Soft Tissue Sarcoma with Gout Tophi

An 80-year-old man, who could not walk because of a large mass on his right leg, was brought to the emergency department. The mass had been increasing in size on the anterior region of his right thigh for approximately 6 months. The patient also complained of “lumps” that had developed on his extremities during the past 2 months.

He had been drinking 6 beers per day for over 60 years and had not seen a physician in more than 30 years.

Drs Timothy Goggins and Bruce Houghton of Creighton University, Omaha, report the patient was alert and oriented; his blood pressure was 160/82 mm Hg. Multiple hard nodular masses were noted on his feet, hands, elbows, and the ulnar aspect of his wrists. The right anterior thigh mass measured 40 × 30 cm and was firm and nonmobile. No bruits were heard over the mass. Active and passive right leg ranges of motion were intact.

Roentgenographs revealed the thigh mass had no bony involvement. MRI showed an inhomogeneous mass that was likely a sarcoma; there was no evidence of bone destruction. A CT scan of the abdomen and chest disclosed bilateral pleural effusions with a right lower lobe nodular density. A head CT scan was normal.

A core needle biopsy of the mass found a high-grade malignant sarcoma. The complete blood cell (CBC) count indicated normocytic normochromic anemia with a hemoglobin level of 9.8 g/dL (normal, 14 to 18 g/dL). Uric acid level was 8.8 mg/dL (normal, 2.5 to 8.0 mg/dL); other laboratory findings were unremarkable.

Drs Goggins and Houghton comment that secondary gout may occur in cases of myeloproliferative disorders and other malignancies; allopurinol may be used to reduce elevated uric acid levels in these patients.¹ As in this case, soft tissue sarcomas sometimes are diagnosed late in the course of disease because the patient is reluctant to seek medical evaluation. This patient refused surgical amputation of his right leg and chemotherapy. He was given allopurinol, metoprolol, and oral sustained-release morphine. More than 2000 centigrays of radiation were administered during 10 treatments. The patient died 6 months after the diagnosis was made.

REFERENCE:1.DeConti RC, Calabresi P. Use of allopurinol for prevention and control of hyperuricemia in patients with neoplastic disease. N Engl J Med. 1966;274:481-486.