Entospletinib and Obinutuzumab in Treating Patients With Relapsed Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma, or Non-Hodgkin Lymphoma
Entospletinib and Obinutuzumab in Treating Patients With Relapsed Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma, or Non-Hodgkin Lymphoma
This phase I/II trial studies the side effect and best dose of entospletinib when giving
 together with obinutuzumab and to see how well they work in treating patients with chronic
 lymphocytic leukemia, small lymphocytic lymphoma, or non-Hodgkin lymphoma that has come back.
 Entospletinib may stop the growth of cancer cells by blocking some of the enzymes need for
 cell growth. Monoclonal antibodies, such as obinutuzumab, may interfere with the ability of
 cancer cells to grow and spread. Giving entospletinib and obinutuzumab together may work
 better in treating patients with chronic lymphocytic leukemia, small lymphocytic lymphoma, or
 non-Hodgkin lymphoma.
PRIMARY OBJECTIVES:

 I. To evaluate the safety and tolerability of entospletinib administered in combination with
 obinutuzumab in patients with relapsed/refractory chronic lymphocytic leukemia/small
 lymphocytic lymphoma (CLL/SLL) and non-Hodgkin lymphoma (NHL), and identify the dose for
 phase 2 expansion. (Phase I) II. To evaluate the efficacy of entospletinib in combination
 with obinutuzumab in patients with relapsed or refractory CLL/SLL, as measured by complete
 response (CR) rate. (Phase II)

 SECONDARY OBJECTIVES:

 I. Objective response rate (ORR, defined as complete remission, complete response with
 incomplete marrow recovery, partial remission and nodular partial response). (Phase II) II.
 Event free survival defined as the interval between the date of first study treatment and the
 date of objective signs of disease recurrence, subsequent anti-leukemic therapy, or death,
 whichever is first reported. (Phase II) III. Safety and tolerability of entospletinib in
 combination with obinutuzumab by adverse events (AEs). (Phase II)

 EXPLORATORY OBJECTIVES:

 I. Peripheral blood B-cell depletion and recovery. II. Preliminary assessment of the
 predictive value of minimal residual disease (MRD).

 III. Pharmacodynamics effects of in vivo administration of entospletinib on NFkappaB
 activation and expression of anti-apoptotic proteins in CLL cells.

 IV. Association of established biomarkers (chromosomal abnormalities, immunoglobulin heavy
 chain [IGHV] mutational status, p53 mutational status) with response (ORR and event-free
 survival [EFS]) to entospletinib (ENTO) in combination with obinutuzumab in patients with
 relapsed/refractory CLL.

 OUTLINE: This is a phase I, dose-escalation study of entospletinib followed by a phase II
 study.

 Patients receive entospletinib orally (PO) either once a day (QD) or twice a day (BID) on
 days -7 to -1 (run-in phase) depending on the assigned dose level. Patients also receive
 obinutuzumab intravenously (IV) on days 1, 2, 8, and 15 of the first cycle and on day 1 of
 all subsequent cycles. Treatment with obinutuzumab repeats every 28 days for up to 6 cycles
 and daily treatment with entospletinib continues every 28 days for up to 12 cycles in the
 absence of disease progression or unexpected toxicity. Patients who do not receive MRD may
 continue receive entospletinib beyond 12 cycles with approval from the treating physician and
 sponsor-investigator in the absence of disease progression or unacceptable toxicity.

 After completion of study treatment, patients are followed up every 3 months for 12 months
 then every 6 months thereafter.
Inclusion Criteria:

 -  Phase I portion of the study: Histologically or flow cytometry confirmed diagnosis of
 B-CLL/SLL according to National Cancer Institute (NCI)-Working Group (WG) 1996
 guidelines

 -  Phase I portion of the study: The following types of NHL as documented by medical
 records and with histology based on criteria established by the World Health
 Organization (WHO):

 -  Mantle cell lymphoma (MCL)

 -  Follicular lymphoma (FL) - grades 1-3a

 -  Lymphoplasmacytic lymphoma (LPL)

 -  Marginal zone lymphoma (MZL)

 -  CLL in Richter's transformation

 -  B-cell prolymphocytic leukemia

 -  Phase I portion of the study: Patients with histologically confirmed classical hairy
 cell leukemia (HCL)

 -  Phase II portion of the study - histologically or flow cytometry confirmed diagnosis
 of BCLL/SLL according to NCI-WG 1996 guidelines; patients who lack CD23 expression on
 their leukemia cells should be examined for (and found NOT to have) either t(11;14) or
 cyclin D1 overexpression, to rule out mantle cell lymphoma

 -  Patients underwent >= 1 prior chemotherapy-based or immunotherapy-based regimen or
 targeted therapy (e.g., inhibitors of BTK, PI3K etc.) administered for >= 2 cycles,
 and have had either documented disease progression or no response (stable disease) to
 the most recent treatment regimen

 -  Patients with CLL/SLL must demonstrate active disease meeting at least 1 of the
 International Workshop on Chronic Lymphocytic Leukemia (IWCLL) 2008 criteria for
 requiring treatment:

 -  A minimum of any one of the following constitutional symptoms:

 -  Unintentional weight loss > 10% within the previous 6 months prior to
 screening

 -  Extreme fatigue (unable to work or perform usual activities)

 -  Fevers of greater than 100.5 Fahrenheit (F) for >= 2 weeks without evidence
 of infection

 -  Night sweats without evidence of infection

 -  Evidence of progressive marrow failure as manifested by the development of, or
 worsening of anemia or thrombocytopenia

 -  Massive (i.e., > 6 cm below the left costal margin), progressive or symptomatic
 splenomegaly

 -  Massive nodes or clusters (i.e., > 10 cm in longest diameter) or progressive
 lymphadenopathy

 -  Progressive lymphocytosis with an increase of > 50% over a 2-month period, or an
 anticipated doubling time of less than 6 months

 -  Autoimmune anemia or thrombocytopenia that is poorly responsive to
 corticosteroids

 -  Patients with HCL must be intolerant of or not candidates for purine analog-based
 therapy, or failed to achieve response (CR or partial response [PR]) or relapsed
 within 2 years of such therapy, AND meet the standard treatment initiation criteria
 (absolute neutrophil count [ANC] =< 1000/uL, hemoglobin [Hgb] =< 10 g/dL, platelet
 count =< 100,000/uL); patients with indolent lymphoma (FL, LPL, MZL) and patients with
 B-cell prolymphocytic leukemia must have an indication for treatment in the opinion of
 the investigator; patients with MCL and patients with CLL in Richter's transformation
 should have previously received or not be candidates for high dose
 chemotherapy/autologous stem cell transplant

 -  For diseases other than CLL, LPL, and HCL, presence of radiographically measurable
 lymphadenopathy or extra-nodal lymphoid malignancy (defined as the presence of >= 1
 lesion that measures >= 2.0 cm in the longest dimension [LD] and >= 1.0 cm in the
 longest perpendicular dimension [LPD] as assessed by computed tomography [CT] or
 magnetic resonance imaging [MRI]); for LPL, measurable disease will be defined as
 serum monoclonal IgM > 0.5 g/dL or meeting at least 1 of the recommendations from the
 Second International Workshop on LPL for requiring treatment

 -  Patients must have Eastern Cooperative Oncology Group (ECOG) performance status =< 2

 -  Direct bilirubin =< 2 X institutional upper limit of normal (ULN) (unless due to known
 Gilbert's syndrome or compensated hemolysis directly attributable to CLL)

 -  Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) less than 2.5 X
 institutional ULN

 -  Estimated creatinine clearance (CrCL) using the Cockcroft-Gault equation >= 50 mL/min

 -  Platelets >= 50,000/mm^3 independent of transfusion support, with no active bleeding

 -  Absolute neutrophil count (ANC) >= 1000/mm^3, unless due to disease involvement in the
 bone marrow

 -  Ability to understand and the willingness to sign a written informed consent document

 Exclusion Criteria:

 -  Prior therapeutic intervention with any of the following:

 -  Therapeutic anticancer antibodies within 4 weeks (rituximab), except within 6
 months for obinutuzumab or a similar investigational type II monoclonal antibody;

 -  Radio- or toxin-immunoconjugates within 10 weeks;

 -  Inhibitors of BTK (ibrutinib), PI-3K (idelalisib), BH3-mimetic venetoclax,
 lenalidomide and other "targeted" therapy (including but not limited to
 investigational BTK and PI-3K inhibitors, etc.) - within 6 half-lives (i.e., 36
 hours for ibrutinib)

 -  All other chemotherapy, radiation therapy within 3 weeks prior to initiation of
 therapy

 -  SYK inhibitors at any time

 -  Inadequate recovery from adverse events related to prior therapy to grade =< 1
 (excluding grade 2 alopecia and neuropathy)

 -  Chronic use of corticosteroids in excess of prednisone 30 mg/day or its equivalent

 -  Stem cell transplant recipients must have no evidence of and not receive treatment for
 graft-versus-host disease

 -  Concomitant use or use in the prior two weeks of moderate or strong CYP3A and CYP2C9
 inducers or strong CYP2C9 inhibitors, including nutraceutical preparations, e.g.,
 grapefruit juice and St John's wort

 -  History prior malignancy except:

 -  Malignancy treated with curative intent and no known active disease present for
 >= 2 years prior to initiation of therapy on current study

 -  Adequately treated non-melanoma skin cancer or lentigo maligna (melanoma in situ)
 without evidence of disease

 -  Adequately treated in situ carcinomas (e.g., cervical, esophageal, etc.) without
 evidence of disease

 -  Asymptomatic prostate cancer managed with "watch and wait" strategy

 -  Myelodysplastic syndrome which is clinically well controlled and no evidence of
 the cytogenetic abnormalities characteristic of myelodysplasia on the bone marrow
 at screening

 -  Uncontrolled immune hemolysis or thrombocytopenia (positive direct antiglobulin test
 in absence of hemolysis or history of immune-mediated cytopenias are not exclusions)

 -  History of human immunodeficiency virus (HIV) infection or active hepatitis B or C

 -  Major surgery (requiring general anesthesia) within 2 weeks prior to initiation of
 therapy

 -  Inability to swallow and retain an oral medication; patients with clinically
 significant medical condition of malabsorption, inflammatory bowel disease, chronic
 conditions which manifest with diarrhea, refractory nausea, vomiting or any other
 condition that will interfere significantly with drug absorption are excluded;
 patients must also have adequate venous access

 -  Need for ongoing therapy with proton pump inhibitors; H2 antagonists are allowed

 -  Active uncontrolled infection

 -  Women who are pregnant or lactating

 -  Fertile men or women of childbearing potential unless 1) permanently sterile or 2)
 using a highly effective measure of contraception such as condoms in males and
 consistent and correct use of one of the following in females: intrauterine device,
 tubal sterilization, Essure micro-insert system, vasectomy in the male partner;
 effective contraception is required for males during treatment with study drug and to
 continue for 3 months after the last dose of either entospletinib or obinutuzumab,
 whichever is later; for women, effective contraception is required to continue for 18
 months after the last dose of obinutuzumab or for 30 days after the last dose of
 entospletinib, whichever is later

 -  Definition of childbearing potential: for this study, a female subject is
 considered of childbearing potential until becoming post-menopausal unless
 permanently sterile or with medically documented ovarian failure; women are
 considered to be in a postmenopausal state when >= 54 years of age with cessation
 of previously occurring menses for >= 12 months without an alternative cause;
 women of any age with amenorrhea of >= 12 months may also be considered
 post-menopausal if their follicle stimulating hormone (FSH) level is in the
 post-menopausal range and they are not using hormonal contraception or hormonal
 replacement therapy; permanent sterilization in females includes hysterectomy,
 bilateral oophorectomy, or bilateral salpingectomy in a female subject of any
 age; permanent sterilization in males include bilateral orchiectomy or medical
 documentation of alternative explanation

 -  Any condition for which participation in the study is judged by the Investigator to be
 detrimental to the patient with inter-current illness or psychiatric/social situations
 that would jeopardize compliance with study requirements