Randomised Trial in Waldenstrom's Macroglobulinaemia

Waldenstrom macroglobulinaemia (WM) is a low grade nonHodgkin lymphoma characterised by bone marrow infiltration and the presence of an abnormal protein in the blood (IgM paraprotein. Most patients require treatment at presentation but there is no agreed standard of first line therapy. Current treatment is unsatisfactory with responses often incomplete and slow to attain, while recurrence is inevitable.

The aim of this study is to find out whether a new combination of Bortezomib (Velcade®), Cyclophosphamide and Rituximab (MabThera), is well tolerated and effective for patients with WM. R2W is a randomised, noncomparative, phase II trial of subcutaneous bortezomib, cyclophosphamide, rituximab (BCR, experimental arm) versus fludarabine, cyclophosphamide, rituximab (FCR, control arm) for initial therapy of WM. This is a two stage trial where six patients will be treated initially with BCR to assess tolerability. If BCR is considered tolerable, a further 50 patients will be randomised between BCR and FCR (2:1) in the second stage of the trial. Patients will receive 3 cycles of treatment and then be reassessed. Those with evidence of progression will stop trial treatment. All other patients will continue with a further 3 cycles (to a total of 6) unless there is a clear clinical contraindication to further treatment.

Inclusion criteria

• Age ≥ 18 years
• Confirmed diagnosis of WM (according to consensus panel / WHO criteria) with measurable IgM paraprotein
• Previously untreated disease at any stage requiring therapy at the discretion of the treating physician. Suggested criteria for initiating treatment include:

• haematological suppression to Hb <10 g/dl, or neutrophils <1.5x109/l or platelets <150x109/l
• clinical evidence of hyperviscosity
• bulky lymphadenopathy and/or bulky splenomegaly
• presence of B symptoms
• No previous chemotherapy (prior plasma exchange and steroids are permissible)
• Performance status grade 0 - 2
• Life expectancy of greater than 6 months
• Informed consent
• Agreed compliance with recommended contraceptive precautions where appropriate

Exclusion criteria

• Lymphoplasmacytic lymphoma with no detectable serum IgM paraprotein
• Severe pre-existing neuropathy (> grade 2)
• Autoimmune cytopenias
• Evidence of active Hepatitis B or C infection (patients with evidence of past HepB infection may be eligible - see appendix 6)
• Serological positivity for HIV
• Pregnant or lactating women
• Life expectancy severely limited by other illness
• Renal failure (creatinine clearance <30 ml/min)
• Severe impairment of liver function: alkaline phosphatase/bilirubin >2.5 times upper limit of normal (ULN), ALT/AST >2.5 times ULN not related to lymphoma (patients with Gilbert syndrome are eligible)
• History of allergic reaction to compounds containing boron or mannitol
• Known hypersensitivity to murine compounds.
• Diagnosed or treated for a malignancy other than WM within 5 years before day 1 of Cycle 1 with the exception of complete resection of basal cell carcinoma, squamous cell carcinoma of the skin or any other in situ malignancy
• Active systemic infection requiring treatment
• Concurrent treatment with another investigational agent
• Severe or life-threatening cardiac, pulmonary, neurological, psychiatric or metabolic disease