S5760 Acute Liver Failure Secondary to Metastatic Choroidal Melanoma

Introduction: Choroidal melanoma is a rare type of melanoma that occurs within the uveal tract of the eye, with an incidence rate of about 1,500 cases per year in the United States. The liver is the most common site of metastases, however acute liver failure secondary to hepatic infiltration is extremely rare and there are only a few reported cases in the literature. We report a unique case of a woman who presented with acute liver failure secondary to metastatic choroidal melanoma despite successful ocular radiation treatment 2 years prior. Case Description/Methods: The patient was a 43-year-old woman with a history of choroidal melanoma that was treated with plaque brachytherapy 2 years prior. She had been scheduled to undergo biannual surveillance abdominal imaging however was lost to follow-up. She presented with several weeks of worsening abdominal pain, distention, constipation, and anorexia. Her initial labs were notable for aspartate aminotransferase 199, alanine aminotransferase 62, total bilirubin 1.6, and alkaline phosphatase 44. Computed tomography imaging demonstrated hepatomegaly with right portal vein and hepatic vein thrombus, moderate ascites, and a 1.4 cm hypoenhancing lesion adjacent to the caudate lobe. Analysis of ascitic fluid revealed a SAAG of 2.1, consistent with portal hypertension. Viral, autoimmune, and genetic causes of liver injury were ruled out. Over the next 2 weeks, her clinical condition deteriorated and her labs worsened: aspartate aminotransferase 320, alanine aminotransferase 86, total bilirubin 9.9, Na 127, albumin 2.4, and international normalized ratio 2.6. A repeat MRI abdomen revealed new sub-centimeter lesions throughout the liver and a few peripheral wedge-shaped lesions that were favored to represent infarcts. A trans-jugular liver biopsy showed loosely cohesive cells with high nuclear to cytoplasmic ratios, consistent with metastatic melanoma. The patient became increasingly encephalopathic and lethargic over the next several days. Unfortunately, the patient’s metastatic cancer and poor clinical condition precluded liver transplant candidacy or systemic therapy. Aggressive measures were withdrawn and she expired shortly thereafter. Discussion: Acute liver failure secondary to diffuse involvement of choroidal melanoma is very rare and has been described only a handful of times. This patient’s worsening liver function was secondary to both diffuse hepatic melanoma infiltration and ischemia related to tumor-related necrosis or portal and hepatic vein thrombus. This case highlights that metastases should be considered in a patient with a history of choroidal melanoma and new-onset liver decompensation.