Wazir A

Backgroud: Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in VA hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons’ (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied.

Methods: Nationwide data from the National VA Cancer Cube Registry was analyzed. 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website.

Results: MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality were men (97.44%). The > 70-years age group and the 60-70-years age group were the most common ages at diagnosis with 39.39% and 38.02%, respectively. The proportion of early-onset pancreatic cancer was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.44% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of
8.89% and 8.57%, respectively.

Conclusions: Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.

Backgroud: Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in VA hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons’ (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied.

Methods: Nationwide data from the National VA Cancer Cube Registry was analyzed. 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website.

Results: MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality were men (97.44%). The > 70-years age group and the 60-70-years age group were the most common ages at diagnosis with 39.39% and 38.02%, respectively. The proportion of early-onset pancreatic cancer was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.44% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of
8.89% and 8.57%, respectively.

Conclusions: Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.

Backgroud: Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in VA hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons’ (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied.

Methods: Nationwide data from the National VA Cancer Cube Registry was analyzed. 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website.

Results: MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality were men (97.44%). The > 70-years age group and the 60-70-years age group were the most common ages at diagnosis with 39.39% and 38.02%, respectively. The proportion of early-onset pancreatic cancer was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.44% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of
8.89% and 8.57%, respectively.

Conclusions: Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.

Background: We present a case of a 69-year-old male with a past medical history of RA, Afib, COPD, and DVT with pulmonary embolism. He presented to the emergency department with encephalopathy and severe abdominal pain. On exam the patient was septic with a diffusely tender abdominal exam with peritoneal signs. The CT scan showed pneumoperitoneum. The patient underwent emergent laparotomy which revealed fecal peritonitis from a cecal perforation. After washout, patient had bowel resection of the involved intestine with a primary anastomosis. Biopsy of his resected small bowel and cecum showed submucosal blood vessels with numerous lymphoid cells. Immunohistochemical staining showed aberrant expression for CD43 and CD30 with an increased proliferation index (Ki67 80-90%). Molecular studies of both the lymphoid aggregates
and the atypical intravascular cells were negative for Ig heavy chain, t(11:18) & t(14,19). A diagnosis of intravascular lymphoma was still made. Patient underwent four further abdominal washouts with reconstruction of anterior abdominal wall with Permacol™ biological mesh. The patient condition continued to deteriorate, and he was transitioned to palliative care. He died a month after. An autopsy was not performed.

Discussion: Intravascular lymphoma is a rare and very aggressive malignancy characterized by proliferation of atypical B cell confined mostly to the vascular lumen. Its presentation is protean depending on the organs involved. It has been referred to as “the oncologists great imitator.” In a series of 38 patients by Ferreri et al, the most common symptoms were fever, cutaneous symptoms, neurological symptoms followed by abdominal pain. Most patients present in an advanced state, one series of 96 patients by Murase et al, 91% of the patient presenting with clinical stage III or stage IV disease.

There remain no standard diagnostic criteria for intravascular lymphoma. First step is demonstration of lymphoma cells in small- and medium-sized blood vessels with characteristic sparing of surrounding tissue. B cell clones are most common, but T and NK cells have also been reported. Molecular, immune histochemical and flow cytometry techniques may aid in establishing diagnosis. Prognosis remains poor even with aggressive treatment, the largest series by Murase et al, with mean survival of just 13 months with treatment.

Background: We present a case of a 69-year-old male with a past medical history of RA, Afib, COPD, and DVT with pulmonary embolism. He presented to the emergency department with encephalopathy and severe abdominal pain. On exam the patient was septic with a diffusely tender abdominal exam with peritoneal signs. The CT scan showed pneumoperitoneum. The patient underwent emergent laparotomy which revealed fecal peritonitis from a cecal perforation. After washout, patient had bowel resection of the involved intestine with a primary anastomosis. Biopsy of his resected small bowel and cecum showed submucosal blood vessels with numerous lymphoid cells. Immunohistochemical staining showed aberrant expression for CD43 and CD30 with an increased proliferation index (Ki67 80-90%). Molecular studies of both the lymphoid aggregates
and the atypical intravascular cells were negative for Ig heavy chain, t(11:18) & t(14,19). A diagnosis of intravascular lymphoma was still made. Patient underwent four further abdominal washouts with reconstruction of anterior abdominal wall with Permacol™ biological mesh. The patient condition continued to deteriorate, and he was transitioned to palliative care. He died a month after. An autopsy was not performed.

Discussion: Intravascular lymphoma is a rare and very aggressive malignancy characterized by proliferation of atypical B cell confined mostly to the vascular lumen. Its presentation is protean depending on the organs involved. It has been referred to as “the oncologists great imitator.” In a series of 38 patients by Ferreri et al, the most common symptoms were fever, cutaneous symptoms, neurological symptoms followed by abdominal pain. Most patients present in an advanced state, one series of 96 patients by Murase et al, 91% of the patient presenting with clinical stage III or stage IV disease.

There remain no standard diagnostic criteria for intravascular lymphoma. First step is demonstration of lymphoma cells in small- and medium-sized blood vessels with characteristic sparing of surrounding tissue. B cell clones are most common, but T and NK cells have also been reported. Molecular, immune histochemical and flow cytometry techniques may aid in establishing diagnosis. Prognosis remains poor even with aggressive treatment, the largest series by Murase et al, with mean survival of just 13 months with treatment.

Background: We present a case of a 69-year-old male with a past medical history of RA, Afib, COPD, and DVT with pulmonary embolism. He presented to the emergency department with encephalopathy and severe abdominal pain. On exam the patient was septic with a diffusely tender abdominal exam with peritoneal signs. The CT scan showed pneumoperitoneum. The patient underwent emergent laparotomy which revealed fecal peritonitis from a cecal perforation. After washout, patient had bowel resection of the involved intestine with a primary anastomosis. Biopsy of his resected small bowel and cecum showed submucosal blood vessels with numerous lymphoid cells. Immunohistochemical staining showed aberrant expression for CD43 and CD30 with an increased proliferation index (Ki67 80-90%). Molecular studies of both the lymphoid aggregates
and the atypical intravascular cells were negative for Ig heavy chain, t(11:18) & t(14,19). A diagnosis of intravascular lymphoma was still made. Patient underwent four further abdominal washouts with reconstruction of anterior abdominal wall with Permacol™ biological mesh. The patient condition continued to deteriorate, and he was transitioned to palliative care. He died a month after. An autopsy was not performed.

Discussion: Intravascular lymphoma is a rare and very aggressive malignancy characterized by proliferation of atypical B cell confined mostly to the vascular lumen. Its presentation is protean depending on the organs involved. It has been referred to as “the oncologists great imitator.” In a series of 38 patients by Ferreri et al, the most common symptoms were fever, cutaneous symptoms, neurological symptoms followed by abdominal pain. Most patients present in an advanced state, one series of 96 patients by Murase et al, 91% of the patient presenting with clinical stage III or stage IV disease.

There remain no standard diagnostic criteria for intravascular lymphoma. First step is demonstration of lymphoma cells in small- and medium-sized blood vessels with characteristic sparing of surrounding tissue. B cell clones are most common, but T and NK cells have also been reported. Molecular, immune histochemical and flow cytometry techniques may aid in establishing diagnosis. Prognosis remains poor even with aggressive treatment, the largest series by Murase et al, with mean survival of just 13 months with treatment.

Background: Under-treatment of metastatic pancreatic cancer (MPC) continues to be a problem. Recent data presented at AVAHO 2016 (poster 21) by Ahmed et al showed patients in the VA system with MPC had treatment rates substantially lower than ACOS certified hospitals (41.5% vs 53.2%).

Objective: We aim to determine the treatment rate of MPC at the Stratton VA Medical Center (SVAMC), an ACOS-certified VA hospital, compare it with the national VAH and ACOS hospitals, and conduct a root-cause analysis for this under-treatment.

Methods: We retrospectively reviewed the medical records of MPC patients at the SVAMC between January 2010 and December 2016. All patients who presented to SVAMC with biopsy-proven MPC were included. Charts were reviewed to determine whether patients received systemic therapy, the specific type of therapy each patient received, survival rates, and the stated reason for not receiving chemotherapy.

Results: Thirty-five patients were identified to have had likely MPC. Three were excluded as they did not have a tissue biopsy. Of the remaining 32, 19 (59.4%) received systemic therapy. Thirteen (40.6%) were found not to have been treated with systemic chemotherapy. The stated reasons for non-treatment were low functional status (8 patients, 61.5%), patient refusal (3 patients, 23.1%) and other reasons (2 patients, 15.4%). Median survival of metastatic pancreatic adenocarcinoma was 233 days in the Chemotherapy group vs 60 days in the group that did not receive systemic therapy (P = .012 for mean survival). The treatment rate for MPC at SVAMC was determined to be 59.4%, which is higher than both VAH (41.5%) and ACOS certified hospitals (53.2%).

Conclusions: Our study showed that treatment rates for MPC at the SVAMC was higher than national average VA data. The vast majority of non-treatments (patient refusal, diminished ECOG status) were appropriate and in line with NCCN guidelines. National averaged data may mask regional trends and heterogeneity in practice in various VA centers. Further studies should explore this heterogeneity and identify possible causes.

Background: Under-treatment of metastatic pancreatic cancer (MPC) continues to be a problem. Recent data presented at AVAHO 2016 (poster 21) by Ahmed et al showed patients in the VA system with MPC had treatment rates substantially lower than ACOS certified hospitals (41.5% vs 53.2%).

Objective: We aim to determine the treatment rate of MPC at the Stratton VA Medical Center (SVAMC), an ACOS-certified VA hospital, compare it with the national VAH and ACOS hospitals, and conduct a root-cause analysis for this under-treatment.

Methods: We retrospectively reviewed the medical records of MPC patients at the SVAMC between January 2010 and December 2016. All patients who presented to SVAMC with biopsy-proven MPC were included. Charts were reviewed to determine whether patients received systemic therapy, the specific type of therapy each patient received, survival rates, and the stated reason for not receiving chemotherapy.

Results: Thirty-five patients were identified to have had likely MPC. Three were excluded as they did not have a tissue biopsy. Of the remaining 32, 19 (59.4%) received systemic therapy. Thirteen (40.6%) were found not to have been treated with systemic chemotherapy. The stated reasons for non-treatment were low functional status (8 patients, 61.5%), patient refusal (3 patients, 23.1%) and other reasons (2 patients, 15.4%). Median survival of metastatic pancreatic adenocarcinoma was 233 days in the Chemotherapy group vs 60 days in the group that did not receive systemic therapy (P = .012 for mean survival). The treatment rate for MPC at SVAMC was determined to be 59.4%, which is higher than both VAH (41.5%) and ACOS certified hospitals (53.2%).

Conclusions: Our study showed that treatment rates for MPC at the SVAMC was higher than national average VA data. The vast majority of non-treatments (patient refusal, diminished ECOG status) were appropriate and in line with NCCN guidelines. National averaged data may mask regional trends and heterogeneity in practice in various VA centers. Further studies should explore this heterogeneity and identify possible causes.

Background: Under-treatment of metastatic pancreatic cancer (MPC) continues to be a problem. Recent data presented at AVAHO 2016 (poster 21) by Ahmed et al showed patients in the VA system with MPC had treatment rates substantially lower than ACOS certified hospitals (41.5% vs 53.2%).

Objective: We aim to determine the treatment rate of MPC at the Stratton VA Medical Center (SVAMC), an ACOS-certified VA hospital, compare it with the national VAH and ACOS hospitals, and conduct a root-cause analysis for this under-treatment.

Methods: We retrospectively reviewed the medical records of MPC patients at the SVAMC between January 2010 and December 2016. All patients who presented to SVAMC with biopsy-proven MPC were included. Charts were reviewed to determine whether patients received systemic therapy, the specific type of therapy each patient received, survival rates, and the stated reason for not receiving chemotherapy.

Results: Thirty-five patients were identified to have had likely MPC. Three were excluded as they did not have a tissue biopsy. Of the remaining 32, 19 (59.4%) received systemic therapy. Thirteen (40.6%) were found not to have been treated with systemic chemotherapy. The stated reasons for non-treatment were low functional status (8 patients, 61.5%), patient refusal (3 patients, 23.1%) and other reasons (2 patients, 15.4%). Median survival of metastatic pancreatic adenocarcinoma was 233 days in the Chemotherapy group vs 60 days in the group that did not receive systemic therapy (P = .012 for mean survival). The treatment rate for MPC at SVAMC was determined to be 59.4%, which is higher than both VAH (41.5%) and ACOS certified hospitals (53.2%).

Conclusions: Our study showed that treatment rates for MPC at the SVAMC was higher than national average VA data. The vast majority of non-treatments (patient refusal, diminished ECOG status) were appropriate and in line with NCCN guidelines. National averaged data may mask regional trends and heterogeneity in practice in various VA centers. Further studies should explore this heterogeneity and identify possible causes.