Multidisciplinary Tumor Board Discussion Research Articles

The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment.

Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety. This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution. The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires. Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%. The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

Patterns of presentation and delivery of care of appendiceal neoplasms in the largest municipal health care delivery system in the United States.

14 Background: Appendiceal neoplasms (AN) are rare tumors with a broad spectrum of referral and treatment patterns. NYC Health+Hospital (HHC) is the largest municipal health care system in the United States. Here, we study patterns of presentation and management of AN in this safety-net setting. Methods: We identified 92 patients in HHC with AN between 01/01/2017 to 07/01/2023. Statistical analyses were performed in Python. Results: There were 38 (41.3%) mucinous neoplasms, 24 (26.1%) adenocarcinomas, 23 (25.0%) neuroendocrine, and 7 (7.6%) ex-goblet cell adenocarcinomas. 16 cases of pseudomyxoma peritonei were identified. The median age at diagnosis was 55 (IQR: 45-65). 49% were Hispanic, and African Americans were the largest racial block (28%). 50% of cases presented as appendicitis. Appendectomy and a second surgical intervention were more common in this group (p<0.001 and p=0.044, respectively). Other surgical interventions included colon resections and cytoreduction ± Hyperthermic intraperitoneal chemotherapy. Among the patients with mucinous neoplasm or adenocarcinoma, 35 had multidisciplinary tumor board discussion (15 mucinous neoplasm and 20 adenocarcinomas). The median follow-up period was 22.0 months (95% CI: 11.5-30.7 months). Surveillance modalities included CT (75%), CEA (74%), and colonoscopy (35%). 85% remained within HHC during treatment. 16 patients were planned to have chemotherapy, including 9 pseudomyxoma peritonei cases. 5 patients did not follow through, and the other cases had a median of 10 cycles. The following adjuvant chemotherapy regimens were employed: 50% FOLFOX, 20% FOLFIRI, 20% XELODA, and 10% CapeOX and FOLFIRI. There were 2 cancer-related deaths (pseudomyxomas). Excluding pseudomyxomas, none had evidence of disease at the last follow-up. Conclusions: Minorities and immigrants constitute the majority of the population of HHC. 50% of AN presented as appendicitis emphasizing the need for a robust system to identify these cases. Despite challenges encountered in providing long-term oncological care, HHC has treated and provided vigorous follow-up for this underserved population. [Table: see text]

Timely Initiation of Radiation Treatment for Primary Head and Neck Squamous Cell Carcinoma in an Urban Safety Net Hospital during the COVID-19 Pandemic

Delayed initiation of radiation treatment for head and neck squamous cell cancer (HNSCC) may lead to worse survival, higher recurrence, and increased financial burden on patients. In times of limited resources, timely treating underserved population of HNSCC patients pose a special challenge to a safety net setting. This single-institutional study aims to characterize and compare treatment delays in HNSCC before and during the COVID-19 pandemic at an urban safety net hospital in Los Angeles to assess the success of efforts made to deliver timely care. Patients who received definitive or post-operative radiotherapy for treatment of primary HNSCC at LAC+USC Medical Center between 2010-2021 were retrospectively reviewed. Time to treatment initiation (TTI) was defined as date of histopathological diagnosis to date of first radiation treatment for definitive and date of surgery to date of first radiation treatment for post-operative patients. Among 70 patients with HNSCC (mean age at diagnosis 55 years, 79% male), 31 patients (18 pre-pandemic, 13 peri-pandemic) were treated definitively with chemoradiation, and 39 patients (24 pre-pandemic, 15 peri-pandemic) were treated post-operatively. Overall, the median TTI was 50 days (interquartile range, IQR 42-74 days); median TTI for pre-pandemic HNSCC patients was 49 days (IQR 43-70 days) and median TTI for peri-pandemic HNSCC patients was 51 days (IQR 43-75 days). The median TTI for definitive radiation was 52 days (IQR 42-93) for pre-pandemic and 52 days (IQR 44-61) for peri-pandemic patients. The median TTI for post-operative radiation was 47 days (IQR 41-75) for pre-pandemic and 50 days (IQR 48-73) for peri-pandemic patients. During the pandemic, there were fewer (38% vs 44%) definitive patients whose TTI exceeded 60 days, whereas more (40% vs 33%) post-operative patients had TTI >60 days. By prioritizing treatment of definitive and high-risk post-operative HNSCC patients according to ASTRO-ESTRO consensus guidelines, expanding the use of telephone follow-up to ensure continuity of care, teleconferencing for multidisciplinary tumor board discussions, and initiating COVID-19 protocols in which mildly symptomatic patients were treated at the end of the day, we were able to maintain timely initiation of radiation treatment not compromised by the pandemic.

An open-label window of opportunity trial to evaluate the activity of durvalumab and tremelimumab with platinum-based chemotherapy (gemcitabine and cisplatin) in intrahepatic cholangiocarcinoma.

TPS4189 Background: Following surgical resection, the rate of recurrence of intrahepatic cholangiocarcinoma (ICC) is high. Expert groups recommend preoperative systemic therapy, particularly for resectable ICC with features that portend a high risk of recurrence. Based on data from ABC-02 the combination of gemcitabine and cisplatin (GC) is often used. This provides an objective response rate (ORR) of only 20% in ICC. The addition of durvalumab, an anti-PDL1 inhibitor to GC improves overall survival (OS) in the metastatic setting and is associated with an ORR of about 30%. On the other hand, while the addition of nab-Paclitaxel to GC provides an ORR of 34%, it was not associated with an improvement in OS in biliary tract cancer. It is therefore rationale to continue to explore and optimize immune checkpoint inhibitor development in ICC. We designed this study to determine the activity of durvalumab (D) and tremelimumab (T) (anti-CTLA4 ICPI) in combination with GC in resectable ICC with high-risk features. We plan to explore tumor intrinsic and tumor microenvironment related factors that will be associated with response (or lack thereof) to ICPI. Methods: This is a multicenter open-label, window of opportunity trial of the combination durvalumab and tremelimumab in combination with GC in resectable ICC with high-risk features. Inclusion criteria includes patients ≥18years with radiologically measurable and biopsy proven ICC that is surgically resectable but with high risk features (based on multidisciplinary tumor board discussion). Prespecified high-risk features include tumor size >5cm, T1b-T4 lesion, multifocal tumors/tumor with satellite lesions, suspicious or involved lymph nodes (N1) and vascular involvement all thought to be technically resectable. Patients with extrahepatic metastasis will be excluded. D will be administered at 1500mg IV on Day 1 every 3 weeks for up to a maximum of 4 cycles. T, 300mg will be administered on Day 1 of cycle 1 only. G (1000mg/m2) and C (25mg/m2) will be administered by IV infusion on Days 1 and 8 every 3 weeks for a maximum of 4 cycles. The primary outcome measure is to demonstrate an ORR of 52%. Secondary objectives are to assess the feasibility and safety of the combination in ICC. Given the historical objective response rate of 25% and using one-sided exact test for single proportion, we will have 80% power to reject 25% ORR at α=0.05 when we observe ORR of 52% (Ho: Po=0.25 vs. Ha: Pa=0.52) from the study sample. The study is open at the O’Neal Comprehensive Cancer Center at the University of Alabama and will be open at other centers in the next few months. Clinical trial information: NCT04989218 .

Abstract 54: Influence of Neuro Oncology Capacity Development on Diagnosis of Pediatric Primary CNS Tumors in Northern Tanzania

Abstract Purpose: The diagnosis of CNS tumors requires a multidisciplinary team including oncologists, neurosurgeons, radiologists and pathologists. We review the impact of expanding diagnostic capacity on the identification and diagnosis of primary pediatric CNS tumors at Bugando Medical Centre (BMC), the regional cancer referral hospital in the lake zone region of Mwanza Tanzania. Methods: Patients who presented to BMC from 2016-2022 and received a radiographic or pathologic diagnosis of primary brain or spinal cord tumor were included a CNS tumor registry. Collected data included basic demographics, most specific diagnosis, and diagnostic method. Data was measured and compared before and after initiating key capacity development milestones: 2018 – installation of CT scan, 2020 – arrival of neurosurgical specialist, 2021 – initiation of multidisciplinary tumor board and WhatsApp chat. Results: A total of 7 spinal and 71 brain tumors were diagnosed among patients aged < 18yo, with (46%) female (n=31) and average age of 7 years. The number of cases per year increased from 3 in 2016, to 17 in 2022. Prior to availability of CT scan (2016-2017), there were an average of 2.5 cases/year, compared to 14.6/year in 2018-2022. With the arrival of the neurosurgeon in 2020, the number of diagnoses/year increased from 11 to 20 from the year prior, but only 50% of patients had a confirmed radiologic or histologic diagnosis. Following initiation of Multidisciplinary Tumor Board Discussion and WhatsApp group, 88% of patients registered in 2022 had a radiographic or histologic diagnosis. Conclusion: This retrospective study demonstrated the step wise influence of key development milestones on the diagnostic capacity for CNS tumors in a LMIC. While introduction of CNS imaging allowed the identification of more tumors, the multidisciplinary team discussion of the imaging, clinical presentation and pathology results had the greatest overall impact on diagnostic capacity in our setting and should be a key component in future program development. Citation Format: Kristin Schroeder, Taryn Kerley, James Lubuulwa, Margreth Magambo, Jacqueline Kamanga, Heronima Joas. Influence of Neuro Oncology Capacity Development on Diagnosis of Pediatric Primary CNS Tumors in Northern Tanzania [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 54.

PHSOR09 Presentation Time: 1:10 PM: Establishing a Cs-131 Intraoperative Mesh Brachytherapy Program: Physics Perspective

<h3>Purpose</h3> Cs-131 has shown promise for the treatment of many cancers with its shorter half-life and more intense energy deposition compared to I-125. Cs-131 mesh has seeds embedded within a vicryl mesh, which keeps the seeds in place for about 30-35 days. Mesh applications have been limited to a few premier institutions. We present our process for the Intraoperative mesh brachytherapy program as a foundation for other new users to build upon. <h3>Methods and Materials</h3> A patient was selected after multidisciplinary tumor board discussion. Radiation Oncologist (RO) provided a written directive with the treatment site and prescription dose (60 Gy). TPS commissioning was carried out for Cs-131 (Cs-1, rev 2, IsoRay Medical Inc., Richland WA) utilizing half-life, source geometry, active source dimensions, dose rate constant, radial dose function, anisotropy function, air-kerma to activity conversion factor, etc. per TG43U1. Treatment planning CT with 1 mm slices was acquired. Target volume and nearby OARs were contoured. Pre-treatment plan was created in Varian Brachytherapy TPS v.15.6. Hand calculations and RadCalc were used to independently verify the TPS dose calculation. Planning CT was reconstructed with 1 cm slice thickness to match the mesh seed spacing. Seeds were modeled as line sources and placed within the target volume while modifying seed strength to achieve target coverage with the prescribed dose while sparing OARs. RO approved pre-plan. Mesh with optimal seed strength and number was ordered. 10% extra loose seeds plus 1 calibrated seed (same activity as determined per pre-plan) were ordered for strength verification. The mesh is received in sterile packaging. After a wipe test of the mesh container to ensure no radiation contamination, source strength for the loose seeds were verified using a well chamber (IVB1000 HO32871) calibrated for Cs-131.Vendor provided radiographs confirmed total seed number. A second independent physicist verified seed strength. Radiation safety training was completed with all personnel involved with the procedure. On implant day, MP and RO were both present. Mesh was taken to the OR after confirming the need for IORT per pathology. MP surveyed radiation levels throughout the procedure. RO and surgeon determined the mesh size to be implanted based on the at risk area. Once the implant was complete, the MP surveyed the OR room and accounted for total seed count. Numbers were verified by residual mesh radiography. Unused seeds were inventoried and stored in a lead container in the hot lab for decay. Post implant, radiation levels at 1 m were monitored periodically by the MP during the patient's hospital stay. Safety information was delivered to patient specific personnel by daily rounds, patient alerts and written instructions placed in the patient chart. MP provided verbal and written radiation safety recommendations to the patient and family members prior to discharge. A postoperative CT scan was acquired within 24 hours of the implant to review final implant dosimetry. <h3>Results</h3> The seed strength required per the pre-plan was 3.0 U. All loose seed strengths were within 2.3% of the vendor specified value. Post implant plan confirmed target coverage. Follow-up images acquired at 2 months confirmed nonsignificant seed migration. The exposure reading at 1 m from the patient was 1.0 mR/h immediately following the implant, and 0.5 mR/h at the day of discharge. The ring and collar badge readings for those directly handling the seed mesh were under regulatory limits. <h3>Conclusions</h3> An intraoperative mesh brachytherapy program has been safely established within our institution with the first patient successfully treated using the process described here.

S2294 Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC. Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Figure 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR. Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (Figure 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Figure 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well. Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (Table). Tumor board and shared decision making are key patient centric strategies that reflect best practice.Figure 1.: A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR. Table 1. - Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles Pre-procedure consultation (nonemergent diagnostic/elective procedures) Pre-procedure planning (labs, imaging) Optimization of treatment for co-morbidities Anesthesia consultation Detailed high-risk informed consent Shared decision making Multidisciplinary GI tumor board discussion Medical record documentation Guideline-based anti-thrombotic management Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

Buccal Mucosal Metastasis of Renal Cell Carcinoma: A Case Report and Review of Literature

Background: Intraoral metastasis of RCCs are unusual, especially when it comes to buccal mucosal metastases, which are extremely rare, accounting for less than 1% of metastatic RCC. The buccal mucosal metastatic lesion from RCC poses a challenge in diagnosis and treatment. Due to their scarcity, there doesn’t exist any literature primarily concentrating on them. Case Report: In this work, we describe the case of a 58-year-old man affected and operated on for renal cell cancer, brought to our care for the appearance of a buccal mucosal ulcer. Pathological analysis revealed a metastasis compatible with clear-cell carcinoma. Its renal origin was confirmed by immunohistochemical technique. The patient was evaluated and managed after post multidisciplinary tumor board discussion with palliative radiotherapy for local disease. Conclusion: There should be no hurry in starting treatment for a buccal mucosal lesion, and it should be histopathologically evaluated keeping in mind a differential of metastasis from the distant primary. Multidisciplinary tumor board discussion plays an important role in such rare scenarios.

Extra-Pleural Pneumonectomy (EPP) in Children and Adults with Locally Advanced Sarcoma: A CanSaRCC Study.

Simple SummaryExtra-pleural pneumonectomy (EPP) involves the removal of the parietal and visceral pleura, ipsilateral lungs, pericardium, and hemi diaphragm. In patients with advanced sarcoma in the pleura, EPP is often the only option for local control. The aim of our study was to review our institutional experience with EPP. Of ten patients in our study, five were alive without disease at last follow-up after multi-modality therapy including EPP. Two patients had local recurrence and died of progressive disease. One patient died of brain metastasis, one patient died of radiation induced sarcoma, and one patient died of surgical complications. Our results suggest that EPP is a feasible option for patients when used in combination with chemotherapy and radiation. Moreover, high-volume cancer centers should discuss the use of EPP during tumor board discussion.Sarcoma can present as locally advanced disease involving pleura for which extra-pleural pneumonectomy (EPP) may be the only surgical option to ensure adequate local control. Data were collected on patients who underwent EPP between January 2009 and August 2021 at Princess Margret Hospital and SickKids (Toronto) using the CanSaRCC (Canadian Sarcoma Research and Clinical Collaboration). Ten patients with locally advanced sarcoma involving the pleura, aged 4 to 59 years (median 19.5 years) underwent EPP. Nine (90%) received pre-operative chemotherapy and eight (80%) achieved an R0 resection. Hemithoracic radiation was administered preoperatively (n = 6, 60%) or postoperatively (n = 4, 40%). Five (50%) patients were alive without disease at last follow-up (median 34.2 months) and time from EPP to last FU was median 29.2 months (range 2.2–87.5). Two patients (20%) had local recurrence, 4.3 and 5.8 months from EPP, and both died from progressive disease, 13.1 and 8.2 months from EPP, respectively. One patient died from brain metastasis (17 months), one died from radiation associated osteosarcoma (66 months), and one died from surgical complications (heart failure from constrictive pericarditis). EPP offers a feasible and life-prolonging surgical consideration for patients with locally advanced sarcoma involving the pleura in combination with chemotherapy and radiation. Consequently, EPP should be considered during multi-disciplinary tumor board discussions at high-volume centers.

Improving coordination of lung cancer care at a tertiary healthcare center in Saudi Arabia.

ABSTRACTObjectives:To evaluate the impact of coordination of care of lung cancer in a tertiary care center.Methods:A retrospective study was carried out on all patients diagnosed with lung cancer between 2016-2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Data were collected from medical records, which included demographic data, the interval between cancer suspicion and definitive therapy, multidisciplinary tumor board (MTB) data, and palliative care.Results:A total of 60 (41 males and 19 females) cases of lung cancer were analyzed. The majority of patients had adenocarcinoma (63.3%) and stage IV (70%) lung cancer. A total of 32 (76.2%) of stage IV patients were referred to palliative care. Only 40 (66.7%) of the patients were presented in the MTB, of whom new findings were found in 15 (37.5%) patients including pathology findings in 3 (7.5%), radiology findings in 7 (17.5%), and staging data in 5 (12.5%). Multidisciplinary tumor board discussion had impacted the management in 14 (35%) of patients presented.Conclusion:Discussion of lung cancer cases in MTB had a positive influence on the coordination of patients’ care.

INNV-27. AN INNOVATIVE VIRTUAL MULTI-INSTITUTIONAL, MULTIDISCIPLINARY NEURO-ONCOLOGY TUMOR BOARD: THE NIH-NOB EXPERIENCE DURING THE COVID-19 PANDEMIC

BACKGROUNDThe American Academy of Neurology Institute and Society for Neuro-Oncology recommend multidisciplinary tumor board (MTB) meetings as a quality metric in neuro-oncology. With the COVID-19 pandemic resulting in travel restrictions, we expanded our existing MTB by transitioning to a virtual format that maintained our commitment to providing consultation for primary CNS tumor cases. This transition permitted participation by neuro-oncology teams from over 30 Brain Tumor Trials Collaborative (BTTC)/National Cancer Institute-Comprehensive Oncology Network Evaluating Rare CNS Tumors (NCI-CONNECT) centers across the United States. Here, we describe results from opening our MTB remotely to these teams.METHODSWe retrospectively reviewed records from remote MTB meetings held between April 2020 and March 2021. To gauge the impact of our MTB on clinical management, we administered a brief survey querying BTTC members.RESULTSTwenty-eight providers presented 41 cases during 24 virtual MTB meetings (range: 1-4 cases per meeting). Two cases (5%) were presented only for educational value. Approximately half (54%) of the cases discussed dealt with diagnosis/management of an NCI-CONNECT rare CNS tumor. During MTB discussions of the 39 cases seeking diagnosis/management recommendations, 32% received clinical trial recommendations, 10% were suggested to enroll in the NCI Neuro-Oncology Branch (NOB) Natural History Study (NCT02851706), 17% received a recommendation to obtain central neuropathology review, and 100% received recommendations for further disease management. Most BTTC survey respondents (83%) found these recommendations impactful in the management/treatment of their presented case or generally useful/informative for their clinical practice.CONCLUSIONWe describe the feasibility and utility of an innovative virtual multi-institutional MTB. These novel remote meetings allowed for discussion of complex neuro-oncology cases and recommendations from experts, particularly important for those with rare CNS tumors. Our study’s findings during the COVID-19 pandemic of the value of providing remote access to MTBs should apply post-pandemic.

Concurrent TTFields (200 kHz) With Chemoradiation for Patients With Newly Diagnosed Glioblastoma May Increase the Rate of Pseudoprogression: Analysis of a Pilot Clinical Trial

Standard of care for glioblastoma includes concurrent chemoradiation and maintenance temozolomide with tumor treating fields (TTFields). Data suggest that TTFields, may reversibly affect the blood-brain-barrier (BBB), with a maximum effect at 100 KHz. We suspect this may increase the rate of pseudoprogression (PsP) in patients who received concurrent chemoradiation with TTFields (200 kHz) in our pilot clinical trial. We report the rates of PsP among consecutive patients enrolled on our clinical trial of trimodality therapy to inform this hypothesis.The current analysis included all patients enrolled on the single arm pilot study of concurrent TTFields with chemoradiation (clinicaltrials.gov Identifier: NCT03477110). Adult patients (age ≥ 18 years) with newly diagnosed glioblastoma and a KPS of ≥ 60 were eligible. All patients received concurrent scalp-sparing radiation (60 Gy in 30 fractions), standard concurrent temozolomide (75 mg/m2 daily), and TTFields (200 kHz). Radiation treatment was delivered through TTFields arrays. The rate of PsP was assessed based on the first MRI following completion of trimodality therapy. PsP was defined as radiographic progression of enhancing lesions within 3 months of completion of chemoradiation without clinical decline and remained stable or improved on subsequent imaging. PsP was defined based upon the radiology report and multidisciplinary tumor board discussion. If subsequent imaging demonstrated worsening progression or the patient deteriorated clinically this was classified as true progression.A total of 30 patients were enrolled on the trial and 29 had evaluable imaging. Twenty were male, and ten were female, with a median age of 58 years (range 19 to 77 years). Median KPS was 90 (range 70 to 100). Median follow-up was 8.9 months (range 1.6 to 21.4 months). Twenty (66.7%) patients had an unmethylated MGMT promotor and ten (33.3%) patients had a methylated promoter. Median time from surgery to radiation was 34 days (26 to 49 days). Median time from completion of ChemoRT + TTFields to first follow-up MRI was 25 days (1 to 40 days). In the entire cohort, 16 of 29 patients (55%) had findings consistent with PsP. The rate of PsP among patients with a methylated MGMT promotor was 40% (4 of 10), 63% (12 of 19) among patients with an unmethylated MGMT promotor.Among patients receiving concurrent TTFields with chemoradiation treatment, 55% of patients demonstrated findings consistent with PsP. Although limited by the small sample size, the incidence of PsP may be greater than historical reports, especially in patients without MGMT promoter methylation. Further data are needed to verify if TTFields (200 kHz) disrupts the BBB and if this can lead to increased rates of PsP among larger cohorts.J. Taylor: None. R.C. Miller: None. A. Ali: None. V. Bar-Ad: None. N. Martinez: None. J. Glass: None. I. Alnahhas: None. D.W. Andrews: None. K. Judy: None. C. Farrell: None. H. Liu: None. W. Shi: Independent Contractor; Wenyin Shi. Research Grant; Novocure, Brainlab, Regeneron. Consultant; Varian, Brainlab, Zai lab.

Impact of multidisciplinary tumor board (MTB) discussion on the outcome of patients with liver-limited metastasis from colorectal cancer (LMCRC).

50 Background: MTB is a valuable tool in complex cases, since they involve different medical fields aiming for a more comprehensive decision-making process. Our aims are to describe MTB decisions in complex LMCRC, to analyze decisions compliance and evaluate outcomes. Methods: This is a retrospective analysis of medical records of patients diagnosed with liver metastasis of colorectal carcinoma (LMCRC) discussed at a single center, weekly-basis MTB from January 2019 to December 2020. Descriptive statistics was used for demographic and treatment characteristics and adhesion to MTB decisions. Survival was estimated by Kaplan-Meier method and log-rank tests. Results: Out of 1033 cases discussed at MTB, 63 met the inclusion criteria. Median age was 56.5 years (range 32 – 81), 61.9% were male, ECOG was 0-1 in 96.8%. Regarding primary tumor sidedness: 81% and 19% were left and right, respectively. Synchronous metastasis was present in 69.8% and wild-type RAS was found in 52.4% and MSI-H in 4.8%. At time of MTB, 68.3% and 4.8% had realized a first or second-line chemotherapy (CT) respectively. No previous therapy was described in 19% and 7.9% had received adjuvant CT. Previous hepatic resections occurred in 20.6%. After MTB, liver resection was recommended for 44.5%. Preoperative CT followed by one or two-stage surgery for 23.8%. Non-surgical treatments were offered for 17.5% and palliative CT for 14.3%. Decisions from the MTB were implemented in 93.6%. Reason for not performing (N = 4) were: one for disease progression, one for bureaucratic restriction and two for other reasons. Median follow-up time was 17.2m. At date of analysis, 31 patients (49.2%) had relapsed or progressed and 8 had died. Restricting for patients who underwent MTB decision (N = 59), mPFS was 14.71m. In resected cases (N = 40), who were discussed at the onset of liver metastasis diagnosis (without CT in the metastatic setting) had mPFS not reached, while who were discussed after first or second-line had mPFS of 9.39m (p 0.002). R0 resections were reached in 92.5%. Evaluating the 30-day postoperative mortality, there was one death. mPFS for palliative CT was 6.83m. Conclusions: In our analysis the adherence to MTB recommendation was high (above 90%) and patients selected for surgery presented a prolonged PFS. Our data suggest that selection of patients for liver metastasis resection in a MTB discussion should occur early in the course of treatment.

Treatment Patterns and Outcomes in Patients with Esophageal Cancer: An Analysis of a Multidisciplinary Tumor Board Database.

Multidisciplinary management strategies are standard in esophageal cancer. Based on a multidisciplinary tumor board (MTB) database in a high-volume center, we aimed to evaluate real-world treatment patterns and patient outcomes in patients with esophageal cancer. In addition, we determined the impact of MTB discussions on patient prognosis. Patients diagnosed with esophageal cancer between 2010 and 2019 were retrospectively reviewed. The pattern of treatment modalities and overall survival (OS) of patients with limited, locally advanced, and advanced/metastatic disease were reported. Data from 1132 patients, including 247 patients with limited esophageal cancer, 606 patients with locally advanced esophageal cancer, and 279 patients with advanced/metastatic esophageal cancer were included. Upfront surgery was the most common (56.3%) treatment modality for patients with limited esophageal cancer, while treatment for locally advanced esophageal cancer included upfront surgery (19.1%), neoadjuvant chemoradiotherapy (44.9%), and definitive chemoradiotherapy (36.0%); however, 27.9% of patients undergoing neoadjuvant chemoradiotherapy did not receive planned esophagectomy. Definitive chemoradiotherapy was mainly used for patients with locally advanced and advanced/metastatic disease, but had an incompletion rate of 22.0% and 33.7%, respectively. Regarding survival, the 5-year OS rates were 56.4%, 26.3%, and 5.1% in patients with limited, locally advanced, and advanced/metastatic disease, respectively. Additionally, patients whose clinical management was discussed in the MTB had a significantly better 5-year OS rate than the other patients (27.3% vs. 20.5%, p<0.001). We report the real-world data of treatment patterns and patient outcomes in patients with esophageal cancer with respect to multidisciplinary management, and demonstrate the positive impact of MTB discussions on patient prognosis.

MUCOEPIDERMOID CARCINOMA MASKED BY ADJACENT BENIGN NEURAL LESION: A CASE REPORT

<h3>Introduction</h3> Mucoepidermoid carcinomas demonstrate a heterogeneous clinical presentation, occasionally mimicking other lesions (such as mucocele in the oral cavity). We present an unusual case arising in the parotid gland, masked by a neuroma. <h3>Clinical Presentation</h3> A 25-year-old female patient presented to neurology with left facial muscle twitching of 7 years duration, following chemotherapy for Hodgkin lymphoma. Clinical examination revealed muscle fasciculations under the left eye, nose, and angle of mouth. Cranial nerve examination and vision tests were otherwise normal. Magnetic resonance imaging revealed a lesion affecting the extracranial portion of the left facial nerve, with an adjacent parotid gland abnormality, determined as Schwannoma. The patient returned at age 28 with worsening facial weakness, and new magnetic resonance imaging revealed extension of the lesion through the stylomastoid foramen. Following further deterioration of facial muscle function, the lesion was resected with a facial nerve graft. <h3>Histopathology</h3> Sections revealed a well-circumscribed nodule of neural tissue demonstrating direct intraneural infiltration by islands of a cystic epithelial tumor lined by bland cuboidal/columnar epithelium with occasional clear, mucous and intermediate cell types. ABPAS staining confirmed the presence of mucin. The features were of a neuroma infiltrated by mucoepidermoid carcinoma. <h3>Outcome</h3> Following multidisciplinary tumor board discussion, the patient will undergo temporal bone resection, radical parotidectomy, and selective neck dissection. Further outcome will be presented. <h3>Conclusions</h3> Mucoepidermoid carcinomas are the most common salivary malignancies. Our case report highlights that these tumors can show a wide variety of presentation depending on site and size. In this case an adjacent pathology, albeit benign, confused the clinical picture.

Reusing Decisions Made with One Decision Support System to Assess a Second Decision Support System: Introducing the Notion of Complex Cases.

The guideline-based decision support system (GL-DSS) of the DESIREE project and OncoDoc are two clinical decision support systems applied to the management of breast cancer. In order to evaluate the DESIREE GL-DSS, we decided to reuse a sample of clinical cases previously resolved by the multidisciplinary tumor board (MTB) of the Tenon Hospital (Paris, France) when using OncoDoc. Since we had two different knowledge representation models to represent clinical parameters and decisions, and two formalisms to represent guidelines, we developed a transformation sequence, involving the creation of synthetic patients, the enrichment of DESIREE ontology, and the translation of clinical cases and their decisions, to transform OncoDoc data into the DESIREE representation. Considering MTB decisions as the gold standard, the 84% compliance rate of DESIREE recommendations was rather satisfactory. Some situations (0.7%) concerned clinical cases that were compliant neither with OncoDoc nor with DESIREE that we defined as complex cases, not handled by guidelines, which necessitate effective MTB discussions.

Activity of erlotinib in patients (pts) with advanced chordoma: A retrospective study.

11528 Background: Chordoma is a rare tumor with no approved therapy. Preclinical studies have shown expression of EGFR and activated EGFR family kinases (EGFR, HER2 and HER4). Erlotinib and other anti-EGFR agents (gefitinib and cetuximab) have shown clinical activity in advanced chordoma in single case reports or small series. We aimed to evaluate the activity of erlotinib in a larger, homogeneous series of pts with advanced chordoma. Methods: We retrospectively reviewed the electronic medical records of consecutive adult pts with advanced chordoma progressive over 6 months (+/- 2 weeks, according to RECIST 1.1), treated with erlotinib (150 mg daily) at Gustave Roussy (Villejuif, France) following multidisciplinary tumor board discussion, from January 2010 to January 2021. All cases were confirmed by an expert pathologist. Response was evaluated according to RECIST 1.1, and survival was estimated using the Kaplan-Meier method. Results: Thirty-one pts [median age : 60 years (range : 32-88), median PS : 2 (range : 1-3), 30 males)] were identified. Twenty-seven (87%) had locally advanced disease; the median number of metastatic sites was 1 (range : 1-2) in the remaining 4 pts. Primary tumor site was sacral (25), lumbar (3) or cervical (3). All pts but 6 had undergone prior surgery, and 29 (94%) had undergone radiotherapy of the primary tumor. Eight pts had received previous systemic treatments (imatinib in 4, sorafenib and regorafenib in 2 each). Best tumor response by RECIST 1.1 was PR (4 pts, 13%), SD (14 pts, 45%) or PD (13 pts, 42%). Median PFS was 6.2 months (95%CI : 4.5-9.8), and median OS was 15.9 months (95%CI : 10.6-20.2). Fourteen pts (45%) remained progression-free after 1 year, and three (10%) after two years under erlotinib. Grade 3 diarrhea occurred in 4 pts (13%) and grade 3 skin rash in 13 pts (42%). Twelve pts (39%) required dose reduction to 100 mg daily due to multiple grade 2 toxicities. Ongoing studies are exploring whether candidate biomarkers such as EGFR and HER2 expression or amplification, and their mutational status could help predicting the benefit of erlotinib in pts with advanced chordoma. Conclusions: Erlotinib has clinically meaningful but unpredictable activity in advanced chordoma. Molecular profiling would probably be of high interest in this setting. This series may serve as a benchmark for future clinical trials in chordoma.

Liver Metastasectomy for Metastatic Breast Cancer Patients: A Single Institution Retrospective Analysis.

The liver represents the first metastatic site in 5–12% of metastatic breast cancer (MBC) cases. In absence of reliable evidence, liver metastasectomy (LM) could represent a possible therapeutic option for selected MBC patients (patients) in clinical practice. A retrospective analysis including MBC patients who had undergone an LM after a multidisciplinary Tumor Board discussion at the Hepatobiliary Surgery Unit of Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS in Rome, between January 1994 and December 2019 was conducted. The primary endpoint was overall survival (OS) after a MBC-LM; the secondary endpoint was the disease-free interval (DFI) after surgery. Forty-nine MBC patients underwent LM, but clinical data were only available for 22 patients. After a median follow-up of 71 months, median OS and DFI were 67 months (95% CI 45–103) and 15 months (95% CI 11–46), respectively. At univariate analysis, the presence of a negative resection margin (R0) was the only factor that statistically significantly influenced OS (78 months versus 16 months; HR 0.083, p < 0.0001) and DFI (16 months versus 5 months; HR 0.17, p = 0.0058). A LM for MBC might represent a therapeutic option for selected patients. The radical nature of the surgical procedure performed in a high-flow center and after a multidisciplinary discussion appears essential for this therapeutic option.

Synchronous dual malignancies: Carcinoma larynx and hepatocellular carcinoma

Synchronous cancers are defined as two or more primary cancers diagnosed in the same patient at the same time or within 6 months of diagnosis of each other. The diagnosis of multiple primary malignancies is not uncommon. A 70-year-old male reported to our hospital with chief complaints of change in voice and difficulty in swallowing solid food for 2 months accompanied anorexia since 20 days. The patient revealed occasional consumption of alcohol for 3 years and bidi smoking for 50 years (10 bidis per day). The patient was conscious, cooperative, and well oriented to time, place and person with an Eastern Cooperative Oncology Group of 0. On physical examination, the oral cavity and oropharynx were unremarkable. Direct laryngoscopy revealed ulceroproliferative growth in right-sided vallecula, right-sided aryepiglottic fold, right side arytenoid and pyriform sinus, and right vocal cord. Biopsy from this growth turned out to be poorly differentiated squamous cell carcinoma. Computed tomography (CT) scan of the neck and thorax revealed 1.5 cm × 2.6 cm heterogeneously contrast enhancing lesion involving right aryepiglottic fold, pyriform fossa, posterior hypopharyngeal wall, and posterior aspect of both false vocal cords. Few subcentimeter lymph nodes were noted in right side Level II. The CT scan also showed some mass lesion abnormality in the upper section of liver images which could not be properly made out. Hence, triple-phase CT scan of the liver was done which to a great surprise showed 7.7 cm × 6.5 cm × 5.5 cm lesion in segment V and VIII, it showed enhancement on arterial phase, became prominent on portovenous phase and a delayed phase washout. Similar lesion measuring 4.4 cm × 4.1 cm was seen in segment VIII of liver; which was diagnosed radiologically as a multicentric hepatocellular carcinoma. Serum alpha fetoprotein was markedly elevated to a value of 28,600 ng/mL. A multidisciplinary tumor board discussion was done, and an intense literature review was done, and a decision was taken keeping in mind the overall performance score of the patient to commence with a high palliative radiotherapy for laryngeal cancer to a dose of 45 Gray in 15 fractions at a dose of 3 Gray per fraction and tablet tamoxifen at a dose of 60 mg/day till the end of radiation followed by switching over to tablet sorafenib. The patient ultimately developed uremia due to liver failure and died. The patient survived for a period of 3 months from the time of diagnosis of malignancy. Such cases need a meticulous approach for the diagnosis as well as treatment approaches. Keeping in mind the general condition of the patient and available therapeutic options, a patient-based specific approach could be developed.

Do Multidisciplinary Tumor Board Discussions Correlate With Increase in 5-Year Survival? A Meta-Analysis Study.

Due to the complex nature of cancer cases, it is imperative that the involved healthcare providers coordinate the patients care plan in union to reach the best possible outcome in the smoothest and fastest manner. This is what multidisciplinary tumor board (MTB) meetings strive to achieve. Conducting regular MTB meetings requires significant investment of time and finances. It is thus vital to assess the empirical benefits of such practice. A meta-analysis was conducted to evaluate the literature regarding the impact of MTB meetings on patient 5-year survival. Relevant studies were identified by searching Ovid MEDLINE and Embase databases from January 1995 to July 2019. Studies were included if they assessed 5-year survival in cases discussed in MTB meetings and used a comparison group and/or a pretest and posttest design. Five articles met the study's inclusion criteria. Quality of studies was affected by selection bias and the use of historic cohorts. The results showed significantly improved 5-year survival in the MTB group compared with the non-MTB groups (odds ratio for 5-year death rate of 0.59, CI 0.45-0.78, p < 0.001). This meta-analysis showed that cancer MTB meetings have a significant impact on patients' 5-year survival. This could be because of several reasons, such as less time to treatment initiation, better adherence to guidelines, higher numbers of investigational imaging, lesser surgical complications, and recurrence rates. Future prospective studies are needed to further delineate reasons for improvement of outcome to enhance the benefits of this approach.