AVAHO

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Background: A growing body of evidence suggests that palliative care is an important element of comprehensive cancer treatment by assisting with symptom management and establishing goals of care. Research suggests that enhanced integration of palliative care and oncology medicine has a positive effect on mortality and quality of life outcomes, and integration of the two is now considered standard care. However, there are no standard models for how this integration might occur. At our facility, there was no formal connection between the Oncology service and the Palliative Care Team.

Methods: The interdisciplinary Palliative Care Consult Team established weekly “Lightning Rounds” with Heme-Onc trainees, in which trainees answered questions about each patient regarding symptoms, prognosis, goals of care, and whether Palliative Care support was needed. In addition, trainees received brief didactics—“ teaching pearls”—that addressed components of palliative medicine (eg, use of opioids).

Trainees completed surveys Pre- and Post- Lightning Rounds, rating on a scale of 1 to 5 (Not at all to Very Much) how much they understand about, how confident they are in explaining, and how supported they feel by Palliative Care.

Results: From November 2017 – April 2019, we rounded on 105 unique patients in 26 Lightning Rounds sessions. Pre- and Post- samples are not paired. Average ratings of Pre- (n=18) and Post- (n=14) data show an increase in Understanding (4.2 to 4.6 on a 5-point scale); Confidence (4.0 to 4.6) and Support (4.8 to 5).

Conclusions: The current project sought to enhance integration between Oncology and Palliative Care by establishing a brief weekly Lightning Rounds in which Oncology trainees met with Palliative Care team members. We found that trainees’ understanding in what a Palliative Care consult can provide; their confidence in knowing when to offer a Palliative Care consult, and how supported they feel by our Palliative Care team, all increased from pre- to post-Lightning Rounds. These findings support our initial hypotheses and are encouraging continued involvement via this medium.

Background: The use of oral chemotherapy, both as monotherapy and in combination with parenteral chemotherapy, has drastically increased. Goals of oral chemotherapy monitoring include initial patient education, assessment of adherence during therapy, ensuring baseline and routine lab monitoring, and testing. The provision of cost savings is performed when possible. To achieve these goals, a QI initiative was implemented to determine the feasibility of a multi-disciplinary oral chemotherapy monitoring program within a VA oncology clinic.

Methods: The QI initiative was started in February 2019. To facilitate and standardize communication between Oncology providers, Oncology Nursing staff and the Oncology Clinical Pharmacist (CPS), an “Oncology Chemotherapy Consult” was created. Entry of the consult in CPRS by the Oncology Provider alerts Oncology Nursing and Oncology Pharmacy staff to a new patient starting oral chemotherapy. The Oncology CPS receives and reviews the consult and verifies that a pharmacy Prior Authorization Drug Request Consult (PADR) has been entered, if applicable. All available labs are reviewed, and any additional baseline labs or testing are requested by the CPS. The Oncology RN designated for chemotherapy education provides face-to-face education for the medication(s) on the same day of the provider visit and determines the date of the return appointment for a toxicity screen approximately 14 days later. Once the PADR is reviewed and approved, the CPS completes the consult and orders a split-fill (15-day supply) of medication.

Results: The QI initiative to improve oral chemotherapy delivery and monitoring was proven effective and feasible. 95% of new oral chemotherapy patients have been enrolled in this program since its inception. Cost savings analysis is in progress and data will be available prior to the AVAHO meeting. Interventions performed to improve adherence and education will also be available

Conclusion: Based on results since initiation of this quality practice initiative, improved treatment adherence has been observed, early identification and management of toxicity has occurred, and utilization of a split-fill strategy for initial dosing has resulted in cost savings. Even in the early phase of this initiative, feasibility has been identified and increased benefit is predicted.

Background: The use of oral chemotherapy, both as monotherapy and in combination with parenteral chemotherapy, has drastically increased. Goals of oral chemotherapy monitoring include initial patient education, assessment of adherence during therapy, ensuring baseline and routine lab monitoring, and testing. The provision of cost savings is performed when possible. To achieve these goals, a QI initiative was implemented to determine the feasibility of a multi-disciplinary oral chemotherapy monitoring program within a VA oncology clinic.

Methods: The QI initiative was started in February 2019. To facilitate and standardize communication between Oncology providers, Oncology Nursing staff and the Oncology Clinical Pharmacist (CPS), an “Oncology Chemotherapy Consult” was created. Entry of the consult in CPRS by the Oncology Provider alerts Oncology Nursing and Oncology Pharmacy staff to a new patient starting oral chemotherapy. The Oncology CPS receives and reviews the consult and verifies that a pharmacy Prior Authorization Drug Request Consult (PADR) has been entered, if applicable. All available labs are reviewed, and any additional baseline labs or testing are requested by the CPS. The Oncology RN designated for chemotherapy education provides face-to-face education for the medication(s) on the same day of the provider visit and determines the date of the return appointment for a toxicity screen approximately 14 days later. Once the PADR is reviewed and approved, the CPS completes the consult and orders a split-fill (15-day supply) of medication.

Results: The QI initiative to improve oral chemotherapy delivery and monitoring was proven effective and feasible. 95% of new oral chemotherapy patients have been enrolled in this program since its inception. Cost savings analysis is in progress and data will be available prior to the AVAHO meeting. Interventions performed to improve adherence and education will also be available

Conclusion: Based on results since initiation of this quality practice initiative, improved treatment adherence has been observed, early identification and management of toxicity has occurred, and utilization of a split-fill strategy for initial dosing has resulted in cost savings. Even in the early phase of this initiative, feasibility has been identified and increased benefit is predicted.

Background: The use of oral chemotherapy, both as monotherapy and in combination with parenteral chemotherapy, has drastically increased. Goals of oral chemotherapy monitoring include initial patient education, assessment of adherence during therapy, ensuring baseline and routine lab monitoring, and testing. The provision of cost savings is performed when possible. To achieve these goals, a QI initiative was implemented to determine the feasibility of a multi-disciplinary oral chemotherapy monitoring program within a VA oncology clinic.

Methods: The QI initiative was started in February 2019. To facilitate and standardize communication between Oncology providers, Oncology Nursing staff and the Oncology Clinical Pharmacist (CPS), an “Oncology Chemotherapy Consult” was created. Entry of the consult in CPRS by the Oncology Provider alerts Oncology Nursing and Oncology Pharmacy staff to a new patient starting oral chemotherapy. The Oncology CPS receives and reviews the consult and verifies that a pharmacy Prior Authorization Drug Request Consult (PADR) has been entered, if applicable. All available labs are reviewed, and any additional baseline labs or testing are requested by the CPS. The Oncology RN designated for chemotherapy education provides face-to-face education for the medication(s) on the same day of the provider visit and determines the date of the return appointment for a toxicity screen approximately 14 days later. Once the PADR is reviewed and approved, the CPS completes the consult and orders a split-fill (15-day supply) of medication.

Results: The QI initiative to improve oral chemotherapy delivery and monitoring was proven effective and feasible. 95% of new oral chemotherapy patients have been enrolled in this program since its inception. Cost savings analysis is in progress and data will be available prior to the AVAHO meeting. Interventions performed to improve adherence and education will also be available

Conclusion: Based on results since initiation of this quality practice initiative, improved treatment adherence has been observed, early identification and management of toxicity has occurred, and utilization of a split-fill strategy for initial dosing has resulted in cost savings. Even in the early phase of this initiative, feasibility has been identified and increased benefit is predicted.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Background: Approximately 15% of patients with cancer require transfusion for treatment of disease- or chemotherapy-induced anemia. Previous studies have shown that anemia adversely affects patient quality of life (QoL), but QoL significant improves with transfusion. At the BVAMC, providers noted increasing delays in outpatient transfusion access averaging 2-3 days, resulting in prolongation of patient symptom burden (Plan). Additionally, outpatient transfusion is associated with significant patient time burden, patient travel burden, and health care cost, so delay in transfusion delivery also exacerbates these challenges.

Intervention: We created a process map for outpatient transfusion (Do). We learned that if a patient requires same-day transfusion, the patient must be admitted, resulting in a minimum cost of $3000 for a 24-hour hospitalization. We also learned that the outpatient infusion clinic is performing an increasing number of transfusions and non-transfusion related clinical services for other subspecialties, specifically infusion of iron, intravenous immunoglobulin, and biologic medications (i.e. infliximab, tocilizumab). There was a 2.6- times increase in blood transfusions per year since 2013 (78 to 205 units of pack red cells), possibly due to improved oncologic therapies prolonging patient survival. Furthermore, there was a 2-times increase in patient encounters for iron infusions (463 to 923) and a 1.4-times increase for biologics (876 to 1248) since 2010. This significantly increased demand has resulted in limited infusion chair access, precluding same-day transfusion availability (Study).

Outcome: The repercussions of decreased same-day transfusion access was presented to BVAMC administration. New space has been made available for seven additional chairs with transfusion capability. Iron infusions have been moved to the Hematology/Oncology chemotherapy center to increase ease of access, with a plan to move most transfusion to this space as well (Act). We project that access to same-day transfusion will avoid 2 hospitalizations per month at an annual cost of $72,000.

Implications: Access to same-day transfusion for treatment of anemia in patients with cancer decreases patient symptom and time burden and also results in cost savings. We encourage other facilities to explore their infusion space utilization, as demands will likely increase with growing use of intravenous therapies across specialties.

Purpose: To improve patient understanding of recommended antiemetics and self-reported nausea following chemotherapy with a simple pill-identifying calendar handout.

Background: Chemotherapy-induced nausea and vomiting (CINV) is among the most severe adverse effects and important concerns in cancer patients. While there are multiple antiemetics available, dosing and timing can be confusing for patients, especially those with poor health literacy. Inadequate health literacy has been associated with poor self-management behaviors, and greater risk for non-compliance with treatment.

Methods: We assessed CINV in 25 patients treated in the Medical Oncology clinic at the University of Arkansas for Medical Sciences by using the existing validated Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT). We performed a Plan-Do-Study-Act (PDSA) cycle by implementing dosing calendar handouts with images and names of antiemetics scheduled per National Comprehensive Cancer Network (NCCN) guidelines.

Data Analysis: McNemar’s test was used for paired nominal data. Wilcoxon signed-rank test was utilized to evaluate differences in cohort means before and after intervention.

Results: At baseline, we utilized the MAT to document patient-reported incidence and severity of acute and delayed nausea and vomiting on a 10-point scale during one cycle of chemotherapy. Subsequently, we provided handouts for future cycles of chemotherapy. MAT was completed again following this intervention. Nausea was improved in 63% of patients. Vomiting was improved in 82% of patients. Severity of acute and delayed nausea improved from 4.40 (SD 4.25) to 2.54 (SD 2.28; P=0.008) and from 5.84 (SD 3.13) to 3.13 (SD 3.15, P=0.0016), respectively. Mean duration of nausea and vomiting was decreased from 3.72 days (SD 2.79) to 2.0 days (SD 2.55, P=0.0002). In addition, a single question was utilized to assess patient’s confidence in understanding their antiemetic regimen on a 10-point scale, which improved in 16 of 25 patients from a mean score of 7.84 (SD 1.97) to 9.50 (SD 1.18, P=0.0001).

Implications: Our calendar handout with pill images is an effective method to improve understanding of cancer treatment and decrease CINV in patients. As a result, a future PDSA cycle is planned to incorporate these handouts into our institution’s electronic medical record system.

Purpose: To improve patient understanding of recommended antiemetics and self-reported nausea following chemotherapy with a simple pill-identifying calendar handout.

Background: Chemotherapy-induced nausea and vomiting (CINV) is among the most severe adverse effects and important concerns in cancer patients. While there are multiple antiemetics available, dosing and timing can be confusing for patients, especially those with poor health literacy. Inadequate health literacy has been associated with poor self-management behaviors, and greater risk for non-compliance with treatment.

Methods: We assessed CINV in 25 patients treated in the Medical Oncology clinic at the University of Arkansas for Medical Sciences by using the existing validated Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT). We performed a Plan-Do-Study-Act (PDSA) cycle by implementing dosing calendar handouts with images and names of antiemetics scheduled per National Comprehensive Cancer Network (NCCN) guidelines.

Data Analysis: McNemar’s test was used for paired nominal data. Wilcoxon signed-rank test was utilized to evaluate differences in cohort means before and after intervention.

Results: At baseline, we utilized the MAT to document patient-reported incidence and severity of acute and delayed nausea and vomiting on a 10-point scale during one cycle of chemotherapy. Subsequently, we provided handouts for future cycles of chemotherapy. MAT was completed again following this intervention. Nausea was improved in 63% of patients. Vomiting was improved in 82% of patients. Severity of acute and delayed nausea improved from 4.40 (SD 4.25) to 2.54 (SD 2.28; P=0.008) and from 5.84 (SD 3.13) to 3.13 (SD 3.15, P=0.0016), respectively. Mean duration of nausea and vomiting was decreased from 3.72 days (SD 2.79) to 2.0 days (SD 2.55, P=0.0002). In addition, a single question was utilized to assess patient’s confidence in understanding their antiemetic regimen on a 10-point scale, which improved in 16 of 25 patients from a mean score of 7.84 (SD 1.97) to 9.50 (SD 1.18, P=0.0001).

Implications: Our calendar handout with pill images is an effective method to improve understanding of cancer treatment and decrease CINV in patients. As a result, a future PDSA cycle is planned to incorporate these handouts into our institution’s electronic medical record system.

Purpose: To improve patient understanding of recommended antiemetics and self-reported nausea following chemotherapy with a simple pill-identifying calendar handout.

Background: Chemotherapy-induced nausea and vomiting (CINV) is among the most severe adverse effects and important concerns in cancer patients. While there are multiple antiemetics available, dosing and timing can be confusing for patients, especially those with poor health literacy. Inadequate health literacy has been associated with poor self-management behaviors, and greater risk for non-compliance with treatment.

Methods: We assessed CINV in 25 patients treated in the Medical Oncology clinic at the University of Arkansas for Medical Sciences by using the existing validated Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT). We performed a Plan-Do-Study-Act (PDSA) cycle by implementing dosing calendar handouts with images and names of antiemetics scheduled per National Comprehensive Cancer Network (NCCN) guidelines.

Data Analysis: McNemar’s test was used for paired nominal data. Wilcoxon signed-rank test was utilized to evaluate differences in cohort means before and after intervention.

Results: At baseline, we utilized the MAT to document patient-reported incidence and severity of acute and delayed nausea and vomiting on a 10-point scale during one cycle of chemotherapy. Subsequently, we provided handouts for future cycles of chemotherapy. MAT was completed again following this intervention. Nausea was improved in 63% of patients. Vomiting was improved in 82% of patients. Severity of acute and delayed nausea improved from 4.40 (SD 4.25) to 2.54 (SD 2.28; P=0.008) and from 5.84 (SD 3.13) to 3.13 (SD 3.15, P=0.0016), respectively. Mean duration of nausea and vomiting was decreased from 3.72 days (SD 2.79) to 2.0 days (SD 2.55, P=0.0002). In addition, a single question was utilized to assess patient’s confidence in understanding their antiemetic regimen on a 10-point scale, which improved in 16 of 25 patients from a mean score of 7.84 (SD 1.97) to 9.50 (SD 1.18, P=0.0001).

Implications: Our calendar handout with pill images is an effective method to improve understanding of cancer treatment and decrease CINV in patients. As a result, a future PDSA cycle is planned to incorporate these handouts into our institution’s electronic medical record system.

Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.

Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.

Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.

Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.

Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.

Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.

Purpose: To determine the incidence and types of irAEs seen in the ED at VA San Diego Healthcare System (VASDHS).

Background: ICPIs activate T-cells against many tumor types, but they also cause irAEs, which can lead to organ dysfunction. With the increasing use of ICPIs, more patients are visiting the ED due to irAEs. ED providers should be familiar with irAEs to prevent misdiagnosis and further complications.

Methods: This was a retrospective study that included patients who received at least one dose of ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab, or any ICPI combination. The primary outcome was the incidence/types of irAEs seen in the ED. Secondary outcomes included: percent of irAEs leading to hospital admission, percent of ED providers aware of ICPI therapy, and rate of ICPI discontinuation due to irAEs. Patients who experienced severe irAEs (irAEs that warranted an ED visit or ICPI discontinuation) were compared against those who didn’t to identify risk factors. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous data, respectively.

Results: Out of 151 patients who received ICPIs, 22 experienced severe irAEs. Patient characteristics were similar except: more patients in the irAE group were diagnosed with melanoma and had received ipilimumab or >1 ICPI. A total of 246 ED visits were documented: 14 patients made 16 ED visits (6.5%) due to irAEs including colitis, hypophysitis, and hypothyroidism; 15 visits (93.8%) led to hospital admission, and 14 ED providers (87.5%) were aware of ICPI therapy. Ipilimumab and ipilimumab/nivolumab were the most recent ICPIs administered before an irAE. ICPIs were discontinued in 15 patients due to irAEs, 7 of which stopped after an ED visit.

Conclusion: The rate of irAE-related ED visits at VASDHS was lower than published literature (6.5% vs. 25%) which may have been due to small sample size. Most irAEs were associated with ipilimumab and combination ICPIs, similar to previous studies. Most ED providers were aware of ICPI therapy leading to appropriate diagnosis of irAEs. Risk factors for severe irAEs may include treatment with ipilimumab or >1 ICPI. Continuous education of ED staff regarding ICPIs and irAEs is recommended to ensure appropriate diagnosis and treatment.

Purpose: To determine the incidence and types of irAEs seen in the ED at VA San Diego Healthcare System (VASDHS).

Background: ICPIs activate T-cells against many tumor types, but they also cause irAEs, which can lead to organ dysfunction. With the increasing use of ICPIs, more patients are visiting the ED due to irAEs. ED providers should be familiar with irAEs to prevent misdiagnosis and further complications.

Methods: This was a retrospective study that included patients who received at least one dose of ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab, or any ICPI combination. The primary outcome was the incidence/types of irAEs seen in the ED. Secondary outcomes included: percent of irAEs leading to hospital admission, percent of ED providers aware of ICPI therapy, and rate of ICPI discontinuation due to irAEs. Patients who experienced severe irAEs (irAEs that warranted an ED visit or ICPI discontinuation) were compared against those who didn’t to identify risk factors. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous data, respectively.

Results: Out of 151 patients who received ICPIs, 22 experienced severe irAEs. Patient characteristics were similar except: more patients in the irAE group were diagnosed with melanoma and had received ipilimumab or >1 ICPI. A total of 246 ED visits were documented: 14 patients made 16 ED visits (6.5%) due to irAEs including colitis, hypophysitis, and hypothyroidism; 15 visits (93.8%) led to hospital admission, and 14 ED providers (87.5%) were aware of ICPI therapy. Ipilimumab and ipilimumab/nivolumab were the most recent ICPIs administered before an irAE. ICPIs were discontinued in 15 patients due to irAEs, 7 of which stopped after an ED visit.

Conclusion: The rate of irAE-related ED visits at VASDHS was lower than published literature (6.5% vs. 25%) which may have been due to small sample size. Most irAEs were associated with ipilimumab and combination ICPIs, similar to previous studies. Most ED providers were aware of ICPI therapy leading to appropriate diagnosis of irAEs. Risk factors for severe irAEs may include treatment with ipilimumab or >1 ICPI. Continuous education of ED staff regarding ICPIs and irAEs is recommended to ensure appropriate diagnosis and treatment.

Purpose: To determine the incidence and types of irAEs seen in the ED at VA San Diego Healthcare System (VASDHS).

Background: ICPIs activate T-cells against many tumor types, but they also cause irAEs, which can lead to organ dysfunction. With the increasing use of ICPIs, more patients are visiting the ED due to irAEs. ED providers should be familiar with irAEs to prevent misdiagnosis and further complications.

Methods: This was a retrospective study that included patients who received at least one dose of ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab, or any ICPI combination. The primary outcome was the incidence/types of irAEs seen in the ED. Secondary outcomes included: percent of irAEs leading to hospital admission, percent of ED providers aware of ICPI therapy, and rate of ICPI discontinuation due to irAEs. Patients who experienced severe irAEs (irAEs that warranted an ED visit or ICPI discontinuation) were compared against those who didn’t to identify risk factors. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous data, respectively.

Results: Out of 151 patients who received ICPIs, 22 experienced severe irAEs. Patient characteristics were similar except: more patients in the irAE group were diagnosed with melanoma and had received ipilimumab or >1 ICPI. A total of 246 ED visits were documented: 14 patients made 16 ED visits (6.5%) due to irAEs including colitis, hypophysitis, and hypothyroidism; 15 visits (93.8%) led to hospital admission, and 14 ED providers (87.5%) were aware of ICPI therapy. Ipilimumab and ipilimumab/nivolumab were the most recent ICPIs administered before an irAE. ICPIs were discontinued in 15 patients due to irAEs, 7 of which stopped after an ED visit.

Conclusion: The rate of irAE-related ED visits at VASDHS was lower than published literature (6.5% vs. 25%) which may have been due to small sample size. Most irAEs were associated with ipilimumab and combination ICPIs, similar to previous studies. Most ED providers were aware of ICPI therapy leading to appropriate diagnosis of irAEs. Risk factors for severe irAEs may include treatment with ipilimumab or >1 ICPI. Continuous education of ED staff regarding ICPIs and irAEs is recommended to ensure appropriate diagnosis and treatment.

Purpose: With an increasing emphasis on Veteran Women’s Health, we designed a study to see how our VAMC was doing at detecting invasive carcinomas and lesions that progress to carcinoma of the gynecologic tract.

Background: Cervical Cytology (also called a Pap smear) is reported to only be sensitive in detecting CIN II-III or carcinoma in 44%-72% of patients in the private sector. Is it higher in the VA System with higher standards of Quality Control?

Methods: Histology to cytology correlation statistics (all biopsies, cervical cones, and cervical resections), cervical smear diagnosis data, and righ-risk HPV (HR-HPV) status maintained by the Director of Cytopathology at the Houston VAMC (Quality Assurance Program) were reviewed from 2008 to 2018. Only patients with CIN III (severe dysplasia or carcinoma in situ) or invasive squamous cell carcinoma and adenocarcinoma were used for outcomes. All PAP smears are screened by both Staff Cytotechnologists and Staff Cytopathologists.

Results: From 2008-2018, there were 21,086 cervical smears performed and 184 cases of CIN III or Carcinoma were detected. Of the 6 invasive carcinomas, 2 had no previous pap smear and 4 had their 1st PAP smear show CIN III or Carcinoma. In CIN III, which includes Carcinoma In Situ, the first PAP smear showed 58 High Grade Squamous Intraepithelial Neoplasia, 68 Low Grade Squamous Intraepithelial Neoplasia and 52 Atypical Squamous Cells of Undetermined Significance warranting biopsy. Three patients had no VA Pap smear but presented with abnormal cytology in the private sector.

Implications: Compared to the private sector, the Houston VAMC had a 100% detection rate for CIN III and invasive carcinomas when there was a screening pap smear. None of the patients with CINIII/CIS progressed to an invasive carcinoma because they had been treated for their CIN III/CIS. When a strong QA program is used in Cytopathology, results can exceed the private sector.

Purpose: With an increasing emphasis on Veteran Women’s Health, we designed a study to see how our VAMC was doing at detecting invasive carcinomas and lesions that progress to carcinoma of the gynecologic tract.

Background: Cervical Cytology (also called a Pap smear) is reported to only be sensitive in detecting CIN II-III or carcinoma in 44%-72% of patients in the private sector. Is it higher in the VA System with higher standards of Quality Control?

Methods: Histology to cytology correlation statistics (all biopsies, cervical cones, and cervical resections), cervical smear diagnosis data, and righ-risk HPV (HR-HPV) status maintained by the Director of Cytopathology at the Houston VAMC (Quality Assurance Program) were reviewed from 2008 to 2018. Only patients with CIN III (severe dysplasia or carcinoma in situ) or invasive squamous cell carcinoma and adenocarcinoma were used for outcomes. All PAP smears are screened by both Staff Cytotechnologists and Staff Cytopathologists.

Results: From 2008-2018, there were 21,086 cervical smears performed and 184 cases of CIN III or Carcinoma were detected. Of the 6 invasive carcinomas, 2 had no previous pap smear and 4 had their 1st PAP smear show CIN III or Carcinoma. In CIN III, which includes Carcinoma In Situ, the first PAP smear showed 58 High Grade Squamous Intraepithelial Neoplasia, 68 Low Grade Squamous Intraepithelial Neoplasia and 52 Atypical Squamous Cells of Undetermined Significance warranting biopsy. Three patients had no VA Pap smear but presented with abnormal cytology in the private sector.

Implications: Compared to the private sector, the Houston VAMC had a 100% detection rate for CIN III and invasive carcinomas when there was a screening pap smear. None of the patients with CINIII/CIS progressed to an invasive carcinoma because they had been treated for their CIN III/CIS. When a strong QA program is used in Cytopathology, results can exceed the private sector.

Purpose: With an increasing emphasis on Veteran Women’s Health, we designed a study to see how our VAMC was doing at detecting invasive carcinomas and lesions that progress to carcinoma of the gynecologic tract.

Background: Cervical Cytology (also called a Pap smear) is reported to only be sensitive in detecting CIN II-III or carcinoma in 44%-72% of patients in the private sector. Is it higher in the VA System with higher standards of Quality Control?

Methods: Histology to cytology correlation statistics (all biopsies, cervical cones, and cervical resections), cervical smear diagnosis data, and righ-risk HPV (HR-HPV) status maintained by the Director of Cytopathology at the Houston VAMC (Quality Assurance Program) were reviewed from 2008 to 2018. Only patients with CIN III (severe dysplasia or carcinoma in situ) or invasive squamous cell carcinoma and adenocarcinoma were used for outcomes. All PAP smears are screened by both Staff Cytotechnologists and Staff Cytopathologists.

Results: From 2008-2018, there were 21,086 cervical smears performed and 184 cases of CIN III or Carcinoma were detected. Of the 6 invasive carcinomas, 2 had no previous pap smear and 4 had their 1st PAP smear show CIN III or Carcinoma. In CIN III, which includes Carcinoma In Situ, the first PAP smear showed 58 High Grade Squamous Intraepithelial Neoplasia, 68 Low Grade Squamous Intraepithelial Neoplasia and 52 Atypical Squamous Cells of Undetermined Significance warranting biopsy. Three patients had no VA Pap smear but presented with abnormal cytology in the private sector.

Implications: Compared to the private sector, the Houston VAMC had a 100% detection rate for CIN III and invasive carcinomas when there was a screening pap smear. None of the patients with CINIII/CIS progressed to an invasive carcinoma because they had been treated for their CIN III/CIS. When a strong QA program is used in Cytopathology, results can exceed the private sector.

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a  2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a  2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a  2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: A majority of end-stage cancer patients are receiving chemotherapy, regardless of performance status, in the last months of life. Oncologists continue to prescribe disease targeted therapy for patients enrolled in palliative or hospice care in an attempt to alleviate symptoms and extend life expectancy. Research indicates that chemotherapy at end of life does not accomplish either of these goals of care, and may actually do more harm than good.

Methods: An evidence based research review indicates that > 50% of all cancer patients are receiving chemotherapy during their last 4-6 months of life. Data supports a decreased quality of life and decreased life expectancy for patients receiving chemotherapy during the last months of life. There is an increase in visits to the emergency department, hospitalizations, and death in the hospital when cancer patients are actively receiving chemotherapy during end of life.

Overutilization of chemotherapy treatment is poor quality care leading to adverse patient outcomes. The intent of hospice care is to meet the physical, emotional, social, and spiritual needs of a dying patient and their family. The focus of care is on comfort, not cure. The intent of palliative care focuses on symptom control and may include a combination of comfort measures and curative interventions. This review supports further investigation into the practice of chemotherapy administration in terminally ill patients.

Background: A majority of end-stage cancer patients are receiving chemotherapy, regardless of performance status, in the last months of life. Oncologists continue to prescribe disease targeted therapy for patients enrolled in palliative or hospice care in an attempt to alleviate symptoms and extend life expectancy. Research indicates that chemotherapy at end of life does not accomplish either of these goals of care, and may actually do more harm than good.

Methods: An evidence based research review indicates that > 50% of all cancer patients are receiving chemotherapy during their last 4-6 months of life. Data supports a decreased quality of life and decreased life expectancy for patients receiving chemotherapy during the last months of life. There is an increase in visits to the emergency department, hospitalizations, and death in the hospital when cancer patients are actively receiving chemotherapy during end of life.

Overutilization of chemotherapy treatment is poor quality care leading to adverse patient outcomes. The intent of hospice care is to meet the physical, emotional, social, and spiritual needs of a dying patient and their family. The focus of care is on comfort, not cure. The intent of palliative care focuses on symptom control and may include a combination of comfort measures and curative interventions. This review supports further investigation into the practice of chemotherapy administration in terminally ill patients.

Background: A majority of end-stage cancer patients are receiving chemotherapy, regardless of performance status, in the last months of life. Oncologists continue to prescribe disease targeted therapy for patients enrolled in palliative or hospice care in an attempt to alleviate symptoms and extend life expectancy. Research indicates that chemotherapy at end of life does not accomplish either of these goals of care, and may actually do more harm than good.

Methods: An evidence based research review indicates that > 50% of all cancer patients are receiving chemotherapy during their last 4-6 months of life. Data supports a decreased quality of life and decreased life expectancy for patients receiving chemotherapy during the last months of life. There is an increase in visits to the emergency department, hospitalizations, and death in the hospital when cancer patients are actively receiving chemotherapy during end of life.

Overutilization of chemotherapy treatment is poor quality care leading to adverse patient outcomes. The intent of hospice care is to meet the physical, emotional, social, and spiritual needs of a dying patient and their family. The focus of care is on comfort, not cure. The intent of palliative care focuses on symptom control and may include a combination of comfort measures and curative interventions. This review supports further investigation into the practice of chemotherapy administration in terminally ill patients.

Background: Renal Cell carcinoma (RCC) possesses the ability to metastasize to distant places most commonly lungs, lymph nodes, liver, bone, and brain. While RCC can metastasize potentially to any organ, the gastrointestinal tract involvement is exceedingly rare.

Case Presentation: A 76-year-old male veteran presented with complain of hematuria and was diagnosed initially with stage 3 (pT3cN0M0) clear cell RCC of the right kidney. He underwent right radical nephrectomy with caval thrombectomy. He was then followed for surveillance during which, based on his radiological imaging, he was found to have a mesenteric mass inseparable from the transverse colon, multiple pulmonary nodules, and a large hypo density in the liver. He underwent subsequent biopsy of the mesenteric mass, which confirmed metastatic RCC (clear cell).

He was started on sunitinib 50mg based on NCCN guidelines. He did well on sunitinib for a while, but repeat CT chest, abdomen, and pelvis scans showed progression of his disease. He was started on nivolumab as a second line agent as per the NCCN guidelines. While on nivolumab, he presented in early 2019 with an episode of GI bleeding (melena). He underwent repeat radiological imaging as well as an endoscopy, which showed medium size friable soft tissue mass in the 2nd part of duodenum. Biopsy of that mass con rmed RCC eroding into the duodenal mucosa. His case was discussed at the tumor board, and it was recommended that palliative surgery and radiation were not an option for him. A recommendation for palliative and supportive treatment were made. The patient’s condition was discussed with him, and given that he was asymptomatic and at his general baseline health, he opted to continue with the immunotherapy.

Conclusion: RCC metastasis to GI tract is rare. The duodenum is reported to be the least involved segment of the small intestine. The number of cases reports in literature on duodenal metastasis from RCC is estimated to be around 20-25.Treatment of RCC with duodenal metastases depends upon the location and extent of the tumor as well as patient’s fitness for different modalities.

Background: Renal Cell carcinoma (RCC) possesses the ability to metastasize to distant places most commonly lungs, lymph nodes, liver, bone, and brain. While RCC can metastasize potentially to any organ, the gastrointestinal tract involvement is exceedingly rare.

Case Presentation: A 76-year-old male veteran presented with complain of hematuria and was diagnosed initially with stage 3 (pT3cN0M0) clear cell RCC of the right kidney. He underwent right radical nephrectomy with caval thrombectomy. He was then followed for surveillance during which, based on his radiological imaging, he was found to have a mesenteric mass inseparable from the transverse colon, multiple pulmonary nodules, and a large hypo density in the liver. He underwent subsequent biopsy of the mesenteric mass, which confirmed metastatic RCC (clear cell).

He was started on sunitinib 50mg based on NCCN guidelines. He did well on sunitinib for a while, but repeat CT chest, abdomen, and pelvis scans showed progression of his disease. He was started on nivolumab as a second line agent as per the NCCN guidelines. While on nivolumab, he presented in early 2019 with an episode of GI bleeding (melena). He underwent repeat radiological imaging as well as an endoscopy, which showed medium size friable soft tissue mass in the 2nd part of duodenum. Biopsy of that mass con rmed RCC eroding into the duodenal mucosa. His case was discussed at the tumor board, and it was recommended that palliative surgery and radiation were not an option for him. A recommendation for palliative and supportive treatment were made. The patient’s condition was discussed with him, and given that he was asymptomatic and at his general baseline health, he opted to continue with the immunotherapy.

Conclusion: RCC metastasis to GI tract is rare. The duodenum is reported to be the least involved segment of the small intestine. The number of cases reports in literature on duodenal metastasis from RCC is estimated to be around 20-25.Treatment of RCC with duodenal metastases depends upon the location and extent of the tumor as well as patient’s fitness for different modalities.

Background: Renal Cell carcinoma (RCC) possesses the ability to metastasize to distant places most commonly lungs, lymph nodes, liver, bone, and brain. While RCC can metastasize potentially to any organ, the gastrointestinal tract involvement is exceedingly rare.

Case Presentation: A 76-year-old male veteran presented with complain of hematuria and was diagnosed initially with stage 3 (pT3cN0M0) clear cell RCC of the right kidney. He underwent right radical nephrectomy with caval thrombectomy. He was then followed for surveillance during which, based on his radiological imaging, he was found to have a mesenteric mass inseparable from the transverse colon, multiple pulmonary nodules, and a large hypo density in the liver. He underwent subsequent biopsy of the mesenteric mass, which confirmed metastatic RCC (clear cell).

He was started on sunitinib 50mg based on NCCN guidelines. He did well on sunitinib for a while, but repeat CT chest, abdomen, and pelvis scans showed progression of his disease. He was started on nivolumab as a second line agent as per the NCCN guidelines. While on nivolumab, he presented in early 2019 with an episode of GI bleeding (melena). He underwent repeat radiological imaging as well as an endoscopy, which showed medium size friable soft tissue mass in the 2nd part of duodenum. Biopsy of that mass con rmed RCC eroding into the duodenal mucosa. His case was discussed at the tumor board, and it was recommended that palliative surgery and radiation were not an option for him. A recommendation for palliative and supportive treatment were made. The patient’s condition was discussed with him, and given that he was asymptomatic and at his general baseline health, he opted to continue with the immunotherapy.

Conclusion: RCC metastasis to GI tract is rare. The duodenum is reported to be the least involved segment of the small intestine. The number of cases reports in literature on duodenal metastasis from RCC is estimated to be around 20-25.Treatment of RCC with duodenal metastases depends upon the location and extent of the tumor as well as patient’s fitness for different modalities.