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OBJECTIVES Cancer patients are using medical cannabis (MC) to address symptoms; however, little data exist to guide clinicians when counseling patients. We seek to define the patterns of MC use among cancer patients, as well as efficacy and safety of MC. MATERIALS AND METHODS Cancer patients attending oncology office visits at Beaumont Hospital, Michigan from July to December 2018 were anonymously surveyed. The survey included data regarding demographics, diagnosis, treatment, symptom burden, and MC use. Patients who reported MC use since their cancer diagnosis completed a section on patterns of use, efficacy, and safety. RESULTS The response rate was 188 of 327 (57.5%). MC use was reported by 46 of 188 (24.5%). A median composite baseline symptom score ranging from 8 (best) to 32 (worst) was higher in patients using MC versus nonusers; 17.5 versus 14.4 (P

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition of uncontrolled immune activation as a result of an inherited genetic defect or in response to malignancy, autoimmune disease, rheumatological disease, AIDS infection or post-transplant immunosuppression. Described here is the case of a 19-year-old Caucasian man who presented with complaints of worsening fever, new-onset jaundice and lethargy after failing treatment for suspected infectious mononucleosis. Physical examination was significant for fever and splenomegaly while laboratory results revealed transaminitis, cytopaenia, indirect hyperbilirubinaemia and elevated ferritin, raising the likelihood of both autoimmune haemolytic anaemia and HLH. He tested positive for Epstein-Barr virus (EBV), and bone marrow biopsy revealed hypercellular marrow with haemophagocytosis and no evidence of malignancy. High dose steroids were initiated with significant improvement in haemoglobin, resulting in a final diagnosis of HLH secondary to acute EBV infection. The patient was discharged on continued high-dose prednisone with planned taper and consideration of outpatient rituximab therapy for 4 weeks. High clinical suspicion and prompt evaluation were critical to early treatment and decreased morbidity.

Celiac plexus block (CPB) has been widely used as a treatment option for chronic intractable abdominal pain resulting from intra-abdominal malignancies as well as benign conditions. Complications resulting from CPB have been long reported and include diarrhea, back pain, paraplegia, postural hypotension, pneumothorax, and local anesthesia toxicity. Diarrhea and postural hypotension are two most common complications with studies reporting incidences occurring in 44% to 60% and 10% to 52% of patients, respectively. Diarrhea is most often transient, resolving within 48 hours; however, literature reports cases in which diarrhea was chronic, debilitating, and in some instances life threatening. Persistent diarrhea proves difficult to treat. We report a case of a 76-year-old male with unresectable pancreatic adenocarcinoma who underwent computed tomography-guided CBP complicated by persistent diarrhea and fecal incontinence. After conventional antidiarrheal failed to improve the symptoms, octreotide proved to be beneficial and the patient reported significant improvement in symptoms.

Currently world is fighting with global pandemic of coronavirus disease 2019 (COVID-19). At this time of uncertainty, oncologists are struggling to provide appropriate care to cancer patients. They have to weigh risk and benefit of giving cancer treatment vs chances of getting them infected with COVID-19. As cancer patients are immunocompromised and there are high chances of exposure during hospital visits and if they get infected, outcome can be fatal. So through the column of this article, we would like to provide basic guideline in management of cancer patients during COVID-19 pandemic.

Background: Hypercoagulability may contribute to COVID-19 pathogenicity. Evidence comparing clinical outcomes among patients with COVID-19 receiving therapeutic compared to prophylactic dose anticoagulation is limited. We evaluated whether therapeutic anticoagulation (tAC) is associated with improved survival compared to prophylactic (pAC) and no anticoagulation (AC) in hospitalized COVID-19 patients. Methods: This was a retrospective, multi-center cohort study of consecutive COVID-19 patients admitted between March 13th, 2020 and May 5th, 2020 to eight hospitals within a large academic system in Southeast Michigan, USA. Participants were assigned to three groups based on whether they received no AC, pAC throughout most of their hospitalization, or at least 3 days of tAC. Major bleeding was defined as transfusion of five or more units of packed red blood cells within 48 hours regardless of hemoglobin level, hemoglobin < 7g/dL and any red blood cell transfusion or a diagnosis code for major bleeding during the hospitalization or radiological evidence of intracranial hemorrhage Results: A total of 3480 patients were included (mean age, 64.5 years [17.0]; 51.5% female; 52.1% black and 40.6% white). 18.5% (n=642) were treated in the intensive care unit (ICU). 60.9% received pAC (n=2121), 28.7% received at least 3 days of tAC (n=998), and 10.4% (n=361) did not receive AC. Propensity score (PS) weighted Kaplan-Meier plot demonstrated a statistical difference in the 25-day survival probability in the tAC group compared to the pAC group (57.5% vs 50.7%, Figure). In a PS weighted multivariate proportional hazards model adjusting for age, body mass index and ICU status, AC was associated with a reduced risk of death at both prophylactic (hazard ratio [HR] 0.35 [95% confidence interval {CI} 0.22-0.54]) and therapeutic doses (HR 0.14 [95% CI 0.05-0.23]) compared to no AC. Major bleeding occurred more frequently among tAC patients (81 [8.1%]) compared to those who received no AC (20 [5.5%]) or pAC (46 [2.2%]). Conclusions : Higher doses of AC are associated with lower mortality in hospitalized COVID-19 patients. The lowest hazard ratio was observed in ICU patients, but risk was also significantly lower in non-ICU hospitalized patients. Bleeding occurred more frequently with higher doses of anticoagulation. Ongoing randomized trials are warranted to prospectively evaluate efficacy and risk of tAC in patients with COVID-19. Figure Disclosures No relevant conflicts of interest to declare.

A 28-year-old primigravida was evaluated for complaints of difficulty urinating and pelvic pain of 6-weeks duration. She denied fever, night sweats, weight loss or fatigue. Pelvic ultrasonography revealed a single fetal pole with cardiac activity and a 7 cm mass in the anterior vagina which encased the urethra. The diagnosis of diffuse large B-cell lymphoma germinal centre type was made on analysis of biopsied pelvic mass. Whole body MRI revealed the disease was limited to the vagina. The patient received six cycles of Rituximab-cyclophosphamide, doxorubicin, vincristine and prednisone with significant improvement in her symptoms. Serial ultrasounds over the subsequent months showed appropriate development of the fetus. Whole body MRI after treatment showed decreased size and decreased signal of the primary pelvic mass compatible with favourable treatment response. Challenges in the management of this rare presentation of lymphoma are discussed.

Indolent lymphomas may transform into intermediate or high-grade lymphoma, a diagnosis that is usually made reached by tissue biopsy, with unfavorable prognosis. A retrospective study was performed of the clinical characteristics, treatment patterns and outcomes of 73 patients with histologic transformed lymphoma originating as follicular lymphoma (FL), chronic lymphocytic leukemia/small cell leukemia (CLL/SCL), marginal zone lymphoma (MZL), lymphoplasmacytic lymphoma (LPL), or low grade B cell lymphoma not otherwise specified (NOS). The median time to transformation was 55 months (range 1-258) and Diffuse Large B Cell Lymphoma (DLBCL) constituted the majority of HTL diagnosis diagnoses. There was a statistically significant longer time to the development of HTL in patients with CLL and LPL compared to other indolent lymphoma types (FL, MZL and low-grade B cell lymphoma NOS); however, overall survival (OS) at histologic transformation was similar regardless of the indolent lymphoma type preceding HTL. Treatment with Rituximab-containing regimens have increased overall survival in HTL compared with the pre-rituximab era. In the 63 treated cases of HTL, PET showed complete remission (CR) in the majority of patients (55%) with 15% achieving partial remission (PR) and 15% having progressive disease (PD). OS at two years was approximately 60%, and 41% of patients remained alive at 5 years. Univariate analysis identified that treatment with RCHOP conferred better OS when compared to regimens with less or greater intensity than RCHOP, p=0.001. Multivariate analysis confirmed that achievement of CR and LDH level within the normal range statistically predicted better OS. On-going clinical trials may suggest novel therapeutics and provide for more evidence-based management of HTL.

Background. Obesity is a major epidemic affecting all age groups in the USA. It has been associated with venous thromboembolism (VTE), which requires prolonged anticoagulation. Classic options (vitamin K antagonists, heparins) are increasingly replaced by direct oral anticoagulants (DOACs), which have not been well studied in patients with body mass index (BMI) > 40kg/m2 or weight above 120 kg. Despite limited safety and efficacy data, patients and their caregivers often opted for this medication owing to its ease of administration, lack of requirement for frequent laboratory testing and for dietary restrictions. Methods. This is a retrospective study of all morbidly obese patients (BMI > 40kg/m2) diagnosed with acute VTE managed with DOACs at Beaumont hospital between January of 2018 and December of 2018. Data regarding demographics, specific DOAC, major bleeding (hemoglobin decrease by 2 g/dL) and new or progressive thrombosis were recorded during a sixty-day follow up. Data was analyzed using JMP statistical software. Results A total of 42 patients diagnosed with acute VTE received DOACs during the study period. Most were female (76%); the median BMI was 44 (IQR 42-60) and mean age was 57. Most patients had a BMI of 40-50 kg/m2 (n=34, 81%) compared to BMI 50-60 kg/m2 (n=6, 14%) and BMI >60kg/m2 (n=6, 14%). Apixaban was the most frequently used DOAC (n=27, 65%). No clinically significant bleeding occurred during the study period. There were 2 thrombotic episodes (5% of patients) within 60 days of starting a DOAC; both occurred in patients receiving rivaroxaban. One event was present in the BMI 40-50kg/m2 group and one in the >60kg/m2 group. Conclusions DOACs appear to be safe and efficacious for the management of VTE in the morbidly obese population. Future studies may focus on the comparative efficacy of apixaban and rivaroxaban in the morbidly obese population. Disclosures No relevant conflicts of interest to declare.

Background: Heparin-induced thrombocytopenia (HIT) occurs as a result of autoantibodies to the platelet factor 4 (PF4)-heparin complex, which activate the coagulation cascade with subsequent thrombosis. HIT can be fatal if not diagnosed and treated promptly with replacement of all heparin with non-heparin anticoagulants. Classic options are parenteral direct anti-thrombin agents which require intravenous administration and can prolong hospital stay. Direct oral anticoagulants (DOACs) address these inconveniences and are an interesting alternative. However, data regarding their efficacy and safety in HIT is limited. Methods: We retrospectively identified patients with HIT using ICD code 9: 289.84 and ICD code 10: D75.82 at Beaumont Hospital (Royal Oak) between December 2013 and December 2018. Only patients with HIT confirmed by positive serotonin release assay and managed with DOACs were included. Data regarding diagnostic tests, bleeding and thrombosis during the 30-day follow-up were recorded. Results: A total of 229 patients were identified using the ICD codes; only 8 patients had confirmed diagnosis of HIT and were treated with DOACs. The average age was 70 years (51-92 years); most were male (5, 62.5%) and Caucasian (6, 75%). The median optical density of PF4-heparin antibody was 1.97 (0.85-3.108). Six patients (75%) had confirmed HIT-associated thrombosis; one had negative Doppler ultrasonography of the lower extremities (upper extremities were not assessed) and one patient was not assessed for thrombosis. Seven patients (87.5%) received apixaban and one patient received rivaroxaban. The lowest platelet count prior to initiating DOAC was 40,000/microL, while three patients started DOACs when their platelet count was above 150,000/microL. Within the follow-up period, none of the patients on apixaban had bleeding episodes or clot progression. The only patient treated with rivaroxaban was re-admitted within one week of discharge for right upper extremity deep vein thrombosis. Unfortunately, this was the one patient who was not evaluated for thrombosis at the time of HIT diagnosis. Conclusion: In the 30 days following HIT diagnosis, treatment with apixaban resulted in adequate anticoagulation and was not associated with increased bleeding events despite relative thrombocytopenia. Disclosures No relevant conflicts of interest to declare.

e23099 Background: Cancer patients are using medical cannabis (MC) to address symptoms, however, little data exists to guide clinicians when counseling patients regarding use. We seek to define the patterns of MC use among oncology patients as well as efficacy and safety of MC. Methods: Cancer patients attending oncology office visits at Beaumont Hospital, Michigan from July – Dec 2018 were anonymously surveyed. The survey included data regarding demographics, diagnosis, treatment, symptom burden, and MC use. Patients who reported MC since their cancer diagnosis completed a section on patterns of use, efficacy, and safety. Results: Response rate was 188 of 327 (57.1%). Ages ranged from 18 to > 71, 59% were 61 or older. Early stage solid malignancy was 38%, metastatic was 41%, and hematologic malignancy was 21%. Cancer treatment was active in 80%. MC use was reported in 46 of 188 (24.5%). Median composite baseline symptom score ranging from 8 (best) to 32 (worst) was higher in patients using MC vs non-users; 17.5 vs 14.4 (p < 0.001). Pain was the symptom with the highest frequency of improvement 34/42 (81%), followed by appetite 34/44 (77%), and anxiety 32/44 (73%). MC improved ability to tolerate treatment in 24/44 (54%). The most frequent adverse effects were cloudy thinking 7/42 (17%), and decreased energy 4/41 (10%) Use of cannabis prior to cancer had no impact on median composite efficacy score (p = 0.43). Age > 61 was not associated with higher toxicity (p = 0.077). Conclusions: This data confirms MC is being utilized by a significant portion of cancer patients, across age, diagnosis, stage, and treatment. Patients with a higher severity of baseline symptoms are more likely to use MC, and report a favorable efficacy profile of MC with no increased risk of adverse effects in older population and similar efficacy in novel MC users. Minimal toxicity was reported in this cohort. Prospective studies are needed to define the efficacy and safety of MC. [Table: see text]

e23012 Background: Primary central nervous system lymphoma (PCNSL) is a rare and aggressive malignancy. Prognosis remains poor, and data on clinical characteristics or outcomes are limited, particularly in the elderly. In the literature, age over 50 is a major poor prognostic factor. Herein, we report our experience of PCNSL in elderly patients. Methods: The electronic medical records from 2007 to 2015 of the Beaumont Health System were analyzed. Patients with non-Hodgkin’s Lymphoma (NHL) were reviewed and those with PCNSL were identified. Results: Of the 617 NHL patients, 21 (3.4%) had PCNSL, 12 (57.1%) were male and 17 (81.0%) Caucasian. Median age was 76 (range, 55 to 83), and the majority 18 (85.7%) were above age 65. Deep brain lesions occurred in 11 (52.4%) patients. Eighteen (85.7%) received treatment, including 3/18 (16.7%) with high-dose methotrexate (HD-MTX) only, 5/18 (27.8%) HD-MTX plus rituximab (MR), 2/18 (11.1%) HD-MTX with vincristine and procarbazine, 7/18 (38.9%) MR and other chemotherapy, and 1/18 (5.6%) temozolomide and rituximab. MTX dose ranged from 1.8 to 8 g/m2 (median, 3.5 g/m2). The number of treatment cycles ranged from 1 to 11 (median, 3). Whole brain radiation was given to 4 (22.2%) patients with refractory disease after systemic chemotherapy. None of the patients received definitive radiation. Overall response rate was 44.4%, including 4/18 (22.2%) CR and 4/18 (22.2%) PR. Median survival was 4.0 months (95% CI, 2.3 to 5.7 months). At the time of data collection (November, 2018), only four patients were alive. Causes of death included disease progression (58.8%), neutropenic sepsis (23.5%), and MTX toxicity, predominantly acute kidney injury and severe gastrointestinal mucositis (17.7%). Age, lesion depth, treatment, and other clinical characteristics did not impact survival (all p > 0.05). Conclusions: Although HD-MTX remained the backbone of therapy for most patients, we observed a heterogeneous treatment pattern in our elderly patient population. More than 50% had primary refractory diseases, while about 40% had treatment related mortality. This study further emphasized the need for more trials enrolling elderly patients with PCNSL, utilizing novel agents, and investigating molecular prognostic markers.

We report a case of a small-cell variant of anaplastic large-cell lymphoma, with an unusual clinical presentation mimicking sepsis and a fulminant clinic course, in a 48-year-old Caucasian female. In this report, we discuss the diagnostic challenge, histopathologic features, and unique cytogenetic features of this case, in order to raise awareness of this rare presentation and emphasize the importance of meticulous peripheral smear examination and early bone marrow evaluation.

Background: Nearly 5% of patients diagnosed with Hodgkin lymphoma have the nodular lymphocyte predominant Hodgkin lymphoma (NLPHL), also known as Hodgkin paragranuloma or lymphocytic and histiocytic predominant Hodgkin disease. Given the rarity of this variant of Hodgkin lymphoma, there is no consensus on the standard of care/regimen in this subgroup of patients. Therapeutic approach has spanned from radiotherapy alone, combined chemo-radiotherapy to chemotherapy alone or observation and recently the use of Rituximab anti CD20 monoclonal antibody as these cells expresses CD20 marker. We opt to evaluate the outcome of patients with newly diagnosed NLPHL in our institution. We also reviewed outcome of NLPHL patients treated with various chemotherapy such as ABVD, CVP or RCHOP ± Radiation. Methods: We retrospectively reviewed medical records of over 300 patients [mean age 45 (13-76)] with Hodgkin Lymphoma at Beaumont Hospital, an academic community center from January 2007 - January 2017. Given the rarity of the disease, a total of 13 patients were found to have pathologically confirmed diagnosis of NLPHL. Data regarding age, sex, stage of disease, treatment and outcome was analyzed. Results: Total 13 patients with NLPHL with age range from 13 to 80 years were studied. Demographic distribution of studied patients were 8(62%) white, 4 (31%) African Americans and 1 (7.6%) Asian. Out of these, 8 (62%) were males and 5 (38%) females. A total of 9 (69%) patients have stage III disease on diagnosis while 4 (31%) patients had stage II disease on diagnosis. Out of 9 patients with stage III disease, 6 (67%) received chemotherapy alone (ABVD or CVP) whereas 3 (33%) received combined chemotherapy and radiotherapy. One patient in the chemotherapy alone arm, recurred within 24 months of treatment and received local therapy with radiation. Among those with stage II disease on diagnosis, 3 patients received radiation therapy alone while one patient was observed and did not receive any treatment. Overall, out of 13 patients studied, 12 (92%) are still alive and continues to follow with our clinic with no recorded relapse to date. One patient developed astrocytoma grade III and died of intracranial hemorrhage. CONCLUSION: Although the standard therapeutic management for patients with NLPHL remains controversial. Our data showed that regardless of the regimen selected (chemotherapy alone or combined chemo-Radiotherapy), patients with Lymphocyte predominant Hodgkin Lymphoma treated with ABVD ± Radiation have excellent outcome. Although our study represents a single institutional analysis, it concurs with recent studies that clinical outcome in patients with NLPHL is favorable with chemotherapy. Disclosures No relevant conflicts of interest to declare.

Background: Primary effusion lymphoma (PEL) is one of the least common of the AIDS-related lymphomas, accounting for less than 4% of cases. The optimal treatment for primary effusion lymphoma (PEL) remains unclear and there is a paucity of data regarding this neoplasm, which carries a uniformly poor prognosis. Antiretroviral therapy in addition to chemotherapy has shown to improve survival in a few small retrospective studies. Methods: Between 2002 and 2014, all cases of PEL were extracted from the population-based cancer registries of the Surveillance Epidemiology and End Results program (SEER). Instances of PEL were identified with the ICD-O-3 (9678) histological code. Frequency, demographics, and survival data were assessed using SPSS statistical software. Results: A total of 117 cases of PEL were identified. PEL was significantly more prevalent in men (89.7%) and in Caucasians (77.8%) with median age at diagnosis of 49 years. Median overall survival in the entire cohort was 6 months; CI, 3.7 to 8.2 months. Of all PEL cases, 62.4% received chemotherapy and 37.6% did not. Those who received chemotherapy had a median overall survival of 10 months vs less than one month when compared to subjects who did not receive chemotherapy (p = 0.002). PEL was the cause of death in 40.2% of the cases. PEL-specific median overall survival was markedly higher (29.000 months) than that of the entire cohort. Multivariable analysis demonstrated that age and race were not associated with mortality. Chemotherapy was associated with decreased mortality risk (HR, 0.45; CI, 0.28 -0.74; p = 0.002) Conclusions: In confirmation of previously published data, the highest incidence of PEL was found in Caucasian males. Subjects who received chemotherapy were found to have improved overall survival outcome. Other factors not related to PEL were associated with early mortality in this population. Disclosures No relevant conflicts of interest to declare.

Introduction: Arterial and venous thromboembolic events, including stroke and myocardial infarction, are a leading cause of morbidity and mortality in the United States. Anticoagulation therapies are critical in preventing such morbidity and/or mortality. Vitamin K antagonist (VKA) such as warfarin has been the standard therapy for decades until recently with the advent of direct oral anticoagulants (DOACs). These newer agents offer important advantages over warfarin however, the risk of bleeding with these drugs as with all anticoagulants remains an ongoing safety concern. Among the most serious adverse events are intracranial hemorrhages (ICH) and major gastrointestinal bleed (MGIB). For patients who were on anticoagulation prior to these events, there seems to be no consensus on the appropriate timing to resume anticoagulation if at all. Our group reported earlier on the outcome of restarting anticoagulation after ICH (ASH 2017;Oral Abstract #332). Herein, we aim to retrospectively investigate the clinical outcome in terms of recurrent bleeding or thromboembolic events following resumption of anticoagulation post MGIB. Clinical outcome analysis was also extended to compare VKA to DOACs. Method: We retrospectively reviewed medical records of over 800 adults [mean age 68 (22-81)] at Beaumont Hospital, an academic community center from January 2008 to January 2018 with confirmed MGIB. Patients with MGIB who were not on anticoagulation prior to and after the bleeding event were excluded from study. Patients who were on antiplatelet therapy were also excluded. A total of 280 patients met the criteria. MGIB is defined as decrease in hemoglobin by 2 grams below baseline and/or endoscopically confirmed bleeding. Association between restarting anticoagulation (VKA or DOACs) and re-bleeding or thromboembolic event was made using time-to-event adjusted analyses. Results: Demographic distribution of studied patients were 163 (58.2%) white, 89 (31.8%) African Americans and 28 (10%) others. Among these patients, 173 (61.8%) were on VKA, 107 (38.2%) were on one of the DOACs (51.4% rivaroxaban; 29.9% apixaban; 9.3% dabigatran; 2% pradaxa; < 1% edoxaban) (Table 1). Although anticoagulation was not reinstituted in 135 (48.2%) patients following MGIB; 13 (4.6%) patients had anticoagulant restarted within 7 days of diagnosis of MGIB; 42 (15%) patients were restarted between 7-30 days and 88 (31.4%) patients were restarted after 30 days. Majority of patients who restarted anticoagulation within 7 days had severe cardiac dysfunction requiring mechanical valves. Among those who restarted anticoagulation within 2 weeks of MGIB, 21 (7.5%) had recurrent GIB; 18 of those patients were restarted within 7 days whereas 3 were restarted between days 7-12. Majority of the recurrent GIB occurred in the warfarin arm since all patients with mechanical valves were on warfarin. Among the DOACS, rivaroxaban rated highest in terms of recurrent GIB (Table 1). The incidence of thromboembolic event was higher among those whose anticoagulants were discontinued after MGIB compared to those who resumed anticoagulation regardless of timing (86.5% vs 16.2%, p < 0.0001). Conclusion: Given the rising national trend on the use of anticoagulants for various medical necessities, it is imperative that a safe and efficient process be devised on reinstitution of anticoagulation post MGIB to guide Clinicians. Although our study represents a single institutional analysis, it concurs with recent studies that early resumption of anticoagulant following stabilization of MGIB is associated with lower thromboembolic events. Timing for resumption depends largely on the medical reason for anticoagulation; reinstitution by day 7 appear safe for patients on mechanical valve whereas after day 12 maybe appropriate for patients with Atrial fibrillation or venous thromboembolism. Our study further reveals that the risk of recurrent bleed and/or thromboembolism may be less in patients on DOACs when compared to VKA. Among those on DOACs, Rivaroxaban had the highest re-bleeding rate. Nonetheless, randomized clinical trials are needed to evaluate the true risk-benefit profile of anticoagulation resumption after MGIB. Disclosures No relevant conflicts of interest to declare.

e16232Background: Neoadjuvant therapy in BRPC serve to improve margin negative resection rate, however emerging data indicate otherwise. Aim of the study is to retrospectively investigate the clini...

e19535Background: Primary effusion lymphoma (PEL) is one of the least common of the AIDS-related lymphomas, accounting for less than 4% of cases. The optimal treatment for primary effusion lymphoma...

Introduction: Arterial and venous thromboembolic events, including stroke and myocardial infarction, are a leading cause of morbidity and mortality in the United States. Anticoagulation therapies including but not limited to vitamin K anticoagulant (VKA) and direct oral anticoagulants (DOACs) are critical in preventing such morbidity and/or mortality. Adversely, studies have shown an increased risk of bleeding associated with anticoagulation. For instance, there is a two-fivefold increase risk of intracranial hemorrhage (ICH) with warfarin use. On the other hand, 6.5% to 19.6% of all strokes result in ICH which increases mortality. For patients who were on anticoagulation prior to ICH, there seems to be no consensus on the appropriate timing to resume anticoagulation if at all. Most reported observational studies reveal that the decision on whether and when to resume anticoagulation is based on several clinical factors, such as the size and location of the ICH, the recurrence rate of the particular type of ICH, the underlying indication for anticoagulation and social factors. We performed a single institutional analysis on the correlation of anticoagulation resumption with subsequent risk of ICH recurrence and/or thromboembolism Method: We retrospectively reviewed medical records of 600 adults [mean age 69 (22-79)] at Beaumont Hospital, an academic community center from May 2015 to May 2016 with confirmed ICH, of which 125 patients were on prior anticoagulation. Our aim was to determine whether there is correlation between timing of re-institution of anticoagulant post ICH and eventual outcome with regards to recurrent ICH and/or thrombosis. We also compared outcome in patients on VKA to those on DOACs. Statistical analysis was performed by an independent investigator. Results: Demographic distribution of studied patients were 97(77.6%) white, 10 (8.0%) African Americans and 18 (14.4%) others. Among these patients, 75 (60.0%) were on VKA, 18 (14.4%) on Enoxaparin, 26(20.8%) were on one of the DOACs, and 6(4.8%) were on unknown anticoagulant prior to intracranial hemorrhage (ICH) (Table 1). Although anticoagulation was not reinstituted in 71(56.8%) patients following ICH; 5 (4.0%) patients had anticoagulant restarted within 7 days of diagnosis of ICH; 27 (21.6%) patients were restarted between 7-30days and 18 (14.4%) patients were restarted after 30 days. All patients restarted within 7 days of diagnosis were on warfarin due to severe cardiac dysfunction requiring mechanical valves. Using SAS System for Windows version 9.3, statistical analysis was performed on 32 (25.6%) patients who restarted on anticoagulation within 30 days of initial diagnosis to determine the risk of recurrent ICH or thromboembolism. Results showed that 11 (37.5%) patients had recurrent ICH when anticoagulation was restarted within 14 days from initial diagnosis. Of these, 2 (6.25%) patients were on DOACs (specifically, rivaroxaban) while 9 (28.1%) patients were on VKA. Within 30 days of initial ICH diagnosis, 19 (15.2%) patients developed thrombosis. Of those, 16 (12.8%) patients were restarted more than twenty-one days from initial diagnosis; 3 (2.4%) were restarted between fourteen and twenty-one days post diagnosis. Subgroup analysis of the thrombosis arm revealed that 2 (10.5%) were restarted on rivaroxaban while 17 (89.5%) were restarted on VKA. Forty-one (32.8%) patients were alive within the studied time period and the outcome of 28 (22.4%) patients could not be ascertained from our database. Conclusion: Given the rising national trend on the use of anticoagulants for various medical necessities, it is imperative that a safe and efficient process be devised on reinstitution of anticoagulation post ICH. Although our study represents a single institutional analysis, it concurs with recent studies that early resumption of anticoagulant following stable ICH is associated with lower thromboembolic events and similar risk of ICH recurrence. Our study further reveals that the risk of recurrent ICH and/or thromboembolism may be less in patients on DOACs. Nonetheless, randomized clinical trials are needed to evaluate the true risk-benefit profile of anticoagulation resumption after ICH. Disclosures No relevant conflicts of interest to declare.

6580 Background: Functional decline in cancer patients impacts quality of life and overall survival. Increasing attention has been focused on cancer rehabilitation in survivors, largely in the outpatient setting. Beaumont Health System has shifted its focus to include the acute setting by developing an inpatient cancer rehabilitation unit (IPCR) to improve the comprehensive care of patients. Methods: We retrospectively reviewed the patients admitted to IPCR from January 1 - December 31, 2016 for the following: demographics, length of stay (LOS), function independence measure (FIM) gain and efficiency, discharge location, and primary tumor type. Results: IPCR had 117 inpatient admissions; 98 (83.7%) were solid malignancies while 19 (16.3%) were benign hematological disorders and hematological malignancies. Of the 98 patients with solid malignancies, 22 (22.4%) patients had breast cancer, 22 (22.4%) had gastrointestinal cancers, 5 (5.1%) had gynecological cancers, 23 (23.5%) had lung cancer, 8 (8.2%) had CNS malignancies, 11 (11.2%) had other cancers, and 7 (7.2%) had prostate cancer with 81.6% of patients having metastatic disease. Among the hematological malignancies, lymphoma was diagnosed in 11 (57.9%) patients while 3 (15.9%) each had multiple myeloma and leukemia. The mean age of the patients was 68 years and 59% were female. The average LOS was 8.6 days. The mean admission total FIM was 66.7 ±12.8 and discharge total FIM was 87.3 ±16.1. The total improvement in FIM was 20.6 ±13.8 with FIM efficiency of 2.9. There were 21 (18%) patients transferred back to acute care units for decompensation, 7 (6%) went to subacute rehabilitation, 1 (0.85%) went to hospice while 87 (74.3%) were discharge to their homes upon completion of IPCR. Conclusions: Our focused rehabilitation was able to decrease the LOS, well above the 90th percentile Center for Medicare and Medicaid Services (CMS) benchmark and other prior studies, as well as enable patients to safely return home with improved FIM. Creating an IPCR unit proved to be beneficial, allowing for more comprehensive and individualized care, even in the setting of advanced malignancies.

e18160 Background: Studies using the 21-gene recurrence score (RS) have shown low risk pathologic features and RS breast cancers do not benefit from systemic chemotherapy (CTx). However, data is lacking for patients with discordant risk factors and which feature, genomic or clinical, plays more of a role in determining outcomes. Methods: Retrospective analysis was conducted to identify breast cancer patients with discordant features, defined as low genomic/high pathologic factors, from 2011 to 2016. Patients were hormone-receptor positive with RS < 18 and had ³ 2 high risk factors: tumor size ³2cm, lymph node (LN) positivity, or grade 2-3 disease. Results: There were 469 patients with low risk RS were identified of whom 118 met discordant risk criteria. Patients management is depicted in Table 1. Of the 118 discordant patients, 22 had breast cancer recurrence as either metastatic (1) or locoregional (21); 11 being ipsilateral while the remainder were contralateral. Patients with ipsilateral recurrences had partial mastectomy and radiotherapy as initial management. CTx was received in 30 patients despite low RS. Recurrences occurred in 31.8% of patients who received adjuvant CTx. The majority of recurrences occurred >5 years after initial diagnosis. Conclusions: Our results show both genomic and pathologic features were important in determining the need for CTx in early stage breast cancer but neither had a greater impact. Thus, we advocate a more comprehensive and individualized approach, taking into account comorbidities, genomic, and pathologic features, for addition of CTx to standard hormonal therapy. Further studies are needed to determine the proper treatment of this unique patient population. [Table: see text]

Asymptomatic (smoldering) multiple myeloma is a heterogeneous plasma cell proliferative disorder with a variable rate of progression to active multiple myeloma or related disorders. Hypercalcemia, renal insufficiency, anemia, bone lesions or recurrent bacterial infections characterize active multiple myeloma. Some patients with asymptomatic myeloma develop active disease rapidly, and others can stay asymptomatic for many years. Those who are likely to progress within the first 2 years of diagnosis have been categorized as having high-risk disease. The availability of novel agents in the treatment of active multiple myeloma and our better understanding of the heterogeneity of asymptomatic multiple myeloma have spurred interest in the early treatment of these patients. We have reviewed the current proposed definitions of high-risk asymptomatic multiple myeloma, the concerns about future therapy in view of the transient nature, remissions and toxicities of the therapies, and the eventual relapses that characterize this incurable disease.

CONTEXT Chronic Lymphocytic Leukemia (CLL) is a clonal proliferation of small mature B-cell lymphocytes diagnosed clinically when the peripheral blood clonal B lymphocyte count is persistently >5,000/mcL with distinctive immunological markers defined by co-expression of CD5 and CD23 with additional expression of CD19, CD20 (weak) with weak surface immunoglobulin expression, usually IgM heavy chain. Expression of CD79b and FMC7 is typically negative to weakly positive. With the recent advancement in cancer genetics and the continued understanding of the transforming events in CLL, the importance of the various somatic genomic aberrations has been well documented. Multiple studies have shown the clinical implications of these aberrations in terms of their prognostic and predictive relevance in clinical practice and these genomic aberrations are usually assessed clinically by cytogenetic analysis and FISH. OBJECTIVE We proposed this study to determine the incidence of the genomic aberrations in the CLL patients diagnosed at the Rose Cancer Treatment Center of the William Beaumont Hospital between 2010 and 2015 and to determine their impact on survival among the patients diagnosed during the study period. STUDY DESIGN A retrospective review of all the patients diagnosed with CLL between 2010 and 2015 at the Rose Cancer Treatment Center was conducted with the assistance of the staff in the William Beaumont cancer registry office. We determined the demographic variables and analyzed the incidence of CLL among the subjects diagnosed within the study period. Data analysis was performed using SPSS 21 and Kaplan-Meier curves were plotted for survival analysis and log rank (Mantel-Cox) was used to compare these curves. 12-Month and 36-Month overall survival rates were analyzed by actuarial method. The distribution of the various genomic aberrations was determined using descriptive statistical analysis. RESULTS A total of 151 patients were identified at the Rose Cancer Center of the William Beaumont Hospital during the study period. The median age at diagnosis was 74 years (range 38-101) of which 90 were male (59.6%) and 61 female (40.4%). One-hundred and twenty-four (82.1%) patients were white, six patients (4.0%) were African American, two patients (1.3%) were Asian and nineteen (12.6%) patients declined to identify their race. Analysis of cytogenetic distribution showed that, twenty patients (13.2%) had normal cytogenetic, eleven patients (7.3%) had del(13q) alone, eight (5.3%) had both del(13q) and del(11q), four patients (2.6%) had del(13q) plus trisomy 12 aberrations, ten (6.6%) patients had del(13q) and other karyotypes (TP53, RB1, trisomy 1q, del(6q23), unmutated IGHV). Thirteen patients (8.6%) had trisomy 12 abnormality, five patients (3.3%) had del(11q), three patients (2.0%) had del(17p), twenty-five patients (16.6%) had complex cytogenetic abnormalities and fifty-two (34.4%) patients cytogenetic were not checked (see Fig.1). The median follow-up duration for the cohort was 22.5 months (range 0 to 70 months). The survival rates at 12 months and 36 months for the cohorts based on cytogenetic are described in table 1 and fig.2. CONCLUSION Our study showed that majority of our patients (34.4%) did not have their cytogenetics checked at diagnosis, patients with del(13q) abnormality alone had the most favorable 36-Month overall survival rate and those with del(17p) fared worst with the most unfavorable outcome followed by patients with complex cytogenetic abnormalities. Presence of del(13q) with either del(11q) or trisomy 12 abnormalities appeared to ameliorate their poor and intermediate adverse prognostic effects, respectively. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

e14583 Background: Colorectal cancer (CRC) is a common and lethal disease. Age is a major risk factor for developing sporadic CRC. CRC is uncommon before 50 years of age, and it is often discovered...