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2023 Annual Meeting Accepted Abstracts
*Indicates selected for podium presentation
Click on abstract title to view digital poster (if available).
David Alfonso Alejos Castillo, David Alejos, Xiaocao Xu, Jinah Kim, Hibba tul Rehman
University of Vermont Medical Center
Background
Vulvovaginal melanomas are rare tumors and have less response to immune checkpoint inhibitors (ICI) and other therapies used for cutaneous melanomas. Surgery is the preferred primary treatment for vulvovaginal melanomas. Systemic treatment is extrapolated from metastatic cutaneous melanoma. Talimogene laherparepvec (T-VEC) is approved for locally advanced unresectable cutaneous melanoma.
Methods
We present a case of vaginal melanoma with inguinal nodal metastasis treated with single agent immunotherapy and intralesional T-VEC with pathologic complete response (pCR) of inguinal metastases.
Results
An 83 yo woman was diagnosed with vaginal melanoma with left inguinal node metastases. Therapy with nivolumab was started but patient developed grade 3 autoimmune hepatitis requiring steroid therapy and delay of treatment. Pelvic exenteration was recommended but patient declined procedure. Subsequently, patient underwent palliative resection of vaginal lesion due to ongoing bleeding. Nivolumab was restarted with good response to vaginal lesion on imaging but increasing inguinal lymphadenopathy. A US guided FNA biopsy confirmed metastatic melanoma of inguinal lymph nodes. T-VEC injections to abnormal nodes were started. Nivolumab was switched to pembrolizumab to match T-VEC injections, which she received for 1 year. Subsequent repeat inguinal lymph node biopsy showed pCR and no evidence of disease on imaging.
Conclusions
Vulvovaginal melanomas are rare & aggressive subtype of melanomas. There is limited data on systemic therapy for advanced disease. To our knowledge, this is the first case of T-VEC injections and immunotherapy for advanced vaginal melanoma leading to pCR. This case highlights the possibility of adding T-VEC to the limited treatment options for vulvovaginal melanomas.
David Alfonso Alejos Castillo, David Alejos, Xiaocao Xu, Jinah Kim, Rohit Singh, Hibba tul Rehman
The University of Vermont Medical Center
Background
Vascular endothelial grow factor (VEGF) plays a role in tumor angiogenesis and it’s a potential modulator of the innate immune response. Studies have shown increased survival benefits of immunotherapy following chemotherapy combined with VEGF inhibitors.
Methods
We present two cases of metastatic non-small cell lung cancer (NSCLC) with prior immunotherapy resistance that are in remission after developing immune side effects after exposure to VEGF inhibitors.
Results
A 64 y/o female with metastatic NSCLC, PDL-1 1-10%, who received carboplatin/pemetrexed/pembrolizumab and progressed on maintenance therapy. She was switched to docetaxel/ramucirumab with dramatic response but therapy was permanently stopped due to severe AKI and dehydration after developing diarrhea from colitis (which on biopsy was consistent with ICI colitis). She received SBRT to lung and adrenal lesion. Patient has been off therapy for >3 years without evidence of disease.
A 77 y/o male with widely metastatic NSCLC, PDL-1 <1%, no targetable mutations, who progressed after 6 cycles of carboplatin/pemetrexed and was switched to nivolumab. Patient had disease progression RUL node and therapy was switched to docetaxel/ramucirumab with good response to treatment. Therapy was held due to pancreatitis (later one felt to be from prior ICI). He received SBRT to RUL lesion and has been off therapy for 3 years without evidence of recurrent disease or new metastasis, despite having multiple metastasis at diagnosis.
Conclusions
Both our patients developed toxicity that is typical for immune check point inhibitors (ICI) after exposure to VEGF inhibition but achieved remission. There might be resensitization of immune system from VEGF I exposure.
Evaluating the Use of Weighted Blankets as an Anxiety Reduction Tool During Cancer Treatment
Cynthia Arcieri, RN1, Victoria Cole BSN RN OCN2, Cherice Hermann BSN RN OCN2
1 Dana-Farber/NH Oncology-Hematology
2 Dana Farber Cancer Institute
BackgroundAnxiety in cancer is a common emotion. Oncology nurses observe this heightened anxiety, especially early in treatment. Evidence indicated that weighted blankets have few side effects and reduce anxiety in various populations, including cancer patients. Benchmarking revealed few cancer centers use weighted blankets.
To support anxiety reduction by providing weighted blankets for chemo/immunotherapy-naïve patients.
Methods
Patients admitted to the ambulatory infusion clinic for infusions were offered a weighted blanket with their first and second treatment visits after consent. A pre-survey (before infusing chemo/immunotherapy) and post-survey (after wearing blanket for 20 minutes) evaluated self-reported state anxiety levels and patient usability. Nurses were educated on using weighted blankets and voluntarily completed surveys addressing feasibility.
Results
Patients’ anxiety was reduced with use of weighted blankets with dramatic reductions seen with the first infusion visit. Comparisons of pre- and post- survey results showed extreme anxiety reduced from 6% to 0%; moderate anxiety reduced from 28% to 18%; and reports of very little to no anxiety increased. 100% of nurses reported the use of weighted blankets as feasible (easy to apply/carry, did not interfere with care, etc.). Open ended patient survey feedback was overwhelmingly positive. Noted themes included “comforting,” “calming,” and “relaxing,”.
Conclusions
Weighted blankets enhanced patient experience and supported anxiety reduction across treatments. Nurses found them feasible and appreciated the benefits for their patients. Anxiety reduction and management strategies for patients during treatments for cancer are needed. Including weighted blankets in a comprehensive toolkit of strategies may impact important outcomes such as treatment adherence.
Natalie Bales, B.S.1, Christopher J. Anker, M.D.2, Alissa Thomas, M.D.3, Hibba Rehman, M.D.3, Brandon Liebelt, M.D3, John DeWitt, M.D3, Peter Callas, Ph.D.3
1 The Robert Larner, M.D. College of Medicine at The University of Vermont
2 Division of Radiation Oncology, The University of Vermont Medical Center
3 The University of Vermont
Background
For patients with limited brain metastases (≤ 4) from lung cancer or melanoma, stereotactic radiosurgery (SRS) is typically preferred, although immune checkpoint inhibitors (IO) and targeted therapy (TT) have become first-line therapeutic options as well. However, outcomes with IO or TT without SRS compared to a combination approach are poorly defined in terms of oncologic outcomes and risk of radionecrosis.
Methods
Retrospective single-institution review of patients with lung cancer or melanoma brain metastases receiving treatment with IO or TT between 2015-2022.
Results
95 charts met inclusion criteria (Table 1). Median overall survival (OS) for patients treated with IO/TT alone (34) and IO/TT concurrent with SRS (61) was 1.3 and 1.8 years (Figure 1; p=0.53) and median follow-up time for those who survived 4.2 and 3.0 years, respectively. The 3-year OS rate is 38% and 33% for each. Median times to intracranial progression were 2.7 and 1.9 years (p=0.72), and median times to extracranial progression were 0.8 and 1.2 years (p=0.38), respectively (Figures 2 and 3). For patients receiving IO/TT alone, 8/34 (23.5%) required salvage SRS. The rate of radionecrosis among that cohort was 0/8 (0%) compared to 14/61 (23%) in the concurrent group (p=0.19) and 6/14 (43%) received treatment for it.
Conclusions
There was no significant difference in OS among patients receiving IO/TT alone versus IO/TT and SRS. Radionecrosis was avoided in patients receiving salvage therapy. This may suggest the ability to delay or eliminate the need for SRS for intracranial disease control in patients who are candidates for IO or TT.
Collaboration and interdisciplinary simulation yields inspiring results
Anne Cogan, MSN, RN, OCN, NPD-BC, Kate Poole MSN, RN, NPD-BC, CPAN, CST, Julie Cole MSN, RN NPD-BC
Wentworth-Douglass Hospital
Background
To better serve the prostate cancer patient population a community hospital planned to expand their options to include high-dose rate (HDR) brachytherapy treatment. Simulation was used to train and identify barriers prior to initiating this low-volume high-risk procedure involving multiple healthcare disciplines.
Methods
This project required Nurse Professional Development (NPD) practitioners to coordinate training for interdisciplinary care teams from multiple departments: registered nurses from radiation oncology and surgical services, surgical technologists, urologists, anesthesiologists, radiation therapists, physicists, and a radiation oncologist. The expected outcomes of training were to coordinate safe and effective treatments, as well as identify potential barriers. NPD practitioners used the principles of the NPD practice model and best practices for simulation to guide their work. Elements of planning for the NPD practitioners included environmental scanning, observation of HDR treatment in another facility, reviewing standards of practice and applying principles of andragogy. NPD practitioners conducted an initial simulation with the operating room and radiation oncology teams to make critical decisions related to the treatment process, build relationships, and introduce the radiation oncology team to the operating room environment. A second simulation involving 36 participants replicated the entire HDR brachytherapy process.
Results
Simulation allowed participants to practice providing treatment in a safe environment while identifying barriers. The NPD team prepared and disseminated a summative report that provided actionable items which positively impacted the implementation of HDR brachytherapy prostate cancer treatment at this institution.
Conclusions
Simulation is an effective tool for preparing for high-risk procedures involving multidisciplinary teams.
Integrated Literature Review of Oncology Telephone Triage
Melissa Curran
Monadnock Community Hospital
Background
Telephone triage in oncology practice has become an integral tool for patient care which leans on the performance of telephone triage by way of those answering the call within organizations. The quality, safety, and satisfaction of telephone triage cannot be underestimated when mitigating patient symptoms prompting a search for best practices.
Methods
Integrated literature review approach and AHRQ themes of quality, patient safety and satisfaction as constructs to discern methods of approach for positive patient outcomes.
Results
Evidence shows that Implementation of a protocol/tool to perform oncology telephone triage promotes patient quality, safety and patient satisfaction.
Conclusions
Oncology telephone triage using a protocol/tool also promotes adherence to treatment regimen, earlier symptom management relief and lessens the burden on additional services including emergency room visits and hospital admissions.
Tiffany D'cruze1, Julie R. Doherty MA3, Christi Ann Hayes M.D.2, Kenneth R. Meehan M.D.2, Kate L. Caldon RN2, Charlotte M. Coughenour2, Anna N. A. Tosteson ScD3, Aricca D. Van Citters MS3
1 Geisel School of Medicine at Dartmouth, Lebanon, NH
2 Department of Hematology, Dartmouth Cancer Center, Dartmouth Hitchcock Clinics & Medical Center, Lebanon, NH
3 The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
Background
Patient-centered care requires an understanding of patient values in order to prioritize goals for treatment. Pre-visit questionnaires (PVQs) completed by patients prior to a visit can elicit patient concerns and improve communication. In this pilot study, we aimed to identify the primary concerns and goals of care expressed by people receiving HSCT.
Methods
Adults receiving HSCT at an NCI comprehensive cancer center completed an electronic PVQ up to seven days prior to visits to assess their top concerns and goals of care. We conducted a qualitative analysis of patient responses between January 2022 to August 2023.
Results
We collected 262 PVQs that identified goals or concerns from 92 HSCT patients. The most common concerns identified prior to visits included physical issues (n=135, 52% of visits) and planning ahead issues (n=50, 19%). Physical symptoms most often included stable or increased pain (n=44, 33%) or decreased energy (n=35, 26%). Planning ahead issues most often included questions about treatment (n=31, 62%). Although patients were able to select multiple concerns associated with the visit, patients categorized 40% (n=105) of visits as a “routine visit”. When asked what mattered most, patients cited achieving personal goals (n=54, 21%), such as traveling or spending time outdoors.
Conclusions
Open-ended agenda setting PVQs provide valuable insight into patients’ concerns and offer an opportunity to support agenda setting and create treatment plans that best meet shared goals. This study is ongoing and future steps will examine the frequency and impact of disease-related anxiety through patient interviews.
Janice Dallacosta, RN, OCN, Janice DallaCosta, RN, MBA, OCN, Ny Tran, NP,Patrick Skeffington PHarmD, MHA, MSRA
Southcoast Health
Background
Cisplatin and cetuximab can cause hypomagnesemia thought to be related injury to the ascending limb of the loop of Henle where the majority of magnesium is reabsorbed. This injury can occur as much as six years after treatment is complete. Unfortunately, the symptoms of hypomagnesemia mimic the side effects that patients experience when on these treatments; nausea, vomiting, poor appetite, weakness, fatigue, muscle cramps and confusion. This can lead to misdiagnosis and treatment. As the number of patients receiving cisplatin and cetuximab increased, pharmacy noticed an increase in electrolyte replenishment infusions ordered. There was a corresponding increase in urgent care visits for evaluation of electrolyte imbalances. With support of the medical staff: SCH nurse practitioners, pharmacists and nursing staff met to develop and institute a plan to minimize incidence of hypomagnesemia and to treat it should it occur.
Methods
- Nurse practitioners, pharmacy staff and nursing joined forces to update chemotherapy treatment plans in the Southcoast Epic platform to have frequent lab monitoring along with provider visits to ensure that labs are evaluated in a timely manner
- Oral magnesium prescriptions have been added to all plans that include cisplatin and cetuximab
Results
This group developed an electrolyte replacement protocol to allow nursing staff to follow a thorough protocol that outlines replacement and monitoring parameters based on lab levels and patient symptoms
Conclusions
- Decrease in IV magnesium infusions required by patients
- Decrease in hospital admissions related to electrolyte imbalances
Janice Dallacosta, RN, OCN, Patrick Skeffington, PharmD, MHA, MSRA, Virginia Camisa, rPH, Donna Raymond, rPH
Southcoast Health
Background
Drug shortages have plagued pharmacy departments for the last two decades with the injectable drugs shortage at 50%. Of the Top 5 drug classes, chemotherapy shortages account for 25% of drugs unavailable. Recent study cited reasons for shortages given by Big Pharma as supply/demand issues, manufacturing woes and business decisions. However 56% of the time, actual reason given is, “unknown or manufacturer would not provide” (University of Utah Drug Information Service). This is a huge burden on pharmacies, prescribers and nurses treating patients in need of chemotherapy.
Methods
Groups such as ASCO drug advisory group and Society for Gynecologic Oncology have issued clinical guidance on treatment alternatives during shortages and GI treatment guidelines come from these groups. Prescribers at SH reviewed these guidelines and patients were evaluated for alternative therapies based on both the guidelines and availability of chemotherapy that pharmacy was able to procure.
Results
May thru August 2023; three drugs were evaluated as critical shortages at the SH; cisplatin, carboplatin and fluorouracil. Due to intermittent releases of product, carboplatin and cisplatin usage for curative patients was not interrupted but prescribers considered alternative therapies for palliative patients. Fluorouracil patients, priority was given to curative patients, palliative patients suggested to switch to capecitabine containing regimens. For those not tolerant of oral capecitabine, removal of IVP fluorouracil bolus and rounding down of fluorouracil IV pump doses was suggested.
Conclusions
Capecitabine usage increased significantly as did corresponding workload for pharmacy and nurse navigators as oral chemotherapy administration includes much patient preparation.
Post-transplant cyclophosphamide: A double-edged sword
Adam J Ephraim M.D.1, James N Kaz D.O.2, Michael L Baker M.D.2,cJohn M Hill, Jr M.D.3
1 Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
2 Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
3 Department of Internal Medicine, Section of Hematology & Oncology, Dartmouth Cancer Center, Lebanon, NH
Background
Long-term survival for adults with secondary acute myeloid leukemia (AML) is poor. Allogeneic stem cell transplant (SCT) represents the only potentially curative modality for such patients, by replacing diseased bone marrow with a healthy donor graft to utilize an adoptive immunotherapeutic response against the leukemia, known as the graft-versus-leukemia effect. However, many patients lack a suitable donor, warranting haploidentical SCT, yet this carries a high risk for graft-versus-host disease (GVHD). Luznik, et al. reported utilization of high-dose, post-transplant cyclophosphamide (PTCY) to minimize GVHD via destruction of allo-reactive donor T cells following haploidentical SCT.
Results
A 69 year old male with secondary AML underwent haploidentical SCT via Flu/Cy/TBI conditioning with PCTY. His post-transplant course was complicated by hypoxic respiratory failure, and imaging showed progressive, multilobar opacities with a ground glass component, prompting bronchoscopy that was unrevealing for hemorrhage or infection. He unfortunately expired, and autopsy demonstrated acute lung injury most consistent with interstitial pneumonitis-like fibrosis, felt indicative of cyclophosphamide toxicity. Cardiac and renal findings were unremarkable, and, notably, there was no evidence of hemorrhagic myocardial necrosis.
Conclusions
This case highlights rare but potentially severe pulmonary toxicity associated with high-dose cyclophosphamide, which can manifest as early-onset pneumonitis or late fibrosis. While PTCY has revolutionized haploidentical SCT delivery and is, thus, now increasingly used in HLA-matched SCTs, clinicians must remain vigilant for potential adverse effects. Further data are needed to better elucidate the incidence, risk factors, and optimal management strategies for pulmonary complications associated with PTCY in the context of SCT.
Hypodysfibrinogenemia: A Case of a Rare Bleeding Disorder
Garima Gautam M.D., Ashish Sharma M.D., Ritika Vankina M.D.
UCONN Health, Internal Medicine and Hematology Oncology
Background
Hypodysfibrinogenemia, a rare bleeding disorder; is among the congenital fibrinogen disorders. It shares features of both hypo and dysfibrinogenemia.
Methods
A 32-year-old female presented recurrent epistaxis, prolonged bleeding from minor wounds, menorrhagia, tonsillectomy with blood transfusion, and a post-surgery muscle hematoma. The patient scored 18 on the ISTH bleeding assessment tool. Mother had an undiagnosed bleeding disorder. Laboratory studies revealed normal PT 10 s, PTT 27s, and Reptilase time of 18.6 seconds. High Thrombin time 21.3s, low fibrinogen level 135 mg/dL, fibrinogen antigen 133 mg./dl.
Results
Gene sequencing identified heterozygous FGG gene (c.1129+632A>G)Variant of Uncertain Significance (VUS) and also heterozygous FGG gene (c.323C>G; p.Ala108Gly)VUS.
Conclusions
The patient appears to have congenital hypo dysfibrinogenemia, therefore she was assessed for FGA, FGB, and FGG genes. Interestingly genetic sequencing showed two VUS in the FGG gene. Approximately 10% of the time a VUS may later be reclassified as disease-causing (pathogenic). The FGG gene would be a strong phenotypic fit given her clinical picture. Her FGG variant(s) may have the potential to be diagnostic in the future as more data is gathered.
Age is Just a Number: A Case Report of Prostate Cancer in a Young Patient with Hematuria
Shree Spandana Ghanta
St. Elizabeth's Medical Center
Background
Prostate cancer is a prevalent form of cancer among males. There has been a recent rise in prostate cancer incidence among younger individuals. Most cases of prostate cancer are asymptomatic and detected at localized stages, some may present with lower urinary tract symptoms like frequency, urgency, and hesitancy.
Methods
40-year-old male presented with gross hematuria and urinary urgency. Further investigation showed papillary lesion in anterior bladder neck, biopsy showed prostatic adenocarcinoma with Gleason score of 7. His PSA was very high at 89.7, and MRI showed PI-RADS 5 lesion in the left peripheral zone with extension into the bladder neck and seminal vesicle, as well as left external iliac regional lymphadenopathy. He underwent PSMA PET/CT scan, which showed intense radiotracer uptake in the left side of prostate extending into the center and up to the bladder neck, consistent with prostate cancer. Genetic testing was negative for germline mutations.
Results
The patient was started on bicalutamide, Lupron, abiraterone, and prednisone. His PSA levels started to downtrend from 89.7 to 44.4, then 9.33, and then 1.87. He received radiotherapy to the prostate and lymph nodes, and now he is being prepped for consolidative surgery.
Conclusions
We recently encountered a case of a 40-year-old male who has been experiencing hematuria for the past 3 years. Treatment for prostate cancer in young males remains controversial as many have a poor prognosis and aggressive disease. However, recent research indicates that they benefit from chemotherapy, radiotherapy, and surgery, demonstrating a positive response to these treatments.
Emicizumab: A Novel Approach to Treat Acquired Hemophilia A
Fnu Janamejey1, Janamejey Gaur1, Daniel C. Winokur2, Andrew B. Wilks2
1 Department of Medicine, Saint Vincent Hospital
2 Department of Hematology & Oncology, University of Massachusetts
Background
Acquired hemophilia A is a rare hematologic disorder caused by the development of autoantibodies against factor VIII. Below, we discuss a case of AHA that failed routine therapy but responded to Emicizumab.
Methods
A 67-year-old female presented with ecchymosis over her left upper extremity following a fall. Laboratory results were significant for PTT 93.7, D-dimer 4.21, and fibrinogen 499. Her PTT did not correct with mixing studies. Factor VIII activity was measured at < 1% with an inhibitor titer of 4.7 BU. She had worsening subcutaneous bleed, requiring multiple blood transfusions. Hence, prednisone was started. Over the next seven days, PTT trended down to 38.7 and patient discharged on steroid taper. Unfortunately, four days later, patient was re-admitted with high PTT (123.6) and elevated inhibitor titer (21 BU). She was subsequently treated with rituximab. Over the next 72 hours, her blood transfusion requirements increased, and her subcutaneous bleeding worsened dramatically, covering a large total body surface area. Given clinical instability, she was started on daily recombinant factor VIIa and cyclophosphamide. The patient continued to have progressive soft tissue bleeding. Emicizumab was initiated, and within 12 hrs, her PTT became normal.
Results
N/A
Conclusions
For AHA patients with clinical instability, a bypassing agent is recommended. High-dose FVIII replacement is ineffective when the inhibitor titer is very high. There is limited evidence supporting the appropriate immunosuppressive regimen in AHA. We hope such case reports will enhance the understanding of this rare entity and refine our therapeutic strategies, including the use of emicizumab in a multi-refractory patient.
Immune Checkpoint Inhibitor-induced Type 1 Diabetes Mellitus
Fnu Janamejey1, Janamejey Gaur1, Daniel C. Winokur2, Andrew B. Wilks2
1 Department of Medicine, Saint Vincent Hospital
2 Department of Hematology & Oncology, University of Massachusetts
Background
The prevalence of immune checkpoint inhibitors (ICIs) in the management of solid tumors is increasing rapidly. Pembrolizumab is one such medication directed against programmed cell death protein 1 (PD-1). Immune-mediated Diabetes Mellites Type 1 has a reported incidence of 0.2% with pembrolizumab. Here, we report a fascinating case of this entity.
Methods
A 65-year-old woman with a past medical history significant for melanoma status post resection presented with fatigue, polydipsia, polyuria, weight loss and altered mental status. Her labs showing blood glucose 498 mg/dl, beta-hydroxybutyrate 9.15, and anion gap 23 mEq/l, were consistent with diabetic ketoacidosis. Hemoglobin A1c 5 months prior was 5.5%, but it rose to 9.7% during the current admission. Additionally, C-peptide was low, and GAD-65, zinc transporter 8, and IA-2 antibodies were negative. She was started on adjuvant pembrolizumab around 8 months ago and plan was to give her a total of 9 cycles. But she presented in DKA after her 6th cycle. Pembrolizumab was held, and the patient was initiated on insulin for ICI-induced Type 1 diabetes.
Conclusions
This complication, as opposed to other immune-related adverse events, is not glucocorticoid responsive. Rather, insulin replacement therapy is indicated and is generally required lifelong due to the permanent destruction of beta cells. We present this case to raise awareness amongst our colleagues regarding this rare irAE. Given the unique management and presentation of this toxicity, it is important to maintain a high index of suspicion, especially as the use of ICIs continues to expand in clinical practice.
Exploring barriers to cancer genetic services in Maine
Ashley Kennes, MS, CGC1, Luanna Buchanan2, Stephanie Sharp2, Courtney Shearstone3, Eric Anderson2, Lauren Couture2, Garrett Baron2, Susan Miesfeldt2
1 Maine Medical Center Cancer Risk and Prevention Program
2 Maine Health
3 Graduate Student
Background
Genetic counseling and testing promotes awareness of hereditary cancer risk and management. Barriers exist to cancer genetic services and impact not only the ability to access a referral but to follow through with scheduling and the initial consult. Our own institutional data reveal a >50% drop-off in referral to consult rates across the MaineHealth Cancer Care Network (MHCCN) service area.
Methods
A retrospective medical records review of referrals to the MHCCN Cancer Risk and Prevention program from January 2017 through December 2022 were evaluated for variables.
Results
There were a total of 9039 referrals over the study period. The number of patients who completed their appointments decreased over this period with the most significant drop-off in 2022. Patients between 70-79 years were more likely to complete appointments, while patients between 18-29 years were least likely to follow through. Patients self-identified as White, Native Hawaiian/Pacific Islander or declined to provide race attended at least 50% of their appointments while those identified as Black/African American, Asian, American Indian/Alaska Native, Multi-racial, or other race attended <50% of their appointments. Most referral closures (69.2%) occurred automatically after 90 days, reflecting the inability to contact a patient to schedule or lack of response.
Conclusions
Access to cancer genetics services varied by patient race, age, and year at which the referral was made. Strategies such as educational materials summarizing the purpose of the visit and streamlining the scheduling process are needed to support patients in following through with their genetics referrals, with a focus on those with healthcare disparities.
Shruti Adidam Kumar, MBBS1, Victoria Forbes, M.D., MS2, Dong Chen, M.D., PHD3
1 University of Connecticut, School of Medicine
2 UConn Health Center Carole and Ray Neag Comprehensive Cancer Center
3 University of Connecticut Department of Hematopathology
Background
VEXAS syndrome is an adult-onset condition causing hematologic and autoimmune manifestations first described in 2020 in the NEJM. It is associated with a variant in the X-linked UBA1 gene involved in the ubiquitin pathway. Cytopenias and increased risk of malignancies can be seen. It affects 1 in 4000 men and 1 in 26238 females above 50 years of age.
Methods
Our patient is a 59-year-old male with a history of non-ischemic dilated cardiomyopathy status post heart transplant, Hirschsprung disease status post surgery, personal history of heterozygous gene mutation in Titin c.88721delG (p.Arg29574Leufs*38), heterozygous VUS in SLC22A5 who was followed by Dermatology for progressive subacute cutaneous lupus erythematosus despite immunosuppression. Given the recalcitrant nature of his illness, he was referred to Hematology for concern for VEXAS syndrome.
Results
Genetic testing revealed a mutation in UBA1 p.Met41Leu. Bone marrow biopsy featured atypical trilineage hematopoiesis with megakaryopoiesis (hypo-lobulated nuclei in small megakaryocytes), erythropoiesis (karyorrhexis, cytoplasmic vacuolizations and multinucleation in erythroid precursors), and cytoplasmic vacuolization in myeloid cells. Karyotype was normal. His complete blood count was unremarkable. Combining the evidence of UBA1 mutation, cytoplasmic vacuoles, male gender, and autoinflammation, a diagnosis of VEXAS syndrome was made.
Conclusions
Our case highlights the need to consider this rare syndrome and UBA1 testing among patients with progressive inflammatory and hematologic symptoms. Although treatments are limited, research is underway examining stem cell transplant as a possible treatment. Early Hematology referral can help elucidate the diagnosis, direct patients to treatment, and lead to increased surveillance for the development of malignancies.
Kara K. Landry, M.D.1, Stephen J. Foley2, Heather M. Feldman, PhD1, Sarah A. Nowak, PhD3, Hannah L. Taylor1, Marie R. Johns1, Wendy C. McKinnon, MS1, Laura S. Colello, MS1, Sarah Spinette, PhD1, Sarah M. Nielsen, MS4, Edward D. Esplin, M.D., PhD4, Marc S. Greenblatt, M.D.1, Marie E. Wood1
1 Division of Hematology and Oncology, University of Vermont Medical Center, Burlington, VT
2 Larner College of Medicine at the University of Vermont, Burlington, VT
3 Department of Pathology & Laboratory Medicine UVM Medical Center, Burlington, VT
Background
Streamlined processes for genetic testing are needed. Our study assessed the feasibility of a novel approach in which patients with cancer underwent genetic testing first with genetic counseling after if needed.
Methods
Patients with metastatic solid tumors were referred by their oncologist and underwent germline testing with an 84-cancer gene panel. Results were called if testing was negative or if found to have a variant of uncertain significance. Patients with a PGV were scheduled to meet with the genetics team for full counseling. Patient and provider satisfaction surveys were administered in follow-up.
Results
125 patients were eligible and 91 enrolled. The mean age of patients was 66 (SD 12.6). 60 (65%) were male and 43 (47.3%) resided in a rural area. A PGV was identified in 13 (14.8%) participants. 10 (76.9%) had follow up with a genetic counselor, 2 (15.4%) declined and 1 (7.7%) died prior to being seen. PGVs identified include: MUTYH (n=5), MITF (n=2), CHEK2 (n=2), WRN (n=1), RAD51D (n=1), CDH1 (n=1), NTHL1 (n=1). 74 (81.3%) participants completed the survey. The vast majority appreciated having undergone testing (n=70, 94.6%) and having testing incorporated into an existing appointment (n= 69, 93.2%). All providers (n=16, 100%) were satisfied with this testing process and most (n=15, 93.8%) felt that genetic test results were obtained in a timelier fashion and reported interest in continuing this testing process.
Conclusions
This process of genetic testing first and counseling after removes known barriers to testing and is feasible and acceptable for cancer patients.
From Sun to Dysphagia: A Case Report of Metastatic Melanoma of the Esophagus
Martha Lodyga, M.D.1,2, Kareen Moore, M.D.2, Mina Botros, M.D.2, Seetha Muthavarapu, M.D.2, Thomas Fynan, M.D.2, Ali Abbas, M.D.2
1 Dartmouth-Hitchcock Medical Center
2 Berkshire Medical Center, Pittsfield, MA
Background
Melanoma is the most serious form of cutaneous malignancy. most are detected early, a proportion of patients have metastatic disease at time of diagnosis. Metastasis occurs via lymph nodes to lungs, brain, liver and bone, which accounts for most morbidity and mortality. Extremely rare, is metastasis to the esophagus.
Methods
Patient's chart and clinical course were observed. Literature review preformed via PubMed using keywords: "malignant melanoma" and "esophagus".
Results
A 60-year-old female with tobacco dependence, food and housing insecurity presented with dysphagia and hematemesis. Labs were remarkable for acute-on-chronic anemia with positive stool guaiac. Gastroenterology was consulted and endoscopy showed severe melanosis in the entirety of the esophagus. Biopsy was negative for BRAF, however, positive for S100 and SOX-10 metastatic melanoma. A complete full body skin examination was performed locating an obvious malignant lesion on her back representing the primary source of melanoma metastases. The patient unfortunately expired prior to further interventions.
Conclusions
Metastatic esophageal melanoma is extremely rare presenting similarly to other esophageal carcinomas with dysphagia, epigastralgia or weight loss. Majority of gastrointestinal melanomas are located in the anorectum and oral cavity. Surgery is the treatment of choice and recurrence is common. Immunochemical testing provides additional prognostic information as higher Melan-A expression is predictive of lower mortality rates, whereas higher S100 levels are associated with poor survival. Despite radical surgery, survival rates are low. Prognosis greatly depends on the stage at time of diagnosis, thus early detection is critical and routine full body skin examinations result in decreased overall mortality.
Adapting TSET for patients unable to stand with minimal burden to patient and staff
Allison Matous, M.D.1, Colleen J. Fox1, Benjamin B. Williams1, Joi B. Carter1, Frederick Lansigan1, David J. Gladstone2, Lesley A. Jarvis
1 Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth
2 Thayer School of Engineering, Dartmouth College
Background
Mycosis Fungoides (MF) is commonly treated with total skin electron therapy (TSET) using the Stanford technique. This treatment requires patients to maintain 6 standing positions, which presents challenges for patients who cannot stand.
Methods
A custom treatment bench was developed to adapt TSET for patients unable to stand. Bench height was designed to allow patients to lean supported while remaining upright. Rails were added to facilitate posing while providing balance. Feasibility was demonstrated in a patient with MF and paraplegia. Prescribed dose was 1200 cGy given in 3 cycles of 400 cGy per cycle (1 cycle delivered over 2 days) with 6MeV electrons. Optically stimulated luminescent dosimeters (OSLDs) were placed on his umbilicus anteriorly and an analogous site posteriorly to measure dose for one cycle.
Results
The treatment course was completed and was well tolerated. OSLDs read 323 cGy and 371 cGy at the anterior and posterior umbilicus. Clinically, he was free of lesions for several months. With treatment, patient-reported outcomes on the Dermatology Life quality Index improved from moderate (7) to mild burden (4).
Conclusions
TSET with custom bench may be an option for patients with MF who cannot stand. This bench, constructed from easily accessible materials, can be implemented in a range of radiation oncology facilities and does not require device commissioning. OSLD measurements were lower than prescribed, likely reflecting body habitus. Nevertheless, our patient had an excellent clinical response. Disparities in medicine exist for patients with disabilities, and in radiation oncology customized treatments are often necessary.
From active treatment to surveillance: How the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients*
Elizabeth McGrath, DNP, AGACNP-BC, AOCNP, ACHPN1, Jennifer Alford-Teaster, MA, MPH1,2, Danielle Vaclavik, PhD3, Inger Imset4, Jenna Schiffelbein1, Kathleen Lyons5, Nirav Kapadia1,2, Ardis Olson1, Elizabeth B. McGrath1, Karen Schifferdecker, PhD3, Tracy Onega PhD, MA, MS6
1 Dartmouth Cancer Center, Lebanon, New Hampshire, United States
2 Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, United States
3 Center for Program Design and Evaluation (CPDE) at the Dartmouth Institute for Health Policy and Clinical Practice (TDI), Lebanon, New Hampshire, United States
4 Population Health, Dartmouth Health, Lebanon, New Hampshire, United States
5 MGH Institute of Health Professions, Boston, Massachusetts, United States
6 Department of Population Health Sciences, University of Utah and Huntsman Cancer Institute, Salt Lake City, Utah, United States
Background
Survivorship care planning refers to an orderly process by which clinicians and survivors navigate the transition from active treatment to post-treatment. The importance of survivorship care planning has been underscored recently by the American College of Surgeons’ Commission on Cancer (Standard 4.8), which details elements to promote and enhance the use of survivorship care plans and includes goals for the development of survivorship care programs within hospitals. The purpose of this study was to identify the barriers and facilitators associated with transition from active cancer treatment to survivorship, with a particular focus on exploring the feasibility and role of telehealth in potentially supportive interventions for survivorship care.
Methods
A multi-method study was conducted consisting of: a) key informant interviews with primary care and oncology clinicians b) a survey of a broader cohort of oncology and primary care clinicians, and c) a survey and focus group discussions with cancer survivors. The methodological approach was tiered by first interviewing clinicians then conducting focus groups with survivors separately, and then following up with additional surveys to enhance understanding of barriers and facilitators.
Results
Demographic and respondent analysis will be highlighted. Key benefits and barriers to delivering survivorship care through telehealth will be emphasized. Seven qualitative themes emerged in this study and will be discussed.
Conclusions
Our study suggests that there are opportunities for appropriately placed telehealth appointments in the context of survivorship. Specifically, telehealth services for augmented survivorship care could include telepsychiatry, nutritional counseling, ongoing financial support counseling, and transition from oncology to primary care.
Kriti Mehra, M.D., Chidambaram Ramasamy, M.D., Navya Reddy Perkit M.D., Abhishek Singh M.D., Madhan Srinivasan Kumar M.D., Kala Seetharaman M.D.
Department of Medicine, Saint Vincent Hospital, Worcester, MA
Department of Hematology and Oncology, Saint Vincent Hospital, Worcester, MA
Background
Neutrophilia,lymphopenia,monocytosis can enhance tumor growth of malignant plasma cells. A low platelet count is linked to a worse prognosis in multiple myeloma (MM) patients due to a greater marrow myeloma burden. Hence, we aimed to study the role of Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and platelet-to-lymphocyte ratio (PLR) in the prognosis of MM patients.
Methods
This is a retrospective study that analyzed MM patients diagnosed between 2012-2022 at Saint Vincent Cancer Center, Worcester, MA. NLR, PLR and MLR were calculated based on pre-treatment complete blood count. Cutoffs for High NLR(≥2), Low NLR(<2), High PLR(≥120.00), low PLR(<120.00), high MLR(≥0.27), and low MLR(<0.27) were used. SPSS was used for analysis of data. Logistic regression was used to calculate the Odds ratio(OR). A p-value less than equal to 0.05 was considered significant.
Results
97 patients were analyzed. 66% of the patients belonged to the high NLR group, 61.9% to the high PLR group and 64.9% to the high MLR group. 56.7% were alive at 5 years. High NLR was associated with lower odds of 5-year survival [p-value 0.037 with 95% confidence interval(0.095-0.931)]. High MLR was associated with lower odds of 5-year survival with a p value of 0.042 and a 95% confidence interval(0.124-0.962). PLR did not correlate with 5-year survival and was not statistically significant(p value of 0.157).
Conclusions
Based on our study, a high NLR (≥2) and high MLR (≥0.27) were associated with lower odds of 5-year survival. Hence NLR and MLR are independent prognostic factors in newly diagnosed multiple myeloma patients.
Win win win! Fewer side effects, shorter treatment and closer to home
Eileen Mullen, RN, Stephanie K. Marcotte, BSN, RN, OCN, ONN-CG, Anne Cogan MSN, RN, NPD-BC, OCN
Mass General Cancer Center at Wentworth-Douglass Hospital
Background
High dose rate (HDR) brachytherapy combined with external beam radiation for patients with clinically localized prostate cancer has been shown to be an effective treatment option with fewer side effects and reduced treatment time compared to traditional treatment. On the day of treatment HDR brachytherapy involves surgical placement of needles under anesthesia, anesthesia recovery, simulation, planning time, treatment, removal of needles and a voiding trial before discharge. The patient is transferred between multiple departments and is cared for by multiple disciplines. The complexity of treatment can be a barrier to offering this at community hospitals. Our goal was to bring the option of safe, effective HDR brachytherapy for prostate cancer patients to our cancer center.
Methods
An interdisciplinary team headed by an expert in project management worked for a year to plan the workflow, determine equipment needs, purchase equipment, train staff, develop protocols and create patient education. Barriers that needed to be overcome were balancing the need to reduce transfers between departments with providing care in the optimal environment, availability of equipment during a time of supply challenges, educating the multiple teams involved and creating communication tools for disciplines that do not usually work together.
Results
This treatment option has been safely and effectively administered to multiple patients. Careful planning has resulted in few adjustments needed to the process and workflow.
Conclusions
Bringing complex treatments closer to patient’s homes reduces the impact of cancer treatment and can improve their quality of life.
Challenges and opportunities with implementing a CAR T-cell program in a rural setting
Peter A. Palumbo1, John M Hill Jr M.D.2
1 Geisel School of Medicine at Dartmouth, Hanover, NH
2 Department of Internal Medicine, Section of Hematology, Dartmouth Cancer Center, Lebanon, NH
Background
Chimeric Antigen Receptor T-Cell therapy (CAR T) has proved a transformative treatment modality to produce complete, durable responses in patients experiencing relapsed/refractory malignancy. Despite the long-term benefits of CAR T treatment, the potential for significant complications has restricted its delivery to major, urban academic centers. As of June 2023, 213 centers offered this care nationwide, with our site being the only center located in a non-metro designated area. While CAR T management has been well characterized in the literature, there are no formal models for initiating a CAR T program in a rural setting.
Methods
Complicated by the SARS-Cov2 pandemic, we nevertheless initiated this therapy, utilizing inpatient chemotherapeutic lymphodepletion to minimize risk for post-screening COVID exposure. Patients were discharged to a local hotel for short-term observation, given widely varied travel distances. Both clinical and administrative algorithms were constructed to provide clear guidance for the management and transfer of patients between clinical units. Further, in-depth reviews were scheduled with clinical sections to reinforce CAR T standards, and interdepartmental case scenarios were conducted to scrutinize these patient pathways.
Results
Since May 2020, our site has treated twenty-seven CAR T patients across five malignancies. Treatment has been well tolerated, with primarily low-grade toxicities that have been reversible in all cases. Efficacy has been highly favorable, with most patients exhibiting durable responses. One patient succumbed to progressive malignancy.
Conclusions
Based on these outcomes, our program represents a feasible model for safe and effective implementation of CAR T-cell therapy in a rural setting.
Cannabis Use Among Patients with Gastrointestinal Cancer in a Rural Academic Medical Center
Jacqueline Peabody1, E. McGrath2 , M. Stannard2, U. Goldberg3 , K. Broglio3
1 Rivier University Department of Nursing
2 DHMC, Dartmouth Cancer Center
3 DHMC, Palliative Care
Background
Cannabis is becoming legalized for medical use across the country. Patients acquire medical cannabis cards to be used at dispensaries by obtaining a provider's signature. Signature does not endorse the use, merely establishes the patient is under a prescriber's care. Once a patient has obtained cannabis, they get the relief they are seeking by adjusting the amount and route of cannabis used. In New Hampshire, medical cannabis was legalized in 2016, whereas Vermont legalized cannabis in 2004. Recreational cannabis is illegal in NH but is legal in VT. Patients who do not have a cannabis card obtain cannabis from other sources, rather than a state-run dispensary. These patients might identify their reason for use as a form of alternative therapy, rather than solely recreational use.
Methods
This cross-sectional descriptive study will include 100 ambulatory patients from the Dartmouth Cancer Center in Lebanon, New Hampshire. Participants will have a diagnosis of a gastrointestinal malignancy. Each patient will be given an anonymous questionnaire on a tablet that will be completed before their visit. Questions will gather information about demographics, cancer diagnosis, and cannabis use. If a patient answers that they have used cannabis in the past 30 days, the survey will ask seven more detailed questions about the frequency, purpose, and efficacy of their use.
Results
Pending
Conclusions
Pending
Molecular Profiling of Melanoma Patients in Rural Maine
Tristan Prokop, High School Student1, Michael Babcock1, Dorothy Smith1, Marek Skacel1, David Prokop2
1 Dahl-Chase Pathology, Bangor, Maine
2 Saint Joseph's Hospital, Bangor, Maine
Background
Metastatic melanoma is the leading cause of skin cancer death with 5-year survival of 32%. Highly aggressive melanomas that spread to regional structures and nodes are typically >1 mm in depth and ulcerated with a high frequency of recurrence and metastasis to distant parts of the body. Therefore, early detection is key to survival by determining metastatic risk and identifying treatment options through molecular profiling.
Methods
Tumor characteristics were correlated with data from gene expression and molecular profiling to determine risk recurrence and targeted therapy eligibility. Breslow thickness, ulceration status, and stage were obtained from 136 melanoma patient cases analyzed between 2019-2023. Categorization of metastatic risk (1A, 1B, 2A, or 2B) was determined by gene expression analysis using a 31-gene expression profile. Mutational status was determined by next-generation sequencing for metastatic tumors according to NCCN guideline (BRAF, NRAS, KIT).
Results
Ulceration was present in 8.1% (n=11); however, 9 were present in tumors >1 mm in Breslow thickness (81.8%). 86.4% of cases (n=102/118) with Breslow thickness <1mm were determined to be of low metastatic risk (1A or 1B) versus all 92.9% of high-risk (2A or 2B) cases were >1 mm. Several non-NCCN guideline mutations were present in metastatic cases that were >2 mm in depth.
Conclusions
Low-risk melanomas were found to be predominately without ulceration and <1 mm in Breslow thickness. In addition, non-NCCN guidelines mutations were identified in multiple tumors suggesting expanded molecular profiling may give patients better access to precision medicine.
Laryngeal lymphoma: a rare presentation of small lymphocyte lymphoma recurrence
Chidambaram Ramasamy, M.D.1, Jackson Clark D.O.2, Kapil Meleveedu M.D.2
1 University of Connecticut
2 Department of Hematology/Oncology, UConn Health
Background
Extranodal laryngeal lymphomas are rare, accounting for less than 1% of laryngeal neoplasms. The most reported subtype is DLBCL, typically treated with chemoradiation. Surgery is reserved for laryngeal obstruction.
Methods
A 53-year-old male with a history of small lymphocytic lymphoma (SLL) was evaluated for a 2-month history of hoarseness of voice in 2022. He denied stridor, dysphagia, or B symptoms. He was originally diagnosed with SLL in 2008 with bone marrow involvement and received six cycles of fludarabine and rituximab, with an eventual complete response. At the time of presentation, he was believed to be in remission. CT neck revealed a polypoid mass [1.8x1.7cm] in the left paraglottic space. No lymphadenopathy was identified on the CT chest, abdomen, and pelvis. Biopsy revealed small, monomorphic cells positive for CD20, CD5, BCL2, LEF-1, and CD23 and negative for CD10, Cyclin D-1, and BCL6, consistent with SLL. PET-CT showed an FDG avid left vocal cord lesion. He was treated with intensity-modulated radiation therapy to the larynx with 3000 cGy over 15 fractions. At the 3-month follow-up, his symptoms resolved, and PET CT showed no radiotracer uptake in the left vocal cord
Results
To our knowledge, this is the first report of SLL recurrence presenting as laryngeal lymphoma. Our case report corroborates that low-grade B cell lymphomas localized in the larynx can be successfully treated with radiation therapy alone.
Conclusions
More data is needed to define optimum treatment for low-grade laryngeal lymphoma.
Leukoerythroblastosis in metastatic prostate cancer: a clue to diffuse bone marrow carcinomatosis
Chidambaram Ramasamy, M.D.1, Victoria Forbes M.D., M.S.2, Dong Chen, M.D., Ph.D.3
1 University of Connecticut
2 Department of Hematology/Oncology, UConn Health
3 Department of Pathology and Laboratory Medicine, UConn Health
Background
Leukoerythroblastosis is commonly seen in primary myelofibrosis, bone marrow (BM) infiltration, sepsis, or marked bone marrow response to acute blood loss. Appearance of this phenomenon has been recognized as a warning sign of BM involvement by metastatic carcinoma.
Methods
A 78-year-old male recently diagnosed with high-grade (Gleason 5+5) metastatic prostate cancer with extensive skeletal metastasis, was evaluated in the hospital for thrombocytopenia (platelets 12,000/microliter) and normocytic anemia (Hb 9.8 g/dl, MCV 93.2). His workup revealed normal vitamin B12, folate, and ferritin levels. His PT, PTT, and fibrinogen were within normal limits. There was no evidence of hemolysis and his PLASMIC score was 2 (low risk of TTP). Alkaline phosphatase and PSA levels were elevated at 1,082 U/L and 98.7ng/mL respectively. Peripheral smear revealed nucleated red blood cells, tear drop cells, and early myeloid cells without dysplastic features or blasts suggestive of leukoerthyroblastosis. BM biopsy revealed sheets of atypical cells positive for NKX3.1 suggestive of prostatic adenocarcinoma. He was diagnosed with diffuse bone marrow carcinomatosis due to prostate cancer and started on combined androgen blockade
Results
BM provides a fertile microenvironment for metastatic tumor cells. Detection of BM metastasis heralds a poor prognosis in prostate cancer with increased morbidity and mortality. It should be suspected in the context of unexplained thrombocytopenia and anemia with leukoerythroblastosis.
Conclusions
This case illustrates the importance of prompt BM examination once recognizing leukoerythroblastosis in patients with advanced prostatic adenocarcinoma.
Paraneoplastic eosinophilia and Non-small cell lung cancer: A case report
Gunjan Rana, M.D.1, Janamejey Gaur1, Edison Tsui2
1 Internal Medicine Resident, Saint Vincent Hospital, Worcester, MA
2 Hematologist-Oncologist, Reliant Medical Group, Worcester, MA
Background
An Absolute Eosinophil Count of more than 500 eosinophils/microL is consistent with eosinophilia. The differential remains broad, including allergic, drug-induced, infectious, inflammatory, and neoplastic etiologies. Paraneoplastic eosinophilia is a rare complication observed in 1% of solid tumors and is associated with poor prognosis when present.
Methods
A 76-year-old man presented to the hospital with fatigue, weight loss, and night sweats for the past several months.
Results
His blood work demonstrated eosinophilic leukocytosis (WBC 55 x 103/mcL, manual eosinophil 36%). CT chest, abdomen, and pelvis with contrast revealed a 10 cm heterogeneous mass in the left lung, multiple hepatic lesions and, mediastinal, supraclavicular and retroperitoneal lymphadenopathy. Flow cytometry and testing for primary eosinophilia were negative. A week later, he presented with shortness of breath in the setting of steroid non-compliance. His repeat WBC count was 90 x 103/mcL with a manual eosinophil of 59%. Results from a left supraclavicular lymph node biopsy demonstrated tumor cells positive for CK AE1/AE3 and CK7. They depicted rare TTF-1 positivity. Clinical, radiological, and immunohistochemistry impressions confirmed the diagnosis of metastatic large-cell neuroendocrine tumor. The patient declined chemotherapy and opted for hospice.
Conclusions
1. Our case highlights the importance of ruling out an exhaustive list of differentials in diagnosing hypereosinophilic syndrome.
2. Despite there being no specific treatment for paraneoplastic hypereosinophilia, we want to emphasize the significance of steroids in symptomatic management besides treating the underlying malignancy.
Molecular Profiling of Hematopathology Patients in Rural Maine
Gabrielle Rentosa1, Michael Babcock2, Kate Brawn, Marek Skacel2, Sheila Pascual3
1 John Bapst Memorial High School
2 Dahl-Chase Pathology
3 Northern Light Cancer Institute
Background
New clinical classifications have been established by the World Health Organization (WHO) and the National Comprehensive Cancer Network (NCCN) for acute myeloid leukemia (AML), myeloid dysplastic syndrome (MDS), myeloproliferative neoplasms (MPN), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML), chronic myelomonocytic leukemia (CMML), and juvenile myelomonocytic leukemia (JMML) with recommendations for mutational analysis. In this retrospective study, patient mutational profiles were analyzed to improve patient management.
Methods
Next-generation sequencing (NGS) was performed using a 69-gene panel (40-DNA genes; 29-gene RNA fusions) on 1124 blood-based specimens from patients with a variety of myeloid and lymphoid disorders; including but not limited to, AML (n=262), MDS (n=241), CLL (n=113), MPN (n=75), CMML (n=24), and CML (n=12).
Results
753 cases were found to contain at least one mutation, whereby 17.6% (n=198) had more than one mutation. Gene mutations in TET2 were detected most frequently in MDS (48.4%; n=59/122), TP53 was found most often in AML (49.3%; n=36/76), SRSF2 were equally detected in AML (n=20) and MDS (n=20), SF3B1 was found predominately in MDS (77.8%; n=35/45), and as expected, JAK2 was detected most frequently among MPN (84.8%; n=28/33), in particular patients with polycythemia vera. Two MDS patients were identified with TP53 co-mutations. Seven patients with SF3B1 mutations had abnormal cytogenetic FISH profiles. Eight patients with SF3B1 mutations had normal MDS (n=7) or AML (n=1) cytogenetic FISH results and 19 were not tested by cytogenetics.
Conclusions
Genomic findings were able to subclassify 10 patients according to updated clinical guidelines.
Abinesh Sekar, M.D.1, Chidambaram Ramasamy M.D.2, Harinivaas Shanmugavel Geetha M.D.1, Madhan Srinivasan Kumar M.D.1, Masood Pasha Syed M.D.3, Kala Seetharaman M.D.1, George M. Abraham M.D.1
1 Saint Vincent Hospital, Worcester, MA
2 University of Connecticut, Hartford, CT
3 University of Pittsburgh Medical Center, Pittsburgh, PA.
Background
The PRISM score (Prior VTE, Race, IMiD, Surgery, Metaphase Cytogenetics) is a risk prediction tool for VTE in Multiple Myeloma(MM) and was published in 2022. Based on the score, patients were stratified into three groups: low (0), intermediate (1-6), and high risk ( ≥ 7). Our primary objective was to externally validate the PRISM score.
Methods
Newly diagnosed MM patients from 2008 to 2022 were included in our analysis. Variables were collected through a retrospective chart review. Model discrimination was assessed by calculating the AUROC and logistic regression was also performed.
Results
A total of 214 patients were included. The AUROC of the model was 0.759 (95% CI, 0.644-0.874). The cumulative incidence of VTE at 6 months, 12 months, and more than 1 year was 6%, 7%, and 11.2% of the patients respectively. Each 1-point increase in the score was associated with a significantly higher chance of VTE occurrence. Among the parameters, patients with a history of VTE (HR= 1.55, 95% CI (1.26-1.91), P<0.001] and with abnormal metaphase cytogenetics (HR= 2.35, 95% CI (1.37-4.05), P<0.001] had a higher strength of association with the development of VTE after induction. Furthermore, among 9 patients with a high-risk PRISM score ( ≥ 7), 7 (77%) developed VTE within the first 6 months after treatment initiation.
Conclusions
Our findings suggest that PRISM score could statistically predict VTE outcomes and Abnormal metaphase cytogenetics was a significant predictor of VTE in the validation cohort.
Abinesh Sekar, M.D., Sajid Shaik M.D., Navya Reddy Perkit M.D., Abhishek Singh M.D., Chidambaram Ramasamy M.D., Yuvaraj Singh M.D., Kala Seetharaman M.D., George Abraham M.D.
Saint Vincent Hospital, Worcester, MA
Background
Blood neutrophils to lymphocytes ratio (NLR) could reflect a balance between pro and antitumor immune phenotypes, hence impacting tumor prognosis. We aimed to assess the prognostic value of pretreatment neutrophil to lymphocyte ratio (NLR) among non–small cell lung cancer (NSCLC) patients.
Methods
Newly diagnosed NSCLC at Saint Vincent Hospital from 2012 to 2022 were included in our analysis. Pretreatment neutrophil and lymphocyte counts, and one-year survival data were collected by a retrospective chart analysis. Pretreatment NLR was calculated by dividing neutrophils by lymphocytes measured in peripheral blood. Patients were divided into a high NLR (ratio >4) and a low NLR group (ratio <4), and their one their survival data were analyzed. Sub-group analysis was done for patients who received immunotherapy or chemotherapy. Binomial Logistic regression analyses were used to calculate the odds ratio.
Results
Among 211 patients, at treatment initiation, 43% of patients (n=91) had NLR less than 4. The one-year survival rate was 59 % (n=124). Patients with a low NLR ratio were found to have a high one-year survival with an odds ratio of 2.46 (p<0.05). In the subgroup analysis, patients with low NLR who received either chemotherapy or immunotherapy were found to have a higher one-year survival with an odds ratio of 5.43 (p<0.05) and 11.0 (p<0.05), respectively.
Conclusions
Patients with pretreatment low NLR are associated with higher rates of one-year survival when compared with patients with high NLR. It is a cost-effective, readily available, and inexpensive biomarker.
Implementation of a population scale single platform for clinical and research genomic analysis
Parth Shah, M.D., Donald Green, Shrey Sukhadia, Greg Tsongalis, Edward Hughes, Laura Tafe
Dartmouth Hitchcock Medical Center, Norris Cotton Cancer Center
Background
Health-systems are now faced with an ever increasing volume of genomic data resulting in increasing regulatory complexities while implementing multiple applications, instruments and workflows analysis pipelines for next generation sequencing (NGS). Implementing a single, integrated system supporting multiple NGS analysis applications, data storage, reporting as well as research dashboards while retaining control of the data is crucial for genomically abled health systems.
Methods
We deployed a customized genomics analysis platform, AUGMET to accommodate all relevant clinical and research NGS workflows. A HIPAA compliant private cloud environment, the Dartmouth Cloud, was created while maintaining full connectivity with on premises infrastructure. Clinical validation was performed according to the AMP/CAP Guidelines, for solid tumor somatic whole exome sequencing(sWES), tumor mutational burden and hematological sWES. Germline whole exome, transcriptome sequencing, pharmacogenomics and a cell free assay are completing validation for launch in end 2023. The Dartmouth Genomics Portal(DGP), an integrated population and research database was implemented as a direct hands free extension.
Results
AUGMET decreased manual interventions for primary and secondary analysis in our solid tumor testing workflow and hematologic workflow by 50% and 60% respectively. Processing time for 1400Gb of somatic data was <10 hour without the need for manual intervention. Multiple research collaborations have been initiated utilizing the DGP allowing investigators to easily obtain summary genomic data.
Conclusions
AUGMET provides a single platform for NGS DNA and RNA analysis without compromising quality and flexibility and produced a fully automated NGS pipeline in our laboratory with similar benefits expected in collaborating laboratories.
Temozolomide-Associated Myelodysplastic Syndrome in a Patient with Glioblastoma
Ashish Sharma, M.D.1, Victoria Forbes, M.D.2, James Vredenburgh, M.D.2
1 University of Connecticut Health Center
2 University of Connecticut
Background
The alkylating agent Temozolomide has proven effective in high-grade glioma treatment, notably Glioblastoma (GBM), enhancing overall survival. However, its potential long-term adverse effects, notably the risk of secondary malignancies like Myelodysplastic Syndrome (MDS), remain underexplored, necessitating research attention.
Methods
Here we present a 68-year-old patient who presented with left hand weakness leading to a diagnosis of GBM. Successful craniotomy and tumor resection were performed. After radiation therapy and 11 cycles of Temozolomide, patient subsequently developed cytopenias and was diagnosed with MDS with 9% blasts with high risk TP53 mutation.
Results
Patient presented with left-hand weakness, prompting a brain MRI that revealed a mass. Subsequent craniotomy and tumor resection confirmed Glioblastoma with a methylated MGMT promoter. Radio-chemotherapy involving Temozolomide was initiated, and 11 cycles were completed. Following this, a CBC displayed decreased WBC (2.9), hemoglobin (12.8), and platelets (64,000 then 32,000). The 12th cycle was omitted due to cytopenias, prompting a bone marrow biopsy. This biopsy unveiled MDS with 9% blasts, a TP53 mutation, and high-risk cytogenetics (-5, +7, -17, -20).
Conclusions
The occurrence of MDS with a TP53 mutation in patients following Temozolomide treatment for Glioblastoma raises concerns about its potential association with secondary hematological malignancies. Temozolomide is used in high-grade glioma treatment, particularly GBM, extends patient survival. Nevertheless, this case underscores the necessity of monitoring for secondary malignancies, like MDS, among Temozolomide-treated patients. Limited literature accentuates the necessity for additional research and clarification.
Rohit Singh, Akshee Batra, Samantha Schuetz, Helen Gandler, Jacob Barker, Derek Devine, Hibba tul Rehman, Shahid Ahmed
University of Vermont Medical Center
Background
Gut microbiota influences the outcomes in cancer patients treated with immune checkpoint inhibitors (ICIs). Concomitant medications, such as antibiotics (ATBs), proton pump inhibitors (PPIs), and corticosteroids, can change the biodiversity and distribution of gut microbiota, resulting in dysbiosis, which can impact the efficacy of ICIs.
Methods
Patients who received ICIs as a first-line therapy between January 2017 and June 2022 at the UVMMC. Patients who received ATBs, PPIs, and corticosteroids one month before starting ICIs and during the first six months of ICIs were compared to those who did not. We calculated RR of death using SAS, Charlson’s Comorbidity Index (CCI) was used to reduce the bias.
Results
We identified 266 patients, of which 99 (37%) died. The mean age was 64 years, lung cancer was the most commonly identified malignancy at 36%, and 55% of the cancers were stage IV. 62% received antibiotics, 67% received steroids, 45% received PPIs, 31% received two of the three, and 27% received all three. The relative risk (RR) of death who received antibiotics was 1.53 (p = 0.02), which received steroids was 1.73 (p = 0.006), and who received PPIs was 1.61 (p = 0.006). For the group that received two or all three medications, the RR was 2.18 (p = 0.003).
Conclusions
Our study suggests that patients who received any of the gut microbiome-modifying medications are at higher risk of death. Large prospective studies looking at this association are needed to understand the risk and potential outcomes.
Martin Skacel, Michael Babcock, Kathlene Gravelin, Adam Curtis, Catherine Chodkiewicz
Dahl-Chase Pathology, Bangor, Maine
Northern Light Cancer Center, Brewer, Maine
Background
LS is a hereditary cause of about 3% of CRCs, heralded by high-level MSI (MSI-H), which also occurs sporadically. LS testing has evolved over the past decade to only recent wide adoption of universal testing. Our institution has been testing all CRC patients for LS since 2010 and we have reviewed our decade-long experience.
Methods
MSI testing with reflex Mismatch Repair (MMR) immunohistochemistry and BRAF sequencing were performed on 1354 consecutive CRC patient samples between 2010-2019, using standard methodologies. The data was analyzed using SPSS and correlated with clinical and pathologic features.
Results
With overall 21.2% MSI-H frequency, 93% was of sporadic type (MLH1/PMS2 loss +/- BRAF V600E mutation) and 7% (1.6% overall) of Lynch pattern (loss of MSH2/MSH6). MSI-H was overall more frequently seen in women and patients over 70 years of age, while Lynch pattern was more frequent in patients under 70 (all p<0.001) without gender predilection. BRAF V600E was seen in 71% of sporadic MSI-H cases and rare Lynch pattern case (<5%). Overall, MSI-H was more frequent in right sided, low stage (1-2), poorly differentiated and mucinous tumors (all p<0.001).
Conclusions
The detected 21.2% overall frequency of MSI-H was higher than the typically reported 15% average, but the Lynch pattern accounted for only 1.6% of cases, compared to the typically reported 2-3%. The increased overall MSI-H frequency in the studied CRC population of rural Maine is not due to the genetically attributable LS but may reflect higher patient age, lower gender ratio, or other factors.
Probiotics and immune checkpoint inhibitors: Southcoast Health experience
Patrick Skeffington, PharmD, MHA, MSRA, Janice DallaCosta, RN, SN, OCN MBA
Southcoast Center for Cancer Care
Background
Immune checkpoint inhibitors (ICI) are widely prescribed for various cancers. Increased use of ICIs has led to a rise in immune related adverse events (ir AEs). Gastrointestinal AEs such as colitis can be common occurring in 35 to 50% of patients receiving ICIs. Probiotics are used to improve digestion and restore normal flora to the gut. A better understanding of the interaction between immunotherapy and gut microbiome and if modulation of this biome affects immunotherapy is needed to determine if probiotics are helpful or harmful in this setting.
Methods
Studies looking at advantages and disadvantages of probiotics in patients on ICI therapy have thus far shown mixed results. One study looking at probiotic influence on the gut microbiome and melanoma immunotherapy concluded: no probiotic use produced a better response in melanoma patients, another study looked at positive impact of probiotics in patients on ICI with lung cancer.
Results
SH evaluated data on ICI therapy in various cancers as to incidence of colitis and self-reported use of probiotics.
Conclusions
It is too early to recommend use of probiotics to patients on ICI therapy. Concerns such as long-term risk of neutropenia, lack of strict standards for efficacy and safety of probiotics and possibility of differences in types of cancer all favor a wait and see attitude with respect to prescribing probiotics for general use in this treatment population.
A Rare Case of HTLV-1 Associated Adult T-Cell Leukemia/Lymphoma in a South Indian Male
Jonathan Steinmetz, D.O., Monika Lewkowicz D.O., Jessie Romano M.D., Ashish Sharma M.D., Nicole Anastasio D.O., Upendra Hegde M.D.
University of Connecticut
Background
Adult T-Cell Leukemia/Lymphoma was the first cancer to be associated with the HTLV-1 virus. HTLV-1 infects nearly 10 million people worldwide and is endemic in southern Japan, the Caribbean, West and Central Africa. It is rare in non-endemic regions such as the U.S., but there have been reports of an increase of cases in parts of southern India.
Methods
We describe a case of a patient from south India who was diagnosed with HTLV-1 associated ATLL.
Results
A 68-year-old male presented with drowsiness, weakness, diarrhea, and intermittent abdomen pain.
Laboratory results showed marked leukocytosis (WBC 50.3) with lymphocytic predominance (62.8%), low hemoglobin (10.1), and platelets of 69000/microliter. Elevated serum calcium (14.3 mg/dL), ionized calcium (1.76 mmol/L), creatinine (4.8 mg/dL), and LDH (826) were observed. CT indicated splenomegaly without lymphadenopathy.
Peripheral blood smear demonstrated atypical lymphocytosis. Flow cytometry revealed an abnormal T-cell population expressing CD2, dim CD3, CD4, CD5, CD25, and CD45. Neoplastic T-cells were noted and negative for MPO, TDT, cCD79a, and positive for CD3. T-cell clonality study showed rearrangement of T-cell receptor (TCRG) and beta (TCRB) genes. HTLV I/II antibodies were positive by western blot. Bone marrow aspiration and biopsy confirmed ATLL.
The patient was started on Zidovudine and peg-Interferon since he was not a candidate for systemic chemotherapy. Unfortunately, his condition worsened, and he passed away after two months.
Conclusions
The prognosis for patients diagnosed with acute ATLL is poor, necessitating intensive treatment. With intensive chemotherapy, median survival remains approximately 10 months, and therefore enrollment in clinical trials is strongly recommended.
Assessing Prognostic Uncertainty in Cancer Survivors Presenting for Surveillance Visits
Christian A. Thomas, M.D.1, Franklin, A1, Wilding, H2, Aregawi, D2, Glantz, M2, Han, PKJ3, Bogden, P4
1 New England Cancer Specialists, Department of Clinical Research, Scarborough, ME
2 Departments of Neurosurgery and Oncology, Penn State Cancer Institute, Hershey, PA
3 Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
4 The Roux Institute Northeastern University, Department of Computer Science, Portland, ME.
Background
Cancer survivors face uncertainty about their future because of the possibility of cancer recurrence. Preliminary evidence suggests that prognostic uncertainty might confer benefits because it may give patients a chance to hope for a more favorable outcome. We evaluated levels of uncertainty and emotional well-being among cancer survivors.
Methods
Adult cancer survivors presenting for follow-up appointments to discuss surveillance test results at two practice sites, New England Cancer Specialists and Hershey Medical Center, were asked to fill out a survey about their attitudes regarding cancer recurrence, cancer-related distress, and coping strategies, along with sociodemographic information, cancer stage, and cancer status. Patients also completed measures of health-related quality of life and symptoms.
Results
Initial data from 105 patients at NECS are available. Preliminary results suggest a significant association between age and patient uncertainty about cancer recurrence. Younger patients (age 49-59) reported higher uncertainty compared to older patients (age 60-89). Other descriptive and correlational data will be presented at the conference.
Conclusions
Evaluating important patient-reported outcomes including cancer survivors’ attitudes towards cancer recurrence is feasible in a high-volume cancer clinic. Initial results suggest a correlation between patients’ age and their uncertainty about cancer recurrence. The study is ongoing and will serve as a platform for future investigations to support cancer survivors.
Christian A. Thomas, M.D3., Christoforo, C, OMS II1, Haley, P2, Thomas, CA, M.D.3
1 University of New England College of Osteopathic Medicine, Biddeford, Maine
2 Dana Farber Cancer Institute, Boston, Massachusetts
3 New England Cancer Specialists, Department of Oncology, Scarborough, Maine
Background
Extended Panel Molecular Testing (EPMT) is increasingly utilized for patients with advanced malignancies. We aimed to determine the impact of EPMT results on the treatment of patients with metastatic breast, colon, lung, and prostate cancer by assessing the number and potential actionability of EPMT and their effect on patients' treatment selection. We also examined EPMT test utilization (tissue versus circulating tumor DNA testing).
Methods
Between 2016 and 2023, 2,136 patients with stage IV lung, breast, colon, and prostate cancer at NECS were evaluated for ctDNA or solid tissue EPMT results and assigned tiers of actionability (I-III). Using chart review we recorded reasons to not initiate targeted therapy.
Results
We evaluated 941 tests between 2016 and 2023, (544 lung, 147 breast, 124 colon, and 126 for prostate cancer). Actionable mutations: 65% (n=94, breast cancer), 64.7% (lung cancer, n= 352), 66% (colon cancer, n=82), 37% (n=47, prostate cancer). Targeted therapy received: 107 lung (30%), 31 breast (33%), colon 2 (2%), prostate 4 (8.5%). Reasons to not receive EPMT-directed therapy: standard therapy (38%), clinical trial (9%), poor performance status (15%), patient refusal (2%). EPMT testing, especially circulating tumor DNA testing, increased over time.
Conclusions
EPMT is increasingly utilized especially due to an increased circulating tumor DNA testing. We identified reasons why patients with actionable results did not receive targeted therapy. We hypothesize that the number of molecular testings will continue to increase over time, thus increasing potential treatment options for patients with malignancies for whom standard of care treatment is no longer effective.
Ryan Thomas, M.D., Sienna Searles, M.D., Sakshi Jasra, M.D.
University of Vermont Medical Center
Background
As survival of patients with malignancies improves, quality of life (QOL) measures have gained importance. Cancer therapies can have an impact on fertility in patients of childbearing age. Previous studies have highlighted disparities in access to oncology care in rural patients, with negative effects on health outcomes and QOL. This study aims to explore the impact of rurality on fertility preservation in adult young adult (AYA) population.
Methods
We examined 145 patients with a new diagnosis of leukemia or lymphoma, ages 15-39, between 2017-2022 at the University of Vermont Medical Center. We looked at data on demographics, insurance, zip codes, and if there was a fertility preservation referral.
Results
Most patients were rural (N=81 or 56%) and most did not receive a referral for fertility preservation (N=77 or 53%). More urban patients received referrals (N=38 or 56%) (OR=2.5, 95% CI 1.2-5.14, p=0.0074) and patients with private insurances were more likely to receive a referral compared to those who had no insurance or had Medicare/Medicaid, (N=41 or 60% vs. N=27 or 40%) (OR=2.13, 95% CI 1.04-4.38, p=0.0243).
Conclusions
We found that rural AYA patients with hematologic malignancies were less likely to receive referrals for fertility preservation. Patients with private insurances had the highest rates of referrals, while patients with Medicare/Medicaid or no insurance were less likely to be referred. This study highlights disparities in access to fertility preservation in rural cancer patients, with significant potential impact on quality of life.
Development of a Physical Activity Assessment and Staff Education for Oncology Nurses
Laurie Tyer, DNP, MSN, RN
Exeter Hospital, Clinical Director of Center for Cancer Care
Background
Physical activity and mobility are key indicators of treatment and disease tolerance in cancer patients. Patients are living longer during and after cancer treatment, and staying active prevents many side effects of the disease and the treatment. Staying mobile also prevents some conditions from occurring including bone and muscle loss. A nursing educational platform was identified as a need in the facility site’s cancer center on the importance of patients staying physically active throughout cancer treatment. Nurses did not feel confident to coach patients on their activity levels, and this was an identified gap in their nursing practice.
Methods
A nursing educational program was constructed utilizing a conceptual nursing model based on patient-centered care and the application of research to practice. The Partnering with Patients Model of Nursing Interventions supported the development and implementation of the nursing educational PowerPoint presentation and the development of targeted assessment questions about activity. A pre- and post-survey was utilized to assess comfort level and feasibility of patient physical activity education during interactions with nurses.
Results
The results showed a +17% increase in comfort level after the presentation. The most significant increase were the questions on having a tool to recommend and feeling prepared to recommend. Understanding the importance of this education was extremely important.
Conclusions
Proposed recommendations included patient teaching materials, acquisition of exercise tools for the outpatient clinic, and recommendations to cancer rehabilitation services for patients with identified individual needs. The information will be shared when orienting new oncology nurses.
Radioresistant but Alectinib Responsive Isolated Intramedullary ALK Positive Histiocytosis
Joshua Van Allen, D.O.1, Brendan Killory2,3, David Raggay4, Joseph DiGiuseppe4, Mark Dailey1,5
1 Department of Hematology and Oncology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
2 Department of Neurosurgery, University of Connecticut School of Medicine, Farmington, Connecticut, USA
3 Department of Neurosurgery, Hartford Hospital, Hartford, Connecticut, USA
4 Department of Pathology, Hartford Hospital, Hartford, Connecticut, USA
5 Deparment of Hematology and Oncology, Hartford Hospital, Hartford, Connecticut, USA
Case Report
A 56-year-old woman with a history of C4-C5 myelomeningocele repair as a newborn and cervical syringomyelia presented with one week of rapidly worsening bilateral lower extremity weakness and numbness, saddle anesthesia and bladder incontinence. MRI of the entire spine revealed a 1.5 x 0.5 cm homogenously enhancing intramedullary lesion at T7-T8 with associated cord edema and rostral syrinx formation. MRI of the brain and FDG PET-CT scan were unremarkable. She was taken to the operating room for T6-T8 laminectomy and biopsy. H&E staining revealed a relatively dense mononuclear-cell infiltrate, which comprised numerous medium-sized cells with round, irregular, or reniform nuclei, slightly dispersed chromatin, and relatively abundant eosinophilic, and occasionally, somewhat vacuolated cytoplasm. Immunohistochemical staining was strongly positive for CD163, PU1, CD68 and ALK. FISH studies demonstrated ALK rearrangement in 70% of nuclei. DNA testing detected a KIF5B/ALK gene fusion. She received radiotherapy with 2000 cGY in 200 cGy fractions to T6-T9 with no change in lesional size or enhancement. She was started on the ALK inhibitor alectinib. Subsequent MRI showed a complete response. She has had no evidence of disease recurrence on alectinib for 18 months. ALK positive histiocytosis is a recently described distinct clincopathologic entity. Our case is notable for older age at diagnosis, isolated intramedullary involvement, radioresistance but later marked targeted therapy response, thus furthering the understanding of the spectrum of ALK positive histiocytosis biology.
Lisa Wesinger, RN BSN OCN BMTCN, Judi Gentes1, Carissa Morton1, Ashley Prokopik1, Sara Cooke1, Kate Caldon1, Thomas Long2, Elizabeth McGrath1, Jean Coffey2
1 Dartmouth Cancer Center
2 University of Connecticut
Background
A team of clinical oncology nurses share their journey of creating a unique case study method. The nurses caring for patients/care partners receiving transplant or cellular therapy (TCT) sought a process to educate the TCT health care team about the patient/care partner experience through transplant in hopes of improving care for this patient population.
Methods
Patients were selected based on their diagnosis and TCT protocol. IRB approval was obtained and participants were consented. The nurses proceeded to interview participants about their TCT experience. Using Interpretative Phenomenological Analysis, each nurse embraced the researcher role, bringing the patient/care partner journey to life through individual case studies.
Results
The medical case study and narrative were intertwined to provide a glimpse into the life of a transplant recipient. Art and poetry were included to enhance the findings from the study. The process took over 7 years and was all done on the nurses’ own time. Each nurse created a unique narrative illuminating the respective individual experiences of the study participants as influenced by their diagnosis and their life situation.
Conclusions
With tenacious determination, this team stayed focused through many obstacles, including a worldwide pandemic. The case studies have been compiled into a book. The book outlines the unique approach to the case study which could be replicated and applied to any diagnoses.
Trastuzumab deruxtecan (T-DXd) induced Takotsubo cardiomyopathy
Xiaocao Xu, David Alejos, Peter A. Kaufman
University of Vermont
Background
T-DXd is an antibody–drug conjugate (ADC) consisting of an anti-HER-2 monoclonal antibody linked to a topoisomerase I inhibitor payload, deruxtecan. Recent randomized trials have demonstrated impressive benefits for T-DXd, leading to FDA approvals in both breast and other cancers. HER-2 targeted agents have a rare incidence of cardiomyopathy. Takotsubo cardiomyopathy has been reported in association with trastuzumab. However, T-DXd related Takotsubo cardiomyopathy has not been previously reported. Here we report to our knowledge, the first case of T-DXd related Takotsubo cardiomyopathy.
Case Report
A 52-year-old female presented with a 3 day history of chest pain and shortness of breath after finishing her third cycle of TDxd for HER-2+ metastatic breast cancer. EKG demonstrated ST segment abnormalities, labs were remarkable for an elevated troponin, and markedly increased proBNP. Echocardiographic findings were consistent with Takotsubo cardiomyopathy, left ventricle ejection fraction (LVEF) was 30-35%. Left heart catheterization revealed normal coronary arteries. Repeat Echocardiogram 1.5 months later revealed normalized left ventricular function and wall motion.
Conclusions
HER-2 targeted therapy is associated with cardiotoxicity, specifically a decrease in LVEF. T-Dxd is a new HER-2 targeting ADC. It is currently being evaluated in earlier lines of treatment in metastatic breast cancer and additionally in early stage breast cancer. T-Dxd mediated cardiac toxicity is not fully understood, the incidence of cardiomyopathy associated with T-Dxd is low, as reported in various trials. We report here the first case, to our knowledge, of T-Dxd induced Takotsubo cardiomyopathy.
What quacks like a duck is not always a duck
Xiaocao Xu, Jinah Kim, David Alejos, Rohit Singh, Hibba tul Rehman
University of Vermont
Background
Brain metastases are a common complication of cancer. In patient with history of malignancy, high suspicious of brain metastasis and prompt treatment are often life-saving. However, tissue diagnosis are needed to establish the correct diagnosis as brain mass can rarely be caused by bacterial infection, reported 0.3-0.9/100000 per year. Listeria monocytogenes is an opportunistic, anaerobic organism that is known to cause meningeal infections in immunocompromised individuals. Herein, we present a case of a brain abscess caused by Listeria in an immunocompetent patient with history of breast cancer.
Case Report
A 60-year-old female, BRCA2 carrier, history of ductal carcinoma in situ of the left breast who was admitted due to aphasia and seizure and oncology was consulted. Magnetic Resonance Imaging of the brain revealed a 1 cm mass on the left side with vasogenic edema. Computed tomography scans of the chest, abdomen, and pelvis did not indicate any evidence of disease. The patient underwent a left parietal craniotomy for resection, during which purulent fluid was drained, raising concern for a brain abscess. Fluid culture confirmed the presence of Listeria monocytogenes. Pathology of mass exhibited features consistent with an abscess, characterized by reactive brain tissue with macrophages and neutrophilic inflammation. The patient recovered well after surgery and was discharged with antibiotics.
Conclusions
Solitary brain mass in patient with history of cancer is often thought to be metastasis. However, rarely, brain abscess could be the culprit instead. Biopsy to establish the diagnosis of brain mass is critical for proper treatment.
Naji Yerokun1, Leah Graham, PhD2, Lindsey Kelley, MPH, CGC2, Petra Helbig, CCRP2, Lory Gaitor, CCRC2, Jens Rueter, M.D.2
1 Colby College
2 MCGI team and MCGI Steering Committee
Background
Over the last decade, there has been a notable rise in FDA-approved targeted therapies for cancer treatment. However, staying updated on these approvals and the constantly changing landscape of scientific literature and clinical trials can be challenging. To address this, the Maine Cancer Genomics Initiative (MCGI) has been offering Genomic Tumor Boards (GTBs) since 2017 to oncologists in Maine. Recognizing that incorporating off-label and clinical trial considerations into GTBs increases treatment options for patients, we analyzed how often these considerations were discussed for the 474 cases presented at the MCGI GTBs from 2017 to 2023.
Methods
We analyzed GTB minutes for “off-label” and “clinical trial” treatments considerations for the 10 most commonly discussed tumor types. We used descriptive statistics to compare treatment considerations based on tumor type.
Results
Off-label treatments were considered the most frequently in Esophageal (44.2%) and Head and Neck (38.5%), and least frequently in Breast (15.7%) and Colorectal (23%) cancers. Breast cancer was also the least likely to be considered for clinical trials (53.9%), while it was common to consider clinical trials for pancreatic cancer (80.3%).
Conclusions
Recent advancements in targeted treatments have prompted increased exploration of off-label and clinical trial treatments. However, some tumor types are less likely to be considered for these additional options for treatment. Considerations should be given to these gaps in recommendations to address potential barriers and ensure equitable access to clinical trials and off-label treatments across all cancer types in Maine.
Northern New England Clinical Oncology Society
P.O. Box 643
Sandown, NH 03873-0643
Telephone (603) 887-1948
info@nnecos.org
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