1/20/17 Intern Morning Report – Tumor Lysis Syndrome, Metastatic Melanoma

CC: Masses, back pain, fatigue

ID: 58 yo incarcerated man with HTN and history of smoking/IVDU presents with soft tissue masses on his back and legs starting 3 months ago. He started to feel low back pain at this time, along with significant fatigue. Other symptoms include weight loss over the past 8 months and intermittent fevers the past 3 weeks. Exam was notable for firm masses on his R back, R buttock, and L inner thigh as well as bilateral pitting edema. BMP on admission was notable for hyperkalemia, hyperphosphatemia, anion gap metabolic acidosis and renal failure; additional labs ordered showed a uric acid level of 13.6 mg/dL and LDH >5000 U/L. MRI Lumbar spine showed enlarged bilateral paraspinal muscles with possible underlying mass and hematomas. CT images showed revealed extensive metastatic involvement of skeletal muscles and thoracic/retroperitoneal lymph nodes. The patient underwent an ultrasound-guided biopsy of the back mass; pathology revealed malignant melanoma. He was also diagnosed with tumor lysis syndrome (prior to any chemotherapy administration) and was started on IV fluids, allopurinol, and rasburicase.

metastatic-melanoma
CT Abdomen/Pelvis: Extensive metastatic involvement of skeletal muscles and thoracic/retroperitoneal lymph nodes.

Pearls from morning report:

  • Allopurinol alone is insufficient to treat hyperuricemia since its action is in decreasing uric acid formation – use rasburicase for preexisting hyperuricemia.
  • Be aggressive about IVF hydration!  See the Pearls from 11/4/16 morning report for indications for renal replacement therapy in TLS.
  • Spontaneous tumor lysis syndrome is rare, but is usually seen in Non-Hodgkin’s Lymphoma and acute leukemia.

Random trivia:

President Jimmy Carter was diagnosed with metastatic melanoma to the liver and brain.  He received immunotherapy with pembrolizumab and now reports he is now cancer free!


Want to read more?

How I treat hematologic emergencies in adults with acute leukemia (Blood)
Tumor lysis syndrome (New England Journal of Medicine)


References: 

Howard SC, Jones DP, Pui CH. Tumor Lysis Syndrome. N Engl J Med. 2011;364(19):1844-54.

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