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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
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Sexo feminino, 25 anos, Linfoma de Hodgkin Esclerose Nodular (IVBX) bulky mediastinal, refratário a 6 ciclos de AVD, recaída precoce após 3 ciclos de ICE, resposta parcial após 4 ciclos de Brentuximab. Em Março/2021, diagnosticada com Covid-19, RT-PCR persistentemente positivo, sendo suspenso Brentuximab. TC de Tórax de 26/04/2021, devido a piora da dispneia, com sinais de TEP acometendo as porções distais das artérias pulmonares bilaterais;massa mediastinal com 13,6 x 9,7 cm, atividade glicolítica ao PET-CT (Deauville 4). Internou na Unidade de TMO do Hospital Monte Sinai para realização de TMO Autólogo. Coleta de células tronco periféricas em 01/05/2021. Realizado ecocardiograma prévio ao condicionamento em 07/05/2021: 2 imagens hiperecogênicas intra-atriais à direita (maior com 2,7 x 1,8 cm), sugestivas de trombos intracavitários, confirmados pelo ECO-TE, associados a cateter totalmente implantável fundidos à parede atrial. Função ventricular esquerda preservada e aumento de ventrículo direito. Pela gravidade do quadro e impossibilidade cirúrgica, indicado anticoagulação plena com Heparina Não-Fracionada em BIC e condicionamento iniciado em 11/05/2021 com esquema: Lomustina, Etoposide, Ciclofosfamida, Mesna. Infusão de CTP em 16/05/2021. Período de neutropenia sem maiores intercorrências, com pega medular em 26/05/2021 e alta hospitalar em seguida. Em 11/06/2021, intercorreu com febre e bacteremia, internada para tratamento de infecção associada a catéter de curta permanência (implantado para infusão de CTP) por S. hominis sensível à oxacilina. No dia 24/06/2021, apresentou piora clínica importante da dispneia e anasarca. ECO-TE: PSAP em 90 mmHg, aumento da disfunção de VD. Nova Angio-TC de tórax sem trombos novos. Iniciado Milrinone na Unidade Coronariana e discutido cirurgia de urgência, sendo novamente contra-indicados pelas equipes assistentes. Em 27/06/2021 paciente evolui com choque obstrutivo, evoluindo a óbito em 30/06/2021. Discussão: Cateteres totalmente implantáveis podem ser em pacientes com Linfoma de Hodgkin, pois têm menos infecção em comparação com outros cateteres. As complicações associadas aos cateteres são incomuns e incluem infecções e tromboses, porém a trombose atrial direita ainda é rara e potencialmente fatal. A formação desses trombos é assintomática e altamente associado a posição da ponta do cateter no átrio direito. A incidência é incerta, variando entre 3-23%. A mortalidade geral é de 27,1% e parece estar relacionada a sua associação com TEP grave e ao tipo de tratamento instituído. A presença do trombo cardíaco é um marcador prognóstico. O manejo ainda é controverso. As opções terapêuticas incluem anticoagulação com heparina, embolectomia cirúrgica ou trombólise. Sendo este último com taxa de mortalidade de 11,3% em comparação a 28,6% com anticoagulação e 23,8% com embolectomia. No caso relatado, foi contra-indicado o tratamento com trombolítico, pelo tempo da evidência do trombo em exame de imagem (mais de 14 dias), e o procedimento cirúrgico, por paciente apresentar massa mediastinal extensa. Portanto foi optado por manter a anticoagulação com heparina não fracionada. Conclusão: O diagnóstico de trombo em átrio direito é desafiador. O receio de complicações em um paciente grave, explica o tratamento conservador utilizado. Ainda não existe um consenso sobre o tratamento mais adequado, sendo necessária a avaliação individualizada dos casos.
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Introduction The standard of care for patients with multiple myeloma (MM) involves autologous hematopoietic stem cell transplantation (ASCT). Pre-ASCT mobilization chemotherapy for MM, vinorelbine and high dose cyclophosphamide (VC), has been historically given in the inpatient (IP) setting. Due to rising bed occupancy rates and patients' preferences for treatment in the ambulatory setting, our team has offered eligible patients an option to receive VC outpatient (OP) since 2018. Our study aims to audit the feasibility and safety of this initiative, and review potential healthcare-related cost savings. Methods Eligibility criteria for OP chemotherapy were developed by a multidisciplinary team based on patients' age, functional status, medical comorbidities and social factors (Figure 1). The chemotherapy regimen was modified for an OP setting (Figure 2), of which the main alteration involved changing the route of administration of intravenous (IV) mesna to a combination of IV and oral. A retrospective review was conducted for 35 MM patients (18 IP and 17 OP) who received VC for mobilisation at our center from 2018 to 2019. The patient characteristics were similar between the two groups (Table 1). Patient data were analyzed from the day of admission for VC (IP) or day 1 of VC (OP), to the day before admission for stem cell harvesting. Clinical charts were reviewed for unexpected complications and unplanned admissions. Costs incurred were calculated using the value-driven-outcome (VDO) informatics analysis of the hospital. Results There were no unexpected clinical complications or unplanned admissions in both groups. The median length of hospital stay for the IP cohort was 3 days, amounting to a saving of 51 hospital days over 2 years in the OP cohort. Median costs were 73% lower in the OP cohort (Figure 3). The difference was mainly due to certain costs not incurred in the OP setting. These included room charges and daily treatment fees (which accounted for an average of 46% and 19% of IP charges respectively). Investigation costs were also 55% lower in the OP cohort, which could be attributed to more investigations being performed in the IP setting such as screening for methicillin-resistant Staphylococcus aureus and nonurgent radiographs ordered after hours by the on-call physician upon admission. Conclusions Our findings show that OP mobilization chemotherapy for MM is safe, feasible and associated with improved bed utilization and cost savings. Other components of the stem cell transplantation process are also increasingly being transitioned from the IP to OP setting in our center as part of an ongoing paradigm shift in right-siting treatment services, which has been accelerated by the COVID-19 pandemic's strain on inpatient capacity. These results provide an affirmation of our efforts to optimize the utilization of healthcare resources. [Formula presented] Disclosures: Chng: Takeda: Consultancy;GlaxoSmithKline: Consultancy;Johnson & Johnson: Consultancy, Research Funding;Aslan: Research Funding;Antengene: Consultancy;Abbvie: Consultancy;Pfizer: Consultancy;Novartis: Research Funding;Sanofi: Consultancy;Amgen: Consultancy;BMS/Celgene: Consultancy, Research Funding.