Glofitamab and Axicabtagene Ciloleucel as Second-Line Treatment for Patients with Relapsed or Refractory Large B-Cell Lymphoma

Inclusion Criteria

• Histologically proven CD19- and CD20-positive LBCL, including transformation from indolent lymphomas
• Have disease that is refractory to or relapsed =< 12 months after the completion of first line chemoimmunotherapy * Refractory disease defined as no complete response (CR) to first-line therapy; patients who are intolerant to first-line therapy are excluded ** Progressive disease (PD) as best response to first-line therapy ** Stable disease (SD) as best response after at least 4 cycles of first-line therapy (e.g., 4 cycles of rituximab, cyclophosphamide, doxorubicin, prednisone, vincristine [R-CHOP]) ** Partial response (PR) as best response after at least 6 cycles, and biopsy-proven residual disease or disease progression ≤ 12 months from completion of therapy * Relapsed disease defined as CR to first-line therapy followed by biopsy-proven disease relapse ≤ 12 months of completing first-line therapy
• Patients must have received first-line therapy including: * Anti-CD20 monoclonal antibody * An anthracycline containing chemotherapy regimen
• Age 18 or older
• Eastern Cooperative Oncology Group (ECOG) performance status of ≤ 2
• Patient must be willing and able to comply with protocol-mandated hospitalization upon administration of the first dose of glofitamab
• Absolute neutrophil count ≥ 1000/μL
• Platelet count either ≥ 75,000/μL or > 50K if documented lymphomatous involvement of bone marrow
• Absolute lymphocyte count ≥ 100/μL
• Creatinine clearance (as estimated by Cockcroft Gault) ≥ 30 ml/min
• Serum alanine aminotransferase and aspartate aminotransferase ≤ 2.5 upper limit of normal (ULN)
• Total bilirubin ≤ 1.5 mg/dL, except in patients with Gilbert’s syndrome
• Cardiac ejection fraction ≥ 45% , no evidence of pericardial effusion (except trace or physiological) as determined by an echocardiogram (ECHO), and no clinically significant electrocardiogram (ECG) findings
• No clinically significant pleural effusion
• Baseline oxygen saturation > 92% on room air
• At least 2 weeks must have elapsed since any prior systemic therapy at the time the patient is planned for leukapheresis
• Toxicities due to prior therapy must be recovered to grade 1 or less (except for clinically non-significant toxicities such as alopecia)
• No suspicion of central nervous system (CNS) involvement of lymphoma
• Patient must be willing and able to comply with protocol-mandated hospitalization upon administration of the first dose of glofitamab and with axi-cel
• For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
• Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
• Patients with treated secondary CNS lymphoma are eligible if follow-up brain imaging after CNS directed therapy shows no evidence of disease
• Patients with malignancy ≤ 2 years, whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen
• Patients should be without any active cardiac symptoms and an ejection fraction > 45%, and a clinical risk assessment of cardiac function be class 2B or better using the New York Heart Association Functional Classification
• Females of childbearing potential must have a negative serum or urine pregnancy test (females who have undergone surgical sterilization or who have been postmenopausal for at least 2 years are not considered to be of childbearing potential)
• Patients must agree to either remain completely abstinent or to use two effective contraceptive methods that result in a failure rate of < 1% per year from screening until at least 3 months after pre-treatment with obinutuzumab or 2 months after the last dose of glofitamab (whichever is longer) if the patient is a male. If the patient is a female, effective contraception should be used until at least 18 months after pre-treatment with obinutuzumab or 2 months after the last dose of glofitamab (whichever is longer)
• Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of cycle-6 (C6) of glofitamab administration, and must refrain from donating sperm during this same period * Not engaging in sexual activity for the total duration of the trial and the drug washout period is an acceptable practice; however periodic abstinence, the rhythm method, and the withdrawal method are not acceptable methods of birth control
• Ability to understand and the willingness to sign a written informed consent document
• Autoimmune disease: * Patients with a history of autoimmune-related hypothyroidism on a stable dose of thyroid replacement hormone may be eligible for this study * Patients with a history of disease-related immune thrombocytopenic purpura or autoimmune hemolytic anemia may be eligible for this study * Patients with a history of type I diabetes mellitus who are well controlled (defined as a screening hemoglobin A1c < 8% and no urinary ketoacidosis) are eligible * Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with dermatologic manifestations only (e.g., patients with psoriatic arthritis are excluded) are eligible for the study provided all of following conditions are met: ** Rash must cover < 10% of body surface area ** Disease is well controlled at baseline and requires only low-potency topical corticosteroids ** No occurrence of acute exacerbations of the underlying condition requiring methotrexate, retinoids, biologic agents, oral calcineurin inhibitors, or high potency oral corticosteroids within the previous 12 months
• Patients with a history of stroke who have not experienced a stroke or transient ischemic attack in the past 2 years and have no residual neurologic deficits, as judged by the investigator, are allowed

Exclusion Criteria

• Prior CAR T-cell therapy or glofitamab therapy
• History of severe, immediate hypersensitivity reaction attributed to aminoglycosides
• Presence or suspicion of fungal, bacterial, viral, or other infection that is uncontrolled or requiring hospitalization and/or intravenous (IV) antimicrobials for management within 4 weeks of treatment initiation; simple urinary tract infection and uncomplicated bacterial pharyngitis are permitted if responding to active treatment and after consultation with the sponsor’s medical monitor
• History of uncontrolled human immunodeficiency virus (HIV) infection (HIV+ patients are not excluded from study if they have CD4 counts ≥ 200/µl, are on stable antiretroviral therapy for at least 1 month prior to study entry, and who have an undetectable viral load) or acute or chronic active hepatitis B or C infection; patients with history of hepatitis infection must have cleared their infection as determined by standard serological and genetic testing per current Infectious Diseases Society of America guidelines
• Presence of any in dwelling line or drain (e.g., percutaneous nephrostomy tube, indwelling Foley catheter, biliary drain, or pleural/peritoneal/pericardial catheter); dedicated central venous access catheters, such as a Port-A-Cath® or Hickman® catheter, are permitted
• Patients with detectable cerebrospinal fluid malignant cells, brain metastases, or active CNS lymphoma
• History or presence of CNS disorder, such as seizure disorder, cerebrovascular ischemia/hemorrhage, dementia, cerebellar disease, or any autoimmune disease with CNS involvement
• Patients with cardiac lymphoma involvement
• History of significant or extensive cardiovascular disease such as New York Heart Association class III or IV cardiac disease or Objective Assessment class C or D, myocardial infarction within the last 3 months, unstable arrhythmias, or unstable angina
• Requirement for urgent therapy due to tumor mass effects (e.g., blood vessel compression, bowel obstruction, or transmural gastric involvement)
• Primary immunodeficiency
• History of autoimmune disease, including but not limited to myocarditis, pneumonitis, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener’s granulomatosis, Sjögren’s syndrome, Guillain-Barré syndrome, multiple sclerosis, vasculitis, or glomerulonephritis
• History of symptomatic deep vein thrombosis or pulmonary embolism within 6 months of enrollment
• Any medical condition likely to interfere with assessment of safety or efficacy of study treatment
• History of allergic reactions attributed to compounds of similar chemical or biologic composition to axi-cel, glofitamab, obinutuzumab, or other agents used in the study
• Administration of a live, attenuated vaccine within 4 weeks before obinutuzumab (Gazyva) pretreatment (Gpt) infusion or anticipation that such a live attenuated vaccine will be required during the study. (Note: Influenza vaccination should be given during influenza season only). Patients must not receive live, attenuated influenza vaccine (e.g., Flumist®) at any time during the study treatment period
• Patients who have not recovered from adverse events (AEs) due to prior anti-cancer therapy (i.e., have residual toxicities > grade 1) with the exception of alopecia
• Patients who are receiving any other investigational agents
• Women of childbearing potential who are pregnant or breastfeeding. Females who have undergone surgical sterilization or who have been postmenopausal for at least 2 years are not considered to be of childbearing potential
• Patients who are not willing to practice birth control for the duration of study participation, and 4 months after completion of cycle (C) 6 of glofitamab administration
• In the investigator’s judgment, the patient is unlikely to complete all protocol-required study visits or procedures, including follow-up visits, or comply with the study requirements for participation
• Patients with a known or suspected history of hemophagocytic lymphohistiocytosis (HLH)
• Patients with known or suspected chronic active Epstein Barr virus (EBV) or cytomegalovirus (CMV) infection
• Prior treatment with systemic immunotherapeutic agents, including but not limited to radio-immunoconjugates, antibody-drug conjugates, immune/cytokines and monoclonal antibodies (e.g., anti-CTLA4, anti-PD1 and anti-PDL1) within 4 weeks or five half-lives of the drug, whichever is shorter, before Gpt infusion
• Prior solid organ transplantation
• Patient with history of confirmed progressive multifocal leukoencephalopathy (PML)
• Current or past history of CNS disease, such as stroke, epilepsy, CNS vasculitis, or neurodegenerative disease
• Diagnosis with SARS-CoV-2 infection within 30 days prior to the first study treatment, including asymptomatic SARS-CoV-2 infection