-Author name in bold denotes the presenting author
-Asterisk * with author name denotes a Non-ASH member
Clinically Relevant Abstract denotes an abstract that is clinically relevant.

PhD Trainee denotes that this is a recommended PHD Trainee Session.

Ticketed Session denotes that this is a ticketed session.

811 Impact of Immunochemotherapy with R-Bendamustine or R-CHOP in the Post-Induction Management of Treatment Naïve Advanced Stage Follicular Lymphoma Patients: A Subset Analysis of the FOLL12 Trial By the Fondazione Italiana Linfomi (FIL)

Program: Oral and Poster Abstracts
Type: Oral
Session: 623. Mantle Cell, Follicular, and Other B-Cell Lymphomas: Clinical and Epidemiological: Follicular Lymphoma: Advances in Treatment Approaches
Hematology Disease Topics & Pathways:
Clinical Trials, Biological, Antibody Therapy, Clinical Research, Therapies, Immunotherapy
Monday, December 13, 2021: 4:30 PM

Stefano Luminari, MD1,2, Maria Elena Nizzoli, MD3*, Annalisa Chiarenza, MD, PhD4*, Donato Mannina, MD5*, Alessandra Tucci, MD6*, Carola Boccomini, MD7*, Lucia Farina, MD8*, Jacopo Olivieri, MD9*, Luigi Marcheselli10*, Simone Ferrero, MD11, Luca Arcaini, MD12,13*, Alessandro Pulsoni, MD14*, Gerardo Musuraca, MD, PhD15*, Catello Califano, MD16*, Michele Merli17*, Alessia Bari, MD18*, Annarita Conconi, MD19*, Francesca Re20*, Monica Balzarotti, MD21*, Marco Ladetto, MD22,23, Caterina Patti, MD24*, Antonello Pinto25*, Maria Giuseppina Cabras, MD26*, Pellegrino Musto, MD27, Guido Gini, MD28*, Annalisa Arcari, MD29*, Martina Manni, PhD2*, Annibale Versari, MD30* and Massimo Federico, MD31*

1Hematology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
2Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
3Hematology, Azienda Unitа Sanitaria Locale-IRCCS - Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
4U.O.C. Ematologia, A.O.U. Policlinico “G. Rodolico – S. Marco”, Catania, Italy
5UOC di Ematologia, Azienda Ospedaliera Papardo, Messina, Italy
6Hematology, Department of Hematology, ASST Spedali Civili, Brescia, Italy
7Division of Haematology, Città della Salute e della Scienza, Turin, Italy
8Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
9SOC Clinica Ematologica, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
10Fondazione Italiana Linfomi - Onlus, Modena, Italy
11Ematologia Universitaria, University of Torino/AOU Città della Salute e della Scienza di Torino, Torino, TO, Italy
12Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
13Department of Molecular Medicine, University of Pavia, Pavia, Italy
14Dipartimento di Biotecnologie Cellulari ed Ematologia, Sapienza University of Rome, Rome, Italy
15Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
16U.O. Medicina-Oncoematologia, Presidio Ospedaliero A. Tortora, Nocera Inferiore, Italy
17Division of Hematology, University Hospital Ospedale di Circolo e Fondazione Macchi-Azienda Socio-Sanitaria Territoriale Sette Laghi, University of Insubria, Varese, Italy
18Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto, Università di Modena e Reggio Emilia, Modena, Italy
19Division of Hematology, Ospedale degli Infermi, Biella, Italy
20Division of Hematology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
21Unit of Hematology, Humanitas Clinical and Research Center, Rozzano, Italy
22Division of Hematology, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
23Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Alessandria, Italy
24Division of Hematology, A.O. Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
25Hematology-Oncology & Stem Cell Transplantation Unit, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Napoli, Italy
26Struttura Complessa di Ematologia e CTMO, Ospedale Oncologico Businco, Cagliari, Italy
27Hematology Section, Department of Emergency and Transplantation, University of Bari Medical School, Bari, Italy
28Hematology, Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
29U.O. Ematologia, Ospedale Guglielmo da Saliceto, Piacenza, Italy
30Nuclear Medicine Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
31Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, MO, Italy

Introduction. The administration of immuno-chemotherapy (ICT) followed by rituximab maintenance (RM) is the recommended approach for the front-line therapy of high tumor burden follicular lymphoma (HTB-FL) patients. Among available ICT regimens, RB (Rituximab-bendamustine) and R-CHOP regimen, are preferred options with high, similar efficacy. Regarding RM, its use is strongly supported after R-CHOP by the results of the PRIMA randomized trial; conversely, no prospective data are available to confirm the efficacy of RM in patients initially treated with RB. The FOLL12 trial was conducted to try to demonstrate that a response adapted post induction management of patients with HTB-FL could be as effective as standard RM in terms of Progression Free Survival (PFS). The trial actually showed the better efficacy of standard RM compared to the experimental approach thus providing indirect confirmation of the efficacy of RM after ICT, 10 years after the PRIMA trial. We here analyse the impact of initial ICT in the FOLL12 study that left treatment choice between RB and R-CHOP at physician discretion and on an individual patient basis.

Methods. FOLL12 is a multicenter, randomized, phase III trial that compared standard RM vs. a response adapted post induction management in treatment naïve adult patients with grade 1-3a, stage II-IV and a HTB-FL. All patients received induction immunochemotherapy with 6 cycles of either R-CHOP or R-Bendamustine both followed by two additional doses of rituximab. Choice of ICT was at the physicians' discretion. After ICT, patients in the standard arm received bimonthly rituximab for up to two years. Patients in the experimental arm were managed according to centrally reviewed metabolic and molecular response. Patients achieving complete metabolic (CMR) and molecular response were managed with observation only, those in CMR with molecular persistence received 4 weekly rituximab doses. Patients not achieving CMR were treated with radioimmunotherapy with ibritumomab tiuxetan followed by standard RM. Primary study endpoint was 3 years progression free survival (PFS).

Results. A total of 786 eligible patients were enrolled and 1:1 randomized either to standard or experimental arm. By backbone therapy, 341 patients received RB and 445 received RCHOP induction immunochemotherapy. RB was more frequently prescribed in older and female patients (OR 1.6, p=0.001) whereas RCHOP was preferred in patients with bulky disease (>6cm) and grade 3a histology (OR 0.65, p=0.013). The median follow-up of the analysis was 56 months (range 1-71). In the non-randomized comparison between RB and RCHOP, no difference in terms of PFS was observed between the two regimens (HR for RB 1.07, 95%CI 0.83-1.38, p=0.597, Figure 1). Standard maintenance arm was more effective than experimental arm both in patients initially treated with RCHOP and in those treated with RB (HR RCHOP 1.61, 95% CI 1.16-2.25; HR RB 1.89, 95% CI 1.27-2.82). An unequal interaction between RB and RCHOP and post-induction therapy was observed for sex and for bone marrow involvement. Considering grade 3 to 5 adverse events (AEs), neutropenia was less frequently observed in RB (35.7%) compared to RCHOP (46.2%). Among extra-hematological AEs, higher frequency of grade 3-4 infections and of cutaneous toxicity were observed in RB treated patients (3.8% vs. 1.2% and 2.4% vs. 0.2%). Overall, 54 second malignancies (SM) have been observed including 23 hematologic malignancies and 31 solid cancers. Cumulative incidence of secondary cancer (excluding non melanoma skin cancers) at 3 and 5 years was 3.7% (95%CI 2.4-5.3%) and 8.1% (95%CI 5.8-10.9%).

Conclusion. The current update of the FOLL12 trial demonstrated superiority of standard RM compared to the response adapted post induction management irrespective of prescribed regimen thus proving a first prospective non-randomized evidence of RM efficacy in patients with high tumor burden follicular lymphoma patients treated with RB. Both R-CHOP and RB were associated with a similar efficacy profile.

Figure 1. Progression free survival for the standard maintenance arm (A) versus response oriented experimental arm (B) of the FOLL12 trial in patients treated with R-CHOP or R-Bendamustine (RB).

Disclosures: Luminari: Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accomodations, Expenses; Janssen: Other: Travel, Accomodations, Expenses; Incyte: Consultancy; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees; Regeneron: Consultancy; Genmab: Consultancy; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees. Tucci: janssen: Membership on an entity's Board of Directors or advisory committees; Gentili: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees. Ferrero: Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; EUSA Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Gilead: Research Funding, Speakers Bureau; Morphosys: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees; Clinigen: Membership on an entity's Board of Directors or advisory committees; Servier: Speakers Bureau. Arcaini: Gilead Sciences: Research Funding; Bayer, Celgene, Gilead Sciences, Roche, Sandoz, Janssen-Cilag, VERASTEM: Consultancy; Celgene: Speakers Bureau; Celgene, Roche, Janssen-Cilag, Gilead: Other: Travel expenses. Pulsoni: Roche: Consultancy, Speakers Bureau; Takeda, Pfizer, Sandoz, Merk: Consultancy; Gilead, Bristol: Speakers Bureau. Musuraca: Janssen, Roche, Incyte: Honoraria; Janssen, Roche, Incyte: Membership on an entity's Board of Directors or advisory committees; Janssen, Incyte, Roche: Consultancy.

Previous Abstract | Next Abstract >>
*signifies non-member of ASH