Delayed Solid Tumor Presentations in Adolescent and Young Adults Patients in the Bronx

Adolescent and young adults (AYAs) require support from their parents and caregivers. While there are formal programs available for patients with complex medical problems, <20% of pediatric practices are performing transition readiness processes in patients aged 12-17 years to effective transition. Although cancer is the most common cause of disease-related death in AYAs in high-income countries, AYA oncology patients have not attained the same clinical improvements as pediatric patients, and their outcomes remain poorer. While there are published data on an expected degree of lag time for patients presenting with solid tumors, due to the underlying biology and slow growth of the cancer, we have recently witnessed extreme delays in the presentation to medical care. In this article, we share the cases of two young adults.

A nine-month-old boy with regression of milestones and severe constipation: an unusual case of a large spinal NTRK1 fusion pilocytic astrocytoma

INTRODUCTION

Pilocytic astrocytoma, a World Health Organization grade 1 tumor, is the most common brain tumor in children between 5 and 14 years of age and the second most common in children younger than 5 and older than 14. Although classical to the cerebellum and hypothalamic regions, it can also arise in the spinal cord. Larotrectinib, a selective inhibitor of tropomyosin receptor kinase, has been effective in pediatric tumors with NTRK fusion mutations in children as young as 1-month-old.

CASE

We share the case of a 9-month-old boy who presented with a 4-month history of regression of his milestones and severe constipation who was found to have a large spinal pilocytic astrocytoma with multiple intracranial periventricular lesions.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative

PURPOSE

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes.

MATERIALS AND METHODS

A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions.

RESULTS

Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p = .001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p = .059), from 0.71 to 0.78 for signs of sepsis (p = .65), from 0.57 to 1.00 for accurate choice of on-call number (p = .004), and from 0.71 to 0.94 for antiemetic management (p = .14).

CONCLUSION

Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

Omicron variant of SARS-CoV-2, an epidemiologic assessment of pediatric oncology patients in the Bronx

BACKGROUND

Children receiving cytotoxic therapy for cancer have increased risk of infection due to drug-induced neutropenia and are therefore treated empirically for bacteremia when febrile or ill-appearing. However, viral infections, which are not frequently life-threatening, are the most common etiology of febrile episodes and there has been increased effort to differentiate patients who may have a higher risk for adverse outcomes.

CASE

We performed a retrospective chart review of pediatric oncology patients diagnosed with COVID-19 between December 20, 2021 and February 22, 2022 during the Omicron (B.1.1.529) surge at The Children's Hospital at Montefiore, a tertiary care center in the Bronx.

CONCLUSION

We found that no patients in our cohort developed respiratory distress, bacteremia, or serious illness after COVID-19 infection during the Omicron surge. Future studies will aid in understanding the relationship between community-acquired infections and bacteremia, and this knowledge can then be applied to develop optimal infection prevention clinical care guidelines.

Abstract 6211: Targeting the tumor microenvironment of metastasis to treat metastatic Ewing sarcoma

Introduction: Ewing sarcoma (EWS) is the second most common bone cancer in adolescents and young adults. Intensive multimodal treatment cures almost 75% of patients who present with localized disease. However, only 25% of patients who present with metastases become long term survivors, and those who suffer a metastatic relapse are almost never cured. Recently, a 3-cell assembly consisting of an invasive cancer cell, a Tie2-high expressing macrophage, and an endothelial cell (termed the Tumor Microenvironment of Metastasis, or TMEM), has been described as the doorway through which breast cancer cells enter the vasculature and disseminate to distant sites. We hypothesized that EWS cells use a similar mechanism for dissemination, and that targeting TMEM offers a novel therapeutic opportunity to prevent metastatic recurrence.

Methods: Formalin-fixed, paraffin embedded tissue samples were obtained from 16 patients with EWS treated at our institution, and these were evaluated for the presence of TMEM structures by immunohistochemistry. We also evaluated samples obtained from our novel, clinically relevant murine model of spontaneous distant EWS metastasis. Fragments of EWS either from cell line-derived tumors or patient-derived xenografts (PDX) orthotopically or subcutaneously. After tumors grew, mice were injected with fluorescent dextran in the tail vein and tumors harvested 60 minutes later. Intravascular dextran remains inside blood vessels because the molecular weight is too large to allow diffusion between endothelial cells. As TMEM disrupts the endothelial barrier, dextran leaks out of blood vessels and can be detected and quantified using fluorescence microscopy. Tumors were evaluated for the presence of TMEM structures by immunohistochemistry (IHC), and for the presence of localized vascular leakiness, (the hallmark of functional TMEM), by fluorescence microscopy.

Results: We found TMEM assemblies in all patient samples, at numbers well in excess of those seen in samples of metastatic breast cancer. Interestingly, although there was no difference in TMEM counts from patients who were survivors compared with those who died from metastatic disease, there was an increase in TMEM counts in samples from tumors that were exposed to chemotherapy compared to diagnostic biopsy samples, something also reported in breast cancer patients. We also identified TMEM assemblies and localized vascular leakiness in EWS PDX tumors implanted orthotopically.

Discussion: TMEM assemblies are present in both EWS patient samples and PDX models, suggesting that this important mechanism of tumor intravasation into the vasculature may be contributing to distant metastasis. Future work will focus on identifying drugs that inhibit the function of TMEM, with the goal of translating this work into clinical trials aimed at diminishing the burden of metastasis in EWS patients.

Citation Format: Rachel Offenbacher, Yu Lin, George Karagiannis, Maja Oktay, David Loeb. Targeting the tumor microenvironment of metastasis to treat metastatic Ewing sarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6211.

LGG-05. A Nine-month-old Boy with Regression of Milestones and Severe Constipation: An Unusual Case of a Spinal Pilocytic Astrocytoma

Pilocytic astrocytoma (PA), a World Health Organization Grade 1 tumor, is the most common brain tumor in children between 5 and 14 years of age and the second most common in children younger than 5 and older than 14. Although classical to the cerebellum and hypothalamic regions, it can also arise in the spinal cord. A nine-month-old boy with a history of torticollis and plagiocephaly presented with a four-month history of regression of milestones, irritability and severe constipation. He was noted to have flaccid paralysis of the lower extremities and decreased reflexes. Ophthalmologic exam was significant for papilledema and magnetic resonance imaging of the spine were notable for a large infiltrative heterogeneously enhancing lesion extending from T4 to the conus containing several loculated intratumoral cysts with abnormal enhancing margins from T4 to T8. He underwent embolization and complete tumor resection. Post-op MRI was notable for an oval shape non-enhancing soft tissue measuring 8 mm along the medial wall of the left lateral ventricle. Comprehensive tumor molecular profiling on the resected spinal tumor tissue (Caris MI), revealed an NTRK1 fusion, MEF2D-NTRK1, Exon 12. Larotrectinib was initiated at 100mg/m2 per dose oral twice daily to target this specific mutation. Follow up imaging 3 months later showed decrease in the size of intracranial lesions. To date, there is only one other case report demonstrating intracranial metastasis from a spinal PA. Due to the size of his spinal lesion, we believe this was his primary site; however, as described in the literature, there is no definitive way to determine the initiating lesion. The use of comprehensive molecular profiling facilitated the discovery of a targetable oncogenic mutation that changed initial management. To the best of our knowledge there has been only one other case report describing this specific fusion in a pediatric spinal CNS tumor.

Respiratory Failure in a Child With Pulmonary Metastatic Osteosarcoma and COVID-19

The novel coronavirus, SARS-CoV-2, causes much more severe disease in adults than in children. Although it is anticipated that immune compromised children and children with cancer may be at higher risk of developing severe or fatal COVID-19, there are no currently published reports of fatal disease in a child with cancer. Because of the discrepancy in disease severity between adult and pediatric patients, we report the case of an adolescent with pulmonary metastatic osteosarcoma who died of COVID-19 early in the course of the pandemic in New York City in the hope that heightening awareness that pulmonary metastatic disease may predispose to a more severe outcome will increase surveillance in this vulnerable population.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions

BACKGROUND

One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit.

METHODS

An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions.

RESULTS

A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation.

CONCLUSIONS

Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

An 8-Year-Old Boy With Fever, Splenomegaly, and Pancytopenia

An 8-year-old boy with no significant past medical history presented to his pediatrician with 5 days of fever, diffuse abdominal pain, and pallor. The pediatrician referred the patient to the emergency department (ED), out of concern for possible malignancy. Initial vital signs indicated fever, tachypnea, and tachycardia. Physical examination was significant for marked abdominal distension, hepatosplenomegaly, and abdominal tenderness in the right upper and lower quadrants. Initial laboratory studies were notable for pancytopenia as well as an elevated erythrocyte sedimentation rate and C-reactive protein. Computed tomography (CT) of the abdomen and pelvis showed massive splenomegaly. The only significant history of travel was immigration from Albania 10 months before admission. The patient was admitted to a tertiary care children's hospital and was evaluated by hematology-oncology, infectious disease, genetics, and rheumatology subspecialty teams. Our multidisciplinary panel of experts will discuss the evaluation of pancytopenia with apparent multiorgan involvement and the diagnosis and appropriate management of a rare disease.

Systemic manifestations of extraskeletal myxoid chondrosarcoma associated with a novel t(2;22)(q34;q12) EWS translocation in a child and a review of the literature

Extraskeletal myxoid chondrosarcoma (EMC), a soft-tissue sarcoma with unique clinicopathologic features and characteristic chromosomal translocations, is extremely rare in the pediatric population. We, herein, present the case of a 7-year-old boy with profound microcytic hypochromic anemia, poor weight gain and a mid-thoracic paraspinal mass that was identified as EMC. Systemic manifestations of localized, nonmetastatic EMC have never been described in the pediatric population, yet our patient's anemia and poor weight gain resolved after successful surgical resection of the tumor, suggesting that localized EMC can present with systemic manifestations. The tumor also contained a novel t(2;22)(q34;q12) translocation involving the EWSR1 gene, which is consistent with additional reports suggesting that a growing list of translocations can drive formation of, and potential new management strategies for, EMC.