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Pembrolizumab Alone or With Idelalisib or Ibrutinib in Treating Patients With Relapsed or Refractory Chronic Lymphocytic Leukemia or Other Low-Grade B-Cell Non-Hodgkin Lymphomas

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ClinicalTrials.gov Identifier: NCT02332980
Recruitment Status : Recruiting
First Posted : January 7, 2015
Last Update Posted : July 2, 2017
Sponsor:
Collaborator:
National Cancer Institute (NCI)
Information provided by (Responsible Party):
Mayo Clinic

Brief Summary:
This phase II trial studies how well pembrolizumab alone or with idelalisib or ibrutinib works in treating patients with chronic lymphocytic leukemia or other low-grade B-cell non-Hodgkin lymphomas that have returned after a period of improvement or have not responded to treatment. Monoclonal antibodies, such as pembrolizumab, block cancer growth in different ways by targeting certain cells and allow the immune system to attack the cancer. Idelalisib and ibrutinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Giving pembrolizumab alone or with idelalisib or ibrutinib may be an effective treatment in patients with chronic lymphocytic leukemia or other low-grade B-cell non-Hodgkin lymphomas.

Condition or disease Intervention/treatment Phase
Recurrent Chronic Lymphocytic Leukemia Recurrent Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue Recurrent Grade 1 Follicular Lymphoma Recurrent Grade 2 Follicular Lymphoma Recurrent Grade 3 Follicular Lymphoma Recurrent Lymphoplasmacytic Lymphoma Recurrent Marginal Zone Lymphoma Recurrent Nodal Marginal Zone Lymphoma Recurrent Small Lymphocytic Lymphoma Recurrent Splenic Marginal Zone Lymphoma Refractory Chronic Lymphocytic Leukemia Refractory Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue Refractory Follicular Lymphoma Refractory Lymphoplasmacytic Lymphoma Refractory Nodal Marginal Zone Lymphoma Refractory Small Lymphocytic Lymphoma Refractory Splenic Marginal Zone Lymphoma Richter Syndrome Waldenstrom Macroglobulinemia Drug: Ibrutinib Drug: Idelalisib Other: Laboratory Biomarker Analysis Biological: Pembrolizumab Phase 2

  Show Detailed Description

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 68 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Phase II Study of Anti-PD-1 Antibody (MK-3475) in Relapsed/Refractory Chronic Lymphocytic Leukemia (CLL) and Other Low Grade B Cell Non-Hodgkin Lymphoma (NHL)
Actual Study Start Date : February 19, 2015
Estimated Primary Completion Date : January 5, 2020
Estimated Study Completion Date : January 5, 2020


Arm Intervention/treatment
Experimental: Treatment (pembrolizumab, idelalisib, or ibrutinib)

Patients receive pembrolizumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 12 months in the absence of disease progression or unacceptable toxicity. Patients receiving benefit may continue to receive treatment for an additional 12 months at the discretion of the investigator. Patients with CLL or CLL with Richter's transformation experiencing stable disease without partial remission or progressive disease at 3 months of treatment with pembrolizumab proceed to the treatment continuation phase.

CONTINUATION PHASE: Patients receive pembrolizumab IV over 30 minutes on day 1. Patients also receive idelalisib PO BID on days 1-21 OR ibrutinib PO QD on days 1-21. Treatment repeats every 21 days for up to 12 or 24 months in the absence of disease progression or unacceptable toxicity. Patients receiving benefit may continue to receive treatment for an additional 12 months at the discretion of the investigator.

Drug: Ibrutinib
Given PO
Other Names:
  • BTK Inhibitor PCI-32765
  • CRA-032765
  • Imbruvica
  • PCI-32765
Drug: Idelalisib
Given PO
Other Names:
  • CAL-101
  • GS 1101
  • GS-1101
  • Phosphoinositide-3 Kinase Delta Inhibitor CAL-101
  • Zydelig
Other: Laboratory Biomarker Analysis
Correlative studies
Biological: Pembrolizumab
Given IV
Other Names:
  • Keytruda
  • Lambrolizumab
  • MK-3475
  • SCH 900475



Primary Outcome Measures :
  1. Proportion of patients who achieve a confirmed response [ Time Frame: Up to 1 year ]
    Confirmed response is defined to be a partial response, nodular partial response, clinical complete response, confirmed response with incomplete blood count recovery or confirmed response (Arm A and B), or complete metabolic response, partial metabolic response, partial response, or confirmed response (Arm C). The proportion of successes will be estimated by the number of successes divided by the total number of evaluable patients. Exact binomial confidence intervals for the true success proportion will be calculated.


Secondary Outcome Measures :
  1. Complete response rate, defined as complete response or incomplete blood count recovery [ Time Frame: Up to 1 year ]
    Estimated by the number of patients who achieve a incomplete blood count recovery or complete response divided by the total number of evaluable patients. All evaluable patients will be used for this analysis. Exact binomial 95% confidence intervals for the true complete response rate will be calculated.

  2. Duration of response [ Time Frame: Date at which the patient's objective status is first noted to be a partial or nodular partial response, clinical complete response, incomplete blood count recovery, or complete response to the earliest date relapse is documented, assessed up to 1 year ]
    The distribution of duration of response will be estimated using the method of Kaplan-Meier.

  3. Incidence of adverse events as measured per National Cancer Institute-Common Terminology Criteria for Adverse Events version 4.0 [ Time Frame: Up to 1 year ]
    The maximum grade for each type of adverse event will be recorded for each patient, and frequency tables will be reviewed to determine patterns. Additionally, the relationship of the adverse event(s) to the study treatment will be taken into consideration. Adverse events will be evaluated for single-agent pembrolizumab in each arm and also for the combination of pembrolizumab and the signal inhibitor in Arm A and Arm C.

  4. Overall response rate of patients treated with combination therapy [ Time Frame: Up to 1 year ]
    Overall response rate will be estimated by the number of patients with an objective status of complete response, incomplete blood count recovery, nodular partial response, clinical complete response or partial response while on the combination therapy divided by the total number of evaluable patients. Exact binomial 95% confidence intervals for the true overall response rate to the combination will be calculated. In addition, the responders on this study will be further examined in an exploratory manner to determine if there are any patterns in prognostic factors or disease characteristics, in

  5. Progression-free survival of patients treated with combination therapy [ Time Frame: From initiation of treatment with the combination therapy to the earliest date of documentation of disease progression while on combination therapy or death due to any cause, assessed up to 1 year ]
    The distribution of progression-free survival will be estimated using the method of Kaplan-Meier.

  6. Progression-free survival of patients treated with single pembrolizumab [ Time Frame: The time from registration to the earliest date of documentation of disease progression or death due to any cause, assessed up to 1 year ]
    The distribution of progression-free survival will be estimated using the method of Kaplan-Meier.

  7. Time to next treatment for patients on combination therapy [ Time Frame: From initiation of combination therapy to the date of initiation of subsequent treatment for chronic lymphocytic leukemia/small lymphocytic lymphoma, assessed up to 1 year ]
    The distribution of time to next treatment will be estimated using the method of Kaplan-Meier.

  8. Time to next treatment for patients treated with single-agent pembrolizumab [ Time Frame: The time from registration to the date of initiation of subsequent treatment for chronic lymphocytic leukemia/small lymphocytic lymphoma or lymphoma, assessed up to 1 year ]
    The distribution of time to next treatment will be estimated using the method of Kaplan-Meier.

  9. Treatment-free survival of patients treated with combination therapy [ Time Frame: Time from initiation of combination therapy to the date of initiation of subsequent treatment for chronic lymphocytic leukemia/small lymphocytic lymphoma or death due to any cause, assessed up to 1 year ]
    The distribution of treatment-free survival will be estimated using the method of Kaplan-Meier.

  10. Treatment-free survival of patients treated with single-agent pembrolizumab [ Time Frame: The time from registration to the date of initiation of subsequent treatment for chronic lymphocytic leukemia/small lymphocytic lymphoma or lymphoma or death due to any cause, assessed up to 1 year ]
    The distribution of reatment-free survival will be estimated using the method of Kaplan-Meier.


Other Outcome Measures:
  1. Change in immune profiles [ Time Frame: Baseline to up to 1 year ]
    Summarized descriptively by median, minimum, maximum, and interquartile range (continuous factors) or frequency distribution (categorical factors) at each time point. Patterns over time summarized by absolute difference or relative change. Changes across time will be assessed using paired analyses, including Wilcoxon signed rank tests for continuous measures and McNemar's tests for categorical measures. Overall response and complete response will be correlated with continuous factors using Wilcoxon rank sum tests. Jitplots will be used to visually examine differences between groups for continu

  2. Change in markers of immune modulation [ Time Frame: Baseline to up to 1 year ]
    Summarized descriptively by median, minimum, maximum, and interquartile range (continuous factors) or frequency distribution (categorical factors) at each time point. Patterns over time summarized by absolute difference or relative change. Changes across time will be assessed using paired analyses, including Wilcoxon signed rank tests for continuous measures and McNemar's tests for categorical measures. Overall response and complete response will be correlated with continuous factors using Wilcoxon rank sum tests. Jitplots will be used to visually examine differences between groups for continu

  3. PD-1 levels [ Time Frame: Up to 1 year ]
    Measured at baseline and during treatment. Summarized descriptively by median, minimum, maximum and interquartile range. Overall response and complete response will be correlated with each measure using Wilcoxon rank sum test. The relationship between each measure and time to event measures will be evaluated using Cox proportional hazard models.

  4. PD-L1 levels [ Time Frame: Up to 1 year ]
    Measured at baseline and during treatment. Summarized descriptively by median, minimum, maximum and interquartile range. Overall response and complete response will be correlated with each measure using Wilcoxon rank sum test. The relationship between each measure and time to event measures will be evaluated using Cox proportional hazard models.

  5. PD-L2 levels [ Time Frame: Up to 1 year ]
    Measured at baseline and during treatment. Summarized descriptively by median, minimum, maximum and interquartile range. Overall response and complete response will be correlated with each measure using Wilcoxon rank sum test. The relationship between each measure and time to event measures will be evaluated using Cox proportional hazard models.



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Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • CLL/SLL PATIENTS (ARM A) ONLY
  • Diagnosis of CLL according to the National Cancer Institute (NCI) criteria or SLL according to the World Health Organization (WHO) criteria; this includes previous documentation of:

    • Biopsy-proven small lymphocytic lymphoma or
    • Diagnosis of CLL according to NCI working group criteria as evidenced by all of the following:

      • Peripheral blood B cell count of > 5 x 10^9/L consisting of small to moderate size lymphocytes
      • Immunophenotyping consistent with CLL defined as:

        • The predominant population of lymphocytes share both B-cell antigens (cluster of differentiation [CD]19, CD20 [typically dim expression] or CD23) as well as CD5 in the absence of other pan-T-cell markers (CD3, CD2, etc.)
        • Clonality as evidenced by kappa or lambda light chain expression (typically dim immunoglobulin expression) or other genetic method (e.g. immunoglobulin heavy chain variable [IGHV] analysis)
        • NOTE: splenomegaly, hepatomegaly, or lymphadenopathy are not required for the diagnosis of CLL
      • Before diagnosing CLL or SLL, mantle cell lymphoma must be excluded by demonstrating a negative fluorescent in situ hybridization (FISH) analysis for t(11;14)(immunoglobulin H [IgH]/cyclin D1 [CCND1]) on peripheral blood or tissue biopsy or negative immunohistochemical stains for cyclin D1 on involved tissue biopsy
  • Patients must be previously treated with at least one prior line of therapy; EXCEPTION: CLL patients with Richter's transformation or Hodgkin transformation do not need prior therapy to enroll

    • NOTE:

      • Prior chemotherapy or biologic novel therapy or anti-cancer monoclonal antibody based therapy for treatment of CLL will be considered prior therapy; nutraceutical treatments with no established benefit in CLL (such as epigallocatechin gallate or EGCG, found in green tea or other herbal treatments) will not be considered "prior treatment"
      • Prior oral corticosteroid therapy for an indication other than CLL will not be considered "prior treatment"
      • Previous use of corticosteroids in the combination with other therapy for treatment of autoimmune complications of CLL does constitute prior therapy for CLL
  • CLL/SLL patients must have progressive disease with any one of the following characteristics based on standard criteria for treatment as defined by the NCI-Working Group (WG) 1996

    • Symptomatic CLL characterized by any one of the following:

      • Weight loss >= 10% within the previous 6 months
      • Extreme fatigue attributed to CLL
      • Fevers >= 100.5 degree Fahrenheit (F) for 2 weeks without evidence of infection
      • Drenching night sweats without evidence of infection
    • Evidence of progressive bone marrow failure with hemoglobin =< 11 g/dL or platelet count =< 100 x 10^9/L
    • Symptomatic or progressive lymphadenopathy, splenomegaly, or hepatomegaly
    • Note: marked hypogammaglobulinemia or the development of a monoclonal protein in the absence of any of the above criteria for active disease are not sufficient for protocol therapy OR biopsy proven Richter's transformation or Hodgkin transformation of the CLL; NOTE: both untreated and previously treated patients in this category can be enrolled; they do not need to meet the progressive disease criteria in first bullet as long as measurable disease can be detected by positron emission tomography (PET)/computed tomography (CT) or CT (>= 1.5 cm in diameter)
  • LOW GRADE B-NHL PATIENTS ONLY
  • Histologically confirmed relapsed (response to last treatment >= 6 months duration) or refractory (no response to last treatment or response duration < 6 months) indolent/low grade B cell NHL; NOTE: if patient has received previous anti-PD-1 or anti-PDL-1 consult with study chair

    • Follicular lymphoma, grades 1, 2 and 3
    • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type
    • Splenic and nodal marginal zone lymphoma
    • Lymphoplasmacytic lymphoma including Waldenstrom macroglobulinemia;
  • Measurable disease (at least 1 lesion of >= 1.5 cm in diameter) as detected by CT or the CT images of the PET/CT; NOTE: patients with Waldenstrom macroglobulinemia are not required to have measurable disease by CT or PET/CT if monoclonal protein is detectable by serum protein electrophoresis and/or immunoglobulin M (IgM) level is at least 2 times upper limit of normal
  • CLL WITH RICHTER's TRANSFORMATION (ARM C) ONLY
  • CLL diagnosis confirmed as have biopsy proven Richter's transformation; NOTE: both untreated and previously treated patients in this category can be enrolled as long as measurable disease can be detected by PET/CT or CT (>=1.5 cm in diameter)
  • ALL PATIENTS
  • Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1 or 2
  • Creatinine =< 1.5 x upper limit of normal (ULN) OR creatinine clearance >= 60 mL/min for subject with creatinine levels > 1.5 x institutional ULN
  • Platelet count >= 25 x 10^9/L
  • Absolute neutrophil count >= 0.5 x 10^9/L
  • Total bilirubin =< 1.5 x upper limit of normal (ULN) unless due to Gilbert's disease; if total bilirubin is > 1.5 x ULN, a direct bilirubin should be performed and must be =< upper limit of normal
  • Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) or alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 X ULN
  • Negative pregnancy test done =< 7 days prior to registration, for women of childbearing potential only
  • Provide informed written consent
  • Willing to return to enrolling institution for follow-up (during the Active Monitoring Phase of the study)

    • Note: during the Active Monitoring Phase of a study (i.e., active treatment and observation), participants must be willing to return to the consenting institution for follow-up
  • Willing to provide bone marrow, tissue, and blood samples for correlative research purposes
  • Must have failed or be unable to tolerate or refused other available Food and Drug Administration (FDA) approved effective therapies; NOTE: patients should not have other treatment options considered curative

Exclusion Criteria:

  • Currently participating in or has participated in a study of an investigational agent or using an investigational device =< 28 days prior to registration
  • Receiving systemic steroid therapy or any other form of systemic immunosuppressive therapy =< 7 days prior to registration; EXCEPTIONS:

    • Low doses of steroids (=< 20 mg of prednisone or equivalent dose of other steroid/day) used for treatment of non-hematologic medical conditions
    • Previous use of corticosteroids is allowed
    • After initiation of MK-3475 therapy, steroid can be used for management of potential immune mediated adverse events (AE) for less than 8 weeks of therapy
    • Topical, ocular, intra-articular, intranasal, and inhalational corticosteroids (with minimal systemic absorption) are permitted
  • Prior anti-cancer monoclonal antibody =< 28 days prior to registration or who has not recovered (i.e., =< grade 1 or at baseline) from adverse events due to agents administered more than 4 weeks earlier
  • Prior chemotherapy or radiation therapy =< 14 days prior to registration or who has not recovered (i.e., =< grade 1 or at baseline) from adverse events due to a previously administered agent

    • Note: subjects with =< grade 2 neuropathy are an exception to this criterion and may qualify for the study
    • Note: if subject received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy
  • Known additional malignancy that is progressing or requires active treatment; EXCEPTIONS (these following exceptions are permitted to enroll in this trial):

    • Basal cell carcinoma or squamous cell carcinoma or melanoma of the skin that has undergone or will undergo potentially curative therapy
    • In situ cervical cancer that has undergone or will undergo potentially curative therapy
  • Active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease/syndrome difficult to control in the past; EXCEPTIONS:

    • Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule
    • Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study
    • Subjects with hypothyroidism stable on hormone replacement, diabetes or Sjogrens syndrome are permitted for the study
    • Patients who have a positive Coombs test but no evidence of hemolysis are permitted for participation
    • Patients with psoriasis not requiring systemic treatment are permitted for participation
    • Conditions not expected to recur in the absence of an external trigger are permitted to enroll
  • Evidence of interstitial lung disease or active, non-infectious pneumonitis
  • Active infection requiring systemic therapy; NOTE: when the infection is controlled, patients are permitted for this study
  • Known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial
  • Any of the following:

    • Pregnant women
    • Nursing women
    • Men or women of childbearing potential who are unwilling to employ adequate contraception starting with the pre-screening or screening visit through 120 days after the last dose of trial treatment
  • Known to be human immunodeficiency virus (HIV) positive
  • Known active hepatitis B (e.g., hepatitis B surface antigen [HBsAg] reactive) or hepatitis C (e.g., hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] is detected); NOTE: patients with active hepatitis B defined by hepatitis B surface antigen positivity or core antibody positivity in the presence of hepatitis B deoxyribonucleic acid (DNA) are not eligible for this study; patients with a positive hepatitis B core antibody but with negative hepatitis B DNA may participate, but must have hepatitis serologies and hepatitis B DNA monitored periodically by the treating physician

    • NOTE: intravenous immunoglobulin (IVIG) can cause a false positive hepatitis B serology; if patients receiving routine IVIG have core antibody or surface antigen positivity without evidence of active viremia (negative hepatitis B DNA) they may still participate in the study, but should have hepatitis serologies and hepatitis B DNA monitored periodically by the treating physician
  • Received a live vaccine =< 30 days prior to registration
  • New York Heart Association classification III or IV cardiovascular disease or recent myocardial infarction or unstable angina pectoris or cardiac arrhythmia (< 30 days)
  • Active central nervous system (CNS) lymphoma or cerebrospinal fluid involvement with malignant lymphoma cells that requires therapy
  • Has a clinically significant coagulopathy per investigator's assessment
  • Has received an allogeneic stem cell transplant
  • CLL ARMS (ARM A and ARM C) FOR COMBINATION THERAPY INCLUDING IBRUTINIB or IDELALISIB:
  • Is chronically taking a strong cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A) inhibitor or inducer and cannot be switched to an alternative agent at least 7 days prior to idelalisib or ibrutinib initiation that in the opinion of investigator/treating physicians precludes utilization of either Ibrutinib or Idelalisib; caution is recommended for patients taking moderate inhibitors of CYP3A
  • CLL ARMS (ARM A and ARM C) FOR COMBINATION THERAPY INCLUDING IDELALISIB ARM:
  • Is chronically taking a sensitive CYP3A substrate or a CYP3A substrate with a narrow therapeutic index and cannot be switched to an alternative agent at least 7 days prior to study initiation that in the opinion of investigator/treating physicians precludes utilization of idelalisib
  • A history of chronic diarrhea, colitis, or intestinal perforation that in the opinion of the investigator precludes utilization of idelalisib

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02332980


Locations
United States, Arizona
Mayo Clinic in Arizona Recruiting
Scottsdale, Arizona, United States, 85259
Contact: Clinical Trials Referral Office    855-776-0015      
Principal Investigator: Jose F. Leis         
United States, Minnesota
Mayo Clinic Recruiting
Rochester, Minnesota, United States, 55905
Contact: Clinical Trials Referral Office    855-776-0015      
Principal Investigator: Wei Ding         
Sponsors and Collaborators
Mayo Clinic
National Cancer Institute (NCI)
Investigators
Principal Investigator: Wei Ding Mayo Clinic

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: Mayo Clinic
ClinicalTrials.gov Identifier: NCT02332980     History of Changes
Other Study ID Numbers: MC1485
NCI-2014-02561 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) )
MC1485 ( Other Identifier: Mayo Clinic )
P30CA015083 ( U.S. NIH Grant/Contract )
First Posted: January 7, 2015    Key Record Dates
Last Update Posted: July 2, 2017
Last Verified: May 2017

Additional relevant MeSH terms:
Lymphoma
Leukemia
Lymphoma, Follicular
Lymphoma, Non-Hodgkin
Leukemia, Lymphoid
Leukemia, Lymphocytic, Chronic, B-Cell
Lymphoma, B-Cell, Marginal Zone
Waldenstrom Macroglobulinemia
Lymphoma, B-Cell
Neoplasms by Histologic Type
Neoplasms
Lymphoproliferative Disorders
Lymphatic Diseases
Immunoproliferative Disorders
Immune System Diseases
Leukemia, B-Cell
Neoplasms, Plasma Cell
Hemostatic Disorders
Vascular Diseases
Cardiovascular Diseases
Paraproteinemias
Blood Protein Disorders
Hematologic Diseases
Hemorrhagic Disorders
Pembrolizumab
Idelalisib
Antineoplastic Agents
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action