AVAHO

Purpose: It is conventional to treat pelvic lymph nodes, followed by prostate boost in a sequential manner, requiring 8-9 weeks to complete therapy. In the last several years there have been several randomized studies of implementing moderate hypofractionated radiotherapy in prostate cancer to shorten the treatment time, which has proven to be non-inferior to conventional treatment. The purpose of this retrospective study is to evaluate the acute toxicities of hypofractionated SIB radiotherapy in treating the lymph nodes with prostate boost.

Methods: Between 2015 and 2017, twenty five high risk prostate cancer patients received pelvic node radiotherapy with prostate boost in 25 fractions with SIB technique with neo-adjuvant and concurrent hormone therapy to 50 Gy/25 fractions at 2 Gy/fraction to pelvic nodes and prostate boost for a total of 67.5 - 75 Gy at 2.7 to 3.0 Gy/fraction. We followed QUNTAC dose-volume constraints for the rectum, bladder and bowel. All these patients received long-term hormone therapy.

Results: The median age was 66 years (range 57-81 years). There were 6 stage II C, 7 III A, 15 III C, and 1 stage IV A. All patients were restaged as per American Joint Committee on Cancer 8th edition. Gleason Score: 6 (1), 7 (4+3) (4), 8 (5), and 9-10 (15). The average PSA was 17.2 ng/mL with a range of 5.6 to 51.92 ng/mL, and average number of positive cores was 74%. These factors put the majority of patients into the very high risk group. The median follow up was 24 months. The majority of the patients tolerated treatment well. Grade 0 genitourinary (GU) toxicity occurred
in 8 (33%) patients, grade II 16 (67%) patients, one patient had a Foley catheter during treatment, a majority of patients were on alpha blockers either before, during or post radiotherapy. Grade 0 gastrointestinal (GI) toxicity occurred in 21 (84%) patients, grade 1 in one, and grade II in 3 (12%) patients. There were no grade 3 or 4 GU or GI toxicities.

Conclusions: Simultaneous integrated boost with VMAT is well tolerated in treating pelvic nodes and prostate boost, without any major acute toxicities. This technique is used in mostly for very high risk localized prostate cancer patients, reducing number of fractions from conventional sequential treatment.

Purpose: It is conventional to treat pelvic lymph nodes, followed by prostate boost in a sequential manner, requiring 8-9 weeks to complete therapy. In the last several years there have been several randomized studies of implementing moderate hypofractionated radiotherapy in prostate cancer to shorten the treatment time, which has proven to be non-inferior to conventional treatment. The purpose of this retrospective study is to evaluate the acute toxicities of hypofractionated SIB radiotherapy in treating the lymph nodes with prostate boost.

Methods: Between 2015 and 2017, twenty five high risk prostate cancer patients received pelvic node radiotherapy with prostate boost in 25 fractions with SIB technique with neo-adjuvant and concurrent hormone therapy to 50 Gy/25 fractions at 2 Gy/fraction to pelvic nodes and prostate boost for a total of 67.5 - 75 Gy at 2.7 to 3.0 Gy/fraction. We followed QUNTAC dose-volume constraints for the rectum, bladder and bowel. All these patients received long-term hormone therapy.

Results: The median age was 66 years (range 57-81 years). There were 6 stage II C, 7 III A, 15 III C, and 1 stage IV A. All patients were restaged as per American Joint Committee on Cancer 8th edition. Gleason Score: 6 (1), 7 (4+3) (4), 8 (5), and 9-10 (15). The average PSA was 17.2 ng/mL with a range of 5.6 to 51.92 ng/mL, and average number of positive cores was 74%. These factors put the majority of patients into the very high risk group. The median follow up was 24 months. The majority of the patients tolerated treatment well. Grade 0 genitourinary (GU) toxicity occurred
in 8 (33%) patients, grade II 16 (67%) patients, one patient had a Foley catheter during treatment, a majority of patients were on alpha blockers either before, during or post radiotherapy. Grade 0 gastrointestinal (GI) toxicity occurred in 21 (84%) patients, grade 1 in one, and grade II in 3 (12%) patients. There were no grade 3 or 4 GU or GI toxicities.

Conclusions: Simultaneous integrated boost with VMAT is well tolerated in treating pelvic nodes and prostate boost, without any major acute toxicities. This technique is used in mostly for very high risk localized prostate cancer patients, reducing number of fractions from conventional sequential treatment.

Purpose: It is conventional to treat pelvic lymph nodes, followed by prostate boost in a sequential manner, requiring 8-9 weeks to complete therapy. In the last several years there have been several randomized studies of implementing moderate hypofractionated radiotherapy in prostate cancer to shorten the treatment time, which has proven to be non-inferior to conventional treatment. The purpose of this retrospective study is to evaluate the acute toxicities of hypofractionated SIB radiotherapy in treating the lymph nodes with prostate boost.

Methods: Between 2015 and 2017, twenty five high risk prostate cancer patients received pelvic node radiotherapy with prostate boost in 25 fractions with SIB technique with neo-adjuvant and concurrent hormone therapy to 50 Gy/25 fractions at 2 Gy/fraction to pelvic nodes and prostate boost for a total of 67.5 - 75 Gy at 2.7 to 3.0 Gy/fraction. We followed QUNTAC dose-volume constraints for the rectum, bladder and bowel. All these patients received long-term hormone therapy.

Results: The median age was 66 years (range 57-81 years). There were 6 stage II C, 7 III A, 15 III C, and 1 stage IV A. All patients were restaged as per American Joint Committee on Cancer 8th edition. Gleason Score: 6 (1), 7 (4+3) (4), 8 (5), and 9-10 (15). The average PSA was 17.2 ng/mL with a range of 5.6 to 51.92 ng/mL, and average number of positive cores was 74%. These factors put the majority of patients into the very high risk group. The median follow up was 24 months. The majority of the patients tolerated treatment well. Grade 0 genitourinary (GU) toxicity occurred
in 8 (33%) patients, grade II 16 (67%) patients, one patient had a Foley catheter during treatment, a majority of patients were on alpha blockers either before, during or post radiotherapy. Grade 0 gastrointestinal (GI) toxicity occurred in 21 (84%) patients, grade 1 in one, and grade II in 3 (12%) patients. There were no grade 3 or 4 GU or GI toxicities.

Conclusions: Simultaneous integrated boost with VMAT is well tolerated in treating pelvic nodes and prostate boost, without any major acute toxicities. This technique is used in mostly for very high risk localized prostate cancer patients, reducing number of fractions from conventional sequential treatment.

Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.

Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.

Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.

Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.

Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.

Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.

Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.

Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.

Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.

Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.

Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.

Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.

Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.

Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.

Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.

Purpose: Describe how case management by a nurse navigator has positively impacted the coordination and timeliness of care for Veterans newly diagnosed with esophageal cancer.

Background: Veterans with esophageal cancer have a complicated work-up and treatment course, involving many providers and ancillary services to support them through multi-modality treatment. Veterans are at high-risk for experiencing delays in care due to the complex coordination required.

Methods: A Cancer Care Navigation Team (CCNT) RN is dedicated to the case management of all newly diagnosed esophageal cancer cases. The RN completes an intake to identify barriers to completing timely work-up and accessing treatment and identifies education deficits related to their new suspicion or diagnosis. The RN provides an overview of the work-up process, identifies the providers involved in caring for the patient, and describes the ancillary supportive services, such as a specialized dietician and social worker. The RN educates the Veteran on possible treatment modalities and lodging options for treatment. The RN involves caregivers in education and treatment planning. Advance directives and release of information are completed to facilitate care planning and communication. The RN accompanies the Veteran to all treatment planning appointments with thoracic surgery, medical oncology, radiation oncology, and attends esophageal tumor board when the case is discussed. The RN facilitates communication and collaboration between providers and ancillary services as needed. The RN stays in close contact with the Veteran and caregivers throughout treatment to keep updated on the plan of care, provide support, and proactively identify barriers. The relationship developed by the RN with the patient and caregivers allows for ongoing discussions related to goals of care and, when necessary, end-of-life support.

Results: In the two years a CCNT RN has been case managing esophageal cancer cases, there has been an increase in patients verbalizing satisfaction with the education they receive about their disease, improved clustering of appointments and reduction of travel, and improved
coordination between VA and non-VA treating facilities. The multidisciplinary team has expressed increased satisfaction with the management of these cases. Next steps include formalizing a multidisciplinary clinic for esophageal cancer and finalizing esophageal cancer-specific educational materials.

Purpose: Describe how case management by a nurse navigator has positively impacted the coordination and timeliness of care for Veterans newly diagnosed with esophageal cancer.

Background: Veterans with esophageal cancer have a complicated work-up and treatment course, involving many providers and ancillary services to support them through multi-modality treatment. Veterans are at high-risk for experiencing delays in care due to the complex coordination required.

Methods: A Cancer Care Navigation Team (CCNT) RN is dedicated to the case management of all newly diagnosed esophageal cancer cases. The RN completes an intake to identify barriers to completing timely work-up and accessing treatment and identifies education deficits related to their new suspicion or diagnosis. The RN provides an overview of the work-up process, identifies the providers involved in caring for the patient, and describes the ancillary supportive services, such as a specialized dietician and social worker. The RN educates the Veteran on possible treatment modalities and lodging options for treatment. The RN involves caregivers in education and treatment planning. Advance directives and release of information are completed to facilitate care planning and communication. The RN accompanies the Veteran to all treatment planning appointments with thoracic surgery, medical oncology, radiation oncology, and attends esophageal tumor board when the case is discussed. The RN facilitates communication and collaboration between providers and ancillary services as needed. The RN stays in close contact with the Veteran and caregivers throughout treatment to keep updated on the plan of care, provide support, and proactively identify barriers. The relationship developed by the RN with the patient and caregivers allows for ongoing discussions related to goals of care and, when necessary, end-of-life support.

Results: In the two years a CCNT RN has been case managing esophageal cancer cases, there has been an increase in patients verbalizing satisfaction with the education they receive about their disease, improved clustering of appointments and reduction of travel, and improved
coordination between VA and non-VA treating facilities. The multidisciplinary team has expressed increased satisfaction with the management of these cases. Next steps include formalizing a multidisciplinary clinic for esophageal cancer and finalizing esophageal cancer-specific educational materials.

Purpose: Describe how case management by a nurse navigator has positively impacted the coordination and timeliness of care for Veterans newly diagnosed with esophageal cancer.

Background: Veterans with esophageal cancer have a complicated work-up and treatment course, involving many providers and ancillary services to support them through multi-modality treatment. Veterans are at high-risk for experiencing delays in care due to the complex coordination required.

Methods: A Cancer Care Navigation Team (CCNT) RN is dedicated to the case management of all newly diagnosed esophageal cancer cases. The RN completes an intake to identify barriers to completing timely work-up and accessing treatment and identifies education deficits related to their new suspicion or diagnosis. The RN provides an overview of the work-up process, identifies the providers involved in caring for the patient, and describes the ancillary supportive services, such as a specialized dietician and social worker. The RN educates the Veteran on possible treatment modalities and lodging options for treatment. The RN involves caregivers in education and treatment planning. Advance directives and release of information are completed to facilitate care planning and communication. The RN accompanies the Veteran to all treatment planning appointments with thoracic surgery, medical oncology, radiation oncology, and attends esophageal tumor board when the case is discussed. The RN facilitates communication and collaboration between providers and ancillary services as needed. The RN stays in close contact with the Veteran and caregivers throughout treatment to keep updated on the plan of care, provide support, and proactively identify barriers. The relationship developed by the RN with the patient and caregivers allows for ongoing discussions related to goals of care and, when necessary, end-of-life support.

Results: In the two years a CCNT RN has been case managing esophageal cancer cases, there has been an increase in patients verbalizing satisfaction with the education they receive about their disease, improved clustering of appointments and reduction of travel, and improved
coordination between VA and non-VA treating facilities. The multidisciplinary team has expressed increased satisfaction with the management of these cases. Next steps include formalizing a multidisciplinary clinic for esophageal cancer and finalizing esophageal cancer-specific educational materials.

Introduction: Systemic mastocytosis (SM) is a rare myeloid neoplasm that is caused by accumulation of abnormal mast cells in the bone marrow, liver, spleen, and skin. The KIT D816V mutation encodes a constitutively activated receptor tyrosine kinase that drives disease pathogenesis. We present a case of systemic mastocytosis with associated clonal hematological non-mast cell disease (SM-AHNMD).

Background: A 71-year-old man presented with anemia, thrombocytopenia, absolute monocyte count of 2,000-4,000 and weight loss in August 2016. A CT showed splenomegaly and lymphadenopathy. Bone marrow biopsy revealed positive CD117 mast cells, CD34 myeloblasts and reticulin fibrosis consistent with SM. Immunohistochemistry confirmed the neoplastic cells were positive for CD25, but negative for CD2. PCR analysis revealed KIT D816V point mutation. Serum tryptase was 295 ug/L (normal 2.2-13.2). He was started on imatinib mesylate. However, his anemia, thrombocytopenia and splenomegaly worsened. He developed bilateral femoral neck fractures in April 2017. Imatinib was discontinued. He underwent bilateral hip hemiarthroplasty. Histology was consistent with SM (positive CD25 and CD117) with dysplastic megakaryocytes and increased monocytosis. By WHO classification he has SM-AHNMD with chronic myelomonocytic leukemia. He was started on cladribine for 4 cycles with good response in splenomegaly, anemia and thrombocytopenia, but he developed leukocytosis. Serum tryptase initially decreased to 141 but then rose to 243. Midostaurin 100 mg orally twice a day was initiated in December 2017. His cytopenia and splenomegaly improved. In March 2018 he was admitted for sigmoid colon obstruction due to inflammation or mass and underwent diverting loop ileostomy. Biopsy could not be performed. His serum tryptase decreased to 178 but increased to 275 in June 2018. He continues on midostaurin.

Discussion: SM-AHNMD constitutes approximately 40% of all SM with poor prognosis. SM is resistance to imatinib because of KIT D816V mutation. Cladribine has some activity. Midostaurin inhibits non-mutant and mutant KIT D816V with 58% response rate and median overall survival of 20 months. Our patient has a good response to both drugs.

Conclusions: Clinicians should be able to diagnose and treat SM. Cladribine and midostaurin are active drugs for SM.

Introduction: Systemic mastocytosis (SM) is a rare myeloid neoplasm that is caused by accumulation of abnormal mast cells in the bone marrow, liver, spleen, and skin. The KIT D816V mutation encodes a constitutively activated receptor tyrosine kinase that drives disease pathogenesis. We present a case of systemic mastocytosis with associated clonal hematological non-mast cell disease (SM-AHNMD).

Background: A 71-year-old man presented with anemia, thrombocytopenia, absolute monocyte count of 2,000-4,000 and weight loss in August 2016. A CT showed splenomegaly and lymphadenopathy. Bone marrow biopsy revealed positive CD117 mast cells, CD34 myeloblasts and reticulin fibrosis consistent with SM. Immunohistochemistry confirmed the neoplastic cells were positive for CD25, but negative for CD2. PCR analysis revealed KIT D816V point mutation. Serum tryptase was 295 ug/L (normal 2.2-13.2). He was started on imatinib mesylate. However, his anemia, thrombocytopenia and splenomegaly worsened. He developed bilateral femoral neck fractures in April 2017. Imatinib was discontinued. He underwent bilateral hip hemiarthroplasty. Histology was consistent with SM (positive CD25 and CD117) with dysplastic megakaryocytes and increased monocytosis. By WHO classification he has SM-AHNMD with chronic myelomonocytic leukemia. He was started on cladribine for 4 cycles with good response in splenomegaly, anemia and thrombocytopenia, but he developed leukocytosis. Serum tryptase initially decreased to 141 but then rose to 243. Midostaurin 100 mg orally twice a day was initiated in December 2017. His cytopenia and splenomegaly improved. In March 2018 he was admitted for sigmoid colon obstruction due to inflammation or mass and underwent diverting loop ileostomy. Biopsy could not be performed. His serum tryptase decreased to 178 but increased to 275 in June 2018. He continues on midostaurin.

Discussion: SM-AHNMD constitutes approximately 40% of all SM with poor prognosis. SM is resistance to imatinib because of KIT D816V mutation. Cladribine has some activity. Midostaurin inhibits non-mutant and mutant KIT D816V with 58% response rate and median overall survival of 20 months. Our patient has a good response to both drugs.

Conclusions: Clinicians should be able to diagnose and treat SM. Cladribine and midostaurin are active drugs for SM.

Introduction: Systemic mastocytosis (SM) is a rare myeloid neoplasm that is caused by accumulation of abnormal mast cells in the bone marrow, liver, spleen, and skin. The KIT D816V mutation encodes a constitutively activated receptor tyrosine kinase that drives disease pathogenesis. We present a case of systemic mastocytosis with associated clonal hematological non-mast cell disease (SM-AHNMD).

Background: A 71-year-old man presented with anemia, thrombocytopenia, absolute monocyte count of 2,000-4,000 and weight loss in August 2016. A CT showed splenomegaly and lymphadenopathy. Bone marrow biopsy revealed positive CD117 mast cells, CD34 myeloblasts and reticulin fibrosis consistent with SM. Immunohistochemistry confirmed the neoplastic cells were positive for CD25, but negative for CD2. PCR analysis revealed KIT D816V point mutation. Serum tryptase was 295 ug/L (normal 2.2-13.2). He was started on imatinib mesylate. However, his anemia, thrombocytopenia and splenomegaly worsened. He developed bilateral femoral neck fractures in April 2017. Imatinib was discontinued. He underwent bilateral hip hemiarthroplasty. Histology was consistent with SM (positive CD25 and CD117) with dysplastic megakaryocytes and increased monocytosis. By WHO classification he has SM-AHNMD with chronic myelomonocytic leukemia. He was started on cladribine for 4 cycles with good response in splenomegaly, anemia and thrombocytopenia, but he developed leukocytosis. Serum tryptase initially decreased to 141 but then rose to 243. Midostaurin 100 mg orally twice a day was initiated in December 2017. His cytopenia and splenomegaly improved. In March 2018 he was admitted for sigmoid colon obstruction due to inflammation or mass and underwent diverting loop ileostomy. Biopsy could not be performed. His serum tryptase decreased to 178 but increased to 275 in June 2018. He continues on midostaurin.

Discussion: SM-AHNMD constitutes approximately 40% of all SM with poor prognosis. SM is resistance to imatinib because of KIT D816V mutation. Cladribine has some activity. Midostaurin inhibits non-mutant and mutant KIT D816V with 58% response rate and median overall survival of 20 months. Our patient has a good response to both drugs.

Conclusions: Clinicians should be able to diagnose and treat SM. Cladribine and midostaurin are active drugs for SM.

Background: High-risk human papilloma virus (HPV) has been established as prognostic and predictive factor in oropharyngeal cancers. However, its prognostic implication in non-oropharyngeal head and neck squamous cell cancers is elusive. We hypothesize that HPV (p16+) status is predictive of treatment effect and has positive prognostic impact in squamous cell carcinoma of hypopharynx (HypSCC).

Purpose: To evaluate prevalence frequency, clinical characteristics, prognostic impact of p16+ status and prognostic stratification ability of current American Joint Committee on Cancer (AJCC) staging in HypSCC.

Methods: We queried the National Cancer Database (data from 1,500 CoC centers, 70% of newly diagnosed cancers nationwide, including VA cancer centers) from 2010-2015 for patients with HypSCC with known HPV status.

Results: Amongst 10,577 hypopharyngeal cancer patients, 3,043 had squamous cell histology with known HPV status and no distant metastasis. Median age was 63.79 years, 2,419 (79%) were males, median follow-up was 25.12 months. p16+ status was prevalent in 614 (20%). Hyp-SCC p16+ were more often whites (87% vs 81%; P = .02), younger (60 years 50% vs 39%, P < .001), higher socioeconomic status P < .05, poorly differentiated (35% vs 31%; P = .02), lower T stage(P < .001) and higher N stage (P = .001). Median OS of p16- vs. p16+ was 30 months vs not reached (P < .001). Multivariate cox-regression revealed p16 status, age, comorbidity index, type of insurance, T stage, N stage and treatment modality as significant prognostic factors. HypSCC p16- subgroup: OS was worse with chemoradiation vs. surgery radiation (34 vs 61 months; P <
.001). HypSCC p16+ subgroup: OS was better with chemoradiation vs surgery radiation (not reached vs .63 months; P < .001). HypSCC p16+ subgroup analysis showed no difference in OS in different AJCC stage groups (P = .182); AJCC T stage stratification significantly differentiated OS
(P < .001); N staging failed to differentiate OS (P = .99). HypSCC p16+ multivariate analysis showed treatment modalities, insurance type and AJCC T stage as significant prognostic factors for OS.

Conclusions/Implications: HPV positive status is a positive prognostic factor for HypSCC and predictive of better outcomes with chemoradiation. HPV status should guide treatment selection for HypSCC patients and future trials should stratify HypSCC patients based on HPV status. Current AJCC stage grouping fails to stratify HypSCC p16+ into optimal prognostic groups; hence, staging needs to be revisited. Health care disparities may affect survival outcomes and should be further investigated to mitigate this difference.

Background: High-risk human papilloma virus (HPV) has been established as prognostic and predictive factor in oropharyngeal cancers. However, its prognostic implication in non-oropharyngeal head and neck squamous cell cancers is elusive. We hypothesize that HPV (p16+) status is predictive of treatment effect and has positive prognostic impact in squamous cell carcinoma of hypopharynx (HypSCC).

Purpose: To evaluate prevalence frequency, clinical characteristics, prognostic impact of p16+ status and prognostic stratification ability of current American Joint Committee on Cancer (AJCC) staging in HypSCC.

Methods: We queried the National Cancer Database (data from 1,500 CoC centers, 70% of newly diagnosed cancers nationwide, including VA cancer centers) from 2010-2015 for patients with HypSCC with known HPV status.

Results: Amongst 10,577 hypopharyngeal cancer patients, 3,043 had squamous cell histology with known HPV status and no distant metastasis. Median age was 63.79 years, 2,419 (79%) were males, median follow-up was 25.12 months. p16+ status was prevalent in 614 (20%). Hyp-SCC p16+ were more often whites (87% vs 81%; P = .02), younger (60 years 50% vs 39%, P < .001), higher socioeconomic status P < .05, poorly differentiated (35% vs 31%; P = .02), lower T stage(P < .001) and higher N stage (P = .001). Median OS of p16- vs. p16+ was 30 months vs not reached (P < .001). Multivariate cox-regression revealed p16 status, age, comorbidity index, type of insurance, T stage, N stage and treatment modality as significant prognostic factors. HypSCC p16- subgroup: OS was worse with chemoradiation vs. surgery radiation (34 vs 61 months; P <
.001). HypSCC p16+ subgroup: OS was better with chemoradiation vs surgery radiation (not reached vs .63 months; P < .001). HypSCC p16+ subgroup analysis showed no difference in OS in different AJCC stage groups (P = .182); AJCC T stage stratification significantly differentiated OS
(P < .001); N staging failed to differentiate OS (P = .99). HypSCC p16+ multivariate analysis showed treatment modalities, insurance type and AJCC T stage as significant prognostic factors for OS.

Conclusions/Implications: HPV positive status is a positive prognostic factor for HypSCC and predictive of better outcomes with chemoradiation. HPV status should guide treatment selection for HypSCC patients and future trials should stratify HypSCC patients based on HPV status. Current AJCC stage grouping fails to stratify HypSCC p16+ into optimal prognostic groups; hence, staging needs to be revisited. Health care disparities may affect survival outcomes and should be further investigated to mitigate this difference.

Background: High-risk human papilloma virus (HPV) has been established as prognostic and predictive factor in oropharyngeal cancers. However, its prognostic implication in non-oropharyngeal head and neck squamous cell cancers is elusive. We hypothesize that HPV (p16+) status is predictive of treatment effect and has positive prognostic impact in squamous cell carcinoma of hypopharynx (HypSCC).

Purpose: To evaluate prevalence frequency, clinical characteristics, prognostic impact of p16+ status and prognostic stratification ability of current American Joint Committee on Cancer (AJCC) staging in HypSCC.

Methods: We queried the National Cancer Database (data from 1,500 CoC centers, 70% of newly diagnosed cancers nationwide, including VA cancer centers) from 2010-2015 for patients with HypSCC with known HPV status.

Results: Amongst 10,577 hypopharyngeal cancer patients, 3,043 had squamous cell histology with known HPV status and no distant metastasis. Median age was 63.79 years, 2,419 (79%) were males, median follow-up was 25.12 months. p16+ status was prevalent in 614 (20%). Hyp-SCC p16+ were more often whites (87% vs 81%; P = .02), younger (60 years 50% vs 39%, P < .001), higher socioeconomic status P < .05, poorly differentiated (35% vs 31%; P = .02), lower T stage(P < .001) and higher N stage (P = .001). Median OS of p16- vs. p16+ was 30 months vs not reached (P < .001). Multivariate cox-regression revealed p16 status, age, comorbidity index, type of insurance, T stage, N stage and treatment modality as significant prognostic factors. HypSCC p16- subgroup: OS was worse with chemoradiation vs. surgery radiation (34 vs 61 months; P <
.001). HypSCC p16+ subgroup: OS was better with chemoradiation vs surgery radiation (not reached vs .63 months; P < .001). HypSCC p16+ subgroup analysis showed no difference in OS in different AJCC stage groups (P = .182); AJCC T stage stratification significantly differentiated OS
(P < .001); N staging failed to differentiate OS (P = .99). HypSCC p16+ multivariate analysis showed treatment modalities, insurance type and AJCC T stage as significant prognostic factors for OS.

Conclusions/Implications: HPV positive status is a positive prognostic factor for HypSCC and predictive of better outcomes with chemoradiation. HPV status should guide treatment selection for HypSCC patients and future trials should stratify HypSCC patients based on HPV status. Current AJCC stage grouping fails to stratify HypSCC p16+ into optimal prognostic groups; hence, staging needs to be revisited. Health care disparities may affect survival outcomes and should be further investigated to mitigate this difference.

Purpose: Symptom assessment in cancer patients is associated with improved quality of life and prolonged survival; we sought to evaluate the use of a systematic symptom assessment tool in VA.

Background: Veterans Affairs (VA) Symptom Assessment Scale (VSAS) is a clinical tool for VA nurses and providers to capture symptom burden in patients with cancer. It includes 10 physical factors (pain, tiredness, anorexia, nausea, vomiting, diarrhea, constipation, shortness of breath at rest and with exertion, and drowsiness) and 3 emotional factors (depression, anxiety, and distress). Each symptom is scored on a scale of 0 (absence) to 10 (worst possible symptom). Here, we report symptom prevalence, VSAS reliability and internal consistency.

Methods: VSAS data were collected from the VA Corporate Data Warehouse. Symptom prevalence at baseline (initial hematology or oncology visit) and at subsequent follow-up is described. Reliability was assessed using factor-level test-retest correlation within a one week time period. Internal consistency and reliability of “physical” and “emotional” factors were assessed using Cronbach’s alpha.

Results: From January 2015 through June 2018, 5,995 patients were administered 21,761 VSAS assessments in two VA medical centers. At baseline, patients were most likely to report tiredness (68%), shortness of breath with exertion (49%), and pain (45%). Severe symptoms (scores 7-10) included tiredness (23%), pain (17%), and shortness of breath with exertion (13%). The most common symptoms recorded on follow-up were tiredness (70%; 21% severe), shortness of breath with exertion (51%; 17% severe), and pain (45%; 11% severe). Factor correlation upon retesting within one week was moderate, ranging from 0.40 to 0.62. Internal consistency across all factors was high with a Cronbach alpha of 0.86. Internal reliability of physical and emotional symptoms was also high at 0.81 and 0.87, respectively.

Conclusions: Cancer patients treated in the VA have a high symptom burden. The most prevalent symptoms were pain, tiredness, and shortness of breath. We evaluated reliability and consistency of VSAS factors, validating this method of measuring and documenting cancer-related symptoms. This preliminary report establishes VSAS as a tool that can be implemented widely within the VA with the goal of improving quality of care in VA oncology patients.

Purpose: Symptom assessment in cancer patients is associated with improved quality of life and prolonged survival; we sought to evaluate the use of a systematic symptom assessment tool in VA.

Background: Veterans Affairs (VA) Symptom Assessment Scale (VSAS) is a clinical tool for VA nurses and providers to capture symptom burden in patients with cancer. It includes 10 physical factors (pain, tiredness, anorexia, nausea, vomiting, diarrhea, constipation, shortness of breath at rest and with exertion, and drowsiness) and 3 emotional factors (depression, anxiety, and distress). Each symptom is scored on a scale of 0 (absence) to 10 (worst possible symptom). Here, we report symptom prevalence, VSAS reliability and internal consistency.

Methods: VSAS data were collected from the VA Corporate Data Warehouse. Symptom prevalence at baseline (initial hematology or oncology visit) and at subsequent follow-up is described. Reliability was assessed using factor-level test-retest correlation within a one week time period. Internal consistency and reliability of “physical” and “emotional” factors were assessed using Cronbach’s alpha.

Results: From January 2015 through June 2018, 5,995 patients were administered 21,761 VSAS assessments in two VA medical centers. At baseline, patients were most likely to report tiredness (68%), shortness of breath with exertion (49%), and pain (45%). Severe symptoms (scores 7-10) included tiredness (23%), pain (17%), and shortness of breath with exertion (13%). The most common symptoms recorded on follow-up were tiredness (70%; 21% severe), shortness of breath with exertion (51%; 17% severe), and pain (45%; 11% severe). Factor correlation upon retesting within one week was moderate, ranging from 0.40 to 0.62. Internal consistency across all factors was high with a Cronbach alpha of 0.86. Internal reliability of physical and emotional symptoms was also high at 0.81 and 0.87, respectively.

Conclusions: Cancer patients treated in the VA have a high symptom burden. The most prevalent symptoms were pain, tiredness, and shortness of breath. We evaluated reliability and consistency of VSAS factors, validating this method of measuring and documenting cancer-related symptoms. This preliminary report establishes VSAS as a tool that can be implemented widely within the VA with the goal of improving quality of care in VA oncology patients.

Purpose: Symptom assessment in cancer patients is associated with improved quality of life and prolonged survival; we sought to evaluate the use of a systematic symptom assessment tool in VA.

Background: Veterans Affairs (VA) Symptom Assessment Scale (VSAS) is a clinical tool for VA nurses and providers to capture symptom burden in patients with cancer. It includes 10 physical factors (pain, tiredness, anorexia, nausea, vomiting, diarrhea, constipation, shortness of breath at rest and with exertion, and drowsiness) and 3 emotional factors (depression, anxiety, and distress). Each symptom is scored on a scale of 0 (absence) to 10 (worst possible symptom). Here, we report symptom prevalence, VSAS reliability and internal consistency.

Methods: VSAS data were collected from the VA Corporate Data Warehouse. Symptom prevalence at baseline (initial hematology or oncology visit) and at subsequent follow-up is described. Reliability was assessed using factor-level test-retest correlation within a one week time period. Internal consistency and reliability of “physical” and “emotional” factors were assessed using Cronbach’s alpha.

Results: From January 2015 through June 2018, 5,995 patients were administered 21,761 VSAS assessments in two VA medical centers. At baseline, patients were most likely to report tiredness (68%), shortness of breath with exertion (49%), and pain (45%). Severe symptoms (scores 7-10) included tiredness (23%), pain (17%), and shortness of breath with exertion (13%). The most common symptoms recorded on follow-up were tiredness (70%; 21% severe), shortness of breath with exertion (51%; 17% severe), and pain (45%; 11% severe). Factor correlation upon retesting within one week was moderate, ranging from 0.40 to 0.62. Internal consistency across all factors was high with a Cronbach alpha of 0.86. Internal reliability of physical and emotional symptoms was also high at 0.81 and 0.87, respectively.

Conclusions: Cancer patients treated in the VA have a high symptom burden. The most prevalent symptoms were pain, tiredness, and shortness of breath. We evaluated reliability and consistency of VSAS factors, validating this method of measuring and documenting cancer-related symptoms. This preliminary report establishes VSAS as a tool that can be implemented widely within the VA with the goal of improving quality of care in VA oncology patients.

Purpose: To determine which sequence of abiraterone (ABI) and enzalutamide (ENZA) shows better survival outcomes in Veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC) at VA San Diego.

Background: Prostate cancer is the leading cancer diagnosis among American men who eventually develop mCRPC. Therapies for mCRPC include androgen receptor pathway inhibitors like ABI and ENZA. Both improve survival independently; however, the optimal treatment sequence has not been determined. Retrospective studies have shown that the ABI-ENZA sequence significantly improves progression-free survival (PFS) and combined prostate-specific antigen PFS (cPSA-PFS), but not overall survival (OS).

Methods: A retrospective chart review was conducted in subjects with mCRPC who had received ABI and ENZA sequentially in either order. Subjects must have received at least one month of each drug; those who had an interruption of treatment sequence were excluded. The primary outcomes were to compare cPSA-PFS and OS between the two sequences; cPSA-PFS represented time from start of drug 1 to > 25% PSA increase from baseline/nadir on drug 2, while OS represented time from start of drug 1 to death from any cause. OS and cPSA-PFS were reported via Kaplan-
Meier curves and hazard ratios (HR). Ninety-eight subjects per group were needed to reach 80% power for an effect size of 0.404 in cPSA-PFS.

Results: Forty subjects were identified and 8 were excluded; of the remaining, 9 received ENZA-ABI and 23 received ABIENZA. Baseline characteristics were similar. There were no differences in cPSA-PFS between ENZA-ABI and ABI-ENZA: median 406 days versus 534 days (HR 1.39, 95% CI 0.59-1.53, P = .59), respectively. OS did not differ between ENZAABI and ABI-ENZA: median 711 days versus 803 days (HR 0.88, 95% CI 0.35-1.59, P = .21), respectively.

Conclusions: There were no significant differences in outcomes between sequences although ABI-ENZA showed longer cPSA-PFS and OS. This is consistent with previous studies where ABI-ENZA had significantly longer PFS and cPSA-PFS; ABI-ENZA OS was longer but not significantly different in those studies. Limitations included a small sample size and uneven groups. Ultimately, ABI-ENZA should be considered as the sequence-of-choice for treatment of mCRPC until prospective studies confirm the optimal sequence.

Purpose: To determine which sequence of abiraterone (ABI) and enzalutamide (ENZA) shows better survival outcomes in Veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC) at VA San Diego.

Background: Prostate cancer is the leading cancer diagnosis among American men who eventually develop mCRPC. Therapies for mCRPC include androgen receptor pathway inhibitors like ABI and ENZA. Both improve survival independently; however, the optimal treatment sequence has not been determined. Retrospective studies have shown that the ABI-ENZA sequence significantly improves progression-free survival (PFS) and combined prostate-specific antigen PFS (cPSA-PFS), but not overall survival (OS).

Methods: A retrospective chart review was conducted in subjects with mCRPC who had received ABI and ENZA sequentially in either order. Subjects must have received at least one month of each drug; those who had an interruption of treatment sequence were excluded. The primary outcomes were to compare cPSA-PFS and OS between the two sequences; cPSA-PFS represented time from start of drug 1 to > 25% PSA increase from baseline/nadir on drug 2, while OS represented time from start of drug 1 to death from any cause. OS and cPSA-PFS were reported via Kaplan-
Meier curves and hazard ratios (HR). Ninety-eight subjects per group were needed to reach 80% power for an effect size of 0.404 in cPSA-PFS.

Results: Forty subjects were identified and 8 were excluded; of the remaining, 9 received ENZA-ABI and 23 received ABIENZA. Baseline characteristics were similar. There were no differences in cPSA-PFS between ENZA-ABI and ABI-ENZA: median 406 days versus 534 days (HR 1.39, 95% CI 0.59-1.53, P = .59), respectively. OS did not differ between ENZAABI and ABI-ENZA: median 711 days versus 803 days (HR 0.88, 95% CI 0.35-1.59, P = .21), respectively.

Conclusions: There were no significant differences in outcomes between sequences although ABI-ENZA showed longer cPSA-PFS and OS. This is consistent with previous studies where ABI-ENZA had significantly longer PFS and cPSA-PFS; ABI-ENZA OS was longer but not significantly different in those studies. Limitations included a small sample size and uneven groups. Ultimately, ABI-ENZA should be considered as the sequence-of-choice for treatment of mCRPC until prospective studies confirm the optimal sequence.

Purpose: To determine which sequence of abiraterone (ABI) and enzalutamide (ENZA) shows better survival outcomes in Veterans diagnosed with metastatic castration-resistant prostate cancer (mCRPC) at VA San Diego.

Background: Prostate cancer is the leading cancer diagnosis among American men who eventually develop mCRPC. Therapies for mCRPC include androgen receptor pathway inhibitors like ABI and ENZA. Both improve survival independently; however, the optimal treatment sequence has not been determined. Retrospective studies have shown that the ABI-ENZA sequence significantly improves progression-free survival (PFS) and combined prostate-specific antigen PFS (cPSA-PFS), but not overall survival (OS).

Methods: A retrospective chart review was conducted in subjects with mCRPC who had received ABI and ENZA sequentially in either order. Subjects must have received at least one month of each drug; those who had an interruption of treatment sequence were excluded. The primary outcomes were to compare cPSA-PFS and OS between the two sequences; cPSA-PFS represented time from start of drug 1 to > 25% PSA increase from baseline/nadir on drug 2, while OS represented time from start of drug 1 to death from any cause. OS and cPSA-PFS were reported via Kaplan-
Meier curves and hazard ratios (HR). Ninety-eight subjects per group were needed to reach 80% power for an effect size of 0.404 in cPSA-PFS.

Results: Forty subjects were identified and 8 were excluded; of the remaining, 9 received ENZA-ABI and 23 received ABIENZA. Baseline characteristics were similar. There were no differences in cPSA-PFS between ENZA-ABI and ABI-ENZA: median 406 days versus 534 days (HR 1.39, 95% CI 0.59-1.53, P = .59), respectively. OS did not differ between ENZAABI and ABI-ENZA: median 711 days versus 803 days (HR 0.88, 95% CI 0.35-1.59, P = .21), respectively.

Conclusions: There were no significant differences in outcomes between sequences although ABI-ENZA showed longer cPSA-PFS and OS. This is consistent with previous studies where ABI-ENZA had significantly longer PFS and cPSA-PFS; ABI-ENZA OS was longer but not significantly different in those studies. Limitations included a small sample size and uneven groups. Ultimately, ABI-ENZA should be considered as the sequence-of-choice for treatment of mCRPC until prospective studies confirm the optimal sequence.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: The translocation t(11;14)(q13;q32) typically considered a hallmark of mantle cell lymphoma(MCL), has also been implicated in some cases of non-MCL lymphoproliferative disorders. Although uncommon, it has been reported in 2-5% of chronic lymphocytic leukemia (CLL) cases. Most of the cases identified have been observed mostly in relapsed CLL. This genetic aberration can be considered a significant prognostic indicator for CLL. t(11;14) positive CLL at the time of diagnosis has been rarely reported. We describe a case of a patient
diagnosed with CLL who was positive for this genetic abnormality.

Case Report: A 64-year-old white male presented with absolute lymphocytosis of 7 years. Lymphocyte immunophenotype detected a CD5(+) CD10(-) CD23(+) CD38(-) CD43(+) FMC7(partial dim) kappa-restricted B-cell population consistent with CLL. CT chest, abdomen, pelvis showed mildly prominent mediastinal and hilar lymph nodes only and was thus classified as Rai stage I. Peripheral FISH came back positive for t(11:14), cyclin D1-IgH translocation. His EPO, Jak2 and BCR-ABL mutation were all negative (done for mild erythrocytosis). Immunoglobulin and SPEP were negative. UPEP showed high Kappa/Lambda ratio. Although this tumor carries t(11;14) (q13;q32) translocation, immunostaining for BCL-1 was negative. It is possible that the gene is not expressed. Based on the staining and the clinical presentation, MCL was excluded. Per NCCN guidelines, patient is receiving clinical monitoring for stage I CLL.

Conclusions: Translocations involving the immunoglobulin genes are commonly identified. Uncommon genomic abnormalities in CLL should be recognized as significant independent predictors of disease progression and survival. It is important to recognize cases of CLL with t(11;14) translocation to achieve risk-adapted treatment strategies, which might be required to treat such patients.

Background: The translocation t(11;14)(q13;q32) typically considered a hallmark of mantle cell lymphoma(MCL), has also been implicated in some cases of non-MCL lymphoproliferative disorders. Although uncommon, it has been reported in 2-5% of chronic lymphocytic leukemia (CLL) cases. Most of the cases identified have been observed mostly in relapsed CLL. This genetic aberration can be considered a significant prognostic indicator for CLL. t(11;14) positive CLL at the time of diagnosis has been rarely reported. We describe a case of a patient
diagnosed with CLL who was positive for this genetic abnormality.

Case Report: A 64-year-old white male presented with absolute lymphocytosis of 7 years. Lymphocyte immunophenotype detected a CD5(+) CD10(-) CD23(+) CD38(-) CD43(+) FMC7(partial dim) kappa-restricted B-cell population consistent with CLL. CT chest, abdomen, pelvis showed mildly prominent mediastinal and hilar lymph nodes only and was thus classified as Rai stage I. Peripheral FISH came back positive for t(11:14), cyclin D1-IgH translocation. His EPO, Jak2 and BCR-ABL mutation were all negative (done for mild erythrocytosis). Immunoglobulin and SPEP were negative. UPEP showed high Kappa/Lambda ratio. Although this tumor carries t(11;14) (q13;q32) translocation, immunostaining for BCL-1 was negative. It is possible that the gene is not expressed. Based on the staining and the clinical presentation, MCL was excluded. Per NCCN guidelines, patient is receiving clinical monitoring for stage I CLL.

Conclusions: Translocations involving the immunoglobulin genes are commonly identified. Uncommon genomic abnormalities in CLL should be recognized as significant independent predictors of disease progression and survival. It is important to recognize cases of CLL with t(11;14) translocation to achieve risk-adapted treatment strategies, which might be required to treat such patients.

Background: The translocation t(11;14)(q13;q32) typically considered a hallmark of mantle cell lymphoma(MCL), has also been implicated in some cases of non-MCL lymphoproliferative disorders. Although uncommon, it has been reported in 2-5% of chronic lymphocytic leukemia (CLL) cases. Most of the cases identified have been observed mostly in relapsed CLL. This genetic aberration can be considered a significant prognostic indicator for CLL. t(11;14) positive CLL at the time of diagnosis has been rarely reported. We describe a case of a patient
diagnosed with CLL who was positive for this genetic abnormality.

Case Report: A 64-year-old white male presented with absolute lymphocytosis of 7 years. Lymphocyte immunophenotype detected a CD5(+) CD10(-) CD23(+) CD38(-) CD43(+) FMC7(partial dim) kappa-restricted B-cell population consistent with CLL. CT chest, abdomen, pelvis showed mildly prominent mediastinal and hilar lymph nodes only and was thus classified as Rai stage I. Peripheral FISH came back positive for t(11:14), cyclin D1-IgH translocation. His EPO, Jak2 and BCR-ABL mutation were all negative (done for mild erythrocytosis). Immunoglobulin and SPEP were negative. UPEP showed high Kappa/Lambda ratio. Although this tumor carries t(11;14) (q13;q32) translocation, immunostaining for BCL-1 was negative. It is possible that the gene is not expressed. Based on the staining and the clinical presentation, MCL was excluded. Per NCCN guidelines, patient is receiving clinical monitoring for stage I CLL.

Conclusions: Translocations involving the immunoglobulin genes are commonly identified. Uncommon genomic abnormalities in CLL should be recognized as significant independent predictors of disease progression and survival. It is important to recognize cases of CLL with t(11;14) translocation to achieve risk-adapted treatment strategies, which might be required to treat such patients.