Introduction Lung cancer remains the most common cause of cancer-related deaths worldwide, with Non-Small Cell Lung Cancer (NSCLC) the predominant histologic subtype. Increasingly, molecular mutations are identified and used as therapeutic targets. We describe the case of a woman diagnosed with locally metastatic NSCLC, and distinct pulmonary masses, later identified as two independent primary lung tumors based on molecular profiling. Case Report A 58-year-old-female presented with cough and hemoptysis. Chest Computed Tomography (CT) revealed a 4.3cm mass in the right lung apex, 2.0 cm nodule in the right lower lobe (RLL), and right paratracheal/hilar adenopathy. Subsequent Positron Emission Tomography-Computed Tomography (PET-CT) showed uptake in the right upper lobe (RUL) (SUV 12.2) and RLL (standard uptake value (SUV) 2.5) masses and mediastinal lymph nodes, but no distant metastases. Bronchoscopic biopsy of the RUL mass and 4R lymph node were positive for poorly differentiated adenocarcinoma, and molecular analysis revealed Epidermal Growth Factor Receptor (EGFR) L858R mutation. Subsequent Electromagnetic Navigation (EMN) biopsy of the RLL lesion also showed adenocarcinoma, but with an EGFR exon-19 deletion. Both were negative for T790M mutation. She was therefore diagnosed with two separate primaries instead of intrathoracic metastases. She started erlotinib and after 4 months, repeat PET-CT showed complete response (CR) in the RLL and partial response (PR) in the RUL. Decision was made to pursue surgery with RUL/RLL bilobectomy. Pathology showed evidence of N2 disease; therefore, at time of surgery she was stage IIIA, presumably from the RUL mass. The RLL mass was presumed to be stage I. These were successfully resected, and she was deemed to have no evidence of disease (NED) post-operatively. Discussion Although co-mutations within the same tumor have been reported in up to 12% of patients,28 we are not aware of other cases in which a single patient was diagnosed with two separate primary lung tumors based on genetic profiles. Consequently, she was able to be treated with curative rather than palliative intent.

369 Background: Recently, there has been a dramatic increase in the use of oral antineoplastics for the treatment of various malignancies. The development of these agents has been so rapid that the infrastructure needed for their appropriate supervision has trailed their availability. Previously at Virginia Mason, there was no standard work established for the management of patients starting these agents and consequently there were defects noted, including delays in the medications’ delivery to the patient, lack of appropriate teaching regarding potential medication toxicities and even delayed provider follow-up. The goal of this project was to create standard work around the treatment initiation and follow-up of all patients starting outpatient oral antineoplastic therapy. Methods: A multi-disciplinary team of providers, nurses, and pharmacists held a flow mapping session to identify defects and waste points in the process between the prescription being written until the first provider follow-up visit after medication delivery. The team focused on decreasing the amount of time between prescription initiation and first clinic follow up, as well as increasing the percentage of RN teaching sessions performed and documented. This involved the creation of a dedicated inbox in the Electronic Medical Record (EMR) to which pharmacy and care manager nurses had exclusive access to facilitate rapid communication between team members. The work also resulted in the creation of an antineoplastics teaching template which was used to document teaching on potential treatment toxicities. Results: Standard work was created for the outpatient oral antineoplastic administration process and teaching documentation. Using the new tools, lead time was improved by 21.7% and teaching documentation was improved by 185% at the 30-day mark. These metrics were monitored over a 3 month period, and at the end of 90 days the lead time improvement was maintained at 21.2% and teaching documentation improvement at 110% (Table). Conclusions: The rapid development of oral antineoplastic medications has required Oncology practices to develop more robust workflow infrastructure to administer these medications properly and safely. We created standard work for the proper initiation and follow-up of oral antineoplastic therapy. In doing so we identified specific defects and instances of waste and were able to improve the workflow process to address these issues, resulting in measurable quality improvements and overall better patient care.[Table: see text]