MDT Discussion Research Articles

BS O04 - Audit of outcome of SADIS- Results from a single Bariatric center

Abstract Background SADIS- Single anastomosis Duodeno-ileal switch is a bariatric procedure that has been accepted widely as a bariatric procedure. Literature has shown that it gives good outcomes in terms of weight loss and resolutions of obesity related morbidity. There has been criticism about the nutritional deficiencies associated with SADIS. It is a technically challenging procedure, so it is not extremely popular in the bariatric world where sleeve is the most done procedure and RYGB is the gold standard. Method All the patients at our centre undergo MDT assessment. Based on the MDT discussion and the patient preference, the decision of surgery is made. All the patients who underwent SADIS were included in the study Primary aim: Weight loss at 6 months, 1 year, 2 years and 6-10 years ORM resolution at 6 months, 1 year, 2 years and 6-10 years Nutritional deficiencies in the short term and long term. Results 17 patients underwent SADIS. Average BMI 55, it is higher than the usual BMI cohort, saying that higher BMI patients were offered SADIS as compared to the lower BMIs, who were offered Sleeve, Bypass. The weight loss pattern followed by SADIS patients was more than bypass patients over 6 m, 1 y and 2 y. The SADIS patients had better sustained weightloss over 6-10 y. One crucial factor in patient profile is the ratio of psychological vs physiological co-morbidities is higher than the average; which corresponds to our findings of the feasibility study for bariatric surgery for BMI >65 Conclusion SADIS gives good outcomes in terms of weight loss and resolution of co-morbidities. Long term results with SADI in terms of sustained weight loss are better than bypass. It did not lead to increased nutritional deficiencies.

BS SO08 - Prospective audit of weight loss and resolution co-morbidities of various bariatric surgeries and Comparisions of weight loss and ORM resolution between bypass and sleeve-1 years follow up- Audit outcomes from Jan 2019-2023

Abstract Background Bariatric surgery is the gold standard in managing bariatric patients. There are various bariatric surgeries that have been approved. Sleeve gastrectomy is the most common procedure to be done globally. RYGB is considered the gold standard surgery as it gives the best weight loss and comorbidity resolution. OAGB is now a well-established procedure. Other procedures which are offered to the patients are duodenal switch and SADIS. Method We prospectively analysed the patients who underwent bariatric surgery at our center. All the bariatric surgery patients were included. Aim To calculate EBWL at 6 m, 1 year Resolutions of obesity related morbidity Comparision of the outcomes between Sleeve and Bypass Results 1024 patients underwent bariatric surgery. All the patients undergo MDT discussion and the decision of choice of surgery is made based on MDT discussion and patients' preference. For the first 6 months both sleeve and bypass fair equal in terms of weight loss and resolution of comorbidities. Subsequently weight loss is better with bypass. It is also better sustained with the bypass. Resolution of comorbidities is the best within the first 6 months post-surgery. Conclusion There is a direct relationship between weight loss and resolution of co-morbidities. These patients are under follow up for outcomes at 2 years. Results will be published at the time of conference presentation

OGC SO21 - Role of Staging Laparoscopy on oesophageal and junctional cancer management

Abstract Background Staging laparoscopy and peritoneal cytology is currently recommended as a staging tool required for oesophageal and gastro-oesophageal junction (OGJ) adenocarcinomas. However, evidence is variable regarding the utility of this investigation, leading to heterogenous practice in the UK. With improved staging sensitivity of CT and PET imaging and inclusion of routine MDT discussion for upper GI cancer patients, staging laparoscopy may not be necessary for all patients with oesophago-gastric cancer, and in fact may delay their treatment. We thus aimed to assess the impact of staging laparoscopy on the treatment algorithm of patients with oesophago-gastric cancer. Method All staging laparoscopies undertaken between January 2022 and March 2024 were identified from our surgical database. Patients were included if they had oesophago-gastric adenocarcinoma, with a plan for curative treatment. Data collected included age, gender, location of primary tumour, CT/PET staging, laparoscopy findings, impact on treatment intention, neoadjuvant treatment, and final histology. Primary outcome was incidence of positive microscopic or macroscopic peritoneal disease for oesophageal and OGJ malignancy. Results 127 patients were identified - 69 (55%) oesophageal, 25 (20%) GOJ, and 32 (24.4%) gastric cancer. 1/70 (1.4%) patient diagnosed endoscopically with oesophageal cancer had positive peritoneal disease, which was suspected due to pre-operative imaging findings of ascites and suspicions of linitis plastica. Of patients diagnosed with GOJ cancer, 4/25 patients (16%) had peritoneal disease present. None of the 39 patients with oesophageal/junctional tumours with clinical T1-2 disease were found to have peritoneal disease on staging laparoscopy. 6/32 (19%) patients with gastric cancer were found to have unexpected peritoneal disease present. Conclusion This study found minimal impact staging laparoscopy has on the management of primary oesophageal cancers. Consideration can be made of limiting staging in oesophageal cancer to patients with suspicious findings on CT/PET imaging. For GOJ tumours, there may be a role for limiting staging laparoscopy for Siewert 1 tumours to T3/4 tumours based on CT/PET findings. Importantly, accurate identification on primary endoscopy of the location of the tumour in relation to the gastro-oesophageal junction is necessary to help guide ongoing management.

MS O02 - OGC An audit of waiting times of the oesophagogastric cancer diagnostic pathway at a high-volume, tertiary centre

Abstract Background The oesophagogastric cancer (OGC) staging pathway is extensive, contributing to prolonged waiting times from referral to treatment. NHS England guidance details the ideal timeframe from referral to finalisation of the patient’s treatment plan and stipulates a time of 21 days from OGD to communication of the treatment plan to the patient. This audit aims to compare pathway times at a tertiary cancer centre, which accepts referrals from seven different hospitals, to the current NHS target and further stratify pathway times according to patient characteristics and referring hospitals. Method Data was collected using a prospectively collected database of OGC patients who underwent staging investigations at the tertiary centre between October 2022 and October 2023. The primary outcome was OGD to communication of the treatment plan. Secondary outcomes included time from OGD to first staging investigation and the proportion of patients that had a next-day computed tomography (CT) scan. Outcomes were stratified to investigate inter-hospital variation and the effect of curative status and tumour location. Data was expressed as median and interquartile range (IQR) for continuous data or n (%) if categorical. Results 263 patients were included in this audit with a median age of 69.0 (IQR 61.5-77.0). 13.8% of patients satisfied the target time of 21 days from OGD to communication of treatment plan. Curative patients had a longer median pathway time than palliative patients (49.0 vs 35.0 days), whereas oesophageal and gastric cancer patients had similar pathway times (44.0 vs 44.5 days). Patients diagnosed at the tertiary centre had a faster time from OGD to first staging investigation than patients diagnosed at non-specialist centres. Only 13.3% of patients had a next-day CT scan following their OGD (median time 5.0 days). Conclusion The OGC staging pathway is considerably slower than the target. Faster pathway times in palliative patients can be attributed to many of these patients not requiring further staging post-CT. Potentially, targets should be re-evaluated to distinguish between palliative and curative patients. The faster staging process at the central hospital may be explained by more regular clinics run by specialist clinicians and the prompt requesting of staging investigations without awaiting MDT discussions. Alongside increasing the proportion of next-day CT scans, these factors must be addressed to streamline the entire pathway.

BN SO55 - Rare case of Ectopic pancreatitis in stomach and its Surgical Management

Abstract Background This presentation covers the case of Mr. D, a 38-year-old male who presented with upper abdominal pain and vomiting, initially treated as gastritis but later developing more complex symptoms. This case highlights the diagnostic challenges and management of ectopic pancreatitis, a rare condition characterized by pancreatic tissue located outside its usual anatomical position.Mr. D, a personal trainer with a history of asthma and Meckel's diverticulum excision, experienced recurring epigastric pain, bloating, and early satiety. His pain was particularly related to eating, fasting and often disrupted his sleep. Despite treatment with proton pump inhibitors (PPIs), his symptoms persisted, prompting further investigation Method Initial investigations including ultrasound, chest X-ray, and ECG showed no significant abnormalities. However, subsequent gastroscopy and CT scans suggested a gastrointestinal stromal tumor (GIST), leading to referral for endoscopic ultrasound (EUS) and biopsy. The findings indicated a highly vascular, mixed echogenic lesion in the submucosa, likely a GIST, but initial biopsies were inconclusive Results Following conservative treatment, Mr. D's inflammation significantly reduced, though he experienced recurrent pain necessitating surgical intervention. Diagnostic laparoscopy and gastroscopy revealed extensive adhesions and an inflammatory mass. The patient underwent a pyloric-preserving sleeve gastrectomy, with histology confirming pancreatic heterotopia with inflammation and cystic degeneration. Post-operatively, Mr. D initially struggled with dietary intake but improved over time, tolerating a solid diet by the last follow-up. Conclusion This case underscores the complexity of diagnosing and managing rare conditions like ectopic pancreatitis. It highlights the importance of a multidisciplinary approach and the potential need for surgical intervention when conservative management fails. The presentation aims to provide valuable insights into the diagnostic process, the role of MDT discussions, and the therapeutic challenges associated with ectopic pancreatitis.

HPB SO06 - An advanced clinical practitioner (ACP) led pancreatic cyst surveillance programme

Abstract Background The prevalence of pancreatic cysts (PCs), including intraductal papillary mucous neoplasms (IPMNs), has increased substantially over recent decades. This rising prevalence is due largely to the increasing volume and quality of medical imaging technology. Although PC's are often an incidental finding in asymptomatic individuals, a small number do harbour a certain malignant potential and thus raise warranted concern. The challenge therefore is identifying the high-risk lesions for early resection through robust, guideline-driven surveillance. To ensure a consistent and evidence-based approach to PC surveillance, our trust has adopted a dedicated surveillance programme led by an Advanced Clinical Practitioner (ACP) in gastroenterology. Method A PC surveillance clinic was designed and delivered from April 2023. The service underwent a formal inauguration and was promoted at the regional HPB MDT. All patients receive a standardised approach to surveillance in-line with the current international guidelines or regional MDT recommendation. Surveillance diagnostics are arranged by the ACP and patients are updated with regard to their results and next steps during a telephone or face-to-face consultation. A robust database was designed to capture relevant patient details and serve as a future research aid. Results 144 referrals have been received (04/23-04/24). 134 are undergoing surveillance, with discontinuation due to frailty, patient choice, diagnosis of an inflammatory cyst or relocation in 10 cases. Most PCs under surveillance are side-branch IPMNs (70.9%). Malignant transformation has not yet been observed, however 18 cases display worrisome features and 3 have high-risk stigmata. These are undergoing intensive surveillance or awaiting MDT discussion. 93% of surveyed patients (16) report a greater sense of involvement in their PC surveillance and a greater awareness of their surveillance protocol (93%). Referrer feedback (7) has been positive and staff are satisfied with this service (100%). Conclusion Robust surveillance of patients with PC will likely improve early detection and prognosis of pancreatic cancer by enabling early identification of resectable cases. A centralised service that adopts a single agreed guideline will reduce variation in the management of these cysts, ensure these complex lesions are under specialist observation and offer a single point of contact which will improve retainment and follow-up of these patients. It is intended that synchronous data collection will serve to generate a comprehensive repository of information relating to PC. This databases will aid future research into this evolving field and steer future guideline development.

BN SO04 - The value of routine histopathology analysis of gallbladder specimens after elective and emergency laparoscopic cholecystectomy

Abstract Background Gallbladder cancer is not among the 20 most common cancers in the UK, accounting for less than 1% of all new cancer cases with a peak rate at 85-89 years of age. There is a dominant routine conception among surgeons to send the gallbladder specimen for histopathology even if there is no gross features that raise suspicion for neoplasm. In this study, we are trying to get evidence of the value of routine histopathology analysis of gallbladder specimens after elective and emergency laparoscopic cholecystectomy surgeries in Warwick hospital. Method The record of all the patients who underwent laparoscopic cholecystectomy ( elective, expiated and emergency ) in Warwick hospital in the period between 01/07/2023 – 30/01/2024 ( 7 months) were collected, reviewed and underwent data analysis Results A total of 171 specimens were sent for histo-pathology analysis. Only one patient had low grade dysplasia with no malignant features. No routine follow-up decided for him/her after upper GIT MDT discussion. The incidence rate was 0% of neoplasm and 0.6% of low-grade dysplasia. Conclusion No specimen in the study had suspicious gross features of malignancy. Using a selective system is more logical and economic than the routine sending for histopathology after elective and emergency laparoscopic cholecystectomy if there are no suspicious features in the specimen.

RE-VISITING BIOPSIES FOR SUSPECTED CNS LYMPHOMAS: TO BIOPSY OR NOT TO BIOPSY?

Abstract AIMS It is a common practice to get a histological diagnosis before treatment of suspected CNS (central nervous system) lymphoma. Should CNS lesions be routinely biopsied in patients with background systemic lymphoma? METHOD A 10-year retrospective review of biopsy-proven CNS lymphoma was conducted. Data was analyzed using SPSS for Windows, version 25 (SPSS, Inc., Chicago, Illinois, USA), and a p-value < 0.05 was considered significant for the appropriate test statistic. RESULTS Patients with background systemic lymphoma whose brain MRI appearances were in favour of lymphoma after MDT discussion all had histologically-proven lymphoma after brain biopsy. Pre-biopsy MDT diagnosis was congruent with post-biopsy histology in 87.6% of cranial lesions (p-value 0.003) and 40% of spinal lymphomas (p-value 0.002). Secondary CNS lymphoma was seen in 21.2%. Stereotactic brain biopsy was the most common biopsy technique for cranial lesions (79.8%). Histology was Diffuse B Cell Lymphoma in 93% of cases. The mean Ki67 percentage for cranial lymphomas was higher than that of spine (p-value 0.028) The complication rate for cranial biopsy was 8.9%. Transient motor deficits (4.4%) and post-operative haematoma (2.2%) were the most common. The 24-hour post-brain biopsy mortality rate was 1.1%, while overall 30-day post-op mortality rate was 4.4%. The mean percentage of Ki67 was higher among patients who had complications (p-value 0.001). CONCLUSION In a setting of properly constituted neurooncology MDT, a sub-set of patients with suspected brain lymphoma and background systemic lymphoma might not require brain biopsy. KEY WORDS Lymphoma, Brain, Spine, Biopsy, Complication

FP4.12 - Enterocolic lymphocytic phlebitis masquerading as a malignant stricture in the cecum

Abstract Introduction Enterocolic lymphocytic phlebitis (ELP) is an idiopathic form of venous inflammation which is limited to the gastrointestinal tract. It is characterised by inflammation of the veins with no involvement of the arteries. Usually, It presents with gastrointestinal symptoms such as abdominal pain, and imaging may suggest malignancy. Case history A 56-year-old woman presented with fresh blood in her stools, abdominal pain and diarrhoea. All blood tests were normal; however, she had a raised CRP of 105 mg/L (normal < 5 mg/L). CT abdomen and pelvis showed thickening in the transverse colon and intussusception of the terminal ileum into the caecum. She was treated conservatively and discharged when symptoms resolved with an outpatient colonoscopy. The colonoscopy was incomplete due to an unresolvable sigmoid loop; CT colonography showed caecal wall thickening, which was suggestive of caecal malignancy. Following the MDT discussion, the patient was booked for a right hemi-colectomy. The right hemicolectomy specimen histology showed no malignancy, and lymphocytic phlebitis of the submucosal, subserosa and mesenteric veins, but the arteries were normal; hence, a diagnosis of enterocolic lymphocytic phlebitis was made. Conclusion ELP is a rare idiopathic form of venous inflammation localised to the gastrointestinal tract, which can occasionally present similar to bowel malignancy. The diagnosis is usually confirmed with a histopathology assessment. We present this case in light of its rarity to add to the literature on this entity.

ThP2.4 - Unveiling the Odds: Identifying the Axillary Recurrence rates in Invasive Breast Cancer Surgery in a district general hospital - Seventeen years of Surgical Performance decoded

Abstract Introduction Axillary recurrence should be minimised by effective staging and treatment where appropriate Minimum standard <5% axillary recurrence at 5 years Target <3% axillary recurrence at 5 years according to UK ABS guidelines. Methods All patients with primary cancer diagnosed at our institution between January 2004 and December 2020 were identified from a prospectively maintained database of operations obtained from the medical coding department. Demographics of the patients, pre-operative investigations, MDT discussion outcomes, operative details (and complications), post-operative pathology, neo-adjuvant and adjuvant therapy regimens and follow-up data were recorded. All patients were followed up to the censoring date of December 2021 which gave a median follow-up of 18 months (range, 12- 204). Axillary recurrence and treatment regimens were recorded. Primary outcome measures were overall axillary recurrence and disease-free. IBM SPSS Statistics (Version 26.0 (IBM Corporation, Armonk, NY, USA) was used for statistical analysis to determine patient and pre-operative pathological characteristics that were predictive of isolated axillary recurrence after completion of the primary treatment course. Significance was defined as P<0.05. Results There were 4024 women diagnosed with breast cancer in Midyorks trust between this period who were referred and had surgical intervention. Of these, 107 patients were identified with recurrences. 12 were found to have an isolated axillary recurrence (8 ANC 4 SLNB) Conclusion The 17-year isolated axillary recurrence rate of women treated was 0.3%. Multimodality management at the time of recurrence, including axillary surgery, radiation, and systemic therapy, significantly improved the morbidity

EP142 - "Unravelling the Enigma: Navigating the Diagnostic Dilemma of Abdominal Toxoplasmosis"

Abstract Introduction Abdominal toxoplasmosis, an infrequent yet medically significant manifestation of Toxoplasma infection, primarily caused by the protozoan parasite Toxoplasma gondii. Although toxoplasmosis can affect various organs, its occurrence in the abdominal region introduces unique diagnostic complexities, presenting symptoms such as abdominal pain, gastrointestinal disruptions, and systemic complications. Case Report In a notable case, a middle-aged patient presented with perplexing gastrointestinal symptoms, including nausea, vomiting, abdominal pain, and irregular bowel habits. With a history of anaemia and thrombocytopenia necessitating transfusions and yielding inconclusive bone marrow biopsies, the patient underwent OGD and colonoscopy with biopsies during initial management, revealing a hiatus hernia and diverticulosis that did not explain the symptoms. Despite being discharged pending biopsy results, subsequent normal findings failed to clarify. Upon readmission with persistent gastrointestinal complaints, a CTAP revealed two suspicious neoplastic focal areas of small bowel wall thickening and enlarged mesenteric lymph nodes. The MDT discussions ensued to rule out malignancy, leading to a follow-up PET scan suggesting nodal disease, raising concerns about lymphoma, small bowel adenocarcinoma, or carcinoid tumour and recommended an ultrasound-guided lymph node biopsy, 5 HIAA if asymptomatic, and diagnostic laparoscopy if symptomatic or obstructed. Subsequent core biopsy of a neck lymph node unveiled appearances consistent with toxoplasmosis, prompting treatment with anti-parasitic drugs. The patient awaits capsule endoscopy, and a follow-up CT scan displayed a reduction in bowel lesions and lymph nodes. Conclusion This case highlights the swift and precise identification of toxoplasmosis, resulting in an optimal patient outcome. The clinical manifestations of toxoplasmosis are diverse and lack distinct characteristics, making it challenging to definitively diagnose, particularly in immunocompetent individuals.

Beyond mere appendicitis: A case report on an unforeseen diagnosis of appendiceal schwannoma

IntroductionAppendiceal schwannomas are a rare diagnosis, with little evidence to guide management and follow-up. There are currently no case reports focusing on follow-up for appendiceal schwannomas after complete surgical resection. Presentation of caseA 64-year-old female presented to the emergency department, febrile, with migratory right iliac fossa pain and focal peritonism, consistent with acute appendicitis. The diagnosis was supported by a computed tomography scan and she underwent a laparoscopic appendicectomy. Histopathology was reported as acute appendicitis associated with a schwannoma at the appendiceal base. The patient underwent a colonoscopy six weeks after her initial surgery with no abnormal findings. Following multidisciplinary team discussion it was decided that no further follow up was required. DiscussionThere are only 15 case reports of appendiceal schwannomas in the literature. As a result, the management and follow up in this case was guided from evidence reported in studies of other schwannomas elsewhere in the gastrointestinal tract, standard management of benign appendiceal lesions and MDT discussion. One retrospective single-centre cohort study of histopathology records collected over a 20 year period showed that in 44 patients with GI schwannomas, there was no malignant transformation or recurrence during a mean follow up period of 5.0 ± 4.31 years (Singh et al., 2022). Based on this study there is a very low risk of malignant transformation associated with these lesions. ConclusionBased on limited published data resection remains the mainstay of management of appendiceal schwannomas. Colonoscopy is recommended to exclude any underlying lesion or synchronous pathology.

Enhancing thoracic oncology in Armenia: Impact of the implementation of an expert-guided virtual multidisciplinary tumor board.

e13808 Background: The importance of expert-guided multidisciplinary tumor boards (MDTs) in the management of patients with complex malignancies is well established. Modern global telecommunication platforms allow for holding specialized virtual MDT discussions led by international experts even in limited-resource settings. The creation of such a group is of high importance for Armenia given the high incidence and increasing complexity of thoracic malignancies. We describe the initial impact of the implementation of the Thoracic Tumors Working Group (TTWG) of Armenia from August 2022 through January 2024. Methods: The TTWG of Armenia is an MDT comprised of medical oncologists, radiation oncologists, thoracic surgeons, pathologists, and radiologists. The group was formed under the Immune-Oncology Research Institute in August 2022 to discuss the management of patients with complicated thoracic malignancies. For each case, the clinical history, imaging, pathologic findings, and patient management plans are discussed. Updates on treatment paradigms and ongoing clinical trials are also reviewed. The MDTs are held biweekly via the Zoom platform under the supervision of international experts in thoracic oncology. Recordings of MDTs were reviewed to retrospectively identify case characteristics and the impact on patient management. Results: From August 2022 through January 2024, 89 cases were discussed during 33 TTWG MDTs. On average, each MDT was attended by 14 physicians and trainees in Armenia, and by two international experts in thoracic medical and radiation oncology. Median meeting length was 55 minutes with a median of 3 cases presented. Diagnoses included lung adenocarcinoma (n=31, 37.3%), squamous cell lung carcinoma (n=15, 18.0%), neuroendocrine tumors (n=16, 19.3%), small cell lung cancer (n=16, 19.3%), and thymic epithelial tumors (n=6, 7.3%). All disease stages were represented: I 3.7%, II 4.9%, III 31.7%, and IV 47.9%. The male-to-female ratio was 3.6:1 and the median age was 63 years (range: 29-76). Based on MDT discussion, the pre-MDT diagnosis was confirmed in 95.5% (n=85) of patients with down-staging in 3.4% (n=3). The proposed pre-MDT treatment plan was significantly altered in 42.7% (n=38) of patients. Additional studies, mainly PET/CT, bronchoscopy, and broader molecular profiling were recommended for 29.2% (n=26) of patients. Follow-up discussions were held for 7.9% (n=7) of patients based on information arising from prior MDT discussions. The TTWG of Armenia continues to be active. Conclusions: Our initial data suggest that the TTWG of Armenia has had a meaningful influence on patient management by providing access to specialty-expert care and physician education. The impact on patient outcomes will continue to be assessed. The TTWG of Armenia can serve as a model to improve outcomes in other resource-limited settings.

CRS-HIPEC following neo-adjuvant pressurized intraperitoneal aerosol chemotherapy (PIPAC) with systemic chemotherapy in primarily advanced inoperable epithelial ovarian cancer: An ISPSM collaborative study.

e17504 Background: PIPAC has shown improved objective response rate with improved quality of life in combination with IV chemotherapy when compared to IV chemotherapy alone in salvage situations. Methods: All patients with primarily inoperable advanced epithelial ovarian cancer not been able to receive optimal IV chemotherapy or not responding to first line of chemotherapy who could not undergo CRS-HIPEC were challenged with PIPAC & IV chemotherapy as a salvage situation after discussion in MDT. Patients who subsequently underwent CRS-HIPEC were analysed to study their clinical characteristics, extent of disease and peri-operative outcomes. PIPAC was given with Cisplatin 15mg/m2 and doxorubicin 3mg/m2. Intravenous chemotherapy was given within one week of PIPAC. Each cycle was repeated once in 4-5 weeks. Patients who underwent subsequently CC0 cytoreduction got HIPEC with Injection cisplatin 100mg/m2. All outcomes were prospectively entered in the registry and analysed retrospectively. Results: 120 PIPAC applications were done in 45 patients. 30 patients received 3 cycles of PIPAC with IV chemotherapy given within one week of PIPAC. Mean PCI initially was 25±5 with nearly 55% of them having ECOG 2 performance status and mean ascities volume of 500±55 ml . Out of 45 patients 28 underwent CRS-HIPEC subsequently. Mean age 54.5±10.74, PCI 15±5, duration of surgery 9.6±1.2 hrs. The mean drop in PCI who completed 3 PIPAC with IV chemotherapy was 10±3. Out of 45 patients nearly 60% showed PRGS 1, 25% PRGS 2 and 15% PRGS 3. 30.4% had total peritonectomy, 12.7% had multivisceral resection, 30% required diaphgramatic resections, 25%required mesentric stripping, 45.8% had one bowel resections and stoma rate was 4.5%. Overall G3-G5 morbidity was 25.4% with major ones being post-operative intra-abdominal collection (21.8%), electrolyte imbalance (16.4%), pulmonary (16.4%) followed by hematological (12.7%). The 30 day mortality was 3.8%. During PIPAC + IV chemotherapy no significant grade 3-4 morbidity was seen. Conclusions: Neo-adjuvant PIPAC with Intravenous chemotherapy might be a promising combination for inducing good response rates in advanced epithelial ovarian carcinoma. CRS-HIPEC following neo-adjuvant PIPAC + IV chemotherapy is safe, feasible and tolerable. PIPAC repeated every 4-5 weeks along with systemic chemotherapy provides a ideal scenario to monitor & assess response to loco regional and systemic chemotherapy.

Abstract PO3-02-09: Breast cancer in women under the age of 40 years.A south Wales UK reflection on incidence, tumour biology and outcomes over 10 years

Abstract Introduction: The incidence of breast cancer in the under 40-year-old age group is approximately 7% (Anders et al., 2009). Studies suggests that the management of Breast cancer in adolescent and young women is more challenging, with this age group under-represented in clinical trials. We investigated the management and outcomes of a cohort of 98 patients seen between 2013 and 2023 in the Hywel Dda NHS University Health Board, Wales, UK. Methods: A retrospective review was performed. Demographic, surgical and outcome data for patients under the age of 40 years was collated and analysed. Results: The cohort size was 98, representing 2.45% of the breast cancer population treated in the Health Board during this timeframe. The age of the cohort ranged from 23 years to 40 years, 12 out of 98 (12.24%) were under 30 years. Mean age was 35.28 years. Unfortunately, 8.16% (8/98) of the cohort died between 12 months to 96 months. Two patients were lost to follow up. Tumour biology results confirmed that most of the cohort had invasive ductal carcinoma (IDC), with 13.27% Grade 1, 37.76 % Grade 2 and 40.82% Grade 3. There were 4 (4.08%) invasive lobular carcinomas (ILC) in the cohort, 2 Grade 2 and 2 Grade 3. The remaining tumour groups were, 1 case of DCIS (Grade-2 intermediate grade), Grade-1 mucinous carcinoma, 1 Grade-1 ductal-lobular breast cancer and 1 medullary carcinoma. 10.20% of the cohort had triple negative cancers (ER, PR, Her-2 negative) and 10.20% were ER, PR, HER2 positive [Triple positive]. 40.82% metastatic axillary lymph nodes involvement on histology either on presentation or following sentinel node biopsy. Operative details confirmed that the 51.02% (50/98) of the cohort underwent mastectomy. 10 out of those 50 patients underwent contralateral risk reducing mastectomy .46 patients had breast conservation surgery. One patient is awaiting surgery, the other has been diagnosed with metastatic breast cancer at diagnosis. Patients received both neoadjuvant and adjuvant chemotherapy depending on initial assessment and MDT discussion [ACP, FEC, Taxane and platinum-based chemotherapy, Anti Her-2]. NAC was provided for all HER-2+ patients. Endocrine treatment and ovarian function suppression, and adjuvant Radiotherapy was also given. Some patients had a complete pathological response to NAC; however, some did not respond well. In addition, 10.20% of the cohort underwent bilateral salpingo-oophorectomy during their treatment and follow up. Genetic assessment confirmed that 3/98 (3.06%) of the cohort were BRCA2 positive, one BRCA1 carrier, 2 patients were BRCA negative, two have been referred for genetics assessment and two still awaiting consultation with genetics. In one patient somatic mutation was found in PTEN, BIRC3, HRAS, TP53, PMS, (5 gene panel). In one patient, panel was reassuring. PALB-2, TP53 was also reassuring in one patient. One patient who passed away at the age of 34 did not have any alteration in 5 gene panel. Three patients developed other malignancies during the 10-year period: 1 uterine, 1 cervix, 1 papillary thyroid cancer. 6/98 (6.12%) developed metastatic disease and one developed a local recurrence. One patient developed metastasis while pregnant, and by contrast one patient gave birth to a baby after stopping her endocrine treatment. One patient who passed away had no response to neoadjuvant chemotherapy (NAC). Discussion: The results from the cohort confirm that the incidence of TNBC and triple positive cancers is like that found in the general breast cancer population (10-15%). Our engagement with the genetics team has increased since the initial 2013 cohort. There is now an established system for referrals for young women with breast cancer. It is probably not surprising that other primary invasive cancers were found, whilst on follow up. Citation Format: Sohail Khan, Saira Khawaja, Yousef Sharaiha, Asma Munir, Anita Huws. Breast cancer in women under the age of 40 years.A south Wales UK reflection on incidence, tumour biology and outcomes over 10 years [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-02-09.

Summary of surgical experience of an elderly patient who underwent simultaneous dual minimally invasive TA-TAVR and McKeown procedures

BackgroundCases of simultaneous TA-TAVR and Mckeown dual minimally invasive surgery are very rare. A retrospective analysis of the clinical features, perioperative surgical cooperation and care of an elderly patient with esophageal cancer combined with moderate-to-severe aortic regurgitation. MethodsAn elderly patient with esophageal cancer combined with moderate to severe aortic valve regurgitation was admitted to the Department of Thoracic Surgery, West China Hospital, Sichuan University in September 2022. Through preoperative MDT discussion, two minimally invasive surgical options were identified and analyzed to develop personalized and standardized perioperative operating room care and surgical coordination. Informed written consent and institutional review board approval were both obtained (No. 2021-879; July 25, 2022) for the surgery and the publication of the study data. ResultsAfter a thorough preoperative MDT discussion and the development of a personalized and standardized operating room care plan, the two surgeries lasted a total of 5h 35mins with a total bleeding volume of 150 ml. The surgeries went smoothly, and the patients were sent to the ICU and transferred back to the general ward on the second day after surgery without complications. ConclusionThe simultaneous performance of dual minimally invasive level IV surgery is indeed a high-risk procedure, which is a new challenge for both patients and health care workers. Standardized OR care planning and surgical coordination are also important aspects of MDT, reflecting that OR care is an indispensable role in the surgical team as well.

Identification, Monitoring and Reversibility of PARP Inhibitor Associated Clonal Haematopoiesis and Myelodysplastic Syndrome: A Case Series

Background: Poly ADP ribose polymerase inhibitors (PARPi) are widely used as maintenance treatment for ovarian cancer (OC) after response to platinum chemotherapy in the first line setting and recurrent disease. Their use has significantly improved outcomes, particularly in patients with BRCA mutations in whom first-line PARPi maintenance therapy increases progression-free survival from 13.8 to 56.0 months (Hazard Ratio, 0.33; 95% CI, 0.25-0.43). However, a recent meta-analysis of clinical trial adverse events and pharmacovigilance data showed that PARPi therapy significantly increases the risk of therapy related myeloid neoplasms (tMN), myelodysplastic syndrome (MDS) and acute myeloid leukaemia with poor outcomes. Platinum based chemotherapy is the mainstay of OC treatment and is associated with clonal haematopoiesis (CH) with mutations in DNA damage response genes. CH is recognised as a premalignant myeloid state but real world data on clonal dynamics during PARPi therapy are lacking. We present a case series of OC patients receiving PARPi-therapy referred for haematological review for beyond-expected HT or unexplained full blood count (FBC) abnormalities with serial FBC and myeloid next generation sequencing (mNGS) clonal monitoring in relation to PARPi therapy. Methods: Seven patients with stage III/IV high-grade OC were referred to haematology at the discretion of the treating oncologist between February 2017 and May 2022 (mean age (SD): 68 (7.0) years, median PARPi duration: 18 months (range: 4-86)). All patients had received prior platinum-based chemotherapy and were screened with mNGS in peripheral blood (PB) or bone marrow aspirate and trephine (BMAT) at initial assessment. Results: Reasons for referral are detailed in Table 1 and include two patients with isolated elevated nucleated red blood cell (NRBC) counts. Six patients had clonal pathology (CP), five of whom had single-nucleotide variants typical of platinum-exposure defined by the involved gene or platinum-associated mutational signatures. Clinical details including BRCA-status, haematological diagnosis and mNGS results are detailed in Table 1. PARPi-therapy was discontinued in four patients with CP, with resolution or improvement of FBC and m-NGS abnormalities (variant allele frequencies (VAFs) and/or copy number variations (CNVs)) in three patients. These findings were most marked in Patient 1, referred with grade 3 thrombocytopenia and transfusion dependence and in whom PARPi cessation resulted in transfusion independence and resolution of morphological and cytogenetic abnormalities (clinical course including BMAT results and haematological parameters illustrated in Figure 1), and Patient 3, who demonstrated selective regression of a TP53 mutated clone on PARPi cessation. Two patients with germline BRCA mutations continued PARPi therapy with 3 monthly PB mNGS monitoring after discussion at multidisciplinary team meetings. Conclusions: We show using sequential molecular and haematological monitoring before and after PARPi cessation that morphological, FBC and clonal abnormalities can be reversed on PARPi discontinuation, potentially mitigating the risk of life-threatening tMNs in some patients. We also highlight that, in addition to cytopenias, persistently elevated NRBCs may be an indicator of clinically relevant CP not well described in pharmacovigilance data based on common terminology criteria for adverse events criteria. Large scale prospective data on clonal dynamics in PARPi therapy are needed to inform mNGS screening and tMN risk stratification as scoring systems based on age associated clonal haematopoiesis of indeterminate potential may not be applicable. Until these data are available we demonstrate the value in MDT discussion and serial PB mNGS monitoring in formulating case-by-case therapeutic decisions regarding CP and PARPi therapy, particularly patients with high risk BRCA mutated OC.

The role of the multidisciplinary tumor board after endoscopic resection of malignant tumors: is it worth it?

The value of multidisciplinary tumor boards (MTBs) in the treatment of gastrointestinal cancer patients is well known. Most of the current evidence focuses on advanced cancer cases, whereas little is known about the effect of MTBs on early tumors, especially after endoscopic resection. The aim of our study is to evaluate the value of the MTB after endoscopic resection of malignant tumors of the gastrointestinal tract. We retrospectively analyzed all endoscopically resected malignant tumors in our department between 2011 and 2019, focusing on the existence of an MDT recommendation after endoscopic resection, the MDT adherence to the current guidelines, and the implementation of the recommendation by the patients. We identified 198 patients fulfilling our inclusion criteria, of whom 168 (85%) were discussed in the MDT after endoscopic resection. In total, 155 of the recommendations (92%) were in accordance with the current guidelines, and 147 (88%) of them were implemented by the patients. The MDT discussion itself did not influence the overall survival, whereas the implementation of the MTB recommendation was associated with a significantly better prognosis. Deviations of the MDT recommendation from the guidelines had no effect on the overall survival. The discussion of endoscopically resected malignant tumors in the MTB is crucial for the treatment of patients with this type of cancer, since the implementation of the MTB recommendation, even if it deviates from the current guidelines, improves the prognosis.

HPB P54 First Reported Case of Primary Serous Cystadenocarcinoma of the Spleen

Abstract Background Tumours of the spleen are uncommon, and the majority are metastases from primary malignancies in other organs. The two main subdivisions of primary malignancies of the spleen are lymphoid and non-lymphoid. Primary splenic cystadenocarcinomas are extremely rare, and only tumours of the mucinous subtype have been recorded. The spleen usually exhibits secondary infiltration from primary cystadenocarcinomas in other organs such as the ovaries and pancreas. Methods We present the case of an elderly white female who was found to have an incidental splenic tumour. This showed interval increase in size on serial imaging and was confirmed to be a complex mass with a cystic component on MRI. After MDT discussion and further investigations, including FDG-PET, EUS and diagnostic laparoscopy, she underwent a distal pancreatectomy, partial gastrectomy and splenectomy for a presumed tail of pancreas adenocarcinoma. Results The splenic hilum contained a large partly cystic tumour conglomerate measuring up to 5.8cm in maximum dimension, which contained thick, dark red, gelatinous material. It was well-circumscribed and demarcated from the rest of the splenic parenchyma, and the distal pancreas appeared to be uninvolved. Histology showed low columnar to cuboidal cells with moderate to patchy marked nuclear pleomorphism, and no cytoplasmic mucin was identified. The tumour had a predominantly papillary and focal tubular architecture, with hierarchical branching of papillae. The neoplastic cells stained positive for CK7, ER and WT1 expression and negative for CK20 and CA. Conclusions Histological and immunohistochemical analyses were consistent with the first recorded case in the literature of primary serous cystadenocarcinoma of the spleen, which we believe developed through malignant transformation of a benign epidermoid cyst. This is the commonest type of true cysts of the spleen and one which has tumorigenic potential, being able to undergo metaplasia and dysplasia. The patient remains well as per her latest follow-up with no evidence of recurrence or metastases. However, given the rarity of splenic cystadenocarcinomas, uncertainty remains on the long-term prognosis and optimal management of such cancers, including adjuvant treatment options.

A cost-analysis of managing secondary and apparent treatment-resistant hypertension in a specialist multidisciplinary hypertension clinic.

A knowledge gap exists around the costs and budget impact of specialist hypertension clinics. This study reports on the cost of providing care in a multidisciplinary hypertension clinic staffed by nephrologist, endocrinologist and cardiologist, which manages patients with suspected secondary hypertension and/or apparent treatment-resistant hypertension. The aim of this study is to provide the evidence required to inform policy and planning care pathways for this patient group. A cost analysis from a healthcare provider perspective using micro-costing techniques was conducted to estimate the direct implementation costs of existing standard practice for the care pathway of patients attending the multidisciplinary hypertension clinic. Sixty-five patients originally recruited for a study of medication adherence in hypertension were included in the sample. The total care-pathway cost per patient, taking into account clinic visits, clinical reviews, investigations and MDT discussion, was estimated to be €3277, on average. For the patient subgroups, the average cost was €5644 for patients diagnosed with primary aldosteronism and €1446 for patients diagnosed with essential hypertension. There is significant cost associated with providing specialized hypertension care for patients with apparent treatment-resistant hypertension. Given the high rates of nonadherence in this population, it is likely that some of this cost could be avoided with better detection and management of medication adherence in this challenging population. Future studies should consider the cost-effectiveness of this or similar models of care by exploring the benefit to patients and the wider healthcare context of providing care of this type.