Vorinostat, Fludarabine Phosphate, Cyclophosphamide, and Rituximab in Treating Patients With Previously Untreated Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma
Vorinostat, Fludarabine Phosphate, Cyclophosphamide, and Rituximab in Treating Patients With Previously Untreated Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma
This phase I/II trial studies the side effects and best dose of vorinostat when given
 together with fludarabine phosphate, cyclophosphamide, and rituximab and to see how well they
 work in treating patients with previously untreated B-cell chronic lymphocytic leukemia (CLL)
 or small lymphocytic lymphoma (SLL). Vorinostat may stop the growth of cancer cells by
 blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as
 fludarabine phosphate and cyclophosphamide, work in different ways to stop the growth of
 cancer cells, either by killing the cells or by stopping them from dividing. Monoclonal
 antibodies, such as rituximab, may block cancer growth in different ways by targeting certain
 cells. Giving vorinostat together with fludarabine phosphate, cyclophosphamide, and rituximab
 may be a better treatment for CLL or SLL.
PRIMARY OBJECTIVES:

 I. To estimate the maximum tolerated dose (MTD) of vorinostat that can be combined with
 fludarabine (fludarabine phosphate), cyclophosphamide and rituximab (FCR) in patients with
 previously untreated CLL/SLL.

 II. To evaluate potential efficacy in terms of 2-year after FCR plus vorinostat induction
 followed by rituximab plus vorinostat maintenance therapy for previously untreated CLL/SLL
 patients.

 SECONDARY OBJECTIVES:

 I. To eliminate residual disease (documented by flow cytometry and/or polymerase chain
 reaction [PCR]) in patients who have achieved a complete response (CR) after FCR plus
 vorinostat.

 II. To estimate the rate of conversion of partial response (PR) to CR after FCR plus
 vorinostat.

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

 INDUCTION THERAPY: Patients receive vorinostat orally (PO) once daily on days 1-5 and 8-12;
 cyclophosphamide intravenously (IV) over 30-60 minutes and fludarabine phosphate IV over
 30-60 minutes on days 1-3; and rituximab IV on day 1, 2, 3, 4, or 5. Treatment repeats every
 28 days for 4-6 courses in the absence of disease progression or unacceptable toxicity.

 MAINTENANCE THERAPY: Beginning 3 months after the completion of induction therapy, patients
 receive vorinostat PO on days 1-14 and rituximab IV on day 1. Treatment repeats every 3
 months for 2 years in the absence of disease progression or unacceptable toxicity.

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

 -  Patients must have a confirmed diagnosis of CLL/SLL

 -  Patients with previously untreated cluster of differentiation (CD)20+ CLL/SLL must
 have either Rai stage III/IV disease or be Rai stage I/II with evidence of disease
 activity as defined by the National Cancer Institute (NCI) 1996 guidelines; patients
 with SLL must be Stage III or IV per Ann Arbor staging system

 -  Patient must have consented to participate in the study and signed and dated an
 appropriate institutional review board (IRB)-approved consent form that conforms to
 federal and institutional guidelines

 -  Patient must have an Eastern Cooperative Oncology Group (ECOG) performance status of
 0, 1 or 2

 -  Patient must have an anticipated (untreated) survival of at least 3 months

 -  Female patient of childbearing potential has a negative serum pregnancy test
 beta-human chorionic gonadotropin (hCG) within 2 weeks prior to receiving the first
 dose of vorinostat

 -  Female patient is either post menopausal, free from menses for >= 2 years, surgically
 sterilized or willing to use 2 adequate barrier methods of contraception to prevent
 pregnancy or agrees to abstain from heterosexual activity throughout the study,
 starting with Visit 1

 -  Male patients not sterilized must be willing to use adequate barrier methods of
 contraception to prevent pregnancy or agrees to abstain from heterosexual activity
 throughout the study, starting with Visit 1

 -  Absolute Neutrophil Count (ANC) >= 1,500/mcL

 -  Platelets >= 100,000/mcL

 -  Hemoglobin >= 9 g/dL

 -  Prothrombin time or international normalized ratio (INR) =< 1.5 upper limit of normal
 (ULN) unless receiving therapeutic anticoagulation

 -  Partial thromboplastin time (PTT) =< 1.2 times the ULN unless the patient is receiving
 therapeutic anticoagulation

 -  Potassium level within normal limits

 -  Magnesium level within normal limits

 -  Serum creatinine =< 1.5 x ULN OR if creatinine is > 1.5 ULN the calculated creatinine
 clearance must be >= 60 mL/min

 -  Serum total bilirubin =< 1.5 times ULN; patients with Gilbert's disease or similar
 syndrome involving slow conjugation of bilirubin are eligible with total bilirubin >
 1.5 times upper limit of normal; principal investigator (PI) review and approval
 required for anything above 2 times ULN

 -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and
 alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5
 ULN

 -  Alkaline phosphatase =< 2.5 ULN

 -  Patients with cytopenias due to disease or pseudohyperkalemia that do not meet these
 criteria, will be considered eligible with review and approval by the PI or Co-PI
 prior to study entry

 Exclusion Criteria:

 -  Patients who have received cytotoxic chemotherapy, radiation therapy, immunotherapy,
 or cytokine treatment prior to study entry for CLL/SLL; patients who have received
 systemic steroids within 1 week of study entry are excluded, except patients on
 maintenance steroid therapy for a noncancerous disease

 -  Patients with active hemolysis

 -  Patients must not require sustained transfusion support of blood products

 -  Patients who have undergone treatment with either stem cell or bone marrow transplant

 -  Patients with active obstructive hydronephrosis

 -  Patients with evidence of any significant systemic illness, active hepatitis B
 infection, active viral hepatitis infection or other active infection at the time of
 study entry

 -  Patients with New York Heart Association class III or IV heart disease symptomatic
 congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or other
 serious illness, such as acute or chronic graft versus host disease, that would
 preclude evaluation

 -  Patients with congenital long QT syndrome and patients taking antiarrhythmic medicines
 or other medicinal products that lead to QT prolongation will only be eligible if
 their baseline corrected QT (QTc) prolongation is =< 500 msec

 -  Patients with known human immunodeficiency virus (HIV) infection

 -  Patients who are pregnant or nursing

 -  Patients with known brain or leptomeningeal involvement by malignancy

 -  Patients who have, in the opinion of the investigator, other medical, social, or
 psychosocial factors that may negatively impact compliance or their safety by
 participation in this study

 -  Patient is currently participating or has participated in a study with an
 investigational compound or device within 30 days of initial dosing with study
 drugs(s)

 -  Patient had prior treatment with an histone deacetylases (HDAC) inhibitor (e.g.,
 romidepsin [Depsipeptide], NSC-630176, MS 275, LAQ-824, belinostat [PXD-101], LBH589,
 MGCD0103, CRA024781, etc); patients who have received compounds with HDAC
 inhibitor-like activity, such as valproic acid, as anti-tumor therapy should not
 enroll in this study; patients who have received such compounds for other indications,
 e.g. valproic acid for epilepsy, may enroll after a 30-day washout period

 -  Patient with a history of a prior malignancy with the exception of cervical
 intraepithelial neoplasia; non-melanoma skin cancer; adequately treated localized
 prostate carcinoma with prostate-specific antigen (PSA) =< 1.0; or who has undergone
 potentially curative therapy with no evidence of that disease for five years, and/or
 who is deemed at low risk for recurrence by his/her treating physician