New-Onset Autoimmune Diabetes Mellitus Presenting As Diabetic Ketoacidosis in Association With Pembrolizumab Therapy and Long Term Follow-Up: Case Report

Pembrolizumab, an immune checkpoint inhibitor (ICI) that acts against receptor programmed cell death-1 (PD-1), is currently being used in the treatment of a variety of cancers. As PD-1 is also present on other non-malignant tissues, this results in side effects involving a multitude of organ systems termed immune-related adverse effects (irAEs). Programmed cell death-1 is expressed on the beta cells of islets of the pancreas, and their destruction can result in hyperglycemia and the onset of new diabetes mellitus (DM). Thus, the anti-PD1 action of pembrolizumab can lead to autoimmune-related DM. We present a case of a 62-year-old male who developed new-onset DM after 12 cycles of pembrolizumab with a severe presentation in the form of diabetic ketoacidosis (DKA) and ICU stay. Our case underscores the importance of physician awareness, frequent lab monitoring and patient education about this rare but potentially fatal irAE of ICI. It also strengthens existing data in literature suggesting the association of irAEs with improved efficacy of ICI therapy.

Incidental Finding of Squamous Cell Carcinoma on a 68Ga-DOTATATE PET Scan

Neuroendocrine tumors (NETs) are a relatively rare entity; however, the incidence and prevalence of these tumors are increasing, likely attributed to improved diagnostic accuracy. The diagnosis of suspected NETs is facilitated by clinical symptoms, laboratory test abnormalities such as elevated chromogranin-A, and other diagnostic modalities such as the use of computed tomography scans, magnetic resonance imaging scans, positron emission tomography (PET) scans, and biopsy. The expression of high levels of somatostatin receptors in NETs enables the use of a specialized PET scan using the radiolabeled somatostatin analogues 68Ga-DOTATATE. The sensitivity and specificity of 68Ga-DOTATATE PET is very high for the diagnosis of NETs, but the specificity decreases especially with no clear symptoms and with only borderline elevated tumor markers. We present a case of a suspected NET, which was initially diagnosed as a metastatic NET by virtue of a positive 68Ga-DOTATATE PET scan; however, on biopsy it was revealed to be a squamous cell carcinoma originating from the head and neck.

A Case of De Novo Psoriasis Secondary to Nivolumab in a Patient With Metastatic Renal Cell Carcinoma

Immune-mediated adverse events are commonly seen with immune checkpoint inhibitors like nivolumab. Oncology specialists usually have to screen patients for risk factors for autoimmune diseases, since immune checkpoint inhibitors can potentially exacerbate these events. Some of the immune-mediated side effects include polyneuropathies, colitis, and cutaneous adverse effects. Non-specific maculopapular rash, pruritus, lichenoid reactions, eczema, and vitiligo are the most common dermatologic side effects. It is thought that these adverse events are due to the blocking of the programmed cell death protein-1 (PD-1) pathway and are mediated by the cytotoxic T cells. Psoriasis has been previously reported as a side effect in a few case reports and most commonly presented as an exacerbation of preexisting psoriasis. However, de novo psoriasis occurrence as a result of nivolumab is a rare entity, especially in a non-melanoma patient. Here, we present a case of renal cell carcinoma treated with immunotherapy with nivolumab, who developed de novo psoriasis with palmoplantar involvement.

Protecting high-risk oncology patients during the pandemic of COVID-19 by creating an outpatient cancer clinic for febrile neutropenia (California clinic)

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Background: Delivering care for vulnerable cancer patients during a pandemic is challenging given the competing risks of death from cancer versus the high case fatality rates from SARS-COV-2 (CV-19). Data currently available suggests a total fatality rate close to 30%-50% with CV-19 in active malignancy patients. In addition to adapting guidelines from national organizations to reduce the social footprint of patients in order to minimize risk of exposure of CV-19, our cancer center implemented an isolated clinic with personal protective equipment (PPE) and direct access to a CV-19 rule out floor (if admission warranted) in order to manage those with febrile neutropenia (FN) who otherwise would have been triaged to the emergency room (ED). Methods: We implemented an outpatient isolated extended hour clinic with access to PPE, blood work, intravenous antibiotics and fluids for FN patients as a pilot project from mid-April with expected duration during the pandemic with the aim to decrease the ED admissions for FN by 50%. We used the Multinational Association of Support Care in Cancer (MASCC) validated tool to assist with outpatient versus inpatient management of these patients. All patients were screened via polymerase chain reaction nasal swab for CV-19 to identify CV-19 in a high-risk population. Our PDSA (Plan Do Study Act) cycles have been in 2-week sessions with constant re-education to multiple providers. Results: Prior to CV-19, our databases show an approximate 15 to 20 FN hematology and oncology patients per month who are triaged to ED during the business hours. Since the implementation of our clinic in the last 45 days, we have screened 8 patients, of which 2 were discharged home with oral antibiotics on isolation until CV-19 testing returned, 6 were directly admitted to CV-19 rule out floor avoiding ED. Our overall patient numbers were low during the peak of the pandemic and we expect to see increasing number of patients utilizing the clinic over the next few months. Conclusions: Implementing the California clinic has thus far successfully decreased the social footprint of our highest-risk cancer patients, those with FN, in hopes of decreasing their possible exposure to CV-19 as well as the unnecessary exposure of the clinical personnel. [Table: see text]

Abstract P1-19-23: Impact of early dose reduction of palbociclib on clinical outcomes in patients with hormone-receptor positive metastatic breast cancer

Background: Palbociclib (palbo), a CDK4/6 inhibitor, is commonly added to an aromatase inhibitor (AI) as the first line therapy in managing estrogen receptor positive, HER2 non amplified (ER+ HER2-) metastatic breast cancer (MBC). Though more tolerable than chemotherapy, palbo may need dose interruption, delay or reduction due to toxicities like neutropenia. Currently, there are no clinical data on the effect of relative dose intensity (RDI) of palbo in the first line setting on clinical outcomes. The primary objective of this study is to explore the correlation of RDI and dose reduction of palbo in the first line setting with median progression free survival (PFS). Methods: This is a retrospective chart review of ER+ HER2- MBC patients (pts) at Wilmot Cancer Center from Jan 1st 2015 to Feb 1st 2019 who had received palbo plus an AI in the first line setting. Men/women more than 18 years old with biopsy proven MBC, who were started on 125 mg of palbo daily, had completed at least 1 cycle of palbo, and did not have disease progression within the first 12 weeks were eligible. Pts receiving fulvestrant with palbo or those switched to other CDK4/6 inhibitors in the first 12 weeks were excluded. Statistical analyses were performed at 12 and 36 weeks landmarks (LM) to compare clinical outcomes. RDI was defined as the total amount of palbo actually taken per total amount of palbo planned within respective LM. RDI-high-12 and RDI-low-12 cohorts were defined as pts receiving palbo with RDI >/= 80% and RDI <80% during the first 12 weeks, respectively. Reduction-12 and No-reduction-12 cohorts were defined as pts who had any reduction and no reduction of the dose of palbo during the first 12 weeks, respectively. Cohorts for 36 weeks LM analysis were defined in a similar fashion. PFS was assessed from the LM rather than from the start of palbo. Objective response rate (ORR) was defined as the rate of complete or partial responses (CR or PR). Response to therapy and clinical benefit (CR, PR or stable disease for at least 6 months) were assessed after LM. Results: 172 charts were screened yielding 56 eligible pts for final analysis. 54% of eligible patients were > 60 years old, 71% had ECOG performance status (PS) 0-1, 88% were post-menopausal, 21% had de novo MBC, and 57% had visceral metastases. By 12 weeks, 24 (43%) pts had a dose reduction and 8 (14%) had RDI <80%. Causes of dose reduction were neutropenia (83%), thrombocytopenia (21%), anemia (8%) and fatigue (8%). Kaplan Meier analysis at 12-week LM showed a median PFS of 17.1 months in RDI-high-12 vs. 6.8 months in RDI-low-12 cohort (p = 0.0014). After adjusting for PS, menopausal status, cancer stage at diagnosis, visceral metastases, and disease-free interval between initial diagnosis and metastatic disease using multivariable Cox proportional hazard model, RDI-low-12 was associated with almost 5 times higher risk for progression compared to RDI high-12 cohort (hazard ratio 4.98. 95% CI 1.87 - 13.28, p=0.001). There was a 7.0 month improvement in median PFS in No-reduction-12 cohort vs. Reduction-12 cohort (17.1 versus 9.8 months, p = 0.1229). At the 36-week LM, median PFS was not reached in RDI-high-36 cohort vs. 8.6 months in RDI-low-36 cohort (p=0.0714). 82.14% of No-reduction-12 achieved clinical benefit compared to 71.43% of Reduction-12 (p=0.49). No-reduction-12 had ORR of 85.7% while Reduction-12 had ORR of 65.0% (p=0.1622). Conclusions: Reduced RDI of palbo (<80%) during the first 12 weeks, when used in combination with an AI in the first line setting in ER+ HER2- MBC, is associated with significantly shorter PFS compared to palbo dose intensity >/= 80%. Similarly, there is a trend towards shorter PFS among pts with RDI of palbo <80% in the first 36 weeks compared to those with RDI >/= 80%. A larger study is needed to validate these findings.

Citation Format: Bahar Moftakhar, Manidhar Reddy Lekkala, Myla Strawderman, Tae C Smith, Philip Meacham, Bryan Fitzgerald, Ajay Dhakal. Impact of early dose reduction of palbociclib on clinical outcomes in patients with hormone-receptor positive metastatic breast cancer [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 P1-19-23.

Efficacy and toxicities of immune checkpoint inhibitors (ICIs) in advanced melanoma: A single institution experience

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Background: Historically, the prognosis of advanced melanoma has been poor. Recent landmark studies (KEYNOTE-006, CheckMate 066, CheckMate 037 and CheckMate 067) have shown significant improvement in outcomes of patients with advanced melanoma treated with ICIs. In a single institution retrospective study, we evaluated the efficacy and toxicities of ICIs in patients with advanced melanoma treated in real-world clinical practice. Methods: We included patients who received pembrolizumab (PEMBRO), nivolumab (NIVO), or ipilimumab plus nivolumab (IPI/NIVO) at the University of Rochester Medical Center from June 2015 to December 2018. Patient- and cancer-related characteristics were collected and compared between treatment groups. Outcomes including duration of treatment, response rates, and adverse events (AEs) were captured. Progression free survival (PFS) and overall survival (OS) were summarized using the Kaplan-Meier method. Results: We included 89 patients (55 received PEMBRO, 20 received NIVO, and 14 received IPI/NIVO); median age at ICI initiation was 68 years (range, 28-92) and 29% had Eastern Cooperative Oncology Group Performance Status (ECOG PS) of ≥2. Forty-five patients (51%) had ≥2 co-morbidities. Nine patients (10%) had autoimmune diseases prior to initiating ICIs and 34 patients (38%) had brain metastasis. ICIs were given as first line in 71 patients (80%). Compared to those who received PEMBRO or NIVO, patients who received IPI/NIVO were younger (median age was 61 vs.71 vs. 70, p=0.003) and had better ECOG PS (ECOG PS ≥2 was 0% vs. 40% vs. 33%, p=0.007). Table shows the outcomes for the three groups. Conclusions: Patients with advanced melanoma treated with ICIs derived similar response rates to those seen in published landmark studies. However, median OS was shorter (range was 38 months to not reached in published studies). [Table: see text]

Evaluating end-of-life (EOL) care at the University of Rochester Medical Center (URMC) using quality oncology practice initiative (QOPI) metrics

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Background: Inpatient mortality, defined as death within 30 days of an acute hospital admission, is often used as a quality benchmark for healthcare institutions and is an important metric for evaluating quality of care of patients with advanced malignancies. In this study we aimed to utilize QOPI performance data to identify areas of weakness in our practice that may contribute to inpatient mortality. Methods: We analyzed 11 EOL measures within the QOPI database which we collected between 2015 and 2018. These included all EOL measures related to hospice enrollment (measure IDs 42-47), chemotherapy administered within the last 2 weeks of life (ID 48), percentage of patients who died from cancer with at least one emergency department (ED) visit in the last 30 days of life (ID 49ed), and the percentage of patients who died from cancer admitted to the Intensive Care Unit (ICU) in the last 30 days of life (ID 49icu). Our rate was calculated for each measure and compared against QOPI aggregate data. We used a fisher’s exact test to determine statistical significance for each metric. Results: The number of patients from our institution included in each analysis ranged from 27 to 46. Compared to our peers, patients treated at our institution were more likely to visit an ED in the last 30 days of life (68% vs. 32%; P < 0.0001), more likely to be admitted to the ICU in the last 30 days of life (29% vs. 9%; P = 0.0003), and more likely to be enrolled on hospice within the last 7 days of death (63% vs. 32%; P = 0.001). Conclusions: Analysis of QOPI EOL performance scores identified several metrics that may contribute to inpatient mortality at URMC. Ongoing participation in QOPI with a focus on EOL metrics will strengthen this analysis. We plan to use this data to guide quality improvement initiatives aimed at reducing impatient mortality and improving end of life care at our institution.