Ibrutinib, Rituximab, Etoposide, Prednisone, Vincristine Sulfate, Cyclophosphamide, and Doxorubicin Hydrochloride in Treating Patients With HIV-Positive Stage II-IV Diffuse Large B-Cell Lymphomas
Ibrutinib, Rituximab, Etoposide, Prednisone, Vincristine Sulfate, Cyclophosphamide, and Doxorubicin Hydrochloride in Treating Patients With HIV-Positive Stage II-IV Diffuse Large B-Cell Lymphomas
This phase I trial studies the side effect and best dose of ibrutinib in combination with
 rituximab, etoposide, prednisone, vincristine sulfate, cyclophosphamide, and doxorubicin
 hydrochloride in treating patients with human immunodeficiency virus (HIV)-positive stage
 II-IV diffuse large B-cell lymphomas. Ibrutinib may stop the growth of cancer cells by
 blocking some of the enzymes needed for cell growth. Monoclonal antibodies, such as
 rituximab, may interfere with the ability of cancer cells to grow and spread. Drugs used in
 chemotherapy, such as etoposide, prednisone, vincristine sulfate, cyclophosphamide, and
 doxorubicin hydrochloride, work in different ways to stop the growth of cancer cells, either
 by killing the cells, by stopping them from dividing, or by stopping them from spreading.
 Giving ibrutinib and etoposide, prednisone, vincristine sulfate, cyclophosphamide, and
 doxorubicin hydrochloride may work better in treating patients with HIV-positive diffuse
 large B-cell lymphomas.
PRIMARY OBJECTIVES:

 I. To assess the safety and tolerability of ibrutinib and rituximab (R)-dose adjusted
 (da)-etoposide, prednisone, vincristine sulfate, cyclophosphamide, and doxorubicin
 hydrochloride (EPOCH) in participants with acquired immunodeficiency syndrome (AIDS)-related
 lymphomas (ARL).

 SECONDARY OBJECTIVES:

 I. To evaluate the complete response (CR) rates of ARL to ibrutinib and R-da-EPOCH.

 II. To measure the 1-year and 2-year overall and progression-free survival of participants
 with ARL treated with combination ibrutinib and R-da-EPOCH, including preliminary comparison
 of non-germinal center B-cell (GCB) with historical controls treated with R-da-EPOCH.

 III. To categorize and compare the cell-of-origin by gene expression profiling (GEP) gene
 expression-based classification (GCB, activated B-cell-like, unclassifiable) to
 immunohistochemistry (IHC) classification (GCB, non-GCB), estimate the discordant
 classification, and correlate each biological classification (IHC and GEP) with treatment
 response rates and survival.

 IV. To calculate the percentage of participants who receive two or more cycles of R-da-EPOCH,
 and are able to continue on a minimum dose level of cyclophosphamide of -1 and above after
 dose adjustments for hematologic toxicities.

 V. To determine the average number of days per cycle participants are able to stay on planned
 dose of ibrutinib at the recommended phase II dose (RP2D).

 VI. To assess the effect of ibrutinib and R-da-EPOCH on the human immunodeficiency virus
 (HIV) long-term latency reservoir.

 VII. To assess the effect and degree of ibrutinib and R-da-EPOCH on T-cell receptor signaling
 via ITK inhibition.

 VIII. To assess the effect of ibrutinib and R-da-EPOCH on B-cell receptor signaling pathway
 including BTK activity in ARL.

 IX. To evaluate the soluble cytokine response to ibrutinib and R-da-EPOCH. X. To characterize
 the pharmacokinetics of doxorubicin, etoposide, and vincristine in the presence of ibrutinib,
 and vice versa, and assess the clinical relevance of any drug-drug interaction and correlate
 with pharmacodynamics outcomes.

 OUTLINE: This is a dose escalation study of ibrutinib.

 Patients receive rituximab intravenously (IV) on day 1 (for CD20 positive patients only),
 etoposide IV over 96 hours on days 1-4, doxorubicin hydrochloride IV over 96 hours on days
 1-4, vincristine sulfate IV over 96 hours on days 1-4, prednisone orally (PO) daily on days
 1-5, cyclophosphamide IV over 1 hour on day 5, and ibrutinib PO once daily (QD) on days 1-21.
 Treatment repeats every 21 days for up to 6 courses in the absence of disease progression or
 unacceptable toxicity. Patients also receive pegfilgrastim subcutaneously (SC) from 1
 calendar day up to 48 hours or filgrastim SC beginning on day 6 for up to 10 days until
 absolute neutrophil count (ANC) is satisfactory.

 After completion of study treatment, patients are followed up every 3 months for 2 years, and
 then every 6 months for up to 5 years.
Inclusion Criteria:

 -  Participants must have histologically (via at least a core or ideally, incisional or
 excisional biopsy) documented CD20 positive or negative diffuse large B-cell lymphoma
 (DLBCL)

 -  Tissue available from the diagnostic biopsy in the form of blocks, tissue cores, or
 slides available for submission to central pathology is required for all participants
 enrolled to this study; formalin-fixed paraffin-embedded tissue from diagnostic tissue
 is acceptable and recommended; submission of the institutional diagnostic slides is
 also preferred for all participants enrolled in the study

 -  Stage II-IV disease; participant will need measurable disease by computed tomography
 (CT) or positron emission tomography (PET) scans if enrolled in the dose-expansion
 cohort

 -  HIV positive; documentation of HIV-1 infection by means of any one of the following:

 -  Documentation of HIV diagnosis in the medical record by a licensed health care
 provider;

 -  Documentation of receipt of ART (at least three different medications) by a
 licensed health care provider (documentation may be a record of an antiretroviral
 therapy (ART) prescription in the participant's medical record, a written
 prescription in the name of the participant for ART, or pill bottles for ART with
 a label showing the participant's name);

 -  HIV-1 ribonucleic acid (RNA) detection by a licensed HIV-1 RNA assay
 demonstrating > 1000 RNA copies/mL;

 -  Any licensed HIV screening antibody and/or HIV antibody/antigen combination assay
 confirmed by a second licensed HIV assay such as a HIV-1 western blot
 confirmation or HIV rapid multispot antibody differentiation assay

 -  NOTE: a "licensed" assay refers to a United States (U.S.) Food and Drug
 Administration (FDA)-approved assay, which is required for all investigational
 food drug (IND) studies

 -  Only participants whose lymphoma is untreated are allowed for the dose-finding
 portion; for the dose expansion cohort both untreated and participants who have
 received a maximum of one cycle of combination chemotherapy, including
 rituximab-containing regimens R-cyclophosphamide, doxorubicin hydrochloride,
 vincristine sulfate, prednisone (CHOP) and R-EPOCH, prior are eligible; the start of
 previous chemotherapy cycle must occur at least 21 days prior and 28 days maximum to
 beginning treatment under this protocol, and such cycle will count towards the maximum
 of 6 cycles under this study (i.e. cycle off study will count as cycle 1)

 -  Eastern Cooperative Oncology Group (ECOG) performance status =< 2 (Karnofsky >= 50%)

 -  CD4 count >= 100 in the dose-finding cohort; once the dose-finding cohort is complete
 and if safety is established, participants with any CD4 count, including CD4 count <
 100, will be allowed in the dose-escalation phase

 -  Absolute neutrophil count: >= 1,000/mm^3, unless decreased due to bone marrow
 involvement with lymphoma

 -  Platelets: >= 75,000/mm^3, unless decreased due to bone marrow involvement with
 lymphoma

 -  Total bilirubin: =< 1.5 institutional upper limit of normal (ULN); if potential due to
 lymphoma, the first cycle may be given without ibrutinib and if transaminitis and
 bilirubinemia improves to meet parameters, participant mat be enrolled on the clinical
 trial

 -  Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase
 [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]):
 < 2 institutional ULN; if potentially due to lymphoma, the first cycle will be given
 without ibrutinib and if transaminitis and bilirubinemia improves to meet parameters,
 participant may be enrolled on trial

 -  Creatinine levels within normal institutional limits; or, creatinine clearance >= 60
 mL/min/1.73 m^2 for participants with creatinine levels above institutional normal;
 unless decreased due to renal involvement by lymphoma

 -  Participants must not be on medications, including antiretroviral (ARV) regimens such
 as cobicistat, indinavir, or ritonavir, or agents with moderate or strong CYP3A4
 inhibition; if on a moderate or strong CYP3A4 inhibitor regimen prior to study
 enrollment, participants must be switched to a qualifying regimen with the last dose
 of the strong CYP3A4 inhibitor taken at least one week before administration of
 ibrutinib

 -  Willingness of sexually active participants to use adequate contraception; both men
 and women of child-bearing potential treated or enrolled on this study must agree to
 use adequate contraception (hormonal or barrier method of birth control; abstinence)
 before study entry, for the duration of study participation, 90 days after completion
 of ibrutinib, and 12 months after the last dose of rituximab, whichever comes last;
 men who only have sex with other men do not need to use contraception specifically for
 this study (should a woman become pregnant or suspect she is pregnant while she or her
 partner is participating in this study, she should inform her treating physician
 immediately)

 -  All participants will be required to be screened for hepatitis B; all participants who
 present with acute hepatitis B or show normal transaminases and are hepatitis B
 surface antigen (HBsAg) positive (+) and IgM+ for hepatitis core antigen will not be
 eligible for trial enrollment; per Infectious Diseases Society of America (IDSA) and
 Assistance for AIDS Specific Drugs (AASD) guidelines, those participants that show no
 immunity, defined by the lack of hepatitis B surface antibody, and show evidence of
 chronic infection (i.e. hepatitis B [HB]sAg+, HBcore+, hepatitis B surface antibody
 [HBsAB] negative [-]) will be required to be on anti-hepatitis B therapy, during the
 study, in order to be eligible; the exact hepatitis B therapy will be at the
 discretion of the infection disease specialist or investigator; if infected with
 hepatitis B, participants will be permitted to enroll in the study provided liver
 function tests meet criteria listed above, there is no evidence of cirrhosis AND
 participants will be required to be on anti-hepatitis B therapy

 -  All participants will be required to be screened for hepatitis C; if hepatitis C
 antibody positive, with or without a positive hepatitis C RNA level, participants will
 be permitted to enroll in the study provided liver function tests meet criteria
 listed, and have no evidence of cirrhosis; participants diagnosed with hepatitis C
 less than 6 months from trial enrollment will be considered to have acute hepatitis C,
 and will be excluded from study UNLESS hepatitis C viral load is undetectable

 -  Adequate cardiac function defined as an ejection fraction on echocardiogram (ECHO) or
 multi-gated acquisition (MUGA) that is at or above the institutional normal limits

 -  Participants must be able to swallow oral pills

 -  Ability to understand and willing to sign a written informed consent document

 Exclusion Criteria:

 -  Participants who have had chemotherapy other than R-EPOCH or R-CHOP, or radiotherapy
 other than palliative radiation for medical emergencies (like cord compression),
 within the last 4 weeks

 -  Prior cytotoxic chemotherapy or radiotherapy for this lymphoma

 -  Rituximab within 12 months prior to study registration; only exception will be if
 rituximab was given for indications other than the treatment of aggressive lymphoma,
 or for one prior cycle of treatment

 -  Participants who are receiving any other investigational agents

 -  Participants who have previously received ibrutinib for another indication

 -  Expected survival < 2 months

 -  Participants with a history of an opportunistic fungal infection or active fungal
 infection requiring, or at high risk of requiring, prophylactic or treatment with
 fluconazole, voriconazole or posaconazole

 -  Participants with known brain metastases from solid tumors should be excluded from
 this clinical trial

 -  Presence of second active tumor, other than non-melanoma skin cancer, carcinoma in
 situ of the cervix, or Kaposi's sarcoma (KS) that requires systemic therapy

 -  In the dose-finding portion of the study, participants with known or suspected
 parenchymal brain, spinal cord, leptomeningeal disease prior to study enrollment will
 be excluded; in the dose-expansion portion of the study, known or suspected
 parenchymal brain or spinal cord disease, and/or suspected or symptomatic
 leptomeningeal disease prior to study enrollment will be excluded; asymptomatic
 leptomeningeal disease only will be allowed in the dose-expansion cohort

 -  History of allergic reactions attributed to compounds of similar chemical or biologic
 composition to ibrutinib or other agents used in study

 -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active
 infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
 arrhythmia, or psychiatric illness/social situations that would limit compliance with
 study requirements

 -  Pregnancy or breastfeeding; a pregnancy test must be performed within 7 days prior to
 ibrutinib initiation in women of childbearing potential; pregnant women; breastfeeding
 must be discontinued because of unknown but potential risks in the nursing infant

 -  Unable to comply with the requirements of the protocol, or unable to provide adequate
 informed consent in the opinion of the principal investigator

 -  Serious, ongoing, non-malignant disease or infection, which in the opinion of the
 investigator and/or the sponsor would compromise other protocol objectives;
 participants with active opportunistic infections are ineligible

 -  Major surgery, other than diagnostic surgery, occurring 4 weeks prior to study entry;
 splenectomy will not be considered an exclusionary major surgery

 -  History of cutaneous or mucocutaneous reactions, or diseases in the past, due to any
 cause, severe enough to cause hospitalization or an inability to eat or drink for > 2
 days; this exclusion relates to the long-term possibility of severe cutaneous or
 mucocutaneous reactions to rituximab that might occur at increased frequency in
 participants who have had severe skin disease or reactions in the past

 -  Myocardial infarction (MI) within 6 months prior to study entry, New York Heart
 Association (NYHA) class II or greater heart failure, uncontrolled angina, severe
 uncontrolled ventricular arrhythmias, clinically significant pericardial disease, or
 electrocardiographic evidence of acute ischemic or active conduction system
 abnormalities