Ibrutinib and Ixazomib Citrate in Treating Participants With Relapsed or Refractory Waldenstrom Macroglobulinemia

PRIMARY OBJECTIVES:

I. To determine the efficacy (as assessed by complete response [CR] rate) of the combination
of ixazomib citrate (ixazomib) and ibrutinib in Waldenstrom macroglobulinemia (WM) patients.

SECONDARY OBJECTIVES:

I. To assess the overall response rate (ORR=partial response [PR] or better) in WM patients
treated with ixazomib and ibrutinib.

II. To assess the time to progression (TTP) in WM patients treated with ixazomib and
ibrutinib.

III. To further characterize the safety and toxicity of the combination of ibrutinib and
ixazomib.

IV. To assess the overall survival (OS) in WM patients treated with ixazomib and ibrutinib.

CORRELATIVE OBJECTIVES:

I. To determine the role of members of the BTK signalosome in achievement or lack thereof of
response to ibrutinib and ixazomib.

II. To explore biologic effects of ibrutinib and ixazomib on microenvironment in WM and
correlate with response to treatment.

III. Effect of ibrutinib+ixazomib on platelet aggregation. IV. To evaluate the clinical
pharmacokinetics of the drug combination.

OUTLINE:

Participants receive ixazomib citrate orally (PO) on days 1, 8, and 15 and ibrutinib PO daily
on days 1-28. Treatment repeats every 28 days for up to 24 courses in the absence of disease
progression or unacceptable toxicity.

After completion of study treatment, participants are followed up every 3 months for up to 2
years.

Inclusion Criteria:

- Histological confirmation of WM for which the patient has received at least one prior
treatment; patients may have relapsed or refractory disease;(definition: relapse;
patients who have received prior treatment for WM and now have disease recurrence;
refractory; patients who have received anti-WM therapy and are noted to have
progressive disease while on therapy, or those patients who demonstrated disease
progression within 6 months of the last anti-WM treatment)

- Presence of measurable disease as defined by: presence of immunoglobulin M (IgM)
paraprotein, measurable lymphadenopathy on imaging studies and/or physical exam,
and/or bone marrow infiltration > 10%

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

- Obtained ? 14 days prior to registration: absolute neutrophil count (ANC) ? 1000/mm^3

- Obtained ? 14 days prior to registration: platelet count ? 75,000/mm^3 (NOTE: platelet
transfusions in order to help patients meet eligibility criteria are not allowed)

- Obtained ? 14 days prior to registration: hemoglobin ? 9.0 g/dL

- Obtained ? 14 days prior to registration: total bilirubin ? 1.5 x upper limit of
normal (ULN) unless due to Gilbert?s syndrome, in which case the direct bilirubin must
be ? 1.5 x ULN

- Obtained ? 14 days prior to registration: aspartate transaminase (AST) and alanine
aminotransferase (ALT) ? 3 x ULN

- Obtained ? 14 days prior to registration: calculated creatinine clearance must be ? 30
ml/min using the Cockcroft Gault formula

- Negative pregnancy test done at screening and ? 3 days (72 hours) prior to
registration, for women of childbearing potential

- Provide written informed consent

- Willingness to provide mandatory blood specimens and bone marrow specimens for
correlative research

- Willingness to return to enrolling institution for follow-up

Exclusion Criteria:

- Failure to have fully recovered (i.e., ? grade 1 toxicity) from the reversible effects
of prior treatment for WM

- Major surgical procedure (including open biopsy, excluding central line intravenous
(IV) and port-a-cath placement) within ? 14 days prior to initiating study treatment,
or anticipation of the need for major surgery during the course of the study treatment

- Radiotherapy ? 14 days prior to registration; if the involved field is small, 7 days
will be considered a sufficient interval between treatment and administration of the
ixazomib

- Systemic treatment, ? 14 days before registration, with strong CYP3A inducers
(rifampin, rifapentine, rifabutin, carbamazepine, phenytoin, phenobarbital), or St.
John?s wort

- Systemic anti-cancer therapy or participation in other clinical trials, including
those with other investigational agents not included in this trial, ? 28 days of
registration and throughout the duration of active treatment in this trial

- Patients that have previously been treated with ixazomib, or participated in a study
with ixazomib whether treated with ixazomib or not; (NOTE: prior ibrutinib treatment
is allowed as per: patients with prior exposure to ibrutinib will be allowed if they
do not have disease refractory to ibrutinib; patient receiving ibrutinib will be
allowed on this trial if they have measurable disease and did not have disease
progression while receiving ibrutinib; prior bortezomib treatment is allowed as per:
patients with prior exposure to bortezomib will be allowed if they do not have disease
refractory to bortezomib)

- Central nervous system involvement (Bing-Neel syndrome)

- Infection requiring systemic antibiotic therapy or other serious infection ? 7 days
prior to registration

- Evidence of current uncontrolled cardiovascular conditions, including uncontrolled
hypertension, serious cardiac arrhythmia requiring medication (other than adequately
rate-controlled atrial fibrillation), symptomatic congestive heart failure, unstable
angina, stroke/transient ischemic attack (TIA) within the past 6 months or myocardial
infarction within the past 6 months

- Known allergy to any of the study medications, their analogues, or excipients in the
various formulations of any agent

- Known gastrointestinal (GI) disease or GI procedure that could interfere with the oral
absorption or tolerance of ixazomib or ibrutinib, including difficulty swallowing

- History of any other prior malignancy; (NOTE: Exception to this are adequately treated
non-melanoma skin cancers, any in situ cancer, adequately treated stage I or II cancer
from which the patient is currently in complete remission, or any other cancer from
which the patient has been disease free for at least two years prior to study
enrollment)

- Patient has ? grade 2 peripheral neuropathy or grade 1 peripheral neuropathy with pain
on clinical examination during the screening period

- Any of the following

- Pregnant women

- Nursing women

- Men or women of child bearing potential (WCBP) who are unwilling to employ
effective contraception; effective contraception would be defined as utilizing 2
simultaneous methods of contraception from the time of signing consent through 90
days after the last dose of the study drugs unless they agree to participate in
true abstinence when this is in line with the preferred and usual lifestyle of
the subject; (women of child bearing potential [WCBP]: a female who is sexually
mature and who: [1] has not undergone a hysterectomy or bilateral oophorectomy;
or [2] has not been naturally postmenopausal for at least 24 consecutive months
[i.e., has had menses at any time in the preceding 24 consecutive months])

- Evidence of any other serious medical condition (such as psychiatric illness,
infectious diseases, physical or laboratory findings) that may interfere with the
planned treatment, affect compliance or place the patient at high risk from
treatment-related complications or potentially interfere with the completion of the
treatment as per the protocol

- Ongoing, active hepatitis B or C virus infection, or known human immunodeficiency
virus (HIV) positive

- Liver disease with Child-Pugh class B or C liver dysfunction

- Current treatment with a combination of ibrutinib and strong CYP3A inhibitors