Surveillance Scans Research Articles

Non Double-Hit Diffuse Large B Cell Lymphoma Treated with R-CHOP Has Excellent Overall Survival If Interim Scan Shows Partial or Complete Response

R-CHOP chemoimmunotherapy is first line therapy for diffuse large B cell non Hodgkin lymphoma (DLBCL), although R-CHOP may be suboptimal treatment for some subtypes of DLBCL, in particular double-hit (DH) or triple-hit (TH) lymphoma. For assessment of response to chemoimmunotherapy, it has been proposed that PET-CT scan may be superior to CT scan and, in particular, demonstration of metabolic complete response (CR) by PET-CT scan at end of treatment (EOT) may be an important indicator of long term survival. However, the usefulness of follow up scans in asymptomatic patients remains debatable. We wished to assess the role of an interim CT or PET-CT scan (after 3-4 courses of chemoimmunotherapy) in predicting overall survival in patients at our centre with stage II- IV DLCBCL (Lugano Modification of Ann Arbor Classification) who received chemoimmunotherapy with curative intent. We also recorded results of scans at EOT and any further follow up scans. Between 1/7/15 and 1/7/19, 43 consecutive patients receiving R-CHOP had an interim CT or PET-CT scan. 3 of 4 patients with DH lymphoma by FISH testing changed to dose adjusted R-EPOCH after one course of R-CHOP. 39 patients had no evidence of DH, with 37 showing either partial response (PR) (N = 11) or CR (N=26) on interim CT or PET-CT scan. Of these 37 cases, one patient died of neutropenic sepsis, whilst 36 remain alive with 35 in complete remission. 30 of these 37 patients had CT scan and/or PET-CT scan at EOT: 27 were in CR, 2 were in stable PR and 1 patient (in CR on interim PET -CT scan) showed relapse on PET-CT scan. 16 patients in CR at EOT had 55 follow up surveillance scans (median 2, range 1-8) -two further relapses were detected on PET-CT scan, both 4 months after EOT. Two of the relapsed cases are in CR following further chemoimmunotherapy and allogeneic stem cell transplant whilst the other relapsed case is currently responding to further chemoimmunotherapy. 2 patients without evidence of DH showed disease progression on interim scan and were refractory to further chemotherapy, dying within 3 months and 18 months of diagnosis. All 4 patients with DH lymphoma had PR or CR at interim scan but relapsed within 5 to 8 months after diagnosis and proved chemotherapy refractory with death in 3. One patient with DH lymphoma remains in CR following local radiation and maintenance therapy with rituximab, lenalidomide and metformin. In our experience, patients with DLBCL, without DH or TH, who have evidence of response to R-CHOP at interim scan have an excellent prognosis. In this patient cohort, 85 EOT and follow up scans detected 3 relapses, suggesting that the detection rate of follow up scans in asymptomatic patients in this good prognosis group is low and of questionable usefulness. The 3 relapsed patients were readily salvageable by further chemoimmunotherapy with or without allogeneic stem cell transplant. In contrast, patients with DH lymphoma or evidence of disease progression on interim scan have very poor prognosis and urgently require alternative therapy approaches. Disclosures No relevant conflicts of interest to declare.

The Value of Follow-up Following Complete Remission with Frontline Chemotherapy for DLBCL

Introduction Following completion of chemotherapy with curative intent for DLBCL, for those in remission (CR), numerous national and international guidelines suggest on-going follow-up primarily to detect relapse of disease. For example, the NCCN guidelines suggest that clinical history, examination and blood investigations should be performed every 3-6 months for 5 years and as clinically indicated thereafter. This is essentially a "screening programme" for an at-risk population that continues based on historical routine rather than due to evidence it is of benefit to the patient. Numerous papers have been published suggesting that routine surveillance scans or bloods such as LDH are not useful in this setting. We sought to analyse whether the screening procedures that are performed in the follow-up setting are useful in the detection of relapse in patients followed up in a single centre. Uniquely, we examined each time point separately rather than group all follow-up events together. Methods Data was obtained retrospectively from electronic patient records for all patients in remission following treatment with frontline chemotherapy for DLBCL at the Royal Marsden Hospital between 2005-2016. Screening assessments analysed were symptoms check, clinical examination, LDH >upper limit of normal, lymphocyte: monocyte ratio (LMR) <2.8, routine CT scans. Time-points for analysis of routine clinic appointments were derived from the British guidelines which advise 3 monthly follow up in the first year, 6 months in year 2 and annually up to 5 years. True positives were defined as patients who had a positive result and relapsed within that specified time period or within 6 months, whereas false negatives were only considered for those patients who had a negative test within the time period that they relapsed. Results Complete data from 262 patients who achieved a CR and were followed up was available. Median age was 63 years (17-94) with 59 patients with stage 1 disease, and 100 with stage 4 disease. The relapse rate was 59/261 (23%), with a median time to relapse of 13 months (2-120). Of the 59, 52 had symptoms they had noted prior to clinic, of whom 28 requested an early appointment to clinic and 22 waited until their routine clinic appointment or sought advice from other health professionals initially. Only 7 patients were picked up only on investigations performed at the hospital, 1 with hypercalcemia and 6 on routine scan with no symptoms, 3 at 3-6months, 2 and 9-12months and 1 at 12-18 months. Of these, 4/7 patients achieved a CR with subsequent therapy. The remaining 202 patients had 2853 clinic appointments, median number per patient 13 (1-44). The negative predictive value of clinical history, examination, LDH, LMR and CT scan was consistently very high (>90%) at all time points. However, the positive predictive value was low for symptoms, 0-35% with the higher values being in the first year. Clinical examination had better PPV due to fewer positive results, including both true and false. LDH and LMR were associated with a poor PPV at all time points. PPV for CT scans was variable (Table 1). Conclusions The "screening" of patients who are in remission from DLBCL requires considerable health resources and cost and also leads to increased exposure of the patient to hospitals which during the COVID-19 pandemic is being discouraged. Likelihood of relapse (which decreases with time) has an impact on the effectiveness of a screening programme, the relapse rate in this cohort was 23% in keeping with other published data. Importantly, the majority of patients had symptoms suggestive of relapse and so the screening was not required. In the few that were asymptomatic when relapse was diagnosed, there was insufficient data to know whether this earlier detection led to a better outcome, however this has not been seen in other published cohorts. Finally the effectiveness of the screening is dependent on the predictive value of the "tests" being used and this dataset shows that whilst the negative predictive value is high, the positive predictive value is very variable and generally poor for all tools used. We propose that educating the patient regarding symptoms of relapse and having patient directed clinical follow-up rather than routine appointments would lead to marked savings in health resources, reduce hospital exposure of patients by eliminating unnecessary visits without compromising the outcome of the patients. Disclosures Cunningham: Lilly: Research Funding; MedImmune: Research Funding; Merck: Research Funding; AstraZeneca: Research Funding; Celgene: Research Funding; Bayer: Research Funding; Janssen: Research Funding; Merrimack: Research Funding; Amgen: Research Funding; 4SC: Research Funding; Clovis Oncology: Research Funding; Sanofi: Research Funding; OVIBIO: Membership on an entity's Board of Directors or advisory committees. Iyengar:Beigene: Consultancy; Janssen: Honoraria; Abbvie: Honoraria; Takeda: Consultancy, Honoraria, Speakers Bureau; Gilead: Consultancy, Honoraria, Speakers Bureau. El-Sharkawi:Abbvie: Consultancy, Honoraria, Speakers Bureau; AstraZeneca: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Takeda: Honoraria, Speakers Bureau; Innate: Consultancy.

The utility of initial staging PET-CT as a baseline scan for surveillance imaging in stage II and III melanoma

BackgroundThis study evaluates the utility of whole-body PET-CT for the initial staging and subsequent surveillance imaging of patients with completely resected stage II and stage III melanoma. MethodsA single-center, retrospective review of patients who received perioperative whole-body PET-CT from January 1, 2005 to December 1, 2019 within three months of initial melanoma diagnosis was performed. ResultsOf 258 total patients with completely resected melanoma who had a PET-CT within 3 months after their melanoma diagnosis, 113 had stage II and 145 had stage III melanoma. PET-CT detected distant metastasis in 3 (2.7%) of 113 stage II patients and 7 (4.8%) of 145 stage III patients.179 of 258 patients had adequate follow-up time to determine whether they received surveillance cross-sectional imaging and whether they had a melanoma recurrence. 143 (79.9%) received subsequent surveillance imaging, 74 of whom developed a recurrence. In 64 (86.5%) of 74 cases, recurrence was detected by routine surveillance. 26 (34.2%) of 76 stage II and 65 (63.1%) of 103 stage III patients developed a recurrence. The median time to recurrence among the 179 patients for stage II and III was 16.3 and 13.0 months, respectively. ConclusionsThese findings indicate that baseline staging with whole-body PET-CT rarely provides information that changes initial management. Rather, the value of the initial PET-CT is as a baseline for subsequent surveillance scans. Therefore, it may be premature to discourage cross-sectional imaging for patients with stage II and III melanoma without supportive evidence or a reliable biomarker of recurrent disease.

Changes in Frequency of Surveillance Imaging of Survivors of Diffuse Large B-Cell Lymphoma After the American Society of Hematology Choosing Wisely Recommendations.

In 2013, the American Society of Hematology (ASH) published recommendations with Choosing Wisely to limit surveillance imaging in aggressive lymphoma. We studied surveillance imaging practice patterns for diffuse large B-cell lymphoma (DLBCL) before and after the ASH Choosing Wisely campaign. We used OptumLabs Data Warehouse, a national insurance claims database, to retrospectively study imaging frequency in survivors of DLBCL from 2008 to 2016. Three time periods were defined: Period 1 (2008 to 2010), Period 2 (2011 to 2013), and Period 3 (2014 to 2016). One thousand four hundred seventy-two patients were included. Median follow up was approximately 2 years. During the first and second years of surveillance, imaging remained stable between Period 1 (years 1 and 2: 199 [91%] and 137 [83%], respectively) and Period 2 (years 1 and 2: 257 [88%] and 172 [77%], respectively; P = .38), but decreased in Period 3 (years 1 and 2: 315 [78%] and 83 [61%], respectively; P < .01). In a multivariable logistic regression, year after 2012 was a significant predictor of decreased overuse (more than two scans per year in the first year of surveillance; [odds ratio, 0.49 for 2013 v 2008; P = .02]). Our study demonstrated the rate of surveillance scans-both computed tomography and positron emission tomography imaging-in DLBCL decreased after the ASH Choosing Wisely campaign. Multiple factors, such as changes in recommendations, reimbursement, and provider knowledge base, may have all contributed and should be studied further.

A Simulation Framework to Support the Design and Evaluation of Adaptive Scanning for Phased-Array Weather Radars

AbstractWe propose a simulation framework that can be used to design and evaluate the performance of adaptive scanning algorithms on different phased-array weather radar designs. The simulator is proposed as tool to 1) compare the performance of different adaptive scanning algorithms on the same weather event, 2) evaluate the performance of a given adaptive scanning algorithm on several weather events, and 3) evaluate the performance of a given adaptive scanning algorithm on a given weather event using different radar designs. We illustrate the capabilities of the proposed framework to design and evaluate the performance of adaptive algorithms aimed at reducing the update time using adaptive scanning. The example concept of operations is based on a fast low-fidelity surveillance scan and a high-fidelity adaptive scan. The flexibility of the proposed simulation framework is tested using two phased-array-radar designs and three complementary adaptive scanning algorithms: focused observations, beam clustering, and dwell tailoring. Based on a significant weather event observed by an operational NEXRAD radar, our experimental results consist of radar data that were simulated as if the same event had been observed by arbitrary combinations of radar systems and adaptive scanning configurations. Results show that simulated fields of radar data capture the main data-quality impacts from the use of adaptive scanning and can be used to obtain quantitative metrics and for qualitative comparison and evaluation by forecasters. That is, the proposed simulator could provide an effective interface with meteorologists and could support the development of concepts of operations that are based on adaptive scanning to meet the evolutionary observational needs of the U.S. National Weather Service.

S2620 Cloudy With a Chance of Histocyte Showers: A Case Report Involving Erdheim-Chester Disease

INTRODUCTION: Erdheim-Chester Disease (ECD) is a rare non-Langerhans histiocytic disorder that has a very low prevalence, with less than 1000 cases reported in the US. ECD can affect multiple organ systems, and in over 90% of ECD cases, histiocytes tend to deposit in skeletal muscle or bone. Gastrointestinal involvement is exceedingly rare, and we present a case where mass deposits of histiocytes were noted at a visceral level. CASE DESCRIPTION/METHODS: A 56-year-old Hispanic male presented with two years of progressive abdominal discomfort and distention, weight gain of 25 pounds, and dyspnea on exertion. He also noticed enlarging masses across his stomach. On physical examination, firm abdominal masses were noted in bilateral upper quadrants, as well as bilateral pitting edema. Other than hypoalbuminemia, his initial lab testing, including LFTs, were unremarkable. CT scans showed invasive perirenal masses, measuring 30.4 × 19.0 × 38.4 cm on the right and 26.2 × 18.9 × 37.0 cm on the left and multiple sclerotic lesions. Additionally, nodular hepatic hypodensities were noted. Overall, these findings were concerning for an infiltrative process. An echocardiogram showed a pericardial effusion and compression of the IVC and hepatic veins by these masses. Biopsies confirmed the diagnosis of BRAF non-mutated ECD and his tumor markers were positive for CD68, CD34, and Vim. He began treatment with interferon-alpha and surveillance scans thereafter have revealed a gradual decline in size of these masses. DISCUSSION: Classic radiological and histological features of this rare disorder have been identified, but the clinical spectrum shows an extensive variation, ranging from asymptomatic organ infiltration to complete organ failure. The diagnosis of ECD was challenging, as he presented with nonspecific symptoms, including abdominal discomfort, weight gain, and evidence of malnutrition with hypoalbuminemia. Although ECD typically presents with bone pain due to sclerotic lesions, our patient was asymptomatic from this standpoint. It is uncommon to see deposition in renal and hepatic tissue and it is interesting that he had normal lab tests; this is an indication that lab findings may not preclude organ involvement in ECD. In cases like this, it reminds clinicians to have a wide differential diagnosis when approaching abdominal masses.Figure 1.: CT Abdomen (sagittal view) showing massive extension of tissue into the abdomen.Figure 2.: CT Abdomen (axial view) showing perirenal proliferation.Figure 3.: CT Abdomen (axial view) showing liver hypodensities.

Abstract PO-010: Changes in lung cancer treatment as a result of the COVID19 pandemic: A prospective observational study

Abstract Background: Patients with lung cancer are at high risk from COVID19. Efforts are ongoing to limit exposure of patients with lung cancer to the health care system. As a result, the COVID19 pandemic has drastically changed cancer care, but the extent and type of these changes are unknown. The goal of this study was to evaluate the changes in lung cancer treatment during the peak of the COVID19 pandemic. Methods: We prospectively assessed the cancer management plan of all patients seen in the thoracic oncology clinic at our center between March 2 and April 30, 2020. Inclusion criteria for this study were a diagnosis of either non-small cell lung cancer or small-cell lung cancer. Those who had a diagnosis of COVID19 were excluded from the study. Primary endpoints were to describe the extent of changes in the cancer treatment plan and qualify the types of changes observed. Results: A total of N=289 patients were evaluated between March 2 and April 30, 2020. N=14 patients were excluded due to presence of other tumor histology, and 2 patients were COVID19-positive. Among the 275 patients included, median age was 68 and 47% were male. Among the 238 patients (86.5%) with non-small cell lung cancer, 172 (62.5%) had advanced disease. Among the 37 patients (13.5%) with small-cell lung cancer, 11 (4%) had extensive disease. 211 were receiving active treatment (76.5%), with 35.1% on chemotherapy, 21.8% on oral agents, 31.8% on immune checkpoint inhibitors, and 11.4% on combination therapy. 121 (57%) of patients experienced at least one change in their lung cancer treatment plan as a direct result of the COVID19 pandemic, with 19 (9.0%) patients experiencing more than one change. The majority of changes encompassed delay or cessation of palliative treatment, N=48 (39.7%), N=18 (14.9%), respectively. Mean time to resumption of palliative treatment was 36 days, and 3% of patients stopped palliative treatment permanently as a direct result of the pandemic. Changes in dosing and schedule occurred in N=32 (26.4%), which included changing pembrolizumab to q 6 weeks or durvalumab to q 4 weeks. A minority of patients experienced delays in adjuvant chemotherapy administration (N=3 (2.5%)) with a mean delay of 42 days. Lastly, 6.6% of patients experienced deferrals or cancellations of surveillance scans or visits due to COVID19. Other changes included the decision not to pursue palliative chemotherapy. Conclusion: Our study demonstrated that a significant proportion (57%) of patients experienced changes in their lung cancer management plan as a direct result of the COVID19 pandemic. Given the preliminary findings that active cancer treatment is not associated with increased complications from COVID19, lung cancer treatments and surveillance visits should continue to proceed with caution, and oncology care providers should continue to carefully proceed with evidence-based care in lung cancer. Citation Format: Suzanne Kazandjian, Nathaniel Bouganim, Arielle Elkrief. Changes in lung cancer treatment as a result of the COVID19 pandemic: A prospective observational study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-010.

Counterbalancing COVID-19 with Cancer Surveillance and Therapy: A Survey of Patients with Renal Cell Carcinoma

BackgroundWhile providers are challenged with treatment decisions during the coronavirus disease 2019 (COVID-19) crisis, decision making ultimately falls in the hands of patients—at present, their perspective is poorly understood. ObjectiveTo ascertain renal cell carcinoma (RCC) patients’ perspectives on COVID-19 and understand the associated implications for treatment. Design, setting, and participantsAn online survey of RCC patients was conducted from March 22 to March 25, 2020, disseminated through social media and patient networking platforms. The survey comprised 45 items, including baseline demographic, clinicopathologic, and treatment-related information. Patients were additionally queried regarding their anxiety level related to COVID-19 and associated implications for their cancer diagnosis. InterventionAn online survey study. Outcome measurements and statistical analysisDescriptive statistics with graphical outputs were used to characterize survey results. Results and limitationsA total of 539 patients (male:female 39%:58%) from 14 countries responded. Of them, 71% felt that their risk of COVID-19 infection was higher than the general population, and 27% contacted their physician to establish this. Among patients with localized disease (40%), most (42%) had scheduled surveillance scans within 6 wk–65% were unwilling to delay scans. Among patients with metastatic disease, 76% were receiving active therapy. While most patients preferred not to defer therapy (51%), patients receiving immune therapy regimens were less amenable to deferring therapy than those receiving targeted treatment (20% vs 47%). ConclusionsDespite high levels of anxiety surrounding COVID-19, many patients with RCC were inclined to adhere to existing schedules of surveillance (localized disease) and systemic treatment (metastatic disease). Patient summaryThe coronavirus disease 2019 (COVID-19) pandemic has prompted many doctors to develop different treatment strategies for cancer and other chronic conditions. Given the importance of the patient voice in these strategies, we conducted a survey of patients with kidney cancer to determine their treatment preferences. Our survey highlighted that most patients prefer to continue their current strategies of kidney cancer treatment and monitoring.

Electromagnetic navigation bronchoscopy as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway: an initial retrospective single centre series.

BackgroundThe performance of electromagnetic navigation bronchoscopy (ENB) is reported with substantial variation, which may question its clinical usefulness. However, ENB may hold its true value when used as an additional minimal invasive diagnostic option before potential surgery in selected diagnostically challenging patients where traditional diagnostic methods have failed. We evaluated the safety and performance of ENB when used as an adjunct diagnostic tool in the Danish lung cancer diagnostic pathway (DLCDP) and its ability to reduce surgical diagnostic procedures.MethodsA retrospective study was performed on eighty-two consecutive patients at Odense University Hospital from June 2016 to March 2018 with diagnostically challenging pulmonary lesions referred for ENB as an adjunct diagnostic procedure under the DLCDP. Patients with benign or inconclusive ENB pathology were either referred for further biopsies, surgery or repeated computer tomography (CT) scans for surveillance purposes.ResultsEighty-one ENB procedures were performed in 80 patients. In 87.7% of the cases previous diagnostic methods had been unsuccessful. The mean target diameter was 1.55 cm and the average follow-up duration was 11 months. The diagnostic accuracy was 75%, while the diagnostic yield/sensitivity, negative predictive value and negative likelihood ratio was 51%, 67% and 0.49, respectively. No pneumothoraces and only one intrapulmonary haemorrhage was recorded, which was managed conservatively. The learning curve revealed an increase in diagnostic accuracy from 67.5% to 82.9% when comparing the first 40 ENB procedures with the last 41 procedures, however, this was not statistically significant (p-value: 0.11).ConclusionsENB was found to be a safe procedure with an acceptable diagnostic accuracy and yield in highly selected diagnostically challenging patients. The introduction of ENB carried a notable learning curve but proved to be a valuable adjunct diagnostic option in the DLCDP, which may help to reduce the number of potentially unnecessary or harmful surgical procedures in frail patients.

Currarino Syndrome

Currarino syndrome (CS) is a congenital disorder that consists of a triad of anomalies: presacral mass, sacral dysgenesis, and anorectal malformations. Few cases of CS with neuroendocrine tumors (NETs) have been reported. In this study, we sought to determine the prevalence and characteristics of NET in patients with CS. Mayo Clinic electronic medical records were searched for patients with CS. Data on demographics, CS diagnosis, family history, genetic testing, and NET diagnosis were extracted. A total of 26 patients with CS were identified with 3 (11.5%) of them having an additional diagnosis of NET. Three patients had a family history of NET (11.53%), and 7 patients had a family history of CS (26.9%). Of the 3 NET/CS patients, 2 had a confirmed primary NET from the presacral mass, with the third patient demonstrating focal uptake on the somatostatin receptor imaging within the presacral. Two patients received octreotide, followed by peptide receptor radionuclide therapy. The other patient was not treated because of complete resection of presacral mass and is currently undergoing surveillance scans. In our patients with CS, the prevalence of NET is 11.53%. The coexistence of 2 rare conditions, CS and presacral NET, suggests that there may be an etiological connection.

Prioritizing COVID-19 tests based on participatory surveillance and spatial scanning

ObjectivesThis study aimed to identify, describe and analyze priority areas for COVID-19 testing combining participatory surveillance and traditional surveillance. DesignIt was carried out a descriptive transversal study in the city of Caruaru, Pernambuco state, Brazil, within the period of 20/02/2020 to 05/05/2020. Data included all official reports for influenza-like illness notified by the municipality health department and the self-reports collected through the participatory surveillance platform Brasil Sem Corona. MethodsWe used linear regression and loess regression to verify a correlation between Participatory Surveillance (PS) and Traditional Surveillance (TS). Also a spatial scanning approach was deployed in order to identify risk clusters for COVID-19. ResultsIn Caruaru, the PS had 861 active users, presenting an average of 1.2 reports per user per week. The platform Brasil Sem Corona started on March 20th and since then, has been officially used by the Caruaru health authority to improve the quality of information from the traditional surveillance system. Regarding the respiratory syndrome cases from TS, 1588 individuals were positive for this clinical outcome. The spatial scanning analysis detected 18 clusters and 6 of them presented statistical significance (p-value < 0.1). Clusters 3 and 4 presented an overlapping area that was chosen by the local authority to deploy the COVID-19 serology, where 50 individuals were tested. From there, 32 % (n = 16) presented reagent results for antibodies related to COVID-19. ConclusionParticipatory surveillance is an effective epidemiological method to complement the traditional surveillance system in response to the COVID-19 pandemic by adding real-time spatial data to detect priority areas for COVID-19 testing.

Growth Rates of Small Abdominal Aortic Aneurysms Identified in a Contemporary Practice

In December 2019, the U.S. Preventive Task Force recommended, with moderate benefit, 1ne-time screening for abdominal aortic aneurysms (AAAs) in men aged 65 to 75 years with a positive smoking history. The U.S. Preventive Task Force suggested research to evaluate rescreening benefits for persons with negative screening results for a 5.5-cm AAA and the timing of additional imaging studies. The purpose of the present study was to evaluate the natural history of AAAs identified during a 10-year period to outline the follow-up surveillance intervals for detected AAAs. A cohort observational study of all patients screened for AAA from January 1, 2007 to December 31, 2016, within a regional health care system was conducted. AAA was defined as an aortic diameter of ≥3 cm. Clinical data, AAA size, interval from screening to repair, and mortality rates were recorded. All data were analyzed through December 31, 2019. A total of 1196 patients (age, 76.3 ± 6.8 years) had had AAAs detected from screening. The average follow-up period was 6.5 ± 3.3 years from date of screening to the end of the analysis or the date of death. The average interval from AAA screening to repair was 34.1 ± 33.9 months (Fig). A total of 204 AAA repairs were performed on patients identified through screening, including 178 endovascular aneurysm repairs (87%) and 26 open repairs (13%), within the analysis period. Stratified by the initial screened aortic diameter, the median interval from screening to repair was as follows: diameter, 3.0 to 3.4 cm: 6.2 years (95% confidence interval [CI], 5.9-6.4); diameter, 3.5 to 3.9 cm: 5.3 years (95% CI, 4.9-5.7); diameter, 4.0 to 4.4 cm: 3.2 years (95% CI, 2.8-3.5); diameter, 4.5 to 4.9 cm: 2.7 years (95% CI, 2.2-3.2); diameter, 5.0 to 5.4 cm: 0.9 year (95% CI, 0.6-1.2); and diameter, ≥5.5 cm: 0.2 year (95% CI, 0.1-0.2). Each patient had undergone an average 1.6 ± 2.4 ultrasound scans and 0.9 ± 1.5 computed tomography scans for AAA surveillance (Table). Of the 1196 patients, 468 had died (39%) and 9 possible ruptures had occurred during the follow-up period. These possible ruptures had occurred in patients who had refused repair or were too high risk to undergo repair. After the initial AAA diagnosis, we recommend the following surveillance intervals for AAA with a diameter of 3.0 to 5.4 cm until repair: 3.0- to 3.9-cm diameter, every 5 years; 4.0- to 4.4-cm diameter, every 3 years; 4.5- to 4.9-cm diameter, every 2 years, and 5.0- to 5.4-cm diameter, every 6 months. No undiagnosed AAA ruptures were identified during the follow-up period.TableClinical summaryVariableAAA diameter, cmAll (N = 1196)3.0-3.4 (n = 657)3.5-3.9 (n = 231)4.0-4.4 (n = 112)4.5-4.9 (n = 79)5.0-5.4 (n = 56)≥5.5 (n = 61)Age, years75.6 ± 6.677.5 ± 6.876.4 ± 6.878.9 ± 8.175.7 ± 6.376.2 ± 6.676.3 ± 6.8Follow-up length, years6.7 ± 3.16.8 ± 3.36.0 ± 3.66.0 ± 3.36.0 ± 3.45.5 ± 3.56.5 ± 3.3Follow-up ultrasound scans (n = 1948)1.4 ± 2.22.6 ± 2.92.3 ± 2.61.7 ± 1.80.7 ± 1.30.1 ± 0.41.6 ± 2.4Follow-up CT scans (n = 1075)0.7 ± 1.31.1 ± 2.01.2 ± 1.61.3 ± 1.61.4 ± 1.41.0 ± 1.10.9 ± 1.5Interval from screening to repair, months67.6 ± 38.663.8 ± 37.739.7 ± 22.037.6 ± 23.618.2 ± 17.14.8 ± 10.134.1 ± 33.9Interval from screening to repair, years5.6 ± 3.25.2 ± 3.13.3 ± 1.83.1 ± 1.91.5 ± 1.40.4 ± 0.82.8 ± 2.8AAA repairs, total No. (%)35 (5.3)21 (9.1)27 (24.1)33 (41.8)42 (75.0)46 (75.4)204 (17.1) EVAR31 (88.6)20 (95.2)22 (81.5)28 (84.4)40 (95.2)37 (80.4)178 (87.3) Open4 (11.4)1 (4.8)5 (18.5)5 (15.2)2 (4.8)9 (19.6)26 (12.7)Patients who died187 (28.5)100 (43.3)61 (54.5)53 (67.1)31 (55.4)36 (59.0)468 (39.1)AAA, Abdominal aortic aneurysm; CT, computed tomography; EVAR, endovascular aneurysm repair.Data presented as mean ± standard deviation or number (%). Open table in a new tab

Fast dual‐doppler LiDAR retrieval of boundary layer wind profiles

Operational doppler LiDARs (light detection and ranging) are often heavily engaged in specialised phenomenon detection, as well as dedicated surveillance scans, leaving little room for further additions to the tightly packed scanning strategy. This paper presents a fast method for retrieval of the urban boundary layer wind profile using existing scan data from two long-range doppler LiDARs at the Hong Kong International Airport (HKIA). Leveraging occasional range height indicator scans originally designed to aid the monitoring of terrain-induced wind disturbances, vertical profiles of the horizontal winds between 150 and 750m above ground level are estimated near the intersection point. The LiDAR-derived wind profiles are validated against measurements from a nearby wind profiler, as well as Aircraft Meteorological Data Relay (AMDAR) flight observations, for a 1-year period, 2019. Results indicated close agreement in terms of wind speed and direction between the LiDAR-derived profiles and wind profiler measurements, particularly above 300m. A slant angle correction factor is found to effectively alleviate the underestimation of the horizontal wind components at higher beam angles while also improving the consistency of the retrieved wind speed profile across different altitudes. For the AMDAR comparison, large discrepancies in wind speed and direction might be attributed to the natural variability of glide path winds well-known to HKIA. This study demonstrates the potential of extracting additional boundary layer wind information from ‘part-time’ scans of operational doppler LiDARs.

Impact of surveillance among patients with resected pancreatic cancer following adjuvant chemotherapy.

e16795 Background: Pancreatic adenocarcinoma carries a poor prognosis and high risk of recurrence even after surgery and adjuvant chemotherapy (AC). Guidelines recommend against routine surveillance imaging due to lack of evidence supporting a survival benefit. With current first-line chemotherapy options, it is unclear whether surveillance scans allow for early detection of asymptomatic disease and therefore an opportunity to offer fit patients chemotherapy. We describe the patterns of surveillance in patients followed at a Canadian provincial cancer agency and determine whether routine imaging after AC is associated with receipt of palliative chemotherapy (PC). Methods: A retrospective review was completed to identify patients treated at British Columbia (BC) Cancer centres between January 1, 2010 and December 31, 2016 who had undergone curative intent resection and received at least one cycle of AC. Baseline characteristics, number of scans done after completing AC to recurrence, and PC were collected. Logistic regression analysis was performed. Results: A total of 151 patients followed at BC Cancer were identified. Patients who recurred within 28 days after AC were excluded, leaving 142 patients, of which 115 patients had recurrence (81%). We defined 2 cohorts based on number of scans done between completion of AC and recurrence: those with 0-1 scans were “symptomatic” recurrences (22 patients, median age 68y, 64% female, and 91% node-positive) and those with &gt; 1 scan were “surveillance” recurrences (93 patients, median age 64y, 43% female, and 81% node-positive). Patients who underwent surveillance scans were more likely to receive PC at time of recurrence, though statistical significance was not reached (OR 2.11, 95% CI 0.75-6.58, p = 0.17). Conclusions: Despite guidelines, the majority of patients treated in BC underwent surveillance imaging. Within the limits of our sample size, we demonstrated a trend towards increased likelihood of receiving PC in patients who receive surveillance scans following AC. With efficacious PC options available, studies to determine whether receipt of PC in asymptomatic recurrences detected on imaging translates into improved survival and/or quality of life are warranted.

The use of PET/CT to detect early recurrence after resection of high-risk stage III melanoma, prior to the start of adjuvant therapy and during follow-up.

e22039 Background: To date, international consensus concerning the use of PET/CT as a surveillance tool in the follow-up of high-risk melanoma patients after complete resection of disease is lacking. Moreover, with the rise of adjuvant therapy it seems appropriate to investigate the role of this imaging modality to exclude newly developed metastases after resection and prior to starting treatment. The aim of this study was to investigate the use of PET/CT as surveillance tool in the follow-up and prior to adjuvant therapy in asymptomatic patients with complete resection of stage IIIB and IIIC melanoma. Methods: Prospectively two cohorts were set up with stage III melanoma patients with complete resection of disease. In the first cohort (stage IIIB/C AJCC 7th) surveillance PET/CT was performed 6-monthly for two years if patients stayed asymptomatic with normal serum S100B, with a final scan at three years. In the second cohort (stage IIIB/C/D AJCC 8th) patients underwent one screening PET/CT after resection and prior to starting adjuvant treatment. Results: Eighty patients entered follow-up in cohort 1. Of these, the majority did not undergo surveillance scans, because they required treatment for newly detected clinical metastases. Thirty-five patients remained asymptomatic and were included in surveillance cohort one (105 scans) with a median follow-up of 33 months. Twelve patients (34%) developed a recurrence, seven (20%) of which were detected on the first scan at six months. Seven recurrences involved stage IIIC patients, five stage IIIB patients. Sensitivity and specificity were 92% and 100% respectively. Forty-two patients were included in cohort 2. Recurrence was suspected on nine scans, four (10%) of which were true positive. One patient proceeded to undergo a node dissection and then started adjuvant therapy. The other three patients had progressed to stage IV and therefore started radiotherapy and/or systemic immunotherapy. Five (12%) scans were false positive, the suspected lesions were not related to the preceded surgery. The number of scans needed to find one asymptomatic recurrence were 8.8 and 10.5 in cohort one and two, respectively. Conclusions: This study shows that PET/CT is a useful surveillance tool for detecting recurrence in asymptomatic high-risk resected stage III melanoma patients, especially within the first six months after surgery and therefore should be considered when monitoring these patients during follow-up as well as prior to starting adjuvant therapy.

SAT-116 An Affair of the Heart - First Case Report of Immune Checkpoint Inhibitor Associated Cardiac Sarcoidosis Presenting with Non-PTH Medicated Hypercalcemia

Background:Immune checkpoint inhibitors (ICI) are an effective new tool in the treatment of malignancy by rescuing exhausted T-cells and enhancing anti-tumor immunity. The offset of immune self-tolerance can result in autoimmune adverse effects involving gastrointestinal, pulmonary and endocrine systems. Lung and skin sarcoidosis have been described in association with ICI use. We present the first case of non-PTH medicated hypercalcemia due to cardiac sarcoidosis in the setting of immunotherapy.Case Presentation:A 71-year-old man was referred to endocrinology for hypercalcemia. He had a fourteen-year history of scalp melanoma in remission until February 2019, when routine surveillance scans suggested metastatic disease. Computer tomography of the chest showed mediastinal and hilar lymphadenopathy (largest node 5.2 cm) and numerous pulmonary nodules (largest 1.7 cm). Biopsy of the largest pulmonary nodule and mediastinal lymph node (LN) confirmed BRAF wild-type metastatic melanoma. Ipilimumab/nivolumab (antiCTLA4/antiPD-1) combination therapy was started. After two cycles, hypercalcemia was noted on routine laboratory surveillance. He was asymptomatic and physical exam was unremarkable. Initial workup revealed: calcium 10.6 mg/dL (8.6-10.2), albumin 4 g/dL (3.5 - 5.2), phosphorus 3.8 mg/dL (2.7 - 4.5), PTH <0.6 pg/mL (15.0 - 65.0), PTHrP <2.0 pmol/L (0.0 - 2.3), 25 hydroxyvitamin D 22. 9 ng/mL (30 - 60), vitamin A 0.59 mg/L (0.30 - 1.20). He denied taking calcium-containing supplements. He was treated with hydration and immunotherapy was continued for two cycles, followed by single agent nivolumab. After three months on ICI, the metastatic lesions were reduced in size by 30%. His calcium peaked at 12.5 mg/dL and was treated with 4mg of intravenous Zoledronic acid without resolution. He developed worsening functional status, symptomatic hypotension, and elevated troponins. Cardiac MRI demonstrated myocarditis and nivolumab-induced myocarditis was suspected. Surprisingly, endomyocardial biopsy revealed multiple granulomas suggestive of sarcoidosis. AFB, PAS and Congo red stains were negative. He was treated with supportive care and glucocorticoids with resolution of hypercalcemia and improved cardiac function. Unfortunately, serum 1,25 dihydroxy vitamin D was not successfully measured until after the first dose of prednisone and was found at the upper limit of our reference range 62.0 pg/mL (19.9-79.3).Conclusion:Immune checkpoint inhibitors are effective agents in treating various cancers. Adverse effects due to autoimmunity are common and early recognition of life-threatening complications is critical. Although cutaneous and pulmonary sarcoidosis have been described with ICI, to our knowledge, this is the first case report of ICI-related cardiac sarcoidosis presenting with PTH-independent hypercalcemia.

Introduction of surgeon‐performed ultrasound to a head and neck clinic: indications, diagnostic adequacy and a new clinic model?

Surgeon-performed ultrasound (SUS) changes management and surgical decision-making. It allows for immediate ultrasound-guided fine-needle aspiration (US-FNA) for the work-up of neck masses, lymph node metastases and thyroid nodules. We examined the introduction of SUS to an Australian Head and Neck cancer unit, identifying situations where it was used, and evaluated the diagnostic adequacy and accuracy of US-FNA. A prospective database was created for all patients undergoing SUS and US-FNA, performed by two head and neck surgeons, between September 2018 and June 2019. The data were retrospectively analysed to identify when SUS was performed. Diagnostic adequacy and accuracy of US-FNA were determined after evaluating formal cytology and histopathology reports. A total of 183 diagnostic, surveillance and interventional SUS scans were performed for multiple indications. A total of 100 US-FNAs were performed on a number of different sites. Diagnostic adequacy and accuracy were 92% and 85%, respectively. After the introduction of SUS to our weekly routine head and neck cancer clinic, we identified multiple situations where it can be used successfully within our clinical landscape. Our diagnostic US-FNA results compared favourably to current literature, without additional need for clinic attendance by consultant radiologists or pathologists, saving valuable hospital resources. This introduction proposes a promising alternative to current neck lump clinic models.

Identification and Management of Progressive Enhancement After Radiation Therapy for Brain Metastases: Results from a Neurosurgical Survey

There is a lack of consensus regarding diagnosis, timing, and method of intervention for progressive enhancement on surveillance imaging after stereotactic radiosurgery (SRS) treatment of brain metastases. We sought to characterize current practices among neurosurgeons in identifying and treating infield tumor recurrence (TR) or radiation necrosis (RN) after SRS for brain metastases. A voluntary survey was distributed electronically to preidentified neurosurgeons. Results were analyzed using descriptive statistics and χ2 analysis. A total of 120 participants completed the survey from 72 U.S. and 17 international centers. Most (69.2%) agreed that growth over ≥2 surveillance scans spaced ≥90 days apart identified irreversible progression after SRS for brain metastases. Respondents were evenly divided on the need for tissue biopsy to distinguish between TR and RN. Preferred treatment modality and time frame to initiate treatment of suspected RN differed among neurosurgeons based on SRS case volume for brain metastases (P= 0.002 and P= 0.02, respectively). Neurosurgeons who used magnetic resonance-guided laser interstitial thermal therapy (LITT) for brain metastases were more likely to prefer LITT for suspected RN, whereas those with minimal LITT experience preferred steroids (P<0.0001). Neurosurgeons in the United States were more likely to prefer LITT for RN (37.3%) compared with international counterparts (0%). Our survey of practicing neurosurgeons highlights areas of controversy in distinguishing between TR and RN and preferred management of suspected RN.

Impact of Surveillance After Lobectomy for Lung Cancer on Disease Detection and Survival

IntroductionExisting guidelines for surveillance after non–small-cell lung cancer (NSCLC) treatment are inconsistent and have relatively sparse supporting literature. This study characterizes detection rates of metachronous and recurrent disease during surveillance with computed tomography scans after definitive treatment of early stage NSCLC. Materials and MethodsThe incidence of metachronous and recurrent disease in patients who previously underwent complete resection via lobectomy for stage IA NSCLC at a single center from 1996 to 2010 were evaluated. A subgroup analysis was used to compare survival of patients whose initial surveillance scan was 6 ± 3 months (early) versus 12 ± 3 months (late) after lobectomy. ResultsOf 294 eligible patients, 49 (17%) developed recurrent disease (14 local only, 35 distant), and 45 (15%) developed new NSCLC. Recurrent disease was found at a mean of 22 ± 19 months, and new primaries were found at a mean of 52 ± 31 months after lobectomy (P < .01). Five-year survival after diagnosis of recurrent disease was significantly lower than after diagnosis of second primaries (2.3% vs. 57.5%; P < .001). In the subgroup analysis of 187 patients, both disease detection on the initial scan (2% [2/94] vs. 4% [4/93]; P = .44) and 5-year survival (early, 80.8% vs. late, 86.7%; P = .61) were not significantly different between the early (n = 94) and the late (n = 93) groups. ConclusionSurveillance after lobectomy for stage IA NSCLC is useful for identifying both new primary as well as recurrent disease, but waiting to start surveillance until 12 ± 3 months after surgery is unlikely to miss clinically important findings.

PD11-11 SURVEILLANCE AND COMMUNICATION OF SURGICAL RESULTS IN LOCALIZED RENAL CELL CARCINOMA, RESULTS FROM A LARGE INTERNATIONAL PATIENT SURVEY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD11)1 Apr 2020PD11-11 SURVEILLANCE AND COMMUNICATION OF SURGICAL RESULTS IN LOCALIZED RENAL CELL CARCINOMA, RESULTS FROM A LARGE INTERNATIONAL PATIENT SURVEY Dena Battle*, Adam Stern, Cristiane Bergerot, Brian Shuch, Ithaar Derweesh, and Michael Staehler Dena Battle*Dena Battle* More articles by this author , Adam SternAdam Stern More articles by this author , Cristiane BergerotCristiane Bergerot More articles by this author , Brian ShuchBrian Shuch More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , and Michael StaehlerMichael Staehler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000845.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical resection remains the standard of care for localized Renal Cell Carcinoma (RCC). Approximately 75 percent of RCC patients will be diagnosed with localized disease and between 20 to 40 percent will face recurrence after surgery. Despite these high rates of recurrence, consensus on surveillance strategies is lacking. We sought to survey this patient population to determine their understanding of their diagnosis, follow-up experience and assess anxiety that they experience following a diagnosis. METHODS: Data were drawn from an international survey generated by KCCure, a non-profit patient advocacy group. Survivors were invited to participate in the study via social media (e.g., Twitter, Facebook) between 07/19 and 09/19. 412 of 1150 participants were diagnosed with localized disease (56% stage 1, 19% stage 2 and 24% stage 3), with a median time since diagnosis of 18 months. The survey included questions related to demographic and clinical characteristics, histology, stage, surveillance intervals, imaging modalities and distress (1-item measure, ranging from 0 to 10, cutoff of 4). Kruskal-Wallis test was used to compare anxiety prior to surveillance scans with distress as a continuous variable. RESULTS: 32% of patients had a biopsy prior to their surgery. 18% did not have a clear understanding of their diagnosis and did not feel confident about a plan going forward. 42% do not know their T-stage. 22% do not know their grade. 8% do not know their histological subtype. 34% were seeking a second opinion after surgery. Frequency of follow-up care was every three months in 30%, every six months in 43%, annually in 22%, bi-annually in 2% of the patients. 2% were of surveillance until symptoms would arise and 1% did not receive further follow-up visits. Imaging modalities were: CT scan with contrast in 74%, CT scan without contrast in 31%, MRI in 23%, chest x-ray in 33%, PET scans in 4% and ultrasound in 18% of the patients. 2% did not receive any radiological scans.40 percent of patients experienced increased anxiety for a week or more prior to surveillance scans, 34 percent experienced increased anxiety for a few days prior to scans and 12 percent experienced increased anxiety for one day prior to scans. 13 percent reported no increased anxiety. Anxiety was significantly increased to 6.1 on the NCCN distress scale compared to 4.8 at baseline (p>0.001). CONCLUSIONS: Patients lack information about their diagnosis. Surveillance is not standardized, and multiple modalities are used for scanning. Patients suffer from severe anxiety prior to scans. Further research is needed to reduce distress and increase quality of communication. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e257-e258 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dena Battle* More articles by this author Adam Stern More articles by this author Cristiane Bergerot More articles by this author Brian Shuch More articles by this author Ithaar Derweesh More articles by this author Michael Staehler More articles by this author Expand All Advertisement PDF downloadLoading ...