Tertiary Oncology Center Research Articles

High CRLF2 Expression Could Identify Acute Lymphoblastic Leukemia Patients with Poor Outcome but Not IKZF1

Background: Overexpression of cytokine receptor-like factor 2 (CRLF2) caused by different genetic aberrations has been observed in acute lymphoblastic leukemia (ALL) and correlated with poor outcome. Most patients with high CRLF2 expression are clustered in the Philadelphia-like (Ph-like) ALL subgroup. Ph-like ALL is reported to be associated with alterations in IKZF1 gene, encoding the transcription factor Ikaros. Aim: To identify CRLF2 and IKZF1 alterations in Egyptian patients with ALL and to determine their prognostic significance. Methods: Peripheral blood samples from 34 newly diagnosed ALL patients treated at an Egyptian tertiary oncology center and 14 controls were assessed for CRLF2 and IKZF1 mRNA expression using real-time polymerase chain reaction. Results: CRLF2 was significantly overexpressed in ALL patients compared to controls (p = 0.038). The response to treatment was significantly better in patients with low CRLF2 expression (p = 0.029). The rate of remission, relapse and induction death was 82%, 12% and 6% in the low CRLF2 expression group and 41%, 18% and 41% in the high expression one. Overall survival was significantly shorter among ALL with high CRLF2 (p = 0.034). IKZF1 expression level did not differ significantly between patients and controls. Patients with low IKZF1 exhibited significantly higher leucocytic count and lower platelet count (p = 0.038 and 0.044, respectively). IKZF1 overexpression did not correlate significantly with response to treatment or survival. Conclusion: High CRLF2 expression was associated with poor outcome among ALL patients. Further research is needed to improve the diagnostic and therapeutic approaches in ALL patients with poor prognosis.

Two professions against two killer diseases: the rationale, organization, and initial experience of a cardio-oncology service.

Cardiovascular diseases are the most common factor affecting prognosis in cancer survivors. Cardio‑oncology (CO) services have been developed to solve this issue. The outcomes regarding patient demographics and clinical findings are limited and the available data include CO services evaluating patients undergoing only chemotherapy as opposed to those also undergoing radiation therapy. We aimed to show initial experiences of the CO service implemented in a tertiary oncology center. The CO service was designed to include 2 major domains, general CO and electrotherapy consultations. This observational study included patients referred to the CO service with the following data: baseline demographics, cancer type, reasons for referral, cardiac evaluation, and initial clinical outcomes. All patients with cancer referred to our CO service between March 2016 and December 2019 were included in the study. A total of 2762 patients (77% women) at the mean (SD) age of 62 (12) years were referred (63% on an out‑patient basis) for general consultations. The most frequent diagnosis was breast cancer (66%). A total of 18% of patients were referred to the CO service due to cardiovascular complications related to cancer treatment. The CO-cardiac implantable electronic device (CIED) team evaluated 652 patients (515 patients with CIEDs who were qualified for radiotherapy, 48 patients with CIEDs who were assessed with magnetic resonance imaging, and 89 patients with CIEDs who underwent cancer surgery). In the total of 5872 radiotherapy sessions, there were 2 harmful interactions; no other complications during magnetic resonance imaging and surgery were recorded. The CO‑service established within the cancer center seems to be safe and feasible.

Infection Prevalence in Adolescents and Adults With Acute Myeloid Leukemia Treated in an Indian Tertiary Care Center.

PURPOSEInfections remain a major challenge in the treatment of acute myeloid leukemia (AML). Induction-related mortality reported in the literature is approximately < 5% in clinical trials. However, the real-world scenario is different, especially in developing countries, given the high incidence of multidrug-resistant (MDR) organisms, high incidence of fungal pneumonia at baseline, and significant delay before initiation of chemotherapy. We aimed to look at contemporary infections and infection-related mortality and analyze the patterns of infections.MATERIALS AND METHODSThis retrospective study was conducted at a large tertiary care oncology center in India. Patients with newly diagnosed AML who were older than age 15 years, considered fit for intensive therapy, and treated in the general wards of the adult hematolymphoid unit from March 1, 2014, until December 31, 2015, were included.RESULTSOne hundred twenty-one patients were treated during the study period. The most common presenting complaint was fever (85%). The focus of infection at presentation was found in 63% of patients, with respiratory infection being the most common (47%). MDR organisms were isolated in 55% of patients during induction from various foci. Klebsiella pneumoniae was the most common blood culture isolate (42.9%). Fungal pneumonia was diagnosed in 55% of patients during induction despite antifungal prophylaxis. Treatment-related mortality was 10.7% in all phases, with an induction mortality rate of 7.4%. Complete remission was attained in 69% of patients. Of all patients who received induction chemotherapy, 74% completed all three consolidation cycles. The 121 patients were followed up for a median period of 53 months. Four-year event-free survival was 35.8%, and 4-year overall survival was 41.5%.CONCLUSIONInfections and infection-related mortality are major challenges during AML induction. Gram-negative MDR and fungal infections are particularly common in our region.

274P Comparing comorbidity indices in predicting 90-day mortality after radical radiotherapy for head and neck cancer

Treatment of head and neck cancer (HNC) is associated with significant acute toxicity, and accurately identifying patients who will not tolerate aggressive treatment remains a challenge. Comorbidity indices are known prognostic factors for HNC survival outcomes. However, no index has been found to be superior, and their performance in predicting early outcomes in HNC patients is not known. This retrospective analysis aims to determine the role of comorbidity indices in predicting 90-day mortality after radical radiotherapy. Study population included all non-thyroid, non-metastatic HNC patients who received curative intent radiotherapy, with or without chemotherapy, from 2016-2019 in a single tertiary oncology centre. 260 patients were randomly selected for model building and comparison. Multiple logistic regression was used to analyse the performance of six comorbidity scores – the Charlson Comorbidity Index (CCI), age-adjusted CCI (ACCI), head and neck CCI (HNCCI), Simplified Comorbidity Score (SCS), Adult Comorbidity Evaluation-27 (ACE-27) and the Washington University Head and Neck Comorbidity Index (WUNHCI)– in predicting risk of 90-day mortality after radical treatment. ROC analysis was done to identify the best performing index, on which further analysis was carried out to determine the best cut-off. 46 out of a total of 958 eligible patients (4.8%) died within 90 days after radical treatment in our cohort. Four of the six comorbidity scores were independent predictors of early mortality [CCI: odds ratio (OR) 1.298, p=0.004; ACE-27: OR 2.577, p<0.001; ACCI: OR 1.324, p<0.001; HNCCI: OR 2.056, p=0.001]. From ROC analysis of the remaining four comorbidity indices, ACCI was the best performing model (AUC 0.728). Calculation of the Youden Index yielded a threshold of ACCI score > 3 as the most discriminatory cut-off in predicting 90-day mortality. ACCI >3 was associated with more than 20% mortality in our cohort. Age-adjusted CCI > 3 is associated with a higher risk of early mortality in HNC patients after radical radiotherapy. This may be taken as an easily accessible reference for discussion in the clinical setting.

The Added Value of Sentinel Node Mapping in Endometrial Cancer

Study Objective To evaluate long-term oncological outcomes and the added value of sentinel lymph node sampling (SLN) compared to pelvic lymph node dissection (LND) in patients with endometrial cancer. Design During the evaluation phase of SLN for endometrial cancer, we performed LND and SLN and retrospectively compared the oncologic outcome with the immediate non-overlapping historical era during which patients underwent LND. Setting Tertiary gynecology oncology center. Patients or Participants From 2007 to 2010, 193 patients underwent LND and from December 2010 to 2014, 250 patients had SLN mapping with completion LND. Interventions Pelvic lymph node dissection (LND) versus sentinel lymph node sampling (SLN) followed by LND. Measurements and Main Results During a median follow-up period of 6.9 years, addition of SLN was associated with more favorable oncological outcomes compared to LND with 6-year overall survival (OS) of 90% compared to 81% (p=0.009), and progression free survival (PFS) of 85% compared to 75% (p=0.01) respectively. SLN was associated with improved OS (HR 0.5, 95% CI 0.3-0.8, p=0.004), and PFS (HR 0.6, 95% CI 0.4-0.9, p=0.03) in a multivariable analysis, adjusted for age, ASA score, stage, grade, non-endometrioid histology, and LVSI. Patients who were staged with SLN were less likely to have a recurrence in the pelvis or lymph node basins compared to patients who underwent LND only (6-year recurrence-free survival 95% vs 90%, p=0.04). Conclusion Addition of SLN to LND was ultimately associated with improved clinical outcomes compared to LND alone in patients with endometrial cancer undergoing surgical staging, suggesting that the data provided by the analysis of the SLN added relevant clinical information, and improved the decision on adjuvant therapy.

Omitting Lymphadenectomy in Obese Endometrial Cancer Patients Undergoing Sentinel Lymph Node Mapping: More Is Less

Study Objective To evaluate the feasibility of sentinel lymph node (SLN) mapping in obese endometrial cancer patients. Design A retrospective study of obese patients (BMI ≥35 kg/m2), diagnosed with endometrial carcinoma between 2007 and 2017, comparing surgical and oncological outcomes of two patient's cohorts. Setting Tertiary gynecology oncology center. Patients or Participants 223 patients with median BMI of 40.6 kg/m2 including: 140 patients that underwent LND (with or without SLN) and 83 patients that underwent SLN. Interventions Lymph node dissection (LND) with or without SLN versus only SLN for endometrial cancer staging. Measurements and Main Results Patients that had only SLN seemed to have more metastatic pelvic nodal disease (13.3% vs. 7.1%), though this difference did not reach statistical significance (p=0.2). Patients from the SLN only group had significantly higher rate of successful mapping (92.8% vs. 78.4%, p=0.009), bilaterally detected SLN (80.7% vs. 54.5%, p Conclusion Omitting LND from surgical staging where SLN is performed was associated with shorter operative time and minimal bleeding without affecting survival. ICG should be the dye of choice in obese endometrial cancer patients.

Lesions of the heel fat pad.

The heel fat pad (HFP) is a specialized soft tissue structure formed of adipose tissue that overlies the inferior and posterior aspect of the calcaneus and provides the cushioning effect of the heel. Lesions of the HFP are rare and can be a cause of debilitating heel pain that may often pose a challenge to clinicians. This study provides a series of lesions identified within the HFP. A retrospective review of heel pad lesions over a 12 year period was conducted at our tertiary orthopaedic oncology centre. All lesions of the heel fat pad were included in the study. Plantar fasciitis was excluded. There were 17 heel pad lesions identified, of which the majority (n = 15) were benign. We highlight a wide spectrum of pathologies that can occur in the HFP. Although rare, clinicians should be aware of these lesions, to initiate appropriate management.

Tumours of the odontoid peg revisited.

Introduction:Tumours of the odontoid peg are rare but can potentially cause significant morbidity and mortality.Methods:A retrospective review of oncology and radiology database of tertiary orthopaedic oncology centre for all lesions affecting the odontoid peg over the last 12 years was performed.Results:We identified a total of 15 tumours involving the odontoid peg, majority being malignant. Myeloma was the most common tumour.Conclusion:Tumours of the odontoid peg are rare. Spinal surgeons and Radiologists need to be aware of them.

The diagnostic efficacy of tailored multiparametric breast MRI in indeterminate mammographic lesions: A single tertiary oncology center

Aim: Assessing the diagnostic role of multiparametric MRI (mpMRI) in indeterminate mammographic breast lesions and postulated a diagnostic model for MRI interpretation integrating the morphological, and functional parameters. Material and Methods: Two hundred forty patients included in a self-control retrospective study in a tertiary center. All patients examined with 1.5T MR unit using multiparametric studies including morphological analysis followed by functional evaluation via MR diffusion (MR-DWI), spectroscopy(MRS), and kinetic enhanced curves (DCE-MRI). Diagnostic performance of each parameter was evaluated alone and in combination. The histopathological results were the standard of reference. Results: Combined mpMRI parameters possess a moderate agreement (κ=0.435) with 23.5% false discovery rate (FDR) and an overall accuracy of 78%.On the other hand, combined mpMRI data after omitting MRS data show almost perfect agreement (κ=0.923)with histopathological data and recorded 100% specificity, 90% specificity, 5% FDR and zero% for both false omission rate (FOR) and false-negative rate (FNR). The Quantitative analysis of DWI with ADC map shows a significant statistical value for mean ADC (m-ADC) value and relative ADC (r-ADC) value. The former has cutoff value 1.1x10-3 mm2/sec with higher specificity 97.5% while r-ADC has cutoff value 0.42x10-3 mm2/sec with quite lower specificity 85%. Perfect agreement in the interpretation of DCE-MRI curves, MR-DWI, and MRS with κ =0.92,0.9 and 0.84 respectively. Conclusion: Tailored combined multiparametric MRI is a potent diagnostic tool in the characterization of indeterminate mammographic breast lesions.

Characterization of a distinct low-grade oncocytic renal tumor (CD117-negative and cytokeratin 7-positive) based on a tertiary oncology center experience: the new evidence from China.

To examine the clinicopathologic and immunohistochemical features of a group of newly defined low-grade oncocytic renal tumors (LOT) that have the "CD117 negative/cytokeratin (CK)7 positive" immunoprofile. We have queried our hospital database and found 4456 consecutive renal tumors between 2016 and 2019. Among these renal tumors, eight (8) cases meet the morphologic and immunohistochemical characterization for low-grade oncocytic renal tumor (LOT). The eight (8) patients' mean age is 56.6 years (range 39-70 years old), and the male to female ratio is 1:1. Macroscopically, these LOTs generally present with tan-brown and solid cut surfaces and demonstrate similar solid, compact nested growth pattern microscopically. Tumor cells exhibit oncocytic cytoplasm and uniformly rounded to oval nuclei. There are areas of edematous stroma containing dispersed single or small clustered tumor cells. All tumors are negative for CD117 and positive for CK7. Uniform reactivity is also found for BerEP4, cyclin D1, and SDHB. Besides, CD10, vimentin, and AMACR are either negative or only focally positive. All of the tumors are negative for CA9 and TFE. The Ki-67 index is less than 5% in the seven (7) internal cases. Seven (7) of the eight (8) patients who are available for follow-up are alive and without disease recurrence (mean follow-up period of 21.6 months, ranging from 6 to 43 months). We described a group of low-grade oncocytic renal tumors identified retrospectively in a large tertiary cancer center, which was probably the first report originated from China or even Asia in the English literature so far. These tumors demonstrated eosinophilic cytoplasm and low-grade appearing nuclei with a "CD117 negative/CK7 positive" immunoprofile. The incidence rate was about 3.7% of the oncocytic renal tumors and 0.18% of all the renal tumors that were received in our lab during the four-year period. It is necessary to separate this group of tumors by its characteristic morphologic and immunophenotypic features.

Teleoncology or telemedicine for oncology patients during the COVID-19 pandemic: the new normal for breast cancer survivors?

Background: Telemedicine is seen as a savior during the COVID-19 pandemic. Materials & methods: This study is a descriptive cross-sectional study conducted with cancer patients who were interviewed via telemedicine from a tertiary care comprehensive oncology center. Results: A total of 421 patients were included in the study and 118 of them (28.0%) were >65 years old. Communication was provided most frequently by voice call (n = 213; 50.5%). The majority of the patients contacted by telemedicine had breast cancer (n = 270; 64.1%). For 135 patients (32.1%) no further examination or intervention was required and the previously planned follow-up visit was postponed by the clinician. Conclusion: This study showed that telemedicine could open a new era for medical oncology specialists.

Primary Synovial Chondromatosis of the Elbow

We present a rare case of primary synovial chondromatosis of the elbow joint as well as a review of the literature and discuss the clinical, imaging, histological findings and clinical outcome of this condition. It is a benign condition characterized by nodular proliferation and metaplasia of the synovium. Histology findings however suggest that the condition is not solely a metaplasia as the cartilage is often very cellular and could be interpreted as a neoplastic process. This may explain in rare cases the incidence of recurrences and malignant transformation of this condition. Awareness of the atypical histology is paramount and therefore referral to a tertiary oncology centre is mandatory. An experienced pathologist is crucial for the correct diagnosis, prognosis and management of this condition.

Treatment of metastatic castration resistant prostate cancer with radium-223: a retrospective study at a US tertiary oncology center

BackgroundGuidelines for optimal sequencing of radium-223 and chemotherapy for metastatic castration resistant prostate cancer (mCRPC) do not exist. This study evaluated treatment patterns and overall survival (OS) among patients with mCRPC treated with radium-223 in an academic clinical setting.MethodsA retrospective study was conducted of bone metastases-predominant mCRPC patients treated with radium-223. Treatment patterns from 2013 to 2018 were evaluated in patients treated with radium-223 pre- vs. post-chemotherapy. OS was examined using Kaplan–Meier medians and 95% confidence intervals.ResultsIn total, 220 patients were treated with radium-223 (64 pre-chemotherapy, 83 post-chemotherapy, 73 no chemotherapy). Mean radium-223 injections per patient was 5.3 and 4.3 in the pre- vs. post-chemotherapy cohorts, respectively (p < 0.001). The number of chemotherapy cycles was similar for chemotherapy given pre- or post-radium-223. Mean line of mCRPC therapy of radium-223 was 3rd and 5th when given pre- and post-chemotherapy, respectively (p < 0.001). 41.8% patients were treated with radium-223 in combination with another mCRPC therapy, commonly abiraterone acetate (43.5%) or enzalutamide (52.2%). The majority received combination therapy for the duration of radium-223 treatment; 20.7% started another agent after radium-223 initiation; 20.7% initiated radium-223 while on established therapy. Median OS from first mCRPC treatment was 39.4 months (95% CI 33.0, 48.8) for patients with radium-223 pre-chemotherapy vs. 37.4 months (95% CI 32.0, 43.5) post-chemotherapy (and 35.2 months [95% CI 27.9, 43.3] vs. 32.0 months [95% CI 26.9, 36.0] for patients with radium-223 combination vs. monotherapy).ConclusionsThis retrospective analysis of patients treated with radium-223 demonstrates that administration of radium-223 pre-chemotherapy increased likelihood of completion of radium-223 treatment. Radium-223 given pre- or post-chemotherapy and with or without combination therapy did not result in significant differences in OS. Additional studies are needed to determine the optimal sequencing strategy of mCRPC in the modern era.

Standard operating procedure of image-guided intervention during the COVID-19 pandemic: a combined tertiary musculoskeletal oncology centre experience

AIMTo evaluate the response measures in continuing an image-guided intervention service in two tertiary-level musculoskeletal oncology centres during the COVID-19 pandemic.MATERIALS AND METHODSThis study was a retrospective review of all patients undergoing image-guided intervention in the computed tomography (CT) and normal ultrasound (US) rooms from 24 March 2020 to 24 May 2020 (during the COVID-19 pandemic peak) at Royal National Orthopaedic Hospital, London, and Royal Orthopaedic Hospital, Birmingham, UK. Measures were put in place to address air pressures, airflow direction, aerosol generation, and the safe utilisation of existing scanning rooms and work lists for interventional procedures.RESULTSThree hundred and thirty-one patients (164 at Royal National Orthopaedic Hospital and 167 at Royal Orthopaedic Hospital) underwent image-guided procedures at both sites in the CT and US rooms. At the Royal National Orthopaedic Hospital, 40% of all procedures were performed under general anaesthesia. These consisted of 47 CT biopsies, 7 CT radiofrequency ablations (RFAs), and 12 US biopsies. At the Royal Orthopaedic Hospital, 86% of all procedures were performed under local anaesthetic, with no general anaesthetic procedures. These consisted of 61 CT biopsies and 83 US biopsies. All 256 patients having procedures in the CT room had no post-procedural complications or COVID-19-related symptoms and morbidity on follow-up.CONCLUSIONBy adopting a pragmatic approach with meticulous planning, a limited, but fully functional image-guided interventional list can be run without any adverse patient outcomes.

Challenges in platelet inventory management at a tertiary care oncology center during the novel coronavirus disease (COVID-19) pandemic lockdown in India

The novel coronavirus disease (COVID-19) has been declared a pandemic by the world health organization and to limit the spread of the disease, many countries in the world, including India, had enforced a lockdown. Despite no restriction over the platelet donation activities, plateletpheresis donors became apprehensive regarding the possible risk of spread of the COVID-19 during the platelet donation and in the hospital premises. Many of them started hesitating for platelet donations. With this, the blood center started having an acute shortage of platelets. Various confidence-building steps were implemented by the blood center to promote voluntary plateletpheresis. The blood center staff and individual donors were educated to prevent the spread of COVID-19. The donor organizations and plateletpheresis donors were informed about the steps to be taken by the blood center during the donation and necessary steps for the prevention of the possible spread of COVID-19. With the help of these measures, the confidence of the individual platelet donors and the donor organizations was restored in the blood center and regular plateletpheresis was continued. These measures may also be useful to other blood centers in the COVID-19 pandemic and this experience may be useful if a similar pandemic lockdown happens in the future.

Assessment of organizational readiness to implement an electronic health record system in a low-resource settings cancer hospital: A cross-sectional survey.

Organizational readiness for change is a key factor in success or failure of electronic health record (EHR) system implementations. Readiness is a multifaceted and multilevel abstract construct encompassing individual and organizational aspects, which makes it difficult to assess. Available tools for assessing readiness need to be tested in different contexts. To identify and assess relevant variables that determine readiness to implement an EHR in oncology in a low-and-middle income setting. At the Uganda Cancer Institute (UCI), a 100-bed tertiary oncology center in Uganda,we conducted a cross-sectional survey using the Paré model. This model has 39 indicator variables (Likert-scale items) for measuring 9 latent variables that contribute to readiness. We analyzed data using partial least squares structural equation modeling (PLS-SEM). In addition, we collected comments that we analyzed by qualitative content analysis and sentiment analysis as a way of triangulating the Likert-scale survey responses. One hundred and forty-six clinical and non-clinical staff completed the survey, and 116 responses were included in the model. The measurement model showed good indicator reliability, discriminant validity, and internal consistency. Path coefficients for 6 of the 9 latent variables (i.e. vision clarity, change appropriateness, change efficacy, presence of an effective champion, organizational flexibility, and collective self-efficacy) were statistically significant at p < 0.05. The R2 for the outcome variable (organizational readiness) was 0.67. The sentiments were generally positive and correlated well with the survey scores (Pearson's r = 0.73). Perceived benefits of an EHR included improved quality, security and accessibility of clinical data, improved care coordination, reduction of errors, and time and cost saving. Recommended considerations for successful implementation include sensitization, training, resolution of organizational conflicts and computer infrastructure. Change management during EHR implementation in oncology in low- and middle- income setting should focus on attributes of the change and the change targets, including vision clarity, change appropriateness, change efficacy, presence of an effective champion, organizational flexibility, and collective self-efficacy. Particularly, issues of training, computer skills of staff, computer infrastructure, sensitization and strategic implementation need consideration.

Correlation of platelet crossmatch results by Solid Phase Red Cell Adherence Assay (SPRCA) with post-transfusion platelet count increment in adult hemato-oncology patients of a tertiary care oncology centre in India

AimsTo assess platelet crossmatch result by SPRCA and find its correlation with post-transfusion platelet count increment among adult hemato-oncology patients. MethodsA prospective observational pilot study of 50 adult hematologic malignancy patients previously transfused, but not already known to be transfusion-refractory and without any nonimmune causes for inadequate response to platelet transfusion were included after obtaining informed consent. They were transfused one unit of ABO identical single donor platelet. Ten minutes to 1 -h post-transfusion CCI was calculated.CCI ≥ 7500 was considered as adequate response. Post-transfusion crossmatching by SPRCA was performed by using preserved platelet samples from donor units with the serum of the respective patient. Statistical analysis of the correlation between platelet crossmatch results and CCI was done. ResultsOut of 50 crossmatches, 78% (39/50) showed compatible and 22% (11/50) showed incompatible results. Among 39 compatible results, 87.2% (34/39) showed adequate CCI and 12.8% (5/39) showed inadequate CCI. Among 11 incompatible results, 18.2% had adequate CCI and 81.8% had inadequate CCI. The difference between the response in terms of CCI to compatible and incompatible crossmatches was found to be statistically significant (p < 0.05). Other variables like age, sex, number of previous transfusions and underlying clinical condition of the patient were not found to have any effect on the compatibility of crossmatch. ConclusionsTransfusion of crossmatched platelets to non-refractory, multiply transfused hematological malignancy patients without serious illness might provide a small benefit over transfusing randomly selected platelets, though these data must be confirmed with a larger sample size.

Immunophenotypic profile and aberrancies in Acute Leukaemia: A study from tertiary oncology centre in south India

Immunophenotypic profile and aberrancies in Acute Leukaemia: A study from tertiary oncology centre in south India

Abstract A133: Comparison of radiation therapy initiation timelines among varied referral streams to identify sources of delay

Abstract Purpose/Objective(s): Tertiary radiation oncology centers receive referrals from diverse care settings, including private facilities, Veteran’s Affair (VA) hospitals, and county hospitals. An exploratory study of county patients treated at our institution identified that each missed consult or simulation (sim) appointment was associated with a greater than three-week delay from referral to radiation (RT) start. We sought to validate this in a larger sample and compared RT referral-to-start timelines for a variety of referral streams. Materials and Methods: Up to 60 consecutively referred patients from each facility (internal health system, VA, county hospital, and external private facilities) between June to December 2018 were included. Primary disease site, interpreter requirements, and dates of referral, consultation, sim, and RT start were recorded. Linear regression and analysis of variance models were developed to identify variables associated with delays in RT. Results: Of 214 patients were included; 55 (26%) internal, 53 (25%) from the VA, 60 (29%) from the county hospital, and 46 (22%) from other facilities. Among the 33 patients requiring interpreters, 28 (85%) were county patients. The most common referrals were for genitourinary (GU) cancers (n = 63, 29%), followed by breast (n = 29, 14%), lung (n = 26, 12%), and head and neck (n = 21, 10%) cancers. The median days from referral to consult was 16 (IQR 7-28), with the shortest time to consult for bone (1.5 days, IQR 1-5) and central nervous system sites (5 days, IQR 3-9) and the longest for gynecologic cancers (21.5 days, IQR 8.5-44). Excluding GU patients, who often require two months of neoadjuvant hormone therapy prior to RT, the median days from consult to sim was 13 (IQR 6-20) with no significant differences in referral to consult or consult to sim by referring facility. In all patients, the median days from sim to RT start was 8 (IQR 6-14) with no significant differences by referral facility. In univariate analysis among non-GU patients, referring facility and requirement of an interpreter were not associated with referral-to-start delays; only missing one or more consult/sim appointments was significant (p &amp;lt; 0.001). Each missed appointment was associated with a 37-day delay (95% CI 26 – 48) in referral-to-start. Conclusion: In a patient cohort with heterogeneous cancer diagnoses, no facility-specific delays were identified despite county hospital patients having known socioeconomic vulnerability. Efforts to decrease RT delays may require department-wide, as opposed to interfacility, interventions. Future goals involve using site-specific referral-to-start benchmarks (e.g. one week for palliation and 10 weeks for GU) to further discriminate differences. Citation Format: Melody J Xu, Sumi Sinha, Sunny Wang, Terence Friedlander, Steve E Braunstein. Comparison of radiation therapy initiation timelines among varied referral streams to identify sources of delay [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A133.

SAT-178 Incidence, Patterns of Clinical Presentation, and Outcomes of Patients with Brain Metastasis Due to Adrenocortical Carcinoma

Background: Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy, with a heterogeneous but, frequently, dismal prognosis; patients with metastatic ACC have a five-year survival that ranges between 0 and 28%. Metastatic ACC may be present at diagnosis or during follow-up as disease recurrences. The most common sites of metastatic lesions include the liver, lungs, lymph nodes and bones. The brain has only rarely been reported as a site of metastasis in this neoplasia and, to the authors’ knowledge, little is known regarding the incidence, patterns of clinical presentation and disease progression, and outcomes. Objective: The aim of this report was to describe the clinical characteristics of adult patients with ACC who developed brain metastasis evaluated at a tertiary oncological center (ICESP) from Brazil. Methods: Retrospective analysis of medical records including evaluation of laboratory and imaging exams and pathologic data (in cases where surgical resection of the metastasis was performed). Results: In the last ten years (2009-2019), fifty-four patients have been treated for ACC at ICESP; all of them with advanced disease (locally advanced disease and metastatic disease). The median age at the time of diagnosis of ACC was 44 (range 24-61 yrs.). No patients presented metastasis at central nervous system (CNS) at the initial diagnosis; however, during follow-up, we identified brain metastasis in six patients (11.1%). The median time between ACC diagnosis and the detection of brain metastasis was 20.8 months (range 5-53 mo.). In all of these six cases, at least three other sites of metastatic involvement were already present when the brain involvement was diagnosed and, therefore, all of them had already been treated with mitotane in association with at least one line of cytotoxic chemotherapy. The number of brain metastasis in each of these six patients varied from one to eight and median size of lesion was 1.7 cm (range 0.5-4.0 cm). Secondary headache and seizure were the main symptoms of presentation and one or two of these symptoms occurred in all but in one patient, in which diagnosis was due to screening with brain MRI. In four patients with stable disease elsewhere, surgical resection of one or two brain metastases was performed. In these cases, SF1-positive immunohistochemistry confirmed the adrenocortical origin of the lesion. The median time between CNS metastasis detection and death was 3.8 months (range 0.4-59.6 mo.), and complications due to brain metastasis were the leading cause of death. Conclusions: In our institute, brain metastasis occurred in 11.1% of advanced ACC, a prevalence that is higher than previously reported in literature. Despite the relative small number of patients included in this study, we highlight the possibility of brain metastasis in patients with ACC, particularly in cases with a prolonged disease course and multiple systemic treatments.