Intraoperative tumor lysis syndrome in a giant teratoma: a case report

BACKGROUND

Tumor lysis syndrome is an unusual metabolic emergency in solid tumors. Perioperative occurrence of this syndrome is extremely rare but may have fatal consequences if not detected and treated on time.

CASE REPORT

We report a 19-year patient with testicular germ cell tumor after first line chemotherapy with giant growing teratoma syndrome in retroperitoneum. He underwent radical resection, however, perioperatively, a fatal case of heart failure due to unrecognized intraoperative tumor lysis syndrome developed.

CONCLUSION

Surgeons, anesthesiologists and oncologists should be aware of this complication in order to be prepared for such an emergency.

A Case Report of Atezolizumab Induced Tumor Lysis Syndrome

Patient: Female, 67

Final Diagnosis: Atezolizumab induced tumor lysis syndrome

Symptoms: Generalized weakness • hematuria • nausea • vomiting

Medication: Atezolizumab

Clinical Procedure: —

Specialty: Oncology

Tumor lysis syndrome following cabazitaxel administration for metastatic castration-resistant prostate cancer: A case report

Introduction

Tumor lysis syndrome is a rare and potentially fatal complication of oncological treatment. It is characterized by biochemical changes associated with the rapid lysis of malignant cells, usually after chemotherapy. Tumor lysis syndrome is typically noted in patients with hematological malignancies, and it rarely occurs in patients with solid tumors.

Case presentation

We report a case of tumor lysis syndrome after cabazitaxel administration for metastatic castration‐resistant prostate cancer. To our knowledge, tumor lysis syndrome after cabazitaxel therapy has not been reported previously. The patient was a 77‐year‐old man who developed clinical tumor lysis syndrome after a single dose of cabazitaxel for metastatic castration‐resistant prostate cancer. He was treated with hydration and the recombinant uricolytic agent rasburicase, and his condition improved.

Conclusion

It is extremely important to assess the risk factors for tumor lysis syndrome and to perform active prevention procedures in order to avoid fatal outcomes. It may be beneficial to use rasburicase in patients with established tumor lysis syndrome.

Tumour lysis syndrome

Tumour lysis syndrome (TLS) is a life-threatening emergency characterised by a massive cytolysis with the release of intracellular electrolytes, nucleic acids, and metabolites into the circulation. TLS comprises laboratory derangements (hyperuricaemia, hyperkalaemia, hyperphosphataemia, and hypocalcaemia) responsible for acute kidney injury. In patients with hematologic malignancies after cytotoxic therapy or spontaneously and also in advanced solid tumours. Assessment of disease specific risk level for TLS in patients receiving anti-tumoural therapy is essential for early diagnosis. Prophylaxis is the mainstay of management of TLS. It is important to routinely initiate a risk-adapted prophylactic strategy to correct metabolic alterations and preserve renal function. High and intermediate risk patients and patients with established TLS should be managed with multidisciplinary medical care in a hospital unit to receive monitoring and medical care. Renal replacement therapy should be considered in patients with refractory TLS.

Volumetric decrease of pancreas after abdominal irradiation, it is time to consider pancreas as an organ at risk for radiotherapy planning

Background

Volumetric shrinkage of normal tissues such as salivary glands, kidneys, hippocampus are observed after radiotherapy. We aimed to assess the alterations in pancreatic volume of patients who received abdominal radiotherapy and define pancreas as an organ at risk for radiation treatment planning.

Material-methods

Forty-nine patients operated for gastric adenocarcinoma who received adjuvant abdominal radiotherapy were in the study group, 27 patients with early stage disease who did not need adjuvant treatment after surgery comprised the control group. An experienced radiologist contoured the pancreas of all the patients from computed tomographies imported to the planning system obtained either for radiation planning purpose or for follow-up after surgery. The same procedure was repeated one year later for both groups. Measured volume of the pancreas was expressed in cm³.

Results

Mean pancreatic volumes were similar in both groups at the onset of the study, 51,34 ± 20,33 cm³, and 50,12 ± 23,75 cm³ in the irradiated and the control groups respectively (p = 0,63). One year later, mean pancreatic volumes were significantly decreased in each group; 22,48 ± 10,53 cm³, 44,18 ± 23,08 cm³ respectively, p < 0,001. However, the decrease in pancreatic volume was significantly more pronounced in the irradiated group in comparison to the control group, p < 0,001.

Conclusion

Volumetric decrease in normal tissues after radiotherapy is responsible for loss of organ function and radiation related late side effects. Although pancreas is a radiation sensitive organ losing its volume and function after radiation exposure, it is not yet considered as an organ at risk for radiation treatment planning. Pancreas should be contoured as an organ at risk, dose-volume histogram for the organ should be created, and safe organ doses should be determined. This is the first study declaring pancreas as an organ at risk for radiation toxicity and the necessity of defining dose constraints for the organ.

Iron in the Tumor Microenvironment-Connecting the Dots

Iron metabolism and tumor biology are intimately linked. Iron facilitates the production of oxygen radicals, which may either result in iron-induced cell death, ferroptosis, or contribute to mutagenicity and malignant transformation. Once transformed, malignant cells require high amounts of iron for proliferation. In addition, iron has multiple regulatory effects on the immune system, thus affecting tumor surveillance by immune cells. For these reasons, inconsiderate iron supplementation in cancer patients has the potential of worsening disease course and outcome. On the other hand, chronic immune activation in the setting of malignancy alters systemic iron homeostasis and directs iron fluxes into myeloid cells. While this response aims at withdrawing iron from tumor cells, it may impair the effector functions of tumor-associated macrophages and will result in iron-restricted erythropoiesis and the development of anemia, subsequently. This review summarizes our current knowledge of the interconnections of iron homeostasis with cancer biology, discusses current clinical controversies in the treatment of anemia of cancer and focuses on the potential roles of iron in the solid tumor microenvironment, also speculating on yet unknown molecular mechanisms.

Osteoporosis development and vertebral fractures after abdominal irradiation in patients with gastric cancer

Background

Decrease in bone mineral density, osteoporosis development, bone toxicity and resulting insufficiency fractures as late effect of radiotherapy are not well known. Osteoporosis development related to radiotherapy has not been investigated properly and insufficiency fractures are rarely reported for vertebral bones.

Methods

Ninety-seven patients with gastric adenocarcinoma were evaluated for adjuvant treatment after surgery. While 73 out of 97 patients treated with adjuvant chemoradiotherapy comprised the study group, 24 out of 97 patients with early stage disease without need of adjuvant treatment comprised the control group. Bone mineral densities (BMD) of lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry after surgery, and one year later in both groups.

Results

There was statistically significant decline in BMDs after one year in each group itself, however the decline in BMDs of the patients in the irradiated group was more pronounced when compared with the patients in the control group; p values were 0.02 for the decline in BMDs of lumbar spine, and 0.01 for femoral neck respectively. Insufficiency fractures were observed only in the irradiated patients (7 out of 73 patients) with a cumulative incidence of 9.6%.

Conclusions

Abdominal irradiation as in the adjuvant treatment of gastric cancer results in decrease in BMD and osteoporosis. Insufficiency fracture risk in the radiation exposed vertabral bones is increased. Calcium and vitamin D replacement and other measures for prevention of osteoporosis and insufficiency fractures should be considered after abdominal irradiation.

Risk of diabetes after para-aortic radiation for testicular cancer

Background

While the risk of diabetes is increased following radiation exposure to the pancreas among childhood cancer survivors, its association among testicular cancer (TC) survivors has not been investigated.

Methods

Diabetes risk was studied in 2998 1-year TC survivors treated before 50 years of age with orchidectomy with/without radiotherapy between 1976 and 2007. Diabetes incidence was compared with general population rates. Treatment-specific risk of diabetes was assessed using a case–cohort design.

Results

With a median follow-up of 13.4 years, 161 TC survivors were diagnosed with diabetes. Diabetes risk was not increased compared to general population rates (standardised incidence ratios (SIR): 0.9; 95% confidence interval (95% CI): 0.7–1.1). Adjusted for age, para-aortic radiotherapy was associated with a 1.66-fold (95% CI: 1.05–2.62) increased diabetes risk compared to no radiotherapy. The excess hazard increased with 0.31 with every 10 Gy increase in the prescribed radiation dose (95% CI: 0.11–0.51, P = 0.003, adjusted for age and BMI); restricted to irradiated patients the excess hazard increased with 0.33 (95% CI: −0.14 to 0.81, P = 0.169) with every 10 Gy increase in radiation dose.

Conclusion

Compared to surgery only, para-aortic irradiation is associated with increased diabetes risk among TC survivors.

Role of intravenous iron in the treatment of anemia in patients with gastrointestinal tract tumors undergoing chemotherapy: a single-center, observational study

Purpose

The prevalence of anemia ranges between 30% and 90% in cancer patients, affecting the health status, quality of life, and treatment outcome. Therefore, a proper diagnosis and management of anemia is crucial in these patients. Iron deficiency is diagnosed in~32%–60% of the cases. In this observational study, we evaluated the efficacy and safety of intravenous iron (ferric carboxymaltose [FCM], Ferinject^®) in the treatment of iron-deficiency anemia in patients with gastrointestinal tumors undergoing palliative or adjuvant chemotherapy.

Patients and methods

Thirty patients with gastrointestinal tumors undergoing chemotherapy diagnosed with iron-deficiency anemia were included in the study and received at least one FCM administration. The need for iron replacement therapy was evaluated by the assessment of hemoglobin and iron status parameters, and patients could be treated with FCM during 12–14 weeks. Paired t-test approach was used to evaluate the mean differences between the baseline and the end of the study. A p-value of <0.05 was considered statistically significant.

Results

Data showed that there was a statistically significant increase in the mean of hemoglobin (10.3 vs 11.2 g/dL), ferritin (230.3 vs 877.0 ng/mL), transferrin saturation (13.0% vs 19.7%), and serum iron (42.3 vs 59.6 mg/mL) from the baseline to the end of the study in cancer patients. Most of the patients (n=25) were only administered one dose of FCM. There was one FCM-related adverse event during the study.

Conclusion

FCM was well tolerated and had a positive impact in the treatment of iron-deficiency anemia in patients with gastrointestinal tract tumors undergoing chemotherapy.

Pancreatic radiation effect in apoptosis-related rectal radiation toxicity

Pancreatic radiation effect (PRE) can be a component of gastrointestinal tract (GIT) radiotoxicity. This inter-organ correlation between the GIT and the pancreas was assessed through a rat model. Separate local irradiation to the abdomen and the pelvis was applied concurrently for 8-week-old male Sprague Dawley rats. Abdominal irradiation was categorized into pancreatic shield (PS) and non-pancreatic shield (NPS) irradiation. After 5 Gy and 15 Gy irradiation, the rectal mucosa was analyzed at the first week (early phase, Ep) and the 14th week (late phase, Lp). A slow gain in body weight was observed initially, particularly in the NPS group receiving a 15 Gy dose (P < 0.001). The large number of apoptotic bodies after 15 Gy at Ep decreased at Lp. At Ep for the 5-Gy group, the NPS group revealed more fibrotic change than the PS group (P = 0.002). Cleaved caspase-3 (CCP3) expression was greater at Lp, and the Ep-Lp increase was prominent in the NPS-15-Gy group (P = 0.010). At Lp, for 15 Gy irradiation, CCP3 was expressed more in the NPS group than in the PS group (P = 0.032). Despite no direct toxicity difference between the PS and NPS groups, small changes in parameters such as fibrosis or CCP3 expression suggest that pancreatic shielding does have an effect on the radiation response in the rectal mucosa, which suggests a need for a multi-organ effect-based approach in GIT radiotoxicity assessment.

Predictive value of pancreatic dose-volume metrics on sarcopenia rate in gastric cancer patients treated with adjuvant chemoradiotherapy

OBJECTIVE

To evaluate the relationship of sarcopenia with the pancreatic dose-volume histogram (DVH) in gastric cancer patients treated with adjuvant chemoradiotherapy (CRT) after radical gastrectomy.

METHODS

A retrospective study was performed on the data in Zhongnan Hospital of Wuhan University from January 2008 to December 2016. Skeletal muscle index (SMI) was analyzed by cross-sectional areas of body composition at the level of third lumbar (L3) vertebrae, which was measured using single-slice computer tomograph (CT) prior to CRT, at 6 months and 12 months after CRT respectively. Logistic regression analysis was conducted to explore the potential clinical risk factors of sarcopenia in this patients cohort. Regarding the dosimetrics of pancreas, the sarcopenia rate was compared between the two groups divided according to the cut-off value determined by the receiver operating characteristic (ROC) curves.

RESULTS

One hundred and fifty-three gastric cancer patients were eligible in this study. The median postoperative follow-up was 36 (7-115) months. The mean dose of pancreas was 4399.7 ± 396.0 cGy. The incidence of sarcopenia prior to CRT, at 6 months and 12 months later were 29.4% (45/153), 27.3% (35/128) and 37.0% (37/100). Both sarcopenia at 6 months (HR = 2.038, 95%CI = 1.084-3.833, P = 0.027) and sarcopenia at 12 months (HR = 2.216, 95%CI = 1.007-4.873, P = 0.048) were the independent prognostic factor of gastric cancer patients. V46 remained to be the only independent risk factor of sarcopenia at 6 months (OR = 3.889, 95%CI = 1.099-13.764, P = 0.035) and 12 months (OR = 6.067, 95%CI = 1.687-21.821, P = 0.006) in multivariate logistic regression analysis. Among the dosimetric parameters used for ROC analysis, the V46 showed the highest area under the curve (AUC = 0.707). Here is the relationship between sarcopenia rate and the cut-off value for V46. Higher sarcopenia rate at 6 months was noted in 42.6% patients with V46 ≥ 57% compared with 9% of patients with V46 < 57% (P < 0.001). The sarcopneia rate at 12 months was 52% with V46 ≥ 57% and 25% with V46 < 57% (P = 0.010).

CONCLUSION

Gastric cancer with sarcopenia after adjuvant CRT had poorer survival. Higher dose and larger irradiated volume of pancreas correlated with higher risk of sarcopenia. Appropriated administration of pancreas dose-volume may be conducive to reduce the risk of sarcopenia and improve survival in gastric cancer patients treated with adjuvant CRT.

Management of tumour lysis syndrome during first-line palliative chemotherapy for high-volume colorectal cancer

Tumour lysis syndrome (TLS) is a rare oncological emergency in solid tumours. Because it is associated with bad short-term prognosis, early recognition and treatment are mandatory. This case refers to a middle-aged woman who presented with stage IV colon cancer, with massive hepatic involvement. After three cycles of first-line FOLFOX (folinic acid, 5-fluorouracil and oxaliplatin), she developed acute kidney injury and hyperkalaemia that did not respond to standard measures. High suspicion of TLS prompted further corroborating investigations and early intensive care unit admission. With vigorous hydration and allopurinol, TLS completely resolved and the patient was discharged. Prophylaxis of subsequent TLS recurrence was complicated by biopsy-proven neutrophilic vasculitis secondary to allopurinol. Prevention of TLS with hydration and rasburicase was performed prior to each subsequent cycle of chemotherapy. This case report is intended to highlight risk factors for TLS in solid tumours and focus on treatment and secondary prophylaxis of TLS.

Tumor lysis syndrome associated with docetaxel and carboplatin in a case with recurrent endometrial cancer

Tumor lysis syndrome (TLS) is an oncological life-threatening complication characterized by hyperuricemia, hyperphosphatemia, and hyperkalemia, which can lead to acute renal failure, cardiac arrhythmias, cardiac arrest and seizures. Although TLS is a rare complication in patients with non-hematological malignancy, the mortality rate of TLS in solid tumors is higher than that in hematological malignancies. Acute renal injury is the most common cause of mortality associated with TLS in solid tumors. We report a case of TLS following chemotherapy for a recurrent uterine serous carcinoma. In this case, we speculated that the cause of death might be a pulmonary tumor embolism caused by TLS.

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Tumor lysis syndrome (TLS) is an oncological life-threatening complication.

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The mortality rate of TLS in solid tumors is high, acute renal injury being the most common cause.

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We report a case of TLS following chemotherapy for a recurrent uterine serous carcinoma.

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We speculated that the cause of death might be a pulmonary tumor embolism caused by TLS.

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Clinicians need to assess the risk of TLS before chemotherapy, which should be given to high risk patient appropriately.

Impact of preoperative anemia on outcomes in patients undergoing curative resection for gastric cancer: a single-institution retrospective analysis of 2163 Chinese patients

We sought to evaluate whether preoperative anemia was an important determinant of survival in gastric cancer (GC). A single institution cohort of 2163 GC patients who underwent curative resection were retrospectively analyzed. Anemia was defined as a preoperative hemoglobin level <120 g/L in males and <110 g/L in females. Overall survival (OS) was analyzed using the Kaplan-Meier method, and a multivariate Cox proportional hazards model was performed to identify the independent prognostic factor. Anemic patients had a poorer OS compared with nonanemic patients after resection for tumor-nodes-metastasis (TNM) stage III tumors (5-year OS rate: 32.2% vs. 45.7%, P < 0.001) but not stage I (P  =  0.480) or stage II (P  =  0.917) tumors. Multivariate analysis revealed that preoperative anemia was an independent prognostic factor in TNM stage III (hazard ratio [HR], 1.771; 95% CI, 1.040-3.015; P = 0.035). In a stage-stratified analysis, preoperative anemia was still independently associated with OS in TNM stages IIIa through IIIc (P < 0.001, P = 0.075, and P = 0.012, respectively), though the association was only marginal in stage IIIb. Of note, preoperative mild anemia had a similar prognostic value in TNM stage III GC. Furthermore, preoperative anemia was significantly associated with more perioperative transfusions, postoperative complications and several nutritional-based indices, including the prognostic nutritional index (PNI), preoperative weight loss and performance status (all P < 0.05). Preoperative anemia, even mild anemia, was an important predictor of postoperative survival for TNM stage III GC.

Oncologic Metabolic Emergencies

Cancer and its therapies may lead to several metabolic emergencies that emergency providers (EPs) should be well-versed in identifying and managing. With prompt recognition and treatment initiation in the emergency department, lives can be saved and quality of life maintained. Most oncologic metabolic emergencies occur in advanced cancer states, but some follow initiation of treatment or may be the presenting syndrome that leads to the cancer diagnosis. This article reviews the 2 most emergent oncologic metabolic diagnoses: tumor lysis syndrome and hypercalcemia of malignancy. A discussion on associated cancers and conditions, pathogenesis and pathophysiology, and management recommendations is included.

Spontaneous tumor lysis syndrome in colon cancer: a case report and literature review

Although tumor lysis syndrome is well described, it is rarely seen or suspected in solid malignancies. Early recognition of this entity is paramount in reducing morbidity and mortality. Treating physicians should be aware of this possibility in solid tumor patients with either bulky disease or extensive liver involvement.

What is the optimal radiation dose for non-operable esophageal cancer? Dissecting the evidence in a meta-analysis

The standard radiation dose 50.4 Gy with concurrent chemotherapy for localized inoperable esophageal cancer as supported by INT-0123 trail is now being challenged since a radiation dose above 50 Gy has been successfully administered with an observable dose-response relationship and insignificant untoward effects. Therefore, to ascertain the treatment benefits of different radiation doses, we performed a meta-analysis with 18 relative publications. According to our findings, a dose between 50 and 70 Gy appears optimal and patients who received ≥ 60 Gy radiation had a significantly better prognosis (pooled HR = 0.78, P = 0.004) as compared with < 60 Gy, especially in Asian countries (pooled HR = 0.75, P = 0.003). However, contradictory results of treatment benefit for ≥ 60 Gy were observed in two studies from Western countries, and the pooled treatment benefit of ≥ 60 Gy radiation was inconclusive (pooled HR = 0.86, P = 0.64). There was a marginal benefit in locoregional control in those treated with high dose (> 50.4/51 Gy) radiation when compared with those treated with low dose (≤ 50.4/51 Gy) radiation (pooled OR = 0.71, P = 0.06). Patients that received ≥ 60 Gy radiation had better locoregional control (OR = 0.29, P = 0.001), and for distant metastasis control, neither the > 50.4 Gy nor the ≥ 60 Gy treated group had any treatment benefit as compared to the groups that received ≤ 50.4 Gy and < 60 Gy group respectively. Taken together, a dose range of 50 to 70 Gy radiation with CCRT is recommended for non-operable EC patients. A dose of ≥ 60 Gy appears to be better in improving overall survival and locoregional control, especially in Asian countries, while the benefit of ≥ 60 Gy radiation in Western countries still remains controversial.

Systemic chemotherapy with pronounced efficacy and neutropenia in a granulocyte-colony stimulating factor-producing advanced gastric neuroendocrine carcinoma

An advanced granulocyte-colony stimulating factor (G-CSF)-producing tumor is rare, and it exhibits leukocytosis in association with high serum G-CSF levels. A 67-year-old male with a 1-month history of bloody emesis and black stools was revealed to exhibit leukocytosis, anemia and a high serum concentration of G-CSF. During a gastrointestinal endoscopy, an ulcerating tumor was identified in the stomach. Computed tomography and a fluorodeoxyglucose-positron emission tomography scan demonstrated direct invasion of the gastric tumor into the transverse colon, regional lymphadenopathy, lung nodules and diffuse high uptake of FDG in bone marrow. The histological diagnosis was a G-CSF-producing neuroendocrine carcinoma (NEC) (tumor 4b, node 2, metastasis 1, pulmonary, clinical stage IV). Systemic chemotherapy consisting of cisplatin and irinotecan was started. Common terminology criteria of adverse events grade 3 tumor lysis syndrome and gastric penetration appeared. Grade 4 neutropenia lasted for 10 days despite intensive G-CSF administration. Prominent shrinkage of the primary and the metastatic tumors was observed subsequent to 3 cycles of chemotherapy. Total gastrectomy and resection of the transverse colon were subsequently performed. Systemic chemotherapy was effective for a G-CSF-producing advanced gastric NEC with careful monitoring and appropriate supportive care for severe adverse events.

Spontaneous tumour lysis syndrome in hepatocellular carcinoma presenting with hypocalcemic tetany: An unusual case and systematic literature review

Tumour lysis syndrome is an oncological emergency which is usually seen following chemotherapy for rapidly proliferating haematological malignancies. Spontaneous tumour lysis syndrome is rare in solid tumour and even rarer with hepatocellular carcinoma (HCC). Tumour lysis syndrome in the setting of HCC is usually reported as a consequence of therapeutic interventions like sorafenib administration or trans-arterial chemoembolization. We report about a case of a young lady with chronic hepatitis B related HCC who developed spontaneous tumour lysis syndrome and presented with hypocalcemic tetany. We also compare this case with the previously reported cases of spontaneous tumour lysis syndrome in hepatocellular carcinoma.

Steroid-induced tumour lysis syndrome in small-cell lung cancer

A 64-year-old male presented to hospital with breathlessness and weight loss. Ultrasound-guided biopsy of supraclavicular lymph node confirmed a diagnosis of small-cell lung cancer. The patient was started on Dexamethasone 8 mg twice daily for symptom control while awaiting urgent oncology assessment. Three days later he was admitted with acute kidney injury and worsening breathlessness. Biochemical changes confirmed tumour lysis syndrome (TLS) that had occurred following steroid therapy. He was given allopurinol followed by rasburicase. His clinical condition continued to worsen and he died of multi-organ failure. To our knowledge, TLS in small-cell lung cancer solely attributed to steroid therapy has not been described before. Due to its rarity, physicians have a very low index of suspicion of TLS in lung cancer when prescribing corticosteroids for palliation of symptoms. Patients with risk factors should be identified and baseline blood tests performed and appropriate prophylaxis commenced.

Spontaneous Tumor Lysis Syndrome in a Patient with Metastatic Small Cell Lung Cancer: A Case Report

Tumor lysis syndrome is an oncologic emergency that usually occurs after chemotherapy in patients with hematologic malignancies. Tumor lysis syndrome is rare in cases of solid tumors, especially when it occurs spontaneously. Herein, we present a case of spontaneous tumor lysis syndrome in a 55-year-old woman who presented with dyspnea and was found to have extensive metastatic small cell lung cancer. She developed acute oliguric renal failure and multiple electrolyte abnormalities requiring hemodialysis. The findings of this case suggest that clinicians should maintain a high index of suspicion for patients with malignancies who demonstrate the classic symptom of laboratory abnormalities even in the absence of chemotherapy.

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.

Tumor lysis syndrome in solid tumors: Clinical characteristics and prognosis

INTRODUCTION AND OBJECTIVE

Tumour lysis syndrome (TLS) is an uncommon complication in solid tumors following treatment initiation, and its spontaneous development (STLS) is exceptional. In this study, we analyse the main clinical and prognostic features of a case series with TLS and STLS.

MATERIAL AND METHODS

Observational retrospective study in which we included all patients with solid tumours diagnosed with TLS and STLS over a period of 16 years, according to Cairo-Bishop criteria.

RESULTS

Nineteen patients were included in the study (mean age 63±16 years): 10 patients (53%) with TLS, and 9 (47%) STLS. The primary tumour in 8 cases (42%) was lung cancer. All patients had severe renal impairment at the time of diagnosis along with hyperuricemia (16±6mg/dl) and hyperkalemia (6±0.9mmol/l). Despite treatment with intravenous fluids, urinary alkalinisation and rasburicase, 3 patients (16%) required dialysis, and 12 (63%) died during the follow-up period.

CONCLUSIONS

The development of TLS in solid tumors is associated with increased mortality and therefore, a high index of suspicion is essential for early diagnosis and treatment initiation.

Neurologic Emergencies in the Patients With Cancer

Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.

A Case of Spontaneous Tumor Lysis Syndrome in Malignant Melanoma

A 62-year-old man with a complaint of back pain lasting 2 months was admitted. He also presented a huge abdominal tumor. Diagnostic imaging showed metastatic tumors in the liver, lumbar vertebrae and bilateral lung. An ultrasound-guided needle biopsy revealed a lung tumor containing melanic tissue. Subsequently, there was an evident elevation in uric acid, phosphoric acid, potassium and lactate dehydrogenase concentrations in serum. Continuous hemodiafiltration and administration of rasburicase was initiated following the diagnosis of tumor lysis syndrome (TLS). However, he died on the fourth day owing to arrhythmia. An autopsy revealed metastatic deposits in the liver, lung, spine, ribs, and lymph nodes along the biliary system. Microscopic examinations revealed massive necrosis of normal hepatocytes and tumor cells with disseminated tumor thrombi in the portal system. The catastrophic progression of TLS appears to be influenced by a persistent portal blood flow deficiency by portal tumor thrombus in this case.

Prospective Study of Malabsorption and Malnutrition After Esophageal and Gastric Cancer Surgery

OBJECTIVE

To study malabsorption and malnutrition after curative resection of esophageal and gastric cancer.

DESIGN

Prospective cohort study.

BACKGROUND

Improved cure rates for esophageal and gastric cancer have increased focus on health-related quality of life (HR-QL) in survivorship. Although malnutrition is well described in long-term follow-up, and gastrointestinal symptoms are common, data on gut and pancreatic-related malabsorption are scant.

METHODS

Disease-free patients at least 18 months after esophageal or gastric oncologic resections represented the study cohort. A modified Gastrointestinal Symptom Rating Scale questionnaire was completed, and weight, fecal elastase (FE), albumin, vitamins, and micronutrients measured preoperatively and at 1, 6, and 18 to 24 months postoperatively. Small intestinal bacterial overgrowth (SIBO) and changes in body composition were also evaluated postoperatively.

RESULTS

At a median follow-up of 23 months, 45 of 66 patients in a consecutive series were disease-free. Mean weight (78 ± 19 vs 67 ± 16 kg), body mass index (27 ± 5 vs 24 ± 5 kg/m), Vitamin A (1.7 ± 0.6 vs 1.2 ± 0.4 umol/L), and Vitamin E (28 ± 7 vs 20 ± 7 umol/L) were significantly decreased (P < 0.01) at last follow-up compared with preoperatively. Malabsorption was evident in 73% of patients, of whom 44% had FE < 200 μg/g and 38% had evidence of SIBO. Total body fat-free mass (175 ± 96 vs 84 ± 71, P < 0.001) and skeletal muscle index (44 ± 8 vs 39 ± 8, P = 0.007) were significantly decreased at 18 to 24 months.

CONCLUSIONS

Malabsorption and malnutrition are prevalent in survivorship of esophageal and stomach cancer. This may be underappreciated, and both gut and pancreatic insufficiency represent modifiable targets in the interdisciplinary approach to recovery of HR-QL.

Radiation-induced injury of the exocrine pancreas after chemoradiotherapy for gastric cancer

BACKGROUND AND PURPOSE

The pancreas is located almost entirely within the treatment area for radiotherapy of gastric cancer. The aim of this study was to analyze radiation-induced injury of the exocrine pancreas.

MATERIAL AND METHODS

The study included 127 gastric cancer patients, who underwent preoperative or postoperative chemoradiotherapy. A total dose of 45 Gy was given in 25 fractions. Concurrent chemotherapy was 5-fluorouracil-based. Lipase and α-amylase were assayed before, during and after treatment.

RESULTS

Lipase and α-amylase deficiencies were found in 48.2% and 19.7% of patients, respectively. In the univariant analysis, age and pretreatment α-amylase and lipase activities influenced on risk of injury of the exocrine pancreas (p<0.05). Younger patients (<65 years) had a lower risk of hypoamylasemia than older patients. The probability of insufficiency was lower than 0.2 for patients with pretreatment α-amylase and lipase activities above 50 U/L and 55 U/L, respectively. The multivariate analyses of the time to hypolipasemia showed that only pretreatment lipase activity was significant.

CONCLUSIONS

Gastric cancer patients have an increased risk of exocrine pancreatic insufficiency after chemoradiotherapy. Thus, the pancreas should be regarded as an OAR. Measuring lipase activity should be the standard for assessing radiation-induced pancreatic injury.

Spontaneous Tumor Lysis Syndrome in Small-Cell Lung Cancer: A Rare Complication

Tumor lysis syndrome (TLS) is a life-threatening condition which consists of a constellation of electrolyte imbalances, acute renal failure, seizure, and arrhythmias. It is most commonly seen with hematologic malignancies after the initiation of chemotherapy. However, it can also occur spontaneously, prior to treatment with cytotoxic agents. TLS has been rarely described with non-hematologic solid tumors, and it is even more uncommon to have spontaneous tumor lysis syndrome (STLS) in solid tumors. To our knowledge, only two cases of STLS in small-cell lung cancer (SCLC) were reported in the literature. Herein, we present the case of a patient with metastatic SCLC who developed STLS. Our case highlights that in the setting of metastatic solid tumors, STLS must be in the differential diagnosis, to allow prompt initiation of prophylaxis and treatment.

Lhermitte's Sign following VMAT-Based Head and Neck Radiation-Insights into Mechanism

Purpose/Objectives

We observed a number of patients who developed Lhermitte’s sign (LS) following radiation to the head and neck (H/N), since instituting volumetric modulated arc therapy (VMAT). We aimed to investigate the incidence of LS following VMAT-based RT without chemotherapy, and determine the dosimetric parameters that predict its development. We explored whether the role of inhomogeneous dose distribution across the spinal cord, causing a “bath-and-shower” effect, explains this finding.

Methods and Materials

From 1/20/2010–12/9/2013, we identified 33 consecutive patients receiving adjuvant RT using VMAT to the H/N without chemotherapy at our institution. Patients’ treatment plans were analyzed for dosimetric parameters, including dose gradients along the anterior, posterior, right, and left quadrants at each cervical spine level. Institutional Review Board approval was obtained.

Results

5 out of 33 (15.2%) patients developed LS in our patient group, all of whom had RT to the ipsilateral neck only. LS patients had a steeper dose gradient between left and right quadrants across all cervical spine levels (repeated-measures ANOVA, p = 0.030). Within the unilateral treatment group, LS patients received a higher mean dose across all seven cervical spinal levels (repeated-measures ANOVA, p = 0.046). Dose gradients in the anterior-posterior direction and mean doses to the cord were not significant between LS and non-LS patients.

Conclusions

Dose gradients along the axial plane of the spinal cord may contribute to LS development; however, a threshold dose within the high dose region of the cord may still be required. This is the first clinical study to suggest that inhomogeneous dose distributions in the cord may be relevant in humans. Further investigation is warranted to determine treatment-planning parameters associated with development of LS.

Incidence and predictors of Lhermitte's sign among patients receiving mediastinal radiation for lymphoma

PURPOSE

To prospectively examine the risk of developing Lhermitte's sign (LS) in patients with lymphoma treated with modern-era chemotherapy followed by consolidation intensity-modulated radiation therapy.

METHODS

We prospectively interviewed all patients with lymphoma who received irradiation to the mediastinum from July 2011 through April 2014. We extracted patient, disease, and treatment-related variables from the medical records of those patients and dosimetric variables from treatment-planning systems and analyzed these factors to identify potential predictors of LS with Pearson chi-square tests.

RESULTS

During the study period 106 patients received mediastinal radiation for lymphoma, and 31 (29 %) developed LS. No correlations were found between LS and any of the variables examined, including total radiation dose, maximum point dose to the spinal cord, volume receiving 105 % of the dose, and volumes receiving 5 or 15 Gy.

CONCLUSION

In this group of patients, treatment with chemotherapy followed by intensity-modulated radiation therapy led to 29 % developing LS; this symptom was independent of radiation dose and seemed to be an idiosyncratic reaction. This relatively high incidence could have resulted from prospective use of a structured interview.

β-elemene enhances the radiosensitivity of gastric cancer cells by inhibiting Pak1 activation

AIM: To explore the potential of β-elemene as a radiosensitizer for gastric cancer cells and the underlying mechanisms.

METHODS: SGC7901, MKN45, MKN28, N87, and AGS human gastric cancer cell lines were used to screen for radioresistant gastric cancer cell lines. A 3-(4,5-dimeth-ylthiazol-2-yl)-2,5-diphenyltetrazolium (MTT) assay was used to determine the effects of β-elemene and IPA-3 on cell viability in MKN45 and SGC7901 gastric cancer cell lines. A clonogenic survival assay and annexin V-FITC/PI apoptosis detection assay were used to evaluate cellular radiosensitivity and radiation-induced cell death, respectively. A proteomic method, isobaric tags for relative and absolute quantitation (iTRAQ), was employed to screen the proteins regulated by β-elemene pretreatment prior to ionizing radiation (IR) in SGC7901 gastric cancer cell line. IPA-3 was used as a specific small molecule inhibitor of p21-activated protein kinase 1 (Pak1) to target Pak1 signaling. Protein levels of PAK1IP1 (p21-activated protein kinase-interacting protein 1), total Pak1 (t-Pak1), phospho-Pak1 (T423), phospho-ERK1/2 (Thr202/Tyr204), and cleaved caspase-3 (17 kDa) were assessed by western blotting.

RESULTS: MKN45 and SGC7901 gastric cancer cell lines were relatively more resistant to IR. β-elemene pretreatment decreased clonogenic survival following IR in MKN45 and SGC7901 gastric cancer cell lines. Additionally, β-elemene pretreatment prior to IR increased radiation-induced cell death compared with IR alone in MKN45 (10.4% ± 0.9% vs 34.8% ± 2.8%, P < 0.05) and SGC7901 (11.6% ± 0.9% vs 46.7% ± 5.2%, P < 0.05) human gastric cancer cell lines, respectively, consistent with the level of cleaved caspase-3 (17 kDa). Through iTRAQ analysis and western blot validation, we found that β-elemene upregulated PAK1IP1 and downregulated phospho-Pak1 (T423) and phospho-ERK1/2 in SGC7901 gastric cancer cells. IR increased the level of phospho-Pak1 (T423). Pretreatment with β-elemene decreased radiation-induced Pak1 and ERK1/2 phosphorylation. Inhibition of Pak1 using IPA-3 decreased clonogenic survival following IR. In addition, IPA-3 increased radiation-induced cell death in MKN45 (13.4% ± 0.3% vs 26.6% ± 1.0%, P < 0.05) and SGC7901 (16.0% ± 0.6% vs 37.3% ± 1.7%, P < 0.05) gastric cancer cell lines, respectively, consistent with the level of cleaved caspase-3 (17 kDa). Western blotting showed that IPA-3 decreased radiation-induced Pak1 and ERK1/2 phosphorylation.

CONCLUSION: This is the first demonstration that β-elemene enhances radiosensitivity of gastric cancer cells, and that the mechanism involves inhibition of Pak1 signaling.

Lhermitte Sign as a Presenting Symptom of Thoracic Spinal Pathology: A Case Study

A 54-year-old male with ankylosing spondylitis presented with complaints of progressively worsening bilateral leg weakness and difficulty ambulating of 2-week duration. He also felt a sharp, electric, shock-like sensation radiating from his lower back into his legs upon flexing the trunk. There was no history of trauma or other inciting events within the 2 weeks prior to presentation. Thoracic MRI at this visit showed a three-column fracture at T11-T12. He underwent spinal fusion surgery and within 2 days after surgery the radiating electrical sensation with spinal flexion had completely resolved.

A Case of Spontaneous Tumor Lysis Syndrome in a Patient with Ovarian Cancer

Tumor lysis syndrome (TLS) is a potentially life-threating complication of tumors or chemotherapy treatment. TLS commonly occurs in hematological malignancies, but it is very rare in patients with a solid tumor. In cases of solid tumors, TLS usually occurs spontaneously and after the initiation of anticancer therapy, and it has a high mortality rate. We present the novel case of a 62-year-old woman with an ovarian tumor who spontaneously developed TLS. Surgical reduction of the tumor mass vastly improved her condition. She showed no sign of tumor recurrence 8 months after treatment. As TLS is life-threatening, successful treatments must be seriously considered.

Increment of serum C-peptide measured by glucagon test closely correlates with human relative beta-cell area

Pancreatic beta-cell mass contributes to glucose tolerance. The aim of this study was to evaluate the relationships between human beta-cell mass and various clinical parameters, including insulin secretory capacity. The study included 32 Japanese patients who underwent pancreatectomy and were naive to oral hypoglycemic agents and insulin. They were classified into those with normal glucose tolerance (n=13), impaired glucose tolerance (n=9) and diabetes (n=10), and their insulin secretory capacity and insulin resistance were evaluated. Immunohistochemistry was used to determine relative beta-cell area (%) which represented the proportion of insulin-positive cell area to whole pancreatic section. Increment of C-peptide immunoreactivity level by glucagon test (ΔC-peptide, increment of serum C-peptide [nmol/L] at 6 min after intravenous injection of 1-mg glucagon; r=0.64, p=0.002), homeostasis model assessment of beta-cell function (HOMA-beta, fasting immunoreactive insulin [μIU/mL] x 20 / (fasting plasma glucose [mmol/L] - 3.5); r=0.50, p=0.003), C-peptide index (CPI, fasting C-peptide [nmol/L] / fasting plasma glucose [mmol/L]; r=0.36, p=0.042), and fasting immunoreactive insulin (F-IRI [pmol/L]; r=0.36, p=0.044) correlated significantly and positively with the relative beta-cell area. The area under the curve of plasma glucose level from 0 to 120 min by 75 g-OGTT (AUC0-120) also correlated significantly and inversely with the relative beta-cell area (r=-0.36, p=0.045). Stepwise multiple regression analysis identified ΔC-peptide as the only independent and significant determinant of the relative beta-cell area. We conclude that ΔC-peptide, HOMA-beta, CPI, F-IRI and AUC0-120 correlated closely with the relative beta-cell area, and ΔC-peptide was the most valuable index for the prediction of the area.

Tumor lysis syndrome in metastatic breast cancer after a single dose of paclitaxel

Tumor lysis syndrome (TLS) is an oncologic emergency characterized by spillage of intracellular material into the blood caused by disruption of massive load of tumor cells. It is more commonly reported in hematological cancers and can have fatal consequences due to renal and multi-organ failure and arrhythmias due to electrolyte imbalance. We describe a case with metastatic breast cancer who presented with TLS after a single dose of paclitaxel, second such case in literature. The development of a risk stratification score to assess the need for hospitalization or close observation of these patients and the documentation of appropriate preventive strategies could help prevent such fatal occurrences. TLS should be included in the differential when cancer patients on treatment present with acute decompensation.

Lhermitte's phenomenon and platinum, beware of latency

BACKGROUND

Lhermitte's sign (LS) is characterized by electric shock-like sensations, spreading along the spine in a cervico-caudal direction and into the arms and legs. It is felt upon flexion of the neck and reflects a myelopathy resulting from damage to sensory axons at the dorsal columns of the cervical spinal cord. In patients with cancer, LS can occur due to direct tumour involvement of the spine or in relation to radiotherapy. Chemotherapy-related LS has only rarely been reported.

CASE REPORT

We present the case of a 44-year-old patient treated with platinum- and etoposide-based chemotherapy for metastatic seminoma, who subsequently developed severe disabling LS. The severity and duration of LS in this case exceeds prior reports. We review the literature on chemotherapy-related LS and discuss the practice implications.

CONCLUSION

Neuropathy and LS related to cisplatin-based chemotherapy can result in significant adverse effects. Raised awareness of this complication could aid sub-phenotyping of the population most at risk and assist strategies to avert discomfort and disability post chemotherapy.

Preoperative chemoradiotherapy in locally advanced gastric cancer, a phase I/II feasibility and efficacy study

OBJECTIVES

This study was initiated to investigate the feasibility and efficacy of preoperative radiotherapy with weekly paclitaxel and carboplatin in locally advanced gastric cancer.

METHODS

In a prospective study, patients with locally advanced gastric cancer stage IB-IV(M0) were treated with chemoradiotherapy followed by surgery 4-6 weeks after the last irradiation. Chemoradiotherapy consisted of radiation to a total dose of 45 Gy given in 25 fractions of 1.8 Gy, combined with concurrent weekly carboplatin and paclitaxel.

RESULTS

Between December 2007 and January 2012, 25 patients with cT3 (64%) or cT4 (36%) gastric cancer were included. One patient discontinued concurrent chemotherapy in the 4th week due to toxicity, but completed radiotherapy. Another patient discontinued chemoradiotherapy after the 3rd week due to progressive disease. Grade III adverse events of chemoradiotherapy were: gastrointestinal 12%, haematological 12% and other 8%. All patients, except one who developed progressive disease, were operated. Surgical complications were: general/infectious 48%, anastomotic leakage 12%, and bowel perforation 8%. Postoperative mortality was 4%. Microscopically radical resection rate was 72%. Pathological complete response rate was 16% and near complete response rate 24%.

CONCLUSIONS

In this study, preoperative chemoradiotherapy for patients with locally advanced gastric cancer was associated with manageable toxicity and encouraging pathological response rates.