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The use of novel small molecule inhibitors alone or in combination with anti-CD20 monoclonal antibodies for chronic lymphocytic leukemia (CLL) has raised a number of questions on efficacy, tolerability, long-term treatment adherence in patients with heterogeneous clinical features. To fill this gap, we designed a study focusing on treatment sequencing in patients with CLL in order to (i) compare the outcome of patients treated with chemoimmunotherapy (CIT) combinations in first-line versus those receiving Bruton's tyrosine kinase inhibitors (BTKi); (ii) characterize the efficacy and tolerability of venetoclax-based regimens; (ii) understand the impact of treatment sequencing when it comes to chemo-free options including venetoclax after BTKi and vice versa. Data from consecutive sets of patients diagnosed with CLL between 2000-2020 attended at 77 institutions affiliated with ERIC were collected and analyzed. Collected variables included: demographics, clinical stage at diagnosis, IGHV gene somatic hypermutation status; cytogenetic status for chromosomes 11q, 13q 17p and 12 determined by fluorescence in situ hybridization; TP53 gene mutation status; treatment; treatment response; discontinuation; reason for discontinuation; death. We included 9173 patients with a diagnosis of CLL who received at least one line of treatment. The median age at diagnosis was 67 years with a male:female ratio of 1.9. The median follow-up was 78 months (IQR, 48-120 months). Regarding novel targeted agents, 1860/9173 (20.2%) patients had received at least one line of treatment with BTKi (ibrutinib, n=1788; acalabrutinib, n=72) over the disease course; 631/9173 (6.9%) with venetoclax; and, 447/9173 (4.9%) with the PI3K inhibitor idelalisib. Seventy-nine patients were treated with both BTKi and venetoclax (59 BTKi followed by BCL2i, 20 vice versa). At last follow-up, 5870/9173 patients (64.0%) were alive, 3229/9173 (35.2%) died and 74/9173 (0.8%) were lost to follow-up. Patients treated with BTKi in first-line were enriched for TP53 aberrations [del(17p) 27.6%, TP53 mutation 26.3%] and unmutated IGHV genes (69%) and obtained an ORR of 87.7%. Of these, 136 (26.3%) discontinued treatment after a median of 1.2 years (0.07-5.98); main reasons of discontinuation were toxicity (40.5%) and failure (26.2%). Among 631 patients treated with venetoclax at any line, 100 (15.8%) received BCL2 +/- anti-CD20 as first-line; 170 (26.9%) as second line (125 previously treated with CIT, 27 with BTKi); and, 361 as third or subsequent line. ORR ranged between 71.5% (≥3 lines) with 30.5% CR/CRi to 90.3% (first-line) with 68.1% CR/CRi. Treatment discontinuation was due to toxicity in 28.6% of patients treated in the first-line, and 17.6% and 21.8% of patients treated in second and third-or-higher-line, respectively. Disease progression led to treatment discontinuation in 14.3%, 20.6% and 33.6% in first, second and third-or-higher line, respectively. CIT was used as front-line treatment in 5465 patients (59.6%). Of these, 2070 (37.9%) and 1018 (18.6%) patients received a second and third line of treatment, respectively. The great majority (865/1086 cases, 79.7%) of patients who received a second line before 2014 were retreated with CIT, most commonly Bendamustine-Rituximab (284/1086, 26.1%) and Fludarabine-Cyclophosphamide-Rituximab (252/1086, 23.2%); alemtuzumab monotherapy was used in 55/1086 (5%) of patients. After 2014, 415/984 patients (42.1%) were retreated with BTKi; 93 (9.5%) with venetoclax; 70 (7.2%) with idelalisib; 50 (5%) with Alemtuzumab monotherapy, and 315 (32%) with CIT. Similarly, in the third-or-higher line of treatment, most patients (86.3%) were retreated with CIT before 2014, while BTKi, BCL2i, and PI3Ki were mainly used after 2014 (in 43.1%, 15.7% and 14.7% of cases, respectively). Finally, our cohort included 1075 patients with TP53 aberrations. The ORR of patients receiving BTKis (n=171) as first-line of treatment was 86.5% (22.2 CR+64.3 PR), while the ORR with venetoclax +/- anti-CD20 (n=15) was 91% (45.5% CR+45.5 PR). Patients treated with CIT (n=694) had an ORR of 68.7% (28.3% CR+40.4% PR). In conclusion, in a large international study we provide real world data regarding the selection and sequencing of treatment in CLL, charting a major shift in treatment patterns before and after the introduction of novel trargeted agents and confirming their efficacy even in high-risk CLL. Disclosures Scarfo: Janssen: Honoraria, Other: Travel grants; Astra Zeneca: Honoraria; Abbvie: Honoraria. Iacoboni: BMS/Celgene, Gilead, Novartis, Janssen, Roche: Honoraria. Collado: Abbvie,: Other: pharmaceutical Company, Research Funding; Janssen: Other: Pharmaceutical Company, Research Funding. Galimberti: AbbVie, Janssen: Honoraria, Other: Travel grants; Incyte: Speakers Bureau. García-Serra: AbbVie: Other: Educational grands; Janssen: Other: Educational grants; Novartis: Other: Educational grants. Gozzetti: Janssen: Honoraria; AbbVie: Honoraria. Hatzimichael: Amgen, Roche, Genesis, Novartis, Bristol Mayer Squibb, Celgene, Pfizer: Consultancy; Abbvie, Amgen, Bristol Mayer Squibb, MSD, Gilead, Janssen Cilag, Genesis Pharma, Roche, Takeda: Honoraria. Herishanu: AbbVie: Honoraria, Research Funding; Janssen: Honoraria; Roche: Honoraria; Medison: Honoraria. Jaksic: Roche, Oktal-Pharma/Celtrion, Sandoz: Consultancy, Honoraria. Kater: Janssen, AstraZeneca: Other: Ad Board, steering committee, Research Funding; Abbvie: Honoraria, Other: Ad Board, Research Funding; BMS, Roche/Genentech: Other: Ad Board, , Research Funding; Genmab, LAVA: Other: Ad Board, Steering Committee. Kotsianidis: Astellas: Other: NONE, Research Funding, Speakers Bureau; Genesis: Consultancy, Other: NONE; Janssen Hellas: Consultancy, Other: NONE, Speakers Bureau; Bristol Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Novartis Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Abbvie: Consultancy, Other: NONE, Research Funding, Speakers Bureau. Kreitman: NIH: Patents & Royalties: Moxetumomab Pasudotox; Genentech: Research Funding; Teva: Research Funding; AstraZeneca/MedImmune: Research Funding; Innate: Research Funding; GSK/Novartis: Research Funding; Array BioPharma/Pfizer: Research Funding. Laribi: BeiGene: Other: Personal Fees; Jansen: Research Funding; Novartis: Other: Personal Fees, Research Funding; Astellas Phama, Inc.: Other: Personal Fees; AstraZeneca: Other: Personal Fees; Le Mans Hospital: Research Funding; Takeda: Other: Personal Fees, Research Funding; AbbVie: Other: Personal Fees, Research Funding; IQONE: Other: Personal Fees. Lopez-Garcia: Roche: Other: Speaker Honoraria, Travel and accommodation grants; Novonordisk: Other: Speaker Honoraria; Fresenius: Other: Speaker Honoraria; Celgene: Other: Speaker Honoraria; Abbvie: Other: Speaker Honoraria, Advisor, Travel and accommodation grants; Janssen: Other: Speaker Honoraria, Advisor, Travel and accommodation grants, Research Funding. Milosevic: Roche: Honoraria; Abbvie,: Honoraria; Janssen: Honoraria; Sandoz: Honoraria. Reda: Beigene: Consultancy; Astra Zeneca: Consultancy; Abbvie: Consultancy; Janssen: Consultancy. Ruchlemer: AbbVie: Consultancy, Honoraria, Research Funding. Šimkovič: Janssen, Gilead, Roche, AstraZeneca, and AbbVie: Other: consultancy fees, advisory board participation fees, travel grants, and honoraria; University Hospital Hradec Kralove: Current Employment; AbbVie: Consultancy, Current equity holder in publicly-traded company, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; AstraZeneca: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses; Merck: Current equity holder in publicly-traded company; Eli Lilly: Current equity holder in publicly-traded company; J&J: Current equity holder in publicly-traded company; Gilead: Other: Travel, Accommodations, Expenses. Špaček: AbbVie, AstraZeneca, Gilead, Janssen, and Roche: Honoraria. Tadmor: Janssen: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding. Visentin: Italfarmaco and Gilead: Speakers Bureau. Vassilakopoulos: AstraZeneca: Honoraria; Amgen: Honoraria, Research Funding; Pfizer: Research Funding; Dr. Reddy's: Research Funding; Novartis: Consultancy, Honoraria; GlaxoSmithKline: Honoraria, Other: Travel; Merck: Honoraria, Research Funding; Integris: Honoraria; Roche: Consultancy, Honoraria, Other: Travel; Genesis Pharma: Consultancy, Honoraria, Other: Travel; Takeda: Consultancy, Honoraria, Other: Travel, Research Funding; AbbVie: Consultancy, Honoraria; Karyopharm: Research Funding. Vitale: Janssen: Honoraria. Yáñez: Gilead-Kite, Janssen, AbbVie, AstraZeneca, Beigene, Roche, Pfizer, Jazz, BMS, and Merck: Other: Advisory board participation fees ; Janssen, AbbVie, AstraZeneca, Gilead-Kite, Roche, Pfizer, and Merck: Speakers Bureau. Antic: AbbVie, Janssen, and Roche: Honoraria. Coscia: Janssen: Honoraria, Other, Research Funding; Gilead: Honoraria; AstraZeneca: Honoraria; AbbVie: Honoraria, Other. Cuneo: AstraZeneca: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Gilead: Consultancy, Speakers Bureau; AbbVie: Consultancy, Speakers Bureau. Gaidano: Beigene: Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astrazeneca: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Guièze: Janssen: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Astrazeneca: Consultancy, Honoraria. Laurenti: AstraZeneca: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria, Research Funding; Roche: Honoraria, Research Funding; Gilead: Honoraria; Janssen: Consultancy, Honoraria; BeiGene: Honoraria. Murru: Abbvie: Consultancy, Honoraria, Other: travel and accommodation; Janssen: Consultancy, Honoraria. Sportoletti: AstraZeneca: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria. Tam: Beigene: Research Funding; Janssen: Research Funding; Abbvie: Research Funding; Loxo: Honoraria; Beigene: Honoraria; Janssen: Honoraria; Abbvie: Honoraria. Trněný: Amgen: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; Gilead Sciences: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses; Incyte: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; MorphoSys: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; Celgene: Consultancy; 1st Faculty of Medicine, Charles University, General Hospital in Prague: Current Employment; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Portola: Honoraria, Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Honoraria; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses. Bosch Albareda: Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria; Abbvie: Consultancy; AstraZeneca: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria, Research Funding, Speakers Bureau; Takeda: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Kite: Honoraria; Sanofi: Honoraria; Lilly: Honoraria. Doubek: Janssen-Cilag, AbbVie, AstraZeneca, Amgen, Gilead, Novartis: Honoraria, Research Funding. Chatzidimitriou: Abbvie: Honoraria, Research Funding; Janssen: Honoraria, Research Funding. Ghia: AbbVie: Consultancy, Honoraria, Research Funding; Acerta/AstraZeneca: Consultancy, Honoraria, Research Funding; AstraZeneca: Consultancy, Honoraria, Research Funding; ArQule/MSD: Consultancy, Honoraria; BeiGene: Consultancy, Honoraria; Celgene/Juno/BMS: Consultancy, Honoraria; Gilead: Consultancy, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Sunesis: Research Funding. Stamatopoulos: AstraZeneca: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; Gilead: Honoraria, Research Funding; Janssen: Honoraria, Research Funding.

Introduction Immunoglobulin heavy chain variable region (IGHV) repertoire narrowing could be an evidence for the involvement of a limited set of antigens in the development of lymphomas. For chronic lymphocytic leukemia (CLL) the existence of more than 200 subgroups of tumor IGHV antigen-binding sites, so called “stereotypical” antigen receptors (SAR) has been shown. For others lymphomas the possibility of SARs is also suggested. The aim of this study is to compare the tumor IGHVs and possible SARs in various B-cell malignancies in Russia and other countries. Materials and Methods The study included samples of 1800 CLL patients, 52 patients with mantle cell lymphoma, 48 patients with hairy cell lymphoma and 37 patients with splenic marginal cell lymphoma. The nucleotide sequences of the IGHV genes were determined according to ERIC protocol. Results In CLL most common IGHV genes were IGHV1-69, IGHV1-2, IGHV3-30 and IGHV4-34. The most common SARs were CLL#1, CLL#6, CLL#2, CLL#3. In MCL the most common genes were IGHV4-34, IGHV3-21, IGHV3-23. In 5 MCL patients CDR3 sequences were identified matching definitions of a stereotyped. In the half of SMZL patients was identified gene IGHV1-2. Other IGHV genes were much less common. Two pairs of SMZL patients have motives similar to each other. In HCL IGHV repertoire was the most variable, no trends for antigen receptor stereotypy were observed. It was found that SARs are highly disease-specific both at the level of nucleotide and amino acid sequences. Conclusion Our results suggest that antigens crucial for the pathogenesis of B-cell malignancies could be disease-specific. Further studies on extended samples of non-CLL patients concerning the role of SARs in pathogenesis of these diseases may also contribute to the development of new diagnostic and prognostic markers.

Background Therapy with irreversible Bruton's tyrosine kinase inhibitor ibrutinib in chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL) is associated with bleeding. Objectives To propose the predictive markers of such bleeding, as well as mechanisms responsible for decreased bleeding at later therapy stages. Patients/methods We investigate platelet functional activity in 50 CLL and 16 MCL patients on ibrutinib using flow cytometry and light transmission aggregometry. Results Prior to treatment, both patient groups had decreased platelet counts; impaired aggregation with adenosine diphosphate (ADP); and decreased binding of CD62P, PAC1, and annexin V upon stimulation. Bleeding in patients treated with ibrutinib was observed in 28 (56%) CLL patients, who had decreased aggregation with ADP and platelet count before therapy. Their platelet count on therapy did not change, platelet aggregation with ADP steadily improved, and aggregation with collagen first decreased and then increased in anticorrellation with bleeding. Bleeding in MCL was observed in 10 (62%) patients, who had decreased dense granule release before therapy. ADP and ristocetin induced platelet aggregation in ibrutinib-treated MCL patients increased on therapy, while collagen-induced aggregation evolved similarly to CLL patients. Conclusions Our results suggest that ibrutinib-dependent bleeding in CLL patients involves three mechanisms: decreased platelet count (the most important discriminator between bleeding and non-bleeding patients), impaired platelet response to ADP caused by CLL, and inhibition by ibrutinib. Initially, ibrutinib shifts the balance to bleeding, but then it is restored because of the improved response to ADP.

Chronic lymphocytic leukemia (CLL) is a disease of the elderly, characterized by immunodeficiency. Hence, patients with CLL might be considered more susceptible to severe complications from COVID-19. We undertook this retrospective international multicenter study to characterize the course of COVID-19 in patients with CLL and identify potential predictors of outcome. Of 190 patients with CLL and confirmed COVID-19 diagnosed between 28/03/2020 and 22/05/2020, 151 (79%) presented with severe COVID-19 (need of oxygen and/or intensive care admission). Severe COVID-19 was associated with more advanced age (≥65 years) (odds ratio 3.72 [95% CI 1.79–7.71]). Only 60 patients (39.7%) with severe COVID-19 were receiving or had recent (≤12 months) treatment for CLL at the time of COVID-19 versus 30/39 (76.9%) patients with mild disease. Hospitalization rate for severe COVID-19 was lower (p < 0.05) for patients on ibrutinib versus those on other regimens or off treatment. Of 151 patients with severe disease, 55 (36.4%) succumbed versus only 1/38 (2.6%) with mild disease; age and comorbidities did not impact on mortality. In CLL, (1) COVID-19 severity increases with age; (2) antileukemic treatment (particularly BTK inhibitors) appears to exert a protective effect; (3) age and comorbidities did not impact on mortality, alluding to a relevant role of CLL and immunodeficiency.

Background. Ibrutinib became available for patients (pts) with relapsed/refractory (R/R) mantle cell lymphoma (MCL) in Russia in the end of 2015 based on the results of phase 2 study by M. Wang from MD Anderson Cancer Center (NEJM 2013, Blood 2015). However, pts in routine clinical practice tend to differ significantly from the patients selected for clinical trials, which may lead to poorer results in off study treated patients. Aim. To assess efficacy and toxicity of ibrutinib monotherapy in pts with R/R MCL in routine community clinical practice outside of clinical trials. Materials & Methods. We analyzed the charts of all pts with R/R MCL who started ibrutinib from April 2016 to July 2019 in 7 Moscow's hospitals. The following criteria were used to initiate ibrutinib monotherapy: the age > 18 years, confirmed MCL diagnosis with nuclear hyperexpression of cyclin D1 and/or presence of the t(11;14)(q13;q32); symptomatic relapse or failure to achieve at least PR with a prior regimen. Poor physical status, pancytopenia grade 3-4, infectious complications (except for life-threatening conditions), blastoid variant and the number of previous treatment lines were not regarded as contraindications to ibrutinib therapy. Patients with CNS involvement were excluded from this analysis. Ibrutinib was administered once a day at a dose of 560 mg until progression or intolerable toxicity. Response to therapy was assessed every 2-3 months utilizing CT scan, PET/CT and bone marrow examination were required to confirm CR. Results. 54 pts with R/R MCL received ibrutinib monotherapy between April 2016 and July 2019. 26 pts (48%) were refractory to a prior therapy. The median age was 68 years (range 40-81); 69% of pts were men; ECOG > 2 in 22% of pts. 15 pts (28%) underwent a repeated biopsy before starting ibrutinib. 23 pts (43%) had an aggressive variant of MCL: either blastoid morphology (13/54 at diagnosis and 5/54 after repeated biopsy) or classical morphology with Ki-67>40% (4/54 at diagnosis and 1/54 after repeated biopsy). The median number of previous treatment lines was 2 (1-11). The response was evaluated in 53/54 pts. ORR was 81%, CR rate was 30% in the whole group. Pts with aggressive variants of MCL (group 1) had ORR of 65%, CR rate of 7%. In the group with classical morphology and Ki-67≤40% (group 2) ORR and CR rates were 93% and 47%. 2 pts with a response to therapy stopped ibrutinib early on their own accord, without signs of toxicity above gr.1. The median EFS for all pts was 394 days (95% CI: 261-526). In group 1 the median EFS was 173 days (95% CI: 112-234), in the group 2 the median EFS was 759 days (95% CI: 521-996, p The most common complications were myalgia and muscle cramps (60%, all gr.1-2), diarrhea (gr.1-2 in 58% and gr.3 in 4%); hemorrhagic complications (65%, all gr. 1-2); skin, nail toxicity and a rash (15%, all gr.1-2) and arrhythmia (9%). Infections were reported in 30% of pts (gr.3 in 6%). Skin/nails toxicity developed mainly after 6 months of ibrutinib intake. In 14 (26 %) pts ibrutinib treatment had to be adjusted (dose reduction or treatment interruption for 3-10 days) due to toxicity and planned surgeries. 4 pts (9%) required dose reduction from 560 to 420 mg. None of ibrutinib recipients had to completely discontinue ibrutinib therapy due to complications (with exception of 2 patients who stopped taking ibrutinib on their own). None of the patients received alloSCT. Conclusion. These data on the use of ibrutinib in actual clinical practice are comparable with the results of international multicenter studies (PCYC-1104, SPARK, and RAY). Favorable toxicity profile and rather short time to antitumor response allow for ibrutinib administration in cases of poor performance status due to disease, low blood count, and even infectious complications. Ibrutinib monotherapy results in the durable disease control in 93% of patients with non-blastoid MCL with the median EFS 25 months, but only 65% with blastoid type with the median EFS 6 months. However, some adverse effects are manifested not earlier than after 6-month treatment, which calls for continuous monitoring, especially when preparing for surgeries. Figure Disclosures Vorobyev: AstraZeneca: Consultancy; Abbvie: Consultancy, Speakers Bureau; Roche: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Sanofi: Consultancy. Ptushkin:JSC GENERIUM: Research Funding; Alexion Pharmaceuticals, Inc:: Consultancy, Research Funding; Janssen: Consultancy; Roche: Consultancy; AbbVie: Consultancy.

Background: Recent studies have shown that addition of bypassing agents to immuno-tolerance induction (ITI) protocol for patients with hemophilia A and inhibitor results in better control of bleeding episodes and improves quality of life. Few publications have addressed prophylactic usage of recombinant factors VIIa in these settings. Due to relatively low infusion volume, convenience of administration and high efficacy rFVIIa - Coagil-VII seems to be especially reasonable for ITI protocol. Aim: To assess the efficacy and safety of rFVIIa - Coagil-VII (SJC "GENERIUM", Russia) for prophylactic use during ITI protocol in patients with hemophilia A and inhibitor. Methods: Seven patients aged between 2 to 7 years with severe hemophilia A and inhibitor have been treated with ITI protocol using plasma derived factor VIII with von Willebrand factor. Seven of them simultaneously received treatment with Coagil-VII in individual doses (100-250 mkg/kg) and regimens (every 12 - 48 hours). When inhibitor reached level of 3 BU (Bethesda Unit) either dose or frequency of Coagil-VII administration were gradually reduced. After 1 BU the patients were given factor VIII only. Number and severity of bleeding events were assessed. Results: Five patients with high responding inhibitors and poor prognosis (history of high titer of factor VIII inhibitor, prolonged time between first inhibitor appearance and the beginning of ITI) received Coagil-VII in high doses 150 - 250 mkg/kg every 12-24 hours in 1-4 years. At time of booster effect titer of inhibitors reached 92 -16 000 BU. One of patients had ITI failure because of interruption of protocol, while 4 patients continue treatment. Level of 3 BU was reached by 4 patients at 40, 12, 35, and 3 months of treatment. Level of 1 BU was reached by 2 patients at 6 and 42 months of treatment. Significant clinical effect was achieved after 6 months of treatment. Time of bleeding episode was decreased from 7 (±2) to 2 (±1) days. Total number of hemorrhagic events, including hemarthrosis, hematomas and bleedings decreased by 3,7 fold (3,7 events per patient-month during first 6 months versus 1,0 events per patient-month). Only 1 hospital admission with bone fracture was recorded. All children have an active lifestyle and attend school. Two patients with low responding inhibitor and good prognosis received Coagil-VII in low doses 90 - 170 mkg/kg every 24-48 hours. Maximal titer of inhibitor was 1.3 - 1.9 BU. Both patients completed treatment with Coagil-VII in 2 and 4 months and continue ITI protocol and both achieved undetectable level of inhibitor. No bleeding episodes were recorded in these patients since the beginning of treatment. There was no clinical or laboratory evidence of thrombosis, thrombocytopenia, or disseminated intravascular coagulation. Conclusion: We report our experience of prolonged (2 months - 4 years) prophylactic treatment with recombinant activated factor VII (rFVIIa) - Coagil-VII in patients with hemophilia A and inhibitor. This prophylaxis is efficacious when doses and treatment regimens are individually determined. This approach results in reduction of bleeding episodes in all patients, as well as increase of quality of life. No any adverse events (AE and SAE) with prolonged use of Coagil-VII have been registered so far. Disclosures No relevant conflicts of interest to declare.

INTRODUCTION. Ibrutinib is an oral small-molecule drug that irreversibly inhibits Bruton's tyrosine kinase and thus suppresses proliferation of B cells. Ibrutinib therapy in chronic lymphocytic leukemia (CLL) and in mantle cell lymphoma (MCL) is associated with frequent bleeding complications that were reported to be more severe in CLL. This difference was suggested to be related to differential adenosine diphosphate (ADP) disruption by CD39, expressed by tumor cells. Here we investigate platelet functional activity in CLL and MCL patients before initiation of ibrutinib. MATERIALS. Fifty one adult patients with relapsed and refractory CLL and MCL and 20 healthy donors were included in the study. Platelet functional activity was characterized by flow cytometry before and after activation with SFLLRN plus collagen-related peptide. Levels of CD42b, CD61, CD62P, PAC1, annexin V binding, and mepacrine release were determined. Aggregation with collagen, ADP and ristocetin were measured. RESULTS. Among 36 CLL patients 25 (69%) were men, the median age was 66 (range, 31 to 83 years) and 23 (64%) had a refractory disease. In 34 previously treated patients the median number of prior treatments was 2 (range, 1 - 6). Two CLL patients with del (17p) received ibrutinib as a first line. In a group of MCL patients (n=15) there were 12 men (80%), the median age was 63 years (range, 49-79). Seven (54%) patients had a high MIPI score. The median number of previous chemotherapy lines in MCL patients was 1 (range, 1 - 6). Lymphocyte count before initiation of ibrutinib was significantly higher in CLL group (median 17,5 х 109/L range 0,48 - 189,7) compared to MCL group (median 1,75 х 109/L, range 0,35 - 6,59, p=0,037). Initial platelets count was also different being lower in CLL than in MCL patients (127 х 109/L (15 - 248) versus 186 х 109/L (63 - 311), p=0,005). Platelets of untreated patients with CLL had statistically significant impairments in their responses compared to those with MCL. Specifically, they had decreased integrin activation in response to stimulation (46±19% versus 73±18%; for healthy donors, 100±17%), and relative mepacrine release (2.9±0.9 versus 3.5±0.8; healthy, 4.0±0.7). P-selectin release was impaired milder (77±17% versus 92±14%; healthy, 100±10%), and procogulant platelet formation impairment was not statistically significant (8±6% versus 12±7%; healthy, 12±3%). In control experiments, addition of MeS-AMP and MRS2179, selective inhibitors of ADP receptors, had comparable effects on the healthy donor platelets. Aggregation in response to ADP was dramatically impaired in CLL compared with MCL (24±18% versus 42±16%), as well as that in response to collagen (47±23% versus 72±13%). Upon ibrutinib treatment, further decrease of PAC1 binding and procoagulant platelets formation almost to the level of resting platelets were observed; activation with SFLLRN alone produced a similar result with donor platelets. CONCLUSIONS. Patients with CLL and MCL have initially impaired response of platelets. The defects of platelet function in CLL is much greater suggesting a possible explanation of the different clinical severity. Disclosures Vorobyev: Janssen: Speakers Bureau. Ptushkin:Janssen: Speakers Bureau.

Efficacy and safety of a new domestically produced rFVIII-BDD (moroctocog alfa, Octofactor, CJSC "GENERIUM", Russia) was investigated in a controlled, open, prospective, multicenter clinical trial. After screening and a 4-days washout period 12 previously treated patients adolescents (age 12-18 years old) with severe hemophilia A (the activity of FVIII was less than 1%) were included in the clinical trial. The patients were given the moroctocog alfa as prophylactic treatment in a dose of 35±5 ME/kg 3 times per week during 21±1 weeks. Before participation in this clinical trial 2 pts had received treatment with another recombinant FVIII, 2 pts had therapy with pdFVIII and 8 pts had been treated with rFVIII and pdFVIII. The main criterion of drug efficacy was the incidence of spontaneous bleeding occurred within 48 hours after of the moroctocog alfa injection. The additional criteria were: · The severity of spontaneous bleeding occurred in 21 ± 1 week. · Number of injections needed for the one episode of bleeding according of its severity. · The total amount of drug administered over a period of prophylactic treatment and treatment "on demand". · The number of patients with severe hemophilia A with a residual activity of FVIII ≥1% in 48 hours after the injection on prophylactic therapy. During the follow up period (21±1 week) 17 bleeding episodes were registered, 2 of them (11,8%) were severe, 10 (58,8%) were moderate and 5 (29,4%) were mild (Tab.1). Number of bleeding episodes (spontaneous and traumatic) was 17 (1.55 in average). Number of spontaneous bleeding was 3 (17,6%), 1 of them was mild and 2 were moderate. The average number of injections that stop one bleeding episode was 1.7±0.8. The total amount of moroctocog alfa administered over a period was 1.502.000 ÌÅ for prophylactic treatment and 64.750 ÌÅ for "on demand" treatment. The number of patients with severe hemophilia A with a residual activity of FVIII ≥1% in 48 hours after injection on prophylactic therapy was 63,6% on visit 2, 90,09% on visit 3 and 81,1% on visit 4. The safety assessment was performed in 12 patients. There were 8 adverse events and 7 of them were not associated with drugs administration. There was one serious adverse effect, allergic reaction accompanied by arthralgia and cephalalgia. The patient was excluded from the trial without consequences for life and health. There were no infection transmissions and de novo inhibitor incident. The study showed that moroctocog alfa is effective and safe in prophylactic treatment and stopping of bleeding in adolescents with severe hemophilia A. Table 1. Efficacy evaluation Table 1. Efficacy evaluation Disclosures No relevant conflicts of interest to declare.

The efficiency and safety of a new Russian recombinant factor IX - FIX (nonacog alpha, Innonafactor®, GENERIUM) in prevention of bleeding episodes in patients with severe and moderate hemophilia B (part 1 of phase II-III clinical trial) were studied in a controlled randomized open prospective multicenter clinical trial in comparison with plasma derived FIX - Octanine® F (filtered) (Octapharmazeutika Produktionsges mbH, Austria). The main objective of this study was to test therapeutic equivalence and safety of nonacog alfa compared to Octanine F® in patients with severe and moderate hemophilia B. The safety and efficiency were studied in "on demand" treatment in 18 patients. According to randomization, patients were divided into 2 groups. Patients in the 1st group (n=9) received the nonacog alfa (Innonafactor) and patients of the 2nd group were given the Octanine F®. In the 1st group there were 6 patients with severe hemophilia B (activity of FIX was less than 1%) and 3 patients with moderate form of the disease (activity of FIX was 1-5%). In the 2nd group 4 patients had severe and 5 patients moderate hemophilia B. During the follow up period (13±1 week) 64 bleeding episodes were registered in patients of the 1st group; 51 of them (79.7%) were mild and 13 (20.3%) were moderate (Tab.1). In the 2nd group 70 bleeding episodes were recorded, of which 4 (5,7%) were mild, 65 (92,9%) were moderate and 1 (1.4%) was severe. The average number of bleeding episodes in patients of the 1st group (7,11±3,72) was slightly less than in patients of the 2nd group (7,78±5,22; p=0,93). The average total duration of bleeding, as well as the average duration of one bleeding episode were lower in patients of the 1st group (9,44±5,53 versus 13,78±15,39 days and 1,3±0,43 versus 1,65±1,38 days). The differences were statistically non-significant for both measures (p=0,86; p=0,93). The vast majority of bleedings were stopped with 1 - 2 doses of study drugs: 64 (100%) episodes in the 1st group and 67 (95,71%) episodes in the 2nd group (p=0,512). There were no difference in the average number of injections required to stop one bleeding episode 1,06±0,08 in the 1st group versus 1,39±0,89 in the second group (p=0,96). During follow up period patients of the 1st group required fewer doses of drug to stop bleeding (7,56±3,91) than patients of the 2nd group (11,56±11,2), but the differences were statistically not significant (p=0,859). The average amount of drug that stanched one episode of bleeding was less in the 1st group (3346,01±801,51 ME) than in the 2nd one (4264,38±2987,58 ME; p=0,93). The average number of drug to stop all episodes of bleeding in one patient in the 1st group was less (23222,22±11659,52 ME) than in the 2nd group (35722,22±34726,71 ME; p=0,929). The average value of the maximum assessment of the pain severity by a visual analogue scale during episodes of bleeding in patients of the 1st group (5,5±1,6 points) did not differ significantly from the same indicator in patients of the 2nd group (5,38±score 1,19; p=0,914). The safety assessment was performed in 18 patients. There is no any side effects, infection transmission, or de novo inhibitor incident. Thus, the study showed that nonacog alfa is effective to stop bleeding in patients with severe and moderate hemophilia B, the results are comparable with the results of the use of Octanine F. Nonacog alfa is safe, and its use not accompanied with toxic, thrombogenic, immunogenic and allergic reactions. Table 1. Efficacy and Safety Evaluation * p-values are presented descriptively (n=9). Table 1. Efficacy and Safety Evaluation. / * p-values are presented descriptively (n=9). Disclosures No relevant conflicts of interest to declare.

During a controlled, randomized, open, prospective, multicenter clinical trial the efficacy and safety of a new domestically produced recombinant factor IX (FIX, nonacog alfa, CJSC "GENERIUM", Russia) were investigated in comparison with plasma drug Octanine® F (filtered) ("Octapharma pharmazeutika produktionsges mbH", Austria) for the prophylactic treatment of bleedings in patients with severe and moderate hemophilia B. After screening and a 4-day washout period 18 patients with moderate (n=8) and severe (n=10) hemophilia B were divided into 2 groups according to randomization: the 1st group patients (n=9) received the nonacog alfa, the 2nd group (n=9) Octanine F (fig. 1). In the 1st group there were 4 patients with severe hemophilia B (activity of FIX was less than 1%) and 5 patients with the moderate form of the disease (activity of FIX was 1-3%). In the 2nd group 6 patients had severe and 3 moderate hemophilia B (activity of FIX was 1-2,6%). In order to prevent bleeding nonacog alfa was injected slowly intravenously at a dose of 50±5 IU kg-1. Octanine F was infused at a dose of 30±5 IU kg-1. Drugs were injected 2-3 times per a week during 26±1 weeks (6 months). The main criterion of drug efficacy was the average number of bleedings within 6 months of prophylactic treatment. Anticipated average number of bleedings was determined based on the effectiveness of the original drug Benefix® (Pfizer, USA) and was 9±3 cases. Additional criteria of efficacy were severity of bleeding, activated partial thromboplastin time (APTT) and FIX activity before and 30 min after drug administration compared with normal values. In the 1st group 2 moderate bleeding episodes occurred in 2 patients, while in the 2nd group 10 hemorrhagic episodes occurred in 4 patients (1 episode was severe, 1 - moderate, and 8 were low grade). There were no significant differences in frequency of bleeding events. The average number of bleedings during the analyzed period in patients of the 1st group was 0,22±0,44. In patients of the 2nd group it was 1,11±1,97; the differences were statistically insignificant (p=0,24). In patients of both groups, the average number of bleeding was within planned range (fig. 2). Pharmacokinetics was evaluated by K-value (incremental recovery) and in vivo recovery (IVR). After carrying out of prophylactic therapy during 6 months, Incremental recovery of nonacog alfa was 1,24 ± 0,32 IU/DL per IU/kg. The Incremental recovery (K-value) of Octanine F was analogous and amounted to 1,14 ±0,29 IU/DL per IU/kg. During 6 months IVR of nonacog alfa was 47,56 ±13,56% and the IVR of Octanine F was not different and amounted to 49,05 ±15,68%. Prophylactic therapy was accompanied by normalization of coagulation activity of blood. On the 26th week of therapy APTT values taken 30 minutes after drug administration were 38,04 ±3,63 sec. in 1st group and 41,49 ± 3,44 sec. in the 2nd group. Safety assessment was performed in 18 patients. There were 6 adverse events in the 1st group and 12 in the 2nd group. All adverse events were not associated with drugs administration. Thus, the study shows that nonacog alfa (Innonafactor) is effective in prophylaxis of bleeding in patients with severe and moderate hemophilia B. The results are comparable with the results of the use of Octanine F. The study demonstrated that nonacog alfa (Innonafactor) with its pharmacodynamic and pharmacokinetic characteristics is comparable to Octanine F. Administration of nonacog alfa (Innonafactor)to patients with severe and moderate hemophilia B was accompanied by normalization of APTT and FIX activity and rising activity of FIX and its degree of recovery. Treatment with nonacog alfa (Innonafactor) was safe and without side effects, infection transmission, de novo inhibitor incident. Disclosures No relevant conflicts of interest to declare.

Abstract 4592 The optimal treatment of patients with chronic lymphocytic leukemia (CLL) and concomitant renal impairment is unclear. Fludarabine containing regimens are contraindicated in patients with glomerular filtration rate less then 30 ml/min. Alkylating agents are either contraindicated or require dose reduction due to their relatively large renal clearance. Treatment choice is especially difficult in cases with refractoriness to alkylating drugs. The aim of this study was to assess safety and efficacy of bendamustine monotherapy in CLL patients with concomitant chronic renal failure. Seven patients with proven diagnosis of CLL and chronic kidney disease were treated with bendamustine monotherapy. The median age of patients was 66 years (range 61 – 83). All patients were males. The median creatinine level was 183 mkmol/L (range 165 – 573), the median level of glomerular filtration rate was 39 ml/min (range 23 – 47). The causes of chronic renal failure: membranous proliferative glomerulonephritis and focal CLL infiltration – 1 case, nephrectomy for cancer and massive CLL infiltration – 1 case, nephrectomy for cancer and pyelonephritis of sole kidney – 1 case, massive diffuse CLL infiltration with no other causes identified – 1 case, drug associated tubulointerstitial nephritis with development of irreversible renal failure – 1 case, chronic gout and urolithiasis in 1 case, unknown – 1 case. None of the patients required hemodialysis. Treatment consisted of bendamustine monotherapy, administered for two days every 4 weeks. Treatment in all patients started with dose 70 mg/m2/day. If the first course was well tolerated the dose was escalated to 100 mg/m2 on the next courses. Three patients were newly diagnosed and four patients had relapsed disease, after a medium of 2 lines of therapy (range 1 – 2). Two patients were refractory to alkylating drugs. Before initiation of bendamustine 4 patients had Binet stage C, and 3 Binet stage B. Four patients received all planned 6 cycles of therapy with dose escalation to 100 mg/m2/day. In three patients treatment was stopped prematurely. In one patient treatment was discontinued after the 4th cycle because of the grade III skin rush and grade II polyneuropathy. One severely cardio compromised patient of 72 years developed grade III bradicardia after first cycle, requiring installation of cardiac pacemaker. One patient of 83 years with refractoriness to previous treatment died after 2 cycles from infectious complications. Neutropenia grade III was observed in 5 cycles in 3 patients. Aggravation of thrombocytopenia (grade II) was observed in 2 patients and aggravation of anemia (grade I) in 3 patients. In no case there was worsening of renal function. Decrease of creatinine and urea level was observed in 5 patients. Response can be evaluated in 5 patients. 2 patients achieved a nodular PR, and 3 patients achieved a PR. In conclusion, monotherapy with bendamustine can be safely used in patients with CLL and renal impairment. Doses up to 100 mg/m2 are tolerated and do not cause worsening of renal function or severe hematological toxicity. Disclosures: No relevant conflicts of interest to declare.