We have evaluated a global screening test for the protein C pathway, the 'ProC Global' (Dade Behring Ltd, Milton Keynes, UK). Patient groups tested included inherited protein C or S deficient and inherited/acquired activated protein C resistance. Results showed that protein C deficiencies and activated protein C resistance could be successfully detected with this test whereas deficiencies of protein S were less readily distinguished from the normal population. The ProC Global was unreliable in patients with antiphospholipid antibodies, raised plasma factor VIII:C and in those receiving oral anticoagulant therapy.

To date there is no routinely used reliable diagnostic test that can be performed in the post-mortem period to investigate whether a deceased had a coagulation disorder. This paper describes a series of experiments to assess the use of an antigen-based method to investigate the vitamin K-dependent factor II function in the deceased. It illustrates that by using this approach the functional status of factor II can be investigated in the postmortem period. The abnormal proteins that are investigated by this method appear to remain stable for at least 72 h and potentially up to at least 7 days. The method that is illustrated could thus be reliably used in the postmortem period to identify a natural or drug-induced factor II abnormality. The potential for other protein components of the coagulation cascade to be investigated by similar antigen-based methodology is suggested.

BACKGROUND: Despite recent advances in the treatment of relapsed/refractory (R/R) CLL/SLL, patients (pts) with genetically high-risk disease, particularly complex abnormal karyotype and deletion(17p), continue to demonstrate inferior survival. Dinaciclib, a selective inhibitor of cyclin-dependent kinases (CDKs), has demonstrated activity in high-risk CLL/SLL. In an effort to improve response rates and reduce the risk for hyperacute tumor lysis syndrome (TLS), we conducted a NCI-sponsored phase 1b/2 study (NCI 9268) to characterize the safety and efficacy of dinaciclib when given in combination with the anti-CD20 monoclonal antibody ofatumumab. METHODS: Pts with CLL/SLL R/R after ≥1 prior therapy, age ≥ 18 years, ECOG ≤ 2, and retained end-organ function received ofatumumab according to the approved dose and schedule (weekly x 8, monthly x 4) starting on Cycle 1 Day 1. Dinaciclib was administered as a 2-hour infusion on days 1, 8, and 15 of a 28-day cycle beginning on Cycle 2 Day 1 and continued for up to 6 cycles. Pts could then continue single-agent dinaciclib indefinitely at MD discretion. During the phase 1b portion of the study, 3 pts were treated with 7 mg/m2 on Day 1 escalated to 10 mg/m2 on Day 8 (DL1); 3 additional phase 1b pts and all pts enrolled to the phase 2 were escalated to 14 mg/m2on Day 15 (DL2). All pts received aggressive hydration and pre-medication prior to dinaciclib to prevent TLS, peg-filgrastim on Day 16 of Cycles 2-7, and required antimicrobial prophylaxis (val-/acyclovir, ciprofloxacin, and TMP/SMX). Response was assessed with CT imaging according to IWCLL 2008 criteria at the end of cycle 1, after odd-numbered cycles, and every 3 months during follow-up. RESULTS: As of 30 July 2014, 36 pts (DL1 n = 4; DL2 n=32) have been treated: median age 62.5 years (range 35-80), 13 (36%) female, ECOG ≤1 in 32 (89%), and median number prior therapies was 2 (range 1-5). Del (17p) was present in 25 pts (69%), del (11q) in 16 (44%), and complex abnormal karyotype in 15 (42%). No dose limiting toxicities were observed in the phase 1b portion of the study. The most common grade ≥ 3 adverse events (without regard to attribution) included hyperglycemia in 5 pts (16%), hypocalcemia in 4 (13%), hypophosphatemia in 13 (41%), leukopenia in 12 (37%), anemia in 11 (34%), and thrombocytopenia in 9 (28%). Neutropenia was common (18% grade 3, 47% grade 4), but grade ≥ 3 infections were rare (1 pleural, 5 lung, 2 sepsis). Only 1 pt with highly proliferative disease refractory to both ibrutinib and IPI-145 developed TLS, which was further complicated by grade 5 sepsis. Pts have received a median 4 cycles (range 1-12), and 4 pts (11%) remain on treatment. Reasons for discontinuation are listed in the table. Best protocol response of partial response was recorded for 12 pts (33%), and an additional 20 (56%) patients achieved stable disease. Responses were observed in all genetic subgroups and deepened with continued dinaciclib treatment (see table). Estimated median PFS was 10.4 months (95%CI 8.2-12.2 months) and median overall survival (OS) had not been reached (95%CI 13.2-NR). CONCLUSIONS: Dinaciclib can be safely administered with ofatumumab to pts with R/R CLL/SLL. Serious non-hematologic adverse events are infrequent, and supportive measures help limit infectious complications. Initiating treatment with ofatumumab, stepwise dose escalation of dinaciclib, and rigorous prophylaxis abrogate the risk for TLS. These results confirm the activity of dinaciclib in a population enriched for genetically high-risk CLL/SLL. Responses improved with continued therapy, and discontinuation prior to best response likely impacted observed response rates. Further study of dinaciclib in combination with novel monoclonal antibodies and/or other kinase inhibitors is warranted, particularly in genetically high-risk disease. Table Reason for Discontinuation n=36 (%) Completed planned therapy 13 (41) Adverse event/complication 6 (19) Disease progression 6 (19) Alternative therapy 3 (9) Death on study 2 (6) Other 2 (6) Best Protocol Response to Date n=36 (%) PR 12 (33) SD 20 (56) PD 2 (6) IE 1 (3) Cycle 2 Response n=34 (%)* PR 0 SD 32 (94%) PD 2 (6) Cycle 4 Response n=23 (%) PR 5 (22) SD 18 (78) PD 0 Cycle 6 Response n=15 (%) PR 11 (73) SD 4 (27) PD 0 *1 pt with probable PD discontinued during Cycle 1 Disclosures Off Label Use: Dinaciclib is an investigational agent made available through NCI/CTEP. Awan:Boehringer Ingelheim: Consultancy; Lymphoma Research Foundation: Research Funding. Maddocks:Pharmacyclics, Seattle Genetics, MorphoSys: Advisory Board Other, Research Funding. Byrd:Pharmacyclics: Research Funding.

BACKGROUND: Patients (pts) with CLL/SLL are at high risk for infections, and pts with genetically high-risk disease are at increased risk for early disease progression and death. Lenalidomide, an oral immunomodulatory agent with demonstrated activity in treatment-naïve CLL/SLL, can potentially restore immune system dysfunction associated with CLL/SLL. We present results from an NCI/CTEP-sponsored, randomized phase 2 study (NCI 8834) of low-dose lenalidomide designed to assess the ability of lenalidomide to restore immune synapse response and humoral immunity, as well as delay progression of asymptomatic, genetically high-risk, early-stage CLL/SLL. METHODS: Pts with genetically high-risk CLL/SLL (unmutated IGHV, deletion(17p)/(11q), and/or complex abnormal karyotype) were eligible if they were treatment-naïve, did not meet IWCLL 2008 criteria for initiating therapy, age ≥ 18 but < 80 years, ECOG ≤ 2, no history of autoimmune cytopenia, no venous thromboembolic event ≤6 months prior, and adequate end-organ function. Pts were randomized to receive lenalidomide either concurrent with (Arm A) or sequential to (Arm B) 2 doses of 13-valent protein-conjugated pneumococcal vaccine (Prevnar-13) administered 2 months apart (see figure). Lenalidomide was dosed at 2.5 mg/day during the first 28-day cycle to reduce risk for tumor flare and increased to 5 mg/day for the second and subsequent cycles as tolerated. Treatment continued for at least 24 cycles in the absence of disease progression or irreversible Grade ≥ 3 adverse event (AE). Anti-pneumococcal antibody titers, the primary endpoint of the study, were measured in each arm at 1 and 2 months after the second dose of vaccine and every 6 months thereafter. Secondary endpoints included clinical response, IWCLL 2008 response after 24 cycles, and progression-free survival (PFS). RESULTS: 49 pts were randomized. Median age at enrollment was 59 (range 40-70) years, median time from diagnosis 1.26 (range 0.15-9) years, and ECOG = 0 in 96%. Baseline clinical and genetic risk factors were similar between the 2 arms (see table). In general, AE were mild and manageable. Gr ≥3 AE were uncommon and included (in ≥10% pts): neutropenia in 10 (20%) and hypophosphatemia in 6 (12%). The most common treatment-emergent Gr 1/2 AEs included neutropenia in 27 pts (55%), diarrhea in 26 (53%), rash in 25 (51%), and thrombocytopenia in 23 (47%). Gr 1/2 infections were reported in 17 (35%), but only 1 Gr 3 infection (pneumonia) was observed. Gr 1/2 tumor flare was observed in 2 pts (4%). There were no thromboembolic events. Seroprotection against 7 pneumococcal serotypes (1, 3, 4, 5, 14, 19F, and 23F) was measured 4 weeks after the second dose of vaccine. All but 4 pts (3 in Arm A, 1 in Arm B) achieved seroprotection against ≥1 serotype, and the median number against which seroprotection was achieved was 3 (range: 0-7) in both arms. Mean IgG/IgM/IgA levels at baseline were 722/109/49, and improved to 820/136/51 and 947/197/59 after 12 and 24 cycles of treatment, respectively. Disposition of study patients and treatment responses are summarized in the table; after median 31 cycles received, 59% of patients remain on treatment. 75% of patients achieved a clinically assessed disease response, and of the 34 patients that completed IWCLL response assessment after 24 cycles of therapy (including CT scans and bone marrow biopsy), 9 achieved a PR, 23 SD, and 2 PD. Median PFS has not yet been reached; 1 year PFS was 88% (95%CI 74-94), 2 year PFS was 78% (63-88), and estimated 3 year is PFS 72% (95%CI 56-83). CONCLUSIONS: Low-dose lenalidomide can be administered to asymptomatic, genetically high-risk, early-stage CLL patients with modest toxicity and high rates of durable clinical response. Some anti-pneumococcal vaccine response was achieved by nearly all treated patients on both schedules. Lenalidomide effectively prevented and/or reversed the expected progression of hypogammaglublinemia, which may explain the low incidence of infection, and near absence of severe infection, observed here. Figure Figure. Disclosures Jones: Genentech: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees, Research Funding. Awan:Novartis Oncology: Consultancy; Innate Pharma: Research Funding; Pharmacyclics: Consultancy. Andritsos:Hairy Cell Leukemia Foundation: Research Funding. Woyach:Morphosys: Research Funding; Karyopharm: Research Funding; Acerta: Research Funding. Lozanski:Stemline Therapeutics Inc.: Research Funding; Genentech: Research Funding; Beckman Coulter: Research Funding; Boehringer Ingelheim: Research Funding.