Nivolumab with DA-REPOCH Chemotherapy Regimen in Treating Patients with Aggressive B-Cell Non-Hodgkin's Lymphoma

Inclusion Criteria

• In order to eligible for participation in this trial, the subject must have one the following non-Hodgkin lymphoma (NHL) subtypes diagnosed histologically. Up to one prior cycle of treatment is allowed as discussed below. Steroids for palliation prior to enrollment are allowed * Diffuse large B-cell lymphoma (DLBCL) with the following high risk features: ** Ki67 proliferation index >= 80% ** Increased expression of MYC (>= 40%) and BCL2 (>= 50%) by immunohistochemistry (IHC) ** Presence of MYC translocation ** Non-germinal center B cell (GCB) subtype as determined by IHC utilizing HANS algorithm ** Human immunodeficiency virus (HIV) associated DLBCL * Primary mediastinal (thymic) large B cell lymphoma * High grade B-cell lymphoma (HGBCL) not otherwise specified (NOS), or HGBCL with translocations of MYC and BCL2 and/or BCL6 * B-cell lymphoma, unclassifiable (BCLu) with features intermediate between DLBCL and classical Hodgkin’s lymphoma * Histologic transformation of indolent NHL to DLBCL without prior cytotoxic chemotherapy for low grade lymphoma with the following high risk features: (Steroids, rituximab, and external beam radiation therapy as prior therapy for indolent lymphoma is allowed. Subjects with Richter’s transformation from chronic lymphocytic leukemia are NOT eligible) ** Ki67 proliferation index >= 80% ** Increased expression of MYC (>= 40%) and BCL2 (>= 50%) by IHC ** Presence of MYC translocation ** Non-GCB subtype as determined by IHC utilizing HANS algorithm ** Associated with HIV infection
• Be willing and able to provide written informed consent/assent for the trial.
• Measurable disease (defined as >= 1.5 cm in diameter) or at least one PET avid area of disease.
• Eastern Cooperative Oncology Group (ECOG) performance status of 0-2.
• Absolute neutrophil count (ANC) >= 1,000 /mcL (within 16 days of treatment initiation).
• Platelets >= 75,000 / mcL in the absence of transfusion support within 7 days of determining eligibility (within 16 days of treatment initiation).
• Hemoglobin >= 8 g/dL (within 16 days of treatment initiation).
• Serum creatinine =< 1.5 X upper limit of normal (ULN) OR measured or calculated creatinine clearance >= 40 mL/min creatinine clearance (glomerular filtration rate [GFR] can also be used in place of creatinine or creatinine clearance [CrCl]) (within 16 days of treatment initiation). * Creatinine clearance should be calculated per institutional standard.
• Serum total bilirubin =< 1.5 X ULN OR except subjects with Gilbert syndrome, who can have total bilirubin < 3.0 mg/dL (within 16 days of treatment initiation).
• Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3.0 X ULN (within 16 days of treatment initiation).
• Female subject of childbearing potential should have a negative serum pregnancy at screening.
• Female subjects of childbearing potential should be willing to use 2 methods of birth control or be surgically sterile, or abstain from heterosexual activity for the course of the study through 5 months following the last dose of nivolumab. Subjects should agree to ongoing pregnancy testing during the course of the study and after the end of study therapy. Female subjects of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year.
• Male subjects should agree to use an adequate method of contraception starting with the first dose of study therapy through 7 months following the last dose of nivolumab. Males must refrain from donating sperm during study participation and for 7 months after the last dose of nivolumab.
• Revised Ann Arbor stage II-IV disease * Stage I primary mediastinal B-cell lymphoma or mediastinal B cell lymphoma unclassifiable with features intermediate between DLBCL and classical Hodgkin’s lymphoma will also be eligible.
• Be willing and able to understand and give written informed consent and comply with all study related procedures.
• Patients may have received: * A maximum of one cycle of combination chemotherapy, including the rituximab containing regimens R-CHOP or R-EPOCH prior to enrollment. The start of the previous chemotherapy cycle must occur at least 21 days but no more than 28 days prior to beginning treatment under this protocol, and such a cycle will count towards the 6 cycles on induction therapy (i.e. cycle off study will count as Cycle 1). OR * One prior cycle of limited therapy including cyclophosphamide and/or rituximab and/or glucocorticoids to improve hepatic or renal function impaired due to lymphoma involvement. The start of this therapy may occur up to 28 days prior to beginning treatment under this protocol; cyclophosphamide administration must have been completed at least 14 days prior to initiation of protocol therapy. Such treatment will not count towards the maximum of 6 cycles under this study (i.e. participants will receive 6 cycles on study).
• Eligibility to begin nivolumab maintenance: * Patients will be eligible to begin post induction nivolumab monotherapy under the following conditions: ** Patient has achieved an object response to induction therapy (complete response [CR] or partial response [PR] by Lugano criteria) on end of therapy PET evaluation ** ECOG performance status of =< 2 at follow-up evaluation following completion of induction therapy ** Criteria to permanently discontinue nivolumab not met during induction therapy ** Immune related adverse events have resolved to grade =< 1 with exception of endocrinopathies adequately controlled with physiologic hormone replacement (i.e. hypothyroidism controlled with levothyroxine) and patient does not require immunosuppression for immune related adverse events ** Patient is fit in the judgement of the investigator to continue treatment and begin nivolumab monotherapy

Exclusion Criteria

• Known hypersensitivity to any of the study drugs.
• History of other malignancy that could affect compliance with the protocol or interpretation of the results.
• Has a diagnosis of immunodeficiency excluding HIV infection or is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment. Subjects may use topical or inhaled corticosteroids or low-dose steroids (=< 10 mg of prednisone or equivalent per day) as therapy for comorbid conditions. During study participation, subjects may receive systemic or enteric corticosteroids as needed for treatment-emergent comorbid conditions.
• Has a known history of active TB (Bacillus tuberculosis).
• Prior cytotoxic chemotherapy treatment for indolent NHL (prior single agent rituximab is permitted).
• Has known active central nervous system (CNS) lymphoma.
• Richter’s transformation from chronic lymphocytic leukemia (CLL).
• Major surgery within 3 weeks prior to start of study treatment.
• Has active autoimmune disease that has required systemic treatment in the past 2 years (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Replacement therapy (thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment. Conditions expected to not recur in the absence of an external trigger.
• Has an active infection requiring intravenous systemic therapy or uncontrolled systemic infection including viral, bacterial, or fungal.
• Is unable to swallow capsules or malabsorption syndrome, disease or condition significantly affecting gastrointestinal function.
• Clinically significant cardiovascular disease, including uncontrolled arrhythmia, New York Association class 2- 4 congestive heart failure, or history of myocardial infarction within 6 months.
• Known contraindication to any medication in the treatment plan, including clinically significant peripheral neuropathy.
• Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the pre-screening or screening visit through 120 days after the last dose of trial treatment.
• Female patients who are not surgically sterile or postmenopausal (for at least 1 year) must practice at least one of the following methods of birth control throughout the duration of study participation and for at least 5 months after study treatment: * Total abstinence from hetero-sexual intercourse * A vasectomized partner * Hormonal contraceptives (oral, parenteral, vaginal ring, or transdermal) that started at least 3 months prior to study drug administration * Double-barrier method (condom + diaphragm or cervical cup with spermicidal contraceptive sponge, jellies, or cream) * Non-vasectomized male patients must comply with at least one of the following methods of birth control throughout the duration of study participation and for at least 3 months after study treatment: * A partner who is surgically sterile or postmenopausal (for at least 1 year) or who is taking hormonal contraceptives (oral, parenteral, vaginal ring, or transdermal) for at least 3 months prior to study drug administration * Total abstinence from hetero-sexual intercourse * Double-barrier method (condom + diaphragm or cervical cup with spermicidal, contraceptive sponge, jellies, or cream).
• Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.
• Acute hepatitis C (defined as positive hepatitis C virus (HCV) ribonucleic acid (RNA) [qualitative] and diagnosis within the past 6 months).
• Positive hepatitis C antibody with evidence of cirrhosis.
• Active hepatitis B (subjects with a positive hepatitis B virus [HBV] core antibody or surface antigen are eligible as long as they have an undetectable HBV DNA polymerase chain reaction [PCR] and receive concurrent antiviral therapy with entecavir or tenofovir, and continued for a minimum of 6 months after completion of therapy).
• HIV infection AND CD4 count < 100 cells/ mm^3, evidence of resistant strain of HIV, or HIV viral load >= 50 copies HIV RNA/mL if on highly active antiretroviral therapy (HAART) or HIV viral load >= 10,000 copies HIV RNA/mL if not on anti-HIV therapy.