Adults with hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD) frequently require surgery and invasive procedures. However, there is variability in perioperative management guidelines. We describe our periprocedural outcomes in this setting. A retrospective chart review from January 2006 to December 2012 of patients with HA, HB, and VWD undergoing surgery or invasive procedures was conducted. Type of procedures, management including the use of continuous factor infusion, and administration of antifibrinolytics were reviewed. Adverse outcomes were defined as acute bleeding (<48 hours), delayed bleeding (≥48 hours), transfusion, inhibitor development, and thrombosis. We identified 59 patients with HA and HB. In all, 24 patients had severe hemophilia and 12 had mild/moderate hemophilia. Twelve patients had inhibitors. There were also 5 female carriers of HA and 6 patients with VWD. There were 34 major surgeries (26 orthopedic, 8 nonorthopedic) and 129 minor surgeries. Continuous infusion was used in 55.9% of major surgeries versus 8.5% of minor surgeries. Antifibrinolytics were administered in 14.7% of major surgeries versus 23.2% of minor surgeries. In all, 4 patients developed acute bleeding and 10 patients developed delayed bleeding. Delayed bleeding occurred in 28.6% of genitourinary procedures and in 16.1% of dental procedures. Five patients acquired an inhibitor and 2 had thrombosis. In conclusion, patients with HA, HB, or VWD had similar rates of adverse outcomes when undergoing minor surgeries or major surgeries. This finding underscores the importance of an interdisciplinary management and procedure-specific guidelines for patients with hemophilia and VWD prior to even minor invasive procedures.

In patients with confirmed or suspected type 1 von Willebrand disease (VWD), adenotonsillectomy has been reported to be associated with a rate of peri-operative hemorrhage between 8 and 23%. Desmopressin acetate (DDAVP, 1-deamino 8-D arginine- vasopressin) is the treatment of choice for type 1 patients with baseline von Willebrand factor levels of 10 IU/dL or greater. DDAVP is generally well tolerated; however, severe hyponatremia and seizures have been reported in young children less than 2 years of age, limiting its use in this age group. Antifibrinolytic therapy plays an important adjunctive role in the effective treatment of mucocutaneous bleeding, particularly in the oropharynx where the salivary concentration of fibrinolytic enzymes is high. During the past 10 years, we treated 6 pediatric patients with mild/moderate type 1 VWD undergoing an adenotonsillar procedure at our institution with the same hemostatic regimen consisting of one single dose of DDAVP and an extended use of EACA. In this small case series, the above mentioned prophylactic treatment regimen was both well tolerated and efficacious in controlling hemorrhage. Furthermore, DDAVP-related complications were avoided in a pediatric population with a higher risk of developing them.

The PRO-RBDD is a prospective study of fibrinogen and FXIII deficiency designed to collect data on demographics, laboratory phenotype, genotype, clinical manifestations, obstetric data, surgery, treatment type and its efficacy and safety. Central laboratory testing is also available for diagnosis confirmation and genotyping. The aims of the study are to evaluate the prevalence of bleeding episodes, establish the minimum coagulant activity level to prevent bleeding (spontaneous or post-traumatic), and to monitor patients’ therapeutic regimens (efficacy and complications). The PRO-RBDD network involved 52 Hemophilia Treatment Centers (HTCs) worldwide for a predicted 380 and 573 patients with fibrinogen and FXIII deficiency, respectively. Data collection started in February 2013 and will continue for 3 years (baseline and 6 follow-up visits are planned). Clinical bleeding episodes were classified into four categories of severity relying on the location and potential clinical impact as well as spontaneity of bleeding. Statistical analysis was performed using chi-square. Linear regression analysis was used to explore the association between coagulation factor activity level and clinical bleeding severity, with the relationship between the two variables defined through the coefficient β. Currently, 26 HTCs have obtained local ethical committee approval and 15 have started data entry for 89 and 109 fibrinogen and FXIII deficient patients, respectively. Demographic data showed a similar distribution between males and females with a median age of 21 years (range: 1-84) and 19 years (range: 3-71) for fibrinogen and FXIII deficiency respectively; 38% and 22% of fibrinogen and FXIII deficient patients, respectively, were children (<12 years). The Table reports the association between residual coagulant level (laboratory severity) and clinical bleeding severity for both patient groups (p<0.01). Linear regression confirmed this association (fibrinogen: β=-0.29, p<0.01; FXIII: β=-12.94, p<0.01). Patient age at diagnosis and the type of treatments utilized are also reported (Table). In 33 women with fibrinogen deficiency and 21 with FXIII deficiency, 10 (30%) and 2 (10%), respectively, had menorrhagia; 5 out of 27 pregnancies (18%) in women with fibrinogen deficiency, and 16 out of 26 pregnancies (61%) in women with FXIII deficiency, resulted in spontaneous abortion; bleeding during pregnancy was observed in only 3/21 (14%) FXIII deficient women (only 1 of whom was on prophylaxis). Follow-up data are available for up to 500 days for 51 and 28 patients with fibrinogen and FXIII deficiencies, respectively. Three out of 6 patients with fibrinogen deficiency (50%) on prophylaxis (30-45 mg/kg/month fibrinogen concentrate), experienced bleeding, while no bleeding was observed for 39 of the 45 fibrinogen deficient patients treated on-demand. Of the 14 patients with FXIII deficiency not on prophylaxis, 2 (14%) had spontaneous bleeds. No bleeding was reported for patients with FXIII deficiency on prophylaxis. No thrombotic events were recorded for any patients. Preliminary data from the PRO-RBDD study of patients with fibrinogen and FXIII deficiency confirmed a strong association between coagulant activity levels and clinical severity in both deficiencies, and the efficacy of prophylaxis in patients with FXIII deficiency. For fibrinogen deficiency, the optimal prophylactic treatment regimen requires further study. Abstract 2838. Table Fibrinogen patients FXIII patients Laboratory severity Severe undetectable Moderate 0.1-1 g/L Mild >1 g/L Severe undetectable Moderate 5-30% Mild >30% Bleeding severity Asymptomatic (no documented bleeding episodes) 1 (1%) 16 (19%) 12 (14%) 0 0 9 (10%) Grade I (bleeding after trauma or drug ingestion) 1 (1%) 7 (8%) 4 (5%) 2 (2%) 3 (3%) 2 (2%) Grade II (spontaneous minor bleeding) 4 (5%) 4 (5%) 5 (6%) 1 (1%) 1 (1%) 1 (1%) Grade III (spontaneous major bleeding) 22 (26%) 9 (10%) 0 70 (74%) 6 (6%) 0 Age at diagnosis median (min,max) 1.5 (0,24) 9 (0,84) 29 (0,64) 5 (0,54) 7 (0,36) 30 (2,46) Treatment type On demand 17 (20%) 38 (43%) 21 (24%) 8 (8%) 8 (8%) 7 (7%) Prophylaxis 11 (13%) 0 0 67 (71%) 2 (2%) 4 (4%) Disclosures Peyvandi: Biotest: Research Funding; Baxter: speaker's fee Other; Bayer: speaker's fee Other; Grifols: speaker's fee, speaker's fee Other; LFB: speker's fee, speker's fee Other; CSL Behring: speaker's fee, speaker's fee Other; NovoNordisk: Research Funding, speaker's fee Other; Kedrion biopharma: Research Funding. Mumford:NovoNordisk: Consultancy, speaker fee Other.

BACKGROUND There is no effective therapy for patients (pts) with IDH-mutant gliomas that progress after RT and chemotherapy. At time of progression, these tumors have often transformed to glioblastoma (GBM) and have increased numbers of somatic mutations, i.e. have a “hypermutator phenotype”. We hypothesized that there is synergistic efficacy of Avelumab (anti-PD-L1) combined with HFRT in pts with secondarily transformed IDH-mutant GBMs. Safety-lead-in results will be presented. METHODS This is a phase II, open-label, single-arm, multicenter study of Avelumab with HFRT in adults with transformed IDH-mutant GBM who previously received RT and TMZ and/or PCV. All pts received Avelumab 10 mg/kg IV followed at Day 8 by HFRT (25 Gy in 5 daily 5-Gy fractions) and then Avelumab 10 mg/kg IV every 2 weeks. A 3 + 3 design was used for a 6-patient safety-lead-in cohort. Adverse events were recorded according to CTCAE. RESULTS Six pts (F=4, M=2) with a median age= 45.5 yrs (range 31.5–54.4 yrs) were enrolled in the safety-lead-in cohort. No DLT was observed. Grade ≥ 3 AEs included increased cerebral edema (3 pts), hyponatremia (1 pt) and worsening hemiparesis (3 pts). Grade ≤ 2 AEs included nausea, hypothyroidism, lymphopenia, thrombocytopenia, transaminase elevation, and fever/chills. Median follow-up time was 8.9 mo. Best treatment response was SD in 1 patient. At time of last follow-up all pts have discontinued treatment for PD. Median PFS was 4.2 mo (range 1.4–5.7). Median OS was 10.1 (range 6.8–21+) mo. 4 pts (67%) died, 2 pts remain alive in follow-up at 6.9 and 21.6 months after treatment initiation. The study was closed after the safety lead-in completed enrollment due to slow accrual. CONCLUSIONS Avelumab combined with HFRT was tolerable without dose-limiting toxicity in this safety-lead-in cohort of adult patients with transformed IDH-mutant GBM. Further studies are necessary to determine efficacy of this treatment regimen.

Introduction Adults with hemophilia and von Willebrand disease (VWD) frequently require surgical and invasive procedures. There is variability in current practice of peri-operative management in major surgery and in the management of invasive procedures. The purpose of this study was to evaluate outcomes and management strategies in patients with hemophilia and VWD undergoing surgical and invasive procedures in a comprehensive hemophilia center at a tertiary care hospital. Methods A retrospective review of electronic medical records was carried out from patients with hemophilia and VWD seen at the Weill Cornell Hemophilia Treatment Center undergoing surgery or an invasive procedure from January 2006 to December 2012. Information on demographics, diagnosis, severity, and presence of inhibitors was also collected. Procedures and treatment strategies were reviewed including the type of procedure, use of factor bolus/DDAVP, continuous infusion(CI), and antifibrinolytics. Outcomes from these cases were reviewed for acute bleeding (<48 hours after procedure), delayed bleeding (>48 hours after procedure), transfusion of blood products, inhibitor development, and post-procedure thrombosis. Data were compared using Fischer’s exact test. Results Our study population consisted of 59 patients (mean age=58, range 21-77). Our hemophilia group included 41 with hemophilia A and 7 with hemophilia B. Our hemophilia patients were severe (n=24), mild-mod (n=12), and 12 had inhibitors. We also identified 5 female carriers of hemophilia A.We identified 6 VWD patients including Type 1 (n=3), 2A (n=1), 3 (n=2). We reviewed 34 major surgeries (26 orthopedic, 8 non-orthopedic) and 91 invasive procedures. We covered all patients an initial dose of either factor VIII/IX or DDAVP. In addition, 55.9% of major procedures were covered by continuous factor infusion (CI), whereas only 9.9% of minor procedures were covered by CI. Conversely, antifibrinolytics were used in 14.7% of major surgeries and 34.1% of minor procedures. Antifibrinolytics were used in all types of minor procedures except those involving the genitourinary tract. Hematologic outcomes are shown in Table 1. We identified 4 cases of acute bleeding and 10 cases of delayed bleeding. We also identified 5 cases of inhibitor development. We identified one thrombotic episode in an orthopedic surgery case. We further examined several classes of procedures including dental, GI endoscopies, GU procedures, biopsies, and GYN procedures in carriers. One transfusion was needed in the case of a liver biopsy; acute bleeding was noted in 2 biopsies and 1 endoscopy. Delayed bleeding accompanied 28.6% of GU procedures and 16.1% of dental procedures. Inhibitor development was noted after 1 GU procedure and 2 dental procedures. Conclusions Our adult hemophilia and VWD population undergoing minor procedures showed similar rates of adverse hematologic outcomes compared to major surgery. This finding highlights the significant risk of even minor procedures in adults with bleeding disorders. Appropriate treatment standards should be designed to take into account patient responses, procedure type, and anticipated outcomes. Disclosures: No relevant conflicts of interest to declare.