TGR-1202 and Ibrutinib in Treating Patients With Relapsed or Refractory Diffuse Large B-Cell Lymphoma

• Sponsor: Matthew Lunning, DO (Other)
• Overall Status: Completed
• CT.gov ID: NCT02874404
• Collaborator: National Cancer Institute (NCI) (NIH)
• Enrollment: 13
• Location: 1
• Arms: 3
• Duration (Months): 33
• Patients Per Site Per Month: 0.4

Study Details

Study Description

Brief Summary

This phase IIa trial studies the side effects and how well TGR-1202 and ibrutinib work in treating patients with diffuse large B-cell lymphoma that has returned after a period of improvement or does not respond to treatment. TGR-1202 and ibrutinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.

Condition or Disease	Intervention/Treatment	Phase
Recurrent Diffuse Large B-Cell Lymphoma; Refractory Diffuse Large B-Cell Lymphoma	Drug: Ibrutinib; Other: Laboratory Biomarker Analysis; Drug: PI3K-delta Inhibitor TGR-1202	Phase 2

Detailed Description

PRIMARY OBJECTIVES:

1. To determine the safety and tolerability of PI3K delta inhibitor TGR-1202 (TGR-1202) and ibrutinib in relapsed and refractory (rel/ref) diffuse large B-cell lymphoma (DLBCL).

SECONDARY OBJECTIVES:

1. To determine the overall response rate (ORR) defined as the sum of complete responses (CR) and partial responses (PR).

2. To determine the event-free survival (EFS), time to response (TTR), and duration of response (DOR) in patients with rel/ref DLBCL.

TERTIARY OBJECTIVES:

1. To evaluate molecular profiling of patient samples (optional lymph node biopsies) obtained at days 0 (pre-treatment; core biopsy), day 8 (fine needle aspiration) and end of treatment (progressive disease or end of study treatment-1 year; core biopsy).

2. To evaluate the baseline characteristics and dynamic shifts in mutational Landscape, transcriptional signatures and intracellular signaling cascades in primary tumor cells.

3. To define the mutational status of 384 genes that mutated in DLBCL, including cluster of differentiation (CD)79B, caspase recruitment domain family member 11 (CARD11), and myeloid differentiation primary response 88 (MYD88).

4. To evaluate signatures of B-cell receptor signaling and the back-up pathway of oxidative phosphorylation.

5. To measure the basal and induced level of activation of components within parallel signaling pathways downstream of the B-cell receptor.

6. To monitor changes in T-cell characteristics in response to exposure to TGR-1202 and ibrutinib.

7. To perform quantitative response evaluation by peripheral blood cell-free deoxyribonucleic acid (DNA) sequencing at enrollment, day 8, 1 month, at every response assessment time point compared to standard radiographic response evaluation by positron emission tomography (PET)/ computed tomography (CT) or CT and end of treatment (progressive disease or end of study treatment-1 year).

8. To evaluate the genetic profiling for drug resistance mutations. IX. To evaluate DLBCL subtype analysis by immunohistochemistry compared to Nanostring assessment.

OUTLINE: Patients are assigned to 1 of 3 groups.

GROUP A: Patients receive PI3K delta inhibitor TGR-1202 orally (PO) once daily (QD) on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.

GROUP B: Patients receive ibrutinib PO QD on days 1-28 and PI3K delta inhibitor TGR-1202 PO QD and days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.

GROUP C: Patients then receive PI3K delta inhibitor TGR-1202 PO QD and ibrutinib PO QD on days 1-28. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up for 30 days and after 1 year.

Study Design

• Study Type: Interventional
• Actual Enrollment: 13 participants
• Allocation: Non-Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Single-Center Phase IIa Study Evaluating the Safety and Tolerability of TGR-1202 and Ibrutinib in Patients With Relapsed or Refractory Diffuse Large B-Cell Lymphoma: A Trial of the Lymphoma Precision Medicine Laboratory
• Study Start Date: Oct 1, 2016
• Actual Primary Completion Date: Jul 1, 2019
• Actual Study Completion Date: Jul 1, 2019

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Group A (PI3K delta inhibitor TGR-1202, ibrutinib) Patients receive PI3K delta inhibitor TGR-1202 PO QD on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.	Drug: Ibrutinib; Given PO; Other Names: BTK Inhibitor PCI-32765 CRA-032765 Imbruvica PCI-32765 ; Other: Laboratory Biomarker Analysis; Correlative markers; Drug: PI3K-delta Inhibitor TGR-1202; Given PO; Other Names: RP5264 TGR-1202
Experimental: Group B (Ibrutinib, PI3K delta inhibitor TGR-1202) Patients receive ibrutinib PO QD on days 1-28 and PI3K delta inhibitor TGR-1202 PO QD and days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.	Drug: Ibrutinib; Given PO; Other Names: BTK Inhibitor PCI-32765 CRA-032765 Imbruvica PCI-32765 ; Other: Laboratory Biomarker Analysis; Correlative markers; Drug: PI3K-delta Inhibitor TGR-1202; Given PO; Other Names: RP5264 TGR-1202
Experimental: Group C (PI3K delta inhibitor TGR-1202, ibrutinib) Patients then receive PI3K delta inhibitor TGR-1202 PO QD and ibrutinib PO QD on days 1-28. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.	Drug: Ibrutinib; Given PO; Other Names: BTK Inhibitor PCI-32765 CRA-032765 Imbruvica PCI-32765 ; Other: Laboratory Biomarker Analysis; Correlative markers; Drug: PI3K-delta Inhibitor TGR-1202; Given PO; Other Names: RP5264 TGR-1202

Outcome Measures

Primary Outcome Measures

1. Percentage of Participants With Adverse Events Assessed Using NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03 [Up to 112 days (course 4)]

   Notable serious or recurrent adverse events (SAEs or AEs) of interest occurring across all cycles regardless of attribution

Secondary Outcome Measures

1. Overall Response Rate (ORR) [Up to 4 years]

   ORR is defined as number of patients achieving a best response of complete response or partial response at any disease assessment time point. Response is based on PET/CT (Deauville 3 or less) or CT alone if CR is achieved by PET/CT. Response criteria, modified from the Lugano response criteria. DLBCL is considered FDG avid. Complete response: Complete disappearance of all detectable clinical evidence of disease and definitely disease-related symptoms if present before therapy. Criteria for Partial Response (PR): Regression of measurable disease and no new sites

2. Estimated Progression-free Survival (PFS) at 6 Months [Time between study registration and documented progression or death if no progression was observed, assessed up to 4 years (6 Month estimate shown)]

   PFS is defined as the time between study registration and documented progression or death if no progression was observed.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 19 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Histologically confirmed diffuse large B-cell lymphoma (DLBCL) or transformed DLBCL

• Hematoxylin and eosin (H&E) stain and immunohistochemistry (IHC) slides or a representative formalin-fixed, paraffin-embedded (FFPE) tissue block along with the pathology report from initial diagnosis, (as well as, an optional 8 unstained slides of 4 micron thickness to store for future IHC and DNA specified research use), should be sent to be reviewed, and the diagnosis confirmed by University of Nebraska Medical Center (UNMC) (retrospective diagnostic review: treatment may commence prior to the UNMC review); please NOTE: the diagnostic H&E slide and IHC slides will be returned after review; only the optional 8 unstained slides will be retained and stored for future unspecified research use

• Patients with relapsed or refractory DLBCL that has relapsed post-transplant or that has been determined to be ineligible or unsuitable for transplant; patients must have to have received at least one prior systemic therapy

• Patients must have measurable (>= 1.5 cm) or evaluable disease; baseline measurements and evaluations must be obtained within 6 weeks of registration to the study; abnormal PET scans will not constitute evaluable disease, unless verified by CT scan or other appropriate imaging; measurable disease must have at least one objective measurable disease parameter; a clearly defined, bi-dimensionally measurable defect or mass measuring at least 1.5 cm in diameter on a CT scan will constitute measurable disease; proof of lymphoma in the liver is required by a confirmation biopsy; skin lesions can be used as measurable disease provided bi-dimensional measurements are possible

• Absolute neutrophil count (ANC) >= 1.0 x 10^9/L

• By automated or manual review, whichever is greatest

• Platelets >= 100 x 10^9/L:

• Unless due to bone marrow infiltration then eligible if platelets > 50 x 10^9/L)

• Total bilirubin =< 1.5 x upper normal limit if documented hepatic involvement with lymphoma, or =< 5 x upper normal limit if history of Gilbert's disease

• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 2.5 x upper limit of normal (ULN) if no liver involvement or =< 5 x the ULN if documented liver involvement

• Creatinine =< 2.0 mg/dL OR calculated creatinine clearance >= 50 mL/min (as calculated by the Cockcroft-Gault method)

• Eastern Cooperative Oncology Group (ECOG) performance status =< 2 or expected survival duration of > 2 months

• Ability to swallow and retain oral medication

• Women must not be pregnant or breast-feeding

• All female patients of child-bearing potential must have a negative serum pregnancy test within 2 weeks prior to treatment to rule out pregnancy

• Pregnancy testing is not required for post-menopausal or surgically sterilized women

• Male and female patients of reproductive potential must agree to follow accepted birth control measures throughout the study period and for 30 days after the last dose of either study drug for females and 3 months after the last dose of study drug for males

• Patient must be able to adhere to the study visit schedule and other protocol requirements

• Patient must be aware of the neoplastic nature of his/her disease and willingly sign (or their legally-acceptable representatives must sign) an informed consent document indicating that they understand the purpose of and procedures required for the study, including biomarkers, and are willing to participate in the study

• No serious disease or condition that, in the opinion of the investigator, would compromise the patient's ability to participate in the study

Exclusion Criteria:

• Currently receiving cancer therapy (i.e., chemotherapy, radiation therapy, immunotherapy, biologic therapy, hormonal therapy, and surgery and/or tumor embolization) or any investigational drug within 7 days of cycle 1/day 1, 14 days of cycle 1/day 1 for limited palliative radiation, and/or five half-live of an oral therapy

• Corticosteroid therapy started at least 7 days prior to initiation of treatment (prednisone =< 10 mg daily or equivalent) is allowed as clinically warranted); topical or inhaled corticosteroids are permitted

• Major surgery or a wound that has not fully healed within 4 weeks of enrollment

• History of stroke or intracranial hemorrhage within 6 months prior to enrollment

• Requires anticoagulation with warfarin or equivalent vitamin K antagonists (eg, phenprocoumon)

• Vaccinated with live, attenuated vaccines within 4 weeks of enrollment

• Autologous hematologic stem cell transplant within 3 months of study entry

• Allogeneic hematologic stem cell transplant within 12 months of study entry

• Active graft versus-host disease and must not be on immunosuppression

• Wide field radiotherapy within 28 days of cycle 1/day 1 or active side effects of such therapy

• Active hepatitis B (hepatitis B virus [HBV]) or C (hepatitis C virus [HCV]) infection (negative serology required excluding those with are seropositive due to prior vaccination) and/or known history of human immunodeficiency virus (HIV)

• Primary central nervous system involvement only

• Require treatment with strong cytochrome P450 family 3 subfamily A (CYP3A) inhibitors

• Known history of drug-induced liver injury, alcoholic liver disease, primary biliary cirrhosis, ongoing extra-hepatic obstruction caused by stones, cirrhosis of the liver or portal hypertension

• Any life-threatening illness, severe and/or uncontrolled medical condition, or organ system dysfunction, laboratory abnormality, psychiatric illness or other condition which, in the Investigator's opinion, could compromise the subject's safety, interfere with the absorption or metabolism of ibrutinib capsules, put the study outcomes at undue risk or affect their participation in the study such as

• Symptomatic, or history of documented congestive heart failure New York Heart Association (NYHA) functional classification III-IV (NYHA)

• Corrected QT interval using Fridericia's formula (QTcF) > 470 msec (unless related to pacemaker) on echocardiogram (EKG) within 7 days of initiation of treatment

• Angina not well-controlled by medication

• Poorly controlled or clinically significant atherosclerotic vascular disease including cerebrovascular accident (CVA), transient ischemic attack (TIA), angioplasty, cardiac or vascular stenting within 6 months prior to enrollment

• Prior malignancies within the past 1 year with exception of adequately treated basal cell, squamous cell skin cancer, or thyroid cancer; carcinoma in situ of the cervix or breast; prostate cancer of Gleason grade 6 or less with stable prostate specific antigen (PSA) levels

• Women who are pregnant or breastfeeding; women who agree to stop breastfeeding would be eligible

• Known hypersensitivity to either study drug (TGR-1202 or ibrutinib)

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of Nebraska Medical Center	Omaha	Nebraska	United States	68198

Sponsors and Collaborators

• Matthew Lunning, DO
• National Cancer Institute (NCI)

Investigators

• Principal Investigator: Matthew Lunning, University of Nebraska

Study Documents (Full-Text)

• Study Protocol and Statistical Analysis Plan - Oct 7, 2019
• Informed Consent Form - Oct 25, 2018

More Information

Publications

None provided.

• Responsible Party: Matthew Lunning, DO, Principal Investigator, University of Nebraska
• ClinicalTrials.gov Identifier: NCT02874404
• Other Study ID Numbers: 345-16; NCI-2016-01082; 345-16; P30CA036727
• First Posted: Aug 22, 2016
• Last Update Posted: Feb 26, 2020
• Last Verified: Feb 1, 2020

• Additional relevant MeSH terms: Lymphoma; Lymphoma, B-Cell; Lymphoma, Large B-Cell, Diffuse

Study Results

Participant Flow

Recruitment Details	Subjects were statified to Arms A, B, or C for correlative sample collection purposes only. Clinical study outcomes are not viewed differently among the groups, so subjects are presented as one arm/group.

Arm/Group Title	All Subjects
Arm/Group Description	Patients receive PI3K delta inhibitor TGR-1202 PO QD and ibrutinib PO QD on days 1-28. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
Period Title: Overall Study
STARTED	13
COMPLETED	13
NOT COMPLETED	0

Baseline Characteristics

Arm/Group Title	All Subjects
Arm/Group Description	Patients then receive PI3K delta inhibitor TGR-1202 PO QD and ibrutinib PO QD on days 1-28. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
Overall Participants	13
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	68.5 (14.0)
Sex: Female, Male (Count of Participants)
Female	4 30.8%
Male	9 69.2%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	0 0%
Asian	0 0%
Native Hawaiian or Other Pacific Islander	0 0%
Black or African American	1 7.7%
White	12 92.3%
More than one race	0 0%
Unknown or Not Reported	0 0%
Region of Enrollment (participants) [Number]
United States	13 100%

Outcome Measures

1. Primary Outcome

Title	Percentage of Participants With Adverse Events Assessed Using NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03
Description	Notable serious or recurrent adverse events (SAEs or AEs) of interest occurring across all cycles regardless of attribution
Time Frame	Up to 112 days (course 4)

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	All Subjects
Arm/Group Description	Patients receive PI3K delta inhibitor TGR-1202 PO QD on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
Measure Participants	13
G 3-4 elevated AST/ALT	0 0%
G 3-4 nausea	15 115.4%
G 3-4 diarrhea	15 115.4%

2. Secondary Outcome

Title	Overall Response Rate (ORR)
Description	ORR is defined as number of patients achieving a best response of complete response or partial response at any disease assessment time point. Response is based on PET/CT (Deauville 3 or less) or CT alone if CR is achieved by PET/CT. Response criteria, modified from the Lugano response criteria. DLBCL is considered FDG avid. Complete response: Complete disappearance of all detectable clinical evidence of disease and definitely disease-related symptoms if present before therapy. Criteria for Partial Response (PR): Regression of measurable disease and no new sites
Time Frame	Up to 4 years

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	All Patients
Arm/Group Description	Patients receive PI3K delta inhibitor TGR-1202 PO QD on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
Measure Participants	13
Complete Response	1 7.7%
Partial Response	3 23.1%

3. Secondary Outcome

Title	Estimated Progression-free Survival (PFS) at 6 Months
Description	PFS is defined as the time between study registration and documented progression or death if no progression was observed.
Time Frame	Time between study registration and documented progression or death if no progression was observed, assessed up to 4 years (6 Month estimate shown)

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	All Patients
Arm/Group Description	Patients receive PI3K delta inhibitor TGR-1202 PO QD on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
Measure Participants	13
Number (95% Confidence Interval) [percentage of participants]	8 61.5%

Adverse Events

Time Frame	Adverse Event reporting is only for TGR 1202 and Ibrutinib "study medications," until 30 days after last administration of study medication. ( approximately 13 months)
Arm/Group Title	All Patients
Arm/Group Description	Patients receive PI3K delta inhibitor TGR-1202 PO QD on days 1-28 and ibrutinib PO QD on days 9-28 of course 1 and days 1-28 of subsequent courses. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.
All Cause Mortality
	All Patients
	Affected / at Risk (%)	# Events
Total	8/13 (61.5%)
Serious Adverse Events
	All Patients
	Affected / at Risk (%)	# Events
Total	6/13 (46.2%)
Blood and lymphatic system disorders
anemia	1/13 (7.7%)	1
Cardiac disorders
atrial fibrillation	1/13 (7.7%)	1
sinus tachycardia	1/13 (7.7%)	1
Gastrointestinal disorders
abdominal pain	1/13 (7.7%)	1
nausea	2/13 (15.4%)	2
vomiting	1/13 (7.7%)	1
General disorders
edema limbs	1/13 (7.7%)	1
fever	1/13 (7.7%)	1
pain	1/13 (7.7%)	1
general disorders, other	1/13 (7.7%)	1
Infections and infestations
Infections and infestations, Other	1/13 (7.7%)	1
Infections and infestations, Other	1/13 (7.7%)	1
enterocolitis infectious	1/13 (7.7%)	1
sepsis	1/13 (7.7%)	1
Metabolism and nutrition disorders
hypercalcemia	2/13 (15.4%)	2
dehydration	2/13 (15.4%)	2
diarrhea	1/13 (7.7%)	1
hyponatremia	1/13 (7.7%)	1
Musculoskeletal and connective tissue disorders
muscle weakness, general	1/13 (7.7%)	1
Psychiatric disorders
confusion	1/13 (7.7%)	1
Respiratory, thoracic and mediastinal disorders
hypoxia	1/13 (7.7%)	1
pleural effusion	2/13 (15.4%)	2
Surgical and medical procedures
Other, infected port	1/13 (7.7%)	1
Other (Not Including Serious) Adverse Events
	All Patients
	Affected / at Risk (%)	# Events
Total	12/13 (92.3%)
Gastrointestinal disorders
nausea	6/13 (46.2%)	8
diarrhea	3/13 (23.1%)	7
abdominal pain	2/13 (15.4%)	3
dysphagia	2/13 (15.4%)	2
vomiting	2/13 (15.4%)	2
General disorders
alkaline phosphatase increased	2/13 (15.4%)	4
Fever	2/13 (15.4%)	4
chills	2/13 (15.4%)	2
Infections and infestations
upper respiratory infection	3/13 (23.1%)	3
Infections and infestations, Other	1/13 (7.7%)	2
Investigations
alanine aminotransferase increased	4/13 (30.8%)	8
Aspartate aminotransferase increased	4/13 (30.8%)	6
platelet count decreased	1/13 (7.7%)	2
Metabolism and nutrition disorders
Other, decreased appetite	2/13 (15.4%)	2
hyperkalemia	1/13 (7.7%)	2
hypokalemia	2/13 (15.4%)	2
Musculoskeletal and connective tissue disorders
Other, left shoulder pain	1/13 (7.7%)	2
Nervous system disorders
headache	2/13 (15.4%)	2
Respiratory, thoracic and mediastinal disorders
cough	3/13 (23.1%)	3
sore throat	2/13 (15.4%)	2
Skin and subcutaneous tissue disorders
Other, skin rash	1/13 (7.7%)	2

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.