Everolimus and Bortezomib in Treating Patients With Relapsed or Refractory Lymphoma

OBJECTIVES:

Primary

- Determine the maximum tolerated dose of everolimus (up to 10 mg PO daily) in
combination with bortezomib in patients with relapsed/refractory indolent or mantle
cell non-Hodgkin's lymphoma (NHL) including cutaneous forms, or relapsed/refractory
aggressive NHL ineligible for hematopoetic stem cell transplantation

Secondary

- Evaluate the toxicity of this combination.

- Assess the pharmacokinetics interactions between these agents.

- Assess the response rate and 6-month progression-free survival in treated patients.

- Obtain preliminary data to assess associations between tumor characteristics and
response to treatment. in those subjects who underwent biopsy prior to study treatment.

OUTLINE: This is a dose-escalation study.

Patients receive bortezomib IV on days 1, 4, 8, and 11. Patients also receive oral
everolimus once daily or once every other day on days 1-21 in all courses. Courses repeat
every 21 days in the absence of disease progression or unacceptable toxicity.

Patients will undergo blood sample collection on Cycle 1, Day 11 for pharmacokinetic
studies. Baseline tumor expression of mTOR and NFkB -related proteins (i.e., pS6K, pAKT, and
cREL) and FOXP3 is assessed by immunohistochemistry.

Inclusion Criteria:

- Able to provide voluntary written informed consent, with the understanding that
consent may be withdrawn by the subject at any time without prejudice to future
medical care.

- Diagnosed with relapsed or refractory NHL, limited to subtypes listed below. The
subject must have histologic information of diagnosis according to review at the
Cleveland Clinic Foundation, either at initial diagnosis or at any subsequent
relapse. (Biopsy is not required at relapse, but is suggested. Biopsy at outside
institution, reviewed at the Cleveland Clinic, is acceptable.)

- "Relapsed or refractory" refers to patients who have received at least 1 prior
treatment regimen for lymphoma (which may include prior autologous stem cell
transplantation) and have demonstrated evidence of progressive disease by
clinical and/or radiographic characteristics.

- "Indolent lymphoma" is included, and refers to small lymphocytic lymphoma/B-cell
chronic lymphocytic leukemia (SLL/CLL); lymphoplasmacytic lymphoma (with or
without Waldenstrom's macroglobulinemia); hairy cell leukemia; follicular
lymphoma (FL) of any grade; marginal zone B-cell lymphoma; or mantle cell
lymphoma.

- Transformed lymphoma is included if patients are ineligible for (or refuse)
hematopoetic stem cell transplant.

- In addition, cutaneous B and T cell lymphoma are permitted. Cutaneous T cell
lymphoma must be refractory to 1 prior systemic therapy (topical therapy,
photopheresis, radiation are not considered systemic therapy). Transformed B and
T cell cutaneous lymphoma are also permitted.

- Relapsed/refractory diffuse large B cell lymphoma (DLBCL) is allowed if the
patient is not eligible for, or refuses, hematopoetic stem cell transplant.

- Relapsed/refractory nodal, leukemic, and extranodal T cell lymphomas are
eligible. Subtypes eligible include anaplastic large cell lymphoma,
angioimmunoblastic T cell lymphoma, PTCL-NOS, nasal or disseminated extranodal
T/NK lymphoma, enteropathy-associated T cell lymphoma, hepatosplenic gamma/delta
T cell lymphoma, subcutaneous panniculitis-like T cell lymphoma,
T-prolymphocytic leukemia, Adult T-cell leukemia/lymphoma, large granular
lymphocytic leukemia, aggressive NK leukemia.

- Plasma cell myeloma and Hodgkin lymphoma are excluded.

- Prior therapy with bortezomib is allowed. Patients who have received prior bortezomib
therapy must have received bortezomib >6 months ago, and must have shown some
response. Patients that did not respond to prior bortezomib therapy are not eligible.

- Measurable disease by one of the following: radiographic criteria (≥2 cm by computed
tomography); lymphoma involving peripheral blood with more than 5000 leukemia
cells/mm3, or any degree of bone marrow infiltration on bone marrow biopsy. Skin
involvement with or without nodal or bone marrow involvement permitted for cutaneous
lymphomas is also permitted. (see section 6.0, Measurement of Effect).

- Eastern Cooperative Group (ECOG) Performance Status of 0-2.

- Serum bilirubin levels ≤1.5 times the upper limit of the normal (ULN) range for the
laboratory. Higher levels are acceptable if these can be attributed to active
hemolysis or ineffective erythropoiesis. Serum AST or serum ALT levels must be ≤2.5 x
ULN, or ≤5 x ULN for patients with liver involvement by lymphoma.

- Must have adequate bone marrow function:

- Absolute neutrophil count (ANC) ≥1,000/uL

- Platelet count (Plt) ≥ 75,000/uL

- Hemoglobin (Hgb) ≥ 9.0 g/dL

- Must have adequate renal function: Creatinine ≤ 1.5 X ULN.

- Women of childbearing potential (WCBP) must have a negative serum or urine pregnancy
test within 7 days of starting study drug. In addition, sexually active WCBP must
agree to use adequate contraceptive methods (tubal ligation; intrauterine device; or
barrier contraceptive with spermicide) while on study. Oral, implantable, or
injectable contraceptives may be affected by cytochrome P450 interactions, and are
therefore not considered effective for this study. WCBP must agree to have pregnancy
tests every 4 weeks while on study drug. Male subject agrees to use an acceptable
method of contraception for the duration of the study.

- Female patients who:

- Are postmenopausal for at least 1 year before the Screening visit, OR

- Are surgically sterile, OR

- If they are of childbearing potential, agree to practice 2 effective methods of
contraception, at the same time, from the time of signing the informed consent
through 30 days after the last dose of study treatment, OR agree to completely
abstain from heterosexual intercourse

- Male patients, even if surgically sterilized (ie, status post-vasectomy), who:

- Agree to practice effective barrier contraception during the entire study
treatment period and through 30 days after the last dose of study treatment, OR

- Agree to completely abstain from heterosexual intercourse

- Able to adhere to the study visit schedule and other protocol requirements.

Exclusion Criteria:

- Prior treatment with any investigational drug, chemotherapy, or monoclonal antibody
within the preceding 1 month

- Chronic treatment with systemic steroids or another immunosuppressive agent.

- Patients should not receive immunization with attenuated live vaccines during study
period.

- History of allogeneic stem cell transplantation.

- Any patient with known diabetes mellitus currently requiring insulin therapy, or any
patient with preexisting diabetes mellitus in poor control, defined as a hemoglobin
A1C (HbA1C) value of over 9% within 4 weeks of starting therapy

- Fasting serum cholesterol >300 mg/dL OR >7.75 mmol/L or fasting triglycerides > 2.5 x
ULN. NOTE: In case one or both of these thresholds are exceeded, the patient can only
be included after initiation of appropriate lipid lowering medication.

- Uncontrolled brain or leptomeningeal metastases, including patients who continue to
require glucocorticoids for brain or leptomeningeal metastases.

- Other malignancies within the past 3 years except for adequately treated carcinoma of
the cervix or basal or squamous cell carcinomas of the skin, or low-risk prostate
cancer after curative therapy.

- Patients who have any severe and/or uncontrolled medical conditions or other
conditions that could affect their participation in the study such as:

- unstable angina pectoris, any history of congestive heart failure, any history
of known myocardial infarction, uncontrolled cardiac arrhythmia

- severely impaired lung function

- uncontrolled diabetes as defined by fasting serum glucose >1.5x ULN, off
medications

- any active (acute or chronic) or uncontrolled infection/ disorders.

- nonmalignant medical illnesses that are uncontrolled or whose control may be
jeopardized by the treatment with the study therapy

- liver disease including a known history of viral hepatitis B or C, evidence of
cirrhosis, chronic active hepatitis or chronic persistent hepatitis

- a known history of HIV seropositivity

- Impairment of gastrointestinal function or gastrointestinal disease that may
significantly alter the absorption of RAD001 (e.g., ulcerative disease,
uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome or small bowel
resection)

- Patients with an active, bleeding diathesis

- Breast feeding or pregnant females

- Patients with a known hypersensitivity to everolimus or other rapamycins (sirolimus,
temsirolimus) or to its excipients, or to bortezomib, boron, or mannitol

- History of noncompliance to medical regimens

- Patients unwilling or unable for any reason (personal, medical, or psychiatric) to
comply with the protocol

- Patients with preexisting peripheral neuropathy grade ≥ 2 will not be eligible

- Patients taking concomitant medications (chronically or within 1 week of study drug
administration) which are strong inhibitors of hepatic metabolism via P450/CY3PA4
isoenzyme will be excluded.

- Patients who have received hematopoietic growth factors (filgrastim, pegfilgrastim,
or sargramostim) within 28 days of first dose of screening.

- Patient had myocardial infarction within 6 months prior to enrollment or has New York
Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, severe
uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute
ischemia or active conduction system abnormalities. Prior to study entry, any ECG
abnormality at screening must be documented by the investigator as not medically
relevant.