Oncologic Evaluation Research Articles

Multiple Aneuploidy Pattern Detected by Non-invasive Prenatal Screening in Successive Pregnancies [25K

INTRODUCTION: We present a case where non-invasive prenatal screening (NIPS) detected a similar pattern of multiple aneuploidies in sequential pregnancies. METHODS: Case Presentation (with patient consent): A 25 year-old G3P2 patient had NIPS, by massively parallel sequencing (MPS), in her second and third pregnancies. Her first NIPS result was positive for trisomies 18 and 21. Further bioinformatics review revealed possible partial trisomy 13 and complete trisomies 14 and 20, in addition to the previously reported trisomies. NIPS by MPS repeated at another lab was non-reportable. Amniocentesis revealed normal karyotype, microarray, FISH for the chromosomes of interest, and chromosome 14 uniparental disomy testing. Maternal karyotype, microarray, and chromosomal breakage studies were normal. Patient had a negative oncology evaluation. Patient had an insignificant medical and medication history. Patient delivered a healthy girl. Placenta was small with a normal karyotype. Her current pregnancy shows a similar NIPS pattern. Patient declined amniocentesis and further aneuploidy screening. Second trimester ultrasound detected fetal hyperechoic bowel. Repeat maternal chromosomal breakage studies were normal. CONCLUSION: NIPS analyzes cell-free DNA in maternal blood originating from maternal and cytotrophoblast cells. The similar NIPS pattern in both pregnancies indicates a likely maternal etiology. When multiple aneuploidies are observed by NIPS, possible etiologies include maternal benign tumor or malignancy and fetal, placental or maternal chromosome abnormalities. However, subsequent fetal and maternal evaluations were normal. This case highlights that NIPS may yield unexpected results that are not representative of the fetal or maternal karyotypes and an extensive multi-specialty work-up may be recommended in these scenarios.

Validation of irtGPUMCD, a GPU-based Monte Carlo internal dosimetry framework for radionuclide therapy

PurposeMonte Carlo (MC) simulations are highly desirable for dose treatment planning and evaluation in radiation oncology. This is true also in emerging nuclear medicine applications such as internal radiotherapy with radionuclides. The purpose of this study is the validation of irtGPUMCD, a GPU-based MC code for dose calculations in internal radiotherapy. MethodsThe female and male phantoms of the International Commission on Radiological Protection (ICRP 110) were used as benchmarking geometries for this study focused on 177Lu and including 99mTc and 131I. Dose calculations were also conducted for a real patient. For phantoms, twelve anatomical structures were considered as target/source organs. The S-values were evaluated with irtGPUMCD simulations (108 photons), with gamma branching ratios of ICRP 107 publication. The 177Lu electrons S-values were calculated for source organs only, based on local deposition of dose in irtGPUMCD. The S-value relative difference between irtGPUMCD and IDAC-DOSE were evaluated for all targets/sources considered. A DVHs comparison with GATE was conducted. An exponential track length estimator was introduced in irtGPUMCD to increase computational efficiency. ResultsThe relative S-value differences between irtGPUMCD and IDAC-DOSE were <5% while this comparison with GATE was <1%. The DVHs dosimetric indices comparison between GATE and irtGPUMCD for the patient led to an excellent agreement (<2%). The time required for the simulation of 108 photons was 1.5 min for the female phantom, and one minute for the real patient (<1% uncertainty). These results are promising and let envision the use of irtGPUMCD for internal dosimetry in clinical applications.

Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer.

The proximity of the very low rectum rectal cancer to the anal sphincter raises a specific problem: how and until when can we preserve the anal continence without compromising the oncological result of the tumor resection? In this situation, intersphincteric resection (ISR) offers an excellent alternative to abdominoperineal resection (APR), but the selection of patients for this option must be extremely precise. This complex choice justifies the simultaneous consideration of an oncological approach with a functional approach in order to provide a full benefit to the patient. When a circumferential resection margin of at least 1 mm can be performed with a distal resection margin of at least 1 cm with or without preoperative radiotherapy, ISR ensures a safety choice. The oncological results of ISR reported in the literature when performed properly found a 5-year disease-free survival of 80.2% with a local recurrence rate of only 5.8%. In parallel to this oncological evaluation, the expected post-operative functional outcome and the resulting quality of life must be properly assessed pre-operatively, since partial or total resection of the internal sphincter impacts significantly on the functional outcome. Based on data from the literature, this work reports the essential anatomical considerations and then the oncological and functional elements indispensables when an anal continence preservation is evoked for a tumor of the very low rectum. Finally, the precise selection criteria and the major surgical principles are outlined in order to guarantee the safety of this modern choice for the patient.

3:54 PM Abstract No. 304 Hepatobiliary toxicity in nivolumab-treated hepatocellular carcinoma in the presence or absence of transarterial chemoembolization

To compare hepatobiliary toxicity in unresectable hepatocellular carcinoma (HCC) patients receiving nivolumab alone with those receiving nivolumab after transarterial chemoembolization (TACE). This single-institution retrospective study analyzed 28 patients who had received nivolumab therapy for treatment of HCC during 2018-2019. Patients that had undergone prior TACE (N = 11) had mean age of 68 years, with Child-Pugh Class A (64%), Class B (27%), and Class C (9%). Patients without prior TACE (N = 17) had a mean age of 64 years, with Child-Pugh Class A (59%), Class B (23%), Class C (18%). Hepatobiliary complications were graded using the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0), with the exception of portal hypertension, as a majority of patients had portal venous involvement prior to treatment. Comparison was made between a patient’s initial oncology evaluation for nivolumab and the follow-up visit after their last known treatment with nivolumab (average 127 ± 118 days). Patients that had undergone prior TACE had an average of 2 TACE treatments and 4 cycles (range, 1 to 17) of nivolumab, with an average of 215 days between last TACE treatment to initiation of nivolumab. Patients without prior TACE had undergone an average of 5 cycles (range, 1 to 24) of nivolumab. Hepatobiliary complications occurred in 45% (5/11) of patients that had undergone prior TACE, which included of CTCAE v5.0 grade I (27%, N = 3) and grade 3 (18%, N = 2) complications. Hepatobiliary complications occurred in 47% (8/17) patients that had not undergone TACE, which included grade 1 (18%, N = 3), grade 2 (12%, N = 2) and grade 3 (18%, N = 3) complications. Prior treatment with TACE did not result in increased hepatobiliary toxicity in patients undergoing treatment with nivolumab.

Implementation of systematic genetic counseling (GC) and multigene germline testing (MGT) for pancreatic cancer (PC) patients (pts).

678 Background: MGT identifies cancer susceptibility gene variants in 4-10% of unselected PC pts. Such data have prompted national guidelines to recommend GC and MGT of all PC pts, but the benefits and barriers to implementing systematic testing are unknown. This study’s aim was to study the implementation of universal GC for all PC pts seen in an academic oncology practice. Methods: In 12/2016, all Dana-Farber Cancer Institute (DFCI) gastrointestinal oncologists were recommended to refer all PC pts for GC and MGT. In 10/2018, workflows were changed such that PC patients were automatically scheduled for GC consultation on the same day as their initial oncologic evaluation (unless patients opted out), rather than relying on provider referral. Clinical and germline data were collected on a consecutive cohort of PC pts undergoing GC and MGT from 3/1/2017-3/31/2019. Two additional months (4/1/2019-5/31/2019) were collected for clinical quality assessment purposes. Results: 1305 (48.3/month) PC pts were seen for oncologic new patient visits, 318 (25.1%; 12.1/month) of whom underwent GC. Rates of GC/MGT increased significantly after the 10/2018 workflow change (8.2 PC pts/month [17.2% of all new PC pts seen] versus 20.3 PC pts/month, [40.9% of all new PC pts seen]; p&lt;0.01). Of the 318 PC pts who underwent GC, 29 (9.1%; 95% CI 6.4-11.9%; 2.2% of all PC pts seen) were found to carry germline PC susceptibility gene mutations on MGT. Rates of mutation carrier identification increased after the clinical workflow change from 0.79 mutation carriers/month (1.6% of all new PC pts seen) to 1.75 mutation carriers/month (3.5% of all new PC pts seen). The majority of identified mutation carriers have either received therapy targeted towards their germline mutation or are undergoing first-line palliative systemic therapy with potential for future targeted therapy. Conclusions: Clinical implementation of routine GC/MGT in PC pts is feasible and results in the detection of mutations that are actionable for PC pts and at-risk family members. Systematized workflows for GC evaluation not reliant on active referral result in markedly higher uptake of MGT and mutation carrier identification. Clinical trial information: NCT03060720.

Video-assisted thoracoscopic thymectomy is feasible for large thymomas: a propensity-matched comparison.

Video-assisted thoracoscopic thymectomy is becoming the preferable approach for early-stage thymoma. However, large thymomas are still recognized as a relative contraindication due to the possible risk of incomplete resection or capsular disruption. Thus, the aim of this study is to evaluate the feasibility of video-assisted thoracoscopic thymectomy for large thymomas. Patients diagnosed with Masaoka stage I-IV thymoma between April 2001 and December 2018 were retrospectively reviewed. All patients were divided into 2 groups: thymoma <5.0 cm (group A) and thymoma ≥5.0 cm (group B). Propensity score matching analysis was performed to compare postoperative results. Recurrence-free survival and overall survival were compared for oncological evaluation. A total of 346 patients were included in this study. In the propensity score matching analysis, 126 patients were included both in group A and group B. There was no significant difference between these 2 groups in terms of the R0 resection rate (95.2% vs 94.4%, P = 1.000), conversion rate (1.6% vs 3.2%, P = 0.684), operation time (119.4 ± 48.4 vs 139.1 ± 46.6 min, P = 0.955), blood loss (93.2 ± 231.7 vs 100.5 ± 149.3 ml, P = 0.649), duration of chest drainage (2.7 ± 1.6 vs 2.8 ± 2.0 days, P = 0.184), length of hospitalization (5.0 ± 3.9 vs 5.2 ± 2.9 days, P = 0.628) or postoperative complications (5.9% vs 8.5%, P = 0.068). There was no significant difference between these 2 groups in terms of the overall survival (P = 0.271) and recurrence-free survival (P = 0.288). Video-assisted thoracoscopic thymectomy is a safe and effective approach for large thymomas (≥5 cm) with comparable surgical and oncological results.

A Prediction Model to Help with Oncologic Mediastinal Evaluation for Radiation: HOMER.

Rationale: When stereotactic ablative radiotherapy is an option for patients with non–small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease.Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound–guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals.Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography–computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34).Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.

Haemorrhage in pre-existing adrenal masses. A case series

IntroductionAdrenal haemorrhage in the context of a pre-existing adrenal mass is a rare, underestimated and potentially fatal surgical emergency. It is a rare cause of acute abdominal pain. Presentation of casesData from 13 patients with adrenal haemorrhage in a pre-existing adrenal mass were prospectively collected during a 9 year period from a single institution. All patients underwent CT imaging which formed the basis of diagnosis and a complete endocrinological evaluation. Seven out of 13 patients underwent an elective surgical procedure and 2 patients underwent emergency laparotomy. Five out of 13 patients were diagnosed with metastatic disease. One patient was diagnosed with pheochromocytoma. DiscussionThe likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious. Complete patient evaluation includes testing for hormonally active adrenal tumors and malignancy. Emergency surgery is reserved for cases where conservative management fails. ConclusionHaemorrhage of an adrenal mass constitutes a diagnostic and therapeutic challenge. Most patients respond well to initial resuscitation efforts. When feasible, patients should undergo a complete hormonal and oncologic evaluation before surgical intervention is considered.

Systemic atherosclerotic plaque vulnerability in patients with Coronary Artery Disease with a single Whole Body FDG PET-CT scan.

Cardiovascular disease is a leading cause of morbimortality with over half cardiovascular events occurring in the asymptomatic population by traditional risk stratification. This preliminary study aimed to evaluate systemic plaque vulnerability in patients with prior Coronary Artery Disease (CAD) with a single Whole Body [FDG] PET-CT scan in terms of plaque inflammation and calcifications. Twenty-two patients referred for oncological evaluation and with prior history of advanced CAD or age and gender matched controls without cardiovascular disease, underwent a Whole Body PET-CT scan 90 min after injection of 18F-FDG. A total of 975 transaxial PET images were retrospectively analysed to assess plaque inflammation using a standardized method of analysis with averaged Target-to-Background Ratios (TBRs) at different levels, in the thoracic and abdominal aorta, carotids, LAD, common iliac and femoral arteries, and were correlated with calcium scores from the CT images. TBRs from the thoracic aorta were higher in male patients than controls (1.49±0.11, p<0.05) and a gradient was observed (ascending > descending > aortic arch), and were also higher in the carotids in female patients (1.43±0.07) versus controls (p<0.05). A tendency for higher levels of plaque inflammation in the abdominal aorta was noted in all groups, but no significant FDG uptake was found either in the iliac or femoral arteries in any group. Plaque inflammation was also higher in the LAD in males but with large variations. Higher levels of calcifications were noted in the LAD, infra-renal abdominal aorta and common iliac arteries, but without significant correlation with plaque inflammation except sporadic overlapping. Patients with advanced CAD are at risk for vulnerable inflamed atheromas in other territories such as the thoracic aorta and carotid arteries, underpinning the systemic nature of the atherosclerotic disease. Coexistence with calcifications is rare, suggesting a different functional status of the plaques and different stages of the disease. Evaluation of subclinical systemic plaque vulnerability in CAD with a Whole Body [FDG] PET-CT scan is feasible and a potentially useful biomarker to assess subclinical vascular risk for risk stratification and treatment optimization, but further studies are needed.

Romatolojik ayırıcı tanıda onkolojik değerlendirme

Romatolojik ayırıcı tanıda onkolojik değerlendirme

PCN448 IMPROVING THE ACCURACY AND REDUCING UNCERTAINTY OF PROBABILISTIC PARTITIONED SURVIVAL ANALYSES, BY CONSIDERING THE RELATIONSHIP BETWEEN PFS AND OS

Partitioned survival analysis (PartSA) is a commonly used modelling technique for economic evaluations in oncology. This method typically involves parametrising and extrapolating progression free survival (PFS) and overall survival (OS) to estimate costs and effects of interventions and their comparators. In probabilistic analyses, the PFS and OS estimates are often sampled independently, which ignores the relationship that exists between these two outcomes. We illustrate a straightforward method to factor in this relationship by bootstrapping the underlying trial data. The trial data is repeatedly resampled with replacement, for many iterations (in this example, 10,000). Within each of the 10,000 resamples, the OS and PFS models are re-fitted and their coefficients recorded. This results in 10,000 sets of OS and PFS model coefficients which are internally consistent with each other. The OS/PFS relationship can be factored into subsequent probabilistic PartSA analyses, by either estimating a covariance matrix across the OS and PFS coefficients, or by simply drawing from a random row of the 10,000 coefficient sets (dependent modelling). We compare the uncertainty impact of the dependent modelling approach with the conventional independent approach, by using two publicly available cancer datasets (pancreatic and liver cancer) and observing the distribution of probabilistic post-progression survival. In the pancreatic data, the dependent modelling method considerably reduced the uncertainty of PPS compared to independent sampling (standard deviation of 18 vs 46 days). This is a direct result of factoring in the relationship between PFS and OS (correlation coefficient of 0.84, vs zero). A similar pattern is observed in the liver cancer data. It is typical for costs to be strongly associated with PFS (due to treat-until-progression regimens), and QALYs to be strongly associated with OS. Therefore, the relationship between PFS and OS (and hence PPS) is a crucial to the validity of cost-effectiveness results.

Effectiveness of Multi-Prognostic Index in older patients with advanced malignancies treated with immunotherapy

BackgroundOlder adults with cancer are less likely to be offered treatment for cost-benefit concern. The Multi-Prognostic Index (MPI) has been validated in various clinical settings for survival estimation. We aimed to evaluate MPI as a screening tool for older adults with cancer eligible to receive immunotherapy. Patients and MethodsOlder adults with advanced or metastatic cancer, admitted to the Oncology Day Hospital of the University Hospital of Pisa from January 2017 to May 2018, eligible to receive immunotherapy were prospectively enrolled. In addition to routine oncological evaluation, each patient received a comprehensive geriatric assessment with MPI calculation. Overall survival (Cox-adjusted curve) was stratified by tertiles of MPI score. Drug toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events (Version 4.03: June 14, 2010). ResultsSeventy-nine patients [26.6% women, mean age (±SD) 74.0 ± 6.1 years] were enrolled with the following diagnosis: melanoma (51.9%), non-small cell lung cancer (25.3%), renal cell cancer (12.7%), urothelial cancer (8.9%) and Merkel cell carcinoma (1.2%). Median follow-up was 7 months (range 1–35). The patients' survival rate resulted progressively longer proceeding from the first to the third MPI tertile [HR 1.76 (0.49–6.31) Vs 2nd tertile, p < 0.05; HR 5.33 (1.68–16.89) Vs 3rd tertile, p < 0.01]. ConclusionsMPI score is an effective tool for the stratification of older patients with cancer eligible for immunotherapy with checkpoint inhibitors. Further studies are required to achieve conclusive remarks on MPI usefulness in different underlying tumor types.

1486 Rectal Melanoma Occurring in a Properly CRC Screened Patient

INTRODUCTION: Rectal melanoma is a very rare, highly aggressive malignancy. Anal melanoma is the 3rd most common melanoma after the cutaneous and ocular varieties. It is the most common site of primary GI melanoma. Cutaneous melanoma metastasizes to the GI tract only 2% of the time, and only 2% of these metastases are to the rectum. CASE DESCRIPTION/METHODS: A 68-year-old male with a past medical history of HTN presented for evaluation of changed bowel movements. His stool diameter had decreased, and he noticed bright red blood mixed with his stool. He sometimes experienced fecal urgency, with no output. Rectal bleeding occurred just before or with bowel movements. He recently changed his diet, because of constipation. He recently lost 10 lbs. unintentionally. He did not use NSAIDs aside from aspirin 81 mg qd. He had a colonoscopy 5 years ago, with a 2 mm polyp removed (no abnormality seen on pathology). He had no family history of colon cancer. He was a retired chiropractor. A colonoscopy was performed, which found a suspicious lesion in the rectum (biopsied). Pathology showed pigmented melanoma. EUS staged the rectal mass as uT2uN1. Immunostains of the biopsy were performed: CK20-, CDX2-, p63-, S100 focally positive, HMB45 diffuse and strongly positive. No evidence of cutaneous melanoma was found. He was referred for surgical and oncology evaluation and treatment. He successfully underwent laparoscopic abdominal perineal resection with end colostomy. 9/10 sampled lymph nodes during surgery were positive for melanoma. He was started on nivolumab/ipilimumab dual therapy. He proceeded to undergo chemotherapy as outpatient (currently on chemotherapy cycle 2). DISCUSSION: Anorectal melanoma is a rare disease, accounting for ∼ 0.05% of all colorectal malignancies, and 1% of all anal cancers. Risk factors for anorectal mucosal melanoma are not currently known, although there is an increased risk associated with HIV infection. Survival is poor, depending on staging (Stage I – 24 month median survival; 5-year survival 26.7%, Stage II – median survival 17 months; 5-year survival 9.8%, Stage III – median survival 8 months; 5-year survival 0%). Adjuvant therapy consists of radiotherapy, however adjuvant immunotherapy with nivolumab has an established role in treating lymph node involvement. Anti-CTLA4 monoclonal antibody ipilimumab has been shown to significantly prolong survival in cutaneous melanoma, however more investigation is necessary to clarify role of ipilimumab in patients with mucosal melanoma.

Pre-Bone Marrow Transplant Physical Therapy Evaluations in Pediatric Oncology

Pre-Bone Marrow Transplant Physical Therapy Evaluations in Pediatric Oncology

1602 Mantle Cell Lymphoma Presenting as Intussuscepting Colon Mass

INTRODUCTION: Mantle Cell Lymphoma (MCL) is a non-Hodgkin lymphoma accounting for 2.5% of lymphoid neoplasms in the United States. Primary gastrointestinal (GI) lymphomas account for 1-4% of all GI malignancies, with few reports of primary mantle cell lymphoma presenting as a single colonic mass and none to our knowledge with colon-colonic intussusception as the presenting finding. Accurate and timely diagnosis is imperative because MCL has rapid progression and early chemotherapeutic intervention results in improved patient outcomes. CASE DESCRIPTION/METHODS: A 61-year-old male presented with 1 month history of nonspecific right sided abdominal pain. Computed Tomography (CT) of the abdomen identified an intussuscepting mass of the proximal ascending colon and an additional 8mm hepatic lesion. Colonoscopy identified a large mass in the corresponding area of colon identified on CT. Histology and immunohistochemistry of biopsied specimen diagnosed MCL. Planned surgical intervention was deferred and the patient was referred for oncologic evaluation and treatment. DISCUSSION: We report the first case to our knowledge of MCL presenting as colon-colonic intussusception and discuss the work-up of this rare lymphoma that clinicians may be required to diagnose and manage. This report serves as a reminder to maintain a broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with a thorough understanding of medical principles and clinical acumen is essential for optimal patient care and, as demonstrated in this case, preventing a potentially unnecessary surgical intervention thus delaying appropriate chemotherapy.

The Oncology Evaluation Center: Implementation of a same-day evaluation and treatment center to avoid unnecessary ED visits.

81 Background: Oncology patients have high rates of both Emergency Department (ED) visits and readmissions. The Hematology-Oncology Division at this urban, 776-bed academic medical center established the Oncology Evaluation Center (OEC) to provide cancer patients with prompt ambulatory evaluation for new symptoms that may otherwise lead to ED visits and unplanned admissions. With new therapeutic options associated with unique complications, the OEC Advanced Practice Providers are knowledgeable in providing care to this high-risk population. ED providers can lack oncology-specific training, comfort, and confidence when caring for cancer patients, resulting in sub-optimal care. Methods: A retrospective review of the chief complaints (CC) of oncology patients presenting to the ED was conducted. Using Plan Do Study Act methodology, in 2016 the OEC was opened to provide same day evaluations and interventions to patients with symptoms related to their cancer diagnosis, their treatment, or their comorbidities. Inclusion and exclusion criteria were developed to ensure appropriate referrals to the OEC. A hospital awareness campaign launched to promote OEC referrals, including educational sessions at multidisciplinary tumor boards. Additionally, two Lean Six Sigma trained infusion RNs led initiatives to promote OEC utilization. Results: The OEC resulted in quick evaluation and intervention for oncology patients. The most common CC are pain, dehydration, fever, nausea/vomiting, and fatigue. Of the 2721 patients seen to date in the OEC, 72% were discharged to home. According to survey results, 81% of oncology providers agree that if the OEC were not in existence, patients referred to the OEC would be referred to the ED. Oncology readmission rates have decreased from 14% (2016) to 12% (2018). Conclusions: The OEC has proven to be an innovative solution for prompt evaluation and ambulatory treatment of cancer patients with complications. This is a valuable component of comprehensive patient-focused care, resulting in ED visit and readmission avoidance. The OEC is an effective low cost, high reward programmatic strategy to expand access to care while improving patient experience.

P10.06 Stiff limb syndrome associated to anti NMDA-R antibodies

Abstract BACKGROUND Stiff person spectrum disorder is a group of rare conditions clinically characterized by the core symptoms of fluctuating muscular stiffness with superimposed spasms and an exaggerated startle response (hyperkplexia). It includes multiple variants amongst which are focal forms like stiff limb syndrome. Up to date, it was described in association with a spectrum of antibodies interfering with gabaergic transmission, most frequently antibodies targeting GAD, glycine receptor, amphiphysin and more rare dipeptidylpeptidase like protein 6, gephyrin, GABAAR and Glycine transporter 2. MATERIAL AND METHODS We report the case of a stiff limb syndrome associated to anti-NMDAR antibodies. The patient, a French 44-year male, with no antecedents presents with a 2-month history of painful spasms in his both legs resulting in a difficulty of walking and multiple falls. The diagnosis was supported by a stiff limb syndrome clinical pattern, a clinical response to treatment with benzodiazepines and baclofen and by the absence of other neurological finding that could have suggested an alternative diagnosis. RESULTS Anti NMDA-R antibodies were identified in blood and CSF samples using both immunofluorescence and cell-based assay. Any other intracellular and surface antibodies were negatives, GAD-ab included. Oncological evaluation was negative. The patient didn’t present encephalopathy signs and neuropsychological evaluation was normal. The patient received immunotherapy with one cure of intravenous immunoglobulins after an only partial improvement with symptomatic treatment. CONCLUSION This is the first case report of an association between the anti NMDA-R and stiff limb syndrome. Further investigations are needed to provide a better understanding of the pathophysiology of stiff person spectrum disorders.

Medulloblastoma: Clinical presentation

Medulloblastomas present generally a-specifically as a fast-evolving posterior fossa tumor. Medical literature is poor concerning clinical features of medulloblastomas and their potential significance. In the present study, we reviewed 91 pediatric observations of medulloblastomas treated in Lille between 1997 and 2017. Clinical and epidemiological variables were collected and intercorrelated. They were also compared with anatomical and pathological findings, and outcome, with the aim of defining clinical-pathological entities. We also compared the group with 32 cases of posterior fossa ependymoma and 130 cases of cerebellar astrocytoma treated during the same period. We found that in medulloblastomas, the M/F ratio was higher and diagnostic delay was shorter than in astrocytomas. Also, the mean age was older than in ependymomas. Intracranial hypertension was constant; we further observed that altered general status was common (16.5%) and correlated with a metastatic tumor. We delineated two clusters: the “nodular” cluster, which associates young age, cerebello-pontine angle tumor, herniation, desmoplastic tumor, and tumor predisposition syndrome; and the “metastatic” cluster, which associates altered status, initial metastases, hydrocephalus, and diagnostic delay. Meticulous collection of clinical data at the initial phase is integral part of the oncological evaluation, with a search for genetic and prognostic risk factors, which then permits us to define clinical-pathological entities.

Do Health Insurance and Other Psychosocioeconomic Determinants of Health Impact Survival Through Treatment Delays with Stereotactic Body Radiation Therapy in Borderline Resectable and Locally Advanced Pancreatic Cancer Patients?

The biopsychosocial model of health suggests that focusing only on the biologics of disease neglects areas for improvement that may affect outcomes. Costs of stereotactic body radiation therapy (SBRT) for borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer may be prohibitive for insurance companies to approve in a timely fashion given the debated necessity of neoadjuvant SBRT. We hypothesized that psychosocioeconomic factors contribute to delayed initiation of SBRT, which leads to poor survival outcomes. Retrospective analysis of an IRB approved database of BRPC and LAPC patients treated with SBRT yielded 223 patients that met our selection criteria from 2009-2016. Patients were treated according to an institutional treatment pathway, with systemic therapy regimens based on the discretion of the treating medical oncologist consisting of either gemcitabine-based regimens or FOLFIRINOX. This was followed by 5 fraction SBRT. All patients undergoing SBRT were assessed for psychosocial needs prior to therapy. Delayed initiation of SBRT was defined as >21 days from the end of chemotherapy to the first day of SBRT. Delayed start of SBRT (18.4 vs 12.0 months, p<0.001), no secondary insurance prior to SBRT treatment (12.0 vs 16.5 months, p=0.009), and no reliable transportation (11.5 vs 15.0 months, p=0.045) were all independently associated with poor overall survival. Delayed SBRT starts were associated with not having private insurance (p=0.005), not having United (p=0.020), having financial concerns (p=0.041), and living in a lower valued home (p=0.008). Proxies of lower socioeconomic status are associated with delayed SBRT starts, which, in this cohort, is also tied to poor overall survival. As stewards of the healthcare system, it is imperative for clinicians to holistically assess patients that may be vulnerable to these non-biologic factors, as this may impede time sensitive treatments. Referral for radiation oncology evaluation prior to or shortly after initiation of systemic therapy may allow earlier identification of these factors so that these issues can be addressed proactively, mitigating potential delays in SBRT delivery.

Characteristics of Patients and Treatment Recommendations from a Multidisciplinary Spinal Tumor Program

Spinal tumors arise frequently for patients with advanced cancer and optimal management involves consideration of neurologic, oncologic, mechanical, and systemic features. We describe characteristics of patient and treatment recommendations from a multidisciplinary spinal tumor board at one institution. A multidisciplinary spinal tumor program including radiation oncology, neuroradiology, orthopedic surgery, neurosurgery, and palliative care providers convened weekly to review complex spine cases and formulate a consensus plan. Patient and tumor characteristics were abstracted from electronic medical record with IRB approval, and treatment recommendations descriptively summarized. Between April 2017 and February 2019, 622 cases were reviewed, representing 438 unique patients. The median age was 62 years (range 21-92), comprising 52.5% men (n=230). In total, 31% (n=236) patients were deceased at last follow up. Most patients (91.8%) had metastatic disease, most commonly, breast (15.2%, n=67), NSCLC (14.8%, n=65), prostate (11.6%, n=51), renal cell (9.1%, n=40), or sarcoma (6.4%, n=28). 4.3% of patients had primary CNS tumors (n=19), and 2.5% had benign findings after pathology review, including 2 with infection. Radiation treatment was recommended in 52% of cases, including conventional EBRT in 34% (n=210) and SBRT in 18% (n=111). Surgical intervention was recommended for 26.2% (n=163) of patients. Vertebroplasty/kyphoplasty, biopsy, nerve root injection, or cryoablation was recommended for 15.9% (n=99), 9.3% (n=58), 0.8% (n=5), and 3.7% (n=23) of cases, respectively. Primary palliative care or medical oncology evaluation was recommended in 4.5% (n=28) and 5.3% (n=33). Additional imaging was requested for 16.6% (n=103), and 4% (n=25) cases had no further intervention recommended. Multidisciplinary care characterized 30% (n=189) of treatment recommendations, involving coordination of care of at least 2 (n=181) or 3 (n=8) disciplines for further local therapy or intervention. Multidisciplinary input is integral to the optimal care of spinal tumor patients. The risk of death for this patient population highlights the need to prioritize modalities that optimize overall quality of life in the context of a patient’s individual prognosis.