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Introduction: Individuals with chronic hepatitis B virus infection (HBV) or previous infection with HBV are at increased risk of HBV exacerbation or reactivation when they receive treatment with anti-CD20 monoclonal antibodies like rituximab (RTX). HBV screening and appropriate use of prophylactic antiviral therapy is recommended to prevent reactivation. A software program named Beacon Oncology was integrated into Epic, which creates an automated alert for HBV screening before starting first dose of chemotherapy with RTX and results the previously resulted HBV test results. Retrospective data analysis for screening was done after implementation of the software and its impact was assessed. Methods: We conducted retrospective chart review on screening for HBV before starting treatment with RTX before and after implementation of the electronic health record (EHR) alert system. Results: A baseline review (before software introduction) of 165 patients showed that only 40 (24%) had screening tests for HBV (hepatitis B surface antigen [HBsAg] and hepatitis B core antibody [anti-HBcAb]) before receiving rituximab. Following introduction of the automated electronic alert system, chart review for HBV testing rates among patients being initiated onto rituximab was performed. There was a marked increase in pre-rituximab testing for HBsAg from 24% to 88% and for anti-HBcAb from 24% to 76%. The remainder cases also had the HBV screening done but after the first dose of the RTX chemotherapy between 1.3 to 7.5 days. There was one patient identified as anti-HBcAb-positive after the implementation of the protocol. Conclusions: This retrospective single-institution study clearly indicates that simple strategies can markedly improve appropriate HBV screening. There was a more than 3-fold increase in HBV testing before the first dose of HBV after implementation of the EHR alert system. There has been increased use of EHR alert systems recently to improve implementation of clinical guidelines, and they have been shown to improve patient outcomes. In conclusion, an automated EHR alert directed toward screening for HBV before initiating RTX effectively increased the number of HBV screening tests completed, and similar protocols could be implemented to identify other at-risk patient groups.

We report a rare case of severe hyponatremia due to cisplatin-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in a 74-year-old male with a history of squamous cell carcinoma of the tongue who presented with a five days history of worsening confusion. He was found to have severe hyponatremia. His clinical and laboratory findings were consistent with hyponatremia due to SIADH. He was treated with fluid restriction and salt tablets after which his serum sodium markedly improved. Drugs including diuretics, antidepressants, antipsychotics are well known to cause hyponatremia. Cisplatin is a very common antineoplastic drug for solid tumors. Clinicians need to have prompt recognition of this rare side effect of cisplatin to prevent life-threatening hyponatremia.

We report a rare case of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGC) in a 62-year-old female who presented with a three-month history of bilateral flank pain and significant unintentional weight loss. Computed tomography (CT) scan of the abdomen showed pancreatic tail mass, concerning for malignancy. She underwent endoscopic ultrasound (EUS) which also revealed a pancreatic mass invading into the splenic artery. CT chest and positron emission tomography (PET) scan did not reveal any metastases. The patient had a distal pancreatectomy, splenectomy, and left partial adrenalectomy. Histopathology revealed undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (OGCs). The patient was recently started on adjuvant chemotherapy with capecitabine and gemcitabine and the plan is to repeat imaging to assess response. We present this case to increase clinical awareness of this rare clinical entity, and also review controversies in the management and surveillance of UC-OGC.

Metastatic brain tumors are the leading cause of central nervous system malignancies in adults, surpassing primary central nervous system with non-small cell lung cancer, accounting for more than 50% of all cases. The emergence of immunotherapies such as antibodies targeting the immune check points has led to significant advancement in the field of cancer treatment since these approaches have overwhelmingly impacted outcomes in patients with metastatic non-small cell lung cancer. Here we report two cases of metastatic non-small cell lung cancer treated with immunotherapy. While one patient achieved an excellent systemic response but developed new metastatic brain lesions, the other showed remarkable systemic as well as central response. These cases highlight variable central nervous system penetration of programmed death 1 (PD-1) antibodies, and we also review the available literature on blood brain barrier permeability of PD-1 antibodies.

Introduction: Nivolumab, is a monoclonal antibody directed against programmed cell death-1 receptor (anti PD-1), and is used in adjuvant treatment of melanoma. With the widespread use of immunotherapies, the incidence of autoimmune diseases referred to as immune related adverse events (irAE) is also increasing. Our case highlights a rare side effect of autoimmune insulin dependent diabetes mellitus (IDDM) related to immunotherapy, in a patient with no detectable diabetes related antibodies. We also review management of this rare side effect. Clinical Case: A 52-year-old woman with a diagnosis of stage IIIC malignant melanoma and no previous history of diabetes mellitus presented with abdominal pain and nausea. She had received 10 doses of Nivolumab as adjuvant therapy for melanoma. She denied any family history of diabetes or autoimmune disorders. Physical exam including vital signs was normal. Lab work up was significant for blood glucose of 280 mg/dl and glycated hemoglobin (HbA1c) was 7.4%, and additional blood work up showed low serum C-peptide 0.5 ng/ml (normal range 1.1-4.4 ng/mL) and negative results were obtained for all islet cell autoantibodies. Arterial blood gas (ABG) revealed high anion gap metabolic acidemia with pH 7.11, pCO2 25 mm Hg, bicarbonate (HCO3) 12 mmol/L, high anion gap 22 and serum lactate 0.8 mmol/L, consistent with diabetic ketoacidosis (DKA). Prior to initiation of Nivolumab, her HbA1c was 5.7%. The patient was diagnosed with DKA due to autoimmune-mediated IDDM secondary to Nivolumab therapy. She was treated with an insulin drip and intravenous fluids after which the anion gap and her symptoms resolved. She was discharged home with a subcutaneous basal bolus insulin regimen. Conclusion: Immunotherapies such as Nivolumab can cause new onset IDDM by inducing autoimmune response. Most likely mechanism of developing IDDM in patients treated with Nivolumab is inappropriate activation of T cells leading to destruction of pancreatic islet cells. Our patient had low serum C-peptide level which correlates with low insulin secretion suggestive of islet cell destruction. Median time of onset of IDDM is 4.4 months after starting Nivolumab. Most common endocrinopathies associated with Nivolumab are hypophysitis, thyroiditis or primary adrenal insufficiency. New onset IDDM is very uncommon irAE, and so far it has been reported in less than 1% of patients. In contrast to other irAE such as colitis there is limited data regarding role of high dose steroids in autoimmune diabetes and it can even exacerbate hyperglycemia and DKA. References: 1. Godwin, James Luke, et al. "Nivolumab-induced autoimmune diabetes mellitus presenting as diabetic ketoacidosis in a patient with metastatic lung cancer." Journal for immunotherapy of cancer 5.1 (2017): 40. 2. Zaied, Ali, and Augustine Lee. "Nivolumab-Induced Autoimmune Diabetic Ketoacidosis." Chest 150.4 (2016): 255A. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Denosumab is a monoclonal antibody that has been widely used for the prevention of skeletal-related events in patients with cancer with solid tumours and bone metastases, and acts by reducing the release of calcium from bones into the bloodstream. Severe hypocalcaemia is a rare and dangerous side effect of denosumab. We present a case of a patient with metastatic prostate cancer who developed severe hypocalcaemia after receiving a single dose of denosumab. Further laboratory analysis showed that the patient had a low vitamin D level, which contributed to the development of hypocalcaemia. He required an inpatient admission for repeated doses of intravenous calcium.

A 17-year-old female presentedwith acute disseminated encephalomyelitis (ADEM), a demyelinating disease ofthe central nervous system, fourweeks after receiving a meningococcalvaccination. The report highlights a rare but known presen- tation following routine vaccination that requires a high degree ofsuspicion in recognition and management. Early initiation of steroid therapy, followed by a steroid taper over one month resulted in a favorable outcome of complete neurological recovery.

Cases of metastatic anal carcinoma managed with a combination of systemic chemotherapy and local therapies to both solitary sites of metastases and the primary site have been reported in the literature. We present a case of a 55-year-old male with metastatic anal squamous cell carcinoma to the liver treated with induction chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5FU) followed by liver resection and radiation to the anal primary with concurrent 5FU and mitomycin. This approach resulted in control of disease without evidence of recurrence, and no increased toxicities now 19 months from initial diagnosis to time of reporting. This novel approach resulted in a good treatment response as documented by imaging and symptom improvement and a long disease free interval.

Creutzfeldt-Jakob Disease (CJD) is a fatal neurologic disorder caused by an infectious agent called a human prion protein. CJD can be classified as sporadic CJD, familial CJD, variant CJD, and iatrogenic CJD. We report a 64-year-old man diagnosed with CJD three months after cataract surgery. Although sporadic CJD is the most common type, the patient's cataract surgery elicited the possibility of an iatrogenic transmission. It is important to consider whether visual symptoms are a manifestation of sporadic CJD, rather than cataract surgery resulting in iatrogenic CJD. Preceding cataract surgeries have been reported with CJD, but there is no proven causality. This case highlights consideration of sporadic versus iatrogenic cause when seen in association with cataract surgery.

207 Background: A breast cancer (BC) diagnosis can affect psychosocial wellbeing. The goal of the current study is to identify the severity of and specific risk factors for depression, anxiety, and quality of life impairment in a sample of BC patients. Early identification of at risk individuals can expedite appropriate referrals and interventions. Methods: Data from 53 female BC patients referred to a Behavioral Medicine service at a large academic medical center in 2013-2015 by medical providers who identified distress at routine clinic visits were analyzed. Patients completed the Center for Epidemiology Studies Depression Scale, State Trait Anxiety Inventory, McGill Pain Questionnaire, and the Short Form 12 Quality of Life Inventory as part of their initial assessment following referral. Demographic factors, disease and treatment related factors were analyzed for correlation with psychosocial wellbeing. Results: Mean age was 52. The majority of the population were Caucasian (79%), and 53% were married. All stages of disease were represented. Significant depression, anxiety and psychological quality of life impairment were seen in 53%, 50%, and 39% of patients respectively. There was a trend towards a significant difference in higher anxiety scores in patients who were not on chemotherapy (M=44.2, SD 5.4) compared to those on chemotherapy at the time of assessment (M=38.54, SD 9.3; t (51) = -1.94 p=0.077). A positive correlation was seen between depression and pain scores (r 0.294, p=0.038). Depression and psychological quality of life scores were negatively correlated (r -0.632 p

144 Background: Adjuvant chemotherapy for breast cancer has undergone many changes over the past 10 yrs. The objective of the study was to review prescribing trends in adjuvant chemotherapy regimens for early stage breast cancer in a single institution, over a decade. Methods: A retrospective chart review was conducted of patients (pts) with early stage breast cancer treated at YNHH from 2002 to 2011.Total charts analyzed was 1097 and 308 pts had complete data. Results: The HER 2 positive group accounted for 64 pts. The most commonly used regimen was ACTH (doxorubicin and cyclophosphamide 4-14 d cycles, paclitaxel and trastuzumab weekly for 12 weeks, and trastuzumab for 1 yr). This regimen was utilized in 35% of pts and was most likely to be used in node positive (N+ve) pts compared to node negative (N-ve) pts (OR 2.9 (95 % CI 0.97-9.1)).TCH (docetaxel, carboplatin, trastuzumab,6-21 d cycles and trastuzumab for 1 year) was the second most common regimen used in 21% of pts and predominantly in N-ve pts(OR 12.4 (95% CI 02.45-63.2)). Majority of the study group (184 pts) were ER+PR+ and HER 2- .The predominant chemo regimen was DD AC T (dose dense AC followed by paclitaxel in 4 -14d cycles each) in 50% of pts, and TC (Docetaxel, cyclophosphamide4-21d cycles) utilized in 48 pts (26.09 %). Majority of the N-ve pts were treated with TC (OR 12.4(95% CI 2.4-63.27) whereas N+ve pts were predominately treated with DDACT (OR 2.98(95% CI 0.97-9.16). The Triple negative group included a total of 57 pts .The most frequent chemo regimen through the years was DDACT (54.39% of pts) followed by TC (21.05% of pts). N+ve pts were more likely to be treated with DDACT (OR 8.91(95% CI (2.65-29.94)) whereas N-ve pts mostly received TC (OR 8.75(95% CI (1.70-45.00)) The methotrexate and 5 fluorouracil based regimens were utilized more frequently in earlier years of study and less frequently in later years. Conclusions: Anthracycline and taxane based regimens have gained precedence over older regimens. HER 2 +ve pts were most commonly treated with ACTH, and TCH. N+ve HER 2+ pts were most likely to be treated with ACTH and N-ve HER2+ pts with TCH. In Her 2 negative and triple negative pts, DDACT was more utilized in N+ve pts whereas, TC regimen in the N-ve pts.

Dural vein thrombosis is an important but rare cause of headache. Therapy with cyclosporine has been reported to result in thrombotic events. We report an unusual case of superior sagittal and transverse sinus thrombosis associated with cyclosporine therapy in a kidney transplant patient.