AVAHO

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Background: Dual immune checkpoint blockade (DICB) is utilized for a variety of malignancies. These therapies have a unique and often unpredictable side effect profile compared to conventional chemotherapy. We describe a lethal case of aplastic anemia (AA) as a result of DICB and a review of the literature regarding this rare entity.

Case Presentation: A 64-year-old male underwent complete resection for right renal cell carcinoma. He developed metastasis 1 year after resection and was started on nivolumab 240 mg and ipilimumab 1mg/kg every 21 days. After 4 cycles, he had an asymptomatic elevation of liver function tests (LFT) with a total bilirubin of 6.4 mg/DL (Ref Range 0.2-1.2 mg/dL). Immunotherapy was discontinued, and he started IV methylprednisolone. His LFTs normalized after 5 weeks of steroid taper and CT demonstrated complete response.

6 months after his final dose of DICB, he developed progressive fatigue and a petechial rash. Labs were signi cant for white blood cell count of 0.9 K/cm² (absolute neutrophil count of 0.3 k/cm²), hemoglobin of 12 g/dL and platelets of 11 K/cm². His complete blood count 2 weeks prior was normal. A bone marrow biopsy demonstrated severely hypocellular marrow (10%) with marked decrease in all hematopoietic precursors. He was treated for DICB AA and started on 1mg/kg prednisone, granulocyte colony stimulating factor and erythropoietin.

After no count recovery he was started on antithymocyte globulin and received 7 doses. Despite aggressive supportive care and prophylactic antibiotics, he developed bacteremia and died of septic shock four weeks after admission.

Discussion: On review of the literature, there are only two reported cases of DICB AA. Our particular case has a few unique features. First, hepatotoxicity developed prior to AA. Second, pancytopenia occurred 6 months after his last dose of DICB. There are no other case reports of AA so far out from last infusion.

Conclusion: This case demonstrates the need to promptly recognize rare toxicities of immunotherapies such as AA and identify effective therapies for serious toxicities that are not steroid responsive.

Background: Dual immune checkpoint blockade (DICB) is utilized for a variety of malignancies. These therapies have a unique and often unpredictable side effect profile compared to conventional chemotherapy. We describe a lethal case of aplastic anemia (AA) as a result of DICB and a review of the literature regarding this rare entity.

Case Presentation: A 64-year-old male underwent complete resection for right renal cell carcinoma. He developed metastasis 1 year after resection and was started on nivolumab 240 mg and ipilimumab 1mg/kg every 21 days. After 4 cycles, he had an asymptomatic elevation of liver function tests (LFT) with a total bilirubin of 6.4 mg/DL (Ref Range 0.2-1.2 mg/dL). Immunotherapy was discontinued, and he started IV methylprednisolone. His LFTs normalized after 5 weeks of steroid taper and CT demonstrated complete response.

6 months after his final dose of DICB, he developed progressive fatigue and a petechial rash. Labs were signi cant for white blood cell count of 0.9 K/cm² (absolute neutrophil count of 0.3 k/cm²), hemoglobin of 12 g/dL and platelets of 11 K/cm². His complete blood count 2 weeks prior was normal. A bone marrow biopsy demonstrated severely hypocellular marrow (10%) with marked decrease in all hematopoietic precursors. He was treated for DICB AA and started on 1mg/kg prednisone, granulocyte colony stimulating factor and erythropoietin.

After no count recovery he was started on antithymocyte globulin and received 7 doses. Despite aggressive supportive care and prophylactic antibiotics, he developed bacteremia and died of septic shock four weeks after admission.

Discussion: On review of the literature, there are only two reported cases of DICB AA. Our particular case has a few unique features. First, hepatotoxicity developed prior to AA. Second, pancytopenia occurred 6 months after his last dose of DICB. There are no other case reports of AA so far out from last infusion.

Conclusion: This case demonstrates the need to promptly recognize rare toxicities of immunotherapies such as AA and identify effective therapies for serious toxicities that are not steroid responsive.

Background: Dual immune checkpoint blockade (DICB) is utilized for a variety of malignancies. These therapies have a unique and often unpredictable side effect profile compared to conventional chemotherapy. We describe a lethal case of aplastic anemia (AA) as a result of DICB and a review of the literature regarding this rare entity.

Case Presentation: A 64-year-old male underwent complete resection for right renal cell carcinoma. He developed metastasis 1 year after resection and was started on nivolumab 240 mg and ipilimumab 1mg/kg every 21 days. After 4 cycles, he had an asymptomatic elevation of liver function tests (LFT) with a total bilirubin of 6.4 mg/DL (Ref Range 0.2-1.2 mg/dL). Immunotherapy was discontinued, and he started IV methylprednisolone. His LFTs normalized after 5 weeks of steroid taper and CT demonstrated complete response.

6 months after his final dose of DICB, he developed progressive fatigue and a petechial rash. Labs were signi cant for white blood cell count of 0.9 K/cm² (absolute neutrophil count of 0.3 k/cm²), hemoglobin of 12 g/dL and platelets of 11 K/cm². His complete blood count 2 weeks prior was normal. A bone marrow biopsy demonstrated severely hypocellular marrow (10%) with marked decrease in all hematopoietic precursors. He was treated for DICB AA and started on 1mg/kg prednisone, granulocyte colony stimulating factor and erythropoietin.

After no count recovery he was started on antithymocyte globulin and received 7 doses. Despite aggressive supportive care and prophylactic antibiotics, he developed bacteremia and died of septic shock four weeks after admission.

Discussion: On review of the literature, there are only two reported cases of DICB AA. Our particular case has a few unique features. First, hepatotoxicity developed prior to AA. Second, pancytopenia occurred 6 months after his last dose of DICB. There are no other case reports of AA so far out from last infusion.

Conclusion: This case demonstrates the need to promptly recognize rare toxicities of immunotherapies such as AA and identify effective therapies for serious toxicities that are not steroid responsive.

Background: Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient and caregiver outcomes are not well understood.

Methods: We evaluated the effects of integrated outpatient palliative and oncology care for advanced cancer on patient and caregiver outcomes. Following a standard protocol (PROSPERO: CRD42017057541), investigators independently screened reports to identify randomized controlled trials or quasi-experimental studies that evaluated the effect of integrated outpatient palliative and oncology care interventions on quality of life, survival, and healthcare utilization among adults with advanced cancer. Data sources were English-language peer-reviewed publications in PubMed, CINAHL, and Cochrane Central through November 2016. We subsequently updated our PubMed search through July 2018. Data were synthesized using random-effects meta-analyses, supplemented with qualitative methods when necessary.

Results: Eight randomized controlled and two cluster randomized trials were included. Most patients had multiple advanced cancers, with median time from diagnosis or recurrence to enrollment ranging from eight to 12 weeks. All interventions included a multidisciplinary team, were classified as “moderately integrated,” and addressed physical and psychological symptoms. In a meta-analysis, short-term quality of life improved; symptom burden improved; and all-cause mortality decreased. Qualitative analyses revealed no association between integration elements, palliative care intervention elements, and intervention impact. Utilization and caregiver outcomes were often not reported.

Conclusion: Moderately integrated palliative and oncology outpatient interventions had positive effects on short-term quality of life, symptom burden, and survival. Evidence for effects on healthcare utilization and caregiver outcomes remains sparse.

Background: Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient and caregiver outcomes are not well understood.

Methods: We evaluated the effects of integrated outpatient palliative and oncology care for advanced cancer on patient and caregiver outcomes. Following a standard protocol (PROSPERO: CRD42017057541), investigators independently screened reports to identify randomized controlled trials or quasi-experimental studies that evaluated the effect of integrated outpatient palliative and oncology care interventions on quality of life, survival, and healthcare utilization among adults with advanced cancer. Data sources were English-language peer-reviewed publications in PubMed, CINAHL, and Cochrane Central through November 2016. We subsequently updated our PubMed search through July 2018. Data were synthesized using random-effects meta-analyses, supplemented with qualitative methods when necessary.

Results: Eight randomized controlled and two cluster randomized trials were included. Most patients had multiple advanced cancers, with median time from diagnosis or recurrence to enrollment ranging from eight to 12 weeks. All interventions included a multidisciplinary team, were classified as “moderately integrated,” and addressed physical and psychological symptoms. In a meta-analysis, short-term quality of life improved; symptom burden improved; and all-cause mortality decreased. Qualitative analyses revealed no association between integration elements, palliative care intervention elements, and intervention impact. Utilization and caregiver outcomes were often not reported.

Conclusion: Moderately integrated palliative and oncology outpatient interventions had positive effects on short-term quality of life, symptom burden, and survival. Evidence for effects on healthcare utilization and caregiver outcomes remains sparse.

Background: Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient and caregiver outcomes are not well understood.

Methods: We evaluated the effects of integrated outpatient palliative and oncology care for advanced cancer on patient and caregiver outcomes. Following a standard protocol (PROSPERO: CRD42017057541), investigators independently screened reports to identify randomized controlled trials or quasi-experimental studies that evaluated the effect of integrated outpatient palliative and oncology care interventions on quality of life, survival, and healthcare utilization among adults with advanced cancer. Data sources were English-language peer-reviewed publications in PubMed, CINAHL, and Cochrane Central through November 2016. We subsequently updated our PubMed search through July 2018. Data were synthesized using random-effects meta-analyses, supplemented with qualitative methods when necessary.

Results: Eight randomized controlled and two cluster randomized trials were included. Most patients had multiple advanced cancers, with median time from diagnosis or recurrence to enrollment ranging from eight to 12 weeks. All interventions included a multidisciplinary team, were classified as “moderately integrated,” and addressed physical and psychological symptoms. In a meta-analysis, short-term quality of life improved; symptom burden improved; and all-cause mortality decreased. Qualitative analyses revealed no association between integration elements, palliative care intervention elements, and intervention impact. Utilization and caregiver outcomes were often not reported.

Conclusion: Moderately integrated palliative and oncology outpatient interventions had positive effects on short-term quality of life, symptom burden, and survival. Evidence for effects on healthcare utilization and caregiver outcomes remains sparse.

Purpose: The US Food and Drug Administration (FDA) approved the biologic medication filgrastim to mobilize hematopoietic progenitor cells (HPCs) into the peripheral blood for collection by leukapheresis for hematopoietic stem cell transplant (HSCT). The FDA-approved biosimilar tbo-filgrastim is currently used off-label for this indication in both autologous and allogeneic HSCT at the Tennessee Valley Healthcare System. This study compares the efficacy of filgrastim and tbo-filgrastim for these indications.

Methods: This was a retrospective, single center, observational cohort study approved by the Institutional Review Board. Patients were identified from the bone marrow transplant clinic and included in data collection if they received filgrastim or tbo-filgrastim for HPC mobilization between September 1, 2012 and September 1, 2018. The primary outcome was the proportion of patients with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for autologous transplantation. Secondary outcomes were the proportion of donors with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for allogeneic transplantation and the use of plerixafor in both patient populations.

Continuous data were described using mean and standard deviation. Associations between independent and dependent variables were assessed using t-tests for continuous variables and Fishers Exact tests for dichotomous variables.

Results: A total of 469 patients were identified for study inclusion; 367 underwent mobilization for autologous and 102 for allogeneic HSCT. Primary outcome was achieved in 47.5% of patients who received filgrastim compared with 50.24% who received tbo-filgrastim (P=0.67). There was no difference in patients eligible for collection on day 4 of filgrastim or tbo-filgrastim administration in the allogeneic HSCT population (97.6% vs 100% respectively; P=0.41). No statistically significant differences were identified in the number of patients requiring plerixafor use in the autologous or allogenic HSCT populations.

Conclusion: The use of the biosimilar tbo-filgrastim for mobilization in either autologous or allogeneic HSCT has comparable outcomes to that of the biotherapeutic reference product filgrastim at a reduced cost.

Purpose: The US Food and Drug Administration (FDA) approved the biologic medication filgrastim to mobilize hematopoietic progenitor cells (HPCs) into the peripheral blood for collection by leukapheresis for hematopoietic stem cell transplant (HSCT). The FDA-approved biosimilar tbo-filgrastim is currently used off-label for this indication in both autologous and allogeneic HSCT at the Tennessee Valley Healthcare System. This study compares the efficacy of filgrastim and tbo-filgrastim for these indications.

Methods: This was a retrospective, single center, observational cohort study approved by the Institutional Review Board. Patients were identified from the bone marrow transplant clinic and included in data collection if they received filgrastim or tbo-filgrastim for HPC mobilization between September 1, 2012 and September 1, 2018. The primary outcome was the proportion of patients with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for autologous transplantation. Secondary outcomes were the proportion of donors with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for allogeneic transplantation and the use of plerixafor in both patient populations.

Continuous data were described using mean and standard deviation. Associations between independent and dependent variables were assessed using t-tests for continuous variables and Fishers Exact tests for dichotomous variables.

Results: A total of 469 patients were identified for study inclusion; 367 underwent mobilization for autologous and 102 for allogeneic HSCT. Primary outcome was achieved in 47.5% of patients who received filgrastim compared with 50.24% who received tbo-filgrastim (P=0.67). There was no difference in patients eligible for collection on day 4 of filgrastim or tbo-filgrastim administration in the allogeneic HSCT population (97.6% vs 100% respectively; P=0.41). No statistically significant differences were identified in the number of patients requiring plerixafor use in the autologous or allogenic HSCT populations.

Conclusion: The use of the biosimilar tbo-filgrastim for mobilization in either autologous or allogeneic HSCT has comparable outcomes to that of the biotherapeutic reference product filgrastim at a reduced cost.

Purpose: The US Food and Drug Administration (FDA) approved the biologic medication filgrastim to mobilize hematopoietic progenitor cells (HPCs) into the peripheral blood for collection by leukapheresis for hematopoietic stem cell transplant (HSCT). The FDA-approved biosimilar tbo-filgrastim is currently used off-label for this indication in both autologous and allogeneic HSCT at the Tennessee Valley Healthcare System. This study compares the efficacy of filgrastim and tbo-filgrastim for these indications.

Methods: This was a retrospective, single center, observational cohort study approved by the Institutional Review Board. Patients were identified from the bone marrow transplant clinic and included in data collection if they received filgrastim or tbo-filgrastim for HPC mobilization between September 1, 2012 and September 1, 2018. The primary outcome was the proportion of patients with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for autologous transplantation. Secondary outcomes were the proportion of donors with a CD34+ count > 15 ×103 cells/uL on day 4 of filgrastim or tbo-filgrastim mobilization for allogeneic transplantation and the use of plerixafor in both patient populations.

Continuous data were described using mean and standard deviation. Associations between independent and dependent variables were assessed using t-tests for continuous variables and Fishers Exact tests for dichotomous variables.

Results: A total of 469 patients were identified for study inclusion; 367 underwent mobilization for autologous and 102 for allogeneic HSCT. Primary outcome was achieved in 47.5% of patients who received filgrastim compared with 50.24% who received tbo-filgrastim (P=0.67). There was no difference in patients eligible for collection on day 4 of filgrastim or tbo-filgrastim administration in the allogeneic HSCT population (97.6% vs 100% respectively; P=0.41). No statistically significant differences were identified in the number of patients requiring plerixafor use in the autologous or allogenic HSCT populations.

Conclusion: The use of the biosimilar tbo-filgrastim for mobilization in either autologous or allogeneic HSCT has comparable outcomes to that of the biotherapeutic reference product filgrastim at a reduced cost.

Purpose: To inform stakeholders of a newly formed, VAbased, research oriented collaborative group, the Veterans Radiation Oncology Consortium (VET-ROC).

Background: To strengthen, promote and enhance VA oncology and radiation oncology centered research, VET-ROC was conceived in October 2018 at the San Antonio VA Radiation Oncology Field Based Meeting and formed with the consent of 18 members sites.

Results: An email sent to all 85 known VA radiation oncologists in October 2018 drew 18 positive responses to join a clinical research consortium within VA. Members responded to 2 questionnaires about the state of their program in October 2018 and April 2019. Per their responses, VET-ROC sites consist of approximately 47 FTE Radiation Oncologists and > 26 FTE Physicists. The sites reported a total of 7.1 FTEE Clinical Research Coordinators (CRC’s) in October 2018 and 10.2 FTE CRC’s in April 2019 with most sites sharing CRC’s with other specialties. Five sites reported a lack of any research coordinator in October 2018, and in April 2019, 3 of those 5 sites had received approval from their resource management committees to hire CRCs.

The group had a face to face meeting in FEB 2019 and has held conference calls every 4-6 weeks since then to review opportunities for research, shared best practices, partake in educational webinars, identify barriers to research development, opportunities for research proposals with at least 2 groups of members submitting Merit Review awards to CSR&D that may have been possible as a result of VET-ROC. Feedback on the progress the group has made has been largely positive. Individual responses noted that the group had created opportunities that would not have been possible otherwise. There were suggestions to formalize the structure of the group.

Conclusion: Since its formation, VET-ROC has been a very positive experience for its members who consist of a select group of Radiation Oncologists with shared common interests in clinical research. The group will likely continue to move grow and move forward if it can translate its momentum into research support obtained from a diverse source of funding mechanisms.

Purpose: To inform stakeholders of a newly formed, VAbased, research oriented collaborative group, the Veterans Radiation Oncology Consortium (VET-ROC).

Background: To strengthen, promote and enhance VA oncology and radiation oncology centered research, VET-ROC was conceived in October 2018 at the San Antonio VA Radiation Oncology Field Based Meeting and formed with the consent of 18 members sites.

Results: An email sent to all 85 known VA radiation oncologists in October 2018 drew 18 positive responses to join a clinical research consortium within VA. Members responded to 2 questionnaires about the state of their program in October 2018 and April 2019. Per their responses, VET-ROC sites consist of approximately 47 FTE Radiation Oncologists and > 26 FTE Physicists. The sites reported a total of 7.1 FTEE Clinical Research Coordinators (CRC’s) in October 2018 and 10.2 FTE CRC’s in April 2019 with most sites sharing CRC’s with other specialties. Five sites reported a lack of any research coordinator in October 2018, and in April 2019, 3 of those 5 sites had received approval from their resource management committees to hire CRCs.

The group had a face to face meeting in FEB 2019 and has held conference calls every 4-6 weeks since then to review opportunities for research, shared best practices, partake in educational webinars, identify barriers to research development, opportunities for research proposals with at least 2 groups of members submitting Merit Review awards to CSR&D that may have been possible as a result of VET-ROC. Feedback on the progress the group has made has been largely positive. Individual responses noted that the group had created opportunities that would not have been possible otherwise. There were suggestions to formalize the structure of the group.

Conclusion: Since its formation, VET-ROC has been a very positive experience for its members who consist of a select group of Radiation Oncologists with shared common interests in clinical research. The group will likely continue to move grow and move forward if it can translate its momentum into research support obtained from a diverse source of funding mechanisms.

Purpose: To inform stakeholders of a newly formed, VAbased, research oriented collaborative group, the Veterans Radiation Oncology Consortium (VET-ROC).

Background: To strengthen, promote and enhance VA oncology and radiation oncology centered research, VET-ROC was conceived in October 2018 at the San Antonio VA Radiation Oncology Field Based Meeting and formed with the consent of 18 members sites.

Results: An email sent to all 85 known VA radiation oncologists in October 2018 drew 18 positive responses to join a clinical research consortium within VA. Members responded to 2 questionnaires about the state of their program in October 2018 and April 2019. Per their responses, VET-ROC sites consist of approximately 47 FTE Radiation Oncologists and > 26 FTE Physicists. The sites reported a total of 7.1 FTEE Clinical Research Coordinators (CRC’s) in October 2018 and 10.2 FTE CRC’s in April 2019 with most sites sharing CRC’s with other specialties. Five sites reported a lack of any research coordinator in October 2018, and in April 2019, 3 of those 5 sites had received approval from their resource management committees to hire CRCs.

The group had a face to face meeting in FEB 2019 and has held conference calls every 4-6 weeks since then to review opportunities for research, shared best practices, partake in educational webinars, identify barriers to research development, opportunities for research proposals with at least 2 groups of members submitting Merit Review awards to CSR&D that may have been possible as a result of VET-ROC. Feedback on the progress the group has made has been largely positive. Individual responses noted that the group had created opportunities that would not have been possible otherwise. There were suggestions to formalize the structure of the group.

Conclusion: Since its formation, VET-ROC has been a very positive experience for its members who consist of a select group of Radiation Oncologists with shared common interests in clinical research. The group will likely continue to move grow and move forward if it can translate its momentum into research support obtained from a diverse source of funding mechanisms.

Purpose: To improve breast cancer care and support services to the growing population of younger female Veterans diagnosed with breast cancer. To develop partnerships with non-profit community resources to meet specif c needs and increase resources for all patients living with a breast cancer diagnosis.

Background: Historically, the New Mexico Veterans Affairs Healthcare System (NMVAHCS) has provided care to a predominately male population. However, this demographic is evolving significantly due to an increased number of women serving during Operation Iraqi Freedom and Operation Enduring Freedom conflicts and with improved detection women are being diagnosed younger. Younger women diagnosed with breast cancer experience unique concerns and providers often neglect or avoid discussions involving these difficult topics.

Methods: We utilized grant funding through Living Beyond Breast Cancer (LBBC) to provide education and outreach support specific for younger women diagnosed before 45 years of age. The Surgical Cancer Care Coordinator attended training and was provided educational slide content, handouts, and media templates to promote on-site educational seminars. Four sessions were held: sex and intimacy, early menopause, late complications, and the role of genetics. Telehealth allowed women in rural sections of the state to participate.

Results: Pre and post-surveys were conducted at each session. Pre-survey results: 10% of attendees reported providers initiated sexual function conversations and 5% stated providers seemed comfortable answering questions regarding sexual function Postsurvey results: 100% of attendees felt empowered with knowledge and resources to improve intimacy and sexual relations with their partners. All 4 sessions provided information on topics not previously discussed and developed camaraderie support.

Conclusion: Educating and encouraging young women to discuss symptoms with their providers remains essential. While the VAHCS begins to increase access to women’s health, facilities can develop community partnerships to support unmet needs. Partnering with LBBC Young Women’s Initiative is an example of improving survivorship care without impacting facility budgets or experiencing bureaucratic constraints.

Purpose: To improve breast cancer care and support services to the growing population of younger female Veterans diagnosed with breast cancer. To develop partnerships with non-profit community resources to meet specif c needs and increase resources for all patients living with a breast cancer diagnosis.

Background: Historically, the New Mexico Veterans Affairs Healthcare System (NMVAHCS) has provided care to a predominately male population. However, this demographic is evolving significantly due to an increased number of women serving during Operation Iraqi Freedom and Operation Enduring Freedom conflicts and with improved detection women are being diagnosed younger. Younger women diagnosed with breast cancer experience unique concerns and providers often neglect or avoid discussions involving these difficult topics.

Methods: We utilized grant funding through Living Beyond Breast Cancer (LBBC) to provide education and outreach support specific for younger women diagnosed before 45 years of age. The Surgical Cancer Care Coordinator attended training and was provided educational slide content, handouts, and media templates to promote on-site educational seminars. Four sessions were held: sex and intimacy, early menopause, late complications, and the role of genetics. Telehealth allowed women in rural sections of the state to participate.

Results: Pre and post-surveys were conducted at each session. Pre-survey results: 10% of attendees reported providers initiated sexual function conversations and 5% stated providers seemed comfortable answering questions regarding sexual function Postsurvey results: 100% of attendees felt empowered with knowledge and resources to improve intimacy and sexual relations with their partners. All 4 sessions provided information on topics not previously discussed and developed camaraderie support.

Conclusion: Educating and encouraging young women to discuss symptoms with their providers remains essential. While the VAHCS begins to increase access to women’s health, facilities can develop community partnerships to support unmet needs. Partnering with LBBC Young Women’s Initiative is an example of improving survivorship care without impacting facility budgets or experiencing bureaucratic constraints.

Purpose: To improve breast cancer care and support services to the growing population of younger female Veterans diagnosed with breast cancer. To develop partnerships with non-profit community resources to meet specif c needs and increase resources for all patients living with a breast cancer diagnosis.

Background: Historically, the New Mexico Veterans Affairs Healthcare System (NMVAHCS) has provided care to a predominately male population. However, this demographic is evolving significantly due to an increased number of women serving during Operation Iraqi Freedom and Operation Enduring Freedom conflicts and with improved detection women are being diagnosed younger. Younger women diagnosed with breast cancer experience unique concerns and providers often neglect or avoid discussions involving these difficult topics.

Methods: We utilized grant funding through Living Beyond Breast Cancer (LBBC) to provide education and outreach support specific for younger women diagnosed before 45 years of age. The Surgical Cancer Care Coordinator attended training and was provided educational slide content, handouts, and media templates to promote on-site educational seminars. Four sessions were held: sex and intimacy, early menopause, late complications, and the role of genetics. Telehealth allowed women in rural sections of the state to participate.

Results: Pre and post-surveys were conducted at each session. Pre-survey results: 10% of attendees reported providers initiated sexual function conversations and 5% stated providers seemed comfortable answering questions regarding sexual function Postsurvey results: 100% of attendees felt empowered with knowledge and resources to improve intimacy and sexual relations with their partners. All 4 sessions provided information on topics not previously discussed and developed camaraderie support.

Conclusion: Educating and encouraging young women to discuss symptoms with their providers remains essential. While the VAHCS begins to increase access to women’s health, facilities can develop community partnerships to support unmet needs. Partnering with LBBC Young Women’s Initiative is an example of improving survivorship care without impacting facility budgets or experiencing bureaucratic constraints.

Background: Liposarcoma is the most common malignant soft tissue sarcoma (STS). Surgical resection is the most utilized therapeutic option. In this study, we aim to explore the effects of varying degrees of surgical margins on survival in patients with dedifferentiated liposarcoma (DDLPS).

Methods: The National Cancer Database (NCDB) was used to select patients with DDLPS to determine if surgical margins and other variables were associated with decreased overall survival after accounting for age, gender, race, Charlson-Deyo score, anatomic site, treatment approach, tumor size, tumor grade, and presence of metastases through multivariable analysis.

Results: Of the 1004 selected patients, 64.4% were male, 87.0% were white, and the median age was 63 years. About 95% had no metastases at the time of diagnosis, and 91.5% had high grade liposarcoma. For the status of surgical margins, 50.8% had no residual tumors, 26.1% had microscopic residual tumors, 4.3% had macroscopic residual tumors. In general, the risk of death was higher for older males (25.8% increased risk of mortality) and those with metastases (312.9% increased risk of mortality) as well as patients with high grade liposarcoma (112.4% increased risk of mortality). Patients with macroscopic residual tumors in comparison to those with no residual tumors had a 96.7% increased risk of death (HR 95% CI:1.24 to 3.13; P=0.004).

Conclusion: Older age, presence of metastasis, male patients, retroperitoneal/abdomen primary site, highgrade tumors, and macroscopic or residual tumor present after surgery lead to an increased risk of mortality. These outcomes highlight the importance and benefits of negative or complete surgical margins as prognostic indicators for patients with DDLPS, especially considering that resection is the most commonly utilized therapeutic option. The NCDB contains about 70% of cancer incidents within the US, therefore a future study incorporating the Surveillance, Epidemiology, and End Results (SEER) registry could enhance and possibly add to the results brought forth by this study.

Background: Liposarcoma is the most common malignant soft tissue sarcoma (STS). Surgical resection is the most utilized therapeutic option. In this study, we aim to explore the effects of varying degrees of surgical margins on survival in patients with dedifferentiated liposarcoma (DDLPS).

Methods: The National Cancer Database (NCDB) was used to select patients with DDLPS to determine if surgical margins and other variables were associated with decreased overall survival after accounting for age, gender, race, Charlson-Deyo score, anatomic site, treatment approach, tumor size, tumor grade, and presence of metastases through multivariable analysis.

Results: Of the 1004 selected patients, 64.4% were male, 87.0% were white, and the median age was 63 years. About 95% had no metastases at the time of diagnosis, and 91.5% had high grade liposarcoma. For the status of surgical margins, 50.8% had no residual tumors, 26.1% had microscopic residual tumors, 4.3% had macroscopic residual tumors. In general, the risk of death was higher for older males (25.8% increased risk of mortality) and those with metastases (312.9% increased risk of mortality) as well as patients with high grade liposarcoma (112.4% increased risk of mortality). Patients with macroscopic residual tumors in comparison to those with no residual tumors had a 96.7% increased risk of death (HR 95% CI:1.24 to 3.13; P=0.004).

Conclusion: Older age, presence of metastasis, male patients, retroperitoneal/abdomen primary site, highgrade tumors, and macroscopic or residual tumor present after surgery lead to an increased risk of mortality. These outcomes highlight the importance and benefits of negative or complete surgical margins as prognostic indicators for patients with DDLPS, especially considering that resection is the most commonly utilized therapeutic option. The NCDB contains about 70% of cancer incidents within the US, therefore a future study incorporating the Surveillance, Epidemiology, and End Results (SEER) registry could enhance and possibly add to the results brought forth by this study.

Background: Liposarcoma is the most common malignant soft tissue sarcoma (STS). Surgical resection is the most utilized therapeutic option. In this study, we aim to explore the effects of varying degrees of surgical margins on survival in patients with dedifferentiated liposarcoma (DDLPS).

Methods: The National Cancer Database (NCDB) was used to select patients with DDLPS to determine if surgical margins and other variables were associated with decreased overall survival after accounting for age, gender, race, Charlson-Deyo score, anatomic site, treatment approach, tumor size, tumor grade, and presence of metastases through multivariable analysis.

Results: Of the 1004 selected patients, 64.4% were male, 87.0% were white, and the median age was 63 years. About 95% had no metastases at the time of diagnosis, and 91.5% had high grade liposarcoma. For the status of surgical margins, 50.8% had no residual tumors, 26.1% had microscopic residual tumors, 4.3% had macroscopic residual tumors. In general, the risk of death was higher for older males (25.8% increased risk of mortality) and those with metastases (312.9% increased risk of mortality) as well as patients with high grade liposarcoma (112.4% increased risk of mortality). Patients with macroscopic residual tumors in comparison to those with no residual tumors had a 96.7% increased risk of death (HR 95% CI:1.24 to 3.13; P=0.004).

Conclusion: Older age, presence of metastasis, male patients, retroperitoneal/abdomen primary site, highgrade tumors, and macroscopic or residual tumor present after surgery lead to an increased risk of mortality. These outcomes highlight the importance and benefits of negative or complete surgical margins as prognostic indicators for patients with DDLPS, especially considering that resection is the most commonly utilized therapeutic option. The NCDB contains about 70% of cancer incidents within the US, therefore a future study incorporating the Surveillance, Epidemiology, and End Results (SEER) registry could enhance and possibly add to the results brought forth by this study.

Background: In 2018, a male aged 62 years with a history of squamous cell tonsillar cancer, which was successfully treated by concurrent chemoradiation and selective neck dissection in 2014, was diagnosed with primary right sided lung adenocarcinoma (Stage IV, cT4c cN3 cM1a) after presenting with post-obstructive pneumonia. Molecular analysis was about 100% positive for PDL-1 and negative for EGFR, ALK, BRAF, and ROS. The patient was started on Pembrolizumab. After 5 cycles, he developed worsening dyspnea. A CT scan of his chest revealed a large pericardial effusion and decrease in size of right upper lobe lesion. An echocardiogram confirmed cardiac tamponade physiology. 400 ml of fluid was removed by emergent pericardial window and surgical drain was placed. Cytopathological analysis of pericardial fluid returned negative for malignant cells. The patient was treated with high dose prednisone with tapering, and pembrolizumab was discontinued. Patient responded very well. A repeat CT and ECHO after 3 months of treatment confirmed nearresolution of effusion.

Discussion: Distinguishing immune mediated pericardial effusion from malignant effusion is vital. Development of pericardial effusion with concurrent improvement or stability of malignant lesion, negative cytology and brisk response to corticosteroids indicates an immune etiology.

Pericardiocentesis or pericardial window is the key intervention in acute management. The critical step in immune mediated pericardial effusions is initiation of high-dose corticosteroids (1-2 mg/kg of Prednisone) with tapering of at least 4 weeks in severe cases. In unresponsive cases, corticosteroids at transplant rejection dose (1 g methylprednisone daily) and addition of mycophenolate mofetil, in iximab or antithymocyte globulin should be considered. As per ‘ASCO Practice Guideline’, any grade of cardiotoxicity above grade 1 warrants holding or permanently discontinuing the immunotherapy. For pericardial effusions secondary to pseudoprogression, immunotherapy can be continued.

Based on our literature review, concurrence of other immune related adverse events and recurrence of effusions with discontinuation of corticosteroids is reported with immune mediated pericardial effusions.

Conclusion: Early identification of immune related adverse events is very important. In immune mediated pericardial effusion, pericardial fluid should be drained, and corticosteroids should be started promptly. Permanent discontinuation of immunotherapy is recommended for grade 3 and 4 cardiotoxicity. Re-challenge of immunotherapy after treating the adverse event is a subject that needs further research.

Background: In 2018, a male aged 62 years with a history of squamous cell tonsillar cancer, which was successfully treated by concurrent chemoradiation and selective neck dissection in 2014, was diagnosed with primary right sided lung adenocarcinoma (Stage IV, cT4c cN3 cM1a) after presenting with post-obstructive pneumonia. Molecular analysis was about 100% positive for PDL-1 and negative for EGFR, ALK, BRAF, and ROS. The patient was started on Pembrolizumab. After 5 cycles, he developed worsening dyspnea. A CT scan of his chest revealed a large pericardial effusion and decrease in size of right upper lobe lesion. An echocardiogram confirmed cardiac tamponade physiology. 400 ml of fluid was removed by emergent pericardial window and surgical drain was placed. Cytopathological analysis of pericardial fluid returned negative for malignant cells. The patient was treated with high dose prednisone with tapering, and pembrolizumab was discontinued. Patient responded very well. A repeat CT and ECHO after 3 months of treatment confirmed nearresolution of effusion.

Discussion: Distinguishing immune mediated pericardial effusion from malignant effusion is vital. Development of pericardial effusion with concurrent improvement or stability of malignant lesion, negative cytology and brisk response to corticosteroids indicates an immune etiology.

Pericardiocentesis or pericardial window is the key intervention in acute management. The critical step in immune mediated pericardial effusions is initiation of high-dose corticosteroids (1-2 mg/kg of Prednisone) with tapering of at least 4 weeks in severe cases. In unresponsive cases, corticosteroids at transplant rejection dose (1 g methylprednisone daily) and addition of mycophenolate mofetil, in iximab or antithymocyte globulin should be considered. As per ‘ASCO Practice Guideline’, any grade of cardiotoxicity above grade 1 warrants holding or permanently discontinuing the immunotherapy. For pericardial effusions secondary to pseudoprogression, immunotherapy can be continued.

Based on our literature review, concurrence of other immune related adverse events and recurrence of effusions with discontinuation of corticosteroids is reported with immune mediated pericardial effusions.

Conclusion: Early identification of immune related adverse events is very important. In immune mediated pericardial effusion, pericardial fluid should be drained, and corticosteroids should be started promptly. Permanent discontinuation of immunotherapy is recommended for grade 3 and 4 cardiotoxicity. Re-challenge of immunotherapy after treating the adverse event is a subject that needs further research.

Background: In 2018, a male aged 62 years with a history of squamous cell tonsillar cancer, which was successfully treated by concurrent chemoradiation and selective neck dissection in 2014, was diagnosed with primary right sided lung adenocarcinoma (Stage IV, cT4c cN3 cM1a) after presenting with post-obstructive pneumonia. Molecular analysis was about 100% positive for PDL-1 and negative for EGFR, ALK, BRAF, and ROS. The patient was started on Pembrolizumab. After 5 cycles, he developed worsening dyspnea. A CT scan of his chest revealed a large pericardial effusion and decrease in size of right upper lobe lesion. An echocardiogram confirmed cardiac tamponade physiology. 400 ml of fluid was removed by emergent pericardial window and surgical drain was placed. Cytopathological analysis of pericardial fluid returned negative for malignant cells. The patient was treated with high dose prednisone with tapering, and pembrolizumab was discontinued. Patient responded very well. A repeat CT and ECHO after 3 months of treatment confirmed nearresolution of effusion.

Discussion: Distinguishing immune mediated pericardial effusion from malignant effusion is vital. Development of pericardial effusion with concurrent improvement or stability of malignant lesion, negative cytology and brisk response to corticosteroids indicates an immune etiology.

Pericardiocentesis or pericardial window is the key intervention in acute management. The critical step in immune mediated pericardial effusions is initiation of high-dose corticosteroids (1-2 mg/kg of Prednisone) with tapering of at least 4 weeks in severe cases. In unresponsive cases, corticosteroids at transplant rejection dose (1 g methylprednisone daily) and addition of mycophenolate mofetil, in iximab or antithymocyte globulin should be considered. As per ‘ASCO Practice Guideline’, any grade of cardiotoxicity above grade 1 warrants holding or permanently discontinuing the immunotherapy. For pericardial effusions secondary to pseudoprogression, immunotherapy can be continued.

Based on our literature review, concurrence of other immune related adverse events and recurrence of effusions with discontinuation of corticosteroids is reported with immune mediated pericardial effusions.

Conclusion: Early identification of immune related adverse events is very important. In immune mediated pericardial effusion, pericardial fluid should be drained, and corticosteroids should be started promptly. Permanent discontinuation of immunotherapy is recommended for grade 3 and 4 cardiotoxicity. Re-challenge of immunotherapy after treating the adverse event is a subject that needs further research.