RECURRENT PULMONARY EMBOLISM

SESSION TITLE: Variety in Risk Factors and Treatment of VTE SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pulmonary embolism is a very common clinical entity that health care providers face routinely. Recurrent pulmonary embolism while on anti-coagulation therapy happens in about 2 to 4% of patients, but failure of multiple modalities of anti-coagulation is unusual and should prompt a closer evaluation. In this case we present an unusual cause of anti-coagulation failure. CASE PRESENTATION: A 65-year-old male patient diagnosed in 2016 with colon cancer status post hemi-colectomy and followed with CT surveillance. In 2016 he was also diagnosed with pulmonary embolism which was deemed secondary to his malignancy;this was treated with anti-coagulation for a finite duration. On surveillance CT scan in 2019 a new pulmonary embolism was diagnosed, and he was started on Apixaban therapy. In December of 2020 he was diagnosed with COVID19 which was mild to moderate in severity. A CT chest that was done at the time showed progression of the pulmonary embolism, so he was switched to low molecular weight heparin (LMWH). He presented in March of 2021 with hemoptysis and chest pain and another CT scan showed the same left pulmonary artery filling defect despite being on therapeutic LMWH. At this point we suspected an endovascular pathology, and a PET/CT scan was preformed which demonstrated an FGD positive left pulmonary artery endovascular lesion concerning for malignancy. Bronchoscopy and EBUS was done by interventional pulmonary team and biopsies from the left PA artery were taken. Pathology came back highly suspicious for angiosarcoma. The patient received chemotherapy (AIM;Adriamycin, Ifosfamide with MESNA) with an excellent response. DISCUSSION: Pulmonary artery sarcoma is a rare tumor that usually originates from the intimal layer of the pulmonary artery. It can mimic pulmonary embolism in clinical presentation and on imaging studies. In an observational analysis study published in Journal of Thoracic Disease;nearly half of 391 confirmed cases were originally misdiagnosed as pulmonary embolism. The treatment of pulmonary artery sarcoma is typically surgical intervention, although some patients may benefit from the use of chemotherapy. CONCLUSIONS: Pulmonary embolism is by far the most common cause of pulmonary artery filling defect on CT scan, typically treated with anti-coagulation with good outcomes. In the setting of therapy failure other etiologies must be considered. Although difficult to distinguish from PE, knowing the distinguishing clinical and radiologic will aid an accurate diagnosis. Reference #1: Symptoms, Diagnosis, and Therapy of Primary Sarcomas of the Pulmonary Artery. By I. Kruger, A. Borowski, M. Horst, E.R. de Vivie, W. Gross-Fengels. Thorac Cardiovasc Surg. 1990 Apr;38(2):91-5. doi: 10.1055/s-2007-1014001 Reference #2: Primary pulmonary artery sarcoma: a close associate of pulmonary embolism, 20-year observational analysis. Debabrata Bandyopadhyay, 1 Tanmay S. Panchabhai,2 Navkaranbir S. Bajaj,3 Pradnya D. Patil,4 and Matthew C. Bunte5 J Thorac Dis, v.8(9);2016 Sep, PMC5059338 doi: 10.21037/jtd.2016.08.89 Reference #3: Al-Mehisen, Rabah et al. "Primary pulmonary artery sarcoma: A rare and overlooked differential diagnosis of pulmonary embolism. Clues to diagnosis." International journal of surgery case reports vol. 65 (2019): 15-19. doi:10.1016/j.ijscr.2019.10.014 DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Mark Peicher

Diffuse Large B-cell Lymphoma-Treatment Failure, Recovery and COVID-19: A Case Report

Diffuse Large B-cell Lymphoma (DLBCL) is the most common form of non Hodgkin lymphoma, involving multiple organ system including lymph node, bone marrow, spleen etc. Among overall cases of DLBCL, 40% are extranodal in origin and stomach being the most common site. While most of the (60%) are not diagnosed until the disease reach stage 3 or 4. While in the present case, patient had predominant involvement of neck lymph nodes. Following the final diagnosis, patient was given first line treatment in the form of Rituximab, Cyclophosphamide, Hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and Prednisone (R-CHOP) regimen, to which patient didn’t respond and further the patient was given Rituximab, Ifosfamide, Carboplatin, and Etoposide (R-ICE)regimen, to which patient responded quickly. With Coronavirus Disease 2019 (COVID-19) pandemic, the patient encountered infection with its associated complication. The following case report is all about the timely management of DLBCL and patient’s survival with COVID-19 and its related complication. Haematological malignancy such as lymphomas, leukaemias, myelomas cause severe myelosuppression and lymphodepletion increasing the risk for development of COVID-19. Studies have shown that patients with malignancy had an estimated two-fold increased risk of contracting Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) than the general population. The survival rates strongly depend on COVID-19 stage and other factors such as immune (neutropenia) status and systemic inflammation.

Feasibility and safety of outpatient administration of ifosfamide and etoposide for pediatric patients with Ewing sarcoma in a resource-limited setting amid the COVID-19 pandemic.

BACKGROUND: To assess feasibility and safety of outpatient administration of ifosfamide and etoposide (IE) for pediatric Ewing sarcoma (EWS) patients in a resource-limited setting amid the COVID-19 pandemic. MATERIALS AND METHODS: Retrospective study of patients with EWS who received outpatient IE from January 2020 until January 2021 at our institution. Ifosfamide 1800 mg/m2 was given for 5 days with MESNA (2-mercaptoethane sulfonate sodium) infusion and additional boluses before and after 9 hours of hydration. Patients >10 years of age with the ability to drink orally at home, no pre-existing renal dysfunction or history of hematuria were included. They were monitored for hemorrhagic cystitis with a urine dipstick before, midway, and at end of infusion. A urine analysis was done 24 hours after the last dose of ifosfamide. RESULTS: Forty-seven (100%) cycles were given as outpatient during the study period. Thirty-five (74%) cycles were given on time, two (4%) cycles were delayed due to mucositis, two (4%) due to delayed count recovery, and eight (18%) due to unavailability of outpatient appointments. The median interval between these cycles was 15 days (range 14-44 days). No episode of hemorrhagic cystitis was reported. Urine analysis was not done at 24 hours for 27 (58%) cycles, so microscopic hematuria may have been missed. This outpatient protocol saved 32% (USD 299) per cycle in cost and 282 days of hospitalization. CONCLUSION: Outpatient administration of IE for pediatric patients with EWS is feasible, safe, and cost-effective during the COVID-19 pandemic.

Transitioning ifosfamide chemotherapy regimens to the ambulatory setting: reviewing cost savings and safety profile.

PURPOSE: To characterize and compare both the outcome and cost of treatment of outpatient (OP) and inpatient (IP) ifosfamide therapy. METHODS: A single-center retrospective chart review of patients 18 years and older receiving ifosfamide therapy. The primary endpoint compares and evaluates the side effect profiles of ifosfamide-treated patients in the OP/IP settings. The adverse event grading system was characterized using the CTCAE Version 5.0. The highest grade was documented per cycle. The secondary endpoint of this study compares the costs of OP/IP therapy. It was assumed that the cost of medication was equivalent for IP/OP treatments. The cost saved with OP administration was determined by the average cost of hospital stay for IP admission. RESULTS: Ifosfamide therapy of 86 patients (57 OP, 29 IP) was reviewed. The predominant OP regimens were doxorobucin-ifosfamide-mesna (AIM) with 43.9% and ifosfamide-etoposide (IE) with 29.8%. Grade 4 anemia, thrombocytopenia, and neutropenia were most frequent in IP vs OP therapies (22.9% IP vs 4.3% OP, 21.6% IP vs 9.2% OP, and 22.8% IP vs 19.6% OP respectively). Neutropenic fever (NF) occurred in 20 OP patients which were predominantly treated with AIM or IE and led to average hospital stay of 6 days. Neurotoxicity, treated with methylene blue (MB) occurred in 4 OP patients. OP therapy saved a total of 783 hospital days, leading to a cost savings of $2,103,921. CONCLUSIONS: Transitioning ifosfamide to the OP setting is feasible for academic and community infusion centers with the OP administration being safe, well-tolerated, and associated with decreased total cost of care. The current processes allow for safe transition of chemotherapy of chemotherapy under times of COVID.