Ibrutinib and Ixazomib Citrate in Treating Newly Diagnosed, Relapsed or Refractory Waldenstrom Macroglobulinemia

Study Overview
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Brief Summary
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This phase II trial studies the side effects of ibrutinib citrate when given with ixazomib, and determines how well they work in treating patients with Waldenstrom macroglobulinemia that is newly diagnosed, has come back (recurrent) or does not respond to treatment (refractory). Enzyme inhibitors, such as ibrutinib and ixazomib citrate, may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.

Detailed Description
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PRIMARY OBJECTIVE: I. To determine the efficacy (as assessed by complete response [CR] rate) of the combination of ixazomib citrate (ixazomib) and ibrutinib in Waldenstrom macroglobulinemia (WM) patients. SECONDARY OBJECTIVES: I. To assess the overall response rate (ORR=partial response [PR] or better) in WM patients treated with ixazomib and ibrutinib. II. To assess the time to progression (TTP) in WM patients treated with ixazomib and ibrutinib. III. To further characterize the safety and toxicity of the combination of ibrutinib and ixazomib. IV. To assess the overall survival (OS) in WM patients treated with ixazomib and ibrutinib. CORRELATIVE RESEARCH OBJECTIVES: I. To determine the role of members of the BTK signalosome in achievement or lack thereof of response to ibrutinib and ixazomib. II. To explore biologic effects of ibrutinib and ixazomib on microenvironment in WM and correlate with response to treatment. OUTLINE: Patients receive ixazomib citrate orally (PO) on days 1, 8, and 15 and ibrutinib PO daily on days 1-28. Treatment repeats every 28 days for up to 24 cycles in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months for up to 2 years.

Official Title
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Phase II Study of Ibrutinib in Combination With Ixazomib in Patients With Waldenström Macroglobulinemia

Conditions
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Recurrent Waldenstrom Macroglobulinemia, Refractory Waldenstrom Macroglobulinemia, Waldenstrom Macroglobulinemia

Intervention / Treatment
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* Drug: Ibrutinib
* Drug: Ixazomib Citrate
* Other: Laboratory Biomarker Analysis
* Other: Pharmacodynamic Study
* Other: Pharmacokinetic Study


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histological confirmation of WM; patients may have newly diagnosed, relapsed, or refractory disease; (definition: newly diagnosed; patients previously untreated for WM, relapse; patients who have received prior treatment for WM and now have disease recurrence; refractory; patients who have received anti-WM therapy and are noted to have progressive disease while on therapy, or those patients who demonstrated disease progression within 6 months of the last anti-WM treatment); NOTE: Ibrutinib naïve patients are allowed; if previously treated with ibrutinib, subject must have reached a response of at least stable disease (SD) and cannot have progressed while on ibrutinib; if subject stopped taking ibrutinib for reasons other than progression, they cannot have progressed for at least 6 months post last dose of ibrutinib Presence of measurable disease as defined by: presence of immunoglobulin M (IgM) paraprotein, measurable lymphadenopathy on imaging studies and/or physical exam, and/or bone marrow infiltration > 10% Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0, 1, or 2 Absolute neutrophil count (ANC) >= 1000/mm^3 (obtained =< 14 days prior to registration) Platelet count >= 75,000/mm^3 (obtained =< 14 days prior to registration) (NOTE: platelet transfusions in order to help patients meet eligibility criteria are not allowed) Hemoglobin >= 9.0 g/dL (obtained =< 14 days prior to registration) Total bilirubin =< 1.5 x upper limit of normal (ULN) unless due to Gilbert's syndrome, in which case the direct bilirubin must be =< 1.5 x ULN (obtained =< 14 days prior to registration) Aspartate transaminase (AST) and alanine aminotransferase (ALT) =< 3 x ULN (obtained =< 14 days prior to registration) Calculated creatinine clearance must be >= 30 ml/min using the Cockcroft Gault formula (obtained =< 14 days prior to registration) Negative pregnancy test done at screening and =< 3 days (72 hours) prior to registration, for women of childbearing potential Provide written informed consent Willingness to provide mandatory blood specimens and bone marrow specimens for correlative research Willingness to return to enrolling institution for follow-up Exclusion Criteria: Failure to have fully recovered (i.e., =< grade 1 toxicity) from the reversible effects of prior treatment for WM Major surgical procedure (including open biopsy, excluding central line intravenous (IV) and port-a-cath placement) within =< 14 days prior to initiating study treatment, or anticipation of the need for major surgery during the course of the study treatment Radiotherapy =< 14 days prior to registration; if the involved field is small, 7 days will be considered a sufficient interval between treatment and administration of the ixazomib Systemic treatment, =< 14 days before registration, with strong CYP3A inducers (rifampin, rifapentine, rifabutin, carbamazepine, phenytoin, phenobarbital), or St. John's wort Systemic anti-cancer therapy or participation in other clinical trials, including those with other investigational agents not included in this trial, =< 28 days of registration and throughout the duration of active treatment in this trial Patients that have previously been treated with ixazomib, or participated in a study with ixazomib whether treated with ixazomib or not; prior bortezomib treatment is allowed as per: patients with prior exposure to bortezomib will be allowed if they do not have disease refractory to bortezomib) Central nervous system involvement (Bing-Neel syndrome) Infection requiring systemic antibiotic therapy or other serious infection =< 7 days prior to registration Evidence of current uncontrolled cardiovascular conditions, including uncontrolled hypertension, serious cardiac arrhythmia requiring medication (other than adequately rate-controlled atrial fibrillation), symptomatic congestive heart failure, unstable angina, stroke/transient ischemic attack (TIA) within the past 6 months or myocardial infarction within the past 6 months Known allergy to any of the study medications, their analogues, or excipients in the various formulations of any agent Known gastrointestinal (GI) disease or GI procedure that could interfere with the oral absorption or tolerance of ixazomib or ibrutinib, including difficulty swallowing History of any other prior malignancy; (NOTE: Exception to this are adequately treated non-melanoma skin cancers, any in situ cancer, adequately treated stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for at least two years prior to study enrollment) Patient has >= grade 2 peripheral neuropathy or grade 1 peripheral neuropathy with pain on clinical examination during the screening period Any of the following because this study involves an investigational agent whose genotoxic, mutagenic and teratogenic effects on the developing fetus and newborn are unknown Pregnant women Nursing women Men or women of child bearing potential (WCBP) who are unwilling to employ effective contraception; effective contraception would be defined as utilizing 2 simultaneous methods of contraception from the time of signing consent through 90 days after the last dose of the study drugs unless they agree to participate in true abstinence when this is in line with the preferred and usual lifestyle of the subject; (WCBP: A female who is sexually mature and who: [1] has not undergone a hysterectomy or bilateral oophorectomy; or [2] has not been naturally postmenopausal for at least 24 consecutive months [i.e., has had menses at any time in the preceding 24 consecutive months]) Evidence of any other serious medical condition (such as psychiatric illness, infectious diseases, physical or laboratory findings) that may interfere with the planned treatment, affect compliance or place the patient at high risk from treatment-related complications or potentially interfere with the completion of the treatment as per the protocol Ongoing, active hepatitis B or C virus infection, or known human immunodeficiency virus (HIV) positive Liver disease with Child-Pugh class B or C liver dysfunction Current treatment with a combination of ibrutinib and strong CYP3A inhibitors

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Treatment (ixazomib citrate, ibrutinib)<br>Patients receive ixazomib citrate PO on days 1, 8, and 15 and ibrutinib PO daily on days 1-28. Treatment repeats every 28 days for up to 24 cycles in the absence of disease progression or unacceptable toxicity. | Drug: Ibrutinib<br>* Given PO<br>* Other names: PCI-32765;Drug: Ixazomib Citrate<br>* Given PO<br>* Other names: Ninlaro;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Other: Pharmacodynamic Study<br>* Correlative studies<br>* Other names: PHARMACODYNAMIC;Other: Pharmacokinetic Study<br>* Correlative studies<br>* Other names: PK Study;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Complete response rate (CR) | Complete response rate to be defined as an objective status of CR at any time, where confirmation of the complete response status is required on two consecutive evaluations with a second immunofixation before calling the patient a CR. The proportion of successes will be estimated by the number of successes divided by the total number of evaluable patients. 95% confidence intervals for the true success proportion will be calculated according to the approach of Duffy and Santner. | Up to 5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall response rate | Overall response rate will be estimated by the total number of patients who achieve a CR, very good partial response (VGPR), or partial response (PR) divided by the total number of evaluable patients. All evaluable patients will be used for this analysis. Exact binomial 95% confidence intervals for the true overall response rate will be calculated. | Up to 5 years | 
| Time to progression | The distribution of time to progression will be estimated using the method of Kaplan-Meier. | From study registration to the earliest date of documentation of disease progression, assessed up to 5 years | 
| Overall survival | The distribution of overall survival will be estimated using the method of Kaplan-Meier. | Up to 5 years | 
| Incidence of adverse effects (AE) graded according to Common Terminology Criteria for Adverse Events (CTCAE) version (v.) 4.0 | The maximum grade for each type of AE will be recorded for each patient, and frequency tables will be reviewed to determine patterns. Additionally, the relationship of the AE(s) to the study treatment will be taken into consideration. | Up to 5 years |