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Background: Little is known on the effects of delirium onset and duration on outcome in critically ill patients with cancer. Objectives: To determine the impact of delirium onset and duration on intensive care unit (ICU) and hospital mortality and length of stay (LOS) in patients with cancer. Methods: Of the 915 ICU patients admitted in 2018, 371 were included for analysis after excluding for terminal disease, <24-h ICU stay, lack of active cancer and delirium. Delirium was defined as early if onset was within 2 days of ICU admission, late if onset was on day 3 or later, short if duration was 2 days or less, and long if duration was 3 days or longer. Patients were placed into 4 combination groups: early-short, early-long, late-short, and late-long delirium. Multivariate analysis controlling for sex, age, metastatic disease, and predelirium hospital LOS was performed to determine ICU and hospital mortality and LOS. Exploratory analysis of long-term survival was also performed. Restricted cubic splines were performed to confirm the use of 2 days to distinguish between early versus late onset and short versus long duration. Results: A total of 32.9% (n = 122) patients had early-short, 39.1% (n = 145) early-long, 16.2% (n = 60) late-short, and 11.9% (n = 44) late-long delirium. Late-long delirium was independently associated with increased ICU (OR 4.45, CI 1.92-10.30; P <.001) and hospital (OR 2.91, CI 1.37-6.19; P =.005) mortality and longer ICU (OR 1.97, CI 1.58-2.47; P <.001) LOS compared to early-short delirium. Early delirium had better overall survival at 18 months than late delirium. Long-term survival further improved when delirium duration was 2 days or less. Prediction heatmaps confirm the use of a 2-day cutoff. Conclusion: Late delirium, especially with long duration, significantly worsens outcome in ICU patients with cancer and should be considered a harbinger of poor overall condition. [ABSTRACT FROM AUTHOR]

Purpose: Enucleation is a common treatment modality performed for pediatric retinoblastoma patients, and the resultant defects are reconstructed using an ocular prosthesis. The prostheses are modified or replaced periodically, as the child develops due to orbital growth and patient‐error. The purpose of this report is to evaluate the replacement frequency of prostheses in the pediatric oncologic population. Methods: A retrospective review was completed by the two senior research investigators, of patients that had ocular prostheses fabricated following enucleation of their retinoblastoma from 2005 to 2019 (n = 90). Data collected from the medical records of the patient included the pathology, date of surgery, date of prosthesis delivery, and the replacement schedule of the ocular prosthesis. Results: During the 15‐year study period, 78 enucleated observations (ocular prosthesis fabricated) were included for analysis. The median age of the patients at the time of delivery of their first ocular prosthesis was calculated to be 2.6 years (range 0.3–18 years). The median time to the first modification of the prosthesis was calculated to be 6 months. The time to modification of the ocular prosthesis was further stratified by age. Conclusion: Pediatric patients require modification of their ocular prostheses throughout their growth and development period. Ocular prostheses are reliable prostheses with predictable outcomes. This data is helpful to set an expectation among the patient, parent, and provider. [ABSTRACT FROM AUTHOR]

Simple Summary: Telemedicine became widespread during the COVID-19 pandemic, but little is known about its persistence in routine cancer care after the pandemic's peak. This study examined telemedicine use for breast and prostate cancer patients at a New York City cancer center before, during, and after the pandemic's peak. Telemedicine usage increased from 2% before the pandemic to 50% during the peak and then decreased to 30% after the peak. Both during and after the peak, psychiatry, social work, and nutrition conducted almost all visits remotely, while surgery and nursing maintained low telemedicine usage. Most departments continued to use telemedicine at or above peak levels, except for medicine, neurology, and survivorship. Anesthesiology and neurology used telemedicine more for follow-ups, while nursing used it more for new visits. These findings highlight specific contexts where patients and providers choose telemedicine even when other options are available. However, more research is needed to assess telemedicine's suitability for and impact on cancer care. While COVID-19 catalyzed a shift to telemedicine, little is known about the persistence of remote cancer care in non-emergent times. We assessed telemedicine use at a high-volume academic cancer center in New York City and analyzed breast and prostate cancer visits pre-COVID-19, peak COVID-19, and post-peak. Descriptive statistics assessed visit mode (in person, telemedicine) and type (new, follow-up, other) by department/specialty, with Fisher's exact tests comparing peak/post-peak differences. The study included 602,233 visits, with telemedicine comprising 2% of visits pre-COVID-19, 50% peak COVID-19, and 30% post-peak. Notable variations emerged by department/specialty and visit type. Post-peak, most departments/specialties continued using telemedicine near or above peak levels, except medicine, neurology, and survivorship, where remote care fell. In psychiatry, social work, and nutrition, nearly all visits were conducted remotely during and after peak COVID-19, while surgery and nursing maintained low telemedicine usage. Post-peak, anesthesiology and neurology used telemedicine seldom for new visits but often for follow-ups, while nursing showed the opposite pattern. These trends suggest department- and visit-specific contexts where providers and patients choose telemedicine in non-emergent conditions. More research is needed to explore these findings and evaluate telemedicine's appropriateness and impact across the care continuum. [ABSTRACT FROM AUTHOR]

Purpose: The role of locoregional therapy compared to systemic chemotherapy (SYS) for unresectable intrahepatic cholangiocarcinoma (IHC) remains controversial. The importance of hepatic disease control, either as initial or salvage therapy, is also unclear. We compared overall survival (OS) in patients treated with resection, hepatic arterial infusion pump (HAIP) chemotherapy, or SYS as it relates to hepatic recurrence or progression. We also evaluated recurrence after resection to determine the efficacy of locoregional salvage therapy. Patients and Methods: In this single‐institution retrospective analysis, patients with biopsy‐proven IHC treated with either curative‐intent resection, HAIP (with or without SYS), or SYS alone were analyzed. Propensity score matching (PSM) was used to compare patients with liver‐limited, advanced disease treated with HAIP versus SYS. The impact of locoregional salvage therapies in patients with liver‐limited recurrence was analyzed in the resection cohort. Results: From 2000 to 2017, 714 patients with IHC were treated, 219 (30.7%) with resectable disease, 316 (44.3%) with locally advanced disease, and 179 (25.1%) with metastatic disease. Resected patients were less likely to recur or progress in the liver (hazard ratio [HR] 0.41, 95% CI 0.34–0.45) versus those that received HAIP or SYS (HR 0.58, 95% CI 0.50–0.65 vs. HR 0.63, 95% CI 0.57–0.69, respectively). In resected patients, 161 (64.4%) recurred, with 65 liver‐only recurrences. Thirty of these patients received subsequent locoregional therapy. On multivariable analysis, locoregional therapy was associated with improved OS after isolated liver recurrence (HR 0.46, 95% CI 0.29–0.75; p = 0.002). In patients with locally advanced unresectable or multifocal liver disease (with or without distant organ metastases), PSM demonstrated improved hepatic progression‐free survival in patients treated with HAIP versus SYS (HR 0.65; 95% CI 0.46–0.91; p = 0.01), which correlated with improved OS (HR 0.59, 95% CI 0.43–0.80; p < 0.001). Conclusion: In patients with liver‐limited IHC, hepatic disease control is associated with improved OS, emphasizing the potential importance of liver‐directed therapy. [ABSTRACT FROM AUTHOR]

Purpose: Although delirium is known to negatively affect critically ill patients, little data exist on delirium in critically ill patients with cancer. Methods: We analyzed 915 critically ill patients with cancer between January and December 2018. Delirium screening was performed using the Confusion Assessment Method for the intensive care unit (ICU), performed twice daily. Confusion Assessment Method-ICU incorporates four features of delirium: acute fluctuations in mental status, inattention, disorganized thinking, and altered levels of consciousness. Multivariable analysis controlling for admitting service, pre-ICU hospital length of stay (LOS), metastatic disease, CNS involvement, Mortality Probability Model II score on ICU admission, mechanical ventilation, and others was performed to determine precipitating factors for delirium, ICU, and hospital mortality and LOS. Results: Delirium occurred in 40.5% (n = 317) of patients; 43.8% (n = 401) were female; the median age was 64.9 (interquartile range, 54.6-73.2) years; 70.8% (n = 647) were White, 9.3% (n = 85) were Black, and 8.9% (n = 81) were Asian. The most common cancer types were hematologic (25.7%, n = 244) and gastrointestinal (20.9%, n = 191). Delirium was independently associated with age (OR, 1.01; 95% CI, 1.00 to 1.02; P = .038), longer pre-ICU hospital LOS (OR, 1.04; 95% CI, 1.02 to 1.06; P < .001), not resuscitating on admission (OR, 2.18; 95% CI, 1.07 to 4.44; P = .032), CNS involvement (OR, 2.25; 95% CI, 1.20 to 4.20; P = .011), higher Mortality Probability Model II score (OR, 1.02; 95% CI, 1.01 to 1.02; P < .001), mechanical ventilation (OR, 2.67; 95% CI, 1.84 to 3.87; P < .001), and sepsis diagnosis (OR, 0.65; 95% CI, 0.43 to 0.99; P = .046). Delirium was also independently associated with higher ICU mortality (OR, 10.75; 95% CI, 5.91 to 19.55; P < .001), hospital mortality (OR, 5.84; 95% CI, 4.03 to 8.46; P < .001), and ICU LOS (estimate, 1.67; 95% CI, 1.54 to 1.81; P < .001). Conclusion: Delirium significantly worsens outcome in critically ill patients with cancer. Delirium screening and management should be integrated into the care of this patient subgroup. [ABSTRACT FROM AUTHOR]

PURPOSE: Patient portal secure messages are not always authored by the patient account holder. Understanding who authored the message is particularly important in an oncology setting where symptom reporting is crucial to patient treatment. Natural language processing has the potential to detect messages not authored by the patient automatically. METHODS: Patient portal secure messages from the Memorial Sloan Kettering Cancer Center were retrieved and manually annotated as a predicted unregistered proxy (ie, not written by the patient) or a presumed patient. After randomly splitting the annotated messages into training and test sets in a 70:30 ratio, a bag-of-words approach was used to extract features and then a Least Absolute Shrinkage and Selection Operator (LASSO) model was trained and used for classification. RESULTS: Portal secure messages (n = 2,000) were randomly selected from unique patient accounts and manually annotated. We excluded 335 messages from the data set as the annotators could not determine if they were written by a patient or proxy. Using the remaining 1,665 messages, a LASSO model was developed that achieved an area under the curve of 0.932 and an area under the precision recall curve of 0.748. The sensitivity and specificity related to classifying true-positive cases (predicted unregistered proxy-authored messages) and true negatives (presumed patient-authored messages) were 0.681 and 0.960, respectively. CONCLUSION: Our work demonstrates the feasibility of using unstructured, heterogenous patient portal secure messages to determine portal secure message authorship. Identifying patient authorship in real time can improve patient portal account security and can be used to improve the quality of the information extracted from the patient portal, such as patient-reported outcomes. We created an NLP model to determine when other people send portal messages on the patient's behalf [ABSTRACT FROM AUTHOR]

Objective: We sought to define the prognostic significance of histologic subtype for extremity/truncal liposarcoma (LPS). Background: LPS, the most common sarcoma, is comprised of 5 histologic subtypes. Despite their distinct behaviors, LPS outcomes are frequently reported as a single entity. Methods: We analyzed data on all patients from a single-institution prospective database treated from July 1982 to September 2017 for primary, nonmetastatic, extremity or truncal LPS of known subtype. Clinicopathologic variables were tested using competing risk analyses for association with disease-specific death (DSD), distant recurrence (DR), and local recurrence (LR). Results: Among 1001 patients, median follow-up in survivors was 5.4 years. Tumor size and subtype were independently associated with DSD and DR. Size, subtype, and R1 resection were independently associated with LR. DR was most frequent among pleomorphic and round cell LPS; the former recurred early (43% by 3 years), and the latter over a longer period (23%, 3 years; 37%, 10 years). LR was most common in dedifferentiated LPS, in which it occurred early (24%, 3 years; 33%, 5 years), followed by pleomorphic LPS (18%, 3 years; 25%, 10 years). Conclusions: Histologic subtype is the factor most strongly associated with DSD, DR, and LR in extremity/truncal LPS. Both risk and timing of adverse outcomes vary by subtype. These data may guide selective use of systemic therapy for patients with round cell and pleomorphic LPS, which carry a high risk of DR, and radiotherapy for LPS subtypes at high risk of LR when treated with surgery alone. [ABSTRACT FROM AUTHOR]

PURPOSE: To detect alterations in DNA damage repair (DDR) genes, measure homologous recombination deficiency (HRD), and correlate these findings with clinical outcome in patients with leiomyosarcoma (LMS). PATIENTS AND METHODS: Patients with LMS treated at Memorial Sloan Kettering (MSK) Cancer Center who consented to prospective targeted next-generation sequencing with MSK-IMPACT were screened for oncogenic somatic variants in one of 33 DDR genes; where feasible, an experimental HRD score was calculated from IMPACT data. Progression-free survival (PFS) and overall survival (OS) were estimated after stratifying patients by DDR gene alteration status and HRD score. RESULTS: Of 211 patients with LMS, 20% had an oncogenic DDR gene alteration. Univariable analysis of PFS in 117 patients who received standard frontline chemotherapy in the metastatic setting found that an altered homologous recombination pathway gene was significantly associated with shorter PFS (hazard ratio [HR], 1.79; 95% CI, 1.04 to 3.07; P =.035). Non- BRCA homologous recombination gene alteration was associated with shorter PFS (HR, 2.61; 95% CI, 1.35 to 5.04; P =.004) compared with BRCA -altered and wild-type homologous recombination genes. Univariable analysis of OS from diagnosis in the entire cohort of 211 patients found that age, tumor size, number of metastatic sites, localized disease, and non- BRCA homologous recombination gene alteration were significantly associated with OS. On multivariable analysis, non- BRCA homologous recombination pathway gene alteration remained significant (HR, 4.91; 95% CI, 2.47 to 9.76; P <.001). High HRD score was not associated with a different PFS or OS. CONCLUSION: Patients with LMS with homologous recombination pathway gene alterations have poor clinical outcomes, particularly those with non- BRCA gene alterations. HRD score calculated from a targeted exome panel did not discern disparate clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: PI3K pathway activation is common in endometrial cancer. We evaluated the safety and efficacy of the dual PI3K/mTOR inhibitor, LY3023414, in patients with advanced endometrial cancer harboring activating mutations in the PI3K pathway.Methods: We conducted a single-arm phase 2 study of monotherapy LY3023414. Eligible patients had advanced endometrial cancer of any grade, prior management with 1-4 cytotoxic lines, and PI3K pathway activation prospectively defined as a loss-of-function PTEN alteration or activating alteration in PIK3CA, AKT1, PIK3R1, PIK3R2, or MTOR. The primary objective was best overall response rate (ORR) per RECIST 1.1.Results: Twenty-eight patients were treated; histologies included endometroid (39%), carcinosarcoma (25%), serous (21%), and mixed (14%). Patients were heavily pretreated, with a median of 2 prior cytotoxic lines (range, 1-3). The most common alterations involved PIK3CA (68%), PTEN (43%), and PIK3R1 (32%). In the 25 efficacy-evaluable patients, the ORR was 16% (90% CI, 7%-100%), and the clinical benefit rate was 28% (90% CI, 16%-100%). Four patients had a confirmed partial response, and 2 responses lasted for >9 months. The median progression-free survival and overall survival were 2.5 months (95% CI, 1.2-3.0) and 9.2 months (95% CI, 5.0-15.9), respectively. The most common all-grade treatment-related adverse events were anemia (71%), hyperglycemia (71%), hypoalbuminemia (68%), and hypophosphatemia (61%). No correlation between molecular alterations and response was observed.Conclusion: In patients with heavily pretreated advanced endometrial cancer prospectively selected for tumors with activating PI3K pathway mutations, LY3023414 demonstrated modest single-agent activity and a manageable safety profile. [ABSTRACT FROM AUTHOR]

Deep and durable hematologic remissions following RA-ASCT are associated with improved organ function and extended overall survival in AL amyloidosis. While depth of hematologic response by standard criteria are important, this study assessed additional factors that influence RR and time to RR. All patients (pts) with AL and renal involvement undergoing RA-ASCT at Memorial Sloan Kettering Cancer Center between January 1, 2007 to December 31, 2016 were included. Pts with follow up <12 months (mos) post RA-ASCT and hemodialysis prior to RA-ASCT were excluded. Melphalan dose was assigned based on age, cardiac involvement and renal compromise. Hematologic and organ response was assessed at 3 (early) and 12 mos post RA-ASCT. Consolidation with bortezomib and dexamethasone was offered to pts with less than complete response (CR) at 3 mos. Logistic regression models were used to assess association with RR (Palladini Blood 2014) by 12 mos. Covariates for adjustment in multivariate models were chosen based on univariate analyses and clinical relevance. Sixty-four patients with renal AL meeting the inclusion criteria were identified; 3 died within 12 mos post RA-ASCT were excluded. Median age was 61 years (44-73), 51% female and 34% had cardiac involvement. Median 24 hr proteinuria pre ASCT was 5014 mg/day (2632-7514) and eGFR 68 ml/min/1.73 m2 (44-91). Renal amyloid stage I:II:III was 33%:52%:15%. Mayo cardiac stage (2004) I:II:III was 28%:61%:11% and revised Mayo stage (2012) I:II:III:IV was 13%:57%:21%:8%. Median BM plasma cells pre ASCT was 9% (2-14%). 46% received treatment prior to ASCT. Melphalan dose (mg/m2) 200:140:100 was 44%:43%:11% and 46% received consolidation. Hematologic response early post ASCT was CR 44%, very good partial (VGPR) 29% and partial response (PR) 20%. dFLC <1mg/dL was achieved in 63%. RR by 12 mos was achieved in 32 pts (53%); median time to RR was 5.8 mos (5.1 – 11.3). Amongst renal responders, 50% achieved CR, 53% MRD negative, and 78% dFLC <1mg/dL early post RA-ASCT. In pts with dFLC <1mg/dL early post RA-ASCT, 66% achieved RR. By univariate analysis, early post ASCT dFLC <1mg/dL (OR 3.00, 95% CI 1.01-8.93, p = 0.048) and VGPR (7.80, 1.69-36.06, p = 0.009), at 12 mos dFLC <1mg/dL (7.20, 2.14-24.21, p = 0.001) and CR (10.27, 1.14-92.26, p = 0.038) were associated with RR. By multivariate analysis, dFLC <1mg/dL early post ASCT (OR 4.52, 95% CI 1.26-16.24, p = 0.021) was associated with RR when adjusted for renal amyloid stage and Mayo cardiac stage (2004). In this single center study, we found that RA-ASCT results in RR in more than half (53%) of pts at 1 year. Achieving dFLC <1mg/dL early post ASCT is prognostic of RR independent of renal stage. Early MRD-negativity did not predict RR. Our study suggests maximal suppression of the pathologic light chains is important for organ recovery. Larger studies using dFLC <1mg/dL as an end point are warranted. [ABSTRACT FROM AUTHOR]