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This is a case of a young woman who developed neurological and psychiatric symptoms 3 days after resection of an immature teratoma. She was diagnosed with anti-NMDA receptor encephalitis via positive serum antibody titres, which was later confirmed with cerebrospinal fluid antibody titres. Given her cancer diagnosis, she underwent treatment with bleomycin, etoposide and cisplatin chemotherapy in addition to 5 days of high-dose steroids (1 g of intravenous methylprednisolone) for the encephalitis. This treatment regimen led to significant clinical improvement 3 weeks after completion of one cycle of chemotherapy.

Ellery Altshuler,1 Raymond Richhart,1 Mahmoud Aryan,2 William King,1 Kelsey Pan,1 Akash Mathavan,1 Akshay Mathavan,1 Diana Rodriguez,1 Bishal Paudel,1 Nathan Northern,1 Brian Ramnaraign,3 Ilyas Sahin,3 Jesus C Fabregas3 1Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, USA; 2Department of Internal Medicine, University of Alabama Birmingham College of Medicine, Birmingham, AL, USA; 3Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, FL, USACorrespondence: Jesus C Fabregas, Department of Hematology and Oncology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL, 32608, USA, Tel +1 305-389-6231, Email jesus.fabregas@medicine.ufl.eduBackground: Although up to one in five cases of hepatocellular carcinoma (HCC) occurs in patients without cirrhosis, there is scarce literature characterizing non-cirrhotic HCC (NCHCC). Existing NCHCC research is primarily limited to surgical case series and there is a lack of data on unresectable NCHCC.Aim: The purpose of this retrospective review was to compare the characteristics of unresectable NCHCC and cirrhotic hepatocellular carcinoma (CHCC).Methods: A retrospective chart review of adult patients with unresectable HCC treated from 2007 to 2017 was performed at the University of Florida Shands Hospital. The data set was stratified into two cohorts: NCHCC and CHCC. Continuous variables were compared using Wilcoxon-Mann–Whitney tests and Kruskal–Wallis rank-sum tests. Categorical variables were compared using Pearson’s Chi-squared tests and Fisher’s exact tests. Overall survival was explored utilizing the Kaplan-Meier and log-rank method.Results: There were 1494 adult patients included in the final analysis, including 264 patients (17.7%) with NCHCC and 1230 patients (82.3%) with CHCC. Median age was 61.0 years old and median follow-up time was 30.2 months. NCHCC patients were older than CHCC patients (66.3 years vs 61.9 years; p < 0.0001). NHCC tumors were larger than CHCC tumors (7.92 ± 4.85 vs 4.38 ± 3.12 cm; p < 0.0001) and more likely to be associated with distant metastases (23.35% vs 15.91%; p = 0.0055). There was no difference in overall survival, with a median of 23.5 months in NCHCC and 22.4 months in CHCC (p = 0.9196).Conclusion: Our findings suggest that unresectable NCHCC and CHCC have unique characteristics but similar overall survival. To the best of our knowledge, this is the largest comparison of CHCC and NCHCC.Keywords: hepatocellular carcinoma, cirrhosis, non-cirrhotic

Abdominal pain can arise from numerous sources, including those extra‐abdominal. It is important to obtain additional imaging in the setting of clinical suspicion for malignancy.

Anemia is a commonly encountered finding either during the preoperative assessment or during the postoperative management of the patient. Anemia often gets overlooked while more emphasis is paid to cardiovascular and pulmonary evaluation. Evidence, however, suggests that the presence of anemia in the perioperative period can predispose patients to other complications. Awareness of the consequences of anemia in the perioperative period can lead to better recognition and early management of this potentially modifiable risk factor. In this review, we focus on the effects of anemia on the cardiac, pulmonary, neurologic, cognitive, and functional status outcomes of patients. We also review management strategies that could be employed, depending on the available time and resources.

Background Cluster of differentiation 26/dipeptidyl peptidase-4 (DPP4) is a cell surface glycoprotein with multifaceted roles, including immune regulation, glucose metabolism, and tumorigenesis. Recent literature has identified DPP4 inhibitors to improve survival in diabetic patients with prostate cancer. DPP4 inhibitors have been proposed to play a role in prostate cancer, as DPP4 is found at higher levels in malignant prostate tissue compared to benign and correlates with PSA levels and cancer stage. In this multi-center retrospective study, we aim to define the effects of DPP4 inhibitors on progression-free survival (PFS) in diabetic patients with advanced-stage prostate cancer. Methodology We performed a retrospective analysis of 161 patients with diabetes and advanced-stage (III or IV) prostate cancer at the University of Florida Health Cancer Center and Moffitt Cancer Center. Our cohort included 120 patients on metformin (control group) and 41 on a DPP4 inhibitor (study group). Results No significant difference in progression of prostate cancer was identified between those on DPP4 inhibitors versus metformin (hazard ratio [HR]: 1.01; 95% confidence interval [CI]: 0.64-1.61; p = 0.955). Median time to progression was 3.5 years (range: 2.4-4.6 years). Conclusions Despite prior literature indicating survival benefit of DPP4 inhibitors in prostate cancer, our study did not identify a statistically significant improvement of PFS in diabetic patients with advanced prostate cancer. Additional analysis with larger sample sizes and prospective investigation with study of tumor microenvironment are needed to evaluate clinical impact and potential survival benefit of DPP4 inhibitors in prostate cancer.

CD26/Dipeptidyl peptidase IV (DPPIV) is a cell surface glycoprotein with numerous roles including glucose metabolism, immunomodulation, and tumorigenesis. CD26/DPPIV is well recognized in diabetes, with DPPIV inhibitors being a class of oral hypoglycemic drugs called gliptins that are commonly used to treat type two diabetes mellitus. Recent work also indicated a potential role for CD26 in infectious diseases, including COVID-19, and immune-mediated disorders such as rheumatoid arthritis, inflammatory bowel disease, and graft-versus-host disease. In cancer, CD26/DPPIV expression has been characterized in numerous tumors such as hematologic malignancies, malignant pleural mesothelioma (MPM), renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), gastrointestinal stromal tumor (GIST), and prostate, lung, colorectal, and ovarian (PLCO) cancer. Hence, CD26 has been frequently studied as a tumor biomarker and therapeutic target. CD26/DPPIV-targeted therapies have been evaluated in various cancers, including the use of anti-CD26 monoclonal antibodies as anticancer treatment in selected neoplasms. This review highlights our current understanding of the role of CD26 in cancer, diabetes, immune-mediated diseases, and infectious diseases. Enhanced understanding of CD26 biology and function may lead to novel therapeutic approaches in multiple human diseases.

e18636 Background: A written advanced directive (AD) allows patients to indicate their preferences for medical care should they ever lose the ability to make their wishes known. This may take the form of a living will or designation of a healthcare surrogate. AD completion rates remain poor on inpatient oncology units, with only 20-40% of patients having an AD. This is despite the fact nearly all cancer patients (95%) believe discussing ADs is an important issue. It has recently been shown that nearly 87% of cancer patients would support a policy in which admitting physicians offered to have a conversation regarding ADs. The goal of our project was to increase the percentage of patients with documented ADs on our inpatient oncology unit from 30% to 50% using the participation of internal medicine residents. Our secondary objective was to initially assess resident knowledge, confidence and skills with AD discussions. Methods: We carried out a prospective QI project in which we first calculated the percentage of consecutive patients on our inpatient oncology unit with documented ADs. After providing educational materials and delivering AD forms to the resident workroom to increase accessibility, we again calculated the percentage of consecutive patients with documented ADs. We also initially surveyed residents about their knowledge, comfort levels, and barriers to having AD discussions with patients. Results: Pre-intervention, 15 out of 50 (30%) consecutive patients on our inpatient oncology unit had documented ADs. Post-intervention, 13 of 27 (48%) consecutive patients in our oncology unit had documented ADs. Most residents felt their knowledge of ADs was average (46.88%, n = 15) or good (28.13%. n = 9). When asked about comfort in filling out ADs with patients, most responded as average (28.13%, n = 9) or poor (28.13%, n = 9). The main barrier to completing ADs was lack of time (25%, n = 20) followed by lack of knowledge (25%, n = 8) and not feeling the responsibility (12.5%, n = 4). Most residents were interested (65.53%, n = 21) or maybe interested (28.13%, n = 9) in further teaching on ADs. Conclusions: Our study showed that AD completion rates on an inpatient oncology unit can be improved using the participation of internal medicine residents. This was done through a standardized approach of housestaff offering to discuss ADs on admission after they had received short small group teaching sessions on AD discussions. Furthermore, we identified that most internal medicine residents had average or poor comfort in initiating advanced care discussions, but were interested in obtaining further knowledge to help discuss ADs with patients.

UNSTRUCTURED Anemia is a commonly encountered finding either during the preoperative assessment or during postoperative management of the patient. Anemia often gets overlooked while more emphasis is paid to cardiovascular and pulmonary evaluation. Evidence however suggests that presence of anemia in the perioperative period can predispose patients to other complications. Awareness of the consequences of anemia in the perioperative period can lead to better recognition and early management of this potentially modifiable risk factor. In this review we focus on the effects of anemia on the cardiac, pulmonary, neurologic, cognitive and functional status outcomes of patients. We also review management strategies that could be employed, depending on the available time and resources.

OBJECTIVES Primary pancreatic signet ring cell carcinoma (SRCC) is a rare histologic variant of pancreatic carcinoma. A population-based analysis of pancreatic SRCC was performed to determine the predictive effects of epidemiological factors and treatment interventions on overall survival (OS) and disease-specific survival (DSS). MATERIALS AND METHODS The Surveillance, Epidemiology, and End Results registry was searched for pancreatic SRCC cases diagnosed between January 1, 1973 and December 31, 2013. Statistical analysis was performed using the Fisher exact test, χ(2) analysis, Kaplan-Meier method, log-rank test, and Cox proportional hazards regression. RESULTS The mean age among 497 patients was 66.6 years (SD, 11.9). Most patients were white (82.7%) and male (54.5%). The 1-, 2-, and 5-year OS rates were 17%, 9%, and 4%, respectively, while the corresponding 1-, 2-, and 5-year rates for DSS were 18%, 10%, and 5%, respectively. On univariable analysis; age, site, grade, stage, and treatment were predictive of OS and DSS (P

e16546 Background: Radium-223 (Xofigo) has been shown to increase overall survival (OS) in patients with metastatic castration-resistant prostate cancer (mCRPC) via the phase 3 ALSYMPCA study. The side effect of persistent pancytopenia was noted in 2% of the patients, however, the incidence seen in our institutional clinical practice is higher than reported in the literature. This analysis serves to identify predictive factors and thereby help impact future therapy directions in this patient population. Methods: A retrospective analysis was performed analyzing patients with mCRPC who received xofigo at UFHealth in a 3 year span (from January 2014 to January 2017). Data collected included CBC, ECOG functional status, kidney and liver function, evidence of bony disease on imaging, prior chemotherapy regimens, total radiation dose, and PSA. This study was IRB approved. Results: 52 patients with mCRPC were identified, 27 of which received xofigo. 23 patients received treatment at UF, and one was lost to follow-up. 16 patients (73%) completed the full course (6 doses) of xofigo, while 6 did not. 10 patients (45%) developed pancytopenia, with 2 recovering counts within eight months while the other 8 had persistent cytopenias (6 of which were transfusion-dependent). Older age (74.0 ± 8.8 vs 68.7 ± 10.2) and higher ECOG score (1.6 ± 0.7 vs 1.2 ± 0.6) correlated with increased risk of pancytopenia. In addition, a higher percentage of patients who received prior radiation therapy were more likely to develop pancytopenia (90% vs 75%). All patients studied had bony disease and received prior chemotherapy. Conclusions: Albeit with a limited sample size, we found a higher rate of xofigo-induced pancytopenia in our patient population than the 2% reported in the literature. This may influence clinical decision making in the treatment of mCRPC, as pancytopenia may preclude patients from other survival-prolonging therapies. Factors such as age, functional status, and prior radiation therapy are important to keep under consideration prior to xofigo treatment. Additional larger studies are necessary to further quantify this effect.

109 Background: Dipeptidyl peptidase IV (DPP4), also known as Cluster of differentiation 26 (CD26) is a commonly expressed cell surface protein found in many cell types that can function as a tumor suppressor or activator, depending on the cancer type its interactions with the tumor microenvironment. DPP4 has been studied as a tumor biomarker due to its expression in various primary tumors and metastases. Recent literature established benefits of DPP4 inhibitors on progression free survival (PFS) of diabetic patients with advanced colorectal and airway cancers. In this study, we examine the effect of DPP4 inhibitors on PFS in diabetic patients (pts) with advanced-stage prostate cancer. Methods: We performed a multi-center retrospective analysis at Moffitt Cancer Center and the University of Florida of diabetic pts with advanced stage (III or IV) prostate cancer. All pts were on anti-hyperglycemic therapy and received either surgery, radiation therapy, or both for their prostate cancer. The control group included pts on metformin and a sulfonylurea, and the study group included pts on a DPP4 inhibitor and metformin. PFS was calculated for both groups, and Cox proportional hazards regression was used to determine statistical significance. Kaplan-Meier survival analysis was done to predict the effect of DPP4 inhibition and radiation therapy on PFS. Results: Our study population consisted of 161 pts, with 120 pts in the control group and 41 in the study group. No significant difference in progression of prostate cancer was found between those on DPP4 inhibitor vs. Metformin. Specifically, 24 of 41 (59%) of patients on DPP4 inhibitors progressed, while 73 of 120 (61%) of patients on Metformin had progression of prostate cancer (HR 1.01, 95% CI 0.64 to 1.61, p= 0.955). Median time to progression was 3.3 years in the DPP4 group versus 3.5 years in the Metformin group. However, radiation therapy was associated with improved PFS (HR 0.56, 95% CI 0.37 to 0.84, p= 0.0006). Conclusions: Contrary to what has been shown in pts with diabetes and advanced colorectal or airway cancers, exposure to DPP4 inhibitors did not lead to statistically significant improvement in PFS in pts with advanced stage prostate cancer. Recent data suggests that DPP4 may act as a tumor suppressor gene to the androgen receptor (AR) pathway, and that DPP4 inhibition can result in emergence of resistance to androgen deprivation therapy (ADT). Further analysis with larger sample sizes is necessary to elucidate if this is applicable to prostate cancer as a whole, or if this effect is specific to castrate-sensitive prostate cancer (CSPC) vs. castrate-resistant prostate cancer (CRPC).

We examined trends from 1991-2009 in total energy intake and food group intake, and examine whether shifts varied by age or generation.Longitudinal time series (1991, 1993, 1997, 2000, 2004, 2006, 2009).Nine provinces in China.Older Chinese aged ≥60 years (n=5,068) from the China Health and Nutrition Survey from 1991-2009.Using three 24-hour recalls and a household food inventory collected over three consecutive days, the top twenty food group contributors to total energy intake from 1991-2009 were identified, and the mean kilocalorie (kcal) difference between 1991 and 2009 for each food group was ranked. The top twenty food group contributors to total energy intake from 1991-2009 were identified, and the mean kilocalorie (kcal) difference between 1991 and 2009 for each food group was ranked. Linear regression was used to examine changes in mean calorie intake of food groups between 1991 and 2009, adjusting for age, sex, and region. In addition, we examined changes in the mean kcal per capita intake to examine shifts by age group and generation.Mean total energy intake increased significantly among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009 (Older Chinese adults in recent generations show an increase in total calorie intake compared to older Chinese of earlier generations, paired with a less significant decrease in calorie intake as they age. Increased consumption of high-fat, non-staple high-carbohydrate foods such as plant oil and wheat buns suggests that diet quality of older Chinese adults is becoming less healthful in recent years.