mr-2021.md (6392B)
1 # Morning Report 08/23/2021 2 3 <time id="post-date">2021-08-23</time> 4 5 Details modified, generalized, and otherwise fudged to be HIPAA-compliant. 6 7 ## HPI 8 9 72F with chest pain, abdominal pain, and constipation. 10 11 2-3mo weight loss, night sweats. 12 13 2-3wk +perineal ?cyst, initially ttp and hurt to walk, but now nontender. 14 15 ~1wk constipation, BRB on TP. 16 17 +crampy LLQ pain 8/10, x3-4 days, improves with positioning (supine with head raised somewhat, 3-4 pillows). 18 19 +LUQ and left-sided chest pain x1-2 days, radiates to L arm, not related to exertion, lasts a few minutes. 20 21 ## OP Meds 22 - duloxetine 60mg 23 - ASA 81mg 24 - melatonin 6mg 25 - no notable allergies 26 27 ## PMSHx 28 - TVH-BSO for fibroids and endometriosis (~20y ago) 29 - hemorrhoids (no surgeries) 30 - s/p Moderna COVID vaccine (~4wk ago) 31 - UTD on mammograms, colonoscopies, no deviations from regular schedule 32 33 ## SHx 34 - monogamous x45y, G2P2 sons, 6yo grandson, all healthy 35 - never smoker 36 - social EtOH, none this year 37 - no non-Rx medicines 38 - previously secretary 39 - likes to DIY: painting, home crafts, gardening 40 41 ## FHx 42 - M GM: uterine cancer (~40yo) 43 - P GF: lung ca, unknown type (~70yo) 44 45 ## PE 46 - VS: wnl 47 - GEN: NAD 48 - HEENT: no LAD 49 - PULM: fine 50 - CV: fine 51 - ABD: NTND, +splenomegaly 52 - GYN: 0.5cm lesion R side of anterior perineum, NT, freely mobile 53 - NEURO: fine 54 55 ## Labs 56 - Hgb 12.7 57 - WBC 58.3 58 - 0 blasts 59 - 0 atypical lymphs 60 - + slight L shift 61 - Plt 490 62 - BMP grossly wnl (gluc 202, [Cr fine](https://www.ashclinicalnews.org/viewpoints/editors-corner/illegitimi-epic-non-carborundum-dont-let-epic-bastards-grind/)) 63 - LFTs fine 64 - Trop <0.01 65 - urate 10.4 66 - phos 5.0 67 - LDH 330 68 - fibrinogen 355 69 70 ## Other studies 71 - EKG wnl 72 - CT-PE -ve 73 - CT a/p wwo 74 - +10x7cm pelvic mass (central/R adnexum, exerting mass effect on sigmoid colon) 75 - spleen ~20cm largest dimension w ?infarcts x2, 76 - L internal iliac vein filling defects c/w nonocclusive DVT 77 - PET/CT 78 - splenomegaly with diffusely increased uptake, diffuse FDG uptake of axial and appendicular skeleton, mild uptake of abdominal pelvic lymph nodes, and minimal to mild uptake in the pelvic mass. 79 80 ## Further notes on hospital course 81 - CEA 1.7 (wnl), CA-125 52 (-) 82 - urate 9.5 5d later w IVF, given rasburicase 3mg x1 -> urate 3.8 83 - phos similarly without movement, sevelamer eventually helpful 84 - pelvic mass bx: smooth muscle 85 - BMBx: hypercellular >90%, no blasts, +trilineage atypica > myeloid, MF-1 fibrosis. 86 - JAK2 -ve, BCR/ABL -ve 87 - NGS 88 - BRAF 5% (MGUS, MM, hairy cell, hystiocytic/dendritic cell, solid tumors, therapy-related myeloid neoplasms) 89 - KRAS 39% (MDS, AML, MDS/MPN inc CMML and JMML) 90 - BCOR 49% (?, possibly germline since allele fraction ~50%) 91 - BCORL1 48% (ditto) 92 - EZH2 93% (?, likely germline w loss of heterozygosity) 93 94 ## And then... 95 96 <p id="post-excerpt"> 97 Diagnosis is... MDS/MPN/MF NOS. 98 i.e., who knows. 99 </p> 100 101 Started on hydroxyurea and decitabine, c/b recurrent bacteremia, so currently tx on hold. 102 103 --- 104 105 ## TLS 106 107 The big idea, and a few finer points. 108 109 [](https://jamanetwork.com/journals/jamaoncology/fullarticle/2680750) 110 111 ### Cairo-Bishop classification system 112 113 (Most of the following derived from 114 [Chapter 4](https://www.asn-online.org/education/distancelearning/curricula/onco/Chapter4.pdf) 115 of the American Society of Nephrology online 116 [Onco-Nephrology curriculum](https://www.asn-online.org/education/distancelearning/curricula/onco/), 117 which is good and great.) 118 119 ### Laboratory TLS 120 121 Definition: 122 Chemotherapy plus the two or more of the following 123 within 3d before or 7d after initiation 124 (so doesn't account for the spontaneous TLS seen in our patient). 125 126 | Metabolite/Electrolyte | Criterion | 127 | :----------------------- | :----------------------------------------: | 128 | Uric Acid | >=8 mg/dL or 25% increase from baseline | 129 | Potassium | >=6mEq/L or 25% increase from baseline | 130 | Phosphorus | >=4.5mg/dL or 25% increase from baseline | 131 | Calcium | 25% *decrease* from baseline | 132 133 134 The "25% increase/decrease" part is contested, 135 as it may not be clinically meaningful 136 if the value stays within the normal range. 137 138 ### Clinical TLS 139 140 | Laboratory TLS and one or more of | 141 | :-------------------------------- | 142 | creatinine >= 1.5 ULN (Note: just use AKI criteria) | 143 | cardiac arrhythmia or sudden death | 144 | seizure | 145 146 - risk assessment 147 148 ### Treating TLS 149 150 IVF, electrolytes, rasburicase. 151 152 Rasburicase is the subject of a recent "Things We Do for No Reason." 153 154 [Pay-walled article](https://www.journalofhospitalmedicine.com/jhospmed/article/241443/hospital-medicine/things-we-do-no-reasontm-rasburicase-adult-patients-tumor), 155 [PDF made available by the authors](https://cdn.mdedge.com/files/s3fs-public/JHM01607424.PDF) 156 157 TL;DR: 158 the evidence is thin, but could be reasonable to 159 - ppx w IVF and allopurinol for low-med risk, 160 - use single 3mg dose rasburicase as ppx in high-risk disease (don't use weight-based dosing), 161 - tx active TLS (laboratory or clinical) with aggressive fluid resuscitation and electrolyte mgmt, 162 possibly single 3mg dose. 163 164 Hard outcomes in support of rasburicase are generally lacking, e.g. consistently reducing renal injury, renal failure, length of stay. 165 166 It also seems like the classification criteria need revamping, 167 with a larger N. 168 It's been a while. 169 However, like redefining fever, 170 it's difficult to get a clean slate, 171 because we act on the established criteria so aggressively. 172 173 --- 174 175 ## MDS/MPN overlap syndromes 176 177 Not much to say here, 178 except that the dx is not always clear-cut, 179 even with BMBx and NGS data, 180 so the clinical picture matters, 181 and sometimes we have to shoot in the dark. 182 183 184 --- 185 186 Last updated: 2021-08-22