Study of Blinatumomab in Richter Transformation
Study of Blinatumomab in Richter Transformation
The goal of this clinical research study is to learn if blinatumomab can help to control
 Richter Transformation (RT, a type of blood cancer). The safety of this drug will also be
 studied.

 This is an investigational study. Blinatumomab is FDA approved and commercially available for
 the treatment of acute lymphoblastic leukemia (ALL). It is investigational to use
 blinatumomab to treat patients with RT. The study doctor can explain how the study drug is
 designed to work.

 Up to 21 participants will be enrolled in this study. All will take part at MD Anderson.
Study Drug Administration:

 The study has 2 study cycles. Cycle 1 is 8 weeks, followed by a 4-8 week break, and then
 Cycle 2 is 4 weeks.

 If you are found to be eligible to take part in this study, you will receive blinatumomab by
 a central venous catheter (CVC) continuously (non-stop) for 1-2 cycles, depending on how you
 are responding to the study drug. A CVC is a sterile flexible tube that will be placed into a
 large vein while you are under local anesthesia. Your doctor will explain this to you in more
 detail, and you will be required to sign a separate consent form for this procedure.

 During Cycle 1, the blinatumomab infusion will be started in the hospital. You will be in the
 hospital for up to at least 16 nights/17 days so that you can be checked for side effects.
 During Cycle 2, the blinatumomab infusion will also be started in the hospital. You will be
 in the hospital for at least 2 nights/3 days. Your doctor will decide when you can leave the
 hospital. Also, if treatment is interrupted for more than 4 hours, for any reason, you will
 need to be admitted to the hospital to restart the treatment.

 Blinatumomab will be delivered by a small pump, which you will carry with you for the whole
 time you receive the drug. You will be given a shoulder or belt bag to hold the pump and
 infusion bag. You will be able to wear regular clothes, walk around, and perform daily living
 activities. You will be given instructions for taking a shower and other activities. There
 will be some things that you should not do, such as go swimming. The study staff will give
 you more information on activities you should not do while receiving the drug.

 You will need to come to MD Anderson to have the infusion bags changed every 48 hours. The
 study staff will let you know when you need to return to the clinic.

 You will be given standard drugs, such as dexamethasone, to help decrease the risk of side
 effects. You may ask the study staff for information about how the drugs are given and their
 risks.

 If you have severe side effects, your study doctor may decide to stop treatment permanently
 or temporarily. If you recover or if the symptoms have improved, the treatment may be
 continued. If the doctor thinks it is needed, you will have an MRI and possibly also a spinal
 tap (lumbar puncture) to test the fluid around the brain, before you restart treatment.

 Length of Study:

 You may receive blinatumomab for up to 2 cycles. You will no longer be able to take the study
 drug if the disease gets worse, if serious side effects occur, or if you are unable to follow
 study directions. Additionally, if your doctor feels it is in your best interests to receive
 an alternative treatment for your Richter Transformation, such as allogeneic stem cell
 transplantation, you will no longer be able to receive blinatumomab.

 Your participation on this study will be over after you have completed follow-up.

 Study Visits:

 At any time the doctor thinks it is needed, you may have a neurological exam.

 Based on the results of the below tests after Cycle 1, the study doctor will decide if you
 will continue to receive the study drug during Cycle 2. If you do not receive the drug during
 Cycle 2, you will have an end-of-study visit (described below).

 On Days 1-17 of Cycle 1 (the time you are in the hospital), every week during Cycle 1, Days
 1-3 of Cycle 2, and every week of Cycle 2:

 -  You will have a physical exam.

 -  Blood (about 2-3 teaspoons) will be drawn for routine tests.

 About 2-4 weeks after Cycles 1 and 2:

 -  You will have a physical exam.

 -  Blood (about 2-3 teaspoons) will be drawn for routine tests.

 -  You will have a bone marrow biopsy/aspiration to check the status of the disease.

 -  You will have a PET/CT or CT scan.

 About 24 weeks after the first dose of study drug and then every 12 weeks after that for up
 to 96 weeks:

 -  You will have a physical exam.

 -  Blood (about 2-3 teaspoons) will be drawn for routine tests.

 -  You will have a PET/CT or CT scan to check the status of the disease.

 End-of-Study Visit:

 After the last dose of study drug, you will continue to receive routine medical care as part
 of your standard care. However, if the disease comes back or worsens while you are receiving
 the study drug:

 -  You will have a physical exam.

 -  Blood (about 2-3 teaspoons) will be drawn for routine tests.

 -  You will have a bone marrow biopsy/aspiration

 -  You will have a PET/CT scan to check the status of the disease.

 -  If the doctor thinks it is needed, you may have a lymph node biopsy to confirm that the
 disease has come back.

 -  If you can become pregnant, blood (about 1 teaspoon) or urine will be collected for a
 pregnancy test.

 Long-Term Follow-up:

 After you have completed your participation in this study, you will be asked to participate
 in a separate leukemia department protocol (DR09-0223). The purpose of this protocol is to
 determine how long patients live after receiving leukemia treatment. On this study, if you
 are not having follow-up at MD Anderson, study staff will contact you via phone, email, or
 MyMDAnderson every 6-12 months, to see how you are doing. Phone calls will take approximately
 5-10 minutes. If you agree, you will sign a separate consent form for this study.
Inclusion Criteria:

 1. Patients with previously treated CLL and biopsy-proven Richter's transformation with
 DLBCL histology according to IWCLL criteria (Richter Transformation - RT) and CD19
 positive by flow cytometry OR immunohistochemistry.

 2. Eastern Co-operative Oncology Group (ECOG) performance status < or =2.

 3. Age > or =18 years at the time of informed consent.

 4. Able to provide informed consent and be willing to participate in study schedule and
 events.

 Exclusion Criteria:

 1. Other active malignancy receiving systemic therapy.

 2. History or presence of clinically relevant disorder affecting the CNS such as
 epilepsy, childhood or adult seizure, paresis, aphasia, stroke, severe brain injuries,
 dementia, Parkinson's disease, cerebellar disease, organic brain syndrome, or
 psychosis, with the exception of a history of CNS lymphoma that is controlled with
 intrathecal therapy.

 3. Known active DLBCL in the CNS (confirmed by CSF analysis).

 4. Current autoimmune disease requiring >/= 20mg/day of prednisone or systemic
 immunosuppressive therapy (eg. with cyclosporine or azathioprine).

 5. Allogeneic HSCT within 24 weeks before the start of protocol-specified therapy.

 6. Active Graft-versus-Host Disease (GvHD), grade 2-4 according to the Glucksberg
 criteria, active chronic GvHD requiring systemic treatment or requirement for GvHD
 prophylaxis with cyclosporine or tacrolimus.

 7. Cancer chemotherapy within 2 weeks before start of protocol-specified therapy, with
 the exception of intrathecal chemotherapy, dexamethasone, and oral small molecule
 inhibitors such as BTK-inhibitor, PI3K-inhibitor, or Bcl-2-inhibitor, which are
 allowed until the start of protocol-specified therapy). In addition, any subject whose
 organ toxicity (excluding hematologic) from prior treatment has not resolved to no
 more than CTCAE grade 1.

 8. Radiotherapy within 2 weeks before the start of protocol-specified therapy.

 9. Abnormal screening laboratory values as defined as following: a) ALT (SGOT) and/or ALT
 (SGPT) and/or ALP > or =5 x upper limit of normal (ULN); b) Total bilirubin > or = 1.5
 x ULN, unless due to Gilbert's disease; c) Creatinine > or = 2.0 x ULN or creatinine
 clearance <50 mL/min (calculated).

 10. Known infection with human immunodeficiency virus (HIV) or chronic infection with
 hepatitis B virus (HBsAg positive) or hepatitis C virus (anti-HCV positive).

 11. Patient is pregnant or breast feeding.

 12. Woman of childbearing potential and is not willing to use 2 highly effective methods
 of contraception while receiving protocol-specified therapy and for an additional 24
 hours after the last dose of protocol-specified therapy.

 13. Male who has a female partner of childbearing potential, and is not willing to use 2
 highly effective forms of contraception while receiving protocol-specified therapy and
 for at least an additional 24 hours after the last dose of protocol-specified therapy.

 14. Male who has a pregnant partner, and is not willing to use a condom during sexual
 activity while receiving protocol-specified therapy and for 3 months after the last
 dose of protocol-specified therapy.

 15. Currently receiving treatment in another investigational device or drug study.

 16. Subject previously treated with blinatumomab.

 17. History or evidence of any other clinically significant disorder, condition or disease
 (with the exception of those outlined above) that, in the opinion of the Principal
 Investigator would pose a risk to subject safety or interfere with the study
 evaluation, procedures or completion.