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Anuric Kidney Failure in a Patient With Metastatic Melanoma

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 53-year-old man received a diagnosis of stage IV melanoma with metastatic disease to the spine and brain 3 months before presentation. Four weeks following receipt of immunotherapy with ipilimumab and nivolumab, he developed acute abdominal pain in the setting of a rapidly rising lactic acid dehydrogenase levels, prompting hospital admission. Imaging results showed mild disease progression (new ascites and periportal metabolic lymph node). Splenic infarct and portal/splenic vein thrombi were identified as etiologies of his acute pain and were presumed to be secondary to hypercoagulable state of malignancy.

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C. Acute tubular necrosis secondary to kidney melanoma metastasis

The kidney is an uncommon site of clinically apparent melanoma metastases. While kidney micrometastases may be found in up to half of patients with a history of melanoma on postmortem evaluation, they are typically subclinical small cortical nodules.2,3 The few cases of symptomatic kidney involvement from melanoma have been secondary to large cortical masses that can be visualized on imaging.47 Thus, symptomatic kidney micrometastases and/or isolated tumor cells with intracapillary involvement are a rare phenomenon.

The patient’s biopsy findings were suggestive of acute tubular necrosis (ATN) that followed metastatic melanoma cells occluding kidney capillaries and limiting blood flow to tubules. The specimen stained with hematoxylin and eosin showed intracapillary atypical cells with enlarged nuclei, prominent nucleoli, and abundant cytoplasm (Figure, A) and diffuse mild acute tubular injury with tubular dilatation and extensive isometric cytoplasmic vacuolization of tubular epithelial cells (Figure, B), which were consistent with ATN. Intracapillary atypical cells were positive for melanin-A (Figure, C), Sry-related HMg-Box gene 10, S-100, and human melanoma black–45 stains, which indicated the presence of melanoma micrometasases. These findings may account for the abnormal intraparenchymal flow that was visualized on ultrasonography, although no positron emission tomography avidity was appreciated in the kidneys.

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Article Information

Corresponding Author: Janice Mehnert, MD, Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, 522 First Ave, SML1304 New York, NY 10016 (janice.mehnert@nyulangone.org).

Published Online: August 19, 2021. doi:10.1001/jamaoncol.2021.3515

Conflict of Interest Disclosures: Dr Mehnert reported research funding from Amgen, BMS, Novartis, Merck, AstraZeneca, Macrogenics, and EmdSerono; honoraria from Regeneron, BMS, Seattle Genetics, Array Biopharma, and Pfizer/Emdserono; and consulting fees from Merck. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

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