MLN4924 Compared With MLN4924 Plus Chemotherapy for Large B-cell Lymphoma

Background:

- Diffuse large B-cell lymphomas (DLBCL) have been molecularly sub-classified into
germinal center like B-cell (GCB) and activated B-cell like (ABC) DLBCL.

- Clinically, the ABC subtype has a significantly higher rate of drug resistance and
lower survival. The ABC subtype has constitutive activation of the NF-KappaB pathway
which may account for the drug resistance.

- The ability of NF-KappaB to inhibit responses to cancer therapeutic agents may also
contribute to the refractory clinical behavior of ABC subtype, and inhibition of
NF-KappaB can synergize with chemotherapy to kill tumor cells.

- Because a phase II randomized design is not clinically or technically practical at this
early stage to address the scientific endpoints, we have designed a novel endpoint
based on relative efficacy of DA-EPOCH-R + MLN 4924 (DA-EPOCH-RN) in ABC and GCB DLBCL.
Based on our study that shows that survival of relapsed ABC and GCB DLBCL are
comparable and poor following initial R-CHOP, we hypothesize that significantly
improved survival of ABC compared to GCB DLBCL after DA-EPOCH-RN is strongly indicative
of preferential activity of MLN4924 in ABC DLBCL.

Objectives:

- Assess response of MLN4924 in relapsed/refractory DLBCL

- Assess toxicity and safe tolerated dose of MLN4924 and DA-EPOCH-R

- Assess difference in response (CR/PR) and OS in ABC and GCB DLBCL

Eligibility:

- Relapsed/refractory de novo DLBCL greater than or equal to 18 years.

- No PMBL DLBCL

- No patients with active CNS lymphoma.

- No pregnant or breast-feeding women.

- Adequate organ function (as defined in protocol).

Study Design:

- This is a single center with a sequential treatment design. The study is divided into
two parts (A and B). Clinical end points are to assess the activity of MLN4924 alone
(Part A) and in combination with DA-EPOCH-R (Part B), and to assess the toxicity and
MTD of DA-EPOCH-RN.

- In Part A, MLN4924 will be given alone for 6 cycles.

- In Part B, MLN4924 will be initially escalated to determine the maximum tolerated dose
(MTD) in combination with DA-EPOCH-R at dose levels (to be determined) and schedule
every 21 days. Responding or stable patients may receive up to 6 cycles of DAEPOCH-RN.

- Patients will be restaged every 2 cycles during treatment, and every 3, 4 and 6 months
during years one, two and three respectively, thereafter. Standard response criteria
will be applied.

- A total of 56 patients will be enrolled depending on the relative differences in
response observed between the ABC and GCB subtypes to MLN4924.

- INCLUSION CRITERIA:

- Biopsy-proven relapsed or refractory Large B-cell lymphoma.

- Confirmed pathological diagnosis by the Laboratory of Pathology, NCI.

- Age greater than or equal to 18 years.

- ECOG performance status 0-2.

- Adequate renal function or creatinine clearance > 50 ml/min/1.73m(2) unless lymphoma
related.

- Adequate hepatic and hematological function, as defined by:

- Bilirubin must be less than or equal to ULN, except less than or equal to 2
mg/dl (total) in patients with Gilbert s syndrome (as defined by > 80%
unconjugated hyperbilirubinemia);

- ALT and AST must be less than or equal to Grade 1.

- ANC > 1000 and platelets > 75,000 unless lymphoma related.

- Prothrombin time (PT) and activated partial thromboplastin time (aPTT) must be
less than or equal to 1.5 times the upper limit of the normal range (ULN);
except if, in the opinion of the Investigator, the aPTT is elevated because of a
positive Lupus Anticoagulant.

- Left ventricular ejection fraction (LVEF) > 45% as assessed by echocardiogram or
MUGA

- Voluntary written informed consent before performance of any study-related procedure
not part of normal medical care, with the understanding that consent may be withdrawn
by the subject at any time without prejudice to future medical care.

- Female subject is either post-menopausal or surgically sterilized or willing to use
an acceptable method of birth control (i.e., a hormonal contraceptive, intra-uterine
device, diaphragm with spermicide, condom with spermicide, or abstinence) for the
duration of the study.

- Male patients must use an appropriate method of barrier contraception (eg, condoms),
inform any sexual partners that they must also use a reliable method of contraception
(ie, a hormonal contraceptive, an intrauterine device, diaphragm with spermicide, or
abstinence), and refrain from blood and semen donation during the study and for 4
months after the last dose of study treatment.

EXCLUSION CRITERIA:

- Female subject pregnant or breast-feeding. Confirmation that the subject is not
pregnant must be established by a negative serum Beta-human chorionic gonadotropin
(Beta-hCG) pregnancy test result obtained during screening. Pregnancy testing is not
required for women without child-bearing potential.

- History of a prior invasive malignancy in past 5 year.

- 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 has to be documented by the investigator as not medically
relevant.

- Patient has greater than or equal to Grade 2 peripheral neuropathy within 14 days
before enrollment

- Serious concomitant medical illnesses that would jeopardize the patient s ability
to receive the regimen with reasonable safety.

- HIV positive patients

- Systemic cytotoxic therapy within 3 weeks of treatment

- Serious medical or psychiatric illness likely to interfere with participation in this
clinical study.

- CYP3A inducers within 14 days before the first dose of MLN4924. Moderate and strong
CYP3A inhibitors and CYP3A inducers are not permitted during the study. Patients must
have no prior history of chronic amiodarone use in the 6 months prior to the first
dose of MLN4924.

- Patients currently taking statins who are unwilling or unable to refrain from using
statins on the day prior to, day of, and day after each MLN4924 administration

- Diarrhea > Grade 1, based on the NCI CTCAE categorization despite use of optimal
antidiarrheals

- Known hepatitis B surface antigen-positive, or known or suspected active hepatitis C
infection

- Clinically uncontrolled central nervous system (CNS) involvement (Patients who have a
history of CNS involvement, but no evidence of active CNS disease are not excluded.)

- Ongoing anticoagulant therapy (eg, aspirin, Coumadin, heparin) that cannot be held to
permit bone marrow sampling. Patients who require anticoagulant therapy, and can not
be maintained on low molecular weight heparin should not be considered for this
study.

INCLUSION OF WOMEN AND MINORITIES:

-Both men and women and members of all races and ethnic groups are eligible for this
trial.