Acute tumor lysis syndrome in patients with high-grade non-Hodgkin's lymphoma

Management of tumor lysis syndrome: prevention and treatment

OBJECTIVES

To provide a review of the preventive and treatment strategies for tumor lysis syndrome (TLS).

DATA SOURCES

Primary and tertiary literature and clinical experience.

CONCLUSIONS

The oncology nurse can optimize outcomes in the patient at risk for TLS through a variety of prevention and treatment interventions: (1) aggressive patient monitoring for early identification and treatment; (2) minimize risk factors via thorough medication and nutritional histories, and assurance of proper prophylactic regimens; (3) assessment of optimal routes of drug delivery to assure medication bioavailability; and (4) reinforcement of the above with comprehensive patient education.

IMPLICATIONS FOR NURSING PRACTICE

Awareness and effective use of prophylactic and treatment regimens related to TLS will positively impact patient outcomes. The oncology nurse is at the front line to identify issues related to effective management of TLS.

Acute tumor lysis syndrome in a patient with mixed small cell and non-small cell tumor

Tumor lysis syndrome, caused by massive tumor cell death, is an infrequent occurrence in solid tumors, and only a few cases of tumor lysis syndrome occurring in patients with lung cancer have been reported. We present a case of tumor lysis syndrome in a patient with mixed small cell and non-small cell lung cancer complicated by Listeria sepsis. Despite aggressive supportive measures with fluids, electrolytes, antibiotics, pressor agents, ventilation, and alkalinization of the urine, multiorgan failure developed, and the patient died on day 5 in the intensive care unit. Physicians should be aware of this infrequent but potentially fatal complication occurring in critically ill patients with bulky solid tumors so that early and aggressive therapeutic measures can be initiated and appropriate monitoring can be performed.

Dexamethazone-induced acute tumor lysis syndrome in a T-cell malignant lymphoma

We report a case of steroid-induced acute tumor lysis syndrome and review the literature. A 60-year-old woman was started on steroid therapy for dyspnea due to bilateral pleural effusion and a large mass involving the anterior mediastinum. The final diagnosis was precursor T-lymphoblastic lymphoma-leukemia. Following steroid therapy, the patient developed acute renal failure and laboratory evidence of metabolic changes induced by massive cytolysis. She received vigorous hydration, diuretic and allopurinol therapy, and haemodialysis. Her diuresis, renal function and laboratory data returned to normal within 2 weeks. A review of the medical literature on T-cell lymphoma revealed only one similar case of steroid-induced acute tumor lysis syndrome, a life-threatening metabolic emergency. This risk should be kept into account in the management of patients with lymphoproliferative disorders.

Tumor lysis syndrome after hydrocortisone treatment in metastatic melanoma: a case report and review of the literature

Tumor lysis syndrome (TLS) is 1 of the complications that usually follows chemotherapy treatment of myelo-lymphoproliferative diseases. Corticosteroids (CS) could also induce TLS in this type of malignancies. On the other hand, TLS in solid tumors is less frequent, and CS treatment was never reported to be associated with TLS in solid tumor. Here we report the first case of TLS in a solid tumor (melanoma) after CS treatment.

Tumor lysis syndrome in small cell lung cancer

Tumor lysis syndrome, resulting from the abrupt release of intracellular ions into the blood stream due to sudden tumor cell death, is a serious complication of chemotherapy treatment. This syndrome occurs more frequently in hematologic malignancies and lymphomas. Its incidence in solid tumors is rare, but has a high mortality rate owing to the lack of prophylactic therapy to prevent this complication. We report a case of tumor lysis syndrome accompanied by death in a patient with extensive stage small cell lung cancer who was treated with cisplatin and etoposide, and review the risk factors associated with the syndrome in solid tumor patients who are likely to respond to chemotherapy.

Presentation of M4 acute myeloid leukemia in anuric renal failure with hyperuricemia and enlarged kidneys

Extramedullary acute myeloid leukemia (AML) is not uncommon. It has been shown to involve the kidneys in most postmortem cases but is most often clinically insignificant. By contrast, acute tumor lysis syndrome is rare in AML, especially at initial diagnosis. The authors report the management of a patient with AML who had acute tumor lysis syndrome that was probably potentiated by renal leukemia and resulted in renal failure. This patient achieved remission with dose-modified induction chemotherapy administered while he was dialysis-dependent.

Fluid and electrolyte abnormalities

Patients with cancer are at risk for developing a variety of fluid and electrolyte disturbances caused by the disease process or by complications from therapy. An understanding of the pathophysiology of these potential abnormalities allows the clinician to manage patients expectantly and to avoid severe metabolic disarray by correcting imbalances promptly.

Acute tumour lysis syndrome following a single-dose corticosteroid in children with acute lymphoblastic leukaemia

Acute tumour lysis syndrome (ATLS) is a well recognised complication of treatment of a variety of malignant disorders. It commonly occurs in patients with non-Hodgkin's lymphoma (NHL) and acute lymphoblastic leukaemia (ALL) with the administration of combined cytotoxic chemotherapy. It is rarely reported after single-agent corticosteroid therapy. We present two children with acute lymphoblastic leukaemia of T-cell lineage who developed acute tumour lysis syndrome after a single dose of prednisolone, and methylprednisolone at the beginning of the induction chemotherapy. In the first case (an 11-yr-old) ATLS had occurred after an oral dose of prednisolone as small as 12 mg and within 18 h. The second case was a 14-yr-old boy with ALL who developed ATLS following a single dose of methylprednisolone. A few similar cases in the English literature are summarised in the report. These cases indicate that acute tumour lysis syndrome may occur after a single dose of corticosteroids. One should be aware of this potentially life-threatening complication especially while prescribing corticosteroids to patients with NHL and leukaemia.

Acute spontaneous tumor-lysis syndrome in a pregnant woman with non-Hodgkin's lymphoma

Both non-Hodgkin's lymphoma (NHL) in pregnancy and acute spontaneous tumor-lysis (ASTL) syndrome are rare. Here we present a 32-year-old Egyptian woman in the 27th week of pregnancy, who was admitted with epistaxis, lethargy, vomiting and dehydration. This patient developed ASTL syndrome secondary to undiagnosed NHL, but was not on any medication associated with the syndrome. At 28 weeks, she gave birth to a healthy baby who, unfortunately, died within a few days. To our knowledge, this is the first case of ASTL syndrome in a pregnant woman.

Acute renal failure as presentation of a Burkitt's lymphoma

Acute renal failure due to diffuse renal infiltration is rarely the presenting manifestation of non-Hodgkin's lymphoma. We report a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a Burkitt's lymphoma. The presence of bilateral renal enlargement, an elevated serum lactate dehydrogenase (LDH), and lymphopenia should suggest the diagnosis, which can be confirmed by renal biopsy.

Stability of cytotoxic luteinizing hormone-releasing hormone conjugate (AN-152) containing doxorubicin 14-O-hemiglutarate in mouse and human serum in vitro: implications for the design of preclinical studies

Recently, we developed a series of cytotoxic peptide conjugates containing 14-O-glutaryl esters of doxorubicin (DOX) or 2-pyrrolino-DOX (AN-201). Serum carboxylesterase enzymes (CE) can partially hydrolyze these conjugates in the circulation, releasing the cytotoxic radical, before the targeting is complete. CE activity in serum of nude mice is about 10 times higher than in human serum. Thus, we found that the t(1/2) of AN-152, an analog of luteinizing hormone-releasing hormone (LH-RH) containing DOX, at 0.3 mg/ml is 19. 49 +/- 0.74 min in mouse serum and 126.06 +/- 3.03 min in human serum in vitro. The addition of a CE inhibitor, diisopropyl fluorophosphate (DFP), to mouse serum in vitro significantly (P < 0. 01) prolongs the t(1/2) of AN-152 to 69.63 +/- 4.44 min. When DFP is used in vivo, 400 nmol/kg cytotoxic somatostatin analog AN-238 containing AN-201 is well tolerated by mice, whereas all animals die after the same dose without DFP. In contrast, DFP has no effect on the tolerance of AN-201. A better tolerance to AN-238 after DFP treatment is due to the selective uptake of AN-238 by somatostatin receptor-positive tissues. Our results demonstrate that the suppression of the CE activity in nude mice greatly decreases the toxicity of cytotoxic hybrids containing 2-pyrrolino-DOX 14-O-hemiglutarate and brings this animal model closer to the conditions that exist in humans. The use of DFP together with these peptide conjugates in nude mice permits a better understanding of their mechanism of action and improves the clinical predictability of the oncological and toxicological results.

Hyperuricemia and renal insufficiency associated with malignant disease: urate oxidase as an efficient therapy?

Hyperuricemia is a common finding in patients with malignant diseases. Chemotherapy can induce life-threatening tumor lysis syndrome with severe hyperuricemia, other metabolic abnormalities, and acute renal failure. Intrarenal precipitation of uric acid contributes to renal insufficiency in this situation. Allopurinol, by preventing the conversion of hypoxanthine and xanthine to uric acid, has been long considered the standard pharmacological approach to hyperuricemia and prevention of tumor lysis syndrome. However, allopurinol itself may facilitate precipitation of xanthine crystals and has little influence on already-formed uric acid crystals deposited in the kidney. Urate oxidase further oxidizes uric acid to the highly water-soluble allantoin in mammals, except humans, who lack this enzyme. We report four cases of hyperuricemia (initial serum uric acid concentrations, 14.0 to 25.0 mg/dL) associated with malignant diseases treated with exogenous urate oxidase. Two of the patients showed full-blown tumor lysis syndrome. A single urate oxidase infusion (1,000 U) readily reduced serum uric acid levels in all patients. Furthermore, renal insufficiency, determined by serum creatinine concentrations, improved in three of the four patients. No adverse effects were observed. Currently, a recombinant urate oxidase is undergoing clinical testing and may make this efficient therapy more widely available. We believe that treatment with urate oxidase is a safe and efficient therapy for patients with cancer-associated hyperuricemia and may be effective even in individuals with only moderately elevated serum uric acid concentrations.

Rituximab therapy in hematologic malignancy patients with circulating blood tumor cells: association with increased infusion-related side effects and rapid blood tumor clearance

PURPOSE

Rituximab was recently approved for use in relapsed, low-grade non-Hodgkin's lymphoma; however, few data exist regarding the safety of this agent in patients with a high number of tumor cells in the blood.

METHODS AND RESULTS

After the observation at our institution of a rapid reduction of peripheral-blood tumor cells with associated severe pulmonary infusion-related toxicity in two patients with refractory hematologic malignancies, data on three additional cases were collected from physician-submitted reports of adverse events related to rituximab treatment. Five patients with hematologic malignancies possessing a high number of blood tumor cells were treated with rituximab and developed rapid tumor clearance. The median age was 68 years (range, 26 to 78 years). Patients were diagnosed with B-cell prolymphocytic leukemia (n = 2), chronic lymphocytic leukemia (n = 2), or transformed non-Hodgkin's lymphoma (n = 1). All of these patients had bulky adenopathy or organomegaly. All five patients developed a unique syndrome of severe infusion-related reactions, thrombocytopenia, rapid decrement in circulating tumor cell load, and mild electrolyte evidence of tumor lysis, and all required hospitalization. In addition, one patient developed ascites. These events resolved, and four patients were subsequently treated with rituximab without significant complications.

CONCLUSION

Rituximab administration in patients who have a high number of tumor cells in the blood may have an increased likelihood of severe initial infusion-related reactions. These data also suggest that rituximab may have activity in a variety of other lymphoid neoplasms, such as chronic lymphocytic leukemia and B-cell prolymphocytic leukemia.

Oncologic emergencies in the patient with lymphoma

OBJECTIVES

To provide a brief overview of the oncologic emergencies most commonly occurring in lymphoma patients.

DATA SOURCES

Published articles, research studies, and reference books.

CONCLUSIONS

As a result of their malignancy and the treatments they receive, lymphoma patients are at an increased risk for the development of the following oncologic emergencies: superior vena cava syndrome, cardiac tamponade, sepsis, acute tumor lysis syndrome, and increased intracranial pressure. If not recognized and treated quickly, these complications can be deadly. With appropriate medical and nursing management, these emergencies either can be prevented or their complications minimized.

IMPLICATIONS FOR NURSING PRACTICE

An awareness of which patients are at risk for these complications and the pathophysiology of each emergency will assist nurses in the implementation of treatment measures.

Tumor lysis syndrome and acute renal failure after treatment of non-small-cell lung carcinoma with combination irinotecan and cisplatin

Tumor lysis syndrome, characterized by multiple metabolic abnormalities resulting from abrupt tumor cell death and release of intracellular constituents and metabolites, is most commonly associated with the treatment of highly chemotherapy-sensitive lymphoid and leukemic neoplasms. The authors report a case of tumor lysis syndrome accompanied by acute renal failure that occurred in a patient with stage IV non-small-cell lung cancer who was treated with topoisomerase I inhibitor, irinotecan, and cisplatin. Consistent with the rapid tumor lysis, an objective, marked, early clinical response was observed. Attention to adequate hydration, electrolytes, and renal function should be given to outpatients with non-small-cell lung cancer who receive newer chemotherapeutic agents that have greater efficacy toward this group of tumors.

Management of tumor lysis syndrome with standard continuous arteriovenous hemodialysis: case report and a review of the literature

Tumor lysis syndrome (TLS) is a critical illness with few treatment options. This report describes the clinical course of a patient with non-Hodgkin's lymphoma, who developed TLS and required renal replacement therapy. Institution of the standard therapeutic approach, intermittent hemodialysis, was not possible because of persistent hypotension. Instead, the patient was treated with a short course of continuous arteriovenous hemofiltration (CAVH) and conventional continuous arteriovenous hemodialysis (CAVHD) with dialysate flow rate of 1 L/h), which resulted in effective control of serum uric acid, potassium, urea nitrogen, phosphorus, and extracellular fluid volume. This case is in distinction to a previous report of TLS treatment with CAVHD using 4 L/h dialysate flow rate. We conclude that continuous renal replacement therapies with standard dialysate flow rates and replacement volumes should be considered for the treatment of TLS, particulary if the syndrome is accompanied by hypotension.

Spontaneous acute tumor lysis syndrome in acute myeloid leukemia? A single case report with discussion of the literature

Acute tumor lysis syndrome (ATLS), a condition which results from a rapid destruction of tumor cells with massive release of cellular breakdown products, has been well described following the treatment of various malignancies. However, only a handful of cases of spontaneous ATLS have been reported in the literature. We describe the first reported case of spontaneous ATLS in acute myeloid leukemia (AML). A previously healthy 63 year old woman presented with a two month history of fatigue and a one week history of easy bruising. On admission she had oliguric acute renal failure, with marked elevation in serum uric acid and phosphate. A bone marrow biopsy showed AML M7 with fibrosis. The renal failure resolved with supportive care and institution of allopurinol therapy. Following this, AML induction chemotherapy resulted in complete remission. Her biochemical and clinical course were very similar to the classical ATLS seen in patients after chemotherapy. Therefore, this case represents a rare instance of acute renal failure from spontaneous ATLS, and in our opinion the first reported occurrence of spontaneous ATLS associated with AML.

ARDS associated with tumor lysis syndrome in a patient with non-Hodgkin's lymphoma

ARDS developed in association with tumor lysis syndrome (TLS) in a patient with non-Hodgkin's lymphoma. Although a number of life-threatening complications have been noted to occur following TLS, this appears to be the first report of ARDS developing in association with TLS.

Tumor lysis syndrome in small cell carcinoma and other solid tumors

OBJECTIVE

To review the risk factors and clinical findings associated with tumor lysis syndrome (TLS) in patients with small cell carcinomas and other solid tumors.

METHODS

Reports of TLS in the English-language literature were identified by searching MEDLINE and the bibliographies of relevant case reports, journal articles, and book chapters. All reports identified through these searches, including abstracts from national meetings, were reviewed and included in this analysis. Data regarding clinical and biochemical parameters relevant to the occurrence of TLS were extracted from each report.

RESULTS

Of the 25 reported solid tumor patients who developed TLS, 7 had small cell carcinoma, 5 breast cancer, and 4 neuroblastoma. TLS was associated with a variety of treatment regimens, including chemotherapy, immunotherapy, hormonal therapy, radiation therapy, and surgery. Common risk factors for TLS in this population included pretreatment renal insufficiency, elevated serum lactate dehydrogenase (LDH), and hyperuricemia. Among the typical biochemical findings of TLS, acute renal insufficiency and hyperuricemia were identified in nearly all patients and hyperkalemia, hyperphosphatemia, hypocalcemia, and increased serum LDH were reported in over 75% of patients. In addition, seven patients, including the current case, presented with profound metabolic acidosis. Nine of 25 patients died during the acute episode of TLS.

CONCLUSIONS

Although TLS occurs infrequently in patients with solid tumors, the risk factors and biochemical abnormalities associated with this potentially fatal complication of therapy must be recognized to allow for adequate monitoring and early initiation of appropriate therapeutic measures.

Non-Hodgkin's lymphoma

Pediatric lymphomas are the third most common group of malignancies in children and adolescents. Unlike lymphomas in adults, pediatric lymphomas are diffuse, aggressive neoplasms with a propensity for widespread dissemination. Intensification of conventional treatment approaches along with improvements in supportive care have resulted in dramatic improvement in event-free survival rates of close to 90% in patients with B-cell lymphomas and only slightly lower in patients with T-cell lymphomas. Lymphoid neoplasms arise because of genetic changes that result in altered growth and differential patterns of lymphoid cells. The characterization of these molecular abnormalities and an understanding of their consequences has led to new approaches to diagnosis and the detection of minimal residual disease and also provides the basis for the future development of novel treatment approaches targeted specifically to the neoplastic cells.

Hypercalcemia and electrolyte disturbances in malignancy

Hypercalcemia and electrolyte abnormalities are common problems in patients with malignancy. In this article we discuss the pathophysiology, clinical features, and management of hypercalcemia, which is the most common metabolic abnormality. We also analyze the electrolyte disturbances that occur in association with malignancy, including hyponatremia, hypokalemia, hypomagnesemia, hypophosphatemia, and hyperkalemia. Recognition and treatment of these disturbances are important parts of the management of patients with malignant disease.

Acute tumor lysis syndrome in high grade lymphoblastic lymphoma after a prolonged episode of fever

Acute tumor lysis syndrome occurs in rapidly growing lymphoid malignancies, usually as a consequence of chemotherapy or corticosteroids. We present what appears to be the first reported case of tumor lysis occurring after a sustained episode of high fever of 42.0 degrees C in a patient with high grade lymphoblastic lymphoma and a high tumor burden.

Clinical versus laboratory tumor lysis syndrome in children with acute leukemia

Renal and metabolic complications of tumor lysis syndrome (TLS) were recognized frequently in the 1960s and 1970s. Strategies were designed to prevent TLS. We conducted a retrospective chart review study to identify the current TLS risk in children with acute leukemia. Children were considered to have "laboratory tumor lysis syndrome" (LTLS) if two of the following metabolic changes occurred within 4 days of the start of chemotherapy: a 25% increase in serum phosphate, potassium, uric acid, or blood urea nitrogen levels, or a 25% decline in serum calcium concentration. Clinical TLS (CTLS) was defined as LTLS plus a serum potassium level higher than 6.0 mmol/L or acute renal failure. Twenty-one of 30 children developed LTLS; one developed CTLS. Absolute blast count, pretreatment white blood cell count, pretreatment lactic dehydrogenase, and sex or tumor DNA index did not correlate with the development of LTLS. LTLS is still frequent in children undergoing chemotherapy for acute leukemia; CTLS, however, is much less common.

Severe hyperphosphatemia following acute tumor lysis syndrome

We report on a 14-year-old boy with acute lymphoblastic leukemia (lymphoma-leukemia) who had two episodes of acute tumor lysis syndrome during induction of remission with oral prednisolone alone and oral prednisolone, intravenous vincristine, and doxorubicin, respectively. Subsequently he had severe hyperphosphatemia (29.3 and 14.1 mg/dl; 9.46 and 4.55 mmol/L), hypocalcemia, hyperuricemia, hyperkalemia, and azotemia. Multiple stones and tumor cells infiltration were demonstrated in both kidney. He responded favorably to hemodialysis.

Acute spontaneous tumor lysis syndrome

An 83-year-old woman with no previous history of malignancy was admitted to our institution with weakness and anemia and subsequently developed acute tumor lysis syndrome secondary to newly diagnosed Burkitt's leukemia/lymphoma. This syndrome has been previously described in patients with hematologic malignancies; however, its development has been related to the administration of chemotherapy, steroids, or radiotherapy. The spontaneous occurrence of tumor lysis syndrome has not been previously reported; however, Cohen et al. [Am J Med 58:486-491, 1980] report 8 of 37 patients with "clinically insignificant pretreatment derangements" of serum potassium, phosphate, and calcium.

Acute tumour lysis syndrome with no evidence of tumour load

Acute tumour lysis syndrome (ATLS) is a well-recognised complication of the treatment of a variety of malignant disorders in which a large mass of disease is obvious. ATLS may, however, occur even in the absence of bulk disease. We present two cases which, together with a review of previously reported cases, suggest that a cause of this rare phenomenon is primary renal lymphoma which subsequently develops into the leukaemic phase. This is supported by the observation that some bone marrow aspirates which are normal at the time of ATLS have shortly afterwards demonstrated lymphoblasts. Renal biopsy may not exclude primary lymphoma of the kidney. In excluding lymphoproliferative disease in the differential diagnosis of acute hyperuricaemia, the importance not only of bone marrow examination but of exhaustive investigation of the kidneys is stressed.

Acute tumor lysis syndrome in poor-risk germ cell tumors: does it exist?

Acute tumor lysis syndrome (ATLS) is a well-known adverse event described after effective chemotherapy for extensive, highly proliferative, and chemosensitive tumors. While its occurrence with hematological malignancies is frequently described, there have been scattered case reports documenting ATLS in solid tumors. However, such events have not been reported in poor-risk germ cell tumors. We reviewed retrospectively 46 cases of such tumors treated in our department between 1988 and 1993 by aggressive cisplatin-based chemotherapy. All patients received systematically 6 l/24 h hydration according to the cisplatin- protocol administration. Blood chemistry data for potassium, phosphorus, calcium, alkaline reserve, uric acid, creatinine and lactate dehydrogenase were obtained before treatment and during the 7 days of the induction chemotherapy. No metabolic abnormalities suggestive of ATLS were observed. Nevertheless, 2 patients with bulky disease of the chest experienced early death from respiratory distress complicated by multiorgan failure. ATLS seems to be an unlikely event in poor-risk germ cell tumors and therefore special prophylactic therapy may be unnecessary.