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Gartenberg A, Winkel M, Leonard N. Spontaneous tumor lysis syndrome in a patient with chronic myeloid leukemia treated successfully with allopurinol. Am J Emerg Med 2024; 78:242.e1-242.e3. [PMID: 38007380 DOI: 10.1016/j.ajem.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Tumor Lysis Syndrome (TLS) is an oncologic emergency that may occur in any patient with a hematologic malignancy, even prior to initiation of chemotherapy. Spontaneous TLS massive tumor cell destruction with intracellular electrolyte release prior to the initiation of chemotherapy. Spontaneous tumor lysis syndrome is a rare presentation, mainly occurring in Acute Leukemia and non-Hodgkin Lymphoma. Chronic Myeloid Leukemia (CML) is a low-risk disease based on TLS risk stratification. To the best of our knowledge, spontaneous TLS in the chronic phase of CML successfully treated with allopurinol and aggressive hydration has yet to be reported in the literature. A case report is described regarding a 67 year old Jamaican female with a history of hypertension who presented to the emergency department with abdominal pain, nausea, and vomiting for 1 day. The patient was found to have leukocytosis to 344,000 with 4% Blasts, hyperuricemia, and acute kidney injury. A peripheral blood smear confirmed the diagnosis of CML. Bone marrow biopsy was performed with evidence of the chronic phase of CML. The patient met clinical criteria for spontaneous tumor lysis syndrome. The patient was started on aggressive intravenous hydration, allopurinol, hydroxyurea and imatinib. Creatinine and uric acid level improved on this regimen within 48 h of initiation.
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Affiliation(s)
- Ariella Gartenberg
- Emergency Medicine, Jacobi Medical Center and Montefiore Medical Center, Bronx, NY, United States of America.
| | - Maia Winkel
- Emergency Medicine, Jacobi Medical Center and Montefiore Medical Center, Bronx, NY, United States of America
| | - Nicole Leonard
- Jacobi Medical Center and North Central Bronx Hospital, Bronx, NY, United States of America
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Cheung WL, Hon KL, Fung CM, Leung AKC. Tumor lysis syndrome in childhood malignancies. Drugs Context 2020; 9:2019-8-2. [PMID: 32158483 PMCID: PMC7048108 DOI: 10.7573/dic.2019-8-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/18/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tumor lysis syndrome (TLS) is the most common life-threatening oncological emergency encountered by physicians treating children with lymphoproliferative malignancies. Healthcare providers should be aware of the condition in order to prevent occurrence and prompt timely management to avoid severe consequences. OBJECTIVE To provide an update on the current understanding, evaluation, and management of tumor lysis syndrome in childhood malignancies. METHODS A PubMed search was performed in Clinical Queries using the keywords 'tumor lysis syndrome' and 'malignancies' with Category limited to clinical trials and reviews for ages from birth to 18 years. RESULTS There were 22 clinical trials and 37 reviews under the search criteria. TLS is characterized by acute electrolyte and metabolic disturbances resulting from massive and abrupt release of cellular contents into the circulation due to breakdown of tumor cells. If left untreated, it can lead to multiorgan compromise and eventually death. Apart from close monitoring and medical therapies, early recognition of risk factors for development of TLS is also necessary for successful management. CONCLUSIONS Prophylactic measures to patients at risk of TLS include aggressive fluid management and judicious use of diuretics and hypouricemic agents. Both allopurinol and urate oxidase are effective in reducing serum uric acid. Allopurinol should be used as prophylaxis in low-risk cases while urate oxidase should be used as treatment in intermediate to high-risk cases. There is no evidence on better drug of choice among different urate oxidases. The routine use of diuretics and urine alkalinization are not recommended. Correction of electrolytes and use of renal replacement therapy may also be required during treatment of TLS.
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Affiliation(s)
- Wing Lum Cheung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, People’s Republic of China
| | - Kam Lun Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, People’s Republic of China
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Cheuk Man Fung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, People’s Republic of China
| | - Alexander KC Leung
- Department of Pediatrics, The University of Calgary, Alberta Children’s Hospital, Calgary, AB, Canada
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Theodorou D, Lagoudianakis E, Pattas M, Drimousis P, Tsekouras DK, Genetzakis M, Katergiannakis V, Manouras A. Pretreatment Tumor Lysis Syndrome Associated with Bulky Retroperitoneal Tumors. Recognition is the Mainstay of Therapy. TUMORI JOURNAL 2019; 92:540-1. [PMID: 17260497 DOI: 10.1177/030089160609200613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute pretreatment tumor lysis syndrome is a rare complication of cancer. Early recognition and aggressive management are mandatory for prevention of the adverse sequelae of the syndrome. Here we present 2 cases of pretreatment tumor lysis syndrome, concluding that this clinical entity should be in the differential diagnosis of acute renal failure associated with malignancy, as early recognition is in fact the mainstay of treatment.
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Affiliation(s)
- Dimitrios Theodorou
- First Department of Propaedeutic Surgery, Hippocrateion Hospital, Athens Medical School, University of Athens, Athens, Greece
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Gangireddy M, Shrimanker I, Nookala VK, Peroutka KA. Spontaneous Tumor Lysis Syndrome in Diffuse Large B-cell Lymphoma: Early Diagnosis and Management. Cureus 2019; 11:e4679. [PMID: 31328070 PMCID: PMC6634345 DOI: 10.7759/cureus.4679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Spontaneous tumor lysis syndrome is a rare oncological emergency associated with multiorgan failure. It is characterized by an elevation of uric acid, hyperphosphatemia, hypocalcemia, hyperkalemia and renal failure in the setting of no active chemotherapy as a result of lysis of massive tumor burden. Early recognition of the disease and prompt management would affect morbidity and mortality. We present the case of an 80-year-old Caucasian male with a history of recently diagnosed diffuse large B-cell lymphoma who had worsening fatigue, weakness and decreased appetite for three days. On admission, laboratory investigations were significant for elevated creatinine, uric acid, and phosphorous. He was started on hemodialysis and rasburicase in view of hyperuricemia. Subsequently, chemotherapy was started. He tolerated chemotherapy initially but later developed multiorgan failure. His family then opted for comfort measures and the patient passed away soon after. In conclusion, spontaneous tumor lysis syndrome is a common association with hematological cancers. Prophylaxis with allopurinol and rasburicase is recommended in all patients who are at an increased risk for tumor lysis syndrome.
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Affiliation(s)
- Mounika Gangireddy
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
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Na YS, Park SG. A Rare Case of Spontaneous Tumor Lysis Syndrome in Idiopathic Primary Myelofibrosis. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:146-150. [PMID: 30712053 PMCID: PMC6369657 DOI: 10.12659/ajcr.912682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patient: Male, 51 Final Diagnosis: Spontaneous tumor lysis syndrome • idiopathic primary myelofibrosis Symptoms: Abdominal pain • general weakness Medication: — Clinical Procedure: Continuous renal replacement therapy • bone marrow biopsy Specialty: Hematology
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Affiliation(s)
- Yong Sub Na
- Department of Pulmonology, Chosun University Hospital, Gwangju, South Korea
| | - Sang-Gon Park
- Department of Hemato-Oncology, Chosun University Hospital, Gwangju, South Korea
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Yun S, Vincelette ND, Phan T, Anwer F. Spontaneous tumour lysis syndrome associated with contrast dye iohexol use in mantle cell lymphoma. BMJ Case Rep 2014; 2014:bcr-2014-204113. [PMID: 25028407 DOI: 10.1136/bcr-2014-204113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of a 73-year-old man who presented with right-sided abdominal pain associated with palpable mass. Initial laboratory examination was normal except lactate dehydrogenase level. Subsequent CT image showed situs inversus and splenic mass with multiple lymph nodes enlargement. Biopsy taken from the splenic mass demonstrated mantle cell lymphoma. Staging CT examination was performed with intravenous contrast, and patient developed altered mental status, respiratory failure and acute kidney injury requiring intensive care unit care. Laboratory examination revealed hyperuricaemia, hyperphosphataemia, hyperkalaemia and hypocalcaemia, which are consistent with spontaneous tumour lysis syndrome. The patient was successfully treated with rasburicase and haemodialysis, and completed the first course of chemotherapy without further complications.
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Affiliation(s)
- Seongseok Yun
- Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA
| | | | - Tuan Phan
- Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA
| | - Faiz Anwer
- Department of Hematology, Oncology, Blood Marrow Transplantation, University of Arizona Medical Center, Tucson, Arizona, USA
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Yun S, Walker CN, Vincelette ND, Anwer F. Acute renal failure and type B lactic acidosis as first manifestation of extranodal T-cell lymphoblastic lymphoma. BMJ Case Rep 2014; 2014:bcr-2014-205044. [PMID: 24913086 DOI: 10.1136/bcr-2014-205044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We describe a rare case of a 19-year-old male patient with a history of epilepsy and developmental delay who presented with acute renal failure (ARF) and lactic acidosis (LA) as the first manifestation of T-cell lymphoblastic lymphoma. Renal ultrasound and CT of the abdomen showed renal parenchymal infiltration, and renal biopsy demonstrated T-cell lymphoblastic lymphoma. LA, ARF and electrolyte abnormalities were refractory to the initial treatment of bicarbonate infusion and hydration. However, these abnormalities rapidly normalised after the initiation of chemotherapy, suggesting that the LA and ARF were secondary to lymphomatous renal infiltration.
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Affiliation(s)
- Seongseok Yun
- Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA
| | - Courtney N Walker
- Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA
| | | | - Faiz Anwer
- Department of Internal Medicine, University of Arizona Medical Center, Tucson, Arizona, USA
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Acute Spontaneous Tumor Lysis Syndrome as the Initial Presentation of ALK-Positive Diffuse Large B-Cell Lymphoma. Appl Immunohistochem Mol Morphol 2014; 22:317-21. [DOI: 10.1097/pai.0b013e3182275c02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Malaguarnera G, Giordano M, Malaguarnera M. Rasburicase for the treatment of tumor lysis in hematological malignancies. Expert Rev Hematol 2014; 5:27-38. [DOI: 10.1586/ehm.11.73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Tumor lysis syndrome (TLS) is an oncological emergency that results from massive cytolysis of malignant cells with a sudden release of their contents into the systemic circulation. TLS was rarely described in patients with malignant melanoma. In this article, we describe two patients with malignant melanoma who developed this syndrome. In one of them, the syndrome occurred spontaneously, and this is the second description of spontaneous tumor lysis in a patient with melanoma. We reviewed the previous patients with melanoma-induced TLS and discussed the manifestations and the pathophysiology of the syndrome in our patients.
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Abstract
OBJECTIVES To provide an up-to-date review of current literature on the pathophysiology, diagnosis, and management of five key malignancy-related complications: superior vena cava syndrome, malignant pericardial effusion, malignant spinal cord compression, hypercalcemia, and acute tumor lysis syndrome. DATA SOURCES Database searches and review of relevant medical literature. DATA SYNTHESIS Malignancy-related complications demand increased attention from intensivists due to their frequency and increasing cancer prevalence. Although such complications portend a poor prognosis, proper acute management can improve short-term outcomes by facilitating either definitive care of the underlying malignancy or the institution of appropriate palliative measures. CONCLUSIONS Knowledge of malignancy-induced complications in critically ill patients expedites the ability of the intensivist to properly manage them. Five complications commonly requiring emergency management are addressed in this review. Specifically, superior vena cava syndrome may warrant radiation, chemotherapy, vascular stenting, or surgical resection. Malignant pericardial effusion may require emergency pericardiocentesis if cardiac tamponade develops. Malignant spinal cord compression demands immediate spinal imaging, glucocorticoids, and either surgery or radiation. Hypercalcemia requires aggressive intravenous hydration and a bisphosphonate. Acute tumor lysis syndrome necessitates intravenous hydration, rasburicase, and management of associated electrolyte abnormalities.
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Firwana BM, Hasan R, Hasan N, Alahdab F, Alnahhas I, Hasan S, Varon J. Tumor lysis syndrome: a systematic review of case series and case reports. Postgrad Med 2012; 124:92-101. [PMID: 22437219 DOI: 10.3810/pgm.2012.03.2540] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tumor lysis syndrome (TLS) is a clinical condition that is caused by a massive lysis of tumor cells that accumulate very rapidly and disturb hemodynamics. This oncologic emergency requires immediate intervention. Tumor lysis syndrome was first described in the 19th century. Since then, it has become a well-known disease with improved management measures. Tumor lysis syndrome can occur after any type of neoplasm. It is highly associated with rapidly proliferating tumors compared with those that are well demarcated, such as acute lymphoblastic leukemia and high-grade non-Hodgkin lymphoma. Initiation of chemotherapy, radiotherapy, or steroid treatment may trigger TLS, or it may develop spontaneously. The release of massive quantities of intracellular contents may produce hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute renal failure. Prevention and treatment measures include intravenous hydration, use of allopurinol and rasburicase, management of TLS-associated electrolyte abnormalities, and renal replacement therapy; the use of urine alkalinization remains controversial. In this article, we summarize the findings of case series and case reports published over the past 6 years in an effort to help familiarize clinicians better recognize and manage TLS.
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Affiliation(s)
- Belal M Firwana
- Department of Internal Medicine, University of Missouri, Columbia, USA
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Affiliation(s)
- Darren J. Hunt
- Department of Surgery University of Tennessee College of Medicine Chattanooga, Tennessee
| | - Anna M. Royer
- Department of Surgery University of Tennessee College of Medicine Chattanooga, Tennessee
| | - Robert A. Maxwell
- Department of Surgery University of Tennessee College of Medicine Chattanooga, Tennessee
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Park SG, Chung CH, Park CY. Spontaneous tumor lysis syndrome with resolution of pancytopenia and disappearance of lymphadenopathy in a patient with peripheral T cell lymphoma unspecified. Int J Hematol 2011; 93:394-399. [DOI: 10.1007/s12185-011-0788-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 02/07/2011] [Accepted: 02/09/2011] [Indexed: 11/30/2022]
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Akoz AG, Yildirim N, Engin H, Dagdas S, Ozet G, Tekin IO, Ceran F. An unusual case of spontaneous acute tumor lysis syndrome associated with acute lymphoblastic leukemia: a case report and review of the literature. Acta Oncol 2009; 46:1190-2. [PMID: 17851839 DOI: 10.1080/02841860701367860] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zeh HJ, Lotze MT. Addicted to death: invasive cancer and the immune response to unscheduled cell death. J Immunother 2005; 28:1-9. [PMID: 15614039 DOI: 10.1097/00002371-200501000-00001] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The development of an invasive cancer involves a progressive switch from predominantly apoptotic (scheduled) to necrotic (unscheduled) tumor cell death. This switch is associated with chronic and increasing release of intracellular factors that in turn promote reactive angiogenesis and stromal proliferation and mediates the disordered tumor microenvironment associated with local immune suppression. The authors review the relevant immunobiology of these factors, including the nuclear protein HMGB1; the products of purine metabolism (uric acid, ATP, and adenosine); the S100 family members; and the heat shock proteins, which we believe drive futile cycles of cell death followed by reparative cell growth. The authors also present a novel and provocative hypothesis that suggests that most of the derangements that we associate with progression of cancer and the associated immunologic consequences can indeed be ascribed to the consequences of disordered tumor cell death rather than cell growth. Thus the fundamental defect in invasive human cancers, in the authors' view, is not one of cell growth but rather one of disordered cell death, resulting in turn in a tumor microenvironment that encourages tumor growth, progression, and local immunosuppression, a condition the authors have termed "addicted to death." This new understanding could inform and drive the development of more effective biologic therapies for patients with cancer.
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Affiliation(s)
- Herbert J Zeh
- University of Pittsburgh School of Medicine Institute, Room 411, 300 Technology Drive, Pittsburgh, PA 15219, USA
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