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Sickle trait (Hb SA) or sickle disease (Hb SS) carries increased risk of venous thromboembolism (VTE). Hb SS patients are young and lack common comorbid conditions that qualify them for VTE prophylaxis (VTEP).Retrospective, multicenter analysis of Hb SS/Hb SA adult patients between January 2013 and December 2018.There were 803 Hb SA (525 patients) and 1020 Hb SS admissions (262 patients). VTEP use was similar between Hb SA and controls (42% vs. 46%; p-value = .06) and Hb SS and controls (45% vs. 42%; p-value = .13). Hb SS/Hb SA patients more frequently received more than half of prescribed doses of VTEP. In multivariate analysis, increasing age and longer hospitalizations were positive predictors. Odds of VTEP use varied with treatment site for Hb SS patients, whereas comorbid conditions, admission hemoglobin and platelet count were not predictive. By contrast, in Hb SA patients, comorbid conditions, higher admission hemoglobin, and higher admission platelet counts raised the odds of VTEP being offered.VTEP is underused in Hb SS/Hb SA patients. There may be a trend toward offering more VTEP in Hb SS disease, but not in Hb SA patients, where VTEP prescribing is driven by comorbid conditions rather than genotype. Patient compliance does not appear to play a major role, but intercenter variability suggests provider education may improve VTEP use.

Recognition of the adverse events of inferior vena cava filters (VCFs) has prompted the Food and Drug Administration (FDA) to issue safety warnings (2010 and 2014), advocating for removal, once the risk of pulmonary embolism has abated. Despite an initial increase in retrieval rates, these remain low (25–30% at 1 year in 2014). We retrospectively investigated retrieval trends in adults with VCFs placed between 2015 and 2018 at a single institution. The rate of retrievable VCF removal accounting for the competing risk of death was the main outcome. There were 494 VCFs placed (305 retrievable). The cumulative incidence of retrieval remained low (21% at 1 year), even after the second FDA warning (2014). Patients who resumed anticoagulation (AC) at any time were more likely to have retrieval (hazard ratio [HR] = 3.6, p

Background: Male breast cancer is rare accounting for less than 0.5% of all cancer diagnoses in men. Previous epidemiological studies reported conflicting results regarding the prognosis of male breast cancer in comparison to female breast cancer. As treatment for breast cancer has improved significantly, we conducted this study to evaluate male breast cancer characteristics and mortality. Methods: All patients diagnosed with breast cancer between 2010 and 2015 from the population-based cancer registries of the Surveillance Epidemiology and End Results program (SEER) were analyzed. Descriptive statistics, Kaplan-Meier analysis and COX regression model were used to examine the data. Results: A total of 380,116 cases of breast cancer were found including 2,978 cases of male breast cancer. The age-adjusted incidence rate for male breast cancer during the study period was 1.2 per 100,000 individuals per year which is slightly higher than the rate during the 10 years period preceding our study date (1.1 per 100,000 per year). Out of all male breast cancer patients, 80.7% of them were white, 14.6% black and 4.7% from other races. The median age of diagnosis was 68. 34% of male breast cancer patients were diagnosed with stage I, 41.6% with stage II, 16.2% with stage III and 8.2% with stage IV. 97% of male breast cancer cases were ER/PR positive and 11.9% were HER2 positive. 5-year survival rate for male breast cancer patients was 90% for stage I, 86% for stage II, 78% for stage III and 28% for stage IV. Cox proportional-hazards model revealed a slight increase in mortality associated with male breast cancer in comparison to female breast cancer (adjusted hazard ratio, 1.15; 95% confidence interval, 1.06 to 1.24; P Conclusions: Male breast cancer represents less than 1% of breast cancer cases. Its age-adjusted incidence rate has slightly increased. It is mostly diagnosed as early stage with positive hormone receptors status. After controlling for other risk factors, male breast cancer patients have a worse survival outcome than female patients. Citation Format: John Khoury, Nwabundo Anusim, David Macari, Ishmael Jaiyesimi. Demographics and survival in male breast cancer: An updated analysis of SEER database [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-17-07.

Background: Inflammatory breast cancer (IBC) is a rare and aggressive malignancy, distinguished by characteristic skin changes with/without breast mass. While new therapies have improved the survival of IBC, the prognosis of metastatic disease (stage IV) remains poorly described. The current analysis is aimed at investigating the demographics of metastatic IBC and the impact of chemotherapy use and tumor subtype on survival. Methods: Using ICD-O-3 histology code 8530/3 in the Surveillance Epidemiology and End Results database (SEER), demographics and survival data on metastatic IBC diagnosed between 2010 and 2015 were abstracted. JMP 14 statistical software was used for data analysis. The SEER database does not record specific age above 85 years and these cases were excluded. Results: Over five years, 378 patients were diagnosed with metastatic IBC. All were women and most were Caucasian (282, 75%). Mean age was 60±14 years. During the observation period 284 (75%) patients died and of which 218 deaths were attributable to IBC. Cancer subtype was unknown in 61 patients; for the rest, Luminal A was the most common (121, 38%), followed by triple negative (74, 23%), HER2 enriched (62, 20%) and luminal B (60, 19%). Median overall survival (OS) was 18 months (95% CI 14-20), with a survival rate of 39% at 24 months from diagnosis. In unadjusted analyses, patients receiving chemotherapy (n=191) had increased survival at every time point compared to those who did not (n=93), (median OS 22 (95% CI 18-26) vs 5 months (95% CI 2-11), p Conclusion: From our data, IBC is common in Caucasian women in their 7th decade of life. Luminal B was the least common cancer subtype and had the best overall survival. Chemotherapy appears to play an important part in increasing survival; but ethnicity and tumor subtype are also important predictors of mortality. Keywords: Inflammatory breast cancer, Metastatic, Survival, Demographics Citation Format: Nwabundo Anusim, Filip Ionescu, John Khoury, Anish Konde, Ishmael Jaiyesimi. Demographics and survival in metastatic inflammatory breast cancer. SEER data analysis [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-15-05.

Nuclear carcinoma of the testis (NUT) midline carcinoma are rare, poorly differentiated tumors resulting from t(15; 19) rearrangement, clinically characterized by aggressive and rapid progression to death. No optimal treatment regimen has been established for this rare malignancy. Surgery, chemotherapy, and radiation have been used for treatment alone or in combination, depending on location and staging of the disease, and may confer short periods of remission; however, re-emergence of the disease inevitably occurs. Targeted therapies such as bromodomain and extra-terminal domain protein (BET) inhibitors are currently in early phases of clinical trials. Here we describe a 49-year-old-male with no comorbidities who presented with acute worsening of chronic cough, new onset hemoptysis and left sided chest pain for 2 weeks. Workup revealed stage IIIB NUT midline carcinoma (NMC) of the lung with next-generation sequencing confirming the presence of a NUTM1-BRD4 fusion. The tumor was unresectable, and he began concurrent chemoradiation with weekly carboplatin and paclitaxel for 5 weeks. The follow-up CT scan showed partial response, so maintenance was continued with durvalumab. Two months later, he presented with metastasis to the posterior muscle compartment of the left arm, which was treated with local radiotherapy. Four months later he developed progression of lung disease with multiple pulmonary nodules. Durvalumab was discontinued and he was prescribed the BET inhibitor molibresib, 120 mg daily. After nearly 3 months of treatment with molibresib, he presented with brain metastasis for which he had a craniotomy with tumor resection and gamma knife radiation to solitary metastatic lesions. He was then prescribed chemo-immunotherapy with carboplatin plus pemetrexed and pembrolizumab. After two cycles of treatment his disease progressed, and he succumbed to it. Total survival was 18 months. In conclusion, NUT midline lung carcinoma is a rare but aggressive malignancy and patients have limited treatment options especially in advanced stages. Few targeted therapies have shown promising results in early clinical trials but more treatment options are awaited.

We present a case of a woman in her early 60s with multiple myeloma who, while undergoing treatment with cyclophosphamide, bortezomib and dexamethasone (CyBorD), noticed a whitish nodular swelling on the eyelid. This occurred after one cycle of CyBorD and on subsequent treatment, it also involved the contralateral eyelid. The lesions were initially managed with conservative measures by applying warm compresses, but the lesions progressively increased in size. CyBorD was discontinued and topical antibiotics and anti-inflammatories were initiated, resulting in a decrease in size of the lesions. On resolution of symptoms, she was rechallenged with CyBorD, and symptoms did not recur. The temporal relationship between bortezomib and the development of chalazion is based on connection and no association has been proven.

Plasma cell leukemia is rare and could be life-threatening. Even rarer and equally life-threatening is cryoglobulinemia. Both of them occurring together paints a grim clinical picture. We present the case of a 63-year-old male with plasma cell leukemia complicated by cryoglobulinemia with skin lesions. The report briefly reviews the clinical and diagnostic characteristics of plasma cell leukemia and well as available treatment options. It also highlights the need to consider non-chemotherapy-based regimens and clinical trials in the care of plasma cell leukemia patients.

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition of uncontrolled immune activation as a result of an inherited genetic defect or in response to malignancy, autoimmune disease, rheumatological disease, AIDS infection or post-transplant immunosuppression. Described here is the case of a 19-year-old Caucasian man who presented with complaints of worsening fever, new-onset jaundice and lethargy after failing treatment for suspected infectious mononucleosis. Physical examination was significant for fever and splenomegaly while laboratory results revealed transaminitis, cytopaenia, indirect hyperbilirubinaemia and elevated ferritin, raising the likelihood of both autoimmune haemolytic anaemia and HLH. He tested positive for Epstein-Barr virus (EBV), and bone marrow biopsy revealed hypercellular marrow with haemophagocytosis and no evidence of malignancy. High dose steroids were initiated with significant improvement in haemoglobin, resulting in a final diagnosis of HLH secondary to acute EBV infection. The patient was discharged on continued high-dose prednisone with planned taper and consideration of outpatient rituximab therapy for 4 weeks. High clinical suspicion and prompt evaluation were critical to early treatment and decreased morbidity.

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. While patients with COVID-19 most frequently present with pneumonia, respiratory failure and acute respiratory distress syndrome, increasing cases of immune-mediated disorders such as autoimmune thrombocytopenia, haemolytic anaemia and antiphospholipid syndrome have been reported. In this article we describe a rare case of cold agglutinin syndrome (CAS) in a patient with COVID-19. The patient was a 77-year-old man with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented with COVID-19 infection and acute respiratory failure. Initially he was started on intravenous steroids, antibiotics and hydroxychloroquine. Laboratory analysis revealed haemolytic anaemia with a positive direct anti-globulin test (DAT) and high titres of cold agglutinins. Hydroxychloroquine was stopped due to suspicion of haemolysis due to G6PD deficiency but the haemolysis persisted. Unfortunately, the respiratory failure progressed and the patient died. In summary, this article describes a rare case of CAS associated with COVID-19. CAS is a heterogenous group of cold autoimmune haemolytic anaemias occurring secondary to infections or malignancies. No definite treatment for CAS in COVID-19 patients has been approved so far. LEARNING POINTS Autoimmune haemolytic anaemia has been reported in COVID-19 patients. Cold agglutinin syndrome (CAS) can occur in patients with COVID-19. Efforts to determine the optimal management of CAS in COVID-19 patients must continue. Keywords: Coronavirus disease 2019, cold agglutinin syndrome, case report, autoimmune hemolytic anemia INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel enveloped RNA betacoronavirus that emerged in December 2019 in Wuhan, China and rapidly spread worldwide [1]. This virus is responsible for causing a multi-system disorder called coronavirus disease 2019 (COVID-19) syndrome. It has now been established that the hyperinflammatory response induced by SARS-CoV-2 causing fulminant and fatal cytokine release is a major cause of disease severity and death in infected patients [2,3]. While hypercoagulability [4], autoimmune cytopenias[5] and anti-phospholipid antibody syndrome[4] have emerged as the most common haematological disorders in COVID-19 patients, 14 cases of autoimmune haemolytic anaemiahave also been reported [6–12]. Individuals with autoimmune haemolytic anaemiaproduce warm, coldor mixed-reactive antibodiesthat are directed against antigens on the surface of red blood cells (RBCs) [13].Cold antibody autoimmune haemolytic anaemias can be further divided into cold agglutinin disease (CAD), which is primarily a low-grade clonal lymphoproliferative disorder, and cold agglutinin syndrome (CAS), which is a rare heterogenous group of cold immune haemolytic anaemias that occur secondary to infection or malignancy [14]. Here, we report a case of acute CAS associated with SARS-CoV-2.

Background: Lung cancer is one of the leading causes of cancer mortality in the US. The use of precision medicine in the past 10 years has significantly changed the therapeutic landscape of lung cancer. Management of advanced non-small cell lung cancer (NSCLC) has transitioned from a chemotherapeutic approach to targeted treatments and immunotherapeutic agents. Several tyrosine kinase inhibitors (TKIs) have been approved for patients with targeted mutations while patients who do not have driver mutations; immunotherapy has been recently approved as frontline therapy, which has resulted in marked improvement in overall survival and added a new tool in our armamentarium. Aims: The purpose of this review is to highlight recent advancements in diagnostic approach and management strategies in patients with metastatic NSCLC. Materials and methods: Published studies included in Medline (via PubMed) and National Comprehensive Cancer Network Guidelines were reviewed for data gathering. Conclusion: The use of next generation sequencing has significantly changed our understanding of molecular oncogenic mechanisms of lung cancer. These advancements have created a paradigm shift in the treatment strategies of metastatic lung cancer from primarily chemotherapeutic approach to increasing use of targeted therapies and immune check point inhibitors (ICI) leading to better survival rates and lesser toxicity.

Background Lung cancer is one of the leading causes of cancer mortality in the United States. The use of precision medicine in the past 10 years has significantly changed the therapeutic landscape of lung cancer. Management of advanced nonsmall cell lung cancer (NSCLC) has transitioned from a chemotherapeutic approach to targeted treatments and immunotherapeutic agents. Several tyrosine kinase inhibitors (TKIs) have been approved for patients with targeted mutations and patients who do not have driver mutations; immunotherapy has been recently approved as frontline therapy, which has resulted in marked improvement in overall survival and added a new tool in our armamentarium. Aims The purpose of this review is to highlight recent advancements in diagnostic approach and management strategies in patients with metastatic NSCLC. Materials and methods A literature search was conducted on Medline (via PubMed) and National Comprehensive Cancer Network Guidelines using the keywords "precision diagnosis," "advanced non-small cell lung cancer," "target therapies," and "immunotherapy." Conclusion The use of next-generation sequencing has significantly changed our understanding of molecular oncogenic mechanisms of lung cancer. These advancements have created a paradigm shift in the treatment strategies of metastatic lung cancer from primarily chemotherapeutic approach to increasing use of targeted therapies and immune checkpoint inhibitors (ICI) leading to better survival rates and lesser toxicity.

Background Sickle cell disease (SCD) is an inherited disorder of red blood cell (RBC) caused by a mutation in the beta-globin gene resulting in abnormal hemoglobin known as hemoglobin S (HbS) or the sickle hemoglobin. Several clinical variants of SCD have been elucidated, all driven by two fundamental pathophysiologic processes: RBC hemolysis and intermittent vaso-occlusive vasculopathy resulting in tissue ischemia/infarction. These two processes underscore the many complications and eventual multi-organ damage that may develop in patients with the most severe types of SCD. Cardiopulmonary complications including heart failure, pulmonary hypertension and acute chest syndrome (ACS) are major drivers of morbidity and mortality among patients with SCD. With regards to ACS, patients often present with fever, cough and shortness of breath caused by vaso-occlusive crisis affecting the lungs. This is particular concerning in view of its similar features to symptomatic COVID-19 infection. Methods We retrospectively identified SCD patients with COVID-19 infection admitted to Beaumont hospitals in Michigan between March 1st 2020 and July 1st 2020. Data was abstracted using the ICD 10 code of U07. 1 for COVID-19, ICD 9 and 10 codes of 282.60 and D57 for sickle cell disease. We excluded patients with sickle cell trait. Data regarding the demographics, presentation, management and outcomes were abstracted. Results A total of eleven patients with sickle cell disease were identified as having a positive SARS-Cov19 polymerase chain reaction test (Table I). All were African American and predominantly female (64%) with a mean age of 44 (22-60) years and mean BMI of 30.2 kg/m2. Genotypes identified were HbSS in 5 (45%) patients, HbSC in 4 (36%), HbS/beta-thalassemia in 1 (9%) and HbS/alpha-thalassemia in 1 (9%). All of the patients had seen a haematologist since their diagnosis but none of the patients were on hydroxyurea, voxeloter, L-glutamine or crizanlizumab at admission. The predominant clinical presentation was fever, chest pain, chills, exertional shortness of breath and cough but this was not consistent across all patients. All the patients were managed with intravenous hydration, pain management as well as hydroxychloroquine/azithromycin per institutional guideline at that time. Three patients (cases 1-3) had recurrent visits to the hospital for similar symptoms and new bone pain crises. Case 1 had a pulmonary embolus which was evident on re-admission. Two patients (cases 3 and 10) succumbed to COVID-19. Two patients (cases 5 and 7) presented with bone pain crisis and no respiratory symptoms, but chest imaging was suggestive of COVID-19 infection necessitating treatment with antibiotics, possibly indicating that the virus can trigger vaso-occlusive crises without respiratory symptoms. Case 8 had a high Charlson comorbidity index and age over 60, had the lengthiest hospital stay complicated by renal failure and polyneuropathy, and was discharged to a long-term acute care facility: an outcome which is consistent with current data showing that the elderly and unfit patients are more likely to have a higher morbidity and mortality with COVID-19. Conclusion To date, there no compelling evidence to provide guidelines for the management of SCD patients with COVID-19. However, following existing recommendations in managing acute chest syndrome and those for COVID-19 symptomatic infection, is a good place to start. We continue to seek to improve management of these patients as new evidence of successful treatment emerges, and also encourage patients to participate in clinical trials. Disclosures No relevant conflicts of interest to declare.

A 28-year-old primigravida was evaluated for complaints of difficulty urinating and pelvic pain of 6-weeks duration. She denied fever, night sweats, weight loss or fatigue. Pelvic ultrasonography revealed a single fetal pole with cardiac activity and a 7 cm mass in the anterior vagina which encased the urethra. The diagnosis of diffuse large B-cell lymphoma germinal centre type was made on analysis of biopsied pelvic mass. Whole body MRI revealed the disease was limited to the vagina. The patient received six cycles of Rituximab-cyclophosphamide, doxorubicin, vincristine and prednisone with significant improvement in her symptoms. Serial ultrasounds over the subsequent months showed appropriate development of the fetus. Whole body MRI after treatment showed decreased size and decreased signal of the primary pelvic mass compatible with favourable treatment response. Challenges in the management of this rare presentation of lymphoma are discussed.

Introduction: The presence of hetero- (sickle trait) or homozygous (sickle disease) hemoglobin S gene is associated with increased risk of venous thromboembolism (VTE). However, sickle disease patients in particular are relatively young, lack common comorbid conditions that would qualify them for inpatient VTE prophylaxis (VTEP) and there are limited published data on trends of VTEP use in these populations. Methods: This was a retrospective analysis of all hospitalizations of sickle trait or disease adult medical patients occurring between January 2013 and December 2018 at three hospitals in Southeast Michigan, USA. Admissions for bleeding or thrombosis, requirement of intensive care stay or surgery, those occurring within 45 days of orthopedic surgery, as well as all patients already on anticoagulation or with known hypercoagulable states were excluded. Hospitalized controls were matched for race, age, sex and length of stay. Trends of VTEP use and predictive patient factors over multiple admissions were modeled using generalized estimating equations. Results: There were 803 sickle trait (525 patients; mean age 43 ± 19; 85% female) and 1020 sickle disease admissions (262 patients; mean age 34 ± 13; 57% female); all patients were Black. The percentage of hospitalizations in which subjects were offered any VTEP was similar to that of controls in both groups of interest (Figure); however, there were more encounters in which patients received greater than 50% of expected VTEP doses in the sickle trait (80% vs 51%; p Conclusions: VTEP is underused in sickle trait and disease patients. There may be a trend towards offering more VTEP in sickle disease, but not in sickle trait, where the decision is driven by comorbid conditions rather than hemoglobin genotype. Patient refusal does not appear to play a major role, but the finding of significant inter-center variability suggests provider education may result in improved use as hemoglobin genotype is currently not part of risk stratification tools that help clinicians decide on inpatient VTEP. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: Hypercoagulability may contribute to COVID-19 pathogenicity. Evidence comparing clinical outcomes among patients with COVID-19 receiving therapeutic compared to prophylactic dose anticoagulation is limited. We evaluated whether therapeutic anticoagulation (tAC) is associated with improved survival compared to prophylactic (pAC) and no anticoagulation (AC) in hospitalized COVID-19 patients. Methods: This was a retrospective, multi-center cohort study of consecutive COVID-19 patients admitted between March 13th, 2020 and May 5th, 2020 to eight hospitals within a large academic system in Southeast Michigan, USA. Participants were assigned to three groups based on whether they received no AC, pAC throughout most of their hospitalization, or at least 3 days of tAC. Major bleeding was defined as transfusion of five or more units of packed red blood cells within 48 hours regardless of hemoglobin level, hemoglobin < 7g/dL and any red blood cell transfusion or a diagnosis code for major bleeding during the hospitalization or radiological evidence of intracranial hemorrhage Results: A total of 3480 patients were included (mean age, 64.5 years [17.0]; 51.5% female; 52.1% black and 40.6% white). 18.5% (n=642) were treated in the intensive care unit (ICU). 60.9% received pAC (n=2121), 28.7% received at least 3 days of tAC (n=998), and 10.4% (n=361) did not receive AC. Propensity score (PS) weighted Kaplan-Meier plot demonstrated a statistical difference in the 25-day survival probability in the tAC group compared to the pAC group (57.5% vs 50.7%, Figure). In a PS weighted multivariate proportional hazards model adjusting for age, body mass index and ICU status, AC was associated with a reduced risk of death at both prophylactic (hazard ratio [HR] 0.35 [95% confidence interval {CI} 0.22-0.54]) and therapeutic doses (HR 0.14 [95% CI 0.05-0.23]) compared to no AC. Major bleeding occurred more frequently among tAC patients (81 [8.1%]) compared to those who received no AC (20 [5.5%]) or pAC (46 [2.2%]). Conclusions : Higher doses of AC are associated with lower mortality in hospitalized COVID-19 patients. The lowest hazard ratio was observed in ICU patients, but risk was also significantly lower in non-ICU hospitalized patients. Bleeding occurred more frequently with higher doses of anticoagulation. Ongoing randomized trials are warranted to prospectively evaluate efficacy and risk of tAC in patients with COVID-19. Figure Disclosures No relevant conflicts of interest to declare.

Introduction COVID-19 in patients with hematologic malignancies are poorly characterized. Theoretically, it is believed that patients with malignancies having a significant chance of succumbing to COVID-19 due to the immunosuppression from the disease and myelosuppression from the cancer therapy compared to their counterparts without malignancies. However, there is scant evidence to support this claim. Here we analyze the outcomes of patients with hematologic malignancies and COVID-19. Methods This is a retrospective review of all patients with hematologic malignancies with confirmed COVID-19 admitted to any one of the Beaumont hospitals in Michigan between March 1st,2020 and July 1st ,2020. Data regarding the demographics, cancer diagnosis and management, covid-19 management and outcomes were abstracted. Results A total of 32 patients with hematologic malignancies were identified. Of these 32 patients, five patients also had solid malignancies. Median age was 70.5 years (22-91 years) with patients being predominantly female 18 (56 %) and Caucasians 16 (50%). Median BMI was 26.5 kg/m2 (15-79 kg/m2). The most prevalent hematologic malignancies were Chronic/Small Lymphocytic lymphoma 7(25%) and Multiple Myeloma 6(19%). The median length of stay in the hospital was 9 days (2-61days). Twelve patients were on active therapy prior to COVID-19 diagnosis. Therapies administered include radiation, surgery, anti-CD30 antibody drug conjugate, immunomodulatory agents, proteasome inhibitors, Bruton tyrosine kinase inhibitors, steroids and chemotherapy. These agents were held at the time of diagnosis of COVID-19 Twenty two patients (69%) patients received a combination of hydroxychloroquine and azithromycin which were standard of care at that time. A total of 31 (97%) patients were on anticoagulation of which 14 (45%) were on therapeutic doses while 17 (55%) were on prophylactic dose. Four (13%) of the patients were admitted in the ICU. A total of 6 deaths were reported and the median age was 83 years (66-91 years). Four deaths were attributed to COVID-19. Two non-COVID-19 deaths were as a result of aspiration pneumonia and hospital acquired pneumonia. Only one patient with COVID-19 received treatment for malignancy (surgical cytoreduction) but succumbed to COVID-19 four days later. All patients who died received a combination of hydroxychloroquine and azithromycin. Conclusion Our study, though limited by sample size, shows that about a third of patients received treatment for their hematologic malignancies around the time of COVID-19 diagnosis and only one death was reported. Patients are currently being advised to participate in clinical trials to better evaluate outcomes while on treatment for hematologic malignancies. Disclosures No relevant conflicts of interest to declare.

A female aged 84 years with a history of Clostridium difficile-associated diarrhoea presented from an extended care facility with altered mental status and respiratory distress. She was haemodynamically unstable and initial laboratory results revealed hyperleucocytosis (110.3×109/L). The presence of immature myeloid precursors, thrombocytopenia and respiratory distress, raised concern for an acute leukaemic process requiring emergent leucapheresis. However, on evaluation of the peripheral smear, prominent left shift and toxic granulation were noted, along with absence of blast cells. Considering her history of C. difficile infection, a CT scan of the abdomen and pelvis was obtained, which was suggestive of toxic megacolon. She was taken to the operating room for emergent colectomy. The pathology specimen showed pseudomembrane formation consistent with fulminant C. difficile infection. She was treated with oral vancomycin and intravenous metronidazole, followed by clinical improvement and resolution of leucocytosis and thrombocytopenia.

Indolent lymphomas may transform into intermediate or high-grade lymphoma, a diagnosis that is usually made reached by tissue biopsy, with unfavorable prognosis. A retrospective study was performed of the clinical characteristics, treatment patterns and outcomes of 73 patients with histologic transformed lymphoma originating as follicular lymphoma (FL), chronic lymphocytic leukemia/small cell leukemia (CLL/SCL), marginal zone lymphoma (MZL), lymphoplasmacytic lymphoma (LPL), or low grade B cell lymphoma not otherwise specified (NOS). The median time to transformation was 55 months (range 1-258) and Diffuse Large B Cell Lymphoma (DLBCL) constituted the majority of HTL diagnosis diagnoses. There was a statistically significant longer time to the development of HTL in patients with CLL and LPL compared to other indolent lymphoma types (FL, MZL and low-grade B cell lymphoma NOS); however, overall survival (OS) at histologic transformation was similar regardless of the indolent lymphoma type preceding HTL. Treatment with Rituximab-containing regimens have increased overall survival in HTL compared with the pre-rituximab era. In the 63 treated cases of HTL, PET showed complete remission (CR) in the majority of patients (55%) with 15% achieving partial remission (PR) and 15% having progressive disease (PD). OS at two years was approximately 60%, and 41% of patients remained alive at 5 years. Univariate analysis identified that treatment with RCHOP conferred better OS when compared to regimens with less or greater intensity than RCHOP, p=0.001. Multivariate analysis confirmed that achievement of CR and LDH level within the normal range statistically predicted better OS. On-going clinical trials may suggest novel therapeutics and provide for more evidence-based management of HTL.

Renal cell carcinoma (RCC) has unusual presentation affecting elderly males with a smoking history. The incidence of RCC varies while the incidence of spread of RCC to the clivus is rare. The typicality of RCC presentation includes hematuria, flank pain, and a palpable flank mass; however, RCC can also present with clival metastasis. The unique path of the abducens nerve in the clivus makes it susceptible to damage in metastasis. We report a case of a 54-year-old African American female that was evaluated for back pain, weakness, numbness, and tingling of bilateral lower extremities and subsequently disconjugate gaze and diplopia. Brain MRI confirmed metastasis to the clivus. She was started on radiotherapy and was planned for chemotherapy and transfer to a nursing home. When a patient presents with sudden unusual cranial nerve pathology, the possibility of metastatic RCC should be sought.

e17101 Background: Renal cell carcinoma (RCC) with sarcomatoid differentiation is a highly aggressive form of RCC. The presence of even a small component of sRCC was shown to independently predict poor survival compared to RCC without sarcomatoid features. We studied the epidemiology and survival outcome of sRCC compared to ccRCC by reviewing the SEER data. Methods: Patients (pts) with histologically confirmed sRCC and ccRCC between 2012-2015 were reviewed in SEER database. Variables included age, gender, ethnicity, histologic grade, stage at diagnosis, and nephrectomy. Primary outcome was 5 year Disease Specific Survival (DSS). Data was analyzed using Kaplan Meier curves and Cox proportional hazards model. Results: A total of 31, 293 pts with RCC were identified in SEER database between 2012 to 2015. 611 pts had sRCC while 30, 682 had ccRCC. The two groups had almost similar demographic features, including mean age (63 ±12 for sRCC vs 61±12 years for ccRCC), male: female ratio (vs 2.3:1 vs 1.7:1) and Caucasian ethnicity (82% vs 85%). More than half of sRCC patients (62%) were metastatic at diagnosis compared to only 11% of ccRCC, which presented most commonly as stage I disease (63%). The histologic grade was higher in sRCC patients (43% grade 4 vs 45% grade 2 in ccRCC subjects). Nephrectomy rates were almost similar for stages I-III in the two groups (94% in sRCC vs 93% in ccRCC) while lower in stage IV sRCC (44% vs 54%). Across all stages and at every time point, sRCC was associated with increased mortality in the univariate analysis. In the multivariate regression analysis (table), advanced stage was the strongest independent predictor of mortality (HR 11.9), followed by high histologic grade (HR 3.6) and sarcomatoid histology (HR 2.9). Nephrectomy was protective (HR 0.3). Age was associated with worse outcomes (HR 1.016 per unit change). Conclusions: sRCC are more aggressive and tend to present as metastatic disease. sRCC has worse outcomes across all stages compared to ccRCC even after adjusting for potential confounders. Advanced stage and histologic grade remain the two strongest predictors of disease-specific mortality, sarcomatoid histology demonstrated a significant impact on outcome. [Table: see text]

Background: Heparin-induced thrombocytopenia (HIT) occurs as a result of autoantibodies to the platelet factor 4 (PF4)-heparin complex, which activate the coagulation cascade with subsequent thrombosis. HIT can be fatal if not diagnosed and treated promptly with replacement of all heparin with non-heparin anticoagulants. Classic options are parenteral direct anti-thrombin agents which require intravenous administration and can prolong hospital stay. Direct oral anticoagulants (DOACs) address these inconveniences and are an interesting alternative. However, data regarding their efficacy and safety in HIT is limited. Methods: We retrospectively identified patients with HIT using ICD code 9: 289.84 and ICD code 10: D75.82 at Beaumont Hospital (Royal Oak) between December 2013 and December 2018. Only patients with HIT confirmed by positive serotonin release assay and managed with DOACs were included. Data regarding diagnostic tests, bleeding and thrombosis during the 30-day follow-up were recorded. Results: A total of 229 patients were identified using the ICD codes; only 8 patients had confirmed diagnosis of HIT and were treated with DOACs. The average age was 70 years (51-92 years); most were male (5, 62.5%) and Caucasian (6, 75%). The median optical density of PF4-heparin antibody was 1.97 (0.85-3.108). Six patients (75%) had confirmed HIT-associated thrombosis; one had negative Doppler ultrasonography of the lower extremities (upper extremities were not assessed) and one patient was not assessed for thrombosis. Seven patients (87.5%) received apixaban and one patient received rivaroxaban. The lowest platelet count prior to initiating DOAC was 40,000/microL, while three patients started DOACs when their platelet count was above 150,000/microL. Within the follow-up period, none of the patients on apixaban had bleeding episodes or clot progression. The only patient treated with rivaroxaban was re-admitted within one week of discharge for right upper extremity deep vein thrombosis. Unfortunately, this was the one patient who was not evaluated for thrombosis at the time of HIT diagnosis. Conclusion: In the 30 days following HIT diagnosis, treatment with apixaban resulted in adequate anticoagulation and was not associated with increased bleeding events despite relative thrombocytopenia. Disclosures No relevant conflicts of interest to declare.

Method: A query was generated to retrieve all cases treated with CPX-351 at Beaumont Health System. SPSS software was used to perform descriptive statistics. Results: We found 11 cases treated with CPX-351 from 2017 to 2019. Six patients were male and 5 females. The median age at diagnosis was 67. Eight patients were Caucasian, two African American and one Asian. The median body mass index (BMI) was 27.1 and median body surface area (BSA) was ! treated with CPX-351 after a diagnosis of AML-MRC and 4 patients (36.3%) with t-AML. The median hospital stay was 35 days. The median units of red blood cells transfusion during hospital stay were 9 units and the median number of transfused platelet units was 6. Only 2 patients (18.1%) achieved complete response (CR) and 2 patients (18.1%) achieved complete response with incomplete blood count recovery (CRi). Three patients developed allergic reactions presented as a rash, 2 patients had significant bleeding and all 11 patients developed neutropenic fever. Three patients died during induction therapy and 2 patients underwent allogeneic hematopoietic stem cell transplant. Six patients (54.5%) died within 90 days of starting induction therapy. Conclusion: t-AML and AML-MRC remain to have dismal prognosis. Our study highlights the high early mortality rate associated with induction therapy with CPX-351. The most common cause of death was refractory or relapsed leukemia. The high incidence of neutropenic fever was also more prevalent to what has been reported. Disclosures No relevant conflicts of interest to declare.

Background. Obesity is a major epidemic affecting all age groups in the USA. It has been associated with venous thromboembolism (VTE), which requires prolonged anticoagulation. Classic options (vitamin K antagonists, heparins) are increasingly replaced by direct oral anticoagulants (DOACs), which have not been well studied in patients with body mass index (BMI) > 40kg/m2 or weight above 120 kg. Despite limited safety and efficacy data, patients and their caregivers often opted for this medication owing to its ease of administration, lack of requirement for frequent laboratory testing and for dietary restrictions. Methods. This is a retrospective study of all morbidly obese patients (BMI > 40kg/m2) diagnosed with acute VTE managed with DOACs at Beaumont hospital between January of 2018 and December of 2018. Data regarding demographics, specific DOAC, major bleeding (hemoglobin decrease by 2 g/dL) and new or progressive thrombosis were recorded during a sixty-day follow up. Data was analyzed using JMP statistical software. Results A total of 42 patients diagnosed with acute VTE received DOACs during the study period. Most were female (76%); the median BMI was 44 (IQR 42-60) and mean age was 57. Most patients had a BMI of 40-50 kg/m2 (n=34, 81%) compared to BMI 50-60 kg/m2 (n=6, 14%) and BMI >60kg/m2 (n=6, 14%). Apixaban was the most frequently used DOAC (n=27, 65%). No clinically significant bleeding occurred during the study period. There were 2 thrombotic episodes (5% of patients) within 60 days of starting a DOAC; both occurred in patients receiving rivaroxaban. One event was present in the BMI 40-50kg/m2 group and one in the >60kg/m2 group. Conclusions DOACs appear to be safe and efficacious for the management of VTE in the morbidly obese population. Future studies may focus on the comparative efficacy of apixaban and rivaroxaban in the morbidly obese population. Disclosures No relevant conflicts of interest to declare.

Background: Inferior vena cava (IVC) filters are indicated in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) who either have contraindications to or have failed anticoagulation (AC). Given rising concerns about their safety and efficacy, the FDA has issued a communication urging clinicians to remove filters (optimally, within 90 days post-implantation). According to national data retrieval rates remain low. Our study aimed to assess IVC filter retrieval rates and factors that influence retrieval. Methods: This is a single center, retrospective cohort study of patients who had IVC filter placement between December 2015 and December 2018. Subjects were identified using procedural codes for IVC filter insertion; data regarding demographics, comorbidities, retrieval, IVC filter-related complications and subsequent thromboembolic events were obtained by direct chart review. Survival analyses and a Cox regression model were performed using JMP statistical software. Results: Over 3 years, 494 patients with IVC filters were identified; 305 (62%) were retrievable. The average age at placement was 69±16 years; 249 (50%) were men and 332 (67%) were Caucasian. After excluding patients who died or were lost to follow-up within 30 days of placement or were discharged to hospice from the index admission, 258 patients with retrievable filters remained (54 retrieved). Indications for IVC filter placement were PE ± DVT 90 (35%), proximal DVT 159 (62%) and prophylactic 9 (3%). Forty two percent of patients (109) were restarted on AC at discharge, while an additional 18% (total 155) received AC at some point thereafter. The rate of retrieval was 8% at 90 days, 23% at 1 year and 28% at 2 years (Figure A). The proportional hazards model identified resumption of AC at any time (HR 3.11, 95%CI 1.6-6.8, p=0.0006) as the strongest predictor of retrieval; AC at discharge was not predictive. Advanced age at placement (HR 0.97 per unit change, 0.96-0.99, p=0.004) and active malignancy (HR 0.5, 95%CI 0.24-0.98, p=0.04) were associated with a lower likelihood of retrieval. The initial thrombotic event, the reversibility of the contraindication to AC, the placing service, sex, ethnicity and other comorbid conditions did not have an impact on retrieval. Kaplan-Meier analysis revealed that subjects who ever resumed AC had significantly higher rates of retrieval at 90 days (11% vs 3.4%) and at 1 year (33% vs 9.7%, log-rank p=0.0003, Figure B) when compared to those who did not. Only four patients experienced IVC filter-related complications (2 filter thrombosis, 1 IVC penetration, 1 device tilting); all occurred 2 or more years after placement. Recurrent thromboembolic events occurred in 50 patients (5 PE, 48 proximal DVT) with no significant difference in frequency between subjects with retrieved and non-retrieved filters; one PE and one DVT occurred at 1 month and 1 week respectively after retrieval. Conclusion: Despite efforts to increase awareness of IVC filter-associated complications, the unweighted retrieval rate remained below the nationally reported average of 30%. Persistent risk factors for thrombosis such as active malignancy or increasing age and poor prognosis may play a role in the decision to defer retrieval. In our study, resumption of AC proved a powerful predictor of retrieval, with rates approaching expected values in this population. Active surveillance for resolution of contraindications to AC post-IVC filter placement is crucial in increasing retrieval rates. Figure Disclosures No relevant conflicts of interest to declare.

Background: Nearly 5% of patients diagnosed with Hodgkin lymphoma have the nodular lymphocyte predominant Hodgkin lymphoma (NLPHL), also known as Hodgkin paragranuloma or lymphocytic and histiocytic predominant Hodgkin disease. Given the rarity of this variant of Hodgkin lymphoma, there is no consensus on the standard of care/regimen in this subgroup of patients. Therapeutic approach has spanned from radiotherapy alone, combined chemo-radiotherapy to chemotherapy alone or observation and recently the use of Rituximab anti CD20 monoclonal antibody as these cells expresses CD20 marker. We opt to evaluate the outcome of patients with newly diagnosed NLPHL in our institution. We also reviewed outcome of NLPHL patients treated with various chemotherapy such as ABVD, CVP or RCHOP ± Radiation. Methods: We retrospectively reviewed medical records of over 300 patients [mean age 45 (13-76)] with Hodgkin Lymphoma at Beaumont Hospital, an academic community center from January 2007 - January 2017. Given the rarity of the disease, a total of 13 patients were found to have pathologically confirmed diagnosis of NLPHL. Data regarding age, sex, stage of disease, treatment and outcome was analyzed. Results: Total 13 patients with NLPHL with age range from 13 to 80 years were studied. Demographic distribution of studied patients were 8(62%) white, 4 (31%) African Americans and 1 (7.6%) Asian. Out of these, 8 (62%) were males and 5 (38%) females. A total of 9 (69%) patients have stage III disease on diagnosis while 4 (31%) patients had stage II disease on diagnosis. Out of 9 patients with stage III disease, 6 (67%) received chemotherapy alone (ABVD or CVP) whereas 3 (33%) received combined chemotherapy and radiotherapy. One patient in the chemotherapy alone arm, recurred within 24 months of treatment and received local therapy with radiation. Among those with stage II disease on diagnosis, 3 patients received radiation therapy alone while one patient was observed and did not receive any treatment. Overall, out of 13 patients studied, 12 (92%) are still alive and continues to follow with our clinic with no recorded relapse to date. One patient developed astrocytoma grade III and died of intracranial hemorrhage. CONCLUSION: Although the standard therapeutic management for patients with NLPHL remains controversial. Our data showed that regardless of the regimen selected (chemotherapy alone or combined chemo-Radiotherapy), patients with Lymphocyte predominant Hodgkin Lymphoma treated with ABVD ± Radiation have excellent outcome. Although our study represents a single institutional analysis, it concurs with recent studies that clinical outcome in patients with NLPHL is favorable with chemotherapy. Disclosures No relevant conflicts of interest to declare.

Introduction: Arterial and venous thromboembolic events, including stroke and myocardial infarction, are a leading cause of morbidity and mortality in the United States. Anticoagulation therapies are critical in preventing such morbidity and/or mortality. Vitamin K antagonist (VKA) such as warfarin has been the standard therapy for decades until recently with the advent of direct oral anticoagulants (DOACs). These newer agents offer important advantages over warfarin however, the risk of bleeding with these drugs as with all anticoagulants remains an ongoing safety concern. Among the most serious adverse events are intracranial hemorrhages (ICH) and major gastrointestinal bleed (MGIB). For patients who were on anticoagulation prior to these events, there seems to be no consensus on the appropriate timing to resume anticoagulation if at all. Our group reported earlier on the outcome of restarting anticoagulation after ICH (ASH 2017;Oral Abstract #332). Herein, we aim to retrospectively investigate the clinical outcome in terms of recurrent bleeding or thromboembolic events following resumption of anticoagulation post MGIB. Clinical outcome analysis was also extended to compare VKA to DOACs. Method: We retrospectively reviewed medical records of over 800 adults [mean age 68 (22-81)] at Beaumont Hospital, an academic community center from January 2008 to January 2018 with confirmed MGIB. Patients with MGIB who were not on anticoagulation prior to and after the bleeding event were excluded from study. Patients who were on antiplatelet therapy were also excluded. A total of 280 patients met the criteria. MGIB is defined as decrease in hemoglobin by 2 grams below baseline and/or endoscopically confirmed bleeding. Association between restarting anticoagulation (VKA or DOACs) and re-bleeding or thromboembolic event was made using time-to-event adjusted analyses. Results: Demographic distribution of studied patients were 163 (58.2%) white, 89 (31.8%) African Americans and 28 (10%) others. Among these patients, 173 (61.8%) were on VKA, 107 (38.2%) were on one of the DOACs (51.4% rivaroxaban; 29.9% apixaban; 9.3% dabigatran; 2% pradaxa; < 1% edoxaban) (Table 1). Although anticoagulation was not reinstituted in 135 (48.2%) patients following MGIB; 13 (4.6%) patients had anticoagulant restarted within 7 days of diagnosis of MGIB; 42 (15%) patients were restarted between 7-30 days and 88 (31.4%) patients were restarted after 30 days. Majority of patients who restarted anticoagulation within 7 days had severe cardiac dysfunction requiring mechanical valves. Among those who restarted anticoagulation within 2 weeks of MGIB, 21 (7.5%) had recurrent GIB; 18 of those patients were restarted within 7 days whereas 3 were restarted between days 7-12. Majority of the recurrent GIB occurred in the warfarin arm since all patients with mechanical valves were on warfarin. Among the DOACS, rivaroxaban rated highest in terms of recurrent GIB (Table 1). The incidence of thromboembolic event was higher among those whose anticoagulants were discontinued after MGIB compared to those who resumed anticoagulation regardless of timing (86.5% vs 16.2%, p < 0.0001). Conclusion: Given the rising national trend on the use of anticoagulants for various medical necessities, it is imperative that a safe and efficient process be devised on reinstitution of anticoagulation post MGIB to guide Clinicians. Although our study represents a single institutional analysis, it concurs with recent studies that early resumption of anticoagulant following stabilization of MGIB is associated with lower thromboembolic events. Timing for resumption depends largely on the medical reason for anticoagulation; reinstitution by day 7 appear safe for patients on mechanical valve whereas after day 12 maybe appropriate for patients with Atrial fibrillation or venous thromboembolism. Our study further reveals that the risk of recurrent bleed and/or thromboembolism may be less in patients on DOACs when compared to VKA. Among those on DOACs, Rivaroxaban had the highest re-bleeding rate. Nonetheless, randomized clinical trials are needed to evaluate the true risk-benefit profile of anticoagulation resumption after MGIB. Disclosures No relevant conflicts of interest to declare.

Malignant mesothelioma (MM) is an aggressive cancer that has been closely linked to asbestos exposure. Initially recognized as an occupational cancer in male workers, MM was later found to occur in their family members as well. We report the case of an 89-year-old female who presented with abdominal distention, pain, and findings consistent with malignant ascites. Family history was significant for fatal mesothelioma in her husband of 40 years, who was a worker at a tile factory. The diagnosis of MM was confirmed on pathologic examination of the omental core biopsy.

Clindamycin is a bacteriostatic lincosamide antibiotic with a broad spectrum. Side effects include nausea, vomiting, diarrhea, and metallic taste; however, hepatotoxicity is rare. The incidence is unknown. It is characterized by increases in aspartate and alanine transaminases. There may be no symptoms and the treatment is to stop the administration of clindamycin. We have described a 62-year-old African American female medicated with acetaminophen and clindamycin who had initially presented to the dental clinic for the evaluation of gum pain following tooth extraction. She had significantly increased levels of liver transaminases, which trended downwards on quitting the medication.

Hairy cell leukemia is a rare lymphoid neoplasm arising from mature B-lymphocytes. Clinically, the disease presents with splenomegaly and abdominal discomfort, frequent infections, fatigue and bleeding because of related cytopenias. Bone marrow biopsy is essential for diagnosis. Below we describe a case of a 70-year-old African-American male who presented to our hematology clinic complaining of fatigue. Clinical exam and computed tomography imaging did not reveal splenic enlargement. Blood work-up revealed pancytopenia and bone marrow was diagnostic for hairy cell leukemia.The patient was started on cladribine, with gradual improvement of his symptoms and blood count abnormalities. Therefore, it is essential to keep hairy cell leukemia in the differential of pancytopenia even in the absence of a splenomegaly.

An 81-year-old man with a medical history of hypertension, hyperlipidaemia, chronic kidney disease, coronary artery disease presented to the ear, nose and throat (ENT) physician with symptoms of hoarseness of voice which had persisted for over 6 weeks. Otolaryngoscopy was negative for obvious malignancy and he was diagnosed as having left vocal cord paralysis with a suspicion of thoracic aorta pathology. CT angiogram showed type B dissecting aortic aneurysm …