ACCEPTED ABSTRACTS

Rectal Rebellion: A Case Report of Plasmacytoid Urothelial Carcinoma with Rectal Metastasis

Janani Arunachalam - University of Connecticut; Anand Bhagat - UConn; Brian Byrne MD - Hartford Healthcare

Background: Plasmacytoid Urothelial Carcinoma (PUC) is a rare subtype of urothelial cancer,

characterized by morphologic resemblance to plasma cells with a CDH1 mutation.Conventional UC

commonly spreads to lymph nodes, bones, lungs, and liver.​​

Methods: We present a unique case of newly found metastasis of PUC to the rectum.

Results: A 61 y.o. M with high-grade UC stage IIIA status post cystoprostatectomy and pelvic lymph node

dissection on gemcitabine/cisplatin presented with three weeks of lower abdominal cramping and fecal

urgency after eating. He reported intermittent loose stools with 10-15 small formed bowel movements a

day. He denied hematochezia, melena, fevers, chills, or weight loss. A restaging computed tomography

scan of the abdomen and pelvis showed a new anorectal wall thickening. Colonoscopy showed a

partially obstructing large circumferential mass measuring 4cm in the mid-rectum. Pathology showed

acutely inflamed, congested rectal mucosa with no neoplasm identified. However, due to high suspicion

of metastasis, magnetic resonance imaging and positron emission tomography scans were pursued. MRI

of the pelvis showed circumferential rectal wall thickening and intramural edema from the rectosigmoid

junction to the anorectal junction. PET showed moderately intense hypermetabolism within a

circumferentially thickened rectum. He subsequently underwent endoscopic ultrasound and repeat

biopsy showing metastatic urothelial carcinoma in the rectal wall. The patient was treated with

pembrolizumab and enfortumab, showing radiographic and clinical improvement.

Conclusions: This case underscores the importance of remaining vigilant for uncommon metastatic

patterns in aggressive PUC especially in the gastrointestinal tract as pathology can mimic other

malignancies.

The presence and impact of disease-related anxiety among transplant and cellular therapy

recipients: A pilot study

Tiffany Dcruze - Geisel School of Medicine at Dartmouth; Julie R. Doherty MA - The Dartmouth Institute for Health Policy & Clinical Practice; Aricca D. Van Citters, MS - Department of Hematology, Dartmouth Cancer Center, Christi Ann Hayes MD - DHMC - Norris Cotton Cancer Center

Background: Disease-related anxiety (DRA) is an important consequence that follows cancer survivors

after remission. We aimed to identify the presence and impact of DRA among transplant and cellular

therapy (TCT) recipients.

Methods: A convenience sample of ten adults who received TCT at an NCI-designated cancer center

were asked to complete semi-structured interviews and three validated anxiety measures: Generalized

Anxiety Disorder-7 (GAD-7), Fear of Progression Questionnaire (FoP-Q), and Intolerance of Uncertainty

Scale (IUS). The primary clinician team also provided subjective assessments of DRA for each patient. A

mixed-methods approach was used to analyze responses.

Results: All patients received allogeneic transplants for hematologic malignancies and one patient also

received CAR-T cell therapy. Most were female (n=8). Five themes were shared among all patients: fear

of relapse, thoughts about disease and its complications, lifestyle changes from curative therapy,

treatment satisfaction with their care team, and importance of support and resources. Half of patients

exceeded clinical cut-offs on the GAD-7 and FoP-Q. Half scored above 50% on the IUS. Of patients with

clinically significant scores, clinicians’ subjective assessments identified less than half with clinically

relevant DRA.

Conclusions: While all patients self-reported anxiety regarding their disease process, not all patients had

clinically significant scores on validated anxiety measures, and even fewer were identified to have DRA

by subjective clinician assessments. Despite lasting emotional and physical effects of TCT, patients

continued to share a positive outlook of their treatment and towards their support system. Future steps

include examining changes in DRA according to time elapsed since TCT.

A Not So Benign Problem: Strategies to Improve Access to Hematologic Care in Rural Northern

New England

Christi Hayes, MD - DHMC - Norris Cotton Cancer Center; Matthew Sullivan, Heather Jarvis, Robyn Longley, Alisa Health, Ryan Montano - Dartmouth Health

Background: The demand for hematologic consultations is rising while the number of current and

predicted hematologists declines. Volume and incomplete referral information create delays in patient

access.

Methods: We conducted a 3-month review of the incoming hematology referral process to identify

barriers to access and to decrease the referral to appointment time. Barriers were identified and multi-

modal intervention was piloted to address these concerns. Phase 1 of the invention involved the

conversion of some referrals to e-consults after under the direction of two hematologists.

Results: Over three months, 30% of referrals to our hematology service reviewed by the provider team

were converted to e-consults. Average referral to appointment time for routine hematologic referrals

were reduced from 44 days to 28 days.

Conclusions: E-consults for appropriate patients are one strategy to improve access to hematologic care.

Simple questions can be answered electronically. This in turn, allows more complex patients to be seem

faster by strategically using the available in-person appointments. We are piloting additional

interventions to further decrease wait times. We are developing more detailed referral forms to

capture all relevant data for each referral. In addition, we are piloting “new patient” clinic sessions to

decrease the backlog of referrals.

Community Cancer Program Integrated Team Approach to Oral Anticancer Therapy

Sonya Perkins, BSN, RN, MSCRN, OCN, Oncology Nurse Navigator - Mercy Cancer Care; Jessica Charland BSN, RN, Oncology Nurse Navigator - Mercy Cancer Care

Background: With the use of oral oncolytics growing exponentially; this poses challenges around

prescribing, dispensing, adherence, and patient/family education, especially in smaller cancer programs

without separate oral adherence teams. The shift from intravenous administration within controlled

clinical settings to the home, heightens the need for strong workflows to facilitate the same safety

systems and multidisciplinary approach to care as patients on parental therapy.

Methods: At Northern Light Mercy Cancer Care we developed a patient centric oral therapy workflow

between physicians, pharmacy, ancillary and nursing to eliminate barriers, provide education, monitor

symptoms, and monitor for adherence. The hallmark of the program being a multidisciplinary approach

and combination of high touch and technology, using the electronic medical record to support all

aspects of the process.

Results: The process begins at initial consult with a warm handoff between provider and nurse who

meets with the patient same day, initiates a learning needs and barriers to care assessment. Financial

advocates receive electronic notifications, starting the prior authorization and financial barriers

assessment. Dose verification is done before script is sent to pharmacy. Patients attend an individualized

multidisciplinary teaching session. The nurse verifies start date with patient. Structured cadence for

adherence and symptom assessment calls is initiated. Adherence calls alternate with clinic visits allowing

for close observation of laboratory values and toxicities.

Conclusions: Combining technology, with human touch points has helped decrease discrepancies in care

and fostered a seamless system for initiating and managing patients on oral oncolytic medication.

Spatial Genomic Characterization in Multifocal Bladder Cancer

M. Talha Ugurlu, MD - Internal Medicine, Carney Hospital, Tufts University; Rachel Goldberg - Johns Hopkins University, Department of Otolaryngology; Leslie Cope - Johns Hopkins University, Department of Otolaryngology; David Sidransky - Johns Hopkins University, Department of Oncology; Mohammad O.

Hoque - Johns Hopkins University, Department of Otolaryngology

Background: Urothelial cancer of bladder (UCB) is a well-known multifocal disease with varying

morphology and gene mutation profiles. Although it doesn't entirely explain the UCB, there are two

different proposals regarding the origin of spatially independent tumors in the bladder. This could occur

either through clonal expansion where a single mutated cell extends to a distinct tumor with further

mutations or field effect where carcinogens affect the bladder lining by synchronous transformation of

multiple cells. A clear understanding of the origin of multifocal UCB has important implications for the

effective tailoring of personalized diagnostics and treatment. Despite efforts to identify intratumoral

and intertumoral heterogeneity, the clonal origin of UCB is still debated.

Methods: To better understand the genetic mechanism behind the multifocality of UCB, we performed

targeted next-generation sequencing (NGS) on 40 UCB lesions obtained from 15 bladders that were

removed by cystectomy. We used germline distant muscle DNAs as a control group. After we detected

mutations with NGS, we validated selected mutational events by using ultra-sensitive droplet digital PCR

(ddPCR).

Results: Tumors from individual patients display nearly identical mutational landscapes, with few

heterogeneous events. These heterogeneous events may have been acquired at a later point during the

cancer development. Sequencing demonstrated similar genetic drivers within the same patient and

revealed that clonal expansion is an early event of tumorigenesis. We also found distinct gene mutations

in different UCB patients suggesting interpatient heterogeneity of clonal events in the UCB. Our result

showed that TP53, FGFR3 and NOTCH4 are the most frequently mutated genes. Utilizing ddPCR, we

validated alterations associated with tumorigenesis in TP53, FGFR3, AKT, PIK3CA genes.

Conclusions: Our study provides insight into the clonal origin of multifocal UCB and demonstrates that

targeted next-generation sequencing is a reliable and sensitive method for interpreting the genetic

landscape of UCB. These findings have the potential to inform clinical practice as sequencing of one

single focus from a patient with the multifocal disease might be sufficient to understand the mutational

profile and guide personalized treatment and risk stratification.