Efficacy and Safety of Zanubrutinib Plus Tislelizumab Treatment with or Without Sonrotoclax for Patients with Richter Transformation

Inclusion Criteria:

1. Confirmed diagnosis of CLL according to iwCLL criteria (Hallek et al, 2018)

2. Confirmed histopathological diagnosis of RT (diffuse large B-cell lymphoma orHodgkin's lymphoma [Hodgkin's lymphoma only when not eligible for more in-tensivetreatment])

3. Previously untreated RT or patients with objective response or non-tolerance tofirst-line RT treatment

4. Adequate bone marrow function as defined by:

• Absolute neutrophil count (ANC) ≥ 1000/mm3, except for patients with bonemarrow involvement in which ANC must be ≥ 500/mm3

• Platelet ≥ 75,000/mm3, except for patients with bone marrow involvement inwhich the platelet count must be ≥ 30,000/mm3

5. Creatinine clearance ≥30ml/min calculated according to the modified formula ofCockcroft and Gault or directly measured with 24hr urine collection or an equivalentmethod.

6. Adequate liver function as indicated by a total bilirubin≤ 2 x, AST/ALT ≤ 2.5 x theinstitutional ULN value, unless directly attributable to the patient's CLL/RT or toGilbert's Syndrome, in which case a max. total bilirubin ≤ 3 x and AST/ALT ≤ 5 x theinstitutional ULN value are required.

7. Negative serological testing for hepatitis B (HBsAg negative and anti-HBc nega-tive;patients positive for anti-HBc may be included if PCR for HBV DNA is negative andHBV-DNA PCR is performed every two months until 2 months af-ter last dose ofzanubrutinib), negative testing for hepatitis-C RNA and negative HIV test within 6weeks prior to registration

8. Age at least 18 years

9. ECOG performance status 0-2, ECOG 3 is only permitted if related to CLL or RT (e.g.due to anaemia or severe constitutional symptoms)

10. Life expectancy ≥ 3 months

11. Ability and willingness to provide written informed consent and to adhere to thestudy visit schedule and other protocol requirements

Exclusion Criteria:

1. Patients who did not respond to previous line of RT therapy (i.e. primaryprogressive patients)

2. Patients with more than one prior line of RT therapy

3. Allogenic stem cell transplantation within the last 100 days or signs of active GVHDafter prior allogeneic stem cell transplantation within any time

4. Patients with confirmed PML

5. Uncontrolled autoimmune condition

6. Malignancies other than CLL currently requiring systemic therapies (unless themalignant disease is in a stable remission at the discretion of the treatingphy-sician)

7. Uncontrolled infection currently requiring systemic treatment

8. Any comorbidity or organ system impairment rated with a CIRS (cumulative ill-nessrating scale) score of 4, excluding the eyes/ears/nose/throat/larynx organ system ,or any other life-threatening illness, medical condition or organ system dysfunctionthat - in the investigator´s opinion could comprise the patients safety or interferewith the absorption or metabolism of the study drugs

9. Requirement of therapy with strong CYP3A4 inhibitors/ inducers

10. Requirement of therapy with phenprocoumon or other vitamin K antagonists.

11. Known active infection with HIV, or serologic status reflecting active hepatitis Bor C infection as follows:

• Presence of hepatitis B surface antigen (HBsAg) or hepatitis B core anti-body (HBcAb). Patients with presence of HBcAb, but absence of HBsAg, are eligible ifhepatitis B virus (HBV) DNA is undetectable (< 20 IU), and if they are willingto undergo monitoring every 4 weeks for HBV reactivation.

• Presence of hepatitis C virus (HCV) antibody. Patients with presence of HCVantibody are eligible if HCV RNA is undetectable.

12. Major surgery within 4 weeks of the first dose of study drug.

13. Any uncontrolled or clinically significant cardiovascular disease including thefollowing:

• Myocardial infarction within 6 months before screening

• Unstable angina within 3 months before screening

• New York Heart Association class III or IV congestive heart failure

• History of clinically significant arrhythmias (eg, sustained ventriculartachy-cardia, ventricular fibrillation, torsades de pointes)

14. History of severe bleeding disorder such as hemophilia A, hemophilia B, vonWillebrand disease, or history of spontaneous bleeding requiring blood trans-fusionor other medical intervention

15. History of stroke or intracranial hemorrhage within 6 months before first dose ofstudy drug

16. Severe or debilitating pulmonary disease

17. Unable to swallow capsules or disease significantly affecting gastrointestinalfunction such as malabsorption syndrome, resection of the stomach or small bowel,bariatric surgery procedures, symptomatic inflammatory bowel disease, or partial orcomplete bowel obstruction

18. Use of investigational agents, e.g. monoclonal antibodies or other experimentaldrugs within clinical trials, which might interfere with the study drug within 28days (or 5 times half-life [t1/2] of the compound, whichever is longer) prior toregistration

19. Known hypersensitivity to tislelizumab, zanubrutinib, sonrotoclax or any of theexcipients

20. Pregnant women and nursing mothers (a negative pregnancy test is required for allwomen of childbearing potential within 7 days before start of treatment)

21. Fertile men or women of childbearing potential unless:

• surgically sterile or ≥ 2 years after the onset of menopause, or

• willing to use two methods of reliable contraception including one highlyef-fective contraceptive method (Pearl Index <1) and one additional effective (barrier) method during study treatment and for 6 months after the end of studytreatment.

22. Vaccination with a live vaccine <28 days prior to randomization

23. Legal incapacity

24. Prisoners or subjects who are institutionalized by regulatory or court order

25. Persons who are in dependence to the sponsor or an investigator