Brief report: risk stratification following curative therapy for stage I NSCLC.

Introduction: Surveillance with computed tomography (CT) imaging following curative treatment of stage I non-small cell lung cancer (NSCLC) is important to identify recurrence or second primary lung cancers (SPLC). The pattern and risks of recurrence following curative therapy and optimal duration of surveillance scans remain unknown. The objective of our study is to assess the pattern of recurrence and development of SPLC to risk stratify patients with stage I NSCLC following curative therapy. Methods: We identified 261 patients who received curative therapy for stage I NSCLC at Mayo Clinic Florida. Data was collected on clinical and demographic features including gender, smoking history, stage, treatment, histologic subtype, and tumor grade. Kaplan-Meier method was used to evaluate the disease free survival (DFS). Cox proportional hazard model was used to identify risk factors for recurrence. Results: Negative tobacco history and stage IA tumors were associated with significantly prolonged DFS after adjusting for co-variates (p=0.001 and p=0.005). Univariate Cox proportional hazards model identified tobacco history and stage 1B as risk factors for recurrence with unadjusted hazard ratio (HR) of 2.8 and 2.0, respectively. After adjusting for covariates, only stage IB was statistically significant predictor of recurrence with a hazard ratio of 2.1 (Confidence Interval (CI) 95% 1.2-3.6; p=0.007). Conclusions: An individualized approach that considers risk factors of stage and smoking history may be useful in determining whether to continue annual CT surveillance after five years post curative therapy for stage I NSCLC.

Evaluation of Hepatotoxicity from Peptide Receptor Radionuclide Therapy in Patients with Gastroenteropancreatic Neuroendocrine Tumors and a Very High Liver Tumor Burden.

The aim of the current study was to describe the risk of hepatotoxicity for patients with gastroenteropancreatic neuroendocrine tumors undergoing peptide receptor radionuclide therapy (PRRT) with a very high liver tumor burden, defined as tumor involving more than 75% of the liver. Methods: We conducted a retrospective analysis of 371 patients who received at least 1 cycle of 177Lu-DOTATATE at Mayo Clinic for advanced gastroenteropancreatic neuroendocrine tumors. We identified 15 total patients with more than 75% liver involvement on 68Ga-DOTATATE PET/CT and with either a contrast-enhanced abdominal MRI or dual-phase abdominal CT examination. Results: Of the 15 patients with more than 75% liver involvement, 1 experienced hepatotoxicity (i.e., worsening liver enzymes or bilirubin) as defined by the Common Terminology Criteria for Adverse Events, version 5.0. No patients had grade 3-5 hepatotoxicity (i.e., clinical signs of liver failure). Conclusion: When considering the risk of liver injury from PRRT due to burden of disease, our data suggest that PRRT may be a safe option in patients with more than 75% liver involvement. Future efforts should be made to determine the safety profile of PRRT in patients with varying degrees of liver involvement.

A Quality Improvement Approach to Decrease the Utilization of Docusate in Hospitalized Patients.

BACKGROUND AND OBJECTIVES: Docusate sodium is a commonly prescribed medication to relieve constipation, but several studies have demonstrated its ineffectiveness. Its continued use in the hospital setting adds unnecessary cost and risk to patients. At the Mayo Clinic Florida campus, docusate was ordered for 9.7% of patients admitted to the internal medicine resident (IMED) teaching services during the month of January 2020, and the average hospital length of stay (LOS) was 3.1 days. METHODS: A multidisciplinary team of internal medicine resident physicians and pharmacists collaborated to address this quality gap through a quality improvement project. It sought to reduce the number of patients admitted to the IMED teaching services who had an order placed for docusate by 50% in less than 6 months without adversely impacting hospital LOS. Two separate interventions were devised using Six Sigma methodology and implemented to reduce the frequency of docusate orders, which involved educating internal medicine residents and hospital pharmacists, and creating an additional process-related barrier to docusate orders. RESULTS: The percentage of docusate orders decreased from 9.7% to 2.4% ( P = .004) with a grossly unchanged LOS of 3.1 days to 2.7 days ( P = .12) after 5 weeks. CONCLUSION: The implementation of a dual-pronged intervention successfully decreased the use of an ineffective medication in hospitalized patients without impacting the balancing measure, and serves as a model that can be adopted at other institutions with the hope of promoting evidence-based medical care.

Atypical Lung Carcinoid With EML4/ALK Fusion Detected With Circulating Tumor DNA.

Atypical carcinoids are a rare subset of neuroendocrine tumors that originate from cells within the bronchopulmonary tree. Compared to typical carcinoids, atypical carcinoids are associated with a worse prognosis. EML4-ALK fusions are reported in 5% of non-small cell lung carcinoma, but are rare in atypical carcinoids with only five previously reported cases. We report a case of a 70-year-old female with atypical carcinoid with metastasis to the liver and axial skeleton. She did not respond to standard of care chemotherapy with carboplatin and etoposide and was elected to enroll in hospice because of worsening clinical status. However, a circulating tumor DNA (ctDNA) sample was obtained the same day which revealed an EML4-ALK fusion gene. She immediately began therapy with the second-generation ALK inhibitor alectinib, with a remarkable symptomatic and radiographic response. Seven months later, the disease progression was demonstrated in the liver and the patient was switched to the third-generation ALK inhibitor lorlatinib. At the time of writing, the patient has continued to demonstrate sustained clinical, radiographic, and biochemical responses while on lorlatnib for two years. The dramatic treatment results highlighted in this case make the argument to consider ctDNA after the diagnosis of locally advanced or metastatic atypical carcinoid.

Limiting Screening Mammography Recalls for Vaccine-Induced Adenopathy, a Single Institution Experience.

RATIONALE AND OBJECTIVES: Reported incidence of vaccine-induced adenopathy varies widely, with higher estimates in early reports and small series. Objective was to evaluate a large sample of vaccinated patients undergoing screening mammography, to determine callback rates associated with vaccine-induced adenopathy and their outcomes. MATERIALS AND METHODS: Single-institution retrospective review of patients who received at least 1 dose of a COVID-19 vaccine prior to presentation for screening mammography from January 15 through May 31, 2021. Patient-related vaccination information (dose, brand, arm, date) was obtained by mammography technologists and available for interpreting radiologists. Patients recalled for axillary adenopathy were included; other causes for recall were excluded. Follow-up imaging and outcomes were tracked. Wilcoxon rank-sum test, Fisher exact test, multivariable logistic regression modeling, and receiver operating characteristic curve analyses were utilized. All tests were two-sided; p < 0.05 considered statistically significant. RESULTS: Total of 2304 vaccinated patients underwent screening mammography; 24 (1.0%) recalled for ipsilateral adenopathy. There was no significant difference in presence of adenopathy associated with patient age, dose, or brand of vaccine. Presence of adenopathy significantly decreased as days from vaccination increased (p < 0.001). Receiver operating characteristic curve suggested 28.5 days as the best cutoff point to distinguish presence or absence of adenopathy on mammogram. Of 24 callbacks, 13 (54.2%) had benign results, 2 (8.3%) are still undergoing surveillance, and 9 (37.5%) are overdue for subsequent follow-ups. No cases resulted in biopsy or malignancy. CONCLUSION: Low recall rates related to vaccine-induced adenopathy are achievable and can limit unnecessary workups, improve access, and promote flexible timing of vaccinations and screening exams.