Ibrutinib With Rituximab and Lenalidomide for Patients With Recurrent/Refractory Primary or Secondary Central Nervous System Lymphoma (PCNSL/SCNSL)

Inclusion Criteria:

- Participants must be able to understand and be willing to sign a written informed
consent document.

- Men and woman who are at least 18 years of age on the day of consenting to the study.

- Histologically documented PCNSL or histologically documented systemic diffuse large
B-cell lymphoma (DLBCL).

- Patients must have relapsed/refractory PCNSL or relapsed/refractory SCNSL

- All patients need to have received at least one prior CNS directed therapy. There is
no restriction on the number of recurrences.

- Patients with parenchymal lesions must have unequivocal evidence of disease
progression on imaging (MRI of the brain or head CT) 21 days prior to study
registration. For patients with leptomeningeal disease only, CSF cytology must
document lymphoma cells and/or imaging findings consistent with CSF disease 21 days
prior to study registration (at the discretion of the investigator).

- Participants must have an ECOG performance status of 0, 1, or 2.

- Participants must have adequate bone marrow and organ function shown by:

- Absolute neutrophil count (ANC) ≥ 1.0 x 10^9/L

- Platelets ≥ 75 x 10^9/L and no platelet transfusion within the past 21 days prior
to study registration

- Hemoglobin (Hgb) ≥ 8 g/dL and no red blood cell (RBC) transfusion within the past
21 days prior to study registration

- International Normalized Ratio (INR) ≤ 1.5 and PTT (aPTT) ≤ 1.5 times the upper
limit of normal

- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 3 times the
upper limit of normal

- Serum bilirubin ≤ 1.5 times the upper limit of normal; or total bilirubin ≤ 3
times the upper limit of normal with direct bilirubin within the normal range in
patients with well documented Gilbert Syndrome.

- Serum creatinine ≤ 2 times the upper limit of normal

- Escalation: calculated creatinine clearance(CrCl) ≥ 60ml/min using the
Cockcroft-Gault equation (Men: CrCl (min/ml) = (140-age) X (actual weight in kg)
/ 72 X serum creatinine (mg/dL); Women: CrCl (ml/min) = (140-age) X (actual
weight in kg) X 0.85 / 72 X serum creatinine (mg/dL))

- Extension: calculated creatinine clearance(CrCl) ≥30ml/min using the
Cockcroft-Gault equation (Men: CrCl (min/ml) = (140-age) X (actual weight in kg)
/ 72 X serum creatinine (mg/dL); Women: CrCl (ml/min) = (140-age) X (actual
weight in kg) X 0.85 / 72 X serum creatinine (mg/dL))

- Woman of reproductive potential must agree to use highly effective methods of birth
control during the period of therapy and for 30 days after the last dose of the study
drug. Men who are sexually active must agree to use highly effective contraception
during the period of therapy and for 3 months after the last dose.

- Female subjects of childbearing potential must have a negative plasma pregnancy test
upon study entry. See section on Pregnancy and Reproduction.

- Patients must be able to tolerate MRI/CT scans.

- Patients must be able to tolerate lumbar puncture and/or Ommaya taps.

- Participants must have recovered to grade 1 toxicity from prior therapy.

- Participants should be able to submit up to 20 unstained formalin-fixed,
paraffinembedded (FFPE) slides from the initial tissue diagnosis prior to study
registration for confirmation of diagnosis and correlative studies

- All study participants must be registered into the mandatory Revlimid REMS® program,
and be willing and able to comply with the requirements of the REMS® program.

- Females of reproductive potential must adhere to the scheduled pregnancy testing as
required in the Revlimid REMS® program.

NOTE: Prior autologous stem cell transplant as well as prior radiation to the CNS does NOT
prevent patients from enrollment into the trial.

Exclusion Criteria:

- Patients with SCNSL actively receiving treatment for extra-CNS disease are excluded.

- Patient is concurrently using other approved or investigational antineoplastic agents.

- Patient has received chemotherapy, monoclonal antibodies or targeted anticancer
therapy ≤ 4 weeks or 5 half-lives, whichever is shorter, or 6 weeks for nitrosourea or
mitomycin-C prior to starting the study drug, or the patient has not recovered from
the side effects of such therapy.

- Patient has received external beam radiation therapy to the CNS within 21 days of the
first dose of the study drug.

- Patient requires more than 8 mg of dexamethasone daily or the equivalent

- Patient has an active concurrent malignancy requiring active therapy

- The patient has been treated with radio- or toxin-immunoconjugates within 70 days of
the first dose of the study drug.

- Patient is allergic to components of the study drug.

- Patient is using warfarin or any other Coumadin-derivative anticoagulant or vitamin K
antagonists. Patients must be off warfarin-derivative anticoagulants for at least
seven days prior to starting the study drug. Low molecular weight heparin is allowed.
Patients with congenital bleeding diathesis are excluded.

- Patient is taking a drug known to be a moderate and strong inhibitor or inducers of
the P450 isoenzyme CYP3A. Participants must be off P450/CYP3A inhibitors and inducers
for at least two weeks prior to starting the study drug.

- Patient is using systemic immunosuppressant therapy, including cyclosporine A,
tacrolimus, sirolimus, and other such medications, or chronic administration of > 5
mg/day or prednisone or the equivalent. Participants must be off immunosuppressant
therapy for at least 28 days prior to the first dose of the study drug.

- Patient has significant abnormalities on screening electrocardiogram (EKG) and active
and significant cardiovascular disease such as uncontrolled or symptomatic
arrhythmias, congestive heart failure, hypertension, valvular disease, pericarditis,
or myocardial infarction within 6 months of screening,

- Patient has a known bleeding diathesis (e.g. von Willebrand‟s disease) or hemophilia.

- Patient is known to have human immunodeficiency virus (HIV) infection.

- Patient is known to have a history of active or chronic infection with hepatitis C
virus (HCV) or hepatitis B virus (HBV) as determined by serologic tests.

- Patient is known to have an uncontrolled active systemic infection.

- Patient underwent major systemic surgery ≤ 4 weeks prior to starting the trial
treatment or who has not recovered from the side effects of such surgery, or who plan
to have surgery within 2 weeks of the first dose of the study drug.

- Patient is unable to swallow capsules or has a disease or condition significantly
affecting gastrointestinal function, such as malabsorption syndrome, resection of the
stomach or small bowel, or complete bowel obstruction.

- Patient has poorly controlled diabetes mellitus with a glycosylated hemoglobin >8% or
poorly controlled steroid-induced diabetes mellitus with a glycosylated hemoglobin of
>8%.

- Patient has a life-threatening illness, medical condition, or organ system dysfunction
that, in the opinion of the investigator, could compromise the subject‟s safety or put
the study outcomes at undue risk.

- Women who are pregnant or nursing (lactating), where pregnancy is defined as a state
of a female after conception until the termination of gestation, confirmed by a
positive serum hCG laboratory test of > 5 mIU/mL (See section on Pregnancy and
Reproduction)

- Patient has undergone prior allogenic stem cell transplant (autologous stem cell
transplant is NOT an exclusion)

- The patient is unwell or unable to participate in all required study evaluations and
procedures

- Known hypersensitivity to ibrutinib, thalidomide or lenalidomide

- Females who are pregnant.

Women:

- Women are considered post-menopausal and not of child bearing potential if they have
had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile
(i.e. age appropriate, history of vasomotor symptoms) or six months of spontaneous
amenorrhea with serum FSH levels >40 mIU/mL and estradiol < 20 pg/mL or have had
surgical bilateral oophorectomy with or without hysterectomy at least six weeks prior
to enrollment in the study. In the case of oophorectomy alone, only when the
reproductive status of the woman has been confirmed by follow up of hormone level
assessment is she considered not of child bearing potential.

- Women of child-bearing potential, defined as all women physiologically capable of
becoming pregnant, must use highly effective contraception during study treatment and
for 4 weeks after study discontinuation. Highly effective contraception is defined as
either

- True abstinence: When this is the line with the preferred and usual lifestyle of
the subject. Periodic abstinence (e.g. calendar, ovulation, symptothermal,
post-ovulation methods) and withdrawal are not acceptable methods of
contraception

- Sterilization: Surgical bilateral oophorectomy, with or without hysterectomy, or
tubal ligation at least six weeks prior to study enrollment.

- Male partner sterilization (with appropriate post-vasectomy documentation of the
absence of sperm in the ejaculate). For female patients participating in the
study, the vasectomized male partner should be the sole partner for that patient.

- Use of a combination of any two of the following:

- Placement of an intrauterine device (IUD) or intrauterine system (IUS)

- Barrier methods of contraception: Condom or occlusive cap (diaphragm or cervical
vault caps) with spermicidal form/gel/film/cream/vaginal suppository

- Women of child-bearing potential must have two negative serum pregnancy tests at
screening

- In addition to having a negative pregnancy test confirmed at screening, all female
participants of child bearing potential must have a negative pregnancy test confirmed
within 48 hours prior to dosing with the study drug.

- Blood Donation: Patients must not donate blood during treatment with lenalidomide and
for 4 weeks following discontinuation of the drug because the blood might be given to
a pregnant female patient whose fetus must not be exposed to lenalidomide.

Men:

- Fertile males, defined as all male subjects physiologically capable of conceiving
offspring, must use a condom during study treatment and for 12 weeks after study
discontinuation and should not father a child in this period.

- Female partner of a male study subject should use a highly effective method of
contraception while the male partner is receiving the study agent and for 12 weeks
after the final dose of the study therapy

- Male patients taking lenalidomide must not donate sperm

- Blood Donation: Patients must not donate blood during treatment with lenalidomide and
for 4 weeks following discontinuation of the drug because the blood might be given to
a pregnant female patient whose fetus must not be exposed to lenalidomide.