Entinostat and Clofarabine in Treating Patients With Newly Diagnosed, Relapsed, or Refractory Poor-Risk Acute Lymphoblastic Leukemia or Bilineage/Biphenotypic Leukemia

PRIMARY OBJECTIVES:

I. To determine the feasibility, tolerability, toxicities, and maximum tolerated dose (MTD)
of entinostat plus clofarabine for: adult patients age 40 and over with newly diagnosed,
poor-risk Philadelphia chromosome negative (Ph-) acute lymphoblastic leukemia (ALL) or
bilineage/biphenotypic leukemia (ABL) prior to traditional cyclical multi-agent
chemotherapy, and adults age 21 and over with relapsed or refractory ALL/ABL.

II. To determine if entinostat plus clofarabine can induce clinical responses in adults with
newly diagnosed, poor-risk ALL/ABL and in adults with relapsed/refractory ALL/ABL

SECONDARY OBJECTIVES:

I. To determine pharmacokinetics (PK) of entinostat alone and in combination with
clofarabine.

II. To obtain descriptive preliminary pharmacodynamic (PD) data regarding the effects of
entinostat alone and in combination with clofarabine on histone acetylation and global and
gene specific methylation in leukemic blasts.

III. To obtain descriptive preliminary data regarding the effects of entinostat alone and in
combination with clofarabine on deoxyribonucleic acid (DNA) damage and apoptosis in leukemic
blasts and residual disease monitored by 6-color flow cytometry.

OUTLINE: This is a dose-escalation study of entinostat.

Patients receive entinostat orally (PO) on days 1 and 8 and clofarabine intravenously (IV)
over 2 hours on days 3-7. Courses repeat every 21 days in the absence of disease progression
or unacceptable toxicity (only for patients at least 60 years of age with newly diagnosed
acute lymphoblastic leukemia [ALL] or bilineage/biphenotypic leukemia [ABL] who are unable
or unwilling to tolerate standard multi-agent chemotherapy and patients with relapsed or
refractory ALL or ABL).

Patients 40-59 years of age with newly diagnosed ALL receive standard multi-agent induction
chemotherapy beginning on day 11. Patients at least 21 years of age in their first relapse
with sensitive disease begin initiation of allogeneic transplant after one course of
entinostat and clofarabine.

After completion of study treatment, patients are followed up at 30, 60, 90, 180, and 360
days.

Inclusion Criteria:

- Adults age >= 40 years with the established, pathologically-confirmed diagnoses of
newly diagnosed ALL or ABL are eligible for study; adults with relapsed and
refractory ALL or ABL who are > 21 years of age and who have progressive disease
following their last therapy are eligible for study; the additional following
criteria must be met:

- For adults with relapsed/refractory ALL, no more than 5 previous regimens

- Eastern Cooperative Oncology Group (ECOG) performance status 0, 1, or 2

- Patients must be able to give informed consent

- Female patients of childbearing age must have negative pregnancy test

- Total white blood cell count (WBC) =< 150,000 with no evidence for ongoing or
impending leukostasis

- Total bilirubin =< 2.0 mg/dL unless elevated due to Gilbert's disease, hemolysis or
leukemic infiltration

- Aspartate transaminase (AST)/alanine transaminase (ALT) =< 2.5 × upper limit of
normal (ULN) unless due to leukemic infiltration

- Serum creatinine =< 2.0 mg/dL

- Left ventricular ejection fraction (LVEF) >= 45% as measured by echocardiogram (ECHO)
or multiple gated acquisition (MUGA) scan

- Women of child-bearing potential and men must agree to use adequate contraception
(hormonal or barrier method of birth control; abstinence) prior to study entry and
for 30 days after study participation; should a woman become pregnant or suspect she
is pregnant while participating in this study, she should inform her treating
physician immediately

- Patients who have undergone stem cell transplantation (SCT), autologous or
allogeneic, are eligible provided that they are >= 4 weeks from stem cell infusion,
have no active graft-vs-host disease (GVHD), and meet other eligibility criteria

- Patients who fail primary induction therapy or relapse after achieving complete
remission (CR) are eligible if they have undergone no more than 5 prior cytotoxic
regimen, >= 14 days off cytotoxic chemotherapy, and >= 2 weeks radiation therapy;
patients must be off biologic therapies >= 7 days, must be off hematopoietic growth
factors >= 3 days; if using hydroxyurea steroids, imatinib, arsenic, interferon, or
other non-cytotoxics for blast count control, patient must be off for >= 24 hrs
before starting entinostat plus clofarabine

Exclusion Criteria:

- Philadelphia chromosome positive ALL

- Patients may not have received previous treatment with entinostat or other histone
deacetylase (HDAC) inhibitors (including valproic acid) or clofarabine within the
previous 6 months

- Concomitant chemotherapy, radiation therapy, or immunotherapy

- Hyperleukocytosis with >= 150,000 blasts/uL (If using hydroxyurea, steroids,
maintenance doses of 6-mercaptopurine and/or methotrexate, arsenic, interferon or
leukapheresis for blast count control, patient must be off those agents for 24 hours
prior to beginning entinostat plus clofarabine)

- Active disseminated intravascular coagulation (DIC)

- Active central nervous system (CNS) leukemia; patients with known previous CNS
leukemia may continue to receive intrathecal therapy with cytarabine (ara-C),
methotrexate, and/or thiotepa plus steroids as prophylaxis against reactivation of
active CNS disease

- Use of investigational cytotoxic agents within 30 days or any anticancer therapy
within 14 days before study entry, except for hydroxyurea and steroids, both of which
must be discontinued at least 24 hours before study entry; the patient must have
recovered from all acute toxicities from any previous therapy

- The patient must have recovered from all acute toxicities from any previous therapy

- Patients must have discontinued all growth factors at least 3 days before study

- History of severe coronary artery disease, including myocardial infarction within the
previous 3 months, arrhythmias other than atrial flutter or fibrillation requiring
medication, or uncontrolled congestive heart failure

- Dyspnea at rest or with minimal exertion

- Active uncontrolled infection; patients with infection under active treatment and
controlled with antibiotics are eligible

- Patients with active >= grade 2 graft versus host disease (GVHD)

- Presence of other life-threatening illness

- Patients with mental deficits and/or psychiatric history that preclude them from
giving informed consent or from following protocol

- Pregnant or nursing women; breastfeeding should be discontinued if the mother is
treated with entinostat

- Male and female patients who are fertile who do not agree to use an effective barrier
method of birth control (ie, hormonal or barrier method of birth control; abstinence)
to avoid pregnancy during the study and for a minimum of 30 days after study
treatment

- Previous history of or current seizure disorder

- Human immunodeficiency virus (HIV) infected patients who have cluster of
differentiation (CD4) cell count =< 350/mm^3 or a history of acquired
immunodeficiency syndrome (AIDS)-defining conditions