Fludarabine plus mitoxantrone with and without rituximab versus CHOP with and without rituximab as front-line treatment for patients with follicular lymphoma

Purpose: Promising new therapeutic options for follicular lymphoma (FL) include fludarabine plus mitoxantrone (FM) and the mouse/human anti-CD20 antibody, rituximab. We performed a randomized comparative trial of FM with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) front-line chemotherapy with and without sequential rituximab. Patients and Methods: All previously untreated CD20⁺ FL patients presenting in 15 Italian cooperative institutions from October 1999 were randomly allocated to FM or CHOP. Following clinical or molecular restaging, patients in complete remission (CR) with bcl-2/lgH negativity (CR^-) received no further treatment; those in CR with bcl-2/lgH positivity (CR⁺) received rituximab, as did those in partial remission (PR) with bcl-2/lgH negativity (PR^-) or positivity (PR⁺); nonresponders (NR subgroup) were off study. Results: After chemotherapy, the FM arm achieved higher rates of CR (68% [49 of 72 patients] v 42% [29 of 68 patients]; P = .003) and CR^- (39% [28 of 72 patients] v 13 of 68 patients [19%]; P = .001). Rituximab elicited CR ^- in 55 of 95 treated patients (58%). The final CR^- rate was higher in the FM arm(71% [51 of 72 patients] v 51% [35 of 68 patients]; P = .01). However, with a median follow-up of 19 months (range, 9 to 37 months), no statistically significant difference was found among the various study arms in terms of both progression-free (PFS) and overall survival (OS). Conclusion: These results indicate that FM is superior to CHOP for front-line treatment of FL and that rituximab is an effective sequential treatment option. However, they also confirm that this superiority is unlikely to translate into either better PFS or OS.