Everolimus and Alemtuzumab in Treating Patients With Recurrent Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma
Everolimus and Alemtuzumab in Treating Patients With Recurrent Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma
RATIONALE: Everolimus may stop the growth of cancer cells by blocking some of the signaling
 molecules needed for cell growth. Monoclonal antibodies, such as alemtuzumab, can bind to and
 kill malignant lymphocytes.

 PURPOSE: This phase I/II trial is studying the side effects and best dose of everolimus when
 given together with alemtuzumab and will see how well they work in treating patients with
 recurrent chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL).
PRIMARY OBJECTIVES: I. Test the safety and tolerability of the combination of everolimus and
 alemtuzumab. (Phase I) II. Determine the maximum tolerated dose of everolimus in this
 combination. (Phase I) III. Assess the rate of overall responses in patients with
 relapsed/refractory CLL to treatment with the maximum tolerated dose of everolimus together
 with a standard dose of alemtuzumab using conventional NCI-WG 1996 response criteria. (Phase
 II) IV. To assess the complete responses to this combination regimen using conventional
 NCI-WG 1996 criteria and an expanded definition of response, including CT scans of
 chest-abdomen-pelvis, immunohistochemical analysis for residual disease in the bone marrow,
 and sensitive flow cytometry for minimal residual disease in patients in complete clinical
 remission. V. To monitor and assess toxicity of this regimen. SECONDARY OBJECTIVES: I. To
 determine the overall and progression-free survival, duration of response, and time to next
 treatment. II. To assess the correlation between the individual prognostic markers (17p-, p53
 gene mutations, 11q-, unmutated VH gene, use of VH3-21, ZAP70+, CD38+, CD49d, B2
 microglobulin) and clinical outcome. III. Serial measurement of clinical status and
 lymphocyte counts to test the rate of reduction in CLL tumor burden. TERTIARY OBJECTIVES: I.
 Determine the effect of everolimus on the sensitivity of CLL cells to alemtuzumab CDC and
 ADCC. II. Determine the effect of everolimus on the CLL cell-stroma interaction. III. Detail
 the in vivo effect of the everolimus-alemtuzumab regimen on critical aspects of the immune
 system in CLL. OUTLINE: This is a phase I, dose escalation study of everolimus followed by a
 phase II study. Patients receive oral everolimus thrice weekly for 9 weeks and alemtuzumab
 subcutaneously thrice weekly for 7 weeks in the absence of disease progression or
 unacceptable toxicity. After completion of study treatment, patients are followed
 periodically for up to 5 years. PROJECTED ACCRUAL: A total of 44 patients will be accrued for
 this study.
Inclusion

 -  Diagnosis of CLL manifested by minimum threshold peripheral lymphocyte count of > 5 x
 10^9/L (CLL variant) OR palpable adenopathy >= 1cm or clinically palpable splenomegaly
 (SLL variant); AND immunophenotypic demonstrations of a population of B lymphocytes
 (as defined by CD19+) which are monoclonal (by light chain exclusion)

 -  CLL will be diagnosed if these cells have >= 3 of the following characteristics: CD5+,
 CD23+, dim surface light chain expression, dim surface CD20 expression, AND FISH
 analysis is negative for IGH/CCND1 and/or immunostaining is negative for cyclin D1
 expression to exclude mantle cell lymphoma Previous treatment for CLL Progressive
 disease: symptomatic CLL (weight loss>10% within 6 months, extreme fatigue,
 fevers>38.5 C, drenching night sweats without evidence of infection) OR evidence of
 progressive bone marrow failure (hemoglobin<11g/dL, platelet count<100 x 10^9/L) OR
 massive (>6 cm below left costal margin) or progressive palpable splenomegaly OR
 massive (>10 cm) or measurable and progressive lymphadenopathy

 -  Please contact study investigator and/or consult protocol document for specific
 details on laboratory criteria CD52 expression by CLL cells Willing to provide
 mandatory biospecimen samples for research studies as required by the protocol
 Negative serum pregnancy test done =< 7 days prior to registration, for women of
 childbearing potential only Willingness to return to the enrolling institution for
 follow-up

 -  ECOG Performance Status (PS) 0, 1, or 2--Exceptions: Grade 3 allowed if caused by CLL
 and not other co-morbidities Provide informed written consent Life expectancy >= 3
 months

 Exclusion

 -  Any of the following comorbid conditions: NYHA class III-IV heart disease, recent
 myocardial infarction (< 6 months prior to registration), uncontrolled infection,
 infection with the human immunodeficiency virus (HIV/AIDS), serological evidence of
 active hepatitis B infection (HBsAg or HBeAg positive) or positive hepatitis C
 serology, as further severe immunosuppression with this regimen may occur

 -  Evidence of active autoimmune hemolytic anemia, immune thrombocytopenia, or pure red
 blood cell aplasia Other active primary malignancy requiring treatment or that limits
 survival to =< 2 years Any major surgery =< 4 weeks prior to registration Concurrent
 investigational drug therapy Any of the following: pregnant women,nursing women, men
 or women of childbearing potential who are unwilling to employ adequate contraception
 (condoms, diaphragm, birth control pills, injections, intrauterine device [IUD],
 surgical sterilization, abstinence, etc.)

 -  Concomitant use of the following CYP3A4 strong inhibitors: Clarithromycin, Nefazodone,
 Telithromycin, Aprepitant, Indinavir, Nelfinavir, Diltiazem, Borisonazole,
 Itrazonazole, Ritonavir, Erythromycin, Ketoconazole, Saquinavir, Fluconazole (may be
 used if drug levels can be monitored)

 -  Patients with any known bleeding diathesis (any congenital bleeding disorder that
 affects platelet function and/or coagulation including von Willebrand's Disease)

 -  Severely impaired lung function as defined as spirometry and DLCO that is 50% of the
 normal predicted value and/or O2 saturation that is 88% or less at rest on room air
 Receiving anticoagulant therapy