Multi-center phase II trial of bortezomib and rituximab maintenance combination therapy in patients with mantle cell lymphoma after consolidative autologous stem cell transplantation

Mantle cell lymphoma (MCL) is an aggressive lymphoma characterized by chromosomal translocation t(11;14)(q13;q32) resulting in overexpression of cyclin D1. It accounts for approximately 6% of all non-Hodgkin lymphomas and has a median overall survival of less than 10 years [1]. Consolidative autologous stem cell transplantation (auto-HCT) following induction chemotherapy has been shown to prolong progression-free survival (PFS) and is currently the standard of care for younger patients with MCL [2‐5]. The benefit of consolidative auto-HCT was demonstrated by the European MCL network in a trial that compared consolidative auto-HCT to maintenance interferon and showed improved PFS in the auto-HCT arm (median of 39 versus 17 months [P = .0108]) [2].

Rituximab, an anti-CD20 monoclonal antibody, has been shown to improve PFS as maintenance therapy in patients with MCL not undergoing auto-HCT [6] or undergoing auto-HCT [7‐9]. Le Gouill et al. showed in a randomized trial that rituximab maintenance can prolong PFS and overall survival (OS) in patients with MCL post consolidative auto-HCT [7]. Bortezomib therapy has been shown to be tolerable and effective in treating MCL patients in the relapsed/refractory setting [8‐14]. Till et al. [10] explored the role of bortezomib as maintenance therapy for patients not undergoing auto-HCT, and Kaplan et al. [15] showed that bortezomib as a maintenance therapy improved PFS when compared to historical controls. However, to date, no study has been conducted to assess the use of combined rituximab and bortezomib maintenance therapy after auto-HCT in MCL patients. We tested the hypothesis that the addition of bortezomib to rituximab post-auto-HCT would be tolerable and demonstrate improved anti-lymphoma activity in an open-label, multicenter phase II trial. In addition, we explored the use of quantitative CCND1 mRNA values to monitor disease.

Between September 2011 and October 2016, 23 patients were accrued; all 23 patients were evaluable. The majority of patients were male (96%), received auto-HCT in CR1 (83%), had advanced stage MCL at diagnosis (70% stage IV), and were considered young with a median age of 59 years (range 45–66) (Table 1). Ten out of 23 patients had low-risk disease and 12/23 had intermediate risk disease by the mantle cell international prognostic index (MIPI). The median follow-up was 35.9 months. The 2-year DFS was 93.8% (95% CI 63–99) and the 2-year OS was 92.3% (95% CI 57–99) for the 19 patients who received induction therapy followed by auto-HCT and rituximab/bortezomib maintenance in CR1. The 2-year DFS and OS for all patients were 90.2% (95% CI 66–97) and 94.7% (95% CI 68–99) respectively (Fig. 1).

The treatment was well tolerated; patients received a median of 8 cycles maintenance bortezomib/rituximab (each cycle = 3 months). The median duration of therapy was 19.9 months. The most common grade 3/4 toxicities in patients included neutropenia (74%), lymphopenia (35%), pneumonia (9%), anemia (9%), skin infections (4%), hypertension (4%), and thrombocytopenia (4%). The incidence of peripheral neuropathy was low with grade 1 events occurring in 11 patients (48%) and grade 2 events occurring in 2 patients (9%) (Table 2). There were no grade 3 or 4 peripheral neuropathies seen. One patient did develop MDS. There were three deaths: two from relapsed MCL and one from allogeneic HCT for MDS.

Setting JVM2 as positive control at 100%, high CCND1 mRNA (15600%) was detected in an untreated patient with MCL and low CCND1 mRNA (10%) was detected in a normal healthy control. Disease monitoring was performed using CCND1 mRNA at baseline and 12 later time points ranging from 1 month through 60 months on 18 patients treated at City of Hope (Fig. 2). There were a total of 151 samples, with 1–13 samples/time points available per patient and 3–17 samples/patients available per time point. The 151 CCND1 mRNA samples ranged from 0 to 11.6%, with only two samples > 10% (2/151 = 1.3%) and nine samples > 5% (9/151 = 6.0%). Baseline CCND1 mRNA had a mean of 2.7% (range 0.8–6.1%); the average CCND1 mRNA for the 12 later time points had a mean of 2.6% (range 1.8%–4.7%). With 1–13 samples per patient, the average CCND1 mRNA within a patient had a mean of 2.3% (range 0.9–4.7%). Unfortunately, no samples were obtained at or after relapse/progression from the two patients who developed progressive disease, one due to withdrawal of consent prior to relapse and the other due to urgent start of treatment. CCND1 mRNA remained low for all patients in remission.

As MCL is considered an incurable disease with frequent relapses, studies have focused on the use of maintenance therapy to prolong remission either post-induction or post-auto-HCT. While prior studies have shown the importance of maintenance with either rituximab or bortezomib post-auto-HCT [6, 7, 9, 10, 15], this trial is the first to study the combination in this setting. In this multicenter phase II prospective trial, we showed that the combination of rituximab and bortezomib as maintenance therapy post-consolidative auto-HCT is feasible, well tolerated, and yielded a 2-year DFS of 90.2%. Due to the premature closure of the trial, we did not achieve our target accrual of 34 patients. While the trial was ultimately underpowered per the trial design, the estimated DFS of 90.2% (95% CI 66–97) at 2 years exceeded the expected desired result of 80% DFS at 2 years with a lower-bound of the 95% confidence limit that excludes 60%. Therefore, we cautiously conclude that our trial did meet the positive expectation.

As our trial was the first to study the combination regimen of rituximab and bortezomib in a post-auto-HCT population, there was a concern of tolerability. However, we found that the combination was well tolerated; no patients withdrew from the study due to adverse events, and with the exception of hematological toxicities, there were few grade 3 or 4 events. Hematological toxicities were easily managed by the use of intermittent growth factors. Even though the use of bortezomib has been associated with peripheral sensory neuropathy, the incidence of peripheral neuropathy was low in our trial most likely due to dosing schedule and sc route of administration. One patient did develop myelodysplastic syndrome (MDS). However, this was a heavily pretreated patient prior to auto-HCT (RCHOP and R-HyperCVAD), and it took 6 days and two attempts at stem cell mobilization to collect enough stem cells for an auto-HCT. The development of MDS was not attributed to the study combination.

Traditional methods of MRD monitoring include real-time quantitative polymerase chain reaction (PCR) analysis of rearranged immunoglobulin heavy chain (IgH) genes and multicolor flow cytometry [19‐21]. These approaches are limited by low sensitivity, failure of marker identification, and requirement for patient-specific strategies. Faham et al. [22] used next-generation sequencing (NGS) which uses locus-specific primer sets of IgH and IgK regions to amplify and sequence cancer-derived clones. These cancer-derived sequences are then used as targets that assess for the presence of MRD in follow-up samples. However, this method still requires baseline patient tumor samples and is relatively cumbersome and expensive to perform. As CCND1 mRNA is expressed in the majority of MCL tumor cells, we explored the use of quantitative CCND1 mRNA from peripheral blood to monitor MRD. As CCND1 mRNA can also be expressed on normal hematopoietic cells, peripheral blood should be more ideal than BM as there would be less contamination [23]. Low CCND1 mRNA was detected in all samples from patients while on maintenance rituximab/bortezomib without radiographic progression of disease. Setting the cutoff at < 10% of control (JVM2 cells), we were able to show 100% specificity of our assay. As this trial started with patients in remission, and there were relatively few relapses, we were not able to correlate progression with rising CCND1 mRNA levels. Therefore, we could not comment on the sensitivity of this method; nevertheless, we have demonstrated its feasibility. We plan to address the issue of sensitivity in a future therapeutic trial where patients will have baseline MCL involvement.

In this study, we demonstrated that bortezomib and rituximab maintenance therapy in MCL patients following consolidative auto-HCT is both tolerable and active. Unfortunately, our study closed prematurely due to slow accrual. Some patients found the four weekly injections (once every 3 months) for a total of 2-year duration laborious, especially as needed to return to the transplant center for the therapy, and chose not to enroll in the trial. However, our study is a proof of concept that addition of proteasome inhibitors to rituximab is feasible and active in the post-auto-HCT setting. As novel oral agents such as Bruton’s tyrosine kinase (BTK) inhibitors, BCL2 inhibitor, and other oral proteasome inhibitors are now available, future studies involving combinations of oral agents with rituximab may be more appealing to patients. Additionally, we demonstrate that low CCND1 mRNA seems to correlate with clinical remission. We plan in future studies to correlate fluctuations in intra-patient CCND1 mRNA as a surrogate marker for disease response in patients with active MCL.

Our study is limited by the small sample size and single-arm nature but suggests the addition of bortezomib to maintenance rituximab after consolidative auto-HCT may improve DFS and OS in MCL patients.