Chimeric antigen receptor (CAR) T cell therapy is a revolutionary form of immunotherapy that has proven to be efficacious in the treatment of many hematologic cancers. CARs are modified T lymphocytes that express an artificial receptor specific to a tumor-associated antigen. These engineered cells are then reintroduced to upregulate the host immune responses and eradicate malignant cells. While the use of CAR T cell therapy is rapidly expanding, little is known about how common side effects such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS) present radiographically. Here we provide a comprehensive review of how side effects present in different organ systems and how they can be optimally imaged. Early and accurate recognition of the radiographic presentation of these side effects is critical to the practicing radiologist and their patients so that these side effects can be promptly identified and treated.

One out of eight women will be affected by breast cancer during her lifetime. Imaging plays a key role in breast cancer detection and management, providing physicians with information about tumor location, heterogeneity, and dissemination. In this review, we describe the latest advances in PET/CT imaging of breast cancer, including novel applications of 18F-FDG PET/CT and the development and testing of new agents for primary and metastatic breast tumor imaging and therapy. Ultimately, these radiopharmaceuticals may guide personalized approaches to optimize treatment based on the patient's specific tumor profile, and may become a new standard of care. In addition, they may enhance the assessment of treatment efficacy and lead to improved outcomes for patients with a breast cancer diagnosis.

Treatment of non-small cell lung cancer (NSCLC) has undergone a paradigm shift. Once a disease with limited potential therapies, treatment options for patients have exploded with the availability of molecular testing to direct management and targeted therapies to treat tumors with specific driver mutations. New in vitro diagnostics allow for the early and non-invasive detection of disease, and emerging in vivo imaging techniques allow for better detection and monitoring. The development of checkpoint inhibitor immunotherapy has arguably been the biggest advance in lung cancer treatment, given that the vast majority of NSCLC tumors can be treated with these therapies. Specific targeted therapies, including those against KRAS, EGFR, RTK, and others have also improved the outcomes for those individuals bearing an actionable mutation. New and emerging therapies, such as bispecific antibodies, CAR T cell therapy, and molecular targeted radiotherapy, offer promise to patients for whom none of the existing therapies have proved effective. In this review, we provide the most up-to-date survey to our knowledge regarding emerging diagnostic and therapeutic strategies for lung cancer to provide clinicians with a comprehensive reference of the options for treatment available now and those which are soon to come.

Background: Pneumonitis has been described as a side effect of immunotherapy as well as traditional chemo-therapy. Although immune-related adverse event (IRAE) pneumonitis has been extensively characterized, the relationship between IRAE pneumonitis and pneumonitis secondary to chemotherapy is less clear. Here, we present the first analysis of radiographic features of pneumonitis secondary to immunotherapy compared to chemotherapy.ethods: Using our radiology records system, we searched chest computed tomography (CT) reports for the term "pneumonitis". We evaluated medical records to establish chronicity of pneumonitis occurring after medication administration and excluded cases where radiation therapy appeared to be the cause of pneumonitis. We also obtained information regarding demographic, clinical, and treatment characteristics for comparison.Results: Patients treated with immunotherapy demonstrated more specific features of pneumonitis including consolidation, ground glass opacities, septal thickening, traction bronchiectasis, and pulmonary nodules compared to those treated with chemotherapy. Immunotherapy treatment correlated with the development of pulmonary nodules (p = 0.048), and administration of more than one immunotherapy agent correlated with a greater incidence of development of nodules (p = 0.050). Radiographic features in patients treated with immunotherapy all decreased over time. Conversely, in patients treated with chemotherapy the incidence of ground glass opacities, traction bronchiectasis, pulmonary nodules, and mediastinal/hilar adenopathy increased over time. Conclusions: IRAE-pneumonitis has distinct features and a distinct clinical course compared to pneumonitis secondary to chemotherapy. Importantly, IRAE-pneumonitis features decreased over time, suggesting that careful consideration of the benefit-risk ratio may allow for continuation of immunotherapy in some patients who develop pneumonitis.

Melanoma is a deadly disease that often exhibits relentless progression and can have both early and late metastases. Recent advances in immunotherapy and targeted therapy have dramatically increased patient survival for patients with melanoma. Similar advances in molecular targeted PET imaging can identify molecular pathways that promote disease progression and therefore offer physiological information. Thus, they can be used to assess prognosis, tumor heterogeneity, and identify instances of treatment failure. Numerous agents tested preclinically and clinically demonstrate promising results with high tumor-to-background ratios in both primary and metastatic melanoma tumors. Here, we detail the development and testing of multiple molecular targeted PET-imaging agents, including agents for general oncological imaging and those specifically for PET imaging of melanoma. Of the numerous radiopharmaceuticals evaluated for this purpose, several have made it to clinical trials and showed promising results. Ultimately, these agents may become the standard of care for melanoma imaging if they are able to demonstrate micrometastatic disease and thus provide more accurate information for staging. Furthermore, these agents provide a more accurate way to monitor response to therapy. Patients will be able to receive treatment based on tumor uptake characteristics and may be able to be treated earlier for lesions that with traditional imaging would be subclinical, overall leading to improved outcomes for patients.

Objective: Here we analyze trends in breast cancer imaging over the past decade to evaluate the impact of changes in access to care and the COVID-19 pandemic on breast imaging utilization. Methods: We queried our radiology record system to identify numbers of specific breast imaging studies from 01/01/2010 to 03/31/21. We retrospectively assessed yearly numbers of exams since 2010 and weekly numbers during the COVID-19 pandemic in the greater New York City region. We performed Wilcoxon signed ranks tests to compare three-month periods during the pandemic to the same time period the prior year. Results: Ten-year trends in breast imaging showed an increase in screening mammography in the early part of the decade, which declined later in the decade. These changes corresponded to implementation of the Affordable Care Act in 2010 and the American Cancer Society Screening guidelines change in 2015. Breast MRI increased from 2017-2019, likely a delayed effect of research demonstrating a mortality benefit to high-risk women. Both screening mammography and breast MRI sharply declined during the height of the COVID-19 pandemic. Breast MRI has since rebounded, while screening mammography remains significantly reduced compared to 2019 exam numbers. Conclusion: Breast imaging exam numbers are affected by external events. Most recently, the COVID-19 pandemic significantly decreased screening mammograms and these have not rebounded to pre-pandemic levels. Given the proven benefit of screening mammography, this could have serious long-term effects for patients and should be carefully followed to ensure that all women get needed breast imaging and care.

BACKGROUND:Immunotherapy has become a critical class of anticancer therapy in recent years, functioning by releasing brakes on the immune system that ultimately results in immune cell activation which eliminates cancer cells. Immune related adverse events (IRAEs) are a specific type of adverse event described in patients taking checkpoint inhibitor immunotherapy which results from unrestrained immune activation. Immune related pericardial effusion has been described however has not been comprehensively characterized. Here, we present the most extensive report to date detailing this adverse event.METHODS:We queried our medical record system to retrospectively identify patients on checkpoint inhibitor therapy for lung cancer who subsequently developed pericardial effusion. We analyzed the clinical and radiographic characteristics, prior therapies, treatment for the effusion, and outcomes in patients with immune related pericardial effusion and compared them to similar patients with pericardial effusion not attributable to checkpoint inhibitor therapy.RESULTS:Our data demonstrate that most of these pericardial effusions were small and not clinically significant. The majority were successfully treated with steroids or resolved spontaneously. Anti-PD-1 inhibitors were the most common checkpoint inhibitor preceding pericardial effusion, and a significant number of patients who went on to develop IRAE pericardial effusion previously had treatment with carboplatin for their cancer.CONCLUSIONS:These data suggest that IRAE pericardial effusion is not a clinically significant adverse event however it sometimes leads to permanent discontinuation of checkpoint inhibitor therapy which is not necessary.

10539 Background: Guidelines for screening mammography have changed several times since initiation of regular screening mammography in the 1970’s. Most recently, in 2015, the American Cancer Society (ACS) revised their screening guidelines, recommending that a patient discuss screening mammography with her primary care doctor (PCP) between the ages of 40-44 and should begin yearly screening at age 45; after age 54, ACS recommended screening every other year. Prior to this, from 2003-2015, ACS had recommended screening mammography every year beginning at the age of 40. We hypothesized that these guidelines were adopted to varying degrees in different patient populations and may have disproportionately reduced screening mammography utilization in socioeconomically disadvantaged populations. Methods: Here, we analyzed monthly screening mammography rates over time in two large New York City hospitals, one in a socioeconomically advantaged area and the other in a socioeconomically disadvantaged area. Using our radiology records query system, we searched for monthly screening mammography numbers for women by decade from 2012 to 2018. We performed statistical analysis to evaluate changes in number of exams over time. Student’s t-tests were used to evaluate for significant differences. Results: In both groups of 40-49 year old patients, monthly mammograms increased from 2012-2016. In the socioeconomically advantaged group, this increase continued until 2018 resulting in an overall 400% increase in screening mammograms over time. The change in ACS screening guidelines had no effect on the rate of screening mammography in this group. Conversely, after the revision of the ACS guidelines in 2015, there was a marked decline in screening mammography in the 40-49 year old group in the socioeconomically disadvantaged population. By 2018, there was a statistically significant difference in women screened in all age groups (40-49, p<.0001; 50-59, p<.0001; 60-69, p<.01; 70-79, p<.0001; 80+, p<.0001) between these two patient populations. Conclusions: These data suggest that implementation of the 2015 ACS screening guidelines had a disproportionate effect on patients from socioeconomically disadvantaged areas and that these effects have led to significant disparities in screening mammography trends over time. We postulate that lower levels of health literacy may have contributed to misunderstanding of the screening guidelines. More research is needed to elucidate the underlying etiology of these disparities and ensure that women from all socioeconomic backgrounds receive appropriate screening mammography. Over time, this may result in disproportionate breast cancer morbidity and mortality in populations not receiving appropriate screening.

Purpose: To compare overall survival (OS) in patients who underwent surgery for early-stage pancreatic adenocarcinoma (rPca) based on sequence (NAT, neoadjuvant therapy and/or AT, adjuvant therapy) and type (SA, single-agent or MA, multi-agent) of chemotherapy received. Methods: Using the National Cancer Database, patients with clinical stage I/II rPca diagnosed between 2010 and 2014 were identified and five comparison matches (1: NAT vs. upfront resection (UR); 2: multi-agent neoadjuvant (MA NAT) vs. single-agent adjuvant therapy (SA AT), single-agent neoadjuvant therapy (SA NAT), multi-agent adjuvant therapy (MA AT); 3: MA NAT vs. MA AT; 4: NAT thorn AT vs NAT; 5: NAT thorn AT vs AT) were constructed using minimum distance matching strategy. Median OS (mOS) was analysed using KaplanMeier method, log-rank test and Cox proportional hazard model. Results: A total of 18,470 patients with stage I/II rPca were eligible for analysis. NAT showed a 5 month (mo.) improved OS compared with UR (3271 patients/group, 28.1 vs 23.2 mo. P < 0.0001 hazard ratio [HR]: 0.79). MA-NAT was shown to be superior to other chemotherapy approaches SA AT, SA NAT, and MA AT (1349 patients/group: 30 vs. 25.9 mo., P = 0.0001 [HR: 0.82]). MA NAT showed a survival advantage over MA-AT (1349 patients/group, 30 vs 26.1 mo., P = 0.0008 [HR: 0.86]). The combination of NAT and AT showed a better outcome when compared with NAT alone ( 1128 patients/group, 31.6 vs 27.4 mo., P = 0.0011 [HR: 0.81]) or AT alone (1128 patients/group, 31.6 vs. 25.2 mo., P < 0.0001 [HR: 0.76]). Conclusions: In patients with stage I/II rPca, MA NAT showed improved mOS compared to UR and all other chemotherapy sequences except both NAT plus AT. These findings support the use of MA NAT in stage I/II rPca patients and warrant prospective trials evaluating MA NAT and post-resection maintenance therapies. (C) 2021 Elsevier Ltd. All rights reserved.

4120 Background: While surgical resection can cure pancreatic cancer (PC), the majority of patients who undergo resection recur. As newer multi-agent chemotherapy regimens have evolved for metastatic PC, there has been increased interest in its use in the neoadjuvant (NAT) setting. However, U.S. clinical practice patterns vary widely. We evaluated the effect of systemic therapy sequence and regimen on prognosis in resected PC. Methods: Adult patients with resected, clinical stage I or II PC were identified in the NCDB from 2010-2015. Patients who received NAT followed by resection were matched by a minimum distance approach with those who underwent upfront resection (UR) with or without adjuvant therapy (AT) based upon demographics and disease-specific variables. OS was compared with Kaplan-Meier curves in matched cohorts. The effects of single-agent (SA) versus multi-agent (MA) chemotherapy (CT) on OS was evaluated using multivariate Cox proportional hazards regression model. Results: We identified 23,576 patients with clinical stage I or II resected PC. 3,446 patients who received NAT were matched with 3,446 patients who underwent UR. Those who received NAT had improved OS compared to those who underwent UR with or without AT (median survival time [MST] 27.9 versus 23.3 months, respectively; log-rank p < 0.0001). Among different treatment sequences, patients who received both NAT and AT had the longest OS compared to those who received either NAT or AT alone (MST 31.3 versus 26.2 versus 26.5 months, respectively; log-rank p < 0.0001). In patients treated with NAT alone, those who received MA CT had an improved OS compared to those who received SA CT (adjusted HR 0.72, 95% CI 0.64-0.81). In patients who received MA chemotherapy, MA NAT was associated with an 18% reduction in risk of death compared to those treated with MA AT (adjusted HR 0.82, 95% CI 0.73-0.93). Conclusions: In resectable PC, patients who received both NAT and AT had improved survival compared to those who receive NAT or AT alone. This supports future evaluation of maintenance therapy in the adjuvant setting. MA NAT was associated with improved survival compared to SA NAT. This supports current clinical practice and ongoing clinical trials.

361 Background: In 2009, adults had 4.7 million cancer-related hospitalizations. Adult hospital stays with cancer identified as the principal diagnosis cost $20.1 billion and accounted for 6% of adult inpatient hospital costs. GI cancer-related healthcare utilization has not been well-defined. The aim of this study was to evaluate the trends in the incidence and costs of GI cancer-related hospital admissions in the U.S. Methods: We reviewed the National Inpatient Sample Database (NIS) from 1997-2014. All patients with principle discharge diagnoses of esophageal, stomach, colon, rectum and anus, liver and intrahepatic bile duct and pancreas cancer were analyzed. Temporal trends in the number of hospital admissions, length of stay, hospitalization cost and mortality rates were obtained by HCUPnet. Results: GI cancer-related hospital admissions decreased from 230,537 in 1997 to 221,220 in 2014. Although the number of hospital admissions decreased for esophageal (12,157 to 11,885), stomach (23,528 to 21,800), colon (110,939 to 90,135), rectum and anus cancer (43,807 to 40,160), it has increased for liver and intrahepatic bile duct (11,243 to 21,775, p < 0.001) and pancreas cancer (28,862 to 35,465, p < 0.001). While the mean length of stay decreased from 9.6 days in 1997 to 7.6 days in 2014, the mean hospital charges per patient (adjusted for inflation) increased 127% from $34,747 in 1997 to $78,742 in 2014. The highest increase in mean hospital charges per patient were in liver and intrahepatic bile duct ($27,128 to $74,619 (175%), p < 0.001), rectum and anus ($32,566 to $80,789 (148%), p < 0.001) and pancreas cancer ($33,562 to $75,981 (126%), p < 0.001). Conclusions: GI cancer-related hospital admissions decreased from 1997 to 2014. Despite decrease in the mean length of hospital stay, the costs of hospitalizations have increased substantially, especially in liver and intrahepatic bile duct, rectum and anus and pancreas cancer. Our study suggests that shorter length of stay alone has not reduced costs of hospitalizations in GI cancers. There remains a growing need to understand healthcare costs and to develop effective value-based interventions in GI cancer-related hospital admissions.

196 Background: Patients with cancer have nearly twice the incidence of suicide compared to the general population. To date, identifying patients at risk for suicide remains challenging. Colorectal cancer (CRC) is the third most common cancer in the US. The purpose of this study was to identify risk factors associated with higher suicide rates (SR) among patients with CRC. Methods: A retrospective analysis was completed using Surveillance, Epidemiology, and End Results data from 1973 to 2014. Comparisons with the general US population were based on US mortality data collected by the National Center for Health Statistics. Suicide incidence, rates and standardized mortality ratio (SMR) were obtained by SEER*Stat 8.3.4. Results: Among 414788 patients with CRC observed for 2785811 person-years, 747 suicides were identified, for an adjusted SR of 26.7/100,000 person-years (SMR 1.40 [95% CI 1.30-1.50]). Higher SRs were associated with male sex, non-white or non-black race, being unmarried and having advanced disease at diagnosis (Table 1). SR was highest in the first year after diagnosis (SMR 2.00 [95% CI 1.68-2.37]) and with increasing age at diagnosis among unmarried patients. In patients 60 to 64 years at diagnosis, SR was highest in unmarried men (SMR 3.72 [95% CI 2.61-5.15]) and lowest in married women (SMR 0.61 [95% CI 0.17-1.57]). Conclusions: CRC is one of the most common cancers in the US. Patients with CRC have a 1.5-fold increase in SR compared to the general population. Suicide screening should especially target those in their first year after diagnosis, particularly older, unmarried patients. [Table: see text]

197 Background: Patients with cancer have nearly twice the incidence of suicide compared to the general population(1). To date, identifying patients at risk for suicide remains challenging. The purpose of this study was to identify risk factors of suicide among patients with GI cancer. Methods: A retrospective analysis was completed using Surveillance, Epidemiology, and End Results data from 1973 to 2014. Comparisons with the general US population were based on US mortality data collected by the National Center for Health Statistics. Suicide incidence, rates and standardized mortality ratio (SMR) were obtained by SEER*Stat 8.3.4. Results: Among 711859 patients with GI cancer observed for 3373014 person-years, 1116 suicides were identified, for an adjusted suicide rate of 33.1/100,000 person-years (SMR 1.74 [95% CI 1.64-1.85]). The highest suicide risks (SR) were in esophageal (SMR 5.42 [95% CI 4.30-6.75]), pancreatic (SMR 4.91 [95% CI 3.83-6.19]) and liver or intrahepatic biliary cancer (SMR 3.36 [95% CI 2.35-4.65]). Higher SRs were associated with unmarried status, age 40 years and older at diagnosis and the first 5 years after diagnosis. In esophageal (EC) and pancreatic (PC) cancer, SR was 8 folds higher in unmarried patients compared to the general population with a SMR of 8.31 [95% CI 5.68-11.73] and 7.68 [95% CI 5.18-10.97], respectively. In EC and PC, SR was highest in patients > 80 years (SMR 7.09 [95% CI 3.40-13.03]) and 40-59 years at diagnosis (SMR 7.10 [95% CI 1.93-18.18]), respectively. Patients have especially high SR the first year after diagnosis in EC (SMR 10.25 [95% CI 7.65-13.44]) and PC (SMR 7.72 [95% CI 5.83-10.03]). Conclusions: While overall, patients with GI cancer have nearly twice the SR, those with certain cancer subtypes have up to 5 times the SR when compared to the general population. SRs are highest in esophageal, pancreatic and liver or intrahepatic biliary cancer. Suicide screening should especially target patients with EC and PC who are unmarried or lack a support system and within the first year after cancer diagnosis.

Tyrosine kinase inhibitors (TKIs) have emerged as the mainstay treatment for renal cell carcinoma (RCC). Despite growing popularity of TKIs, the treatment safety and tolerability in elderly patients are yet to be fully understood. As new assessment tools become available in identifying elderly patients with cancer at risk for severe treatment-related toxicities, much remains to be learned about how to integrate these tools into our management of elderly patients with cancer. We present a case of a 75year-old man with RCC who was initially treated with pazopanib and subsequently treated with sunitinib. We review the safety and toxicity profiles of TKIs in treating elderly patients with RCC.

504 Background: Response Evaluation Criteria in Solid Tumors (RECIST) has become widely accepted as gold standard for response evaluation in clinical trials. It remains underutilized in routine clinical practice. We compared tumor response assessment made with and without RECIST. Methods: This study included patients with solid tumors who underwent imaging from January 2013 to December 2014 at a single academic center. Tumor response was assessed by a radiologist using RECIST and by an oncologist (Onc) and resident (Res) without using RECIST (standard report). Tumor response was classified as progressive disease (PD), stable disease (SD), partial response (PR) and complete response (CR). Agreement in assessment between RECIST and standard report was determined by percent agreement and Kappa statistic. Results: 292 imaging studies were included. Concordance between RECIST and Onc-interpreted standard report is presented in Table 1. Overall agreement between RECIST and Onc-interpreted standard report was 56% (95% CI: 46-65%) and Kappa was 0.31 (95% CI: 0.19-0.44). Similar results were seen between RECIST and Res-interpreted standard report (Table 1). Overall agreement between RECIST and Res-interpreted report was 54% (95% CI: 44%-63%) and Kappa was 0.26 (95% CI: 0.13-0.40). Conclusions: Our study found variability in tumor response assessment between clinicians and radiologists. RECIST-classified PD was often interpreted as SD and vice versa, a distinction that affect treatment decisions. Our study highlights the need to standardize tumor response assessment. [Table: see text]

New areas of research continue to examine the role of non-androgen receptor pathways in prostate cancer treatment. The phosphatidylinositol 3-kinase/Akt/mammalian target of rapamycin (mTOR) pathway may be a target for prostate cancer therapy. Somatostatin receptor signaling inhibits intracellular PI3K/Akt signaling, making it an attractive target for combination therapy. We conducted a phase II open label clinical trial examining the use of somatostatin receptor agonist, pasireotide (SOM230) in combination with mTOR inhibitor, everolimus in metastatic castrate-resistant chemotherapy-naïve prostate cancer patients. Of the 6 patients enrolled in the study, only 1 patient had >50% PSA reduction from baseline. Three patients withdrew due to grade 3 adverse events. The study was closed early due to toxicity profiles and no further development was planned for this combination treatment in prostate cancer.

OBJECTIVE:Venous thromboembolism (VTE) is a common complication in cancer patients. This review summarizes some of the most current knowledge of the epidemiology, risk factors, risk models, prophylaxis, and treatment of VTE in cancer patients.METHODS:A literature search was conducted using PubMed; the search terms were venous thromboembolism, anticoagulation, and cancer. The bibliographies of pertinent studies and review articles were reviewed for additional references.RESULTS:Venous thromboembolism is the second leading cause of death in patients with cancer. Cancer patients with VTE have poorer outcomes compared with noncancer patients with VTE. Many risk factors have been identified for VTE in patients with cancer that are patient-related, cancer-related, or treatment-related. Several biomarkers have been identified as potentially predictive of VTE risk. Risk assessment models such as the Khorana Risk Score stratify cancer patients with low, intermediate, and high risk of developing VTE based on baseline clinical and laboratory variables. Currently, enoxaparin is the preferred anticoagulant for initial VTE treatment in cancer patients. Low molecular weight heparin (LMWH) is recommended for both initial and long-term management of cancer-related VTE. Because the optimal duration of anticoagulation in cancer patients with VTE is unknown, the decision to extend anticoagulation requires weighing the risk of recurrent thrombosis against the risk of major bleeding. Patients with recurrent VTE can be bridged with LMWH, transitioned to full-dose LMWH or treated with LMWH dose escalation. While there is insufficient data to determine whether anticoagulation should be held in the setting of thrombocytopenia, full-dose anticoagulation is typically considered unsafe when platelets are < 50 000/μL. Inferior vena cava filters are currently recommended only for patients with acute VTE and contraindications to anticoagulation. Although management of catheter-associated thrombosis has not been well studied in cancer patients, it is recommended that cancer patients with catheter-associated thrombosis be treated with therapeutic anticoagulation for ≥ 3 months. Venous thromboembolism prophylaxis with UFH, LMWH, or fondaparinux is recommended in all hospitalized nonsurgical cancer patients and cancer patients undergoing major cancer surgery. Primary thromboprophylaxis is only currently recommended in high-risk ambulatory cancer patients such as multiple myeloma patients receiving thalidomide- or lenalidomide- based therapy.CONCLUSION:Cancer-associated thrombosis is a common problem. As we begin to better understand the risk factors and biomarkers for cancer-associated VTE, we can further refine and develop risk-assessment models to determine those patients who would most likely benefit from anticoagulation. While LMWH products are generally preferred in cancer-related VTE, more research will continue to evolve our understanding of treatment and thrombopprophylaxis in cancer-associated VTE.