Malignant neoplasms are unlikely to be considered in the clinical differential diagnosis of incidental umbilical nodules in patients presenting for unrelated reasons and may even be missed unless a through examination is performed. We present a case of a patient who presented with complaints of body aches following a fall, and was found to have an umbilical nodule with metastatic malignant mesothelioma. A literature review revealed only rare cases of patients presenting for unrelated complaints, and who were found to have umbilical metastasis of malignant mesothelioma. We conclude that umbilical metastasis (Sister Mary Joseph's nodule) from malignant peritoneal mesothelioma is rare, especially as an initial finding. Clinicians should include it in their list of differential diagnosis in patients presenting with umbilical nodules even in the absence of history of asbestos exposure.

e14686 Background: Hepatocellular carcinoma (HCC) is the 3rd leading cause of cancer death globally with most deaths occurring within 1 year of diagnosis. Arsenic trioxide (ATO) has proven activity in the treatment of both solid and hematologic tumors. ATO cytotoxicity and apoptosis induction has been demonstrated in vitro with numerous human cancer cell lines including HCC. Methods: Patients with advanced measurable HCC, no more than one prior systemic treatment or no treatment, ECOG PS 0-2 and Child-Pugh class A received ATO 0.35 mg/kg on days 1, 8, 15, and 22 of each 28-day cycle. The primary endpoints were the feasibility of administering this regimen and the qualitative and quantitative toxicities of treatment. Secondary endpoints were response to treatment, duration of progression-free survival, patterns of failure, and survival. Results: 9 patients were enrolled from 10/13/04 to 9/5/07. Median age of patients was 57 years (range 50-62 years) and included 8 males and 1 female. No patients had previous systemic therapy. 3 patients did not complete the first cycle and were not evaluable for response. 6 patients had progressive disease on therapy. 1 patient received 8 cycles of therapy, achieved a partial response lasting 8 months and is still alive. Most common adverse effects (AEs) were fatigue and QTC prolongation and all AEs were less than grade 3. No patients had APL differentiation syndrome. Conclusions: Although ATO demonstrated 1 partial response in this trial, ATO appears to be less active than sorafenib which is FDA approved for treatment of advanced HCC. Given the complexity of therapy and potential cardiotoxicity, further development of ATO in this setting appears unwarranted. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Cepahlon, GlaxoSmithKline, Lilly Cepahlon

A 27-year-old woman presented with progressive dyspnoea, orthopnoea, left-sided pleuritic chest pain (improved on upright posture), 20 mm of pulsus paradoxus, distant heart sounds, and impending pericardial tamponade (confirmed on two-dimensional echocardiogram). One litre of bloody fluid was removed by pericardiocentesis. A two-dimensional Doppler echocardiogram and transoesophageal echocardiogram demonstrated …

Background The prevalence of clinically significant gastroesophageal reflux (GERD) in the general population varies between 3 and 6%. We observed GERD to be one of the major complaints of our patient population with monoclonal gammopathy of unknown significance (MGUS). There is no literature available on the incidence of GERD in MGUS. Moreover, there have been conflicting reports on the prevalence of Helicobacter pylori and MGUS. Objective To study the incidence and relationship of GERD, H. pylori, and MGUS. Methods We identified 394 patients with MGUS at Veterans Affairs Medical Center, Kansas City, diagnosed over the last 20 years. The control group consisted of patients with chronic lymphocytic leukemia (CLL) followed over the same period (20 years) at the same institution. Charts on these patients were reviewed for endoscopic findings, pathologic biopsies, and H. pylori staining on histology. Results Forty-one percent (162/394) of patients with MGUS were noted to have moderate to severe symptoms of GERD compared with 10% (47/460) in the control group. The median age of the patients was similar in both groups. Sixty percent (97/162) of MGUS patients with GERD underwent endoscopies compared with 25% (12/47) of patients in the control group. Histology was positively stained for H. pylori in 27.8% patients (27/97) in MGUS and 25% (3/12) of the control group. We found no correlation between H. pylori positivity and type or level of monoclonal protein in MGUS. In addition, we observed no change in immunoglobulin levels following treatment and eradication of H. pylori in MGUS patients. Conclusion At our institution, patients with MGUS have a higher prevalence of GERD. Our findings need to be confirmed and verified in further prospective studies. No correlation was seen between H. pylori infection and MGUS.

8117 Monoclonal gammopathy of undetermined significance (MGUS) increase in prevalence with age and it is associated with risk of progression to plasma cell disorder. According to ASH guidelines, patients (pts) should have a complete blood count (CBC), creatinine, calcium, and a complete bone survey and periodic follow up. There has been no clear-cut guideline regarding the role of bone marrow biopsy in these patients. There is suggestion in the literature that bone marrow aspiration and biopsy is indicated if the M protein is 1.5 g/dL. Hypothesis We hypothesize that the increase in serum immunoglobulin is correlated with an increase in plasma cell in the bone marrow biopsy. Methods: We performed a retrospective chart review of 327 MGUS veteran patients seen from 2002 to 2005. Diagnostic criteria for MGUS were defined as <3 g/dL serum monoclonal protein, <10 % plasma cells in the bone marrow and absence of radiographic or laboratory abnormality related to the plasma cell proliferative process. Patients with smoldering myeloma were excluded. Bone marrow biopsies were available on 97/327 patients. Bone marrow biopsy with plasma cell percentage, serum protein electrophoresis (SPEP) and immunofixation (SFE), and immunoglobulin levels of these patients were retrieved and statistical analysis was performed by using Pearson correlation coefficient and linear regression analysis to detect the correlation between plasma cell percentage and immunoglobulin levels. Results: Of the 97 patients whom the bone marrow biopsy was available, 66 patients had IgG, 15 had IgA and 16 had IgM monoclonal paraprotein. There was linear correlation between serum IgG and IgA levels with the percentage of plasma cells in the bone marrow. (p< 0.001 and < 0.02 respectively. By regression analysis, using a cut off value of 10% plasma cells in the bone marrow, the predicted level of IgG and IgA immunoglobulin was 2124 mg /dl and 1564 mg/dl respectively. There was no correlation between IgM immunoglobulin and plasma cell percentage in the marrow. Conclusion: There is a linear correlation between serum IgG and IgA immunoglobulin with plasma cell percentage in the bone marrow. Bone marrow biopsy with plasma cell percentage of 10% or higher may be predicted in patients with MGUS with IgG or IGA above 2g/dl and 1.5g/dl respectively. No significant financial relationships to disclose.

18533 Background: Patients with stage IV lung cancer have median survival of 4–6 months. Randomized trials have shown chemotherapy may have small but significant survival benefit. To achieve this small gain,patients may have to spend their last few days of life in the office visits and hospitalization. Last few days of person’s life need to be spent comfortably and most effective manner in accordance to their wishes, desires and priorties.We attempted to study the “Time Lost” in the stage IV lung cancer patients who either did not choose or were not offered the palliative care/Hospice. Methods: We retrospectively reviewed charts of patients diagnosed with stage IV lung cancer (at their initial presentation) from Jan 2002 to Dec 2005 at our institution. We calculated their inpatient and out patient visit hrs and hence “Time Lost” during the last few days of their life. Patients were divided into two groups—Group A (n = 12): Patients who opted to choose palliative/hospice care immediately after the diagnosis and GroupB (n = 46): Patients who either refused or were not offered palliative/hospice care. Results: The median age at diagnosis was similar in both groups (71 vs 69.5 yrs). The median survival was also similar in both groups (4 months vs 4 months). Patients in group B (non hospice) had 1 month “Lost Time” out of their median survival of 4 months. In comparison patients in group A (hospice) had median survival of 4 months with “No Lost Time”. Thus patients who were not offered hospice or refused hospice spent 25% of their precious time during last stages of their life in inpatient stays and outpatient visits. Conclusions: Patients with stage IV lung cancer should be actively offered palliative/Hospice care, though studies with large number of patients is further required. [Table: see text] No significant financial relationships to disclose.

The antiseptic effectiveness and acceptability of a commercial alcohol-based waterless (ABWL) and an alcohol-based water-aided (ABWA) scrub solution were compared with a brush-based iodine solution (BBIS) under conditions encountered in community hospital operating rooms. This randomized partially blinded study was based on guidelines from the American Society for Testing and Methods. The three scrub solutions were compared for antimicrobial efficacy, using criteria within the Food and Drug Administration's Tentative Final Monograph for Healthcare Antiseptic Products (FDA-TFM), and for participants' acceptance of the products. Volunteer surgical staff that worked daily in the same operating room for the entire duration of the study were enrolled. In total, 1126 surgical scrub procedures were performed over the duration of the study. Only the ABWL met all of the FDA-TFM criteria. The BBIS performed better than both of the alcohol-based solutions at the end of Day 1 (P=0.03), but the ABWL was more efficacious than the ABWA and the BBIS at the end of Days 2 and 5 (P=0.02 and 0.01, respectively). When colony-count reductions were compared over the entire duration of the study, there was no significant difference between the three solutions (P=0.2). The participants found the ABWL easiest to use (P<0.001), with the fewest adverse effects on skin (P=0.007), and it was their preferred product (P<0.001). Although both of the commercially available alcohol-based solutions may be considered as acceptable alternatives to the BBIS for presurgical antisepsis, the ABWL was found to have significantly higher user acceptability.

18549 Background: Infections are the major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (CLL). Hypogammaglobulinemia, in general, increases the susceptibility to infections in patients with CLL. We conducted a case-control study to investigate whether hypogammaglobulinemia (Immunoglobulin-G (IgG) level <600 mg/dL) increases the risk of febrile neutropenic episodes in CLL patients with chemotherapy associated neutropenia (absolute neutrophil count (ANC) <0.5 × 109/L). Methods: The source cohort consisted of all consecutive patients with CLL seen at our institution between Jan 2002 to June 2005.We identified 8 cases of chemotherapy associated febrile neutropenia; controls consisted of 18 patients, with neutropenia but no fever (n = 4) or no neutropenia (n = 14). Results: The two groups were comparable except for a higher proportion of patients with Rai stage-4 disease in the febrile neutropenia cohort (100% vs. 17%, p < 0.001). Eight of the 8 patients in febrile neutropenia group were found to be hypogammaglobulinemic as compared to 2 of 18 controls (100% vs 11%, P value < 0.001). The median IgG level was 400 mg/dL (range, 300–488 mg/dL) in the febrile neutropenia group compared to 820 mg/dL (range, 121–1700 mg/dL) in the control group (p = 0.003).The relative risk of developing chemotherapy associate febrile neutropenia in the presence of underlying hypogammaglobulinemia was 4.5 (95% confidence intervals, 1.9–10.7). Conclusions: Patients with CLL who are hypogammaglobulinemic are candidates for prophylactic administration of intravenous immune-globulin prior to initiation of myelosuppressive chemotherapy. [Table: see text] No significant financial relationships to disclose.

A 46-year-old woman presented with fullness in the right flank, abdominal discomfort, weight loss of 35 pounds over the course of 1 year, and a palpable, nontender, movable mass in the right flank. Laboratory test results all were within normal limits. A computed tomography scan of the abdomen showed a mass in the medial aspect of the ascending colon. A right hemicolectomy and a bilateral salphingo-oophorectomy showed a 17-cm mass in the cecum and ascending colon, pushing up the colonic mucosa and causing ulceration (Figure A). A spindle-cell neoplasm with a vague storiform pattern and extensive necrosis was present. The nuclei were pleomorphic, hyperchromatic, with abundant mitoses including atypical mitosis (Figure B). Immunohistochemical stains were negative for epithelial, muscle, mesothelial, and neural markers, and vimentin and α1-antitrypsin were positive, consistent with malignant fibrous histiocytoma. Twenty-three pericolonic lymph nodes were negative but bilateral ovaries were positive for metastasis. The patient did not receive any chemotherapy or radiotherapy. An extensive work-up did not find any metastasis elsewhere. The patient is alive without recurrence 36 months after surgery.View Large Image Figure ViewerDownload (PPT) Malignant fibrous histiocytoma is a high-grade sarcoma that usually arises in the deep soft tissues of the extremities and the retroperitoneum.1Enzinger F.M. Weiss S.W. Malignant fibrohistiocytic tumors.in: Enzinger F.M. Weiss S.W. Soft tissue tumors. Mosby Year Book, St. Louis1995: 351-380Google Scholar The cell of origin is a primitive mesenchymal cell that retains both fibroblastic and histiocytic potential. Presenting symptoms are similar to colonic adenocarcinomas and include abdominal pain, diarrhea, and hematochezia. The tumors tend to be large and may involve any part of the colon. Malignant spindle cells in a storiform pattern with enlarged pleomorphic nuclei are seen with abundant mitotic activity. Immunohistochemical stains are the key to diagnosis and help rule out other sarcomas and sarcomatoid carcinoma. Complete surgical resection is the main treatment modality. The median survival time is reported to range from 9 to 84 months, depending on stage of the sarcoma. The roles of chemotherapy and radiotherapy remain unclear. Prognostic factors of primary colorectal malignant fibrous histiocytoma remain uncertain, although the presence of surface ulceration is reported to have a higher likelihood of recurrences or metastasis.2Makino M. Kimura O. Kaibara N. Radiation-induced malignant fibrous histiocytoma of the transverse colon a case report and review of the literature.J Gastroenterol. 1994; 29: 767-771Crossref PubMed Scopus (11) Google Scholar

Objective Mullerian papillary serous tumors are a spectrum of gynecological tumors. We reviewed papillary serous carcinoma of peritoneum (PSCP) and compared its clinical behavior to stage III and IV of ovarian, uterine, and fallopian tube papillary serous carcinomas. Methods of Study Medical records and pathological records were reviewed for the period from November 1992 to July 2002, at Coney Island Hospital, Brooklyn, NY. There were 6 patients with PSCP and they were compared with 8 patients with ovarian papillary serous carcinoma (OPSC), 5 patients with uterine papillary serous carcinoma (UPSC), 2 with fallopian tube papillary serous carcinoma (FTPSC), and 1 with multifocal papillary serous carcinoma. Symptoms of abdomen distention and pain, loss of appetite, weight loss, vaginal bleed, and signs of ascites, palpable mass, uterine polypoid mass and laboratory data of CA-125 at admission were compared. The pathological grade, postoperative residual disease, recurrence, disease-free survival (DFS) and overall survival (OS) were also compared. Results Patients with UPSC were older than PSCP and OPSC. The commonest symptoms in patients with PSCP and OPSC were abdominal pain, distention, and ascites compared to women with UPSC who presented with vaginal bleeding and polyp or polypoidal mass in uterus. Mean CA-125 levels were lower in patients with PSCP (539.00 U/mL) compared to OPSC (2996.70 U/mL). Overall patients with OPSC and UPSC had a better DFS and overall survival compared to those with PSCP. Also, low-grade tumors in all groups had a better survival and DFS compared to those with moderate and high grade tumors within the same group. Conclusions The patients with PSCP had poorer OS and shorter DFS compared to OPSC and UPSC. Patients with high-grade tumor had residual disease after debulking surgery. Overall low-grade tumors in all groups had a better OS and DFS compared to moderate and high-grade tumors within the same group. Also, patients with high-grade OPSC and PSCP and higher levels of CA-125 at the time of diagnosis had a poorer outcome.