Rituximab, Romidepsin, and Lenalidomide in Treating Patients With Recurrent or Refractory B-cell Non-Hodgkin Lymphoma

PRIMARY OBJECTIVES:

I. To establish the maximum tolerated dose (MTD) of the combination of romidepsin, rituximab
and lenalidomide in patients with relapsed/refractory B-cell non-Hodgkin lymphoma (NHL).
(Phase I) II. To assess the overall response rate (ORR) of this combination in patients with
transformed follicular lymphoma (FL). (Phase II)

SECONDARY OBJECTIVES:

I. To assess the toxicity and safety of romidepsin in combination with lenalidomide and
rituximab.

II. To assess complete response rate (CR), progression free survival (PFS), and overall
survival (OS) of this combination in patients with transformed FL.

TERTIARY OBJECTIVES:

I. To assess the impact of B-cell leukemia/lymphoma 2 (BCL2) mutations on ORR among patients
treated with this combination.

II. To assess the impact of BCL2 mutations on PFS among patients treated with this
combination.

OUTLINE: This is a phase I, dose-escalation study of romidepsin and lenalidomide followed by
a phase II study.

Patients receive rituximab intravenously (IV) over 90 minutes on day 1; romidepsin IV over 4
hours on either day 1, days 1 and 8, or days 1, 8, and 15; and lenalidomide orally (PO) on
days 1-21. Treatment repeats every 28 days for up to 6 courses in the absence of disease
progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for 2 years and
then every 6 months for 3 years.

Inclusion Criteria:

- PHASE I: Histological confirmation of relapsed (recurrent after previous
therapy[ies]) or refractory (no response to previous therapy[ies]) B-cell NHL; note:
patients with small lymphocytic lymphoma (SLL) are eligible however patients with
chronic lymphocytic leukemia (CLL) are not eligible

- PHASE II: Histological confirmation of transformation of FL lymphoma to diffuse large
B cell lymphoma or aggressive lymphoma

- The biopsy confirming diagnosis can be up to 12 weeks prior to registration as long
as there is no intervening therapy; note: if patient has had lymphoma treatment since
previous biopsy, a biopsy should be repeated

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

- Measurable disease (at least 1 lesion of >= 1.5 cm in diameter) as detected by
computed tomography (CT) or the CT images of the positron emission tomography
(PET)/CT

- Absolute neutrophil count (ANC) >= 1500/mm^3

- Platelet count >= 75,000/mm^3

- Total bilirubin =< 1.5 x upper limit of normal (ULN) or if total bilirubin is > 1.5 x
ULN, the direct bilirubin =< ULN

- Alkaline phosphatase =< 3 x ULN unless due to direct lymphoma involvement, and then
=< 5 x ULN

- Aspartate transaminase (AST) =< 3 x ULN unless due to direct lymphoma involvement,
and then =< 5x ULN

- Calculated creatinine clearance >= 50 mL/min using the Cockcroft-Gault formula

- Magnesium >= 1.6 mg/dL

- Potassium >= 3.5 mg/dL

- Females of reproductive potential must adhere to the scheduled pregnancy testing as
required in the Revlimid Risk Evaluation and Mitigation Strategy (REMS)® program

- Willing to be registered into the mandatory Revlimid REMS® program, and willing and
able to comply with the requirements of the REMS® program

- If currently not on anticoagulation medication, willing and able to take aspirin (325
mg) daily; note: if aspirin is contraindicated, the patient may be considered for the
study after if on therapeutic dose warfarin or low molecular weight heparin; patients
unable to take any prophylaxis are not eligible

- Life expectancy >= 3 months

- Ability to complete medication diary by themselves or with assistance

- Ability to provide informed written consent

- Willing to return to enrolling institution for follow-up (during the active
monitoring phase of the study)

- Note: during the active monitoring phase of a study (i.e., active treatment and
observation), participants must be willing to return to the consenting
institution for follow-up

- Willing to provide tissue for central review and blood samples for correlative
research purposes

Exclusion Criteria:

- Prior therapy with histone deacetylase (HDAC) inhibitors or immunomodulatory drugs
(IMDs) (lenalidomide or thalidomide)

- Any of the following:

- Pregnant women

- Nursing women

- Men or women of childbearing potential who are unwilling to employ adequate
contraception

- Active central nervous system (CNS) lymphoma or cerebrospinal fluid involvement with
malignant lymphoma cells that requires therapy

- Prolongation of corrected QT interval of > 480 ms

- Receiving any medications that prolong the corrected QT (QTc) and have a known risk
for Torsades de pointes; note: providers should use caution with drugs with possible
increased risk for Torsades de pointes; patient will be eligible if they can be taken
off these medications prior to initiation of therapy and no less than 4 half-life of
the medication

- Receiving any medications or substances that are strong inhibitors of cytochrome
P450, family 3, subfamily A, polypeptide 4/5 (CYP3A4/5)

- Use of the following strong inhibitors are prohibited =< 7 days prior to registration

- Boceprevir (Victrelis™)

- Clarithromycin (Biaxin®, Biaxin XL®)

- Conivaptan (Vaprisol®)

- Grapefruit juice

- Indinavir (Crixivan®)

- Itraconazole (Sporanox®)

- Ketoconazole (Nizoral®)

- Lopinavir/ritonavir (Kaletra®)

- Mibefradil

- Nefazodone (Serzone®)

- Nelfinavir (Viracept®)

- Posaconazole (Noxafil®)

- Ritonavir (Norvir®)

- Saquinavir (Invirase®)

- Telaprevir (Incivek®)

- Telithromycin (Ketek®)

- Receiving any medications or substances that are inducers of CYP3A4

- Use of the following inducers are prohibited =< 12 days prior to registration

- Avasimibe

- Bosentan (Tracleer®)

- Carbamazepine (Carbatrol®, Epitol®, Equetro™, Tegretol®, Tegretol-XR®)

- Efavirenz (Sustiva®)

- Modafinil (Provigil®)

- Phenobarbital (Luminal®)

- Phenytoin (Dilantin®, Phenytek®)

- Rifabutin (Mycobutin®)

- Rifampin (Rifadin®)

- St. John's wort

- Co-morbid systemic illnesses or other severe concurrent disease which, in the
judgment of the investigator, would make the patient inappropriate for entry into
this study or interfere significantly with the proper assessment of safety and
toxicity of the prescribed regimens

- Known positivity for human immunodeficiency virus (HIV); note: baseline testing for
HIV is not required

- 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; note: patients with hepatitis B and C are eligible at the
discretion of the treating physician; appropriate counseling regarding the risks of
rituximab should be provided

- Receiving any other investigational agent which would be considered as a treatment
for the primary neoplasm

- Other active malignancy requiring therapy; exceptions: non-melanotic skin cancer or
any cancer that in the judgment of the investigator will not interfere with treatment
plan and response assessment; patients with >= 25% of the bone marrow radiated for
other diseases are not eligible

- History of myocardial infarction =< 6 months prior to registration, unstable angina,
or congestive heart failure requiring use of ongoing maintenance therapy for
life-threatening ventricular arrhythmias

- History of life threatening or recurrent thrombosis/embolism; patients may
participate if they are on anticoagulation during the treatment

- Receiving erythroid stimulating agents (erythropoietin [EPO]: Procrit, Aranesp)

- History of allogeneic bone marrow or stem cell transplantation