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1 <!DOCTYPE html> 2 <html lang="en"> 3 <head> 4 <link rel="stylesheet" href="/style.css" type="text/css"> 5 <meta charset="utf-8"> 6 <meta http-equiv="Content-Type" content="text/html; charset=utf-8"> 7 <meta name="viewport" content="width=device-width, initial-scale=1.0"> 8 <link rel="stylesheet" type="text/css" href="/style.css"> 9 <link rel="icon" href="data:image/svg+xml,%3Csvg xmlns='http://www.w3.org/2000/svg' viewBox='0 0 100 100'%3E%3Cstyle%3E %23m %7B opacity:0; %7D%0A@media (prefers-color-scheme: dark) %7B %23m %7B opacity:1; %7D %23e %7B opacity:0 %7D%0A%7D %3C/style%3E%3Ctext id='m' y='.9em' font-size='90'%3E🏕️%3C/text%3E%3Ctext id='e' y='.9em' font-size='90'%3E🌞%3C/text%3E%3C/svg%3E"> 10 <title></title> 11 </head> 12 <body> 13 <div id="page-wrapper"> 14 <div id="header" role="banner"> 15 <header class="banner"> 16 <div id="banner-text"> 17 <span class="banner-title"><a href="/">beauhilton</a></span> 18 </div> 19 </header> 20 <nav> 21 <a href="/about">about</a> 22 <a href="/now">now</a> 23 <a class="nav-active" href="/posts">posts</a> 24 <a href="https://notes.beauhilton.com">notes</a> 25 <a href="https://talks.beauhilton.com">talks</a> 26 <a href="https://git.beauhilton.com">git</a> 27 <a href="/contact">contact</a> 28 <a href="/feed.xml">rss</a> 29 </nav> 30 </div> 31 <main> 32 <h1> 33 Morning Report 08/23/2021 34 </h1> 35 <p> 36 <time id="post-date">2021-08-23</time> 37 </p> 38 <p> 39 Details modified, generalized, and otherwise fudged to be 40 HIPAA-compliant. 41 </p> 42 <h2> 43 HPI 44 </h2> 45 <p> 46 72F with chest pain, abdominal pain, and constipation. 47 </p> 48 <p> 49 2-3mo weight loss, night sweats. 50 </p> 51 <p> 52 2-3wk +perineal ?cyst, initially ttp and hurt to walk, but now 53 nontender. 54 </p> 55 <p> 56 ~1wk constipation, BRB on TP. 57 </p> 58 <p> 59 +crampy LLQ pain 8/10, x3-4 days, improves with positioning (supine 60 with head raised somewhat, 3-4 pillows). 61 </p> 62 <p> 63 +LUQ and left-sided chest pain x1-2 days, radiates to L arm, not 64 related to exertion, lasts a few minutes. 65 </p> 66 <h2> 67 OP Meds 68 </h2> 69 <ul> 70 <li> 71 duloxetine 60mg 72 </li> 73 <li> 74 ASA 81mg 75 </li> 76 <li> 77 melatonin 6mg 78 </li> 79 <li> 80 no notable allergies 81 </li> 82 </ul> 83 <h2> 84 PMSHx 85 </h2> 86 <ul> 87 <li> 88 TVH-BSO for fibroids and endometriosis (~20y ago) 89 </li> 90 <li> 91 hemorrhoids (no surgeries) 92 </li> 93 <li> 94 s/p Moderna COVID vaccine (~4wk ago) 95 </li> 96 <li> 97 UTD on mammograms, colonoscopies, no deviations from regular 98 schedule 99 </li> 100 </ul> 101 <h2> 102 SHx 103 </h2> 104 <ul> 105 <li> 106 monogamous x45y, G2P2 sons, 6yo grandson, all healthy 107 </li> 108 <li> 109 never smoker 110 </li> 111 <li> 112 social EtOH, none this year 113 </li> 114 <li> 115 no non-Rx medicines 116 </li> 117 <li> 118 previously secretary 119 </li> 120 <li> 121 likes to DIY: painting, home crafts, gardening 122 </li> 123 </ul> 124 <h2> 125 FHx 126 </h2> 127 <ul> 128 <li> 129 M GM: uterine cancer (~40yo) 130 </li> 131 <li> 132 P GF: lung ca, unknown type (~70yo) 133 </li> 134 </ul> 135 <h2> 136 PE 137 </h2> 138 <ul> 139 <li> 140 VS: wnl 141 </li> 142 <li> 143 GEN: NAD 144 </li> 145 <li> 146 HEENT: no LAD 147 </li> 148 <li> 149 PULM: fine 150 </li> 151 <li> 152 CV: fine 153 </li> 154 <li> 155 ABD: NTND, +splenomegaly 156 </li> 157 <li> 158 GYN: 0.5cm lesion R side of anterior perineum, NT, freely 159 mobile 160 </li> 161 <li> 162 NEURO: fine 163 </li> 164 </ul> 165 <h2> 166 Labs 167 </h2> 168 <ul> 169 <li> 170 Hgb 12.7 171 </li> 172 <li> 173 WBC 58.3 174 <ul> 175 <li> 176 0 blasts 177 </li> 178 <li> 179 0 atypical lymphs 180 </li> 181 <li> 182 <ul> 183 <li> 184 slight L shift 185 </li> 186 </ul> 187 </li> 188 </ul> 189 </li> 190 <li> 191 Plt 490 192 </li> 193 <li> 194 BMP grossly wnl (gluc 202, <a href="https://www.ashclinicalnews.org/viewpoints/editors-corner/illegitimi-epic-non-carborundum-dont-let-epic-bastards-grind/">Cr 195 fine</a>) 196 </li> 197 <li> 198 LFTs fine 199 </li> 200 <li> 201 Trop <0.01 202 </li> 203 <li> 204 urate 10.4 205 </li> 206 <li> 207 phos 5.0 208 </li> 209 <li> 210 LDH 330 211 </li> 212 <li> 213 fibrinogen 355 214 </li> 215 </ul> 216 <h2> 217 Other studies 218 </h2> 219 <ul> 220 <li> 221 EKG wnl 222 </li> 223 <li> 224 CT-PE -ve 225 </li> 226 <li> 227 CT a/p wwo 228 <ul> 229 <li> 230 +10x7cm pelvic mass (central/R adnexum, exerting mass effect on 231 sigmoid colon) 232 </li> 233 <li> 234 spleen ~20cm largest dimension w ?infarcts x2, 235 </li> 236 <li> 237 L internal iliac vein filling defects c/w nonocclusive DVT 238 </li> 239 </ul> 240 </li> 241 <li> 242 PET/CT 243 <ul> 244 <li> 245 splenomegaly with diffusely increased uptake, diffuse FDG uptake of 246 axial and appendicular skeleton, mild uptake of abdominal pelvic lymph 247 nodes, and minimal to mild uptake in the pelvic mass. 248 </li> 249 </ul> 250 </li> 251 </ul> 252 <h2> 253 Further notes on hospital course 254 </h2> 255 <ul> 256 <li> 257 CEA 1.7 (wnl), CA-125 52 (-) 258 </li> 259 <li> 260 urate 9.5 5d later w IVF, given rasburicase 3mg x1 -> urate 261 3.8 262 </li> 263 <li> 264 phos similarly without movement, sevelamer eventually helpful 265 </li> 266 <li> 267 pelvic mass bx: smooth muscle 268 </li> 269 <li> 270 BMBx: hypercellular >90%, no blasts, +trilineage atypica > 271 myeloid, MF-1 fibrosis. 272 </li> 273 <li> 274 JAK2 -ve, BCR/ABL -ve 275 </li> 276 <li> 277 NGS 278 <ul> 279 <li> 280 BRAF 5% (MGUS, MM, hairy cell, hystiocytic/dendritic cell, solid 281 tumors, therapy-related myeloid neoplasms) 282 </li> 283 <li> 284 KRAS 39% (MDS, AML, MDS/MPN inc CMML and JMML) 285 </li> 286 <li> 287 BCOR 49% (?, possibly germline since allele fraction ~50%) 288 </li> 289 <li> 290 BCORL1 48% (ditto) 291 </li> 292 <li> 293 EZH2 93% (?, likely germline w loss of heterozygosity) 294 </li> 295 </ul> 296 </li> 297 </ul> 298 <h2> 299 And then… 300 </h2> 301 <p id="post-excerpt"> 302 Diagnosis is... MDS/MPN/MF NOS. 303 i.e., who knows. 304 </p> 305 <p> 306 Started on hydroxyurea and decitabine, c/b recurrent bacteremia, so 307 currently tx on hold. 308 </p> 309 <hr> 310 <h2> 311 TLS 312 </h2> 313 <p> 314 The big idea, and a few finer points. 315 </p> 316 <p> 317 <a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2680750"></a> 319 </p> 320 <h3> 321 Cairo-Bishop classification system 322 </h3> 323 <p> 324 (Most of the following derived from <a href="https://www.asn-online.org/education/distancelearning/curricula/onco/Chapter4.pdf">Chapter 325 4</a> of the American Society of Nephrology online <a href="https://www.asn-online.org/education/distancelearning/curricula/onco/">Onco-Nephrology 326 curriculum</a>, which is good and great.) 327 </p> 328 <h3> 329 Laboratory TLS 330 </h3> 331 <p> 332 Definition: Chemotherapy plus the two or more of the following within 333 3d before or 7d after initiation (so doesn’t account for the spontaneous 334 TLS seen in our patient). 335 </p> 336 <p> 337 | Metabolite/Electrolyte | Criterion | | :———————– | 338 :––––––––––––––––––––: | | Uric Acid | >=8 mg/dL or 25% increase from 339 baseline | | Potassium | >=6mEq/L or 25% increase from baseline | | 340 Phosphorus | >=4.5mg/dL or 25% increase from baseline | | Calcium | 341 25% <em>decrease</em> from baseline | 342 </p> 343 <p> 344 The “25% increase/decrease” part is contested, as it may not be 345 clinically meaningful if the value stays within the normal range. 346 </p> 347 <h3> 348 Clinical TLS 349 </h3> 350 <p> 351 | Laboratory TLS and one or more of | | :–––––––––––––––– | | 352 creatinine >= 1.5 ULN (Note: just use AKI criteria) | | cardiac 353 arrhythmia or sudden death | | seizure | 354 </p> 355 <ul> 356 <li> 357 risk assessment 358 </li> 359 </ul> 360 <h3> 361 Treating TLS 362 </h3> 363 <p> 364 IVF, electrolytes, rasburicase. 365 </p> 366 <p> 367 Rasburicase is the subject of a recent “Things We Do for No 368 Reason.” 369 </p> 370 <p> 371 <a href="https://www.journalofhospitalmedicine.com/jhospmed/article/241443/hospital-medicine/things-we-do-no-reasontm-rasburicase-adult-patients-tumor">Pay-walled 372 article</a>, <a href="https://cdn.mdedge.com/files/s3fs-public/JHM01607424.PDF">PDF made 373 available by the authors</a> 374 </p> 375 <p> 376 TL;DR: the evidence is thin, but could be reasonable to 377 </p> 378 <ul> 379 <li> 380 ppx w IVF and allopurinol for low-med risk, 381 </li> 382 <li> 383 use single 3mg dose rasburicase as ppx in high-risk disease (don’t 384 use weight-based dosing), 385 </li> 386 <li> 387 tx active TLS (laboratory or clinical) with aggressive fluid 388 resuscitation and electrolyte mgmt, possibly single 3mg dose. 389 </li> 390 </ul> 391 <p> 392 Hard outcomes in support of rasburicase are generally lacking, e.g. 393 consistently reducing renal injury, renal failure, length of stay. 394 </p> 395 <p> 396 It also seems like the classification criteria need revamping, with a 397 larger N. It’s been a while. However, like redefining fever, it’s 398 difficult to get a clean slate, because we act on the established 399 criteria so aggressively. 400 </p> 401 <hr> 402 <h2> 403 MDS/MPN overlap syndromes 404 </h2> 405 <p> 406 Not much to say here, except that the dx is not always clear-cut, 407 even with BMBx and NGS data, so the clinical picture matters, and 408 sometimes we have to shoot in the dark. 409 </p> 410 <hr> 411 <p> 412 Last updated: 2021-08-22 413 </p> 414 </main> 415 <div id="footnotes"></div> 416 <footer></footer> 417 </div> 418 </body> 419 </html>