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We are presenting a 63-year-old Caucasian male who complained of 2 months of progressive dysphagia. Upper endoscopy discovered a mass in the distal esophagus near the gastroesophageal junction. Biopsy was consistent with adenocarcinoma. Endoscopic ultrasound (EUS) showed extension beyond the muscularis propria, with an enlarged paraesophageal lymph node (T3N1). Initial positron emission tomography (PET)/computed tomography (CT) showed hypermetabolic portocaval lymphadenopathy presumed to be metastatic, but otherwise without distant disease extension. Neoadjuvant treatment included induction FOLFOX followed by 5,600 cGy over 28 fractions in combination with 5-FU and oxaliplatin. Approximately 3.5 weeks after completion, a repeat PET/CT revealed reduced uptake in both the primary esophageal mass and regional lymph nodes. Of note there were several new mass-like foci of hypermetabolism in the liver, specifically the left lobe, concerning for metastatic disease. Image-guided biopsy did not show any identifiable lesions, but sampling was performed based on anatomical landmarks. Pathology revealed benign parenchyma with minimal inflammation and mild reactive regeneration. In light of this, the patient proceeded to undergo definitive resection via robotic Ivor-Lewis esophagectomy with only 1 positive lymph node. Given pleural involvement by the tumor, staging was revised to pT4aN1 with final histology characterized as adenosquamous carcinoma. Postoperative course was fairly uneventful, with a mild exacerbation of his chronic heart failure. The patient was discharged on post-operative day 7, with his feeding tube removed at his 2-week post-operative clinic visit. This scenario is of particular educational value from the standpoint that when the post-treatment PET/CT images are registered to the radiotherapy treatment planning CT and dose, the areas of abnormal uptake in the liver fall within the higher dose regions. Given this and the liver biopsy findings, caution should be exercised before declaring progressive disease following radiotherapy without first reviewing the treatment plan.

The standard of care for locally advanced rectal cancer (clinical T3/4N0 or T any N+) has evolved from upfront surgery followed by postoperative adjuvant therapy to a paradigm delivering neoadjuvant chemoradiation (CRT). More recently, the sequence of therapies has been re-examined, delivering all treatment (CRT and chemotherapy) in a total neoadjuvant approach. Subgroups of patients with locally advanced or earlier stage disease may achieve a clinical complete response (cCR), allowing highly selected patients to defer or avoid major pelvic surgery, managed by a rectal-preserving non-operative management (NOM) strategy. In rare instances, early and severe toxicity may occur during CRT which can be associated with genetic alterations that disrupt DNA damage response pathways. In this case report, we highlight the clinical course of a patient with T2N0 rectal cancer who declined APR and subsequently experienced early toxicity during treatment, ultimately discovered to be a carrier for Fanconi anemia after broad panel testing for hereditary cancer. Summary Acute toxicities secondary to pelvic radiotherapy are common, however, most are not treatment-limiting. In rare instances, radiotherapy can induce acute and severe toxicities which may be attributed to genetic alterations. Pathogenic genetic variants in DNA damage response genes can be associated with radiation-induced toxicity. Herein, we describe a patient with rectal cancer receiving pelvic irradiation with significant early toxicity subsequently confirmed to have a heterozygous Fanconi anemia mutation in the FANCD2 gene.

Background US health care is increasingly defined by over expenditure and inefficiency. Optimizing patient follow-up is critical, especially in cancers treated with high control rates. To optimize patient care, this study assessed time to disease recurrence or toxicity in patients with anal carcinoma. Materials and methods In total, 140 patients with biopsy-proven, nonmetastatic anal carcinoma, treated with chemoradiation utilizing intensity-modulated radiation therapy, were identified from our institutional database. This retrospective study evaluated local recurrence (LR), distant metastasis (DM), overall survival (OS), and late ≥grade 3 toxicity (LG3T). Patients were followed posttreatment every 3 months for 2 years, every 6 months in years 3 to 5, then yearly thereafter per NCCN recommendations. Results The median age and follow-up was 58 years and 27 months, respectively. Patients were categorized into high (n=61; 44%) and low (n=77; 55%) risk groups based on stage. The 2-year LC, DMFS, and OS were 93%, 94%, and 89% and 5-year LC, DMFS, OS were 92%, 87%, and 85%, respectively. Overall, there were 29 events (9 LR, 11 DM, and 9 LG3T), with 62% of events occurring within year 1 and 79% within 2 years. Stratified by event type, at 2 years 89% of LR, 64% of DM, and 89% LG3T were identified. At the remaining follow-up points, the event incidence rate was 1.3%. Conclusion With the majority of recurrences/toxicities occurring within the first 2 years, a reduction in follow-up during years 3 to 5 may provide adequate surveillance. Revisions of the current recommendations could maximize resources while improving patient quality of life.

The volumes, rates and grain size distributions of sediment supplied from hillslopes represent the initial input of sediment delivered from upland areas and propagated through sediment routing systems. Moreover, hillslope sediment supply has a significant impact on landscape response time to tectonic and climatic perturbations. However, there are very few detailed field studies characterising hillslope sediment supply as a function of lithology and delivery process. Here, we present new empirical data from tectonically-active areas in southern Italy that quantifies how lithology and rock- strength control the landslide fluxes and grain size distributions supplied from hillslopes. Landslides are the major source of hillslope sediment supply in this area, and our inventory of ~2800 landslides reveals that landslide sediment flux is dominated by small, shallow landslides. We find that lithology and rock strength modulate the abundance of steep slopes and landslides, and the distribution of landslide sizes. Outcrop-scale rock strength also controls the grain sizes supplied by bedrock weathering, and influences the degree of coarsening of landslide supply with respect to weathering supply. Finally, we show that hillslope sediment supply largely determines the grain sizes of fluvial export, from catchments and that catchments with greater long-term landslide rates deliver coarser material. Therefore, our results demonstrate a dual control of lithology on hillslope sediment supply, by modulating both the sediment fluxes from landslides and the grain sizes supplied by hillslopes to the fluvial system.

170 Background: Few epidemiological studies address differences in outcomes by gender in locoregional esophageal cancer (LEC) for which the current standard of care is chemoradiation followed by surgical resection. Although male gender is associated with the majority of LEC cases, we sought to determine if gender could impact clinical presentation as well as surgical and oncologic outcomes in our single institution 20 year experience. Methods: A retrospective query of our institution’s IRB-approved database of patients that had surgical therapy between 2008 and 2019 for esophageal cancer (EC) was performed. Patients were stratified by gender and analyzed based on characteristics such as tumor histology, tumor location, clinical stage at presentation, age at diagnosis, receipt of neoadjuvant therapy, surgical intent, surgical complications, length of post-operative hospital stay, response to neoadjuvant therapy, final pathology, and recurrence. Chi-square, ANOVA and Kaplan Meier survival analysis were performed on the previously defined groups. Results: The cohort studied included 1180 patients with resection for EC. Of those, 1005 (85.2%) had adenocarcinoma, 145 (12.3%) had squamous cell cancer (SCC), 10 (0.8%) had adenosquamous carcinoma, and 20 (1.7%) had other histological variants. There were 985 (83.5%) male patients and 195 (16.5%) female patients. SCC was more common in females (29.2% in females vs. 8.9% in males, p = 0.000) and females tended to have tumor location in the upper thoracic esophagus more often (4.7% in females vs. 0.9% of males, p = 0.000). Additionally, females developed surgical complications more often than males (72.2% vs. 64.7%, p = 0.045). Staging at diagnosis (p = 0.508), receipt of neoadjuvant treatment (p = 0.676), and age at diagnosis (65.3 years in males vs. 66.3 years in females, p = 0.934) had no association with gender. Response to neoadjuvant therapy (p = 0.157) and cancer recurrence (p = 0.434) did not have significant associations with gender. The median overall survival was not statistically significantly different but trended to be longer for females (73.4 months in females [95% CI: 51.5-95.4] vs. 47.0 months in males [95% CI: 39.6-54.5], p = 0.160). Conclusions: Based on our high-volume cancer center study, female patients were more likely to have SCC, upper thoracic esophageal lesions, and surgical complications following resection. While univariate analysis did not demonstrate significant differences in overall survival between genders, there are plans to report additional data after controlling for other variables. Further studies are warranted to validate these findings, given the potential for higher prioritization of an organ preservation approach for this patient population.

Background: Obesity rates are higher among rural versus urban adolescents. To examine possible mechanisms for the rural-urban adolescent obesity disparity, we examined the direct and indirect effects of food purchasing patterns, and the home, school, and consumer food environments on dietary intake among rural adolescents. Methods: A baseline survey was conducted among adolescents in eight rural high schools (four in Eastern Kentucky, and four in Eastern North Carolina). Participants answered questions about food purchasing patterns, dietary intake, home food availability, and demographics. The school and consumer food environments were assessed using validated measures from the School Meals Cost Study (United States Department of Agriculture-Mathematica) and the Nutrition Environment Measurement Survey for Stores, Restaurants, and Corner Stores. Results: Of 432 adolescents, 55% were normal weight, 24% were overweight, and 21% were obese. There was a direct association between unhealthy food purchasing patterns (shopping frequently at gas stations, fast food, and dollar stores) and consuming more added sugars, when compared to those with a healthy shopping pattern (shopping less frequently at gas stations, fast food, and dollar stores) [Odds Ratio = 2.41 (95% CI (confidence interval) 0.99, 3.82)]. Those who reported always having fruits and vegetables in the home consumed more servings of fruits and vegetables [OR = 0.31 cups (95% CI 0.22, 0.44)] compared to those who reported never having fruits and vegetables in the home. Adolescents attending a school with a low healthy food availability score consumed fewer servings of fruits and vegetables [−0.001 (95% CI −0.001, 0.0001)] compared to those attending a school with a high healthy food availability score. Conclusions: There are direct associations between food purchasing patterns, the home and school food environments, and dietary intake among rural adolescents. These cross-sectional results informed the development of the “Go Big and Bring it Home” program, a text messaging intervention to improve adolescents’ fruit, vegetable, and healthy beverage intake.

Aims: To describe co-occurring non-alcohol substance use in veterans with PTSD and alcohol use disorder (AUD) entering controlled trials of topiramate. Methods: Baseline psychological, alcohol and non-alcohol substance use (NASU) measures are reported for 77 veterans with comorbid AUD and PTSD entering trials of topiramate treatment. PTSD, anxiety, anddepression, aswell as smoking, non-alcohol substance use (NASU) and NASU disorder diagnoses (NASUDs) were calculated. Subjects with andwithout smoking or NASUwere compared on alcohol use, PTSD, depression, and anxiety severity. Results: Mean age was 50.4±12.6, 93.5% were male. 41.6% were Vietnam era and 23.4% were Iraq/Afghanistan veterans. All met criteria for DSM-IV alcohol dependence and PTSD. 58.4% had combat-related PTSD. Mean Clinician Administered PTSD Scale (CAPS) score was 77.9±17.2; mean Beck Depression and Anxiety scores were 22.2±12.3 and 24.4±11.5 respectively. During the past 90 days prior to screening, participants had on average 5.4 drinking days per week, 4.5 heavy drinking days per week and consumed 63.7 drinks per week and 12.9 drinks per drinking day. 57.1% were smokers and 41.6% reported NASU in the past 30 days: 36.4% cannabis, 16.9% cocaine, 5.2% amphetamines, and 3.9% opioids. Urine drug screens were positive for cannabis in 23.4%, cocaine in 6.5%, amphetamines in 3.9%, and opiates in 7.6%. 28.6% met SCID NASUD criteria. Compared to nonsmokers, smokers had more drinks per week (72.7 vs. 51.4, p= .048) and more drinks per drinking day (15.7 vs. 9.4, p= .011) in the past 90 days. Smokers did not have higher mean CAPS, BDI, or BAI scores than nonsmokers. Patients with NASU also had more drinks per week (74.1 vs. 53.5, p= .05); but not higher CAPS, BDI or BAI scores than those negative for NASU. Conclusions: Smoking and other non-alcohol substance use were related with higher amounts of alcohol use but not greater PTSD, depression and anxiety severity in veterans with PTSD and AUD entering pharmacotherapy clinical trials. Financial support: W81XWH-05-2-0094, W81XWH-11-20245, and W81XWH-12-2-0137.

Purpose/Objective(s) For patients with Borderline Resectable (BR) and Locally Advanced (LA) pancreatic adenocarcinoma, multi-fraction ablative stereotactic body radiotherapy (SBRT) by MRgRT provides a highly effective approach for locoregional therapy. Traditionally, the first post treatment scan is performed with multi-phase CT, but a multiparametric and multisequence MRI may offer a better approach to evaluate post-treatment response using a reproducible exam with functional imaging and quantifiable biomarkers. The objective of this study is to develop MR biomarkers to more accurately and reproducibly evaluate treatment response and to differentiate between post-treatment inflammatory response resulting in pseudoprogression from background post-treatment fibrosis and residual disease. Materials/Methods With institutional review board approval, patients with BR and LA pancreatic adenocarcinoma who were imaged with MRI 3-5 months following MRgRT with pre- and post-SBRT pancreas protocol CT scans were included. Primary endpoints were to assess for treatment response, to identify residual foci of disease, and to identify pseudoprogression caused by inflammation, fibroinflammatory change, post-treatment fibrosis, and necrotic change. A specific diagnostic MRI protocol was developed at our institution to evaluate for post treatment changes. Results Ten patients satisfied the above inclusion criteria. Employing a morphologic approach with traditional RECIST criteria, all patients demonstrated an increase in the size of the primary tumor between pre-treatment and post treatment CT scans (an average increase of 24 % +/- 13.4%). On MRI these post-treatments beds demonstrated functional imaging signs of response with an average apparent diffusion coefficient (ADC) above a threshold level of 1500 µm2/sec (average of 1993.9 µm2/sec +/- 437), consistent for necrotic change or cystic debris. Additionally, the normalized tumor contrast ratio measured below 0.5 (average of 0.194 +/- 0.13), consistent for no appreciable internal enhancement with kinetic profiles showing no rapid wash in or contrast persistence. Functional T2 map values were greater than 150 ms (average of 217 ms +/- 81.2), highlighting residual inflammation, while functional T1 map values were obscured by this same inflammatory signal (range, 1036 -3966 ms; average of 1930 +/- 1143). Conclusion Specialized post-SBRT multisequence MRI protocols with functional imaging detail pseudoprogression that is frequently characterized by CT as stable or worsening disease. These findings have important implications for assessment of post SBRT treatment response and further therapy options. Further data is needed to clarify the kinetics of response to determine the most appropriate post treatment imaging acquisition time point. Future validation with prospective post SBRT MRI imaging with specific sequencing protocols to assess response is warranted.