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Background: Washing red blood cell (RBC) units mitigates severe allergic transfusion reactions. However, washing reduces the time to expiration and the effective dose. Automated washing is time‐ and labor‐intensive. A shortage of cell processor tubing sets prompted review of medical necessity for washed RBC for patients previously thought to require washing. Study Design and Methods: A single‐center, retrospective study investigated discontinuing wash RBC protocols in chronically transfused adults. In select patients with prior requirements for washing, due to a history of allergic transfusion reactions, trials of unwashed transfusions were performed. Patient demographic, clinical, laboratory, and transfusion data were compiled. The per‐unit washing cost was the sum of the tubing set, saline, and technical labor costs. Results: Fifteen patients (median age 34 years interquartile range [IQR] 23–53 years, 46.7% female) were evaluated. These patients had been transfused with a median of 531 washed RBC units (IQR 244–1066) per patient over 12 years (IQR 5–18 years), most commonly for recurrent, non‐severe allergic reactions. There were no transfusion reactions with unwashed RBCs aside from one patient with one episode of pruritus and another with recurrent pruritus, which was typical even with washed RBC. We decreased the mean number of washed RBC units per month by 72.9% (104 ± 10 vs. 28.2 ± 25.2; p <.0001) and saved US $100.25 per RBC unit. Conclusion: Washing of RBCs may be safely reconsidered in chronically transfused patients without a history of anaphylaxis. Washing should be implemented judiciously due to potential lack of necessity and logistical/operational challenges. [ABSTRACT FROM AUTHOR]

Background: Red blood cell (RBC) transfusion remains a major treatment for sickle cell disease (SCD). Patients with SCD have a high prevalence of renal impairment and cardiorespiratory disease, conferring risk of transfusion‐associated circulatory overload (TACO). Study Design and Methods: We describe an approach, titled euvolemic automated transfusion (EAT), to transfuse SCD patients with severe anemia who are at risk of TACO. In EAT, plasmapheresis is performed using donor RBCs, rather than albumin or plasma, as replacement fluid. Euvolemia is maintained. A retrospective analysis was conducted of patients with SCD who underwent EAT at our institution over a 10‐year period, to evaluate the efficacy and safety of EAT. Results: Eleven SCD patients underwent 109 EAT procedures (1–59 procedures per patient). The median age was 42 years (IQR = [30–49]) and 82% (n = 9) were female. Most (82%; n = 9) patients had severe chronic kidney disease and 55% (n = 6) had heart failure. One (9%) patient had a history of life‐threatening TACO. Mean pre‐ and post‐procedure Hct values were 19.8% (SD ± 1.6%) and 29.1% (SD ± 1.4%), respectively. The average Hct increment was 3.2% per RBC unit. Only two EAT‐related complications were recorded during the 109 procedures: central line‐associated infection and citrate toxicity (muscle cramping). EAT used an average of two RBC units less than that projected for standard automated RBC exchange. Conclusion: Our findings suggest that EAT is safe and effective to treat patients with SCD and severe anemia, who are at risk for TACO. EAT requires fewer RBC units compared to automated RBC exchange. [ABSTRACT FROM AUTHOR]

Merkel cell carcinoma (MCC) is a rare, neuroendocrine carcinoma seen in fair-skinned people over age 65. Typically arising from Merkel cells of the skin, it may also develop in less common sites, including the parotid gland. MCCs are associated with ultraviolet light, impaired immune function, and Merkel cell polyomavirus. We describe a case of a 58-year-old Hispanic male, diagnosed with primary MCC of the parotid gland, with metastasis to the femur, without primary lesions of the skin. The patient presented after a 2-week duration of knee pain. A large neck mass was observed and explained to be rapid growing and painless. Upon palpation, the mass was firm, immobile, and 2cm in diameter. Exam findings were otherwise unremarkable. Laboratory studies showed normal calcium and alkaline phosphatase levels. Facial CT revealed two large necrotic masses in the left parotid gland. Fine needle aspiration of these masses confirmed Merkel Cell Carcinoma (MCC). Staging with CT imaging, revealed many necrotic lymph nodes. Evaluation for metastasis was warranted due to the knee pain, in which X-ray revealed lytic lesions throughout the femur. Confirmatory MRI showed an aggressive intramedullary lesion of the right distal femur. As per patient, the MCC parotid growth duration was less than 1 year, yet resulted in spread to lymph nodes, distal femur and knee, confirming the aggressive nature of the tumour. This case joins the few reported cases of parotid gland MCC, serving to educate that this elusive cancer may present anywhere and should be considered when evaluating all masses. [ABSTRACT FROM AUTHOR]

Objective: To raise awareness of Primary Peritoneal Carcinosarcomas. Carcinosarcomas are biphasic malignant tumours, consisting of an admixture of carcinomatous components alongside sarcomatous components. These tumours most commonly arise from the uterus, but in rare cases, can arise from ectopic sites, termed primary peritoneal carcinosarcomas (PPC). We describe a case of a 74-year-old female who presented with generalized lower abdominal pain for five days. CT Abdomen/Pelvis showed a large gas and fluid collection in the pelvis, likely related to perforated diverticulitis or appendicitis. Intraoperatively, there was intra-abdominal purulent fluid and an abscess in the pelvis. Additionally, a pearly cobblestoning tumour was identified, which grossly appeared to have eroded either from the colonic mucosa into the adnexa or from the adnexa into the colon. Pathology received a segment of colon with an area of perforation. The serosa of the colon consisted of a rough, nodular friable mass surrounding a perforation. The colonic mucosa was grossly unremarkable. Sectioning through the mass revealed necrotic surfaces covered with mucin grossly appearing extra-luminal. Microscopic evaluation revealed a tumour consisting of carcinomatous (undifferentiated carcinoma with squamous and glandular differentiation) and sarcomatous components (high grade myxoid sarcoma with chondroid differentiation). The combination of macroscopic, microscopic and immunohistochemical studies determined the diagnosis of carcinosarcoma. Conclusion: The origin of this tumour has not been determined. Differential diagnoses include primary peritoneal carcinosarcoma (PPC) versus tumour seeding. PPC has been reported in literatures but are rare. Pathological, clinical and radiographic correlation unable to make distinction in this case. [ABSTRACT FROM AUTHOR]

Carcinoid tumours are neuroendocrine in origin, arising predominately from enterochromaffin cells of the gastrointestinal tract (90%), pancreas, and lung, with 5- 10% of these primary tumours metastasizing to the liver, resulting in carcinoid syndrome. In rare cases (0.3%), carcinoid tumours can originate in the liver, termed, Primary Hepatic Neuroendocrine Tumours (PHNET). In more rare instances, PHNETs can present with a coexisting malignancy, as described here. We describe a case of a 63-year-old female without any significant past medical or surgical history, who initially presented in 2010 with a left-sided breast lump, ultimately diagnosed as invasive ductal carcinoma. Due to noncompliance, patient was lost to follow-up, until resurfacing 2 years later, presenting with an ipsilateral breast mass and ispilateral axillary lymphadenopathy. Subsequent CT-Imaging and biopsies lead to the diagnosis of Grade II ER+/PR+/HER2- invasive ductal carcinoma with pulmonary and axillary metastases. After completing the treatment regimen of Arimidex, chemotherapy, and radiation therapy, a follow-up PET CT revealed a segment VI liver lesion, 1.3cm in diameter. Biopsy of the lesion, with immunohistochemical staining confirmed the diagnosis of a rare PHNET. There have been less than 150 cases of PHNETs reported in current English literature. After extensive literature review, there has not been a reported case of PHNET with concomitant invasive ductal breast carcinoma. Due to the rarity of PHNETs, little is known of the clinical features, treatment modalities, and outcomes, and therefore this case serves to educate and raise awareness about these tumours when identifying liver lesions, with or without concomitant malignancies. [ABSTRACT FROM AUTHOR]