through this phase for possible toxicities and delays in dosing. Dose modifications will be made as required according to dose modification rules. Patients will be treated with six courses of therapy with a thirteen day rest period between them. Courses 1 and 4 will be scheduled with the association of bortezomib and rituximab at day 1-8-15-22. Courses 2,3,5 and 6 will be scheduled with the administration of bortezomib alone at day 1-8-15-22. All courses will be restarted at day 36.

At the end of the third course all patients enrolled will be evaluated for tumor response. All patients with responsive or stable disease

Version 09/01/2007 23


(CR, Cru, PR, MR and SD) will receive the remaining 3 courses of treatment at the same schedule and doses

Patients with progressive disease at any time will be withdrawn from the study.

3.A follow-up phase. patients will be followed for disease progression and survival until the end of the study which is expected to be 24 months after the last patients enrolled into the study completed the treatment.

The study design is presented in the figure below

PRETREATMENT SCREENING PHASE

4. STUDY POPULATION

RESTAGING PHASE

I course

II course

III course

CR, CRu, PR, MR, SD

Day 1 - 8 - 15 - 22 Bortezomib 1.6 mg/mq

Day 1 - 8 - 15 - 22 Bortezomib 1.6 mg/mqRituximab 375 mg/mq

IV course

V course

VI course

Day 1 - 8 - 15 - 22 Bortezomib 1.6 mg/mq

Day – 28 to 0

Day + 1 to 22

Day + 36 to 58

Day + 72 to 94

Day 1 - 8 - 15 - 22 Day + 108 to 130 Bortezomib 1.6 mg/mq

Rituximab 375 mg/mq

Day + 130 to 152

Day + 166 to 188

Version 09/01/2007 24


4.1 General Considerations

Patients men and women , > 18 years old are eligible for this clinical trial if they have indolent non follicular B cell or mantle cell lymphoma: the disease must be relapsed or refractory following one or more lines of prior chemotherapy. If the prior regimen included rituximab, the patients must have responded and the TTP from the last dose to rituximab must have been 6 months or more. This study is designed for patients not eligible for high dose chemotherapy with autologous stem cell transplantation.

Specific inclusion and exclusion criteria for enrolling subjects in this study are described in the following sections.

4.2. Inclusion Criteria

Patients must be satisfy the following criteria to be enrolled in the study:

1. Patients with naïve or sensitive rituximab indolent non-follicular and mantle cell non-Hodgkin’s Lymphoma disease that had failed to respond or relapsed after primary therapy. There is a demonstrated progressive disease requiring further treatment. Histological subtype included into the study are are as follows (Attachment 2: WHO classification of Lymphoma)

• Small lymphocytic/lymphoplasmocytic lymphoma; • Nodal marginal zone Lymphoma ( MALT lymphoma are

excluded) • Splenic marginal zone lymphoma • Mantle cell lymphoma

A lymphnode biopsy is advisable if it is not harmful for the patients, before enrollement of the patient into the study in order to confirm diagnosis and to rule out histologic transformation. Lymphnode biopsy should be performed within 6 months before study entry.

2. Age >18-75 3. Relapse or failure to respond after one or more (maximum three) lines

of chemotherapy

Version 09/01/2007 25


4. Any type of prior chemotherapy, rituximab included. Patients who

had received high dose chemotherapy and ASCT can be enrolled into the study

5. Naïve or sensitive rituximab disease. If the patient received Rituximab, he/she must have responded and the TTP from the last dose to rituximab must have been 6 months or more.

6. Measurable and/or evaluable disease. 7. Adequate haematological counts: ANC > 1.0 x 109/L and PLTs

counts > 75 x 109/L unless due to bone marrow involvement by lymphoma.

8. Conjugated bilirubin up to 2 x ULN. 9. Alkaline phosphatase and transaminases up to 2 x ULN. 10. Creatinine clearances ≥30 m/min. 11. Non peripheral neuropathy or CNS disease. 12. Life expectancy > 6 months. 13. Performance status < 2 according to ECOG scale. 14. Written informed Consent

4.3. Exclusion Criteria

Potential patients who meet any of the following criteria will be excluded from participating in the study:

1. Has known or suspected hypersensitivity or intolerance to rituximab, boron, mannitol, or heparin, if an indwelling catheter is used

2. History of clinically relevant liver or renal insufficiency; significant cardiac, vascular, pulmonary, gastrointestinal, endocrine, neurologic, rheumatologic, hematologic, psychiatric, or metabolic disturbances

3. Uncontrolled diabetes (if receiving antidiabetic agents, subjects must be on a stable dose for at least 3 months before first dose of study drug

4. Uncontrolled or severe cardiovascular disease including myocardial infarction within 6 months of enrollment, New York Heart Association (NYHA) Class III or IV heart failure (Attachment 5,

Version 09/01/2007 26


NYHA Classification of Cardiac Disease), uncontrolled angina, clinically significant pericardial disease, or cardiac amyloidosis

5. History of hypotension or has decreased blood pressure (sitting systolic blood pressure [SBP] ≤100 mmHg and/or sitting diastolic blood pressure [DBP] ≤60 mmHg)

6. Pregnant or breastfeeding

7. Peripheral Neuropathy or Neuropathic Pain ≥Grade 2

8. HIV positivity

9. HBV positivity with the exception of patients with HBVcAb +, HbsAg -, HBs Ab+/- with HBV-DNA negative

10. HCV positivity with the exception of patients with no signs of active chronic hepatitis histologically confirmed

11. Active opportunistic infection

12. Receipt of extensive radiation therapy, systemic chemotherapy, or other antineoplastic therapy within 4 weeks before enrollment

13. Exposure to Rituximab within 24 weeks before screening

14. Have received an experimental drug or used an experimental medical device within 4 weeks before the planned start of treatment. Concurrent participation in non-treatment studies is allowed, if it will not interfere with participation in this study.

15. Any other co-existing medical or psychological condition that would preclude participation in the study or compromise ability to give informed consent

Version 09/01/2007 27


5. DOSAGE AND ADMINISTRATION 5.1. Drug Administration

The amount (in mg) of VELCADE to be administered will be determined based on body surface area (BSA) using a standard calculation provided in Attachment 6, Suggested Body Surface Area Calculation.

Instructions including calculation of the subject’s dose, preparation and handling of the VELCADE injection, discarding of used study drug supplies, and precautions and care if contact with skin are provided in Attachment 2, Instructions for the Preparation and Handling of VELCADE Injections.

Study drug will be administered only to eligible subjects under the supervision of the investigator or identified subinvestigator(s).

5.1.1. TREATMENT SCHEDULE AND DOSES Patients will be treated with six courses of therapy with a thirteen day rest period between them. Courses will be restarted at day 36.

FIRST COURSE:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22 (Bortezomib will be administrated prior of Rituximab infusion)

Rituximab 375 mg/m2 as slow iv infusion day 1-8-15-22

SECOND COURSE:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22

THIRD COURSE:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22.

Clinical and molecular response on bone marrow will be assessed after the first three courses of therapy.

Patients with responsive or stable disease ( CR, PR, MR, SD) will proceed to further three courses of therapy with the same schedule and doses.

Version 09/01/2007 28


FOURTH COURSE as the first one:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22 (Bortezomib will be administrated prior of Rituximab infusion)

Rituximab 375 mg/m2 as slow iv infusion day 1-8-15-22

FIFTH COURSE as the second one:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22

SIXTH COURSE as the third one:

Bortezomib 1,6 mg/m2 iv bolus days 1-8-15-22.

Clinical and molecular response on bone marrow will be assessed two months after the completion of the whole therapy.

Patients with progressive disease at any time will be withdrawn from the study.

5.2. Dose Modification and Delay Before each dose of study drug, the subject will be evaluated for possible toxicities that may have occurred after the previous dose(s). Toxicities are to be assessed according to the National Cancer Institute Common Toxicity Criteria for Adverse Events (NCI CTCAE), Version 3.0 (provided in a separate study manual). Previously established or new toxicities observed at any time, with the exception of VELCADE-related neuropathic pain and/or peripheral sensory neuropathy, are to be managed as follows:

• If the subject experiences ≥Grade 3 neutropenia with fever, Grade 4 neutropenia lasting more than 7 days, a platelet count <10,000 cells/µL, or any ≥Grade 3 non-hematologic toxicity considered by the investigator to be related to VELCADE, then study drug is to be held. – For non-hematologic toxicities, VELCADE is to be held for

up to 2 weeks until the toxicity returns to Grade 2 or better. – For hematologic toxicities, VELCADE is to be held for up to

2 weeks until the subject has an ANC ≥750 cells/µL and a platelet count ≥30,000 cells/µL.

Version 09/01/2007 29


• If, after VELCADE has been held, the toxicity does not resolve,

as defined above, then study drug must be discontinued. • If the toxicity resolves, as defined above, and VELCADE is to be

restarted, the dose must be reduced by approximately 25%, as follows: – If the subject was receiving 1.6 mg/m2, reduce the dose to 1.3

mg/m2. – If the subject was receiving 1.3 mg/m2, reduce the dose to 1.0

mg/m2. – If the subject was receiving 1.0 mg/m2 following a previous

dose reduction, reduce the dose to 0.7 mg/m2. – If the subject was receiving 0.7 mg/m2 following previous

dose reduction, discontinue VELCADE. Dose reductions below 0.7 mg/m2 are not permitted.

5.3. VELCADE Dose Modifications for Neuropathic Pain or Peripheral Sensory Neuropathy

Subjects who experience VELCADE-related neuropathic pain and/or peripheral sensory neuropathy are to be managed as presented in the following table:

Version 09/01/2007 30


Management of Subjects with VELCADE-Related Neuropathic Pain or Peripheral Sensory Neuropathy

Peripheral Sensory Neuropathy (NCI CTCAE Grade [Version 3.0])

0 1 2 3 4

Normal

Asymptomatic; Loss of

deep tendon reflexes or paresthesia (including

tingling) but not

interfering with

function

Sensory alteration or paresthesia (including tingling)

interfering with

function, but not

interfering with ADL

Sensory alteration or paresthesia

interfering with ADL Disabling

0 None

No action No action Reduction by 1 dose

level

Hold; reduction by 2 dose levels;

schedule ∆ required

Discontinue VELCADE

1 Mild pain not

interfering with

function

No action No action Reduction by 1 dose

level



Discontinue VELCADE

2 Moderate pain: pain

or analgesics interfering

with function, but not


Reduction by 1 dose

level

Reduction by 2 dose

levels

Hold; reduction by 2 dose

levels



Discontinue VELCADE

3 Severe pain: pain or

analgesics severely



levels; schedule ∆ required





Discontinue VELCADE

Discontinue VELCADE

NeuropathicPain (NCI CTCAE Grade [Version 3.0])

4 Disabling Discontinue VELCADE

Discontinue VELCADE

Discontinue VELCADE

Discontinue VELCADE

Discontinue VELCADE

Version 09/01/2007 31


ADL = activities of daily living Hold = Interrupt VELCADE for up to 3 weeks until the toxicity returns to Grade 1 or better. Schedule ∆ Required = Schedule change from VELCADE twice weekly (Days 1, 4, 8, 11) to once weekly (Days 1, 8) required. If the subject is already on a once weekly schedule, then VELCADE will be given every other week (i.e., Day 1, Day 22)<<?>>.

For subjects previously treated with 1.3 mg/m2 of VELCADE, “reduction by 1 dose level” means reduction to 1.0 mg/m2 of VELCADE, and “reduction by 2 dose levels” means reduction to 0.7 mg/m2 of VELCADE (+ schedule ∆ if indicated by the table). For subjects previously treated with 1.0 mg/m2 of VELCADE, “reduction by 1 dose level” means reduction to 0.7 mg/m2 of VELCADE; in case of “reduction by 2 dose levels” a reduction to 0.7 mg/m2 of VELCADE always combined with a schedule ∆ should be applied. For subjects previously treated with 0.7 mg/m2 of VELCADE, in case of “reduction by 1 dose level” and “reduction by 2 dose levels” a schedule ∆ should be applied.

Velcade dose modification for other toxicities

For clinically significant non-hematological toxicities other than neuropathic pain or peripheral sensory neuropathy that cannot be managed with supportive care, VELCADE is to be held until the toxicity return to grade 2 or better. If in the previous cycle 2 or more of the 4 doses of velcade were skipped due to toxicity, the dose of velcade will be reduced in the following cycles from 1.6 to 1.3 mg/m2, 1.3 to 1.0 mg/m2 or 1.0 to .07 mg/m2. Dose re-escalation subsequent cycles are permitted at the discretion of the investigator.

5.4. RITUXIMAB dose modification Rituximab administration and dose modification must follow labeling instructions and guidelines. Please refer to the approved product label for instructions

Patients who develop severe infusion reactions should have rituximab infusion discontinued and supportive care measures as medically indicated ( e.g. fluids, vasopressors, oxygen, bronchodilators, acetaminophen , etc.) In most cases, the infusion can be resumed at 50% reduction rate (e.g. from 100 mg/hr to 50 mg/hr (when symptoms have completely resolved. Patients requiring close monitoring during first and all subsequent infusions include those pre-existing cardiac and pulmonary conditions, those with prior clinically significant cardiopulmonary adverse events, and whose with high numbers of circulating malignant cells (>25 x 109/l) with or without evidence of high tumor burden.

Version 09/01/2007 32


6. COMPLIANCE The investigator, or designated study personnel will maintain a log of all study drugs. Drug supplies for each subject will be inventoried and accounted for throughout the study. A log of all disposed materials will also be maintained.

7. CONCOMITANT THERAPY All concomitant medications for medical conditions other than B-NHL are permitted, as clinically indicated.

All supportive therapies other than anti-cancer treatment needed for the management of patients enrolled in this study are permitted.

7.1. Permitted Therapy The following medications and support therapies that may be used if needed during this study:

• Antiviral profilaxis with acyclovir 800-1200 mg at day since the beninning of therapy is strongly recommended in patients with herpes virus infection riactivation Additional profilaxis with levoxacine or ciprofloxacine will be administrated in case of neutropenia <1.0 x 109/l.

• G- CSF is allowed and will be given according to primary physician decision in presence of neutropenia < 1.0 x 109/L.

• Platelets and red blood cell transfusion are allowed ,if needed. • Immunoglobulin assay is advisable once a month during the therapy with

immunoglobulin replacement in case of IgG level < 0.3-0.5 gr/dl and frequent infectious events. Packed red cells and platelets transfusions will be given with filtered and irradiated products in case of Hb < 8 g/dL or Plts < 10 x 109/L. Erytropoietin therapy is allowed according to AH/ASCO guidelines

• Loperamide for the treatment of diarrhea, starting after the first watery stool. The dose regimen should be according to standard practice

• Bowel care is recommended to prevent costipation and should be administrered per standard practice

• Antiemetic agents • Bisphosphonates • Premedication for rituximab infusion with paracetamol and diphenhydramine should

be considered before each infusion of rituximab, because it may reduce infusion reactions.

• Use of corticosteroids is allowed only if needed in emergency or as pre-medication for rituximab infusion

Version 09/01/2007 33


7.2. Prohibited Therapy The following medications and supportive therapies are prohibited at all times:

• Any antineoplastic agent other than VELCADE or rituximab with the exception of medications that may have antineoplastic activity but are taken for other reasons (e.g., megestrol [Megace®], Cyclo-oxygenase-2 [COX-2] inhibitors, and bisphosphonates)

• Any experimental agent other than VELCADE

8. STUDY EVALUATIONS 8.1. Study Procedures

8.1.1.OVERWIEW Patients partecipation will include:

1. The pretreatment (screening) phase will be 28 days for all laboratory tests and radiographic imaging phase and up to 60 days for bone marrow evaluation. Lymphnode biopsy is strongly advisable before study entry, it should be performed withinh 6 months before study entry.

2. The open label treatment phase will extend from the first day of the first course to a maximum of 6 courses.

3.The follow-up phase will begin after the completion of the treatment phase. Follow-up will continue until disease progression (PD) is documented, the patient decides to withdraw from the study, death or the study is ended (expected to be 24 months from the date of the last patient’s end of therapy).

Hematology results must be available and reviewed by the investigator before subsequent VELCADE dosing to evaluate for possible hematological toxicity. Serum ß-HCG and urine pregnancy tests will be performed for all women of childbearing potential; if results are positive the subject will not be enrolled/continue in the study.

All subjects will be monitored for adverse events throughout the study and for 30 days after administration of the last dose of VELCADE.

a. screening phase

All patients must satisfy all the inclusion criteria and none of exclusion criteria listed in section 2.1 and 2.1 and sign informed consent before the first dose of study drug can be administrated. Results of procedures performed as part of standard medical care before signing the informed consent may be used as part of the screening evaluation if

Version 09/01/2007 34


performed within 28 days of beginning of therapy for laboratory tests and imaging studies, within 60 days for bone marrow biopsy and aspirate and within 6 months for lymphnode biopsy.

The latest measurements taken on day 1 of course 1 before administration of velcade or at screening will be defined as baseline values

At the baseline will be evaluated:

• Complete medical history

• Concomitant diseases and treatment

• Recent clinical history ( B symptoms)

• Physical examination (size of lymphnodes, sign of organ involvement)

• ECOG performance status

• ECG and echocardiogram or blood pool cardioscintigraphy

• Chest and abdomen computer tomography

• Hematology (hematocrit, hemoglobin, RBC WBC and differential, Platelets, CD3+, CD4+, CD8+, CD19+, CD20+)

• Blood chemistry (AST, ALT, serum alkaline phosphatase, gGT, total bilirubin, BUN, creatinine, Na, K, Ca, P, uric acid, total protein, albumin)

• Serum LDH

• Beta-2-microglobulin

• IgA, IgG, IgM

• HIV

• HBsAg, HbsAb, HBVcAb and HBV-DNA

• HCV

• Bone marrow biopsy and aspirate

• Lymphonodes biopsy is strongly recommended

Version 09/01/2007 35


• Immunohistochemical detection of CD20 on lymphoma-cells (lymphnode)

• Additional assessments if necessary according to the local standards and if clinically indicated at the discretion of the treating physician.

• Pregnancy test (if applicable)

• Written informed consent.

b. treatment phase

The open label treatment phase begins on Day 1 of course 1 (total 6 courses) of treatment with study drug and continues until completion of study therapy or discontinuation of treatment with the study drug ( end of treatment visit).

Before each course will be evaluated: • Physical examination • Hematology (Whole blood cell counts and differential) • Blood chemistry (AST, ALT, serum alkaline phosphatase, gGT, total bilirubin, BUN,

creatinine, Na, K, uric acid).

After each course will be evaluated: Patients will be evaluated through this phase for possible toxicities and delays in dosing: dose modification will be made as required according to dose modification rules identified in section 5.2 Patients who discontinued study drug due to toxicity will have end of treatment procedures completed and enter in the follow up phase. The assessments will not have to be documented in the CRFs unless AE or SAE procedures apply. Additional assessments have to be performed according to the local standards and if clinically indicated at the discretion of the treating physician. AFTER COURSE 3:

• Physical examination (size of lymphnodes, signs of organ involvement) • ECOG performance status • Hematology (hematocrit, hemoglobin, RBC WBC and differential, Platelets, CD3+,

CD4+, CD8+, CD19+, CD20+)

• Blood chemistry (AST, ALT, serum alkaline phosphatase, gGT, total bilirubin, BUN, creatinine, Na, K, Ca, P, uric acid, total protein, albumin)

Version 09/01/2007 36


• Serum LDH • Beta-2-microglobulin • IgA, IgG, IgM • Bone marrow biopsy (Should be performed only if it was abnormal at baseline visit) • Chest and abdomen computer tomography • Additional assessments if necessary according to the local standards and if clinically

indicated at the discretion of the treating physician. All patients with disease in CR, PR, MR or SD will continue the trial and will be treated with 3 courses of therapy with the same drug doses and assessment.

All patients in PD will be considered out of study and the therapy with the study drug will be discontinuated

c. Follow phase

The follow up phase begins with the end treatment visit that will be performed one month after the last dose of study drug is administrated.

The end treatment visit will include end of treatment procedures and collection of adverse events during the month after the last dose of study drug administration : in this visit will be evaluated:

Recent clinical history ( B symptoms)

Physical examination (size of lymphonodes, sign of organ involvement)

ECOG performance status

Chest and abdomen computer tomografy

Hematology (hematocrit, hemoglobin, RBC WBC and differential, Platelets, CD3+, CD4+, CD8+, CD19+, CD20+)

Blood chemistry (AST, ALT, serum alkaline phosphatase, gGT, total bilirubin, BUN, creatinine, Na, K, Ca, P, uric acid, total protein, albumin)

Serum LDH

Beta-2-microglobulin

IgA, IgG, IgM

Bone marrow biopsy and aspirate (should be performed only if involved at the screening evaluation)

Version 09/01/2007 37


Additional assessments if necessary according to the local standards and if clinically indicated at the discretion of the treating physician. After the completion of the end of treatment evaluation all patients will enter in the follow up phase. The follow up phase will end in case of dead or progressive disease.

During the follow up phase will be evaluated:

Every 2 months:






Serum LDH


IgA, IgG, IgM

Additional assessments if necessary

At months 6, 12 and 24:




Chest and abdomen computer tomografy



Version 09/01/2007 38


Serum LDH


IgA, IgG, IgM

Bone marrow biopsy and aspirate (should be performed only if involved at the screening evaluation)

Additional assessments if necessary according to the local standards and if clinically indicated at the discretion of the treating physician.

8.2.Statistical considerations and Sample size

8.2.1. EFFICACY CRITERIA The primary objective of the study is to demonstrate a clinical benefit in Overall Response Rate (ORR) with Bortezomib-Rituximab association in relapsed/refractory indolent and mantle cell non-Hodgkin’s lymphoma.

ORR (Complete Remission, Complete Remission unconfirmed and Partial Remission) was used to determine the sample size of the study.

The comparison data for the study design and sample size calculations come from those ones reported by Pivotal trial with Rituximab alone. However this study included only a small subset of indolent non-follicular lymphomas. The ORR for this subset of patients was 12% in the Pivotal trial22. No other reference studies are available in this subset of relapsed/refractory patients. The expected ORR for relapsed/refractory indolent non-follicular and mantle cell lymphoma with the same characteristics indicated into the study and treated with standard Rituximab salvage therapy ± chemotherapy may be estimated 20%. We would consider a positive result to increase ORR from 20% to 40%.

This phase II study has been designed according to Simon’s two-stage Optimal Design, since it is the design that minimizes the expected sample size given a 'bad' response rate.

Parameter specifications:

• Standard proportion of ORR: p0= 0.2

• Minimum required ORR for the new regimen: p1= 0.4

• alpha= 0.05

Version 09/01/2007 39


• power= 0.8

Sample size:

• 48 subjects (total)

• 13 will be accrued during stage 1

• 30 during stage 2

Stopping rules:

Given that the 'true' response probability is 20%, there is a 74.73% probability of ending the trail during stage 1, with an expected sample size for the trail of 20.58.

However, if the 'true' response probability is 40%, there is only a 16.86% probability that the trail will be stopped in stage 1.

If 3/13 or fewer responses are observed during the first stage then the trail is stopped early.

If 12/43 or fewer responses are observed by the end of the trail, then no further investigation of this regimen is warranted.

Losses to follow-up:

Assuming a 10% losses for any reasons, the total number of patients to be enrolled is 48.

8.2.2. ENDPOINT DEFINITIONS Overall Response Rate (ORR): Complete Remission, Complete Remission Unconfirmed, Partial Remission.

A patient is defined as a responder if he has a complete or partial response. Patients without response assessment (due to whatever reason) will be considered as non-responder.

Criteria for evaluation

A modification of the recently published recommendations of an International Workshop to Standardise Response Criteria for Non-Hodgkin´s Lymphomas [Cheson et al., 1999] will be applied. Response criteria will be determined as follows:

Version 09/01/2007 40


Complete Remission (CR): CR is defined as complete disappearance of all symptoms

and objective signs of disease including enlarged lymphonodes as well as hepatomegaly

and splenomegaly. CR must be documented for a period of at least 3 months following

the definitive re-evaluation at the end of therapy. In case of initial bone marrow

involvement, clearance of bone marrow by lymphoma must be documented by bone

marrow biopsy, normalisation of blood counts with granulocytes > 1.500/µl, Hb > 12

g/dl, and platelets > 100.000/µl.

Complete Remission, undocumented/unconfirmed (CRu): CRu is defined as the

disappearance of all symptoms and nearly all measurable lesions, but persistence of

some radiologic abnormalities with normalisation of all biologic abnormalities and

normalisation of the performance status. If persisting lymphoma cells are demonstrated

in a re- biopsy, the response will be defined as partial remission (PR). Similar to CR,

CRu must be documented for a period of at least 3 months after the definite evaluation

of therapy. CRu implies that the treating physician does not deem further chemotherapy

to be necessary.

Partial Remission (PR): PR is defined as at least 50% reduction (≥ 50 %) of

measurable and evaluable lymphoma involvement for a period of at least 4 weeks

without occurrence of new manifestations, and normalisation of blood counts. If

possible, all previously involved areas should be checked at the time of definitive re-

evaluation. PR implies that the treating physician diagnoses remaining signs of active

disease and recognises the necessity for further treatment (radiotherapy or

chemotherapy).

Note:

1. This definition of response criteria assumes that the kinetics of regression of large

measurable lesions is an indicator for the regression of all lesions. Therefore,

measuring all lesions is not always necessary for the evaluation of the response to

treatment.

If there are any doubts or questions when defining the response rate, it is suggested to

contact the Principal Investigator.

Version 09/01/2007 41


Stable Disease (SD): Tumour regression of less than 50% of measurable and

evaluable lymphoma involvement, no new manifestations, and progression of less

25% of manifestations of lymphoma.

Progression Disease (PD): Progressive disease is defined as:

• increase of frequency and severity of symptoms

• new nodal or extranodal manifestations of lymphoma

• enlargement of manifestations of lymphoma of more than 25% of their initial

diameter

Relapse: Reappearance of parameters as described for progression (PD) in patients

who have achieved a remission (CR, CRu) for at least 2 months. Relapse occurring

within 2 months after achieving remission assessed at the definitive evaluation after

completion of study therapy is regarded as progression (PD).

Overall survival will be determined from the date of enrollment into the study to the

date of death from any cause. Patients who have not died at the time of the final

analysis will be censored at the date of the last contact.

Time to failure will be measured from the day of randomisation to the date of

documented disease progression, relapse or death from any cause.

Progression-free survival will be measured from the first day of recruitment to the

date of progressive disease. Responding patients and patients who are lost to follow up

will be censored at their last assessment date.

8.3. Safety Evaluations

The study will include the following evaluations of safety and tolerability:

• Adverse Events Adverse events will be reported by the subject (or, when appropriate, by a caregiver, surrogate, or the subject’s legally acceptable representative) for the duration of the study.

Version 09/01/2007 42


• Clinical Laboratory Tests All laboratory tests should be performed at the laboratory of the investigational site: laboratory certificates or accreditation and normal ranges must be submitted before the patient’s enrollement

• Electrocardiogram • Vital Signs (pulse, temperature, blood pressure, respiration rate) [

• Physical Examination Any clinically significant abnormalities persisting at the end of the study will be followed by the investigator until resolution or until reaching a clinically stable endpoint.

Safecty and feasibility of VELCADE-RITUXIMAB association: severe toxicities ( grade 3-4) expected in less than 30% of patients.

9. SUBJECT COMPLETION/WITHDRAWAL9.1. Completion

A subject will be considered as having completed the study if he/she has completed all assessments at Week 30 of the [open label] treatment phase.] [Subjects who discontinue study treatment due to lack of efficacy are also considered to have completed the study.]

9.2. Discontinuation of Treatment A patient should be discontinued from study treatment if

• the investigator believes that for safety reasons (e.g., adverse event) it is in the best interest of the subject to stop treatment

• the subject becomes pregnant (if pregnancy is specified as an exclusion criterion) • the subject has disease progression at any time

• the subject has no response after the third course of therapy • The subject has > grade 3 toxicity for > 2 weeks

9.3. Withdrawal From the Study A subject will be withdrawn from the study for any of the following reasons:

• Lost at follow up • withdrawal of consent

Version 09/01/2007 43


• discontinuation of study treatment (final assessments will be obtained) if applicable When a subject withdraws before completing the study, the reason for withdrawal is to be documented on the CRF and in the source document. Study drug assigned to the withdrawn subject may not be assigned to another subject.

10. ADVERSE EVENT REPORTING Timely, accurate, and complete reporting and analysis of safety information from clinical studies are crucial for the protection of subjects and are mandated by regulatory agencies worldwide.

10.1. Definitions 10.1.1 ADVERSE EVENTS DEFINITION AND CLASSIFICATION • Adverse Event

An adverse event is any untoward medical occurrence in a clinical study subject administered a pharmaceutical product. An adverse event does not necessarily have a causal relationship with the treatment. An adverse event can therefore be any unfavorable and unintended sign (including an abnormal finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product. (Definition per International Conference on Harmonization [ICH]) This includes any occurrence that is new in onset or aggravated in severity or frequency from the baseline condition, or abnormal results of diagnostic procedures, including laboratory test abnormalities.

• Serious Adverse Event A serious adverse event as defined by ICH is any untoward medical occurrence that at any dose meets any of the following conditions:

– results in death – is life-threatening

(The subject was at risk of death at the time of the event. It does not refer to an event that hypothetically might have caused death if it were more severe.)

– requires inpatient hospitalization or prolongation of existing hospitalization – results in persistent or significant disability/incapacity, or – is a congenital anomaly/birth defect

Note: Medical and scientific judgment should be exercised in deciding whether expedited reporting is also appropriate in situations other than those listed above. For example, important medical events may not be immediately life threatening or result in death or hospitalization, but may jeopardize the subject or may require intervention to prevent one of the outcomes listed in the definition above. Any

Version 09/01/2007 44


adverse event is considered a serious adverse event if it is associated with clinical signs or symptoms judged by the investigator to have a significant clinical impact.

• Unlisted (Unexpected) Adverse Event An unlisted adverse event, the nature or severity of which is not consistent with the applicable product information. For an investigational product, the expectedness of an adverse event will be determined by whether or not it is listed in the Investigator's Brochure.

• Associated With the Use of the Drug An adverse event is considered associated with the use of the drug if the attribution is possible, probable, or very likely by the definitions listed in Section 12.1.2.

10.1.2.ATTRIBUTION DEFINITIONS Intensity (Severity) Reporting and Attribution

For both serious and non-serious adverse events, the investigator must determine both the intensity of the event and the relationship of the event to study drug administration.

Intensity for each adverse event will be determined by using Version 3.0 of the National Cancer Institute Common Toxicity Criteria (NCI CTC) as a guideline, wherever possible. The criteria will be provided to the investigator as a separate document. In those cases where the NCI CTC do not apply, intensity should be defined according to the following criteria:

• Mild Awareness of sign or symptom, but easily tolerated • Moderate Discomfort enough to cause interference with normal

daily activities • Severe Inability to perform normal daily activities • Life Threatening Immediate risk of death from the reaction as it occurred Relationship to study drug administration will be determined as follows:

• Not related An adverse event which is not related to the use of the drug.

• Unlikely/Doubtful An adverse event for which an alternative explanation is more likely, e.g., concomitant drug(s), concomitant disease(s), or the relationship in time suggests that a causal relationship is unlikely.

• Possible An adverse event which might be due to the use of the drug. An alternative explanation, e.g., concomitant drug(s), concomitant disease(s), is inconclusive. The relationship in time is reasonable; therefore, the causal relationship cannot be excluded.

Version 09/01/2007 45


• Probable An adverse event which might be due to the use of the drug. The relationship in time is suggestive (e.g., confirmed by dechallenge). An alternative explanation is less likely, e.g., concomitant drug(s), concomitant disease(s).

Definite/Very Likely An adverse event which is listed as a possible adverse reaction and cannot be reasonably explained by an alternative explanation, e.g., concomitant drug(s), concomitant disease(s). The relationship in time is very suggestive (e.g., it is confirmed by dechallenge and rechallenge).

10.2. Procedures 10.2.1.ALL ADVERSE EVENTS All adverse events other than disease progression will be reported from the time a signed and dated informed consent form is obtained until 30 days after the last dose of study drug. All events that meet the definition of a serious adverse event will be reported as serious adverse events, regardless of whether they are protocol-specific assessments

All adverse events, regardless of seriousness, severity, or presumed relationship to study therapy, must be recorded using medical terminology in the source document and the CRF. Whenever possible, diagnoses should be given when signs and symptoms are due to a common etiology (e.g., cough, runny nose, sneezing, sore throat, and head congestion should be reported as “upper respiratory infection”). Investigators must record in the CRF their opinion concerning the relationship of the adverse event to study therapy. All measures required for adverse event management must be recorded in the source document and reported according to sponsor instructions.

All grade 3 and 4 adverse events, considered related, must be followed until resolution of the event, or the event improves to a grade 2 or better. The events of interest in the table above of grade 2 or higher will be followed until grade 1 or better. The unresolved aforementioned events will be followed for a maximum of 6 months.

Sections of the CRFs containing adverse event information will be submitted by the investigator to a representative of the sponsor. Serious adverse event reports will be submitted as described in Section 12.2.2, Serious Adverse Events.

The Investigator-Sponsor must report adverse events to the appropriate Independent Ethics Committee/Institutional Review Board (IEC/IRB) that approved the protocol unless otherwise required and documented by the IEC/IRB. The Investigator-Sponsor

Version 09/01/2007 46


assumes responsibility for appropriate reporting of adverse events to regulatory authorities.

10.1.2.SERIOUS ADVERSE EVENTS All serious adverse events occurring during clinical studies must be reported to the appropriate sponsor contact person (Dr Alessandro Levis SC. Ematologia, Azienda Ospedaliera S. Antonio e Biagio, Alessandria) and to Janssen Cilag by investigational staff within 24 hours of their knowledge of the event.

Information regarding serious adverse events will be transmitted to the sponsor using the Serious Adverse Event Form, which must be signed by a member of the investigational staff. The initial report of a serious adverse event may be made by facsimile (fax) or telephone. It is preferable that serious adverse events be reported via fax.

The cause of death of a subject in a clinical study, whether or not the event is expected or associated with the investigational agent, is considered a serious adverse event. Any event requiring hospitalization (or prolongation of hospitalization) that occurs during the course of a subject’s participation in the clinical study must be reported as a serious adverse event, except hospitalizations for:

• A standard procedure for protocol therapy administration will not be reported as a serious events

• social reasons in absence of an adverse event • surgery or procedure planned before entry into the study (must be documented in the

CRF) • study drug administration

• study related procedures defined in the protocol

11. STUDY DRUG INFORMATION 11.1. Physical Description of Study Drug(s)

VELCADE (bortezomib for injection) is an antineoplastic agent available for i.v. use only. Each single dose vial contains 3.5 mg of bortezomib as a sterile lyophilized (white to off-white) cake or powder. Inactive ingredient: 35 mg mannitol, USP.

Version 09/01/2007 47


11.2. Packaging VELCADE will be supplied in boxes of bulk vials.

11.3.Labeling Study drug labels will contain information to meet the applicable regulatory requirements.

11.4.Preparation and Handling VELCADE

Unopened vials of VELCADE may be stored at controlled room temperature 25°C (77°F); excursions permitted from 15°C to 30°C (59°F to 86°F). It should be retained in the original package to protect from light. VELCADE contains no antimicrobial preservative. When reconstituted as directed, VELCADE may be stored (at these same temperatures) in the original vial or syringe. The product may be stored for up to 3 hours in a syringe, however total storage time for the reconstituted material must not exceed 8 hours.

VELCADE injections should be prepared and handled according to the instructions provided in Attachment 2, Instructions for the Preparation and Handling of VELCADE Injections.

RITUXIMAB

For additional information refer to the package insert for rituximab.

11.5. Drug Accountability The clinical investigator is responsible for ensuring that all study drug received at the site is inventoried and accounted for throughout the study. Study drug must be handled strictly in accordance with the protocol and the container label and will be stored in a limited access area or in a locked

Study drug should be dispensed under the supervision of investigator, a qualified member of the investigational staff, or by a hospital/clinic pharmacist. Study drug will be supplied only to subjects participating in the study. Returned study drug must not be dispensed again, even to the same subject. Study drug may not be relabeled or reassigned for use by other subjects. The investigator agrees neither to dispense the study drug form, nor store it at any site other than study sites agreed upon the sponsor.

Version 09/01/2007 48


12. ETHICAL ASPECTS 12.1. Study-Specific Design Considerations

• Heart failure may occasionally occur in patients at risk, and existing symptoms may worsen.

• Laboratory tests show that VELCADE may damage DNA. Based on this information, it is possible that VELCADE may cause infertility in men or women.

The study was designed for patients with naïve or sensitive rituximab indolent non-follicular non-Hodgkin’s Lymphoma disease that had failed the response or relapsed after primary therapy

12.2.Regulatory Ethics Compliance 12.2.1.INVESTIGATOR RESPONSIBILITIES [The investigator is responsible for ensuring that the clinical study is performed in accordance with the protocol, current ICH guidelines on Good Clinical Practice (GCP), and applicable regulatory requirements.

GCP is an international ethical and scientific quality standard for designing, conducting, recording, and reporting studies that involve the participation of human subjects. Compliance with this standard provides public assurance that the rights, safety, and well being of study subjects are protected, consistent with the principles that originated in the Declaration of Helsinki, and that the clinical study data are credible.

12.3.Independent Ethics Committee or Institutional Review Board (IEC/IRB)

Before the start of the study, the investigator will provide the IEC/IRB with current and complete copies of the following documents:

• final protocol and, if applicable, amendments • informed consent form (and any other written materials to be provided to the

subjects) • Investigator’s Brochure (or equivalent information) and amendments • information on compensation for study-related injuries or payment to subjects for

participation in the study, if applicable • investigator’s curriculum vitae or equivalent information (unless not required, as

documented by IEC/IRB) • information regarding funding, institutional affiliations, other potential conflicts of

interest, and incentives for subjects • any other documents that the IEC/IRB requests to fulfill its obligation

Version 09/01/2007 49


If study drug is being provided, it will not be shipped until after IEC/IRB has given full approval of the final protocol, amendments (if any), the informed consent form, applicable recruiting materials, and subject compensation programs, and the Investigator-sponsor has received a copy of this approval. This approval letter must be dated and must clearly identify the documents being approved.

During the study the investigator will send the following documents to the IEC/IRB for their review and approval, where appropriate:

• protocol amendments • revision(s) to informed consent form and any other written materials to be provided

to subjects • if applicable, new or revised subject recruiting materials approved by the sponsor • revisions to compensation for study-related injuries or payment to subjects for

participation in the study, if applicable • Investigator’s Brochure amendments or new edition(s) • summaries of the status of the study (at least annually or at intervals stipulated in

guidelines of the IEC/IRB) • reports of adverse events that are serious, unlisted, and associated with the

investigational drug • new information that may affect adversely the safety of the subjects or the conduct of

the study • deviations from or changes to the protocol to eliminate immediate hazards to the

subjects • report of deaths of subjects under the investigator's care • notification if a new investigator is responsible for the study at the site • any other requirements of the IEC/IRB For protocol amendments that increase subject risk, the amendment and applicable informed consent form revisions must be submitted promptly to the IEC/IRB for review and approval before implementation of the change(s).

At least once a year, the IEC/IRB will be informed about the clinical ongoing of this clinical study. This request should be documented in writing.

At the end of the study, the investigator (or sponsor where required) will notify the IEC/IRB about the study completion.

Version 09/01/2007 50


12.3.1.INFORMED CONSENT Each subject (or a legally acceptable representative) must give written consent according to local requirements after the nature of the study has been fully explained. The consent form must be signed before performance of any study-related activity. The consent form that is used must be approved by Millennium or Jansen-Cilag and by the reviewing IEC/IRB. The informed consent should be in accordance with principles that originated in the Declaration of Helsinki, current ICH and GCP guidelines, applicable regulatory requirements, and sponsor policy.

Before entry into the study, the investigator or an authorized member of the investigational staff must explain to potential subjects or their legally acceptable representatives the aims, methods, reasonably anticipated benefits, and potential hazards of the study, and any discomfort it may entail. Subjects will be informed that their participation is voluntary and that they may withdraw consent to participate at any time. They will be informed that choosing not to participate will not affect the care the subject will receive for the treatment of his/her disease. Subjects will be told that alternative treatments are available if they refuse to take part and that such refusal will not prejudice future treatment.

The subject or legally acceptable representative will be given sufficient time to read the informed consent form and the opportunity to ask questions. After this explanation and before entry to the study, consent should be appropriately recorded by means of either the subject's or his/her legally acceptable representative's dated signature. After having obtained the consent, a copy of the informed consent form must be given to the subject.

Subjects will also be asked to consent to participate in a genetic research component of the study. Refusal to participate will not result in ineligibility for the rest of the clinical study unless participation in genetic testing is required as an inclusion criterion. After informed consent is appropriately obtained, the subject or his/her legally acceptable representative will sign and personally date a separate DNA informed consent form indicating agreement or refusal to participate in the genetic testing. A copy of this informed consent form will be given to the subject.

If the subject or legally acceptable representative is unable to read or write, an impartial witness should be present for the entire informed consent process (which includes reading and explaining all written information) and personally date and sign the informed consent form after the oral consent of the subject or legally acceptable representative is obtained.

Version 09/01/2007 51


12.3.2.PRIVACY OF PERSONAL DATA The collection and processing of personal data from subjects enrolled in this study will be limited to those data that are necessary to investigate the efficacy, safety, quality, and utility of the investigational product(s) used in this study.

These data must be collected and processed with adequate precautions to ensure confidentiality and compliance with applicable data privacy protection laws and regulations.

The investigator-sponsor ensures that the personal data will be

• processed fairly and lawfully • collected for specified, explicit, and legitimate purposes and not further processed in

a way incompatible with these purposes • adequate, relevant, and not excessive in relation to said purposes • accurate and, where necessary, kept current

Explicit consent for the processing of personal data will be obtained from the participating subject (or his/her legally acceptable representative) before collection of data. Such consent should also address the transfer of the data to other entities and to other countries.

The subject has the right to request through the investigator access to his/her personal data and the right to request rectification of any data that are not correct or complete. Reasonable steps should be taken to respond to such a request, taking into consideration the nature of the request, the conditions of the study, and the applicable laws and regulations.

13.ADMINISTRATIVE REQUIREMENTS

13.1.Data Quality Assurance Steps to be taken to ensure the accuracy and reliability of data include the selection of qualified investigators and appropriate study centers, review of protocol procedures with the investigator and associated personnel before the study. Written instructions will be provided for collection, preparation, and shipment of blood, plasma, and urine samples. CRF completion guidelines will be provided and reviewed with study personnel before the start of the study. The sponsor will review CRFs for accuracy and completeness during on-site monitoring visits and after their return to the sponsor; any discrepancies will be resolved with the investigator or designee, as appropriate

Version 09/01/2007 52


Investigator will permit trial-related monitoring, providing direct access to source documents/data

13.2.Record Retention The results of the study will be reported in a Clinical study Report generated by the investigator-sponsor and will contain all data from all investigational sites.

Provide identification of any data to be recorded directly on the CRFs (electronic record of data), and to be considered to be source data.

13.3.On-Site Audits investigator/institution will permit trial-related audits, providing direct access to source documents/data

Version 09/01/2007 53


14. REFERENCES 1. VELCADE (bortezomib) [SmPC].Beerse Belgium. Janssen-Cilag International

NV; April 2005

2. Adams J, Palombella VJ, Sausville EA, Johnson J, Destree A, Lazarus DD et al.

Proteasome inhibitors: a novel class of potent and effective antitumor agents.

Cancer Res 1999;59(11):2615-22.

3. Steiner P, Neumeier H, Lightcap E, Sadis S, Pien C, Pink M et al. Adaptation of

human tumor cell lines to PS-341. AACR-NCI-EORTC International Conference,

2001; Miami Beach, FL. Millennium Pharmaceuticals, Inc., 75 Sidney Street,

Cambridge, MA 02139. Abstract

4. Teicher BA, Ara G, Herbst R, Palombella VJ, Adams J. The proteasome inhibitor

PS-341 in cancer therapy. Clin Cancer Res 1999;5(9):2638-45.

5. Cusack JC, Jr., Liu R, Houston M, Abendroth K, Elliott PJ, Adams J et al.

Enhanced chemosensitivity to CPT-11 with proteasome inhibitor PS-341:

implications for systemic nuclear factor-kappa B inhibition. Cancer Res

2001;61(9):3535-40.

6. LeBlanc R, Catley LP, Hideshima T, Lentzsch S, Mitsiades CS, Mitsiades N et al.

Proteasome inhibitor PS-341 inhibits human myeloma cell growth in vivo and

prolongs survival in a murine model. Cancer Res 2002;62(17):4996-5000.

7. Pink MM, Pien CS, Ona VO, Worland P, Adams J, Kauffman MG. PS-341

enhances chemotherapeutic effect in human xenograft models. Proc Am Assoc

Cancer Res, 2002; San Francisco, CA. Abstract 787.

8. Papandreou C, Daliani D, Millikan RE, Tu S, Pagliaro L, Adam J. Phase I study of

intravenous (I.V.) proteasome inhibitor PS-341 in patients (pts) with advanced

malignancies. Proc Am Soc Clin Oncol, 2001. Abstract 340.

9. McConkey DJ, Pettaway C, Elliott P, Adam J, Papandreou C, Herrmann JL et al.

The proteasome as a new drug target in metastatic prostate cancer. 7th Annual

Genitourinary Oncology Conference, 1999; Houston, TX. Abstract.

10. Hideshima T, Richardson P, Chauhan D, Palombella VJ, Elliott PJ, Adams J et al.

The proteasome inhibitor PS-341 inhibits growth, induces apoptosis, and

overcomes drug resistance in human multiple myeloma cells. Cancer Res

2001;61(7):3071-6.

Version 09/01/2007 54


11. Lightcap ES, McCormack TA, Pien CS, Chau V, Adams J, Elliott PJ. Proteasome

inhibition measurements: clinical application. Clin Chem 2000;46(5):673-83.

12. Aghajanian C, Soignet S, Dizon DS, Pien CS, Adams J, Elliott PJ et al. A Phase I

trial of the novel proteasome inhibitor PS341 in advanced solid tumor

malignancies. Clin Cancer Res 2002;8(8):2505-11.

13. Papandreou CN, Daliani Dd, Nix D, et al. Phase I trial of proteasome inhibitor

bortezomib in patients with advanced solid tumors with observations in androgen-

independent prostate cancer. J Clin Oncol 2004;22(11):2108-2121

14. Orlowski RZ, Stinchcombe TE, Mitchell BS, Shea TC, Baldwin AS, Stahl S et al.

Phase I trial of the proteasome inhibitor PS-341 in patients with refractory

hematologic malignancies. J Clin Oncol 2002; 20 (22):4420-7.

15. Blade J, Samson D, Reece D, Apperley J, Bjorkstrand B, Gahrton G et al. Criteria

for evaluating disease response and progression in patients with multiple myeloma

treated by high-dose therapy and haemopoietic stem cell transplantation. Myeloma

Subcommittee of the EBMT. European Group for Blood and Marrow Transplant.

Br J Haematol 1998; 102(5):1115-23.

16. Richardson PG, Barlogie B, Berenson J, Singhal S, Jagannath S, Irwin D, et al. A

phase 2 study of bortezomib in relapsed, refractory myeloma. New Eng J Med

2003;348(26):2609-2617.

17. Richardson PG, Briemberg H, Jagannath, et al. Peripheral neuropathy following

Bortezomib (VELCADETM, formerly PS-341) therapy in patients with advanced

multiple myeloma: characterisationand reversibility [abstract] Blood. November

2003; 102. Abstract 512.

18. Richardson PG, Sonneveld P, Schuster MW, et al. Bortezomib or high-dose

Dexamethasone for relapsed Multiple Myeloma. New Eng J Med 2005;352

(24):2487-2498.

19. Jagannath S, Durie BGM, Wolf J, et al Bortezomib (VELCADE™, formerly PS-

341) as first-line therapy in patients with multiple myeloma (MM). [abstract] Blood

November 2003:102. Abstract 1650.

20. McConkey D, Williams S, Papandreou. Role of p53 in proteasome inhibitor-based

combination chemotherapy in LNCAP cells. Proc Am Assoc Cancer Res 2000.

41:651. Abstract 4136.

Version 09/01/2007 55


21. Jagannath S, Barlogie B, Berenson J, Siegel D, Irwin D, Richardson PG et al. A

Phase II multicenter randomised study of the proteasome inhibitor bortezomib

(VELCADE™, formerly PS-341) in multiple myeloma (MM) patients (Pts)

relapsed after front-line therapy. 44th Annual Meeting of the American Society of

Hematology, 2002; Philadelphia, PA. Abstract 3702.

22. Richardson P, Barlogie B, Berenson J, Traynor A, Singhal S, Jagannath S. A phase

II multicenter study of the proteasome inhibitor bortezomib (VELCADE™,

formerly PS-341) in multiple myeloma patients (pts) with relapsed/refractory

disease. 44th Annual Meeting of the American Society of Hematology, 2002;

Philadelphia, PA. Abstract 385.

23. P. McLaughlin, F.B. Hagemeister and A. J. Grillo-Lopez “ Rituximab in indolent

lymphoma: the single agent Pivotal trial “ Seminars in Oncology vol 26, n5 suppl

14, 79-87, 1999

24. Mor V, Laliberte L, Morris JN, et al. The Karnofsky Performance Status Scale: an

examination of its reliability and validity in a research setting. Cancer

1984;53:2002-2007.

25. Calhoun EA, Welshman EE, Chang CH, et al. Psychometric evaluation of the

Functional Assessment of Cancer Therapy/Gynecologic Oncology

Group-Neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic

chemotherapy. Int J Gynecol Cancer 2003;13:7416

26. The Criteria Committee of the New York Heart Association, Inc.: Diseases of the

heart and blood vessels; Nomenclature and criteria for diagnosis, 6th Ed. Boston:

Little, Brown; 1964.

27. O’Connor OA, Wright J, Moskowitz C et al. Phase II clinical experience with the

novel proteosome inhibitor bortezomib in patients with indolent non-Hodgkin

lymphoma and mantle cell lymphoma. J Clin Oncol 2005; 23(4): 676-84.

28. O’Connor OA. The emerging role of bortezomib in the treatment of indolent non-

Hodgkin’s and mantle cell Lymphomas. Curr Treat Options Oncol 2004; 5 (4):

269-81.

29. Paoluzzi L, O’Connor OA. Mechanistic rationale and clinical evidence for the

efficacy of proteasome inhibitors against indolent and mantle cell lymphomas.

BioDrugs 2006; 20 (1): 13-23.

Version 09/01/2007 56


30. Treon S, Hunter ZR, Matous J et al. Phase II study of Bortezomib in

Waldenstrom’macroglobulinemia: results of WMTCTG Trial 03-248. 47th Annual

Meeting of the American Society of Hematology, 2005. Blood 2005; 106 (11):

490a.

31. Goy A, Younes A, McLaughlin P et al. Phase II study of proteasome inhibitor

bortezomib in relapsed or refractory B-cell non-Hodgkin’s Lymphoma. J Clin

Oncol 2005; 23 (4): 667-75.

32. Goy A, de Vos S, Dakhil S et al. Bortezomib plus Rituximab in patients with

indolent non Hodgkin lymphoma (NHL): a phase II study. 11th Congress of the

European Hematology Association, Amsterdam. Haematologica 2006; 91(S1):

187a.

33. Leonard JP, Furman RR, Cheung YKk, et al. Phase I/II trial of Bortezomib +

CHOP-Rituximab in Diffuse Large B Cell (DLBCL) and Mantle Cell Lymphoma

(MCL): Phase I Results. Blood 2005; 106 (11): 491a.

15. ATTACHMENTS

Version 09/01/2007 57


Attachment 1: performance status scales24

The following table presents the Karnofsky performance status scale.

Which of the following descriptions best describes the subject’s level of performance at this time:

Eastern Cooperative Oncology Group

(Zubrod-ECOG)1,2

KARNOFSKY SCORE

Description Grade Scale Description

Fully active, able to carry on all

pre-disease activities without restriction.

0 100

90

Normal, no complaints,

no evidence of disease.

Able to carry on normal activity,

minor symptoms or signs of disease.

Restricted in physically strenuous

Activity but ambulatory and able to carry

out work of a light or sedentary nature

e.g. light house work, office work.

1 80

70

Normal activity with effort, some signs

or symptoms of disease.

Cares for self, unable to carry on normal

activity or to do active work.

Ambulatory and capable of all self care

but unable to carry out any work activities.

Up and about more than 50%

of waking hours.

2 60

50

Requires occasional assistance, but is

able to care for most of his needs.

Requires considerable assistance and

frequent medical care.

Capable of only limited self care,

confirmed to bed or chair more than 50%

of waking hours.

3 40

30

Disabled, requires special care

and assistance.

Severely disabled, hospitalisation is

Version 09/01/2007 58


indicated although death is not

imminent.

Completely disabled. Cannot carry on

any self care.

Totally confined to bed or chair.

4 20

10

0

Hospitalisation necessary, very sick, active supportive treatment necessary

Moribund, fatal processes progressing rapidly

Dead

1 Zubrod, C.G., et al. Appraisal of Methods for the Study of Chemotherapy of Cancer in Man. Journal of Chronic Diseases, 11:7-33, 1960. 2 Oken, M.M., et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol (CCT) 5: 649-655, 1982 3 Karnofsky, D.A., Abelmann, W.H., Craver, L.F., and Burchenal, J.H., The use of the nitrogen mustards in the palliative treatment of carcinoma. Cancer (Philad.) 1:634, 1948. 4 Schag, C.C., Heinrich, R.L., Ganz, P.A., Karnofsky Performance Status Revisited : Reliability, Validity, and Guidelines, Clinical Oncology. 2:187-193, 1984. 5 Mor V, Laliberte L, Morris JN, et al. The Karnofsky Performance Status Scale: an examination of its reliability and validity in a research setting. Cancer 1984;53:2002-2007.

Version 09/01/2007 59


Attachment 2: WHO CLASSIFICATION FOR lymphoma

B-cell neoplasms

Precursor B-cell neoplasm Precursor B-Lymphoblastic leukemia/lymphoma Peripheral B-cell neoplasm Chronic lymphocitic leukemia Small lymphocitic lymphoma (SLL) With/without a monoclonal component With/without plasmacytoid differentiation B-cell prolymphocitic leukemia Hairy cell leukemia Lymphoplasmocytoid lymphoma (LPL) or immunocytoma Marginal zone B-cell lymphoma (MZL)

Mucosa-associated lymphoid tissue (MALT type lymphoma)

Splenic marginal zone lymphoma (+/- villous lymphocytes)*

Nodal lymphomas (+/- monocytoid B-cells)* Follicular lymphomas (FL) Grade I (<15% centroblasts) Grade II (>15% to 50% centroblasts) Grade III (>50% centroblasts) Mantle cell Lymphoma Diffuse large B-cell Lymphoma (DLCL) Variants Centroblastic lymphoma Immunoblastic lymphoma B-cell lymphoma rich in T-cells B-cell lymphoma rich in histiocytes Anaplastic large B-cell lymphoma Burkitt-like lymphoma Lymphomatoid granulomatosis Subtypes Mediastinal lymphoma Intravascular lymphoma Serous lymphoma Burkitt's lymphoma/leukemia (BL)

Version 09/01/2007 60


T-cell neoplasms

Precursor T-cell neoplasm Precursor T-Lymphoblastic leukemia/lymphoma Peripheral T/NK-cell neoplasm Chronic lymphocitic leukemia

T-cell chronic lymphocytic leukemia/prolymphocytic leukemia Large granular lymphocyte leukemia T-cell type NK-cell type Mycosis fungoides/Sezary syndrome Peripheral T-cell lymphomas Angioimmunoblastic T-cell lymphoma (AILD) Angiocentric lymphoma Intestinal T-cell lymphoma (+/- enteropathy-associated) Adult T-cell lymphoma/leukemia (ATL) Anaplastic large cell lymphoma (ALCL) CD30+, T- and null-cell types Anaplastic large cell lymphoma, Hodgkin's like*

Hodgkin's disease Predominantly lymphocytic nodular Hodgkin's lymphoma*

Classic variant Predominantly lymphocytic With nodular sclerosis Mixed-cell With lymphocyte depletion Hodgkin-like ALCL lymphoma*

Plasma cell diseases Waldenstrom's macroglobulinemia Monoclonal component of uncertain significance Plasmacytoma Solitary plasmacytoma Extra-osseous plasmacytoma Multiple Myeloma Plasma cell sarcoma Plasma cell leukemia

Version 09/01/2007 61


Proliferative diseases due to immunodeficiency

Hereditary immunodeficiency Atipical lymphoid proliferation Large B-cell lymphoma After allogeneic transplantation Polymorfic lymphoproliferative diseases Large B-cell lymphoma Plasmacytoma Peripheral T-cell lymphoma Hodgkin's lymphoma Deficiency due to HIV Burkitt's and Burkitt-like lymphomas Large B-cell lymphoma Immunoblastic lymphoma Serous lymphoma * provisional entities

Version 09/01/2007 62


Attachment 3: Instructions for the Preparation and Handling of VELCADE Injections

A licensed pharmacist or a properly trained designee will prepare all doses of VELCADE. It is very important that the exact dose is accurately dispensed and administered. If possible, the same person should prepare all doses (on all dosing days). VELCADE will be administered only to eligible subjects under the supervision of the investigator or identified subinvestigator(s).

Calculation of Dose

The amount (in mg) of VELCADE to be administered will be determined based on body surface area (BSA). BSA will be calculated based on body weight and height using a standard calculation (Attachment 8, Suggested Body Surface Area Calculation). The VELCADE dose will not be corrected for obese subjects. The dose should be calculated on Day 1 of each cycle and remain consistent during an individual cycle. The dose administered should remain consistent across cycles unless a notable change in weight (e.g., loss or gain of ≥10%) is documented during the Day 1 weight assessment of the cycle, in which case the subject’s dose should be recalculated at that time. In the event of VELCADE-associated toxicity during the study, the dose may be decreased according to the dose reduction schedules provided in Sections 6.2, Dose Modification and Delay and 6.3, VELCADE Dose Modification for Neuropathic Pain or Peripheral Sensory Neuropathy.

Preparation and Handling of Solution

VELCADE is cytotoxic. As with all cytotoxic drugs, caution should be exercised when handling and preparing VELCADE solution. Caution should be taken to avoid accidental ingestion, inhalation, and dermal or ocular contact when handling the test article. Cytotoxic drugs should only be handled by staff who are specially trained in the safe handling of such preparations. The pharmacist will prepare the VELCADE dose under aseptic conditions. The use of gloves and other appropriate protective clothing is recommended.

Study drug will be supplied in sterile, single-use vials containing 3.5 mg of VELCADE. Each vial of VELCADE for injection should be reconstituted with 3.5 mL of normal (0.9%) saline, Sodium Chloride Injection USP, so that the reconstituted solution contains bortezomib at a concentration of 1 mg/mL. Reconstitution should take place under a vertical laminar flow biological cabinet (hood) within 8 hours before dosing. Dissolution is completed in approximately 10 seconds. The reconstituted solution should be clear and colorless, with a final pH of 5 to 6. Reconstituted VELCADE should be administered promptly and in no case more than 8 hours after reconstitution.

Version 09/01/2007 63


Attachment 3: (Continued):Instructions for the Preparation and Handling of VELCADE Injections

Preparation of Syringe for Injection

The appropriate amount of VELCADE will be drawn from the injection vial according to the dosage calculations. Designated study site personnel will administer VELCADE as an i.v. push over 3- to 5-seconds followed by a standard saline flush (e.g., 0.9% Sodium Chloride). Indwelling cannulas may be used for injections. Vials are for single-use administration only. VELCADE should be administered promptly after drawing into syringe and must be administered within 3 hours of drawing into syringe and 8 hours of reconstitution (maintained at controlled room temperature 25°C (77°F). Conditions for storage of VELCADE are provided in Section 13.4, Preparation and Handling. There must be at least 72 hours between VELCADE doses. Procedures to follow in case of VELCADE contact with the skin are provided below.

Discarding of Vial and Syringe

After administration all materials that have been used for preparation should be disposed of according to standard practices. All unused vials must be saved for reconciliation by the study monitor. A log must be kept of all disposed materials.

Procedures to follow in case of skin contact:

Wash the affected area immediately and thoroughly with soap and water and diluted hydrogen peroxide. Remove contaminated clothing and dispose of according to standard procedures. In case of contact with mucous membranes, flush thoroughly with water. Always contact the investigator after any form of body contact.

Version 09/01/2007 64


Attachment 4: dispensing information for rituximab (idec-c2b8) DESCRIPTION

Rituximab is a mouse/human chimeric antibody. The rituximab antibody is produced by a Chinese hamster ovary transfectoma. Rituximab will be provided in l00 mg (l0 mL) and 500 mg (50 mL) pharmaceutical grade vials at a concentration of l0.0 mg of protein per mL (actual concentration should be noted on the product label).

RECOMMENDED PREPARATION AND ADMINISTRATION

1. Refer to the clinical trial protocol for details about the dose and dose schedule.

2. Rituximab should be stored at 2-8°C. Do not freeze or store at room temperature. The product is a protein - HANDLE GENTLY AND AVOID FOAMING. The avoidance of foaming during product handling, preparation and administration is important, as foaming may lead to the de-naturing of the product proteins.

3. All transfer procedures require strict adherence to aseptic techniques, preferably in a laminar flow hood.

4. Prepare the rituximab infusion solution as follows:

(a) Refrigerate (2-8°C) all materials and solutions prior to use. (b) Use sterile, non-pyrogenic, disposable containers, syringes, needles, stopcocks and

transfer tubing, etc. (c) Transfer of the rituximab from the glass vial should be made by using a suitable

sterile graduated syringe and large gauge needle. (d) Transfer the appropriate amount of rituximab from the graduated syringe, into a

partially filled IV pack containing sterile pyrogen-free 0.9% sodium chloride solution, USP (saline solution). The final concentration of rituximab in saline solution should be a maximum of 1 mg/ml. Mix by inverting the bag gently. DO NOT USE A VACUUM APPARATUS to transfer the product from the syringe to the plastic bag.

(e) Place an IV administration into the outflow port of the bag containing the infusion solution.

(f) NOTE: DO NOT USE evacuated glass containers which require vented administration sets because this causes foaming as air bubbles pass through the solution.

5. The administration of rituximab will be accomplished by slow IV infusion. CAUTION: DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS.

6. IV pumps such as the IMED 960 may be used with the rituximab infusion. DO NOT INFUSE CONCOMITANTLY with another IV solution or IV medications. Prime the line with the rituximab solution such that approximately 30 mL are delivered

7. Administration of rituximab

Version 09/01/2007 65


Pre-administration of allopurinol (or suitable alternative): Patients thought to be at risk of tumor lysis syndrome should be well-hydrated and treated with allopurinol (300 mg p.o.) or suitable alternative treatment for 12-24 hours before prior to the first dose of therapy with rituximab.

Caution: Do not administer rituximab as an intravenous push or bolus. Rituximab will be administered intravenously in an out- or in-patient setting. Oral premedication (1000 mg of paracethamole and 50-100 mg diphenhydramine hydrochloride) needs to be administered 30-60 minutes prior to starting each infusion of rituximab. Prednisone/prednisolone as part of the chemotherapy protocol will be administered in the prescribed dose before the infusion of rituximab, preferably as oral medication. A peripheral or central intravenous (iv) line will be established. Before starting the infusion, there should be a ready supply of epinephrine for subcutaneous injection and diphenhydramine hydrochloride for intravenous injection, and resuscitation equipment for the emergency handling of anaphylactic reactions.

The infusion will be started at an initial rate of 50 mg/hour for the first hour. During the rituximab infusion, the patient's vital signs (blood pressure, pulse, respiration and temperature) will be monitored every 15 minutes (4x) for one hour or until stable and then hourly until the infusion is discontinued. If no toxicity is seen during the first hour, the dose rate may be escalated gradually (by increments of 50 mg/hour at 30 minute intervals) to a maximum of 300 mg/hour. If the first dose of rituximab is well-tolerated, the starting flow rate for administration of the second and subsequent infusions will be 100 mg/hour and then increased gradually (by 100 mg/hour increments at 30 minute intervals) not to exceed 400 mg/hour. Patients may experience transient fever and rigors with infusion. If any of the effects below are noted, the antibody infusion should be temporarily discontinued, the patient should be observed, and when the symptoms improve, the infusion should be continued but at half the previous rate.

Dose Rate Fever Rigors/chills Mucosal congestion

Edema

Drop in Systolic

Blood Pressure

Decrease to 1/2

If any of these

Events seen:

> 38.5�C

Mild/Moderate

Mild/Moderate

> 30 mm Hg

Following the infusion the intravenous line should be kept open for medications, as needed. If there are no complications, the intravenous line may be discontinued after one hour of observation.

Version 09/01/2007 66


Dosage: 375 mg/m² body surface body surface total dose 1.4 m² 525.0 mg 1.5 m² 562.0 mg 1.6 m² 600.0 mg 1.7 m² 637.5 mg 1.8 m² 675.0 mg 1.9 m² 712.5 mg 2.0 m² 750.0 mg 1st application further Applications Hours mg/h *) mg-total mg/h *) mg-total 0 – 1 50 50 100 100 1 – 1.5 100 100 150 175 1.5 – 2 150 175 200 275 2 – 2.5 200 275 250 400 2.5 – 3 250 400 300 550 3 – 3.5 300 550 350 725 3.5 – 4 300 700 400 925 4 – 4.5 300 850 *) With a concentration of 1 mg/ml the values of mg/h are equal to ml/h.

Version 09/01/2007 67


Attachment 5: Neurotoxicity Questionnaire25

Subjects should complete the following questionnaire.

By circling one number per line, please indicate how true each statement has been for you during the past 7 days.

CONCERNS Not

at all

A little bit

Some- what

Quite a bit

Very much

I have numbness or tingling in my hands……… 0 1 2 3 4

I have numbness or tingling in my feet………… 0 1 2 3 4

I feel discomfort in my hands…………………. 0 1 2 3 4

I feel discomfort in my feet…………………… 0 1 2 3 4

I have joint pain or muscle cramps…………… 0 1 2 3 4

I feel weak all over…………………………… 0 1 2 3 4

I have trouble hearing………………………… 0 1 2 3 4

I get a ringing or buzzing in my ears………… 0 1 2 3 4

I have trouble buttoning buttons……………… 0 1 2 3 4

I have trouble feeling the shape of small objects when they are in my hand………………………

0 1 2 3 4

I have trouble walking………………………… 0 1 2 3 4

Source: FACT/GOG-Ntx, Version 4.0

Calhoun EA, Welshman EE, Chang CH, et al. Psychometric evaluation of the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic chemotherapy. Int J Gynecol Cancer 2003;13(6):741-8.

Version 09/01/2007 68


Attachment 6: Creatinine Clearance Calculation

Creatinine clearance for men and women will be calculated according to the Cockcroft-Gault formula as follows:

In men: ( ) ( )[ ]( )[ ]dLmgcreatinine

kgweightage

/72

140

×

×−

In women: ( ) ( )[ ]( )[ ] 85.0

/72

140×

×

×−

dLmgcreatinine

kgweightage

Note: Age (in years), weight (in kg), serum-creatinine (in mg/dL) 72 (normalized to 72 kg body weight and a body surface of 1.72 m2)

Version 09/01/2007 69


Attachment 7: New York Heart Association Classification of Cardiac Disease26

The following table presents the NYHA classification of cardiac disease:

Class Functional Capacity Objective Assessment I Patients with cardiac disease but without resulting limitations of

physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

No objective evidence of cardiovascular disease.

II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Objective evidence of minimal cardiovascular disease.

III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

Objective evidence of moderately severe cardiovascular disease.

IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Objective evidence of severe cardiovascular disease.

Source: The Criteria Committee of the New York Heart Association, Inc.: Diseases of the heart and blood vessels; Nomenclature and criteria for diagnosis, 6th Ed. Boston: Little, Brown; 1964.

Version 09/01/2007 70


Attachment 8: Suggested Body Surface Area Calculation

BSA should be determined using the appropriate following calculation:

BSA = 3131)()( lbsWtinchesHt ×

OR

BSA = 3600)()( kgWtcmHt ×

Version 09/01/2007 71


A PHASE II MULTICENTER NON-RANDOMIZED STUDY TO ASSESS SAFETY, TOXICITY AND CLINICAL ACTIVITY OF THE ASSOCIATION OF BORTEZOMID (VELCADE) WITH RITUXIMAB

IN RELAPSED/REFRACTORY INDOLENT NON FOLLICULAR AND MANTLE-CELL NON HODGKIN LYMPHOMA

APPENDIX IX: RELATED BIOLOGICAL STUDIES

Rationale Non-chemotherapeutic treatments are increasingly employed in lymphoid tumours. Despite remarkable advances in the biological characterisation of these neoplasms, treatment choice remains largely empirical. There is thus a strong need for biological markers, which might prove helpful for decision making. The present protocol is a valid opportunity in order to investigate biological factors, which might correlate with response to Rituximab and Bortezomib. The following studies are thus planned and biological samples will be obtained to perform these studies, exclusively employing tissues exceeding diagnostic purposes. This large panel of analyses will be partially supported by independent grants that will be required following protocol approval. These studies will be mainly focused on the following goals: 1) To perform effective monitoring of response below the threshold of standard procedures. 2) To identify biological markers of response to the planned treatment. 3) To characterise the biology of resistance to bortezomib and rituximab. These studies will be performed using both standard and more innovative approaches. These include: a) characterization of the immunoglobulin heavy-chain gene (IgH) rearrangement in order to study the variable region (VH) usage, to study the rate and the nature of somatic hypermutation and to develop tumor specific primers for minimal residual disease analysis; b) detailed evaluation of the genetic imbalances by array based comparative genomic hybridization (array-CGH); c) evaluation of the pattern of serum biomarkers by proteomic profiling, to identify differences in biomarkers regulation. The experimental approach for the planned studies is detailed below. Experimental approach 1) Characterization of the IgH rearrangement and minimal residual disease monitoring The DNA at study entry will be amplified by polymerase chain reaction (PCR) and direct-sequenced to obtain the patient specific IgH rearrangement. For these reactions consensus sense primers derived from the leader (L) and from the first framework region (FR) and one consensus antisense primer derived from the JH region will be employed. The IgH rearrangement will be analysed by specific software (IGBLAST) to characterise VH, DH and JH usage and identify the nature and rate of somatic mutations. If required analysis of ongoing somatic mutations will also be performed. In order to follow the molecular response to the treatment, both qualitative and quantitative PCR strategies will be utilized. These techniques have been developed in our laboratory and are currently employed in several clinical trials. Based on the clonal IgH sequence, tumor specific primers will be designed. They will be located within the complementary determining region CDR2 (forward primer) and CDR3 (reverse primer) that since are highly variable are specific for each patient. Real time quantitative PCR for the IgH rearrangement will be performed using patient-specific primers and consensus probes in order to monitor the residual disease during the treatment. Reactions will be performed in an AbiPrism 7900 thermal cycler (PE Applied Biosystems, Foster City CA). For absolute DNA quantification the RNaseP gene will be used as reference standard to normalize patient samples for DNA quality and quantity.

Version 09/01/2007 72


Clonal cell burden will be evaluated at 3, 6, 12, 24 months form study entry.

2) Pan-genomic characterisation of the tumor clone by array-CGH In non-Hodgkin Lymphoma the identification of genetic abnormalities such as copy number change of genomic regions have been less investigated compared to other genetic lesions, such as balanced translocations. Array-CGH is an highly sensitive genome wide screening tool able to identify losses or gains of DNA along the all genome with a resolution up to 1Mb. This strategy allows the precise mapping of aberrations to the genomic sequence in a single experiment. To perform the array-CGH analysis two micrograms of patient genomic DNA and healthy genomic DNA will be isolated and treated by enzyme digestion. Both DNAs will be differentially labeled with Cy3-dCTP and Cy5-dCTP and cohybridized to BAC arrays in two inverse reactions. Differences in fluorescent intensities will be evaluated by Gene Pix 4000 B scanner and the resulting images will be analysed and converted into graphical plot, where are clearly shown gains or losses of DNA regions. This approach will allow to identify several yet uncharacterised genetic defects and to correlate them with clinical parameters and outcome.

3) Identification of prognostic markers by proteomic profiling of patient serum samples Serum-based prognostic indicators are attractive biomarkers for large widespread use. However few study on Non Hodgkin Lymphoma have been published so far. This line of research, through high-throughput serum proteomic analysis, will be focused to identify possible markers that can help to clarify which microenviromental mechanisms are involved in the lymphoma pathogenesis and in particular we plan to identify deregulation of serum biomarkers related to the response to the treatment. The recent development of antibody-arrays for multi-target screening has opened new possibilities to identify novel candidates. In this study we plan to use the Whatman Chip tool (Whatman Srl, Serum Biomarker Chip & Two Color Labeling and Fluorescent Detection Kit). This multi-ELISA array allows accurate monitoring of more than 100 serum biomarkers reflecting several phenomena such as angiogenesis, immunity, inflammation, bone turnover, etc. In our lab we are currently using this approach to study the proteomic profile of Multiple Myeloma patients. So far we got promising results. This approach consists on comparing serum samples from healthy subjects and patients. After the labeling step, respectively with Biotin-ULS and Fluorescein-ULS they are mixed together, in two specular reactions, and co-hybridized on the antibody chip that will be subsequently probed with Streptavidin-DY 647 and Anti-Fluorescein Antibody-DY 547. The chip will then be scanned with Axon GenePix 4000B Scanner and analysed by the ArrayVision Fast Software that provide an easier representation of protein deregulation related to the healthy sample. The Whatman Chip will be employed on serum samples at study entry. This preliminary screening will allow identifying deregulated targets that will be subsequently evaluated through specific ELISA assays during subsequent treatment phases. Candidate biomarkers will then be correlated with response to different therapeutic schedules in order to identify specific “signatures” of treatment responsivity or resistance. Required materials The mentioned lines of research required the collection of tumor cells for the DNA analysis and serum samples for protein analysis. At the study entry tumour sample derived from bone marrow (BM) or lymph node sections (LN) and blood serum will be collected. In the case of PCR negativity after the analysis of BM sample, availability of a tumor-invaded sample will be recommended. At each restaging time, means at 3, 6, 12, 24 months, BM samples and serum samples needed to be collected. We kindly remind the importance of collecting samples at relapse and at progression time. In the table below is summarised the kind and the quantity of sample required for each analysis at the time of collection.

Version 09/01/2007 73


Study Entry 3^ month 6^ month 12^ month 24^ month Progression

relapse (anytime)

SAMPLE BM and blood serum

BM and blood serum

BM and blood serum

BM and blood serum

BM and blood serum

BM and blood serum

QUANTITY 7 ml each 7 ml each 7 ml each 7 ml each 7 ml each 7 ml each

ANTI-COAGULANT

BM [Sodium Citrate] PB [NONE]



BM [Sodium Citrate] PB [NONE

BM [Sodium Citrate] PB [NONE

BM [SodiuCitrate] PB [NONE]

ADDITIONAL TISSUES

If BM not invaded it is recommended to send tumor invaded tissue (paraffin OK)

Version 09/01/2007 74

Documents

Clinical Protocol A PHASE II MULTICENTER NON-RANDOMIZED …filinf.it/wp-content/uploads/2010/02/Bril-06-protocollo... · 2020. 9. 18. · RELAPSED/REFRACTORY INDOLENT NON FOLLICULAR