A Tale of Two Counties With the Same Telehealth Story: Experience with Cancer Genetics Testing During COVID-19 at a Community Hospital

Introduction: With the onset of the COVID-19 pandemic in 2020, the utilization of telemedicine now offered an alternative diagnostic and treatment resource to providers in many areas of medicine including oncology and cancer genetics. This care option paired with genetic testing labs' ability to send saliva-based DNA collection kits to patients, enabled our community hospital in Detroit to offer diagnostic testing without the patient coming to a healthcare setting for a host of reasons. Social determinants of health have been found to influence success with telehealth, and this study sought to analyze how successful telehealth cancer genetics care was throughout the Detroit Metro area. Methods: Patient demographics for in person visits six months before COVID were analyzed, and then compared with demographics of patients during the 2020-2021 pandemic period where visits were telehealth. Results: Pre-pandemic there were , 192 unique patients seen in person with the top three cities patients were from were Detroit (12.1%), Clinton Township (8.3%), and Saint Clair Shores (10.4%). During the pandemic, with telehealth as the major modality, the top three cities were Macomb (7.2%), Detroit (7%), and Clinton Township (7%). Detroit is in Wayne County, while St.Clair Shores and Clinton Township are in Macomb County. Per the US Census Bureau Macomb county has a median income of $64,641 and Wayne county has a median income of $49,359, and poverty level in Macomb county is 9.2% versus in Wayne the level is 20%. Conclusions: This paper outlines the challenges of initiating a telemedicine program in an urban community area and highlights the benefits of a concierge service in serving cancer patients who may have economic and historically poor perceived technologic abilities.

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An Evaluation of Surgical Management Including Breast Reconstruction During the COVID 19 Pandemic at a Community-Based Academic Hospital

INTRODUCTION: The COVID 19 pandemic caused unprecedented changes in treatment of breast cancer. The aim of this IRB approved retrospective study was to assess trends in surgical management and reconstructive choice after mastectomy during the pandemic. Even as an epicenter at the start of COVID, our hospital prioritized the treatment of breast cancer patients facilitating timely care within accepted standards. METHOD(S): We compared female patients with breast cancer (BC) treated with either lumpectomy (L) or mastectomy (M) during a 12-month period in 2017 and 2020-2021. We stratified based on no reconstruction (NR) versus surgical reconstruction (R), reconstruction using autologous tissue (AT) or tissue expander/implant (TE/I), and age above or below 60 years (< 60, >60). RESULT(S): 399 total patients were treated surgically in 2017 and 2020. In 2017, there were 50 M and 115 L (30.3%/69.7%) versus in 2020, 113 M and 121 L (48.3%/51.7%). In 2017, 9 patients had NR (18.0%) while in 2020, 37 had NR (32.7%). In 2017, 41 had R (82.0%), with 24 receiving AT (58.5%) and 17 had TE/I (41.5%). In 2020, 76 had R (67.3%), with 34 receiving AT (44.7%) and 42 had TE/I (55.3%). For age < 60, 29 had R (70.7%) and 2 had NR (22.2%) in 2017;51 had R (67.1%) and 16 had NR (43.2%) in 2020. For age >60, 12 had R (29.2%) and 7 had NR (77.8%) in 2017;25 had R (32.9%) and 21 had NR (56.8%) in 2020. These data show a 13.8% shift towards TE/I over AT with a 14.7% increase in NR. CONCLUSION(S): Breast cancer patients were prioritized and surgically treated within quality standards. With the changes in availability of hospital resources, staff, and limiting viral exposure, mastectomy rates versus lumpectomy increased dramatically. These trends were possibly due to avoidance of daily facility trips for radiation treatment. Tissue expander/implant rates increased substantially possibly from avoidance of prolonged versus overnight hospital stay. Mastectomy without reconstruction also increased and future studies are needed to determine the number of delayed reconstruction in this group.

Hypofractionated Postmastectomy Radiotherapy (HF-PMRT): What did We Learn from COVID-19 Era?

Objectives: In breast cancer (BC) patients receiving mastectomy, postmastectomy radiotherapy (PMRT) improves long-term outcomes by decreasing local failure and cancer mortality. However, the optimal PMRT schedule is still under investigation. The present review aims to discuss the evidence regarding hypofractionated (HF) PMRT in BC patients in order to identify the optimal treatment approach. Additional purpose is to highlight what we have learned from COVID-19 era regarding HF schedules for PMRT in BC patients. Mechanism: Between February and November 2021, literature and database research were conducted. Key references were detected from a PubMed query. Range of publication date was between 2000 and 2021. Selection criteria included English language publications in humans. Hand searching included meeting proceedings of the European Society for Radiotherapy and Oncology (ESTRO), European Society of Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO). The website clinicaltrials.gov was also searched. Randomized controlled trials evaluating HF-PMRT were included. Findings in brief: Our research returned 87 published papers. Fourteen trials were included in our final analysis. The comparisons of several different schedules of HF-PMRT with conventional fractionated PMRT provided similar results in terms of locoregional disease control without increasing toxicity. Particularly, an acute skin toxicity incidence grade 2 or higher ranged between 10 and 25% among the studies we analyzed. Conclusion(s): The present paper suggests that safety and efficacy of HF-PMRT is comparable with conventional schedules and standard practice guidelines are already available. COVID-19 pandemic has emphasised the need for increasingly tailored treatment protocols. Modern HF regimens should continue to be the standard of treatment in BC patients who receive PMRT also in the post-COVID-19 era.Copyright © 2023 The Author(s).

Desensitization to Pfizer-BioNTech Covid-19 mRNA-based vaccine in patients with severe hypersensitivity to PolyEthylene Glycol and/or Polysorbate 80

Background: Covid-19 viral infection affects strongly the populations in the world by the level of morbidity, mortality and the economic impact. A worldwide vaccination program was developed since the end of 2020 to limit the propagation of the virus and the development of variants. In USA and Europe the risk of an allergic reaction is estimated to be 1.31 (95 % CI, 0.90-1.84) per million vaccine dose. The excipients are considered to be the most probable cause of IgE-mediated allergic reactions: PolyEthylene Glycol (PEG) for the Moderna and the Pfizer-BioNTech vaccines and Polysorbate 80 (P80) for the Astra Zeneca and the Johnson & Johnson. P80 presents clinical cross-reactivity with PEG. Patients with a history of severe allergic reaction to PEG or P80 should avoid the vaccination. However, some of them strongly wanted to be vaccinated because their accumulated risk factors for severe infection. Method(s): To 4 severely PEG/P80 allergic patients (grade 3 of anaphylaxis), we proposed a desensitization protocol (7 steps in 90 min + 60 min of observation) with the Pfizer-BioNTech vaccine. Each injection was performed alternately in the deltoid muscle (SC for 2 treated by apixaban) every 15 min. Two patient received all the injections in the same arm due to insufficient lymphatic drainage post mastectomy. The protocol was repeated 1 month and once again 6 months later for the second and the booster doses respectively. One patient didn't received the last one because she was meanwhile moved in palliative treatment. We followed the modification of their immunological status. All patients took a premedication with bilastine 20 mg and montelukast 10 mg (without PEG/P80) 24 h and 3 h before each protocol. Result(s): No patient developed adverse nor allergic reaction after the successive vaccinations. Conclusion(s): We c an p ropose adesensitization protocol to the COVID-19 Pfizer-BioNTech vaccine to patients with severe hypersensitivity to PEG/P80. The desensitization is well tolerated and followed by an increase of specific antibodies and an evolution of antibody level like patients who received the total dosis (0.3 ml) in one injection. (Figure Presented).

The Body as Memory: Breast Cancer and the Holocaust in Women's Art

The Holocaust is a living trauma in the individual and collective body. Studies show that this trauma threatens to be reawakened when a new and traumatic experience, such as illness, emerges. The two traumas bring to the fore the experiences of death, pain, bodily injury, fear of losing control, and social rejection. This article examines the manifestation of this phenomenon in art through the works of three Jewish artists with autobiographical connections to the Holocaust who experienced breast cancer: the late Holocaust survivor Alina Szapocznikow, Israeli artist Anat Massad and English artist Lorna Brunstein, daughters of survivors. All three matured alongside the rise and development of feminist art, and their works address subjects such as femininity and race and tell their stories through their bodies and the traumas of breast cancer and the Holocaust, transmitting memory, working through trauma, and making their voices heard.

Racial and Ethnic Disparities in Screening Mammography During COVID-19

Purpose: Studies conducted prior to COVID-19 suggested that racial/ethnic disparities in breast cancer screening percentages have substantially reduced over time. COVID-19 has had devastating effects on racial/ethnic minorities and resulted in delays in preventive breast cancer screening. Our purpose was to determine if racial/ethnic minorities were less likely to receive recommended breast cancer screening after the resumption of preventive care during the COVID19 pandemic. Method(s): HIPAA-compliant, institutional review board exempt retrospective cohort study was performed at a multi-location academic medical center located in the Midwest. Patients included women aged 50-74 years old between June 2021 and May 2022, derived from the electronic medical records. Primary outcomes variables included receipt of screening mammogram within the last two years. Primary exposure variables included race (American Indian/Alaska Native, Asian/Native Hawaiian/Other Pacific Islander, Black or African American, White) and ethnicity (Hispanic/Latino, and Not Hispanic/Latino). Binary outcomes were analyzed using logistic regression, adjusted for potential confounders (insurance, age, preferred language, employment status, rural status). Result(s): 37,509 female patients without histories of mastectomies were included (mean age 63.1). 73.8% of eligible patients received a mammogram within the last two years. By race, 74.7% of White patients, 57.6% of Black patients, 67.0% of Asian/Pacific Islander patients, and 60.1% of American Indian patients received a screening mammogram within the last two years. In our unadjusted analyses, Black (OR 0.46, 95% CI 0.41 to 0.52, p < 0.001), Asian (OR 0.69, 95% CI 0.60 to 0.79, p < 0.001), and American Indian patients (OR 0.51, 95% CI 0.39 to 0.66, p < 0.001) were less likely to receive recommended mammography screening. In our adjusted analyses, Black (OR 0.54, 95% CI 0.47 to 0.61, p < 0.001), Asian (OR 0.79, 95% CI 0.68 to 0.92, p = 0.003), and American Indian patients (OR 0.63, 95% CI 0.48 to 0.82, p = 0.001) were less likely to receive recommended mammography screening. By ethnicity, 74.1% of Non-Hispanic patients and 64.2% of Hispanic patients received a screening mammogram within the last two years. In our unadjusted analyses, Hispanic patients (OR 0.62, 95% CI 0.55 to 0.71, p < 0.001) were less likely to receive recommended mammography screening. In our adjusted analyses, Hispanic patients (OR 0.92, 95% CI 0.79 to 1.08, p = 0.338) were comparably likely to receive recommended mammography screening. Patients with non-English preferred languages, uninsured or Medicaid patients, and patients living in rural areas were less likely to receive recommended mammography screening (p < 0.001). Conclusion(s): Racial/ethnic minority patients were less likely to receive recommended cancer screening after the resumption of preventive breast cancer screening during the COVID-19 pandemic. Targeted outreach efforts are required to ensure equitable access to breast cancer screening for racial/ethnic minorities, patients with non-English preferred languages, uninsured, Medicaid, and rural patients.

Change in breast cancer detection method, stage at diagnosis and treatment during the COVID19 Pandemic: 2019-2021

Objective: Identify changes in breast cancer detection method, stage at diagnosis and treatment prior to, during and after stay-at-home orders and restricted health care access due to COVID-19. Method(s): Statistical comparison of detection method (patient (PtD), mammography (MamD) or other), Anatomic TNM Stage 8 (0-IV) and invasive BC treatment change over time by three time periods (time 1: 2019+Q1 2020;time 2: Q2-Q4 2020;time 3: 2021) using chi-square analysis in an institutional retrospective cohort of first primary breast cancer (BC) patients (n=1799), years 20192021. Result(s): In the years prior to the study, 2016-2019, there was no difference in detection method or stage at diagnosis by year with 682 to 733 newly diagnosed BC annually (p=.462). In 2020 (n=535) and 2021 (n=582) annual diagnosed cases dropped 22% and 15% from 2019 levels. Compared to time 1, time 2 MamD BC dropped significantly (64% to 58%) with a subsequent increase in MamD BC to 70% in time 3 (p < .001) creating a U-shaped curve for MamD over time. PtD BC increased in time 2 from 30% to 36% but declined in time 3 to 25% (p <.001). Concurrently, stage at diagnosis shifted from time 1 to time 2 with stage 0 and I declining [stage 0: 21% to 16%, stage I: 40% to 38%] and stage II and IV increasing [stage II: 28% to 33%, stage IV: 2% to 4% stage IV] (p<.001). Subsequently in 2021 stage shifted again with an increase in stage 0 to 22% and stage I to 45% and a decline in stage II (33% to 24%), III (9% to 7%) and IV (4% to 2%) (p<.001). Combining stage 0 and I, the percentage of lower stage BC declined from 61% to 54% and increased to 67% in time 3 (2021) when health services became more readily accessible. There was no change in type of surgery for invasive breast cancer (stage I-III, n=1386) with equivalent numbers of breast conserving surgery (58%), subcutaneous mastectomy (24%) and mastectomy (18%) over the time period. Chemotherapy treatment rates for invasive BC did not change (38%). Radiation therapy increased from 66% (time 1: 2019+Q1 2020) to 73% (time 2: Q2Q4 2020) then back to 64% in time 3: 2021 (p=.007) independent of surgery type but concordant with an increase in stage IA and stage IIB BC among invasive breast cancer cases in time 2: Q2-Q4 2020 (p<.001). Likewise, neoadjuvant therapy increased and then declined from 33% to 38% to 29% from time 1 to time 3 (p<.001). Conclusion(s): Number of diagnosed BC cases fell after the first quarter of 2020 during the time of COVID-19 related shut downs and decreased access to health services. During the Q2-Q4 2020 time period mammography detected BC declined with a relative increase in patient detected breast cancer. When mammography detection declined, BC stage at diagnosis shifted to higher stage concurrent with increased rates of radiation and neoadjuvant therapy. In 2021, the relative increase in mammography detected BC indicates a return to more normal screening patterns with a catch up for screening lost in the prior year due to access limitations. In the third time period: 2021, with the return to prior levels of mammography detected breast cancer, stage shifted back to pre-pandemic expected distribution and the excess treatment with radiation and neoadjuvant therapy declined to previously observed levels. Although the changes in detection method, stage and treatment did not persist they were statistically significant and could represent a need for re-establishing prepandemic screening behavior. (Table Presented).

Recruitment, clinical equipoise, patient acceptance and compliance in the UK-ANZ POSNOC trial

Background: POSNOC is a UK-ANZ multicentre, non-inferiority, randomised trial comparing systemic therapy alone with systemic therapy plus Axillary Treatment (Axillary radiotherapy or ALND) for women with <=2 macrometastases at SNB. The primary outcome is axillary recurrence within 5 years. This paper describes screening, recruitment and compliance data. Method(s): Sites were requested on a monthly basis to upload screening data and provide reasons for nonrecruitment of eligible patients into the trial. Sites entered in the online database whether the patients were compliant with their randomisation allocation. Result(s): The study opened in July 2014 and completed target recruitment of 1900 women (24% of those screened) in July 2021, at 95 sites in the UK and 20 sites in Australia and New Zealand. The reason for non-enrolment was unknown in 1300 women. Of the remaining 4774 women with known reasons, who were screened but not randomised, the most common reasons for non-recruitment were due to either patients (n=2219, 46.5%) or their clinicians (n=782, 16.4%) favouring axillary treatment, or patients (n=490, 10.3%) or their clinicians (n=170, 3.6%) not wishing to have axillary treatment. Over the course of the study, there was an increase in the proportion of patients wanting axillary treatment and declining the trial (Mean % patients declined 2015 - 17.9%, 2021 - 39.1%). Mean number of participants recruited per site per month was 0.24 (SD 0.18) overall, 0.25 (SD 0.19) in the UK, and 0.19(SD 0.15) in ANZ. The mean was < 0.3 in 79 sites and >0.9 in only one site. Recruitment rate remained consistent throughout the study (mean 25.3 per month) except for during the first 6 months of recruitment (5.7) and during the COVID pandemic Apr-Sep 2020 (7.5). Of 89 (4.8%) participants non-compliant with allocation, n=45 (50.6%) received systemic therapy alone and n=44 (49.4%) received systemic therapy plus axillary treatment. There was no fluctuation in the direction of non-compliance during the study duration. There was increasing uptake of axillary radiotherapy to treat the axilla instead of ALND over the course of the study in patients receiving axillary treatment (Number who had ART of all who had axilla treatment2014-2017 - 248/454 (54.6 %);2018-2021 - 315/449 (70.2%)). Conclusion(s): Recruitment and compliance with randomised allocation remained consistent over a seven-year period. POSNOC with in-built radiotherapy QA will provide definitive data on axillary management in patients undergoing mastectomy or BCS with <=2 macrometastases on SNB.

Simultaneous Primary Sinonasal Adenocarcinoma and Breast Adenocarcinoma: A Case Report

Sinonasal cancer accounts for roughly only 3% of upper respiratory tract malignancies and generally presents as a primary malignancy. Although extremely rare, the sinonasal cavity is also a known location for metastasis, with 8% of these cases originating from primary breast cancer. When attempting to differentiate primary disease from metastasis, immunohistochemical analyses play a crucial role in reaching the correct diagnosis. To date, there are a handful of reports describing metastasis involving the paranasal sinuses but even fewer reporting primary sinonasal cancer with coexisting primary malignancy. Here we present a case of primary sinonasal adenocarcinoma in the setting of a long-standing history of breast cancer. The patient, a 73-year-old female, was diagnosed with T1cN1aM0, progesterone receptor positive and estrogen receptor negative ductal carcinoma in situ of the left breast in November 2019. She subsequently underwent bilateral mastectomy and treated with 3 cycles of chemotherapy and anastrozole, which were both discontinued due to intolerance. Of note, in March 2019, MRI of the head incidentally found a 3 x 2 cm mass in right nasal cavity extending into ethmoid sinus. One year later, she presented with mild right sided nasal obstruction and drainage, and biopsy revealed squamous and respiratory mucosa with chronic inflammation. The patient elected to cancel initial surgical resection of the mass due to the COVID-19 pandemic. The patient returned in March 2022 with complaints of eye pressure, double vision, headaches, and worsening nasal obstruction. PET/CT scan was negative for distant metastasis but demonstrated increased uptake in sinus cavity. MRI showed a larger 5 x 3.7 cm mass impressing on medial inferior margins of orbit. Imaging also suggested evidence of dehiscence of lamina and irregular neo-osteogenesis of the skull base. She underwent approach and resection of the mass with histology demonstrating a well differentiated, low grade non-intestinal mucinous adenocarcinoma. Immunohistochemistry was positive for pankeratin and CK7, favoring a primary sinonasal origin. It was estrogen receptor negative and negative for GATA3, a sensitive and fairly specific stain in mammary carcinoma. Adjuvant radiation was recommended postoperatively, however the patient declined this therapy. This case highlights the role of immunohistochemistry to discriminate a new primary cancer from metastasis in patients with a history of breast cancer. Clinically, patients with sinonasal metastasis can present with symptoms ranging from unilateral nasal obstruction, facial pain, diplopia, and decreased vision. On imaging, suspicion of malignancy is raised when there is evidence of destruction of bony boundaries and invasion of surrounding tissues such as the orbit and anterior skull base, as found in our patient. Notably, metastasis to the paranasal sinuses can mimic a primary cancer of the nasal cavity, with both tumors showing epithelial differentiation. However, primary tumors often show neoplastic changes in the overlying respiratory epithelium and do not express estrogen receptor, progesterone receptor, or HER2 positivity, which are known to be correlated with breast cancer. In this setting, GATA3 and estrogen receptor negativity allowed us to diagnose primary nasal cancer more confidently. Therefore, clinicians should be aware of metastatic disease and expand immunohistochemistry panels when appropriate.

The Effects of the COVID-19 Pandemic on Mastectomy Outcomes for Breast Cancer.

BACKGROUND: Single center studies have shown that during the Coronavirus Disease 2019 (COVID-19) pandemic, many patients had surgical procedures postponed or modified. We studied how the pandemic affected the clinical outcomes of breast cancer patients who underwent mastectomies in 2020. METHODS: Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we compared clinical variables of 31,123 and 28,680 breast cancer patients who underwent a mastectomy in 2019 and 2020, respectively. Data from 2019 served as the control, and data from 2020 represented the COVID-19 cohort. RESULTS: Fewer surgeries of all kinds were performed in the COVID-19 year than in the control (902,968 vs. 1,076,411). The proportion of mastectomies performed in the COVID-19 cohort was greater than in the control year (3.18% vs. 2.89%, <0.001). More patients presented with ASA level 3 in the COVID-19 year vs. the control (P < .002). Additionally, the proportion of patients with disseminated cancer was lower during the COVID-19 year (P < .001). Average hospital length of stay (P < .001) and time from operation to discharge were shorter in the COVID vs. control cohort (P < .001). Fewer unplanned readmissions were seen in the COVID year (P < .004). CONCLUSION: The ongoing surgical services and mastectomies for breast cancer during the pandemic produced similar clinical outcomes to those seen in 2019. Prioritization of resources for sicker patients and the use of alternative interventions produced similar results for breast cancer patients who underwent a mastectomy in 2020.

Basosquamous Cell Carcinoma of the Nipple-Areola Complex-Report of a Case.

Basosquamous cell carcinoma (BSCC) is a rare malignancy usually arising on sun-exposed areas of the skin. BSCC is described as a rare variant of Basal cell carcinoma (BCC) which shows clinical and microscopic features of both BCC and of Squamous cell carcinoma (SCC). We report the case of a 70-year-old male with a cutaneous lesion of the nipple-areola complex (NAC); to the best of our knowledge, this is the first ever reported patient with BSCC in this area. The lesion had a fast growth, but, due to the COVID19 crisis, the patient only came to our observation one year after onset of this condition. Physical examination showed a bleeding red ulcerated lesion that involved the NAC, measuring 27 mm × 20 mm. Biopsy showed a BSCC. Pre-operative breast ultrasound scan, mammogram and MRI were all performed before surgery, which consisted of simple mastectomy and sentinel lymph-node biopsy. The patient was discharged home on the 4th post-operative day, and at 18-month follow-up there are no signs or clinical evidence of local recurrence or metastases. Diagnosis of BSCC of the nipple-areola complex requires high index of suspicion and a thorough differential diagnosis, management, and suitable radical treatment due to well described high rates of recurrence and of metastases. Differential diagnosis with similar lesions (e.g., Paget's disease, Bowen's disease, BCC, and SCC) should also be taken into account.

Outcomes of the same-day discharge following mastectomy before, during and after COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: The majority of patients undergoing mastectomy before the COVID-19 pandemic were admitted for 23-h observation to the hospital. Indications for observation included drain care education, pain control and observation for possible early surgical complications. This study compared the rates of outpatient mastectomy before, during, and after the COVID-19 pandemic and indirectly evaluated the safety of same-day discharge. METHODS: We retrospectively analyzed patients undergoing mastectomy using Current Procedural Terminology code 19303. RESULTS: A total of 357 patients were included: 113 were treated pre-COVID-19, 82 patients during COVID-19 and 162 post-COVID-19. The rate of outpatient mastectomies tripled during the pandemic from 17% to 51% (p < 0.001); after the pandemic remain high at 48%. The rate of bilateral mastectomies decreased during the pandemic to 30% from 48% prepandemic (p = 0.015). Pectoralis muscle block utilization increased during the COVID-19 period from 36% to 59% (p = 0.002). No difference in complication rates, including surgical site infections, hematomas, and readmissions, pre and during COVID. CONCLUSIONS: The rate of outpatient mastectomy increased during the COVID-19 pandemic. During this timeframe, perioperative complications did not increase, suggesting the safety of this practice. After the pandemic, the rate of outpatient mastectomy continued to be significantly higher than pre-COVID.

Changes in the operative management of breast cancer during the COVID pandemic-single institution experience

Aims: COVID has had a wide ranging impact on surgical practice;including staffing issues, procedural prioritisation and changes to perioperative practice. We aim to compare The operative management of breast Cancer before and during year 1 of The pandemic. Method(s): A retrospective review of primary breast Cancer Surgery in women between 23/3/2020-23/3/2021 with sub-analysis looking at wave 1 of COVID (23/3/2020-23/7/2020), compared to pre-COVID (1/1/2018-31/12/2018). Data collected include type and complexity of surgery, re-operations and complications. Result(s): Pre-COVID, 606 cancers were included, with 217 (35.8%) Simple BCS, 241(39.8%) oncoplastic BCS, 88 (14.5%) Simple mastectomies and 60 (9.9%) mastectomies with immediate reconstruction. During COVID study period, a total of 398 cancers were included, with operative number (percentages) being 104(26.1%), 176(44.2%), 83(20.9%) and 35(8.8%) respectively. During wave 1, 47 cancers were diagnosed and operated on. The operative numbers (percentages) during initial wave COVID pandemic were 9 (19.1%), 25(53.2%), 12(25.5%) and 1(2.1%) respectively. Conclusion(s): In our unit COVID led to a shift of breast Cancer operative management to more BCS and Simple mastectomies. As a unit, we were able to maintain good oncoplastic BCS service, however, reconstruction options were limited.

ONE MORE FEATHER IN THE CAP (DECITABINE): YET ANOTHER CASE OF CHEMOTHERAPY-INDUCED LUNG INJURY

SESSION TITLE: Drug-Induced and Associated Critical Care Cases Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Lung toxicity due to antineoplastic therapy is reported with both cytotoxic and molecularly targeted agents [1]. We present one such case of lung injury induced by capecitabine. CASE PRESENTATION: A 79-year-old female with history of triple negative infiltrating duct carcinoma of the right breast (status post mastectomy and adjuvant chemotherapy with docetaxel and cyclophosphamide 3 years prior) presented to the hospital with dyspnea on exertion following her fourth cycle of capecitabine therapy for breast cancer recurrence. Patient developed nausea, vomiting, and malaise with cycles 1, 2, and 3 of capecitabine therapy with onset of severe dyspnea on exertion, cough, and hypoxia following cycle 4. Computed tomography (CT) scan of the chest on admission showed consolidative opacities in the right upper, right middle, and anterior right lower lobe along with smaller opacities in the left lung apex and small subcentimeter nodules;no pulmonary embolism. Antibiotics were given for a short duration for suspected pneumonia without improvement. Capecitabine was held on discharge. She presented again to the emergency room with worsening shortness of breath, diarrhea, fatigue, and dizziness. COVID test was negative. Chest x-ray redemonstrated patchy airspace disease involving the right apical, lateral, mid lower lung field. Oral steroids were recommended for suspected organizing pneumonia, but the patient refused due to concerns about side effects. Her hospital course was complicated by Clostridium difficile infection (treated with oral vancomycin) and left lower extremity deep venous thrombosis (treated with anticoagulation). Subsequently she followed up with pulmonology outpatient. Repeat imaging showed evolving infiltrates in the same areas with elevated aspergillus IgG level (18.0 mcg/ml) and IgE (178 kU/L) but negative galactomannan and sputum bacterial/fungal/acid fast cultures. Oral steroids were initiated with clinical and symptomatic improvement. DISCUSSION: Capecitabine is a prodrug of fluorouracil (antimetabolite). It is used as a chemotherapy agent in multiple types of cancer including breast cancer. Respiratory side effects include cough (<7%) and bronchitis (<5%). Lung injury/pneumonitis is a rare complication with only a few cases reported to date [2,3]. The timing of symptoms with chemotherapy administration and the negative infectious work-up supports capecitabine as the inciting etiology of lung injury. Withholding chemotherapy and starting systemic steroids were effective treatments in this case of chemotherapy induced lung toxicity. CONCLUSIONS: Capecitabine induced lung injury is a rare but important entity and should always be kept in mind while evaluating dyspnea in cancer patients. Reference #1: Capri G, Chang J, et al. An open-label expanded access study of lapatinib and capecitabine in patients with HER2-overexpressing locally advanced or metastatic breast cancer. Ann Oncol. 2010;21(3):474. Epub 2009 Oct 8. DOI: 10.1093/annonc/mdp373 Reference #2: C. J. Benthin, G. Allada. Capecitabine-Induced Lung Injury. American Journal of Respiratory and Critical Care Medicine 2016;193:A1653. Reference #3: Andrew K Chan, Bok A Choo, John Glaholm. Pulmonary toxicity with oxaliplatin and capecitabine/5-Fluorouracil chemotherapy: a case report and review of the literature. Onkologie. 2011;34(8-9):443-6. doi: 10.1159/000331133. Epub 2011 Aug 19. DISCLOSURES: No relevant relationships by William Karkowsky No relevant relationships by Chahat Puri No relevant relationships by Sahib Singh

5 Year Re-Operation Rates Following Implant Breast Reconstruction: The Ethical Consideration for Individual Patients and Healthcare Systems During a Global Pandemic

Aim: To compare the reoperation and implant loss rates following implant breast reconstruction after 3 months and 5 years in a single unit cohort included in the large multicentre iBRA study1. Method: Patients undergoing implant breast reconstruction for breast cancer or risk reduction mastectomy were recruited as per the iBRA protocol. Electronic patient records were reviewed in December 2021 and reoperation and implant loss was recorded. Results: The records of 26 patients were analysed, all were recruited to the iBRA study. 3-month implant loss (9%) and reoperation rates (18%) were similar to the initial overall study. By 5 years, implant loss rates and reoperation rates had increased to 19% and 77% respectively. 10 patients (39%) underwent 2 or more further operations during this period, with 3 of these patients requiring 5 operations. We acknowledge this cohort is small and any revision procedures performed outside our trust would be missed. Conclusions: Following Montgomery Vs Lanarkshire2 and the Paterson Inquiry Report3, it is vital that patients are aware of any material risk during the consent process before surgery. Quoting 3-month implant loss and reoperation rates in isolation is potentially misleading and there is a need for robust real-life data to guide informed consent. Covid-19 related disruption to elective surgery is inevitable4 and difficult prioritisation decisions are required. Patients undergoing breast reconstruction in 2022 may experience similar complications to the 2016 cohort, however access to revision surgery is uncertain.

Same-Day Discharge Following Simple and Modified Radical Mastectomies

INTRODUCTION: With the pressure to reduce both cost of care and in-patient hospitalizations, particularly in the COVID era, several groups have reported the feasibility of outpatient mastectomies utilizing enhanced recovery after surgery (ERAS) programs. Having converted most mastectomies to the outpatient setting in 2009, we examined our experience sending patients home the same day, including patient selection, unexpected admission and post-operative complications, to better inform institutions considering their own outpatient mastectomy programs. METHODS: With approval from the Institutional Review Board, we performed a retrospective cohort study of patients undergoing mastectomy at a single academic medical center from 2014-2020. Patient population included all patients undergoing mastectomy for malignant disease or risk reduction and excluded patients having immediate breast reconstruction. RESULTS: Of 1678 patients undergoing mastectomy in this time period, 810 did not have immediate reconstruction. Overall, 428 (53%) were planned as outpatient procedures. This was dependent on the type of procedure;unilateral mastectomy (UM) (70%), modified radical mastectomy (MRM) (50%), bilateral simple mastectomies (BSM) (39%) and MRM with contralateral prophylactic mastectomy (MRM/CPM) (25%). The latter two increased over the time course of the study. Admission was associated with ASA status (34% ASA 1/2 vs 51% ASA 3/4, p< 0.001). The most significant predictor was surgeon, with rates ranging from 85% to 46% for UM, 80% to 13% for MRM, 68% to 18% for BSM and 55% to 9% for MRM/CPM. Overall, 16 (3.7%) same-day surgery patients were admitted while 14 (3.8%) 23-hour admission patients were converted to inpatient admissions. Post-operative hematomas requiring a second operation were more common with planned admission compared to those planned for same day discharge (19 (4.9%) vs. 10 (2.3%), p=0.036). CONCLUSIONS: Mastectomies (including bilateral and modified radical mastectomies) without reconstruction can be safely performed on an outpatient basis. Rates of unexpected hospitalizations and post-operative complications are low and there is no difference between those patients planning on same-day discharge and those planned for admission.

A Case Report of Ribociclib-Induced Pneumonitis

Palbociclib, abemaciclib and ribociclib are cyclin-dependent kinase 4/6 (CDK 4/6) inhibitors used in the current treatment of HR-positive, HER2-negative metastatic breast cancer.1.2 As CDK 4/6 inhibitors are becoming more common it is important to be aware of some potentially fatal side effects. A 54-year-old woman with stage III breast cancer with prior mastectomy currently on hormonal and immunotherapy with anastrozole, ribociclib and goserelin presented with fever and shortness of breath. The patient became febrile with a negative COVID-19 test, and was treated for community acquired pneumonia. The fevers persisted despite antibiotics. CBC notable for leukopenia and uptrending absolute eosinophil count of 280 cells per microlitre. A chest CT scan revealed scattered, predominantly peripheral ground glass opacities in the bilateral upper, bilateral lower, and right middle lobes not present on prior imaging. A diagnostic bronchoscopy with BAL revealed 140 white-blood cells, 4 polys, 60 lymphocytes, 30 monocytes and 6 eosinophils. Flow cytometry yielded predominantly T-cells, abundant macrophages and inflammatory Infectious work up including PCP PCR, gram stain, fungal and AFB culture were negative. Ribociclib was discontinued and the patient improved symptomatically with return to baseline level of function. Reports of CDK 4/6 inhibitor drug-associated lung injury are limited There has been only one case report outside of clinical trials of Ribociclib pneumonitis.7 As these drugs become more commonly used, it is important for clinicians to be aware of this potentially fatal drug associated lung injury. Treatment with drug cessation has varying responses from recovery like in our patient to death.

MINIMAL CHANGE DISEASE SECONDARY TO SARS-COV-2 (COVID-19) INFECTION: A REPORT OF 2 CASES AND REVIEW OF RELATED LITERATURE

BACKGROUND AND AIMS: The COVID-19 pandemic has brought to the forefront a wide spectrum of renal injuries that included glomerulopathies, some of which were recently highlighted in various case reports. These consist of focal and segmental glomerulosclerosis (FSGS) and minimal change disease (MCD).1 These changes were found among seemingly vulnerable populations such as the African American and Caucasian ethnicities with paucity of reports among other races. We present two cases of biopsy-confirmed MCD secondary to COVID-19 infection among adult Filipino patients. METHODS: Case Report RESULTS: Case 1 A 40-year-old Filipino female with a history of right total mastectomy 2 years prior for a low-grade phyllodes tumor and no other medical comorbidities was admitted due to stillbirth. She was noted to have bipedal edema with a positive COVID-19 RT-PCR swab. Further workup revealed a serum creatinine 1.04 mg/dL, urine RBC 1/HPF and a 24-h urine protein of 9.22 g with hypoalbuminemia and dyslipidemia. Serologic workup was noted to be negative. She was started on Losartan, Atorvastatin, and Furosemide. A kidney biopsy was performed which demonstrated unremarkable light microscopy and immunofluorescence and widespread podocyte-foot process effacement. These biopsy findings were interpreted to be consistent with minimal change disease. She was started on Prednisone at 1 mg/kg/day with continuation of both Losartan and Atorvastatin. Six weeks after, the patient achieved complete remission with resolution of both hypoalbuminemia and dyslipidemia. She also reports no further recurrence of edema. Case 2 A 61-year-old Filipino male with a history of type 2 diabetes mellitus, hypertension, dyslipidemia and mild COVID-19 infection 4 months prior now presented with diarrhea. A routine COVID-19 RT-PCR swab revealed a re-infection. Physical examination noted bipedal edema. Further workup demonstrated a serum creatinine 3.39 mg/dL, urine RBC 2/HPF and urine ACR 2.6 g/g. Serologic tests were negative. He was diagnosed with Nephrotic Syndrome and underwent kidney biopsy. Findings showed an unremarkable light microscopy and immunofluorescence with widespread podocyte-foot process effacement. These findings were found to be consistent with minimal change disease and acute tubular injury. He was started on Prednisone (1 mg/kg/day), Losartan, Furosemide and Atorvastatin. Eight weeks later, the patient achieved complete remission with resolution of edema. CONCLUSION: It is currently suspected that APOL1 risk variants found in reported cases of COVID-19-associated glomerulopathies are underlying toxic gain-of-function mutations that drive kidney disease.2 It is interesting to note that APOL1 renal risk variants are found exclusively in African-derived chromosomes and are rarely found among European or Asian chromosomes.3 Even though an APOL1 genotyping was not performed, our case reports provide the first examples of MCD among individuals without a high-risk genotype (APOL1) by epidemiology and enlarge the literature on MCD in COVID-19. We posit that there may be other underlying predispositions or mechanisms that may be driving glomerulopathy formation among COVID-19 patients aside from their inherent APOL 1 risk. Both of our patients were started on steroid therapy with a tapering regimen and achieved complete remission on subsequent follow-up. Existing reports suggest that most cases of COVID-19-associated MCD will often achieve resolution of AKI and proteinuria with steroid therapy, even in those with high-risk APOL1 genotype, emphasizing the need for an accurate histologic classification.4 (Figure Presented).