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Leptomeningeal metastasis (LM), also known as leptomeningeal carcinomatosis (LC), is a devastating complication of metastatic cancer that occurs when neoplastic cells invade the meningeal space. Diagnosis of LM remains challenging given the heterogeneous signs and symptoms at presentation and requires thorough neurological examination, cerebrospinal fluid (CSF) analysis, and MRI of the brain and spine with gadolinium. Detecting neoplastic cells in the CSF is the gold standard for diagnosing leptomeningeal metastases; however, it has low sensitivity and may require multiple CSF samples. New emerging technologies, such as liquid biopsy of CSF, have increased sensitivity and specificity for detecting circulating tumor cells in CSF. The management of LM in patients with NSCLC requires an individualized multidisciplinary approach. Treatment options include surgery for ventricular shunt placement, radiation therapy to bulky or symptomatic disease sites, systemic or intrathecal chemotherapy, molecularly targeted agents, and, more recently, immunotherapy. Targeting actionable mutations in LM from NSCLC, such as EGFR tyrosine kinase inhibitors or anaplastic lymphoma kinase gene rearrangement inhibitors, has shown encouraging results in terms of disease control and survival. Although there are limited data regarding the use of immunotherapy in LM, immunotherapy has produced promising results in several case reports. In this review, we focused on the epidemiology, pathophysiology, clinical presentation, diagnosis, and current treatment strategies, with a special emphasis on novel agents, including targeted therapies and immunotherapy of LM in patients with NSCLC.

Purpose: The azygos system of veins has many anatomical variations that can impact mediastinal and vascular interventions. While radiological reports on these are of great clinical value, this study is among the first to present a high-quality cadaveric dissection of a rare anatomical variant to supplement previously published radiologic studies. The azygos venous system consists of the azygos vein (AV), hemiazygos vein (HAV), and the accessory hemiazygos vein (AHAV), which develop from the last portion of the posterior cardinal veins. The normal anatomical configuration includes drainage of the posterior intercostal veins, vertebral vein, esophageal veins, HAV, and AHAV to an unpaired right-side AV at the level of the 8th/9th thoracic vertebra. Methods: An adult formalin-fixed 70-year-old female Caucasian cadaver was dissected as part of a medical gross anatomy elective course. Results: Gross documentation of a direct connection of the HAV to the AHAV with the AHAV draining into the left brachiocephalic vein. Conclusion: The reported incidence of AHAV draining directly into the left brachiocephalic vein is 1-2%. It is important to note the variations of the azygos system to avoid confusion with a potential pathology such as mediastinal masses. Understanding of the rare variant reported here could be useful in prevention of iatrogenic bleeding from misplacement of venous catheters and help facilitate radiological diagnosis in the incidence of venous clot formation.

A 68-year-old Caucasian man with a history of Waldenstrom macroglobulinemia (WM) on treatment with ibrutinib for 2 years presented with syncope. He had no prior cardiovascular history or risk factors. On the day of presentation, he had an episode of dizziness followed by a sudden loss of

Introduction Bortezomib is a proteasome inhibitor used in the treatment of multiple myeloma, Waldenström’s macroglobulinemia, mantle cell lymphoma. The most reported adverse effects include fatigue, thrombocytopenia, gastrointestinal symptoms, and peripheral neuropathy, which mostly manifests as sensory neuropathic symptoms. We present a case of a patient who experienced motor neuropathy after initiating treatment with bortezomib. Case report An 87-year-old male was diagnosed with multiple myeloma and started on treatment with bortezomib, dexamethasone, and lenalidomide (VRd). After five cycles of therapy, he developed lower extremity weakness, which was severely debilitating, affecting his ability to walk, and this prompted his visit to the emergency department. Management and outcome The patient was admitted for further workup and underwent electromyography, which was consistent with demyelinating polyneuropathy with active denervation. His symptoms were attributed to bortezomib, and his VRd regimen was held. His symptoms failed to improve despite discontinuation of bortezomib. He then received steroids and intravenous immunoglobulin (IViG) with a gradual resolution of his symptoms. He was thereafter restarted on only lenalidomide and dexamethasone with no recurrence of his neuropathy. Discussion Clinicians need to be aware of the likely risk for motor neuropathy associated with bortezomib. Risk factors like older age and pre-existing neuropathy can predispose patients to this adverse effect, and clinicians should monitor for this toxicity and facilitate dose reduction or discontinuation of therapy if warranted. Sometimes, patients may also need further treatment with steroids or IVIG.

Statin-associated myopathy comprises of a spectrum of conditions ranging from benign myalgias to statin-induced immune-mediated necrotizing myopathy. Statin-induced immune-mediated necrotizing myopathy is an autoimmune condition wherein there is a destruction of normal skeletal muscular architecture that can be severely debilitating if not recognized promptly. Given its rarity, management is a challenge. We present one such case that was managed with aggressive immunosuppression.

Spontaneous tumor lysis syndrome (TLS) is a rare condition in solid tumors, particularly in endometrial carcinoma. Spontaneous TLS occurs without the use of cytotoxic therapy but is observed particularly in hematologic malignancies. Given the high morbidity and mortality associated with spontaneous TLS, it is crucial to identify and treat it promptly. There have been only four cases of spontaneous TLS reported to date in the literature from a uterine source. We present a 59-year-old female with a recently diagnosed endometrial carcinoma with neuroendocrine features by dilation and curettage who presented to the hospital with somnolence, decreased oral intake, and lower abdominal pain of three days duration. She was found to have sepsis secondary to endometritis and spontaneous tumor lysis syndrome by clinical and laboratory definitions (hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia). Signs of disease progression were found such as worsening retroperitoneal lymphadenopathy that corresponded with the suspected increased tumoral activity. We report the case of a solid tumor (endometrial) presenting with spontaneous TLS, which highlights the importance of the early identification and initiation of treatment.

Talaromycosis is a fungal infection caused by Talaromyces sp. that is predominantly prevalent in patients with acquired immunodeficiency syndrome in the United States. It is also rarely seen in other individuals who are otherwise immunosuppressed. With the advent of immunotherapy and increasing usage of these novel agents in treating several conditions, the prevalence of talaromycosis may increase, especially in people from endemic regions who might harbor a dormant infection. Clinical presentation is non-specific with respiratory symptoms such as shortness of breath, cough, or even fever that can delay the diagnosis. Little is known about the exact pathogenesis of the condition, and management is largely based on anecdotal evidence and small-sized studies. We present the case of an individual on nintedanib, a tyrosine kinase inhibitor that blocks fibroblast growth factor receptor and used for the treatment of interstitial lung disease, who was diagnosed with talaromycosis.

Oxaliplatin, a platinum-based chemotherapy agent, is commonly used in the treatment of various malignancies. Common adverse effects involve neurological, hematological, gastrointestinal system, and hypersensitivity, and rarely ocular changes have also been reported. We describe the case of a 71-year-old male, who developed reversible ocular toxicity after receiving oxaliplatin for treatment for pancreatic cancer.

e18720 Background: There is a paucity of real-world data regarding rates of recurrent venous thromboembolism (VTE), major bleeding and all-cause mortality among ovarian cancer patients with thrombosis treated with direct oral anticoagulants (DOACs) currently available. We sought to evaluate the effectiveness and safety of rivaroxaban versus low molecular-weight heparin (LMWH) for cancer-associated thrombosis (CAT) treatment in patients with ovarian cancer. Methods: We utilized US Surveillance, Epidemiology and End Results-Medicare–linked data from 2013-2016 to identify adults with active ovarian cancer, undergoing hospitalization/emergency department admission for CAT and prescribed rivaroxaban or LMWH for outpatient anticoagulation. Rivaroxaban and LMWH cohorts were balanced using propensity score overlap weighting . Outcomes included the composite of recurrent thrombosis or major bleeding, each outcome separately and mortality at six-months using an intention-to-treat approach. On-treatment analysis after 12-months was also performed. Hazard ratios (HRs) with 95% confidence intervals using overlap weighted cox regression were reported. Results: We included 33 rivaroxaban and 92 LMWH-managed CAT patients. In each cohort, mean age was 73, 79.5% of patients were white, 46.9% had a history of ≥ stage 3 chronic kidney disease (CKD), two-thirds had metastatic disease at the time of VTE, and 32.6% had a prior VTE. Patients were diagnosed with ovarian cancer an average of 1.40 years prior to the index VTE event and 45.8% had a pulmonary embolism (with or without DVT) as the index event. Our analysis did not detect a significant difference in outcomes with rivaroxaban versus LMWH at six-months (Table). On-treatment analysis at 12-months showed similar results. Conclusions: Rivaroxaban may be a reasonable alternative to LMWH for CAT patients with ovarian cancer. Large observational studies are needed to confirm these results.[Table: see text]

e18748 Background: Prescribers use direct oral anticoagulants and low molecular-weight heparin (LMWH) for the acute treatment and secondary prevention of cancer-associated thrombosis (CAT). We sought to identify predictors impacting the use rivaroxaban versus LMWH for CAT in patients with ovarian cancer. Methods: Using US Surveillance, Epidemiology and End Result-Medicare linked data from 2013-2016, we evaluated adults with ovarian cancer, undergoing hospitalization/emergency department admission for CAT and prescribed rivaroxaban or LMWH for outpatient anticoagulation. Univariate analysis was performed to examine the association between covariates and clinicians’ choice to use rivaroxaban or LMWH. Variables with a p-value < 0.20 upon univariate analysis were deemed significant and subsequently included into a stepwise, backwards multivariable logistic regression model to obtain adjusted odd ratios (ORs) of treatment assignment. Results: Of the 125 ovarian cancer patients included in our analysis, 26% received rivaroxaban and 74% LMWH. All patients had stage 3 or 4 ovarian cancer, 36% were ≥75 years-of-age, 78% were white, and 18% were below the poverty line (p ≥ 0.25). Upon univariate analysis, rural community, time between cancer diagnosis and VTE ≥ 1 year, index VTE without evidence of pulmonary embolism, and CKD ≥ stage 3 were found to be significant predictors of rivaroxaban use when compared to LMWH (p ≤ 0.14 for all). Upon multivariable regression, CKD ≥ stage 3 (OR = 3.13) was shown to be independently associated with rivaroxaban versus LMWH use (p≤0.01). Conclusions: In routine practice, patients were more likely to receive rivaroxaban if they had CKD and lived in a rural area. These differences in prescribing practices may be due to less availability of LMWH in rural areas and less tolerance of injections in CKD patients. Univariate analysis also suggest that low VTE burden (i.e., DVT only) and VTE event ≥ 1 year after cancer diagnosis were also associated with rivaroxaban use over LMWH, which may be due to LMWH therapy as the long-established standard of care for patients with cancer. Large observational studies are needed to confirm these results. [Table: see text]

e18668 Background: Lung cancer is one of the leading causes of cancer-related morbidity and mortality. The 5-year survival rate is 19% but goes up to 57% if diagnosed at early stage. The recommendation for lung cancer screening is low-dose computed tomography (LDCT) for adults of age 55 to 80 years who have a 30 pack-year smoking history and are currently smoking or have quit in the past 15 years. Unfortunately, less than 5% of eligible patients undergo LDCT. Methods: A retrospective chart review was done for patients with any smoking history, who had internal medicine residents as their primary care provider. The data collected included baseline characteristics and the rates of LDCT scan being ordered and completed. Results: 706 medical charts were reviewed. 178 patients (25.2%) qualified for LDCT screening. The average age of patients included was 64.41 years and average BMI was 28.8 kg/m2. 48.3% were female and 51.6% were male. 54% were current smokers and 46% were former smokers. The ethnic/racial distribution was as follows: 19% African American, 36.5% Hispanic,16.2% Caucasian and 27.5% belonging to other groups. The primary insurance was as follows: 48.8% Medicaid, 19.6% Medicare, 25.8% private insurance and 5% were uninsured. 95 patients (53.3%) had a LDCT scan ordered and 73/95 (76.8%) completed the LDCT scan. The rate of compliance among patients based on their race/ethnicity and primary insurance is detailed in the table. Only 30% of the patients initially screened had a follow up LDCT ordered in one year. Conclusions: Low screening rate LDCT may be due to new residents not prioritizing preventative care. Patients at this clinic belong to a lower socioeconomic class with limited resources. There may be barriers to completion of the ordered test, like poor health literacy, scheduling issues, transportation, fear of being diagnosed with cancer and poor understanding of preventative health. Residents need to be educated about the importance of lung cancer screening as early detection translates into better outcomes and lower mortality. Patients need to be informed of the benefit of screening to improve compliance rate. Assessing the barriers these patients face to completing the screening test should also be carefully evaluated to better identify areas of improvement.[Table: see text]

Non-small cell lung carcinoma (NSCLC) is a leading cause of cancer-related death, and some patients can present with advanced metastatic disease mostly involving the brain, bones, liver, or adrenal glands. Eye is an extremely rare site of metastasis. We present a case of a patient with NSCLC with rare vitreal metastasis. A 70-year-old female was admitted to the hospital with hypertensive crisis and on further imaging, was found to have a 4.5 cm spiculated nodule in the upper lobe of the right lung. Outpatient bronchoscopy and biopsy confirmed lung adenocarcinoma and she underwent right upper lobe wedge resection and mediastinal lymph node dissection. The surgical staging for the cancer was pT1a pN0, placing her in stage IA. The cells from the tumor were positive for epidermal growth factor receptor (EGFR) mutations: G719X and S768I. Unfortunately, six months later, she started to experience decreased visual acuity and floaters. Vitrectomy was done, and cytology showed atypical cells concerning for malignancy. These malignant cells were also positive for the same mutations as the lung adenocarcinoma. She was then treated with EGFR inhibitor afatinib to prevent relapse. She currently remains asymptomatic.

245 Background: Despite low-dose computed tomography (LDCT) screening for lung cancer recommended by the United States Preventive Services Task Force (USPSTF) demonstrating a relative reduction in mortality, there remains low rates of testing nationwide. Yet studies are limited regarding specific differences in screening rates amongst various outpatient care settings. Methods: We performed retrospective chart reviews of patients followed by resident providers within an academic internal medicine residency program who met USPSTF guidelines for lung cancer screening between 2015-2020. This was conducted at three separate outpatient clinic sites including a state-funded academic institution, inner city community health center, and veteran affairs medical center. Data collection included patient demographic and smoking histories as well as rates of ordered and completed LDCT screening. Results: A total of 832 patients were identified as current or former smokers between the ages of 55 and 80 years: 320 from Hartford Hospital Community Health Center (HHCHC), 262 from University of Connecticut Health Center (UCHC), and 250 from the Veteran Affairs (VA) Medical Center. 85 (27%) of these patients from HHCHC, 84 (32%) from UCHC, and 56 (22%) from the VA met USPSTF eligibility criteria for LDCT screening. Overall compliance rates of screening were found to be 44% at HHCHC, 59.5% at UCHC, and 51.8% at the VA. Results are outlined in Table. Conclusions: Screening rates for lung cancer with LDCT remain low but have been steadily improving throughout the United States following new recommendations and increased awareness provided by multiple medical organizations. We sought to compare differences in compliance rates amongst various outpatient clinics within the same internal medicine residency program at University of Connecticut. Our findings demonstrate significant differences in LDCT screening for lung cancer between the program’s community health center versus its state and federally funded outpatient clinics. Automatic reminders to providers can potentially improve rates of lung cancer screening. Patients should also be educated about the importance of screening to improve adherence with imaging. [Table: see text]

Ebstein's anomaly (EA) accounts for 1% of congenital heart disease and is characterized by failure of tricuspid valve (TV) delamination, highly variable TV morphology and right ventricle (RV) myopathy. The heart's conduction system can be affected in EA, with issues ranging from first-degree AV