Uveal melanoma (UM) is an intraocular malignancy with poor survival rates due to the propensity for metastatic spread. Although treatment options exist for localized disease, there are fewer definitive guidelines for metastatic UM. Treatment involves a personalized approach that entails patient-specific aspects, including tumor genetics. This case highlights the disease course of a 60-year-old male diagnosed with stage IIB right eye choroidal melanoma. Despite successful therapy for localized UM, he developed widespread metastasis. He received dual immunotherapy and was ultimately maintained on a single-agent regimen. His prognosis has surpassed initial prognosis and survival expectations. This case highlights the use of immunotherapy, both dual and single therapy, to treat this rare malignancy and extend overall survival.
Pancytopenia, a hematologic condition, is a decrease in all three blood cell lines. The two main etiologies include decreased production or increased destruction of cells, as seen in nutritional deficiencies or liver cirrhosis, respectively. Pancytopenia commonly presents with fever, splenomegaly, and lymphadenopathy. Initial workup includes complete blood count, metabolic panel, peripheral smear, anemia panel, erythrocyte sedimentation rate, C-reactive protein, and lactate dehydrogenase. Workup also involves excluding toxins, human immunodeficiency virus (HIV), drug effects, and infectious etiologies. Malignancies can cause impaired production of cell lines. For hematologic malignancies, a bone marrow biopsy is performed. In patients above the age of 55 who are diagnosed with acute leukemia, acute lymphoblastic leukemia (ALL) is known to make up approximately 20% of all cases. Furthermore, ALL requires the presence of more than 20% lymphoblasts seen on bone marrow biopsy. Treatment includes induction, consolidation, and maintenance chemotherapy.We report the case of a 63-year-old male with a history of liver cirrhosis from non-alcoholic fatty liver disease who presented for consultation due to pancytopenia without signs of fever or lymphadenopathy. Imaging revealed cirrhosis, ascites, and moderate splenomegaly while the workup for toxins, infections, and HIV was negative. He presented to the hospital with worsening anasarca and acutely worsening pancytopenia. Peripheral smear showed pancytopenia with no definitive blasts, whereas bone marrow biopsy revealed B-lymphoblastic leukemia. He was transferred to a tertiary center for induction chemotherapy but ultimately transitioned to supportive care due to intolerance. This case demonstrates the importance of having a high suspicion for leukemia with an acute decline in all three cell lines, thereby prompting a bone marrow biopsy. Although lacking in the literature, adult patients with ALL can present with splenomegaly without fever or lymphadenopathy. These examination findings are clinical clues to evaluate for underlying malignancies in patients with pancytopenia, although coexisting etiologies may exist. Lastly, peripheral smear alone is insufficient to screen for diagnosis of ALL as it can be normal despite bone marrow involvement.
6570 Background: Lung cancer is the leading cause of cancer deaths with over 50% of patients diagnosed at an advanced stage. Lung cancer screening (LCS) guidelines were recently updated in 2021, which expanded the age group and reduced the pack years, and thereby increased eligibility. However, the underutilization of low dose computed tomography (LDCT) scans is seen nationwide. In 2015, the National Health Interview Survey found that only 3.9% of eligible adults underwent LCS. The barriers for LCS identified in national literature included failure of electronic medical records (EMR) to notify providers of eligible patients, lack of insurance coverage, patient refusal, and lack of patient and provider awareness. This quality improvement project was performed to improve LCS in primary care clinics (graduate medical education [GME] and non-GME) at a tertiary medical center in northeast Georgia by addressing these barriers. Methods: In GME clinics, the goal was to double LDCT scans from 14 to 28 monthly. In non-GME clinics, the goal was to increase LDCT scans by at least 50% from 28 to 42 weekly. LDCT scans performed between January 1st to May 31st 2022 was used as baseline data. The interventions spanned over six months, from June 1st to November 30th 2022. Multimodal interventions were used to target various barriers. Accurate tobacco history in the EMR was improved by participating in the nationwide Just Ask Campaign. Flyers posted in clinics provided information on current guidelines and a QR code for patients to determine their LCS eligibility. Provider reference guides highlighted LCS guidelines and billing codes. Community events and social media were used to spread LCS awareness. Results: During the implementation phase, the average monthly LDCT scans increased to 23 scans in GME clinics and 40 scans weekly in non-GME clinics. In GME clinics, the goal of 28 scans monthly was achieved in one out of six months. In non-GME clinics, the goal of 42 scans weekly was surpassed in four out of six months. The Long-Range Acoustic Device (L-RAD) scoring system helped diagnose three cancers in the GME clinics and about one cancer for every 10 L-RAD4 in non-GME clinics. The baseline period LDCT scans of 78 (GME) and 656 (non-GME) increased to 177 (GME) and 1109 (non-GME) during the intervention period. Conclusions: This multimodal approach in addressing known barriers to increase LCS across primary care clinics in a single healthcare system is feasible and was associated with short-term improvements. Although the targets were not met every month, there was a notable improvement during the intervention period. A major limitation was the inability to determine which intervention had the greatest impact. A newly identified barrier was the lack of follow up scans being ordered by providers. This project demonstrates the potential to increase LCS using a multimodal approach, which can be implemented in similar healthcare systems.
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