Thoracic Malignancies Research Articles

PO0307: Analysis of the Combined Treatment Efficacy of Radioactive Iodine-125 Seed Brachytherapy and Radiofrequency Ablation for Thoracic Malignancies

PO0307: Analysis of the Combined Treatment Efficacy of Radioactive Iodine-125 Seed Brachytherapy and Radiofrequency Ablation for Thoracic Malignancies

Is extended resection for locally advanced thoracic cancer with cardiopulmonary bypass justified?

BackgroundResection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treating locally advanced mediastinal and lung cancers.MethodsBetween 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB.ResultsRegarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107 months after operations.ConclusionIn certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancers with acceptable perioperative safety and survival.

The relationship between patient-reported experience and patient-reported outcomes in patients with cancer.

248 Background: Measures of patient experience (PEX) and patient-reported outcomes (PRO) are used by health systems across the US to improve care delivery and quality of life, respectively. Despite their widespread use, little is known regarding the relationship between these two types of patient-generated data. From 2018 to 2023, we conducted a pragmatic type-II hybrid effectiveness/implementation study of an electronic health record (EHR)-embedded symptom management program (eSyM) across six diverse cancer centers. This project focused on patients who started chemotherapy (CHEMO) or had surgery (SURG) for a suspected or confirmed gastrointestinal, gynecologic, or thoracic malignancy. Methods: We conducted a cross-sectional study of adults who were eligible for either the control or intervention arm of the eSyM study to determine if patients who reported having an inferior care-team experience were more likely to report having worse symptoms. Participants completed a one-time survey via REDCap that included elements from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and the Patient-Reported Outcomes Measurement Information System (PROMIS). Analyses determined the extent to which PEX measures were associated with PRO measures by evaluating differences in mean PROMIS scores for those who rated their PEX highly vs. not highly. Results: In total, 1419 respondents reported having cancer for which they received care at a participating center: median age 66, 63% female, 5% black, 13% disabled, 66% married/partnered, 23% high school or less education, 22% somewhat-extreme difficulty paying bills. For both CHEMO and SURG patients, 82% rated their overall cancer care-team experience highly (top box score of 9-10). Compared to patients who did not rate their care-team experience highly, those who did reported better scores for depression, fatigue, anxiety, pain interference, physical function, and self-efficacy (Table). PROMIS values differed for other CAHPS measures too. Conclusions: Among patients receiving routine cancer care, there was a significant association between PEX and multiple PROs. Further investigation of the nature and strength of the association between PEX and PRO measures is warranted. If confirmed, this association could lead to the development of interventions that impact both patient satisfaction and quality of life. Clinical trial information: NCT03850912 . Mean difference in PROMIS scores for patients who rated their care-team experience highly versus not highly (P from two-sample T-test). CHEMO (N=889) SURG (N=530) Mean Diff 95%CI P value Mean Diff 95%CI P value Depression -2.7 -4.3, -1.1 0.001 -3.3 -5.3, -1.4 <0.001 Anxiety -3.7 -5.4, -1.9 <0.001 -3.6 -5.7, -1.5 <0.001 Fatigue -2.3 -4.0, -0.5 0.011 -4.5 -6.8, -2.2 <0.001 Pain interference -3.6 -5.3, -1.9 <0.001 -4.7 -6.7, -2.7 <0.001 Physical function 1.6 0.1, 3.1 0.042 3.5 1.4, 5.6 0.001 Self-efficacy 3.9 2.6, 5.2 <0.001 6.4 4.6, 8.1 <0.001

EP.03C.02 The Potential of Fluoropyrimidine to be an Immunologically Optimal Partner of Immunotherapy for Thoracic Malignancies

EP.03C.02 The Potential of Fluoropyrimidine to be an Immunologically Optimal Partner of Immunotherapy for Thoracic Malignancies

The more you test, the more you find: Expansion of routine urine drug screening facilitated through an embedded palliative care clinic in thoracic oncology.

194 Background: Consensus guidelines strongly recommend urine drug screening (UDS) for all patients receiving opioids for cancer pain management. However, implementation of UDS in oncology clinics is underreported. The primary aim of this study was to evaluate incidence of unexpected UDS results among patients with lung cancer after implementation of confirmatory UDS in a thoracic oncology clinic. Methods: This is a single-institution retrospective study of UDS results among patients diagnosed with any stage thoracic malignancy before and after expansion of chromatography-based UDS facilitated by a palliative care provider embedded in a thoracic medical oncology clinic. Patients were included if their first UDS was collected during the year prior to (pre-intervention) or during the 12 months after (post-intervention) opening of the embedded Thoracic Onco-Palliative Clinic on September 5, 2018. In the pre-intervention period, UDS was routinely ordered for only patients referred to a standalone palliative care clinic. This 2-step UDS includes immunoassay and chromatography-based testing followed by interpretation of results by a specialty-trained palliative care clinical pharmacist. In the post-intervention period, UDS was expanded to include any patient seen by Thoracic Medical Oncology regardless of palliative care referral status. A Kaplan-Meier curve and log-rank test were used to compare time to first unexpected UDS between cohorts. Results: More patients had UDS testing in the post-intervention (n = 182) versus pre-intervention (n = 61) period. A higher volume and proportion of patients had unexpected UDS results in the post-cohort (25/182; 13.7%) compared to pre-cohort (6/61; 9.8%), although this difference was not statistically significant (p = 0.43). The number of UDS tests per patient was significantly higher (p < 0.01) in the post-cohort (mean (SD): 2.4 (2.7)) vs. pre-cohort (1.5 (1.3)). A larger proportion of pre-cohort patients completed only one UDS during the study period (pre: 73.8% (45/61); post: 53.3% (97/182); p < 0.01). In the post-cohort, 58 (31.9%) patients completed UDS ordered by oncology team prior to palliative care referral compared to 0 patients in the pre-cohort; 29 (21.4%) patients completed UDS without receiving outpatient palliative care compared to 0 patients in the pre-cohort. Kaplan-Meier curves for the pre- and post-cohorts were similar during the first 6 months of drug screening (p = 0.7) and diverged after 6 months, with a higher probability of detecting an unexplained UDS in the post cohort at 24 months (Pre: 15.0%; Post: 40.0%). Conclusions: Implementation of confirmatory UDS in a thoracic oncology clinic facilitates closer monitoring for nonprescribed substance use during opioid management and continued detection of unexpected UDS results up to 24 months.

Preventive Aortic Stent Graft Implantation Prior to Thoracic Surgery: Early and Midterm Results

Background: There is a paucity of data concerning the feasibility and value of thoracic aortic stent graft implantation (TEVAR) applications for removing tumors infiltrating the aortic wall. This analysis aimed to demonstrate the feasibility of TEVAR and monitor the perioperative risks of morbidity and mortality. Additionally, a literature review was performed. Methods: A retrospective data analysis was performed on patients who received TEVAR prior to thoracic malignancy resection between January 2010 and April 2024. The primary endpoint was technical success. Results: A total of 15 patients (median age: 67 years; range: 23–75; 66.7% female) received TEVAR prior to thoracic surgery of different tumor entities. In 80% of cases (n = 12), the proximal landing zone was in aortic zone 3. In three cases, the supra-aortic debranching of LSA and/or LCCA via bypass implantation or in situ laser fenestration was necessary. No postoperative endograft-related complications were observed. In eight patients, aortic wall infiltration was confirmed intraoperatively. In total, R0 resection was achieved in seven patients (46.7%). The 30-day mortality rate was 6.7% (n = 1). Technical success was achieved in all patients (100%), while procedural success was achieved in 80% due to incomplete tumor resection in three patients. Conclusions: To the best of our knowledge, this is the largest analysis to date that confirms the results of previous smaller studies. Aortic stent grafting prior to thoracic tumor resection allows for extensive resection while maintaining low morbidity and a low 30-day mortality risk.

Abstract C064: Racial and Ethnic Variation in Referral Times for Thoracic Oncologic Surgery in a Major Metropolitan Area

Abstract Objective The study objective was to understand the impact of race/ethnicity on access to thoracic surgical care for patients undergoing lung resection for cancer. Methods We performed a retrospective analysis on 206 consecutive patients who underwent lung resection for cancer (120 female, 86 male; median age 66 years), with respect to how race and ethnicity impact time to referral for thoracic surgery to a major healthcare center. Time between initial radiographic appearance of a lung nodule/mass 1 cm or greater to surgical referral and time from surgical referral to operation were evaluated for 121 White, 30 Asian, 26 Hispanic, 12 African American, and 17 mixed or other race patients. The impact of age, sex, median income of patient's household, national and state Area Deprivation Indices, insurance type, and distance between the patient's domicile and our hospital was evaluated. The influence of the referring physician's practice (hospital-based, hospital-affiliated, or private), internal or external referral, race/ethnicity, and level of specialization was also studied. Results African American, Asian, Hispanic, and mixed/other race patients had significantly longer wait times between initial radiographic finding of a lung nodule/mass 1 cm or greater and surgical referral compared with White individuals (median days: African American, 78; Asian, 95; Hispanic, 92; mixed or other, 65; White, 35). Multiple linear regression analysis demonstrated that race/ethnicity was the only significant predictor of prolonged time to surgical referral when adjusted for age, sex, median household income level, national and state Area Deprivation Indices, insurance type, and distance between patient's home and our hospital. The referring physician's type of practice and internal versus external referral were not significant. However, the physician's race/ethnicity and level of specialization had an impact on referral times, with non-specialists referring patients sooner to thoracic surgery compared with specialists who ordered more workup tests. For all patient races/ethnicities, there was no difference in time between surgical referral and day of operation. Conclusions Race and ethnicity have a major impact on the time from initial radiographic appearance of a lung nodule/mass 1 cm or greater to referral for surgical resection for cancer. This study suggests the need to develop strategies to reduce minority wait times and improve timely access to surgery for patients with thoracic malignancies. Citation Format: Moises Hernandez, Cristian Puerta, Nolan Winicki, Patricia Thistlethwaite. Racial and Ethnic Variation in Referral Times for Thoracic Oncologic Surgery in a Major Metropolitan Area [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C064

Tracheal Tumors: Clinical Practice Guidelines for Palliative Treatment and Follow-Up.

A substantial portion of patients with advanced cancer cannot be cured, regardless of the therapeutic methods employed. Hence, rational palliative causal treatment becomes crucial. Representative studies specifically addressing the exclusive palliative treatment of patients diagnosed with tracheal cancers have not been identified. In most studies, patients treated palliatively constituted a subset of the overall evaluated group. A thorough literature review was conducted, focusing on three types of palliative treatment: palliative radiotherapy, palliative surgical procedures, and systemic treatment for advanced disease. This review uniquely fills a significant gap in the existing literature by providing the first comprehensive and updated clinical practice guidelines specifically focused on the palliative treatment of tracheal tumors. The proposed guidelines emphasize the unique clinical challenges and treatment strategies pertinent to palliative care in tracheal tumors, which are not adequately covered in existing guidelines for other thoracic malignancies.

CN6 Integration of specialized mobile palliative unit care into management of patients with thoracic malignancies: A single center experience

CN6 Integration of specialized mobile palliative unit care into management of patients with thoracic malignancies: A single center experience

American Radium Society Appropriate Use Criteria on Cardiac Toxicity Prevention and Management After Thoracic Radiotherapy

IntroductionThe multidisciplinary American Radium Society Thoracic Committee was assigned to create appropriate use criteria on cardiac toxicity prevention and management for patients undergoing radiotherapy. MethodsA systematic review of the current literature was conducted. Case variants of patients with thoracic malignancies undergoing radiation were created based on presence or absence of cardiovascular risk factors and treatment-related risks assessed by dose exposure to the heart/cardiac substructures. Modified Delphi methodology was used to evaluate the variants and procedures, with less than or equal to three rating points from median defining agreement/consensus. ResultsA total of six variants were evaluated. The panel felt that patients with cardiac comorbidities at high risk for radiation-related cardiac toxicity should undergo a prescreening cardiac-focused history and physical (H&P) examination, electrocardiogram, cardiac imaging including an echocardiogram, and referral to a cardiologist/cardio-oncologist. Recommendations for those without cardiac comorbidities at low risk for cardiac toxicity were to undergo a baseline H&P examination only. Conversely, those without cardiac comorbidities but at high risk for radiation-related cardiac toxicity were recommended to undergo a prescreening electrocardiogram, in addition to a H&P examination. For patients with cardiac comorbidities at low risk for cardiac toxicity, the panel felt that prescreening and postscreening tests may be appropriate. ConclusionsThe American Radium Society Thoracic appropriate use criteria panel has developed multidisciplinary consensus guidelines for cardiac toxicity prevention, surveillance, and management after thoracic radiotherapy based on cardiac comorbidities at presentation and risk of radiation-related cardiac toxicity.

Re-evaluation and operative indications after induction therapy for thymic epithelial tumors.

Thymic epithelial tumors (TETs), encompassing thymoma and thymic carcinoma, represent a rare and heterogeneous group of thoracic malignancies with varying prognoses and treatment strategies. Surgical resection is the cornerstone of therapy for localized stages, but the management of locally advanced or unresectable TETs often involves induction therapy, including chemotherapy and/or radiation therapy, as a neoadjuvant approach aimed at downstaging the tumor to facilitate subsequent resection. This review synthesizes current knowledge on the re-evaluation process and operative indications following induction therapy for TETs, highlighting the pivotal role of accurate assessment in guiding surgical decisions and optimizing patient outcomes. Induction therapy's efficacy is contingent upon precise re-evaluation methods to accurately gauge treatment response and assess resectability post-therapy. This review discusses the various modalities employed in re-evaluation, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT), and the significance of tumor markers, underlining their strengths and limitations. The adoption of modified RECIST criteria for TETs by the International Thymic Malignancy Interest Group (ITMIG) underscores the necessity for standardized assessment guidelines to ensure consistency and reliability across studies and clinical practices. Furthermore, we explore the implications of induction therapy on surgical decision-making, emphasizing the criteria for determining the suitability of patients for surgical intervention post-therapy. The review addresses the challenges and future perspectives associated with the re-evaluation process, including the potential for advanced imaging techniques and the integration of molecular and genetic markers to enhance the precision of treatment response assessment. In conclusion, the re-evaluation of TETs post-induction therapy is a complex but critical component of the multidisciplinary management approach for these patients. Standardizing re-evaluation methodologies and incorporating novel diagnostic tools could significantly improve the prognostication and treatment stratification, ultimately enhancing the therapeutic outcomes for patients with advanced TETs.

Lobar collapse: what radiologists need to know

Radiologists have to diagnose lobar collapse routinely, so they should be familiar with the direct and indirect signs of lobar atelectasis and with uncommon findings, for being able to make early diagnosis. Atelectasis can be caused by several mechanisms: by obstruction (due to neoplastic or non-neoplastic causes), by loss of negative pressure in the pleural space and/or by compression of lung parenchyma (e.g., pneumothorax, hydrothorax, and pleural effusion) or by an increase in alveolar surface tension (e.g., acute respiratory distress syndrome and neonatal respiratory distress syndrome). Collapses, moreover, can be observed in several ways. Lobar atelectasis occurs when entire pulmonary lobe is collapsed. Linear atelectasis (previously “plate like” or “band like”) is a local collapse with linear, plate-like or band-like shape which usually parallels the hemidiaphragms. Rounded atelectasis is a consequence of chronic or recurrent pleural effusion, which could be related to asbestos disease, chronic cardiac or renal failure, and thoracic malignancies. It occurs as a rounded mass abutting the pleura with adjacent pleural thickening. Collapsed lobes can assume quite limited forms and radiologists require familiarity with radiographic findings for helping clinical physician in the diagnostic process.

Patient characteristics, treatment patterns, and survival outcomes for patients with malignant pleural mesothelioma in Denmark between 2011 and 2018: a nationwide population-based cohort study.

Malignant pleural mesothelioma (MPM) is a rare thoracic malignancy with poor prognosis and limited treatment options. Immunotherapy shows potential for improved outcomes; however, real-world evidence on its use will take time to accumulate. This study examined patient characteristics, treatment patterns, overall survival (OS), and predictors of mortality among patients diagnosed with MPM in Denmark prior to the introduction of newer treatments. This historical cohort study based on routinely collected Danish National Registry data included adults newly diagnosed with MPM between 01 January 2011 and 31 May 2018. Summary statistics were used to describe patient characteristics and initial treatment. OS was estimated using Kaplan-Meier methods; Cox regression was used to compare patient mortality against the (age/sex-matched) general population and to investigate mortality predictors. Overall, 880 patients were included; 44% had advanced MPM, 37% had non-advanced MPM, and 19% had unknown MPM stage. Median age at diagnosis was 71.9 years, and 82% of the patients were male. Within 180 days of diagnosis, no treatment was recorded for 215 patients (54%) with advanced MPM and 150 (46%) with non-advanced MPM. Median time-to-initial treatment (interquartile range) was 47 days (31-111) overall, 40 days (28-77) in patients with advanced MPM, and 53 days (35-121) with non-advanced MPM. Median OS was 13.7 months overall (non-advanced MPM: 18.0 months vs. advanced MPM: 10.0 months). Predictors of higher mortality were older age at diagnosis, histology, and advanced MPM stage. These findings provide a baseline upon which to evaluate MPM epidemiology as newer treatments are adopted in routine practice.

Immune-related adverse events requiring hospitalization in patients with lung cancer: implications and insights.

Immune checkpoint inhibitors (ICI) are associated with a distinct spectrum of toxicities. Data on irAE hospitalization rates and clinical course of patients with thoracic malignancies are lacking. Patients with advanced thoracic malignancy treated with ICI (2/2016 to 6/2021) were retrospectively identified. Demographic and clinical data of confirmed irAE hospitalizations were extracted from the medical record and a descriptive analysis was performed. From February 2016 to June 2021, 1312 patients with thoracic malignancy received ICI (monotherapy, combination with 2nd ICI or other agents) with 102 patients (7.7%) hospitalized for irAEs. Treatment intent was first-line therapy in most patients (N = 50, 49%) with 9% (n = 9) receiving adjuvant ICI (N = 9). Sixty patients (59%) received ICI alone, 32% (N = 33) chemo plus immunotherapy, and 7% (N = 7) dual ICI. The median age on admission was 68 years. The median time between ICI initiation and admission was 64 days (1-935 days). Pneumonitis (32.3%; 33/102) was the most frequent indication for admission followed by gastroenterocolitis (19.6%; 20/102), hepatitis (12.7%; 13/102), myo/pericarditis (9.8%; 10/102), and endocrinopathies (9.8%; 10/102). Multi-organ toxicity occurred in 36% (N = 37) of patients. Overall, 85.2% (87/102) of patients received systemic corticosteroids and 17.6% (18/102) required additional lines of immunosuppression. The median length of hospitalization stay was 7 days (2-28 days) with a 25.5% (n = 26) readmission rate within 60 days and an 11.8% (n = 12) in house mortality rate. Severe irAE requiring inpatient admission, although infrequent, results in considerable morbidity, mortality, and healthcare utilization. Pneumonitis was the most common irAE requiring inpatient management in our patient population with a significant risk of mortality despite the use of guideline-directed systemic immunosuppression. This study highlights the continued need for collaborative efforts amongst medical specialties for improving the diagnostic and therapeutic management of patients with irAEs.

Outcomes of Suspected Thoracic Malignancy Patients with Initial non Diagnostic Bronchoscopy

Outcomes of Suspected Thoracic Malignancy Patients with Initial non Diagnostic Bronchoscopy

Single institution experience of MRI-guided radiotherapy for thoracic tumors and clinical characteristics impacting treatment duty cycle.

MRI-guided radiotherapy (MRgRT) allows for direct motion management and real-time radiation treatment plan adaptation. We report our institutional experience using low strength 0.35T MRgRT for thoracic malignancies, and evaluate changes in treatment duty cycle between first and final MRgRT fractions. All patients with intrathoracic tumors treated with MRgRT were included. The primary reason for MRgRT (adjacent organ at risk [OAR] vs. motion management [MM] vs. other) was recorded. Tumor location was classified as central (within 2cm of tracheobronchial tree) vs. non-central, and further classified by the Expanded HILUS grouping. Gross tumor volume (GTV) motion, planning target volume expansions, dose/fractionation, treatment plan time, and total delivery time were extracted from the treatment planning system. Treatment plan time was defined as the time for beam delivery, including multileaf collimator (MLC) motion, and gantry rotation. Treatment delivery time was defined as the time from beam on to completion of treatment, including treatment plan time and patient respiratory breath holds. Duty cycle was calculated as treatment plan time/treatment delivery time. Duty cycles were compared between first and final fraction using a two-sample t-test. Twenty-seven patients with thoracic tumors (16 non-small cell lung cancer and 11 thoracic metastases) were treated with MRgRT between 12/2021 and 06/2023. Fifteen patients received MRgRT due to OAR and 11 patients received MRgRT for motion management. 11 patients had central tumors and all were treated with MRgRT due to OAR risk. The median dose/fractionation was 50 Gy/5 fractions. For patients treated due to OAR (n=15), 80% had at least 1 adapted fraction during their course of radiotherapy. There was no plan adaptation for patients treated due to motion management (n=11). Mean GTV motion was significantly higher for patients treated due to motion management compared to OAR (16.1mm vs. 6.5mm, p=0.011). Mean duty cycle for fraction 1 was 54.2% compared to 62.1% with final fraction (p=0.004). Mean fraction 1 duty cycle was higher for patients treated due to OAR compared to patients treated for MM (61% vs. 45.0%, p=0.012). Duty cycle improved from first fraction to final fraction possibly due to patient familiarity with treatment. Duty cycle was improved for patients treated due to OAR risk, likely due to more central location and thus decreased target motion.

Opportunity cost of oncology subspecialist opinion.

e13578 Background: The adoption of precision oncology has resulted in a drastic rise in the cost of cancer care in the United States. Payers, providers, and professional organizations are implementing strategies to curb this rising cost. These efforts are mainly focused on the providers patterns of care, such as prescribing behavior and risk assessment for needs such as ER visits and hospitalizations. Most efforts are cross-cutting and intended to work across different tumor types. Yet, with the precision nature of cancer care these cross-cutting efforts have not succeeded. AccessHope (AH) provides an independent subspecialist review of the management cancer as a covered benefit through the employer (Accountable Precision Oncology: APO). The aim of this service is optimizing care delivery to the current and evolving paradigms for each cancer type and sub-type. Here we describe overutilization of treatments and assessments of APO. Methods: AH database was accessed for de-identified cases (with contractual de-identification rights) for this analysis. Cases were completed 1/1/2022 – 12/31/2023. Descriptive statistics was used to describe the observed patterns identified. Results: Among 3644 APOs, 428 (11.7%) had evidence of overutilization. Gastrointestinal, hematological, and thoracic cancers represented 75% of the over utilization cases (Table). Overutilization was categorized by systemic therapy, radiation therapy, invasive procedures, imaging, and testing. Systemic therapy was the most common category (67.8%) and included non-indication use and extended duration of use. This was followed by imaging (22.2%). Systemic agents overutilized varied by cancer site. Bevacizumab and oxaliplatin were commonly overutilized in gastrointestinal cancers; rituximab, imatinib, and dasatinib in hematological malignancies; and check point inhibitors (pembrolizumab, atezolizumab, and durvalumab) in thoracic malignancies. In the imaging category, PET scan overutilization was observed across different tumor types (14.7% of the total volume). We also observed overutilization of molecular testing with ctDNA (Signatera) being at the top of the frequently overutilized tests in cases with no data to support a role for it. Conclusions: This patient centered approach identified areas of overutilization in evaluation and treatment of patients through the expert review process. The reviewer’s depth of knowledge about reported data and limitation of treatments and evaluations is the key to this process. Further analyses of patterns of care and categorization of the overutilization patterns is underway. [Table: see text]

Histopathological features of SMARCA4-deficient thoracic malignancies: Data from resource-limited setting.

e20045 Background: SMARCA4 deficient tumors are rare malignancies that develop due to inactivating mutation in switch/sucrose-nonfermenting chromatin remodeling complexes (SWI/SNF). This is an aggressive type of non-small cell lung cancer (NSCLC) with a poor prognosis and mediocre treatment response. The trials and observational research on SMARCA4 deficient thoracic malignancies are lacking, especially in limited resource settings. This study aims to analyze pathological and immunohistochemical (IHC) profiles of patients with SMARCA4 deficient thoracic malignancies in Armenia. Methods: The current research utilizes a retrospective cohort single-center study design. The study setting was the only pathology center in Armenia that runs an IHC panel for SMARCA4/BRG1 protein evaluation. For data collection purposes, a census sampling has been done and all the pathology reports of SMARCA4 deficient thoracic malignancies were reviewed. The study timeframe was from 24 February 2021 up to 11 December 2023. Descriptive statistics through portions were done to analyze the data. Results: In total, 19 patients with SMARCA4 deficient thoracic malignancies were diagnosed. The male-to-female ratio was 15:1 and the median age was 63 years (range: 50-73 years). Of those cases, 21% (n = 4) were excluded from the current analysis as histopathological examination of those tissue samples was not performed. The diagnosis was based on an IHC evaluation to obtain a second opinion. The tissue histopathological architecture was represented: 60% (n = 9) solid, 6.67% (n = 1) trabecular, and 6.67% (n = 1) papillary. Of those samples, 66.7% (n = 10) had hyperchromatic/polymorphic nuclei and 33.3% (n = 5) pleomorphic nuclei. Similarly, the evaluated sample cells have 53.3% (n = 8) eosinophilic, 13.3% (n = 2) clear, and 13.3% (n = 2) scant cytoplasm. All 19 cases were included in the descriptive analysis of the IHC profile as examinations were performed for all the subjects. The IHC profile of the cohort is presented in the table. Ki67 was checked in 47.4% (n = 9) of cases with 70-75% median expression. In general, the most frequently examined markers were TTF1, p40, Chromogranin, and AE1/3. Conclusions: In conclusion, the study shed light on SMARCA4 thoracic tumors spread in Armenia. Considering the rarity of the disease, further research is required to investigate the actual prevalence of SMARCA4 deficient thoracic tumors and treatment approaches in Armenia. [Table: see text]

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

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

Implementation of a virtual tumor board through VA National TeleOncology service.

e13571 Background: Multidisciplinary tumor boards are critical to optimize treatment of patients with malignancies. The Veterans Affairs (VA) National TeleOncology (NTO) service was created to provide equitable, state of the art oncologic care virtually to centers across the largest integrated health care system in the US. According to American Society of Clinical Oncology report, 66% of rural counties have no oncologist. Fifty-six percent of Veterans who received cancer care through NTO in 2022 lived in rural areas. We describe a virtual multi-institutional, multidisciplinary tumor board across several malignancies. Through NTO, virtual tumor board (VTB) demonstrates a novel approach to leveraging nationwide oncologic expertise to support patients receiving cancer care at VA Medical Centers (VAMC) across the US. Methods: A VTB was conducted with participation of multiple VAMCs throughout the US. There were five separate VTB oncologic sub-specialties: hematologic, breast/gynecologic, CNS, thoracic and cutaneous malignancies. Each case was presented by the treating provider or designated representative. Pathology and pertinent imaging were reviewed and presented by disease-specific expert specialists. Core attendees included medical oncologists, surgical oncologists, radiation oncologists, pathologists, radiologists, genetic counselors, clinical pharmacists, advanced practice providers and nurses. VTB records were analyzed from VTB inception on March 1, 2022 to February 1, 2024. Data collected included attendance and case presentation information. Results: A total of 113 VTB sessions were conducted every 2 weeks to monthly depending on specialty (35 hematologic, 32 beast/gyn, 24 thoracic, 13 CNS, 9 cutaneous malignancies) with a total of 233 patient cases presented from 51 VA facilities in 33 states and Puerto Rico. The total unique attendees were 468 in 41 states, DC and Puerto Rico. The highest case volume per VA location were from Durham, Houston, Pittsburgh, Sioux Falls and Salem. The highest attendee locations included Durham, Boston, Palo Alto, Pittsburgh, and Richmond. Conclusions: This study demonstrates the feasibility of a national multi-institutional, multi-disciplinary VTB. Tumor board sessions provide access to specialized oncologic expertise with the goal of improving cancer care across the entire VA healthcare system. Further growth of national VTB to increase participation at additional sites and incorporated discussion of clinical trials is ongoing. Future research evaluating quality and outcomes for those cases discussed at VTB will be considered.