Article

PURPOSE

To improve the time to release of blood products for patients with severe or life-threatening bleeding.

BACKGROUND

Exsanguination, and the resultant coagulopathy, is the number one cause of trauma-related death. Massive transfusion protocols (MTP) improve mortality by shortening the time to transfusion and correcting coagulopathy. Many patients do not meet criteria for massive transfusion (> 10 units RBCs in 24 hours), yet present with clinical instability and require rapid release (RR) of uncrossmatched blood. A quality improvement initiative was performed to identify barriers to the MTP/RR protocol at a single institution.

METHODS/DATA

A multidisciplinary subcommittee was formed to evaluate the safety and efficacy of the current MTP/RR process. Timed mock-MTP/RR trials were conducted to identify areas of delay with a goal to achieve a blood to bedside (B2B) time of under 10 minutes.

RESULTS

Timed mock-MTP/RR trials were conducted, which revealed a baseline B2B time of approximately 30 minutes. We identified problems and categorized them in terms of ordering (phase 1) and processing (phase 2). We found significant delays in phase 1. Reasons for delay were varied and included difficulty logging into the computer, staff unavailable to place orders (involved in resuscitation efforts), orders entered incorrectly, etc. Once orders were received, the blood bank could process them quickly in phase 2. Using root cause analysis, we discovered a critical step was to remove the barrier of electronic ordering. For this, a new process was developed in which the blood bank could accept verbal orders to release uncrossmatched blood during a medical emergency. Over the course of one year, a new policy for MTP/RR was drafted, an education training video was recorded, informational flyers were printed, and training drills were conducted. A repeat mock-MTP/RR scenario was performed after the change showing the B2B time was reduced by 90% from pre-intervention values to under 3 minutes. Since implementation, no new safety signals have been received, and the staff have reported improved satisfaction with the MTP/RR process.

IMPLICATIONS

A critical piece of any MTP/RR is the immediate availability of blood. Allowing verbal orders for blood products reduced time to transfusion by 90%. Through multidisciplinary effort, safe and efficient release of uncrossmatched blood products for nontraumatic massive transfusion can be achieved.

PURPOSE

To improve the time to release of blood products for patients with severe or life-threatening bleeding.

BACKGROUND

Exsanguination, and the resultant coagulopathy, is the number one cause of trauma-related death. Massive transfusion protocols (MTP) improve mortality by shortening the time to transfusion and correcting coagulopathy. Many patients do not meet criteria for massive transfusion (> 10 units RBCs in 24 hours), yet present with clinical instability and require rapid release (RR) of uncrossmatched blood. A quality improvement initiative was performed to identify barriers to the MTP/RR protocol at a single institution.

METHODS/DATA

A multidisciplinary subcommittee was formed to evaluate the safety and efficacy of the current MTP/RR process. Timed mock-MTP/RR trials were conducted to identify areas of delay with a goal to achieve a blood to bedside (B2B) time of under 10 minutes.

RESULTS

Timed mock-MTP/RR trials were conducted, which revealed a baseline B2B time of approximately 30 minutes. We identified problems and categorized them in terms of ordering (phase 1) and processing (phase 2). We found significant delays in phase 1. Reasons for delay were varied and included difficulty logging into the computer, staff unavailable to place orders (involved in resuscitation efforts), orders entered incorrectly, etc. Once orders were received, the blood bank could process them quickly in phase 2. Using root cause analysis, we discovered a critical step was to remove the barrier of electronic ordering. For this, a new process was developed in which the blood bank could accept verbal orders to release uncrossmatched blood during a medical emergency. Over the course of one year, a new policy for MTP/RR was drafted, an education training video was recorded, informational flyers were printed, and training drills were conducted. A repeat mock-MTP/RR scenario was performed after the change showing the B2B time was reduced by 90% from pre-intervention values to under 3 minutes. Since implementation, no new safety signals have been received, and the staff have reported improved satisfaction with the MTP/RR process.

IMPLICATIONS

A critical piece of any MTP/RR is the immediate availability of blood. Allowing verbal orders for blood products reduced time to transfusion by 90%. Through multidisciplinary effort, safe and efficient release of uncrossmatched blood products for nontraumatic massive transfusion can be achieved.

PURPOSE

To improve the time to release of blood products for patients with severe or life-threatening bleeding.

BACKGROUND

Exsanguination, and the resultant coagulopathy, is the number one cause of trauma-related death. Massive transfusion protocols (MTP) improve mortality by shortening the time to transfusion and correcting coagulopathy. Many patients do not meet criteria for massive transfusion (> 10 units RBCs in 24 hours), yet present with clinical instability and require rapid release (RR) of uncrossmatched blood. A quality improvement initiative was performed to identify barriers to the MTP/RR protocol at a single institution.

METHODS/DATA

A multidisciplinary subcommittee was formed to evaluate the safety and efficacy of the current MTP/RR process. Timed mock-MTP/RR trials were conducted to identify areas of delay with a goal to achieve a blood to bedside (B2B) time of under 10 minutes.

RESULTS

Timed mock-MTP/RR trials were conducted, which revealed a baseline B2B time of approximately 30 minutes. We identified problems and categorized them in terms of ordering (phase 1) and processing (phase 2). We found significant delays in phase 1. Reasons for delay were varied and included difficulty logging into the computer, staff unavailable to place orders (involved in resuscitation efforts), orders entered incorrectly, etc. Once orders were received, the blood bank could process them quickly in phase 2. Using root cause analysis, we discovered a critical step was to remove the barrier of electronic ordering. For this, a new process was developed in which the blood bank could accept verbal orders to release uncrossmatched blood during a medical emergency. Over the course of one year, a new policy for MTP/RR was drafted, an education training video was recorded, informational flyers were printed, and training drills were conducted. A repeat mock-MTP/RR scenario was performed after the change showing the B2B time was reduced by 90% from pre-intervention values to under 3 minutes. Since implementation, no new safety signals have been received, and the staff have reported improved satisfaction with the MTP/RR process.

IMPLICATIONS

A critical piece of any MTP/RR is the immediate availability of blood. Allowing verbal orders for blood products reduced time to transfusion by 90%. Through multidisciplinary effort, safe and efficient release of uncrossmatched blood products for nontraumatic massive transfusion can be achieved.

BACKGROUND

Cancer risk assessment and genetic counseling are the processes to identify and counsel people at risk for familial or hereditary cancer syndromes. They serve to inform, educate and empower patients and family members to make informed decisions about testing, cancer screening, and prevention. Additionally, genetic testing can also provide therapeutic options and opportunities for research.

METHODS

Prior to this program initiative, there were no cancer genetics services available at the VA Pittsburgh Medical Center (VAPHS) and 100% of genetics consults were referred to the community. Each year over $100,000 was spent outside of VAPHS on genetic testing and counseling. Community care referral resulted in fragmented care, prolonged wait times of 3 to 5 months, communication issues, and added financial cost to the institution. Corporal Michael J. Crescenz VA Medical Center (CMCVAMC) had previously created a genetics consultation service staffed with an advanced practice nurse that increased access to genetics services and testing rates at the facility-level. VAPHS recently established an interfacility telegenetics clinic with CMCVAMC to provide virtual genetic counseling services to Veterans at VAPHS. Under this program, VAPHS providers place an interfacility consult for Veterans who need cancer genetics services. The consult is received and reviewed by the CMCVAMC team. VAPHS patients are then seen by CMCVAMC providers via VVC or CVT and provide recommendations regarding additional genetic testing and follow-up.

RESULTS

The telegenetics clinic opened in October 2022. The clinic initially focused on patients with metastatic prostate cancer but has since expanded to provide care for all patients for whom genetics testing and/ or counseling is recommended by NCCN guidelines. Since initiation, 29 consults have been placed and 26 have been completed or are in process (89.6%). In the year prior to creation of the clinic, only 31 of 67 (46%) of referred patients completed genetics evaluation.

CONCLUSIONS

Due to the success of the clinic, plans to expand services to the VISN-level and within VAPHS to include high risk breast cancer assessment are underway. Efforts to provide genetic counseling services via virtual care modalities have the potential to increase access to care and to improve outcomes for veterans with cancer.

BACKGROUND

Cancer risk assessment and genetic counseling are the processes to identify and counsel people at risk for familial or hereditary cancer syndromes. They serve to inform, educate and empower patients and family members to make informed decisions about testing, cancer screening, and prevention. Additionally, genetic testing can also provide therapeutic options and opportunities for research.

METHODS

Prior to this program initiative, there were no cancer genetics services available at the VA Pittsburgh Medical Center (VAPHS) and 100% of genetics consults were referred to the community. Each year over $100,000 was spent outside of VAPHS on genetic testing and counseling. Community care referral resulted in fragmented care, prolonged wait times of 3 to 5 months, communication issues, and added financial cost to the institution. Corporal Michael J. Crescenz VA Medical Center (CMCVAMC) had previously created a genetics consultation service staffed with an advanced practice nurse that increased access to genetics services and testing rates at the facility-level. VAPHS recently established an interfacility telegenetics clinic with CMCVAMC to provide virtual genetic counseling services to Veterans at VAPHS. Under this program, VAPHS providers place an interfacility consult for Veterans who need cancer genetics services. The consult is received and reviewed by the CMCVAMC team. VAPHS patients are then seen by CMCVAMC providers via VVC or CVT and provide recommendations regarding additional genetic testing and follow-up.

RESULTS

The telegenetics clinic opened in October 2022. The clinic initially focused on patients with metastatic prostate cancer but has since expanded to provide care for all patients for whom genetics testing and/ or counseling is recommended by NCCN guidelines. Since initiation, 29 consults have been placed and 26 have been completed or are in process (89.6%). In the year prior to creation of the clinic, only 31 of 67 (46%) of referred patients completed genetics evaluation.

CONCLUSIONS

Due to the success of the clinic, plans to expand services to the VISN-level and within VAPHS to include high risk breast cancer assessment are underway. Efforts to provide genetic counseling services via virtual care modalities have the potential to increase access to care and to improve outcomes for veterans with cancer.

BACKGROUND

Cancer risk assessment and genetic counseling are the processes to identify and counsel people at risk for familial or hereditary cancer syndromes. They serve to inform, educate and empower patients and family members to make informed decisions about testing, cancer screening, and prevention. Additionally, genetic testing can also provide therapeutic options and opportunities for research.

METHODS

Prior to this program initiative, there were no cancer genetics services available at the VA Pittsburgh Medical Center (VAPHS) and 100% of genetics consults were referred to the community. Each year over $100,000 was spent outside of VAPHS on genetic testing and counseling. Community care referral resulted in fragmented care, prolonged wait times of 3 to 5 months, communication issues, and added financial cost to the institution. Corporal Michael J. Crescenz VA Medical Center (CMCVAMC) had previously created a genetics consultation service staffed with an advanced practice nurse that increased access to genetics services and testing rates at the facility-level. VAPHS recently established an interfacility telegenetics clinic with CMCVAMC to provide virtual genetic counseling services to Veterans at VAPHS. Under this program, VAPHS providers place an interfacility consult for Veterans who need cancer genetics services. The consult is received and reviewed by the CMCVAMC team. VAPHS patients are then seen by CMCVAMC providers via VVC or CVT and provide recommendations regarding additional genetic testing and follow-up.

RESULTS

The telegenetics clinic opened in October 2022. The clinic initially focused on patients with metastatic prostate cancer but has since expanded to provide care for all patients for whom genetics testing and/ or counseling is recommended by NCCN guidelines. Since initiation, 29 consults have been placed and 26 have been completed or are in process (89.6%). In the year prior to creation of the clinic, only 31 of 67 (46%) of referred patients completed genetics evaluation.

CONCLUSIONS

Due to the success of the clinic, plans to expand services to the VISN-level and within VAPHS to include high risk breast cancer assessment are underway. Efforts to provide genetic counseling services via virtual care modalities have the potential to increase access to care and to improve outcomes for veterans with cancer.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

BACKGROUND

As of May 2023, the Veterans Affairs (VA) National Precision Oncology Program (NPOP) has provided somatic molecular testing for nearly 36,000 Veterans with cancer. Automated tools to monitor test use (locally and nationally) have only been available for NGS testing in advanced stage lung and prostate cancer. To better track utilization of NPOP supported testing across all cancer indications, and to support strategies to promote wider adoption, we developed an automated data architecture to monitor program operations. Here, we describe the development of the NPOP data mart and summarize the core components of the NPOP Somatic Molecular Testing dashboards.

METHODS

SQL Server Integration Services was used to build the backend data mart, which required the ingestion of vendor-specific XML data and subsequent harmonization with data found in the VA’s Corporate Data Warehouse (CDW). The NPOP somatic testing dashboards, developed using Power BI, are securely hosted in the cloud, and accessible through SharePoint.

DATA ANALYSIS

The NPOP dashboard suite displays key measures using descriptive statistics, including counts, proportions, means, medians, and standard deviations. To support the visualization of comparisons we leveraged stacked and clustered bar charts, and violin plots.

RESULTS

The NPOP data mart refreshes nightly providing users with near real-time data. The NPOP somatic testing dashboards include an all vendor combined report and sub-reports organized by vendors: Foundation Medicine, Personalis, and Personal Genome Diagnostics and Tempus. All reports contain four views with the ability to toggle between tests ordered or completed. For current NPOP vendors, patient level data and turnaround time views were developed. Data are stratified by test category (i.e., NGS Solid, NGS Liquid, Heme, IHC) and can be viewed longitudinally (i.e., across time) and filtered by test date, VA facility, patient demographics, and cancer characteristics (diagnosis, stage). To date, over 50,000 tests have been ordered (90% through Foundation Medicine).

IMPLICATIONS

The NPOP data mart and operational dashboards synthesizes vast amounts of data into a visually consumable format that supports monitoring the uptake and variation of somatic molecular testing services being offered across the VA.

BACKGROUND

As of May 2023, the Veterans Affairs (VA) National Precision Oncology Program (NPOP) has provided somatic molecular testing for nearly 36,000 Veterans with cancer. Automated tools to monitor test use (locally and nationally) have only been available for NGS testing in advanced stage lung and prostate cancer. To better track utilization of NPOP supported testing across all cancer indications, and to support strategies to promote wider adoption, we developed an automated data architecture to monitor program operations. Here, we describe the development of the NPOP data mart and summarize the core components of the NPOP Somatic Molecular Testing dashboards.

METHODS

SQL Server Integration Services was used to build the backend data mart, which required the ingestion of vendor-specific XML data and subsequent harmonization with data found in the VA’s Corporate Data Warehouse (CDW). The NPOP somatic testing dashboards, developed using Power BI, are securely hosted in the cloud, and accessible through SharePoint.

DATA ANALYSIS

The NPOP dashboard suite displays key measures using descriptive statistics, including counts, proportions, means, medians, and standard deviations. To support the visualization of comparisons we leveraged stacked and clustered bar charts, and violin plots.

RESULTS

The NPOP data mart refreshes nightly providing users with near real-time data. The NPOP somatic testing dashboards include an all vendor combined report and sub-reports organized by vendors: Foundation Medicine, Personalis, and Personal Genome Diagnostics and Tempus. All reports contain four views with the ability to toggle between tests ordered or completed. For current NPOP vendors, patient level data and turnaround time views were developed. Data are stratified by test category (i.e., NGS Solid, NGS Liquid, Heme, IHC) and can be viewed longitudinally (i.e., across time) and filtered by test date, VA facility, patient demographics, and cancer characteristics (diagnosis, stage). To date, over 50,000 tests have been ordered (90% through Foundation Medicine).

IMPLICATIONS

The NPOP data mart and operational dashboards synthesizes vast amounts of data into a visually consumable format that supports monitoring the uptake and variation of somatic molecular testing services being offered across the VA.

BACKGROUND

As of May 2023, the Veterans Affairs (VA) National Precision Oncology Program (NPOP) has provided somatic molecular testing for nearly 36,000 Veterans with cancer. Automated tools to monitor test use (locally and nationally) have only been available for NGS testing in advanced stage lung and prostate cancer. To better track utilization of NPOP supported testing across all cancer indications, and to support strategies to promote wider adoption, we developed an automated data architecture to monitor program operations. Here, we describe the development of the NPOP data mart and summarize the core components of the NPOP Somatic Molecular Testing dashboards.

METHODS

SQL Server Integration Services was used to build the backend data mart, which required the ingestion of vendor-specific XML data and subsequent harmonization with data found in the VA’s Corporate Data Warehouse (CDW). The NPOP somatic testing dashboards, developed using Power BI, are securely hosted in the cloud, and accessible through SharePoint.

DATA ANALYSIS

The NPOP dashboard suite displays key measures using descriptive statistics, including counts, proportions, means, medians, and standard deviations. To support the visualization of comparisons we leveraged stacked and clustered bar charts, and violin plots.

RESULTS

The NPOP data mart refreshes nightly providing users with near real-time data. The NPOP somatic testing dashboards include an all vendor combined report and sub-reports organized by vendors: Foundation Medicine, Personalis, and Personal Genome Diagnostics and Tempus. All reports contain four views with the ability to toggle between tests ordered or completed. For current NPOP vendors, patient level data and turnaround time views were developed. Data are stratified by test category (i.e., NGS Solid, NGS Liquid, Heme, IHC) and can be viewed longitudinally (i.e., across time) and filtered by test date, VA facility, patient demographics, and cancer characteristics (diagnosis, stage). To date, over 50,000 tests have been ordered (90% through Foundation Medicine).

IMPLICATIONS

The NPOP data mart and operational dashboards synthesizes vast amounts of data into a visually consumable format that supports monitoring the uptake and variation of somatic molecular testing services being offered across the VA.

INTRODUCTION

Prostate cancer rarely metastasizes to the pituitary gland and the close relationship of these sellar masses to cavernous sinuses and major vessels makes management challenging. We describe a unique case of complete reversal of ptosis in metastatic prostate cancer presenting as cavernous sinus syndrome

CASE REPORT

A 76-year-old male presented with left diplopia, ptosis, and facial numbness. Examination showed left oculomotor palsy and numbness in the V1 and V2 distribution of trigeminal nerve. MRI revealed an 11 × 26 × 17 mm posterior sellar mass extending into the left cavernous sinus. Prolactin was slightly elevated, but rest of the pituitary hormones were normal. Resection of the sellar mass showed metastatic prostatic adenocarcinoma positive for NKX-3.1 and prostate-specific antigen (PSA), and Gleason score 4. PSA was elevated at 32 ng/ mL. Positron emission tomography (PET) showed lesions in the left prostatic lobe, pelvic lymph nodes, L5 spine, and right femoral head. FoundationOne testing found no actionable mutations. He was started on leuprorelin-docetaxel and received radiation for the brain and bony lesions. He is currently being maintained on leuprorelin-abiraterone and prednisone, which he is tolerating well.

DISCUSSION

Pituitary metastases (PMs) from prostate cancer are rare and are usually confined to the posterior pituitary. The close relationship of pituitary masses to the cavernous sinuses and internal carotid artery can lead to catastrophic neurovascular consequences. Imaging has limited sensitivity for differentiating non-invasive metastases from adenomas. Older age, new-onset diabetes insipidus, invasive masses, and rapidly growing lesions should raise suspicion for PMs. Intracranial prostatic metastases indicate poor prognosis with a reported median survival of 6-10 months. Timely diagnosis and management can prevent permanent neurologic damage as illustrated by our case in which ptosis and extraocular symptoms were completely resolved by surgery and radiation. Such unique cases underline the significance of suspecting metastatic disease in appropriate demographic groups and the crucial role of multidisciplinary care for oncologic patients.

CONCLUSIONS

A high index of suspicion for PMs in elderly people with new-onset sellar symptoms and early involvement of multidisciplinary teams can lead to prevention and even reversal of serious neurologic symptoms.

INTRODUCTION

Prostate cancer rarely metastasizes to the pituitary gland and the close relationship of these sellar masses to cavernous sinuses and major vessels makes management challenging. We describe a unique case of complete reversal of ptosis in metastatic prostate cancer presenting as cavernous sinus syndrome

CASE REPORT

A 76-year-old male presented with left diplopia, ptosis, and facial numbness. Examination showed left oculomotor palsy and numbness in the V1 and V2 distribution of trigeminal nerve. MRI revealed an 11 × 26 × 17 mm posterior sellar mass extending into the left cavernous sinus. Prolactin was slightly elevated, but rest of the pituitary hormones were normal. Resection of the sellar mass showed metastatic prostatic adenocarcinoma positive for NKX-3.1 and prostate-specific antigen (PSA), and Gleason score 4. PSA was elevated at 32 ng/ mL. Positron emission tomography (PET) showed lesions in the left prostatic lobe, pelvic lymph nodes, L5 spine, and right femoral head. FoundationOne testing found no actionable mutations. He was started on leuprorelin-docetaxel and received radiation for the brain and bony lesions. He is currently being maintained on leuprorelin-abiraterone and prednisone, which he is tolerating well.

DISCUSSION

Pituitary metastases (PMs) from prostate cancer are rare and are usually confined to the posterior pituitary. The close relationship of pituitary masses to the cavernous sinuses and internal carotid artery can lead to catastrophic neurovascular consequences. Imaging has limited sensitivity for differentiating non-invasive metastases from adenomas. Older age, new-onset diabetes insipidus, invasive masses, and rapidly growing lesions should raise suspicion for PMs. Intracranial prostatic metastases indicate poor prognosis with a reported median survival of 6-10 months. Timely diagnosis and management can prevent permanent neurologic damage as illustrated by our case in which ptosis and extraocular symptoms were completely resolved by surgery and radiation. Such unique cases underline the significance of suspecting metastatic disease in appropriate demographic groups and the crucial role of multidisciplinary care for oncologic patients.

CONCLUSIONS

A high index of suspicion for PMs in elderly people with new-onset sellar symptoms and early involvement of multidisciplinary teams can lead to prevention and even reversal of serious neurologic symptoms.

INTRODUCTION

Prostate cancer rarely metastasizes to the pituitary gland and the close relationship of these sellar masses to cavernous sinuses and major vessels makes management challenging. We describe a unique case of complete reversal of ptosis in metastatic prostate cancer presenting as cavernous sinus syndrome

CASE REPORT

A 76-year-old male presented with left diplopia, ptosis, and facial numbness. Examination showed left oculomotor palsy and numbness in the V1 and V2 distribution of trigeminal nerve. MRI revealed an 11 × 26 × 17 mm posterior sellar mass extending into the left cavernous sinus. Prolactin was slightly elevated, but rest of the pituitary hormones were normal. Resection of the sellar mass showed metastatic prostatic adenocarcinoma positive for NKX-3.1 and prostate-specific antigen (PSA), and Gleason score 4. PSA was elevated at 32 ng/ mL. Positron emission tomography (PET) showed lesions in the left prostatic lobe, pelvic lymph nodes, L5 spine, and right femoral head. FoundationOne testing found no actionable mutations. He was started on leuprorelin-docetaxel and received radiation for the brain and bony lesions. He is currently being maintained on leuprorelin-abiraterone and prednisone, which he is tolerating well.

DISCUSSION

Pituitary metastases (PMs) from prostate cancer are rare and are usually confined to the posterior pituitary. The close relationship of pituitary masses to the cavernous sinuses and internal carotid artery can lead to catastrophic neurovascular consequences. Imaging has limited sensitivity for differentiating non-invasive metastases from adenomas. Older age, new-onset diabetes insipidus, invasive masses, and rapidly growing lesions should raise suspicion for PMs. Intracranial prostatic metastases indicate poor prognosis with a reported median survival of 6-10 months. Timely diagnosis and management can prevent permanent neurologic damage as illustrated by our case in which ptosis and extraocular symptoms were completely resolved by surgery and radiation. Such unique cases underline the significance of suspecting metastatic disease in appropriate demographic groups and the crucial role of multidisciplinary care for oncologic patients.

CONCLUSIONS

A high index of suspicion for PMs in elderly people with new-onset sellar symptoms and early involvement of multidisciplinary teams can lead to prevention and even reversal of serious neurologic symptoms.

INTRODUCTION

Leptomeningeal metastasis (LM) is an extremely rare complication of gastroesophageal (GE) cancer. Diagnosis is challenging due to frequently nonspecific clinical presentations, limited sensitivity of diagnostic testing, and potential overlap with neurologic immune-related adverse events (irAE). We describe a case of metastatic gastroesophageal cancer on immunotherapy presenting with LM masquerading as polyneuropathy.

CASE REPORT

A 74-year-old male with HER2+ GE junction cancer with peritoneal metastases diagnosed 6 months ago, on maintenance trastuzumab/pembrolizumab and with no previous history of cranial or spinal disease, presented with worsening ataxia, headache, and diplopia for one month with multiple negative outpatient MRIs. Examination showed left abducens nerve palsy, dysmetria and absent deep tendon reflexes in upper and lower extremities. CT head was unremarkable, and MRI showed non-specific mild enhancement of the right optic nerve, symmetrical lumbosacral nerve roots and cauda equina concerning for paraneoplastic versus immunotherapy-related polyneuropathy. He was started on empiric high-dose corticosteroids. PET-CT was negative for FDG-avid lesions. Cerebrospinal fluid (CSF) analysis revealed moderate pleocytosis with many large atypical cells, elevated protein (118 mg/dL) and LDH (28 IU/L). Immunohistochemistry was positive for CDX2, CA 19-9, CK7, and pankeratin, consistent with metastatic adenocarcinoma, negative for HER2 in contrast to the original tumor. He subsequently developed hydrocephalus requiring a ventriculoperitoneal shunt. He received ten fractions of whole brain irradiation before electing to pursue hospice care.

DISCUSSION

LM is an extremely rare complication of GE cancer with an incidence of <0.2% and carries a poor prognosis. Differentiation between LM and irAE in patients on immunotherapy can be challenging. Diagnosis relies mostly on CSF cytology, and lumbar puncture should not be delayed in patients with new neurologic symptoms. Treatment options are intrathecal chemotherapy, radiation and steroids. A recent phase II trial has shown promise for intrathecal trastuzumab in patients with HER2+ cancers, but options for HER2 negative disease remain mostly palliative.

CONCLUSIONS

Our case highlights the need for suspecting this rare metastatic site, as early diagnosis and genetic characterization allow for exploring more treatment options including targeted therapies which may improve overall survival and quality of life.

INTRODUCTION

Leptomeningeal metastasis (LM) is an extremely rare complication of gastroesophageal (GE) cancer. Diagnosis is challenging due to frequently nonspecific clinical presentations, limited sensitivity of diagnostic testing, and potential overlap with neurologic immune-related adverse events (irAE). We describe a case of metastatic gastroesophageal cancer on immunotherapy presenting with LM masquerading as polyneuropathy.

CASE REPORT

A 74-year-old male with HER2+ GE junction cancer with peritoneal metastases diagnosed 6 months ago, on maintenance trastuzumab/pembrolizumab and with no previous history of cranial or spinal disease, presented with worsening ataxia, headache, and diplopia for one month with multiple negative outpatient MRIs. Examination showed left abducens nerve palsy, dysmetria and absent deep tendon reflexes in upper and lower extremities. CT head was unremarkable, and MRI showed non-specific mild enhancement of the right optic nerve, symmetrical lumbosacral nerve roots and cauda equina concerning for paraneoplastic versus immunotherapy-related polyneuropathy. He was started on empiric high-dose corticosteroids. PET-CT was negative for FDG-avid lesions. Cerebrospinal fluid (CSF) analysis revealed moderate pleocytosis with many large atypical cells, elevated protein (118 mg/dL) and LDH (28 IU/L). Immunohistochemistry was positive for CDX2, CA 19-9, CK7, and pankeratin, consistent with metastatic adenocarcinoma, negative for HER2 in contrast to the original tumor. He subsequently developed hydrocephalus requiring a ventriculoperitoneal shunt. He received ten fractions of whole brain irradiation before electing to pursue hospice care.

DISCUSSION

LM is an extremely rare complication of GE cancer with an incidence of <0.2% and carries a poor prognosis. Differentiation between LM and irAE in patients on immunotherapy can be challenging. Diagnosis relies mostly on CSF cytology, and lumbar puncture should not be delayed in patients with new neurologic symptoms. Treatment options are intrathecal chemotherapy, radiation and steroids. A recent phase II trial has shown promise for intrathecal trastuzumab in patients with HER2+ cancers, but options for HER2 negative disease remain mostly palliative.

CONCLUSIONS

Our case highlights the need for suspecting this rare metastatic site, as early diagnosis and genetic characterization allow for exploring more treatment options including targeted therapies which may improve overall survival and quality of life.

INTRODUCTION

Leptomeningeal metastasis (LM) is an extremely rare complication of gastroesophageal (GE) cancer. Diagnosis is challenging due to frequently nonspecific clinical presentations, limited sensitivity of diagnostic testing, and potential overlap with neurologic immune-related adverse events (irAE). We describe a case of metastatic gastroesophageal cancer on immunotherapy presenting with LM masquerading as polyneuropathy.

CASE REPORT

A 74-year-old male with HER2+ GE junction cancer with peritoneal metastases diagnosed 6 months ago, on maintenance trastuzumab/pembrolizumab and with no previous history of cranial or spinal disease, presented with worsening ataxia, headache, and diplopia for one month with multiple negative outpatient MRIs. Examination showed left abducens nerve palsy, dysmetria and absent deep tendon reflexes in upper and lower extremities. CT head was unremarkable, and MRI showed non-specific mild enhancement of the right optic nerve, symmetrical lumbosacral nerve roots and cauda equina concerning for paraneoplastic versus immunotherapy-related polyneuropathy. He was started on empiric high-dose corticosteroids. PET-CT was negative for FDG-avid lesions. Cerebrospinal fluid (CSF) analysis revealed moderate pleocytosis with many large atypical cells, elevated protein (118 mg/dL) and LDH (28 IU/L). Immunohistochemistry was positive for CDX2, CA 19-9, CK7, and pankeratin, consistent with metastatic adenocarcinoma, negative for HER2 in contrast to the original tumor. He subsequently developed hydrocephalus requiring a ventriculoperitoneal shunt. He received ten fractions of whole brain irradiation before electing to pursue hospice care.

DISCUSSION

LM is an extremely rare complication of GE cancer with an incidence of <0.2% and carries a poor prognosis. Differentiation between LM and irAE in patients on immunotherapy can be challenging. Diagnosis relies mostly on CSF cytology, and lumbar puncture should not be delayed in patients with new neurologic symptoms. Treatment options are intrathecal chemotherapy, radiation and steroids. A recent phase II trial has shown promise for intrathecal trastuzumab in patients with HER2+ cancers, but options for HER2 negative disease remain mostly palliative.

CONCLUSIONS

Our case highlights the need for suspecting this rare metastatic site, as early diagnosis and genetic characterization allow for exploring more treatment options including targeted therapies which may improve overall survival and quality of life.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

INTRODUCTION

Excluding skin cancer, prostate cancer is the most common malignancy affecting men in the United States, accounting for ~33% of VA cancer cases. Androgen deprivation therapy (ADT) is considered standard of care in treating advanced prostate cancer. Pituitary apoplexy is a rare and morbid adverse event associated with GnRH agonist treatment. We describe a patient with advanced prostate cancer who developed pituitary apoplexy shortly after leuprolide therapy.

CASE PRESENTATION

A 70-year-old African-American male was diagnosed with a T2aN1M1 stage IVB prostate cancer, Gleason 4+5, PSA 19.5. Four hours after his first leuprolide injection, he developed vomiting, diaphoresis, myalgia, and a severe frontal headache. Brain MRI revealed a 2.4 × 1.3 × 1.3cm pituitary mass, suspicious for an adenoma with hemorrhage. Labs noted low TSH, prolactin, LH, growth hormone, ACTH, cortisol, and testosterone, consistent with pituitary apoplexy. He was treated with steroids. Three weeks later, testosterone levels remained very low. He started abiraterone and prednisone without further leuprolide.

DISCUSSION

Prostate cancer is ubiquitous among VA patients, and ADT with GnRH agonist is vital in their care. These medications stimulate the pituitary to release LH and FSH resulting in a negative feedback loop, ultimately decreasing the levels of testosterone. Common side effects of GnRH agonists include hot flashes, diaphoresis, and sexual dysfunction. We present a patient who started leuprolide for prostate cancer. Symptoms including a severe headache led to an evaluation confirming pituitary apoplexy. Literature review reveals ~ 21 cases of pituitary apoplexy associated with GnRH agonist treatment for prostate cancer, and apoplexy can occur immediately to months later Undiagnosed pituitary adenomas are common among these patients. Treatment includes pituitary surgery or conservative management. Further prostate cancer treatment needs investigation, but we propose that GnRH modifying treatment can be withheld while testosterone levels remain low.

CONCLUSIONS

Prostate cancer is extremely common in the VA population, and treatment with leuprolide is standard. Pituitary apoplexy is a rare, but devastating complication of this treatment, and providers should be aware of the symptoms in order to intervene quickly. Further testosterone lowering treatment may be withheld if testosterone levels remain low.

INTRODUCTION

Excluding skin cancer, prostate cancer is the most common malignancy affecting men in the United States, accounting for ~33% of VA cancer cases. Androgen deprivation therapy (ADT) is considered standard of care in treating advanced prostate cancer. Pituitary apoplexy is a rare and morbid adverse event associated with GnRH agonist treatment. We describe a patient with advanced prostate cancer who developed pituitary apoplexy shortly after leuprolide therapy.

CASE PRESENTATION

A 70-year-old African-American male was diagnosed with a T2aN1M1 stage IVB prostate cancer, Gleason 4+5, PSA 19.5. Four hours after his first leuprolide injection, he developed vomiting, diaphoresis, myalgia, and a severe frontal headache. Brain MRI revealed a 2.4 × 1.3 × 1.3cm pituitary mass, suspicious for an adenoma with hemorrhage. Labs noted low TSH, prolactin, LH, growth hormone, ACTH, cortisol, and testosterone, consistent with pituitary apoplexy. He was treated with steroids. Three weeks later, testosterone levels remained very low. He started abiraterone and prednisone without further leuprolide.

DISCUSSION

Prostate cancer is ubiquitous among VA patients, and ADT with GnRH agonist is vital in their care. These medications stimulate the pituitary to release LH and FSH resulting in a negative feedback loop, ultimately decreasing the levels of testosterone. Common side effects of GnRH agonists include hot flashes, diaphoresis, and sexual dysfunction. We present a patient who started leuprolide for prostate cancer. Symptoms including a severe headache led to an evaluation confirming pituitary apoplexy. Literature review reveals ~ 21 cases of pituitary apoplexy associated with GnRH agonist treatment for prostate cancer, and apoplexy can occur immediately to months later Undiagnosed pituitary adenomas are common among these patients. Treatment includes pituitary surgery or conservative management. Further prostate cancer treatment needs investigation, but we propose that GnRH modifying treatment can be withheld while testosterone levels remain low.

CONCLUSIONS

Prostate cancer is extremely common in the VA population, and treatment with leuprolide is standard. Pituitary apoplexy is a rare, but devastating complication of this treatment, and providers should be aware of the symptoms in order to intervene quickly. Further testosterone lowering treatment may be withheld if testosterone levels remain low.

INTRODUCTION

Excluding skin cancer, prostate cancer is the most common malignancy affecting men in the United States, accounting for ~33% of VA cancer cases. Androgen deprivation therapy (ADT) is considered standard of care in treating advanced prostate cancer. Pituitary apoplexy is a rare and morbid adverse event associated with GnRH agonist treatment. We describe a patient with advanced prostate cancer who developed pituitary apoplexy shortly after leuprolide therapy.

CASE PRESENTATION

A 70-year-old African-American male was diagnosed with a T2aN1M1 stage IVB prostate cancer, Gleason 4+5, PSA 19.5. Four hours after his first leuprolide injection, he developed vomiting, diaphoresis, myalgia, and a severe frontal headache. Brain MRI revealed a 2.4 × 1.3 × 1.3cm pituitary mass, suspicious for an adenoma with hemorrhage. Labs noted low TSH, prolactin, LH, growth hormone, ACTH, cortisol, and testosterone, consistent with pituitary apoplexy. He was treated with steroids. Three weeks later, testosterone levels remained very low. He started abiraterone and prednisone without further leuprolide.

DISCUSSION

Prostate cancer is ubiquitous among VA patients, and ADT with GnRH agonist is vital in their care. These medications stimulate the pituitary to release LH and FSH resulting in a negative feedback loop, ultimately decreasing the levels of testosterone. Common side effects of GnRH agonists include hot flashes, diaphoresis, and sexual dysfunction. We present a patient who started leuprolide for prostate cancer. Symptoms including a severe headache led to an evaluation confirming pituitary apoplexy. Literature review reveals ~ 21 cases of pituitary apoplexy associated with GnRH agonist treatment for prostate cancer, and apoplexy can occur immediately to months later Undiagnosed pituitary adenomas are common among these patients. Treatment includes pituitary surgery or conservative management. Further prostate cancer treatment needs investigation, but we propose that GnRH modifying treatment can be withheld while testosterone levels remain low.

CONCLUSIONS

Prostate cancer is extremely common in the VA population, and treatment with leuprolide is standard. Pituitary apoplexy is a rare, but devastating complication of this treatment, and providers should be aware of the symptoms in order to intervene quickly. Further testosterone lowering treatment may be withheld if testosterone levels remain low.