Single-institution Study Research Articles

Socioeconomic factors and test preparation strategies are related to success on the USMLE Step 2 clinical knowledge (CK) exam: a single-institution study

BackgroundSince the elimination of numerical scoring of the United States Medical Licensing Examination (USMLE) Step 1, the perceived importance of USMLE Step 2 Clinical Knowledge (CK) scores in residency placement has increased. It is known that socioeconomic status (SES) and other demographic factors can be barriers to success in standardized assessment, but few recent studies report the relationship between student demographics, including SES, with Step 2 CK scores in the context of exam practice material access and usage. In this study, we investigated predictors of Step 2 CK success across two years at one institution.MethodsA survey regarding Step 2 CK exam preparation and demographic factors was administered to two student cohorts at a New York medical school in 2022 and 2023. The cohorts were comprised of all students in a given class year who had taken Step 2 CK. De-identified survey responses were linked to metrics including Step 1, Step 2 CK, shelf exam, and Medical College Admission Test (MCAT) scores.ResultsThe mean Step 2 CK score among the respondents (n = 213) was 254 ± 13. There was a strong positive correlation between Step 2 CK score and composite shelf scores (rho = 0.80, p < 0.01). Almost all participants used the UWorld question-bank to prepare for the exam (98.1%), and completion of more than 2500 unique questions was associated with better exam performance (256 vs. 252, p = 0.04). On bivariate analysis, students had significantly lower mean Step 2 CK scores if they self-identified as socioeconomically disadvantaged (SED) (250 vs. 256, p < 0.01) and self-reported that financial limitations prevented them from purchasing study resources (249 vs. 257, p < 0.01). In adjusted models, there was no longer a relationship between self-identified SED and Step 2 CK score (beta=-3.50, 95% CI (-8.25, 1.26), p = 0.15).ConclusionsThis study provides insight into the relationship between exam performance, study habits, and demographic factors at a single institution where students, on average, performed above the national mean on Step 2 CK. Results support that Step 2 CK scores are modulated by a high composite shelf score, number of unique UWorld questions completed, dedicated study period length, and socioeconomic inequity.Trial registrationStudy registered with our institutional IRB (IRB number 20177537).

The PPP - Perineal Body Preserving PSARP (Posterior Sagittal Anorectoplasty) for Anorectal Malformation with Rectovestibular Fistula in Females-Report of Early Outcomes.

The perineal body preserving posterior sagittal anorectoplasty (PSARP) (PPP) is a novel modification of the original PSARP for female patients with rectovestibular fistulas designed to eliminate the risk of perineal body dehiscence. This study aims to examine the outcomes following PPP. A retrospective, single-institution study was performed examining female patients with rectovestibular fistula who underwent PPP between January /2020 and December 2023. Exposure was done through the intended anoplasty only. Perineal body or posterior sagittal incision was not utilized. No routine postoperative dilations were performed. The postoperative outcomes, day of discharge, time to first feeding, and early stooling patterns were assessed. A total of 15 patients underwent a PPP at a median age of 6 months (range 2 days to 19 months) with median follow-up of 11 months (range 1-36). Three (20%) patients underwent repair within the first 3 months of life. Five (33%) had diverting ostomies prior to referral to our team. There was no incidence of dehiscence or rectal prolapse. Two (13%) patients developed an anal stricture which required revision. Fourteen (93%) patients resumed normal feeds on postoperative day 1. Eleven (73%) were discharged on postoperative day 1. All patients were stooling spontaneously at their most recent clinical encounter with 11 (73%) utilizing laxatives. PPP eliminates the risk of perineal body dehiscence and has a quick return to regular diet and home. There is a 13% stricture rate which could relate to a difference in the distal rectal mobilization compared with the traditional PSARP.

KRAS Variants Are Associated With Survival Outcomes and Genomic Alterations in Biliary Tract Cancers.

KRAS variants are associated with poor outcomes in biliary tract cancers (BTCs). This study assesses the prevalence of KRAS variants and their association with survival and recurrence in patients with intrahepatic cholangiocarcinoma (IHC), extrahepatic cholangiocarcinoma (EHC), and gallbladder adenocarcinoma (GB). In this cross-sectional, single-institution study at Memorial Sloan Kettering, tumors from 985 patients treated between 2004 and 2022 with IHC, EHC, and GB who underwent either curative-intent resection or were treated with chemotherapy for unresectable disease were used for targeted sequencing. Of the 985 patients sequenced, 15% had a KRAS mutation. Five hundred and seventy-two had unresectable disease (n = 395 IHC, n = 71 EHC, n = 106 GB) and 413 were treated with curative-intent resection (n = 175 IHC, n = 119 EHC, and n = 119 GB). Median follow-up time was 18 months (IQR, 11-31). KRAS G12D mutations were most common in IHC (38%) and EHC (37%) tumors. Mutations in SF3B1 co-occurred with mutant KRAS in IHC and EHC, with comutant resectable patients having worse survival after adjusting for tumor type (hazard ratio [HR], 4.04 [95% CI, 1.45 to 11.2]; P = .007). KRAS G12 mutations were associated with worse survival in patients with IHC compared with wild-type (WT) or other KRAS mutations, regardless of resection status (unresectable P < .001, resectable P = .011). After adjusting for clinical covariates, KRAS G12 mutations remained a prognostic indicator for patients with IHC compared with WT (HR, 1.99 [95% CI, 1.41 to 2.80]; P < .001). The adverse impact of KRAS mutations in BTC is driven by G12 alterations in patients with IHC regardless of resection status, which was not observed in GB or EHC. There are unique comutational partners in distinct BTC subsets. These differences have important clinical implications in the era of KRAS-targeted therapeutics.

Predictors of missed hospital appointments in patients with posterior compartment pelvic floor disorders in a tertiary referral centre

Aim:Missed hospital appointments pose a major challenge to the healthcare system leading to worse patient outcomes. We ascertained the incidence of missed hospital appointments in patients with Posterior Compartment Pelvic Floor Disorders (PC-PFD) and associated socio-demographic and clinical predictors. Methods:This is a cross-sectional single-institution study from a tertiary pelvic floor unit (PFU) with data collected from a prospectively maintained database.A missed appointment was marked if patients did not attend two consecutive appointments without informing or asking to re-schedule and were recorded for Telephone Triage Assessment Clinic (TTAC), Specialist-nurse, face-to-face bowel function clinic (BFC), Investigations including endoanal (EAUS) and pelvic floor ultrasound (PFUS) and defecating proctogram (DP). All results yielding p<0.05 were considered significant. Results:PFU received 2001 referrals between 2013 and 2019 with a mean age of 52 years. Missed appointments recorded were: TTAC — 45 (2.2%), BFC — 309 (15.8%), EAUS — 476(24%), PFUS — 484(37.2%) and DP — 432(26.2%).Predictors determined were: Male gender, age <50 years, complaints of rectal pain and bleeding for missing telephone and face-to-face appointments, low socioeconomic status for missing face-to-face appointments, and mixed and other ethnic groups with missing telephone appointments. Conclusion:This is the first study to report the incidence and socio-demographic and clinical predictors for missed appointments in patients with PC-PFD. Future prospective research, including qualitative studies interviewing patients, is needed to identify and address potential barriers patients face when accessing care for PC-PFD. This will help improve patient care and allow better utilisation of already constrained healthcare resources.

Prognostic value of central gland volume on MRI for biochemical recurrence after prostate radiotherapy.

This study evaluates pretreatment prostate magnetic resonance imaging (MRI) metrics and clinical characteristics in predicting biochemical recurrence (BCR) after prostate radiotherapy (RT). In this retrospective single institution study, we identified men in our prostate cancer database who underwent MRI within 6 months prior to completing definitive RT from May 2011 to February 2023. Central gland volume and peripheral zone volume were measured by a radiologist using manual segmentation, along with Prostate Imaging-Reporting and Data System (PI-RADS) score. The primary objective was to determine the association of central gland volume with biochemical recurrence per Phoenix criteria. Multivariable and inverse probability weighted (IPW) Cox proportional hazards regression models were constructed. A total of 373 men were included, with a median follow-up of 28 months. Thirteen (3.5%) were low risk, 97 (26%) favorable intermediate risk, 201 (53.9%) unfavorable intermediate risk, and 62 (16.6%) high risk. Fifty-four (14.5%) patients received conventionally fractionated RT, 105 (28.2%) moderately hypofractionated RT, 121 (32.4%) high-dose rate brachytherapy, and 93 (24.9%) stereotactic body RT. The 3- and 5-year rates of BCR were 7.8% and 18.3%, respectively. Higher central gland volume (per 5cc) was associated with decreased risk of BCR (hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.50-0.94, p = 0.02) on the multivariable Cox model and IPW model (HR: 0.75, 95% CI: 0.65-0.87, p < 0.001). No significant association was seen with peripheral zone volume, PI-RADS score, or RT modality. Increased central gland volume on pretreatment prostate MRI is independently associated with a lower risk of biochemical recurrence after definitive radiation for prostate cancer. Central gland volume may improve patient selection and oncologic risk stratification prior to offering RT.

Management of treatment-naïve Koos grade IV vestibular schwannomas using hypofractionated Gamma Knife radiosurgery: a retrospective single-institution study.

While single-fraction Gamma Knife radiosurgery (GKRS) has shown efficacy in managing vestibular schwannomas (VSs), some concerns have been raised regarding its safety profile, particularly in the context of hearing preservation. Hypofractionation has emerged as a promising approach to improving the safety profile. This retrospective, single-institution study evaluated patient outcomes following hypofractionated GKRS (hf-GKRS) for treatment-naïve Koos grade IV VSs. This study involved all patients with treatment-naïve Koos grade IV VSs who underwent hf-GKRS (3 or 5 fractions) between January 2018 and June 2021, with a follow-up period of ≥ 36 months. The outcomes assessed included local control (LC), the preservation of serviceable hearing as determined by the Gardner-Robertson hearing scale, and procedure-related adverse events. Twenty-nine patients (14 females, median age 49 years) were treated with three different dose regimens: 21 patients received 18Gy in 3 fractions, 6 patients received 20Gy in 5 fractions, and 2 patients received 25Gy in 5 fractions. Prior to treatment, 13 patients (44.8%) had serviceable hearing, one (3.4%) presented with facial palsy, and four (13.8%) had trigeminal nerve dysfunction. The median tumor volume was 10.8 cm3. During a median radiological follow-up period of 60 months (range, 36-78 months), LC was achieved in all patients. All 13 patients retained serviceable hearing at the last follow-up. Trigeminal nerve dysfunction occurred in one patient (3.4%), while another patient (3.4%) needed a ventriculoperitoneal shunt insertion due to new-onset hydrocephalus. No new-onset facial palsy was observed. hf-GKRS shows promise as an effective and safe primary or adjuvant treatment for Koos grade IV VSs with non-life-threatening or debilitating symptoms. Future studies with larger cohorts and extended follow-up periods are needed to validate these findings and to refine fractionation schemes.

Organ-confined prostate cancer with negative surgical margins in an entirely-embedded radical prostatectomy is essentially non-lethal-a retrospective single-institutional study of 520 patients.

There is no risk-based stratification in serum PSA monitoring in prostate cancer (PCa) patients following radical prostatectomy (RP). Those patients with minimal risk of recurrence may be subjected to unnecessarily rigorous monitoring as well as to increased anxiety disproportionate to their actual prognosis. This study aimed to investigate outcomes in PCa patients with favorable pathologic parameters to see whether they can be followed less rigorously than current practice recommendations dictate. 520 consecutive entirely embedded organ-confined RPs with negative margins and undetectable initial postoperative serum PSA at the University of Chicago Medical Center between 2005 and 2017 were retrospectively identified. Clinicopathologic parameters and follow-up data including serum PSA were analyzed. No patients, regardless of their grade group (GG), developed metastasis or succumbed to a PCa-specific death. These patients had a median postoperative follow-up of 109months. 2.2% (22/520) of the patients developed biochemical recurrence (BCR). There were 163, 279, 69, 4, and 5 RPs from GG 1 to 5, respectively. Of these, 0% (0/163), 1.8% (5/279), 18.8% (13/69), 0% (0/4), and 60% (3/5) developed BCR, sequentially. In this study, organ-confined PCa with negative margins in an entirely embedded RP carried no mortality risk. In particular, the patients with GG 1-2 disease may have benefited from less rigorous monitoring. Additionally, enhanced patient reassurance could play a role in reducing anxiety in this subset of patients.

Knowledge and Confidence Among Five Cohorts of Faculty Learners in a Point of Care Ultrasound (POCUS) Program: Factors Defining Learner Success.

Background: The availability of faculty proficient in point of care ultrasound (POCUS) has emerged as a barrier to the ongoing expansion of POCUS across the field of internal medicine. We sought to examine the faculty graduates of our institutional POCUS program to identify characteristics associated with long-term proficiency to inform curricula and guide institutional support. Methods: We emailed a test and survey to the 89 faculty graduates of the annual POCUS course we have run from 2018-2023. Results: Of the 46 participants (52%) who completed the test and survey, the overall median test score was 72%. Graduates were most confident with image acquisition of the lung, and were most likely to use ultrasound to evaluate ascites and dyspnea. All 11 participants reporting completion of an image portfolio were actively teaching POCUS, whereas only 54% of non-completers were teaching. Portfolio completers scored higher on the test compared to non-completers (median 92% and 68%, respectively, p <0.01) and were more confident in image acquisition and interpretation (p<0.001). Conclusions: In this long-term, single-institutional study of faculty graduates of an annual POCUS program, those who reported completing an image portfolio scored significantly higher on a knowledge test, reported higher confidence with image acquisition and interpretation, and reported using and teaching POCUS more frequently compared to graduates who did not complete the portfolio. POCUS education programs should be designed to foster continuous scanning practice and image portfolio completion.

EGS SO32 - Management of Spontaneous Oesophageal Perforations in the era of Endo-Vacuum Therapy- Preliminary Results of a Single-Institution Study

Abstract Background Spontaneous Oesophageal Perforation (SOP) is a rare gastro-intestinal surgical emergency with devastating morbidity and mortality. Given the rarity of the entity, there is no up-to-date evidence on outcomes in the context of centralized esophagogastric services neither consensus guidelines nor standardized treatment algorithms on how these should be optimally managed. Endoscopic Vacuum Therapy (EVT) has emerged as safe and effective option particularly in cases where major invasive surgery would otherwise be deferred. Herein, we sought to explore the effectiveness, patient benefit and related morbidity/mortality by exploring the strategy outcomes in SOPs prior to and during periods where EVT was available. Method A single-centre retrospective cohort study incorporating all consecutive patients (N=72) presented or transferred to our tertiary oesophagogastric unit for SOP management between 01/01/2009-31/12/2023 was undertaken. Patients with anastomotic leak post-surgery or perforation secondary to malignancy, iatrogenic, traumatic or food bolus were excluded. Primary study-outcomes were treatment type including non-operative, EVT after 01/01/2018 or other endoscopic therapy, surgical operation including laparotomy, thoracotomy, primary defect repair or over a T-tube, disconnection with oesophagostomy, stenting or other interventional radiology procedures and their rate of success or failure. Secondary outcomes were length of stay, 90-day complications requiring re-intervention or re-admission, 30-, 90-day, 1-year mortality. Results In 2009-2017 pre-EVT period, 25/72 patients were managed a) 18/25 surgically with thoracotomy and T-tube, b) non-surgical 7/25, four were palliated. 30-day, 90-day mortality were 4/25 and 2/25, 90-day morbidity Clavien-Dindo &amp;gt;IIIa 14/25 (56%), 90-day reintervention 8/25 (32%), median LOS 27 days. In 2018-2023 EVT period , 47/72 patients were treated with a) laparotomy, left thoracotomy, defect repair over t-tube, chest drainage in 18/47, b) non-surgical 15/47, c) endoscopy 6/47, d) EVT in 14/47. 30-day mortality was 6/47, 90-day mortality 2/47, 90-day morbidity Clavien-Dindo &amp;gt;IIIa 32/47 (68%), 90-day reintervention 26/47 (55.3%), median LOS 34 days. 1-year mortality was 5/25 and 3/47 respectively. Conclusion EVT therapy appears to be a feasible additional treatment modality in the management of spontaneous oesophageal perforations. Optimal patient selection, therapeutic endoscopic expertise, knowledge of the technique, multidisciplinary approach and team collaboration are essentials for favourable outcomes. Of note, management of oesophageal perforations in a dedicated UGI centre is directly related to patient outcomes and is recommended as soon as such a diagnosis is confirmed.

EGS SO30 - Management of Iatrogenic Oesophageal Perforations in the era of Endo-Vacuum Therapy- Preliminary Results of a Single-Institution Study

Abstract Background Iatrogenic oesophageal perforation (IOP) following diagnostic and therapeutic interventions at the oesophagus or adjacent organs are responsible for nearly half of oesophageal perforations. If not recognised within 24 hours of injury, then they are associated with devastating morbidity and mortality. Available treatment options encompass non-operative for early perforation without sepsis, endoscopic with endoclip/stent and surgical including primary repair, exclusion and diversion or oesophagectomy. Recently, Endoscopic Vacuum Therapy (EVT) has been introduced as safe and effective alternative approach. We sought to assess treatment outcomes in patients with IOPs prior to and during periods where EVT was available as treatment option. Method A single-centre retrospective cohort study incorporating all consecutive patients (N=30) presented or transferred to our tertiary oesophagogastric unit for IOP management between 01/01/2009-31/12/2023 was undertaken. Patients with anastomotic leak post-surgery or spontaneous perforation secondary to malignancy or benign pathology were excluded. Primary study-outcomes were treatment type including non-operative, EVT after 01/01/2018 or other endoscopic therapy, surgical operation including laparotomy, thoracotomy, primary defect repair or over a T-tube, disconnection with oesophagostomy, stenting or other interventional radiology procedures and their rate of success or failure. Secondary outcomes were length of stay, 90-day complications requiring re-intervention or re-admission, 30-, 90-day and 1-year mortality. Results In 2009-2017 pre-EVT period, 11/30 patients were managed a) non-surgically 7/11, b) endoclip 3/11 and stenting 1/11. 30-day and 90-day mortality were 1/11, 90-day morbidity Clavien-Dindo &amp;gt;IIIa 3/11 (27.3%), 90-day reintervention 8/11 (72.7%), median LOS 27 days. In 2018-2023 EVT period, 19/30 patients were treated with a) laparotomy, left thoracotomy, defect repair over t-tube, chest drainage in 5/19, b) non-surgical 7/19, c) IR NJT, stent or PEG in 6/19 d) EVT in 4/19. 30-day mortality was 0/19, 90-day mortality 1/19 (5.2%), 90-day morbidity Clavien-Dindo &amp;gt;IIIa 7/19 (36.8%), 90-day reintervention 9/19 (47.4%), median LOS 61 days. 1-year mortality was 0/19 for both. Conclusion EVT therapy appears to be a feasible additional treatment modality in the management of iatrogenic oesophageal perforations. Careful patient selection, therapeutic endoscopic expertise, knowledge of the technique, multidisciplinary approach and team collaboration are essentials for favourable outcomes. Of note, management of oesophageal perforations in a dedicated UGI centre is directly related to patient outcomes and is a sine qua non.

OGC SO46 - Improving outcomes after oesophagectomy: The benefits of full robotic-assisted minimally invasive oesophagectomy (RAMIO) demonstrated in the first 100 cases, at a high-volume UK unit

Abstract Background There is a rapid movement towards adoption of robotically assisted minimally invasive oesophagectomy (RAMIO) in the United Kingdom. Transition from an open or laparoscopic oesophagectomy to a RAMIO programme, which carries considerable financial and training cost, must ensure parity of oncological and perioperative outcomes. We sought to compare our centre’s results of the three standard approaches to two-phase oesophagectomy: Open/Open (Open); laparoscopic/robotic abdomen with open chest (Hybrid); and RAMIO. Method This prospective cohort study investigated the experience of five surgeons in a single high-volume UK institution. We analysed consecutive patients undergoing two-phase transthoracic oesophagectomy for oncological reasons between 2018 and 2024. The study period was divided into three cohorts: Open (2018-2020, n=61), Hybrid (2020-2023, n=82) and RAMIO (2023-2024, n=100). Patient demographics, tumour characteristics, perioperative outcomes, and oncological data were compared. Data were analysed using Kruskal-Wallis and Chi-squared statistical tests. Results No significant differences were observed in patient demographics or tumour stage between the groups. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a significant reduction in major complications (Clavien-Dindo ≥III), 34.4% vs. 23.2% vs. 14% (p=0.0014); pulmonary complications, 36.1% vs. 25.4% vs. 13% (p=0.0004); anastomotic leak rate, 11.5% vs. 2.4% vs. 4.0%, (p=0.0370); median length of stay, 14 vs. 12 vs. 8 days (p=0.0001); and mortality, 4.9% vs. 1.2% vs. 0% (p=0.0133) all favouring the RAMIO group in sub-group analysis. Median lymph node yields were comparable across groups, 49 vs. 43 vs. 43 (p=0.0876). Conclusion This single-institution study demonstrates potential benefits of transitioning from open or hybrid to RAMIO for oesophagectomy. RAMIO was associated with significantly reduced pulmonary complications, major complications and a shorter length of hospital stay. Oncological outcomes were maintained across all 3 techniques. These findings have important patient, financial, and resource implications, and support the continued adoption of RAMIO in the UK.

Implementation of structured radiology reporting and its associated accuracy in comparison to pancreas multi-disciplinary clinic expert radiology review.

To evaluate the feasibility of implementation of structured reporting in the setting of a high-volume pancreatic multidisciplinary clinic (PMDC) and to assess its value by comparing the accuracy of structured reports with expert imaging reviews. A single institutional prospective cohort study was conducted during March 2022 to May 2024 to understand the feasibility of implementation of structured reporting (SR) for all patients who were seen in our weekly PMDC. Descriptive and regression analyses were performed to find an association between SR and difference in vascular involvement of the primary pancreatic tumor between the radiology report and expert radiologist review (gold standard) during PMDC. Among 466 patients seen in the PMDC, 426 (91.4%) had reports generated prior to PMDC. Of this, 294 reports met the inclusion criteria. The usage of SR increased from 58.3% in Mar 2022 to 87.8% in June 2024. Majority of the reports that used SR (n = 226, 76.9%), were performed for initial staging (n = 197, 67.0%) of PC. The median years of experience of reading radiologists that used non-SR was 14 (IQR: 8-27) years, while it was 9 (IQR -9-15) years for those who used SR (p = 0.030). Of note, as compared to the radiology report, increased vascular involvement was noted in PMDC review 62.5% (20 out of 32) of the time with non-SRs, whereas increased vascular involvement during PMDC review was noted in only 36.6% (48 out of 132) of the time with SRs. On multivariable analysis, using SR lowered the odds of increase in vascular involvement during PMDC review by 0.29 times (95CIs 0.11-0.79; p = 0.015). SR is feasible and superior to the free-text reporting with respect to the accuracy of peri-pancreatic vascular involvement. While its use cannot replace the PMDC radiology review, it can nonetheless be an indispensable tool in clinical management, particularly in a non-PMDC setting.

NCMP-24. GLIOMA-RELATED EPILEPSY: ANTI-SEIZURE REGIMENS, TOLERABILITY AND SYMPTOM BURDEN

Abstract AIMS Seizures are often the presenting symptom in 30-40% of glioma patients, and play a significant role in patients’ quality of life and symptom burden. Many complex factors are considered when selecting anti-seizure medications (ASM) for the individual patient. This single institution study investigates physician practices, seizure control and adverse effect profiles of ASM regimens in glioma patients. METHOD A retrospective review was undertaken of the electronic health records of glioma patients from 2020-2022 who were followed at the University of Vermont Medical Center. RESULTS Ninety-four patients (90 glioblastoma IDH-WT, 1 astrocytoma, 2 oligodendroglioma, 1 radiological diagnosis of glioma) were included. Levetiracetam was the first line ASM in 93 patients including seizure prophylaxis patients per neurosurgical practice. 30 of the patients presented with seizures and required long term ASMs. 21 required a second-line ASM, 3 required a third-line ASM, and 20 experienced at least one adverse drug effect. 11.4% of patients experienced mood disturbances on levetiracetam, ranging from anxiety to mania. 5% of patients experienced generalized weakness and gait imbalance issues on levetiracetam. 25% of patients experienced breakthrough seizures over the course of their illness despite therapeutic levetiracetam &amp;gt; 1000mg/day. 10.4% of patients presented with breakthrough status epilepticus following the initiation of levetiracetam therapy. No statistically significant differences were seen in rates of breakthrough seizures based on extent of resection, functional status or sex. CONCLUSIONS Seizures are a major cause of morbidity in glioma patients. The overwhelming majority of patients included in this study were placed on levetiracetam as a first-line ASM. Most patients on long-term levetiracetam experienced at least one neuropsychiatric adverse effect. Further studies are required to investigate the efficacy and tolerability of ASM regimens in glioma patients and to understand methods for ASM regimen individualization for varying disease courses.

CTNI-33. EARLY COMPLETE RESPONSE MIGHT NOT BE AN INDICATOR OF LONGER PROGRESSION-FREE SURVIVAL IN NEWLY-DIAGNOSED PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA WITH A COMPLETE RESPONSE BY MTX-BASED INDUCTION THERAPY

Abstract Primary central nervous system lymphoma (PCNSL) is an extra-nodal non-Hodgkin lymphoma solely arising from the central nervous system including eyes. While 70% of patients with newly-diagnosed PCNSL achieve a complete response (CR) after R-MPV, the current standard of care MTX-based induction therapy, recurrence yet frequently occurs (~50%) and clinical factors related to failure are not well defined. Early complete response is associated with lower recurrence rate in various cancers. In this study, we conducted a retrospective, single-institution study to investigate whether early complete response was associated with recurrence in PCNSL. Newly-diagnosed PCNSL patients treated with R-MPV at the authors’ institution between 2011 and 2022 were identified, and progression-free survival (PFS), overall survival (OS) were analyzed along with number of chemotherapy cycles required to achieve a CR or CR unconfirmed (CRu). In total of 92 patients treated with R-MPV identified, 68 (75%) patients achieved a CR or CRu. Among patients who achieved CR or CRu, a median total of seven (1-8) R-MPV cycles were delivered. The median cycle required to achieve CR or CRu was five (1-8). Consolidation whole brain radiation therapy (WBRT) was given to 29 younger patients (median age: 63), while 39 older patients (median age: 74) were treated without WBRT. The number of chemotherapy cycles required to achieve CR or CRu was not associated with PFS or OS in all ages. However, requiring six or more chemotherapy cycles to achieve CR or CRu was associated with longer PFS (p=0.046) in patients treated without WBRT. These data suggest that early complete response might not be indicative of superior survival outcome in newly-diagnosed PCNSL treated without consolidation WBRT. Persisting enhancing lesions during chemotherapy could lead to treatment intensification through delivering greater number of chemotherapy cycles, which might have conferred longer PFS in these patients.

Diagnostic performance of simultaneous PET-MR versus PET-CT in oncology with an overview on clinical utility and referral pattern of PET-MR: a single institutional study.

PET-Magnetic Resonance (PET-MR) imaging is an upcoming investigative modality with a few installations in Asia and only three in India. PET-Computed Tomography (PET-CT) is an established diagnostic cornerstone for oncological indications but with limited resolution for small lesions due to low soft-tissue contrast and additional radiation exposure. Our primary objective was to evaluate the diagnostic performance of simultaneous PET-MR and PET-CT in lesion detection in oncological practice. Secondly to assess the referral pattern and study the clinical utility of PET-MR in a university hospital practice. A total of 100 consecutive biopsy-proven cancer patients (breast or lung malignancy with suspected metastases) underwent 18 F Fluorodeoxyglucose (FDG) PET-MR and PET-CT for staging as a single injection, double examination protocol. Morphological lesion detection on correlative imaging/histopathology was used as the gold standard. Analysing the referral pattern, a total of 9366 patients underwent simultaneous PET-MR imaging for various indications in the past 5 years since installation. 18 F FDG PET-MR detected 100% of primary tumours in breast/lung carcinoma patients while PET-CT was positive in 96%. Overall accuracy of nodal metastases detection for PET-MR and PET-CT was 96 and 88%, while for distant metastases the accuracy was 100 and 93%, respectively. FDG PET-MR proved more sensitive and specific than PET-CT for regional nodal ( P = 0.011 and P < 0.001) and distant metastases detection ( P = 0.017 and P < 0.001, respectively). Analysing the general referral pattern for PET-MR, the majority were oncology referrals when compared to nononcological indications (66.5, 33.5%). About 66.24% were FDG based, followed by 68 Ga Prostate-Specific Membrane Antigen (PSMA) and dodecane tetraacetic acid (DOTA). The general utility of PET-MR was found incremental in better delineation of small lesions especially in head, neck, liver, brain and gynaecological malignancies. In our past 5 years of PET-MR practice, we found that simultaneous PET-MR is a highly recommended ideal imaging technique for oncological and nononcological indications. It has excellent diagnostic performance with high sensitivity, specificity and accuracy when compared to PET-CT in primary tumour, nodal and distant metastases (TNM) staging in specific subgroup of breast and lung malignancy patients.

Association Between Limited English Proficiency and Regional Anesthesia Utilization for Total Joint Arthroplasty: A Retrospective Single-Institution Study.

Association Between Limited English Proficiency and Regional Anesthesia Utilization for Total Joint Arthroplasty: A Retrospective Single-Institution Study.

Efficacy and tolerance of short cycles of palliative radiotherapy in advanced anal sac adenocarcinomas in dogs

Successful management of advanced anal sac gland adenocarcinomas (AGASACA) often requires a multimodal approach. In recent years the role of palliative radiotherapy (pRT) has become increasingly more important, mainly in dogs with severe local clinical signs. This study describes efficacy and tolerance of short cycles of pRT. Retrospective single-institution study including dogs with AGASACA treated with at least one short cycle of pRT (IMRT, 4Gy BID for two consecutive days). All dogs were staged with CT and followed to death. Outcome measures were PFS and OST from the first pRT. Potential prognostic factors were evaluated. Twelve dogs were included (one stage II, four stage III, seven stage IV). Three dogs had one cycle, seven had two cycles, and two had three cycles of pRT. All dogs experienced a clinical benefit after pRT. One dog also had surgery, four systemic treatment, and five both. Eleven dogs died during the follow-up (four for local progression, six for systemic progression, one unknown). The median PFS was 198 days (95% CI 98—298) and the OST was 250 days (95% CI 124—376). Mild, acute, short-term GI toxicity occurred in seven dogs (five G1; two G2). None of the dogs experienced clinically relevant late toxicity. Short cycles of radiotherapy can be effectively used as a palliative treatment for advanced AGASACA with minimal toxicity. The small number of patients did not allow to assess the benefits of combining RT with other treatment modalities or the identification of meaningful prognostic factors.

A retrospective single-institute study reveals a vertical gradient of the density of cutaneous melanoma from head to toe.

The bodily distribution of melanoma is frequently reported without consideration of the skin surface area, which could be misleading in melanoma risk regarding anatomical sites. To gain insights into the melanoma distribution on the body surface when the body surface area is considered. Cutaneous melanoma data were extracted from a single dermatopathology laboratory, and the relative density from each body site was calculated by taking into consideration the skin surface area. Data from a previous publication were analyzed as a validation. Surveillance, Epidemiology and End Results Program data were also used for comparison. Relative tumour density (RTD) of melanoma in men and women exhibits a moderate head-to-toe linear gradient, with the upper body sites showing higher density than the lower body sites in general. In particular, the ear and face show the highest RTD while the least UVR (ultraviolet radiation)-exposed buttock, abdomen and groin have the lowest, followed by the thigh and lower legs. The trend is similar in both sexes, but more obvious for men. It was well documented that the trunk and lower legs are the most frequently diagnosed sites for men and women, respectively. However, when the surface area is considered, the melanoma distribution exhibits a rough head-to-toe gradient, which perhaps reflects a combined effect of solar UVR and clothing coverage. UVR protection on the face and ear should be emphasized as these are the sites with the highest RTDs.

Risk of endometrial carcinoma among patients with atypical endometrial hyperplasia in a population of predominantly racial and ethnic minorities: A single institution study

Risk of endometrial carcinoma among patients with atypical endometrial hyperplasia in a population of predominantly racial and ethnic minorities: A single institution study

Anatomic Distribution and Clinical Presentation of Pulmonary Carcinoids: A Single-institutional Study

BackgroundPulmonary carcinoid tumors (PCTs) have historically manifested predominantly as central lung lesions causing postobstructive symptoms. However, nearly all case series of PCTs to date evaluate cohorts in years before 2010. Because an increased volume of cross-sectional imaging studies results in more frequent detection of incidental lung nodules, we sought to evaluate whether the nature of this cancer’s clinical characteristics may be evolving by studying a contemporary series of patients. MethodsThe study analyzed all patients with a diagnosis of PCT at Thomas Jefferson University Hospital (Philadelphia, PA) between 2006 and 2020. The study evaluated tumor location within the bronchial tree (ie, central or peripheral), the presence or absence of symptoms at diagnosis, patient demographics, and nodule characteristics on computed tomography. ResultsA total of 73 PCTs were analyzed in 72 patients. Most PCTs were detected incidentally (48 of 72; 95% CI: 55%-77%) and located peripherally (41 of 67; 95% CI: 49%-73%). Logistic regression analysis demonstrated that the likelihood of PCTs’ having these features increased over the study period. ConclusionsPCTs manifested predominantly as peripheral lung lesions detected incidentally on computed tomography, which contrasts with the existing literature. This may reflect the changing nature of PCT diagnosis as cross-sectional imaging volume has increased. Clinicians should be mindful that incidental solitary pulmonary nodules detected on chest imaging may represent PCT, especially if the lesions are slow growing.