Donovan, Sean

8590 Background: Merkel Cell Carcinoma (MCC) is an aggressive cutaneous malignancy of neuroendocrine origin associated with immunosuppression presumably through infection with Merkel Cell Polyomavirus present in >80% of patients (pts). The impact of immune status on clinical outcomes in pts with MCC is unknown. The primary objective of this study was to compare clinical characteristics and outcomes of pts with MCC who are immunosuppressed (ISP) versus non-immunosuppressed (non-ISP). Methods: We performed a retrospective chart review on pts with MCC diagnosed at the Mayo Clinic between 1981 and 2009. A dermatopathologist confirmed all cases. ISP was defined as pts diagnosed with chronic lymphocytic leukemia, HIV, solid organ transplant recipients, or chronic immunosuppressive medication. The association between ISP status and overall survival was summarized using the hazard ratio (HR) and 95% confidence interval (CI) estimated from a Cox regression model. Results: Of the 268 pts identified and included in the study, 38 (14%) were ISP. We found no differences in age, tumor size, tumor location, stage of disease, or recurrence rate in ISP vs Non-ISP. Among pts who had Stage 3-4 disease, there was no difference in the size of the primary between groups. Among pts with Stage 1-2 disease, ISP status was not significantly associated with poorer survival (HR 1.5, 95% CI 0.7-3.3). However, among pts with Stage 3-4 disease, ISP pts had significantly poorer survival compared to non-ISP pts (HR 2.7, 95% CI 1.2 - 6.2). Conclusions: Baseline clinical characteristics of pts with MCC do not differ based on immunosuppression, and outcomes do not differ in pts in regards to immunosuppression in early stage MCC (Stage 1-2). However, in pts with Stage III-IV MCC, ISP pts have a worse clinical outcome suggesting that metastatic MCC either behaves more aggressively in ISP pts either through intrinsic differences in the biology of the tumor or improved immune evasion in ISP pts. These results should be cautiously interpreted given the small number (n=12) of immunosuppressed pts with advanced stage MCC. The authors will update their data with an additional 58 patients by the date of presentation.

Introduction. While patients undergoing orthotopic liver transplantation (OLT) have high cardiovascular event rates, preoperative risk stratification may not necessarily predict those susceptible patients. Troponin T (TnT) may help predict patients at risk for cardiovascular complications.Methods. Consecutive patients undergoing OLT at Mayo Clinic in Florida between 1998 and 2010 who had TnT obtained within 10 days following surgery were included. Three groups were compared based on TnT level: (1) normal (TnT≤0.01 ng/mL), (2) intermediate (TnT 0.02–0.11 ng/mL), and (3) elevated (TnT>0.11 ng/mL). Overall and cardiovascular mortality was assessed.Results. Of the 78 patients included, there was no difference in age, gender, severity of liver disease, and echocardiographic findings. Patients in the normal and intermediate TnT groups had a lower overall mortality rate (14.3% and 0%, resp.) when compared with those with elevated TnT (50%;P=0.001). Patients in the elevated TnT group had a cardiovascular mortality rate of 37.5% compared with 1.4% in the other groups combined (P<0.01). The elevated TnT group had a much higher mortality rate when compared with those in the intermediate group (P<0.0001).Conclusion. TnT may accurately help risk stratify patients in the early postoperative setting to better predict cardiovascular complications.

Pneumatosis intestinalis (PI), defined as gas within the bowel wall, is an uncommon radiographic sign which can represent a wide spectrum of diseases and a variety of underlying diagnoses. Because its etiology can vary greatly, management of PI ranges from surgical intervention to outpatient observation (see, Greenstein et al. (2007), Morris et al. (2008), and Peter et al. (2003)). Since PI is infrequently encountered, clinicians may be unfamiliar with its diagnosis and management; this unfamiliarity, combined with the potential necessity for urgent intervention, may place the clinician confronted with PI in a precarious medical scenario. We present a case of pneumatosis intestinalis in a patient who posed a particularly challenging diagnostic dilemma for the primary team. Furthermore, we explore the differential diagnosis prior to revealing the intervention offered to our patient; our concise yet inclusive differential and thought process for rapid evaluation may be of benefit to clinicians presented with similar clinical scenarios.