A Phase 2 Study of Acalabrutinib, Venetoclax, and Obinutuzumab (AVO) for Initial Therapy of Chronic Lymphocytic Leukemia
Phase: PHASE2
Conditions: Chronic Lymphocytic Leukemia (CLL)
Sponsor: Dana-Farber Cancer Institute

1
NCI Protocol #: N/A
DF/HCC Protocol #: 18-226
Funder #: ESR-CL-804
TITLE:  A Phase 2 Study of Acalabrutinib, Venetoclax, and Obinutuzumab (AVO) for Initial 
Therapy of Chronic Lymphocytic Leukemia
Coordinating Center:
Dana-Farber Cancer Institute
Principal Investigator (PI) and DF/HCC Sponsor:
Matthew S. Davids, MD, MMSc
Dana-Farber Cancer Institute
Matthew_Davids@dfci.harvard.edu
Other Investigators:
Jennifer R. Brown, MD, PhD
Adam Olszewski, MD
Dana-Farber Cancer Institute
Lifespan Cancer Institute
Jennifer_Brown@dfci.harvard.edu
aolszewski@lifespan.org
Jon Arnason, MD
Steve Lo, MD
Beth Israel Deaconess Medical Center 
Stamford Hopsital
Jarnason@bidmc.harvard.edu 
SLo@stamhealth.org
Statistician:
 
Svitlana Tyekucheva, PhD
Responsible Research Nurse:
Victoria Patterson, RN
Dana-Farber Cancer Institute
NCI-Supplied Agents: N/A
Other Agent(s):  Acalabrutinib (commercial stock provided free of charge by manufacturer), 
Venetoclax (investigational), Obinutuzumab (investigational)
IND #: 139022
IND Sponsor: Matthew S. Davids, MD, MMSc
Protocol Version # / Version Date:   Version 5.0 / 18 January 2023

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
2
SYNOPSIS
Study Title:  A Phase 2 Study of Acalabrutinib, Venetoclax, and Obinutuzumab (AVO) for 
Initial Therapy of Chronic Lymphocytic Leukemia 
Study Overview: This is an open-label, phase 2 study of acalabrutinib in combination 
venetoclax and obinutuzumab (AVO) in previously untreated patients with CLL in need of 
therapy. Patients will start on cycle 1, day 1 with one month of acalabrutinib monotherapy. 
Obinutuzumab will be added on cycle 2, day 1 and will administered at standard dosing for six 
monthly cycles, with acalabrutinib continued. During the third cycle of obinutuzumab, 
venetoclax will be added for triplet combination therapy. Venetoclax will be initiated in a ramp-
up, stepwise dosing strategy with frequent monitoring to mitigate the risk of tumor lysis 
syndrome. After completion of obinutuzumab, venetoclax and acalabrutinib combination therapy 
will continue through cycle 15. Efficacy assessments will be performed at baseline and after 
cycles 3, 8, and 15, and will include CT scan, bone marrow (BM) biopsy (after cycles 8 and 15), 
and minimal residual disease (MRD) analysis by flow cytometry. At the conclusion of cycle 15, 
patients who have achieved a complete remission (CR) or complete remission with incomplete 
count recovery (CRi) with MRD-negativity in the peripheral blood and bone marrow will have 
the option to discontinue acalabrutinib and venetoclax and will be monitored for disease 
recurrence with peripheral blood MRD testing by flow cytometry every three cycles. Patients 
who have detectable recurrence in the peripheral blood will restart acalabrutinib and venetoclax. 
If subjects do not achieve an MRD-negative CR/CRi after cycle 15, they will continue 
acalabrutinib and venetoclax through cycle 24, with formal efficacy assessments after cycles 19 
and 24, including CT scan, BM biopsy (after cycle 24 only), and MRD testing. Subjects who 
achieve undetectable MRD in both blood and marrow at this time point will also have the option 
to discontinue therapy and be monitored for recurrence.  Should patients recur, they will have the 
option to resume acalabrutinib and venetoclax at that time. Subjects with detectable MRD at the 
24 cycle mark will continue acalabrutinib and venetoclax indefinitely until progression or 
unacceptable toxicity. 
Primary Objective
The primary objective of the study is to assess the rate of bone marrow MRD-negative complete 
response after 15 cycles of treatment with AVO in CLL patients.
Secondary Objectives
Secondary objectives are to assess the following: 

Safety and tolerability of the AVO combination

Rate of partial response after 15 cycles of therapy, as defined by 2018 IW-CLL criteria

Rate of complete remission (including complete remission with incomplete count 
recovery, CRi) after 15 cycles of therapy

Median progression free survival (PFS), 2-year and 3-year PFS 

Median overall survival (OS), 2-year and 3-year OS

Rates of complete remission with bone marrow MRD negativity at 8 cycles and 24 cycles

Rates of best overall response, best CR/CRi, best peripheral blood and bone marrow 
MRD

Rates of therapy discontinuation after 15 cycles and corresponding reasons for therapy 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
3
discontinuation (e.g. disease progression, achievement of MRD-negative CR, or 
intolerability) 

Time to MRD-positive disease recurrence, in patients who have achieved MRD 
negativity after 8, 15, or 24 cycles

Time to clinical progression as defined by IWCLL criteria

Association between established CLL prognostic factors (including FISH cytogenetics 
and IGHV mutation status) and rates of MRD-negativity, CR, PR, recurrence, PFS, and 
OS

Rate of peripheral blood and bone marrow MRD-negativity at 8, 15, and 24 cycles

Correlation between MRD-negativity as measured in the blood with MRD-negativity as 
measured in the bone marrow after 8, 15, and 24 cycles of treatment

Rate of infusion reactions with obinutuzumab

Rate of clinical and laboratory tumor lysis syndrome with venetoclax administration, as 
defined by the Cairo-Bishop Classification system

To perform the above efficacy and safety analyses on cohort 1, cohort 2 plus the patients 
with TP53 aberrant disease in cohort 1, and in the entire group of cohort 1 plus cohort 2
Exploratory Objectives
Exploratory objectives are to assess the following:

Association between novel CLL prognostic factors (including BH3 profiling and somatic 
mutations such as SF3B1, TP53, NOTCH1, and other mutations in the BCR/NFκB 
pathway) and rates of MRD-negativity, CR, PR, PFS, and OS

The development and kinetics of BTK, PLCG2, CARD11, and BCL2 acquired somatic 
resistance mutations

MRD measurements by four-color flow cytometry as compared to those of the Adaptive 
ClonoSEQ sequencing technology at the primary response (15 cycle) endpoint 
Schedule of Administration
Acalabrutinib will be administered orally twice daily during each 28-day cycle. Obintuzumab 
will be given intravenously at the standard dosing of six monthly cycles (with loading doses 
administered weekly during the first month).  Venetoclax will be given orally daily with ramp-up 
stepwise dosing during the first month of therapy until the standard dose is achieved. After the 
six cycles of obinutuzumab are completed, venetoclax and acalabrutinib will continue as 
combination therapy until cycles 15, 24, or indefinitely (as outlined in Study Overview, above).
Definition of Unexpected Toxicities
Unexpected toxicities would include the following events that occur during AVO treatment, 
unless they are clearly due to extraneous causes: any grade 3 or higher clinically significant 
nonhematologic toxicities related to study treatment, grade 4 or higher infusion reaction, grade 4 
or higher tumor lysis syndrome, grade 4 or higher infection, and grade 4 or higher neutropenia. 
Grade 3 or 4 drug-related toxicities occurring after the first cycle of treatment will be discussed 
with the Principal Investigator and will be considered in decisions regarding the recommended 
dose for future studies. The IWCLL Grading Scale for Hematologic Toxicity in CLL Studies will 
be used to grade hematologic toxicities and the National Cancer Institute Common Terminology 
Criteria for Adverse Events (NCI-CTCAE) Version 5.0 will be used to grade non-hematologic 
toxicities during the trial unless otherwise specified.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
4
Study Drug
Acalabrutinib is administered orally twice daily as a tablet formulation. The acalabrutinib drug 
product is supplied as 100mg tablets. Obinutuzumab is administered intravenously.  Venetoclax 
is administered orally daily as a tablet formulation, with tablet strengths varying based on dosing.
Key Eligibility Criteria (for complete eligibility criteria, see section 3.1)
Inclusion Criteria

Subjects must have CLL, SLL, or B-prolymphocytic leukemia (B-PLL)

Subjects must have TP53-aberrant disease, defined as the detection of del(17p) and/or the 
presence of a TP53 mutation

Participants must have measurable disease (lymphocytosis > 5,000 / µl, or palpable or CT 
measurable lymphadenopathy ≥ 1.5 cm, or bone marrow involvement  ≥30%).

Subjects must not have received any prior systemic therapy for CLL or SLL due to 
meeting IWCLL 2018 guidelines, and must currently have an indication for treatment as 
defined by IWCLL 2018 Guidelines below, or must not have received therapy for B-PLL 
and must currently have an indication for treatment:
 Massive or progressive or symptomatic splenomegaly; OR
 Massive lymph nodes, nodal clusters, or progressive lymphadenopathy; OR
 Significant fatigue (i.e. ECOG PS 2 or worse; cannot work or unable to perform 
usual activities); OR
 Fever ≥ 100.5°F for 2 or more weeks without evidence of infection; OR
 Night sweats for ≥ 1 month without evidence of infection; OR
 Presence of weight loss ≥ 10% over the preceding 6 months; OR
 Progressive lymphocytosis with an increase of ≥ 50% over a 2-month period or 
lymphocyte doubling time of less than 6 months; OR
 Evidence of progressive marrow failure as manifested by the development of or 
worsening of anemia and/or thrombocytopenia; OR
 Autoimmune anemia and/or thrombocytopenia that is poorly responsive to 
corticosteroids and another standard therapy such as rituximab
 Symptomatic or functional extranodal involvement (e.g. skin, kidney, lung, spine)

Age greater than or equal to 18 years. 

ECOG performance status ≤2 (see Appendix A)

Participants must have adequate organ and marrow function as defined below:
 total bilirubin ≤1.5 times upper limit of normal
 AST and ALT ≤ 2.5 times the upper limit of normal
 creatinine clearance (CrCl) ≥ 50 mL/min using 24-hour urine collection for 
creatinine clearance or calculated CrCl OR calculated glomerular filtration rate (GFR) 
≥ 50 mL/min/1.73m2 using the CKD-EPI equation
 PT/INR ≤2 times the upper limit of normal and PTT ≤2 times the upper limit of 
normal 
 Absolute neutrophil count ≥750 cells/mm3 (0.75 x 109/L) or ≥500 cells/mm3 in 
subjects with documented bone marrow involvement
 Platelet count without transfusional support must be ≥50,000 cells/mm3 or ≥ 30,000 
cells/mm3 in subjects with documented bone marrow involvement

Women of child-bearing potential must agree to remain abstinent or use highly effective 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
5
contraception during the treatment period and for at least 2 days after the last dose of 
acalabrutinib, 30 days after the last dose of venetoclax, or 18 months after the last dose of 
obinutuzumab, whichever is longer. Men with female sexual partners of childbearing 
potential should agree to remain abstinent or use contraceptive measures which include a 
condom plus an additional contraceptive for at least 30 days after the last dose of 
venetoclax or 6 months after the last dose of obinutuzumab, whichever is longer. 

Ability to understand and the willingness to sign a written informed consent document.
Exclusion Criteria

Participants who have a history of other malignancies, with certain exceptions including 
early stage malignancies treated with curative intent or low risk neoplasms managed with 
active surveillance

Participants who are receiving any other investigational agents

History of severe allergic reactions attributed to compounds of similar chemical or 
biologic composition to obinutuzumab, venetoclax, or acalabrutinib. Patients with 
reactions to other CD20 monoclonal antibodies (e.g. rituximab, ofatumumab) are not 
excluded. 

Unable to receive prophylactic treatment for pneumocystis, herpes simplex virus (HSV), 
and herpes zoster (VZV) at start of treatment

Known or suspected Richter’s transformation or known CNS involvement

Concurrent systemic immunosuppressant therapy (e.g., cyclosporine A, tacrolimus, etc., 
within 28 days of the first dose of study drug or chronic administration of >20 mg/day of 
prednisone within 7 days of the first dose)

Vaccinated with live, attenuated vaccines within 4 weeks of first dose of study drug.

Ongoing or recent infection requiring intravenous antimicrobials at time of screening

Known bleeding disorders (e.g. von Willebrand’s disease) or hemophilia.

Presence of a gastrointestinal ulcer diagnosed by endoscopy within 3 months before 
screening.

History of stroke or intracranial hemorrhage within 6 months prior to enrollment.

Major surgery within 4 weeks of first dose of study drug. If a subject had major surgery 
greater than 4 weeks prior, they must have recovered adequately from any toxicity and/or 
complications from the intervention before the first dose of study drug.

Currently active, clinically significant cardiovascular disease, such as uncontrolled 
arrhythmia or Class 3 or 4 congestive heart failure as defined by the New York Heart 
Association Functional Classification; or a history of myocardial infarction, unstable 
angina, or acute coronary syndrome within 6 months prior to randomization.

Baseline QTcF >480 ms.

Patients who require warfarin or other vitamin K antagonists for anticoagulation (other 
anticoagulants are allowed).

Patients who require treatment with proton pump inhibitors (eg, omeprazole, 
esomeprazole, lansoprazole, dexlansoprazole, rabeprazole, or pantoprazole).  Subjects 
receiving proton pump inhibitors who switch to H2-receptor antagonists or antacids are 
eligible for enrollment to this study.

Patients who require treatment with strong CYP3A inhibitors or inducers

Patients who require P-gp inhibitors or narrow therapeutic index P-gp substrates

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
6

Unable to swallow tablets or malabsorption syndrome, disease significantly affecting 
gastrointestinal function, or resection of the stomach or small bowel if thought by the 
investigator to compromise systemic absorption, active, symptomatic inflammatory 
bowel disease or ulcerative colitis, or partial or complete bowel obstruction.

Lactating or pregnant. 

Patients with human immunodeficiency virus (HIV), human T-cell leukemia virus 
(HTLV), active hepatitis C virus (HCV) or active hepatitis B virus (HBV) infection with 
detectable HBV DNA

Unwilling or unable to participate in all required study evaluations and procedures. 

Unable to understand the purpose and risks of the study and to provide a signed and dated 
informed consent form (ICF) and authorization to use protected health information (in 
accordance with national and local subject privacy regulations)

Significant co-morbid condition or disease which in the judgment of the Principal 
Investigator would place the patient at undue risk or interfere with the 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, 
compromise the subject’s safety, or put the study outcomes at undue risk.
Statistical Methodology
Primary Endpoint:  Rate of bone marrow minimal residual disease (MRD) negative complete 
response (CR) after 15 cycles of AVO therapy.

Secondary Endpoints: The analysis of secondary endpoints will be primarily descriptive, 
including rate of PR after 15 cycles of therapy, rate of CR/CRi after 15 cycles of therapy, 
progression free survival (including 2-year and 3-year landmark rate), overall survival 
(including 2-year and 3-year landmark rate), rate of MRD negativity in the bone marrow 
at 8 and 24 cycles, rate of peripheral blood MRD-negativity at 8, 15, and 24 cycles, 
correlation between MRD-negativity in the peripheral blood and bone marrow, time to 
MRD-positive disease recurrence, time to clinical disease progression, rate of infusion 
related reactions, and rate of tumor lysis syndrome. The Kaplan Meier method will be 
used to estimate the median progression-free and overall survival.  Association between 
clinical response and established CLL prognostic factors (ZAP70, FISH cytogenetics, 
IGHV mutation status, TP53 mutation status) will be tested using Fisher’s exact test.  A 
similar descriptive analysis will be performed for laboratory correlative studies of BH3 
profiling and genomic markers such as SF3B1, NOTCH1, and BCR/NFKB pathway 
somatic mutations.  If feasible, association between clinical response and laboratory 
endpoints will be explored.  The secondary endpoints on this study will be evaluated on 
cohort 1, cohort 2 plus the patients with TP53 aberrant disease in cohort 1, and in the 
entire group of cohort 1 plus cohort 2
Study Design/Sample Size: 
This is a one-stage study to determine the MRD-negative CR/CRi rate in the bone marrow after 
15 cycles of AVO combination therapy. In a previous study of venetoclax plus rituximab in the 
relapsed/refractory population, the CR/CRi rate was 51%, and 80% of these responses were 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
7
bone-marrow MRD-negative, for an MRD-negative CR/CRi rate of 41% (Seymour et al., 2017). 
Furthermore, 21 out of 25 CRs in this study occurred after 18 months of therapy, thus we will 
assume that ~80% of all marrow MRD-negative CRs will have occurred after 15 months of 
therapy here, leading to an expected marrow MRD-negative CR/CRi rate of 33%. Of note, this 
study was done in a relapsed/refractory population. Given that the depth of response is likely to 
be greater in the frontline setting, we are using an MRD-negative CR/CRi rate of 40% as the null 
hypothesis. With the addition of acalabrutinib, we hypothesize that the MRD-negative CR rate 
will be 60% or higher (alternative hypothesis). Initially, we planned to enroll 37 patients, and 
assuming approximately 1 screening failure this meant that 36 patients would be evaluable for 
the primary endpoint. This cohort has now completed enrollment and will be referred to as 
cohort 1. We have now expand the study to include a second cohort of 35 patients with high-risk 
disease (cohort 2), defined as 17p deletion and/or TP53 mutation. In cohort 2, we have 80% 
power and one-sided type I error of 0.07 for an exact one-sample binomial test comparing an 
expected 55% response rate to the assumed 35% response rate for standard-of-care treatment in 
this high risk group.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
8
SCHEMA
Note:  Patients will have two opportunities to electively discontinue therapy: (1) if they reach 
MRD-negative CR/CRi after 15 cycles, or (2) if they reach undetectable MRD after 24 months of 
therapy.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
9
TABLE OF CONTENTS
1.
OBJECTIVES....................................................................................................................13
1.1
Study Design..........................................................................................................13
1.2
Primary Objectives.................................................................................................13
1.3
Secondary Objectives.............................................................................................13
1.4
Exploratory Objectives ..........................................................................................14
2.
BACKGROUND ...............................................................................................................15
2.1
Chronic Lymphocytic Leukemia Therapy.............................................................15
2.2
IND Agents............................................................................................................18
2.3
Rationale ................................................................................................................29
2.4
Rationale for Study Expansion ..............................................................................33
2.5
Rationale for Modifying Treatment Discontinuation Parameters at Cycle 
24............................................................................................................................34
2.6
Correlative Studies Background ............................................................................35
3.
PARTICIPANT SELECTION...........................................................................................37
3.1
Eligibility Criteria..................................................................................................37
3.2
Inclusion of Women and Minorities ......................................................................41
4.
REGISTRATION PROCEDURES ...................................................................................41
4.1
Informed Consent...................................................................................................41
4.2
Medical History .....................................................................................................41
4.3
Confirmation of Eligibility ....................................................................................41
4.4
General Guidelines for DF/HCC Institutions ........................................................41
4.5
Registration Process for DF/HCC Institutions.......................................................42
4.6
General Guidelines for Other Investigative Sites ..................................................42
4.7
Registration Process for Other Investigative Sites.................................................42
5.
TREATMENT PLAN........................................................................................................43
5.1
Treatment Regimen................................................................................................43
5.2
Pre-Treatment Criteria ...........................................................................................46
5.3
Agent Administration.............................................................................................46
5.4
General Concomitant Medication and Supportive Care Guidelines......................52
5.5
Criteria for Taking a Participant Off Protocol Therapy.........................................55
5.6
Duration of Follow Up...........................................................................................56
5.7
Criteria for Taking a Participant Off Study ...........................................................56
6.
DOSING DELAYS / DOSE MODIFICATIONS .............................................................57
6.1
Venetoclax .............................................................................................................57
6.2
Obinutuzumab........................................................................................................60
6.3
Acalabrutinib..........................................................................................................61
6.4
Integrated Toxicity Management Guidelines When the Causative Agent is 
Unclear...................................................................................................................62

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
10
7.
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .............................63
7.1
Expected Toxicities................................................................................................63
7.2
Safety Parameters and Definitions.........................................................................67
7.3
Methods and Timing for Assessing and Recording Safety Variables ...................69
7.4
Adverse Event Reporting.......................................................................................72
7.5
Study Closeout.......................................................................................................76
7.6
Safety Queries........................................................................................................76
7.7
Safety Crisis Management.....................................................................................77
7.8
Adverse Event Characteristics...............................................................................77
7.9
Expedited Adverse Event Reporting......................................................................77
7.10
Expedited Reporting to the Food and Drug Administration (FDA) ......................78
7.11
Expedited Reporting to Hospital Risk Management .............................................78
7.12
Routine Adverse Event Reporting .........................................................................78
8.
PHARMACEUTICAL INFORMATION..........................................................................79
8.1 
Acalabrutinib..........................................................................................................79
8.2
Venetoclax .............................................................................................................81
8.3
Obinutuzumab........................................................................................................83
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................86
9.1 
Laboratory Correlative Studies..............................................................................86
9.2 
Correlative Lab Sample Collection and Shipping Instructions..............................89
10.
STUDY CALENDAR .......................................................................................................91
11.
MEASUREMENT OF EFFECT .......................................................................................98
11.1
Definitions..............................................................................................................98
11.2
Methods for Evaluation of Measurable Disease....................................................98
11.3
Response Criteria...................................................................................................98
11.4
Response Review...................................................................................................98
12.
DATA REPORTING / REGULATORY REQUIREMENTS...........................................99
12.1
Data Reporting.......................................................................................................99
12.2
Data Safety Monitoring..........................................................................................99
12.3
Multicenter Guidelines...........................................................................................99
12.4
Collaborative Agreements Language...................................................................100
13.
STATISTICAL CONSIDERATIONS.............................................................................101
13.1
Study Design/Endpoints ......................................................................................101
13.2
Sample Size, Accrual Rate and Study Duration ..................................................101
13.3
Stratification Factors............................................................................................102
13.4
Interim Monitoring Plan ......................................................................................102
13.5
Analysis of Primary Endpoints............................................................................103
13.6
Analysis of Secondary Endpoints........................................................................103
13.7
Reporting and Exclusions ....................................................................................103
14.
PUBLICATION PLAN ...................................................................................................104

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
11
15.
REFERENCES ................................................................................................................105
APPENDIX A: PERFORMANCE STATUS CRITERIA...........................................................109
APPENDIX B: CLL RESPONSE DEFINITION (HALLEK et al. 2018) ..................................110
APPENDIX C: IW-CLL Grading SCALE For HEMATOLOGIC TOXICITY IN CLL STUDIES
..................................................................................................................114
APPENDIX D: CAIRO-BISHOP DEFINITIONS OF LABORATORY AND CLINICAL 
TUMOR LYSIS SYNDROME (TLS).............................................................................115
APPENDIX E: RECOMMENDATIONS FOR INITIAL MANAGEMENT OF ELECTROLYTE 
ABNORMALITIES AND PREVENTION OF TUMOR LYSIS SYNDROME............116
APPENDIX F: SAMPLE LIST OF EXCLUDED AND CAUTIONARY MEDICATIONS......120
APPENDIX G: ACALABRUTINIB DRUG DIARY .................................................................121
APPENDIX H: VENETOCLAX DRUG DIARY.......................................................................125
APPENDIX I: SAMPLE REQUISITION FORM.......................................................................129
APPENDIX J: DANA-FARBER/HARVARD CANCER CARE DATA SAFETY 
MONITORING PLAN ....................................................................................................130
INTRODUCTION .......................................................................................................................130
Purpose.............................................................................................................................130
Multi-Center Data and Safety Monitoring Plan Definitions............................................130
GENERAL ROLES AND RESPONSIBILITIES .......................................................................131
DF/HCC Sponsor.............................................................................................................131
Coordinating Center.........................................................................................................132
Participating Institution....................................................................................................133
DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS .......................................134
Protocol Distribution........................................................................................................134
Protocol Revisions and Closures .....................................................................................134
Informed Consent Requirements .....................................................................................134
IRB Documentation .........................................................................................................135
IRB Re-Approval.............................................................................................................135
Participant Confidentiality and Authorization Statement................................................135
DF/HCC Multi-Center Protocol Registration Policy.......................................................136
DF/HCC Protocol Case Number......................................................................................137
Safety Assessments and Toxicity Monitoring .................................................................138
Data Management............................................................................................................139
REQUISITIONING INVESTIGATIONAL DRUG....................................................................139

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
12
MONITORING: QUALITY CONTROL....................................................................................140
Ongoing Monitoring of Protocol Compliance.................................................................140
Monitoring Reports..........................................................................................................140
Accrual Monitoring..........................................................................................................140
AUDITING: QUALITY ASSURANCE .....................................................................................141
DF/HCC Internal Audits..................................................................................................141
Audit Notifications...........................................................................................................141
Audit Reports...................................................................................................................141
Participating Institution Performance ..............................................................................141

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
13
1. OBJECTIVES
1.1
Study Design
This is a Phase 2, open label, single arm, investigator-initiated study. Patients with treatment-
naïve chronic lymphocytic leukemia (CLL) in need of therapy will begin with one 28-day cycle 
of acalabrutinib. Obinutuzumab is then given in combination with acalabrutinib during cycles 2 
and 3 to help reduce the disease burden in preparation for starting venetoclax. After these initial 
3 cycles, the first response assessment with a CT scan and bone marrow biopsy will occur.  
Venetoclax will then be started at cycle 4, with a stepwise dose escalation over 4 weeks to 
minimize the risk of TLS. All three drugs will be given together during cycles 4-7, and another 
response assessment will occur at the end of cycle 7, this time including a CT scan,bone marrow 
biopsy, and flow cytometric MRD testing in the bone marrow and peripheral blood with a 
sensitivity of at least 10-4. Acalabrutinib and venetoclax will be continued for cycles 8-15. After 
15 cycles of therapy, the primary re-staging evaluation will occur, including a CT scan, bone 
marrow assessment, and flow cytometric MRD testing in the bone marrow and peripheral blood. 
The primary objective of this study is to assess the rate of complete response (CR) with bone 
marrow MRD negativity after 15 cycles of treatment.
At the end of 15 cycles, patients who achieve a CR with peripheral blood and bone marrow 
MRD-negativity will have the option to stop all therapy and those who do will be monitored by 
serial peripheral blood MRD testing for disease recurrence. If they become MRD positive again, 
they can resume acalabrutinib and venetoclax, continuing treatment until disease progression or 
unacceptable toxicity. Patients who are MRD-positive or in a partial remission (PR) at the end of 
the 15 cycles will continue acalabrutinib and venetoclax until the completion of 24 cycles of 
therapy. Another response evaluation will occur at that time, and patients who have undetectable 
MRD in the blood and marrow (regardless of iwCLL response status) have the option to 
discontinue therapy. Those who remain MRD-positive will continue acalabrutinib and 
venetoclax treatment until time of progression or unacceptable toxicity.
1.2
Primary Objectives
The primary objective of the study is to assess the rate of complete response with bone marrow 
MRD-negativity, as determined by four color flow cytometry, after 15 cycles of treatment with 
AVO in previously untreated CLL patients.
1.3
Secondary Objectives
Secondary objectives are to assess the following: 

Safety and tolerability of the AVO combination

Rate of partial response after 15 cycles of therapy, as defined by 2018 IW-CLL criteria

Rate of complete remission (including complete remission with incomplete count 
recovery, CRi) after 15 cycles of therapy

Median progression free survival (PFS), 2-year and 3-year PFS 

Median overall survival (OS), 2-year and 3-year OS

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
14

Rates of complete remission with bone marrow MRD negativity at 8 cycles and 24 cycles

Rates of best overall response, best CR/CRi, best peripheral blood and bone marrow 
MRD

Rates of therapy discontinuation after 15 cycles and corresponding reasons for therapy 
discontinuation (e.g. disease progression, achievement of MRD-negative CR, or 
intolerability) 

Time to MRD-positive disease recurrence, in patients who have achieved MRD 
negativity after 8, 15, or 24 cycles

Time to clinical progression as defined by IWCLL criteria

Association between established CLL prognostic factors (including FISH cytogenetics 
and IGHV mutation status) and rates of MRD-negativity, CR, PR, recurrence, PFS, and 
OS

Rate of peripheral blood and bone marrow MRD-negativity at 8, 15, and 24 cycles

Rate of infusion reactions with obinutuzumab

Rate of clinical and laboratory tumor lysis syndrome, as defined by the Cairo-Bishop 
classification system

Correlation between MRD-negativity as measured in the blood with MRD-negativity as 
measured in the bone marrow after 8, 15, and 24 cycles of treatment

To perform the above efficacy and safety analyses on cohort 1, cohort 2 plus the patients 
with TP53 aberrant disease in cohort 1, and in the entire group of cohort 1 plus cohort 2
1.4
Exploratory Objectives
Exploratory objectives are to assess the following:

Association between novel CLL prognostic factors (including BH3 profiling and somatic 
mutations such as SF3B1, TP53, NOTCH1, and other mutations in the BCR/NFκB 
pathway) and rates of MRD-negativity, CR, PR, PFS, and OS

The development and kinetics of BTK, PLCG2, CARD11, and BCL2 acquired somatic 
resistance mutations

MRD measurements by four-color flow cytometry as compared to those of the Adaptive 
ClonoSEQ sequencing technology at the primary response (15 cycle) endpoint 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
15
2. BACKGROUND
2.1
Chronic Lymphocytic Leukemia Therapy 
Overview of CLL
Chronic lymphocytic leukemia is a neoplastic disease characterized by the accumulation of 
monoclonal lymphocytes in the blood, bone marrow, and lymphoid tissues. It is the most 
common leukemia of adults. In the U.S. alone, on a yearly basis, about 20,000 new cases are 
diagnosed, with approximately 4,500 patients dying from the disease (Siegel, Miller, & Jemal, 
2017). The natural history of CLL is heterogeneous, with a subset of patients having very 
indolent disease that may never require therapy, while others have steadily progressive or 
aggressive disease. Indications for the treatment of CLL are defined by consensus guidelines and 
include progressive cytopenias, compromised organ function due to lymphadenopathy, massive 
lymphadenopathy (e.g. >10cm), and constitutional symptoms due to the disease. 
Current Approach to CLL Therapy
Current standard treatment options for CLL generally fall into one of two categories: 
combination chemoimmunotherapy or targeted therapy with novel agents. Like other low grade 
lymphomas, CLL has historically been thought of as an incurable disease for which treatment is 
palliative and not curative. Thus, as noted above, therapy is initiated only if the disease is 
causing symptoms or organ dysfunction, and outside of those instances, it can be monitored with 
active surveillance. 
With regard to standard chemoimmunotherapy, over the decades, the paradigm has shifted from 
single agent to combination therapy. This disease was initially treated with alkylating agents like 
chlorambucil, and increased complete remission rates and progression-free survival (PFS) were 
later observed with the nucleoside analogue, fludarabine (Rai et al., 2000). Fludarabine-based 
combinations were then developed, demonstrating superior complete remission rates and PFS 
with the addition of either cyclophosphamide and/or rituximab to fludarabine alone (Byrd et al., 
2005; S. M. O'Brien et al., 2001). More recently, an overall survival benefit has been 
demonstrated by the inclusion of rituximab with fludarabine and cyclophosphamide (FCR) over 
fludarabine and cyclophosphamide alone (FC) in patients with previously untreated CLL (Hallek 
et al., 2010). Furthermore, in a subset of patients with IGHV-mutated disease, combination 
chemoimmunotherapy with FCR can provide very longterm progression free survival, with 
53.9% of IGHV-mutated patients without progression after a median follow-up of 12.8 years in a 
recent study (Thompson et al., 2016). Nevertheless, despite the efficacy of combination 
chemoimmunotherapy, there remain significant drawbacks to this approach. The standard FCR 
regimen commonly causes severe neutropenia and an increased risk of infections, and many 
older patients are not candidates for such a therapy. Additionally, there may be long-term 
complications of chemoimmunotherapy, including prolonged immune dysfunction and resultant 
late infections, pancytopenia, and therapy-related MDS/AML. 
Given the possibility of long-term disease-free survival, chemoimmunotherapy remains a 
reasonable frontline treatment in fit patients without high-risk genetic features. However, for the 
majority of CLL patients, who fall outside of these criteria, the recent discovery and FDA 
approval of targeted therapies have revolutionized the approach to treatment. Specifically, since 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
16
2013, obinutuzumab, ibrutinib, idelalisib, and venetoclax have all been approved for the 
treatment of CLL in various settings, with additional next-generation agents (e.g. acalabrutinib) 
likely to be approved in the coming years. More detailed efficacy data on acalabrutinib and 
venetoclax are reviewed below, but in summary, experience with these agents has led to the 
following conclusions:

Single agent use of targeted therapies (or their use in combination with anti-CD20 
monoclonal antibodies) leads to overall response rates that are comparable to those seen 
with chemoimmunotherapy for most patients, and superior to those seen in patients with 
high-risk (e.g. 17p-deleted) disease.

Targeted therapies each have their own spectrum of unique toxicities, but are generally 
well-tolerated and can be safely given to most older patients with other medical 
comorbidities.

Single agent use of targeted therapies generally leads to partial responses rather than 
complete responses with an MRD-negative state.  Given the low rate of MRD-negativity 
and the correlation between an MRD-negative state and long-term disease-free survival at 
least with chemoimmunotherapy (Kovacs et al., 2016), the current treatment paradigm is 
to continue a novel agent indefinitely until disease progression.
Thus, each category of therapy has its own particular benefits and limitations. By investigating 
time-limited therapy of a combination of targeted agents, this trial hopes to address some of the 
limitations of current treatment options (reviewed further in section 2.3).
Targeting Bruton Tyrosine Kinase in CLL
The B cell receptor (BCR) is a transmembrane protein located on the outer surface of B cells. It 
consists of an antibody, including the antigen recognition site, as well as a signal transduction 
moiety, CD79. Ultimately these two components work to transduce signals across the membrane 
when a cognate antigen is bound. In addition to its central role in the immune response, it is now 
clear that signaling through the B cell receptor pathway is important throughout the life of a B-
cell, and in general promotes proliferation and survival. Furthermore, although not activated by 
somatic mutation, the BCR pathway is constitutively active in CLL and in fact upregulation of 
the BCR pathway is thought to be a hallmark of the pathophysiology underlying the disease 
(reviewed in (M. S. Davids & Brown, 2012)). 
A key protein in the BCR pathway is Bruton Tyrosine Kinase (BTK).  The role of BTK in BCR 
signal transduction is demonstrated by the human genetic immunodeficiency disease X-linked 
agammaglobulinemia and a murine X-linked immunodeficiency disease, both caused by a 
mutation in the BTK gene. These genetic diseases are characterized by reduced BCR signaling 
and a failure to generate mature B-cells.  The BTK protein is expressed in most hematopoietic 
cells with the exception of T-cells and natural killer cells, but the selective effect of BTK 
mutations suggests that its primary functional role is in antigen receptor signaling in B-cells 
(Satterthwaite & Witte, 2000).  In vitro inhibition of BTK results in abrogation of survival 
signaling downstream of the BCR, a decrease in pro-survival cytokines, and modest induction of 
CLL cell apoptosis (Herman et al., 2011).  Moreover, inhibition of BTK in CLL cells in vitro 
with siRNA promotes apoptosis, and BTK inhibition in the TCL1 mouse model of CLL 
significantly delays the development of CLL, suggesting that BTK is a critical kinase for CLL 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
17
development and expansion (Woyach et al., 2014). 
These preclinical data supporting BTK as an important target in CLL have been subsequently 
translated into the clinic with practice-changing results seen with the BTK inhibitor ibrutinib. A 
brief summary of some of the key results is as follows. In the randomized, double-blind phase III 
RESONATE study, ibrutinib monotherapy demonstrated both a PFS and OS benefit over the 
single agent therapy with the CD20 monoclonal antibody ofatumumab in relapsed/refractory 
CLL (Byrd et al., 2014). The complete response rate to ibrutinib monotherapy in this study was 
only 9% after 44 months of follow-up (Montillo et al., 2017). Ibrutinib has also shown efficacy 
in a phase II single arm study limited to patients with previously treated 17p-deleted disease, 
with an impressive ORR of 83% in this difficult-to-treat population (S. O'Brien et al., 2016). 
Finally, ibrutinib has demonstrated efficacy in the front-line setting. Compared to chlorambucil, 
first-line ibrutinib monotherapy demonstrated a significantly higher ORR (86% vs. 35%), longer 
PFS (not reached vs. 18.9 months), and longer OS (estimated survival at 24 months of 98% 
versus 85%) in patients over the age of 65, although again only 4% of patients demonstrated a 
complete response (Burger et al., 2015).
Despite ibrutinib’s efficacy, the drug does have limitations. Resistance mutations in BTK are 
found in up to 85% of patients who relapse while on the drug (Woyach, Ruppert, et al., 2017). 
Ibrutinib use is associated with cardiac arrhythmias. There is a 5-6% incidence of atrial 
fibrillation after 18 months on therapy (Byrd et al., 2015), and ventricular arrhythmias and 
sudden cardiac death have also been reported (Lampson et al., 2017). Bruising and bleeding, 
including life-threatening intracranial bleeding, have been reported with ibrutinib (Burger et al., 
2015; Byrd et al., 2014; Byrd et al., 2015). Both the cardiac arrhythmias and bleeding may be 
due to off-target inhibition of other kinases, as ibrutinib inhibits 19 other kinases with an IC50 of 
<100nM (Honigberg et al., 2010). Thus, more selective drugs such as the next-generation BTK 
inhibitor acalabrutinib may be safer while still retaining efficacy. Additionally, novel approaches 
to the use of BTK inhibitors, such as time-limited therapy, may reduce the cumulative toxicity of 
these agents. 
Targeting the BCL-2 Pathway in CLL
Proteins in the BCL-2 family reside on the outer surface of the mitochondrial membrane and are 
responsible for regulating the process of mitochondrial outer membrane permeabilization 
(MOMP). Anti-apoptotic proteins in this family, including BCL-2, MCL-1, BCL-XL, BCL-w 
and others, block the pro-death signaling cascade and thus promote cellular survival. Targeting 
this signaling cascade leads to tumor cell apoptosis. This is particularly true for CLL, as CLL 
cells are generally highly primed for apoptosis and are dependent on BCL-2 for survival (Del 
Gaizo Moore et al., 2007). Supporting this finding, BCL-2 protein expression levels are typically 
higher in CLL cells than in peripheral blood mononuclear cells. Despite this dependence on 
BCL-2 for survival, genetic mutations or translocations of BCL-2 family members have not been 
identified in CLL. This mirrors the functional dependence of CLL cells on the BCR signaling 
pathway, where activating mutations of key proteins such as BTK are also not present.
These preclinical data supporting BCL-2 as an important target in CLL have translated in the 
clinic with the oral, selective BCL-2 inhibitor venetoclax. As a single agent used for the 
treatment of relapsed/refractory CLL, it induces a response in 80% of patients, including a 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
18
complete response 20% (Roberts et al., 2016). When given in combination with rituximab in a 
phase Ib trial in the setting of relapsed/refractory disease, the complete response rate increased to 
51% (Seymour et al., 2017). Notable adverse events with venetoclax include tumor lysis 
syndrome, neutropenia, and gastrointestinal symptoms. Tumor lysis syndrome at the time of 
treatment initiation was reported in early experience with the drug; this can be avoided with a 
careful stepwise dose escalation of venetoclax when beginning therapy. Additionally, it is 
hypothesized that tumor debulking prior to venetoclax administration may further decrease the 
incidence of tumor lysis syndrome. Venetoclax causes a grade ≥3 neutropenia in about 35-45% 
of patients (Roberts et al., 2016; Seymour et al., 2017), presumably due to on-target BCL-2 
inhibition in neutrophil precursors. Gastrointestinal side effects such as nausea, vomiting, 
constipation, and diarrhea impact approximately half of all patients receiving the drug and are 
typically mild. Shortening the duration of exposure to venetoclax would presumably lessen the 
incidence of side effects such as neutropenia and gastrointestinal symptoms. Thus, these 
toxicities make time-limited therapy with venetoclax, such as that explored in this trial, an 
attractive goal.
Targeting CD20 in CLL
CD20 is a cell surface protein on B cells. The first monoclonal anti-CD20 antibody to be utilized 
for the treatment of CLL was rituximab, a type 1 chimeric antibody.  The addition of rituximab 
to chemotherapy increased the response rate, progression free, and overall survival in a 
randomized, phase III study, the German CLL 8 study (Hallek et al., 2010).  Recently, the 
combination of ibrutinib with rituximab was found to be safe and well-tolerated (Burger et al., 
2014). In 2009, a second anti-CD20 antibody, ofatumumab, was FDA-approved for the treatment 
of relapsed/refractory CLL.  As detailed in section 2.2.2, obinutuzumab is a type II, 
glycoengineered, fully humanized anti-CD20 monoclonal antibody with the ability to induce 
potent antibody dependent cellular cytotoxicity as well as directly inducing CLL cell death.  
Obinutuzumab was FDA approved in combination with chlorambucil for the initial therapy of 
CLL in 2014 (Goede et al., 2014) and was FDA approved in a fixed-duration combination with 
venetoclax for the initial therapy of CLL in 2019 (K. Fischer et al., 2019).
2.2
IND Agents
Acalabrutinib
2.2.1.1
Structure of Acalabrutinib and Preclinical Comparison to Ibrutinib
Acalabrutinib (ACP-196) is an imidazopyrazine analogue specifically designed to be a more 
potent and selective inhibitor of BTK to avoid off-target side effects seen with ibrutinib. 
Acalabrutinib binds covalently to cysteine 481 of BTK. Nonclinical studies with acalabrutinib 
indicate the following improvements over ibrutinib:

Ibrutinib is a potent covalent inhibitor of EGFR (EC50 = 50-70nM). Acalabrutinib does 
not inhibit EGFR even at the highest concentration tested (10µM) (Byrd et al., 2016; 
Covey et al., 2015). The inhibition of EGFR may be the cause of some ibrutinib-related 
adverse events including diarrhea and rash.

At physiologic concentrations, ibrutinib – but not acalabrutinib – reduced NK cell-

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
19
mediated lysis of CLL tumor cells and significantly inhibited rituximab-induced NK cell 
cytokine secretion. Ibrutinib’s inhibition of antibody-dependent cell-mediated 
cytotoxicity is probably due to effects on ITK kinase, which acalabrutinib does not target. 
Thus, these results suggest that acalabrutinib may be a better agent than ibrutinib to use in 
combination with ADCC-dependent antibodies.

Ibrutinib is associated with an increased risk of bleeding and inhibits thrombus formation 
in a murine model. Acalabrutinib does not have any significant effect on thrombus 
formation in the preclinical setting (Wu, Zhang, & Liu, 2016).
Thus, the preclinical results of acalabrutinib studies suggest that the drug may have an improved 
therapeutic window relative to ibrutinib; it may also be more readily combined with other
agents (particularly anti-CD20 antibodies) for the treatment of CLL.
2.2.1.2
Safety of Acalabrutinib Monotherapy in Chronic Lymphocytic Leukemia
As of 01 June 2016, over 1600 subjects have received acalabrutinib as monotherapy or in 
combination with other agents. Here we present an aggregated safety analysis of acalabrutinib 
monotherapy taken from the investigator’s brochure. This pooled population represents 597 
acalabrutinib-exposed subjects with median exposure of 8.4 months (range 0.03-27.4 months).
The most frequently reported Grade ≥3 AEs were neutropenia (6.4%), anemia (6.0%), 
pneumonia (4.9%), and thrombocytopenia (2.8%). The most frequently reported related Grade 
≥3 AE was neutropenia (3.9%). A total of 15 (2.5%) subjects experienced Grade 5 events. Of the 
15 subjects with a reported Grade 5 event, 10 subjects (1.7%) had an infection event, including 5 
subjects (0.8%) who had a reported event of pneumonia, which was the most frequently reported 
fatal event. Serious AEs occurred in a total of 183 (30.7%) subjects. The most frequently 
reported SAEs were pneumonia (4.5%) and pyrexia (2.3%). Of the 183 subjects with a reported 
SAE, 76 (12.7%) subjects had a reported infection event, in which pneumonia (27 [4.5%] 
subjects) and sepsis (7 [1.2%] subjects) were the most commonly reported. A total of 30 (5.0%) 
subjects experienced AEs that led to study drug discontinuation, the most frequent of which 
included diarrhea, pneumonia, glioblastoma multiforme, and dyspnea (2 [0.3%] subjects for 
each).
Across this pooled population, atrial fibrillation of any grade has been reported in 8 subjects 
(1.3%) with Grade ≥3 in 4 subjects (0.7%). There were no reported Grade 4 or Grade 5 events of 
atrial fibrillation and there were no reported events of atrial flutter. Additionally, major 
hemorrhage events have been reported in 9 subjects (1.5%). The most frequently reported 
specific preferred terms representing major hemorrhage events were epistaxis and gastric 
hemorrhage, reported in 4 subjects (0.7%) and 2 subjects (0.3%), respectively. The majority of 
these subjects had confounding factors, which included concomitant use of NSAIDs/oral 
anticoagulants, and/or a medical history of events such as thrombocytopenia, stomach ulcer, and 
epistaxis. All major hemorrhage events were Grade 1-3. The incidence rates of atrial fibrillation 
and major hemorrhage (after a median time on therapy of 8.4 months) are less than what would 
be expected after a similar follow-up time on ibrutinib.
Long term follow-up of a phase I/II multicenter single arm study of acalabrutinib in 134 patients 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
20
with relapsed/refractory CLL has been recently published (Byrd et al., 2020). At time of data 
analysis, patients had received acalabrutinib for a median of 41 months. The most common 
adverse events (all/grade≥3) were diarrhea (52%/5.2%), headache (50.7%/0%) and upper 
respiratory tract infection (37.3%/0.7%). Major (grade ≥3) bleeding events occurred in 5% of 
patients, and atrial fibrillation occurred in 7% of patients, for a rate of 2.9 per 100 patient-years.
2.2.1.3
Safety of Acalabrutinib in Combination with Obinutuzumab
A phase Ib, multicenter, single-arm, open-label study of acalabrutinib in combination with 
obinutuzumab enrolled subjects with R/R or untreated CLL/SLL/PLL (ACE-CL-003). Safety 
data from this study is of particular relevance to the AVO combination investigated here. Safety 
and efficacy data from 45 subjects were recently published (Woyach et al., 2020). After a median 
follow-up of 39 months, the safety profile was favorable. The most common adverse event was 
upper respiratory tract infections (73.3% any grade, 0% grade ≥3). A list of the most frequent 
non-hematologic adverse events is reproduced in Table 1.
Table 1: Selected Adverse Events in a Phase I Trial of Acalabrutinib and Obinutuzumab
Relapsed/Refractory
n=26
Treatment-Naïve
n=19
Total
N=45
Adverse event, n (%)
All Grade
Grade 3/4
All Grade
Grade 3/4
All Grade
Grade 3/4
Any adverse event
26 (100)
20 (76.9)
19 (100)
12 (63.2)
45 (100)
32 (71.1)
Upper respiratory tract 
infection
 19 (73.1)
 0
 14 (73.7)
 0
 33 (73.3)
 0
Weight increased
 18 (69.2)
 2 (7.7)
 14 (73.7)
 2 (10.5)
 32 (71.1)
 4 (8.9)
Rash, maculopapular
 18 (69.2)
 1 (3.8)
 12 (63.2)
 0
 30 (66.7)
 1 (2.2)
Cough
 16 (61.5)
 0
 13 (68.4)
 1 (5.3)
 29 (64.4)
 1 (2.2)
Diarrhea
 19 (73.1)
 2 (7.7)
 10 (52.6)
 0
 29 (64.4)
 2 (4.4)
Headache
 17 (65.4)
 1 (3.8)
 8 (42.1)
 0
 25 (55.6)
 1 (2.2)
Nausea
 16 (61.5)
 0
 8 (42.1)
 0
 24 (53.3)
 0
Arthralgia
 13 (50.0)
 1 (3.8)
 8 (42.1)
 0
 21 (46.7)
 1 (2.2)
Dizziness
 11 (42.3)
 0
 10 (52.6)
 0
 21 (46.7)
 0
Constipation
 13 (50.0)
 0
 7 (36.8)
 0
 20 (44.4)
 0
Contusion
 11 (42.3)
 0
 8 (42.1)
 0
 19 (42.2)
 0
2.2.1.4
Efficacy of Acalabrutinib in Relapsed/Refractory Chronic Lymphocytic Leukemia
As noted above, published experience with acalabrutinib consists of a phase I/II multicenter 
open-label, nonrandomized, sequential group, dose escalation single arm study (ACE-CL-001) of 
the drug in 61 patients with relapsed/refractory CLL (Byrd et al., 2016; Byrd et al., 2020). 
Subjects enrolled in the relapsed/refractory CLL cohort received acalabrutinib either QD or BID. 
The QD dosing cohorts comprised of 100 mg (n=9), 175 mg (n=8), 200 mg (n=33), 250 mg 
(n=7), and 400 mg (n=6). The twice daily dosing cohorts included a dose of 100 mg (n=65) and 
200 mg (n=6) BID. There were no dose-limiting toxicities in any cohort. The acalabrutinib dose 
selected for dose expansion cohorts to support Phase 2 and 3 programs was 100 mg BID, and 
eventually all subjects in this trial were transitioned to the 100 mg BID dose.
The median age reported for the subject population was 66 years. A total of
132 subjects were diagnosed with CLL and 2 subjects were diagnosed with SLL. The median 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
21
time from initial diagnosis was 8.1 years (range 0.2 to 25.5 years). A total of 38.1% of subjects 
had baseline bulky disease of ≥ 5 cm, with 7.5% having ≥10 cm. Baseline Rai stage was 0 (low 
risk) in 0% of subjects, I-II (intermediate risk) in 28% and III-IV (high risk) in 49% (this data 
was missing for 23% of subjects). Subjects had received a median of 2 (range, 1 to 13) prior 
systemic therapies. Baseline ECOG status was 0 in 35.8%; 1 in 60.4% and 2 in 3% of subjects. 
With regard to chromosomal abnormalities, 23.9% of subjects had 17p13.1 deletion; 18.6% had 
11q22.3 deletion without 17p13.1; 23% had 11q22.3 deletion; and 73.6 % had unmutated IGHV 
genes. Median time on study for this population was 15.5 months.
A total of 75 out of 134 subjects remained on study treatment as of the 04 Jan 2019 cutoff date, 
when the median length of follow-up was 41 months (Byrd et al., 2020). Discontinuation reasons 
include progressive disease (21%), adverse events (11%), death (4.5%), physician decision 
(4.5%), and withdrawal by subject (2.2%). The best ORR, including partial responses and partial 
responses with lymphocytosis (PR-L) was 94%. For subjects who experienced a response of PR-
L or better, 63% had a sustained response for 45 months. The rate of progression-free survival at 
12 months and 18 months was 96.1 and 88.6%, respectively. Response data for this subject 
population is provided in the table below.
Table 2: Best Response and Overall Response Rate by Investigator Assessment in Subjects with 
Relapsed/Refractory CLL (ACE-CL-001)
Best Response
All R/R Cohorts (N=134)a
CR
4%
PR
84%
PRL
6%
SD
1%
PD
1%
ORR (CR+CRi+PR+PRL) (95% CI)
94% (89-97%)
Abbreviations: CR = complete response; CRi = complete response with incomplete marrow recovery; PD = 
progressive disease; ORR = overall response rate; PR= partial response; PRL = partial response with lymphocytosis; 
SD = stable disease
a Efficacy evaluable population includes subjects with ≥ 1 response assessment after the first dose of study drug.
2.2.1.5
Efficacy of Acalabrutinib in Treatment-Naïve Chronic Lymphocytic Leukemia
Preliminary efficacy data are available for a total of 99 subjects with treatment-naive CLL 
enrolled in the treatment-naive cohort of study ACE-CL-001. A subset of subjects enrolled in 
this cohort initially received acalabrutinib at a dose level of 200 mg QD. The subjects in this 
dose cohort were subsequently transitioned to the planned expansion dose of 100 mg BID.
The median age reported for this subject population is 64 years. The median time from initial 
diagnosis is 3.4 years (range 0.1 to 16.5 years). A total of 46.5% of subjects had baseline bulky 
disease of ≥ 5cm, with 6.1% of subjects having ≥ 10 cm. Baseline Rai was I-II (intermediate 
risk) in 48.5% and III-IV (high risk) in 50.5%, with no low risk subject enrolled. Baseline ECOG 
status was 0 in 34.3% and 1 in 65.7% of subjects. With regard to chromosomal abnormalities, 
9.9% of subjects had 17p13.1 deletion, 19.8% had 11q22.3 deletion without 17p13.1, 22% had 
11q22.3 deletion, and 62% had unmutated IGHV genes.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
22
Median time on study for this subject population was 14.8 months. A total of 95 out of 99 
subjects remain on study treatment as of the 01 June 2016 cutoff date. Currently
2 (2%) subjects have discontinued treatment due an AE; 1 (1%) subject has discontinued 
treatment due to pregnancy; and 1 (1%) subject withdrew consent. The best ORR, including PR 
and PRL was 97.9%. For subjects who experienced a response of PRL or better, 100% had a 
sustained response for 12 months. The rate of progression-free survival at 12 months and 18 
months was 99% each. Response data for this subject population is provided in the table below.
Table 3: Best Response and Overall Response Rate by Investigator Assessment in Treatment-
Naïve Subjects with CLL (ACE-CL-001)
Best Response
Total (N=96)a
CR
0
CRi
0
PR
88 (91.7)
PRL
6 (6.3)
SD
2 (2.1)
PD
0
ORR (CR+CRi+PR+PRL)
     95% CI
94 (97.9)
(92.7, 99.8)
Abbreviations: CR = complete response; CRi = complete response with incomplete marrow recovery; PD = 
progressive disease; ORR = overall response rate; PR= partial response; PRL = partial response with lymphocytosis; 
SD = stable disease
a Efficacy evaluable population includes treated subjects who have ≥ 1 response assessment after the first dose of 
study drug.
Preliminary efficacy data have also been presented in abstract form for two phase 3 trials of 
acalabrutinib. Most relevant to this study, results from ELEVATE-TN, a phase 3 trial comparing 
acalabrutinib vs. acalabrutinib plus obinutuzumab vs. chlorambucil plus obinutuzumab, were 
presented at ASH in 2019 (Sharman et al., 2019). In this trial, 535 patients with treatment naïve 
CLL (and either age ≥ 65 years or <65 years with coexisting conditions) were randomized 
among the three arms. The study met its primary endpoint, demonstrating an improvement in 
PFS in the acalabrutinib plus obinutuzumab arm (not reached) versus the chlorambucil plus 
obinutumab arm (22.6 months). Toxicities in the acalabrutinib plus obinutuzumab arm included 
headache (40% any grade, 1% grade ≥3), diarrhea (39% any grade, 4% grade ≥3), and 
neutropenia (31% any grade, 30% grade ≥3). The rate of infusion related reactions with 
obinutuzumab was less when the antibody was combined with acalabrutinib (13% any grade, 2% 
grade ≥3) than when the antibody was combined with chlorambucil (40% any grade, 5% grade 
≥3). Preliminary results from a phase 3 trial of acalabrutinib monotherapy versus investigator’s 
choice (either bendamustine/rituximab or idelalisib/rituximab) in relapsed/refractory CLL have 
been presented in abstract form (Ghia et al., 2019; Hebart et al., 2020). This study also met its 
primary endpoint, demonstrating a superior PFS in the acalabrutinib monotherapy arm (not 
reached in the acalabrutinib arm versus 16.5 months in the investigator’s choice arm), with no 
new safety signals seen.
2.2.1.6
Acalabrutinib FDA Approval

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
23
Based on a phase 2 study in mantle cell lymphoma, acalabrutinib was granted accelerated 
approval in October 2017 for the treatment of patients with mantle cell lymphoma who have 
received at least one prior line of therapy. Based on the aforementioned phase 3 ELEVATE-TN 
and ASCEND trials, acalabrutinib (either with or without obinutuzumab) was granted FDA 
approval in November 2019 for the treatment of adult patients with CLL at any line of therapy.
Obinutuzumab
2.2.1.7
Structure and Mechanism of Action of Obinutuzumab
Obinutuzumab (GA101, RO5072759, Gazyva, Gazyvaro) is a glycoengineered type II anti-
CD20 monoclonal antibody characterized by high-affinity binding to a CD20 epitope that is 
different from the epitope targeted by rituximab (which is currently the most widely used anti-
CD20 monoclonal antibody). Obinutuzumab was derived by humanization of the parental B Ly1 
mouse antibody and subsequent glycoengineering leading to the following characteristics:  high-
affinity binding to the CD20 antigen, high antibody-dependent cellular cytotoxicity (ADCC), and 
antibody-dependent cellular phagocytosis (ADCP); low complement-dependent cytotoxicity 
(CDC) activity; and high direct cell death induction.  Preclinical studies with obinutuzumab in 
comparison with rituximab showed significantly greater ADCC and ADCP, increased direct cell-
death induction, and lower CDC.  Superior efficacy to rituximab has also been demonstrated in 
various human lymphoma xenograft models.
2.2.1.8
Tolerability and Efficacy of Obinutuzumab in Chronic Lymphocytic Leukemia
Study BO20999 (GAUGUIN; NCT00517530) (Phase I)
BO20999 was an open-label, multicenter, Phase I/II study to explore obinutuzumab safety and 
activity in relapsed/refractory NHL and CLL.  Thirteen CLL patients received obinutuzumab at 
doses with a range of 4002000 mg (given as a flat dose) across four cohorts (Cartron et al., 
2014).  There were no dose-limiting toxicities (DLTs) and no requirement for dose reductions.  
Infusion-related reactions (IRRs) occurred in all CLL patients and were characterized 
predominantly by National Cancer Institute Common Terminology Criteria (NCI-CTC) Grade 
12 toxicities:  chills, nausea, vomiting, fever, pyrexia, hypertension, hypotension, dyspnea, and 
dizziness.  Ten patients experienced at least one grade ≥3 adverse event, IRRs and cytopenias 
being most common. 
Although the safety profile appeared otherwise similar between NHL and CLL, there was an 
increase in NCI-CTC v3.0 Grade 3/4 neutropenia noted in CLL patients, which were observed in 
7 patients across the four dose levels administered.  Five patients experienced Grade 4 
neutropenia and 2 patients experienced Grade 3 neutropenia as the maximum severity.  All 
received G-CSF per institutional practice, and these patients responded quickly to G-CSF 
support.  It is important to note that these neutropenia events did not appear to be accompanied 
by a higher incidence of infections, as only one patient experienced febrile neutropenia and there 
were no deaths on study. As assessed by 2008 International Workshop on CLL (IWCLL) criteria, 
the end-of-treatment response rate with obinutuzumab monotherapy was 62%, with all 8 
responders having a PR.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
24
Study BO21004 (CLL11; NCT01010061) (Phase III)
This was an open-label, multicenter, three-arm randomized, Phase III study comparing the 
efficacy and safety of obinutuzumab  chlorambucil (GClb), rituximab  GClb (RClb), or Clb 
alone in previously untreated CLL patients with comorbidities (Goede et al., 2014).  BO21004 
enrolled 781 patients and an additional 6 patients during a safety run-in period before 
randomization. None of the pre-defined stopping criteria were met during this safety run-in 
period, and Study BO21004 opened to randomization in April 2010.
Study BO21004 included two separate stages evaluating efficacy and the primary endpoint of 
progression-free survival (PFS).  Stage 1 evaluated obinutuzumab  chlorambucil compared with 
chlorambucil alone.  Compared with chlorambucil, both obinutuzumab  chlorambucil and 
rituximab  chlorambucil demonstrated statistically significant PFS benefit compared with 
chlorambucil alone.  Median PFS of chlorambucil vs. obinutuzumab  chlorambucil was 11.1 vs. 
26.7 months, respectively, (hazard ratio [HR], 0.18 [0.13  0.24]; p 0.001) as assessed by 
independent review. Additionally, obinutuzumab + chlorambucil significantly improved overall 
survival compared to chlorambucil monotherapy (HR 0.41 [0.23-0.74]; p<0.002).
 
In the Stage 2 analysis of this study, obinutuzumab  chlorambucil was compared with 
rituximab  chlorambucil.  At the pre-planned interim analysis, the primary endpoint was met 
early and the results were released by the independent data monitoring board.  Median PFS was 
26.7 months vs. 15.2 months for obinutuzumab  chlorambucil vs. rituximab  chlorambucil, 
respectively. The ORR was 78% vs. 65%, and CR was 21% vs. 7%, respectively. There was a 
non-significant trend towards improved overall survival in the obinutuzumab + chlorambucil 
group. Notably, the rate of MRD-negativity in the bone marrow was also significant higher in the 
obinutuzumab + chlorambucil group versus the rituximab + chlorambucil group (19.5% vs. 
2.6%, respectively) (Goede et al., 2014).
For more information related to safety and efficacy in the CLL indication, please refer to the 
Obinutuzumab US prescribing information (USPI).
2.2.1.9
Additional Safety Overview of Obinutuzumab
Obinutuzumab has been administered in clinical trials to greater than 1,310 patients with 
CD20-positive malignancies.  Both in patients with NHL and with CLL, IRRs were the most 
common AEs in clinical trials conducted to date. Other notable adverse events include 
neutropenia, hepatitis B reactivation, progressive multifocal leukoencephalopathy, tumor lysis 
syndrome, and infections. These events appeared to be more common in patients with CLL 
compared to NHL.
In trials investigating the combination of obinutuzumab and CHOP, FC, chlorambucil or 
bendamustine, the incidence of AEs in the treatment arms with combined use was consistent 
with the known safety profiles of the individual study drugs.  So far, no maximum tolerated dose, 
no dose-limiting toxicities, and no clear dose-related trends in the incidence of AEs have been 
determined.
A pooled analysis of safety data for obinutuzumab collected during the monotherapy studies 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
25
BO20999 and BO21003 was conducted. These two studies included a total of 205 patients with 
NHL (49 aggressive NHL and 156 indolent NHL patients) and 38 patients with CLL who 
received obinutuzumab monotherapy.  In the group of 38 CLL patients treated with 
obinutuzumab monotherapy, the majority of patients (25 [66%]) were treated for 4 weeks to 
6 months. Eleven patients (29%) were exposed for 6-12 months, and two patients (5%) were 
exposed for 12 months or longer. Eight of 38 patients (21%) with CLL were withdrawn during 
the treatment phase; 4 patients (11%) were withdrawn due to AEs, which indicates that AEs were 
mostly manageable. Almost all patients (37/38 [97%]) experienced an IRR. The number of 
patients with Grade 3/4 IRRs was 11/38 (29%).  Infusion related reactions were predominantly 
associated with the first infusion, generally occurring early during the infusion, shortly after, or 
in some cases up to 24 hours after the completion of the infusion with obinutuzumab.  The 
incidence and intensity of IRRs decreased with subsequent infusions of obinutuzumab. In a few 
patients, concurrent signs of tumor lysis syndrome (TLS) were observed. 
As is typical for patients with CLL, blood and lymphatic system disorders were among the most 
frequently reported AEs, in particular neutropenia (13/38 patients [34%]), febrile neutropenia 
(5/38 patients [13%]), and thrombocytopenia (7/38 patients [18%]).
Infections and infestations were common AEs, occurring in 21/38 patients (55%).  Infections 
reported in more than one patient were nasopharyngitis (6 patients), bronchitis and sinusitis (4 
patients each), influenza and lung infection (3 patients each), and herpes zoster and oral herpes 
(2 patients each).
Patients with CLL appeared to be at a higher risk of experiencing an AE of special interest than 
patients with NHL.  The largest difference in the incidences was seen for neutropenia (occurring 
in 47% of patients with CLL [18/38] vs. 8% of patients with aNHL [4/49] and 8% of patients 
with iNHL [13/156]) and treatment-related AEs associated with the infusion (100% [38/38] vs. 
80% (39/49) and 83% [129/156]).
In the Phase III Study BO21004 (CLL11), comparison of obinutuzumab  chlorambucil to 
chlorambucil alone showed that the most common AEs (all grades, Grades 3  4), respectively, 
were IRRs (69% vs. 0, 21% vs. 0), neutropenia (40% vs. 18%, 34% vs. 16%), thrombocytopenia 
(15% vs. 7%, 11% vs. 3%), anemia (12% vs. 10%, 4% vs. 5%), leukopenia (7% vs. 0, 5% vs. 0), 
pyrexia (10% vs. 7%,   1 vs. 0), and cough (10% vs. 7%, 0 vs.   1%).
The incidence of IRRs was 69% with the first infusion of obinutuzumab.  The incidence of 
Grade 3 or 4 IRRs was 21%, with 8% of patients discontinuing therapy.  The incidence of 
reactions with subsequent infusions was 3% with the second 1000-mg dose and <1% thereafter.  
No Grade 3 or 4 IRRs were reported beyond the first 1000-mg infusion.  Of the first 53 patients 
receiving obinutuzumab in the trial, 47 (89%) experienced an IRR.  After this occurrence, study 
protocol modifications were made to require pre-medication with a corticosteroid, antihistamine, 
and acetaminophen.  The first dose was also divided into two infusions (100 mg on Day 1 and 
900 mg on Day 2).  Of the 45 patients for whom these mitigation measures were implemented, 
21 patients (47%) experienced a reaction with the first 1000-mg dose and <2% thereafter.
The incidence of neutropenia reported as an AE was 40% in the obinutuzumab-treated arm and 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
26
18% in the chlorambucil-alone arm, with the incidence of SAEs being 1% and 0%, respectively.  
Cases of late-onset n-eutropenia (occurring 28 days after completion of treatment or later) were 
16% in the obinutuzumab-treated arm and 12% in the chlorambucil-alone arm. The incidence of 
infections was similar between arms.  Thirty-eight percent of patients in the obinutuzumab- 
treated arm experienced an infection, 9% were Grade 3  4, and none were fatal. The incidence 
of Grade 3 or 4 tumor lysis syndrome was 2% in the obinutuzumab-treated arm vs. 0% in the 
chlorambucil-alone arm. AEs related to musculoskeletal disorders, including pain (System Organ 
Class), have been reported with obinutuzumab with higher incidence than with the comparator 
(17% vs. 13%, respectively).
2.2.1.10
Obinutuzumab FDA Approval
Based on the data above including the positive results of the randomized phase III BO21004 
(CLL11) study, obinutuzumab received FDA approval in late 2013 for use in combination with 
chlorambucil in previously untreated patients with CLL. In 2019, obinutuzumab was also 
approved in combination with ibrutinib for the front-line treatment of CLL, as well as in 
combination with venetoclax for the front-line treatment of CLL.
Venetoclax
2.2.1.11
Structure and Mechanism of Action of Venetoclax
Venetoclax (ABT-199, GDC-0199, VenclextaTM) is a novel, orally bioavailable, small-molecule 
Bcl-2 family inhibitor in the biarylacylsulfonamide chemical class.  Venetoclax binds with high 
affinity (Ki < 0.010 nM) to the antiapoptotic protein Bcl-2, and with far lower affinity to other 
antiapoptotic Bcl-2 family proteins, like Bcl-XL and Bcl-w (> 4,000-fold and > 2,000- to > 
20,000-fold lower affinity than to Bcl-2, respectively). Venetoclax was designed to have a 
different safety profile than dual Bcl-2/Bcl-XL inhibitors such as its predecessor molecule 
navitoclax. Platelets depend on Bcl-XL for survival, and thrombocytopenia is therefore a DLT 
caused by inhibition of Bcl-XL in the clinic.  Venetoclax has an improved therapeutic index, and 
thereby maintains efficacy against tumor cells while avoiding dose-limiting thrombocytopenia.
2.2.1.12
Safety of Venetoclax in CLL Patients
The safety of venetoclax was evaluated in study M12-175 (NCT01328626), a phase I, open-
label, multicenter study evaluating the safety and pharmacokinetic profile of venetoclax in a one 
daily dosing schedule (Roberts et al., 2016). The CLL/SLL arm consisted of 116 patients with 
relapsed/refractory disease in need of therapy (56 patients in the dose escalation cohort and 60 in 
the expansion cohort). Patients were assigned sequentially to dose-escalation groups of three 
patients or more according to a 3+3 design. Patients received daily venetoclax until disease 
progression or unacceptable toxicity. 
The most important toxic effect in the dose-escalation cohort was TLS, which occurred in all 
three patients that received a single initial dose of 200mg or 100mg, as well as in two subsequent 
patients (including one who required urgent hemodialysis and one with a fatal event presumed 
due to TLS). Subsequently, the protocol was revised to start at a lower dose of 50 mg, and 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
27
eventually further revised to a starting dose of 20mg with an extended stepwise ramp-up. 
Venetoclax dosing increases weekly as follows: 20mg, 50mg, 100mg, 200mg, and finally 400mg 
daily. Subjects also received TLS prophylaxis according to their level of TLS risk. In the 
expansion cohort that followed this dosing schedule, only one subject had laboratory evidence of 
TLS and no subjects had clinical TLS. The most common adverse event was diarrhea in 52% of 
patients (grade ≥3 in 15%). The most common grade ≥3 adverse event was neutropenia (41% of 
subjects), although the rate of febrile neutropenia was low (6%). The neutropenia responded to 
growth factor administration. 
M13-365 (NCT01682616) was a phase Ib study evaluating venetoclax in combination with 
rituximab. The most common adverse events with this combination were low-grade self-limited 
gastrointestinal events (diarrhea in 55% of patients and nausea in 51% of patients). The most 
common grade ≥3 adverse event was neutropenia in 53% of patients, developing after a median 
time of 51 days which was managed with G-CSF support. Five patients had TLS, including one 
fatality. After the fatality, the protocol was amended to include a lower venetoclax starting dose 
of 20mg and modified TLS prophylaxis. Among 32 patients subsequently treated, no clinical 
TLS was observed (Seymour et al., 2017). 
In study M13-982 (NCT01889186), a phase 2, open label multicenter study evaluating the 
efficacy and safety of venetoclax in patients with relapsed/refractory CLL harboring a 17p13 
(TP53) deletion, the most common treatment-emergent adverse events were neutropenia (grade 
≥3 in 40% of patients) and gastrointestinal disorders (63% of patients, with grade ≥3 in 7%). All 
neutropenia-related events were manageable with dose interruption, dose reduction, or G-CSF 
support; no subject had to permanently discontinue therapy due to neutropenia. Due to the TLS 
events observed in the phase I studies, a stepwise ramp-up strategy was used, starting at 20mg 
every week the dose was increased (20mg, 50mg, 100mg, 200mg, 400mg) until subjects received 
the final 400mg daily dose. With this protocol in place, laboratory evidence of TLS was only 
reported in five patients during the ramp-up period, and in all cases resolved without clinical 
sequelae (Stilgenbauer et al., 2016).
2.2.1.13
Efficacy of Venetoclax in CLL Patients
The studies cited above have also demonstrated the efficacy of venetoclax in CLL patients. In the 
phase I study of venetoclax monotherapy (study M12-175, NCT01328626), the ORR in all 
patients, including both the dose-escalation cohort and the expansion cohort, was 79%. In the 
subgroup of patients with a 17p deletion, the ORR remained high at 71%, and in the subgroup of 
patients refractory to fludarabine, the ORR was 79%. Complete responses (CRs) by IW-CLL 
criteria were seen in 20% of patients (with comparable CR rates in the high-risk subgroups), and 
5% of patients achieved minimal residual disease (MRD) negativity. A report with longer 
follow-up on the cohort of patients who received the recommended phase II dose of 400 mg/day 
was notable for an ORR of 81% (CR rate of 16%) and also highlighted the durability of 
responses, with an estimated 24-month PFS of 62% (M. S. Davids et al., 2016; Roberts et al., 
2016).
Venetoclax was also found to be effective in the phase 2 study specifically limited to patients 
with relapsed 17p deleted CLL (study M13-982, NCT01889186). One hundred seven subjects 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
28
were enrolled in the main cohort. After a median duration of follow-up of 12.1 months, the 
overall response rate (independent review committee assessment) was 79%, with 8% of subjects 
having a CR/CRi. Responses appeared to be durable, although follow-up was short, as the 
median PFS and OS had not been reached. The estimated 12-month PFS was 72% in this 
difficult-to-treat population (Stilgenbauer et al., 2016). Based upon this study, venetoclax was 
FDA-approved as monotherapy for the treatment of patients with CLL with 17p-deletion who 
have received at least one prior therapy.
2.2.1.14
Combination of Venetoclax with Obinutuzumab is Safe and Effective
The combination of venetoclax and obinutuzumab has been demonstrated to be safe in the phase 
1 and phase 3 settings. Preliminary results from the phase I study (GP28331) identified a 
venetoclax dose of 400mg and an obinutuzumab dose of 1000mg as safe in combination (Flinn et 
al., 2014). These doses are equivalent to the recommended doses of each agent when used as 
monotherapy. 
Practice-changing results from a randomized phase 3 trial of venetoclax and obinutuzumab 
versus obinutuzumab and chlorambucil in 432 patients with previously-untreated CLL have been 
published (CLL14) (K. Fischer et al., 2019; Kirsten Fischer et al., 2019). Subjects in the 
venetoclax-obinutuzumab arm received a lead-in with three doses of weekly obinutuzumab, 
followed by daily dosing of venetoclax beginning on day 22 in combination with obinutuzumab. 
This regimen last a fixed duration of time, with obinutuzumab administration ceasing after 6 
months and venetoclax administration ceasing after 12 months. The combination was found to be 
both safe and effective. The study met its primary endpoint, with a superior PFS in the 
venetoclax-obinutuzmab arm compared to the chlorambucil-obinutuzumab arm (HR 0.35, 95% 
CI 0.23-0.53). More patients had a complete response in the venetoclax-obinutuzumab arm 
(49.5%) versus the chlorambucil-obinutuzumab arm (23.1%). There were no unexpected safety 
signals, with the most common grade ≥3 adverse events in the venetoclax-obintuzumab arm 
including neutropenia (52.8% grade ≥3) and infections (17.5% grade ≥3). Based on results of 
this study, venetoclax and obinutuzumab were approved as a fixed-duration regimen for the 
front-line treatment of CLL in 2019.
2.2.1.15
Triple Combination Therapy with Venetoclax, Obinutuzumab and Ibrutinib
The combination of ibrutinib, venetoclax, and obinutuzumab is being studied in a single center 
phase Ib/II open label study that has completed enrollment of 63 patients, OSU-14266 
(NCT02427451) (Jones et al., 2016). There are two arms to the study, one enrolling patients with 
relapsed/refractory disease, and one enrolling treatment naïve patients. The dosing schedule in 
this trial begins with obinutuzumab on cycle 1 day 1 for up to 8 cycles. Beginning in cycle 2, 
subjects receive daily ibrutinib. Beginning in cycle 3, subjects initiate the ramp-up dosing with 
venetoclax. Treatment with ibrutinib and venetoclax continues until disease progression and 
toxicity. Preliminary results after enrollment of 12 patients in the relapsed/refractory arm have 
been presented in abstract form (Jones et al., 2016). Dose-limiting toxicities were not observed at 
any venetoclax dosing level, establishing venetoclax 400mg daily as safe in combination with 
standard doses of obinutuzumab and ibrutinib. The most common grade ≥3 adverse event was 
neutropenia (50%); the most common grade 1/2 adverse events were bruising (83%) and IRRs 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
29
(75%). Of the six patients who were evaluable for a response, there was one patient with a CR in 
the marrow who was also MRD-negative; two additional patients with partial responses were 
also MRD-negative. 
2.2.1.16
Discontinuation of Venetoclax Is Feasible
In the phase Ib, open-label, multicenter study evaluated the safety and tolerability of venetoclax 
in combination with rituximab in 49 patients (Seymour et al., 2017), thirteen of the 49 patients in 
this trial who had a deep response (CR/CRi or PR with negative minimal residual disease) ceased 
venetoclax therapy after a median treatment duration of 10 months. Of the ten patients still being 
followed at the time of study publication, all eight who were MRD-negative at the time of 
therapy discontinuation remained in ongoing remission after a median of 9.7 months. The two 
patients who ceased venetoclax therapy while MRD-positive developed clinically asymptomatic 
disease recurrence (rising ALC) two years later. Venetoclax was re-initiated in both patients and 
they both achieved a partial response on venetoclax alone. 
In the CLL14 trial, venetoclax was administered for a fixed duration of 12 months in 
combination with six cycles of obinutuzumab. All patients then discontinued therapy regardless 
of depth of response. At 24 months after initiation of therapy, 82% of patients in the 
venetoclax/obinutuzumab arm had still not progressed, demonstrating that fixed-duration 
venetoclax-based therapy is a feasible (and now FDA approved) approach. Multiple other trials 
have now incorporated venetoclax discontinuation as part of the trial design.
2.2.1.17
Venetoclax FDA Approval
Based on the aforementioned studies, venetoclax was granted accelerated approval in April 2016 
for the treatment of patients with CLL with 17p deletion who have received at least one prior line 
of therapy, and in June 2018 received full approval for the treatment of patients with CLL who 
have received at least one prior line of therapy with or without 17p deletion. In May 2019, the 
combination of venetoclax and obinutuzumab was approved for the frontline treatment of 
patients with CLL. 
2.3
Rationale
Current Therapy and Its Limitations
Current FDA-approved treatment options for CLL generally fall into one of two categories: 
combination chemoimmunotherapy or targeted therapy with novel agents. Each of these 
categories has their own benefits and drawbacks. For example, combination chemotherapy with 
FCR has demonstrated durable (>10 years) remissions in a subset of young, fit patients with 
lower risk CLL. However, due to cytopenias and an increased risk of severe infections, many 
older patients are not candidates for such therapy. Additionally, there are long-term 
complications of chemoimmunotherapy, including prolonged immune dysfunction and resultant 
late infections, pancytopenia, and therapy-related MDS/AML. 
Novel targeted therapies for CLL have revolutionized the treatment of the disease due to their 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
30
efficacy and good tolerability in a broad patient population.  However, long term novel agent 
monotherapy rarely results in CRs or MRD negativity. This leads to the need for continuous 
therapy, which has several drawbacks. First, consistent exposure to one mechanism of action 
leads to the development of resistance mutations such as the C481S BTK mutation in patients 
treated with ibrutinib. Second, patients continue to have toxicities while on active therapy, even 
with these relatively well-tolerated agents. Furthermore, the challenge of long term adherence as 
well as the financial expense of continuous therapy is burdensome both for patients and society, 
leading some patients to discontinue therapy early, which can have negative effects on their 
outcome. 
With these novel targeted therapies, we are now in the same position that we were with 
chemotherapy many years ago – multiple agents with demonstrated efficacy as monotherapy (or 
in combination with anti-CD20 antibodies), but with the anticipation that combination therapy 
may hold the key to more durable responses. The prospect of developing a novel-agent-only 
approach to time-limited therapy in CLL is now on the horizon. Such an approach may achieve 
the prolonged, MRD-negative remissions seen in some patients with chemoimmunotherapy, but 
may be more tolerable than chemoimmunotherapy, given the non-overlapping toxicity profiles of 
these novel agents.  This may open up the approach of highly effective time-limited therapies to 
the majority of older, frailer CLL patients who are not good candidates for 
chemoimmunotherapy.
Rationale for Combining Novel Agents 
The reasons for combining novel agents can be summarized as follows:
(1) The combination of novel agents may lead to deeper responses, and achievement of deeper 
responses may lead to longer remissions. Combination chemotherapy leads to deeper responses 
in CLL compared to single chemotherapy agents, and current data suggest that the combination 
of novel agents also achieves deeper remissions. For example, the combination of venetoclax and 
rituximab achieves higher CR/CR rates than those typically seen with venetoclax monotherapy in 
a similar patient population (Seymour et al., 2017). Furthermore, at least for patients treated with 
chemoimmunotherapy, deeper responses lead to longer remissions. Patients who achieve MRD-
negative status have a longer median PFS than their MRD-positive counterparts (Kovacs et al., 
2016). Thus, MRD status has prognostic importance, and achieving and sustaining MRD-
negativity is the first step toward a possible cure.
(2) The combination of novel agents leads to deeper responses, and achievement of deeper 
responses may allow for discontinuation of therapy, lessening toxicities, improving adherence, 
and decreasing the financial burden on patients. MRD-negativity has correlated historically with 
a longer time until disease recurrence.  Moreover, MRD-negativity may even identify some 
patients likely to achieve prolonged disease-free survival. This assumption is supported by the 
long term results of FCR therapy, which show a survival plateau in patients with IGHV-mutated 
disease who reached an MRD-negative state in the peripheral blood (Thompson et al., 2016). 
Based on these data, it is possible that a significant fraction of patients who achieve MRD-
negativity are cured of their disease. Therapy discontinuation would be a reasonable approach in 
this subgroup for multiple reasons. This would allow patients to avoid the toxicities and side 
effects that occur with these agents (e.g. neutropenia, gastrointestinal symptoms, etc.). 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
31
Furthermore, in the event of relapse, recurrent disease that developed while off drug may still be 
sensitive to the drug that induced remission in the first place. 
(3) The combination of novel agents may reduce toxicities compared to each agent given as 
monotherapy. The effects of one of the agents in the AVO triplet may decrease toxicities seen 
with the other agents. For example, the tumor debulking that will occur with three months of 
acalabrutinib and obinutuzumab lead-in therapy may reduce the risk of TLS with venetoclax. 
Additionally, there is preliminary data from a trial of ibrutinib and obinutuzumab in CLL to 
suggest that co-administration of ibrutinib with obinutuzumab decreases the rate of infusion 
reactions. No patients suffered infusion reactions when ibrutinib was given prior to, or 
simultaneously with, obinutuzumab; while 63% of patients had infusion reactions when 
obinutuzumab was given prior to ibrutinib (M. Davids et al., 2017). Thus, the administration of a 
BTK inhibitor prior to administration of obinutuzumab may decrease the high rate of infusion 
related reactions seen with obinutuzumab.
Rationale for Combining These Particular Novel Agents
Given the rationale above for exploring combination therapy of multiple novel agents, the exact 
agents to combine must next be considered. In this trial, the combination of acalabrutinib, 
venetoclax, and obinutuzumab has been chosen for investigation.
(1) Acalabrutinib: Acalabrutinib is a next-generation BTK inhibitor that is more specific for 
BTK than ibrutinib. This increased specificity may explain why atrial fibrillation and major 
hemorrhage, two potentially serious toxicities observed with ibrutinib, have not been observed as 
frequently with acalabrutinib monotherapy (Byrd et al., 2016). Furthermore, non-specific 
targeting of other kinases by ibrutinib may antagonize the action of obinutuzumab. Due to effects 
on ITK, ibrutinib has been shown in vitro to limit the efficacy of NK-cell mediated antibody 
dependent toxicity from rituximab (Kohrt et al., 2014). Therefore, a regimen including ibrutinib 
and CD20 antibodies may not be the optimal strategy for patients moving forward. Building an 
optimal chemotherapy-free regimen for CLL may require a more selective and better tolerated 
BTK inhibitor such as acalabrutinib.
(2) Venetoclax: Preclinical data suggest that the non-overlapping mechanisms of action of 
acalabrutinib and venetoclax enhance the effectiveness of either agent alone. We recently studied 
the effects of acalabrutinib on mitochondria in CLL cells using our dynamic BH3 profiling 
assay, a functional test which can identify the key anti-apoptotic proteins a cell depends on for its 
survival (see section 2.4.1).  We found that acalabrutinib causes a significant delta priming in 
response to BAD BH3 peptide and no significant change in response to BIM BH3 peptide, 
suggesting that acalabrutinib selectively enhances the dependence of CLL cells on BCL-2.  
Importantly, we saw these same effects both in CLL cells treated ex vivo with acalabrutinib (left 
panel, below) and in CLL cells from patients treated in vivo with acalabrutinib monotherapy for 
4 weeks on the phase I/II trial (right panel, below).
Acalabrutinib ex vivo treated
Acalabrutinib therapy in vivo (4 wks)

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
32
Based on these data, altho-ugh acalabrutinib can induce a modest amount of apoptosis on its 
own, an agent such as venetoclax that directly targets BCL-2 would be predicted to enhance the 
induction of apoptosis by acalabrutinib in CLL cells.  Conversely, acalabrutinib’s ability to 
release CLL cells from protective stromal microenvironments may enhance the access of 
venetoclax to CLL cells, suggesting that this combination may be synergistic.
(3) Obinutuzumab: Of the anti-CD20 antibodies currently available, obinutuzumab has 
demonstrated superior efficacy to rituximab in a phase III trial in combination with chlorambucil 
(Goede et al., 2014). When choosing which anti-CD20 antibody to incorporate into a 
chemotherapy-free regimen, we have thus chosen the antibody which has demonstrated superior 
efficacy.
Multiple studies are currently investigating novel agent combinations in CLL, including the 
OSU-14266 study investigating a similar combination of ibrutinib, obinutuzumab, and 
venetoclax. However, the study outlined here has some important differences from this other trial 
which should be highlighted to emphasize the unique contributions that our trial will make to the 
CLL field. 
First, this study uses the BTK inhibitor acalabrutinib rather than ibrutinib. As discussed 
previously, acalabrutinib is more selective for BTK than ibrutinib and appears to have a more 
tolerable side effect profile, (see section 2.2.1), which is particularly important in combination 
regimens. Additionally, ibrutinib – but not acalabrutinib – may inhibit antibody-dependent 
cellular cytotoxicity (ADCC). Thus, acalabrutinib is the preferred BTK inhibitor to pair with 
obinutuzumab (which acts in large part through ADCC). Moreover, if the first generation BTK 
inhibitor ibrutinib is replaced over time by the second generation molecule acalabrutinib, we 
believe that our results could provide important preliminary data to support the further 
development of acalabrutinib as the preferred BTK inhibitor for use in combination therapy. 
Second, in this study, patients receive lead-in therapy with the BTK inhibitor, after which 
obinutuzumab is introduced. This contrasts with the OSU study, where subjects receive a lead-in 
period with obinutuzumab followed by addition of ibrutinib. The OSU study had a relatively 
high rate of IRRs at 75%. Multiple lines of evidence suggest that a BTK inhibitor followed by 
administration of obinutuzumab is the preferred order to reduce infusion reactions. For example, 
data from a phase Ib/II combination trial of ibrutinib monotherapy followed by its combination 
with obinutuzumab (without venetoclax) had a very low rate of IRRs, with only one out of nine 
patients suffering a grade 1 IRR, with no grade ≥3 IRRs (Amaya-Chanaga et al., 2016). 
Therefore, in this trial, we will begin with a cycle of acalabrutinib prior to obinutuzumab 
initiation, with the hypothesis that this order may mitigate infusion-related adverse events.
Summary Statement
Acalabrutinib, venetoclax, and obinutuzumab (AVO) are three of the most active new agents in 
CLL. They have complementary mechanisms of action with non-overlapping toxicity profiles 
and preclinical data supporting their combination. Our phase 2 study will provide an initial 
assessment of the efficacy and safety of this combination. Our study could represent the first step 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
33
in a development plan that would eventually allow the AVO regimen to become a new standard 
of care for the treatment of CLL with a novel-agent-only approach.
2.4
Rationale for Study Expansion
Preliminary Safety Data
As of 1/1/2019, 25 patients have enrolled, with no screen failures. Twelve patients have reached 
the portion of the study where they take all three drugs in combination, and no unanticipated 
safety signals have been seen. The most frequent adverse events reported to date have been 
hematologic in nature, as is expected in the CLL patient population.  We have seen a lower than 
expected rate of hospital admissions for TLS monitoring in patients initiating venetoclax, with 
only 1 patient requiring hospital admission due to persistent disease bulk at time of venetoclax 
initiation. This demonstrates that acalabrutinib and obinutuzumab therapy can successfully 
debulk the disease and decrease the risk of TLS with venetoclax initiation. One patient did 
experience laboratory TLS during cycle 2 with initial obinuzutumab administration, but this was 
prior to venetoclax initiation and resolved without clincial sequelae.  No patients have 
discontinued study therapy due to toxicity.
Preliminary Efficacy Data
Twelve participants have reached cycle 4 day 1, when the initial disease re-staging occurs with 
CT scans and an optional bone marrow biopsy. Of the 12 patients who have reached this time 
point, 10 (83%) have already achieved a partial response by CT criteria; the remaining 2 patients 
had a 36% and 49% reduction in nodal burden, just missing the required 50% cut-off to achieve a 
partial response and thus being classified as stable disease. No patients have disease progression 
to date.
TP53-Aberrant Disease Is an Unmet Need
Long-term follow-up data from both chemoimmunotherapy trials and also early trials of novel 
agent monotherapy in CLL have demonstrated that patients with TP53-aberrant disease remain 
an unmet need. TP53 aberrations include deletions of chromosome 17p (detected by either 
karyotype or FISH) or mutations in TP53 itself. It has long been known that patients with TP53 
aberrations have lower response rates and shorter responses to standard chemoimmunotherapy. 
For example, in the CLL8 trial that compared FC to FCR for the up-front treatment of CLL, the 
group of patient with either TP53 mutations or del(17p) had a PFS of approximately 12 months 
and an OS of approximately 40 months, shorter than any other genetically defined subgroup 
(Stilgenbauer et al., 2014). Regarding novel agents, the longest follow-up available is with 
ibrutinib (primarily in relapsed/refractory patients), and again this data suggests that while the 
overall response rates among those with and without del(17p) are similar, the presence of 
del(17p) clearly defines a subgroup of patients with a shorter duration of response to ibrutinib. 
After 5 years of follow-up on patients treated with ibrutinib monotherapy, a median PFS of only 
26 months was seen in patients with del(17p), compared to a median PFS of 51 months for the 
overall group of relapsed/refractory patients. Furthermore, a multivariate analysis in this same 
population demonstrated that del(17p) was an independent risk factor for shorter PFS (S. O'Brien 
et al., 2018). In a study with shorter follow-up that examined the use of ibrutinib in the front-line 
setting outside of a clinical trial, patients with del(17p) again had an inferior PFS compared to 
those without del(17p) (Mato et al., 2018). These data support the conclusion that novel agent 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
34
monotherapy will be unable to reliably achieve durable responses in patients with TP53-aberrant 
disease and provide rationale for expanding this study to include more patients from this high-
risk population. In addition to the unmet need, further justification for focusing our expansion 
cohort on these high risk patients is that the quality of response in our initial 12 patients treated 
on study to date (including 3 patients with TP53-aberrant disease) did not differ based on TP53 
status. This provides preliminary evidence that the “AVO” triplet regimen may potentially be 
able to overcome the inherent resistance of this high risk form of CLL.
Summary
Given the favorable safety profile, preliminary demonstration of efficacy, and rapid accrual of 
the study so far, we are expanding the study to provide additional power to more confidently 
report the primary outcome for the subgroup with TP53-abberant disease, the group most likely 
to benefit from this combination novel agent approach.  Greater patient numbers will also allow 
for more robust analysis of the secondary endpoints including prespecified subgroup analyses, 
and to increase the number of samples available to perform the exploratory and correlative 
objectives.
Additionally, we plan to turn this into a multicenter study to allow our Dana-Farber Cancer Care 
Collaborative sites to participate. These are community sites closely tied to Dana-Farber but a 
different patient population from our main campus. The logistics of opening and monitoring 
these sites are more straightforward than for external sites, and by including these patients, we 
can demonstrate the feasibility of administering the AVO regimen outside of major academic 
medical centers.
2.5
Rationale for Modifying Treatment Discontinuation Parameters at Cycle 24
This trial was initially designed with optional treatment discontinuation at cycle 24 for subjects 
who achieve a complete response by IWCLL criteria as well as undetectable MRD as assessed 
by four color flow cytometry. We now update the trial to allow for treatment discontinuation at 
cycle 24 if the subject achieves undetectable MRD in the blood and marrow, regardless of 
IWCLL response. The primary driver for this change is recent data from CLL14 suggesting that 
the presence or absence of minimal residual disease, rather than the IWCLL response, is a more 
accurate predictor of a durable remission when a patient receives fixed-duration therapy with 
novel agents (Kirsten Fischer et al., 2019). For example, in the venetoclax-obinutuzumab arm of 
CLL14, there was no significant difference in the PFS between those who achieved undetectable 
MRD and a CR/CRi versus those who achieved undetectable MRD and a PR. This finding was 
also seen in the MURANO trial of venetoclax plus rituximab in relapsed/refractory CLL. Again, 
there was no significant difference in progression free survival between the group that achieved 
PR with undetectable MRD and the group that achieved a CR with undetectable MRD (Kater et 
al., 2019). Thus we now modify the treatment discontinuation parameters at cycle 24 to allow for 
cessation of acalabrutinib and venetoclax if the patient achieves undetectable MRD, regardless of 
IWCLL response. MRD will still be monitored in the peripheral blood every three months, with 
acalabrutinib and venetoclax resumed if it is detected. This modification to the study will allow 
some patients to enjoy treatment free periods, while staying within the confines of what is 
reasonable and safe according to currently available evidence. This change will also keep the 
study up-to-date with rapidly evolving standard-of-care approaches for the front-line treatment of 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
35
CLL.   
2.6
Correlative Studies Background
BH3 Profiling
This study will incorporate a laboratory technique known as BH3 profiling, which is a functional
assay we previously developed that detects the proximity of malignant cells to the threshold of
apoptosis (what we call ‘priming’) through physiologic interrogation of BCL-2 family members 
(Ryan, Brunelle, & Letai, 2010). To perform a BH3 profile, we add individual BH3-only 
peptides to gently permeabilized primary CLL cells and use fluorescence activated cell sorting 
(FACS) to determine the amount of mitochondrial depolarization induced by each peptide, as 
measured by cytochrome c release. We previously found that in a small, heterogeneously treated 
cohort of CLL patients, increased priming was associated with improved clinical response (M. S. 
Davids et al., 2012). Building on these initial studies, we will incorporate BH3 profiling into this 
clinical trial to determine whether priming predicts degree of clinical response in this larger, 
homogeneously treated patient population.
Genomic Markers
We will perform whole exome sequencing on CLL cells and normal tissue from patients at
baseline to evaluate for somatic mutations that may confer drug sensitivity and resistance. Our
group and others have recently identified recurrent somatic mutations in the CLL genome which
appear to associate with prognosis; these include NOTCH1 and SF3B1 (Wang et al., 2011). At 
present, whether other recurrent mutations associate with prognosis is less clear. Our group has 
also recently found that the presence of subclonal driver mutations was associated in a 
retrospective analysis with time to next treatment (Landau et al., 2013). In this trial, we will 
assess all of these recently described mutations as well as the presence of a subclonal driver 
mutation as potential predictors of response and progression-free survival. We will also bank 
samples at time of relapse for repeat analysis by whole exome sequencing to assess for the 
acquisition of resistance mutations. We will also evaluate established CLL prognostic markers 
such as cytogenetics by FISH, TP53 mutation, IGHV status, and ZAP-70 status, and will 
determine whether these factors are associated with response to AVO.
Single Cell Sequencing and Cell Free DNA Sequencing Studies
Next generation sequencing (NGS) techniques have the potential for revolutionizing the 
treatment of CLL by allowing the detection of minimal residual disease or resistance mutations 
at levels below the sensitivity of current assays. We plan on using single cell DNA sequencing 
and RNA sequencing to identify the presence of oncogenic mutations, resistance mutations, and 
transcriptomic profiles of circulating CLL cells at various time points during the course of 
therapy. We will also retain plasma samples collected at the same time for cell-free DNA 
analysis, making use of an orthogonal assay to verify or expand upon results obtained from 
single cell sequencing.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
36
ClonoSEQ Next Generation Sequencing Studies
Although conventional minimal residual disease (MRD) testing in CLL provides reasonable 
sensitivity for residual disease detection, novel methods of MRD-detection may allow even more 
sensitive detection with the potential for better prognostic power. Adaptive, Inc. has an assay 
known as ClonoSEQ, in which a baseline sample of genomic DNA is extracted from tumor cells, 
amplified using locus-specific primer sets for IGH and IGK rearrangements, and sequenced.  
Once a patient achieves a MRD-negative state, a peripheral blood sample is examined to 
determine whether tumor DNA is still detectable.  This will be one of the first novel-agent only 
based studies to utilize ClonoSEQ MRD testing in parallel with conventional MRD testing for 
CLL patients who achieve a CR.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
37
3. PARTICIPANT SELECTION
3.1
Eligibility Criteria
Unless otherwise specified, laboratory tests required for eligibility must be completed within 2 
weeks prior to start of protocol therapy. Baseline tumor measurements by CT or PET/CT scan 
must be performed within approximately 30 days of starting study treatment. Bone marrow 
biopsy within approximately 6 months prior to study treatment will be acceptable if there has not 
been significant anti-cancer therapy given since the test was performed. 
Inclusion Criteria
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study:

Subjects must meet IWCLL 2018 guidelines for the diagnosis of CLL or SLL, or WHO 
2017 guidelines for the diagnosis of B-prolymphocytic leukemia (B-PLL)

In cohort 2, subjects must have TP53-aberrant disease defined as: 
o
Del(17p) detected by karyotype, FISH, or next-generation sequencing; OR
o
TP53 mutation

Participants must have measurable disease (lymphocytosis > 5,000 / µl, or palpable or CT 
measurable lymphadenopathy ≥ 1.5 cm, or bone marrow involvement  ≥30%).

Subjects must not have received any prior systemic therapy for CLL or SLL due to 
previously meeting IWCLL 2018 guidelines and must currently have an indication for 
treatment as defined by the IWCLL 2018 guidelines, or must not have received therapy 
for B-PLL and must currently have an indication for treatment:
o
Massive or progressive or symptomatic splenomegaly; OR
o
Massive lymph nodes, nodal clusters, or progressive lymphadenopathy; OR
o
Significant fatigue (i.e. ECOG PS 2 or worse; cannot work or unable to perform 
usual activities); OR
o
Fever ≥ 100.5°F for 2 or more weeks without evidence of infection; OR
o
Night sweats for ≥ 1 months without evidence of infection; OR
o
Presence of weight loss ≥ 10% over the preceding 6 months; OR
o
Progressive lymphocytosis with an increase of ≥ 50% over a 2-month period or 
lymphocyte doubling time of less than 6 months; OR
o
Evidence of progressive marrow failure as manifested by the development of or 
worsening of anemia and/or thrombocytopenia.
o
Autoimmune anemia and/or thrombocytopenia that is poorly responsive to 
corticosteroids and another standard therapy such as rituximab
o
Symptomatic or functional extranodal involvement; OR

Age greater than or equal to 18 years. Because CLL is extremely rare in persons <18 
years of age, children are excluded from this study.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
38

ECOG performance status ≤2 (see Appendix A)

Participants must have adequate organ and marrow function as defined below:
o
total bilirubin ≤1.5 times upper limit of normal, unless there is disease 
involvement of the liver, hemolysis, or a known history of Gilbert’s disease, in 
which case direct bilirubin must be ≤3 times the upper limit of normal
o
AST and ALT ≤ 2.5 times the upper limit of normal. If there is hemolysis or 
documented disease involvement of the liver, then patients with any AST or ALT 
abnormalities remain eligible.
o
creatinine clearance (CrCl) ≥ 50 mL/min using 24-hour urine collection for 
creatinine clearance or calculated CrCl OR calculated glomerular filtration rate 
(GFR) ≥ 50 mL/min/1.73m2 using the CKD-EPI equation
o
PT/INR ≤2 times the upper limit of normal and PTT ≤2 times the upper limit of 
normal
o
Absolute neutrophil count ≥750 cells/mm3 (0.75 x 109/L) or ≥500 cells/mm3 in 
subjects with documented bone marrow involvement 
o
Platelet count without transfusional support must be ≥50,000 cells/mm3 or ≥ 
30,000 cells/mm3 in subjects with documented bone marrow involvement

The effects of the study drugs on the developing human fetus are unknown.  Women of 
child-bearing potential must agree to remain abstinent or use highly effective 
contraception (defined as contraceptive measures that result in a failure rate of <1% per 
year) during the treatment period and for at least 2 days after the last dose of 
acalabrutinib, 30 days after the last dose of venetoclax or 18 months after the last dose of 
obinutuzumab, whichever is longer. Men with female sexual partners of childbearing 
potential should agree to remain abstinent or use contraceptive measures which include a 
condom plus an additional contraceptive method that together result in a failure rate 
of  1% per year during the treatment period and for at least 30 days after the last dose of 
venetoclax or 6 months after the last dose of obinutuzumab, whichever is longer. Men 
should refrain from donating sperm during the same period. 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.  

Ability to understand and the willingness to sign a written informed consent document.
Exclusion Criteria
Participants who exhibit any of the following conditions at screening will not be eligible for 
admission into the study:

Participants who have a history of other malignancies except:
o
Malignancy treated with curative intent and with no known active disease present 
and felt to be at low risk for recurrence by treating physician. Current adjuvant 
hormonal therapy for disease treated with curative intent is permissible.
o
Adequately treated non-melanoma skin cancer or lentigo maligna without 
evidence of disease.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
39
o
Adequately treated carcinoma in situ without evidence of disease.
o
Low-risk prostate cancer on active surveillance

Participants who are receiving any other investigational agents.

History of severe allergic reactions attributed to compounds of similar chemical or 
biologic composition to obinutuzumab, venetoclax, or acalabrutinib. Patients with 
reactions to other CD20 monoclonal antibodies (e.g. rituximab, ofatumumab) are not 
excluded. 

Unable to receive prophylactic treatment for pneumocystis, herpes simplex virus (HSV), 
and herpes zoster (VZV) at start of treatment

Known or suspected Richter’s transformation or known CNS involvement

Concurrent systemic immunosuppressant therapy (e.g., cyclosporine A, tacrolimus, etc., 
within 28 days of the first dose of study drug or chronic administration of >20 mg/day of 
prednisone within 7 days of the first dose)

Vaccinated with live, attenuated vaccines within 4 weeks of first dose of study drug.

Ongoing or recent infection requiring intravenous antimicrobials at time of screening.  
Patients with ongoing use of prophylactic antibiotics are eligible as long as there is no 
evidence of active infection and the antibiotic is not included on the list of prohibited 
medications.

Known bleeding disorders (e.g. von Willebrand’s disease) or hemophilia.

Presence of a gastrointestinal ulcer diagnosed by endoscopy within 3 months before 
screening.

History of stroke or intracranial hemorrhage within 6 months prior to enrollment.

Major surgery within 4 weeks of first dose of study drug. If a subject had major surgery 
greater than 4 weeks prior to the first dose, they must have recovered adequately from 
any toxicity and/or complications from the intervention before the first dose of study 
drug.

Currently active, clinically significant cardiovascular disease, such as uncontrolled 
arrhythmia or Class 3 or 4 congestive heart failure as defined by the New York Heart 
Association Functional Classification; or a history of myocardial infarction, unstable 
angina, or acute coronary syndrome within 6 months prior to randomization. Patients 
with atrial fibrillation are allowed as long as they are adequately rate controlled.

Baseline QTcF >480 ms. NOTE: This criterion does not apply to patients with a left 
bundle branch block.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
40

Patients who require warfarin or other vitamin K antagonists for anticoagulation (other 
anticoagulants are allowed).

Patients who require treatment with proton pump inhibitors (see Appendix F).  Subjects 
receiving proton pump inhibitors who switch to H2-receptor antagonists or antacids are 
eligible for enrollment on this study.

Patients who require concurrent treatment with strong CYP3A inhibitors or strong 
CYP3A inducers are excluded from the study. If patients are receiving strong CYP3A 
inhibitors/inducers at time of screening but do not require continuous administration of 
these agents, these patients are eligible if there is a 3-day washout period between 
discontinuation of the strong CYP3A inhibitor/inducer and initiation of the first study 
drug, acalabrutinib.

Patients who require concurrent treatment with P-gp inhibitors or narrow therapeutic 
index P-gp substrates are excluded from the study. If patients are receiving P-gp 
inhibitors or narrow therapeutic index P-gp substrates at time of screening but do not 
require continuous administration of these agents or can be switched to alternative agents, 
these patients are eligible if there is a 3-day washout period between discontinuation of 
the P-gp inhibitor and initiation of venetoclax.

Unable to swallow tablets or malabsorption syndrome, disease significantly affecting 
gastrointestinal function, or resection of the stomach or small bowel if thought by the 
investigator to compromise systemic absorption, active, symptomatic inflammatory 
bowel disease or ulcerative colitis, or partial or complete bowel obstruction.

Lactating or pregnant women are excluded from this study because venetoclax has been 
shown to decrease implantation, litter size, live fetuses, and fetal body weight in animal 
models. Because there is an unknown but potential risk for adverse events in nursing 
infants secondary to treatment of the mother with venetoclax, breastfeeding should be 
discontinued if the mother is treated with venetoclax. These potential risks may also 
apply to other agents used in this study.

Patients with human immunodeficiency virus (HIV), human T cell leukemia virus 
(HTLV), active hepatitis C virus (HCV), or active hepatitis B virus (HBV) infection. 
HIV-positive participants are ineligible because of the potential for pharmacokinetic 
interactions between certain components of anti-retroviral therapy and venetoclax. 
Patients who are positive for hepatitis B core antibody or hepatitis B surface antigen must 
have a negative polymerase chain reaction (PCR) result before enrollment. Those who 
are PCR positive will be excluded. Those who are positive for either hepatitis B surface 
antigen and/or hepatitis B core antibody but negative for HBV DNA will be managed as 
detailed in section 5.4. Patients who are positive for HCV antibody must be negative for 
HCV by polymerase chain reaction (PCR) to be eligible for study participation.

Unwilling or unable to participate in all required study evaluations and procedures. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
41

Unable to understand the purpose and risks of the study and to provide a signed and dated 
informed consent form (ICF) and authorization to use protected health information (in 
accordance with national and local subject privacy regulations)

Significant co-morbid condition or disease which in the judgment of the Principal 
Investigator would place the patient at undue risk or interfere with the 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, 
compromise the subject’s safety, or put the study outcomes at undue risk.
3.2
Inclusion of Women and Minorities
Both men and women of all races and ethnic groups are eligible for this trial. The eligibility 
criteria will not have a negative impact on enrollment of women, particularly since most women 
with CLL are postmenopausal.  We will make every effort to enroll minorities on this study.
4. REGISTRATION PROCEDURES
4.1
Informed Consent
The subject must read, understand and sign the consent form approved by the institutional review 
board, confirming his or her willingness to participate in this study before initiating any 
screening activity that is not standard of care. Subjects must also grant permission to use 
protected health information, if required by local regulations.
4.2
Medical History
Collect and record the subject’s complete history through review of medical records and by 
interview. Concurrent medical signs and symptoms must be documented to establish baseline 
severities. A disease history, including the date of initial diagnosis and list of all prior anticancer 
treatments, and responses and duration of response to these treatments, also will be recorded.
4.3
Confirmation of Eligibility
Subject eligibility for enrollment will be assessed per Section 3.1.  All screening procedures, 
unless otherwise indicated, should be completed within the timeframe as detailed in section 10.
4.4
General Guidelines for DF/HCC Institutions
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
42
registration will be denied.
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist.
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in the CTMS (OnCore) as soon 
as possible, with an appropriate date and reason entered. 
4.5
Registration Process for DF/HCC Institutions
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.  
4.6
General Guidelines for Other Investigative Sites
Eligible participants will be entered on study centrally at Dana-Farber Cancer Institute by the 
lead site project manager.  All sites should call the project manager to verify dose level and or 
slot availabilities.  
Following registration, participants should begin protocol therapy as soon as feasible. Issues that 
would cause treatment delays should be discussed with the Overall PI.  If the subject does not 
receive protocol therapy following registration, the subject must be taken off-study in the CTMS 
(OnCore) with an appropriate date and reason entered.
4.7
Registration Process for Other Investigative Sites
To register a participant, the following documents should be completed by the research nurse or 
data manager and faxed or e-mailed to the lead site project manager. 

Copy of relevant medical records that support the items on the eligibility checklist 
(with PMI redacted)

Participant consent form signed by both the consenting physician investigator, and the 
participant

HIPAA authorization form (if applicable)

Completed eligibility checklist
The participating site will e-mail the lead site project manager to verify eligibility.  The project 
manager will follow DF/HCC policy (REGIST-101) and register the participant on the protocol.  
The lead site project manager will email the participant study number, and if applicable the dose 
treatment level, to the participating site.  The lead site may also contact the participating site and 
verbally confirm registration. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
43
5. TREATMENT PLAN
5.1
Treatment Regimen
Treatment will generally be administered on an outpatient basis, except in the case that a patient 
meets the high risk criteria for TLS syndrome at the time of venetoclax initiation (see section 
6.1.2 below). The length of each treatment cycle is 28 days. Expected toxicities and potential 
risks as well as dose modifications for venetoclax, obinutuzumab, and acalabrutinib are 
described in Section 6 (Expected Toxicities and Dosing Delays/Dose Modification). No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the participant’s malignancy.
Acalabrutinib Lead-In: Cycle 1
All eligible subjects will begin by receiving one cycle (days 1-28) of acalabrutinib monotherapy. 
Acalabrutinib will be given continuously at the recommended phase 2 dose of 100mg orally 
twice a day (Byrd et al., 2016).
Regimen Description
Agent
Premedications; 
Precautions
Dose
Route
Schedule
Cycle 
Length
Acalabrutinib
None
100mg
oral
bid
28 days 
(4 weeks)
Acalabrutinib and Obintuzumab Combination Therapy: Cycles 2-3
For the next two 28-day cycles, subjects will receive acalabrutinib and obinutuzumab 
combination therapy. Acalabrutinib will be continued at the dose of 100mg orally twice daily. 
Obintuzumab will be given as per the route, timing, and dose of the FDA-approved label. On 
cycle 2 day 1, after the morning dose of acalabrutinib is taken, obinutuzumab will begin with the 
100mg intravenous dose. On cycle 2 day 2, after the morning dose of acalabrutinib is taken, the 
subject will receive 900mg of obinutuzumab. On cycle 2 day 8 and again on cycle 2 day 15, the 
subject will receive 1000mg of obinutuzumab. Finally, on cycle 3 day 1, the subject will receive 
1000mg of obinutuzumab in addition to acalabrutinib.
Regimen Description
Agent
Premedications; 
Precautions
Dose
Route
Schedule
Cycle 
Length
Acalabrutinib
None
100mg
oral
bid
100mg
iv
Cycle 2 Day 1
900mg
iv
Cycle 2 Day 2
1000mg
iv
Cycle 2 Day 8
1000mg
iv
Cycle 2 Day 15
Obinutuzumab
Premedication before 
each infusion, as 
described in section 
5.3.2
1000mg
iv
Cycle 3 Day 1
28 days 
(4 weeks)

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
44
Acalabrutinib, Obintuzumab, and Venetoclax Combination Therapy: Cycles 4-7
For the next four 28-day cycles, subjects will receive acalabrutinib, obinutuzumab, and 
venetoclax combination therapy. Acalabrutinib will be continued at the dose of 100mg orally 
twice daily. Obintuzumab will be given as four monthly 1000mg intravenous doses. Venetoclax 
will be given in a ramp-up dose-escalation fashion. Patients will be restaged after cycle 3 and 
this will be used to determine tumor lysis syndrome risk.
On days where multiple drugs are taken, unless specified otherwise in this document, there is no 
recommended order in which to take the drugs. The order in which the drugs can be taken is at 
the discretion of the treating investigator. On days when Obintuzumab is administered, the oral 
agents are to be dosed prior to the initiation of Obintuzumab. 
Regimen Description
Agent
Premedications; 
Precautions
Dose
Route
Schedule
Cycle 
Length
Acalabrutinib
None
100mg
oral
bid
1000mg
iv
Cycle 4 Day 1
1000mg
iv
Cycle 5 Day 1
1000mg
iv
Cycle 6 Day 1
Obinutuzumab
Premedication before 
each infusion, as 
described in section 5.3.2
1000mg
iv
Cycle 7 Day 1
20mg
oral
Cycle 4 Day 1
50mg
oral
Cycle 4 Days 2-7
100mg
oral
Cycle 4 Days 8-14
200mg
oral
Cycle 4 Days 15-21
400mg
oral
Cycle 4 Days 22-28
Venetoclax
TLS monitoring labs, IV 
fluids, allopurinol prior to 
first dose (or rasburicase 
if deemed necessary) 
400mg
oral
daily, Cycles 5-7
28 days 
(4 weeks)
Acalabrutinib and Venetoclax Combination Therapy: Cycles 8-15
For the next eight 28-day cycles (cycles 8-15), patients will receive acalabrutinib and venetoclax 
combination therapy. Acalabrutinib will be continued at the dose of 100mg orally twice daily. 
Venetoclax will be continued at the dose of 400mg orally once daily. 
Regimen Description
Agent
Premedications; 
Precautions
Dose
Route
Schedule
Cycle 
Length
Acalabrutinib
None
100mg
oral
bid
Venetoclax
None
400mg
oral
daily
28 days 
(4 weeks)
Cycles 15-24 and beyond
A bone marrow biopsy and response assessment will occur at the end of cycle 15. In patients 
who are negative for minimal residual disease in the bone marrow and in the peripheral blood at 
that time (as assessed by flow cytometry with a sensitivity of 10-4) and who are also in complete 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
45
remission or complete remission with incomplete marrow recovery (all as defined in section 11.3 
and Appendix B), acalabrutinib and venetoclax will have the option to discontinue therapy at the 
conclusion of cycle 15. Patients will receive peripheral blood monitoring for minimal residual 
disease at cycles 18, 20, 22, 25, and then every three cycles for two additional years. If 
recurrence is detected, the patient will undergo restaging with a CT scan (if not done within the 
prior three months) and a bone marrow biopsy and rapid heme panel (RHP) (if not done within 
the prior six months). Additionally, if recurrence is detected, the patient may resume 
acalabrutinib 100mg orally twice daily and venetoclax 400mg orally daily, continuing until 
disease progression or unacceptable toxicity. 
In patients who are positive for minimal residual disease in the bone marrow or blood at the end 
of cycle 15 (in the setting of CR/CRi), or in patients who are in partial remission at the 
completion of cycle 15 (irrespective of MRD status), acalabrutinib 100mg orally twice daily and 
venetoclax 400mg orally daily will be continued through cycle 24. At cycle 24, patients will 
receive another bone marrow biopsy and disease assessment. If this demonstrates undetectable 
MRD in both the blood and bone marrow, patients will have the option to discontinue therapy at 
the conclusion of cycle 24. If the cycle 24 bone marrow biopsy or peripheral blood is positive for 
MRD, he/she will continue acalabrutinib 100mg orally twice daily and venetoclax 400mg orally 
daily; both drugs will be continued (acalabrutinib at 100mg bid and venetoclax at 400mg daily) 
until disease progression or unacceptable toxicity. Patients will have the option to discontinue 
therapy at any point after cycle 25 if they achieve two consecutive negative MRD assessments 
that are 3 months apart.
Patients who have discontinued therapy will receive peripheral blood monitoring for minimal 
residual disease (as assessed by flow cytometry with a sensitivity of 10-4) every three cycles for 2 
years after completion of cycle 24. Recurrent disease is defined as the appearance of progressive 
disease as defined by 2018 IWCLL criteria (see Appendix B); in addition, the reappearance of a 
clonal population on peripheral blood MRD testing after achievement of undetectable MRD will 
also be considered recurrent disease. If recurrence is detected, the patient will undergo restaging 
with a CT scan (if not done within the prior three months) and a bone marrow biopsy (if not done 
within the prior six months). Additionally, the patient may resume acalabrutinib and venetoclax. 
Acalabrutinib should be resumed at the dose level the patient was receiving when the drug was 
discontinued. For venetoclax, subjects may resume the drug at their prior dose only if disease 
recurrence is initially detected with peripheral blood flow cytometry MRD monitoring only. In 
that case when dosing is resumed patients should have TLS labs checked pre-dose, 6-8 hours 
post-dose, and 24 hours post-dose for close monitoring of TLS.  If disease recurrence is detected 
through alternative means (e.g. physical exam, radiographic imaging, or complete blood count), 
then the subject should be assessed for risk of tumor lysis syndrome as detailed in section 6.1.2 
and venetoclax should be reinitiated following the ramp-up schedule outlined in section 5.3.2. 
Subjects will then receive acalabrutinib and venetoclax continuously until experiencing 
progression or intolerable toxicity.
In patients who have stable disease or progressive disease at cycle 15 as compared to pre-
treatment baseline scans, investigational therapy will be discontinued and patients will come off 
treatment. Patients deriving clinical benefit from study treatment may continue on therapy at 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
46
the discretion of the treating investigator to bridge to next treatment even if there is evidence of 
progressive disease.
5.2
Pre-Treatment Criteria
Cycle 1, Day 1
Participants must meet all of the inclusion criteria, have none of the exclusion criteria,
and must be registered to the protocol prior to initiating therapy.
C1D1 laboratory results need not meet eligibility parameters again provided that they met
criteria at screening and in the opinion of the treating investigator do not pose any undue
risk to the participant.
Cycle 4 Days 1, 2, 8, 15, 22
These are the days of venetoclax initiation or dose escalation. Tumor lysis labs (potassium, uric 
acid, phosphorous, calcium, and creatinine) must be checked prior to the patient receiving their 
dose of venetoclax, and must not meet Cairo Bishop criteria (Appendix D) for TLS. If criteria for 
TLS are met, the venetoclax dose should be delayed until electrolytes return to baseline.
All cycles subsequent to cycle 1
If labs are checked prior to cycle initiation, then the following criteria must be met:

ANC must be ≥ 500/mm3 

Platelet count must be ≥ 20k/µL (may be 10-20k/µL if transfusion support is also given)

All non-hematologic toxicities must have resolved to ≤ Grade 2, or to the patient’s 
baseline condition
5.3
Agent Administration
The participant will be requested to maintain a medication diary of each dose of medication. The 
medication diary will be returned to clinic staff at study visits. The date, time, and quantity of 
drug taken will be recorded in a drug self-administration diary. Patients should record any 
deviation from taking the full daily dose (e.g. vomited doses, missed doses, doses reduced due to 
missing or lost tablets). Missed doses outside the windows defined above or vomited doses 
should not be taken or repeated. At each visit, a sufficient number of doses will be dispensed so 
that the patient will have the required number of doses until the next visit, taking into account the 
window for the next visit.  In extenuating circumstances study drug can be shipped directly from 
the study site pharmacy to the patient.
On days where multiple drugs are taken, unless specified otherwise in this document, there is no 
recommended order in which to take the drugs. The order in which the drugs can be taken is at 
the discretion of the treating investigator. On days when obintuzumab is administered, the oral 
agents are to be dosed prior to the initiation of obintuzumab.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
47
Acalabrutinib
Acalabrutinib 100 mg will be administered orally twice daily and given in continuous 28-day 
cycles. The first dose of acalabrutinib 100 mg (one 100 mg tablet) will be self-administered by 
patients on C1D1. Acalabrutinib should be administered with 8 ounces (approximately 240 mL) 
of water. The tablets should be swallowed intact and patients should not attempt to break or 
crush tablets, or dissolve them in water. Doses of acalabrutinib should be taken approximately 12 
hours apart, and each dose should be taken at approximately the same time each day. 
Acalabrutinib may be administered without regard to meals. If a dose is not taken at the 
scheduled time, it can be taken as soon as possible up to 3 hours later on the same day, with a 
return to the normal schedule the following day. If a dose is missed by more than 3 hours, it 
should be skipped and the next dose should be taken at its regularly scheduled time. The patient 
should not take extra tablets to make up the missed dose. The total length of acalabrutinib 
therapy will be 15 cycles for patients who have achieved MRD-negative CR/CRi at the 
conclusion of cycle 15 and choose to discontinue therapy. Patients who have not achieved MRD-
negative CR/CRi at cycle 15 will continue acalabrutinib (with venetoclax) until cycle 24, at 
which point there will be another response assessment of the bone marrow. Patients who have 
achieved an MRD-negative CR/CRi  at this time will have the option to cease therapy and begin 
surveillance; patients who are MRD positive will continue acalabrutinib (with venetoclax) until 
disease progression. 
Obinutuzumab
Obinutuzumab will be administered by intravenous infusion over six 28-day cycles, beginning 
on cycle 2. Obinutuzumab will be given as the following doses: 100mg on D1, 900mg on D2, 
1000mg on D8 and D15 in cycle 2, then five 28-day cycles in cycles 3-7. The schedule and 
details for obinutuzumab dosing are as follows. The cycle numbers are specific to this trial:

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
48
Day of treatment cycle
Dose of 
Obinutuzumab
Rate of infusion (in the absence of infusion 
reactions/hypersensitivity during previous 
infusions)
Day 1 
100 mg
Administer at 25 mg/hr over 4 hours. Do not 
increase the infusion rate. 
Day 2 
900 mg 
Administer at 50 mg/hr. The rate of the infusion 
can be escalated in increments of 50 mg/hr every 
30 minutes to a maximum rate of 400 mg/hr. 
Day 8 
1000 mg 
Cycle 2 
(loading doses) 
Day 15
1000 mg
Cycles 3-7
Day 1
1000mg
If no infusion reaction occurred during the 
previous infusion and the final infusion rate was 
100 mg/hr or faster, infusions can be started at a 
rate of 100 mg/hr and increased by 100 mg/hr 
increments every 30 minutes to a maximum of 
400 mg/hr. 
Obinutuzumab must be administered in a clinical setting (inpatient or outpatient).  Full 
emergency resuscitation facilities should be immediately available, and patients should be under 
close supervision by a clinician at all times. Obinutuzumab should be given as a slow IV infusion 
through a dedicated line. IV infusion pumps should be used to control the infusion rate of 
obinutuzumab. Do not administer as an IV push or bolus. After the end of the first infusion, the 
IV line should remain in place for at least 2 hours in order to be able to administer IV drugs if 
necessary.  If no AEs occur after 2 hours, the IV line may be removed.  For subsequent infusions, 
the IV line should remain in place for at least 1 hour from the end of infusion; if no AEs occur 
after 1 hour, the IV line may be removed. There will be 1 hour observation following 
Obinutuzumab infusion in Cycle 2, and observation may be waived if participant has tolerated 
previous infusions without issue beginning with Cycle 3. If less than 100mg is delivered on the 
cycle 2 day 1 dose, the patient may still receive the 900mg dose on cycle 2 day 2, as per standard 
of care.
Patients who experience a significant obinutuzumab infusion reaction may be treated with an 
obinutuzumab desensitization protocol as per institutional standards, provided that this is 
approved by the PI and that the desensitization is done in collaboration with an allergist.
Premedication Requirements
Infusion-Related Reactions
Since some patients may develop hypersensitivity or other infusion-related reactions (IRRs) to 
obinutuzumab, pre-medication is recommended to reduce the risk of infusion reactions. 
Premedication will be given as outlined below. Cycle numbers are specific to this trial: 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
49
Day of 
treatment 
cycle
Patients 
Requiring Pre-
medication
Premedication
Administration
Intravenous 
glucocorticoid: 
methylprednisolone 80mg1
Completed at least one hour prior to 
obinutuzumab infusion.
acetaminophen 1000mg 
orally
Taken at least 30 minutes before 
obinutuzumab infusion.
Cycle 2, 
days 1 and 2 
 
All patients
diphenhydramine 50mg 
intravenously or orally
All patients
acetaminophen 1000mg 
orally
Taken at least 30 minutes before 
obinutuzumab infusion.
acetaminophen 1000mg 
orally
Patients with an 
IRR (Grade 1-
2) with the 
previous 
infusion
diphenhydramine 50mg 
intravenously or orally
Taken at least 30minutes before 
obintuzumab infusion.
intravenous 
glucocorticoid: 
methylprednisolone 80mg1
Completed at least one hour prior to 
obinutuzumab infusion.
acetaminophen 1000mg 
orally
All 
subsequent 
infusions
Patients with a 
Grade 3 IRR 
with the 
previous 
infusion OR 
with a 
lymphocyte 
count > 25x109 
/ L prior to next 
treatment
diphenhydramine 50mg 
intravenously or orally
Taken at least 30 minutes before 
obinutuzumab infusion.
1 Hydrocortisone is not recommended as it has not been effective in reducing the rate of infusion reactions.
If a patient experiences any grade infusion reaction during infusion, adjust the infusion as 
outlined below:

Grade 4 (life threatening): Stop infusion and discontinue obinutuzumab.

Grade 3 (severe): Temporarily interrupt infusion and treat symptoms.  Upon resolution of 
symptoms, restart infusion at no more than half the previous rate (the rate being used at 
the time that the infusion reaction occurred) and, if patient does not experience any 
infusion reaction symptoms, infusion rate escalation may resume at the increments and 
intervals as appropriate for the treatment dose.

Grade 1-2 (mild to moderate): Reduce infusion rate and treat symptoms.  Upon resolution 
of symptoms, continue infusion and, if patient does not experience any infusion reaction 
symptoms, infusion rate escalation may resume at the increments and intervals as 
appropriate for the treatment dose.
Hypotension may be expected to occur during obinutuzumab infusions.  Withholding of 
antihypertensive treatments can be considered for 12 hours prior to and throughout each 
obinutuzumab infusion and for the first hour after administration.  Patients at acute risk of 
hypertensive crisis should be evaluated for the benefits and risks of withholding their 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
50
hypertensive medication.
Venetoclax
Venetoclax will be administered orally once daily and given in continuous 28-day cycles. 
Venetoclax administration will begin on cycle 4 day 1. If patients are in an MRD-negative 
CR/CRi at the end of cycle 15, then patients will have the option to discontinue venetoclax at this 
time. If patients are not in an MRD-negative CR/CRi at the end of cycle 15, then venetoclax will 
be continued (along with acalabrutinib) through cycle 24, at which point another response 
assessment will occur. If patients are not in an MRD-negative state at this time, venetoclax (with 
acalabrutinib) will continue indefinitely until progression or toxicity. If patients are in an MRD-
negative state, they will have the option to discontinue venetoclax  and the patient will be 
monitored for disease recurrence. 
Venetoclax is initiated with a dose ramp-up to reduce the risk of tumor lysis syndrome. In this 
trial, we will use a slightly modified dose escalation strategy since the patients will have already 
had significant debulking of their disease with three prior cycles of acalabrutinib and two prior 
cycles of obinutuzumab. This dosing regimen of escalating from 20 mg to 50 mg on day 2 is 
modeled after the experience from the M13-982 venetoclax trial, which showed that this is a safe 
approach (Stilgenbauer et al., 2016).  The dosing schedule for venetoclax in this trial is as 
follows. Note that this ramp-up schedule cannot be shortened, but may be lengthened if TLS is 
observed.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
51
Day of 
treatment 
cycle
Venetoclax 
Daily Dose
Cycle 4, 
day 1
20mg
Cycle 4, 
days 2-7
50mg
Cycle 4, 
days 8-14
100mg
Cycle 4, 
days 15-21
200mg
Cycle 4, 
days 22-28
400mg
Cycles 5 
and beyond
400mg

For patients at low or medium risk of tumor lysis syndrome (as defined in section 6.1.2), 
venetoclax will be given as a 20mg oral dose on cycle 4 day 1. Patients will receive 
intravenous hydration of 150-200ml/hr while in the outpatient infusion area.  Tumor lysis 
labs (including potassium, uric acid, phosphorous, calcium, and creatinine) must be 
checked on cycle 4 day 1 prior to this dose, approximately 6-8 hours after dosing, and 
again the following day, approximately 24 hours after the initial dose (prior to the second 
dose of venetoclax on cycle 4 day 2). If Cairo-Bishop criteria (Appendix D) for 
laboratory or clinical tumor lysis syndrome (TLS) are met on these follow-up labs, TLS 
management will occur as per Appendix E, and the patient will either have drug held or 
continue at 20mg daily (depending on severity) until the changes resolve, at which point 
the patient will escalate to 50mg daily. If Cairo-Bishop criteria for TLS are not met, the 
patient will dose escalate to 50mg on day 2. TLS labs should be checked again on cycle 4 
day 2 approximately 6-8 hours after dosing and approximately 24 hours post the first 
50mg dose.

Patients at high risk of TLS (as defined in section 6.1.2) will be admitted to the hospital 
for venetoclax initiation. Patients will receive intravenous hydration of 150-200ml/hr, 
prior to receiving their first dose of venetoclax 20mg. Tumor lysis labs will be checked 
on cycle 4 day 1 prior to this initial dose and then at approximately 4, 8, 12, and 24 hours 
later. If Cairo-Bishop criteria for tumor lysis syndrome are not met (see Appendix D), the 
patient will be escalated to 50mg daily on cycle 4 day 2. Tumor lysis labs will then be 
checked approximately 4, 8, 12, and 24 hours after this second dose.
Patients will continue on 50mg daily for cycle 4 days 2-7, then 100mg daily on cycle 4 days 8-
14, then 200mg daily on cycle 4 days 15-21, and finally 400mg daily on cycle 4 days 22-28. For 
the initial doses of 100mg, 200mg, and 400mg, TLS labs should be checked prior to initiating the 
higher dose, approximately 6-8 hours post dose, and approximately 24 hours post dose, with 
dose escalation occurring only if criteria for TLS are not met. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
52
For the remaining length of therapy, venetoclax will be given at a dose of 400mg daily.
Patients should take venetoclax within approximately 30 minutes after the completion of 
breakfast or the subject's first meal of the day.  Patients may not consume:  Grapefruit or 
grapefruit products, Seville oranges (including marmalade containing Seville oranges) or 
starfruit within the 3-day period prior to the first study drug administration and until the last day 
of treatment is completed due to possible CYP3A mediated metabolic interaction.
Other Modality(ies) or Procedures
N/A
5.4
General Concomitant Medication and Supportive Care Guidelines
General Supportive Care
Patients should receive full supportive care, including transfusions of blood and blood 
products, antibiotics, hematopoietic growth factors, analgesics, and antiemetics when 
appropriate.
Tumor Lysis Syndrome Prophylaxis
Tumor lysis syndrome (TLS), characterized by hyperkalemia, hyperuricemia, and 
hyperphosphatemia resulting from the rapid release of potassium, uric acid, and phosphate, has 
been reported in patients with CLL initiating venetoclax. There is a modest risk of TLS in 
patients treated with obinutuzumab, and as such it is recommended that patients receive 
allopurinol prior to starting on obinutuzumab.  The risk of TLS on this study is highest during the 
first cycle of venetoclax combination therapy.  It is strongly recommended that allopurinol 
300mg PO daily begin 3 days before the initiation of venetoclax on cycle 4 day 1, and 
allopurinol should continue through the end of the first cycle of triple combination therapy.  
Patients with an allopurinol allergy should receive alternative TLS prophylaxis (e.g. febuxostat) 
if possible. In addition to pharmacologic TLS prophylaxis, all patients should be instructed to 
maintain adequate hydration and maintain urinary output as an additional measure to reduce the 
risk of TLS.  Based on clinical and laboratory parameters, TLS prophylaxis may be continued or 
restarted as needed at the investigator’s discretion. All patients meeting criteria of laboratory 
TLS or clinical TLS according to the Cairo-Bishop definition of TLS (Appendix D) should 
receive vigorous intravenous hydration and should be considered for rasburicase therapy as 
needed to reduce hyperuricemia, until correction of electrolyte abnormalities. See section 6.1, 
dose modification table, for additional instructions.
Hepatitis B Monitoring and Prophylaxis
Testing for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (HBcAb) is 
required for all subjects at the time of enrollment. Subjects who are positive for either HBsAg 
and/or HBcAb must also be tested for serum HBV DNA. Subjects who are positive for HBV 
DNA are excluded from the study. Subjects who are negative for HBV DNA but positive for 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
53
either HBsAg or HBcAb must receive pharmacologic prophylaxis to prevent HBV reactivation. 
Entecavir is the preferred agent for pharmacologic prophylaxis. Use of an agent other than 
entecavir must be discussed with the principal investigator. Prophylaxis should be administered 
for as long as the subject is receiving a study medication or for up to 12 months after the last 
dose of obinutuzumab, whichever is longer. HBV DNA should be monitored every three months 
while a patient is receiving pharmacologic prophylaxis. If the HBV DNA level becomes 
detectable, all study medications should be discontinued and infectious disease consultation 
should be obtained. If a subject who meets criteria for prophylaxis is not willing or able to 
receive prophylaxis, then he/she will be excluded from the study.
Growth Factor Support
White blood cell growth factor support with Neulasta, Neupogen, or tbo-filgrastim (Granix) will 
be administered at the discretion of the treating investigators with dosing as per standard of care.  
Neulasta, Neupogen, and Granix will be from commercial supply.
Prophylactic Antibiotics
Prophylaxis for Pneumocystis jiroveci pneumonia (PCP) with trimethoprim/sulfamethoxazole 
(typically given as one single-strength tablet daily) or equivalent is mandatory for all 
patients. Anti-herpetic viral prophylaxis with acyclovir (typically given as 400mg po tid) or 
equivalent is mandatory for all patients. 
Intravenous Immunoglobulin
Immunoglobulin replacement with intravenous immunoglobulin (IvIg) therapy is permitted for 
patients who, at the discretion of the investigator, require IvIg for primary prophylactic or 
secondary prevention of infection.
Moderate or Strong CYP3A Modulators
Minor CYP3A4 inducers or inhibitors (e.g. amlodipine) are allowed without any dose changes to 
the study drugs. Patients who require treatment with strong CYP3A inhibitors or inducers (partial 
list in Appendix F) are excluded from enrollment in the study. However, if treatment with strong 
CYP3A inhibitors becomes necessary while subjects are on study treatment, dosing of 
venetoclax and acalabrutinib should be managed as detailed in Table 4 below. Of note, 
venetoclax should held if treatment with strong CYP3A inhibitors or inducers is required during 
the ramp-up phase of drug administration. Dosing of acalabrutinib should be interrupted while 
the subject is on the strong CYP3A inhibitor, as detailed in Table 4 below. Three days after 
discontinuation of the strong CYP3A inhibitor, resume acalabrutinib and resume or increase 
venetoclax to the dose that was used prior to initiating the CYP3A inhibitor. 
If treatment with moderate CYP3A inhibitors (see partial list in Appendix F) is required while 
subjects are on study, dosing of venetoclax and acalabrutinib should be reduced as detailed in 
Table 4 below. Three days after discontinuation of the moderate CYP3A inhibitor, increase 
acalabrutinib and venetoclax to the doses that were used prior to initiating the CYP3A inhibitor.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
54
If treatment with strong or moderate CYP3A inducers is required while the subject is on study, 
doses of venetoclax and acalabrutinib should be modified as detailed in Table 4. Three days after 
discontinuation of the strong CYP3A inducer, reduce acalabrutinib and resume venetoclax at the 
dose that was used prior to initiating the CYP3A inhibitor.
Dosing modifications of acalabrutinib and venetoclax do not need to be made if patients are 
receiving inhibitors or inducers of other CYP450 enzymes.
Table 4: Dosing Modifications in the Setting of CYP3A Modulators and P-gp Inhibitors
Medication Class
Initiation and Ramp-
Up Phase of 
Venetoclax
Steady Daily Dose of 
Venetoclax (after 
ramp up phase)
Steady Daily Dose of 
Acalabrutinib
Strong CYP3A Inhibitor
Contraindicated, hold 
venetoclax
Reduce venetoclax 
dose by 75% (e.g. 
100mg daily)
Interrupt acalabrutinib 
dosing
Moderate CYP3A 
inhibitor
Reduce venetoclax 
dose by 50% 
Reduce venetoclax 
dose by 50% (e.g. 
200mg daily)
Reduce acalabrutinib 
dose by 50% (e.g. 
100mg once daily)
Strong CYP3A Inducer
Contraindicated, hold 
venetoclax
Contraindicated, hold 
venetoclax
Double acalabrutinib 
dose (e.g. 200mg twice 
daily)
Moderate CYP3A 
Inducer 
Contraindicated, hold 
venetoclax
Contraindicated, hold 
venetoclax
Maintain acalabrutinib 
dose (e.g. 100mg twice 
daily)
P-gp Inhibitors or P-gp 
Substrates of Narrow 
Therapeutic Index
Contraindicated, hold 
venetoclax
Reduce venetoclax 
dose by 50% (e.g. 
200mg daily). Take 
inhibitor at least 6 
hours before 
venetoclax.
No change to dose
P-gp Inhibitors or P-gp Substrates of Narrow Therapeutic Index
Patients who require treatment with P-gp inhibitors or P-gp substrates of narrow therapeutic 
index (partial list in Appendix F) are excluded from enrollment in the study. However, if 
treatment with these drugs becomes necessary while subjects are on study treatment, dosing of 
venetoclax should be managed as detailed in Table 4 above. If a narrow therapeutic index P-gp 
substrate must be used, it should be taken at least 6 hours before venetoclax. Resume the 
venetoclax dose that was used prior to initiating the P-gp inhibitor 3 days after discontinuation of 
the inhibitor.
Drug-Drug Interactions
Because there is a potential for interaction of acalabrutinib and venetoclax with other 
concomitantly administered drugs through the cytochrome P450 system, the case report form 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
55
must capture the concurrent use of all other drugs, over-the-counter medications, or alternative 
therapies. If there are known drug-drug interactions between the study drug(s) and other 
medications that the patient is taking, dose reductions of the study drug(s) may occur at the 
discretion of the treating investigator.
5.5
Criteria for Taking a Participant Off Protocol Therapy
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue 
until one of the following criteria applies:

Disease progression

Intercurrent illness that prevents further administration of treatment

Pregnancy

Unacceptable adverse event(s)

Participant demonstrates an inability or unwillingness to comply with the oral 
medication regimen and/or documentation requirements

Participant decides to withdraw from the protocol therapy

General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator

EXCEPTION: patients deriving clinical benefit from study treatment may continue 
on therapy at the discretion of the treating investigator to bridge to next treatment 
even if there is evidence of progressive disease
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF). Alternative care options will be discussed with the 
participant.
An ODQ Treatment Ended/Off Study Form will be filled out when a participant is removed from 
protocol therapy. This form can be found on the ODQ website or obtained from the ODQ 
registration staff. 
In the event of unusual or life-threatening complications, treating investigators must notify the 
Overall PI, Matthew S. Davids, MD, as soon as possible, at 617-632-6331, DFCI pager 57215.
5.6
Duration of Follow Up
Once participants have completed study treatment they will be followed until initiation of new 
therapy, or until death, whichever occurs first. After cycle 24, subjects remaining on 
investigational therapy will be seen every 3 months in clinic for as long as they remain on study 
treatment. Subjects who discontinue acalabrutinib/venetoclax because they are in CR/CRi with 
MRD-negativity will be followed as per the study calendars in section 10. In these subjects, if no 
relapse is detected after 48 cycles of therapy, they may return to follow-up with a local 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
56
hematologist but will be followed by telephone for updates on disease progress and overall 
survival. Participants removed from treatment for unacceptable adverse events will be followed 
until resolution or stabilization of the adverse event, and/or until initiation of new therapy for 
their disease, whichever is longer.
5.7
Criteria for Taking a Participant Off Study
Participants will be removed from study when any of the following criteria apply:

Lost to follow-up

Withdrawal of consent for data submission

Start of new CLL-directed therapy

Disease Progression

Death
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF). Alternative care options will be discussed with the 
participant.
When a participant is removed from protocol therapy and/or is off of the study, the relevant Off-
Treatment/Off-Study information will be updated in OnCore. This form can be found on the 
ODQ website or obtained from the ODQ registration staff.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
57
6. DOSING DELAYS / DOSE MODIFICATIONS
Dose delays and modifications will be made as indicated in the following table(s). Hematologic 
AEs will be graded as per the IWCLL Grading Scale for Hematologic Toxicities in CLL Studies 
(Appendix C). Nonhematologic AEs will be described and graded as per the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. A copy of the CTCAE 
version 5.0 can be downloaded from the CTEP website
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
Given that multiple drugs in this study can cause similar side effects, treating clinician discretion 
in consultation with the Principal Investigator can be used to decide which agent to dose reduce 
when patients experience a side effect that could be attributable to multiple drugs. 
6.1
Venetoclax
Dose Reduction Table
The dose for venetoclax in this study is 400 mg QD (after intra-patient dose ramp-up).  If known 
venetoclax toxicities such as tumor lysis syndrome, gastrointestinal adverse events, or 
neutropenia (as detailed in sections 6.1.2 and 6.1.3) are observed, dose reductions to the 
following dose levels for venetoclax may be utilized:
Table 5: Venetoclax Dose Reduction Schema
Dose at Interruption, mg
Restart Dose, mga
400
300
300
200
200
100
100
50
50
20
20
10
aContinue the reduced dose for 1 week before 
increasing the dose.
Prophylaxis and Management of Tumor Lysis Syndrome
Upon initial treatment of CLL with venetoclax, there is a potential for TLS, especially in those 
with elevated lymphocyte count, bulky lymphadenopathy, and renal dysfunction.  To mitigate 
the risk for TLS, all patients on this study will be restaged with CT scan prior to initiation of 
venetoclax on cycle 4 day 1 to assess for risk of TLS. Patients will be managed according to 
Table 6. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
58
Table 6: Prophylaxis and Monitoring For TLS Syndrome in Patients Receiving Venetoclax
Prophylaxis
Blood Chemistry 
Monitoringc,d 
Tumor Burden
Hydrationa
Antihyperuricemics
Setting and Frequency 
of Assessments
Low 
All LN <5 cm AND 
ALC <25 x109/L 
Medium 
Any LN 5 cm to <10 cm 
OR ALC ≥25 x109/L 
Oral (1.5-2 L) and 
consider 
additional 
intravenous
Allopurinolb
Outpatient 
 Pre-dose, 6-8 hours 
post-dose, and 24 hours 
post-dose, on days where 
patient receives first dose 
of 20, 50, 100, 200, or 
400mg
 Consider hospitalization 
for patients with CrCl 
<80ml/min at first dose of 
20 mg and 50 mg; see 
below for monitoring in 
hospital 
High 
Any LN ≥10 cm OR 
ALC ≥25 x109/L AND 
any LN ≥5 cm 
Oral (1.5-2 L) and 
intravenouse
Allopurinol; consider 
rasburicase if 
baseline uric acid is 
elevatedf
Inpatient:
 Pre-dose, 4, 8,12 and 24 
hours post doses of 20 and 
50mg
Outpatient:
 At subsequent ramp-up 
doses as outlined above 
for low and medium risk 
patients
ALC = absolute lymphocyte count; LN = lymph node.
 
a Administer intravenous hydration for any patient who cannot tolerate oral hydration.
b If possible start allopurinol or xanthine oxidase inhibitor about 3 days prior to initiation of venetoclax.
c Evaluate blood chemistries (potassium, uric acid, phosphorus, calcium, and creatinine); review in real time. During 
the dose ramp-up period, the subsequent dose should not be administered until the 24 hours post-dose laboratory 
values are reviewed by the investigator.
d All same-day laboratory assessments may be taken within ±2 hour window, and 24 hour laboratory assessments 
within a ±6 hour window, if necessary
e Intravenous fluids should be given at 150-200 mL/hr starting the night before the first dose of 20 mg, with a target 
of approximately 1.5 – 2 L/day (or as clinically appropriate), and continued for at least 24 hours after completing the 
50mg dose.
f Rasburicase (given at a flat dose of 6 mg IV x 1, or per institutional standards) should be administered per 
institutional guidelines for patients with elevated uric acid level at baseline (> ULN) as prophylaxis prior to the 
initial dose of venetoclax.  For patients with a contraindication to rasburicase (i.e., glucose-6-phosphate 
dehydrogenase [G6PD] deficiency), the TLS risk-mitigation plan must be reviewed with the Overall PI.
If any significant laboratory changes are observed within the first 24 hours after initiation of 
dosing, see Appendix E (Recommendations for Initial Management of Electrolyte Abnormalities 
and Prevention of Tumor Lysis Syndrome [TLS]), for additional laboratory assessments and 
management guidelines.  If aggressive correction of electrolytes abnormalities was performed, 
the subsequent dose of venetoclax can only be given when electrolytes have been stable without 
any further treatment for approximately 24 hours.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
59
Management of Other Toxicities
The following tables provide recommended guidelines for venetoclax dose reduction based on 
specific toxicities. Any subject who discontinues venetoclax due to toxicity may continue on the 
other study medications.  Management not consistent with these guidelines should be discussed 
with the Overall PI:
Table 7: Dose Reduction Strategy for Patients Experiencing Non-Hematologic Toxicities on 
Venetoclax
Non-hematologic 
Toxicity Grade
Recommended Management/Next Dose for Venetoclax
≤ Grade 1 or 2
No change in dose
Grade 3
Hold* until ≤ Grade 1.  At first occurrence, resume at same dose, no 
dose modification is required. At second and subsequent occurrences,** 
hold venetoclax and follow dose reduction guidelines in Table 5 when 
resuming treatment with venetoclax after resolution.
Grade 4
Permanently cease venetoclax therapy unless toxicity can be attributed 
to an alternative cause
*Participants requiring a hold of >4 weeks of venetoclax due to a toxicity thought to be related to 
venetoclax should go off venetoclax therapy unless approved by the overall PI to remain on 
therapy.
**Participants requiring >3 dose reductions of venetoclax should go off venetoclax unless 
approved by the overall PI to remain on therapy.
With regard to specific nonhematologic toxicities, the recommended management for 
venetoclax-associated diarrhea is loperamide, dosed at 4 mg at first onset, followed by 2 mg with 
each loose bowel movement until diarrhea-free for 12 hours (maximum dosage: 16 mg/24 
hours). Adjunct anti-diarrheal therapy is permitted and should be recorded when used.
Table 8: Dose Reduction Strategy for Patients Experiencing Neutropenia on Venetoclax
Neutropenia in 
patients on 
venetoclax 
Recommended Management/Next Dose for Venetoclax
≤ Grade 1 or 
Grade 2
No change in dose
Grade 3
(ANC 500-999 
cells/mm3)
Hold* until ≤ Grade 2 or continue at current dose as long as growth factor is 
administered. (If venetoclax is continued, repeat ANC within 3 days and if 
still grade ≥3, hold venetoclax until ≤ Grade 2.) If not previously growth 
factor responsive, resume at one dose level lower, if indicated.**
Grade 4
(ANC <500 
cells/mm3)
Hold* until ≤ Grade 3, then resume therapy at the same dose but with G-CSF 
support. On second and subsequent occurrences, follow dose reduction 
guidelines in Table 5 when resuming treatment.** 
*Participants requiring a hold of >4 weeks of venetoclax due to a venetoclax related therapy 
should go off protocol therapy unless approved by the overall PI to remain on therapy.
**Participants requiring >3 dose reductions of venetoclax should go off venetoclax unless with 
approval by the overall PI to remain on therapy.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
60
Neutropenia in 
patients on 
venetoclax 
Recommended Management/Next Dose for Venetoclax
At any time during the study, if the patient presents with febrile neutropenia, it is recommended 
that venetoclax be interrupted until resolution of the fever or infection.  At the first occurrence, 
venetoclax may then be re-initiated at the same dose.  At a second or later occurrence, 
consideration should be given to venetoclax dose reduction.
Growth factor support with filgrastim or pegfilgrastim may be utilized as necessary throughout 
the study and does not require holding venetoclax.
Table 9: Dose Reduction Strategy for Patients Experiencing Venetoclax-Related Hematologic 
Toxicities (excluding Neutropenia) 
Venetoclax-related 
Hematologic 
Toxicities 
Management/Next Dose for Venetoclax
≤ Grade 1, 2, or 3
No change in dose
Grade 4
Hold* until ≤ Grade 3, unless the toxicity is thought to be due to a cause 
other than venetoclax. On first occurrence, venetoclax may be resumed 
at the same dose. On second and subsequent occurrences, follow the 
dose reduction guidelines in Table 5.**
*Participants requiring a hold of >4 weeks of venetoclax due to a venetoclax related therapy 
should go off protocol therapy unless approved by the overall PI to remain on therapy.
**Participants requiring >3 dose reductions of venetoclax should go off venetoclax unless with 
approval by the overall PI to remain on therapy.
6.2
Obinutuzumab
Dose Reduction Table
The dose of obinutuzumab is not modified but doses can be held or delayed as needed. Dose 
delays of obinutuzumab may be made as per the tables below if a toxicity is believed to be at 
least likely related to obinutuzumab. If a subject must permanently discontinue obinuzutumab 
prior to completion of the full six month course, acalabrutinib and venetoclax will continue to be 
administered as per the study calendar detailed in section 10. For the adverse event profile, see 
section 7.1.1 and the obinutuzumab IB.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
61
Table 10: Dose Modifications for Non-Infusion-Related-Reaction, Non-Hematologic Toxicities
Worst CTCAE Grade Toxicity
Recommended Action to be Taken
Grade 1 or 2
None
Grade 3 CTCAE 
Hold dosing of obinutuzumab until toxicity Grade ≤2 
If toxicity remains grade 3 toxicity 
for longer than 2 weeks
Consider permanent discontinuation of obinutuzumab
Recurrence of Grade 3 toxicity
Consider permanent discontinuation of obinutuzumab
Grade 4 CTCAE
Hold dosing of obinutuzumab until toxicity resolves to 
Grade ≤2 
Recurrence of Grade 4 toxicity
Consider permanent discontinuation of obinutuzumab
Infusion Related Reactions
If a patient experiences any grade infusion reaction during infusion, adjust the infusion as 
outlined below:

Grade 4 (life-threatening): Stop infusion and permanently discontinue therapy.

Grade 3 (severe): Temporarily interrupt infusion and treat symptoms.  Upon resolution of 
symptoms, restart infusion at no more than half the previous rate (the rate being used at 
the time that the infusion reaction occurred) and, if patient does not experience any 
infusion reaction symptoms, infusion rate escalation may resume at the increments and 
intervals as appropriate for the treatment dose. The Day 1 infusion rate may be increased 
back up to 25 mg/hr after 1 hour but not increased further.  Consideration can be given to 
following a desensitization protocol for future administration of the antibody.

Grade 1-2 (mild to moderate): Reduce infusion rate and treat symptoms.  Upon resolution 
of symptoms, continue infusion and, if patient does not experience any infusion reaction 
symptoms, infusion rate escalation may resume at the increments and intervals as 
appropriate for the treatment dose. The Day 1 infusion rate may be increased back up to 
25 mg/hr after 1 hour but not increased further.
Hypotension may be expected to occur during obinutuzumab infusions.  Withholding of 
antihypertensive treatments should be considered for 12 hours prior to and throughout each 
obinutuzumab infusion and for the first hour after administration.  Patients at acute risk of 
hypertensive crisis should be evaluated for the benefits and risks of withholding their 
hypertensive medication.
Tumor Lysis Syndrome
Management of tumor lysis syndrome related to obinutuzumab should be managed as per 
standard of care. Subjects should be monitored for TLS after the first infusion of obinutuzumab 
on cycle 2 day 1 as outlined in the study calendar in section 10.
6.3
Acalabrutinib
Treatment with acalabrutinib should be held for any unmanageable, potentially study drug-

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
62
related toxicity that is Grade ≥ 3 in severity. Study drug may be held for a maximum of 28 
consecutive days from expected dose due to toxicity. Acalabrutinib should be permanently 
discontinued in the event of a toxicity thought at least possibly due to acalabrutinib lasting > 28 
days despite holding drug, unless reviewed and approved by the Overall PI. Any subject who 
permanently discontinues acalabrutinib prior to cycle 4 will no longer be eligible for any of the 
study drugs and will come off study treatment but continue to be followed as detailed in section 
5.6. Any subject who discontinues acalabrutinib at cycle 4 or later may continue on the other 
study medications. 
Dose Reduction Table
The actions in Table 11 below should be taken for the following toxicities if thought to be at 
least possibly related to acalabrutinib:

Grade 4 ANC (< 500/μL) for > 7 days (Neutrophil growth factors are permitted and use 
must be recorded on the case report form [CRF]).

Grade 3 or higher platelet decreases in presence of significant bleeding.

Grade 4 platelet decreases.

Grade 3 or 4 nausea, vomiting, or diarrhea, if persistent for >7 days despite optimal 
antiemetic and/or anti-diarrheal therapy. 

Any other Grade 4 toxicity or unmanageable Grade 3 toxicity.
Table 11: Dose Modifications for Acalabrutinib
Occurrence
Action
1st - 2nd
Hold acalabrutinib until recovery to Grade ≤ 1 or baseline; may restart at 
original dose level
3rd
Hold acalabrutinib until recovery to Grade ≤ 1 or baseline; restart at one dose 
level lower (100 mg once daily)
4th
Discontinue acalabrutinib
Any changes to the dosing regimen must be recorded in the Dosage Administration CRF.
If acalabrutinib is reduced for apparent treatment-related toxicity, the dose need not be 
re-escalated, even if there is minimal or no toxicity with the reduced dose.  However, if the 
subject tolerates a reduced dose of acalabrutinib for ≥ 4 weeks then the dose may be increased to 
the next higher dose level, at the discretion of the investigator.  Such re-escalation may be 
particularly warranted if further evaluation reveals that the AE that led to the dose reduction was 
not treatment-related.  
6.4
Integrated Toxicity Management Guidelines When the Causative Agent is Unclear
The study drugs have some overlapping toxicities (e.g. diarrhea with venetoclax and 
acalabrutinib, neutropenia with all three agents), and in certain instances it may be unclear which 
agent is responsible for an adverse event that a patient is experiencing. If the treating clinician 
can identify the specific drug causing an adverse event, then the guidelines in sections 6.1-6.3 
can be used to guide dose reductions of that individual drug. If, however, the treating clinician is 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
63
uncertain which agent is responsible for a particular adverse event, then the guidelines below 
should be used for management of study drug dosing in these circumstances:
For grade 1 or grade 2 toxicities where the causative drug is uncertain, no changes to study drug 
dosing need to be made.
For grade 3 or 4 hematologic and non-hematologic toxicities where the causative drug is 
uncertain, all suspected drugs should be held until the toxicity improves. One drug (at treating 
clinician discretion) should then be introduced (at the same dose as when the medication was 
discontinued). Of note, if one of the suspected causes is obinutuzumab, the other suspected 
agent(s) (with a shorter half-life) should be introduced first. If the toxicity recurs after 
reintroduction of the first drug, then the adverse effect is deemed attributable to this drug and 
management should proceed according to the guidelines in sections 6.1-6.3. The other suspected 
agents may then be reintroduced after the toxicity has improved. If, on the other hand, the 
toxicity does not occur after one week of therapy with the first drug, a second study drug should 
be reintroduced. If the toxicity occurs, then the adverse effect is deemed attributable to this 
second drug and management should proceed according to guidelines in sections 6.1-6.3. If a 
third study drug is also suspected, then it may be introduced one week later if no toxicity has 
been observed after introduction of the first two. 
During cycle 8 and beyond, patients who have to hold either acalabrutinib or venetoclax due to 
drug-specific toxicity for longer than 4 weeks may stay on study and continue on monotherapy 
with the other agent that is not believed to be responsible for that toxicity.
7. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS
The following list of reported and/or potential AEs and the characteristics of an observed AE 
will determine whether the event requires expedited reporting in addition to routine reporting. 
7.1
Expected Toxicities
Adverse Events Lists
7.1.1.1
Adverse Event List for Obinutuzumab
Important risks identified in clinical investigations with obinutuzumab were:  IRRs (infusion-
related reactions), TLS, thrombocytopenia (including acute thrombocytopenia), neutropenia 
(including prolonged and late onset neutropenia), prolonged B-cell depletion, infections 
(including hepatitis B reactivation and PML), worsening of pre-existing cardiac conditions and 
GI perforation.  
Hepatitis B Reactivation
HBV reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can 
occur in patients treated with anti-CD20 antibodies such as obinutuzumab.  HBV reactivation has 
been reported in patients who are HBsAg positive and also in patients who are HBsAg negative 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
64
but are anti-HBc positive.  Reactivation has also occurred in patients who appear to have 
resolved hepatitis B infection (i.e., HBsAg negative, anti-HBc positive, and hepatitis B surface 
antibody [anti-HBs] positive). HBV reactivation is defined as an abrupt increase in HBV 
replication manifesting as a rapid increase in serum HBV DNA level or detection of HBsAg in a 
person who was previously HBsAg negative and anti-HBc positive.  Reactivation of HBV 
replication is often followed by hepatitis, i.e., increase in transaminase levels and, in severe 
cases, increase in bilirubin levels, liver failure, and death. Patients in this study who are positive 
for either HBsAg and/or anti-HBc Ab but negative for HBV DNA should be managed as 
outlined in section 5.4.
Progressive Multifocal Leukoencephalopathy
JC virus infection resulting in progressive multifocal leukoencephalopathy (PML), which can be 
fatal, was observed in patients treated with obinutuzumab.  The diagnosis of PML should be 
considered in any patient presenting with new onset or changes to preexisting neurologic 
manifestations.  Evaluation of PML includes, but is not limited to, consultation with a 
neurologist, brain magnetic resonance imaging, and lumbar puncture.  Discontinue 
obinutuzumab therapy and consider discontinuation of other agents in patients who develop 
PML. 
Infusion Reactions
Obinutuzumab can cause severe and life-threatening IRRs; 65% of patients with CLL 
experienced a reaction to the first 1000 mg infused of obinutuzumab, and 38% of iNHL patients 
experienced a reaction on Day 1 of obinutuzumab infusion.  IRRs within 24 hours of receiving 
obinutuzumab have occurred.  IRRs can also occur with subsequent infusions.  Symptoms may 
include hypotension, tachycardia, dyspnea, and respiratory symptoms (e.g., bronchospasm, 
larynx and throat irritation, wheezing, and laryngeal edema).  Most frequently reported 
symptoms include nausea, fatigue, dizziness, vomiting, diarrhea, hypertension, flushing, 
headache, pyrexia, and chills. Management of IRRs is discussed in section 5.3.1.
Tumor Lysis Syndrome
TLS, including fatal cases, has been reported in patients receiving obinutuzumab.  Patients with 
high tumor burden, high circulating lymphocyte count ( 25  109/L) or renal impairment are at 
greater risk for TLS and should receive appropriate tumor lysis prophylaxis with anti-
hyperuricemics (e.g., allopurinol or rasburicase) and hydration prior to the infusion of 
obinutuzumab.  Continue prophylaxis prior to each subsequent obinutuzumab infusion, as 
needed. The laboratory parameters (including electrolytes and renal function) of patients 
considered at risk for TLS can be monitored as needed for patients at greater risk of TLS.
 
Infections
Serious bacterial, fungal, and new or reactivated viral infections can occur during and following 
the completion of obinutuzumab therapy.  Fatal infections have been reported. Obinutuzumab 
should not be administered to patients with an active infection.  Patients with a history of 
recurring or chronic infections may be at increased risk of infection.
Neutropenia
Severe and life-threatening neutropenia, including febrile neutropenia, has been reported during 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
65
treatment with obinutuzumab.  Patients with Grade 3  4 neutropenia should be monitored 
frequently with regular laboratory tests until resolution.  Anticipate, evaluate, and treat any 
symptoms or signs of developing infection.  Consider administration of granulocyte colony-
stimulating factors (G-CSF) in patients with Grade 3 or 4 neutropenia. Neutropenia can also be 
of late onset (occurring more than 28 days after completion of treatment) and/or prolonged 
(lasting longer than 28 days). Consider dose delays in the case of Grade 3 or 4 neutropenia.  
Patients with severe and long lasting ( 1 week) neutropenia are strongly recommended to 
receive antimicrobial prophylaxis until resolution of neutropenia to Grade 1 or 2. Antiviral and 
antifungal prophylaxis should be considered.
Thrombocytopenia
Severe and life-threatening thrombocytopenia has been reported during treatment with 
obinutuzumab in combination with chlorambucil or bendamustine.  Fatal hemorrhagic events 
during Cycle 1 have also been reported in patients with CLL treated with obinutuzumab. 
Patients will be monitored frequently for thrombocytopenia and hemorrhagic events. 
Management of thrombocytopenia is discussed in section 6.2.1.
 
Immunization
The safety and efficacy of immunization with live or attenuated viral vaccines during or 
following obinutuzumab therapy have not been studied.  Immunization with live-virus vaccines 
is not recommended during treatment and until B-cell recovery. 
Adverse Event List for Venetoclax
Tumor Lysis Syndrome 
Tumor lysis syndrome, including fatal events and renal failure requiring dialysis, has occurred in 
previously treated CLL patients with high tumor burden when treated with venetoclax.
Venetoclax can cause rapid reduction in tumor and thus poses a risk for TLS in the initial ramp-
up phase. Changes in blood chemistries consistent with TLS that require prompt management 
can occur as early as 6 to 8 hours following the first dose of venetoclax and at each dose 
increase. 
The risk of TLS is a continuum based on multiple factors, including tumor burden and 
comorbidities. Reduced renal function (CrCl <80 mL/min) further increases the risk. Patients 
should be assessed for risk and should receive appropriate prophylaxis for TLS, including 
hydration and anti-hyperuricemics, as discussed in section 6.1.2.
 
Concomitant use of venetoclax with strong or moderate CYP3A inhibitors and P-gp inhibitors 
increases venetoclax exposure, may increase the risk of TLS at initiation and during ramp-up 
phase and may require venetoclax dose adjustment.
Neutropenia 
Neutropenia is an important identified risk for venetoclax.  Grade 3 or 4 neutropenia occurs in 
40-50% of patients treated with venetoclax. Clinical data from the oncology studies suggest that 
the neutropenia adverse events are observed among patients who receive venetoclax as a single 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
66
agent or in combination with other therapeutic agents, with slightly higher frequency observed in 
some combination studies. Serious adverse events of neutropenia or neutropenia events that lead 
to discontinuations are few across the entire venetoclax oncology program. Monitor complete 
blood counts throughout the treatment period. Neutropenia management guidelines are provided 
in section 6.1.3.
 
Infections
Infections have been reported in the oncology clinical studies; however, these events are 
confounded by the underlying disease, comorbidities, and other immunosuppressive medications.  
To date, no clear relationship has been noted between serious infectious events and neutropenia.  
The types of infectious events observed generally have been consistent with those anticipated in 
the elderly population of heavily pretreated patients with hematologic malignancies and are 
similar across all indications.  Infections should be closely monitored in this study. Serious 
infections have been reported in patients treated with venetoclax in combination with other 
agents, including obinutuzumab.
Immunization 
Do not administer live attenuated vaccines prior to, during, or after treatment with venetoclax 
until B-cell recovery occurs. The safety and efficacy of immunization with live attenuated 
vaccines during or following venetoclax therapy have not been studied. Advise patients that 
vaccinations may be less effective. 
Reproductive System Effects and Embryo-Fetal Toxicity 
Based on nonclinical studies, there is a potential for decreased spermatogenesis. Non-reversible 
depletion of testicular germ cells has been observed in dogs at all doses tested after 4 weeks of 
dosing. Male patients considering preservation of fertility should bank their sperm before 
treatment with venetoclax. Based on its mechanism of action and findings in animals, venetoclax 
may cause embryo-fetal harm when administered to a pregnant woman. In an embryo-fetal study 
conducted in mice, administration of venetoclax to pregnant animals at exposures equivalent to 
that observed in patients at the recommended dose of 400 mg daily resulted in post-implantation 
loss and decreased fetal weight. There are no adequate and well-controlled studies in pregnant 
women using venetoclax. Advise females of reproductive potential to avoid pregnancy during 
treatment. If venetoclax is used during pregnancy or if the patient becomes pregnant while taking 
venetoclax, the patient should be apprised of the potential hazard to the fetus and discontinued 
from study treatment. Venetoclax use is not advised in lactation either.
Treatment-Emergent Malignancies (Second Primary Malignancies)
Events of second primary malignancies have been reported across the oncology program.
No pattern has been was observed. As venetoclax is being evaluated in subjects with 
relapsed/refractory disease who had previously been treated with various cytotoxic agents, 
second primary malignancies are closely monitored.
Adverse Event List for Acalabrutinib
Hemorrhage
Cases of hemorrhagic events, including central nervous system, respiratory, and gastrointestinal 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
67
hemorrhage, have been reported in clinical trials with acalabrutinib; some of these bleeding 
events resulted in fatal outcomes. The mechanism for hemorrhage is not well understood. 
Patients receiving antiplatelet or anticoagulant therapies may be at increased risk of hemorrhage 
and should be monitored for signs of bleeding. Consider the benefit-risk of withholding 
acalabrutinib for at least 3 days pre- and post-surgery. Subjects with hemorrhage should be 
managed per institutional guidelines with supportive care and diagnostic evaluations as clinically 
indicated. 
Infection
Serious infections, including fatal events, have been reported in clinical studies with 
acalabrutinib.  The most frequently reported Grade 3 or 4 infection was pneumonia.  Across the 
acalabrutinib clinical development program (including subjects treated with acalabrutinib in 
combination with other drugs), cases of hepatitis B virus (HBV) reactivation (resulting in liver 
failure and death in 1 case) and cases of progressive multifocal leukoencephalopathy have 
occurred in subjects with hematologic malignancies. Subjects should be monitored for signs and 
symptoms of infection and treated as medically appropriate. Subjects with infection events 
should be managed according to institutional guidelines with maximal supportive care and 
diagnostic evaluations as clinically indicated. 
Cytopenias
Treatment-emergent Grade 3 or 4 cytopenias including neutropenia, anemia, and 
thrombocytopenia have occurred in clinical studies with acalabrutinib. Monitor blood counts as 
medically appropriate. Subjects with cytopenias should be managed according to institutional 
guidelines with maximal supportive care and diagnostic evaluations as clinically indicated. 
Subjects should be closely monitored as appropriate.
Second Primary Malignancies
Second primary malignancies, including non-skin carcinomas, have been reported in clinical 
studies with acalabrutinib. The most frequent second primary malignancy was skin cancer. 
Subjects with a second primary malignancy should be managed according to institutional 
guidelines with maximal supportive and therapeutic care and diagnostic evaluations as clinically 
indicated.
Atrial Fibrillation
Atrial fibrillation/flutter have been reported in in clinical studies with acalabrutinib, particularly 
in subjects with cardiac risk factors, hypertension, diabetes mellitus, acute infections, and a 
previous history of atrial fibrillation. The mechanism for atrial fibrillation is not well understood.  
Subjects with atrial fibrillation should be managed per institutional guidelines with supportive 
care and diagnostic evaluations as clinically indicated.
7.2
Safety Parameters and Definitions
Safety assessments will consist of monitoring and reporting adverse events and serious adverse 
events per protocol.  This includes all events of death and any study-specific issue of concern.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
68
Adverse Events
Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment. An AE can 
therefore be any unfavorable and unintended sign (e.g., an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of a medicinal product, whether or not 
considered related to the medicinal product. This includes the following:

Adverse events not previously observed in the subject that emerge during the protocol-
specified adverse event reporting period, including signs or symptoms associated with 
CLL that were not present prior to the adverse event reporting period.

Complications that occur as a result of protocol-mandated interventions (e.g., invasive 
procedures such as cardiac catheterizations).

If applicable, adverse events that occur prior to assignment of study treatment associated 
with medication washout, no treatment run-in, or other protocol-mandated intervention.
Preexisting medical conditions (other than the condition being studied) judged by the 
investigator to have worsened in severity or frequency or changed in character during the 
protocol-specified adverse event reporting period.
Serious Adverse Events
An adverse event should be classified as a serious adverse event if the following criteria are met:

It results in death (i.e., the adverse event actually causes or leads to death)

It is life threatening (i.e., the adverse event, in the view of the investigator, places the 
subject at immediate risk of death.  It does not include an adverse event that, had it 
occurred in a more severe form, might have caused death.).

It requires or prolongs inpatient hospitalization.

It results in persistent or significant disability/incapacity (i.e., the adverse event results in 
substantial disruption of the subject’s ability to conduct normal life functions).

It results in a congenital anomaly/birth defect in a neonate/infant born to a mother 
exposed to the investigational medicinal product.

It is considered a significant medical event by the investigator based on medical 
judgment (e.g., may jeopardize the subject or may require medical/surgical intervention 
to prevent one of the outcomes listed above).
Adverse Events of Special Interest
Adverse events of special interest which may be a focus of further analysis in this study include 
the following:

Cases of potential drug-induced liver injury that include an elevated ALT or AST in 
combination with either an elevated bilirubin or clinical jaundice, as defined by Hy’s law 
and based on the following observations:
-
Treatment-emergent ALT or AST > 3x baseline value in combination with total 
bilirubin > 2x ULN (of which > 35% is direct bilirubin)
-
Treatment-emergent ALT or AST > 3x baseline value in combination with 
clinical jaundice

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
69

Cases of suspected transmission of an infectious agent by the study drug (STIAMP), as 
defined below:
-
Any organism, virus, or infectious particle (e.g., prion protein transmitting 
transmissible spongiform encephalopathy), pathogenic or non-pathogenic, is 
considered an infectious agent.  A transmission of an infectious agent may be 
suspected from clinical symptoms or laboratory findings that indicate an infection 
in a patient exposed to a medicinal product.  This term applies only when a 
contamination of the study drug is suspected.

In addition, venetoclax events of special interest are:
-
TLS (irrespective of seriousness, causality, or severity)

In addition, obinutuzumab events of special interest are:
-
TLS (irrespective of seriousness)
-
Second malignancies

In addition, acalabrutinib events of special interest are
-
Any grade atrial fibrillation
-
Grade ≥3 bleeding events
Selected Adverse Events for Obinutuzumab
Selected events (in clinical trials, these are events for which additional data collection or 
analyses will be performed; no special case handling or follow-up is required) include the 
following:

IRRs

Infections (including PML and hepatitis B reactivation)

Neutropenia (including late-onset neutropenia, defined as neutrophil 
count  1000 cells/mm3, occurring 28 days or more after obinutuzumab treatment has 
been completed or stopped; prolonged neutropenia, defined as neutrophil count   1000 
cells/mm3, that does not resolve after 28 days (without obinutuzumab treatment)

Thrombocytopenia (including acute thrombocytopenia occurring during and within 24 
hours post obinutuzumab infusion)

Cardiac events

Second malignancies

GI perforation
7.3
Methods and Timing for Assessing and Recording Safety Variables
The investigator is responsible for ensuring that all adverse events and serious adverse events 
that are observed or reported during the study, are collected and reported to the FDA, appropriate 
Institutional Review Boards (IRBs), AstraZeneca, and Genentech in accordance with instructions 
provided in this section and in Sections 7.4-7.6, as well as in accordance with CFR 312.32 
(Investigational New Drug [IND] Safety Reports).
Adverse Event Reporting Period
The study period during which all adverse events and serious adverse events where the patient 
has been exposed to Genentech product must be reported. This reporting period begins after 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
70
informed consent is obtained. For AstraZeneca, the reporting period starts with first dose of 
AstraZenecaAstraZeneca’s product (acalabrutinib) and for Genentech, the reporting period starts 
with the first dose of either venetoclax or obinutuzumab. The reporting period ends 30 days 
following the last administration of study treatment or study discontinuation/termination, 
whichever is earlier.  After this period, investigators should only report serious adverse events 
that are attributed to prior study treatment.
Assessment of Adverse Events
All adverse events and serious adverse events whether volunteered by the subject, discovered by 
study personnel during questioning, or detected through physical examination, laboratory test, or 
other means will be reported appropriately.  Each reported adverse event or serious adverse event 
will be described by its duration (i.e., start and end dates), regulatory seriousness criteria if 
applicable, suspected relationship to the study drugs (see following guidance), and actions taken.
To ensure consistency of adverse event and serious adverse event causality assessments, 
investigators should apply the following general guideline:
Yes
There is a plausible temporal relationship between the onset of the adverse event and 
administration of acalabrutinib, venetoclax, or obinutuzumab, and the adverse event cannot be 
readily explained by the subject’s clinical state, intercurrent illness, or concomitant therapies; 
and/or the adverse event follows a known pattern of response to acalabrutinib, venetoclax, or 
obinutuzumab; and/or the adverse event abates or resolves upon discontinuation of the study 
drugs or dose reduction and, if applicable, reappears upon re-challenge.
No
Evidence exists that the adverse event has an etiology other than the acalabrutinib, venetoclax, or 
obinutuzumab (e.g., preexisting medical condition, underlying disease, intercurrent illness, or 
concomitant medication); and/or the adverse event has no plausible temporal relationship to 
administration of acalabrutinib, venetoclax, or obinutuzumab (e.g., cancer diagnosed 2 days after 
first dose of study drug).
Expected adverse events are those adverse events that are listed or characterized in the USPI or 
current IB. 
Unexpected adverse events are those not listed in the USPI or current IB or not identified.  This 
includes adverse events for which the specificity or severity is not consistent with the description 
in the USPI or IB.  For example, under this definition, hepatic necrosis would be unexpected if 
the USPI or IB only referred to elevated hepatic enzymes or hepatitis.
For patients receiving combination therapy, causality will be assessed individually for each 
protocol-mandated therapy.
7.3.1.1
Pregnancies
Pregnancies in Female Patients

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
71
If a female patient becomes pregnant while receiving the study drugs or within 18 months after 
the last dose of obinutuzumab or 30 days after the last dose of venetoclax or acalabrutinib, 
whichever is longer, a report should be completed and expeditiously submitted to AstraZeneca 
and Genentech.  Follow-up to obtain the outcome of the pregnancy should also occur. 
Pregnancies in Female Partners of Male Patients
If the female partner of male patients become pregnant while receiving the study drug or within 
3 months after the last dose of obinutuzumab or 30 days after the last dose of venetoclax or 
acalabrutinib, whichever is longer, a report should be completed and expeditiously submitted to 
Genentech and AstraZeneca.  
  
7.3.1.2
Congenital Anomalies / Birth Defects and Abortions
Pregnancy itself is not a serious adverse event, but it is a special situation that should always be 
reported within the same timelines as a serious adverse event. All pregnancies and outcomes 
should be reported to medical safety. Abortion, whether accidental, therapeutic, or spontaneous, 
should always be classified as serious, and expeditiously reported as an SAE. Similarly, any 
congenital anomaly / birth defect in a child born to a female subject exposed to the study drug 
should be reported as an SAE.
7.3.1.3
Post-Study Adverse Events
For studies involving collection of survival data and extended follow-up after the end of the 
adverse event reporting period (defined as 30 days after the last dose of study drug), the 
investigator should report all deaths (regardless of cause) and any serious adverse event 
including development of cancer or a congenital anomaly in a subsequently conceived offspring 
of a female subject who participated in the study (including pregnancy occurring in the partner of 
a male study subject) that is believed to be related to prior exposure to study drug.
Case Transmission Verification will be performed by both parties during this period to ensure 
successful transmission of single case reports. 
7.3.1.4
Reconciliation
The Sponsor agrees to conduct reconciliation (case transmission verification) for the study drugs 
to ensure all single case reports have been adequately received by Genentech (for study drugs 
venetoclax and obinutuzumab) and AstraZeneca (for acalabrutinib). The Sponsor-Investigator 
will agree to the reconciliation periodicity and format, but agree at minimum to exchange 
quarterly line listings of single case reports sent to Genentech (for venetoclax and obinutuzumab) 
and AstraZeneca (for acalabrutinib) in the preceding time period.
The periodic line-listing will be exchanged within seven (7) calendar days of the end of the 
agreed time period. Confirmation of receipt should be received within the time period mutually 
agreed upon.
If discrepancies are identified, the Sponsor-Investigator and AstraZeneca (for acalabrutinib) and 
Genentech (for venetoclax and obinutuzumab) will cooperate in resolving the discrepancies.  The 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
72
responsible individuals for each party shall handle the matter on a case-by-case basis until 
satisfactory resolution. 
Following Case Transmission Verification, single case reports which have not been received by 
Genentech and/or AstraZeneca shall be forwarded by the Sponsor to Genentech and or 
AstraZeneca within five (5) calendar days from request by Genentech.
At the end of the study, a final cumulative Case Transmission Verification report will be sent to    
Genentech.
7.4
Adverse Event Reporting
The sponsor-investigator will be responsible for collecting all protocol-defined Adverse Events 
(AEs)/Serious Adverse Events (SAEs), AEs of Special Interest (AESIs), Special Situation 
Reports (including pregnancy reports) and Product Complaints (with or without an AE) 
originating from the Study for the Product.
The sponsor-investigator must report all serious adverse events to Genentech and AstraZeneca 
within the timelines described below. The completed MedWatch, CIOMS I form, or Genentech 
approved reporting form should be sent immediately upon completion to Genentech Drug Safety 
at:
Fax: (650) 238-6067
Email: usds_aereporting-d@gene.com
and to AstraZeneca at:
Email: AEMailboxClinicalTrialTCS@astrazeneca.com
Relevant follow-up information should be submitted to both Genentech Drug Safety and 
AstraZeneca Drug Safety as soon as it becomes available.
All product complaints (for Genentech products) without an AE should be sent to:
Email: kaiseraugst.global_impcomplaint_management@roche.com
–OR-- 
Serious adverse events, pregnancy reports (including pregnancy occurring in the partner of a 
male study subject), adverse events of special interest (AESIs), product complaints (with or 
without an AE) and special situation reports where the patient has been exposed to Genentech 
products (venetoclax and obinutuzumab) will be sent on a MedWatch or CIOMS I form to 
Genentech. Reports will be submitted to AstraZeneca using AstraZeneca SAE Reporting Form 
for entry into AstraZeneca’s global safety database and cross-reporting to regulatory agencies if 
required. Transmission of these reports (initial and follow-up) will be either electronically or by 
fax and within the timelines specified below.
Serious Adverse Drug Reactions
The investigator-sponsor will notify AstraZeneca’s Medical Safety department, in English, when 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
73
made aware of a Safety Report (Serious Adverse Event (SAE) or Special Situation Report) in a 
patient receiving AstraZeneca’s investigational medicinal product (acalabrutinib). The 
investigator-sponsor will notify Genentech’s Medical Safety department, in English, when made 
aware of a Safety Report (SAE) in a patient receiving obinutuzumab or venetoclax. Serious 
adverse event reports shall be transmitted to Genentech within fifteen (15) calendar days of the 
awareness date and to AstraZeneca within 7 calendar days for fatal or life-threatening events and 
15 calendar days for all other SAEs, special situations, and adverse events of special interest.
Pregnancy Reports
While such reports are not serious adverse events per se, as defined herein, any reports of 
pregnancy (including pregnancy occurring in the partner of a male study subject), where the 
fetus may have been exposed to any of the study drugs, shall be transmitted to Genentech and/or 
AstraZeneca (depending on which drugs the subject was exposed to) within fifteen (15) calendar 
days of the awareness date. Pregnancies will be followed up until the outcome of the pregnancy 
is known, whenever possible, based upon due diligence taken to obtain the follow-up 
information.
Pregnancies in Female Partners of Male Patients
Male patients will be instructed through the Informed Consent Form to immediately inform the 
investigator if their partner becomes pregnant during the study or within 3 months after the last 
dose of obinutuzumab or 30 days after the last dose of venetoclax . A Clinical Trial Pregnancy 
Reporting Form should be completed and submitted to Genentech within thirty (30) calendar 
days of the awareness date.
Adverse Events of Special Interest
AESIs shall be forwarded to Genentech and AstraZeneca within fifteen (15) calendar days of the 
awareness date.  
 
Special Situation Reports
In addition to all adverse events, pregnancy reports and AESIs, the following other Special 
Situations Reports (even in the absence of an Adverse Event) should be collected and transmitted 
to (depending on which drugs the subject was exposed to) Genentech within thirty (30) calendar 
days and AstraZeneca within fifteen (15) calendar days:

Data related to study drug usage during breastfeeding. 

Data related to overdose, abuse, misuse or medication error (including potentially 
exposed or intercepted medication errors). Medication errors refers to any error in the 
prescribing, dispensing, or administration of a medicinal product while in the control of 
the healthcare professional, patient or consumer.

Occupational exposure refers to the exposure to a medicinal product as a result of one’s 
professional or nonprofessional occupation.

Data related to suspected transmission of an infectious agent via a medicinal product

Suspected Adverse Reaction related to quality defect or falsified medicinal products 
(whether suspected or confirmed)
 
In addition, reasonable attempts should made to obtain and submit the age or age group of the 
patient, in order to be able to identify potential safety signals specific to a particular population.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
74
Product Complaints and Reporting 
A product complaint is any written or oral information received from a complainant that 
alleges deficiencies related to identity, quality, safety, strength, purity, reliability, durability, 
effectiveness or performance of a product after it has been released and distributed to the 
commercial market or clinical trial. 
To File A Complaint: 
For all Investigator Initiated Studies (interventional and non-interventional):
Product Complaints with an AE (adverse event) should be reported via email/fax to:
usds_aereporting-d@gene.com OR 650-238-6067
Product Complaints without an AE (adverse event) should be reported via email to:

For Interventional Investigator Initiated Studies:
kaiseraugst.global_impcomplaint_management@roche.com

For Non-Interventional Investigator Initiated Studies:
us-acmo-d@gene.com
All complaints must be filed within one (1) business day for pre-approved products and 
fifteen (15) calendar days for approved products. Complaints can be reported using a 
Medwatch, CIOMS or any Genentech-approved reporting form (same as SAEs, AESI etc.).
Reporting Requirements for Adverse Events Originating from Patient Reported Outcomes
Although sites are not expected to review the patient reported outcome (PRO) data, if 
physician/study personnel become aware of a potential adverse event during site review of the 
PRO questionnaire data, he/she will determine whether the criteria for an adverse event have 
been met and, if so, these must be reported using the Adverse Event and Special Situation 
Reporting Form or MedWatch form.
Aggregate Reports
Investigators will also report events to their IRB as required.
The investigator/sponsor will forward a copy of the Publication to AstraZeneca and 
Genentech/Roche upon completion of the Study.
The Sponsor agrees to share a copy of their own DSUR with AstraZeneca and Genentech/Roche 
as soon as reasonably possible after completion. Genentech/Roche agrees to forward to the 
Sponsor an executive summary of the Genentech/Roche DSUR upon request. Furthermore, 
Genentech/Roche agrees that the Sponsor may cross-reference the executive summary of the 
Genentech/Roche DSUR, as applicable.
MedWatch 3500A Reporting Guidelines
In addition to completing appropriate patient demographic and suspect medication information, 
the report should include the following information within the event description (Section 5) of 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
75
the MedWatch 3500A form:

Study Identifiers (Investigator-sponsor and AstraZeneca protocol number and title 
description) 

Patient Identifiers (unique patient number, age, or sex)

Study drugs including start date, most recent dose date, dose, units, frequency, and route

Description of Serious Adverse Event / Special Situation Narrative and clearly identified 
event term should both be provided including:
o
Onset date
o
Resolution date
o
Outcome
o
Seriousness criteria
o
Action taken with study drugs

Reporter (Investigator name, email, fax, institution name)

Date of Investigator-sponsor awareness of Serious Adverse Event / Special Situation 
Report

Relevant medical history, concomitant medications, or medical test results 

Investigator-sponsor causality assessment of relationship to study drugs (related or 
unrelated) and causality, if not related to study drugs

Investigator-sponsor IND/CTA number 

IND/CTA Holder (if not reporting Investigator-sponsor)
Follow-up Information
Additional information may be added to a previously submitted report by any of the following 
methods:

Adding to the original MedWatch 3500A form and submitting it as follow-up

Adding supplemental summary information and submitting it as follow-up with the 
original MedWatch 3500A form 

Summarizing new information and faxing it with a cover letter, including patient 
identifiers (i.e., date of birth, initial, patient number), protocol description and number (if 
assigned), brief adverse event description, and notation that additional or follow-up 
information is being submitted.  (The patient identifiers are important so that the new 
information is added to the correct initial report.)
Occasionally, Genentech or AstraZeneca may contact the reporter for additional information, 
clarification, or current status of the patient for whom and adverse event was reported.  For 
questions regarding serious adverse event reporting, you may contact the Genentech Drug Safety 
representative noted above or the AstraZeneca Medical Safety team 
(AEMailboxClinicalTrialTCS@astrazeneca.com)  or the Medical Science Liaison assigned to the 
study.  Relevant follow-up information should be submitted to Genentech Drug Safety and 
AstraZeneca Medical Safety as soon as it becomes available and/or upon request.
The MedWatch 3500A (mandatory reporting) form is available at:  
https://www.fda.gov/media/69876/download
IND Annual Reports

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
76
All IND annual reports submitted to the FDA by the Sponsor-investigator should be copied to 
Genentech and AstraZeneca.  Copies of such reports should be emailed to Genentech Drug 
Safety CTV mailbox at ctvist_drugsafety@gene.com and AstraZeneca Drug Safety 
atAEMailboxClinicalTrialTCS@astrazeneca.com.
DF/HCC Expedited Reporting Guidelines
External (Non-DF/HCC) sites will send their report to the lead site project manager and Overall 
PI for review and submission to the appropriate entities according to DFCI IRB policies and 
procedures in reporting adverse events.
DF/HCC Reportable AEs
Attribution
Gr. 2 & 3 AE
Expected
Gr. 2 & 3 AE 
Unexpected
Gr. 4 AE 
Expected
Gr. 4 AE
Unexpected
Gr. 5 AE 
Expected or 
Unexpected
Unrelated
Unlikely
Not required
Not required
Not required
10 calendar 
days
1 business day*
Possible
Probable
Definite
Not required
10 calendar 
days
Not required
10 calendar 
days
1 business day*
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of 
the last intervention, the AE should be reported within 1 business day of learning of the event.
7.5
Study Closeout
Any study report submitted to the FDA by the Sponsor-investigator should be copied to 
Genentech and AstraZeneca. This includes all IND annual reports and the Clinical Study Report 
(final study report).  Additionally, any literature articles that are a result of the study should be 
sent to Genentech and AstraZeneca. Copies of such reports should be mailed to the assigned 
AstraZeneca Medical Affairs contact for the study and to Genentech Drug Safety CTV oversight 
mailbox: ctvist_drugsafety@gene.com.
7.6
Safety Queries
Queries related to the Study will be answered by the Investigator. However, responses to all 
safety queries from regulatory authorities or for publications will be discussed and coordinated 
between the investigator and the funding sponsors. The investigator and funding sponsors agree 
that Genentech and AstraZeneca shall have the final say and control over safety queries relating 
to their respective Product. The Sponsor-Investigator agrees that he shall not answer such queries 
from regulatory authorities and other sources relating to the Product independently but shall 
redirect such queries to Genentech or AstraZeneca.
 
Both the investigator and the funding sponsors will use all reasonable effort to ensure that 
deadlines for responses to urgent requests for information or review of data are met. They will 
clearly indicate on the request the reason for urgency and the date by which a response is 
required.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
77
7.7
Safety Crisis Management
In case of a safety crisis, e.g., where safety issues have a potential impact on the indication(s), on 
the conduct of the Study, may lead to labeling changes or regulatory actions that limit or restrict 
the way in which their respective Product is used, or where there is media involvement, the 
investigator or the funding sponsor (whomever first identified the crisis) will contact the other as 
soon as possible.
 
Both the investigator and the funding sponsors agree that Genentech and/or AstraZeneca shall 
have the final say and control over safety crisis management issues relating to the Product. The 
Sponsor-Investigator agrees that he shall not answer such queries from media and other sources 
relating to the Product but shall redirect such queries to Genentech and/or AstraZeneca.
7.8
Adverse Event Characteristics

IWCLL term (AE descriptions) and grade: The descriptions and grading scales found 
in the IWCLL Grading Scale for Hematologic Toxicities in CLL Studies (Appendix C) 
will be utilized for hematologic AE reporting. 

CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for nonhematologic AE reporting.  All appropriate treatment areas 
should have access to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 
5.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.

For expedited reporting purposes only:  
-
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided.
-
Other AEs for the protocol that do not require expedited reporting are outlined in the 
next section (Expedited Adverse Event Reporting) under the sub-heading of Protocol-
Specific Expedited Adverse Event Reporting Exclusions.

Attribution of the AE:
-
Definite – The AE is clearly related to the study treatment.
-
Probable – The AE is likely related to the study treatment.
-
Possible – The AE may be related to the study treatment.
-
Unlikely – The AE is doubtfully related to the study treatment.
-
Unrelated – The AE is clearly NOT related to the study treatment.
7.9
Expedited Adverse Event Reporting 
Investigators must report to the Overall PI any serious adverse event (SAE) that occurs after the 
initial dose of study treatment, during treatment, or within 30 days of the last dose of treatment 
on the local institutional SAE form. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
78
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for Human 
Research Studies (OHRS) per the DFCI IRB reporting policy.
For Multi-Center Trials where a DF/HCC investigator is serving as the Sponsor, each 
participating institution must abide by the reporting requirements set by the DF/HCC. 
Criteria for reporting to DFCI listed in section 7.4.1. 
This applies to any medical event equivalent to an unexpected grade 2 or 3 with a 
possible, probable or definite attribution, all grade 4 toxicities, (unless specifically 
mentioned above as not requiring expedited reporting) and grade 5 (death) regardless of 
study phase or attribution.
External Site Adverse Event Reporting Guidelines 
In addition to following the SAE reporting requirements for DFCI, AstraZeneca, and Genentech, 
other investigative sites will report SAEs to their respective IRB per the local IRB’s 
policies and procedures. 
7.10
Expedited Reporting to the Food and Drug Administration (FDA)
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA.
7.11
Expedited Reporting to Hospital Risk Management
Participating investigators will report to their local Risk Management office any participant 
safety reports or sentinel events that require reporting according to institutional policy. 
7.12
Routine Adverse Event Reporting
All Adverse Events must be reported in routine study data submissions to the Overall PI on the 
toxicity case report forms.  AEs reported through expedited processes (e.g., reported to the 
IRB, FDA, etc.) must also be reported in routine study data submissions.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
79
8. PHARMACEUTICAL INFORMATION
A list of the adverse events and potential risks associated with the investigational agents 
administered in this study can be found in Section 7.1.
8.1
Acalabrutinib 
8.1.1 Description
The investigational product, acalabrutinib maleate tablet, is presented as an orange film-coated 
tablet containing 129 mg of acalabrutinib maleate (equivalent to 100 mg of acalabrutinib) drug 
substance. The acalabrutinib maleate tablets are oval, biconvex, measuring approximately 7.5 × 
13 mm. The tablets are debossed with ‘ACA 100’ on one side and are plain on the reverse. Each 
tablet also contains the following compendial inactive ingredients: mannitol, microcrystalline 
cellulose, low-substituted hydroxypropyl cellulose and sodium stearyl fumarate.
The tablet coating contains: hypromellose, copovidone, titanium dioxide, polyethylene glycol, 
caprylic/capric triglyceride, yellow iron oxide and red iron oxide.
8.1.2
Form
N/A
Storage and Stability
Acalabrutinib maleate tablets are packed in white, high-density polyethylene (HDPE) bottles 
containing a silica gel desiccant and should be stored according to the storage conditions as 
indicated on the label. Store at 20°C-25°C (68°F-77°F); excursions permitted to 15°C-30°C 
(59°F-86°F).
The investigational products are for investigational use only and are to be used only within the 
context of this study.  The study drug supplied for this study must be maintained under adequate 
security and stored under the conditions specified on the label until dispensed for subject use or 
returned to AstraZeneca.  Labels must remain attached to the containers.
If a temperature excursion is experienced at any site beyond the stated storage parameters, the 
site must report the excursion and associated details to the lead site project manager as soon as 
feasible. 
Compatibility
N/A
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and 
the environment, should undertake the preparation, handling, and safe disposal of the agent in a 
self-contained and protective environment.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
80
Availability
Acalabrutinib will be supplied by AstraZeneca.
Preparation
N/A
Administration
Acalabrutinib is intended to be administered orally twice daily with 8 ounces (approximately 240 
mL) of water. The tablets should be swallowed intact and subjects should not attempt to break 
tablets or dissolve them in water. Acalabrutinib can be taken with or without meals. Patients who 
require treatment with H2-receptor antagonists should take acalabrutinib two hours before taking 
the H2-receptor antagonist. Patients who require treatment with antacids should separate the 
dosing of acalabrutinib by 2 hours.
If a dose is not taken at the scheduled time, it can be taken as soon as possible up to 3 hours later 
on the same day, with a return to the normal schedule the following day. If a dose is missed by 
more than 3 hours, it should be skipped and the next dose should be taken at its regularly 
scheduled time. The patient should not take extra tablets to make up the missed dose. The missed 
dose will not be made up and must be returned to the site at the next scheduled visit.
Ordering
Acalabrutinib will be ordered from McKesson who will ship the drug directly to the DF/HCC 
study sites.
External (Non-DF/HCC) investigative sites will be provided with a study specific drug order 
form by the lead site project manager once all necessary documents are collected, and the site is 
otherwise approved to enroll participants on the study.
The drug will be provided at no cost to the participant. 
 
Accountability
The investigator, or a responsible party designated by the investigator, should maintain a careful 
record of the inventory and disposition of the agent using a drug accountability form.
Destruction and Return
If pre-arranged between AstraZeneca and the site, destruction of used and unused study drug 
may be performed at the site.  Empty containers will be destroyed at the site.  
The Drug Accountability Log will contain the date and amount of study drugs received and 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
81
dispensed. All used and partially used study drug will be destroyed by the site, in accordance 
with the site’s standard operating procedures (SOPs).  All expired drug and any unused drug 
remaining once all patients are off study treatment will be destroyed on site in accordance with 
the site’s standard operating procedures (SOPs).
8.1
Venetoclax
Description
Venetoclax (ABT-199/GDC-0199) is a novel, orally bioavailable, small-molecule Bcl-2 family 
inhibitor in the biarylacylsulfonamide chemical class.  Venetoclax binds with high affinity (Ki < 
0.010 nM) to antiapoptotic protein Bcl-2 and with lower affinity to other antiapoptotic Bcl-2 
family proteins, like Bcl-XL and Bcl-w (> 4,800-fold and > 24,500-fold lower affinity than to 
Bcl-2, respectively).  
In vitro studies have shown that venetoclax is metabolized primarily by CYP3A4.  Interaction of 
venetoclax with co-administered CYP3A inhibitors or inducers may cause an increase or 
decrease in the exposure of venetoclax.  In vivo, venetoclax was also demonstrated to be 
metabolized by CYP3A4.  Venetoclax is also substrate for P-glycoprotein (P-gp) and breast 
cancer resistance protein (BCRP) transporters.  Renal contribution to the elimination of 
venetoclax is negligible, with < 0.1% of the dose being recovered in urine. Based on in vitro 
results, venetoclax was a P-gp, BCRP, and OATP1B1 inhibitor.  It was not a potent in vitro 
inhibitor of CYP3A4, CYP1A2, CYP2B6, or CYP2D6 (IC50 > 30 µM); and it did not induce 
CYP3A4 or CYP1A2 at concentrations up to 10 µM.  Venetoclax is also not predicted to cause 
inhibition of CYP2C19, CYP2C8, CYP2C9, and UGT1A1 at clinically relevant concentrations.  
It is not an inhibitor of UGT1A4, UGT1A6, UGT1A9 and UGT2B7.  Following co-
administration of a single dose of venetoclax with warfarin, R- and S-warfarin Cmax and AUC∞ 
increased by approximately 18% to 28%.  Relatively low variability was observed in warfarin 
pharmacokinetics.
The venetoclax formulation currently used in clinical studies is a tablet formulation with 
strengths of 10, 50, and 100 mg.  The tablet formulation was orally administered after a low-fat 
meal. Food increased the bioavailability of venetoclax by 3- to 5-fold.  Preliminary 
pharmacokinetic results indicated that the absorption of venetoclax after the oral dosing was 
relatively slow.  Venetoclax plasma concentrations peaked at approximately 5 to 8 hours after 
dosing.  The mean harmonic terminal phase half-life from 17 to 41 hours and the mean oral 
clearance was approximately 13 L/hr after a single dose.  Preliminary data did not suggest 
apparent pharmacokinetics differences among subjects with CLL/SLL, NHL, Multiple Myeloma, 
Acute Myeloid Leukemia, or systemic lupus erythematosus.  The combined data from subjects 
with CLL/SLL and NHL suggested that venetoclax exposure was approximately dose 
proportional across the 150 to 800 mg dose levels at steady state.  Additional information about 
venetoclax is available in the package insert.
Form
Venetoclax tablets are film coated and are available in strengths of 10 mg, 50 mg, or 100 mg.  

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
82
Venetoclax will be packaged in high density polyethylene (HDPE) plastic bottles.  Each bottle 
will be labeled per local regulatory requirements.  Labels must remain affixed to the bottle.
Storage and Stability
Venetoclax must be stored at 15° to 25°C (59° to 77°F).  The investigational products are for 
investigational use only and are to be used only within the context of this study.  The study drug 
supplied for this study must be maintained under adequate security and stored under the 
conditions specified on the label until dispensed for subject use or returned to Genentech. Labels 
must remain attached to the containers.
If a temperature excursion is experienced at any site beyond the stated storage parameters, the 
site must report the excursion and associated details to the lead site project manager as soon as 
feasible. 
Compatibility
N/A
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and 
the environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment.
Availability
Venetoclax is provided by Genentech directly to the study site.
Preparation
N/A
Administration
Oral.  Patients should take venetoclax tablets with a meal and water at approximately the same 
time each day. Venetoclax tablets should be swallowed whole and not chewed, crushed, or 
broken prior to swallowing.
If vomiting occurs within 15 minutes after taking venetoclax and all expelled tablets are still 
intact, another dose may be given. Otherwise, no replacement dose is to be given. In cases where 
a dose of venetoclax is missed or forgotten, the patient should take the dose as soon as possible 
and ensure that the minimal interval between the current dose and the next dose is at least 16 
hours in order to avoid excessive drug accumulation after the next dose. 
Any overdose or incorrect administration of study drug should be noted in the medical chart.  

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
83
Adverse events associated with an overdose or incorrect administration of study drug should be 
reported.
Ordering
Venetoclax will be ordered directly from Genentech, who will ship drug directly to the DF/HCC 
study sites with an order form provided at the time of study activation.
External (Non-DF/HCC) investigative sites will be provided with a study specific drug order 
form by the lead site project manager once all necessary documents are collected, and the site is 
otherwise approved to enroll participants on the study.
The drug will be provided at no cost to the participant. 
Accountability
The investigator, or a responsible party designated by the investigator, should maintain a careful 
record of the inventory and disposition of the agent using a drug accountability form.
Destruction and Return
If pre-arranged between Genentech and the site, destruction of used and unused study drug may 
be performed at the site.  Empty containers will be destroyed at the site.  
8.2
Obinutuzumab
Description
Obinutuzumab (GA101, RO5072759), is a glycoengineered, humanized, type II anti-CD20 
monoclonal antibody (mAb).  Obinutuzumab was derived by humanization of the parental B-Ly1 
mouse antibody and subsequent glycoengineering.
Form
Obinutuzumab is provided as a single-use vial.  Each vial contains a sterile liquid formulation in a 
50-mL pharmaceutical-grade glass vial containing a nominal dose of 1000 mg of obinutuzumab 
(G3 material).  The formulated drug product consists of 25 mg/mL drug substance formulated in 
histidine/histidine-HCl, trehalose, and poloxamer 188.  The vial contains 41 mL (with 2.5% 
overfill). 
Storage and Stability
The recommended storage conditions for the obinutuzumab drug product are between 2°C and 
8°C, protected from light.  Chemical and physical in-use stability for obinutuzumab dilutions in 
0.9% sodium chloride (NaCl) at concentrations of 0.2 - 20 mg/mL have been demonstrated for 
24 hours at 2°C - 8°C and an additional 24 hours at ambient temperature and ambient room 
lighting.  The prepared diluted product should generally be used immediately.  If not used 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
84
immediately, in-use storage times and conditions prior to use are the responsibility of the user 
and would normally not be longer than 24 hours at 2°C - 8°C unless reconstitution/dilution has 
taken place in controlled and validated aseptic conditions.  Obinutuzumab should not be frozen 
or shaken.  Mix gently.  All transfer procedures require strict adherence to aseptic techniques.  
Do not use an additional in line filter because of potential adsorption.
If a temperature excursion is experienced at any site beyond the stated storage parameters, the 
site must report the excursion and associated details to the lead site project manager as soon as 
feasible. 
Compatibility
N/A
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and 
the environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment.
Preparation
Obinutuzumab drug product intended for IV infusion is prepared by dilution of the drug product 
into an infusion bag containing 0.9% NaCl. 
One vial may be used to prepare both the 100-mg dose (equals 4 mL) and 900-mg dose (equals 
36 mL) following the directions below.  If both bags are prepared at the same time, the 
reconstitution/dilution has to take place in a controlled and validated aseptic conditions.  
Subsequently store the 900-mg bag for a maximum of 24 hours at 2C  8C and administer the 
next day.
To prepare a 100-mg dose:  The final drug concentration of a 100-mg dose should be in the 
range of 0.4 mg/mL to 4.0 mg/mL.  Using a 250-mL infusion bag containing 0.9% NaCl, 
withdraw and discard 4 mL of the sodium chloride.  Withdraw 4 mL of obinutuzumab from a 
single glass vial and inject it into the infusion bag (discard any unused portion of obinutuzumab 
left in the vial unless reconstitution/dilution has taken place in controlled and validated aseptic 
conditions).  Gently invert the infusion bag to mix the solution.  Do not shake. 
To prepare a 900-mg dose:  The final drug concentration of a 900-mg dose should be in the 
range of 0.4 mg/mL to 4.0 mg/mL.  Using a 250-mL infusion bag containing 0.9% NaCl, 
withdraw and discard 36 mL of the sodium chloride.  Withdraw 36 mL of obinutuzumab from a 
single glass vial and inject it into the infusion bag (discard any unused portion of obinutuzumab 
left in the vial unless reconstitution/dilution has taken place in controlled and validated aseptic 
conditions).  Gently invert the infusion bag to mix the solution.  Do not shake. 
To prepare a 1000-mg dose:  The final drug concentration of a 1000-mg dose should be 4 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
85
mg/mL.  Using a 250-mL infusion bag containing 0.9% NaCl, withdraw and discard 40 mL of 
the NaCl.  Withdraw 40 mL of obinutuzumab from a single glass vial and inject it into the 
infusion bag (discard any unused portion of obinutuzumab left in the vial).  Gently invert the 
infusion bag to mix the solution.  Do not shake.
Administration sets with polyvinyl chloride, polyurethane, or polyethylene as product contact 
surface and IV bags with polyolefin, polypropylene, polyvinyl chloride, or polyethylene as 
product contact surface are compatible and may be used.  Use of a port or peripherally inserted 
central catheter line is acceptable.
Do not use obinutuzumab beyond the expiration date stamped on the carton.
Administration
Obinutuzumab is to be administered by IV infusion for up to 6 total cycles (28-day cycles):

On first cycle, Day 1, 100 mg obinutuzumab will be administered

On first cycle, Day 2, 900 mg of obinutuzumab will be administered

On first cycle, Days 8 and 15, 1000 mg of obinutuzumab will be administered.

On cycles 2-6, Day 1, 1000 mg of obinutuzumab will be administered (see section 
5.3.2)
Obinutuzumab must be administered in a clinical setting (inpatient or outpatient).  Full 
emergency resuscitation facilities should be immediately available, and patients should be under 
close supervision by the investigator at all times.  Obinutuzumab should be given as a slow IV 
infusion through a dedicated line.  IV infusion pumps (such as Braun Infusomat Space) should be 
used to control the infusion rate of obinutuzumab.  Do not administer as an IV push or bolus.  
After the end of the first infusion, the IV line should remain in place for at least 2 hours in order 
to be able to administer IV drugs if necessary.  If no AEs occur after 2 hours, the IV line may be 
removed.  For subsequent infusions, the IV line should remain in place for at least 1 hour from 
the end of infusion; if no AEs occur after 1 hour, the IV line may be removed.
Ordering
Each participating site will utilize a study specific order form from Genentech provided at the 
time of study activation to order obinutuzumab. 
External (Non-DF/HCC) investigative sites will be provided with a study specific drug order 
form by the lead site project manager once all necessary documents are collected, and the site is 
otherwise approved to enroll participants on the study.
The drug will be provided at no cost to the participant. 
Accountability
The investigator, or a responsible party designated by the investigator, should maintain a careful 
record of the inventory and disposition of the agent using the NCI Drug Accountability Record 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
86
Form (DARF) or another comparable drug accountability form. 
Destruction and Return
Destruction of used and unused study drug may be performed at the site as per institutional 
policy.
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
9.1 Laboratory Correlative Studies
9.1.1 BH3 Profiling
BH3 profiling is a functional assay we previously developed that detects the proximity of CLL 
cells to the threshold of apoptosis (what we call ‘priming’) through interrogation of BCL-2 
family members.  To perform a BH3 profile, we add individual BH3-only peptides to gently 
permeabilized malignant cells and use FACS to measure the amount of mitochondrial 
depolarization induced by each peptide, as measured by cytochrome c release. 
We hypothesize that patients whose baseline CLL cells, prior to therapy, undergo significant 
depolarization to BIM BH3 peptide (highly primed) will have superior clinical response to AVO 
combination therapy compared to patients whose cells undergo minimal BIM BH3 
depolarization (unprimed). These assessments will be made on circulating CLL cells from the 
peripheral blood drawn from patients at baseline. We will attempt to identify potential resistance 
mechanisms by looking at whether patients who do not achieve CR have different upfront BH3 
profiles from those who do. Additionally, another sample of peripheral blood will be collected 
from subjects at the time of disease progression, and the BH3 profile of these samples will be 
compared to subjects’ baseline samples to help identify whether a change in anti-apoptotic 
protein dependence is observed as a possible mechanism of resistance.
If we have bone marrow aspirates available, we may also perform BH3 profiling to see whether 
the level of priming in CLL cells from this compartment is a better predictor of response than 
peripheral blood CLL cells.
We hypothesize that CLL cells taken from patients who have received acalabrutinib and 
obinutuzumab combination therapy will be more Bcl-2 dependent than their matched CLL cells 
at baseline. This will be measured by dynamic BH3 profiling, a technique that allows us to 
measure “delta priming,” defined as the difference in mitochondrial response to a BH3 peptide in 
a drug-treated sample versus an untreated control. Specifically, we wish to confirm if 
acalabrutinib increases sensitivity to the BAD BH3 peptide as opposed to the BIM BH3 peptide, 
as we have previously reported (Deng et al., 2017). We will also determine if the potentiation of 
venetoclax activity that we see with acalabrutinib treatment in vitro can predict depth of response 
to the acalabrutinib/venetoclax combination in vivo. After completion of cycle 1 (on cycle 2 day 
1 prior to administration of obinutuzumab) and after completion of cycle 3 (on cycle 4 day 1 
prior to administration of venetoclax) we will obtain a peripheral blood sample.  We will 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
87
compare the dynamic BH3 profile of these samples to a baseline sample, which will allow us to 
assess in vivo the shortterm change in apoptotic priming induced by acalabrutinib and also by 
acalabrutinib and obinutuzumab, respectively. We will correlate this with clinical response to 
subsequent venetoclax therapy. We will also compare the dynamic BH3 profile of a peripheral 
blood sample collected at cycle 8 day 1 (after 4 months of venetoclax therapy) to the dynamic 
BH3 profiles at baseline and immediately prior to venetoclax therapy. 
All peripheral blood samples will promptly be delivered to the laboratory of Dr. Jennifer Brown, 
where they will undergo Ficoll purification and then be viably frozen in FBS with 10% DMSO.  
The viably-frozen samples will be batched and stored, and the BH3 profiling assays will be 
performed in Dr. Davids’ lab (for detailed methods see Ryan et al., 2010).
9.1.2 Genomic Analyses
We plan to perform whole exome sequencing on CLL cells and normal tissue from patients at 
baseline to evaluate for somatic mutations such as TP53, NOTCH1 and SF3B1 that may confer 
drug sensitivity and resistance. If the patient does not have significant circulating CLL cells, we 
will pursue sequencing of bone marrow aspirate samples in patients who require a new bone 
marrow biopsy for screening.  In addition, saliva as a source of germline will be collected prior 
to study initiation and may be collected more than once if inadequate specimen is obtained. All 
samples will promptly be delivered to the laboratory of Dr. Jennifer Brown, where DNA will be 
extracted and then sent to the Broad Institute (Cambridge, MA) for whole exome sequencing.  In 
an exploratory analysis, we will assess novel mutations as potential predictors of response and 
progression-free survival.  We will also collect a sample from each patient at time of relapse or 
progression for repeat analysis by whole exome sequencing to assess for acquired resistance 
mutations.
9.1.3 Adaptive ClonoSEQ Assay
To assess whether the presence of minimal residual CLL cells in the peripheral blood as 
measured by a novel sequencing platform is predictive of progression free and overall survival, 
peripheral blood and/or bone marrow samples will be collected for analysis at the following time 
points: screening visit, cycle 4 day 1, cycle 8 day 1, cycle 13 day 1, cycle 16 day 1, and cycle 25 
day 1. Samples will be sent to the Brown Lab at DFCI where they will be stored initially prior to 
batch shipping to Adaptive for analysis. Using Adaptive’s ClonoSEQ platform, rearranged 
immunoreceptor loci from genomic DNA will be extracted, amplified, and sequenced using V 
and J segment primers for each immunoreceptor gene.  Tumor-specific clonotypes will be 
identified for each patient based on their high prevalence in peripheral blood or bone marrow.  
Sequences will be analyzed using standardized algorithms for clonotype determination.  
Adaptive MRD levels will be quantified using spiked-in reference sequences.
9.1.4 Additional Prognostic Tests
Patients who have not had ZAP-70 and IGHV testing done locally will have baseline samples 
sent for testing to Genzyme/LabCorp. These samples will be shipped alongside the Integrated 
Oncology/LabCorp requisition form ambient priority overnight to:  

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
88
Genzyme/LabCorp Specialty Testing Group
521 West 57th Street 
New York, NY 10000
Table 12: Sample Collection Schedule
Sample Time 
Point
Container1
Sample Type2
Shipping Method
Recipient
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral blood
2 x 6 mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight 
1 x Oragene Kit
Saliva3
Ambient overnight
Brown Laboratory, DFCI 
(BH3 profiling, whole 
exome sequencing, 
Adaptive Clonoseq)
Screening or      
Pre-dose Day 1
2 x 6mL Green 
Top*
Peripheral blood
Fridge pack overnight
Genzyme/LabCorp4
Cycle 2, Day 1 
(start of 
obinutuzumab)
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile)
Cycle 2, Day 8
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile)
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
2 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(Adaptive Clonoseq)
Cycle 4, Day 1 
(start of 
venetoclax)
1 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Mayo Clinic (MRD 
Assessment)5
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
2 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(Adaptive Clonoseq)
Cycle 8, Day 1 
(one cycle after 
completion of 
obinutuzumab)
1 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Mayo Clinic (MRD 
Assessment)5
Cycle 13, Day 1
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral Blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral Blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
2 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(Adaptive Clonoseq)
Cycle 16, Day 1 
(primary endpoint 
assessment of 
MRD)
1 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Mayo Clinic (MRD 
Assessment)5
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral Blood
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
Cycle 25, Day 1
2 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(Adaptive Clonoseq)

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
89
1 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Mayo Clinic (MRD 
Assessment)5
6x 6 mL Green Top
1 x 6 mL Red Top
Peripheral Blood
Fridge pack overnight
Treatment 
Discontinuation
2 x 6mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profile, Adaptive 
Clonoseq)
1 x 6 mL Red Top
Peripheral Blood
Fridge pack overnight
6 x 6 mL Green Top
Peripheral Blood
Relapse/Disease 
Progression
2 x 6 mL Green Top
Bone Marrow 
Aspirate
Fridge pack overnight
Brown Laboratory, DFCI 
(BH3 profiling, whole 
exome sequencing, 
Adaptive Clonoseq)
1 Green top= sodium heparin tube; Red top= no additive; 
2 For time points that mention blood and or aspirate: If patient has few circulating CLL cells in peripheral blood, 
send additional aspirate (1 x 6 mL green top tube) in addition to blood 
3 Oragene kits require approximately 2 mLs of saliva
4 Genzyme/LabCorp only provides requisition form
5 Bone marrow and peripheral blood samples sent to Mayo Clinic for MRD assessment are considered part of 
standard of care disease monitoring, not research.  
* Samples required for all patients at baseline unless previously tested for ZAP-70, IGHV, TP53, and NOTCH1 
(DFCI only). 
Correlative studies note:  While the goal of the correlative studies is to provide supportive data 
for the clinical study, there may be circumstances when a decision is made to stop a collection, 
not perform, or discontinue an analysis due to either practical reasons (e.g., inadequate sample 
number, issues related to the quality of the sample or issues related to the assay that preclude 
analysis, impossibility to perform correlative analyses, etc). Therefore, depending on the results
obtained during the study, sample collection/analysis may be omitted at the discretion of the PI. 
Additional correlative samples may be collected after the 24 cycle time point at the discretion of 
the investigators.
9.2 Correlative Lab Sample Collection and Shipping Instructions
DFCI patient samples will be hand-delivered to the lab of Dr. Jennifer Brown. Other DF/HCC 
sites may send samples via preferred courier service, or hand delivery to the lab. 
External Investigative Site Sample Preparation and Shipment:
Once fresh samples (blood and bone marrow aspirate) are collected, the vacutainers will be 
refrigerated and stored per instructions below. There is no required processing for any of the 
samples by the participating site prior to shipment.
1. Package tubes at room temperature and wrap in a liberal amount of paper towel around 
the tubes to ensure adequate insulation of the specimen(s) and absorption in the event of a 
breakage. 
2. Place wrapped specimen in a biohazard labeled Ziploc bag or sealable bag with a fridge 
pack and securely close. 
3. Wrap bubble wrap around the bag and place in a cardboard box. If space remains in the 
box, stuff with extra paper towel to reduce shifting of samples.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
90
4.  Complete the shipping requisition form using the address listed below. Prepare the 
package for shipping, applying packing tape as needed. 
5. Ship the package using FedEx or UPS next day or overnight delivery the same day the 
sample was collected. 
6. Only ship Monday-Thursday, and avoid shipping before a holiday as the lab does not 
receive packages on Saturday or on holidays. 
7. With each shipment, please include the following:
a.
A sample requisition form (Appendix I), including the patient number, timepoint, 
study number, must accompany each shipment. Please sign and date the form, and 
retain a copy for site record maintenance. 
b. An electronic copy (Word or PDF) of the sample requisition form must also be 
sent via email and include the tracking number of the package. The listing must 
also include a contact name, address and phone number of the person who is 
responsible for the shipment.
8. Please email the Lead Site Research Project Manager and Brown Lab contact to notify of 
an incoming shipment at least 48 hours prior to a shipment
9. Samples may be shipped via overnight air to:
      Stacey Fernandes, Principal Research Technician 
DFCI CLL Center, J. Brown lab  
      1 Jimmy Fund Way
SM 648                                     
      Boston, MA 02115, U.S.A. 
      617-632-5828 (phone)

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
91
10. STUDY CALENDAR
Screening imaging should be conducted 30 days or less prior to start of patient registration, 
unless otherwise indicated. PET scans paired with nondiagnostic CT scans may substitute for 
CT scans, either at screening or at any point during the trial, if deemed clinically necessary 
by the investigator. CT scans must include neck, chest, abdomen, and pelvis. Bone marrow 
aspirate and/or biopsy is required within approximately 6 months prior to registration. 
Baseline laboratory testing should be completed within 2 weeks of initiation of therapy, 
unless otherwise indicated. In the event that the participant's condition is deteriorating, 
laboratory evaluations should be repeated within 48 hours prior to initiation of the next cycle 
of therapy.
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered within + 7 days of the protocol-specified date during the 
cycles 1-15, and within +14 days for cycles 16-24 and beyond, unless otherwise noted. 

92
Study Calendar for all patients (Cycles 1-16) 
1 Only required in women of childbearing potential
2 Unilateral bone marrow aspirate and/or biopsy required within 6 months of screening.
3 MRD assessment should be sent on marrow samples taken after cycles 3, 7, 15, and 24.
4 Marrow sample requested for correlative studies if bone marrow biopsy is done as standard of care, or as part of protocol schedule. Flow cytometry (lymphoma 
panel), karyotype, and FISH (CLL) should be performed on all bone marrow biopsies (FISH may be performed on either marrow or blood and is not required on 
both).
5 These baseline serologies may be completed within 4 weeks of initiation of therapy. For those patients who are either hepatitis B core antibody and/or hepatitis 
B surface antigen positive but HBV DNA negative, pharmacologic prophylaxis and monitoring of HBV DNA is required as detailed in section 5.4. HTLV 
serologic testing is not required but is strongly suggested if the treating clinician has a high suspicion for HTLV infection.
6 CBC with differential, hemoglobin, hematocrit, platelets
Cycle = 28 days
Screen
Cycle 
1
Cycle 2 
(± 3 days)
Cycle 3 
(±3 days)
Cycle 411
(±7 days)
Cycle 5
(±7 days)
Cycles 
6-7
(±7 
days)
Cycle 
8
 (±7 
days)
Cycles 
9, 11
(±7 
days)
Cycle 
13
(±7 
days)
Cycle 
1612 
(±14 
days)
 Procedure
Day 
-30 to 0
Day 1
Day 
1
Day 
2
Day 
8
Day 
15
Day 
22
Day 
1
Day 
15
Day 1
Day 2
Day 3
Day 8
Day 9
Day 
15
Day 
16
Day 
22
Day 
23
Day 
1
Day 
15
Day 1
Day 1
Day 1
Day 1
Day 1
Acalabrutinib
X----------------------------------------------------------------------------------------Daily dosing days 1-28-------------------------------------------------------------------------------------------------------------X
Obinutuzumab
X
X
X
X
X
X
X
X
Venetoclax
X----------------------------------------------------------------------Daily dosing days 1-28--------------------------------------------------------X
Informed Consent
X
Medical history, Physical Exam, 
Vital Signs ((height, weight, resp 
rate, HR, BP, temp, O2 sat), ECOG 
Performance Status17
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Urinalysis, EKG
X
Serum Pregnancy Test1
X
Bone Marrow aspirate / biopsy / 
MRD assessment2,3,4, 16
X
X13
X
X
SPEP + Immunoglobulins
X
X
X
X
HIV, HCV, HBV, HTLV serologies5
X
β2 microglobulin, PT, PTT, INR
X
CT scan
X
X
X
X
X
Hematology6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Serum Chemistry7
X
X
X14
X
X
X
X
X
X
X15
X15
X
X15
X
X15
X
X15
X
X
X
X
X
X
X
X
FISH analysis
X
X
X
IGHV, TP53, ZAP-70, NOTCH1
X
Adverse Event Evaluation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
TLS Prophylaxis8
X
X
X---------------------------------------------------------------------------------------X
Peripheral Blood MRD Analysis9, 16
X
X
X
X
Adaptive ClonoSEQ MRD Analysis
X
X
X
X
Other correlative studies10
X
X
X
X
X
X
X

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
93
7 Calcium, Sodium, Potassium, Phosphorus, Chloride, Glucose, Magnesium, Albumin, AST, ALT, Creatinine, BUN, Bicarbonate, Total protein, Total bilirubin 
(and direct bilirubin if total Bilirubin is abnormal), Uric acid, LDH, Alkaline phosphatase
8 TLS prophylaxis will consist of allopurinol in subjects without a history of an adverse reaction to this drug, or an alternative anti-hyperuricemic agent.
9 Peripheral blood MRD analysis will be done by four color flow cytometry through a reference laboratory with a detection limit of 10-4 cells per leukocyte. 
10 Baseline correlative studies may be obtained either at the screening visit or prior to study drug administration on C1D1.
11 Only cycle days requiring outpatient visits or laboratory evaluations are listed. Provided that there is no evidence of TLS or adverse events, venetoclax dosing 
is continuous throughout this cycle at doses as specified in the treatment plan.
12 Subjects will have a response evaluation on cycle 16 day 1 and will continue on therapy until information on disease status is obtained from the restaging 
studies, at which point they will follow one of the two calendars below.
13 Bone marrow biopsy at cycle 4 day 1 is optional.
14 Chemistries to be drawn prior to administration of obinutuzumab and approximately 6-8 hours after initiation of obinutuzumab administration on this day.
15 Chemistries to be drawn prior to administration of venetoclax and approximately 6-8 hours after administration of venetoclax on these days.
16 Bone marrow and peripheral blood samples sent to Mayo Clinic for MRD assessment are considered part of standard of care disease monitoring, not research.
17 Height needs to be collected in screening only.
 Off-study evaluation. Note: for IND/IDE trials, follow up visits or other contact are required in order to identify SAEs during the 30 days following the end of 
study treatment.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
94
Study Calendar for patients who ARE in complete remission with MRD-negativity in the bone marrow and blood at cycle 16 
evaluation and choose to discontinue therapy
(Cycles 17 and beyond)
Cycle = 28 days
Cycle 19
(±14 days)
Cycle 22
(±14 days)
Cycle 25
(±14 days)
Every 3 
cycles7 
(±14 days)
Off Treatment
Off Study8
Procedure
Day 1
Day 1
Day 1
Acalabrutinib1
Obinutuzumab
Venetoclax1
Medical history, physical exam, 
vital signs ( weight, resp rate, 
HR, BP, temp, O2 sat) and ECOG 
Performance Status
X
X
X
X
X
X
Bone Marrow aspirate / biopsy / 
MRD assessment2,3, 9
X
CT scan (+/- 7 days)
X
X
X
Hematology4  and Serum 
Chemistry5
X
X
X
X
X
X
Adverse Event Evaluation
X
X
X
X
X
X
Peripheral Blood MRD 
Analysis6, 9
X
X
X
X
X
X
Adaptive ClonoSEQ MRD 
Analysis
X
X
X
Other correlative studies
X
X
X
1 If relapse is detected (by clinical, radiographic, or MRD testing), subjects will resume acalabrutinib and venetoclax until progression / unacceptable toxicity. 
Follow-up schedule will be modified to match the calendar on the following page.
2 MRD assessment should be sent on marrow sample taken after cycle 24.
3 Marrow sample requested for correlative studies if bone marrow biopsy is done as standard of care, or as part of protocol schedule. Flow cytometry (lymphoma 
panel), karyotype, and FISH (CLL) should be performed on marrow at all bone marrow biopsies (FISH may be performed on either marrow or blood and is not 
required on both).
4 CBC with differential, hemoglobin, hematocrit, platelets
5 Calcium, Sodium, Potassium, Phosphorus, Chloride, Glucose, Magnesium, Albumin, AST, ALT, Creatinine, BUN, Bicarbonate, Total protein, Total bilirubin 
(and direct bilirubin if total Bilirubin is abnormal), Uric acid, LDH, Alkaline phosphatase
6 Peripheral blood MRD analysis will be done by four color flow cytometry through a reference laboratory with a detection limit of 10-4 cells per leukocyte. 
7 Subjects with CR/CRi and MRD-negativity at C16D1 who choose to discontinue therapy will be seen in clinic on cycles 19, 22, and 25 and then every three 
cycles for 2 years (i.e. through cycle 48). If relapse is detected by PB flow cytometry at any of these time points, subjects will be re-staged with CT scan (if not 
done in the three months prior) and bone marrow biopsy (if not done in the six months prior) and will resume acalabrutinib and venetoclax until progression / 
unacceptable toxicity per the follow-up schedule on the following page. If no relapse is detected by cycle 48, subjects who are no longer on study treatment may 
return to follow-up with a local hematologist but will be followed by telephone for updates on disease progress and overall survival.
8 If at the time of coming off study the subject is ≤2 weeks from coming off of therapy, the evaluations done at the off-treatment visit will suffice and need not be 
repeated. Follow-up data will be collected every three cycles until death, up to 5 years after the initial dosing.
9Bone marrow and peripheral blood samples sent to Mayo Clinic for MRD assessment are considered part of standard of care disease monitoring, not research.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
95
Study Calendar for patients who ARE NOT in complete remission with MRD-negativity in the bone marrow and blood at cycle 16 
evaluation OR who are in complete remission yet choose to continue therapy
(Cycles 17 and beyond)
Cycle = 28 days
Cycle 19
(±14 days)
Cycle 22
(±14 days)
Cycle 256
(±14 days)
Every 3 cycles 
until cycle 487 
(±14 days)
Clearance of 
MRD from the 
blood8
Off 
Treatment
Off Study9
Procedure
Day 1
Day 1
Acalabrutinib
X--------------------Daily dosing days 1-28-----------------X
X
Obinutuzumab
Venetoclax
X---------------------Daily dosing days 1-28-----------------X
X
Medical history, physical exam, 
vital signs ( weight, resp rate, 
HR, BP, temp, O2 sat), and 
ECOG Performance Status
X
X
X
X
X
X
Bone Marrow aspirate / biopsy / 
MRD assessment1,2, 10
X
X
CT scan (+/- 7 days)
X
X
X
X
Hematology3 and Serum 
Chemistry4
X
X
X
X
X
X
X
Adverse Event Evaluation
X
X
X
X
X
X
Peripheral Blood MRD 
Analysis5, 10
X
X
X
X
X
X
Adaptive ClonoSEQ MRD 
Analysis
X
X
X
X
Other correlative studies
X
X
X
X
1 MRD assessment should be sent on marrow samples taken after cycle 24.
2 Marrow sample requested for correlative studies if bone marrow biopsy is done as standard of care, or as part of protocol schedule. Flow cytometry (lymphoma 
panel), karyotype, and FISH (CLL) should be performed on marrow at all bone marrow biopsies (FISH may be performed on either marrow or blood and is not 
required on both).
3 CBC with differential, hemoglobin, hematocrit, platelets
4 Calcium, Sodium, Potassium, Phosphorus, Chloride, Glucose, Magnesium, Albumin, AST, ALT, Creatinine, BUN, Bicarbonate, Total protein, Total bilirubin 
(and direct bilirubin if total Bilirubin is abnormal), Uric acid, LDH, Alkaline phosphatase
5 Peripheral blood MRD analysis will be done by four color flow cytometry through a reference laboratory with a detection limit of 10-4 cells per leukocyte. 
6 Acalabrutinib and venetoclax are continued until cycle 24. Subjects who are MRD-negative at cycle 24 restaging will stop acalabrutinib and venetoclax. These 
subjects receive peripheral blood monitoring for minimal residual disease every three cycles for up to 2 years after completion of cycle 24 (i.e. cycle 48). If there 
is detectable recurrence by peripheral blood flow cytometry during that time, subjects will be re-staged (with CT scan if not done in the three months prior and 
bone marrow biopsy and rapid heme panel (RHP) if not done in the six months prior) and acalabrutinib and venetoclax will be resumed until clinical progression 
or unacceptable toxicity. Subjects who are MRD-positive at cycle 24 restaging will continue acalabrutinib and venetoclax with every three month follow-up 
visits until disease progression or unacceptable toxicity.
7 Subjects will continue to be seen every three cycles for monitoring, for up to two years after cycle 24 (i.e. through cycle 48). After these two years, subjects who 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
96
are no longer on study treatment may return to follow-up with a local hematologist but will be followed by telephone for updates on disease progress and overall 
survival. Subjects who remain on study therapy will continue to be seen every three months. CT scans will be obtained every six months in patients who are not 
in remission and who are still on study therapy.
8 Subjects who eventually achieve MRD-negativity in the blood after cycle 24 should have complete disease re-staging with studies as outlined in the table. 
These re-staging studies should occur within approximately one month of achievement of MRD-negativity. Per protocol, these subjects should continue to 
remain on therapy until the results of the MRD assessment are obtained. Patients will have the option to discontinue therapy at any point after cycle 25 if they 
achieve two consecutive negative MRD assessments that are 3 months apart.
9 If at the time of coming off study the subject is ≤4 weeks from coming off of therapy, the evaluations done at the off-treatment visit will suffice and need not be 
repeated. Follow-up data will be collected every three cycles until death, up to 5 years after the initial dosing.
10 Bone marrow and peripheral blood samples sent to Mayo Clinic for MRD assessment are considered part of standard of care disease monitoring, not research.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
97
Study Calendar for patients in whom recurrence is detected after ceasing study therapy (Retreatment Cycles 1 and beyond)
1 Marrow sample requested for correlative studies if bone marrow biopsy is done as standard of care, or as part of protocol schedule. Flow cytometry (lymphoma 
panel), karyotype, and FISH (CLL) should be performed on marrow at all bone marrow biopsies (FISH may be performed on either marrow or blood and is not 
required on both).
3 CBC with differential, hemoglobin, hematocrit, platelets. RHP (rapid heme panel) should be done if not done within 6 months of disease recurrence. 
4 Calcium, Sodium, Potassium, Phosphorus, Chloride, Glucose, Magnesium, Albumin, AST, ALT, Creatinine, BUN, Bicarbonate, Total protein, Total bilirubin 
(and direct bilirubin if total Bilirubin is abnormal), Uric acid, LDH, Alkaline phosphatase
5 Subjects who develop disease recurrence must be re-evaluated with the studies listed in this column. These re-staging studies must occur within one month of 
detection of disease recurrence.
6 Venetoclax may be reinitiated on retreatment cycle 1 day 1 at the patient’s previously tolerated maximum daily dose only if recurrence was detected using 
peripheral blood MRD testing and the subject otherwise still meets IWCLL complete response criteria (as based on CT scans, bone marrow biopsy, and 
peripheral blood sampling). If the subject has recurrent disease and no longer meets complete response criteria then the subject should be re-assessed for TLS risk 
as discussed in section 6.1.2 and venetoclax should be re-initiated following the ramp-up schedule used in cycle 4 and detailed in section 5.3.3. 
7  If at the time of coming off study the subject is ≤4 weeks from coming off of therapy, the evaluations done at the off-treatment visit will suffice and need not 
be repeated. Follow-up data will be collected every three cycles until death, up to 5 years after the initial dosing.
8 Bone marrow and peripheral blood samples sent to Mayo Clinic for MRD assessment are considered part of standard of care disease monitoring, not research.
Cycle = 28 days
Detection of 
disease 
recurrence5
Retreatment 
Cycle 16
Retreatment 
Cycle 2
(±3 days)
Retreatment 
Cycle 3
(±3 days)
Every 3 cycles 
(±14 days)
Off Treatment
Off Study7
Procedure
Day 1
Day 1
Day 1
Acalabrutinib
X-------------------Daily dosing days 1-28---------------------X
Obinutuzumab
Venetoclax
X-------------------Daily dosing days 1-28---------------------X
Medical history, physical exam, 
vital signs ( weight, resp rate, 
HR, BP, temp, O2 sat), and 
ECOG Performance Status
X
X
X
X
X
X
X
Bone Marrow aspirate / biopsy1
X
CT scan (+/- 7 days)
X
X
X
Hematology3 and Serum 
Chemistry4
X
X
X
X
X
X
X
Adverse Event Evaluation
X
X
X
X
X
X
Peripheral Blood MRD Analysis8
X
X
Adaptive ClonoSEQ MRD 
Analysis
X
X
X
Other correlative studies
X
X
X
X

98
11. MEASUREMENT OF EFFECT
11.1
Definitions
Evaluable for toxicity: All participants who receive at least one dose of study treatment will be 
evaluable for toxicity from the time of their first treatment on cycle 1 / day 1.
Evaluable for objective response: All subjects who have received at least one dose of study drug 
are evaluable for response. These participants will have their response classified according to the 
definitions stated below.
11.2
Methods for Evaluation of Measurable Disease
All baseline evaluations (physical exam and radiographic evaluations) should be performed as 
closely as possible to the beginning of treatment and not more than 30 days before the beginning 
of the treatment.
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination when both methods have been used to assess the 
anti-tumor effect of a treatment.  
Clinical lesions. Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes). For the case of skin lesions, documentation by 
color photography, including a ruler to estimate the size of the lesion, is recommended.  All 
lymph node measurements should be taken and recorded in metric notation, using a ruler, 
calipers, or digital measurement tool.
Conventional CT and MRI. These techniques should be performed with cuts of 10 mm or less in 
slice thickness contiguously. Spiral CT should be performed using a 5 mm contiguous 
reconstruction algorithm. This applies to tumors of the chest, abdomen, and pelvis.
11.3
Response Criteria
Response and progression will be evaluated in this study using the 2018 IWCLL criteria for CLL 
(Hallek et al., 2018). These criteria are detailed in Appendix B.
11.4
Response Review
Radiology will be centrally reviewed by the DF/HCC Tumor Imaging Metrics Core (TIMC).

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
99
12. DATA REPORTING / REGULATORY REQUIREMENTS
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements).
12.1
Data Reporting
12.1.1 Method
The Office of Data Quality (ODQ) will collect, manage, and perform quality checks on the data 
for this study.
12.1.2 Responsibility for Data Submission
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or data 
forms to the Office of Data Quality in accordance with DF/HCC SOPs.
12.2
Data Safety Monitoring
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 
team.
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 
summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request. 
 
12.3
Multicenter Guidelines
This protocol will adhere to the policies and requirements of the DF/HCC Multi-Center Data and 
Safety Monitoring Plan.  The specific responsibilities of the Overall PI, Coordinating Center, and 
Participating Institutions and the procedures for auditing are presented in Appendix B.

The Overall PI/Coordinating Center is responsible for distributing all IND Action Letters 
or Safety Reports to all participating institutions for submission to their individual IRBs 
for action as required.

Mechanisms will be in place to ensure quality assurance, protocol compliance, and 
adverse event reporting at each site.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
100

Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from supplier.  A participating site may order the agent(s) only after the 
initial IRB approval for the site has been forwarded to the Coordinating Center.
12.4
Collaborative Agreements Language
N/A

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
101
13. STATISTICAL CONSIDERATIONS
13.1
Study Design/Endpoints
This is an open-label, single-arm, phase 2 study to assess the rate of bone marrow MRD negative 
complete response after 15 cycles of therapy with acalabrutinib, venetoclax, and obinutuzumab 
(AVO) combination therapy in previously untreated CLL patients. Acalabrutinib will be given at 
100mg orally twice daily as monotherapy for one month. This will be followed by acalabrutinib 
and obinutuzumab combination therapy for two months. Then, acalabrutinib, obinutuzumab, and 
venetoclax therapy will be given as a triplet for four months, followed by acalabrutinib and 
venetoclax combination therapy. Disease assessments will be performed at baseline and after 
cycles 3, 7, and 15, with the primary endpoint of MRD-negativity in the bone marrow assessed at 
the completion of cycle 15. Patients who are in complete remission with marrow and peripheral 
blood MRD-negativity at this time will have the option to discontinue acalabrutinib and 
venetoclax and will be monitored for recurrence. Patients who are in partial remission and/or are 
marrow or blood MRD-positive at cycle 15 will continue acalabrutinib and venetoclax therapy 
through cycle 24, at which point another disease assessment will take place. Patients who are 
MRD-negative in marrow and blood at the end of cycle 24 will have the option to discontinue 
acalabrutinib and venetoclax and will be monitored for recurrence as per the study calendar in 
section 10. Patients who are MRD-positive at will continue acalabrutinib and venetoclax 
indefinitely until disease progression or unacceptable toxicity.
Primary Endpoint: Rate of bone marrow minimal residual disease (MRD) negative complete 
responses (CRs/CRis) assessed after 15 cycles of therapy.
13.2
Sample Size, Accrual Rate and Study Duration
This is a one-stage study to determine the MRD-negative CR/CRi rate in the bone marrow after 
15 cycles of AVO combination therapy. In a previous study of venetoclax plus rituximab in the 
relapsed/refractory population, the CR/CRi rate was 51%, and 80% of these responses were 
bone-marrow MRD-negative, for an MRD-negative CR/CRi rate of 41% (Seymour et al., 2017). 
Furthermore, 21 out of 25 CRs in this study occurred after 18 months of therapy, thus we will 
assume that ~80% of all marrow MRD-negative CRs will have occurred after 15 months of 
therapy here, leading to an expected marrow MRD-negative CR/CRi rate of 33%. Of note, this 
study was done in a relapsed/refractory population. Given that the depth of response is likely to 
be greater in the frontline setting, we are using an MRD-negative CR/CRi rate of 40% as the null 
hypothesis. With the addition of acalabrutinib, we hypothesize that the MRD-negative CR/CRi 
rate will be 60% or higher (alternative hypothesis). Initially, we planned to enroll 37 patients, 
and assuming approximately 1 screening failure this meant that 36 patients would be evaluable 
for the primary endpoint. This cohort has now completed enrollment and is referred to as cohort 
1. We will now expand the study to include a second cohort of 35 patients with high-risk disease, 
defined as 17p deletion and/or TP53 mutation (cohort 2). In cohort 2, we will have 80% power 
and one-sided type I error of 0.07 for an exact one-sample binomial test comparing an expected 
55%  response rate to the assumed 35% response rate for standard-of-care treatment in this high 
risk group. A patient will be considered unevaluable for response and replaced if the patient 
decides to withdraw from the study prior to the administration of the first dose of study drug.
Based on the accrual rate of the study to date of 3 patients per month, we anticipate that accrual 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
102
of this study will complete within approximately 12 months from activation of cohort 2. Up to an 
additional 15 months of follow-up will be required on the last participant accrued to observe 
participant response after the 15th cycle of protocol therapy, for a total study duration of 
approximately 2.5 years. Evaluation of secondary endpoints, such as 3 year overall survival, will 
take up to three years after enrollment of the final subject.
Gender of subjects will not be used as a criterion for inclusion or exclusion in this study and 
there are no restrictions on the accrual of minorities. In the CLL patient population at DFCI, 
approximately 70% of patients were men and approximately 15% of patients were minorities. 
Based on this self-reported ethnicity and gender, the anticipated accrual in subgroups defined by 
gender and race is summarized in the table below.
Accrual Targets
Sex/Gender
Ethnic Category
Females
Males
Total
Hispanic or Latino
2
+
2
=
4
Not Hispanic or Latino
19
+
48
=
67
Ethnic Category: Total of all subjects
      21               (A1) +                  50     (B1) =
71
(C1)
Racial Category
American Indian or Alaskan Native
+
=
0
Asian
3
+
3
=
6
Black or African American
3
+
4
=
7
Native Hawaiian or other Pacific 
Islander
+
=
White
15
+
43
=
58
Racial Category: Total of all subjects
21
(A2)
+
50
(B2) =
71
(C2)
(A1 = A2)
(B1 = B2)
(C1 = C2)
13.3
Stratification Factors
There will be no stratification of patients on this study.
13.4
Interim Monitoring Plan
Data safety and monitoring will be performed per DFCI guidelines. We first note that 
veneteoclax and obinutuzumab (K. Fischer et al., 2019; Fischer et al., 2017), acalabrutinib and 
obinutuzumab (Woyach, Awan, et al., 2017; Woyach et al., 2020), and venetoclax plus ibrutinib 
(a related BTK inhibitor) (Tam et al., 2018) combination therapy has been tested in patients 
without any concerning safety signals so far. If in the first 10 patients who receive at least one 
cycle of triple therapy with acalabrutinib, venetoclax, and obinutuzumab, 3 or more patients 
develop unexpected toxicity, this will trigger a consultation with the DSMC about whether to 
stop accrual. Unexpected toxicities would include the following events that occur during the first 
cycle of triple therapy, unless they are clearly due to extraneous causes: grade 4 or higher 
infusion reaction, grade 4 or higher infection, grade 4 or higher neutropenia, any cases of clinical 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
103
TLS, or other grade 3 or higher, clinically significant nonhematologic toxicity related to study 
treatment, except asymptomatic laboratory abnormalities or nausea/vomiting/diarrhea that 
improves with supportive care. With this design, the probability of triggering a consultation is 
0.07 if the true but unknown rate of grade 3 or higher treatment related toxicity is 10%, 0.18 if 
the rate is 15%, 0.74 if the rate is 35%, and 0.83 if the rate is 40%.
13.5
Analysis of Primary Endpoints
Please refer to section 13.1.
13.6
Analysis of Secondary Endpoints
The analysis of secondary endpoints will be primarily descriptive, including rate of PR after 15 
cycles of therapy, rate of CR/CRi after 15 cycles of therapy, rate of best overall response, best 
rate of CR/CRi, best rate of peripheral blood and bone marrow MRD, progression free survival 
(including 2-year and 3-year landmark rate), overall survival (including 2-year and 3-year 
landmark rate), rate of MRD negativity in the bone marrow at 8 and 24 cycles, rate of peripheral 
blood MRD-negativity at 8, 15, and 24 cycles, correlation between MRD-negativity in the 
peripheral blood and bone marrow, time to MRD-positive disease recurrence in the peripheral 
blood, time to clinical disease progression, rate of infusion related reactions, and rate of tumor 
lysis syndrome. A descriptive analysis of rates of therapy discontinuation after 15 cycles will be 
performed, with subjects grouped by reasons for discontinuation (e.g. achievement of MRD-
negative CR, progressive disease, or intolerability). Rates of discontinuation of individual 
components of the regimen will also be included in this analysis. The Kaplan Meier method will 
be used to estimate the median progression-free survival time, progression-free survival, median 
overall survival time, and overall survival.  Association between clinical response and 
established CLL prognostic factors (ZAP70, FISH cytogenetics, IGHV mutation status, TP53 
mutation status) will be tested using Fisher’s exact test.  A similar descriptive analysis will be 
performed for laboratory correlative studies of BH3 profiling and genomic markers such as 
SF3B1, NOTCH1, and BCR/NFKB pathway somatic mutations.  If feasible, association between 
clinical response and correlative endpoints will be explored. A descriptive safety analysis with 
attention to adverse events, adverse events of special interests, and serious adverse events will 
also be performed.  We also plan to perform the above efficacy and safety analyses on cohort 1, 
cohort 2 plus the patients with TP53 aberrant disease in cohort 1, and in the entire group of 
cohort 1 plus cohort 2
13.7
Reporting and Exclusions
Subjects who never start protocol therapy will be excluded from all analyses.
Evaluation of Toxicity
All participants who receive any amount of study therapy will be evaluable for toxicity from the 
time of their first treatment.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
104
Evaluation of the Primary Efficacy Endpoint
All participants who receive at least one dose of at least one of the study drugs will be considered 
evaluable for the primary efficacy endpoint in an intent-to-treat analysis.  
14. PUBLICATION PLAN
The results should be made public within approximately 24 months of reaching the end of the 
study. The end of the study is the time point at which the last data items are to be reported, or 
after the outcome data are sufficiently mature for analysis, as defined in the section on Sample 
Size, Accrual Rate and Study Duration. If a report is planned to be published in a peer-reviewed 
journal, then that initial release may be an abstract that meets the requirements of the 
International Committee of Medical Journal Editors. A full report of the outcomes should be 
made public no later than three (3) years after the end of the study. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
105
15. REFERENCES
Amaya-Chanaga, C. I., Choi, M. Y., Nguyen, N., DeVore, E., MacCarthy, C., Hilger-Rolfe, J., . . . Castro, J. E. 
(2016). A Phase Ib/II Study of Ibrutinib in Combination with Obinutuzumab-Gazyva As First-Line 
Treatment for Patients with Chronic Lymphocytic Leukemia &gt; 65 Years Old or with Coexisting 
Conditions. Blood, 128(22), 2048-2048. 
Burger, J. A., Keating, M. J., Wierda, W. G., Hartmann, E., Hoellenriegel, J., Rosin, N. Y., . . . O'Brien, S. (2014). 
Safety and activity of ibrutinib plus rituximab for patients with high-risk chronic lymphocytic leukaemia: a 
single-arm, phase 2 study. Lancet Oncol, 15(10), 1090-1099. doi:10.1016/S1470-2045(14)70335-3
Burger, J. A., Tedeschi, A., Barr, P. M., Robak, T., Owen, C., Ghia, P., . . . Investigators, R.-. (2015). Ibrutinib as 
Initial Therapy for Patients with Chronic Lymphocytic Leukemia. N Engl J Med, 373(25), 2425-2437. 
doi:10.1056/NEJMoa1509388
Byrd, J. C., Brown, J. R., O'Brien, S., Barrientos, J. C., Kay, N. E., Reddy, N. M., . . . Investigators, R. (2014). 
Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med, 371(3), 213-
223. doi:10.1056/NEJMoa1400376
Byrd, J. C., Furman, R. R., Coutre, S. E., Burger, J. A., Blum, K. A., Coleman, M., . . . O'Brien, S. (2015). Three-
year follow-up of treatment-naive and previously treated patients with CLL and SLL receiving single-agent 
ibrutinib. Blood, 125(16), 2497-2506. doi:10.1182/blood-2014-10-606038
Byrd, J. C., Harrington, B., O'Brien, S., Jones, J. A., Schuh, A., Devereux, S., . . . Furman, R. R. (2016). 
Acalabrutinib (ACP-196) in Relapsed Chronic Lymphocytic Leukemia. N Engl J Med, 374(4), 323-332. 
doi:10.1056/NEJMoa1509981
Byrd, J. C., Rai, K., Peterson, B. L., Appelbaum, F. R., Morrison, V. A., Kolitz, J. E., . . . Larson, R. A. (2005). 
Addition of rituximab to fludarabine may prolong progression-free survival and overall survival in patients 
with previously untreated chronic lymphocytic leukemia: an updated retrospective comparative analysis of 
CALGB 9712 and CALGB 9011. Blood, 105(1), 49-53. doi:10.1182/blood-2004-03-0796
Byrd, J. C., Wierda, W. G., Schuh, A., Devereux, S., Chaves, J. M., Brown, J. R., . . . Furman, R. R. (2020). 
Acalabrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia: updated 
phase 2 results. Blood, 135(15), 1204-1213. doi:10.1182/blood.2018884940
Cartron, G., de Guibert, S., Dilhuydy, M. S., Morschhauser, F., Leblond, V., Dupuis, J., . . . Hallek, M. (2014). 
Obinutuzumab (GA101) in relapsed/refractory chronic lymphocytic leukemia: final data from the phase 1/2 
GAUGUIN study. Blood, 124(14), 2196-2202. doi:10.1182/blood-2014-07-586610
Covey, T., Barf, T., Gulrajani, M., Krantz, F., van Lith, B., Bibikova, E., . . . Kaptein, A. (2015). Abstract 2596: 
ACP-196: a novel covalent Bruton's tyrosine kinase (Btk) inhibitor with improved selectivity and in vivo 
target coverage in chronic lymphocytic leukemia (CLL) patients. Cancer Research, 75(15 Supplement), 
2596-2596. doi:10.1158/1538-7445.am2015-2596
Davids, M., Kim, H. T., Savell, A., Santiago-Medero, C., Francoeur, K., Abramson, J. S., . . . Brown, J. R. (2017). 
Initial Results of a Phase Ib Study of Ibrutinib in Combination with Obinutuzumab in Patients with 
Relapsed or Refractory Chronic Lymphocytic Leukemia Blood. 
Davids, M. S., & Brown, J. R. (2012). Targeting the B cell receptor pathway in chronic lymphocytic leukemia. Leuk 
Lymphoma, 53(12), 2362-2370. doi:10.3109/10428194.2012.695781
Davids, M. S., Deng, J., Wiestner, A., Lannutti, B. J., Wang, L., Wu, C. J., . . . Letai, A. (2012). Decreased 
mitochondrial apoptotic priming underlies stroma-mediated treatment resistance in chronic lymphocytic 
leukemia. Blood, 120(17), 3501-3509. doi:10.1182/blood-2012-02-414060
Davids, M. S., Roberts, A. W., Seymour, J. F., Gerecitano, J. F., Kahl, B. S., Kipps, T. J., . . . Wierda, W. G. (2016). 
Safety, efficacy and immune effects of venetoclax 400 mg daily in patients with relapsed chronic 
lymphocytic leukemia (CLL). ASCO Meeting Abstracts, 34(15_suppl), 7527. Retrieved from 
http://meeting.ascopubs.org/cgi/content/abstract/34/15_suppl/7527
Del Gaizo Moore, V., Brown, J. R., Certo, M., Love, T. M., Novina, C. D., & Letai, A. (2007). Chronic lymphocytic 
leukemia requires BCL2 to sequester prodeath BIM, explaining sensitivity to BCL2 antagonist ABT-737. J 
Clin Invest, 117(1), 112-121. doi:10.1172/JCI28281
Deng, J., Isik, E., Fernandes, S. M., Brown, J. R., Letai, A., & Davids, M. S. (2017). Bruton's tyrosine kinase 
inhibition increases BCL-2 dependence and enhances sensitivity to venetoclax in chronic lymphocytic 
leukemia. Leukemia. doi:10.1038/leu.2017.32
Fischer, K., Al-Sawaf, O., Bahlo, J., Fink, A. M., Tandon, M., Dixon, M., . . . Hallek, M. (2019). Venetoclax and 
Obinutuzumab in Patients with CLL and Coexisting Conditions. N Engl J Med, 380(23), 2225-2236. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
106
doi:10.1056/NEJMoa1815281
Fischer, K., Al-Sawaf, O., Fink, A. M., Dixon, M., Bahlo, J., Warburton, S., . . . Hallek, M. (2017). Venetoclax and 
obinutuzumab in chronic lymphocytic leukemia. Blood, 129(19), 2702-2705. doi:10.1182/blood-2017-01-
761973
Fischer, K., Ritgen, M., Al-Sawaf, O., Robrecht, S., Tandon, M., Fink, A.-M., . . . Hallek, M. (2019). Quantitative 
Analysis of Minimal Residual Disease (MRD) Shows High Rates of Undetectable MRD after Fixed-
Duration Chemotherapy-Free Treatment and Serves As Surrogate Marker for Progression-Free Survival: A 
Prospective Analysis of the Randomized CLL14 Trial. Blood, 134(Supplement_1), 36-36. 
doi:10.1182/blood-2019-125825
Flinn, I., Brunvand, M., Dyer, M. J., Hillman, P., Jones, J., Lymp, J., . . . Kipps, T. J. (2014). Preliminary Results of 
a Phase 1b Study (GP28331) Combining GDC-0199 (ABT-199) and Obinutuzumab in Patients with 
Relapsed/Refractory or Previously Untreated Chronic Lymphocytic Leukemia. Blood, 124(21), 4687-4687. 
Ghia, P., Pluta, A., Wach, M., Lysak, D., Kozak, T., Simkovic, M., . . . Jurczak, W. (2019). Acalabrutinib vs 
Rituximab Plus Idelalisib (IdR) or Bendamustine (BR) by Investigator Choice in Relapsed/Refractory 
(R/R) Chronic Lymphocytic Leukemia: Phase 3 ASCEND Study. Clinical Lymphoma Myeloma & 
Leukemia, 19, S280-S281. doi:10.1016/j.clml.2019.07.217
Goede, V., Fischer, K., Busch, R., Engelke, A., Eichhorst, B., Wendtner, C. M., . . . Hallek, M. (2014). 
Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions. N Engl J Med, 370(12), 
1101-1110. doi:10.1056/NEJMoa1313984
Hallek, M., Cheson, B. D., Catovsky, D., Caligaris-Cappio, F., Dighiero, G., Dohner, H., . . . Kipps, T. J. (2018). 
Guidelines for diagnosis, indications for treatment, response assessment and supportive management of 
chronic lymphocytic leukemia. Blood. doi:10.1182/blood-2017-09-806398
Hallek, M., Fischer, K., Fingerle-Rowson, G., Fink, A. M., Busch, R., Mayer, J., . . . German Chronic Lymphocytic 
Leukaemia Study, G. (2010). Addition of rituximab to fludarabine and cyclophosphamide in patients with 
chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial. Lancet, 376(9747), 1164-1174. 
doi:10.1016/S0140-6736(10)61381-5
Hebart, H., Ghia, P., Jurczak, W., Pluta, A., Wach, M., Lysak, D., . . . Lee, J. H. (2020). Ascend Phase 3 Study of 
Acalabrutinib vs Investigator's Choice of Rituximab Plus Idelalisib (IDR) or Bendamustine (BR) in 
Patients with Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia (CLL). Oncology Research and 
Treatment, 43, 128-129. Retrieved from <Go to ISI>://WOS:000517158700310
Herman, S. E., Gordon, A. L., Hertlein, E., Ramanunni, A., Zhang, X., Jaglowski, S., . . . Byrd, J. C. (2011). Bruton 
tyrosine kinase represents a promising therapeutic target for treatment of chronic lymphocytic leukemia and 
is effectively targeted by PCI-32765. Blood, 117(23), 6287-6296. doi:10.1182/blood-2011-01-328484
Honigberg, L. A., Smith, A. M., Sirisawad, M., Verner, E., Loury, D., Chang, B., . . . Buggy, J. J. (2010). The 
Bruton tyrosine kinase inhibitor PCI-32765 blocks B-cell activation and is efficacious in models of 
autoimmune disease and B-cell malignancy. Proc Natl Acad Sci U S A, 107(29), 13075-13080. 
doi:10.1073/pnas.1004594107
Jones, J. A., Woyach, J., Awan, F. T., Maddocks, K. J., Whitlow, T., Ruppert, A. S., & Byrd, J. C. (2016). Phase 1b 
Results of a Phase 1b/2 Study of Obinutuzmab, Ibrutinib, and Venetoclax in Relapsed/Refractory Chronic 
Lymphocytic Leukemia (CLL). Blood, 128(22), 639-639. 
Kater, A. P., Seymour, J. F., Hillmen, P., Eichhorst, B., Langerak, A. W., Owen, C., . . . Kipps, T. J. (2019). Fixed 
Duration of Venetoclax-Rituximab in Relapsed/Refractory Chronic Lymphocytic Leukemia Eradicates 
Minimal Residual Disease and Prolongs Survival: Post-Treatment Follow-Up of the MURANO Phase III 
Study. J Clin Oncol, 37(4), 269-277. doi:10.1200/JCO.18.01580
Kohrt, H. E., Sagiv-Barfi, I., Rafiq, S., Herman, S. E., Butchar, J. P., Cheney, C., . . . Byrd, J. C. (2014). Ibrutinib 
antagonizes rituximab-dependent NK cell-mediated cytotoxicity. Blood, 123(12), 1957-1960. 
doi:10.1182/blood-2014-01-547869
Kovacs, G., Robrecht, S., Fink, A. M., Bahlo, J., Cramer, P., von Tresckow, J., . . . Bottcher, S. (2016). Minimal 
Residual Disease Assessment Improves Prediction of Outcome in Patients With Chronic Lymphocytic 
Leukemia (CLL) Who Achieve Partial Response: Comprehensive Analysis of Two Phase III Studies of the 
German CLL Study Group. J Clin Oncol. doi:10.1200/JCO.2016.67.1305
Lampson, B. L., Yu, L., Glynn, R. J., Barrientos, J. C., Jacobsen, E. D., Banerji, V., . . . Brown, J. R. (2017). 
Ventricular arrhythmias and sudden death in patients taking ibrutinib. Blood, 129(18), 2581-2584. 
doi:10.1182/blood-2016-10-742437
Landau, D. A., Carter, S. L., Stojanov, P., McKenna, A., Stevenson, K., Lawrence, M. S., . . . Wu, C. J. (2013). 
Evolution and impact of subclonal mutations in chronic lymphocytic leukemia. Cell, 152(4), 714-726. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
107
doi:10.1016/j.cell.2013.01.019
Mato, A. R., Roeker, L. E., Allan, J. N., Pagel, J. M., Brander, D. M., Hill, B. T., . . . Nabhan, C. (2018). Outcomes 
of front-line ibrutinib treated CLL patients excluded from landmark clinical trial. Am J Hematol, 93(11), 
1394-1401. doi:10.1002/ajh.25261
Montillo, M., Byrd, J. C., Hillmen, P., O'Brien, S., Barrientos, J. C., Reddy, N. M., . . . Brown, J. R. (2017). Long-
term Efficacy and Safety in the RESONATE Study: Ibrutinib in Patients with Previously Treated Chronic 
Lymphocytic Leukemia with up to Four Years Follow-up. Hematological Oncology, 35, 235-236. 
doi:10.1002/hon.2438_98
O'Brien, S., Furman, R. R., Coutre, S., Flinn, I. W., Burger, J. A., Blum, K., . . . Byrd, J. C. (2018). Single-agent 
ibrutinib in treatment-naive and relapsed/refractory chronic lymphocytic leukemia: a 5-year experience. 
Blood, 131(17), 1910-1919. doi:10.1182/blood-2017-10-810044
O'Brien, S., Jones, J. A., Coutre, S. E., Mato, A. R., Hillmen, P., Tam, C., . . . Stilgenbauer, S. (2016). Ibrutinib for 
patients with relapsed or refractory chronic lymphocytic leukaemia with 17p deletion (RESONATE-17): a 
phase 2, open-label, multicentre study. Lancet Oncol, 17(10), 1409-1418. doi:10.1016/S1470-
2045(16)30212-1
O'Brien, S. M., Kantarjian, H. M., Cortes, J., Beran, M., Koller, C. A., Giles, F. J., . . . Keating, M. (2001). Results 
of the fludarabine and cyclophosphamide combination regimen in chronic lymphocytic leukemia. J Clin 
Oncol, 19(5), 1414-1420. doi:10.1200/JCO.2001.19.5.1414
Rai, K. R., Peterson, B. L., Appelbaum, F. R., Kolitz, J., Elias, L., Shepherd, L., . . . Schiffer, C. A. (2000). 
Fludarabine compared with chlorambucil as primary therapy for chronic lymphocytic leukemia. N Engl J 
Med, 343(24), 1750-1757. doi:10.1056/NEJM200012143432402
Roberts, A. W., Davids, M. S., Pagel, J. M., Kahl, B. S., Puvvada, S. D., Gerecitano, J. F., . . . Seymour, J. F. (2016). 
Targeting BCL2 with Venetoclax in Relapsed Chronic Lymphocytic Leukemia. N Engl J Med, 374(4), 311-
322. doi:10.1056/NEJMoa1513257
Ryan, J. A., Brunelle, J. K., & Letai, A. (2010). Heightened mitochondrial priming is the basis for apoptotic 
hypersensitivity of CD4+ CD8+ thymocytes. Proc Natl Acad Sci U S A, 107(29), 12895-12900. 
doi:10.1073/pnas.0914878107
Satterthwaite, A. B., & Witte, O. N. (2000). The role of Bruton's tyrosine kinase in B-cell development and function: 
a genetic perspective. Immunol Rev, 175, 120-127. Retrieved from 
https://www.ncbi.nlm.nih.gov/pubmed/10933597
Seymour, J. F., Ma, S., Brander, D. M., Choi, M. Y., Barrientos, J., Davids, M. S., . . . Roberts, A. W. (2017). 
Venetoclax plus rituximab in relapsed or refractory chronic lymphocytic leukaemia: a phase 1b study. 
Lancet Oncol, 18(2), 230-240. doi:10.1016/S1470-2045(17)30012-8
Sharman, J. P., Banerji, V., Fogliatto, L. M., Herishanu, Y., Munir, T., Walewska, R., . . . Byrd, J. C. (2019). 
ELEVATE TN: Phase 3 Study of Acalabrutinib Combined with Obinutuzumab (O) or Alone Vs O Plus 
Chlorambucil (Clb) in Patients (Pts) with Treatment-Naive Chronic Lymphocytic Leukemia (CLL). Blood, 
134(Supplement_1), 31-31. doi:10.1182/blood-2019-128404
Siegel, R. L., Miller, K. D., & Jemal, A. (2017). Cancer Statistics, 2017. CA Cancer J Clin, 67(1), 7-30. 
doi:10.3322/caac.21387
Stilgenbauer, S., Eichhorst, B., Schetelig, J., Coutre, S., Seymour, J. F., Munir, T., . . . Wierda, W. G. (2016). 
Venetoclax in relapsed or refractory chronic lymphocytic leukaemia with 17p deletion: a multicentre, open-
label, phase 2 study. Lancet Oncol, 17(6), 768-778. doi:10.1016/S1470-2045(16)30019-5
Stilgenbauer, S., Schnaiter, A., Paschka, P., Zenz, T., Rossi, M., Dohner, K., . . . Dohner, H. (2014). Gene mutations 
and treatment outcome in chronic lymphocytic leukemia: results from the CLL8 trial. Blood, 123(21), 
3247-3254. doi:10.1182/blood-2014-01-546150
Tam, C. S., Anderson, M. A., Pott, C., Agarwal, R., Handunnetti, S., Hicks, R. J., . . . Roberts, A. W. (2018). 
Ibrutinib plus Venetoclax for the Treatment of Mantle-Cell Lymphoma. N Engl J Med, 378(13), 1211-
1223. doi:10.1056/NEJMoa1715519
Thompson, P. A., Tam, C. S., O'Brien, S. M., Wierda, W. G., Stingo, F., Plunkett, W., . . . Keating, M. J. (2016). 
Fludarabine, cyclophosphamide, and rituximab treatment achieves long-term disease-free survival in 
IGHV-mutated chronic lymphocytic leukemia. Blood, 127(3), 303-309. doi:10.1182/blood-2015-09-
667675
Wang, L., Lawrence, M. S., Wan, Y., Stojanov, P., Sougnez, C., Stevenson, K., . . . Wu, C. J. (2011). SF3B1 and 
other novel cancer genes in chronic lymphocytic leukemia. N Engl J Med, 365(26), 2497-2506. 
doi:10.1056/NEJMoa1109016
Woyach, J. A., Awan, F. T., Jianfar, M., Rogers, K. A., Jones, J., Covey, T., . . . Byrd, J. C. (2017). Acalabrutinib 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
108
with Obinutuzumab in Relapsed/Refractory and Treatment-Naive Patients with Chronic Lymphocytic 
Leukemia: The Phase 1b/2 ACE-CL-003 Study. Blood, 130(Suppl 1), 432-432. 
Woyach, J. A., Blachly, J. S., Rogers, K. A., Bhat, S. A., Jianfar, M., Lozanski, G., . . . Byrd, J. C. (2020). 
Acalabrutinib plus Obinutuzumab in Treatment-Naive and Relapsed/Refractory Chronic Lymphocytic 
Leukemia. Cancer Discov, 10(3), 394-405. doi:10.1158/2159-8290.CD-19-1130
Woyach, J. A., Bojnik, E., Ruppert, A. S., Stefanovski, M. R., Goettl, V. M., Smucker, K. A., . . . Johnson, A. J. 
(2014). Bruton's tyrosine kinase (BTK) function is important to the development and expansion of chronic 
lymphocytic leukemia (CLL). Blood, 123(8), 1207-1213. doi:10.1182/blood-2013-07-515361
Woyach, J. A., Ruppert, A. S., Guinn, D., Lehman, A., Blachly, J. S., Lozanski, A., . . . Byrd, J. C. (2017). 
BTKC481S-Mediated Resistance to Ibrutinib in Chronic Lymphocytic Leukemia. J Clin Oncol, 35(13), 
1437-1443. doi:10.1200/JCO.2016.70.2282
Wu, J., Zhang, M., & Liu, D. (2016). Acalabrutinib (ACP-196): a selective second-generation BTK inhibitor. J 
Hematol Oncol, 9, 21. doi:10.1186/s13045-016-0250-9

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
109
APPENDIX A: PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
100
Normal, no complaints, no evidence 
of disease.
0
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction.
90
Able to carry on normal activity; 
minor signs or symptoms of disease.
80
Normal activity with effort; some 
signs or symptoms of disease.
1
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work).
70
Cares for self, unable to carry on 
normal activity or to do active work.
60
Requires occasional assistance, but 
is able to care for most of his/her 
needs.
2
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours.
50
Requires considerable assistance and 
frequent medical care.
40
Disabled, requires special care and 
assistance.
3
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours.
30
Severely disabled, hospitalization 
indicated.  Death not imminent.
20
Very sick, hospitalization indicated. 
Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair.
10
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
110
APPENDIX B: CLL RESPONSE DEFINITION (HALLEK ET AL. 2018)
Complete Remission (CR):
CR requires all of the following criteria:
Peripheral blood lymphocytes (evaluated by blood and differential count) below 
4x109/L (4000/μL). 
Absence of significant lymphadenopathy by physical examination and CT scan. 
Lymph nodes should be < 1.5cm in longest diameter.
No hepatomegaly or splenomegaly by physical examination. A CT scan of the 
abdomen should be performed at response assessment and should show no evidence 
for lymphadenopathy and splenomegaly. A measurement of 13cm in cranio-caudal 
length has been accepted as a consensus definition for splenomegaly.
Absence of disease-related constitutional symptoms.
Blood counts above the following values: Neutrophils more than 1.5 x 109/L 
(1,500/μL) without need for exogenous growth factors, Platelets more than 100 x 
109/L (100,000/μL) without need for exogenous growth factors, Hemoglobin more 
than 11.0 g/dL without red blood cell transfusion or need for exogenous 
erythropoietin.
Bone marrow aspirate and biopsy must be at least normocellular for age, without 
evidence for typical CLL lymphocytes by morphological criteria. This evaluation is 
not based on a flow cytometry-based MRD assessment. When performing marrow 
biopsies in clinical trials, lymphoid nodules can be found that may reflect residual 
disease. These nodules may be recorded as “nodular PR”. Immunohistochemistry may 
be performed to define whether the nodules are comprised primarily of T cells, of B 
cells other than CLL cells or of CLL cells. If nodules are not composed of CLL cells, a 
CR can be documented provided all other criteria are met.
Complete Remission with incomplete marrow recovery (CRi):
Some patients fulfill all the criteria for a CR, but have a persistent anemia, thrombocytopenia or 
neutropenia apparently unrelated to CLL, but related to drug toxicity. These patients should be 
considered as a different category of remission, CR with incomplete marrow recovery (CRi). For 
the definition of this category, CRi, the marrow evaluation should be performed with scrutiny 
and not show any clonal disease infiltrate. 
Minimal Residual Disease
Patients who achieve CR or CRi will be assessed for minimal residual disease (MRD). Such 
patients who have fewer than 0.01% (10-4) CLL cell percentage of leukocytes in the bone 
marrow, as assessed by four-color flow cytometry, will be considered to be MRD-negative.
Partial Remission
To define a partial remission, at least one parameter of group A and one parameter of group B 
need to improve, if previously abnormal (see Table 13 and sections 5.2.1-5). If only one 
parameter of both groups A and B was abnormal prior to therapy, only 1 needs to improve. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
111
Constitutional symptoms persisting for more than 1 month should be recorded.
Group A
a. Decrease in the number of blood lymphocytes by 50% or more from the value before therapy.
b. Reduction in lymphadenopathy compared to baseline (by cross-sectional imaging scans in 
clinical trials or by palpation in general practice) as defined by:

A decrease in lymph node size by 50% or more in the sum of the products of the same 
enlarged lymph nodes selected at baseline as assessed by imaging (up to 6 lymph nodes if 
possible) AND the sum of the longest diameters of the same enlarged lymph nodes 
selected at baseline as assessed by physical exam.

No increase in any lymph node, and no new enlarged lymph node (diameter ≥ 1.5 cm). 
For small lymph nodes (longest diameter < 1.5 cm), an increase of < 25% is not 
considered to be significant.
c. A regression of ≥ 50% of the extent of enlargement of the spleen below the costal margin 
defined by palpation, or normalization in size. When assessed by CT, scan spleen size must have 
regressed by ≥ 50% in length beyond normal. A persistence of splenomegaly post therapy may 
have limited influence on outcome in CLL.
d. A regression of ≥ 50% of the extent of enlargement of the liver below the costal margin 
defined by palpation, or normalization in size. Given the impact of numerous medical conditions, 
liver size by physical examination or by CT scan is not a reliable measure of hepatic involvement 
by CLL and should only be counted if hepatomegaly is clearly attributable to lymphoid 
involvement. 
Group B
a. Blood count should show one of the following:

Platelet count >100 x 109/L (100 000/μL) or 50% improvement over baseline.

Hemoglobin >110 g/L (11.0 g/dL), or 50% improvement over baseline without requiring 
red blood cell transfusions or exogenous erythropoietin.
Progressive Disease
Progressive disease during or after therapy is characterized by at least one of the following, 
when compared to nadir values:

Lymphadenopathy. Progression of lymphadenopathy is often discovered by physical 
examination and should be recorded. For CT scans used to confirm progression or 
relapse of lymphadenopathy, progression is defined as:
o
Appearance of any new lesion such as enlarged lymph nodes (≥ 1.5 cm), 
splenomegaly, hepatomegaly or other organ infiltrates. Transient increases of 
lymph node size during treatment with novel inhibitors may occur and should not 
be counted as PD. 
o
An increase by 50% or more in greatest determined diameter of any previous site 
(≥ 1.5 cm).

An increase in the spleen size by 50% or more or the de novo appearance of 
splenomegaly. In the setting of splenomegaly, the splenic length must increase by ≥ 50% 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
112
of the extent of its prior increase beyond baseline (e.g., a 15-cm spleen must increase to 
≥16 cm). If no prior splenomegaly was observed at baseline or if splenomegaly has 
resolved with treatment, the spleen must increase by at least 2 cm from baseline.

An increase in the liver size of ≥ 50% of the extent enlargement of the liver below the 
costal margin defined by palpation, or the de novo appearance of hepatomegaly. Given 
the impact of numerous medical conditions, liver size by physical examination or by CT 
scan is not a reliable measure of hepatic involvement by CLL and should only be 
counted if hepatomegaly is clearly attributable to lymphoid involvement. 

An increase in the number of blood lymphocytes by 50% or more with at least 5.000 B 
lymphocytes per µL. (Note: because of the well-described lymphocyte redistribution 
phenomenon, any increase in lymphocyte count during acalabrutinib monotherapy or 
any increase during combination therapy in the setting of improvement of lymph nodes 
or cytopenias will not be considered disease progression)

Transformation to a more aggressive histology (eg, Richter syndrome). This diagnosis 
must be established by lymph node biopsy.

Occurrence of cytopenia (neutropenia, anemia, or thrombocytopenia) due to CLL.
o During therapy, cytopenias cannot be used to define disease progression.
o After therapy, the progression of any cytopenia (unrelated to autoimmune 
cytopenia), as documented by a decrease of Hb levels by more than 2 g/dL or to 
less than 10 g/dL, or by a decrease of platelet counts by ≥50% or to less than 100 
000/μL, which occurs at least 3 months after treatment, defines disease 
progression, if the marrow biopsy is consistent with the cytopenia due to 
increased marrow infiltration of clonal CLL cells and is not considered a 
treatment related toxicity.
Stable Disease
Patients who have not achieved a CR or a PR, and who have not exhibited progressive disease, 
will be considered to have stable disease.
Treatment failure
Responses that should be considered clinically beneficial include CR and PR; all others (eg, stable 
disease, non-response, progressive disease, or death from any cause) should be rated as a treatment 
failure.
Time to Progression, progression-free survival, and overall survival
“Progression-free survival” (PFS) is defined as the interval between the first treatment day to the 
first sign of disease progression or death from any cause. Subjects without progression are 
censored at date of last disease evaluation. “Event-free survival” (EFS) is defined as the interval 
between the first treatment day to the first sign of disease progression or start of a new treatment 
or withdrawal from the trial due to toxicity or death (whichever occurs first). “Overall survival” 
(OS) is defined as the interval between the first treatment day to death. Living subjects are 
censored at date last known alive. “Time to next treatment” is defined as interval between the 
first treatment day until the patient starts an alternative therapy for progressive CLL.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
113
Table 13: Response definition after treatment for CLL patients

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
114
APPENDIX C: IW-CLL GRADING SCALE FOR HEMATOLOGIC TOXICITY IN CLL 
STUDIES
Grade#
Decrease in Platelets* or 
Hb˚ (nadir) from Baseline 
Value, %
Absolute neutrophil 
count/µL (nadir)§
0
No change to 10%
≥2000
1
11% - 24%
≥1500 and <2000
2
25% - 49%
≥1000 and <1500
3
50% - 74%
≥ 500 and <1000
4
≥75%
<500
# Grades: 1, mild; 2, moderate; 3 severe; 4 life-threatening; 5 fatal. Death occurring as a result of
toxicity at any level of decrease from baseline will be recorded as grade 5.
* - Platelet counts must be below normal levels for grades 1-4. If, at any level of decrease the 
platelet count is <20,000/µL, this will be considered grade 4 toxicity, unless a severe or life-
threatening decrease in the initial platelet count (e.g. 20,000/µL) was present at baseline, in 
which case the patient is not evaluable for toxicity referable to platelet counts.
˚ - Hb levels must be below normal levels for grades 1 to 4. Baseline and subsequent Hb
determinations must be performed before any given transfusions. The use of erythropoietin is
irrelevant for the grading of toxicity but should be documented.
§ - If the absolute neutrophil count (ANC) reaches < 1000/μL, it should be judged to be grade 3 
toxicity. Other decreases in the white blood cell count, or in circulating granulocytes, are not to 
be considered, since a decrease in the white blood cell count is a desired therapeutic endpoint. A 
gradual decrease in granulocytes is not a reliable index in CLL for stepwise grading of toxicity. 
If the ANC was < 1000/μL prior to therapy, the patient is not evaluable for toxicity referable to 
the ANC. The use of growth factors such as G-CSF is not relevant to the grading of toxicity, but 
should be documented.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
115
APPENDIX D: CAIRO-BISHOP DEFINITIONS OF LABORATORY AND CLINICAL 
TUMOR LYSIS SYNDROME (TLS)
Table 1.              Cairo-Bishop Definition of Laboratory Tumor Lysis Syndrome‡
Element
Value               
Change from Baseline
Uric Acid
Potassium
Inorganic Phosphorus
Calcium
≥ 476 μmol/L or 8 mg/dL
≥ 6.0 mmol/L or 6 mg/L
 ≥1.45 mmol/L or 5mg/dL
≤ 1.75 mmol/Lor 7mg/dL
25% increase
25% increase
25% increase
25% decrease
Table 2.       Cairo-Bishop Clinical Tumor Lysis Syndrome Definition and Grading†
Grade
Complication
0
1
2
3
4
5
Creatinine*
≤ 1.5 ×
1.5 × ULN
1.5 – 3.0 × ULN
> 3.0 – 6.0 ×
> 6.0 × ULN
Death
ULN
ULN
Cardiac
None
Intervention
Non-urgent
Symptomatic and
Life-threatening
Death
Arrhythmia*
not
medical
incompletely
(e.g., arrhythmia
indicated
intervention
controlled
associated with
indicated
medically or
CHF,
controlled with
hypotension,
device (e.g.,
syncope, shock)
defibrillator)
Seizure*
None
–
One brief,
Seizure in which
Seizure of any
Death
generalized
consciousness is
kind which are
seizure; seizure(s)
altered; poorly
prolonged,
well controlled by
controlled seizure
repetitive or
anticonvulsants or
disorder; with
difficult to control
infrequent focal
breakthrough
(e.g., status
motor seizures
generalized
epilepticus,
not interfering
seizures despite
intractable
with ADL
medical
epilepsy)
intervention
ULN = upper limit of normal; CHF = congestive heart failure; ADL = activities of daily living
‡       Two or more values from Table 1 must have the prespecified change to meet criteria for laboratory TLS. Either the 
absolute value or the percent change for each element can count towards one criterion.    
*      Not directly or probably attributable to therapeutic agent.
†          Clinical tumor lysis syndrome is defined as laboratory tumor lysis syndrome and at least one clinical complication.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
116
APPENDIX E: RECOMMENDATIONS FOR INITIAL MANAGEMENT OF 
ELECTROLYTE ABNORMALITIES AND PREVENTION OF TUMOR LYSIS 
SYNDROME
1. FIRST DOSE OF VENETOCLAX OR DOSE INCREASE

Within the first 24 hours after either the first dose or dose increase, if any laboratory criteria 
below are met, the patient should be hospitalized for monitoring and the investigator notified.  
No additional venetoclax doses should be administered until resolution.  A rapidly rising 
serum potassium level is a medical emergency.

Nephrology (or acute dialysis service) must be consulted/contacted on admission (per 
institutional standards to ensure emergency dialysis is available).

IV fluids (e.g., D5 1/2 normal saline) should be initiated at a rate of at least 1 mL/kg/h 
rounded to the nearest 10 mL (target 150 to 200 mL/h; not  50 mL/h).  Modification of fluid 
rate should also be considered for individuals with specific medical needs.

Monitor for symptoms or signs of TLS (e.g., fever, chills, tachycardia, nausea, vomiting, 
diarrhea, diaphoresis, hypotension, muscle aches, weakness, paresthesias, mental status 
changes, confusion, and seizures).  If any clinical features are observed, recheck potassium, 
phosphorus, uric acid, calcium, and creatinine within 1 hour.

Vital signs should be taken at time of all blood draws or any intervention.

The management recommendations below focus on the minimum initial responses required.  
If a diagnosis of TLS is established, ongoing intensive monitoring and multi-disciplinary 
management will be per institutional protocols.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
117
Recommendations for Initial Management of Electrolyte Abnormalities and Prevention of 
Tumor Lysis Syndrome (TLS)
Abnormality
Management Recommendations
Hyperkalemia (including rapidly rising potassium)
Potassium  0.5 mmol/L 
increase from prior value 
(even if potassium within 
normal limits [WNL])

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 hour.  If further  0.2 mmol/L increase in 
potassium, but still  upper limit of normal (ULN), manage per 
potassium  ULN. Otherwise recheck in 1 hour.

Resume per protocol testing if change in potassium 
is  0.2 mmol/L, and potassium  ULN, and no other evidence of 
tumor lysis.

At discretion of investigator, may recheck prior to hospitalization. 
If stable or decreased, and still WNL, hospitalization is at the 
discretion of the investigator.  Potassium, phosphorus, uric acid, 
calcium, and creatinine must be rechecked within 24 hours.
Potassium  upper limit of 
normal

Perform immediate ECG and commence telemetry.

Nephrology notification with consideration of initiating dialysis

Administer Kayexalate 60 g (or Resonium A 60 g).

Administer furosemide 20 mg IV  1.

Administer calcium gluconate 100 to 200 mg/kg IV slowly if there 
is ECG/telemetry evidence of life-threatening arrhythmias.

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 hour.

If potassium  ULN 1 hour later, repeat potassium, phosphorus, 
uric acid, calcium, and creatinine 1, 2, and 4 hours later, if no 
other evidence of tumor lysis.
Potassium  6.0 mmol/L 
(6.0 mEq/L) and/or 
symptomatic
(e.g., muscle cramps, 
weakness, paresthesias, 
nausea, vomiting, 
diarrhea)

Perform immediate ECG and commence telemetry.

Nephrology assessment with consideration of initiating dialysis

Administer Kayexalate 60 g (or Resonium A 60 g).

Administer furosemide 20 mg IV  1.

Administer insulin 0.1 U/kg IV  D25 2 mL/kg IV.

Administer sodium bicarbonate 1 to 2 mEq/kg IV push.
-
If sodium bicarbonate is used, rasburicase should not be 
used as this may exacerbate calcium phosphate 
precipitation.

Administer calcium gluconate 100 to 200 mg/kg IV slowly if there 
is ECG/telemetry evidence of life-threatening arrhythmias.  Do 
not administer in same IV line as sodium bicarbonate.

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine every hour.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
118
Abnormality
Management Recommendations
Hyperuricemia
Uric acid  8.0 mg/dL 
(476 mol/L)

Consider rasburicase (dose per institutional guidelines).
-
If rasburicase is used, sodium bicarbonate should not be 
used as this may exacerbate calcium phosphate 
precipitation.

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 hour.
Uric acid  10 mg/dL 
(595 µmol/L)
OR
Uric acid  8.0 mg/dL 
(476 µmol/L) with 25% 
increase and creatinine 
increase  0.3 mg/dL 
( 0.027 mmol/L) from 
predose level

Administer rasburicase (dose per institutional guidelines).
-
If rasburicase is used, sodium bicarbonate should not be 
used as this may exacerbate calcium phosphate 
precipitation.

Consult nephrology.

Recheck potassium, phosphorus, uric acid, calcium and 
creatinine in 1 hour.

If uric acid  8.0 mg/dL 1 hour later, repeat potassium, 
phosphorus, uric acid, calcium, and creatinine 2 and 4 hours 
later, if no other evidence of tumor lysis.
Hypocalcemia
Corrected calcium 
 7.0 mg/dL 
(1.75 mmol/L)
AND
Patient symptomatic 
(e.g., muscle cramps, 
hypotension, tetany, 
cardiac arrhythmias) in 
the presence of 
hypocalcemia

Administer calcium gluconate 50 to 100 mg/kg IV slowly with 
ECG monitoring.

Telemetry.

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 hour.

If calcium normalized 1 hour later, repeat potassium, 
phosphorus, uric acid, calcium, and creatinine 2 and 4 hours 
later, if no other evidence of tumor lysis.

Calculate corrected calcium and ionized calcium if albumin is low.
Hyperphosphatemia
Phosphorus  5.0 mg/dL 
(1.615 mmol/L) with 
 0.5 mg/dL 
(0.16 mmol/L) increase

Administer a phosphate binder (e.g., aluminum hydroxide, 
calcium carbonate, sevelamer hydroxide, or lanthanum 
carbonate).

Nephrology notification (dialysis required for phosphorus 
 10 mg/dL)

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 hour.

If phosphorus  5.0 mg/dL 1 hour later, repeat potassium, 
phosphorus, uric acid, calcium, and creatinine 2 and 4 hours 
later, if no other evidence of tumor lysis.
Creatinine
Increase  25% from 
baseline

Start or increase rate of IV fluids.

Recheck potassium, phosphorus, uric acid, calcium, and 
creatinine in 1 to 2 hours.
IV  intravenous; ULN  upper limit of normal; WNL  within normal limits.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
119
2. ONGOING DOSING OF VENETOCLAX
Management of electrolyte changes from last value at intervals  24 hours after either the first 
dose or dose increase (e.g., 48 or 72 hours) are as below.  Note:  If the patient is hospitalized, no 
additional venetoclax doses should be administered until resolution. If the patient meets criteria 
for laboratory TLS (i.e. two or more element abnormalities), no additional venetoclax doses 
should be administered until resolution.

For potassium
-
For any increase  1.0 mmol/L (1.0 mEq/L) OR for any potassium   upper limit of 
normal, admit the patient to the hospital if the patient is not already admitted. Refer to 
the table above, “Recommendations for Initial Management of Electrolyte Abnormalities 
and Prevention of Tumor Lysis Syndrome” for guidance regarding interventions.
- 
If a smaller potassium increase is observed that does not meet the criteria for admission 
above, recheck potassium, phosphorus, uric acid, calcium, and creatinine in 24 hours and 
confirm no evidence of TLS prior to further venetoclax dosing.

For uric acid, calcium, phosphorus, and creatinine changes listed in Appendix D Table 1, 
refer to the management guidelines in the table above “Recommendations for Initial 
Management of Electrolyte Abnormalities and Prevention of Tumor Lysis Syndrome).” 
These recommendations are mandatory if the patient meets criteria for laboratory TLS (2 or 
more element abnormalities) in Appendix D Table 1 above.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
120
APPENDIX F: SAMPLE LIST OF EXCLUDED AND CAUTIONARY MEDICATIONS
(this is not an exhaustive list)
Excluded
warfarin
biologic agents
anticancer therapy (excluding adjuvant hormonal therapy)
other investigational agents
proton pump inhibitors
steroid therapy with anti-neoplastic intent
Strong CYP3A Inhibitors (Excluded)
atazanavir
cerivastatin
chloroquine
clarithromycin
conivaptan
eltrombopag
fluvoxamine
indinavir
itraconazole
ketoconazole
lopinavir
lovastatin
nefazodone
nelfinavir
pioglitazone
posaconazole
repaglinide
ritonavir
rosiglitazone
saquinavir
telaprevir
telithromycin
voriconazole
Strong CYP3A Inducers (Excluded)
carbamazepine
mitotane
phenobarbital
phenytoin
rifabutin
rifampin
St. John’s wort
P-gp Inhibitors (Excluded)
amiodarone
azithromycin
captopril
carvedilol
cyclosporine
felodipine
quercetin
quinidine
ranolazine
ticagrelor
Narrow Therapeutic Index P-gp Substrates (Excluded)
digoxin
everolimus
sirolimus
Moderate CYP3A Inducers (Cautionary)
bosentan
efavirenz
etravirine
modafinil
nafcillin
oxcarbazepine
rifapentine
Moderate CYP3A Inhibitors (Cautionary)
ciprofloxacin
diltiazem
dronedarone
erythromycin
fluconazole
verapamil
Proton Pump Inhibitors
dexlansoprazole
esomeprazole
lansoprazole
omeprazole
pantoprazole
rabeprazole
H2-receptor anatagonists
cimetidine
famotidine
nizatidine
ranitidine
Antacids
aluminum hydroxide
magnesium hydroxide
calcium carbonate

121
APPENDIX G: ACALABRUTINIB DRUG DIARY
Study Participant Self-Administration Instructions
The study staff will explain how to take acalabrutinib, but these are points to remember:
1. Take the drug twice daily approximately 12 hours apart. 
2. Take the drug with about 8 ounces of water.  Acalabrutinib can be taken with or without 
meals.
3. Do not open, break, chew, crush, dissolve, or cut the tablets.
4. You may NOT consume:  Grapefruit or grapefruit products, Seville oranges (including 
marmalade containing Seville oranges) or starfruit within the 3-day period prior to the first 
study drug administration and until the last day of treatment is completed due to possible 
CYP3A mediated metabolic interaction.
5. If you miss taking your dose at the scheduled time, it can be taken as soon as possible up to 3 
hours after the scheduled time. If a dose is missed by more than 3 hours, it should be skipped 
and the next dose should be taken at its regularly scheduled time. Please make sure to record 
the reason for missing the dose. If you vomit a dose, do not take it again unless you can see 
the tablet. 
6. Please remember to bring your study drug supply and drug diary with you to your clinic 
appointment. The clinic or research staff will instruct you when to take your study drug on 
those days.
7. The drug can be stored at room temperature. 
8. Keep this drug out of the reach of children.
9. If you are taking this drug in combination with venetoclax, you may take them in any order.
Please call your doctor or research nurse before taking any new prescription or over-the-counter 
medications/supplements other than the study drugs or if any other questions arise.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
122
Study Participant Self-Administration Diary for Acalabrutinib
Please record how many tablets you take and the time you take them and bring the completed diary as well as 
your study drug supply, including empty bottles, to every study visit. This will help us keep track of your study drug 
and how well you are tolerating it.
FOR STUDY TEAM USE ONLY
Staff initials: 
Date dispensed:
Date returned:
# pills/caps/tabs dispensed:
# pills/caps/tabs returned:
# pills/caps/tabs that should have been taken:
Discrepancy Notes:
Participant Identifier: _____________                          Cycle Number: ____________
Protocol #: _____________________                           
Study Doctor: ___________________
Study Nurse: ____________________
Contact Number: ________________
You will take the following number of tablets each time (per dose) as listed in the table below:
Study Drug Name
# of tablets to take per 
dose 
# of times 
each day 
Acalabrutinib

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
123
Day
Date
Number of 
Acalabrutinib 
Tablets
Time of First Dose each day
Number of 
Acalabrutinib 
Tablets
Time of Second Dose each day
1
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
2
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
3
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
4
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
5
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
6
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
7
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
8
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
9
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
10
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
11
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
12
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
13
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
14
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
15
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
16
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
17
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
124
Day
Date
Number of 
Acalabrutinib 
Tablets
Time of First Dose each day
Number of 
Acalabrutinib 
Tablets
Time of Second Dose each day
18
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
19
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
20
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
21
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
22
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
23
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
24
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
25
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
26
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
27
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
28
______:______  □ AM / □ PM 
□ Dose Not Taken  
Why:____________________
______:______  □ AM / □ PM
 □ Dose Not Taken  
Why:_______________
Participant/Caregiver Signature: _______________________________  Date: _______________________

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
125
APPENDIX H: VENETOCLAX DRUG DIARY
Study Participant Self-Administration Instructions
The study staff will explain how to take venetoclax, but these are points to remember:
1. Take the drug once daily at the same time each day. 
2. Take the drug with a meal and water. Tablets should be swallowed whole and not chewed 
or crushed.
3. You may NOT consume:  Grapefruit or grapefruit products, Seville oranges (including 
marmalade containing Seville oranges) or starfruit within the 3-day period prior to the first 
study drug administration and until the last day of treatment is completed due to possible 
CYP3A mediated metabolic interaction.
4. If you miss taking your dose at the scheduled time, it can be taken as soon as possible up 
to 8 hours after the scheduled time. If a dose is missed by more than 8 hours, it should be 
skipped and the next dose should be taken at its regularly scheduled time. Please make 
sure to record the reason for missing the dose. If you vomit a dose, do not take it again 
unless you can see the capsule. 
5. Please remember to bring your study drug supply and drug diary with you to your clinic 
appointment.  The clinic or research staff will instruct you when to take your study drug 
on those days.
6. The drug can be stored at room temperature. 
7. Keep this drug out of the reach of children.
8. If you are taking this drug in combination with acalabrutinib, you may take them in any 
order.
Please call your doctor or research nurse before taking any new prescription or over-the-counter 
medications/supplements other than the study drugs or if any other questions arise.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
126
Study Participant Self-Administration Diary for Venetoclax
Please record how many tablets you take and the time you take them and bring the completed Diary as well as 
your study drug supply, including empty bottles, to every study visit. This will help us keep track of your study drug 
and how well you are tolerating it. 
FOR STUDY TEAM USE ONLY
Staff initials: 
Date dispensed:
Date returned:
# pills/caps/tabs dispensed:
# pills/caps/tabs returned:
# pills/caps/tabs that should have been taken:
Discrepancy Notes:
Participant Identifier: _____________                          Cycle Number: ____________
Protocol #: _____________________                           Venetoclax Dose: _____________ mg
Study Doctor: ___________________
Study Nurse: ____________________
Contact Number: ________________

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
127
Day
Date
Number of 
Venetoclax Tablets
Time of Dose each day
1
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
2
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
3
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
4
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
5
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
6
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
7
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
8
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
9
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
10
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
11
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
12
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
13
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
14
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
15
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
16
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
17
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
18
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
19
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
20
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
21
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
22
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
23
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
128
Day
Date
Number of 
venetoclax Tablets
Time of Dose each day
24
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
25
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
26
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
27
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
28
______:______  □ AM / □ PM 
□ Dose Not Taken  Why:____________________
Participant/Caregiver Signature: _______________________________  Date: _______________________
 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
129
APPENDIX I: SAMPLE REQUISITION FORM
18-226: A Phase 2 Study of Acalabrutinib, Venetoclax, and Obinutuzumab (AVO) for Initial 
Therapy of Chronic Lymphocytic Leukemia
PI: Matthew Davids, MD   Sponsor: Dana-Farber Cancer Institute
Brown Lab Contact: Stacey Fernandes
Davids Lab Contact: Mary Collins
Stacey Fernandes 
Principal Research Technician
DFCI CLL Center, J. Brown lab
1 Jimmy Fund WaySM 648
Boston, MA 02115, U.S.A.
Stacey_Fernandes@dfci.harvard.edu
617-632-5828 (phone)
Instructions: Complete one form for each time point collected. Send one copy with shipment and 
save another copy with subject documentation.  Please email the lab contact and the DFCI 
Project Manager with the completed requisition form and FedEx tracking number. 
NOTE: Do NOT ship samples on Fridays and day prior to a holiday.
Please give 72-hour notice of draw. 
Institution:  
Subject ID: 
Samples sent by: 
Study Timepoint:
E-mail: 
Subject Initials:
Phone: 
Subject MRN:
LAB USE ONLY
Time & Date Received: _________________________________________________________________
Received by: __________________________________________________________________________
Date Entered into Database: ______________________________________________________________
Version 2.0
Active October 2014
Sample type
Number of 
tubes
Date Drawn
Time Drawn:
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
WBC
ALC

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
130
APPENDIX J: DANA-FARBER/HARVARD CANCER CARE DATA SAFETY 
MONITORING PLAN
INTRODUCTION
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan 
(DF/HCC DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research 
protocol. The DF/HCC DSMP serves as a reference for any sites external to DF/HCC that 
are participating in a DF/HCC clinical trial. 
Purpose
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-
Center protocol will comply with Federal Regulations, Health Insurance Portability and 
Accountability Act (HIPAA) requirements and applicable DF/HCC Standard Operating 
Procedures..       
Multi-Center Data and Safety Monitoring Plan Definitions
DF/HCC Multi-Center Protocol:  A research protocol in which one  or more outside 
institutions are collaborating with Dana-Farber/Harvard Cancer Center where  a DF/HCC 
investigator is the sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) 
Network Clinical Trial Affiliates. 
Lead Institution:  One of the Dana-Farber/Harvard Cancer Center consortium members 
(Dana-Farber Cancer Institute (DFCI), Massachusetts General Hospital (MGH), Beth Israel 
Deaconess Medical Center (BIDMC), Boston Children’s Hospital (BCH), Brigham and 
Women’s Hospital (BWH) responsible for the coordination, development, submission, and 
approval of a protocol as well as its subsequent amendments per the DFCI IRB and 
applicable regulatory guidelines (CTEP, Food and Drug Administration (FDA), Office of 
Biotechnology Activities (OBA) etc.).  The Lead Institution is typically the home of the 
DF/HCC Sponsor. The Lead Institution also typically serves as the Coordinating Center for 
the DF/HCC Multi-Center Protocol.  
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol who takes 
responsibility for initiation, management and conduct of the protocol at all research 
locations. In applicable protocols, the DF/HCC Sponsor will serve as the single liaison with 
any regulatory agencies. The DF/HCC Sponsor has ultimate authority over the protocol and 
is responsible for the conduct of the study at DF/HCC and all Participating Institutions. In 
most cases the DF/HCC Sponsor is the same person as the DF/HCC Overall Principal 
Investigator; however, both roles can be filled by two different people.
Participating Institution:  An institution that is outside the DF/HCC and DF/PCC 
consortium that is collaborating with DF/HCC on a protocol where the sponsor is a DF/HCC 
Investigator.  The Participating Institution acknowledges the DF/HCC Sponsor as having 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
131
the ultimate authority and responsibility for the overall conduct of the study.   
Coordinating Center: The entity (i.e. Lead Institution, Medical Monitor, Contract 
Research Organization (CRO), etc) that provides administrative support to the DF/HCC 
Sponsor in order that he/she may fulfill the responsibilities outlined in the protocol 
document and DSMP, and as specified in applicable regulatory guidelines (i.e. CTEP Multi-
Center Guidelines). In general, the Lead Institution is the Coordinating Center for the 
DF/HCC Multi-Center Protocol. 
DF/HCC Office of Data Quality (ODQ): A group within DF/HCC responsible ensuring 
high-quality standards are used for data collection and the ongoing management of clinical 
trials, auditing, and data and safety monitoring. ODQ also coordinates quality assurance 
efforts related to multi-center clinical research.
DF/HCC Research Informatics for Operations (RIO): A group within DF/HCC 
responsible for providing a comprehensive data management platform for managing clinical 
trial data.
GENERAL ROLES AND RESPONSIBILITIES
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and 
the Participating Institutions are expected to adhere to the following general responsibilities: 
DF/HCC Sponsor
The DF/HCC Sponsor, Dr. Matthew Davids, will accept responsibility for all aspects of 
conducting a DF/HCC Multi-Center protocol which includes but is not limited to: 

Oversee the coordination, development, submission, and approval of the protocol as 
well as subsequent amendments. 

Ensure that the investigators, study team members, and Participating Institutions are 
qualified and appropriately resourced to conduct the protocol.  

Include the Multi-Center Data and Safety Monitoring Plan as an appendix to the 
protocol.

Ensure all Participating Institutions are using the correct version of the protocol.

Ensure that each participating investigator and study team member receives 
adequate protocol training (and/or a Site Initiation Visit prior to enrolling 
participants) and throughout trial’s conduct as needed.

Ensure the protocol will be provided to each participating site in a language 
understandable to all applicable site personnel when English is not the primary 
language. 

Monitor progress and overall conduct of the study at all Participating Institutions. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
132

Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable 
(i.e. FDA) reporting requirements are met. 

Review data and maintain timely submission of data for study analysis. 

Act as the single liaison with FDA (investigator-held IND trials).

Ensure compliance with all requirements as set forth in the Code of Federal 
Regulations, applicable DF/HCC requirements, HIPAA requirements, and the 
approved protocol.

Commit to the provision that the protocol will not be rewritten or modified by 
anyone other than the DF/HCC Sponsor.

Identify and qualify Participating Institutions and obtain accrual commitments prior 
to extending the protocol to that site.

Monitor accrual and address Participating Institutions that are not meeting their 
accrual requirements. 
Coordinating Center 
The general responsibilities of the Coordinating Center may include but are not limited to:

Assist in protocol development. 

Maintain FDA correspondence.

Review registration materials for eligibility and register participants from 
Participating Institutions in the DF/HCC clinical trial management system 
(CTMS).

Distribute protocol and informed consent document updates to Participating 
Institutions as needed.

Oversee the data collection process from Participating Institutions.

Maintain documentation of Serious Adverse Event (SAE) reports and 
deviations/violation submitted by Participating Institutions and provide to the 
DF/HCC Sponsor for timely review and submission to the DFCI IRB, as 
necessary. 

Distribute serious adverse events reported to the DF/HCC Sponsor that fall under 
the DFCI IRB Adverse Event Reporting pPolicy to all Participating Institutions.

Provide Participating Institutions with information regarding DF/HCC requirements 
that they will be expected to comply with.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
133

Carry out plan to monitor Participating Institutions either by on-site or remote 
monitoring. 

Maintain Regulatory documents of all Participating Institutions which includes but 
is not limited to the following: local IRB approvals/notifications from all 
Participating Institutions, confirmation of Federalwide Assurances (FWAs) for all 
sites,  all SAE submissions, Screening Logs for all sites, IRB approved consents 
for all sites

Conduct regular communications with all Participating Institutions (conference 
calls, emails, etc) and maintain documentation all relevant communications.
Participating Institution
Each Participating Institution is expected to comply with all applicable federal regulations 
and DF/HCC requirements, the protocol and HIPAA requirements. 
The general responsibilities for each Participating Institution may include but are not limited 
to:

Document the delegation of research specific activities to study personnel.

Commit to the accrual of participants to the protocol.

Submit protocol and/or amendments to their local IRB of record.

Maintain regulatory files as per sponsor requirements.

Provide the Coordinating Center with regulatory documents or source documents as 
requested.

Participate in protocol training prior to enrolling participants and throughout the trial 
as required (i.e. teleconferences).

Update Coordinating Center with research staff changes on a timely basis.

Register participants through the Coordinating Center prior to beginning research 
related activities. 

Submit Serious Adverse Event (SAE) reports to local IRB per institutional 
requirements and to the Coordinating Center, in accordance with DF/HCC 
requirements. 

Submit protocol deviations and violations to local IRB per institutional requirements 
and to the DF/HCC Sponsor in accordance with DF/HCC requirements.

Order, store and dispense investigational agents and/or other protocol mandated 
drugs per federal guidelines and protocol requirements.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
134

Have office space, office equipment, and internet access that meet HIPAA standards.

Participate in any quality assurance activities and meet with monitors or auditors at 
the conclusion of a visit to review findings.

Promptly provide follow-up and/or corrective action plans for any monitoring 
queries or audit findings.
DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS
The following section will clarify DF/HCC Requirements and further detail the expectations 
for participating in a DF/HCC Multi-Center protocol. 
Protocol Distribution
The Coordinating Center will distribute the final DFCI IRB approved protocol and any 
subsequent amended protocols to all Participating Institutions.   
Protocol Revisions and Closures
The Participating Institutions will receive notification of protocol revisions and closures 
from the Coordinating Center.  It is the individual Participating Institution’s responsibility 
to notify its IRB of these revisions.

Non life-threatening revisions: Participating Institutions will receive written 
notification of protocol revisions regarding non life-threatening events from the 
Coordinating Center. Non-life-threatening protocol revisions must be IRB approved 
and implemented within 90 days from receipt of the notification.

Revisions for life-threatening causes: Participating Institutions will receive 
immediate notification from the Coordinating Center concerning protocol revisions 
required to protect lives with follow-up by fax, mail, e-mail, etc.  Life-threatening 
protocol revisions will be implemented immediately followed by IRB request for 
approval.

Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating 
Center, will update the Participating Institutions on an ongoing basis about protocol 
accrual data so that they will be aware of imminent protocol closures.
Informed Consent Requirements

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
135
The DF/HCC approved informed consent document will serve as a template for the 
informed consent for Participating Institutions. The Participating Institution consent form 
must follow the consent template as closely as possible and should adhere to specifications 
outlined in the DF/HCC Guidance Document on Model Consent Language for Investigator-
Sponsored Multi-Center Trials.  This document will be provided separately to each 
Participating Institution upon request.
Participating Institutions are to send their version of the informed consent document and 
HIPAA authorization, if a separate document, to the Coordinating Center for review and 
approval prior to submission to their local IRB. The approved consent form must also be 
submitted to the Coordinating Center after approval by the local IRB for all consent 
versions.
The Principal Investigator (PI) at each Participating Institution will identify the physician 
members of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. Participating institutions must follow the DF/HCC requirement that 
for all interventional drug, biologic, or device research, only attending physicians may 
obtain initial informed consent and any re-consent that requires a full revised consent form.  
IRB Documentation
The following must be on file with the Coordinating Center:

Initial approval letter of the Participating Institution's IRB. 

Copy of the Informed Consent Form(s) approved by the Participating Institution’s 
IRB. 

Participating Institution’s IRB approval for all amendments.

Annual approval letters by the Participating Institution's IRB.
IRB Re-Approval
Verification of IRB re-approval from the Participating Institutions is required in order to 
continue research activities.  There is no grace period for continuing approvals.
The Coordinating Center will not register participants if a re-approval letter is not received 
from the Participating Institution on or before the anniversary of the previous approval date.  
Participant Confidentiality and Authorization Statement
In 1996, congress passed the first federal law covering the privacy of health information 
known as the Health Insurance Portability and Accountability Act (HIPPA). Any 
information, related to the physical or mental health of an individual is called Protected 
Health Information (PHI). HIPAA outlines how and under what circumstances PHI can be 
used or disclosed. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
136
In order for covered entities to use or disclose protected health information during the course 
of a study, the study participant must sign an authorization statement.  This authorization 
statement may or may not be separate from the informed consent document.  The 
Coordinating Center, with the approval from the DFCI IRB, will provide a consent template, 
with information regarding authorization for the disclosure of protected health information. 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in 
its trials. However, because of the nature of these trials, certain protected health information 
must be collected. DF/HCC has chosen to use authorizations, signed by the participant in 
the trial, rather than limited data sets with data use agreements.
 DF/HCC Multi-Center Protocol Confidentiality
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center should 
be de-identified. It is recommended that the assigned protocol case number (as described 
below) be used for all participant specific documents. Participant initials may be included 
or retained for cross verification of identification. 
DF/HCC Multi-Center Protocol Registration Policy
 Participant Registration and Randomization 
To register a participant, the following documents should be completed by the 
Participating Institution and faxed or e-mailed to the Coordinating Center to the 
attention of Samantha Pazienza:  Samantha_Pazienza@dfci.harvard.edu

Copy of required laboratory tests 

Signed informed consent document

HIPAA authorization form (if separate from the informed consent document)

Completed Eligibility Checklist
The Coordinating Center will review the submitted documents in order to verify 
eligibility and consent. To complete the registration process, the Coordinating Center 
will:

Register the participant on the study with the DF/HCC Clinical Trial Management 
System (CTMS).

Upon receiving confirmation of registration, the Coordinating Center will inform 
the Participating Institution and provide the study specific participant case number, 
and, if applicable, assigned treatment and/or dose level. 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
137
Treatment or other protocol-specific interventions may not begin without 
confirmation from the Coordinating Center that the participant has been 
registered. 
 Initiation of Therapy
Participants must be registered with the DF/HCC CTMS before the initiation of treatment 
or other protocol-specific interventions. Treatment and other protocol-specific interventions 
may not be initiated until the Participating Institution receives confirmation of the 
participant’s registration from the Coordinating Center. The DF/HCC Sponsor and DFCI 
IRB must be notified of any violations to this policy.
 Eligibility Exceptions
No exceptions to the eligibility requirements for a protocol without DFCI IRB approval will 
be permitted. All Participating Institutions are required to fully comply with this 
requirement. The process for requesting an eligibility exception is defined below.
DF/HCC Protocol Case Number
At the time of registration, the following identifiers are required for all subjects: initials, 
date of birth, gender, race and ethnicity. Once eligibility has been established and the 
participant successfully registered, the participant is assigned a unique protocol case 
number.  Participating Institutions should submit all de-identified subsequent 
communication and documents to the Coordinating Center, using this case number to 
identify the subject.  
Protocol Deviations, Exceptions and Violations
Federal Regulations require an IRB to review proposed changes in a research activity to 
ensure that researchers do not initiate changes in approved research without IRB review 
and approval, except when necessary to eliminate apparent immediate hazards to the 
participant. DF/HCC requires all departures from the defined procedures set forth in the 
IRB approved protocol to be reported to the DF/HCC Sponsor, who in turn is responsible 
for reporting to the DFCI IRB.
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” 
to describe departures from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional policy 
for reporting to their local IRB.
 Definitions
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol which is prospectively approved prior to its implementation.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
138
Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g.
enrollment of a participant who does not meet all inclusion/exclusion criteria.
Protocol Violation: Any protocol departure that was not prospectively approved by the IRB 
prior to its initiation or implementation. 
 Reporting Procedures
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol exceptions, deviations 
and violations. The DF/HCC Sponsor will also be responsible for ensuring that all protocol 
violations/deviations are promptly reported per DFCI IRB guidelines. 
Participating Institutions: Protocol deviations require prospective approval from the DFCI 
IRB. The Participating Institution must submit the deviation request to the Coordinating 
Center who will then submit the deviation request to the DFCI IRB. Upon DFCI IRB 
approval the deviation is submitted to the Participating Institution IRB, per institutional 
policy. A copy of the Participating Institution’s IRB report and determination will be 
forwarded to the Coordinating Center within 10 business days after the original submission.  
The deviation may not be implemented without all required approvals.
All protocol violations must be sent to the Coordinating Center in a timely manner. The 
Coordinating Center will provide training for the requirements for the reporting of 
violations. 
Coordinating Center:  Upon receipt of the violation/deviation report from the Participating 
Institution, the Coordinating Center will submit the report to the DF/HCC Sponsor for 
review. Subsequently, the Participating Institution’s IRB violation/deviation report will be 
submitted to the DFCI IRB for review per DFCI IRB reporting guidelines. 
Safety Assessments and Toxicity Monitoring
The study teams at all participating institutions are responsible for protecting the safety, 
rights and well-being of study participants. Recording and reporting of adverse events that 
occur during the course of a study help ensure the continuing safety of study participants. 
All participants receiving investigational agents and/or other protocol mandated therapy 
will be evaluated for safety. The safety parameters include all laboratory tests and 
hematological abnormalities, physical examination findings, and spontaneous reports of 
adverse events reported by participants.  All toxicities encountered during the study will 
be evaluated according to the NCI criteria specified in the protocol. Life-threatening 
toxicities must be reported immediately to the DF/HCC Sponsor via the Coordinating 
Center. 
Additional safety assessments and toxicity monitoring will be outlined in the protocol.

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
139
Guidelines for Reporting Serious Adverse Events 
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are 
detailed in protocol section 7.4.
Participating Institutions must report the SAEs to the DF/HCC Sponsor and the 
Coordinating Center following the DFCI IRB Adverse Event Reporting Policy IRB of 
record’s Adverse Event Reporting Policy. 
The Coordinating Center will maintain documentation of all Participating Institution 
Adverse Event reports and be responsible for communicating to all participating 
investigators, any observations reportable under the DFCI IRB Reporting Requirements.  
Participating Institutions will review and submit to their IRB according to their institutional 
policies and procedures
Guidelines for Processing IND Safety Reports 
The DF/HCC Sponsor will review all IND Safety Reports and ensure that all IND Safety 
Reports are distributed to the Participating Institutions. Participating Institutions will 
review/submit to the IRB according to their institutional policies and procedures.
Data Management
DF/HCC RIO develops case report forms (CRF/eCRFs), for use with the protocol.  These 
forms are designed to collect data for each study. DF/HCC RIO provides a web based 
training for all eCRF users.
  
Data Forms Review
Data submissions are monitored for timeliness and completeness of submission. If study 
forms are received with missing or questionable data, the submitting institution will receive 
a written or electronic query from the DF/HCC Office of Data Quality, Coordinating Center, 
or designee. 
Responses to all queries should be completed and submitted within about 14 calendar days.  
Responses may be returned on the written query or on an amended paper case report form, 
or in the case of electronic queries, within the electronic data capture (eDC) system. In the 
case of a written query for data submitted on a paper case report form, the query must be 
attached to the specific data being re-submitted in response.  
If study forms are not submitted on schedule, the Participating Institution will periodically 
receive a Missing Form Report from the Coordinating Center noting the missing forms. 
REQUISITIONING INVESTIGATIONAL DRUG

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
140
The ordering of investigational agent is specified in the protocol section 8.
Participating Institutions should order their own agent regardless of the supplier. 
MONITORING: QUALITY CONTROL
The quality control process for a clinical trial requires verification of protocol compliance 
and data accuracy. The Coordinating Center, with the aid of the DF/HCC Office of Data 
Quality, provides quality control oversight for the protocol.
Ongoing Monitoring of Protocol Compliance
The Participating Institutions may be required to submit participant source documents to the 
Coordinating Center for monitoring. Participating Institution may also be subject to on-site 
monitoring conducted by the Coordinating Center. 
The Coordinating Center will implement ongoing monitoring activities to ensure that 
Participating Institutions are complying with regulatory and protocol requirements, data 
quality, and participant safety. Monitoring practices may include but are not limited to 
source data verification, and review and analysis of eligibility requirements, informed 
consent procedures, adverse events and all associated documentation, review of study drug 
administration/treatment, regulatory files, protocol departures reporting, pharmacy records, 
response assessments, and data management. 
Participating institutions will be required to participate in monthly Coordinating Center 
initiated teleconferences. Emails highlighting overall protocol progress and important 
announcements will be distributed as needed.
Remote Monitoring:  Participating Institutions will be required to forward de-identified 
copies of participants’ medical record and source documents to the Coordinating Center to 
aid in source data verification.
and
On-Site Monitoring:  Source documentation verification (SDV) may be conducted by 
having access to participants’ complete medical record and source documents.
Monitoring Reports
The DF/HCC Sponsor will review all monitoring reports to ensure protocol compliance. 
The DF/HCC Sponsor may increase the monitoring activities at Participating Institutions 
that are unable to comply with the protocol, DF/HCC Sponsor requirements or federal and 
local regulations. 
Accrual Monitoring

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
141
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish 
accrual requirements for each participating institution. Accrual will be monitored for each 
participating institution by the DF/HCC Sponsor or designee. Sites that are not meeting 
their accrual expectations may be subject to termination.  Participating institutions are 
required to accrue 3 patients per site per year.
AUDITING: QUALITY ASSURANCE
Auditing is a method of Quality Assurance and involves the systematic and independent 
examination of all trial related activities and documents.  Audits determine if evaluated 
activities were appropriately conducted and whether data was generated, recorded and 
analyzed, and accurately reported per the protocol, applicable Policies, and the Code of 
Federal Regulations (CFR).
DF/HCC Internal Audits
 
All Participating Institutions are subject to audit by the DF/HCC Office of Data Quality 
(ODQ). Typically, approximately 3-4 participants would be audited at the site over a 2-day 
period. If violations which impact participant safety or the integrity of the study are found, 
more participant records may be audited. 
Audit Notifications
It is the Participating Institution’s responsibility to notify the Coordinating Center of all 
external audits or inspections (e.g., FDA, EMA, NCI) that involve this protocol. All 
institutions will forward a copy of final audit and/or re-audit reports and corrective action 
plans (if applicable) to the Coordinating Center, within 12 weeks after the audit date. 
Audit Reports 
The DF/HCC Sponsor will review all final audit reports and corrective action plans, if 
applicable. The Coordinating Center, must forward any reports to the DF/HCC ODQ per 
DF/HCC policy for review by the DF/HCC Audit Committee. For unacceptable audits, the 
DF/HCC Audit Committee would forward the final audit report and corrective action plan 
to the DFCI IRB as applicable.
Participating Institution Performance
The DF/HCC Sponsor and the IRB of record are charged with considering the totality of an 
institution’s performance in considering institutional participation in the protocol.
Participating Institutions that fail to meet the performance goals of accrual, submission of 
timely and accurate data, adherence to protocol requirements, and compliance with state 
and federal regulations, may be recommended for a six-month probation period. Such 
institutions must respond with a corrective action plan and must demonstrate during the 
probation period that deficiencies have been corrected, as evidenced by the improved 

DF/HCC Protocol #:  18-226
Protocol Version Date: 18 Jan 2023
142
performance measures. Participating Institutions that fail to demonstrate significant 
improvement will be considered by the DF/HCC Sponsor for revocation of participation. A 
DF/HCC Sponsor and/or the DFCI IRB may terminate a site’s participation if it is 
determined that a site is not fulfilling its responsibilities as described above.