High-Percentage of Early Resectable Pancreatic Ductal Adenocarcinoma is Unidentified on Abdominal CT Obtained for Unrelated Diagnosis

Objective: Pancreatic ductal adenocarcinoma (PDAC) has the best survival when detected early with 5-year survival near 40% for small, resectable PDAC. We evaluate the undiagnosed PDAC imaging features on routine CT and their impact on resectability. Methods: 76 of the screened 134 CTs from 1/1/2012 to 12/31/2018 using our tumor registry were obtained prior to PDAC diagnosis for other indications at least one month before presentation. Each cross-sectional study was reviewed for features of early PDAC: pancreatic mass, pancreatic ductal dilatation, perivascular/peripancreatic soft-tissue infiltration, omental lesions/ascites, and lymphadenopathy. When such features were detectible by the reviewing radiologists, the original CT readings were classified as concordant/discrepant. Descriptive statistics are reported for discrepant reads, tumor resectability, and tumor size. Results: Of the 76 cases from 46 unique subjects (30 male/16 female), 25 CTs (33%) had undetected PDAC imaging features: masses (15/19 unreported), ductal dilatation (16/20 unreported), and peripancreatic/perivascular soft-tissue infiltration (20/36 unreported). 63% of early PDAC features were not identified initially. One year before clinical diagnosis, 75-80% of the PDAC cases were resectable; at < 6 months before clinical diagnosis, only 29% were resectable. Conclusion: Improving early detection of key PDAC features on routine CT examinations can potentially improve patient outcomes.

Trends in clinico-epidemiology profile of surgically operated glioma patients in a tertiary care center over 12 years—through the looking glass!

Background Hospital-based cancer registries can provide information on the magnitude and distribution of cancers in a given hospital. Hospital-based brain tumor registry data, focusing on glioma, from a tertiary care rural neurological center is lacking in the scientific literature. This data can be useful in understanding the need for research and funding required for these specific brain tumors. Data of patients operated for glioma, at our institute, was collected between January 2004 and December 2015. Patients’ clinical details and histopathological diagnosis were recorded. Data were analyzed and compared with that of previously published literature, and inferences were drawn on patterns of reporting and epidemiology. Results A total of 1450 cases of glioma, with a mean age of 39.3 (± 17.36 SD) years with males (66.6%) comprising more population as compared to females. Majority of patients 70.8% (n = 1027) belong to the economically active age group of country (18–60 years). Majority of cases (41.4%) were glioblastoma with the next common tumor (22.8%) being diffuse astrocytoma (n = 331) followed by pilocytic astrocytoma (6.2%) and oligodendroglioma (4.5%) in that order. While our data followed similar trends with other Indian data the average age of glioma was a decade younger to what is quoted earlier in Indian and international studies. Conclusion This data for glioma gives a glimpse of the prevalence of this tumor in a primarily rural population and highlights the need for a National Brain Tumor Registry with the need for the development of evidence-based policymaking and enhanced research into this particular ailment.

Compliance with the National Comprehensive Cancer Network guidelines for evaluation and treatment of anemia among patients with solid tumors.

11 Background: Anemia is associated with increased morbidity, mortality and decreased quality of life among oncology patients. The National Comprehensive Cancer Network (NCCN) recommends evaluation and treatment of anemia in patients with cancer. There is a paucity of data investigating compliance with the NCCN guidelines. Methods: A retrospective study of patients diagnosed with any malignant solid tumor at our institution from 2008-2017 was performed. Tumor-registry-confirmed cancer cases were identified using International Classification of Disease-Oncology (ICD-O) codes in the Synthetic Derivative (SD) database, a de-identified copy of the electronic medical record. Patients were included if they were between the ages of 18 and 89 and had a hemoglobin (hgb) within 6 months of diagnosis. Patients were excluded if they had more than one tumor registry entry. Anemia was defined as hgb ≤11g/dL and graded using the CTCAE v.5.0. Absolute and possible functional iron deficiency were defined by NCCN guidelines. B12 and folate deficiency were defined by institutional reference values. Chi-squared tests were conducted in R (Version 3.4.4). P <.05 was interpreted as statistically significant. Results: A total of 25,018 patients met inclusion criteria. The median age was 60 years, and the most common malignancies were respiratory tract, prostate, and urologic (11% each, respectively). Of the 25,018 patients, 1,484 (17%) were noted to be anemic at time of diagnosis and 11,019 (44%) were anemic within 6 months of diagnosis. Of these patients, a plurality (N = 4,686, 43%) had grade 2 anemia and a majority (N = 9,623, 87%) had normocytic anemia. Patients with retroperitoneal/peritoneal cancers had the highest prevalence of anemia (N = 83, 75%). A total of 4,125 (37%) underwent any evaluation of their anemia, of which 1,742 (16%) had iron studies performed and 1,528 (14%) had B12 or folate studies performed. Of those with iron studies performed, 197 (11%) patients had absolute iron deficiency and 103 (6%) had possible functional iron deficiency. Of those with B12 labs, 74 (5%) had B12 deficiency and of those with folate labs, 69 (12%) had folate deficiency. Less than half of anemic patients (N = 4,318, 39%) received treatment for anemia, including blood transfusion (N = 3,528, 32%), oral iron (N = 1,279, 12%), or IV iron (N = 97, 1%). However, treatment of anemia significantly increased as grade of anemia increased (any treatment among mild: 12%; moderate: 31%; severe: 77%; χ2 [2, N = 11,019] = 3020.6; P <.001). Patients with male reproductive tract cancers had the highest prevalence of anemia evaluation (N = 57, 79%). Conclusions: Anemia is common in patients with solid tumors, yet compliance with NCCN guidelines for evaluation and treatment of anemia remains low. There are opportunities to improve compliance with NCCN guidelines for management of anemia across the spectrum of cancer care.

P14.31 Between hospital variation in timings to multidisciplinary glioblastoma care in the Dutch Brain Tumor Registry

BACKGROUND Delay in cancer care may adversely affect emotional distress, treatment outcome and survival. Optimal timings in multidisciplinary glioblastoma care are a matter of debate and clear national guidelines only exist for time to neurosurgery. We evaluated the between-hospital variation in timings to neurosurgery and adjuvant radiotherapy and chemotherapy in newly diagnosed glioblastoma patients in the Netherlands. MATERIAL AND METHODS Data were obtained from the nation-wide Dutch Brain Tumor Registry between 2014 and 2018. All adult patients with glioblastoma were included, covering all 18 neurosurgical hospitals, 28 radiotherapy hospitals, and 33 oncology hospitals. Long time-to-surgery (TTS) was defined as &gt;3 weeks from the date of first brain tumor diagnosis to surgery, long time-to-radiotherapy (TTR) as either &gt;4 or &gt;6 weeks after surgery, and long time-to-chemotherapy (TTC) as either &gt;4 or &gt;6 weeks after completion of radiotherapy. Between-hospital variation in standardized rate of long timings was analyzed in funnel plots after case-mix correction. RESULTS A total of 4203 patients were included. Median TTS was 20 days and 52.4% of patients underwent surgery within 3 weeks. Median TTR was 20 days and 24.6% of patients started radiotherapy within 4 weeks and 84.2% within 6 weeks after surgery. Median TTC was 28 days and 62.6% of patients received chemotherapy within 4 weeks and 91.8% within 6 weeks after radiotherapy. After case-mix correction, three (16.7%) neurosurgical hospitals had significantly more patients with longer than expected TTS. Three (10.7%) and one (3.6%) radiotherapy hospitals had significantly more patients with longer than expected TTR for &gt;4 and &gt;6 weeks, respectively. In seven (21.2%) chemotherapy hospitals, significantly less patients with TTC &gt;4 weeks were observed than expected. In four (12.1%) chemotherapy hospitals, significantly more patients with TTC &gt;4 weeks were observed than expected. CONCLUSION Between-hospital variation in timings to multidisciplinary treatment was observed in glioblastoma care in the Netherlands. A substantial percentage of patients experienced timings longer than anticipated.

P14.40 Trends in distribution of glioblastoma care and patient’s travel distance; results from the Dutch Brain Tumor Registry

BACKGROUND Over the past years, increasing worldwide attention towards centralization of complex cancer care has been pursued as higher volume centers have shown improved outcomes. Changes in distribution of care and the impact on travel distance in glioblastoma patients have not been determined yet. In this study, we determine trends in distribution of glioblastoma care in the Netherlands over the last three decades and assess whether the observed trends affected travel distance for individual patients. MATERIAL AND METHODS Data were obtained from the Dutch Brain Tumor Registry from 1989 to 2018. All glioblastoma patients (≥18 years) were included for analysis. Patients, neurosurgical centers and radiotherapy centers were geocoded. Data were analyzed in six time intervals of 5 years. High volume hospitals were defined as &gt;50 cases per year. Travel distance was examined in two categories, ≤60km and &gt;60km respectively. Trend analyses for proportions were used to analyze hospital volume changes and travel distances. RESULTS A total of 16.477 glioblastoma patients were registered, with an annual increase from 203 patients in 1989 to 917 patients in 2018. Neurosurgical centers increased from 16 to 17 and for radiotherapy from 19 to 22 centers between 1989–1993 and 2014–2018. Mean neurosurgical- and radiotherapy center volumes increased from 12 to 39 (P=0.025) and 7 to 27 (P=0.025) patients per hospital per year from 1989–1993 to 2014–2018. High volume neurosurgical centers were observed since 2004, and an increased number of patients were treated in these centers, 27.8%, 52.6% and 64.1% in the time periods 2004–2008, 2009–2013, and 2014–2018 (P&lt;0.001). High volume radiology centers were observed since 2009, and 15.0% and 27.3% of patients were treated in these centers in the time periods 2009–2013 and 2014–2018 (P&lt;0.001). Patients with a travel distance &gt;60km to the neurosurgical center reduced from 15.8% to 13.2% (P=0.033). Travel distance &gt;60km to the radiotherapy center did not reduce significantly (10.4% to 8.8%, P=0.601). CONCLUSION An increasing number of glioblastoma patients were differentially treated in high volume neurosurgery and radiotherapy centers. The observation that this did not translate into increased travel distances, indicates accessible specialized Neuro-Oncology care for glioblastoma patients in The Netherlands.

Dr. Louise Eisenhardt’s personal notes: how she and Dr. Cushing collected data and followed patients

Dr. Louise Eisenhardt was one of the first neuropathologists and was responsible for the development of tumor diagnosis guidelines. This historical vignette reviews her previously unseen handwritten notes in which she describes methods used by her and Dr. Harvey Cushing to obtain patient follow-up data for their Brain Tumor Registry. Her description spans 50 years, using “every possible clue to be jumped upon in [their] clinical records and correspondence.” Their follow-up was divided into two periods: early follow-up (1912–1932) and registry (1933–1961). During early follow-up, patients were asked to write to them on the anniversary of their operation. The foundation of the registry necessitated the use of “considerable effort on [their] part to gather up old threads” including renewed contact with patients after 15–20 years. Methods of follow-up included continued verbal and written correspondence with patients and “strong-arm methods,” including use of the Fuller Brush man and the exhumation of a body. Drs. Eisenhardt and Cushing believed “every case was important in adding to our collective knowledge of various types of tumors particularly in relationship to life expectancies and suggesting improvement in surgical treatments.” Dr. Eisenhardt’s meticulous record keeping allows for insights into the first known outcomes-related tumor registry in neurosurgery.

Typing of inflammatory lesions of the pituitary

Inflammatory pituitary lesions account for 1.8% of all specimens from the German Pituitary Tumor Registry. They occure in 0.5% of the autoptical specimens and in 2.2% of the surgical cases. Women are significantly more often affected than men and are often younger when first diagnosed. In general, primary and secondary inflammation can be distinguished, with secondary types occurring more frequently (75.1%) than idiopathic inflammatory lesions (15.4%). In primary inflammation, the lymphocytic type is more common (88.5%) than the granulomatous type of hypophysitis (11.5%). The most common causes of secondary inflammation are Rathke’s cleft cysts (48.6%), followed by tumors (17.4%) such as the craniopharyngioma (9.1%), adenoma (5.5%) or germinoma (2.0%). More causes are tumor-like lesions (7.1%) such as xanthogranuloma (3.5%) or Langerhans histiocytosis (3.5%), abscesses (5.5%), generalized infections (5.1%), spreaded inflammations (4.7%) and previous surgeries (4.0%). In 1.6% of all specimens the reason for the inflammation remains unclear. The described classification of hypophysitis is important for specific treatment planning after surgery.

Launching the Quality Outcomes Database Tumor Registry: rationale, development, and pilot data

OBJECTIVE Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal. METHODS The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications. RESULTS As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221). CONCLUSIONS The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.