Purpose: Colorectal cancer (CRC) is the third most common cancer in the United States, and prognosis is greatly influenced by stage at diagnosis. Early colorectal cancer can be subtle on CT scans showing only mild wall thickening, small polyps, or subtle lymph nodes in atypical draining location. Identifying these lesions on CT scan performed for nonspecific symptoms can help identify interval CRC and improve patient outcome. The purpose of the present study is to classify the undetected CRC on abdominal CT scan by their imaging features and whether early identification can downstage CRC patients. Materials and methods:A retrospective analysis was conducted of patients (pts) diagnosed with CRC and receiving treatment or sought second opinion at Banner MD Anderson Cancer Center. Data collection included age, gender, ECOG, KRAS mutation status, and overall survival (OS). CT imaging was obtained from the time of diagnosis, as well as any prior abdominal imaging available. Images were reviewed for multiple CT features including appearance of mass, mesenteric infiltration, abnormal draining lymph nodes, contrast enhancement relative to adjacent mucosa, and intralesional calcifications. Staging was evaluated using available clinical note and CT scan, based on the TNM staging system for CRC. Results:The 41 pts with 51 prediagnostic CTs from 1/1/2012 -12/31/2015 had mean age of 68 years (range:44-90) Mean ECOG status for the population was 1.46. 41% of the prediagnostic CTs had undetected findings. 52 and 43 % of the undetected findings were in the rectosigmoid and ascending colon respectively. Of the 15 undetected masses, 9 appeared as asymmetric wall thickening, 3 as concentric wall thickening, and 3 as polyps. Of the 14 undetected lymph node groups, 2 were excluded due to stability or nonrelated condition. The remaining lymph nodes were found in the associated draining station and averaged 3±1.2 mm in size. On average, the stage at prediagnostic CT was 3A and the diagnostic CT was 3C (p=0.0015). Average time lapse between prediagnostic and diagnostic CT was 21 months (3-64 months). ConclusionOur study demonstrated that high percentage of early-stage CRC findings are undetected on abdominal CT due to their subtle feature, with most undetected location in the rectosigmoid and ascending colon. In general, these subtle features predate the actual diagnosis by up to two years. Early detection of CRC can improve survival by lowering the stage from 3C to 3A, thus providing 36% improvement in 5-year survival. A dedicated search can be performed on the abdominal CT to improve detection by specifically looking for polyps, wall thickening, and small lymph nodes in the draining station.
12 Background: Personalized genomic cancer medicine is an approach that has long shown efficacy in molecularly-defined subsets of breast and lung cancers, amongst others, but has not been employed more broadly, in part, due to limitations in testing technologies. Recent advances in genomic technologies have increasingly alleviated these constraints, thereby enabling precision cancer medicine. Data regarding the quality outcomes of patients treated with precision cancer medicine is an important next step along the path to widespread employment of this approach. Methods: We performed an IRB-approved retrospective analysis evaluating the use of targeted therapies matched to patients’ molecular aberrations as determined by genomic testing and recommended by a Molecular Tumor Board (MTB). This study assessed whether a detailed molecular profile of advanced solid malignancies including, but not limited to, the lung, gastrointestinal tract, bladder, prostate, ovary, uterus and skin, that were subsequently treated with matched targeted therapies resulted in improvements in three quality outcome measures: 1) Progression Free Survival (PFS), 2) treatment related morbidity, and 3) cost of treatment. Results: Preliminary results of the cohort analysis suggest that the costs associated with genomic targeted therapy are comparable to standard therapies; however, the costs of treatment related morbidities is significantly lower for patients receiving genomic cancer medicine compared to standard chemotherapy approaches. In line with these findings, overall treatment related morbidities are significantly reduced in the genomic cancer medicine cohort compared to a control cohort. Data regarding the Progression Free Survival are pending at the time of this report. Conclusions: These retrospective data suggest that personalized genomic cancer medicine approaches result in decreased morbidities and cost savings compared to standard chemotherapeutic approaches. In patients with advanced cancer, genomic-based treatments appear to be cost-effective, safe and viable option for treating advanced cancer patients. Additional data regarding survival outcomes are required to determine efficacy of treatment.
593 Background: Prognosis of colorectal cancer (CRC) is greatly influenced by stage at diagnosis. Early colorectal cancer can be subtle on CT scans showing only mild wall thickening, small polyps, or subtle lymph nodes. Identifying these lesions on CT performed for nonspecific symptoms can help identify interval CRC and improve patient outcome. The purpose of the present study is to classify missed CRC on abdominal CT by their imaging features and whether early identification can downstage CRC patients. Methods: A retrospective analysis was conducted of patients (pts) diagnosed with CRC. Data collection included age, gender, ECOG, KRAS mutation status, overall survival (OS). CT obtained prior to and at diagnosis were evaluated. Images were reviewed for multiple CT features including appearance of mass, mesenteric infiltration, abnormal draining lymph nodes, contrast enhancement relative to adjacent mucosa, and intralesional calcifications. Staging was evaluated using available CT scan and based on the TNM staging system for CRC. Results: The 41 pts with 51 prediagnostic CTs from 1/1/2012 - 12/31/2015 had mean age of 68 years (range:44-90 ) Mean ECOG status for the population was 1.46. 41% of the prediagnostic CTs had missed findings. 52 and 43 % of the missed findings were in the rectosigmoid and ascending colon respectively. Of the 15 missed masses, 9 appeared as asymmetric wall thickening, 3 as concentric wall thickening, and 3 as polyps. Of the 14 missed lymph node groups, 2 were excluded due to stability or nonrelated condition. The remaining lymph nodes were found in the associated draining station and averaged 3±1.2 mm in size. On average, the stage at prediagnostic CT was 3A and the diagnostic CT was 3C (p = 0.0015). Average time lapse between prediagnostic and diagnostic CT was 21 months (3-64 months). Conclusions: High percentage of CRC findings are missed on abdominal CT due to their subtle feature, with most misses in the rectosigmoid and ascending colon. A dedicated search can improve detection by specifically looking for polyps, wall thickening, and small lymph nodes in the draining station. Early detection of CRC can improve survival by lowering the stage from 3C to 3A, thus providing 36% improvement in 5-year survival.
Whole exome sequencing (WES) of matched tumor-normal pairs in rare tumors has the potential to identify genome-wide mutations and copy number alterations (CNAs). We evaluated 27 rare cancer patients with tumor-normal matching by WES and tumor-only next generation sequencing (NGS) as a comparator. Our goal was to: 1) identify known and novel variants and CNAs in rare cancers with comparison to common cancers; 2) examine differences between germline and somatic variants and how that functionally impacts rare tumors; 3) detect and characterize alleles in biologically relevant genes-pathways that may be of clinical importance but not represented in classical cancer genes. We identified 3343 germline single nucleotide variants (SNVs) and small indel variants—1670 in oncogenes and 1673 in tumor suppressor genes—generating an average of 124 germline variants/case. The number of somatic SNVs and small indels detected in all cases was 523:306 in oncogenes and 217 in tumor suppressor genes. Of the germline variants, six were identified to be pathogenic or likely pathogenic. In the 27 analyzed rare cancer cases, CNAs are variable depending on tumor type, germline pathogenic variants are more common. Cell fate pathway mutations (e.g., Hippo, Notch, Wnt) dominate pathogenesis and double hit (mutation + CNV) represent ~18% cases.
Background: Little data exist regarding inpatient opioid prescriptions as a potential contribution to the current opioid crisis. While pain management is essential to inpatient care, the ease of which opioids may be prescribed for all levels of pain may contribute to unnecessary inpatient exposure and new outpatient prescriptions. The aim of this study was to observe patterns of opioid prescribing potentially leading to new opioid prescriptions at hospital discharge for previously opioid-naive patients. Methods: This study was a single-center observational study of opioid-naïve internal medicine patients who were prescribed inpatient opioids. Patient charts were reviewed to assess the patterns of inpatient opioid and non-opioid analgesic use, new opioid prescriptions upon discharge and medical record documentation justifying the need for outpatient therapy. Results: Among the 101 patients included in this study, 71 were prescribed IV opioids and 45 were prescribed both IV and oral opioids. Non-opioid analgesics were available for 78 patients. Twenty patients were discharged with a new prescription. The mean duration of outpatient prescriptions was 3.85 +/- 1.85 days with mean morphine milligram equivalents (MME) of 44.25 +/- 22.16. Among patients receiving these outpatient prescriptions, 11 had reference to the therapy in the discharge summary. Conclusions: This observational study describes an opportunity to improve inpatient opioid prescribing practices which may reduce new prescriptions for continued outpatient therapy. Further work should focus on optimizing use of non-opioid analgesia, minimizing use of IV opioids and requiring prescribers to justify the indication for new opioid prescriptions upon hospital discharge.
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