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Key Clinical Message In patients with known risk factors for hepatocellular carcinoma and an elevated AFP, the diagnosis should remain on the differential even in the absence of hepatic lesions. High index of suspicion is needed, and aggressive diagnostic approaches are needed to not miss this entity.

Background Multiple risk factors have been linked to venous thromboembolism (VTE). It is well established that elevated level of homocysteine correlated with increased risk of VTE. Some studies showed that vitamin B12 deficiency may be the cause for homocysteinemia. Therefore, it is recommended by some groups that vitamin B12 should be supplemented in the patient with high homocysteine to prevent VTE. However, more recent study has shown that there is correlation between the high serum Vitamin B12 level and risk of VTE in cancer patients.[1] provoked VTE after orthopedic surgery was also shown to be associated with elevated vitamin B12 serum levels in elderly patients. The role of vitamin B12 in VTE patients is not fully understood. Our study is to see whether there is correlation between serum Vitamin B12 level and risk of VTE in general population. Methods 177 Patients admitted to Kingsbrook Jewish Medical Center between January 1st, 2015 to December 31st, 2018 with the diagnosis of VTE were identified. 95 cases had measured serum Vitamin B12 results within 3 months. 97 patients without any history of VTE who were seen in the hematology clinic during the same period time were used as control in this study. Demographic information and Vitamin B12 level were collected. T test and chi-square were used for statistical analysis. Results VTE patients had a median age of 70, which is significantly higher than the median age of 57 in the control group. The mean level of vitamin B12 in control group was 620 pg/mL, which was lower than the average vitamin B12 level (770 pg/mL, p=0.0344) in the VTE group. When we divided the patients into 3 groups based on Vitamin B12 level: Low B12 (800 pg/mL). We observed 41% of VTE patients have B12 level more than 800 pg/mL while only 20% of control patients have high B12 level (chi-square, p=0.006). Discussion Our study showed that vitamin B12 level is significantly elevated in patients diagnosed with VTE and more than 40% of those patients actually have vitamin b12 level more than 800 pg/mL. It is known that elevated vitamin B12 level is associated with inflammation and increased mortality.[2] An association between elevated B12 levels and cancer has been reported in several studies [3]. It is unclear elevated vitamin B12 levels predict undiagnosed cancer which is a known risk factor for VTE or vitamin B12 directly contribute hypercoagulation. Nevertheless, we should be cautious when supplementing vitamin B12 and the dosage may need to be titrated closely. More clinical studies are definitely warranted. References 1. Arendt JFH, el al. Elevated plasma vitamin B12 levels and risk of venous thromboembolism among cancer patients: A population-based cohort study. PubMed ID: 26724465 2. Grossfeld A1, et al. Symptomatic venous thromboembolism in elderly patients following major orthopedic surgery of the lower limb is associated with elevated vitamin B12 serum levels. PubMed ID:23000313 3. Johan F.H. Arendt, Henrik T. Sørensen, Laura J. Horsfall and Irene Petersen. Elevated Vitamin B12 Levels and Cancer Risk in UK Primary Care: A THIN Database Cohort Study. EPI-17-1136 Published April 2019 Disclosures No relevant conflicts of interest to declare.

Background Rivaroxaban and apixaban are two direct oral anticoagulants (DOACs) targeting Factor Xa. Each DOAC was separately proven effective and safe when compared to standard treatment (heparin followed by warfarin) in patients diagnosed with venous thromboembolism (VTE). Several retrospective cohort analyses suggest apixaban may be superior to rivaroxaban due to less bleeding rates. One recent study showed the safety of apixaban and rivaroxaban for acute VTE were comparable. Also, long-term anticoagulation with low molecular weight heparin (LMWH), has never been directly compared with Factor Xa inhibitors. Given the patient population at our facility includes a significant percentage of elderly from nursing homes with multiple comorbidities and significantly higher bleeding risks than the general population, we aimed to evaluate the local real-world DOACs and heparin use with particular focus on safety. Methods A retrospective study was conducted at Kingsbrook Jewish Medical Center. Demographics, relevant laboratory/ imaging studies for patients admitted from 1/2016 to 12/2018 with the diagnosis of VTE based on the ICD 9/10 codes were collected from the IT dept. VTE patients who had bleeding events during the same admission for VTE or were admitted for relevant bleeding events based on ICD 9/10 codes within 6 months from the diagnosis of VTE were identified. Major bleeding events were defined as requiring hospitalization, blood transfusion or a significant drop in hemoglobin (more than 2 g/dl). The rest of the bleeding events were classified as minor. Demographics and clinical characteristics were summarized with means/median for continuous variables and with proportions for categorical variables. The differences in covaries were assessed with chi-square, Fisher exact test or t-tests. Results A total of 177 acute VTE patients were identified in the study. 37.9% (n=67) and 32.8% (n=58) patients were started on rivaroxaban and apixaban, respectively, as monotherapy. 29.3% (n=52) patients were given unfractionated heparin (23%, n=12) or LMWH (77%, n=40) based on the renal function. The bleeding rate in the apixaban group (4/58, 6.9%) was slightly higher than that in the rivaroxaban group (3/67, 4.5%), however, there was no statistical significance. Compared to patients received heparin (11/52, 21.2%), patients started on rivaroxaban (p=0.008) or apixaban (p=0.049) had a significantly lower rate of bleeding. Of note, majority of the bleeding event (16/18) was captured during the same admission when VTE was diagnosed. VTE patients in the apixaban group were older (p = 0.007) and had a longer length of stay (LOS, p= 0.024) compared to the ones in the rivaroxaban group. We then combined rivaroxaban and apixaban into DOAC group. Compared to Heparin group (n=11, 21.1%), the bleeding events in DOAC group (n=7, 5.6%) were significantly less (P=0.0045). Heparin group (n=21, 40.4%) included more patients with cancer than the DOAC group (n=9, 7.2%, p We then looked at the bleeding risk in non-cancer patients. Similarly, we didn't observe any superiority between rivaroxaban (n=2, 3.1%) and apixaban (n=3, 5.8%) regarding bleeding events in non-cancer patients with acute VTE. The average LOS in the apixaban group was significantly longer than that in the rivaroxaban group with non-cancer patients. It may be associated with relatively older age in the apixaban group compared to that in the rivaroxaban group. Most importantly, in patients without active malignancy, we found that the bleeding rate in the DOAC group was only 4.3% while the heparin group had a much high bleeding rate of 16.1% (p=0.035). Discussion Our study suggested that the safety of apixaban and rivaroxaban are comparable in VTE patients. In contrast, heparin including LMWH had much higher bleeding risk compared to either DOAC, especially in the beginning. For patients who are hospitalized for acute VTE, heparin intravenously or subcutaneously are usually initiated while the decision for oral anticoagulants are still pending. However, the benefits of such "bridging with heparin" strategy are not warranted, given the high bleeding risk associated with heparin treatment as shown in our study. Except for hemodynamically instability, excessive burden or clots, or impeding procedures, we recommend that DOACs should be used as monotherapy in VTE patients. Disclosures No relevant conflicts of interest to declare.

e19522 Background: BMF is known to occur in a minority of myeloma patients, but its incidence in American patients of African origin is not known. The impact of BMT on presenting clinical and laboratory findings, and its relationship to genetic variants has not been defined. Methods: Kings County Hospital is located in the East Flatbush section of Brooklyn, New York, where the population is mainly of African-Caribbean origin. Records and bone marrow specimens of myeloma patients who presented from 2000 through 2010 were reviewed. Degree of fibrosis was graded according to World Health Organization criteria: mild, moderate and severe. Results: Records of 113 patients were reviewed, 110 (97%) 97 of whom were African American or Caribbean; 62 (55%) were female and 51 (45%) male. Their ages ranged from 38 to 89 (median 65). Of the 27 patients with BMF (24%), 17 (63%) were female. Mild, moderate and severe BMF were present in 14 (52%), 7 (26%) and 6 (22%) patients respectively. Presentation calcium and creatinine levels were normal in all patients. Hemoglobin levels were similar (median 9.6 G/dl) in patients without BMF and in those with mild and moderate grades, the median level was 7.5 G/dl in those with severe BMF. Immunoglobulin G, A and D levels (67, 20 and 1) were similar in patients with and without BMF, but lambda light chain expression was greater in the BMF patients: 41 vs 24%. Cytogenetic data (CGD) was available in 46 patients; and abnormal in 10 (22%). All patients with abnormalities of chromosomal number were hyperdiploid. Of the 27 BMF patients CG data was available in 17, and was abnormal in 2 (12%). FISH results were normal in 23 of 25 patients, and in all of those with BMF. The fraction of the BMF and non BMF patients surviving after median follow up periods of 828 and 885 days were similar. Conclusions: BMF in this population was 24%, and severe in 5%. Female preponderance is a characteristic of MM patients of African origin, and was more marked in those with BMF. The BMF patients were characterized by more severe anemia and greater lambda light chain expression.

e18504 Background: Serologic positivity for HTLV and ATLL are endemic amongst Caribbean populations. Kings County and University Hospital of Brooklyn serve population with large number of immigrants from this region. ATLL in this population is mostly of aggressive (leukemia/lymphomatous) type. Responses to chemotherapy (CT) are brief, and 90% succumb to ATLLwithin 18 months (m) of presentation. Lactic dehydrogenase (LDH) levels are high, but PET is not used in routine staging. Methods: Records of all patients with ATLL presenting to these institutions between 2001-11 were reviewed. The results of PET, including maximum standard uptake value (SUVmx) were recorded for scans obtained before (12) and after (19) initial CT, and at relapse (13). Results: Of 95 T cell lymphoma patients, 73 had ATLL. PET was performed in 26 of the 73 patients; 20 of the 26 had ATLL, 5 had other T cell lymphomas. Infusional etoposide, vincristine, doxorubicin and prednisone (EPOCH) was the CT of 17 of the 20 ATLL patients; relapse occurred after a median of 9.5 m, often followed by salvage CT. Of the 6 male and 6 female patients scanned pre-CT, the median SUVmx was 9.9; range 2.9-33. Their initial median LDH level was 390 (321-683). The median overall survival (OS) was 11.5 (1-24 m). Thirteen patients had 19 post-CT scans, with a median SUVmx of 3.0; only one SUVmx was elevated (8.4); that patient had progressive disease, but the others variously displayed complete and partial remissions, or progression. Their median OS was 13 m (range 4-39 m). Their median LDH at presentation was 523. Eight patients had 13 scans at relapse, with a median SUVmx of 10.6, range 3.7-21. Their median OS was 17 m (range 12-21). OS and SUVmx were not correlated. Conclusions: Like Hodgkin’s and large B cell lymphomas, the pre-CT PET SUVmx levels of ATLL patients were significantly elevated; most fell to normal or slightly elevated levels after CT. PET is thus likely to have some value in staging ATTL. Our results suggest that PET response of ATLL patients to CT correlates poorly with durable relapse-free survival. The latter parameter is probably dependent on factors other than proliferative rate or control of aerobic glycolysis.

e15097 Background: RCC is a surgically curable malignancy; the outcomes are typically based on tumor size/extent and histology. Partial nephrectomy (PN) is preferred as nephron sparing approach over radical nephrectomy (RN), especially in smaller tumors. Methods: We reviewed data from Surveillance, Epidemiology, and End Results (SEER) 17 Regs Research Data registry for adult patients (pts) with RCC who had data about age, race, pathology, surgery and survival outcome. Results: In all 84480 cases of pts: 31605 (37%) females (F) and 52875 (63%) males (M) were reviewed. There were 8663 (10%) African Americans (AA) and 70942 (84%) Caucasians (C). Of the AA pts, there were 3349(39%) AAF and 5314(61%) AAM. Of the C pts, there were 26412(37%) CF and 44530(63%) CM. Clear cell RCC (CRCC) was seen in 69336 (82%); AA pts with CRCC 6166 (71%) , AAF: 2588(77%) and AAM: 3578(67%). C pts with CRCC: 58936(83%) : CM 36443(82%), and CF-22493 (85%) were reviewed. In AA pts with CRCC PN was done 1282 (21%) and RN 4145 (67%)times. AA men had 818 (23%) PN and 2539 (71%) RN, where as AAF had 464 (16%) PN and 1606 (62%) RN. C pts with CRCC had PN 10402 (18%) and RN 37214 (63%) times. CM had PN 6692 (18%) and RN 23594 (65%) times; CF had PN 3710 (16%) and RN 13620 (61%) times. The median size of tumor in pts undergoing PN was 2-3 cm and independent of race or sex. In pts undergoing PN, the median survival for AAM, AAF, CM and CF was 22m, 18m, 23m and 23m respectively. In pts undergoing RN the median survival for AAM, AAF, CM and CF was 23m, 21m, 24m and 23m respectively. In pts over the age of 80, 8240 cases of CRCC were reviewed, and 3950 (48%) pts had no surgery, of pts having any surgery 376 (8%) and 2859 (68%) pts had PN and RN. Median survival of CRCC over 80 years old having no surgery, PN and RN was 5m, 27m and 29m. Race or sex made no impact on proportion of pts having no surgery. Conclusions: C pts esp. CF are more likely to have CRCC histology. The kind of surgery (PN vs. RN) and outcomes after that are similar across both ethnicities and sexes. Pts over 80 yr old are much less likely to have any surgery and have very poor outcomes, this is avoided if they have PN or RN.

Abstract 4300 Introduction: ATRA is the critical component of treatment of APL, and when used in combination with anthracycline chemotherapy can induce remission in over 90% of patients. At initial presentation, patients are at high risk for bleeding or disseminated intravascular coagulation, which may be exacerbated by immediate chemotherapy. Except in patients with marked leukocytosis, ATRA should precede chemotherapy. ATRA is available as 10 mg capsules and should be ingested orally and not crushed. The capsules cannot, therefore, be used in patients unable to swallow, or administered by NGT. Patients and Methods: We present two APL cases where patients unable to swallow and acutely bleeding, received ATRA via NGT. ATRA capsules were opened, the free powder aspirated into a glass syringe, and the remaining capsule contents suspended in soy bean oil and aspirated into the same syringe (Shaw, 1995). Case 1: A 33-year-old female with juvenile onset diabetes and blindness presented with fever vaginal bleeding and coma with response only to painful stimuli. Her white blood count (WBC) was 0.5 k/MicroL with 27% bands, 20% lymphocytes and 10% promyelocytes; platelets were 18 K and PT/PTT was 14.7/33. Bone marrow (BM) was replaced by cells with granular cytoplasm and bilobed nuclei. PML-RARa was not detected by cytogenetics and fluorescent in situ hybridization (FISH), but was by PCR. Daunorubicin was administered and the ATRA oil suspension was given on 14 successive days. Hematologic recovery had occurred by day 16, PCR was negative for PML-RARa by 20, and following consolidation she remains in complete hematologic and cytogenetic remission after 7 months. MRI revealed white matter changes but after IV-HGG she regained consciousness. Case 2: A 66-year-old man with coronary artery disease presented with fever, rectal bleeding and pulmonary hemorrhage, which required intubation and mechanical ventilation. WBC was 7.9 with 3% bands, 19% lymphocytes and 22% promyelocytes. Platelet count was 13 and PT/PTT was 9.6/23.6. BM confirmed APL, with FISH positive for PML- RARa. He was started on ATRA oil suspension via NG tube and daunorubicin. By day 27 FISH was PML-RARa negative, but he continued to require ventilatory support for 3 weeks and succumbed to pneumonia and septic shock. Conclusion: In two patients unable to swallow and bleeding, ATRA administration as an oil suspension via NGT was safe and effective, inducing cytogenetic remission in both. IV liposomal ATRA is not FDA approved and no other parenteral formulation is available. Disclosures: No relevant conflicts of interest to declare.