A Clinical Trial Evaluating the Safety and Efficacy of Venetoclax in Combination with Atezolizumab and Obinutuzumab in Richter Transformation of Cronic Lymphocitic Leukemia

Prior treatment

• Prior treatment for Richter transformation.
• Evidence of significant, uncontrolled concomitant diseases that could affect compliance with the protocol or interpretation of results or that could increase risk to the patient, including renal disease that would preclude chemotherapy administration or pulmonary disease (including obstructive pulmonary disease and history of bronchospasm).
• Patients with a previous history of indolent B cell malignancies other than CLL.
• Known active bacterial, viral, fungal, mycobacterial, parasitic, or other infection (excluding fungal infections of nail beds) at study enrollment, or any major episode of infection requiring treatment with IV antibiotics or hospitalization (relating to the completion of the course of antibiotics) within 4 weeks prior to Cycle 1, Day 1
• Major surgery within 4 weeks of first dose of study drug.
• Currently active, clinically significant cardiovascular disease, such as uncontrolled arrhythmia or Class 2 or higher 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.
• Vaccinated with live, attenuated vaccines within 4 weeks of first dose of study drug.
• Presence of positive PCR for hepatitis B, hepatitis C or positive hepatitis B surface antigen (HbsAg). Patients who are positive for HCV antibody must be negative for HCV by polymerase chain reaction (PCR) to be eligible for study participation. Patients with occult or prior HBV infection (defined as positive total hepatitis B core antibody [HBcAb] and negative HBsAg) may be included if HBV DNA is undetectable. These patients must be willing to receive prophylactic lamivudine or entecavir and undergo monthly DNA testing during treatment and up to 6 months’ post treatment..
• Concurrent systemic immunosuppressant therapy within 28 days of the first dose of study drug.
• Corticosteroids are allowed, but must be dosed at prednisone 30 mg (or equivalent) or lower prior to the start of chemotherapy.
• Male subject who is considering fathering a child or donating sperm during the study or for approximately 6 months after the last dose of study drugs.
• Patients receiving any other study agents
• Concurrent administration of medications or foods that are strong inhibitors or inducers of CYP3A Concurrent administration of medications or foods that are strong inhibitors or inducers of CYP3A see Appendix 9.
• Strong and moderate CYP3A inhibitors within 7 days prior to the first dose of study drug administration
• Patients with infections requiring IV treatment (Grade 3 or 4) within the last 2 months prior to enrolment.
• Prior treatment with obinutuzumab anti PD-1 or PDL-1 antibodies.
• Prior treatment with venetoclax.

Other illness

• Unable to swallow capsules or malabsorption syndrome, symptomatic inflammatory bowel disease or ulcerative colitis, or partial or complete bowel obstruction at time of screening.
• Clinically significant history of liver disease, including autoimmune hepatitis, current alcohol abuse, or cirrhosis.
• Patients with uncontrolled autoimmune hemolytic anemia or immune thrombocytopenia.
• History of active autoimmune disease.
• History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis per chest CT scan at screening. History of radiation pneumonitis in the radiation field (fibrosis) is allowed.
• Known bleeding disorders (eg, von Willebrand's disease) or hemophilia.
• History of severe allergic or anaphylactic reactions to humanized or murine monoclonal antibodies, known sensitivity or allergy to murine products.
• History of human immunodeficiency virus (HIV) or active hepatitis C virus (HCV) or active hepatitis B virus (HBV).
• Any life-threatening illness, medical condition, or organ system dysfunction that, inthe investigator's opinion, could compromise the subject's safety or put the study outcomes at undue risk.
• Hypersensitivity to obinutuzumab, venetoclax or atezolizumab or their formulation excipients.

Age

• History of other malignancy other than CLL and Richter syndrome that could affect compliance with the protocol or interpretation of results with the exception of: a) Patients with curatively treated basal or squamous cell carcinoma or stage 1 melanoma of the skin or in situ carcinoma of the cervix b) Patients with a malignancy that has been treated with surgery alone with curative intent. Individuals in documented remission without treatment for > 2 years prior to enrollment may be included at the discretion of the Sponsor-Investigator. c) Low-risk prostate cancer on active surveillance.

Other

• Patients with the Hodgkin variant transformation of CLL.
• Prolymphocytic transformation.
• Requires anticoagulation with vitamin K antagonists (e.g. phenprocoumon, warfarin)
• Breastfeeding or pregnant
• 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)
• Patients with known CNS involvement
• Unable to receive prophylactic treatment for pneumocystis, herpes simplex virus (HSV), and herpes zoster (VZV) at start of treatment

• Ability to understand and the willingness to sign a written informed consent document
• Contraception/ breastfeeding: For women of childbearing potential: agreement to remain abstinent (refrain from heterosexual intercourse) or use a contraceptive method with a failure rate of < 1% per year during the treatment period and for at least 30 days after the last dose of venetoclax, 5 months after the last dose of atezolizumab or 18 months after the last dose of obinutuzumab, whichever is longer A woman is considered to be of childbearing potential if she is post-menarchal, has not reached a postmenopausal state (>12 continuous months of amenorrhea with no identified cause other than menopause), and has not undergone surgical sterilization (removal of ovaries and/or uterus).
• Signed Informed Consent
• Confirmed diagnosis of chronic lymphocytic leukemia or small lymphocytic lymphoma as IW-CLL 2008 criteria (Hallek et al, 2008) with biopsy proven transformation to diffuse large B cell lymphoma (DLBCL), consistent with Richter's Syndrome
• Age greater than or equal to 18 years
• ECOG performance status <= 2
• Patients must meet the following hematologic criteria at screening, unless they have significant bone marrow involvement of their malignancy confirmed on biopsy: - Absolute neutrophil count >=1000 cells/mm3 (1.0 x 10^9/L). - Platelet count >= 50,000 cells/mm3 (50 x 10^9/L) within 7 days of screening - Total hemoglobin > 9 g/dL (without transfusion support, unless anemia is due to marrow involvement of CLL)
• Subject must have adequate coagulation, renal, and hepatic function, per laboratory reference range at screening as follows: - Activated partial thromboplastin time (aPTT) and International normalized ratio (INR) > 1.5 x ULN for patients not receiving therapeutic anticoagulation; - Creatinine <= 1.5 x ULN or creatinine clearance >= 50 mL/min based on Cockcroft-Gault formula; - Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) <= 2.5 × ULN; - Bilirubin <= 1.5 × ULN;
• Subjects with Gilbert's Syndrome or resolving autoimmunehemolytic anemia may have a bilirubin up to 3.0 × ULN and are still eligible
• Negative pregnancy tests as verified by the investigator prior to starting any treatment