AVAHO

Clinical Presentation

A 58-year-old male was diagnosed 6 years ago with stage IV clear cell renal carcinoma (multiple lung nodules and mediastinal adenopathy). He was offered sunitinib, a tyrosine kinase inhibitor, and achieved a partial response with stable disease. Five years later his scans showed worsening disease. Cabozantinib was offered but was poorly tolerated. He tried ipilimumab plus nivolumab but ipilimumab was dropped after 4 cycles due to diarrhea. His scans improved with 4 more cycles of nivolumab but he had to stop immunotherapy due to hypophysitis, diarrhea, and severe jaw pain. He received a COVID-19 booster vaccine and noticed profound fatigue and anorexia soon after. Over 8 weeks he lost 56 lbs (267 to 211 lb). Relapse was suspected but PET CT showed complete resolution of his lung nodules and multiple areas of adenopathy. Asymptomatic and in remission 6 months after vaccination.

Relevant Literature 

Clear cell renal carcinoma is resistant to standard chemotherapy/radiation, which usually offers partial responses. Complete remissions are few. Low glycemic diets in animal models have anticancer activity. HIV causes B cell apoptosis. Coxsackievirus A21 oncolytic properties lyse myeloma and CD138+ plasma cells via intercellular adhesion molecule interaction. SARS-CoV-2 (COVID 19) proteins have oncolytic properties.

Intervention

The patient eliminated sugary food from his diet 6 years ago. Stopped bread 2 years ago. Sunitinib 37.5 mg daily × 5 years. Cabozantinib—poorly tolerated. Ipilimumab + nivolumab × 4 cycles followed by nivolumab × 4 cycles. Stopped treatment; immune side effects. COVID-19 booster.

Outcome

15 lb weight loss due to a low glycemic diet, which began since diagnosis. After 4 years he stopped eating bread. After COVID-19 vaccine had a rapid 56 lb. weight loss, fatigue, and nausea over 8 weeks. No evidence of disease. Asymptomatic, off therapy, weight is ideal (219 lb) 6 months after the vaccine.

Implications for Practice 

Effects of SARS-CoV-2 (COVID-19) on cancers remain unknown. A few case reports of cancer remissions after infections are emerging. This is the first case of complete remission after COVID-19 vaccination in a patient on immunotherapy/low glycemic diet. Research is needed to study the contribution of a COVID-19 inflammatory response.

Clinical Presentation

A 58-year-old male was diagnosed 6 years ago with stage IV clear cell renal carcinoma (multiple lung nodules and mediastinal adenopathy). He was offered sunitinib, a tyrosine kinase inhibitor, and achieved a partial response with stable disease. Five years later his scans showed worsening disease. Cabozantinib was offered but was poorly tolerated. He tried ipilimumab plus nivolumab but ipilimumab was dropped after 4 cycles due to diarrhea. His scans improved with 4 more cycles of nivolumab but he had to stop immunotherapy due to hypophysitis, diarrhea, and severe jaw pain. He received a COVID-19 booster vaccine and noticed profound fatigue and anorexia soon after. Over 8 weeks he lost 56 lbs (267 to 211 lb). Relapse was suspected but PET CT showed complete resolution of his lung nodules and multiple areas of adenopathy. Asymptomatic and in remission 6 months after vaccination.

Relevant Literature 

Clear cell renal carcinoma is resistant to standard chemotherapy/radiation, which usually offers partial responses. Complete remissions are few. Low glycemic diets in animal models have anticancer activity. HIV causes B cell apoptosis. Coxsackievirus A21 oncolytic properties lyse myeloma and CD138+ plasma cells via intercellular adhesion molecule interaction. SARS-CoV-2 (COVID 19) proteins have oncolytic properties.

Intervention

The patient eliminated sugary food from his diet 6 years ago. Stopped bread 2 years ago. Sunitinib 37.5 mg daily × 5 years. Cabozantinib—poorly tolerated. Ipilimumab + nivolumab × 4 cycles followed by nivolumab × 4 cycles. Stopped treatment; immune side effects. COVID-19 booster.

Outcome

15 lb weight loss due to a low glycemic diet, which began since diagnosis. After 4 years he stopped eating bread. After COVID-19 vaccine had a rapid 56 lb. weight loss, fatigue, and nausea over 8 weeks. No evidence of disease. Asymptomatic, off therapy, weight is ideal (219 lb) 6 months after the vaccine.

Implications for Practice 

Effects of SARS-CoV-2 (COVID-19) on cancers remain unknown. A few case reports of cancer remissions after infections are emerging. This is the first case of complete remission after COVID-19 vaccination in a patient on immunotherapy/low glycemic diet. Research is needed to study the contribution of a COVID-19 inflammatory response.

Clinical Presentation

A 58-year-old male was diagnosed 6 years ago with stage IV clear cell renal carcinoma (multiple lung nodules and mediastinal adenopathy). He was offered sunitinib, a tyrosine kinase inhibitor, and achieved a partial response with stable disease. Five years later his scans showed worsening disease. Cabozantinib was offered but was poorly tolerated. He tried ipilimumab plus nivolumab but ipilimumab was dropped after 4 cycles due to diarrhea. His scans improved with 4 more cycles of nivolumab but he had to stop immunotherapy due to hypophysitis, diarrhea, and severe jaw pain. He received a COVID-19 booster vaccine and noticed profound fatigue and anorexia soon after. Over 8 weeks he lost 56 lbs (267 to 211 lb). Relapse was suspected but PET CT showed complete resolution of his lung nodules and multiple areas of adenopathy. Asymptomatic and in remission 6 months after vaccination.

Relevant Literature 

Clear cell renal carcinoma is resistant to standard chemotherapy/radiation, which usually offers partial responses. Complete remissions are few. Low glycemic diets in animal models have anticancer activity. HIV causes B cell apoptosis. Coxsackievirus A21 oncolytic properties lyse myeloma and CD138+ plasma cells via intercellular adhesion molecule interaction. SARS-CoV-2 (COVID 19) proteins have oncolytic properties.

Intervention

The patient eliminated sugary food from his diet 6 years ago. Stopped bread 2 years ago. Sunitinib 37.5 mg daily × 5 years. Cabozantinib—poorly tolerated. Ipilimumab + nivolumab × 4 cycles followed by nivolumab × 4 cycles. Stopped treatment; immune side effects. COVID-19 booster.

Outcome

15 lb weight loss due to a low glycemic diet, which began since diagnosis. After 4 years he stopped eating bread. After COVID-19 vaccine had a rapid 56 lb. weight loss, fatigue, and nausea over 8 weeks. No evidence of disease. Asymptomatic, off therapy, weight is ideal (219 lb) 6 months after the vaccine.

Implications for Practice 

Effects of SARS-CoV-2 (COVID-19) on cancers remain unknown. A few case reports of cancer remissions after infections are emerging. This is the first case of complete remission after COVID-19 vaccination in a patient on immunotherapy/low glycemic diet. Research is needed to study the contribution of a COVID-19 inflammatory response.

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.

Observations

Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.

Results

A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).

Conclusions

The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Background

Since inception, the Veterans Affairs (VA) National TeleOncology (NTO) service has monitored clinical operations through data tools produced by the Veterans Health Administration Support Service Center (VSSC). Unfortunately, pertinent data are spread across multiple reports, making it difficult to continually harmonize needed information. Further, the VSSC does not account for NTO’s hub and spoke clinical model, leading to inaccuracies when attempting to analyze unique encounters. To address these challenges, NTO partnered with the VA Salt Lake City Health Care System Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS) to develop an informatics architecture and frontend NTO Clinical Operations Dashboard (NCOD). Here, we summarize our dashboard development process and the finalized key reporting components of the NCOD.

Methods

The VA Corporate Data Warehouse (CDW) serves as the primary data source for the NCOD. SQL Server Integration Services was used to build the backend data architecture. Data from the CDW were isolated into a staging data mart for reporting purposes using an extract, transform, load (ETL) approach. The frontend user interface was developed using Power BI. We used a participatory approach1 in determining reporting requirements. Stakeholders included the IDEAS dashboard development team and potential end users from NTO, including leadership, program managers, support assistants, and telehealth coordinators.

Results

The NCOD ETL is scheduled to refresh the data nightly to provide end users with a near real-time experience. The NCOD is comprised of the following four data views: clinic availability, team productivity, patient summary, and encounter summary. The clinic availability view summarizes clinic capacity, no shows, overbookings, and percent utilization. Relative value unit- based productivity is summarized in the team productivity view. The patient summary view presents aggregated data for veterans served by NTO, including geographic distribution, with patient-level drill down displaying demographics, cancer characteristics, and treatment history. Lastly, the encounter view displays utilization trends by modality, while accurately accounting for the hub and spoke clinical model.

Conclusions

An informatics architecture and frontend information display that is capable of synthesizing EHR data into a consumable format has been pivotal in obtaining accurate and timely insight into the demand and capacity of services provided by NTO.

Introduction

Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.

Case Presentation

A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.

Discussion

Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.

Conclusions

Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.

Introduction

Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.

Case Presentation

A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.

Discussion

Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.

Conclusions

Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.

Introduction

Hypereosinophilia can be seen in many medical conditions, including myeloproliferative disorders, and can lead to serious complications if untreated. Sweet syndrome is a rare and painful cutaneous inflammatory condition that has been linked to underlying malignancies.

Case Presentation

A 72-year-old male presented with 6-month history of painful maculopapular rash, night sweats, fever, and weight loss. He was treated with antibiotics and steroids with no improvement. A skin biopsy demonstrated neutrophilic dermatosis consistent with sweet syndrome. Laboratory studies a showed hemoglobin 7.1g/dl, WBC 12.9x103/uL, 30% eosinophils, absolute eosinophil count 3x109/L, and normal platelets. Infectious and immunological work up was negative. CT scan revealed splenomegaly. Bone marrow biopsy showed 100% hypercellularity, trilineage atypia, eosinophils 43% (normal, 1-5%) and 3-4% blasts positive for CD34 and CD117. FISH studies detected loss of PDGFRB signal, cytogenetics revealed a complex karyotype. He was diagnosed with a high-risk (based on IPSS-R) MDS/MPN cross-over with peripheral eosinophilia and is planned to undergo HSCT.

Discussion

Hematologic malignancies are associated with several paraneoplastic syndromes including sweet syndrome, also known as acute febrile neutrophilic dermatosis. The literature describes sweet syndrome occurring mostly with AML but can also be seen with other malignancies like MDS and solid tumor. The distinction between sweet syndrome and infectious or immune-mediated rash can be challenging as it requires histopathologic evaluation and is usually mistreated. Hypereosinophilia is defined as persistent eosinophil count of at least 1.5x109/L. It can be idiopathic or associated with allergic, rheumatologic, infectious, or neoplastic conditions. Clonal hypereosinophilia is most frequently associated with chronic myeloid neoplasms such as myeloproliferative neoplasm (MPN) or overlapping MDS/MPN, and more less frequently with AML. Hypereosinophilia related to hematological malignancies has been linked to gene rearrangements involving PDGFRA, PDGFRB, FGFR1, and JAK2. Patients with documented rearrangements or mutations in PDGFRB are treated with imatinib, which is a potent kinase inhibitor. However, patients with high-risk MDS/MPN with associated eosinophilia are typically treated as MDS and should undergo allogenic HSCT if eligible.

Conclusions

Both hypereosinophlia and sweet syndrome have been linked to myeloid neoplasms. Early recognition of either phenomenon as a paraneoplastic syndrome is important for early diagnosis and treatment.

Background

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.

Presentation

A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.

Diagnosis and Treatment

The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.

After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.

Conclusion

To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.

Background

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.

Presentation

A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.

Diagnosis and Treatment

The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.

After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.

Conclusion

To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.

Background

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors with worse prognosis if arising from the small bowel. Surgery remains the mainstay of treatment for patients with resectable tumors. Imatinib has become the standard treatment in cKIT-positive GISTs with significant morbidity in neoadjuvant, adjuvant, and palliative settings. There are limited data on efficacy and safety of imatinib in dialysis patients, and chemotherapy dosing is challenging in dialysis patients with multiple comorbidities.

Presentation

A 68-year-old male with a history of orthotopic heart transplantation on sirolimus with prednisone, cardiac allograft vasculopathy, plus ESRD on peritoneal dialysis (PD), presented with lower abdominal pain and fever. Abdominal imaging revealed a right lower quadrant (RLQ) mass with concern for bowel perforation.

Diagnosis and Treatment

The patient underwent exploratory laparoscopy with small bowel resection, excision of the mesenteric small bowel mass, drainage and washout of intraabdominal abscess, removal of PD catheter, and transition to hemodialysis. Pathology revealed a 14.5-cm high-grade GIST with mixed spindle and epithelioid types involving the ileal wall and mesentery, consistent with pT4 primary tumor and stage IIIB disease. Molecular testing was positive for c-KIT and DOG-1 mutations.

After a prolonged recovery, repeat abdominal imaging demonstrated metastatic liver disease and a new RLQ lesion. The patient was started on palliative imatinib 100 mg daily with subsequent increase to 200 mg daily. He was monitored closely for toxicities but reported only mild nausea controlled with ondansetron. Hemodialysis was continued 3 times per week. Follow up scans 3 months later showed improvement in RLQ mass and hepatic lesions. The patient remains on the current dose 15 months after the diagnosis.

Conclusion

To our knowledge, this is the first case of a small intestinal GIST in a heart transplant recipient treated with dose-reduced imatinib with concurrent dialysis and immunosuppression. Treatment decision-making was complex given concern for cardiotoxicity with pre-existing cardiac disease and drug-drug interactions with immunosuppressive agents. While some literature suggests standard dose imatinib with dialysis, no large-scale studies evaluated pharmacokinetics of imatinib with creatinine clearance < 20 mL/min. There is a need for further studies to determine dosing strategies for such patients.

Objectives

US Department of Veterans Affairs (VA) patients with genetics referrals are 1.5 times more likely to have multiple cancer screening and preventive procedures if they completed their genetic consultations, but only when completed under a VA traditional model staffed by a team of clinical geneticists and genetic counselors versus a VA nontraditional, centralized telehealth model staffed by genetic counselors working independently. We sought to understand the reasons for these differences in cancer screening and prevention uptake.

Methods

We reviewed randomly selected medical records of patients with cancer genetics referrals stratified by model (142 records from each model). We conducted semi-structured interviews with 15 genetics providers and 36 referring clinicians from 13 VA facilities using purposive sampling. We analyzed annotated medical records and interview transcripts using a rapid assessment process. We characterized annotations as personalized recommendations (eg, begin colonoscopy at age 30 then every 1-2 years), options (eg, consider bilateral mastectomy), and generic messages (eg, refer to guidelines or another provider).

Results

Cancer screening or prevention was documented in 80 traditional-model records (141 annotations) and 106 nontraditional-model records (143 annotations). Personalized recommendations comprised 69% (97/141) of annotations within traditional-model records and 30% (43/143) within nontraditional-model records. Generic messages comprised 17% (24/141) of annotations in traditional-model records and 51% (73/143) in nontraditional-model records. From interview data, referring clinicians expected a broad range of services from genetics providers, including management and screening recommendations, and stated their role was to follow through on recommendations made. Under the traditional model, geneticists formulated recommendations documented by genetic counselors. Under the nontraditional model, scope of practice limited how genetic counselors addressed cancer screening and prevention.

Conclusions/Impacts

Personalized recommendations were typical of traditional-model records, whereas nontraditional-model records usually had generic messages. Compared with the nontraditional model, the traditional model was more patient-centered and better meets expectations of referring clinicians, which might explain in part the differences in patient uptake of cancer screening and preventive procedures.

As the demand for genetic services grows, the VA should promote team-based care under the traditional model for a more patient-centered, coordinated, and effective system of care for precision oncology.

Objectives

US Department of Veterans Affairs (VA) patients with genetics referrals are 1.5 times more likely to have multiple cancer screening and preventive procedures if they completed their genetic consultations, but only when completed under a VA traditional model staffed by a team of clinical geneticists and genetic counselors versus a VA nontraditional, centralized telehealth model staffed by genetic counselors working independently. We sought to understand the reasons for these differences in cancer screening and prevention uptake.

Methods

We reviewed randomly selected medical records of patients with cancer genetics referrals stratified by model (142 records from each model). We conducted semi-structured interviews with 15 genetics providers and 36 referring clinicians from 13 VA facilities using purposive sampling. We analyzed annotated medical records and interview transcripts using a rapid assessment process. We characterized annotations as personalized recommendations (eg, begin colonoscopy at age 30 then every 1-2 years), options (eg, consider bilateral mastectomy), and generic messages (eg, refer to guidelines or another provider).

Results

Cancer screening or prevention was documented in 80 traditional-model records (141 annotations) and 106 nontraditional-model records (143 annotations). Personalized recommendations comprised 69% (97/141) of annotations within traditional-model records and 30% (43/143) within nontraditional-model records. Generic messages comprised 17% (24/141) of annotations in traditional-model records and 51% (73/143) in nontraditional-model records. From interview data, referring clinicians expected a broad range of services from genetics providers, including management and screening recommendations, and stated their role was to follow through on recommendations made. Under the traditional model, geneticists formulated recommendations documented by genetic counselors. Under the nontraditional model, scope of practice limited how genetic counselors addressed cancer screening and prevention.

Conclusions/Impacts

Personalized recommendations were typical of traditional-model records, whereas nontraditional-model records usually had generic messages. Compared with the nontraditional model, the traditional model was more patient-centered and better meets expectations of referring clinicians, which might explain in part the differences in patient uptake of cancer screening and preventive procedures.

As the demand for genetic services grows, the VA should promote team-based care under the traditional model for a more patient-centered, coordinated, and effective system of care for precision oncology.

Objectives

US Department of Veterans Affairs (VA) patients with genetics referrals are 1.5 times more likely to have multiple cancer screening and preventive procedures if they completed their genetic consultations, but only when completed under a VA traditional model staffed by a team of clinical geneticists and genetic counselors versus a VA nontraditional, centralized telehealth model staffed by genetic counselors working independently. We sought to understand the reasons for these differences in cancer screening and prevention uptake.

Methods

We reviewed randomly selected medical records of patients with cancer genetics referrals stratified by model (142 records from each model). We conducted semi-structured interviews with 15 genetics providers and 36 referring clinicians from 13 VA facilities using purposive sampling. We analyzed annotated medical records and interview transcripts using a rapid assessment process. We characterized annotations as personalized recommendations (eg, begin colonoscopy at age 30 then every 1-2 years), options (eg, consider bilateral mastectomy), and generic messages (eg, refer to guidelines or another provider).

Results

Cancer screening or prevention was documented in 80 traditional-model records (141 annotations) and 106 nontraditional-model records (143 annotations). Personalized recommendations comprised 69% (97/141) of annotations within traditional-model records and 30% (43/143) within nontraditional-model records. Generic messages comprised 17% (24/141) of annotations in traditional-model records and 51% (73/143) in nontraditional-model records. From interview data, referring clinicians expected a broad range of services from genetics providers, including management and screening recommendations, and stated their role was to follow through on recommendations made. Under the traditional model, geneticists formulated recommendations documented by genetic counselors. Under the nontraditional model, scope of practice limited how genetic counselors addressed cancer screening and prevention.

Conclusions/Impacts

Personalized recommendations were typical of traditional-model records, whereas nontraditional-model records usually had generic messages. Compared with the nontraditional model, the traditional model was more patient-centered and better meets expectations of referring clinicians, which might explain in part the differences in patient uptake of cancer screening and preventive procedures.

As the demand for genetic services grows, the VA should promote team-based care under the traditional model for a more patient-centered, coordinated, and effective system of care for precision oncology.

Background

Veterans are not well informed of the presumptive conditions associated with toxic exposures endured during military service. A quality improvement project was created to increase awareness. The purpose of this project was to: Raise awareness of presumptive conditions associated with Agent Orange, Camp LeJeune contaminated water and Southwest Asia Burn Pit (fine particulate) exposure, to notify veterans how to initiate the disability benefits application process, and to inform veterans and providers of new changes in legislation (ie, Blue Water and Southwest Asia).

Methods

Using the Cancer Registry, the cancer access coordinator identified veterans with a diagnosis on each of the 3 presumptive condition lists for Agent Orange, Camp Lejeune, and Southwest Asia. These lists were then forwarded to informatics who further screened for military service history. Informative mailers were then sent to the identified veterans, alerting them to their potential eligibility for disability benefits. In addition, the mailers informed veterans how to initiate the benefits application process, how to schedule Disability Benefit Questionnaire (DBQ) exams to expedite the process, as well as contact information for local Veteran’s Service Commission (VSC) and the Veterans Benefits Administration (VBA) for further assistance. These letters were also distributed throughout the medical facility and was shared at cancer committee meetings to increase provider awareness.

Results

In 2021, 604 veterans were identified as potentially eligible for disability benefits and were contacted via mailer. As a result, 153 veterans have been granted service-connected benefits for their identified condition. An additional 91 mailers have been sent since January 2022.

Conclusions

Utilizing this simple practice increases both veteran and provider awareness of presumptive conditions, and aids in veterans receiving the disability compensation they are entitled to. In addition, this practice improves the overall quality of care the veterans receive through the VA and gives us a chance to give back to our veterans.

Background

Veterans are not well informed of the presumptive conditions associated with toxic exposures endured during military service. A quality improvement project was created to increase awareness. The purpose of this project was to: Raise awareness of presumptive conditions associated with Agent Orange, Camp LeJeune contaminated water and Southwest Asia Burn Pit (fine particulate) exposure, to notify veterans how to initiate the disability benefits application process, and to inform veterans and providers of new changes in legislation (ie, Blue Water and Southwest Asia).

Methods

Using the Cancer Registry, the cancer access coordinator identified veterans with a diagnosis on each of the 3 presumptive condition lists for Agent Orange, Camp Lejeune, and Southwest Asia. These lists were then forwarded to informatics who further screened for military service history. Informative mailers were then sent to the identified veterans, alerting them to their potential eligibility for disability benefits. In addition, the mailers informed veterans how to initiate the benefits application process, how to schedule Disability Benefit Questionnaire (DBQ) exams to expedite the process, as well as contact information for local Veteran’s Service Commission (VSC) and the Veterans Benefits Administration (VBA) for further assistance. These letters were also distributed throughout the medical facility and was shared at cancer committee meetings to increase provider awareness.

Results

In 2021, 604 veterans were identified as potentially eligible for disability benefits and were contacted via mailer. As a result, 153 veterans have been granted service-connected benefits for their identified condition. An additional 91 mailers have been sent since January 2022.

Conclusions

Utilizing this simple practice increases both veteran and provider awareness of presumptive conditions, and aids in veterans receiving the disability compensation they are entitled to. In addition, this practice improves the overall quality of care the veterans receive through the VA and gives us a chance to give back to our veterans.

Background

Veterans are not well informed of the presumptive conditions associated with toxic exposures endured during military service. A quality improvement project was created to increase awareness. The purpose of this project was to: Raise awareness of presumptive conditions associated with Agent Orange, Camp LeJeune contaminated water and Southwest Asia Burn Pit (fine particulate) exposure, to notify veterans how to initiate the disability benefits application process, and to inform veterans and providers of new changes in legislation (ie, Blue Water and Southwest Asia).

Methods

Using the Cancer Registry, the cancer access coordinator identified veterans with a diagnosis on each of the 3 presumptive condition lists for Agent Orange, Camp Lejeune, and Southwest Asia. These lists were then forwarded to informatics who further screened for military service history. Informative mailers were then sent to the identified veterans, alerting them to their potential eligibility for disability benefits. In addition, the mailers informed veterans how to initiate the benefits application process, how to schedule Disability Benefit Questionnaire (DBQ) exams to expedite the process, as well as contact information for local Veteran’s Service Commission (VSC) and the Veterans Benefits Administration (VBA) for further assistance. These letters were also distributed throughout the medical facility and was shared at cancer committee meetings to increase provider awareness.

Results

In 2021, 604 veterans were identified as potentially eligible for disability benefits and were contacted via mailer. As a result, 153 veterans have been granted service-connected benefits for their identified condition. An additional 91 mailers have been sent since January 2022.

Conclusions

Utilizing this simple practice increases both veteran and provider awareness of presumptive conditions, and aids in veterans receiving the disability compensation they are entitled to. In addition, this practice improves the overall quality of care the veterans receive through the VA and gives us a chance to give back to our veterans.