Age >= 18 years willing to provide consent and follow-up
Diagnosis of CLL according to the International Workshop on Chronic Lymphocytic Leukemia (IWCLL) 2018 criteria (Hallek et al., 2018) or small lymphocytic lymphoma (SLL) according to the World Health Organization (WHO) 2008 criteria (Harris, 1999). This includes previous documentation of
Biopsy-proven SLL according to WHO 2008 criteria, or
Diagnosis of CLL according to IWCLL 2018 criteria as evidenced by all of the
following
Peripheral blood B cell count of >= 5 x 10^9/L consisting of small to moderate size lymphocytes (If there are enough evidence to document the prior diagnosis of CLL, it is not required to meet the criteria of peripheral blood B cell count more than 5 x 10^9/L )
Immunophenotyping consistent with CLL defined as
The predominant population of lymphocytes share both B-cell antigens (CD19, CD20 [typically dim expression], or CD23) as well as CD5 in the absence of other pan-T-cell markers (CD3, CD2, etc.)
Clonality as evidenced by kappa or lambda light chain expression (typically dim immunoglobulin expression) or other genetic method (e.g. immunoglobulin heavy chain variable [IGHV] analysis)
NOTE: Splenomegaly, hepatomegaly, or lymphadenopathy are not required for the diagnosis of CLL
Before diagnosing CLL or SLL, mantle cell lymphoma must be excluded by
demonstrating a negative fluorescence in situ hybridization (FISH) analysis
for t(11;14)(IgH/CCND1) on peripheral blood or tissue biopsy or negative
immunohistochemical stains for cyclin D1 on involved tissue biopsy
If prior CLL diagnosis was confirmed, or CLL diagnosis was confirmed on bone marrow examination or tissue biopsy, peripheral blood B cell count less than 5 x 10^9/L is allowed
Biopsy proven Richter's transformation of the CLL
NOTE: Previously treated patients including CLL therapy can be enrolled. If Richter's transformation (RT) developed from prior untreated CLL and has not received any RT directed therapy, then patient is not eligible
Richter patients with prior or concurrent CLL diagnosis and do not have other option
for standard therapy per treating physician's discretion
Measurable disease can be detected in positron emission tomography (PET) or computed tomography (CT) (>= 1 cm in diameter)
Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0, 1, or 2
Absolute neutrophil count >= 0.7 x 10^9/L unless marrow was involved by CLL or RT, then absolute neutrophil count (ANC) >= 0.3 x 10^9/L (=< 14 days prior to registration)
Platelet count >= 40 x 10^9/L unless marrow was involved by CLL or RT, then platelet >= 30 x 10^9/L without transfusion =< 1 week prior to study registration (=< 14 days prior to registration)
Hemoglobin (Hgb) >= 8 unless marrow was involved by CLL or RT, then Hgb >= 7 without transfusion =< 1 week prior to study registration (=< 14 days prior to registration)
Total bilirubin =< 1.5 x upper limit of normal (ULN) unless due to confirmed Gilbert's disease (persistent or recurrent hyperbilirubinemia that is predominantly unconjugated in the absence of hemolysis or hepatic pathology), who will be allowed only in consultation with their physician (=< 14 days prior to registration)
Note: If total bilirubin is > 1.5 x ULN, a direct bilirubin should be performed and must be =< upper limit of normal
Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) or
alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) =<
5 X ULN unless liver metastases are present, in which case it must be =< 5 x
ULN (=< 14 days prior to registration)
Calculated creatinine clearance of > 30 mL/min by the Cockcroft-Gault formula (Cockcroft and Gault 1976) (=< 14 days prior to registration)
Negative pregnancy test done =< 7 days prior to registration, for women of childbearing potential only
NOTE: The following restrictions apply while the patient is receiving study treatment and for the specified times before and after
Female patient of child-bearing potential
Female patients of childbearing potential who are not abstinent and intend to be sexually active with a non sterilized male partner must use at least 1 highly effective method of contraception from the time of screening throughout the total duration of the drug treatment and the drug washout period (180 days after the last dose of study treatment). Non-sterilized male partners of a female patient of childbearing potential must use male condom plus spermicide throughout this period. Cessation of birth control after this point should be discussed with a responsible physician. Periodic abstinence, the rhythm method, and the withdrawal method are not acceptable methods of birth control. Female patients should also refrain from breastfeeding throughout this period
Male patients with a female partner of childbearing potential
Non-sterilized male patients who are not abstinent and intend to be sexually active with a female partner of childbearing potential must use a male condom plus spermicide from the time of screening throughout the total duration of the drug treatment and the drug washout period (180 days after the last dose of study treatment). However, periodic abstinence, the rhythm method, and the withdrawal method are not acceptable methods of contraception. Male patients should refrain from sperm donation throughout this period
Female partners (of childbearing potential) of male patients must also use a
highly effective method of contraception throughout this period
Females of childbearing potential are defined as those who are not surgically sterile (i.e., bilateral salpingectomy, bilateral oophorectomy, or complete hysterectomy) or post-menopausal
Women will be considered post-menopausal if they have been amenorrheic for 12 months without an alternative medical cause. The following age-specific requirements apply
Women < 50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of exogenous hormonal treatments and if they have luteinizing hormone and follicle-stimulating hormone levels in the post-menopausal range for the institution
Women >= 50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments, had radiation-induced menopause with last menses > 1 year ago, had chemotherapy-induced menopause with last menses > 1 year ago
Highly effective methods of contraception, defined as one that results in a
low failure rate (i.e., less than 1% per year) when used consistently and
correctly are described below. Note that some contraception methods are not
considered highly effective (e.g. male or female condom with or without
spermicide; female cap, diaphragm, or sponge with or without spermicide; non-
copper containing intrauterine device; progestogen-only oral hormonal
contraceptive pills where inhibition of ovulation is not the primary mode of
action [excluding Cerazette/desogestrel which is considered highly effective]
and triphasic combined oral contraceptive pills)
Effective methods include
Copper T intrauterine device
Levonorgestrel-releasing intrauterine system (e.g., Mirena)
Implants: Etonogestrel-releasing implants: e.g. Implanon or Norplant
Intravaginal: Ethinylestradiol/etonogestrel-releasing intravaginal devices: e.g. NuvaRing
Injection: Medroxyprogesterone injection: e.g. Depo-Provera
Combined pill: Normal and low dose combined oral contraceptive pill
Patch: Norelgestromin/ethinylestradiol-releasing transdermal system: e.g. Ortho Evra
Minipill: Progesterone based oral contraceptive pill using desogestrel: Cerazette is currently the only highly effective progesterone-based
Tubal ligation
Provide informed written consent
Willing to return to Mayo Clinic enrolling institution for follow-up
Willing to provide tissue, blood, and bone marrow samples for mandatory correlative research purposes
Any of the following uncontrolled intercurrent illness
Clinically significant cardiovascular disease such as
Symptomatic arrhythmias
Congestive heart failure
Myocardial infarction =< 3 months prior to registration
Any class 3 or 4 cardiac disease as defined by the New York Heart Association functional classification
Uncontrolled hypertension
Unstable angina pectoris
Note: Subjects with controlled, asymptomatic atrial fibrillation can enroll on study
Serious chronic gastrointestinal conditions associated with diarrhea
History of or ongoing confirmed progressive multifocal leukoencephalopathy (PML)
History of stroke or intracranial hemorrhage within 6 months before first dose of study drug
History of bleeding diathesis (e.g., hemophilia, von Willebrand disease)
Active uncontrolled infection (e.g., bacterial, viral or fungal, including subjects with positive cytomegalovirus [CMV] deoxyribonucleic acid [DNA] polymerase chain reaction [PCR]) requiring systemic therapy. NOTE: When the infection is controlled with systemic therapy, patients are permitted for this study
Active tuberculosis infection (clinical evaluation that includes clinical history, physical examination and radiographic findings, and tuberculosis [TB] testing in line with local practice)
Known human immunodeficiency virus (HIV/acquired immunodeficiency syndrome [AIDS]) infection as further severe immunosuppression with this regimen may occur
Hepatitis B or C serologic status
Hepatitis B surface antigen and hepatitis B PCR positive will be excluded
Hepatitis B core antibody (anti-HBc) positive and who are surface antigen negative, and hepatitis B PCR positive will be excluded
These above patients once treated for hepatitis B and became hepatitis B PCR negative, they will be eligible
Hepatitis C PCR positive will be excluded. Once treated and hepatitis C PCR negative will be eligible
NOTE: Once patients with active hepatitis treated with effective therapy and adequate disease control, they will be allowed for participation
Any of the following because this study involves an investigational agent whose
genotoxic, mutagenic and teratogenic effects on the developing fetus and
newborn are unknown
Pregnant women
Nursing women
Men and women of childbearing potential who are unwilling to employ highly effective method of contraception starting with the screening visit through 180 days after the last dose of trial treatment
Treated with other active investigational agents (excluding venetoclax, acalabrutinib
or ibrutinib) =< 5 half -lives of the previous investigational agents, please
consult study chair for the specific investigational agent
Prior durvalumab treatment. Note: If patients were treated with other prior PD1 blockade or PDL1 blockade, they will still be eligible
Active or recent (=< 2 months) documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], diverticulitis [with the exception of diverticulosis], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc.]) not being controlled
Yes for Active or recent (=< 2 months) documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], diverticulitis [with the exception of diverticulosis], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc.]) not being controlled exclusion criteria 33
No for Active or recent (=< 2 months) documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], diverticulitis [with the exception of diverticulosis], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc.]) not being controlled exclusion criteria 33
Not sure for Active or recent (=< 2 months) documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], diverticulitis [with the exception of diverticulosis], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc.]) not being controlled exclusion criteria 33
Exceptions
Patients with vitiligo or alopecia
Patients with hypothyroidism (e.g., following Hashimoto syndrome) stable on hormone replacement
Any chronic skin condition that does not require systemic therapy
Patients without active disease in the last 3 years may be included but only after consultation with the study physician
Patients with celiac disease controlled by diet alone
Evidence of interstitial lung disease or active, non-infectious pneumonitis
Known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial
Active central nervous system (CNS) lymphoma or cerebrospinal fluid involvement with malignant lymphoma cells that requires therapy
Clinically significant coagulopathy per investigator's assessment (stable anticoagulation except warfarin or other vitamin K antagonist will be allowed)
Received an allogenic stem cell transplant within the last 2 years; Or prior history of allogeneic stem cell transplant with history of graft versus host disease (GVHD)
Active chronic GVHD requiring treatment
Chronically taking a strong CYP3A inhibitor or inducer and moderate inducer and cannot be switched to an alternative agent at least 4 days prior to trial therapy initiation that in the opinion of investigator/treating physicians precludes utilization of trial therapy
Patients taking proton pump inhibitor will be excluded. NOTE: Patient may be switch to an H2 blocker or antiacid
History of another primary malignancy except for
Malignancy treated with curative intent and with no known active disease >= 5 years before the first dose of study drug and of low potential risk for recurrence
Adequately treated non-melanoma skin cancer or lentigo maligna without evidence of disease
Adequately treated carcinoma in situ without evidence of disease
Indolent malignancy with expected life expectancy more than 2 years
Current or prior use of immunosuppressive medication =< 5 half-lives of previous
immunosuppressive medication. The following are exceptions to this criterion
Intranasal, inhaled, topical steroids, or local steroid injections (e.g., intra articular injection)
Systemic corticosteroids at physiologic doses not to exceed =< 30 mg/day of prednisone or its equivalent
Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication)
Receipt of live attenuated vaccine =< 30 days prior to registration. Note: Patients, if enrolled, should not receive live vaccine whilst receiving investigational product (IP) and up to 30 days after the last dose of IP
Any radiation therapy =< 1 week prior to registration
Any major surgery =< 28 days prior to registration (Note: Routine tissue or nodal biopsy or small procedures typically heal fast will not be counted as surgery)
Body weight =< 30 kg
Life expectancy < 12 weeks