Phase II Venetoclax, Obinutuzumab and Bendamustine in High Tumor Burden Follicular Lymphoma as Front Line Therapy

Follicular lymphoma (FL) is the most common low grade lymphoma comprising 70% of low-grade
non-Hodgkin's lymphoma (NHL) and 22% of all cases of NHL. The survival rates for patients
with indolent NHL remained unchanged from the 1950s through the early 1990s, but recent
evidence suggests that outcomes continue to improve. High-risk patients with FL, defined as
having advanced stage and high tumor burden have significantly shorter progression free
survival despite significant advances.

This is an open-label phase II study of venetoclax in combination with obinutuzumab and
bendamustine. Patients will receive induction therapy with obinutuzumab and bendamustine for
six cycles (1 cycle = 28 days). Venetoclax will start with 2nd cycle of induction therapy
(previously started with cycle 1). There will be a formal, detailed toxicity evaluation after
21 patients complete 3 cycles of treatment.

Patients who achieve partial response or stable disease will receive therapy with
obinutuzumab every 2 months for 12 cycles and venetoclax every month for 24 cycles. Patients
who achieve a complete response will receive obinutuzumab every 2 months for 12 cycles.
Patients with progressive disease will not continue onto the maintenance arm.

Tumor assessments will be performed approximately every 12 weeks during induction and every 6
months during maintenance therapy.

Mandatory pre-treatment tumor tissue sample (i.e., obtained during a previous procedure or
biopsy) will be required for research (if sufficient tissue is available). Optional tumor
biopsy samples obtained during treatment or post-treatment will also be requested for
research.

- Patient must have a histologically confirmed (biopsy-proven) diagnosis of follicular
B-cell non-Hodgkin lymphoma (WHO classification: follicular center grades 1, 2, and 3a
[3b patients are not eligible]), with no evidence of transformation to large cell
histology.

- Patient must meet criteria for High Tumor Burden (higher risk) as defined by either
the Groupe D'Etude des Lymphomes Follicularies (GELF) criteria [at least one
criterion] OR the follicular lymphoma international prognostic index (FLIPI) [score of
3, 4, or 5].

- Patient must have Stage II, III or IV disease.

- Baseline measurements and evaluations (PET/ CT) must be obtained within 10 weeks of
randomization to the study. Patient must have at least one objective measurable
disease parameter.

- Age ≥ 18 years.

- Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.

- Ability to understand and willingness to sign Institutional Review Board
(IRB)-approved informed consent.

- Willing to provide mandatory tissue samples (if sufficient tissue available) for
research purposes.

- Adequate organ function as measured by the following criteria:

- Absolute Neutrophil Count (ANC) ≥ 1000/mm³

- Hemoglobin ≥ 8 g/dL

- Platelets ˃75,000/mm³

- Creatinine clearance ≥ 50 mL/min, calculated with the use of 24-hour creatinine
clearance or by Cockcroft-Gault formula

- Total Bilirubin ≤ 1.5x Upper Limit of Normal (ULN) or ≤ 3x ULN for patients with
documented Gilbert's syndrome

- Aspartate aminotransferase (AST)/ alanine aminotransferase (ALT) ≤ 2.5x ULN

- Alkaline Phosphatase <5x ULN

- All females of childbearing potential (not surgically sterilized and between menarche
and 1 year post menopause) must have a blood or urine test to rule out pregnancy
within 2 weeks prior to registration.

- Women must not be pregnant or breastfeeding.

- Patient must have had no prior chemotherapy, radiotherapy or immunotherapy for
lymphoma. For purposes of this trial, prednisone or other corticosteroids used for
non-lymphomatous conditions will not be considered as prior chemotherapy. In addition,
a prior/recent short course (<2 weeks) of steroids for symptom relief of
lymphoma-related symptoms will not make a patient ineligible.

- Patient must have no recent history of malignancy except for adequately treated basal
cell or squamous cell skin cancer, Stage I melanoma of the skin, or in situ cervical
cancer. Individuals in documented remission without treatment for ≥ 2 years prior to
enrollment may be included at the discretion of the investigator.

- Patient must have no active, uncontrolled infections.

- Patients must be tested for hepatitis B virus (HBV), hepatitis B surface antigen
(HBsAg+) and hepatitis C (HCV) antibody within 6 weeks of registration. Patients who
are chronic carriers of HBV with positive HBsAg+ and positive HCV serology are
excluded, as chemotherapy and B-cell depleting therapy have been associated with virus
reactivation and fulminant hepatitis. NOTE: Patients with a past or resolved HBV
infection (defined as the presence of hepatitis B core antibody [anti-HBc] and absence
of HBsAg) may be included if HBV DNA is undetectable. If enrolled, patients must be
willing to undergo monthly HBV DNA testing. Patients with positive HCV antibody must
be negative for HCV by polymerase chain reaction (PCR) to be eligible for study
participation.

- HIV positive patients are not excluded, but to enroll, must meet all of the below
criteria:

- HIV is sensitive to antiretroviral therapy.

- Must be willing to take effective antiretroviral therapy if indicated.

- No history of CD4 prior to or at the time of lymphoma diagnosis <300 cells/mm³.

- No history of AIDS-defining conditions.

- If on antiretroviral therapy, must not be taking zidovudine or stavudine.

- Must be willing to take prophylaxis for Pneumocystis jiroveci pneumonia during
therapy and until at least 2 months following the completion of therapy or until
the CD4 cells recover to over 250 cells/mm³, whichever occurs later.

- 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.

- No major surgery within 2 weeks prior to cycle 1, other than for diagnosis.

- A condition that precludes oral route of administration (venetoclax).

- No known allergies to both xanthine oxidase inhibitors and rasburicase.

- Patient must not require the use of warfarin (because of potential drug-drug
interactions that may potentially increase the exposure of warfarin). Blood thinners
of other classes are permitted.

- Patient may not receive the following agents within 7 days prior to the first dose of
venetoclax:

- Strong and moderate CYP3A inhibitors

- Strong and moderate CYP3A inducers

- Consumed grapefruit, grapefruit products, Seville oranges (including marmalade
containing Seville oranges), or star fruit within 3 days prior to the first dose
of venetoclax.

- Patient must not have serious medical or psychiatric illness likely to interfere with
participation in this clinical study.