AVAHO

PURPOSE: Determine the feasibility of telehealth as a safe and effective modality for CRC surveillance in the post-COVID era.

BACKGROUND: CRC survivors require routine cancer surveillance for a minimum of five years as directed by NCCN Survivorship guidelines. The onset of COVID inMarch 2020 severely limited the ability to have face to face encounters with New Mexico Veterans. Combining social distancing requirements and generalized fear among Veterans made it difficult to maintain routine face to face surveillance.

METHODS: Thirty CRC survivors in the surveillance phase were evaluated using VA Video Connect (VVC) technology. Established CRC Survivorship surveillance notes were completed during the VVC visit. The documented components included COVID screening, general and CRC focused symptomatology, psychological stress, physical exam, laboratory, and radiology studies. All surveillance questions were completed. Veterans were asked to complete a self-exam with video visualization of non-sensitive anatomical regions. Digital rectal exam was deferred. Lab and radiology studies were ordered to be done at a later time in VA/CBOC. To assist with poor hearing or visual acuity, VVC communication was enhanced by utilizing screen sharing with the Veteran to review the most recent lab/radiology results, as well as PowerPoint presentations to explain anatomy, disease process, and plan for continued surveillance. Veterans were assessed for level of anxiety regarding COVID and inability to seek routine medical care.

RESULTS: Veterans and their families were extremely satisfied with the ability to “see” a provider without incurring the risk of exposure and the cost of traveling with the economic hardship of COVID. As a result, the VA did not incur travel fees for remote Veterans. VVC improved access to Veteran specialty care and decreased overall anxiety and concerns regarding possible delayed diagnosis for cancer recurrence due to missed clinic appointments.

CONCLUSIONS: VVC is a viable option for CRC surveillance, however the Veteran still requires interval physical exam, labs, and imaging. A feasible option is to alternate in-person face to face visits with VVC appointments as a means to meet the expected long-term requirements for social distancing while still providing the vital care and reassurance to our Veterans.

PURPOSE: Determine the feasibility of telehealth as a safe and effective modality for CRC surveillance in the post-COVID era.

BACKGROUND: CRC survivors require routine cancer surveillance for a minimum of five years as directed by NCCN Survivorship guidelines. The onset of COVID inMarch 2020 severely limited the ability to have face to face encounters with New Mexico Veterans. Combining social distancing requirements and generalized fear among Veterans made it difficult to maintain routine face to face surveillance.

METHODS: Thirty CRC survivors in the surveillance phase were evaluated using VA Video Connect (VVC) technology. Established CRC Survivorship surveillance notes were completed during the VVC visit. The documented components included COVID screening, general and CRC focused symptomatology, psychological stress, physical exam, laboratory, and radiology studies. All surveillance questions were completed. Veterans were asked to complete a self-exam with video visualization of non-sensitive anatomical regions. Digital rectal exam was deferred. Lab and radiology studies were ordered to be done at a later time in VA/CBOC. To assist with poor hearing or visual acuity, VVC communication was enhanced by utilizing screen sharing with the Veteran to review the most recent lab/radiology results, as well as PowerPoint presentations to explain anatomy, disease process, and plan for continued surveillance. Veterans were assessed for level of anxiety regarding COVID and inability to seek routine medical care.

RESULTS: Veterans and their families were extremely satisfied with the ability to “see” a provider without incurring the risk of exposure and the cost of traveling with the economic hardship of COVID. As a result, the VA did not incur travel fees for remote Veterans. VVC improved access to Veteran specialty care and decreased overall anxiety and concerns regarding possible delayed diagnosis for cancer recurrence due to missed clinic appointments.

CONCLUSIONS: VVC is a viable option for CRC surveillance, however the Veteran still requires interval physical exam, labs, and imaging. A feasible option is to alternate in-person face to face visits with VVC appointments as a means to meet the expected long-term requirements for social distancing while still providing the vital care and reassurance to our Veterans.

PURPOSE: Determine the feasibility of telehealth as a safe and effective modality for CRC surveillance in the post-COVID era.

BACKGROUND: CRC survivors require routine cancer surveillance for a minimum of five years as directed by NCCN Survivorship guidelines. The onset of COVID inMarch 2020 severely limited the ability to have face to face encounters with New Mexico Veterans. Combining social distancing requirements and generalized fear among Veterans made it difficult to maintain routine face to face surveillance.

METHODS: Thirty CRC survivors in the surveillance phase were evaluated using VA Video Connect (VVC) technology. Established CRC Survivorship surveillance notes were completed during the VVC visit. The documented components included COVID screening, general and CRC focused symptomatology, psychological stress, physical exam, laboratory, and radiology studies. All surveillance questions were completed. Veterans were asked to complete a self-exam with video visualization of non-sensitive anatomical regions. Digital rectal exam was deferred. Lab and radiology studies were ordered to be done at a later time in VA/CBOC. To assist with poor hearing or visual acuity, VVC communication was enhanced by utilizing screen sharing with the Veteran to review the most recent lab/radiology results, as well as PowerPoint presentations to explain anatomy, disease process, and plan for continued surveillance. Veterans were assessed for level of anxiety regarding COVID and inability to seek routine medical care.

RESULTS: Veterans and their families were extremely satisfied with the ability to “see” a provider without incurring the risk of exposure and the cost of traveling with the economic hardship of COVID. As a result, the VA did not incur travel fees for remote Veterans. VVC improved access to Veteran specialty care and decreased overall anxiety and concerns regarding possible delayed diagnosis for cancer recurrence due to missed clinic appointments.

CONCLUSIONS: VVC is a viable option for CRC surveillance, however the Veteran still requires interval physical exam, labs, and imaging. A feasible option is to alternate in-person face to face visits with VVC appointments as a means to meet the expected long-term requirements for social distancing while still providing the vital care and reassurance to our Veterans.

BACKGROUND: Mantle cell lymphoma (MCL) is an incurable B-cell non-Hodgkin lymphoma. There is limited data on MCL burden to US veterans. OBJECTIVE: This retrospective cohort analysis aims to examine the clinical burden, costs and healthcare resource utilization of MCL to veterans.

METHODS: Adults who were newly diagnosed with MCL and initiated treatment were identified in the Veteran Health Administration (VHA) dataset (2014-2018). Treatment regimens are mutually exclusive and categorized as: bendamustine-based (alone or in combination); BTK-based (Bruton’s tyrosine kinase inhibitors: ibrutinib or acalabrutinib, alone or in combination); RCHOP-based; rituximab-monotherapy; and other regimen. Treatment discontinuation is defined as no MCL treatment for 60 days from the last day of supply. Treatment regimens, costs and hospitalizations are examined by 1st, 2nd, and 3rd lines of therapy.

RESULTS: Prevalence and incidence of MCL among the VHA population ranged from 8-11 cases, and 0.6-2.6 cases per 100,000 persons, respectively. A total of 390 patients (mean age: 70 years, 85% white) received 1st line (mean duration: 243 days), 146 (37%) patients received 2nd line (mean duration: 259 days), and 47 (12%) received 3rd line (mean duration: 154 days) therapy. Bendamustine-based regimen was the most common 1st line MCL treatment (43%), with lower utilization later (2nd line: 18%; 3rd line: 2%). BTK-based regimen was the second most common 1st line MCL treatment (23%), and the most common MCL treatment in later settings (2nd line: 34%, 3rd line 28%). RCHOP-based regimens were seldomly used in any setting (<5%). The overall treatment discontinuation rate was 82%. Approximately 38% of MCL patients had a hospitalization, with mean length-of-stay (LOS) of 5.6 days. The hospitalization rate was 29% (mean LOS: 3.5), 36% (mean LOS: 4.4), and 26% (mean LOS: 3.1) during 1st, 2nd, and 3rd line, respectively. Per-patient-per-month costs were $19,338 overall, and $19,239, $20,064, and $27,663 respectively, during 1st, 2nd, and 3rd line of therapy.

CONCLUSION: This study showed that bendamustine- based and BTK-based regimens were the common frontline treatments among newly diagnosed MCL patients in the VHA population. Future studies are warranted to understand factors associated with treatment selection, discontinuation and clinical benefits among these MCL Veteran patients.

BACKGROUND: Mantle cell lymphoma (MCL) is an incurable B-cell non-Hodgkin lymphoma. There is limited data on MCL burden to US veterans. OBJECTIVE: This retrospective cohort analysis aims to examine the clinical burden, costs and healthcare resource utilization of MCL to veterans.

METHODS: Adults who were newly diagnosed with MCL and initiated treatment were identified in the Veteran Health Administration (VHA) dataset (2014-2018). Treatment regimens are mutually exclusive and categorized as: bendamustine-based (alone or in combination); BTK-based (Bruton’s tyrosine kinase inhibitors: ibrutinib or acalabrutinib, alone or in combination); RCHOP-based; rituximab-monotherapy; and other regimen. Treatment discontinuation is defined as no MCL treatment for 60 days from the last day of supply. Treatment regimens, costs and hospitalizations are examined by 1st, 2nd, and 3rd lines of therapy.

RESULTS: Prevalence and incidence of MCL among the VHA population ranged from 8-11 cases, and 0.6-2.6 cases per 100,000 persons, respectively. A total of 390 patients (mean age: 70 years, 85% white) received 1st line (mean duration: 243 days), 146 (37%) patients received 2nd line (mean duration: 259 days), and 47 (12%) received 3rd line (mean duration: 154 days) therapy. Bendamustine-based regimen was the most common 1st line MCL treatment (43%), with lower utilization later (2nd line: 18%; 3rd line: 2%). BTK-based regimen was the second most common 1st line MCL treatment (23%), and the most common MCL treatment in later settings (2nd line: 34%, 3rd line 28%). RCHOP-based regimens were seldomly used in any setting (<5%). The overall treatment discontinuation rate was 82%. Approximately 38% of MCL patients had a hospitalization, with mean length-of-stay (LOS) of 5.6 days. The hospitalization rate was 29% (mean LOS: 3.5), 36% (mean LOS: 4.4), and 26% (mean LOS: 3.1) during 1st, 2nd, and 3rd line, respectively. Per-patient-per-month costs were $19,338 overall, and $19,239, $20,064, and $27,663 respectively, during 1st, 2nd, and 3rd line of therapy.

CONCLUSION: This study showed that bendamustine- based and BTK-based regimens were the common frontline treatments among newly diagnosed MCL patients in the VHA population. Future studies are warranted to understand factors associated with treatment selection, discontinuation and clinical benefits among these MCL Veteran patients.

BACKGROUND: Mantle cell lymphoma (MCL) is an incurable B-cell non-Hodgkin lymphoma. There is limited data on MCL burden to US veterans. OBJECTIVE: This retrospective cohort analysis aims to examine the clinical burden, costs and healthcare resource utilization of MCL to veterans.

METHODS: Adults who were newly diagnosed with MCL and initiated treatment were identified in the Veteran Health Administration (VHA) dataset (2014-2018). Treatment regimens are mutually exclusive and categorized as: bendamustine-based (alone or in combination); BTK-based (Bruton’s tyrosine kinase inhibitors: ibrutinib or acalabrutinib, alone or in combination); RCHOP-based; rituximab-monotherapy; and other regimen. Treatment discontinuation is defined as no MCL treatment for 60 days from the last day of supply. Treatment regimens, costs and hospitalizations are examined by 1st, 2nd, and 3rd lines of therapy.

RESULTS: Prevalence and incidence of MCL among the VHA population ranged from 8-11 cases, and 0.6-2.6 cases per 100,000 persons, respectively. A total of 390 patients (mean age: 70 years, 85% white) received 1st line (mean duration: 243 days), 146 (37%) patients received 2nd line (mean duration: 259 days), and 47 (12%) received 3rd line (mean duration: 154 days) therapy. Bendamustine-based regimen was the most common 1st line MCL treatment (43%), with lower utilization later (2nd line: 18%; 3rd line: 2%). BTK-based regimen was the second most common 1st line MCL treatment (23%), and the most common MCL treatment in later settings (2nd line: 34%, 3rd line 28%). RCHOP-based regimens were seldomly used in any setting (<5%). The overall treatment discontinuation rate was 82%. Approximately 38% of MCL patients had a hospitalization, with mean length-of-stay (LOS) of 5.6 days. The hospitalization rate was 29% (mean LOS: 3.5), 36% (mean LOS: 4.4), and 26% (mean LOS: 3.1) during 1st, 2nd, and 3rd line, respectively. Per-patient-per-month costs were $19,338 overall, and $19,239, $20,064, and $27,663 respectively, during 1st, 2nd, and 3rd line of therapy.

CONCLUSION: This study showed that bendamustine- based and BTK-based regimens were the common frontline treatments among newly diagnosed MCL patients in the VHA population. Future studies are warranted to understand factors associated with treatment selection, discontinuation and clinical benefits among these MCL Veteran patients.

PURPOSE: Moderately hypofractionated radiotherapy (MHRT) is a commonly used treatment modality for localized prostate cancer (LPC). In this setting, dosimetric correlations to acute and late toxicities remain poorly defined.

METHODS: Patients with LPC treated with MHRT between September 2008 and April 2018 were retrospectively identified. We excluded those with < 12 months follow up, elective nodal coverage, or additional boost. All patients received either 70Gy/28 fractions or 60Gy/20 fractions. Demographics, clinical outcomes, and toxicity data were obtained. Acute and late (≥3 months following MHRT completion) gastrointestinal (GI) and genitourinary (GU) toxicities were determined per CTCAE 5.0. Univariate and multivariate analyses were performed for acute and late grade 2+ GI/GU toxicity via logistic regression and log rank testing for demographic and dosimetric variables.

RESULTS: A total of 436 patients with LPC were treated with MHRT. Mean age was 64 years (IQR 60-68), median pre-treatment PSA was 8.7 (IQR 5.7-12.2), and T stages included T1a/2a (357), T2b/2c (58), and T3 (21). Acute grade 3 GU and GI toxicities were observed in 16(3.7%) and 3(0.7%) patients respectively, with no acute grade 4 toxicity events. Late grade 3 GU and GI toxicities were observed in 17(3.9%) and 4(0.9%) patients respectively, with two late grade 4 GI (0.05%) events. On multivariate analysis, acute grade 2+ GU toxicity was associated with pre-treatment PSA (odds ratio [OR] 1.02 95% confidence interval [CI] 1.01-1.04, P = 0.011) and pre-radiotherapy AUA SS (OR 1.06 95%CI: 1.03-1.09, P < 0.001); late grade 2+ GU toxicity was associated with pre-treatment AUA (hazard ratio [HR] 1.04 95%CI: 1.02-1.06, P < 0.001), lack of pre-treatment urinary meds (HR 0.65, 95%CI: 0.46-0.92, P = 0.049), and ADT use (HR 1.45, 95%CI: 1.03-2.03, P = 0.034); acute grade 2+ GI toxicity did demonstrate significant correlation; late grade 2+ GI toxicity was associated with ethnicity (Black vs White, HR 0.50, 95% CI: 0.25-0.99, P = 0.008) and pre-treatment PSA (HR 1.02, 95%CI: 1.00- 1.03, P = 0.024).

CONCLUSION: LPC patients completing MHRT experienced low rates of grade 3+ acute and late GU/GI toxicities. No dosimetric variables demonstrated significance on multivariate analysis of acute or late GU/ GI grade 2+ toxicity. Late grade 2+ GU toxicity was associated with ADT use, while late grade 2+ GI toxicity was associated with ethnicity and pre-treatment PSA.

PURPOSE: Moderately hypofractionated radiotherapy (MHRT) is a commonly used treatment modality for localized prostate cancer (LPC). In this setting, dosimetric correlations to acute and late toxicities remain poorly defined.

METHODS: Patients with LPC treated with MHRT between September 2008 and April 2018 were retrospectively identified. We excluded those with < 12 months follow up, elective nodal coverage, or additional boost. All patients received either 70Gy/28 fractions or 60Gy/20 fractions. Demographics, clinical outcomes, and toxicity data were obtained. Acute and late (≥3 months following MHRT completion) gastrointestinal (GI) and genitourinary (GU) toxicities were determined per CTCAE 5.0. Univariate and multivariate analyses were performed for acute and late grade 2+ GI/GU toxicity via logistic regression and log rank testing for demographic and dosimetric variables.

RESULTS: A total of 436 patients with LPC were treated with MHRT. Mean age was 64 years (IQR 60-68), median pre-treatment PSA was 8.7 (IQR 5.7-12.2), and T stages included T1a/2a (357), T2b/2c (58), and T3 (21). Acute grade 3 GU and GI toxicities were observed in 16(3.7%) and 3(0.7%) patients respectively, with no acute grade 4 toxicity events. Late grade 3 GU and GI toxicities were observed in 17(3.9%) and 4(0.9%) patients respectively, with two late grade 4 GI (0.05%) events. On multivariate analysis, acute grade 2+ GU toxicity was associated with pre-treatment PSA (odds ratio [OR] 1.02 95% confidence interval [CI] 1.01-1.04, P = 0.011) and pre-radiotherapy AUA SS (OR 1.06 95%CI: 1.03-1.09, P < 0.001); late grade 2+ GU toxicity was associated with pre-treatment AUA (hazard ratio [HR] 1.04 95%CI: 1.02-1.06, P < 0.001), lack of pre-treatment urinary meds (HR 0.65, 95%CI: 0.46-0.92, P = 0.049), and ADT use (HR 1.45, 95%CI: 1.03-2.03, P = 0.034); acute grade 2+ GI toxicity did demonstrate significant correlation; late grade 2+ GI toxicity was associated with ethnicity (Black vs White, HR 0.50, 95% CI: 0.25-0.99, P = 0.008) and pre-treatment PSA (HR 1.02, 95%CI: 1.00- 1.03, P = 0.024).

CONCLUSION: LPC patients completing MHRT experienced low rates of grade 3+ acute and late GU/GI toxicities. No dosimetric variables demonstrated significance on multivariate analysis of acute or late GU/ GI grade 2+ toxicity. Late grade 2+ GU toxicity was associated with ADT use, while late grade 2+ GI toxicity was associated with ethnicity and pre-treatment PSA.

PURPOSE: Moderately hypofractionated radiotherapy (MHRT) is a commonly used treatment modality for localized prostate cancer (LPC). In this setting, dosimetric correlations to acute and late toxicities remain poorly defined.

METHODS: Patients with LPC treated with MHRT between September 2008 and April 2018 were retrospectively identified. We excluded those with < 12 months follow up, elective nodal coverage, or additional boost. All patients received either 70Gy/28 fractions or 60Gy/20 fractions. Demographics, clinical outcomes, and toxicity data were obtained. Acute and late (≥3 months following MHRT completion) gastrointestinal (GI) and genitourinary (GU) toxicities were determined per CTCAE 5.0. Univariate and multivariate analyses were performed for acute and late grade 2+ GI/GU toxicity via logistic regression and log rank testing for demographic and dosimetric variables.

RESULTS: A total of 436 patients with LPC were treated with MHRT. Mean age was 64 years (IQR 60-68), median pre-treatment PSA was 8.7 (IQR 5.7-12.2), and T stages included T1a/2a (357), T2b/2c (58), and T3 (21). Acute grade 3 GU and GI toxicities were observed in 16(3.7%) and 3(0.7%) patients respectively, with no acute grade 4 toxicity events. Late grade 3 GU and GI toxicities were observed in 17(3.9%) and 4(0.9%) patients respectively, with two late grade 4 GI (0.05%) events. On multivariate analysis, acute grade 2+ GU toxicity was associated with pre-treatment PSA (odds ratio [OR] 1.02 95% confidence interval [CI] 1.01-1.04, P = 0.011) and pre-radiotherapy AUA SS (OR 1.06 95%CI: 1.03-1.09, P < 0.001); late grade 2+ GU toxicity was associated with pre-treatment AUA (hazard ratio [HR] 1.04 95%CI: 1.02-1.06, P < 0.001), lack of pre-treatment urinary meds (HR 0.65, 95%CI: 0.46-0.92, P = 0.049), and ADT use (HR 1.45, 95%CI: 1.03-2.03, P = 0.034); acute grade 2+ GI toxicity did demonstrate significant correlation; late grade 2+ GI toxicity was associated with ethnicity (Black vs White, HR 0.50, 95% CI: 0.25-0.99, P = 0.008) and pre-treatment PSA (HR 1.02, 95%CI: 1.00- 1.03, P = 0.024).

CONCLUSION: LPC patients completing MHRT experienced low rates of grade 3+ acute and late GU/GI toxicities. No dosimetric variables demonstrated significance on multivariate analysis of acute or late GU/ GI grade 2+ toxicity. Late grade 2+ GU toxicity was associated with ADT use, while late grade 2+ GI toxicity was associated with ethnicity and pre-treatment PSA.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.