Avelumab With Decitabine as First Line for AML Treatment of Patients With AML, Who Are Unfit for Intensive Chemotherapy

Inclusion Criteria:

1. Cytologically or histologically confirmed diagnosis of AML (except M3 acute
promyelocytic leukemia) according to WHO classification.

2. Previously untreated AML except for hydroxyurea.

3. Age ≥18 years. Because no dosing or adverse event data are currently available on the
use of avelumab in combination with decitabine in patients <18 years of age, children
are excluded from this study but will be eligible for future pediatric trials.

4. Performance status (ECOG) of 0-2 (see Appendix A).

5. Not considered candidates for intensive remission induction chemotherapy at time of
enrollment based on EITHER:

- 75 years of age OR <75 years of age with at least 1 of the following: Poor
performance status (ECOG) score of 2.

Clinically significant heart or lung comorbidities, as reflected by at least 1 of:

Left ventricular ejection fraction (LVEF) ≤50%. Lung diffusing capacity for carbon
monoxide (DLCO) ≤65% of expected. Forced expiratory volume in 1 second (FEV1) ≤65% of
expected. Chronic stable angina or congestive heart failure controlled with
medication. Liver transaminases >3 × upper limit of normal (ULN). Other
contraindication(s) to anthracycline therapy. Other comorbidity the investigator
judges incompatible with intensive remission induction chemotherapy. The enrollee
declines intensive remission induction chemotherapy.

6. Creatinine clearance as estimated by the Cockcroft-Gault (C-G) or other medically
acceptable formulas ≥30 mL/min.vii. Cytogenetic features justify hypo-methylating
agents as induction treatment.

7. Life expectancy > 12 weeks (3months).

8. Patients may not have received prior azacytidine or decitabine for MDS that has
transformed to AML.

9. Hydroxyurea would be permitted for control of elevated WBC prior to treatment and can
be continued for the first 4 weeks of therapy.

10. Women of childbearing potential (not surgically sterile or one year postmenopausal)
must have a negative result for a serum pregnancy test before study drug
administration on cycle 1 day 1 (within 3 days). Women of childbearing potential (not
surgically sterile or one year postmenopausal) must use a highly effective method of
contraception and must agree to continue use of this method for the duration of the
study and for 30 days after discontinuation of study drug. Acceptable methods of
contraception include abstinence, barrier method with spermicide, intrauterine device
(IUD) known to have a failure rate of less than 1% per year, or steroidal
contraceptive (oral, transdermal, implanted, or injected) in conjunction with a
barrier method.

11. The patient, if a man, is surgically sterile or, if capable of producing offspring, is
currently using an approved method of birth control and agrees to continued use of
this method for the duration of the study (and for 30 days after taking the last dose
of study drug because of the possible effects on spermatogenesis). Acceptable methods
of contraception include abstinence, female partner's use of steroidal contraceptive
(oral, implanted or injected) in conjunction with a barrier method, female partner's
use of an IUD known to have a failure rate of less than 1% per year, or if female
partner is surgically sterile or one year post- menopausal. In addition, male patients
may not donate sperm for the duration of the study and for 30 days after taking study
drug.

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

Exclusion Criteria:

A subject will not be eligible for inclusion in this study if any of the following criteria
apply:

1. Patients who have had chemotherapy or radiotherapy within 4 weeks prior to entering
the study or those who have not recovered from adverse events due to agents
administered more than 4 weeks earlier.

2. Patients who are receiving any other investigational agents.

3. Patients should be excluded if they have had prior treatment with an anti-PD-1,
anti-PD-L1, anti-PD-L2, anti-CTLA-4 antibody, or any other antibody or drug
specifically targeting T-cell co-stimulation or immune checkpoint pathways.

4. Patients with known CNS involvement will be excluded because of poor prognosis and
concerns regarding progressive neurologic dysfunction that would confound the
evaluation of neurologic and other adverse events.

5. History of severe hypersensitivity reaction to any monoclonal antibody.

6. Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements.

7. Pregnant women are excluded from this study because avelumab is an agent with the
potential for teratogenic or abortifacient effects. Because there is an unknown but
potential risk for adverse events in nursing infants secondary to treatment of the
mother with avelumab, breastfeeding should be discontinued if the mother is treated
with avelumab.

8. Patients with known history of testing positive for human immunodeficiency virus (HIV)
or known acquired immunodeficiency syndrome (AIDS) might be enrolled if the viral load
by PCR is undetectable with/without active treatment and absolute lymphocyte count >=
350/ul.

Patients with a positive test for hepatitis B virus surface antigen (HBV sAg) or
hepatitis C virus ribonucleic acid (HCV antibody) indicating acute or chronic
infection might be enrolled if the viral load by PCR is undetectable with/without
active treatment.

9. Patients with active autoimmune disease or history of autoimmune disease that might
recur, which may affect vital organ function or require immune suppressive treatment
including systemic corticosteroids, should be excluded. These include but are not
limited to patients with a history of immune related neurologic disease, multiple
sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome, myasthenia
gravis; systemic autoimmune disease such as SLE, connective tissue diseases,
scleroderma, inflammatory bowel disease (IBD), Crohn's, ulcerative colitis, hepatitis;
and patients with a history of toxic epidermal necrolysis (TEN), Stevens-Johnson
syndrome, or phospholipid syndrome should be excluded because of the risk of
recurrence or exacerbation of disease. Patients with vitiligo, endocrine deficiencies
including thyroiditis managed with replacement hormones including physiologic
corticosteroids are eligible. Patients with rheumatoid arthritis and other
arthropathies, Sjögren's syndrome and psoriasis controlled with topical medication and
patients with positive serology, such as antinuclear antibodies (ANA), anti-thyroid
antibodies should be evaluated for the presence of target organ involvement and
potential need for systemic treatment but should otherwise be eligible.

10. Patients are permitted to enroll if they have vitiligo, type I diabetes mellitus,
residual hypothyroidism due to autoimmune condition only requiring hormone
replacement, psoriasis not requiring systemic treatment, or conditions not expected to
recur in the absence of an external trigger (precipitating event).

11. Patients should be excluded if they have a condition requiring systemic treatment with
either corticosteroids (>10 mg daily prednisone equivalents) or other
immunosuppressive medications within 14 days of study drug administration. Inhaled or
topical steroids and adrenal replacement doses <10 mg daily prednisone equivalents are
permitted in the absence of active autoimmune disease. Patients are permitted to use
topical, ocular, intra-articular, intranasal, and inhalational corticosteroids (with
minimal systemic absorption). Physiologic replacement doses of systemic
corticosteroids are permitted, even if <10 mg/day prednisone equivalents. A brief
course of corticosteroids for prophylaxis (e.g., contrast dye allergy) or for
treatment of non-autoimmune conditions (e.g., delayed-type hypersensitivity reaction
caused by contact allergen) is permitted.

12. Patients who have had evidence of active or acute diverticulitis, intra-abdominal
abscess, GI obstruction and abdominal carcinomatosis which are known risk factors for
bowel perforation should be evaluated for the potential need for additional treatment
before coming on study.

13. Prior organ transplantation including allogenic stem-cell transplantation.

14. Vaccination within 4 weeks of the first dose of avelumab and while on trials is
prohibited except for administration of inactivated vaccines.

15. Clinically significant (i.e., active) cardiovascular disease: cerebral vascular
accident/stroke (< 6 months prior to enrollment), myocardial infarction (< 6 months
prior to enrollment), unstable angina, congestive heart failure (≥ New York Heart
Association Classification Class II), or serious cardiac arrhythmia requiring
medication.

16. Persisting toxicity related to prior therapy (NCI CTCAE v. 4.03 Grade > 1); however,
alopecia, sensory neuropathy Grade ≤ 2, or other Grade ≤ 2 not constituting a safety
risk based on investigator's judgment are acceptable.

17. Other severe acute or chronic medical conditions including colitis, inflammatory bowel
disease, pneumonitis, pulmonary fibrosis or psychiatric conditions including recent
(within the past year) or active suicidal ideation or behavior; or laboratory
abnormalities that may increase the risk associated with study participation or study
treatment administration or may interfere with the interpretation of study results
and, in the judgment of the investigator, would make the patient inappropriate for
entry into this study.