Study of Ibrutinib in Patients With Symptomatic, Previously Untreated Waldenstrom's Macroglobulinemia, and Impact on Tumor Genomic Evolution Using Whole Genome Sequencing

This research study is a Phase II clinical trial. Phase II clinical trials test the safety
and effectiveness of an investigational intervention to learn whether the intervention works
in treating a specific disease. "Investigational" means that the intervention is being
studied.

The FDA (the U.S. Food and Drug Administration) has approved ibrutinib as a form of treatment
for the patient specific disease.

Ibrutinib has been under investigation in research studies in participants with recurrent
B-cell lymphoma, chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), mantle
cell lymphoma (MCL), diffuse large B-cell lymphoma (DLBCL), and prolymphocytic leukemia, and
WM. In a study of ibrutinib in relapsed/refractory WM patients, response rates were high and
the treatment was well tolerated.

The prior studies suggest that ibrutinib may be a useful treatment strategy for untreated WM
patients. This study will test the safety and efficacy of ibrutinib as an option for
untreated WM patients. The study will also conduct genomic sequencing of malignant WM cells
before the start of treatment, and 6, 12, 24, 36 and 48 months afterwards. Genomic sequencing
is the analysis of the entire DNA structure from tumor and normal cells. The purpose of this
sequencing is to study which genetic changes effect how ibrutinib works. The results of these
studies could also help in better understanding the course of WM disease, and be applicable
to the development of other effective drug treatments.

Inclusion Criteria:

- Clinicopathological diagnosis of Waldenstrom's Macroglobulinemia and meeting criteria
for treatment using consensus panel criteria from the Second International Workshop on
Waldenstrom's macroglobulinemia (Kyle et al, 2003).

- Measurable disease, defined as presence of serum immunoglobulin M (IgM) with a minimum
IgM level of ≥ 2 times the upper limit of normal is required.

- Age ≥ 18 years.

- ECOG performance status ≤2 (see Appendix A.).

- Participants must have normal organ and marrow function as defined below:

- Absolute neutrophil count ≥ 1,000/μL

- Platelets ≥ 50,000/μL

- Hemoglobin ≥ 8 g/dL

- Total bilirubin ≤ 2.0. mg/dL or < 2.5 mg/dL if attributable to hepatic
infiltration by neoplastic disease or Gilbert's syndrome.

- AST (SGOT) and ALT (SGPT) ≤ 2.5 X institutional upper limit of normal

- Estimated Creatinine Clearance ≥30ml/min

- Not on any active therapy for other malignancies with the exception of topical
therapies for basal cell or squamous cell cancers of the skin.

- Females of childbearing potential (FCBP) must agree to use two reliable forms of
contraception simultaneously or have or will have complete abstinence from
heterosexual intercourse during the following time periods related to this study: 1)
while participating in the study; and 2) for at least 28 days after discontinuation
from the study. Men must agree to use a latex condom during sexual contact with a FCBP
even if they have had a successful vasectomy. FCBP must be referred to a qualified
provider of contraceptive methods if needed.

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

- Ability to understand and the willingness to sign a written informed consent document.

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

Exclusion Criteria:

- Prior systemic therapy for WM

- Any serious medical condition, laboratory abnormality, uncontrolled intercurrent
illness, or psychiatric illness/social condition that would prevent the participant
from signing the informed consent form.

- Concurrent use of any other anti-cancer treatments or any other investigational
agents.

- Concomitant use of warfarin or other Vitamin K antagonists.

- Concomitant treatment with strong CYP3A4/5 inhibitor.

- Any condition, including the presence of laboratory abnormalities, which places the
participant at unacceptable risk if he/she were to participate in the study or
confounds the ability to interpret data from the study.

- Any life-threatening illness, medical condition, or organ system dysfunction which, in
the investigator's opinion could interfere with the absorption or metabolism of
ibrutinib.

- Known CNS lymphoma.

- Concomitant use of medication known to cause QT prolongation.

- Currently active, clinically significant cardiovascular disease such as uncontrolled
or symptomatic arrhythmias, Class 3 or 4 congestive heart failure as defined by the
New York Heart Association Functional Classification, or history of myocardial
infarction, unstable angina or acute coronary syndrome within 6 months of screening.

- Malabsorption, disease significantly affecting gastrointestinal function, or resection
of the stomach or small bowel, ulcerative colitis, symptomatic inflammatory bowel
disease, or partial or complete bowel obstruction.

- Known history of Human Immunodeficiency Virus (HIV), active infection with Hepatitis B
Virus (HBV), and/or Hepatitis C Virus (HCV). Subjects who are positive for hepatitis B
core antibody or hepatitis B surface antigen must have a negative polymerase chain
reaction (PCR) result before enrollment. Those who are PCR positive will be excluded.

- Lactating or pregnant women.

- Inability to swallow capsules.

- History of non-compliance to medical regimens.

- Unwilling or unable to comply with the protocol.

- Major surgery within 4 weeks of first dose of study drug.

- No active infections requiring systemic therapy.

- Known bleeding disorders with the exception of acquired Von Willebrand Disorder
suspected on the basis of WM.

- History of stroke or intracranial hemorrhage within 6 months prior to enrollment.